Adult-to-adult living donor liver transplantation for fulminant
The outcome of fulminant hepatic failure without timely liver
transplantation is poor. We describe a 19-year-old woman with
fulminant hepatic failure due to acute hepatitis B infection who
received a living donor liver transplant from her sister. The donor's
recovery was uneventful, allowing hospital discharge on Day 6. Two
months after transplantation the recipient developed a biliary
stricture requiring surgery. One year after transplantation, her
liver function was normal.
Anthony K House, Gary P Jeffrey, Katherine A Edyvane, Andrew P Barker, Martin D Chapman,
George Garas, John Ferguson,Peter V van Heerden,
Neville M Gibbs,
Dugal I Heath and Andrew W Mitchell
MJA 2001; 175: 202-204
For editorial comment, see McCaughan and Lynch
Clinical record -
Recipient details -
Donor details -
Donor surgery -
Recipient surgery -
Postoperative details -
More articles on Gastroenterology
Without liver transplantation, the prognosis for fulminant hepatic
failure is extremely poor.1 A shortage of cadaver donors
has resulted in some patients dying while waiting for a suitable
donor.2 In Western Australia, our
experience is that 60% of patients with fulminant hepatic failure die
before a cadaver liver becomes available. Living donor liver
transplantation was initially developed to circumvent waiting list
deaths in children. The technique was subsequently expanded to
include adult patients because of insufficient availability of
cadaveric organs.3 While adult-to-child
living donor liver transplantation is a relatively safe and accepted
practice,4 adult-to-adult living
donor liver transplantation is still controversial. The concern is
that, because adult recipients require larger grafts, healthy adult
donors may be at greater risk of death or complications.5
The world experience in adult-to-adult living donor liver
transplantation is rapidly increasing, and many studies show
recipient outcomes similar to those with whole-organ implants, as
well as low donor risk.2,3,6-9 To date, there have
been no reports of adult-to-adult living donor liver
transplantation in Australia. We report such a case. The Sir Charles
Gairdner Hospital Human Ethics Committee approved an
adult-to-adult living donor transplantation program.
The recipient was a previously well, 71 kg, 19-year-old mother of a
15-month-old son. She had acquired hepatitis B virus (HBV)
infection. Her admission on 15 April 2000 was preceded by 2-3 weeks of
worsening jaundice and constitutional symptoms. Physical
examination revealed deep jaundice, but no signs of chronic liver
At admission, the patient had a serum bilirubin level of 474 µmol/L
(normal, < 20 µmol/L), serum alanine transferase (ALT)
level > 300 U/L (normal, < 40 U/L), and an international
normalised ratio of prothrombin time (INR) of 1.9. She tested
positive for hepatitis B surface antigen (HBsAg) and e antigen
(HBeAg), and negative for antibodies to hepatitis C and HIV.
On the fifth day (20 April 2000), there was a marked clinical
deterioration, with the development of unresponsive coma requiring
intubation and ventilation. The patient met three King's College
Hospital criteria for poor prognosis in fulminant hepatic
- a time interval of more than seven days between
jaundice and the onset of encephalopathy;
- a major disturbance in coagulation; and
- a serum bilirubin level > 300 mmol/L.
The presence of these criteria suggested the likelihood of recovery
without transplantation was less than 7%.10
On transfer to Sir Charles Gairdner Hospital, the patient fulfilled
the Australasian and New Zealand liver group criteria for urgent
listing for orthotopic cadaver liver transplantation. In the event
of no cadaver liver becoming available, the possibility of a living
donor liver transplant was discussed with the family.
The recipient's mother, grandmother and two sisters volunteered as
donors. On blood typing, her grandmother and a sister were found to be
ABO blood group compatible. The sister was the more suitable donor as
the grandmother had cardiovascular comorbidities.
The donor was a 64 kg, 24-year-old woman, with no significant medical
history. She smoked four cigarettes a day, but drank no alcohol.
