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Keywords:

  • Domino liver transplantation;
  • FAP liver donor;
  • operative risks

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. References

Although domino liver transplantation (LT) is an established procedure, data about the operative risks are limited. This study aimed at evaluating the operative risks of domino LT. Two retrospective analyses were conducted (comparison of familial amyloid polyneuropathy [FAP] liver donors [61 patients] vs. FAP nondonors [39 patients] and FAP liver recipients [61 patients] vs. deceased donor liver recipients [61 patients]). First analysis showed a 60-day mortality of 6.6% for FAP donors and 7.7% for FAP nondonors (p = 1.0). No patient developed primary graft nonfunction. Acute rejection was higher in FAP nondonors compared to FAP donors (38.5% vs. 13.1%). Both groups had similar vascular and biliary complication rates. ICU stay was similar, whereas total hospitalization was longer for FAP nondonors. Both groups had similar 1- and 5-year patient and graft survival rates (83.4% vs. 87.2%, and 79.8% vs. 71.8%, p = 0.7) and (83.3% vs. 87.2%, and 79.1% vs.71.8%, p = 0.7). The second analysis showed a 1.6% mortality for FAP liver recipients vs. 3.2% of the control group (p = 1). Both groups had similar morbidity and technical complication rates (18.0% vs. 13.1%, p = 0.45) and (0.18 vs. 0.15, p = 0.65). The domino procedure does not add any risk to FAP donor or recipient. It increases the organ pool allowing transplantation of marginal recipients who otherwise are denied deceased donor liver transplantation.


Abbreviations: 
FAP

familial amyloid polyneuropathy

TTR

transthyretin

TTR/Met 30 mutation

transthyretin/methionine 30 mutation

LT

liver transplantation

ICU

intensive care unit

CIT

cold ischemia time

HAT

hepatic artery thrombosis

DDLT

deceased donor liver transplantation

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. References

Familial amyloid polyneuropathy (FAP) is an autosomic dominant disorder caused by mutation in the transthyretin (TTR) gene, one of the prealbumins. In the most common mutation variant, methionine replaces valine at the 30 position, forming TTR-met 30, and changing its solubility. TTR-met 30 precipitates in the extracellular space, forming fibrillary amyloid deposits (1). More than 80 different point mutations in the gene for TTR have been reported, all of which do not lead to amyloid deposition (2,3). Depending on the type of mutation, the condition becomes symptomatic in the third decade or later, with sensorimotor and autonomic neuropathy due to infiltration of viscera and the nervous system amyloid deposits. The so-called Portuguese variant (TTR-met 30 mutation), the most frequent type in western countries, leads to death within 10–15 years from diagnosis (4,5). Liver transplantation (LT) for FAP first proposed by Holmgren et al. (6–9), remains the best available treatment for FAP since more than 95% of TTR is synthesized in the liver. As the latter is usually anatomically and functionally normal, except for the production of TTR-met 30, the explanted liver can be reutilized to transplant selected patients (domino transplantation) as reported for the first time by Furtado et al. in 1997 (10–18). More than 700 domino transplantations reutilizing explanted FAP livers had been performed by the end of 2009 according to the FAP World Transplant Registry (http://www.fapwtr.org) (19). Long-term results of deceased donor LT in FAP patients and FAP graft recipients have been reported extensively (20–23); however, these reports have focused mainly on the risk of de novo development of FAP neuropathy (24). Inversely, the risks related to the modifications of the surgical technique concerning both the donor and recipient of FAP grafts have never been scrutinized.

The aim of the present study was to address the following two pending questions:

  • 1
    Are the FAP patients accepting to donate their liver for a domino procedure (FAP liver donors) exposed to higher operative risks compared to FAP patients not donating their liver (FAP nonliver donors)?
  • 2
    Do FAP liver recipients have higher operative risks compared to patients receiving a deceased donor graft (deceased donor liver recipients)?

Patients and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. References

Study of FAP liver donors versus FAP nonliver donors

The database of 1310 LTs performed from March 1993 to January 2007 in our center was assessed. Among these cases, 141 transplantations were performed for FAP disease (10.8%). Of the latter group, 100 patients were transplanted with whole deceased donor liver grafts. The remaining 41 FAP patients were excluded from the study because they received either split liver grafts (27 cases), living related liver transplants (8 cases) or had combined liver and kidney transplantation (6 cases). Of the 100 cases included in our study, 61 FAP patients donated their liver for a domino procedure and were compared to 39 nondonor FAP patients. The latter patients were not liver donors because they were transplanted before the domino program was implemented in our center (September 1997).

