大西 康晴

BACKGROUND: Living donor hepatectomy carries a risk of bleeding, and allogeneic transfusion may cause adverse effects. Autologous blood preparation is therefore considered a safer strategy. While preoperative autologous donation (PAD) is widely used, acute normovolemic hemodilution (ANH) may overcome its limitations and offer a practical alternative. However, evidence supporting ANH in donor surgery remains limited. This study compared the clinical utility of ANH and PAD in living donor hepatectomy. METHODS: We retrospectively analyzed 60 consecutive cases of living donor right hepatectomy performed between 2017 and 2025. Among them, 58 donors who received either PAD or ANH were compared using 1:2 propensity score matching. Perioperative laboratory values, surgical outcomes, any allogeneic transfusion, and postoperative complications were evaluated. RESULTS: No unexpected intraoperative adverse events or allogeneic transfusions occurred. All ANH donors received autologous reinfusion, compared with only 6.5% of PAD donors. After matching, 27 donors (18 PAD, 9 ANH) were analyzed. Whole blood viscosity was higher in the ANH group. Weight-adjusted intraoperative bleeding was lower (2.6 vs. 4.6 mL/kg, p = .024; q = 0.106) and operative time was shorter (321 vs. 390 min, p = .007; q = 0.077) in the ANH group. Postoperative complication rates were comparable. Area under the curve analysis indicated better preservation of total protein (p = .038) and prothrombin time-international normalized ratio (p = .010) across the perioperative period in the ANH group. CONCLUSIONS: ANH maintained transfusion avoidance and donor safety comparable to PAD while improving operative efficiency, supporting ANH as a safe, effective alternative in living donor right hepatectomy.

Liver transplantation (LT) from donors with von Willebrand factor (VWF) abnormalities is rarely reported, largely due to concerns over donor safety and potential hemostatic complications in the recipient. Low VWF activity is more prevalent than von Willebrand disease and may present without bleeding symptoms, yet its implications in the context of living donor LT (LDLT) remain poorly characterized. We report a case of successful LDLT from a donor with borderline low VWF activity, highlighting detailed perioperative and long-term coagulation profiles in both donor and recipient. The donor, a healthy young woman with no personal or family history of bleeding, was found to have mildly decreased ristocetin cofactor activity. A test infusion of VWF/FVIII concentrate elicited a favorable biological response. Based on these findings and in accordance with clinical guidelines, open right hepatectomy was performed under perioperative VWF replacement. The donor experienced no bleeding or thrombotic complications and remained clinically stable during 18 months of follow-up. VWF-related parameters remained elevated postoperatively and ultimately returned to baseline or higher, indicating preserved long-term hemostasis. The recipient, who received the graft from the low-VWF donor, showed stable VWF-related coagulation parameters post-transplantation. Despite a transient decline following reperfusion, levels normalized within the expected timeframe and remained within normal range throughout follow-up. This case supports the safety of LDLT from donors with low VWF levels when appropriate perioperative management is applied. It also highlights that low donor VWF activity may not compromise recipient hemostasis, offering important implications for donor eligibility assessment in clinical practice.