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Safety of Donor in Adult-to-Adult Living Donor Liver Transplantation Using Right Lobe Graft
Safety of Donor in Adult-to-Adult Living Donor Liver Transplantation Using Right Lobe Graft X.-Z. Jiang, L.-N. Yan, B. Li, T.-F. Wen, Y. Zeng, W.-T. Wang, J.-C. Zhao, J.-Y. Yang, M.-Q. Xu, Y.-K. Ma, Z.-Y. Chen, and F.-G. Li ABSTRACT Background. The growing gap between the number of patients awaiting liver transplantation and available organs has continued to be the primary issue facing the transplant community. To overcome the waiting list mortality, living donor liver transplantation has become an option, in which the greatest concern is the safety of the donor, especially in adult-to-adult living donor liver transplantation (A-A LDLT) using a right lobe liver graft. Objective. We evaluated the safety of donors after right lobe liver donation for A-A LDLT performed in our center. Methods. From January 2002 to March 2006, 26 patients underwent A-A LDLT using right lobe liver grafts in our center. Seven donors were men and 19 were women (range, 19 – 65 years; median age, 38 years). The right lobe liver grafts were obtained by transecting the liver on the right side of the middle hepatic vein without interrupting the vascular blood flow. The mean follow-up time for these donors was 9 months. Results. These donor residual liver volumes ranged from 30.5% to 60.3%. We did not experience any donor mortality. Two cases (7.69%) experienced major complications: intra-abdominal bleeding and portal vein thrombosis in one each and three (11.54%), minor ones: wound steatosis in two, and transient chyle leak in one. All donors were fully recovered and returned to their previous occupations. Conclusions. A-A LDLT using a right lobe liver graft has become a standard option. The donation of right lobe liver for A-A LDLT was a relatively safe procedure in our center.
L
IVER transplantation is an effective therapeutic option for patients with end-stage liver diseases. However, longer waiting times and increasing numbers of deaths in patients awaiting an organ have become serious problems. Living donor liver transplantation (LDLT) offers a partial solution to the severe shortage of liver grafts worldwide.1 The most serious concern in LDLT, especially in adult-to-adult living donor liver transplantation (A-A LDLT) using right lobe liver grafts, is the risk to the healthy donor who will undergo a major operation without any potential health benefit. It is of paramount importance that the donors be as little “harmed” as possible by the donation.2 The aim of this study was to assess the safety of donors after right lobe liver donation for A-A LDLT performed from January 2002 to March 2006 in our center. 0041-1345/07/$–see front matter doi:10.1016/j.transproceed.2006.10.013 150
MATERIALS AND METHODS Patients Between January 2002 and March 2006, 26 recipients (23 males and 3 females) aged 20 to 53 years (median age 37 years) underwent A-A LDLT using right lobe liver grafts. Their underlying diseases included hepatitis B virus (HBV)-related cirrhosis in 17 cases (4 with acute liver function failure), primary hepatocellular carcinoma in 8 cases, and Budd-Chiari syndrome complicated with liver function failure in 1 case. From the Center of Liver Transplantation, West China Hospital, Sichuan University, Chengdu, People’s Republic of China. Address reprint requests to Dr Yan Lu-Nan, Center of Liver Transplantation, Department of Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, People’s Republic of China. E-mail: [email protected] © 2007 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 39, 150 –152 (2007)
DONOR SAFETY IN LIVER TRANSPLANT
Donors Of the 26 donors who underwent right hepatic lobectomy for living donation, 7 were male and 19 were female (aged 19 to 65 years, median age 38 years). Two were fathers, 4 were brothers, 5 were mothers, 3 were sisters, 5 were wives, 2 were daughters, and 5 donors were friends. All the living donors who volunteered for the procedure underwent a full evaluation, including blood group verification, calculation of body mass index (BMI), and laboratory testing, such as liver and renal biochemistry, complete blood count, coagulation profile, and virologic assays for hepatotropic viruses, serologic screening for human immunodeficiency virus, cytomegalovirus, and Epstein-Barr virus. Electrocardiography and pulmonary function testing were also performed routinely. Size calculations of the right and left liver lobes were carefully assessed using three-dimensional computerized tomographic imaging. Hepatic Doppler ultrasonography and CT measurements were used to determine the anatomical vascular variations. Ultrasound-guided percutaneous liver biopsy was routinely performed to exclude fatty infiltration of more than 30%.3,4 Before surgery we decided the ideal hemi-liver to harvest, with the first objective to be safety for the donor. The ethics committee for our transplantation program assessed the donors for possible coercion and discussed the risks and benefits of the procedures.
