Living donor liver transplantation： an overview

Ki-Hun Kim, MD, PhD
Division of Hepatobiliary surgery and Liver transplantation, Department of Surgery,
University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea

Owing to the shortage of deceased donor organs, living donor liver transplantation (LDLT) has become an established treatment for patients with acute and chronic liver diseases. The first successful paediatric LDLT, of a left lateral section graft from a mother to her son, was performed in Brisbane, Australia in 1989. Since then, this life saving procedure has been applied to adult patients. The greatest impact of LDLT has been in Asian countries, where cadaveric organ donation has been uncommon or non-existent. LDLT using left-lobe was introduced for adult recipients in 1993, but this procedure did not become wide-spread owing to the inability of these relatively small-sized grafts to meet the metabolic demands of all adult recipients. To overcome the inadequate graft volume encountered with left-lobe grafts, transplantation with right-lobe liver grafts was introduced for adult recipients in 1996. Although this method rapidly led to the worldwide use of adult LDLT, right-lobe hepatectomies are associated with a greater surgical risk for live donors than left-lobe hepatectomies, and increased morbidity and mortality rates, owing to the reduced volume of remnant liver in the donor. In LDLT, donor safety is of paramount importance and cannot be compromised regardless of the implication for the intended recipient. Moreover, the absence of hepatic venous drainage to the right anterior sector has led to the right-lobe graft congestion and failure. Although graft size is critical for successful outcomes, the importance of uniformly good venous drainage of the anterior sector of the right-lobe liver graft has been regarded as crucial for maximizing graft function. The reconstruction of the middle hepatic venous tributaries of a right-lobe graft was introduced in 1998. Not all potential donors can donate their right-lobes because safe donation is possible only when the estimated remnant liver volume is more than 30%. If the volume of the right-lobe in potential donors is more than 70%, relative to the volume of the whole liver, one alternative may be dual left-lobe graft LDLT, in which smaller left-lobe grafts from two donors are transplanted into one recipient. This technique was first introduced in 2000 to minimize donor risk and alleviate the small-size graft problem. Until more cadaveric grafts become available, adult LDLT will continue to be a relevant therapy for patients with irreversible end-stage liver disease.

References
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