Living-donor liver transplantation

Recipient outcomes (evidence reviewed in 2006)

A significant amount of literature exists on living‑donor liver transplantation both for child and adult recipients, with a number of comparative studies and many case series studies.

4.1 In a review of primary studies assessing outcomes following adult‑to‑child liver transplantation, median 5‑year survival was generally higher in the living‑donor group (92%) than in the cadaveric‑graft group (81%; based on 8 studies looking at 1091 living grafts and 4550 whole‑organ cadaveric grafts). Graft survival was also higher with living‑donor grafts: the median 5‑year survival rate was 81% in the living‑donor group, compared with 73% in the cadaveric‑graft group.

4.2 The evidence for efficacy in adult‑to‑adult transplantation was based on a systematic review (246 studies, including 9 comparative studies totalling 675 patients) and a large case‑control study (n=2234). No significant differences in recipient survival at 12 months were found in 3 comparative studies included in the review (80–100% in the living‑donor group and 75–90% in the cadaveric‑graft group). In 65 non‑comparative studies included in the review, recipient survival rates ranged from 43–100% at follow‑up of 1–36 months.

4.3 Graft survival was also reported in 3 comparative studies. At follow‑up of at least 12 months, graft survival was 75–89% in the living‑donor groups, compared with 73–89% in the cadaveric‑graft groups.

Donor outcomes (evidence reviewed in 2015)

4.4 A systematic review of living‑donor liver transplantation (LDLT) on adult donor outcomes (n=214 studies) reported that nearly all donors had returned to normal activity by 3 to 6 months (based on 18 studies).

4.5 A systematic review of 11 studies comparing outcomes after right lobe LDLT with or without the middle hepatic vein (MHV) reported no significant differences between the right lobe with MHV versus the right lobe without MHV groups for liver functional recovery. This was based on postoperative peak values of alanine aminotransferase (ALT), aspartate aminotransferase (AST) and total bilirubin (TB) in donors (p=0.08; pooled weighted mean difference −2.88, 95% confidence interval [CI] −6.11 to 0.36). Subgroup analysis showed no difference between the groups for the peak value of ALT (p=0.60), AST (p=0.67) or TB (p=0.06).

4.6 The systematic review of LDLT on donor outcomes (n=214 studies) reported that the non-transplanted part of the donor livers had regenerated to about double the size of their remnant liver within several months, reaching a median of 89% of their original size (follow‑up 7 days to 6 months, based on 16 studies).

4.7 A survey of living donors (n=3565) in 38 Japanese LDLT centres reported liver dysfunction in 3 donors needing admission to an intensive care unit. A case series (survey) of 1508 LDLT donors reported hyperbilirubinaemia in 3% (43/1508) of right lobe liver donors.

4.8 A case series of 997 donors assessed the long‑term health‑related quality of life of donors using the SF‑36 health survey. Of 578 respondents (58%), the scores for donors were better than the Japanese norm scores (scores>50) across all time periods (1990–2004). The scores were similar for left lobe (n=367) and right lobe donors (n=211).

4.9 The majority of specialist advisers noted that living‑donor liver transplantation is an established procedure in end‑stage liver disease, particularly in children. However, there are still some uncertainties about long‑term survival and graft function in comparison with cadaveric‑liver grafts. For donors, the specialist advisers listed efficacy outcomes as survival, recovery and performance status and psychological wellbeing.