Case Study: Living Donor Liver Transplant

Offering hope to end-stage liver disease patients

By Cristiano Quintini, MD; Koji Hashimoto, MD, PhD; Charles Miller, MD; Amy Daneri, RN, BSN

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Introduction

The discrepancy between organ supply and demand has reached an all-time high in the United States, resulting in increased wait times for transplant and a higher number of deaths on the transplant wait list. Living donor liver transplantation (LDLT) is playing a significant role in addressing the shortage of grafts for patients awaiting liver transplantation.

While LDLT offers remarkable benefit to the recipient, it also introduces some risk to a healthy donor. Therefore, modifications to surgical technique that reduce this risk are of great value. In the attempt to decrease donor complications, Cleveland Clinic’s Transplant Center has adopted the use of 3-D imaging and an innovative 3-D navigation system. Here, we present a case of LDLT performed using this technology.

Case Presentation

In March 2011, a 59-year-old man was referred to our Transplant Center for a liver transplant evaluation due to end-stage liver disease secondary to nonalcoholic steatohepatitis. His liver disease was complicated by portal hypertension with intractable ascites, esophageal varices and splenomegaly (Figure 1). Because of severe portal hypertension, a transjugular intrahepatic portosystemic shunt (TIPS) was placed to alleviate his clinical symptoms. Although he continued to deteriorate clinically, he could not receive a liver transplant from a deceased donor because his Model for End-Stage Liver Disease (MELD) score (13-17) was not high enough to give him priority on the waiting list.

The living liver donor was a 42-year-old man who volunteered to donate to his older brother. He was evaluated by the multidisciplinary living donor team and was deemed an appropriate candidate for liver donation by the Donor Advocacy Team and the Patient Selection Committee.

During the donor evaluation, a preoperative 3-D reconstruction of the donor liver was conducted (Figure 2), from which a detailed volumetric study was obtained. Table 1 represents the volumetric analysis for this donor.

The patient underwent an LDLT in July 2012 using a right lobe graft from his brother. Surgery using the navigation system (donor only), along with intraoperative ultrasound to identify the hepatic vein, was uneventful.

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The measured graft weight was 1,038 grams, resulting in a graft-to-recipient body weight ratio (GRWR) of 1.0.

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Figure 1

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Figure 2

Postoperative Course

Both the living liver donor and the recipient had an uncomplicated postoperative course. The donor was discharged on postoperative day 5, and the recipient was discharged on postoperative day 11. At one month after surgery, both donor and recipient liver enzymes normalized. Currently, the patients are followed by our liver transplant clinic with stable liver graft function.

Discussion

With the ever-growing donor shortage, LDLT has emerged as an alternative to deceased donor liver transplantation for patients with end-stage liver disease.

Medical urgency for liver transplant is determined by MELD score, which is calculated based on three blood parameters: total bilirubin, INR and creatinine. However, patients’ clinical symptoms and quality of life aren’t taken into account in calculating MELD scores. This means that there are many critically ill patients with low MELD scores that underestimate the severity of their disease. LDLT is expected to be life-saving for these patients who don’t have priority on the transplant waiting list but who face the risk of death and poor quality of life.

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The number of LDLTs in the United States has recently declined, however, due to the concern for donor safety. Only 247 LDLTs were performed in 2011, which accounted for just 3.9 percent of all liver transplants nationally according to UNOS data.

Many transplant centers are reluctant to perform LDLTs because they are ethically challenging and technically demanding – and the entire process from initial evaluation to post-transplant follow-up is labor-intensive. However, LDLT can be performed safely and successfully. Computer-assisted navigation has the potential to minimize risk to the donor, and experienced surgeons can operate with increased confidence with the use of 3-D imaging, intraoperative ultrasound and real-time tracking of surgical instruments.

Cleveland Clinic has a dedicated multidisciplinary team that is performing an increasing number of LDLTs with survival rates meeting the highest standards as shown by the data extrapolated from the Scientific Registry of Transplant Recipients.

Ms. Daneri can be reached at 216.445.8473 or daneria@ccf.org. Dr. Quintini is available at 216.445.3388 or quintic@ccf.org, Dr. Hashimoto is at 216.445.0753 or hashimk@ccf.org and Dr. Miller is at 216.445.2381 or millerc8@ccf.org.