Methods During the donor’s operation, cholecystectomy and then intraoperative cholangiography were routinely performed to confirm the biliary anatomy. Intraoperative ultrasound was performed routinely to define the hepatic venous drainage of the right liver lobe. In all 26 donors, the middle hepatic vein was preserved to avoid outflow obstruction to the remaining donor segment 4. All the inferior right hepatic veins of over 5 mm diameter were preserved for subsequent anastomosis to the recipient inferior vena cava. Liver resection was performed with an ultrasonic dissector, argon beam, and conventional coagulation. Living donor hepatectomy was performed without interrupting the vascular blood flow. The mean operative time was 455 ⫾ 52.6 minutes (range, 380 – 620 minutes). On the back table, liver grafts were perfused with histidinetrytophan-ketoglutarate (HTK) or University of Wisconsin (UW) solution at 4°C. During the recipient’s operation, some modifications were designed to improve the reconstruction of right hepatic vein, inferior right hepatic vein, and the reconstruction of the tributaries of middle hepatic vein using interposition vein grafts. All cases underwent direct anastomosis of right hepatic vein and inferior vena cava (IVC), of whom 9 cases were added with the reconstruction of right inferior hepatic vein, and 11 cases added reconstruction of the tributaries of the middle hepatic vein by interpositing a vein graft so as to provide sufficient venous outflow. The arterial perfusion of the graft was assured by an end-to-end anastomosis between the graft right hepatic artery and the recipient main hepatic artery. Bile duct reconstruction was performed by suture of the bile ducts to a Roux-en-Y loop or a duct-to-duct anastomosis, without bile duct drainage. Of the 26 recipients, none developed small-for-size syndrome or refractory ascites. All donors were routinely managed in the liver transplantation intensive care unit (LT-ICU) for 48 hours postoperatively. After discharge from the hospital, the follow-up for each donor included weekly visits in the first month, biweekly visits in the second month, monthly visits in the subsequent 4 months, and then yearly re-
151 checks. Laboratory examinations for donors during follow-up included liver and renal biochemistry and complete blood count. Hepatic Doppler ultrasonography and CT scanning were performed routinely to estimate the hepatic vascular status and the profiles of liver grafts.
