The upper age limit for donation in living donor liver transplantation (LDLT) is not well defined from the perspectives of recipient and donor outcomes [1]. However, because there is a perceived higher risk of morbidity for the living liver donor (LLD) and a lower quality graft for the recipient, using elderly donors to enhance the pool of LLDs raises ethical concerns about donor safety [2,3].

The reason behind surgical failure related to donors during donor hepatectomy is hemodynamic instability [4]. Due to the numerous variables that can result in hemodynamic instability during donor hepatectomy, patients with heart illness are not regarded as LLDs.

Choosing a suitable elderly LLD can be the last alternative for failing patients who have no other option in the current era of living donor surgery conducted in Eastern Asia. In this case study, a 74-year-old female with many heart conditions underwent a laparoscopic right hepatectomy to donate her organs to her a 40-year-old son.

A 74-year-old female came to the authors’ facility to assess a living liver donation. She said that her a 40-year-old son, who suffered from alcoholic liver cirrhosis, would be happy to receive a living donor. Due to her advanced age and concomitant conditions, the doctor disqualified the elderly female from being a LLD during the first appointment. She was taking multiple drugs for hypertension, atrial fibrillation, diabetes, and congestive heart failure, such as rivaroxaban, nebivolol, furosemide, spironolactone, empagliflozin, ezetimibe, and atorvastatin. Two years earlier, she had undergone a laparoscopic cholecystectomy because of a gallbladder stone. She showed no signs of discomfort or anguish and looked healthy for her age. But since she was the only option available for her young son, she went multiple times and asked to be considered for a living liver donation. We declined the examination three times due to concerns about donor safety following hepatectomy.

We agreed to move forward with donor screening since she was willing to give her liver as a sign of maternal love for her baby. Healthcare personnel conducted comprehensive physical and behavioral tests after verifying her informed decision to become a living donor. Blood tests, an X-ray of the chest, an electrocardiography, an echocardiogram, and pulmonary function testing were all part of this procedure. A Pap smear and a mammography were used in a gynecologic assessment. There were no abnormal test results. Colonoscopy and esophagogastroduodenoscopy did not reveal any particular lesions.

Doppler ultrasonography revealed no discernible fatty liver, excellent vascular flow, and normal echogenicity and texture. The preoperative triphasic computed tomography (CT) scan revealed the typical vascular structure, and the estimated graft-to-recipient weight ratio was 0.95%. Based on CT volumetry, the remnant left liver was assessed to be 37.8% of the total liver. The recipient’s graft weight to standard liver capacity was 46.6%. A minor dilation of the common bile duct was found during magnetic resonance imaging cholangiography, although the biliary architecture was normal. Atrial fibrillation with left atrium enlargement, modest atrial regurgitation, and a left ventricular ejection fraction of 62.6% were found using advanced two dimensional cardiac echocardiography. To assess preoperative risk and oversee postoperative care, we conferred with a cardiologist. The cardiologist answered that she could have a donor hepatectomy even if there was a modest risk. Therefore, 2 days prior to the donor hepatectomy, the cardiologist advised me not to take rivaroxaban.

The recipient also had gout and alcoholic liver cirrhosis. Seven years prior, he had a mitral valve replacement because of infective endocarditis. The scores for the model for end-stage liver disease (MELD) and the preoperative Child-Pugh were 12 and 30, respectively. Pulmonary function tests and echocardiography were also part of the recipient work-up. Nothing out of the ordinary was discovered. Neurological, renal, pulmonary, and psychiatric consultations were used to assess the recipient.

The body mass indexes of the donor and recipient were 27.0 and 19.0 kg/m², respectively. The Korean Network for Organ Sharing (KONOS) in The National Institute of Organ, Tissue and Blood Management authorized the LDLT. During the laparoscopic right hepatectomy, the donor was put under general anesthesia and positioned in a supine position. Blood pressure, heart rate, inspired and expired gases, pulse oximetry, temperature, and urine output were all continuously monitored during donor hepatectomy. However, central vein cannulation was not performed. A resected liver tissue after trocar insertion revealed no fatty changes. An energy device was used to perform the liver parenchymal transection procedure. Under 196 minutes of general anesthesia, the procedure took 158 minutes, and no blood or blood products were transfused. Following the delivery of the right liver graft, a cryopreserved iliac vein from a deceased donor was used to reconstruct one tributary (V5) of the main hepatic vein during bench preparation (Fig. 1).

Figure 1. Liver images. (A) Explant liver, (B) liver graft in a bench procedure, and (C) implanted liver graft in the recipient.

There were 580 g of graft weight. The weight ratio of the graft to the recipient was actually 1.02%. Following a total hepatectomy, a duct-to-duct biliary reconstruction was used to transplant the recipient’s right liver graft. The graft’s warm and cold ischemia periods were 20 and 75 minutes, respectively. Under general anesthesia for 344 minutes, the operation took 286 minutes. 500 mL of blood were lost during the transplant procedure. The patient received two units of red blood cells and 419 mL of saved blood during the procedure. Before they could exit the operating room, the donor and recipient were both extubated. After spending an hour in the recovery room, the donor was moved from the operation room to the ward. Following LDLT, the patient stayed in the intensive care unit for 3 days. The immunosuppressive medications utilized were tacrolimus and mycophenolate mofetil; the steroids were taken off 3 months following LDLT.