Donor's evaluation

Donation was based on two main principles: (1) the morbidity and mortality of the donor must be kept to a minimum; and (2) graft and recipient survival should be as high as in standard deceased donor LT. In this regard, all donors underwent a careful multistep evaluation protocol, which included exhaustive medical as well as precise liver anatomical studies.

Laboratory assessments included liver function tests, biochemistry, hematology and bleeding profile. Once preliminary tests were normal, all donors underwent 2-dimensional cardiac echocardiography and treadmill test. If findings were inconclusive then they undergo CT-coronary angiography or conventional angiogram to better stratify their risks. Serologies for hepatitis A, B and C, cytomegalovirus, Epstein–Barr virus, Venereal Disease Research Laboratory (VDRL) and human immunodeficiency virus (HIV) were tested. Evaluation of vascular and biliary anatomy was done by noninvasive radiological modalities (CT angiography and MR cholangiography).

The presence of two hepatic arteries (accessory right or left hepatic artery) did not preclude donation. However, recipient patients were informed about technique modifications and associated potential risks (HAT) in the case of variations of hepatic artery. Domino liver grafts were not used for redo transplantation.

Informed consent was obtained from donor FAP patients and from recipients of FAP liver grafts. All patients were informed about the possibility of used veno-venous bypass as well as related complications.

The recipients considered for domino LT fulfilled the same minimal listing criteria established for deceased donor liver transplantation. Patients who received FAP liver grafts were informed they would be relisted in the case of appearance of FAP symptoms. This information was given to all patients prior to listing for LT.

Study of FAP liver recipients versus deceased donor liver recipients

During the study period, 61 patients received whole liver grafts from FAP donors. These patients were matched to 61 control patients transplanted during the same period with deceased donor grafts. The patients of these two groups received whole liver grafts for their first elective transplantation. The two groups were matched for age, disease and disease stage.

Surgical procedure

In order to minimize the cold ischemia time of the livers to be transplanted, three surgical teams (including the organ procurement team)—work in parallel.

Upon confirmation by the procurement team that the deceased donor organ is suitable for transplantation, the FAP liver donor is operated on by the second team. The third team starts the intervention on the FAP liver recipient when the second team confirms that the FAP liver can be used as a graft.

Hepatectomy in the FAP liver donor:  The standard hepatectomy involves the following:

  • 1
    Preservation of tissue viability by minimally dissecting the liver pedicle. Division of the common bile duct in the mid length while avoiding extensive dissection.
  • 2
    Mobilizing the liver entirely, while paying special attention to the adequacy of the caval stump length as the single most important technical aspect during this stage. To achieve this, the diaphragmatic orifice of the vena cava is opened by dividing the diaphragmatic veins, allowing adequate vena cava stumps to be obtained on both sides (recipient and graft). If necessary, the pericardium could be opened to lengthen the superior caval stump.
  • 3
    Evaluation of the hemodynamic and splanchnic tolerance by clamping the portal pedicle and the inferior vena cava followed in some cases (patients who do not tolerate the clamping) by installation of extracorporal veno-venous bypass. Otherwise, for patients with symptomatic cardiac disease and pace makers, the extracorporal veno-venous bypass is installed systematically (25,26).
  • 4
    Completion of the total hepatectomy safely and rapidly. This is achieved by dividing the portal vein 1 cm below its bifurcation as well as the hepatic artery in order to perform a single arterial anastomosis in the recipient (whenever possible).

The preparation of the explanted liver including perfusion with preservation solution is performed during the ‘back-table’ stage. The FAP patients are transplanted according to the standard technique of orthotopic LT (deceased donor graft) with the replacement of vena cava. When the pericardium is opened, a drain should be placed within at the end of the procedure. The transplantation technique used for the patients receiving FAP liver grafts depends on the surgeon's preference i.e. standard technique as described above or transplantation with preservation of the native vena cava and latero–lateral cavo–caval anastomosis.

