Living Related Liver Transplantation

 Short Contents | Full Contents Other books @ NCBI

Search

 

 This book All 

books 

 PubMed

Navigation

About this book

AHCPR Archived 

Technology 

Reviews

13. Living Related 

Liver 

Transplantation

Report

Tables

References

Surgeon General Reports, SAMHSA TIPs, SAMHSA PEPs AHCPR Archived 

Technology Reviews

13. Living Related Liver Transplantation

Living Related Liver Transplantation

Prepared by: S. Steven Hotta, M.D., Ph.D. 

Health Technology Review

No. 13 

Agency for Health Care Policy and Research Office of Health Technology 

Assessment U.S. Department of Health and Human Services Public Health 

Service 

September 1996 

AHCPR Pub. No. 96-0059 

Copyright and Disclaimer

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.chapter.444005/7/2009 2:34:02 PM
Report

 Short Contents | Full Contents Other books @ NCBI

Search

 

 This book All 

books 

 PubMed

Navigation

About this book

AHCPR Archived 

Technology 

Reviews

13. Living Related 

Liver 

Transplantation

Report

Tables

References

Surgeon General Reports, SAMHSA TIPs, SAMHSA PEPs AHCPR Archived 

Technology Reviews 13. Living Related Liver Transplantation

Report

Liver transplantation is a successful and accepted procedure for the treatment 

of patients who have end-stage liver disease (ESLD). However, many ESLD 

patients succumb to their disease before receiving a liver transplant, because 

the number of patients needing transplants exceeds the number of donors. This 

shortage of donors is more acute for pediatric patients, especially for infants, 

due mainly to the relative scarcity of suitably small livers. To address the 

higher pretransplant mortality among pediatric patients with ESLD, procedures 

for reduced-size liver and split-liver transplants were developed and used with 

successful outcomes.(1-5) These results with partial liver transplants 

demonstrated that the transplantation of an appropriately sized segment of the 

liver can successfully restore full, normal liver functions without the need for a 

whole liver transplant.(6)

After the successful use of reduced-size liver transplants, the transplantation of 

a portion of a liver from a living related person into an ESLD patient was 

investigated. A successful transplantation of a portion of the liver from a 

mother into her child was accomplished in 1989.(7) Since then, other living 

related liver transplantations (LRLTs), in which a segment or lobe of the liver 

from the living donor is transplanted into a recipient, have been performed at a 

number of centers in several countries. In general, the outcomes in over 187 

LRLTs, in terms of graft survival and patient survival, have been good. The 

number of LRLTs done and the observed patient and graft survival outcomes 

reported by various centers around the world are given in Table 1.

Although the number of procedures that were performed is small, all centers, 

except at Ankara,(10) reported good patient and graft survival outcomes that 

were comparable to or better than the outcomes with cadaveric livers. For 

example, Heffron et al(11) found that the patient survival of 14 LRLT 

recipients was 93 percent, with a graft survival of 93 percent compared with 83 

and 69 percent, respectively, for patient and graft survival for 43 recipients of 

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.section.44401 (1 of 5)5/7/2009 2:43:28 PM
Report

cadaveric grafts. Katz et al(9) reported similar results of 89 percent patient 

survival and 78 percent graft survival in nine LRLT recipients compared with 

90 and 90 percent, respectively, for 30 cadaveric graft recipients. Most of the 

LRLTs done in the United States were performed at Chicago(3) during the stay 

of Broelsch et al,(14) who reported that, of the first 20 LRLT recipients, 17 

patients (85 percent) were alive 3-18 months postoperatively, for a 1-year 

actuarial survival of 82 percent. Fifteen of the survivors (75 percent) had their 

primary grafts, whereas two of the survivors had received retransplants with 

cadaveric livers when their grafts failed. After Broelsch returned to Hamburg, 

Germany, he and his associates performed a total of 36 LRLTs, with an overall 

patient survival of 72 percent.(8) The largest number of LRLTs have been and 

continue to be performed at Kyoto in Japan. One report from the latter group 

indicated that they performed 70 LRLTs by September, 1993, with very 

reasonable patient and graft survival outcomes.(12) A more recent report from 

this group(15) indicated that the number increased to 100 as of May, 1994, 

with continued good outcomes.

