Jun Mi-Jung, Shim Ju Hyun, Kim So Yeon, Seo Nieun, Kim Kang Mo, Lim Young-Suk, Lee Han Chu, Yu Eunsil, Lee Sung-Gyu
Departments of Internal Medicine, Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
Liver Transpl. 2014 Apr;20(4):437-45. doi: 10.1002/lt.23832. Epub 2014 Feb 25.
The role of liver biopsy in selecting optimal donors is an area of continuing controversy in living donor liver transplantation (LDLT). Our aim was to assess the potential implications of preoperative and intraoperative biopsies for evaluating donor liver fat content. Three thousand eight hundred fifty-nine consecutive subjects underwent predonation needle biopsy of the right lobe, and 1766 of these subjects actually donated their livers for LDLT and underwent intraoperative wedge biopsies of paired right and left lobes. The preoperative workup protocol also included abdominal ultrasonography (USG) and computed tomography (CT). Intersample agreement on steatosis grades (<5%, 5% to <15%, 15% to <30%, and ≥30%) was calculated, and clinicometabolic factors related to sampling variability were evaluated. For detecting ≥30% steatosis in the 3859 potential donors, USG and CT had sensitivities of 84.9% and 57.3%, specificities of 76.3% and 92.7%, positive predictive values of 29.6% and 48.0%, and negative predictive values of 97.7% and 94.8%, respectively. Analyses of the 1766 actual donors showed that with respect to the total steatosis grades of intraoperative right and left biopsies versus preoperative biopsy, 36.7% and 36.0% of the pairs, respectively, differed from the weighted κ values of 0.44 and 0.40. Similar agreement levels existed for macrovesicular and microvesicular steatosis subtypes. The per-subject agreement rate for the total steatosis grade between intraoperative right and left biopsies was 83.6%. According to a multivariate analysis, independent factors affecting the variability of the total steatosis results from preoperative and intraoperative biopsies (major features) were higher systolic blood pressure, body mass index, and alanine aminotransferase values and lower high-density lipoprotein cholesterol values. In conclusion, imaging may be insufficiently sensitive for evaluating donor hepatic steatosis. Preoperative and selective intraoperative liver biopsies are mandatory for assessing donor steatosis in LDLT unless preoperative imaging demonstrates no fat.
在活体肝移植（LDLT）中，肝活检在选择最佳供体方面的作用一直存在争议。我们的目的是评估术前和术中活检对评估供体肝脏脂肪含量的潜在影响。3859名连续受试者接受了右叶预捐献针吸活检，其中1766名受试者实际为LDLT捐献了肝脏，并接受了配对的右叶和左叶术中楔形活检。术前检查方案还包括腹部超声（USG）和计算机断层扫描（CT）。计算了样本间关于脂肪变性分级（<5%、5%至<15%、15%至<30%和≥30%）的一致性，并评估了与采样变异性相关的临床代谢因素。对于检测3859名潜在供体中≥30%的脂肪变性，USG和CT的敏感性分别为84.9%和57.3%，特异性分别为76.3%和92.7%，阳性预测值分别为29.6%和48.0%，阴性预测值分别为97.7%和94.8%。对1766名实际供体的分析表明，就术中右叶和左叶活检与术前活检的总脂肪变性分级而言，分别有36.7%和36.0%的配对与加权κ值0.44和0.40不同。大泡性和小泡性脂肪变性亚型的一致性水平相似。术中右叶和左叶活检之间总脂肪变性分级的受试者间一致率为83.6%。根据多变量分析，影响术前和术中活检（主要特征）总脂肪变性结果变异性的独立因素是收缩压较高、体重指数、丙氨酸转氨酶值较高以及高密度脂蛋白胆固醇值较低。总之，成像对于评估供体肝脂肪变性可能不够敏感。在LDLT中，除非术前成像显示无脂肪，否则术前和选择性术中肝活检对于评估供体脂肪变性是必不可少的。
