American Journal of Transplantation 2015; 15: 274–277 Wiley Periodicals Inc.


Copyright 2014 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.13020

Case Report

Successful Living Donor Liver Transplantation Between Septuagenarians S. H. Kim*, Y. K. Kim, S. D. Lee and S. J. Park National Cancer Center, Goyang-si, Gyeonggi-do, Republic of Korea  Corresponding author: Seong Hoon Kim, [email protected], [email protected]

We report a case of a 76-year-old female who underwent living donor right hepatectomy for her 75-year-old husband with recurrent hepatocellular carcinoma. With her voluntary decision, full medical and psychiatric assessment was performed. The operative time was 130 min in the donor and 399 min in the recipient. Both the donor and recipient had an uneventful recovery and were discharged on days 7 and 10, respectively with normal liver function. The couple has had no complication so far and is currently doing well in good health 26 months after living donor liver transplantation. Abbreviations: AFP, alpha-fetoprotein; CEA, carcinoembryonic antigen; CT, computed tomography; ePTFE, expanded polytetrafluoroethylene; HCC, hepatocellular carcinoma; LDLT, living donor liver transplantation; LDRH, living donor right hepatectomy; MR, magnetic resonance; TACE, transcatheter arterial chemoembolization Received 22 May 2014, revised 21 July 2014 and accepted for publication 07 August 2014

Introduction Insufficient is the evidence defining the upper age limit for donation in living donor liver transplantation (LDLT) from the standpoints of both donor and recipient outcomes. However, the use of elderly donors to expand the living donor pool raises ethical issues about donor safety, because of the perceived increased risk of morbidity to the donor and a lower quality graft to the recipient (1,2). On the other hand, advances in surgical technique and management have resulted in improved outcome of living donor right hepatectomy (LDRH) (3). It was reported that short and mid-term survival following liver transplantation using deceased donors 70 years old can be excellent 274

provided that there is adequate donor and recipient selection (4). In the current era of living donor surgery performed worldwide, selecting a suitable donor in elderly people can be a last resort to the deteriorating patients who have no other choice. We report here a case of a 76-year-old female who underwent LDRH for her 75-year-old husband.

Case Report A 76-year-old woman visited the authors’ institution for evaluation of living donor on April 13, 2012. She expressed her willingness to be the living donor for her 75-year-old husband, who had recurrent hepatocellular carcinoma (HCC). At the initial visit, the physician excluded the eligibility of the old female as a living donor because she was considered too old. However, she looked good for her age with no evidence of distress or discomfort, having no concomitant abnormal medical or psychological condition and was the only donor candidate available for her husband, and the physician couldn’t clearly answer her question: ‘‘How old is too old?’’ She was interviewed independently by a transplant coordinator and registered nurse. After confirming her voluntary decision to become a living donor, full medical and psychiatric assessment by health-care professionals was performed. This process included blood tests, a chest X-ray, electrocardiogram, echocardiography and pulmonary function tests. Serum tumor markers (alphafetoprotein [AFP], carcinoembryonic antigen [CEA]) were added with mammogram and Pap smear. All the tests found no abnormal findings. Esophagogastroduodenoscopy and colonoscopy showed no specific lesions. Doppler ultrasonography demonstrated normal echogenicity and texture, good vascular flow and no definite fatty liver. Preoperative triphasic computed tomography (CT) scan showed conventional vascular anatomy and CT volumetry calculated the remnant left liver as 31.2% of total liver, and estimated graft-to-recipient weight ratio was 1.18%. The graft weight-to-standard liver volume was 36.9% in the recipient. Magnetic resonance (MR) cholangiography revealed mild dilatation of common bile duct but with normal biliary anatomy. The recipient who had hepatitis B virus–related liver cirrhosis had already undergone S6 segmentectomy and

Elderly Living Donor Liver Transplantation

cholecystectomy at an outside hospital on April 26, 2006. The follow-up MR image on April 6, 2011 showed a 3.2 cm sized HCC in S7. So, transcatheter arterial chemoembolization (TACE) was done on April 11, 2011 and there were no residual mass lesion in serial follow-up CT scans for 1 year. The follow-up MR image on April 10, 2012 revealed a 4 cm sized marginal recurred HCC in S7/8. Pretransplant serum level of AFP was 315.9 ng/ml, which had been 197.2 ng/ml 1 month ago and 75.3 ng/ml 2 months ago. Pretransplant metastatic work-up including positron emission tomography and CT scans of chest, abdomen and pelvis showed no evidence of distant metastasis. Preoperative Child-Pugh and Model for EndStage Liver Disease scores were 6 and 10, respectively. The recipient work-up also included echocardiography and pulmonary function tests. CEA, cancer antigen 19-9 and prostate specific antigen were checked with esophagogastroduodenoscopy, colonoscopy and prostate digital exam. There were no abnormal findings. The recipient was evaluated by neurological, renal, pulmonary and psychiatric consultations.

