Split-Liver Transplant Survival Results Similar To Whole

Research indicates that split-liver transplants (SLTs) have similar survival rates to whole-liver grafts.

SLTs first were performed in the United States in the late 1980s in an attempt to provide the proper-sized organ for children. It later was used as a way to try to save two adults.

However, the complex procedure often produced poor outcomes, says Koji Hashimoto, MD, PhD, Department of General Surgery, Digestive Disease Institute at Cleveland Clinic. Dr. Hashimoto led a review of liver transplants performed at Cleveland Clinic from 2004 to 2012.

“It’s very challenging,” he says. “In the last nine years, we did 25. Because of the difficulty, not many doctors in the country wanted to do it.”

Ten to 15 percent of the estimated 16,000 patients needing a liver transplant in the U.S. will die waiting, Dr. Hashimoto says. The shortfall is about 10,000 transplants.

That’s why the research results are significant.

“We can increase the number of transplants, because we can save two patients from one donor at a time,” he says.

Hemi vs. whole

More than 1,000 liver transplants were performed at Cleveland Clinic during the study period. After exclusions, Dr. Hashimoto and his team compared 121 whole-liver transplants with the 25 partial-liver procedures — 10 left lobes and 15 right lobes.

Twelve of the SLT recipients were given primary organ offers and 13 received leftover grafts. Six grafts were shared with other centers.

In 92 percent of donors, the livers were split on site. Hemiliver recipients with severe portal hypertension had a greater graft-to-recipient weight ratio than those without severe portal hypertension (1.96 percent vs. 1.40 percent , P < 0.05).

Although partial liver recipients were more likely to experience biliary complications (32.0 percent vs. 10.7 percent, P = 0.01), the five-year graft survival rate for hemilivers was nearly the same as whole livers — 80% vs. 81.5% (P = 0.43).

“When you split the liver, you may have more complications, but those complications can be fixed,” Dr. Hashimoto says.

Secondary recipients with leftover grafts showed no notable increase in graft failure (P = 0.99) or surgical complications (P = 0.43) vs. primary recipients.

Survival rates were better using right lobes than left ones — 93.3 percent and 80 percent at five years, respectively. The breakdown of the liver graft survival rates was as follows:

• Three months — Hemiliver grafts, 96 percent; whole-liver grafts, 97.5 percent
• One year — Hemiliver, 88 percent; whole, 95 percent
• Five year — Hemiliver, 88; whole, 86.5

Two better than one

Not only does a split-liver transplant potentially provide double the organ donations, but it also is ideal for smaller recipients — those routinely bypassed under the “sickest first” Model for End-Stage Liver Disease (MELD).

“When you transfer a liver, the size of the liver is very important,” Dr. Hashimoto says. “You have to have a good-sized match. If you have a bigger donor and you have two small recipients, I think you have a good situation.”

There are two ways to split the liver: 80-20 and 60-40. The first way enables saving both an adult and child, and the latter method — technically the tougher of the two — allows a transplant for two adults.

“While routine application is still controversial due to various challenges, hemiliver SLT can achieve excellent outcomes under the MELD allocation,” Dr. Hashimoto says.