Innovations in Living-Donor Liver Transplant

The UPMC Center for Liver Care recently hosted its 2024 Annual Update in Medical Hepatology. Among the featured speakers and sessions was a lecture by Kiran Bambha, MD, MSc, on "Innovations in Living Donor Liver Transplant." Dr. Bambha is a professor of Medicine in the Division of Gastroenterology, Hepatology, and Nutrition at the University of Pittsburgh School of Medicine and serves as medical director of Hepatology and director of Liver Transplant Quality and Innovations at UPMC.

Dr. Bambha and the UPMC Center for Liver Care team partner closely with the UPMC Liver Transplant Program to advance research and innovation on living-donor liver transplant. Dr. Bambha's presentation covered many important topics and current questions about living-donor liver transplantation. Among the areas discussed by Dr. Bambha were ethical considerations in living-donor liver transplant, donor organ characteristics and the presence of steatosis in donor and recipient, technical advances, and the use of robotic assistance to improve surgical outcomes.

All these issues related to living-donor liver transplant are deeply intertwined, each driving advancements and improvements in the field. Dr. Bambha's presentation highlighted the importance of navigating these complexities with care and innovation to ensure the best possible outcomes for donors and recipients.

Navigating the Ethical Complexities of Living-donor Liver Transplant

The ethics of living-donor liver transplant are inherently complex, requiring a delicate balance between the imperative to save lives and the need to protect donors from harm. Dr. Bambha emphasized the four core ethical principles in living-donor liver transplant: autonomy, beneficence, nonmaleficence, and distributive justice. Nonmaleficence, or the commitment to "do no harm," is particularly relevant in this context.

"The ethics of living-donor liver transplant will forever remain germane to everything we do, especially as we push the boundaries of surgical technological innovation and what organs we can safely use for transplant,” says Dr. Bambha.

Dr. Bambha discussed the prevalent ethical framework around transplantation, explaining how ethical decisions in living-donor liver transplant balance donor safety, recipient need, and expected outcomes.

“This model can help clinicians navigate the ethical landscape of transplant, ensuring that each decision strives to maximize the ethical good for all involved,” says Dr. Bambha.

Ethical dilemmas also extend to the allocation of nondirected or anonymous donor grafts. Living-donor liver transplant programs, administrators, and clinicians must navigate various practices and policies to maximize the potential good that arises from these donations.

She discussed innovative approaches, such as machine learning models that can predict graft survival outcomes, ultimately facilitating more informed and equitable decisions around nondirected organ allocation.

Steatosis in Donors and Recipients

Hepatic steatosis poses significant challenges in both deceased and living-donor liver transplant. In deceased donor transplantation, large amounts of steatosis are associated with increased risks of ischemia-reperfusion injury, poor liver regeneration, primary non-function, early graft dysfunction, and decreased graft and patient survival. Despite these risks, the severe shortage of deceased donor organs necessitates the use of steatotic livers. In living-donor liver transplant, there has yet to be a consensus on the acceptable level of hepatic steatosis due to varying factors such as donor age, the lobe being donated, the surgeon's threshold, and the recipient's health status.

Dr. Bambha presented data from a retrospective study at Asan Medical Center in South Korea, which included 51 donors with moderate steatosis.

“The study revealed no significant differences in liver regeneration rates or postoperative liver function between steatotic and nonsteatotic donors and recipients,” says Dr. Bambha. “However, in this study, the donors were young with substantial liver remnants. This highlights the need for careful donor selection and further research in this arena.”

Managing steatosis in living donors involves addressing underlying metabolic issues through dietary counseling and weight loss programs. The prevalence of obesity and related metabolic conditions among potential donors should lead to more centers developing comprehensive support programs to manage the condition. An emerging area of focus in the field is the management of donors on GLP-1 agonists.

“There are concerns and a paucity of data right now about the optimal timing of medication cessation before surgery and potential rebound weight gain postdonation,” says Dr. Bambha.

Dr. Bambha also highlighted a study from Japan involving 212 living donors, which found the cumulative incidence of steatosis increasing over time after donation.

“That study identified male sex, higher BMI at donation, and being a parent of a pediatric recipient as risk factors for developing steatotic liver disease,” says Dr. Bambha. “These findings suggest the need for long-term follow-up and management of metabolic syndrome in living donors who may be predisposed to or have a higher risk for developing steatotic liver disease.”

Other Presentation Highlights

Dr. Bambha's presentation covered numerous other aspects of living-donor liver transplant, including:

• Trends in living donor liver transplantation, highlighting the increasing number of procedures and the rise of nondirected donors
• Strategies for managing donor-recipient incompatibility, including desensitization protocols and paired exchange programs
• The potential use of older living donor organs, supported by data showing safe outcomes with well-selected candidates and donors
• The role of living-donor liver transplant in transplant oncology, offering improved survival rates for patients with intrahepatic cholangiocarcinoma and colorectal cancer metastases

Links and Additional Reading

Learn more and listen to Dr. Bambha’s entire presentation archived on UPMCPhysicianResources.com.

Read more about Dr. Bambha and her clinical and research work in living-donor liver transplant.