Most of the recipients of LRLT presented with ESLD due to biliary atresia (e.

g., 80 percent of the recipients at Kyoto(12)), and a number of recipients had 

various inborn errors of metabolism, such as alpha-1 antitrypsin deficiency and 

Wilson's disease, as well as liver failures due to viral hepatitis or chemical 

toxins. Many of the early LRLT recipients were acutely ill, hospitalized, and in 

need of emergency liver transplants. On the other hand, most of the recent 

recipients were transplanted before they became acutely ill. This earlier 

transplantation appeared to be the result of the desire to allow sufficient time 

for the donor to consider adequately the risks and benefits of the procedure and 

assess the psychological impact of participation without having the pressure of 

imminent death as a dominating factor.(5) Thus, patients undergoing LRLT 

recently were in relatively better health than the usual liver transplant patients; 

this was thought to favor better patient survival outcomes. Observations such 

as those reported by Malago et al(8) and Tokunaga et al(12) appeared to 

support the better outcomes with the healthier recipients of LRLTs. For 

example, Malago et al(8) found that the patient survival of 30 relatively 

healthy LRLT recipients was 83 percent compared with 17 percent for six 

acutely ill LRLT recipients who had required emergency transplants. At 

Kyoto, Tokunaga et al(12) reported that the patient survival for the 54 elective 

LRLT recipients was 89 percent, whereas the survival for 16 emergency LRLT 

recipients was 69 percent.

The usual complications associated with liver transplantations, such as 

vascular thromboses, biliary leaks, rejections, and infections, have been 

experienced by recipients of LRLTs. From the available information, it is not 

clear whether the occurrence of complications or the outcomes with LRLTs 

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.section.44401 (2 of 5)5/7/2009 2:43:28 PM
Report

have changed with experience at the transplant centers. On the one hand, 

Lloyd et al(3) reported that most of the surgical complications occurred in the 

first half of the 45 LRLTs done at Chicago and that the patient survival and 

graft survival in the last 14 patients were 100 percent and 93 percent, 

respectively. On the other hand, there was no apparent difference between the 

survival rate for the first 20 recipients(14) and that for the total of 45 LRLTs

(3) in the series; the rates were 85 percent and 87 percent, respectively. 

However, graft survival did appear to improve from 75 percent in the first 20 

transplants(14) to an overall 88.9 percent for the total of 45 recipients.(3) At 

Kyoto, practitioners also found that the patient survival (85 percent) for the 

first 20 procedures(16) was essentially the same as that (84 percent) for the 

total of 70 LRLTs in their series.(12)

Parents or siblings of the patients served as the donors in almost all of the 

LRLTs performed. Although living donors have increased the supply of livers 

for pediatric patients, the use of healthy, living individuals for this purpose had 

raised some issues that needed to be addressed.(17,18) These involved 

questions concerning the exposure of a healthy person to the mortality and 

morbidity of a major surgical procedure and to potential psychological risks. 

Many of the centers that performed LRLTs indicated that these issues were 

addressed by the administration of thorough pretransplant medical and 

psychological examinations.(5,19) Preoperative medical examinations 

included a physical examination, blood analyses, liver function tests, and 

imaging procedures to determine the size of the prospective liver segment and 

to detect anomalies of the vasculature that may compromise the successful 

removal and reconnection of the blood vessels in the recipient.(5,10,20-22) 

Reports from some of the centers described psychological examinations that 

focused attention on an assessment of the donor for the presence or indications 

of possible psychological risks.(3,5,18,23) Lloyd et al(3) tried to minimize the 

pressures of an acutely ill patient by allowing approximately 2 weeks between 

the time of initial consent by the donor and the time of signing of the final 

consent for surgery, while the patient was in relatively good health.

