Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India.
Department of Hepatology, Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India.
Transplantation. 2020 Feb;104(2):308-316. doi: 10.1097/TP.0000000000002847.
The principle in right lobe living donor liver transplantation is to use "near-perfect" grafts to maximize recipient benefit with minimal donor risk. Whether and what degree of graft macrovesicular steatosis is safe for both recipient and donor is debatable.
We compared donor and recipient outcomes in 623 primary right lobe living donor liver transplantations, using grafts with (Group A; 10%-20% steatosis, n = 92) and without (Group B; <10%, n = 531) significant macrovesicular steatosis, on pre- or intraoperative biopsy.
Group A donors had higher body mass index, transaminases, fasting blood sugar, triglyceride, low density lipoprotein level, and lower high density lipoprotein, and liver attenuation index on CT scan, and similar future liver remnant. Mean postoperative day (POD) 7, aspartate aminotransferase (61.13 + 24.77 vs 73.17 + 53.71 IU/L; P = 0.04), and prothrombin time-international normalized ratio (1.16 + 0.36 vs 1.28 + 0.24; P = 0.0001) were lower in Group A donors. POD3 of 7 total bilirubin and alanine aminotransferase; POD3 aspartate aminotransferase and prothrombin time-international normalized ratio; postoperative morbidity (Dindo-Clavien >3b), hospital stay were similar in both groups. Recipients in both groups had similar age, model for end-stage liver disease score. Right lobe graft weight (764.8 + 145.46 vs 703.24 + 125.53 grams; P < 0.0001) and GRWR (1.09 + 0.29 vs 1.00 + 0.21; P = 0.0004) were higher in Group A. All biochemical parameters at POD 3 of 7, as well as hospital stay, 30-day mortality were similar in recipients of both groups, even after matching both groups for age, model for end-stage liver disease, and GRWR.
Use of well-selected right lobe grafts (adequate future liver remnant in donor, GRWR in recipient), with up to 20% macrovesicular steatosis, does not compromise graft function and outcomes and is safe for the donor.
右叶活体肝移植的原则是使用“近乎完美”的移植物，使受体获益最大化，同时使供体风险最小化。对于供体和受体来说，存在多大程度的大块肝细胞脂肪变性是安全的，这一点仍存在争议。
我们比较了 623 例原发性右叶活体肝移植中，供肝存在（A 组；脂肪变性 10%-20%，n=92）和不存在（B 组；<10%，n=531）大块肝细胞脂肪变性的供体和受体结局，这些脂肪变性是通过术前或术中活检确定的。
A 组供体的体重指数、转氨酶、空腹血糖、甘油三酯、低密度脂蛋白水平较高，高密度脂蛋白水平较低，CT 扫描时肝衰减指数也较低，而剩余肝体积相似。术后第 7 天，A 组供体的天冬氨酸转氨酶（61.13±24.77 vs 73.17±53.71 IU/L；P=0.04）和凝血酶原时间国际标准化比值（1.16±0.36 vs 1.28±0.24；P=0.0001）较低。A 组供体的第 3 天总胆红素和丙氨酸转氨酶的第 7 天（POD7）、第 3 天天冬氨酸转氨酶和凝血酶原时间国际标准化比值的第 7 天（POD7）；术后发病率（Dindo-Clavien >3b）、住院时间在两组间相似。两组受体的年龄、终末期肝病模型评分均相似。A 组右叶移植物重量（764.8±145.46 vs 703.24±125.53 克；P<0.0001）和 GRWR（1.09±0.29 vs 1.00±0.21；P=0.0004）更高。两组受体的第 3 天（POD3）的所有生化参数以及住院时间、30 天死亡率均相似，即使在对两组进行年龄、终末期肝病模型和 GRWR 匹配后，结果也相似。
对于供体来说，选择合适的右叶移植物（供体有足够的剩余肝体积，受体的 GRWR），即使有 20%的大块肝细胞脂肪变性，也不会影响移植物的功能和结局，而且对供体是安全的。