RESULTS
In our series, the donor residual liver volumes (left liver lobes), as measured by CT analysis, ranged from 30.5% to 60.3% (mean, 42.8% ⫾ 5.1%). Graft weight ranged from 455 g to 860 g (mean, 635 ⫾ 36 g). The mean blood loss was 427 mL (range, 200 –735 mL). Only one donor (3.85%) required nonautologous blood transfusion, with 21 (80.77%) undergoing autologous blood transfusion, which was called “salvaged autotransfusion.” In the perioperative period the mean albumin administered was 85 g. The donor liver functions were found impaired to some extent, including transient liver enzyme elevation, hyperbilirubinemia, and hypoalbuminemia in the immediate postoperative period, but all the indices rapidly returned to normal at the end of the first week. Prothrombin time was prolonged in the early postoperative period, but in all cases this index normalized within 2 weeks. The liver profiles normalized after a mean of 14 days. Of our 26 donors, the overall complication rate was 19.23% (5 donors). Two cases (7.69%) experienced major complications including intra-abdominal bleeding in one case, and portal vein thrombosis in another; there were 3 (11.54%) minor ones (wound steatosis in 2, and transient chyle leak in 1). The donor with postoperative hemorrhage underwent reoperation, and the one with portal vein thrombosis, which was diagnosed on the 3rd postoperative day with routine daily Doppler ultrasound examination, was treated successfully by relaparotomy and intraoperative tissue plasminogen activator infusion, which then provided good blood flow. The donors with wound steatosis were recovered by local drainage and dressings exchange. The transient chyle leak in one donor ceased spontaneously after 12 days. The mean hospital stay was 16.2 ⫾ 6.8 days (range, 12– 40 days), and the mean follow-up time for these donors was 9 months. We did not experience any donor mortality. All donors were fully recovered and returned to their previous occupations within 6 to 8 weeks after operation. No liver impairment or other long-term complication such as psychological impairment occurred during follow-up. DISCUSSION
The growing gap between the number of patients awaiting liver transplantation and available organs has continued to be the number-one issue facing the transplant community. To overcome the waiting list mortality, living donor liver transplantation (LDLT) has become an option worldwide. After the first successful LDLT reported in 1990,5 this surgical innovation has evolved to established efficacy in the literature. Use of LDLT could provide life-saving therapy to many patients who otherwise would die awaiting an
152
organ. Right lobe donation has been the main type of partial liver graft for A-A LDLT. Regardless of the potential benefits that LDLT offers critically ill patients with end-stage liver diseases, donor safety is the most important clinical issue related to LDLT, especially when using right lobe grafts; however, A-A LDLT has raised special concerns about the safety of living liver donors, because A-A LDLT carries higher donor risks owing to the extensive liver resection. The reported incidence of complications in donors for A-A LDLT varies, but is likely in the range of 10% to 20%.6 It was reported that biliary tract complications were the most common, occurring in 3% to 8% of donors.7 Other significant complications included portal vein thrombosis, pulmonary embolus, bowel obstruction, and incisional hernia.8 Furthermore, it is estimated that at least 12 donors have died during the procedure in different parts of the world.9 Three additional donors have undergone liver transplantation because of complications related to right lobe donation.2,10 The first pediatric LDLT and A-A LDLT in our center was performed in July 2001 and January 2002, respectively. Currently, our center performs A-A LDLT using right lobe liver grafts. Of our 26 donors, 2 cases (7.69%) experienced major complications, and 3 (11.54%) minor ones. At present, donors older than 60 years are usually rejected in most centers worldwide because liver transplants from older donors may result in lower patient and graft survivals than those from younger donors. However, we encountered one patient aged 36 under high urgency status with hepatitis B virus (HBV)–related cirrhosis complicated with acute liver function failure who had to undergo emergency liver transplantation, which could provide lifesaving therapy to the patient who otherwise would die awaiting an organ. Unfortunately, with such a high urgency status, there was no other feasible donor except his mother, aged 65, who showed a strong will to donate. The donor underwent all conventional evaluation tests. It was exciting that no graft loss and donor complication occurred during the study. Although there was also a report in the