Liver and intrahepatic bile ducts - nontumor
Transplantation
Adult to adult live donor liver transplantation

Author: Nalini Bansal, M.D.

Revised: 15 May 2018, last major update April 2018

Copyright: (c) 2003-2018, PathologyOutlines.com, Inc.

PubMed Search: Adult live donor liver transplantation [TI]

Cite this page: Bansal, N. Adult to adult live donor liver transplantation. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/liveradulttoadult.html. Accessed May 22nd, 2018.
Definition / general
  • First attempt at clinical liver transplant (LTX) was by Thomas Starzl in Denver in 1963 (Surg Gynecol Obstet 1963;117:659)
  • Liver transplantation can be from deceased or living donor
  • Deceased donor liver transplant (DDLT) / cadaveric liver transplant: can be whole or split liver graft
  • Living donor living transplant (LDLT):
    • Popular because potential live donors are more plentiful than the limited number of deceased liver donors (Gastroenterol Clin N Am 2018:47;297)
    • Orthotopic, heterotopic or auxiliary; most common is orthotopic (Ann Surg 1990;212:368)
    • Preferred in children as size matching between donor organ and recipient abdominal cavity is important for successful outcome, and DDLT livers usually do not fit well in pediatric abdominal cavity
    • Most LDLT are segmental grafts where a portion of liver from living donor is transplanted to recipient
    • Preferred lobe for pediatric liver transplant is left lateral segment (including segments 2 and 3) or a trisegmented left lobe graft (including segments 2, 3 and 4) in the older larger child (Semin Pediatr Surg 2006;15:218)
    • Right lobe with or without MHV (middle hepatic vein) is main type of graft used for adult LDLT
Essential features
  • Usually done for end stage liver disease; also acute liver failure, extrahepatic biliary atresia with cirrhosis
  • Usually a segment of the donor liver is transplanted into the recipient
  • Acceptable donor graft to recipient weight ratio (GRWR) is > 0.6%, preferred > 0.8%
  • Remnant liver in donor should usually be > 30%
  • In adults, right lobe with or without MHV is main type of graft used
  • In children, left lateral segment (including segments 2 and 3) is preferred or a trisegmented left lobe graft (including segments 2, 3 and 4) in the older larger child
Terminology
  • Orthotopic: replaces removed liver with transplanted allograft liver in the anatomically correct position
  • Heterotopic: placing the liver at extrahepatic site, usually at root of mesentery
  • Auxiliary: placement of donor liver in presence of native liver
  • Segmental: placement of part of donor liver into recipient
Pathophysiology
  • Cadaveric split liver graft: due to organ scarcity, whole cadaveric liver is reduced to two smaller grafts, each retaining its own venous drainage, portal venous inflow, hepatic artery inflow and biliary drainage (Transplant Proc 2006;38:602)
  • Since there are far fewer available deceased liver donors than patients awaiting transplantation, living donor transplantation became popular with an unlimited donor organ supply (Gastroenterol Clin N Am 2018:47;297)
  • LDLT was preferred method of liver transplant in pediatric age groups as size matching between donor organ and recipient abdominal cavity is an important component for a successful outcome

Phases of Surgery in Recipient

  • Liver transplant surgery has 3 phases for the recipient
    • Prehepatic phase: resection of recipient native liver (hepatectomy) with retrohepatic inferior vena cava (IVC)
    • Anhepatic phase: simultaneous complete occlusion of recipient inferior vena cava (IVC) and portal vein; to avoid hemodynamic instability, the veno-venous bypass was developed to allow diversion of blood from the recipient IVC and portal vein directly to the superior vena cava during the anhepatic phase, using heparin bonded cannulae and a motor driven bypass system
    • Reperfusion: usually after completion of these anastomoses, the liver is reperfused with the recipient blood, clamps are removed and recipient venous circulation is reestablished through the new liver

    • Sequence of anastomosis done for grafted liver includes: Hepatic Vein - right hepatic vein (RHV) to IVC:
      Hepatic Vein- RHV to IVC
      Portal vein
      Hepatic artery
      Bile duct
Clinical features
  • Usually done for end stage liver disease
  • Ascites, jaundice, portal hypertension and hepatic encephalopathy
  • Donor safety remains of paramount importance in LDLT (Liver Transpl 2006;12:920)
Diagnosis
  • Model for End Stage Liver Disease (MELD) predicts survival for patients with advanced liver disease
  • MELD is calculated using serum bilirubin, serum creatinine and the International Normalized Ratio for prothrombin time (INR) to predict survival (Chirurg 2008;79:157)
Radiology images

Images hosted on PathOut server:

Contributed by Nalini Bansal, M.D., D.N.B., PDCC, MNAMS
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Triple Phase CT Scan to assess the vascular anatomy is a must before going for transplant MRCP is optional

Criteria for Donor Selection
  • At the University Hospital of Kiel, living donors of hepatic transplants must meet the following general requirements:
    • Age 18 to 60 years
    • A genetic or emotional relationship to the recipient
    • A compatible blood type (exception: a very young recipient in whom isoagglutinin antibodies are not yet demonstrable)
    • Body mass index < 30 (if the BMI is 30 or above, the risk of thromboembolic complications is elevated)
    • Absence of severe pre-existing illnesses or prior major abdominal surgery
    • Planned residual liver volume > 30% of the initial liver volume for the donor
    • Fatty degeneration of the liver < 30% if the left lateral hepatic lobe is to be donated or < 10% if the right hepatic lobe is to be donated
    • Absence of anatomical variations that would necessitate a reconstructive procedure in the donor (Dtsch Arztebl Int 2008;105:101)
Case reports
Clinical images

Images hosted on PathOut server:

Contributed by Nalini Bansal, M.D., D.N.B., PDCC, MNAMS
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Fig 1: Donor hepatectomy

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Fig 2a, b, c: Types of liver graft; Fig 2a: Right lobe graft; Fig 2b: Left lobe with MHV 2c (Left lateral segment graft)

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Fig 3: Recipient surgery


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Fig 4: Anhepatic Phase

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Fig 5: Post portal reperfusion

Types of liver donation
  • Left lateral hepatic lobe (segments 2 - 3, about 20% of the total liver volume) is generally an adequate transplant for children weighing up to 25 kg
  • For children weighing more than 25 kg and smaller adults weighing less than 65 kg, the donor’s left hepatic lobe (segments 1 - 4, about 40% of the total liver volume) is resected; this procedure is rarely performed
  • Adults weighing more than 65 kg generally need to receive the right hepatic lobe as a graft (segments 5 - 8, about 60% of the total liver volume) (Dtsch Arztebl Int 2008;105:101)
Board review question #1
    What is orthotopic liver transplantation?

  1. Replacing the removed liver with the transplanted allograft liver in the anatomically correct position
  2. Replacing the removed liver with the transplanted allograft liver in the extrahepatic position
  3. Placement of the donor liver in the presence of the native liver
  4. None of the above
Board review answer #1
A. Replacing the removed liver with the transplanted allograft liver in the anatomically correct position
Board review question #2
    Indications for liver transplantation include:

  1. Acute liver failure
  2. End stage liver disease
  3. Extrahepatic biliary atresia with cirrhosis
  4. All of the above
Board review answer #2
D. All of the above
Board review question #3
    The most common type of graft used in adult live donor liver transplant is:

  1. Left lobe
  2. Right lobe with or without the middle hepatic vein
  3. Left lateral segment
  4. None of the above
Board review answer #3
C. Right lobe with or without middle hepatic vein