Improvement in Survival Associated With Adult-to-Adult Living Donor Liver Transplantation

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oi:10.1053/j.gastro.2007.09.004 Copyright © 2007 AGA Institute Published by Elsevier Inc.

Clinical–Liver, Pancreas, and Biliary Tract

Improvement in Survival Associated With Adult-to-Adult Living Donor Liver Transplantation

Carl L. Berg, , 1, , W. Gillespie‡, 1, M. Merion§, S. Brown Jr, M. Abecassis¶, F. Trotter#, A. Fisher, E. Freise‡‡, R. Mark Ghobrial§§, Abraham Shaked, H. Fair¶¶, E. Everhart## and A2ALL Study Group #Department of Surgery, University of Colorado, Denver, Colorado##Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, land‡Department of Biostatistics, University of Michigan, Ann Arbor, Michigan‡‡Department of Surgery, University of California, San Francisco, CaliforniaDepartment of Medicine, University of Virginia Health System, Charlottesville, VirginiaDepartment of Surgery, Medical College of Virginia Hospitals, Virginia Commonwealth University, Richmond, VirginiaDepartment of Medicine, Columbia Presbyterian Medical Center, New York, New YorkDepartment of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania§Department of Surgery, University of Michigan, Ann Arbor, Michigan§§Department of Surgery, University of California, Los Angeles, California¶Department of Surgery, Northwestern University, Chicago, Illinois¶¶Department of Surgery, University of North Carolina, Chapel Hill, North Carolina Received 15 June 2007; accepted 23 August 2007. Available online 14 September 2007.

Refers to:

Live Donor Liver Transplantation: Is It Better Than Waiting?Gastroenterology, Volume 133, Issue 6, December 2007, Pages 2040-2042 S. CrippinAbstract | Full Text + Links | PDF (85 K)

Refers to:

Continuing Medical Education Exam 2: December 2007Gastroenterology, Volume 133, Issue 6, December 2007, Pages 2038-2039Abstract | Full Text + Links | PDF (46 K)

Referred to by:

This Month in GastroenterologyGastroenterology, Volume 133, Issue 6, December 2007, Pages 1749-1752Jan Tack and M. CarethersAbstract | Full Text + Links | PDF (877 K)

Referred to by:

Live Donor Liver Transplantation: Is It Better Than Waiting?Gastroenterology, Volume 133, Issue 6, December 2007, Pages 2040-2042 S. CrippinAbstract | Full Text + Links | PDF (85 K)

Background & Aims: More than 2000 adult-to-adult living donor liver transplantations (LDLT) have been performed in the United States, yet the potential benefit to liver transplant candidates of undergoing LDLT compared with waiting for deceased donor liver transplantation (DDLT) is unknown. The aim of this study was to determine whether there is a survival benefit of adult LDLT.

Methods: Adults with chronic liver disease who had a potential living donor evaluated from January 1998 to February 2003 at 9 university-based hospitals were analyzed. Starting at the time of a potential donor’s evaluation, we compared mortality after LDLT to mortality among those who remained on the waiting list or received DDLT. Median follow-up was 4.4 years. Comparisons were made by hazard ratios (HR) adjusted for LDLT candidate characteristics at the time of donor evaluation.

Results: Among 807 potential living donor recipients, 389 underwent LDLT, 249 underwent DDLT, 99 died without transplantation, and 70 were awaiting transplantation at last follow-up. Receipt of LDLT was associated with an adjusted mortality HR of 0.56 (95% confidence interval [CI]: 0.42–0.74; P < .001) relative to candidates who did not undergo LDLT. As centers gained greater experience (>20 LDLT), LDLT benefit was magnified, with a mortality HR of 0.35 (95% CI: 0.23–0.53; P < .001).

Conclusions: Adult LDLT was associated with lower mortality than the alternative of waiting for DDLT. This reduction in mortality was magnified as centers gained experience with LDLT. This reduction in transplant candidate mortality must be balanced against the risks undertaken by the living donors themselves.