literature that the outcome of liver transplantation with livers from donors older than 60 years was satisfactory,11 we insist that only under urgency status could donors older than 60 years be accepted for donation. Bleeding is a major risk factor in liver resection, and our ultimate goal in donor hepatectomy is a homologous bloodless transfusion operation. Problems with hemorrhage can necessitate blood transfusion, in which nonautologous blood transfusion could carry additional risks. Only one donor (3.85%) in our series required nonautologous blood transfusion; 21 (80.77%) underwent autologous blood transfusion which was called salvaged autotransfusion intraoperatively. Pomfret et al12 reported portal vein thrombosis in 1 of 561 donors (0.18%). In our donors, the one with portal vein thrombosis was diagnosed on the 3rd postoperative day
JIANG, YAN, LI ET AL
with routine daily Doppler ultrasound examination, and then treated successfully by relaparotomy and intraoperative tissue plasminogen activator infusion with excellent results. Routine Doppler ultrasonographic evaluation is an effective choice for diagnosing vascular complications postoperatively, and immediate management is required for portal vein thrombosis. All donors in our center are fully recovered and have returned to their previous occupations. No liver impairment or other long-term complication such as psychological impairment occurred during follow-up. Our results are comparable to other reports suggesting that A-A LDLT using right lobe liver grafts is feasible with no mortality and low morbidity in donors. In conclusion, despite technical difficulties, our current series showed promising results of an A-A LDLT program. A-A LDLT with right lobe liver grafts has become a standard option in adult patients with end-stage liver diseases, and the donation of right lobe liver graft for A-A LDLT is a relatively safe procedure provided that the patency of the remnant hepatic vasculature and bile duct is ensured, the volume of the remnant liver exceeds 30% of the total liver volume, and there is no injury to the remnant liver. With refinements in evaluation processes of donors, intensive preoperative planning, and meticulous surgical techniques, we expect improved results. REFERENCES 1. Chen CL, Fan ST, Lee SG, et al: Living-donor liver transplantation: 12 years of experience in Asia. Transplantation 75(3 suppl):S6, 2003 2. Lo CM: Complications and long-term outcome of living liver donors: a survey of 1,508 cases in five Asian centers. Transplantation 75(3 suppl):S12, 2003 3. Marsman WA, Wiesner RH, Rodriguez L, et al: Use of fatty donor liver is associated with diminished early patient and graft survival. Transplantation 62:1246, 1996 4. Hayashi M, Fujii K, Kiuchi T, et al: Effects of fatty infiltration of the graft on the outcome of living-related liver transplantation. Transplant Proc 31:403, 1999 5. Strong RW, Lynch SV, Ong TH, et al: Successful liver transplantation from a living donor to her son. N Engl J Med 322:1505, 1990 6. Brown RS Jr, Russo MW, Lai M, et al: A survey of liver transplantation from living adult donors in the United States. N Engl J Med 348:818, 2003 7. Humar A: Donor and recipient outcomes after adult living donor liver transplantation. Liver Transpl 9(10 suppl 2):S42, 2003 8. Pomfret EA: Early and late complications in the right-lobe adult living donor. Liver Transpl 9(10 suppl 2):S45, 2003 9. Esmat G, Yosry A, El-Serafi M, et al: Donor outcomes in right lobe adult living donor liver transplantation: single-center experience in Egypt. Transplant Proc 37:3147, 2005 10. Surman OS: The ethics of partial-liver donation. N Engl J Med 346:1038, 2002 11. Neipp M, Bektas H, Lueck R, et al: Liver transplantation using organs from donors older than 60 years. Transpl Int 17:416, 2004 12. Pomfret EA, Pomposelli JJ, Lewis WD, et al: Live donor adult liver transplantation using right lobe grafts: donor evaluation and surgical outcome. Arch Surg 136:425, 2001
L
IVER transplantation is an effective therapeutic option for patients with end-stage liver diseases. However, longer waiting times and increasing numbers of deaths in patients awaiting an organ have become serious problems. Living donor liver transplantation (LDLT) offers a partial solution to the severe shortage of liver grafts worldwide.1 The most serious concern in LDLT, especially in adult-to-adult living donor liver transplantation (A-A LDLT) using right lobe liver grafts, is the risk to the healthy donor who will undergo a major operation without any potential health benefit. It is of paramount importance that the donors be as little “harmed” as possible by the donation.2 The aim of this study was to assess the safety of donors after right lobe liver donation for A-A LDLT performed from January 2002 to March 2006 in our center. 0041-1345/07/$–see front matter doi:10.1016/j.transproceed.2006.10.013 150