All donors recovered from the surgical procedures without any notable 

complications. They returned to their pretransplant activities with normally 

functioning liver within a few weeks after spending approximately 1-2 weeks 

postoperatively in the hospital. For example, Lloyd et al(3) reported that all 

donors were alive and well at 2-year followup after an average stay in the 

hospital of 7.5 days. In general, the relatively minor complications, such as 

infections and bile leaks, that occurred in a few donors were treated and healed 

without any sequelae. Yamaoka et al(15) reported that, among the 100 parental 

donors who participated in LRLTs at Kyoto from June 1990 to May 1994, 

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.section.44401 (3 of 5)5/7/2009 2:43:28 PM
Report

there were four cases of bile leakage, one of esophagitis, seven of gastritis, and 

three of gastroduodenal ulcers. All of these donors returned to their normal 

presurgical activities within the first month or two after surgery.

As shown in Table 1, most of the LRLTs (151/187, or 81 percent) were 

performed at the three centers located in Chicago, Hamburg, and Kyoto, with 

70 performed at Kyoto. The relatively good results with LRLTs at these and 

other centers may have reflected the performance of LRLTs at centers that had 

experience with reduced-size liver transplantations and had surgeons 

experienced in performing partial hepatectomies.(17) Although experience 

may have logically influenced the outcomes of LRLTs, as Broelsch et al(5) 

suggested, there is insufficient information available to determine to what 

extent, if any, such prior experience may be necessary at the transplant centers 

undertaking LRLTs.

As stated earlier, there have been no donor deaths reported in published 

accounts of LRLTs. However, in his brief discussion of liver transplantation, 

Hockerstedt(24) mentioned, without reference, that the first death of a living 

donor had occurred recently. Apparently, a donor died postoperatively as the 

result of pulmonary embolism (personal communication, R.P. Wood, 

University of Texas Medical School at Houston, 1995). This death did not 

appear to be the result of direct complications of the partial hepatectomy, but 

seems to represent a sobering reminder of the risk faced by any patient who 

undergoes any major surgical procedure.

In summary, LRLTs were performed successfully in a number of transplant 

centers with patient and graft survival rates that were as good or better than 

those with cadaveric livers. Practically all of the recipients have been infants or 

young children. With few exceptions, the donors of a segment of liver for 

transplantation were parents or other family members of the recipients. Of the 

approximately 200 LRLTs that have been performed, over 80 percent were 

done at three centers, with about half of the total performed at Kyoto. A 

considerable number of LRLTs were performed at two centers by teams 

headed by Broelsch while he was at Chicago and later, at Hamburg. It was 

reported that all donors recovered without sequelae and returned to their 

normal preoperative activities within a few weeks. Apparently, extensive 

medical examinations and some psychological evaluations were done 

preoperatively to assess the suitability of an individual to be a donor. What 

information was used for the selection of the donor was not clear from the 

publications. Similarly, a lack of information precludes the assessment of the 

possible influence of prior experiences of the transplant team with reducedsize liver transplantations and partial hepatectomies at the transplant centers on 

the outcomes of LRLTs. Whether these precautionary measures are in place at 

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.section.44401 (4 of 5)5/7/2009 2:43:28 PM
Report

all centers is not known, but the outcomes reported for the limited number of 

LRLTs from the centers other than those at Kyoto and Hamburg are 

encouraging. The performance of LRLTs on youthful patients who were in 

relatively good health may have contributed to the observed good outcomes.

Health Technology Reviews are brief evaluations of health technologies 

prepared by the Center for Health Care Technology, Agency for Health Care 

Policy and Research (CHCT/AHCPR) of the Public Health Service. Reviews 

may be composed in lieu of a technology assessment because: the medical or 

scientific questions are limited and do not warrant the resources required for a 

full assessment; the available evidence is limited and the published medical or 

scientific literature is insufficient in quality or quantity for an assessment; or 

the time frame available precludes utilization of the full, formal assessment 

process. This report has been prepared in response to a request from the 

Civilian Health and Medical Program of the Uniformed Services 

(CHAMPUS).

