*Purpose: Liver transplants have not been performed in directed donor chains as have evolved for kidney transplants. We report an initial experience using domino and split-liver techniques to achieve liver transplants for 31 patients from 16 deceased donor organs with universal patient and graft survival.

*Methods: A transplant program providing adult, and pediatric liver transplant components, metabolic liver transplants and split liver transplants is required. Patients with metabolic liver diseases including maple syrup urine disease (MSUD) or amyloidosis are considered, educated about and consented for live donation of their liver at the time of transplantation for clinical indication. Size matching, blood type matching and anatomical review by a surgeon experienced in all facets of liver transplantation is conducted. Patients who are candidates for partial liver transplant are selected and matched in this way, such that chains can be conducted. Sixteen patients with MSUD were considered in this experience. Thirty one transplants were performed.

*Results: The Table describes the patients and outcomes of 31 liver transplants yielded from 16 deceased donor organs, and the missed potential for additional transplants. To summarize the findings of this initial experience, we utilized 63% (10 of 16) of the livers from MSUD patients. Another six livers (37%) from domino candidates were unused due to lack of appropriate candidates for those livers at our center at that time, and in one case due to unfavorable anatomy. We split 7 of 16 deceased donor livers to further increase the number of transplants yielding a 94% increase in transplants performed (31 transplants from 16 deceased donor organs). In one case a split/domino transplant was performed in which we received one side of the liver, and performed domino with our patients’ liver, while the other side of the deceased donor liver was transplanted at another center (inter-center sharing). Seven of the 16 deceased donor livers were deemed acceptable to be split. Two were split with both sides used while additionally performing domino liver transplantation with the full metabolic liver. Three additional MSUD patients received left lobe deceased donor grafts while the right lobe of the liver was discarded as no patient had been matched to these lobes (logistics), a missed opportunity for 3 cases. Of the total possible transplants that could be yielded from our experience combining split and domino transplants, we missed 9 opportunities. With perfect execution it could have yielded a total of 40 transplants from the 16 cadaveric organs donated. This would represent a 250% increase in transplants from this selected donor pool.

Table Series of 31 liver transplants achieved from 16 deceased donors using split and domino techniques

*Three additional segments from split grafts were not utilized due to lack of suitable candidates pre-selected for these grafts.

*Conclusions: Transplant swaps are utilized in kidney transplantation to provide organs that are blood type incompatible between donor and recipient matches as previously published. This technique has not been utilized in liver transplantation before, but may be added to our paradigm as shown below. Scenario a. In this case, a blood type incompatible parent wants to donate to their child, but it would increase the risk of rejection to cross the ABO blood group barrier. Rather, this child is offered the domino transplant from an MSUD patient in exchange for bringing the live donor entering the swap as is done in kidney transplantation. Scenario b. An altruistic donor is chosen to provide a partial liver graft for a patient with MSUD. The recipient’s liver then undergoes domino transplantation into another individual. In this case, both transplants are accomplished without any cadaveric donor. The metabolic disease candidate has a non-compatible donor, who gives to another candidate in order to receive the altruistic donor in the swap. Three patients receive transplants. No deceased donor organs are required. Scenario c. One adult cadaveric liver is split. The larger right lobe is transplanted into an adult MSUD patient. That patient’s liver is used for domino liver transplant. It is split and the larger right lobe is transplanted into another adult with cirrhosis. The smaller left lobe of both the initial cadaveric split graft and the adult MSUD recipient are both transplanted into children with cirrhosis. Five successful transplants are performed from a single cadaveric donor. Multiple additional scenarios can be envisioned combining these strategies to provide additional transplants (figure 2).In summary, this pilot demonstrates the feasibility of a program of directed domino and split liver donations to achieve a limited application of swaps. Potential for expansion among centers across the nation might contribute to growth similar to what has occurred in kidney transplantation.

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