anastomosed to the graft right hepatic vein in a side-to-side fashion to form a wide single common orifice that could be anastomosed to the recipient inferior vena cava. The graft weight was 459 g. The actual graft-to-recipient weight ratio was 0.79%. In the recipient, after total hepatectomy, the right liver graft was transplanted with a duct-to-duct biliary reconstruction. Warm and cold ischemic times of the graft were 17 and 35 min respectively. The operative time was 399 min under 500 min of general anesthesia. Intraoperatively, he received one-quarter liter salvaged blood, five units red blood cells, four units fresh frozen plasma and one plateletpheresis unit. Both the donor and recipient was extubated before leaving the operating room. The donor was transferred from the operating room to the ward after 1 h observation in the recovery room. The recipient had 3 days of intensive care unit stay after surgery. Tacrolimus and mycophenolate mofetil was used for immunosuppression with steroids tapered off 3 months after LDLT.

The donor and recipient’s BMIs were 21.4 and 22.4 kg/m2, respectively. The donor had none of 19 categories of comorbidity encompassed in the Charlson Comorbidity Index (5). The recipient had well-compensated cirrhosis. Therefore, the Charlson Comorbidity Indices of the donor and recipient were 4 and 5, respectively, where each four points of the indices was attributed to the 70s the donor and recipient were in.

Prophylaxis for thromboembolism with early mobilization and compressive stockings was started on the day before operation and continued until discharge, and low-molecular weight heparin was used in for 1 week postoperatively. Intravenous patient-controlled analgesia was applied for 3 days after surgery. Levin tube was removed and sips of water were started the next day after operation. Diet and ambulation were started 1 and 3 days after operation in the donor and recipient, respectively.

The donor signed the informed consent about the items deliberated by the Ethics Group of the Vancouver Forum (6), and the LDLT were approved by KONOS (Korean Network for Organ Sharing).

Both the donor and recipient had an uneventful recovery and were discharged on Days 7 and 10, respectively, with normal liver function without any complication. Follow-up CT scan showed sufficient liver regeneration in both the

On April 30, 2012, the donor was placed in the supine position under general anesthesia for LDRH. Continuous intraoperative monitoring included electrocardiography, blood pressure, heart rate, inspired and expired gases, pulse oximetry, temperature and urine output. But, central vein cannulation was not done. Intraoperative liver biopsy showed no fatty change. Liver parenchymal transection was completed using hanging maneuver by Glisson’s approach under upper midline laparotomy (7). The operative duration was 130 min under 195 min of general anesthesia with no transfusion of blood or blood products. The right liver graft was delivered, and during bench preparation, two sizable tributaries of middle hepatic vein were reconstructed using a 7-mm-internal-diameter thin-walled expanded polytetrafluoroethylene (ePTFE) graft (GORETEX, W.L. Gore & Associates, Inc., Newark, NJ). One was a vein draining the segment V (V5) of 7 mm in diameter and the other was a vein draining the segment VIII (V8) of 6 mm in diameter. The V5 was anastomosed to the proximal end of an ePTFE graft in an end-to-end fashion. The V8 was anastomosed to the ePTFE graft in an end-toside fashion. The ePTFE graft draining both V8 and V5 was

donor and recipient (Figures 1 and 2). In the donor, the remnant liver volume was 31.2% of the whole liver volume immediately after surgery and then increased to 53.9% at 1 week, 65.7% at 1 month and 85.3% at 1 year. In the recipient, the right liver graft volume was 55.2% of the standard liver volume immediately after surgery and then increased to 72.5% at 10 days, 91.3% at 3 months and 89.3% at 1 year.

American Journal of Transplantation 2015; 15: 274–277

The couple has had no complication so far and is currently doing well in good health with normal liver function 26 months after LDLT.

Discussion This is the first report of LDLT between septuagenarians with the oldest living liver donor ever reported. What is accepted as low medical risk may differ from one transplant center to another, depending on surgical expertise and team judgment. The decision to offer this LDLT between the two septuagenarians was based on the following four reasons. 275

Kim et al

Figure 1: Computed tomography scans of liver in the donor (A) 7 days and (B) 22 months after right hepatectomy.

First, the major concern in performing this LDLT was the age of 76 in the donor candidate. Otherwise the donor candidate met our selection criteria and passed full medical and psychiatric assessment by health-care professionals. In the absence of specific medical or surgical issues, it was therefore difficult to deny the elderly candidate the opportunity to donate her partial liver solely based on age. We judged that the intrinsically higher perioperative risk of elderly individuals can be kept at acceptably low levels for this donor by using sound selection criteria based on functional status and biologic age (rather than chronological age) and by adopting advanced surgical technique and management. Second, safe and speedy surgery is one of the key success factors to improve the outcomes of LDRH. Various modifications in surgical technique and management (3,7,8) resulted in the current morbidity less than 3% without any major complications, reoperation or blood transfusions for more than 300 LDRHs since 2010. The majority of LDRHs were completed less than 3 h with the shortest at 106 min.

