Journal of Medicine Vol 2 - Amrita Institute of Medical Sciences and ...

Amrita Journal of Medicine
Living Donor Liver Transplantation in Acute Hepatic Failure – viable option in Indian context
King’s College criteria for transplantation in acute liver failure:
Non – acetaminophen cause
INR >6.7
Or any three of
Unfavorable cause (eg. Drug induced, non A
non B hepatitis, Halothane hepatitis)
Age 40 years
Acute/Subacute presentation
Bilirubin level >300mmol/L
Acetaminophen
Arterial pH 300mmol/L
INR > 6.5
INR > 3.5
cipient received 8 units of packed cells and 9 units of
plasma. The donor hepatectomy was accomplished without
the need for red cell transfusion. The donor was
extubated immediately postoperatively while the recipient
was extubated the next day.
Initial immunosuppression was with injectable methyl
prednisolone alone. Oral steroids, Tacrolimus and
Mycophenolate Mofetil were started on the third postoperative
day. Tacrolimus dose was adjusted to maintain
serum trough levels between 5 and 15ng/ml. The convalescence
was rather smooth and she was discharged on
24 th postoperative day. At follow up in 3 rd month, she is
back to near normal life. The donor is back to his routine
activities of daily living.
DISCUSSION
AHF is a clinical syndrome that results from sudden
loss of hepatic parenchymal and metabolic functions and
manifests as coagulopathy and encephalopathy. The
causes differ in various parts of the world. In U.K and
USA 5 acetaminophen and idiosyncratic drug reactions are
the most commonly identified etiologic agents while in
Japan and India acute hepatitis B is the leading cause of
AHF 6 . It is known that spontaneous survival rates from
AHF due to acetaminophen toxicity and Hepatitis A are
high 4 , while the rates for other viral hepatitis and idiosyncratic
drug reactions are low.
AHF constitutes a medical emergency associated with
a high mortality due to the development of cerebral
edema, coagulopathy and bleeding complications. The
role of LT in AHF has been established beyond doubt.
The essential challenge is identifying the crucial timing
for transplantation. This involves maintaining the fine
balance between possible reversibility of the condition
through hepatic regeneration versus development of complications,
which may either contraindicate transplant or
render the condition irretrievable despite a transplant! A
useful tool to assess whether a patient is likely to become
irreversible is the Kings college criteria 7 , for early
identification of indices with a poor prognosis.
Traditional cadaveric graft if available and in a good
condition, is considered ideal because patients with AHF
have a huge metabolic demand. However, even in countries
with an established cadaveric organ-sharing program,
a suitable donor may not be easily available in the emergency
setting of AHF. Over the last few years, the use of
living donor liver transplantation (LDLT) has been evaluated
and the benefits in the setting of AHF are
well-established 8 . The advantages are that graft function
is usually excellent as cold ischaemia time can be kept
to a minimum and the procedure can be completed on
an emergency basis before the patient’s condition deteriorates
irreversibly. The potential disadvantage is possible
inadequacy of available liver volume; hence the safer left
liver grafts (Fig.1) have given way to the functionally larger
right liver, albeit at the cost of significantly higher donor
morbidity and mortality 9 .
Donor related complications can be kept to a minimum
by careful preoperative estimation of the donor liver
volume and a careful delineation of the vascular and biliary
anatomy of the two lobes of the liver. The size of the
graft required by the recipient is estimated by the graft to
recipient weight ratio (GRWR), which is the weight of
the graft divided by the weight of the recipient multiplied
by 100 (ideal GRWR = 1), and balanced against
the 40% of the original liver volume that has to be retained
in the donor. CT volumetry is invaluable in this
regard 10 . It is imperative while planning the parenchymal
transection to ensure adequate vascular inflow and outflow
and biliary drainage of all the segments in both the
lobes of the liver to avoid functional parenchymal loss in
either the donor or recipient. The information obtained
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