THE USE OF LIVERS WITH METABOLIC DISORDERS FOR TRANSPLANTATION - CURRENT STATUS: THE DOMINO LIVER WORLD TRANSPLANT REGISTER (DLTR) VIEWPOINT

OUTCOMES OF LIVER TRANSPLANTATION I

H.E. Wilczek¹, M. Larsson¹, A.J. Stangou², O. Suhr³, B. Ericzon^1
1Dept Of Transplantation Surgery, Karolinska Institute, Stockholm/SWEDEN, ²Institute Of Liver Studies And Amyloidosis Treatment Centre, King's College Hospital, London/UNITED KINGDOM, ³Dept Of Medicine, Umeå University Hospital, Umeå/SWEDEN

Body: Introduction/Methods: The DLTR registers data on liver transplant (LTx) recipients who received explanted livers from patients who themselves underwent LTx. Results: By December 31, 2009, fifty-five different hospitals in 20 countries reported a total of 704 domino liver transplantations (DLT) in 694 patients. A male dominance of approximately 4:1 exists. Mean age at time of transplantation was 54.6±9.7 years, (median 56.0 years, range 3-74 years), unchanged when analyzing males and females separately (54.6±8.9 years and 54.6±11.6 years, respectively). The number of retransplantations is low, approximately 6% of all DLTs. About 50% of the retransplantations occurred within the first month after transplantation. Overall, the dominant diagnoses in DLT recipients were HCC (39%), HCV (18%) and alcoholic cirrhosis (16%), numbers remaining unchanged when analyzing the last 5-year period only. Males and females differ in diagnostic patterns (Table).

	1995 – 2009		2005 - 2009
	Male	Female	Male	Female
HCC	44%	26%	45%	23%
HCV	18%	17%	20%	14%
Alcoholic cirrhosis	17%	11%	19%	12%

In females, PBC also stands out as a major diagnosis (11% for the whole time period 1995 – 2009, 9% in the last 5-year analysis). Most DLT livers (99%) came from FAP/amyloidotically afflicted donors, but livers from donors with metabolic diseases other than amyloidosis have also been used. The commonest DLT donor mutation was the Val30Met. Survival in donor FAP patients did not differ from non-donor FAP patients. Overall 1-year, 5-year and 8-year graft survival in DLT recipients was 80%, 66% and 62%, respectively. Patients with malignancy amounted to 43% in the Val30Met group versus 55% in the non-Val30Met group. DLT recipients with malignancy had inferior survival rates compared to non-malignant recipients. Tumour recurrence and septicaemia accounted for the majority of deaths (40%). A significantly better graft survival was observed in recipients of non-Val30Met mutated livers compared to Val30Met mutated livers (5-year survival 74% and 65%, respectively p<0.05). Three patients have reportedly developed FAP symptoms 7-8 years after LTx. Conclusion: LTx patients can in carefully selected cases serve as liver organ donors, and their livers make a valuable resource. In experienced hands, DLT is safe both for the domino donor and the recipient. The immediate and short-term outcome in the domino recipients is excellent. Considering the poor pretransplant condition and dismal prognosis domino recipients have without transplantation, the long-term survival must also be deemed good. Not surprisingly, survival among domino recipients transplanted because of malignancy was inferior to non-malignant recipients. Recipients of Val30met mutated livers show inferior survival to recipients of other TTR mutated livers, the reason being unclear. Because of the hitherto relatively unknown posttransplant TTR kinetics and a risk of transferring the donor disease to the domino recipient, caution and watchful long-term monitoring is needed.

Disclosure: All authors have declared no conflicts of interest.