MATERIALS AND METHODS Patients Between January 2002 and March 2006, 26 recipients (23 males and 3 females) aged 20 to 53 years (median age 37 years) underwent A-A LDLT using right lobe liver grafts. Their underlying diseases included hepatitis B virus (HBV)-related cirrhosis in 17 cases (4 with acute liver function failure), primary hepatocellular carcinoma in 8 cases, and Budd-Chiari syndrome complicated with liver function failure in 1 case. From the Center of Liver Transplantation, West China Hospital, Sichuan University, Chengdu, People’s Republic of China. Address reprint requests to Dr Yan Lu-Nan, Center of Liver Transplantation, Department of Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, People’s Republic of China. E-mail: [email protected] © 2007 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 39, 150 –152 (2007)
DONOR SAFETY IN LIVER TRANSPLANT
Donors Of the 26 donors who underwent right hepatic lobectomy for living donation, 7 were male and 19 were female (aged 19 to 65 years, median age 38 years). Two were fathers, 4 were brothers, 5 were mothers, 3 were sisters, 5 were wives, 2 were daughters, and 5 donors were friends. All the living donors who volunteered for the procedure underwent a full evaluation, including blood group verification, calculation of body mass index (BMI), and laboratory testing, such as liver and renal biochemistry, complete blood count, coagulation profile, and virologic assays for hepatotropic viruses, serologic screening for human immunodeficiency virus, cytomegalovirus, and Epstein-Barr virus. Electrocardiography and pulmonary function testing were also performed routinely. Size calculations of the right and left liver lobes were carefully assessed using three-dimensional computerized tomographic imaging. Hepatic Doppler ultrasonography and CT measurements were used to determine the anatomical vascular variations. Ultrasound-guided percutaneous liver biopsy was routinely performed to exclude fatty infiltration of more than 30%.3,4 Before surgery we decided the ideal hemi-liver to harvest, with the first objective to be safety for the donor. The ethics committee for our transplantation program assessed the donors for possible coercion and discussed the risks and benefits of the procedures.
Methods During the donor’s operation, cholecystectomy and then intraoperative cholangiography were routinely performed to confirm the biliary anatomy. Intraoperative ultrasound was performed routinely to define the hepatic venous drainage of the right liver lobe. In all 26 donors, the middle hepatic vein was preserved to avoid outflow obstruction to the remaining donor segment 4. All the inferior right hepatic veins of over 5 mm diameter were preserved for subsequent anastomosis to the recipient inferior vena cava. Liver resection was performed with an ultrasonic dissector, argon beam, and conventional coagulation. Living donor hepatectomy was performed without interrupting the vascular blood flow. The mean operative time was 455 ⫾ 52.6 minutes (range, 380 – 620 minutes). On the back table, liver grafts were perfused with histidinetrytophan-ketoglutarate (HTK) or University of Wisconsin (UW) solution at 4°C. During the recipient’s operation, some modifications were designed to improve the reconstruction of right hepatic vein, inferior right hepatic vein, and the reconstruction of the tributaries of middle hepatic vein using interposition vein grafts. All cases underwent direct anastomosis of right hepatic vein and inferior vena cava (IVC), of whom 9 cases were added with the reconstruction of right inferior hepatic vein, and 11 cases added reconstruction of the tributaries of the middle hepatic vein by interpositing a vein graft so as to provide sufficient venous outflow. The arterial perfusion of the graft was assured by an end-to-end anastomosis between the graft right hepatic artery and the recipient main hepatic artery. Bile duct reconstruction was performed by suture of the bile ducts to a Roux-en-Y loop or a duct-to-duct anastomosis, without bile duct drainage. Of the 26 recipients, none developed small-for-size syndrome or refractory ascites. All donors were routinely managed in the liver transplantation intensive care unit (LT-ICU) for 48 hours postoperatively. After discharge from the hospital, the follow-up for each donor included weekly visits in the first month, biweekly visits in the second month, monthly visits in the subsequent 4 months, and then yearly re-
151 checks. Laboratory examinations for donors during follow-up included liver and renal biochemistry and complete blood count. Hepatic Doppler ultrasonography and CT scanning were performed routinely to estimate the hepatic vascular status and the profiles of liver grafts.