Abbreviations: A2ALL, adult-to-adult living donor liver transplantation; ASTS, American Society of Transplant Surgeons; DDLT, deceased donor liver transplantation; HCC, hepatocellular carcinoma; HR, hazard ratio; HRSA, Health Resources and Services Administration; LDLT, adult living donor liver transplantations; MELD, Model for End Stage Liver Disease score; NIDDK, National Institute of Diabetes and Digestive and Kidney Diseases; SRTR, Scientific Registry of Transplant Recipients

Supported in part by the National Institutes of Health (NIDDK grant numbers U01-DK62536, U01-DK62444, U01-DK62467, U01-DK62483, U01-DK62484, U01-DK62494, U01-DK62496, U01-DK62498, U01-DK62505, U01-DK62531); the American Society of Transplant Surgeons; the US Department of Health and Human Services, Health Resources and Services Administration; the National Institute of Diabetes and Digestive and Kidney Diseases through cooperative agreements (listed below); and the Health Resources and Services Administration (HRSA), and the American Society of Transplant Surgeons (ASTS). The ASTS and HRSA played no specific role in the design and conduct of the study; collection, management, and interpretation of the data; and preparation, review, or approval of the manuscript. A representative of NIDDK (J.E.E.) contributed to the design of the study and supervised its conduct and actively participated in the interpretation of the data and in the preparation, review, and approval of the manuscript. In addition to the authors of this manuscript, the following individuals were instrumental in the planning and conduct of the study and/or care of patients enrolled at each of the participating institutions as follows: Columbia University Health Sciences, New York, New York (DK62483): Principal Investigator: Jean C. Emond, MD; study coordinators: Rudina Odeh-Ramadan, PharmD; Taruna Chawla, MD; Northwestern University, Chicago, Illinois (DK62467): Co-PI: s Blei, MD; study coordinator: Patrice Al-Saden, RN, CTCC; University of Pennsylvania Health System, Philadelphia, Pennsylvania (DK62494): Co-PI: Kim M. Olthoff, MD; study coordinators: Kaminski, PA-C; Shaw, RN, BBA; University of Colorado Health Sciences Center, Denver, Colorado (DK62536): Co-PI: Igal Kam, MD; study coordinators: Heese, BA; , BS; University of California Los Angeles, Los Angeles, California (DK62496): Co-PI: W. Busuttil, MD, PhD; study coordinator: Lucy Artinian, RN, MN; University of California San Francisco, San Francisco, California (DK62444): Co-PI: Norah A. Terrault, MD; study coordinator: Dulce MacLeod, RN; University of Michigan Medical Center, Ann Arbor, Michigan (DK62498): DCC staff: R. Armstrong, RN, MS; Margaret Hill-Callahan, BS, LSW; Terese Howell, BS; Lowe, MT(ASCP); Tempie H. Shearon, MS; Lan Tong, MS; Wisniewski, MPH; University of North Carolina, Chapel Hill, North Carolina (DK62505): Co-PI: Roshan Shrestha, MD; study coordinator: A. Nielsen, MA; University of Virginia, Charlottesville, Virginia (DK62484): Co-PI: L. Pruett, MD; study coordinator: Jaye , RN; Medical College of Virginia Hospitals, Virginia Commonwealth University, Richmond, Virginia (DK62531): Co-PI: L. Shiffman, MD; study coordinators: Cheryl Rodgers, RN; Ede Fenick, RN; April Ashworth, RN; National Institute of Diabetes and Digestive and Kidney Diseases, Division of Digestive Diseases and Nutrition, Bethesda, land: Leonard B. Seeff, MD; R. Robuck, PhD; Jay H. Hoofnagle, MD. Supplemental candidate and donor data included here have been supplied by the Arbor Research Collaborative for Health as the contractor for the Scientific Registry of Transplant Recipients (SRTR). The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy of or interpretation by the SRTR or the US government. Conflicts of interest: No conflicts of interest exist. This is publication number 6 of the Adult-to-Adult Living Donor Liver Transplantation Cohort Study.Address requests for reprints to: Carl L. Berg, MD, University of Virginia Health System, PO Box 800708, Charlottesville, Virginia 22908-0708. fax: .1 Dr Berg and Dr Gillespie had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Gastroenterology Volume 133, Issue 6, December 2007, Pages 1806-1813