Preoperative evaluation by an independent psychiatrist
demonstrated no psychosocial impediment to liver donation. Serum
electrolyte levels, liver function tests, full blood analysis, and
coagulation studies were normal, and serology for HIV and hepatitis B
and C viruses was negative. An abdominal computed tomography scan
showed a normal liver with a total volume of 1512 mL. The right lobe
volume was estimated at 1133 mL, giving an estimated graft-to-recipient body weight ratio of > 1.0%; this was adequate for
angiography showed the right hepatic artery arising from the
superior mesenteric artery, and the left originating from the
coeliac axis. Endoscopic retrograde cholangiopancreatography had
to be abandoned because of patient intolerance. A magnetic resonance
imaging cholangiogram showed conventional biliary anatomy, with
the right anterior and posterior ducts joining 5 mm from the
confluence of the right and left hepatic ducts.
Five counselling sessions were conducted over two days between
medical staff and the donor (with and without members of her family).
Informed consent was obtained from the donor, with the understanding
that the donor or her family could stop the process at any time without
giving a reason.
On the fifth day after referral to the transplant unit, the living
donor liver transplantation from sister to sister proceeded
concurrently in adjacent operating theatres.
Donor surgery was performed as previously described through a right
subcostal incision with a midline extension to the xiphoid
Before the completion of the donor right lobectomy, the recipient
hepatectomy was commenced. Final clamping of the donor right lobe
vessels was undertaken when the recipient was ready to receive the
graft. The donor's total estimated blood loss for the procedure was
2000 mL, replaced by two units of packed red blood cells and one unit of
autologous blood perioperatively. The total procedure time was 6 h 15
The recipient surgery was through a similar incision. The entire
liver, which was atrophic, heavily bile stained and showed massive
hepatic necrosis histopathologically, was removed. The donor right
lobe was implanted, hepatic vein end-to-side to the inferior vena
cava ("piggyback" style). The other vessels and the right hepatic
bile duct were joined end-to-end to the recipient structures. The
total operative time was 10 h 10 min and the total ischaemic time was 55
min. The recipient required six units of packed red blood cells, 18
units of platelets and 24 units of fresh frozen plasma
perioperatively. Immunosuppression was initiated with
cyclosporin and methylprednisolone, together with prophylaxis for
hepatitis B virus infection with hepatitis B immunoglobulin
infusions and lamivudine.
The donor was extubated several hours after leaving the operating
theatre and, after 24 hours in the intensive care unit, was
transferred to the general ward. Recovery was complicated by right
basal atelectasis, which was treated by intensive chest
physiotherapy. All liver function tests were normal at discharge on
Day 6. A staphylococcal infection in the drain wound required a
two-day readmission, but responded to flucloxacillin treatment.
The donor returned to normal full activities four weeks later.
The recipient made a slower postoperative recovery. There was an
immediate improvement, and extubation occurred on the fifth day
after surgery, with transfer to the general ward on Day 7. At this time
her serum bilirubin level was 242 µmol/L, serum ALT level was 262 U/L,
and INR was 1.2, improved from the pre-surgery values of 670 µmol/L,
1060 U/L and 5.1, respectively. Her serum lactate level was 8.1 mmol/L
(normal, < 1.3 mmol/L). Complications included
Staphylococcus aureus septicaemia, right middle and lower
lobe consolidation, and an episode of severe acute graft rejection.
On the 33rd day after surgery, the recipient was discharged. Two
months after transplantation, her serum bilirubin level was 341
µmol/L, serum alkaline phosphatase level was 374 U/L (normal, 35-135
U/L), and serum ALT level was 80 U/L. A stricture of the biliary
anastomosis was stented at this time.
Three months after transplantation, there was still no filling of the
right posterior bile duct, necessitating laparotomy and
reanastomosis of the duct. The patient made an uncomplicated
recovery and was discharged on Day 7.
Persisting abnormal liver function tests at five and a half months led
to a liver biopsy. Moderately severe chronic rejection was
diagnosed, and the immunosuppressive medication was changed from
cyclosporin to tacrolimus. At 12 months, results of liver function
tests were normal and the recipient had returned to normal
This case represents the first adult-to-adult living donor liver
transplantation in Australia. To date, there has been one reported
adult-to-child living donor liver transplantation in
The outcome of fulminant hepatic failure is extremely
poor.10 Liver transplantation is
the only effective treatment, but must be timely as delays result in
sicker patients and higher mortality rates.15 In our patient, an urgent
adult-to-adult living donor liver transplantation was undertaken
because of the lack of availability of a cadaver graft.
