Orthotopic Liver Transplantation (OLT) has become a therapy for the treatment of end stage liver diseases over the past 20 years. The demand has rapidly increased, creating a large gap between the number of patients awaiting OLT and the number of patients who actually receive OLT. In the eastern countries, Liver Donor Liver Transplantation (LDLT) has become the sole or major source of grafts offered to the patients whereas in the Western Continent Deceased Donor (DD) grafts have been the only source of OLT. As of late April 2013, United Network of Organ Sharing (UNOS) has reported 15854 patients awiting Liver Transplantation in US. In 2012, total of 6256 liver transplantation has been performed in US with 6010 cadaveric and 246 live donations. Especially, since early-mid 2000’s the number of LDLTs performed in US has dramatically decreased with 3 donor mortalities being reported in the literature, with computed donor risk being calculated as 0.5%.

The alternatives that has been introduced into the daily practice of Liver Transplantation can be outlined as such;

ECD: Extended Criteria Donors: Donor age >55, Donor Hospital Stay > 5 days, Cold Ischemia time >10hours, warm ischemia >40 min. Matching ECD allografts to appropriate recipients have been the main source establishing acceptable transplant outcomes as an alternative to higher waitlist mortality. ECD score of 2 or less is usually associated acceptable outcomes.

DCD: Donation after Cardiac Death: Previously called as non-heart beating donors. It consists of withdrawal of care in the operating room after adequate consent obtained from the family. In contrast to Brain Death Donors (DBD), among DCD donors , after extubation from the respirator, 5 minutes has to pass before the declaration of death. Warm ischemia time to the removal of the organs should be up to 20 minutes for better results. Graft survival is considered to be lower if the warm ischemia time is more than the allotted time. Biliary Complications can be as high as 35% in this group and its association with certain preservation solutions has been reported. Hepatic Artery Thrombosis (HAT) is also higher in this group. Careful donor and recipient match is the crucial part of this type of operation.

Advanced donor Age: Advanced age significantly decreased patient and graft survival in recipients with HCV. If the allograft is found to be suitable, may be appropriate in matched recipients. HCV receipients are recommended to match to an organ less than 55 year of age.

ABO Incompatibility: Not recommended unless in emergency situations for pediatric recipients. Blood type A2 can be given to O Blood type recipient.

Steotosis: Low and moderate steatosis can be considered as an important source and donor liver biopsies are encouraged.

Malignancy: History of Malignancy outside of the Central Nervous System (CNS) should not be used, previous CNS tumors may be acceptable.

HCV positivity: HCV–positive allograft can be accepted for HCV-Positive recipients. Survival is comparable with the use of HCV Negative allografts. Genotyping of the donor is currently is not done in routine practice.

Anti HBc positivity: Such donors can be accepted for non Hep B exposed receipients with the current HBIG and antiviral prophylaxis.

HIV: There is new literature suggesting that HIV positive donors can be accepted for HIV positive recipients.

Infections: Increased screening in endemic areas is important and donor cause of death should be identified before the procurement. West Nile and Rabies are the important CNS viral infections that need to be identified in the donor in advance.

SLT: Split Liver Transplantation; Splitting comes with its technical challenges and not all allografts are appropriate for splitting. Success rate is much higher in specialized centers with appropriate recipient match.

Facebook Phenomenon: Since May 1, 2012, Facebook users have been able to share their organ donor status with friends, family—and the world—as they do other basic information. The information is part of the site’s new Timeline feature, which asks users to share stories and photographs. Since the launch, the results of the Facebook organ donation initiative have been phenomenal, boosting the nationwide increase in registered donors by a staggering 1,183 percent in its first week, a month later, the donor registration rates still were elevated.

References

1. Optimal Utilization of Donor Grafts With Extended Criteria; A Single-Center Experience in Over 1000 Liver Transplants. Cameron AM, Ghobrial RM, Yersiz H, Farmer DG, Lipshutz GS, Gordon SA, Zimmerman M, Hong J, Collins TE, Gornbein J, Amersi F, Weaver M, Cao C, Chen T, Hiatt JR, Busuttil RW. Ann Surg. 2006 Jun;243(6):748-53; discussion 753-5.
2. Waitlist mortality decreases with increased use of extended criteria donor liver grafts at adult liver transplant centers. Barshes NR, Horwitz IB, Franzini L, Vierling JM, Goss JA. Am J Transplant. 2007 May;7(5):1265-70
3. Utilization of extended donor criteria in liver transplantation: a comprehensive review of the literature. Nickkholgh A, Weitz J, Encke J, Sauer P, Mehrabi A, Büchler MW, Schmidt J, Schemmer P. Nephrol Dial Transplant. 2007 Sep;22 Suppl 8:viii29-viii36.
4. Efforts to expand the donor pool for liver transplantation. Sutaria R, Adams DH. Med Rep. 2010 Jun 16;2. pii: 42
5. Optimal utilization of extended hepatic grafts. Gordon Burroughs S, Busuttil RW. Surg Today. 2009;39(9):746-51.
6. Extended donors in liver transplantation. Harring TR, O’Mahony CA, Goss JA. Clin Liver Dis. 2011 Nov;15(4):879-900
7. Histidine-Tryptophan-Ketoglutarate (HTK) is associated with reduced graft survival in deceased donor livers, especially those donated after cardiac death. Stewart ZA, Cameron AM, Singer AL, Montgomery RA, Segev DL. Am J Transplant. 2009 Feb;9(2):286-93
8. Prophylaxis Among HBcAb Positive Liver Transplant Recipients: HBIG Plus Oral Antivirals Versus Antivirals Alone. Mohammad U. Malik,Tsion Abdi,Tinsay Woreta, Berkeley Limketkai , Po-Hung Chen , Brian Kim , Pana Trilianos, Muge Pirtini, Laura Lees, Jennifer Kerney, Andrew Singer, Andrew Cameron, Ahmet Gurakar. Poster Presentation, AASLD Single Topic Meeting. March 21-22, 2013, Arlington Virginia

1. Donor-Transmitted Malignancy in a Liver Transplant Recipient: A Case Report and Review of Literature, Kim B, Woreta T, Chen PH, Limketkai B, Singer A, Dagher N, Cameron A, Lin MT, Kamel I, Gurakar A, Dig Dis Sci. 2012 Dec 16
2. Estimating the potential pool of HIV-infected deceased organ donors in the United States. Boyarsky BJ, Hall EC, Singer AL, Montgomery RA, Gebo KA, Segev DL. Am J Transplant. 2011 Jun;11(6):1209-17.
3. Where are we today in split liver transplantation? Hong JC, Yersiz H, Busuttil RW. Curr Opin Organ Transplant. 2011 Jun;16(3):269-73
4. HTK preservative solution is associated with increase biliary complications among patients receiving DCD liver transplants: A single center experience. Murat T. Gulsen, Mohit Girotra, Guldane Cengiz-Seval, Jennifer Price, Vikesh K. Singh, Dorry L. Segev, Andrew M. Cameron, Ahmet Gurakar. Ann Transplant 2013: 18: 69-75
5. Facebook Phenom, Cameron A. Hopkins Medicine Magazine, Dec 1, 2012 and Personal communication