RESULTS
In our series, the donor residual liver volumes (left liver lobes), as measured by CT analysis, ranged from 30.5% to 60.3% (mean, 42.8% ⫾ 5.1%). Graft weight ranged from 455 g to 860 g (mean, 635 ⫾ 36 g). The mean blood loss was 427 mL (range, 200 –735 mL). Only one donor (3.85%) required nonautologous blood transfusion, with 21 (80.77%) undergoing autologous blood transfusion, which was called “salvaged autotransfusion.” In the perioperative period the mean albumin administered was 85 g. The donor liver functions were found impaired to some extent, including transient liver enzyme elevation, hyperbilirubinemia, and hypoalbuminemia in the immediate postoperative period, but all the indices rapidly returned to normal at the end of the first week. Prothrombin time was prolonged in the early postoperative period, but in all cases this index normalized within 2 weeks. The liver profiles normalized after a mean of 14 days. Of our 26 donors, the overall complication rate was 19.23% (5 donors). Two cases (7.69%) experienced major complications including intra-abdominal bleeding in one case, and portal vein thrombosis in another; there were 3 (11.54%) minor ones (wound steatosis in 2, and transient chyle leak in 1). The donor with postoperative hemorrhage underwent reoperation, and the one with portal vein thrombosis, which was diagnosed on the 3rd postoperative day with routine daily Doppler ultrasound examination, was treated successfully by relaparotomy and intraoperative tissue plasminogen activator infusion, which then provided good blood flow. The donors with wound steatosis were recovered by local drainage and dressings exchange. The transient chyle leak in one donor ceased spontaneously after 12 days. The mean hospital stay was 16.2 ⫾ 6.8 days (range, 12– 40 days), and the mean follow-up time for these donors was 9 months. We did not experience any donor mortality. All donors were fully recovered and returned to their previous occupations within 6 to 8 weeks after operation. No liver impairment or other long-term complication such as psychological impairment occurred during follow-up. DISCUSSION
The growing gap between the number of patients awaiting liver transplantation and available organs has continued to be the number-one issue facing the transplant community. To overcome the waiting list mortality, living donor liver transplantation (LDLT) has become an option worldwide. After the first successful LDLT reported in 1990,5 this surgical innovation has evolved to established efficacy in the literature. Use of LDLT could provide life-saving therapy to many patients who otherwise would die awaiting an
152
organ. Right lobe donation has been the main type of partial liver graft for A-A LDLT. Regardless of the potential benefits that LDLT offers critically ill patients with end-stage liver diseases, donor safety is the most important clinical issue related to LDLT, especially when using right lobe grafts; however, A-A LDLT has raised special concerns about the safety of living liver donors, because A-A LDLT carries higher donor risks owing to the extensive liver resection. The reported incidence of complications in donors for A-A LDLT varies, but is likely in the range of 10% to 20%.6 It was reported that biliary tract complications were the most common, occurring in 3% to 8% of donors.7 Other significant complications included portal vein thrombosis, pulmonary embolus, bowel obstruction, and incisional hernia.8 Furthermore, it is estimated that at least 12 donors have died during the procedure in different parts of the world.9 Three additional donors have undergone liver transplantation because of complications related to right lobe donation.2,10 The first pediatric LDLT and A-A LDLT in our center was performed in July 2001 and January 2002, respectively. Currently, our center performs A-A LDLT using right lobe liver grafts. Of our 26 donors, 2 cases (7.69%) experienced major complications, and 3 (11.54%) minor ones. At present, donors older than 60 years are usually rejected in most centers worldwide because liver transplants from older donors may result in lower patient and graft survivals than those from younger donors. However, we encountered one patient aged 36 under high urgency status with hepatitis B virus (HBV)–related cirrhosis complicated with acute liver function failure who had to undergo emergency liver transplantation, which