Copyright and Disclaimer

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.section.44401 (5 of 5)5/7/2009 2:43:28 PM
Tables

 Short Contents | Full Contents Other books @ NCBI

Search

 

 This book All 

books 

 PubMed

Navigation

About this book

AHCPR Archived 

Technology 

Reviews

13. Living Related 

Liver 

Transplantation

Report

Tables

References

Tables

Table 1. Outcomes 

of living...

Surgeon General Reports, SAMHSA TIPs, SAMHSA PEPs AHCPR Archived 

Technology Reviews 13. Living Related Liver Transplantation

Tables

Table 1. Outcomes of living related liver transplantations

Copyright and Disclaimer

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.section.444025/7/2009 2:44:07 PM
Table 1. Outcomes of living related liver transplantation

 Short Contents | Full Contents Other books @ NCBI

Search

 

 This book All 

books 

 PubMed

Navigation

About this book

AHCPR Archived 

Technology 

Reviews

13. Living Related 

Liver 

Transplantation

Report

Tables

References

Surgeon General Reports, SAMHSA TIPs, SAMHSA PEPs AHCPR Archived 

Technology Reviews 13. Living Related Liver Transplantation Tables

Table 1. Outcomes of living related liver transplantation

Location of 

center

N Transplant 

period

Patient 

survival 

(%)

Graft 

survival 

(%)

Followup 

period 

(months)

Ref 

no.

Chicago 45 a 11/89-4/92 87 b 89 b 3

Hamburg 36 10/91–4/94 83 c 

17 c 

.2-31 8

Houston 9 5/92-12/92 89 b 78 b 9-15 9

Ankara 6 3/90-6/93 33 10

Nebraska 14 7/92-7/93 93 93 11

Kyoto 70 6/90–9/93 89 d 

69 d 

12-36 12

Matsumoto 5 6/90-7/91 80 80 4-17 13

Total LRLTs 187 11/89-1/94 33-93 78-93 .2-36

a Included seven LRLTs performed at Hamburg. 

b Actuarial 1-year patient and graft survivals. 

c Eighty-three percent survival of elective recipients; 17 percent survival of 

emergency liver recipients. Overall patient survival was 72 percent. 

d Eighty-nine percent survival of elective liver recipients; 69 percent survival of 

emergency liver recipients. 

Copyright and Disclaimer

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.table.444035/7/2009 2:46:20 PM
References

 Short Contents | Full Contents Other books @ NCBI

Search

 

 This book All 

books 

 PubMed

Navigation

About this book

AHCPR Archived 

Technology 

Reviews

13. Living Related 

Liver 

Transplantation

Report

Tables

References

Surgeon General Reports, SAMHSA TIPs, SAMHSA PEPs AHCPR Archived 

Technology Reviews 13. Living Related Liver Transplantation

References

Bismuth H, Houssin D. . Reduced size orthotopic liver graft in hepatic 

transplantation in children. Surgery 1984. 95: 367-378. (PubMed) 

Ringe B, Burdelski B, Rodeck B, et al. . Experience with partial liver 

transplantation in Hannover. Clin Transplants 1990. 135-144. 

Lloyd DM, Pieper F, Gundlach M, et al. . Developments in segmental and 

living related liver transplantation. Transplant Proc 1992. 24: 1287-1292. 

