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Table 9.27. Right lobe donor evaluation

History and physical exam (donor advocate physician) Psychosocial evaluation (social work, psychiatry) Laboratory assessment

CBC, chemistry, coagulation profile

Thrombophilia screening, viral serologies (HIV, HBV, HCV, etc.)

ECG, chest radiograph

Cardiac stress testing, if indicated

Liver imaging (MRI, MRA, MRV, MRCP, or CT scan/ERCP) Liver biopsy, if indicated

Family agreement/consent, no evidence of compensation/coercion

Donor and Recipient Procedure

The donor procedure consists of a formal right hepatic lobectomy with extreme care to avoid injury to those structures servicing the residual liver, or left lobe. Intraoperative cholangiogram and ultrasound is often necessary in this regard. Once harvested, the lobe is flushed with preservative solution and, if necessary, vascular reconstruction is completed on the back table in preparation for implantation. The recipient operation involves an IVC-sparing hepatectomy with anastomosis of the donor right-sided structures (vascular, biliary) to the corresponding recipient structures.28 LDLT provides an alternative which may reduce the waiting-list mortality in selected patients. Ongoing studies will determine the true risk to the donors and whether recipient outcomes are comparable to whole liver transplant.

Liver Transplantation - A New Era

Approximately 10,000 liver transplants have been performed to date, mostly in the post-cyclosporine era. For the most part, one-year and five-year patient survival rates are 90 percent and 75 percent, respectively. Graft survival rates may be slightly lower reflecting an incidence of retransplantation. Quality of life studies have shown that most patients have an excellent quality of life following transplantation, although the long-term care of the immunosuppressed patient is an evolving field which presents many interesting challenges. Certainly, chronic side effects of immunosuppressive therapy, de novo malignancies, and recurrence of native disease continue to present significant problems. These important clinical entities form the basis for present and future research in transplantation.

There has been a dramatic shift in the paradigm of liver transplantation in the last decade. Long-term results are unequivocally excellent and there is no longer a need to convince other clinicians that liver transplantation is a worthwhile therapeutic entity. Currently, our most significant hurdle includes a prohibitive organ shortage with resulting ongoing disagreements about allocation. Although living donor transplants have become increasingly utilized in both pediatric and adult recipient, the discrepancy between the need and the supply of organs continues to widen. Until xenotransplantation becomes a clinical reality, live donors will be used increasingly. The inherent risk to the donor requires a meticulous assessment of both clinical and ethical issues. Therefore, it behooves the transplant community to monitor closely the results of adult-to-adult living donor liver transplantation, as well as donor morbidity and mortality. This effort will require funding from the Federal Government so that appropriate registries can be supported. Finally, the resulting longer waiting times will necessitate more aggressive and innovative management algorithms for the complications of cirrhosis.

References

1. Benhamou, JP. Fulminant and sub-fulminant hepatic failure; definition and causes. In: Williams, R, Hughes RD, ed. Acute Liver Failure: Improved Understanding and Better Therapy. London: Mitre Press, 1991:6-10.

2. Schiodt FV, Atillasoy E, Shakil AO, et al. Etiology and outcome for 295 patients with acute liver failure in the United States. Liver Trans Surg 1999; 5:29-34.

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