This safety and stability allowed us to stop central venous catheterization since donor no. 169 in 2009 onward, which contributed to avoid any procedure-related complication such as pneumothorax. Third, the recipient had a single 4 cm sized HCC and underlying liver cirrhosis. So, LDLT was considered to be the first-line treatment option (9). Considering the old age, repeat TACE could have been recommended with the expectation of the best response and survival gain (10,11). However, TACE has no curative intent. Furthermore, after 1st TACE, postembolization syndrome was severe, and transient hepatic and renal dysfunction had been developed with increased serum bilirubin 2 mg/dL, increased serum creatinine >1.5 mg/dL and new-onset ascites. He was reluctant to even consider the option of TACE. Fourth, this LDLT was performed by shared treatment decision making (12). The physicians informed the couple of research information about available recurrent HCC treatments including LDLT and TACE and their benefits and

Figure 2: Computed tomography scans of liver in the recipient (A) 10 days and (B) 22 months after living donor liver transplantation.


American Journal of Transplantation 2015; 15: 274–277

Elderly Living Donor Liver Transplantation

risks while the patients brought personal information about her and his illness, lifestyle and values. This simultaneous interaction led to an agreement on LDLT as the best treatment option. The donor selection criteria and evaluation have been described elsewhere (3,13,14). At the very beginning of our LDLT program in January 2005, the upper age limit was 59 years, and then, after overcoming the learning curve (13), elderly donors aged 60 have been carefully accepted since March 2008 by the selection criteria: preservation of middle hepatic vein, a remnant liver volume 30% and no or mild fatty change in healthy condition. This case provides a good example to show that septuagenarians under careful selection deserve consideration for LDRH in the present era of LDLT with accumulated experience and advanced surgical management. However, the old donor in this report was a highly selected one. As such, this result should not be interpreted as implying that all prospective donors over the age of 70 will have the same low-risk profile to be considered for LDRH.

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

References 1. Patel S, Orloff M, Tsoulfas G, et al. Living-donor liver transplantation in the United States: Identifying donors at risk for perioperative complications. Am J Transplant 2011; 7: 2344–2349.

American Journal of Transplantation 2015; 15: 274–277

2. Dayangac M, Taner CB, Yaprak O, et al. Utilization of elderly donors in living donor liver transplantation: When more is less? Liver Transpl 2011; 17: 548–555. 3. Kim SH, Kim YK. Improving outcomes of living-donor right hepatectomy. Br J Surg 2013; 100: 528–534. 4. Darius T, Monbaliu D, Jochmans I, et al. Septuagenarian and octogenarian donors provide excellent liver grafts for transplantation. Transplant Proc 2012; 44: 2861–2867. 5. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chron Dis 1987; 40: 373–383. 6. Pruett TL, Tibell A, Alabdulkareem A, et al. The ethics statement of the Vancouver Forum on the live lung, liver, pancreas, and intestine donor. Transplantation 2006; 81: 1386–1387. 7. Kim SH, Kim YK. Living donor right hepatectomy using the hanging maneuver by Glisson’s approach under the upper midline incision. World J Surg 2012; 36: 401–406. 8. Kim SH, Cho SY, Lee KW, Park SJ, Han SS. Upper midline incision for living donor right hepatectomy. Liver Transpl 2009; 15: 193– 198. 9. EASL-EORTC clinical practice guidelines: Management of hepatocellular carcinoma. J Hepatol 2012; 56: 908–943. 10. Georgiades C, Geschwind JF, Harrison N, et al. Lack of response after initial chemoembolization for hepatocellular carcinoma: Does it predict failure of subsequent treatment? Radiology 2012; 265: 115–123. 11. Choi J, Shim JH, Shin YM, Kim KM, Lim YS, Lee HC. Clinical significance of the best response during repeated transarterial chemoembolization in the treatment of hepatocellular carcinoma. J Hepatol 2014; 60: 1212–1218. 12. Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: What does it mean? (or it takes at least two to tango). Soc Sci Med 1997; 44: 681–692. 13. Kim SH, Cho SY, Park SJ, et al. Learning curve for living-donor liver transplantation in a fledgling cancer center. Transpl Int 2009; 22: 1164–1171. 14. Kim SH, Kim YK, Lee SD, Park SJ. Selection and outcomes of living donors with a remnant volume less than 30% after right hepatectomy. Liver Transpl 2013; 19: 872–878.


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Successful living donor liver transplantation between septuagenarians.

We report a case of a 76-year-old female who underwent living donor right hepatectomy for her 75-year-old husband with recurrent hepatocellular carcin...
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