**3.2 Types of liver transplantation**

In addition to whole-organ deceased donor liver transplantation (DDLT), which is preferred, various types of liver transplantation may be considered depending on the situation: living donor liver transplants, ABO-compatible transplants, ABO-incompatible transplants and auxiliary liver transplants. In the setting of organ shortage, the risk of mortality awaiting an organ should be weighed against the risk of complications or failure using an alternative graft (Table 3).


Table 3. One-Year Post-Transplant Sruvival Rates for Acute Liver Failure (percent). OLTorthotopic liver transplantation; LDLT-living donor liver transplantation, LT-liver transplantation. OLT (O'Mahony et al., 2007); LDLT (Ichida et al., 2000; S Lee et al., 2007; Miwa et al., 1999; Uemoto et al., 2000); ABO-Compatible (Bismuth et al., 1996b); ABOincompatible (Bismuth et al., 1996b; Farges et al., 1995); Heterotopic (Van Hoek et al., 1999); Auxillary Partial (Van Hoek et al., 1999)

However, there is a great degree of sampling error, and more recently, a multivariate analysis of 97 consecutive patients found that the amount of necrosis was not predictive of

Based upon the available data, the current prognostic scoring systems have not consistently demonstrated reliable accuracy in predicting outcome from ALF and the subsequent need for OLT. Therefore, the American Association for the Study of Liver Diseases (AASLD) does

As previously noted, advances in critical care management of ALF patients has improved the spontaneous survival from 10-20% to about 40% without transplantation (Ostapowicz et al., 2002). For those who will not spontaneously recover; however, OLT remains the only treatment modality that improves survival. With the advent of use of OLT in this setting,

Candidacy for liver transplantation must be determined quickly in the setting of ALF, given the rapid progression of the syndrome. In the US, ALF is one of the few conditions for which a patient can be listed as a United Network for Organ Sharing (UNOS) status 1A (urgent) patient (available at http://www.unos.org) (Table 1). ALF patients may be listed in the "super urgent" category in the United Kingdom. Approximately half of ALF patients undergo liver transplantation; however, ALF accounts for less than 10% of US transplant and 11% in Europe (Freeman et al., 2008; Organ Procurement & Transplantation Network

In addition to whole-organ deceased donor liver transplantation (DDLT), which is preferred, various types of liver transplantation may be considered depending on the situation: living donor liver transplants, ABO-compatible transplants, ABO-incompatible transplants and auxiliary liver transplants. In the setting of organ shortage, the risk of mortality awaiting an organ should be weighed against the risk of complications or failure

**ABO-**

Table 3. One-Year Post-Transplant Sruvival Rates for Acute Liver Failure (percent). OLTorthotopic liver transplantation; LDLT-living donor liver transplantation, LT-liver transplantation. OLT (O'Mahony et al., 2007); LDLT (Ichida et al., 2000; S Lee et al., 2007; Miwa et al., 1999; Uemoto et al., 2000); ABO-Compatible (Bismuth et al., 1996b); ABOincompatible (Bismuth et al., 1996b; Farges et al., 1995); Heterotopic (Van Hoek et al., 1999);

**incompatible** 

**Heterotopic auxiliary LT**  **Auxiliary partial** 

**LT** 

not recommend reliance on any one of these systems (W Lee & Larson, 2005).

mortality (Miraglia et al., 2006; Voigt et al., 2007).

overall survival rates have further improved to about 60%.

**3. Liver transplantation** 

**3.1 Transplant listing criteria** 

**3.2 Types of liver transplantation** 

using an alternative graft (Table 3).

**OLT LDLT ABO-**

Auxillary Partial (Van Hoek et al., 1999)

**Graft** 75 56-90 49-54 39-52

**compatible** 

**Patient** 82 59-90 30 33 71

[OPTN], 2009).

#### **3.2.1 Living donor liver transplantation (LDLT)**

The use of LDLT in this setting remains controversial (Campsen et al., 2008; Liu et al., 2002; Nishizaki et al., 2002; Uemoto et al., 2000). It is imperative to consider the need for an adequately sized graft for the recipient with the requirement of a sufficient residual liver mass for the donor. Grafts over 40% of the standard liver volume are necessary in the setting of ALF, and outcomes are better with a graft-to-recipient weight ratio greater than 0.8, with 1.0 being ideal (Kawasaki et al., 1998Kiuchi et al., 1999). A graft of <40% of standard liver weight is at risk for the development of small-for-size syndrome – portal hypertension following reperfusion leading to sinusoidal damage and graft injury (Man et al., 2003). In the absence of small-for-size syndrome following OLT, the graft and donor livers regenerate to full size in a matter of 4 weeks (Marcos et al., 2000). Despite these risks, right lobe LDLT improves survival in patients with ALF, with overall 1-year survival rates of between 60- 90%, averaging about 75% (Campsen et al., 2008; Ichida et al., 2000; S Lee et al., 2007; Miwa et al., 1999; Uemoto et al., 2000). For children undergoing LDLT, the 1-year survival was 67- 89% and death on the waiting list was decreased to 9% (Casas et al., 1999; Emre et al., 1999). In the SPLIT experience of pediatric transplantation, 57% of the recipients with ALF received partial grafts, without a difference in outcome compared to recipients of whole grafts (Baliga et al., 2004).

Unique ethical issues exist in the setting of LDLT. Given the urgent need for an organ in this setting, the donor evaluation must be expedited. The time required for thorough donor medical and psychosocial evaluation may be truncated in the setting of rapid clinical deterioration of the intended recipient (Abouna, 2001). This carries the risk of an incomplete evaluation and the possibility of donor coercion. The 1997 Council of European Recommendations argued against the use of LDLT for ALF due to the theoretical risk of coercion, with the assumption that patients were undergoing transplantation without significant waiting times (Committee of Ministers, 1997). In regions where cadaveric organs are not as readily available, the risk of the recipient's death while waiting for a cadaveric organ must be weighed against the risk to the living donor, including a 0.2% mortality (Ghobrial et al., 2008; Yasutomi et al., 2000). Protocols will likely need to be established to address these concerns (Carlisle et al., 2011; Reding, 2005).

It has been suggested that instead of comparing the donor risks to the recipient benefits, one should compare the donor risks to the donor benefits. Some individuals may feel rewarded by being a donor (such as parent to child donation) (Spital, 2005). Mathematical modeling suggests the sickest patients or those with highest risk of death while on the waiting list would receive more benefit from living donation than those who are less sick (Durand et al., 2006). Donors surveyed in the year following donation (two thirds responded), appeared to be doing well from a psychosocial perspective, but their well-being was linked to recipient outcomes (Kim-Schluger et al., 2002). A prospective German study evaluated the psychological impact on potential donors during evaluation for urgent indications for LDLT. They found that there was more mental stress compared to the general population, explained by the recipient's severity of illness. Donors had more postoperative pain, particularly somatoform pain, and decreased vitality. Three months after LDLT, donor mental quality of life, depression, and anxiety scores were again normal, although they were somewhat linked to recipient outcomes (Erim et al., 2007). The US Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) group reported that 4.1% of all donors (392) had experienced one or more psychiatric complication. Three had severe psychiatric complications, including suicide, accidental drug overdose, and suicide attempt, despite the well-being of the recipients. Although there was no clear explanation why these donors, despite detailed screening, would be at increased risk for psychiatric problems, they suggested that donors need careful preoperative assessments and perhaps prolonged postoperative monitoring (Trotter et al., 2007).
