Split liver transplantation in adults

Split liver transplantation(SLT),while widely accepted in pediatrics,remains underutilized in adults. Advancements in surgical techniques and donor-recipient matching,however,have allowed expansion of SLT from utilization of the right trisegment graft to now include use of the hemiliver graft as well. Despite less favorable outcomes in the early experience,better outcomes have been reported by experienced centers and have further validated the feasibility of SLT. Importantly,more than two decades of experience have identified key requirements for successful SLT in adults. When these requirements are met,SLT can achieve outcomes equivalent to those achieved with other types of liver transplantation for adults. However,substantial challenges,such as surgical techniques,logistics,and ethics,persist as ongoing barriers to further expansion of this highly complex procedure. This review outlines the current state of SLT in adults,focusing on donor and recipient selection based on physiology,surgical techniques,surgical outcomes,and ethical issues.

Factors predicting futility of liver transplant in elderly recipients:A single-center experience

BACKGROUND As the population of the United States ages,there has been an increasing number of elderly patients with cirrhosis listed for transplant.Previous studies have shown variable results in terms of the relative survival benefit for elderly liver transplant(LT)recipients.There may be factors that are associated with a poor post-transplant outcome which may help determine which elderly patients should and should not be listed for LT.AIM To identify factors associated with futility of transplant in elderly patients.METHODS This was a retrospective study of all patients above the age of 45 who underwent liver transplantation at our tertiary care center between January 2010 and March 2020(n=1019).“Elderly”was defined as all patients aged 65 years and older.Futile outcome was defined as death within 90 d of transplant.Logistic regression analysis was performed to determine what variables,if any were associated with futile outcome in elderly patients.Secondary outcomes such as one year mortality and discharge to facility(such as skilled nursing facility or long-term acute care hospital)were analyzed in the entire sample,compared across three age groups(45-54,55-64,and 65+years).RESULTS There was a total of 260 elderly patients who received LT in the designated time period.A total of 20 patients met the definition of“futile”outcome.The mean Model of End-Stage Liver Disease scores in the futile and non-futile group were not significantly different(21.78 in the futile group vs 19.66 in the“non-futile”group).Of the variables tested,only congestive heart failure was found to have a statistically significant association with futile outcome in LT recipients over the age of 65(P=0.001).Of these patients,all had diastolic heart failure with normal ejection fraction and at least grade I diastolic dysfunction as measured on echocardiogram.Patients aged 65 years and older were more likely to have the outcomes of death within 1 year of LT[hazard ratio:1.937,confidence interval(CI):1.24-3.02,P=0.003]and discharge to facility(odds ratio:1.94,CI:1.4-2.8,P<0.001)compared to patients in younger age groups.CONCLUSION Diastolic heart failure in the elderly may be a predictor of futility post liver transplant in elderly patients.Elderly LT recipients may have worse outcomes as compared to younger patients.