Novel Benchmark for Adult-to-Adult Living-Donor Liver Transplantation. Integrating Eastern and Western Experiences

Abstract

Objective: To define benchmark values for adult-to-adult living-donor liver transplantation (LDLT). Background: LDLT utilizes living-donor hemiliver grafts to expand the donor pool and reduce waitlist mortality. While references have been established for donor hepatectomy, no such information exists for recipients to enable conclusive quality and comparative assessments. Methods: Patients undergoing LDLT were analyzed in 15 high-volume centers (≥10 cases/year) from three continents over 5 years (2016-2020), with a minimum follow-up of one year. Benchmark criteria included MELD ≤20, no portal vein thrombosis, no previous major abdominal surgery, no renal replacement therapy, no acute liver failure, and no ICU admission. Benchmark cutoffs were derived from the 75th-percentile of all centers’ medians. Results: Of 3636 patients, 1864 (51%) qualified as benchmark cases. Benchmark cutoffs including posttransplant dialysis (≤4%), primary nonfunction (≤0.9%), non-anastomotic strictures (≤0.2%), graft loss (≤7.7%), and redo-LT (≤3.6%) at 1-year were below the DDLT benchmarks. Bile leak (≤12.4%), hepatic artery thrombosis (≤5.1%), and CCI® (≤56) were above the DDLT benchmarks, while mortality (≤9.1%) was comparable. The right-hemiliver graft, compared to the left, was associated with a lower CCI® score (34 vs.21, P<0.001). Preservation of the MHV with the right-hemiliver graft had no impact neither on the recipient nor on the donor outcome. Asian centers outperformed other centers with CCI® score (21 vs.47, P<0.001), graft loss (3.0%vs.6.5%, P=0.002), and redo-LT rates (1.0%vs.2.5%, P=0.029). In contrast, non-benchmark low-volume centers displayed inferior outcomes such as bile leak (15.2%), hepatic artery thrombosis (15.2%), or redo-LT (6.5%). Conclusion: Benchmark LDLT offers a valuable alternative to reduce waitlist mortality. Exchange of expertise, public awareness and centralization policy are however mandatory to achieve benchmark outcomes worldwide.