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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThe Thomas E. Starzl Transplant Surgery State-of-the-Art Lecture discussed the controversial topic of living donor liver transplantation.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ETransplantation\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EHepatology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ETransplantation\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EJean C. Emond, MD, Columbia University, New York, New York, USA, presented the Thomas E. Starzl Transplant Surgery State-of-the-Art Lecture, discussing the controversial topic of living donor liver transplantation (LDLT).\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EAccording to Dr Emond, LDLT has saved tens of thousands of lives globally and represents the only option for transplantation in many countries. Following its initial introduction in young children in 1987, improvements in surgical techniques and outcomes of LDLT occurred rapidly over the course of about 4 years. This resulted in a rapid adoption curve, and by the early 1990s, centers around the world were using LDLT and reporting 90% graft survival rates.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EDr Emond noted the high burden of liver disease in Asian countries that have a superior tradition of advanced liver surgery. LDLT has flourished in these countries, particularly because religious and cultural obstacles have served as barriers to deceased donor liver transplantation (DDLT), a situation that will likely continue.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EBy comparison, however, he emphasized that LDLT has not been fully embraced in the United States, where, to date, only a little more than 5000 LDLTs have been performed. These represent about 3% of total liver transplants in adult patients and about 10% of those in pediatric patients.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EDONOR RISKS\u003C\/h2\u003E\n         \u003Cp\u003EDr Emond explained that some of the key factors that have affected the adoption of LDLT in North America and Europe include:\n\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n                  \u003Cp id=\u0022p-7\u0022\u003EReal and perceived risks\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n                  \u003Cp id=\u0022p-8\u0022\u003EDifficulty of the technique\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n                  \u003Cp id=\u0022p-9\u0022\u003EAccess to deceased donors as an alternative transplantation source\u003C\/p\u003E\n               \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n         \u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EThe associated risks to donors, in particular, represent a significant barrier to adoption of LDLT. With respect to catastrophic consequences in living donors in the United States, 4 deaths have been reported in recovering adult donors to date, all in right lobe donors, and 4 more patients have required a liver transplant. One death has also been reported in a pediatric donor.\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EAlthough this procedure does present a risk to donors, it is nevertheless very small, and Dr Emond stressed that zero mortality should not be deemed the requirement for LDLT.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003ENevertheless, he added that refining the technique such that it decreases donor risk, while preserving recipient outcomes, could only be beneficial.\u003C\/p\u003E\n         \u003Cp\u003EFor example, according to Dr Emond, there is some evidence that left lobe LDLT in particular is better for the donor, for a variety of reasons, including:\n\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-2\u0022\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n                  \u003Cp id=\u0022p-14\u0022\u003EUse of a technique that is more amenable to minimal access laparoscopic surgery\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n                  \u003Cp id=\u0022p-15\u0022\u003EImproved early liver function\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\n                  \u003Cp id=\u0022p-16\u0022\u003EA shorter hospital stay\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-7\u0022\u003E\n                  \u003Cp id=\u0022p-17\u0022\u003EEarlier return to work\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-8\u0022\u003E\n                  \u003Cp id=\u0022p-18\u0022\u003ELess liver regeneration\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-9\u0022\u003E\n                  \u003Cp id=\u0022p-19\u0022\u003ELess splenomegaly\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-10\u0022\u003E\n                  \u003Cp id=\u0022p-20\u0022\u003EA suggested lower mortality risk\u003C\/p\u003E\n               \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n         \u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ERECIPIENT OUTCOMES\u003C\/h2\u003E\n         \u003Cp\u003EWith respect to recipient outcomes, recipient livers grow very quickly to adequate size, typically within a few weeks after transplantation. However, complications can arise, and Dr Emond discussed \u201csmall-for-size syndrome\u201d [Dahm et al. \u003Cem\u003EAm J Transplant\u003C\/em\u003E. 2005], a clinical condition that was initially characterized by unfavorable outcomes when transplantations involving small livers in bigger children were introduced about 20 years ago. The syndrome is associated with the transplantation of a liver mass that is too small for the recipient and is characterized by numerous clinical features, including:\n\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-3\u0022\u003E\u003Cli id=\u0022list-item-11\u0022\u003E\n                  \u003Cp id=\u0022p-22\u0022\u003EReduced hepatic synthetic function\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-12\u0022\u003E\n                  \u003Cp id=\u0022p-23\u0022\u003EAscites\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-13\u0022\u003E\n                  \u003Cp id=\u0022p-24\u0022\u003EEncephalopathy\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-14\u0022\u003E\n                  \u003Cp id=\u0022p-25\u0022\u003EPersistent graft injury\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-15\u0022\u003E\n                  \u003Cp id=\u0022p-26\u0022\u003EPortal hypertension\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-16\u0022\u003E\n                  \u003Cp id=\u0022p-27\u0022\u003EReduced renal function\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-17\u0022\u003E\n                  \u003Cp id=\u0022p-28\u0022\u003EImpaired reticuloendothelial activity\u003C\/p\u003E\n               \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n         \u003C\/p\u003E\n         \u003Cp id=\u0022p-29\u0022\u003EAlthough this injury is devastating, it is usually reversible.\u003C\/p\u003E\n         \u003Cp id=\u0022p-30\u0022\u003EResearch has also been performed to investigate methods to optimize preservation of liver grafts. Dr Emond noted that, in general, appropriate reduction in portal flow can protect the small liver, allowing use of a graft with an approximate graft weight to recipient weight ratio of 0.5, corresponding approximately to a left lobe in most cases, and a left lateral segment in some cases [Triosi R et al. \u003Cem\u003EAnn Surg\u003C\/em\u003E. 2003; Ben-Haim M et al. \u003Cem\u003ELiver Transpl\u003C\/em\u003E. 2001].\u003C\/p\u003E\n         \u003Cp id=\u0022p-31\u0022\u003EDespite advances in the technique, Dr Emond described LDLT as \u201chigh stakes,\u201d especially in North America and Europe, predominantly because of the catastrophic donor risk and demoralizing recipient risk. Although clinicians typically seek certainty, he stressed that the reality of LDLT is variance, in particular with respect to factors such as variability of donor liver shape and volume, surgical technique, and recipient condition.\u003C\/p\u003E\n         \u003Cp id=\u0022p-32\u0022\u003EHe added that the only way to overcome variance and improve outcomes is by performing more LDLTs. Biological and surgical progress remains critical for this and must be accomplished utilizing evidence-based progress. For instance, data from high-volume transplant centers have demonstrated the reliability of right liver lobe transplantation, as well as minimal access hepatectomy. Collaboration within a multidisciplinary team is also an important factor in managing the risks associated with LDLT.\u003C\/p\u003E\n         \u003Cp id=\u0022p-33\u0022\u003EConsidering the benefit of evidence-based progress, Dr Emond highlighted the work of the A2ALL consortium, which performed an evidence-based search for progress in LDLT from 2001 to 2014. Their research produced some valuable observations in numerous areas of LDLT, including the surgical learning curve, survival benefit of LDLT for candidates, donor and recipient short- and long-term outcomes, quality of life and psychosocial outcomes, and portal modulation.\u003C\/p\u003E\n         \u003Cp id=\u0022p-34\u0022\u003EWhile he emphasized the need for hepatologists to embrace LDLT, Dr Emond acknowledged the challenge in achieving this. Although the arguments in favor of LDLT are rational, opposition is prevalent among clinicians and the public, and whether biological and technical progress can overcome the resistance remains to be seen.\u003C\/p\u003E\n         \u003Cp id=\u0022p-35\u0022\u003EOverall, LDLT has not yet achieved its promise in North America and Europe, despite the fact that the technique is best for most recipients. The surgery is more difficult than DDLT and transplant teams remain reluctant to promote LDLT, in particular because of the risks involved. The organ allocation system is also problematic because it encourages DDLT. Nevertheless, LDLT will continue to play a role in liver transplantation until alternate donor sources are developed, concluded Dr Emond.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/48\/4\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022The editors would like to thank the many members of the 2014 American Association for the Study of Liver Disease presenting faculty who generously gave their time to ensure the accuracy and quality of the articles in this publication.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-162373898\u0022 data-figure-caption=\u0022The editors would like to thank the many members of the 2014 American Association for the Study of Liver Disease presenting faculty who generously gave their time to ensure the accuracy and quality of the articles in this publication.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure1\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/48\/4\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/48\/4\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/48\/4\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15583\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\n               \u003Cp id=\u0022p-36\u0022 class=\u0022first-child\u0022\u003EThe editors would like to thank the many members of the 2014 American Association for the Study of Liver Disease presenting faculty who generously gave their time to ensure the accuracy and quality of the articles in this publication.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/48\/4.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzoeo2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzoeo2\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}