Statistical analysis

All data were retrieved from the prospective database implemented in our center since 1989. Continuous variables were compared using the independent sample t-test, and categoric variables were compared using the chi-square test. Survivals were estimated using the Kaplan–Meier method with the date of transplantation as starting point. Survival curves were compared using the log-rank test. All statistical analyses were performed with SPSS version 13.0 (SPSS Inc., Chicago, IL), and statistical significance was determined at p < 0.05.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. References

Study of FAP liver donors versus FAP nonliver donors

Clinical characteristics:  As shown in Table 1, FAP liver donors were similar to FAP nondonors in terms of sex distribution, type of TTR mutation, body mass index or presence of a pace maker. The waiting time for transplantation was significantly shorter in the group of FAP nondonors compared to the group of FAP donors (162 + 151 vs. 291 + 157 days, p < 0.001)

Table 1.  Clinical characteristics of 61 FAP liver donors versus 39 FAP nondonors
CharacteristicsOverallFAP liver donorsFAP onliver donorsp-Value
  1. Steatosis was assessed on the liver graft biopsy performed at the beginning of the procurement. Grafts were considered as steatotic (vs. nonsteatotic) when macrovascular steatosis was observed in > 20% of hepatocytes (31,32). Ischemia-reperfusion injury, assessed on the liver biopsy performed before closure of the abdomen, was classified as present (vs. absent) when at least 10% of hepatocytes were necrotic, mainly in the center of the lobule (32).

100 cases61 cases39 cases  
Sex M/F63/3738/2325/140.9
Age, years45.4 + 12.645.3 + 12.945.5 + 12.50.95
TTR-Met 30 mutation, n6939300.11
Body mass index22.1 + 4.322.5 + 4.1 21.4 + 4.60.23
Pace maker, n35 (35%)24 (39%)11 (28%)0.23
Duration on waiting list, days241 + 166291 + 157162 + 151<0.001
Deceased donor age, years45.9 + 20.250.7 + 20.138.4 + 18.40.003
CNS as cause of donor death, n67 (67%)38 (62%)29 (74%)0.21
Deceased donor graft steatosis, n13/100 8/61 5/390.39
Ischemia-reperfusion injury, n35/9622/5913/370.83

Graft and intraoperative characteristics:  Considering the deceased donors for FAP patients, they were significantly younger in the group of FAP nondonors compared to the group of FAP donors (38.4 + 18.4 vs. 50.7 + 20.1 years respectively, p = 0.003). All other graft characteristics were similar for the two groups including the cause of death of deceased donors, graft to body weight ratio, degree of steatosis and degree of ischemia-reperfusion injury (Table 2).

Table 2.  Intraoperative characteristics of transplantation in 61 FAP donors versus 39 FAP nondonors
CharacteristicsOverall 100 casesFAP liver donors 61 casesFAP nondonors 39 casesp-Value
Graft to body weight ratio2.40 ± 0.742.30 ± 0.682.58 ± 0.810.08
Veno-venous bypass, n 51 (51%)42 (69%) 9 (27%)<0.001
Vena cava replaced, n 70 (70%) 61 (100%)12 (32%)<0.001
Cold ischemia time, minutes498 ± 116513 ± 109473 ± 1230.10
Warm ischemia time, minutes38 ± 2038 ± 2138 ± 170.98
Duration of operation, minutes464 ± 103467 ± 105459 ± 1020.73
Transfusion, n blood units2.4 ± 2.82.6 ± 3.22.0 ± 1.90.30

Veno-venous bypass was more frequently used (42 cases, 69% vs. 9 cases, 27%, p < 0.001) and vena cava was more frequently replaced (61 cases, 100% vs. 12 cases, 30.8%, p < 0.001) in the group of FAP donors compared to the group of FAP nondonors. All other intraoperative characteristics were similar including the cold ischemia time (p = 0.1), warm ischemia time (p = 0.98), duration of operation (p = 0.73) and number of blood units transfused (p = 0.29) (Table 2).

Operative mortality and morbidity

Mortality within 60 days of transplantation or during hospitalization (for transplantation) occurred in four cases (6.6%) in the group of FAP liver donors and in three cases (7.7%) in the group of FAP nondonors (p = 1.0). No patient developed primary graft nonfunction in the present series. In terms of medical morbidity, the rate of acute rejection was significantly higher in the group of FAP nondonors compared to the group of FAP donors (38.5% vs. 13.1% respectively, p = 0.004). The rates of acute renal failure, cardiac complications and infection were similar for both groups (Table 3). From a technical point of view, arterial, portal, outflow and biliary complications occurred with similar frequency in both groups (p = 0.6, 1.0, 1.0 and 0.2 respectively, Table 3). There was a trend toward higher overall technical morbidity (30.8% vs. 16.4%, p = 0.09) and a higher number of technical complications per patient (0.36 vs. 0.2, p = 0.13) in the group of FAP nondonors compared to the group of FAP donors; however these differences did not reach statistical significance. Duration of ICU stay was similar in both groups (p = 0.11) whereas total hospitalization stay was significantly longer in the group of FAP nondonors (47.9 + 28.6 vs. 31.9 + 17.7 days, p = 0.003). Two FAP donors were retransplanted (arterial thrombosis and outflow occlusion, one case each) compared to none in the group of FAP nondonors (p = 0.52). Graft survival rates were similar in both groups of FAP donors and FAP nondonors (83.4% vs. 87.2%, and 79.8% vs. 71.8% at 1 and 5 years respectively, p = 0.7). Patient survival was similar in both groups (83.3% vs. 87.2%, and 79.1% vs. 71.8% at 1 and 5 years respectively, p = 0.7).