The day before the procedure, patients began thromboembolism prophylaxis, which included early mobilization and compressive stockings, and it lasted until they were discharged. One week following donor hepatectomy, low-molecular-weight heparin was administered. Three days following surgery, intravenous patient-controlled analgesia was administered. The following day after the procedure, the Levin tube was taken out and the patient began taking water sips. In the case of the donor and receiver, diet and walking were initiated 1 and 3 days following the procedure, respectively. The donor was supposed to be released from the hospital 5 to 6 days following the donor hepatectomy, but she was released 10 days later because she wanted to see a cardiologist and nephrologist. After a smooth recovery, the patient was released on day 14. There were no issues, and the liver functions of the donor and receiver were both normal (Fig. 2).

Figure 2. Laboratory changes in living liver donor after donor hepatectomy. (A) Platelet, (B) AST, (C) ALT, and (D) total bilirubin. LDLT, living donor liver transplantation; POD, post operative day; AST, aspartate transaminase; ALT, alanine transaminase.

Subsequent CT scans revealed adequate liver regeneration in both the recipient and donor. After the donor hepatectomy, the donor’s residual liver volume rose to 85.3% after 3 months. Three months following LDLT, both the donor and the receiver are doing well and have no problems to report. Their liver functions normally.

This is the first case of a septuagenarian with various heart problems receiving a laparoscopic right hepatectomy for living liver donation. Living donor right hepatectomy results have improved due to advances in surgical technique and treatment [5-7]. According to reports, if donors and recipients are properly chosen, there can be great short- and mid-term survival rates after LDLT involving living donors under the age of 70 [3].

Liver transplants are necessary for patients suffering from hepatocellular carcinoma or end-stage liver disease, however, deceased donors are hard to come by in Korea [8]. Consequently, without a high MELD score, receiving a deceased donor liver transplantation is not conceivable. The patient will pass away while waiting an endless amount of time for a deceased donor if there isn’t a suitable donor in the family.

Regardless of their health, a lot of parents are eager to give a portion of their liver if their child requires an LDLT. In our case, a 74-year-old candidate for a living liver donation was involved. Such a donor would typically not be eligible for our program or be able to pass the comprehensive medical and psychological evaluations conducted by medical specialists. Therefore, it was difficult to refuse the old candidate the chance to donate her partial liver based only on age, unless there were significant medical or surgical concerns. She did, however, suffer from diabetes, congestive heart failure, hypertension, and atrial fibrillation. Thankfully, her cardiac conditions were effectively managed with medicine. She persisted in requesting the test even after we first declined to do so since we anticipated a substantial postoperative risk. She persisted in requesting the treatment, even though we had initially declined to test her because we anticipated a high postoperative risk. We believed that by adopting an improved surgical technique and advanced care, as well as appropriate selection criteria based on functional state and biologic age (rather than chronological age), the inherent increased perioperative risk of elderly adults might be decreased for this donor.

The screening and selection criteria for donors have been previously documented [3,7]. One of the keys to enhancing the results of donor hepatectomy is a safe and quick laparoscopic procedure. Since 2013, more than 600 laparoscopic donor hepatectomy procedures have been carried out under our program, with 4.4% and 1.9% of Grade IIIa and Grade IIIb outcomes, respectively [7]. Laparoscopic donor hepatotectomies took an average of 209 minutes to complete; the quickest duration was 177 minutes in 2021 [6]. The current laparoscopic right hepatectomy was completed in a timely manner, safely, and without any difficulties on the LLD. As a result, we were able to stop the central venous catheterization and prevent complications from the procedure, like pneumothorax.

This instance shows that in the current era of LDLT, septuagenarians with carefully chosen, well-controlled heart conditions should be given consideration for living liver donation. This specific donor, who was beyond 70 years old, was, however, closely observed and subjected to testing. Therefore, this finding should not be understood to suggest that every potential donor over 70 years old who wants to donate a living liver will have the same low-risk profile.

This research was supported by the Basic Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science and ICT (NRF-2023R1A2C2005946). The Korean NRF had no influence on study design, data analysis, data interpretation, or drafting of the manuscript.

Jongman Kim is a chief editor of the journal but was not involved in the review process of this manuscript. Any other authors have no conflict of interest.

Conceptualization: JB, JK. Data curation: All. Formal analysis: JK. Funding acquisition: JK. Investigation: JK. Methodology: JB, JK. Project administration: JK. Resources: JB, JK. Software: JK. Supervision: JK. Validation: JK. Visualization: JB, JK. Writing – original draft: JB. Writing – review & editing: JK.