Division of Liver Transplantation, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong.
Curr Opin Organ Transplant. 2019 Oct;24(5):637-643. doi: 10.1097/MOT.0000000000000689.
Application of living donor liver transplantation (LDLT) in model for end-stage liver disease (MELD) 35+ patients has been regarded with skepticism. There is concern that a partial graft may not achieve favourable outcomes, and that a healthy donor is risked for a transplant which might turn out to be futile.
In practice, LDLT improves access to liver graft and allows timely transplantation. Long-term results from high-volume centres revealed that outcomes of LDLT in these patients have not been jeopardized by limited graft volumes. With unimpeded vascular outflow, a partial graft could provide sufficient function to overcome the stress of transplant operation. However, LDLT is a complex operation with immense technical demand. A steep learning curve is encountered before optimal outcomes could be produced. Meanwhile, donor safety remains the paramount concern. Donor should not be evaluated for futile candidates. MELD 35+ patients with refractory sepsis or cardiac event are unlikely to benefit from liver transplantation. Borderline donors, in terms of donor safety or graft quality, should not be accepted. As in recipient operation, accumulation of experience is crucial to reduce donor mortality and morbidity.
LDLT is justified for MELD 35+ in high-volume centres with vast experience. Satisfactory recipient outcomes can be produced with minimal donor morbidity.
在终末期肝病模型（MELD）35+患者中应用活体肝移植（LDLT）一直存在争议。人们担心部分移植物可能无法获得良好的结果，并且健康供体可能面临可能徒劳无益的移植风险。
在实践中，LDLT 增加了肝移植物的获取途径，并允许及时进行移植。来自大容量中心的长期结果表明，这些患者的 LDLT 结果并未因移植物体积有限而受到影响。通过不受阻碍的血管流出，部分移植物可以提供足够的功能来克服移植手术的压力。然而，LDLT 是一项复杂的手术，对技术要求极高。在获得最佳结果之前，需要经历陡峭的学习曲线。同时，供体安全仍然是首要关注的问题。不应该为无意义的候选者评估供体。对于难治性脓毒症或心脏事件的 MELD 35+患者，肝移植不太可能受益。在供体安全或移植物质量方面处于边缘状态的供体不应被接受。与受体手术一样，积累经验对于降低供体死亡率和发病率至关重要。
在经验丰富的大容量中心，LDLT 对于 MELD 35+是合理的。可以在最小的供体发病率下产生令人满意的受者结果。