Table 3.  Mortality, morbidity and durations of hospital stay following transplantation in 61 FAP liver donors versus 39 FAP nondonors
CharacteristicsOverall 100 casesFAP liver donors 61 casesFAP nondonors 39 casesp-Value
Mortality, n (%)7 (7%)4 (6.6%)3 (7.7%)1.0
Primary nonfunction, n000
Medical complications, n (%)
 Acute rejection23 (23%)8 (13.1%)15 (38.5%)0.004
 Acute renal dysfunction18 (18%)9 (14.8%)9 (23.1%)0.30
 ≥ 1 Episode of infection23 (23%)11 (18.3%)12 (30.8%)0.14
 Cardiac complications6 (6%)3 (4.9%)3 (7.7%)0.68
Surgical complications, n (%)
 Arterial4 (4%)2 (3.3%)2 (5.1%)0.64
 Portal2 (2.0%)1 (1.6%)1 (2.6%)1.0
 Out flow block1 (1%)1 (1.6%)01.0
 Biliary6 (6%)2 (3.3%)4 (10.3%)0.21
 Abdominal evisceration6 (6%)4 (6.6%)2 (5.1%)1.0
 Pericardial effusion1 (1%)1 (1.6%)01.0
Durations of stay (days)
 ICU15.0 ± 19.012.1 ± 9.7 19.4 ± 27.30.11
 Hospitalization38.1 ± 23.831.9 ± 17.747.9 ± 28.60.003

Study of FAP liver recipients versus deceased donor liver recipients

Clinical characteristics:  As shown in Table 4, FAP liver and deceased donor liver recipients were similar in terms of age, indication for transplant, severity of underlying cirrhosis, frequency of HIV coinfection. The waiting time for transplantation was significantly shorter in the group of FAP liver recipients compared to recipients of deceased donor liver grafts (195 + 156 vs. 326 + 250 days respectively, p < 0.001).

Table 4.  Clinical characteristics of 61 FAP liver recipients versus 61 deceased donor liver recipients
CharacteristicsOverall 122 casesFAP liver recipients 61 casesDeceased donor liver recipients 61 casesp-Value
Sex M/F101 / 2153/ 848 / 130.23
Age, years52.9 ± 10.554.6 ± 9.951.2 ± 10.70.07
CHILD score, n
A19 9100.80
B4017230.24
C5330230.19
Patients without cirrhosis10 5 51.00
Hepatocellular carcinoma, n8040401.00
HIV coinfection, n2814141.00
Duration on waiting list, days260 ± 217195 ± 156326 ± 2500.001

Graft and intraoperative characteristics:  The group of FAP liver recipients was similar to the one of deceased donor liver recipients in terms of age, sex distribution and indication for transplantation. The graft weight was significantly lower in the group of FAP liver recipients compared to recipients of deceased donor liver grafts. Consequently the graft to body weight ratio was significantly lower in the group of FAP liver recipients compared to recipients of a deceased donor livers (1.66 + 0.44 vs. 2.11 + 0.65 respectively, p < 0.001). Intraoperatively, the use of veno-venous bypass, warm and cold ischemia time and volume of transfusion were similar in both groups (Table 5). Duration of operation was significantly longer in the control group compared to patients who received FAP liver grafts (p = 0.006).

