Graft Related Factors Affecting the Recipient Outcome in Living Donor Liver Transplantation

Abstract Background: Multiple risk factors have been incriminated in poor outcome and survival after Living Donor Liver Trans-plantation (LDLT). We conducted this study to identify graft-related factors that affects recipient outcome and survival after LDLT. Patients and Methods: This is a combined retrospective and prospective study that was conducted at Mansoura Uni-versity Gastrointestinal Surgical Center GISC. We included 460 transplant recipients in the period between June 2004 and July 2016. Moreover, the prospective arm included 50 patients who underwent living donor liver transplantation as a sample size from starting the study in July 2016. After careful pre-operative preparation for both donor and recipient, cases were scheduled for living donor liver transplantation. All cases were performed by the same transplant surgical team using the standard surgical procedure. After procedure, patients were transferred to the liver transplant ICU for 1 week, then to the liver high care unit. In addition to clinical evaluation, follow-up of the recipients was performed by laboratory and radiological investigations. Evaluation of the liver by abdom-inal CT was routinely performed 2 to 3 times over the first year after LT, and then once or twice per year. Results: It was evident that acute rejection was associated with shorter cold ischemia time (31.84 vs. 42.58 minutes-p=0.016). Moreover, larger biliary stoma size was also asso-ciated with acute rejection (4.24 vs. 3.73mm -p=0.045). Re-garding bile leakage, it was found to be associated with smaller hepatic venous reconstruction diameter (26.11 vs. 27.38mm-p=0.036). Additionally, it was found that incidence of biliary strictures was associated with longer warm ischemia time (51.85 vs. 45.32 minutes-p=0.019), smaller vs venous recon-struction diameter (7.41 vs. 8.52-p=0.024), and smaller biliary reconstruction diameter (3.51 vs. 3.84mm -p=0.033). Cases who developed primary graft dysfunction were having signif-icantly prolonged warm ischemia time (66.92 vs. 46.52 min-utes -p 0.011). Chronic graft rejection was associated with larger Makuuchi vein reconstruction diameter (13.40 vs. 9.62mm -p=0.020). However, other graft related factors did not seem to be different between cases who developed and who did not develop chronic rejection.
Portal vein thrombosis was associated with larger Maku-uchi vein reconstruction diameter (20 vs. 9.6mm -p=0.001). Cases who developed hepatic artery thrombosis post-operatively were having larger Makuuchi vein reconstruction diameter (20 vs. 9.71mm -p=0.003), and lower numbers of single arterial reconstruction (p=0.003). In addition, cases who developed disease recurrence after transplantation were having larger arterial reconstruction diameter (2.63 vs. 2.45-p=0.020), and more ratio of multiple biliary ductal anastomoses (p=0.018). HCC recurrence after transplant was associated with larger portal vein reconstruction diameter (12.66 vs. 11.43mm -p=0.004), larger arterial recon-struction diameter (2.78 vs. 2.47mm -p=0.029), and smaller biliary reconstruction diameter (3.24 vs. 3.83-p=0.008). On assessment of graft related factors on survivals, all factors were found to be non-significant apart from number of venous anastomoses that was significantly affecting survival (p= 0.042). Conclusion: Multiple graft related factors were studied as risk factors for outcome, survival, and recurrence after LDLT. The rate of early graft failure is low. This was due to optimum donor selection as regards age, sex, Body Mass Index (BMI) and ABO-compatibility; computer-assisted plan-ning and decision making in calculating optimum GRWR; short cold ischemic time; high level of expertise in our center; and timely detection of vascular, biliary and immunological complications responsible for early graft failure together with early and efficient management. Nevertheless, most of the underlying risk factors affecting either outcome, recurrence, or survival were different from each other according to the complication type as previously shown in the results. This necessitates the need for multiple studies to be conducted at this perspective. However, these studies should be specific targeting only one or a small group of complications to get more specific results.