could provide lifesaving therapy to the patient who otherwise would die awaiting an organ. Unfortunately, with such a high urgency status, there was no other feasible donor except his mother, aged 65, who showed a strong will to donate. The donor underwent all conventional evaluation tests. It was exciting that no graft loss and donor complication occurred during the study. Although there was also a report in the literature that the outcome of liver transplantation with livers from donors older than 60 years was satisfactory,11 we insist that only under urgency status could donors older than 60 years be accepted for donation. Bleeding is a major risk factor in liver resection, and our ultimate goal in donor hepatectomy is a homologous bloodless transfusion operation. Problems with hemorrhage can necessitate blood transfusion, in which nonautologous blood transfusion could carry additional risks. Only one donor (3.85%) in our series required nonautologous blood transfusion; 21 (80.77%) underwent autologous blood transfusion which was called salvaged autotransfusion intraoperatively. Pomfret et al12 reported portal vein thrombosis in 1 of 561 donors (0.18%). In our donors, the one with portal vein thrombosis was diagnosed on the 3rd postoperative day
JIANG, YAN, LI ET AL
with routine daily Doppler ultrasound examination, and then treated successfully by relaparotomy and intraoperative tissue plasminogen activator infusion with excellent results. Routine Doppler ultrasonographic evaluation is an effective choice for diagnosing vascular complications postoperatively, and immediate management is required for portal vein thrombosis. All donors in our center are fully recovered and have returned to their previous occupations. No liver impairment or other long-term complication such as psychological impairment occurred during follow-up. Our results are comparable to other reports suggesting that A-A LDLT using right lobe liver grafts is feasible with no mortality and low morbidity in donors. In conclusion, despite technical difficulties, our current series showed promising results of an A-A LDLT program. A-A LDLT with right lobe liver grafts has become a standard option in adult patients with end-stage liver diseases, and the donation of right lobe liver graft for A-A LDLT is a relatively safe procedure provided that the patency of the remnant hepatic vasculature and bile duct is ensured, the volume of the remnant liver exceeds 30% of the total liver volume, and there is no injury to the remnant liver. With refinements in evaluation processes of donors, intensive preoperative planning, and meticulous surgical techniques, we expect improved results. REFERENCES 1. Chen CL, Fan ST, Lee SG, et al: Living-donor liver transplantation: 12 years of experience in Asia. Transplantation 75(3 suppl):S6, 2003 2. Lo CM: Complications and long-term outcome of living liver donors: a survey of 1,508 cases in five Asian centers. Transplantation 75(3 suppl):S12, 2003 3. Marsman WA, Wiesner RH, Rodriguez L, et al: Use of fatty donor liver is associated with diminished early patient and graft survival. Transplantation 62:1246, 1996 4. Hayashi M, Fujii K, Kiuchi T, et al: Effects of fatty infiltration of the graft on the outcome of living-related liver transplantation. Transplant Proc 31:403, 1999 5. Strong RW, Lynch SV, Ong TH, et al: Successful liver transplantation from a living donor to her son. N Engl J Med 322:1505, 1990 6. Brown RS Jr, Russo MW, Lai M, et al: A survey of liver transplantation from living adult donors in the United States. N Engl J Med 348:818, 2003 7. Humar A: Donor and recipient outcomes after adult living donor liver transplantation. Liver Transpl 9(10 suppl 2):S42, 2003 8. Pomfret EA: Early and late complications in the right-lobe adult living donor. Liver Transpl 9(10 suppl 2):S45, 2003 9. Esmat G, Yosry A, El-Serafi M, et al: Donor outcomes in right lobe adult living donor liver transplantation: single-center experience in Egypt. Transplant Proc 37:3147, 2005 10. Surman OS: The ethics of partial-liver donation. N Engl J Med 346:1038, 2002 11. Neipp M, Bektas H, Lueck R, et al: Liver transplantation using organs from donors older than 60 years. Transpl Int 17:416, 2004 12. Pomfret EA, Pomposelli JJ, Lewis WD, et al: Live donor adult liver transplantation using right lobe grafts: donor evaluation and surgical outcome. Arch Surg 136:425, 2001