The reported experience of living donor liver transplantation in the
high-urgency or emergency setting is limited, but internationally
the outcomes are reported to be similar to conventional cadaver liver
transplantation. Emergency living donor liver transplantation in
15 adults with fulminant hepatic failure had an overall patient
survival rate of 59%,9 which is in the range
reported for urgent cadaver transplantation (50%-68% survival at
one year).1,16 In another series, adult
patients with acute or chronic liver failure who were listed for
high-urgency transplantation and received either living right lobe
or extended living left lobe grafts had a one-year survival rate of
As living donor liver transplantation exposes essentially
healthy individuals to a life-threatening procedure, the processes
of informed consent and patient selection must be strictly adhered
to. Our donor volunteered early in the selection process. In
accordance with the principle of self-selection or free
voluntarism,2 care was taken to ensure
there was no undue pressure on the potential donor from other family
members. All members of the family understood they could stop the
process at any time. If a potential donor does decide to withdraw from
the process, this should remain confidential, and a medical excuse
should be made for the cancellation.17
In our case, the donor made a speedy and uneventful recovery, but the
recipient's recovery was complicated by a stricture at the biliary
anastomosis. Biliary complications occur in 10%-35% of whole-organ
cadaver transplants.17,18 Strictures are
usually anastomotic and develop more than one month after
surgery.19 Presently, there appears
no clear benefit in using duct-to-duct biliary anastomoses or
choledochojejunostomy.17,19 Three months after
transplantation, our patient had a stricture corrected surgically.
Recently, much attention has focused on a decline in the number of
cadaveric organs available for emergency and elective
transplantation. In Japan and Hong Kong, where there are critical
shortages of cadaveric donors because of religious, cultural or
legislative impediments, living donor liver transplantation has
become an important adjunct to cadaveric
transplantation.2,3 Some transplant centres
in Japan and the United States have also been successfully using
living donor liver transplants in the non-emergency
setting.6 In Australia, between 6% and
8% of patients waiting for cadaver liver transplantation die each
year, compared with 10% in the United States.20,21 Most of these patients
are adults, as the number of children on the waiting list has been
reduced significantly by the use of split liver cadaveric and living
donor liver transplantation.22,23 Following the
worldwide experience with living donor liver transplantation, the
Transplant Society of Australia and New Zealand21 has recently
supported the use of living donor liver transplantation in emergency
situations, but has questioned its elective role because of concerns
about donor safety and inadequate data demonstrating a local need.
To date, there have been three reported deaths in 2000 living liver
donors, giving a mortality rate of 0.15%.24,25 Case-series reports
also indicate minimal donor morbidity, with minimal operative blood
loss, and average lengths of stay of one week.2,7,8 Donor morbidities
include minor and major complications in 30%. Of these, biliary
strictures and cholestasis are the more prevalent.25
Adult living donor liver transplantation is likely to be extended to
waiting list patients when death while waiting increases to the
proportions reported from Europe and North America and after
procedures are in place for recipient and potential donor to be fully
informed at transplant listing. Donor mortality and morbidities are
a serious issue, but can be minimised by adequate donor work-up and
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(Received 18 Apr 2001, accepted 22 Jun 2001)
Liver Transplant Service of Western Australia, Sir Charles Gairdner
Hospital, Perth, WA.
Anthony K House, MS, FRACS, Professor, Department of
Surgery, University of Western Australia;
Gary P Jeffrey,
MD, FRACP, Associate Professor, Department of Medicine, University
of Western Australia;
Katherine A Edyvane, BM, BS,
Andrew P Barker, MB BS, FRACS, Surgeon;
D Chapman, MB BS, FRANZCP, Psychiatrist;
MB BS, FRACP, Hepatologist;
John Ferguson, MB ChB, MRCP,
Peter V van Heerden, Mmed, PhD, Intensivist;
Neville M Gibbs, MD, FANZCA, Anaesthetist;
Dugal I Heath, MD,
FRACS, Surgeon and Senior Lecturer, Department of Surgery,
University of Western Australia;
Andrew W Mitchell, MB BS,
FRACS, Senior Lecturer, Department of Surgery, University of
Reprints will not be available from the authors.
Professor A K House, University Department of Surgery, QEII Medical
Centre, M Block, Verdun Road, Nedlands, WA 6907.