Deceased Donor Liver Transplantation in the East - A Viable Opportunity for Growth or a Logistic and Clinical Nightmare?

Background and Aim: Liver transplantation in the east has been dominated by the use of living related donors. However large cohorts of BSD donors are potentially available which has huge implications for chronic liver disease patients in the region. We describe the experiences, evolution and early outcomes from one of India's largest cadaveric liver transplant programmes. Methods: Between August 2009 and December 2012(40mths), we performed 179 orthotopic liver transplants (OLT)in a single centre in south India, of which 64 were performed with cadaveric donors(DDLT). Data was collated reterospectively with particular emphasis on etiology, mortality, and donor sources. The outcomes from the DDLT cohort were compared to the LRLT recipients. Results: of the 64 recipients, 5 recipients were aged 16 or under, and rest adults (Median age 40) of whom 10 were female. There was 1 re-transplant, 2 were performed as auxiliary transplants, and 8 combined liver and kidney transplants (4 LRLT; 1 death). Four of the 13 recipients transplanted for acute liver failure were DDLT. Disease etiology included cryptogenic 17, Budd chiari 1, NASH 8, Ethanol 19, viral hepatitis 12, Wilsons 1, AIH 4, metabolic 1, and biliary atresia 2. Mortality was 8% amongst the LDLT and 23% amongst DDLT (P<0.05). Causes of death were small for size syndrome 4, PNF 4, PTLD 1, abdominal compartment syndrome 1, cerebral oedema 1, DIC/haemolysis 3, sepsis/delayed graft function 6, sepsis/massive blood transfusion 2]. Of the 15 recipient deaths in the DDLT, 12 grafts were procured from out of hospital donors. Of which 5 grafts came from one pheripheral hospital, all of whom died. On review of the last 100 cases (post learning curve), there were 9 deaths (6 DDLT, 4 LDLT). Of the 5 DDLT in the paediatric group, 4 patients died with the only survivor being a donor from our own centre. Conclusions: The development of the cadaveric programme has enabled the utilisation of a scarce resource in an eastern nation. Our report shows that it is possible and worthwhile to push the boundaries to try and achieve success in cadaveric transplantation to harness the potentially large cohort of BSD donors. In our series, a current overall 1 year survival rate after liver transplantation for chronic liver disease in children of 87% suggests acceptable outcomes, considering the early stage of the programme. The survival for paediatric LDLT appears to be better than DDLT. There is however an urgent need to improve donor management and organ transport logistics in the region if we are to develop DDLT further.