Left lobe living donor liver transplantation - evolving paradigm for the double equipoise

Abstract

Background: Despite lower morbidity and mortality in left lobe (LL) donor hepatectomy, right lobe (RL) graft remains the preferred choice for living donor liver transplantation(LDLT) in many transplant centres for fear of shifting donor risk to the recipient. However, solid evidence to support such concern is lacking. Method: Consecutive cohort of adult-to-adult LDLT from 1994-2017 was analysed. Propensity score matching (PSM) was performed before donor and recipient outcomes analyses. Paediatric patients, LDLT using graft types other than hemi-liver graft were excluded. Results: This retrospective analysis involved 1478 patients. The median follow-up for donor and recipient was 124 and 92 months respectively. After PSM, LL donors were found to have significantly lower peak post-operative bilirubin (30 vs 55 mmol/l), international normalization ratio (INR) (1.3 vs 1.5), and shorter prothrombin time (PT) (15.2 vs 17.9s) (all P < 0.001). In addition, LL donors had significantly shorter hospital length of stay (7.4 vs 8.9) days when compared to the RL donors (P = 0.046). Though statistically insignificant, there was a trend of lower overall (10.8% vs 21.7%, P=0.058) and severe (Clavien IIIa or above) (0% in LL vs 5% in RL, P=0.337) operative morbidity. There was no donor hospital mortality in this cohort. Concerning the recipient analyses, the median MELD was 16.4. Despite higher prevalence of small-for-size (SFS) graft in LL group (83% vs 23%, P< 0.001), there was no statistical difference in terms of SFS syndrome (15.4% vs 5.6% P=0.081) and in-hospital mortality rate (7.1% vs 1.6%, P=0.100). The 5-year graft survival for LL and RL recipients were 81% vs 83% (P=0.327) respectively. Conclusion: LL graft is a safe option for both donor and recipient in LDLT and should be the first choice if both LL and RL are suitable.