Patterns of Early Allograft Dysfunction in Adult Live Donor Liver Transplantation: The A2ALL Experience

James J Pomposelli, Nathan P Goodrich, Jean C Emond, Abhinav Humar, Talia B Baker, David R Grant, Robert A Fisher, John P Roberts, Kim M Olthoff, Brenda W Gillespie, Robert M Merion, James J Pomposelli, Nathan P Goodrich, Jean C Emond, Abhinav Humar, Talia B Baker, David R Grant, Robert A Fisher, John P Roberts, Kim M Olthoff, Brenda W Gillespie, Robert M Merion

Abstract

Background: Early allograft dysfunction (EAD) after living donor liver transplantation (LDLT) has often been attributed to inadequate graft size, and termed small-for-size syndrome. Early allograft dysfunction definitions include a variable constellation of findings, including hyperbilirubinemia, coagulopathy, encephalopathy, and ascites formation. Among putative causes of EAD after LDLT are excessive portal pressure and/or flow. Our objective was to evaluate patterns of EAD after LDLT.

Methods: In this study, 631 LDLT recipients were monitored for complications, EAD (defined by postoperative day 7 bilirubin >10 mg/dL or international normalized ratio >1.6), and graft failure. Approximately 200 had portal venous and arterial pressure and flow measurements before and after LDLT. Portal inflow modification (splenic artery ligation, hemiportocaval shunt, or splenectomy) was performed at the discretion of the operating surgeon. Associations between EAD and recipient, donor, and transplant factors were examined using multivariable logistic regression.

Results: Risk of EAD was associated with left lobe grafts, lower graft weight among left lobes, higher preoperative bilirubin, higher portal reperfusion pressure, higher donor age, and higher donor body mass index. The risk of graft loss within the first 90 days was 5.2 times higher for recipients with EAD versus those without EAD (P < 0.001).

Conclusions: Early allograft dysfunction can be defined using postoperative day 7 laboratory values that are highly predictive of early graft failure within 90 days. Risk factors associated with EAD after LDLT include: graft type and size, preoperative bilirubin, portal reperfusion pressure, donor age, and donor body mass index.

Conflict of interest statement

Disclosures/Conflicts of Interest

The authors of this manuscript declare no conflicts of interest.

Figures

Figure 1
Figure 1
Figure 1A. Graft failure by early allograft dysfunction (EAD) Figure 1B. Patient mortality by early allograft dysfunction (EAD)
Figure 1
Figure 1
Figure 1A. Graft failure by early allograft dysfunction (EAD) Figure 1B. Patient mortality by early allograft dysfunction (EAD)
Figure 2
Figure 2
Figure 2A. Scatter plot of portal pressure and graft weight by early allograft dysfunction (EAD) Figure 2B. Scatter plot of portal pressure and graft weight to recipient body weight (GW/RW) ratio by early allograft dysfunction (EAD)
Figure 2
Figure 2
Figure 2A. Scatter plot of portal pressure and graft weight by early allograft dysfunction (EAD) Figure 2B. Scatter plot of portal pressure and graft weight to recipient body weight (GW/RW) ratio by early allograft dysfunction (EAD)
Figure 3
Figure 3
Scatter plot of portal vein flow and hepatic artery flow by early allograft dysfunction (EAD)
Figure 4
Figure 4
Figure 4A. Percentage of recipients with early allograft dysfunction (EAD) by graft weight and lobe. The label of <500 for RL indicates that all right lobes weighing less than 500 gm were included in this category. Any left lobes weighing more than 600gm were included in the bar labeled >600 for left lobe (LL). Figure 4B. Percentage of recipients with early allograft dysfunction (EAD) by graft weight to recipient body weight (GW/RW) ratio and lobe. The label of <.68 for RL indicates that all right lobes with GW/RW less than .68% were included in this category. Any left lobes with GW/RW more than .9% were included in the bar labeled >.9 for LL.
Figure 4
Figure 4
Figure 4A. Percentage of recipients with early allograft dysfunction (EAD) by graft weight and lobe. The label of <500 for RL indicates that all right lobes weighing less than 500 gm were included in this category. Any left lobes weighing more than 600gm were included in the bar labeled >600 for left lobe (LL). Figure 4B. Percentage of recipients with early allograft dysfunction (EAD) by graft weight to recipient body weight (GW/RW) ratio and lobe. The label of <.68 for RL indicates that all right lobes with GW/RW less than .68% were included in this category. Any left lobes with GW/RW more than .9% were included in the bar labeled >.9 for LL.
Figure 5
Figure 5
Flow diagram of patients stratified by GW/RW ≥0.8%, with outcomes of early allograft dysfunction (EAD), and subsequent graft failure.

Source: PubMed

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