Table 5.  Intraoperative characteristics of transplantation in 61 FAP liver recipients versus 61 deceased donor liver recipients
CharacteristicsOverall 122 casesFAP Liver recipients 61 casesDeceased donor Liver recipients 61 casesp-Value
Graft to body weight ratio1.88 ± 0.601.66 ± 0.442.11 ± 0.65<0.001
Veno-venous bypass, n (%)30 (24.6%)19 (31.1%)11 (18%)0.09
Vena cava replaced, n (%)59 (48.4%)37 (60.7%)22 (36%)0.007
Cold ischemia time, minutes457 ± 163436 ± 201478 ± 1060.16
Warm ischemia time, minutes52.3 ± 4053.2 ± 38.7151.5 ± 41.70.82
Duration of operation, minutes453 ± 114424 ± 113482 ± 1090.006
Transfusion, n blood units7.0 ± 8.56.7 ± 8.87.2 ± 8.30.77

Operative mortality and morbidity

Mortality as already defined occurred in one case in the group of FAP liver recipients and in two cases in the control group (1.6% vs. 3.2% respectively, p = 1). The rate of primary nonfunction was zero in both groups. The rates of technical complications (arterial, portal, venous drainage, biliary, hemorrhagic) were similar in both groups also (Table 6). Overall morbidity and the number of complications per patient in the group of FAP liver recipients were similar to the ones of the control group (18.0% vs. 13.1% p = 0.45 and 0.18 vs. 0.15, p = 0.65, respectively). Duration of the ICU stay and hospitalization were similar in both groups (Table 6). One patient of the control group was retransplanted for recurrent cirrhosis 3 years after the first transplantation.

Table 6.  Mortality, morbidity and durations of stays following transplantation in 61 FAP liver recipients and 61 deceased donor liver recipients
CharacteristicsOverall 122 casesFAP liver recipients 61 casesDeceased donor liver recipients 61 casesp-Value
Mortality n (%)3 (2.5%)1 (1.6%)1 (1.6%)1.0
Primary nonfunction n000
Medical complications n (%)
 Acute rejection27 (22.1%)13 (21.3%)14 (22.9%)0.83
 Acute renal dysfunction25 (20.5%)12 (19.7%)13 (21.3%)0.82
 ≥ 1 Episode of infection29 (23.8%)15 (24.6%)14 (22.9%)0.83
 Others28 (23.0%)20 (32.8%)8 (13.1%)0.01
Surgical complications n (%)
 Arterial3 (2.5%)1 (1.6%)2 (3.2%)1.0
 Portal1 (0.8%)01 (1.6%)1.0
 Out flow obstruction1 (0.8%)1 (1.6%)01.0
 Biliary5 (4.1%)3 (4.9%)2 (3.2%)1.0
 Hemorrhage needing reoperation5 (4%)3 (4.9%)2 (5.1%)1.0
Durations of stays (days)
 ICU11.3 ± 7.0 12.2 ± 7.5 10.4 ± 6.4 0.16
 Hospitalization32.8 ± 13.034.7 ± 13.930.9 ± 11.80.1

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. References

The main result of the present study is that neither the FAP patients donating their livers for domino procedure nor the recipients of FAP liver grafts are exposed to any significant additional operative risk compared to their counterparts i.e. FAP patients not donating their livers and deceased donor liver recipients, respectively.

Study of FAP liver donors versus FAP nonliver donors

The explant technique of the FAP liver donor is modified compared to the standard surgical technique for a diseased liver. This modification should not, for evident ethical reasons, carry an additional risk for the FAP liver donor. The principal technical caveat in removing an FAP liver for domino transplantation is in the sectioning of the suprahepatic vena cava. To prevent hepatic outflow obstruction, an adequate caval length for both the donor as well as the FAP liver graft (to be transplanted) is necessary. As mentioned earlier, to achieve an adequate caval length several modifications have been described (27–30). In our series, we did not have to use any modification to deal with the vena cava during domino LTs. However, when transplanting FAP patients with grafts without vena cava (living related LT or split graft without the vena cava) these reconstruction techniques were very useful in our experience (data not shown). Concerning the rate of complications (caval outflow obstruction or Budd–Chiari syndrome), in our series only one FAP donor developed venous outflow occlusion requiring retransplantation.

Another important aspect is the presence of autonomic dysfunction as well as cardiovascular alterations (arrhythmias and conduction abnormalities due to cardiac amyloid infiltration) in FAP patients (33–35). To deal with these specific problems, two strategies can be used: first, the application of percutaneous veno-venous bypass (36–38), and second, the preservation of the retrohepatic vena cava. In this series (consisting of whole domino liver grafts), we used veno-venous bypass in two specific circumstances: (1) hemodynamic and/or splanchnic intolerance to porto-caval clamping; and (2) in patients with pace makers (24 cases). It is worth noting that there was no morbidity related to the bypass and although the veno-venous bypass use was more frequent in the FAP donor group, the CIT (p = 0.1), duration of operation (p = 0.73) and the number of blood units transfused (p = 0.29) were similar for both groups, a finding which is different from other reported experiences (39).

