Adult Living Donor Liver Re-Transplant Following Late Pediatric Liver Transplant Failure: A Case Report

Background

Liver transplantation (OLT) became the standard of care for patients with end-stage liver disease (ESLD) since its introduction in 1967. Despite all the technical pre- and post-operative advances, graft failure following OLT occurs in 10–20% of cases, necessitating re-transplantation [1–3]. Although re-transplantation (re-OLT) can be successful [4], the outcome is inferior to primary OLT [5]; which poses an ethical dilemma in the era of cadaveric organ shortage [6,7]. The remarkable advances in living donor liver transplant (LDLT) partially alleviated the organ shortage crisis, especially in countries where deceased donor liver transplant (DDLT) is done on a small scale as a result of organ scarcity. Re-transplantation utilizing an organ from a living donor (LDLT) avoids the ethical dilemma of depriving a liver from the donor pool and giving it to a recipient who may have inferior outcome; however, this is associated with technical difficulties which translate into a poor outcome, especially if done in the setting of high MELD score (model for end-stage liver disease). As a result, re-transplanting for a late failure of LDLT utilizing a living donor is a rare occurrence. In one of the biggest LDLT centers, with a total of 1312 LDLTs performed over 25 years, there were only 14 re-OLTs after primary LDLT; of which 3 were with a living allograft. Outcomes were poor, with a 1-year mortality rate of 43.5% [8,9]. In this report we describe a case of living donor liver re-transplant for late liver failure secondary to liver fibrosis, progressive cholestasis, and acute portal vein thrombosis in a patient who underwent LDLT 14 years earlier. The degree of adhesion was unexpectedly not severe, permitting safe re-OLT, contrary to what was reported in the literature.

Case Report

ETHICS APPROVAL:

Both living donors were unrelated. Consent for donation was obtained as per the protocol of the liver transplant program at the Multi-Organ Transplant Center at PSMMC and in accordance with the regulations of the Saudi Center of Organ Transplantation (SCOT), which is the official body regulating organ transplantation and organ donation in the Kingdom of Saudi Arabia. Consent was obtained from the patient for reporting the case. Approval was obtained from the Institutional Research Board (IRB) of PSMMC.

Discussion

Most of the data we have on re-OLT are in the setting of DDLT [4–6]. Re-transplant with a deceased graft for failed living donor transplant was explored using data from the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS). This retrospective analysis showed similar outcome when re-OLT was done from cadaveric donor, regardless of whether the first graft was from a living or a cadaveric donor [8].

In Asia, where LDLT is commonly practiced, re-OLT is not common. The 2 largest LDLT centers worldwide reported small number of cases over a long period of time. Re-transplantation for a late failure of a living donor graft utilizing a living donor is associated with inferior results [9], with a 1-year mortality rate of 43.5% [10]. This was attributed to the complexity of surgery as a result of severe adhesions formed after extended time from the primary surgery.

In a more recent study from Asan Medical Center, Korea, which is the largest LDLT center in the world, over 20 years only 55 cases were re-transplanted, of which 33 were done for late graft failure. The 1-year survival rate was only 50%. A significant mortality risk factor for late primary transplant failure was high bilirubin. The operative procedures were associated with longer operative time and more blood loss in the late primary graft failure patients [11].

In our case, re-OLT was performed 14 years after the initial surgery. Portal vein thrombosis, high bilirubin, and high MELD score added to the complexity of the case. The young age of the patient and the preservation of his renal function were positive predictors of survival, which, among other factors, encouraged the surgical team to proceed with the re-OLT despite the potential risk.

In contrast to what is reported in the literature, the transplant was completed within a reasonable operative time with acceptable blood loss. Severe adhesions are the main factor increasing the complexity re-OLT. In our case, the adhesions encountered were mostly grade 2, which contributed to the success of the surgery. It follows that re-OLT should always be considered and that concerns about adhesion should not be a reason to deny patients from undergoing re-OLT. Being the first and only re-OLT in our program is a limitation to our recommending this approach. Assertion of the safety of re-OLT in this setting may be strengthened with more cases. The other limitation to this approach is availability of surgical expertise and set-up in such complicated cases.

Conclusions

Re-transplant for a living donor liver transplant failing graft is associated with inferior survival, especially when done from a living donor. High MELD score, high bilirubin, and late graft failure are potential risk factors for mortality. Proceeding with living donor liver re-OLT can be successful, but risk factors should be considered carefully. Fear of encountering severe adhesions should not be a barrier to performing re-OLT.