Novel Benchmark for Adult-to-Adult Living-donor Liver Transplantation
Zhihao Li, Ashwin Rammohan, Vasanthakumar Gunasekaran, Su young Hong, Itsuko Chih-Yi Chen, Jong Man Kim, Kris Ann Hervera Marquez, Shih Chao Hsu, Elvan Onur Kirimker, Nobuhisa Akamatsu, Oren Shaked, Michele Finotti, Marcus Yeow, Lara Genedy, Philipp Dutkowski, Silvio Nadalin, Markus Boehnert, Wojciech G. Polak, Glenn Kunnath Bonney, Abhisek Mathur, Benjamin Samstein, Jean C. Emond, Giuliano Testa, Kim M. Olthoff, Charles B. Rosen, Julie K. Heimbach, Timuçin Taner, Tiffany Wong, Chung Mau Lo, Kiyoshi Hasegawa, Deniz Balcı, Mark S. Cattral, Gonzalo Sapisochín, Nazia Selzner, Long Bin Jeng, Dieter C. Bröering, Jae‐Won Joh, Chao‐Long Chen, Kyung-Suh Suk, Mohamed Rela, Pierre‐Alain Clavien
Abstract
OBJECTIVE: To define benchmark values for adult-to-adult living-donor liver transplantation (LDLT). BACKGROUND: LDLT utilizes living-donor hemiliver grafts to expand the donor pool and reduce waitlist mortality. Although references have been established for donor hepatectomy, no such information exists for recipients to enable conclusive quality and comparative assessments. METHODS: Patients undergoing LDLT were analyzed in 15 high-volume centers (≥10 cases/year) from 3 continents over 5 years (2016-2020), with a minimum follow-up of 1 year. Benchmark criteria included a Model for End-stage Liver Disease ≤20, no portal vein thrombosis, no previous major abdominal surgery, no renal replacement therapy, no acute liver failure, and no intensive care unit admission. Benchmark cutoffs were derived from the 75th percentile of all centers' medians. RESULTS: Of 3636 patients, 1864 (51%) qualified as benchmark cases. Benchmark cutoffs, including posttransplant dialysis (≤4%), primary nonfunction (≤0.9%), nonanastomotic strictures (≤0.2%), graft loss (≤7.7%), and redo-liver transplantation (LT) (≤3.6%), at 1-year were below the deceased donor LT benchmarks. Bile leak (≤12.4%), hepatic artery thrombosis (≤5.1%), and Comprehensive Complication Index (CCI ® ) (≤56) were above the deceased donor LT benchmarks, whereas mortality (≤9.1%) was comparable. The right hemiliver graft, compared with the left, was associated with a lower CCI ® score (34 vs 21, P < 0.001). Preservation of the middle hepatic vein with the right hemiliver graft had no impact neither on the recipient nor on the donor outcome. Asian centers outperformed other centers with CCI ® score (21 vs 47, P < 0.001), graft loss (3.0% vs 6.5%, P = 0.002), and redo-LT rates (1.0% vs 2.5%, P = 0.029). In contrast, non-benchmark low-volume centers displayed inferior outcomes, such as bile leak (15.2%), hepatic artery thrombosis (15.2%), or redo-LT (6.5%). CONCLUSIONS: Benchmark LDLT offers a valuable alternative to reduce waitlist mortality. Exchange of expertise, public awareness, and centralization policy are, however, mandatory to achieve benchmark outcomes worldwide.