(PubMed) 

Ben-Ami TE, Martich V, Yousefzadeh DK, et al. . Anatomic features of 

reduced-size liver transplant: postsurgical imaging characteristics. Radiology 

1993. 187: 165-170. (PubMed) 

Broelsch CE, Lloyd DM. . Living related donors for liver transplants. Adv Surg 

1993. 26: 209-231. (PubMed) 

Ringe B, Oldhafer K, Rodeck B, et al. . An update of partial liver 

transplantation. Transplant Proc 1993. 25: 2198-2199. (PubMed) 

Strong RW, Lynch SV, Ong TH, et al. . Successful liver transplantation from a 

living donor to her son. N Engl J Med 1990. 322: 1505-1507. (PubMed) 

Malago M, Rogiers X, Burdelski M, et al. . Living related liver transplantation: 

36 cases at the University of Hamburg. Transplant Proc 1994. 26: 3620-3621. 

(PubMed) 

Katz SM, Ozaki CF, Monsour HP, et al. . Pediatric living-related and cadaveric 

liver transplantation: a single center experience. Transplant Proc 1994. 26: 

145-146. (PubMed) 

Haberal M, Buyukpamukcu N, Bilgin N, et al. . Segmental living related liver 

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.biblist.44404 (1 of 3)5/7/2009 2:45:22 PM
References

transplantation in pediatric patients. Transplant Proc 1994. 26: 183-184. 

(PubMed) 

Heffron TG, Antonson DL, Langnas AN, et al. . Pediatric living related 

transplantation affords optimal donor utilization. Transplant Proc 1994. 26: -. 

Tokunaga Y, Tanaka K, Uemoto S, et al. . Risk factors and complications in 

living related liver transplantation. Transplant Proc 1994. 26: 140-143. 

(PubMed) 

Kawarasaki H, Makuuchi M, Ishisone S, et al. . Partial liver transplantation 

from living related donors. Transplant Proc 1992. 24: 1470-1472. (PubMed) 

Broelsch CE, Whitington PF, Emond JC, et al. . Liver transplantation in 

children from living related donors. Ann Surg 1991. 214: 428-439. (PubMed)

(Full Text in PMC) 

Yamaoka Y, Morimoto T, Inamoto T, et al. . Safety of the donor in livingrelated liver transplantation: an analysis of 100 parental donors. 

Transplantation 1995. 59: 224-226. (PubMed) 

Ozawa K, Uemoto S, Tanaka K, et al. . An appraisal of pediatric liver 

transplantation from living relatives: initial clinical experiences in 20 pediatric 

liver transplantations from living relatives as donors. Ann Surg 1992. 216: 547-

553. (PubMed) (Full Text in PMC) 

Broelsch CE, Burdelski M, Rogiers X, et al. . Living donor for liver 

transplantation. Hepatology 1994. 20: 49S-55S. (PubMed) 

Singer PA, Siegler M, Whitington PF, et al. . Ethics of liver transplantation 

with living donors. N Engl J Med 1989. 321: 620-622. (PubMed) 

Heffron TG. . Living-related pediatric liver transplantation. Semin Pediatr 

Surg 1993. 2: 248-253. (PubMed) 

Tanaka K, Uemoto S, Tokunaga Y, et al. . Surgical techniques and innovations 

in living related liver transplantation. Ann Surg 1993. 217: 82-91. (PubMed)

(Full Text in PMC) 

Yamaguchi T, Yamaoka Y, Mori K, et al. . Hepatic vein reconstruction in 

pediatric living donor liver transplantation: An overview of a series of 30 

cases. Transplant Proc 1993. 25: 1098-1101. (PubMed) 

Tanaka K, Uemoto S, Tokunaga Y, et al. . Living related liver transplantation 

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.biblist.44404 (2 of 3)5/7/2009 2:45:22 PM
References

in children. Am J Surg 1994. 168: 41-48. (PubMed) 

Shimahara Y, Awane M, Yamaoka Y, et al. . Analyses of the risk and 

operative stress for donors in living-related partial liver transplantation. 

Transplantation 1992. 54: 983-988. (PubMed) 

Hockerstedt K. . Liver transplantation: a changing concept. Transplant Proc 

1994. 26: 1706-1707. (PubMed) 

Copyright and Disclaimer

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.biblist.44404 (3 of 3)5/7/2009 2:45:22 PM