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toddting@espoir-nova.com
 -ESPOIR NOVA International Medical Service-

Organ Transplantation 器官移植手術

Living Donor Liver Transplantation

Living donor liver transplantation is a highly complex procedure requiring thorough preoperative evaluations for both the healthy donor and recipient, precise coordination during surgery, and intensive postoperative care. The procedure involves removing 60–70% of the donor's liver (right lobe) for adult recipients or 15–40% (left lobe) for pediatric recipients. Donors must be blood relatives or in-laws.

Indications

  • End-stage liver cirrhosis: Common causes in adults include chronic hepatitis, alcoholism, Wilson's disease, and autoimmune liver diseases. In children, biliary atresia is a common cause.

  • Metabolic liver diseases: In cases not controlled by special diets or medications.

  • Liver cancer: Hepatocellular carcinoma within UCSF criteria; chemotherapy-resistant, unresectable hepatoblastoma.

  • Other conditions requiring liver replacement for cure.

Surgical Features

Liver transplantation involves replacing the patient's diseased liver with a healthy whole or partial liver (partial in living donations). With proper immunosuppressive therapy, the transplanted liver can function normally. This is a life-saving procedure.

Surgical Process

Donor and recipient surgeries occur simultaneously in two operating rooms with separate surgical and anesthetic teams. Donor surgery includes laparoscopic dissection of liver ligaments, midline incision to expose hepatic hilum, and liver parenchymal transection. The donor liver is only removed after the recipient's diseased liver is excised, followed by cold perfusion and transfer to the recipient's OR.

  • Donor surgery: ~8 hours

  • Recipient surgery: ~12 hours

Potential Complications

Donors

  • Minor: Bile leak (1–2%), reoperation for bleeding (0.5%), right pleural effusion (1–2%), postoperative ileus (1–2%), dyspepsia (5–10%)

  • Major: Biliary stricture (0.5%), hepatic blood flow thrombosis/stenosis (0.5%)

  • Mortality: 0.1–0.3% (adult donation), 0.1% (pediatric donation)

Recipients

  • Minor: Bile leak (5%), reoperation for bleeding (5–10%), pleural effusion (10%), ileus (5–10%), biliary anastomotic stricture (20–30%)

  • Major: Hepatic inflow/outflow obstruction (3–5%), sepsis (3–5%), other severe complications (5%)

  • Mortality: 3% (non-acute liver failure), 10–20% (acute liver failure)

Living Donor Kidney Transplantation

Donor Eligibility Criteria

  • Aged 20 or older, in good physical and mental health

  • Must be a blood relative within five degrees or a legal spouse (married ≥2 years, with shared children, or married at least one year before diagnosis of end-stage renal disease)

  • Normal bilateral kidney function

  • No history of diabetes, hypertension, tuberculosis, malignancy, or notifiable infectious diseases (e.g., HIV)

  • Voluntary donation with altruistic intent

  • Blood type compatibility:

    • Type O donors can give to any blood type; type O recipients can only receive from type O

    • Type AB recipients can receive from any type

    • ABO-incompatible transplants are possible but involve higher rejection risks

Pre-transplant Treatment for ABO-Incompatible Cases

  • Antibody removal: Plasma exchange + IVIG

  • B-cell suppression: Rituximab (7–10 days pre-op)

  • T-cell suppression: Tacrolimus, Mycophenolate mofetil ± steroids, Basiliximab, Alemtuzumab, ATG

  • If antibody titers are <1:512, outcomes can be comparable to ABO-compatible transplants. Higher titers require closer monitoring.

Outpatient / Inpatient Evaluation Process (4–8 weeks)

Phase 1

  • Blood tests: Liver/kidney function, Hep B/C, syphilis, HIV, blood type, coagulation profile, tissue matching

  • Imaging: Chest X-ray, abdominal ultrasound, breast ultrasound/mammogram (female)

  • Others: ECG, urinalysis, urinary cytology

Phase 2

  • Blood tests: Viral antibodies, tumor markers, thyroid function, TB screening

  • Imaging: Kidney CT scan, ERPF renal function test

Phase 3

  • Psychological and social work evaluations

  • Lymphocyte crossmatch test

  • Ethics Committee Review: As per the Human Organ Transplantation Act, all donations must be approved by the hospital's ethics committee.

Surgery and Postoperative Care

Surgical Approach

Under general anesthesia with central venous and arterial lines and urinary catheter placement.

Two surgical methods:

  • Traditional open surgery: Incision on abdomen/flank to dissect renal vessels and ureter

  • Laparoscopic surgery: Minimally invasive with 3 small incisions and final retrieval through right lower abdomen. Faster recovery, less pain.

Donor Risks and Outcomes

  • With full evaluation, remaining kidney function is normal and life expectancy is unaffected

  • Surgery: ~4–6 hours, hospital stay 5–7 days

  • Mortality: <0.1%

  • Complication rate: 8–16% (infections 2.4%, pneumothorax 1.5%, major bleeding <1%, pulmonary embolism 1%, ureteral stenosis/incontinence 2–10%, mild proteinuria/hypertension in ~30% after 10 years)

Follow-up

  • Weekly outpatient visits after discharge, then biweekly or monthly

  • Monitoring kidney function and immunosuppressant levels

Kidney Transplant Recipients

Eligibility Criteria

  • Must have end-stage renal disease and be on dialysis (except living donor cases)

  • No severe comorbidities (e.g., cancer, infections) beyond original kidney disease

  • Willing and able to understand surgical risks and outcomes

  • Normal bladder and urinary tract function (must be treated if abnormal)

Evaluation Items

  • Blood tests: Liver/kidney function, hepatitis virus load, syphilis, HIV, tumor markers, coagulation, thyroid function, TB, immune profile, HLA typing

  • Imaging: Chest X-ray, abdominal/breast ultrasound

  • Other tests: ECG, urinalysis, cytology

  • Enhanced evaluation: Diabetics, elderly, women (breast/cervical screening), men (prostate/bladder), dental check-up

Surgery and Post-op Care

  • Lower abdominal incision; kidney placed in the pelvic cavity and connected to blood vessels and ureter

  • Native kidneys may be removed if necessary

  • Hospital stay: 10–14 days if no complications/rejections

  • Lifelong immunosuppressants needed; monitor side effects and disease recurrence

  • Blood transfusions may be required during surgery

  • Acute rejection: 10–20%, mostly controlled with drugs; may lead to graft failure

  • Delayed graft function: ~10% (living), ~30% (deceased); some may never function

  • Complications (5–10%): Infection, urine leak, vascular thrombosis, hernia, etc.

  • Original kidney disease may recur in the graft

Immunosuppressant Side Effects

  • Cyclosporine/Tacrolimus: Hypertension, nephrotoxicity, hair loss, hyperkalemia

  • Prednisolone: Moon face, buffalo hump, osteoporosis

  • Mycophenolate: Leukopenia, nausea, hepatotoxicity

  • Sirolimus/Everolimus: Leukopenia, edema, skin rash

  • Basiliximab: Rare side effects; occasional liver enzyme elevation

Post-op Monitoring

  • Weekly follow-ups initially; then biweekly/monthly

  • Regular blood tests, liver/kidney function checks, drug level monitoring

  • Abdominal ultrasound every 3–6 months