On the other hand, the preservation of the retrohepatic vena cava is an alternative strategy to veno-venous bypass (40–45). In order to use (implant) the FAP graft obtained by this technique additional retrohepatic vena cava reconstruction is needed. Recently, Escobar et al. (39) evaluated the influence of the explant technique on the hemodynamic profile during domino LT by comparing a group of 20 FAP liver donors undergoing total hepatectomy including the vena cava with veno-venous bypass to a group of 16 FAP liver donors undergoing hepatectomy with preservation of the vena cava. The authors demonstrated that the two groups were similar in terms of intraoperative hemodynamic profile. In addition, during the postoperative period the incidence of cardiovascular events and of acute renal dysfunction was similar in both groups. In summary, both explant techniques i.e. standard technique with veno-venous bypass and vena cava preservation without bypass can be safely used, and the choice finally depends on the surgeon's preference.

As mentioned earlier, from a technical point of view, arterial, biliary, portal and outflow complications occurred with similar frequency in both groups (p = 0.6, 1.0, 0.2 and 1.0 respectively). Among these complications, hepatic artery thrombosis (HAT) is the most common thrombotic event in the early post-transplantation period with an incidence ranging from 2.5% to 5% (46, 47). The incidence of early HAT in our study was 3.3% in FAP liver donors and 1.8% in FAP liver recipients, lower than rates reported by most series evaluating adult patients. While, in the literature several surgical (47–50) and medical factors (47, 51, 52) have been shown to be linked to early HAT, it is interesting to mention one puzzling risk factor recently reported by Bispo et al. (53). In their study involving 223 liver transplants (86 for FAP) in 213 patients, the investigators demonstrated that the incidence of early HAT in FAP patients was 7.7-fold higher compared to non-FAP patients. In the multivariate analysis, FAP was the only independent factor to be associated with an increased risk of early HAT. In our study, we could not demonstrate such relation.

On the other hand, we found pre- and postoperative differences between the two groups. For instance, the waiting time for the FAP donors was longer compared to the nondonor group. This finding reflects the trend of a longer waiting time for LT in general observed in the last decade. Also, the FAP nondonor group received liver grafts from younger donors compared to their donor counterparts. These differences are not surprising given the fact that the nondonor patients were transplanted during an earlier period of time marked by younger deceased donors. In contrast, at the present time, organs from elderly donors are increasingly being used by transplant units (54,55). In this context, we believe that our findings are a reflection of the current donor trends in Europe and United States (54,55). Concerning the intraoperative differences, we found that all 61 (100%) FAP donor cases had the vena cava replaced compared to 12 (30.8%) patients in the nondonor group (p < 0.001). Lastly, the rejection rate among the FAP nondonors was significantly higher compared to FAP donors. Again, this difference is related to the period of transplantation. The FAP nondonor patients were transplanted during the cyclosporine A era. At present, drugs such as tacrolimus or mycophenolate mofetil often administered in combination have been very effective in reducing the incidence of acute cellular rejection (56,57). Considering that the majority of our FAP donors received these two drugs as their standard maintenance regimen, we can assume that the observed lower rejection rate in the later group is probably due to the introduction of these immunosuppressive regimens.

Study of FAP liver recipients versus deceased donor liver recipients

The safety of the recipient is another important aspect of domino LT. The procedure should not add any significant additional risk to the recipient compared to the risk associated with conventional deceased donor liver transplantation (DDLT). Our experience, shown in Table 6 is quite explicit—the operative safety and early outcome for FAP liver recipients were not compromised. Therefore, patients receiving FAP grafts would benefit from the short waiting time for transplantation.

In conclusion, the domino procedure does not add any significant risk to neither the FAP donor nor to the FAP liver recipient. This procedure is characterized by a very good graft function and low PNF rates. In addition, it has an associated morbidity and mortality related entirely to the recipient's pathology. Lastly, domino liver grafts increase the pool of available organs in an era of donor shortage, in turn allowing transplantation of marginal recipients that otherwise would be denied standard deceased donor LT.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. References

The authors who have taken part in this study declare that have not received any funding from any individual or company to carry out this study.

Disclosure

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. References

The authors of this manuscript have no conflicts to disclose as described by the American Journal of Transplantation.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. References