101
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Jackson KR, Long J, Philosophe B, Garonzik‐Wang J. Liver Transplantation Using Steatotic Grafts. Clin Liver Dis (Hoboken) 2019; 14:191-195. [PMID: 31879563 PMCID: PMC6924967 DOI: 10.1002/cld.847] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 05/16/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Kyle R. Jackson
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMD
| | - Jane Long
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMD
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102
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Schleicher C, Kreipe HH, Schemmer P, Strassburg CP, Fischer-Fröhlich CL, Rahmel A, Flechtenmacher C. [Donor liver histology : Joint recommendations of the DGP, DTG and DSO]. Chirurg 2019; 90:899-904. [PMID: 31214724 DOI: 10.1007/s00104-019-0990-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The indications, implementation and reporting of liver biopsies for deceased organ donation are not mandatory or regulated. Reliable data on outcome quality and prognostic relevance are therefore not available. Defined standards are thus required to enable meaningful studies and to ensure high data quality of a national transplantation registry. OBJECTIVE Presentation of a synopsis of available studies and literature-based recommendations. RESULTS AND CONCLUSION Against the background of an organ shortage and a growing number of older donors, pretransplantation liver histology is of significant relevance to guide clinical decision making. With the joint recommendations of the German Transplantation Society (DTG), the German Society of Pathology (DGP) and the German Organ Transplantation Foundation (DSO) standardized procedures are defined for the first time.
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Affiliation(s)
- C Schleicher
- Region Baden-Württemberg, Deutsche Stiftung Organtransplantation, Kriegerstraße 6, 70191, Stuttgart, Deutschland.
| | - H-H Kreipe
- Institut für Pathologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - P Schemmer
- Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Universität Graz, Graz, Österreich
| | - C P Strassburg
- Medizinische Klinik1, Universitätsklinikum Bonn, Bonn, Deutschland
| | - C-L Fischer-Fröhlich
- Region Baden-Württemberg, Deutsche Stiftung Organtransplantation, Kriegerstraße 6, 70191, Stuttgart, Deutschland
| | - A Rahmel
- Hauptverwaltung, Deutsche Stiftung Organtransplantation, Frankfurt, Deutschland
| | - C Flechtenmacher
- Pathologisches Institut, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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103
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Moosburner S, Ritschl PV, Wiering L, Gassner JMGV, Öllinger R, Pratschke J, Sauer IM, Raschzok N. [High donor age for liver transplantation : Tackling organ scarcity in Germany]. Chirurg 2019; 90:744-751. [PMID: 30707248 DOI: 10.1007/s00104-019-0801-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Liver transplantation is the only curative treatment option for patients with end-stage liver disease; however, the 40% decline of available organ donors in recent years in Germany necessitates the optimization of available resources and possibly extending the criteria to older donors. MATERIAL AND METHODS All 2652 livers made available to the Charité Universitätsmedizin Berlin from 2010 to 2016 were retrospectively analyzed and the clinical outcome of 526 liver transplantations during this time frame were evaluated. RESULTS The median age of donors of transplanted organs increased from 49.3 years in 2010 to 57.3 years in 2016 (p = 0.02). Organs from donors ≥65 years were more frequently discarded than organs from younger donors (n = 344, 18.4% vs. n = 220, 28.1%; p = 0.005). Moreover, the older donors had higher rates of diabetes mellitus and hepatic steatosis. Organs from older donors had a higher donor risk index (2.8 vs. 2.2; p < 0.001) and were transplanted more often in patients with preserved liver function and hepatocellular carcinoma and liver cirrhosis (n = 121, 74.7% of indications). The 3‑year survival after liver transplantation from donors ≥65 and ≥80 years old was not significantly reduced in comparison to younger donors; however, there was an increased retransplantation rate (28.6%; p = 0.005) after transplantation of organs from donors ≥80 years old. CONCLUSION Despite conservative organ acceptance there were higher rates of retransplantation after transplantation from very old donors. In the light of an increasing scarcity of suitable organs this mandates caution and highlights the need for adequate assessment instruments for marginal donor organs before transplantation.
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Affiliation(s)
- S Moosburner
- Chirurgische Klinik, Campus Charité Mitte und Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - P V Ritschl
- Chirurgische Klinik, Campus Charité Mitte und Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland.,BIH Charité Clinician Scientist Program, Berlin Institute of Health (BIH), Berlin, Deutschland
| | - L Wiering
- Chirurgische Klinik, Campus Charité Mitte und Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - J M G V Gassner
- Chirurgische Klinik, Campus Charité Mitte und Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - R Öllinger
- Chirurgische Klinik, Campus Charité Mitte und Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - J Pratschke
- Chirurgische Klinik, Campus Charité Mitte und Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - I M Sauer
- Chirurgische Klinik, Campus Charité Mitte und Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - N Raschzok
- Chirurgische Klinik, Campus Charité Mitte und Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland. .,BIH Charité Clinician Scientist Program, Berlin Institute of Health (BIH), Berlin, Deutschland.
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104
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Ceresa CDL, Nasralla D, Watson CJE, Butler AJ, Coussios CC, Crick K, Hodson L, Imber C, Jassem W, Knight SR, Mergental H, Ploeg RJ, Pollok JM, Quaglia A, Shapiro AMJ, Weissenbacher A, Friend PJ. Transient Cold Storage Prior to Normothermic Liver Perfusion May Facilitate Adoption of a Novel Technology. Liver Transpl 2019; 25:1503-1513. [PMID: 31206217 DOI: 10.1002/lt.25584] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 05/16/2019] [Indexed: 12/12/2022]
Abstract
Clinical adoption of normothermic machine perfusion (NMP) may be facilitated by simplifying logistics and reducing costs. This can be achieved by cold storage of livers for transportation to recipient centers before commencing NMP. The purpose of this study was to assess the safety and feasibility of post-static cold storage normothermic machine perfusion (pSCS-NMP) in liver transplantation. In this multicenter prospective study, 31 livers were transplanted. The primary endpoint was 30-day graft survival. Secondary endpoints included the following: peak posttransplant aspartate aminotransferase (AST), early allograft dysfunction (EAD), postreperfusion syndrome (PRS), adverse events, critical care and hospital stay, biliary complications, and 12-month graft survival. The 30-day graft survival rate was 94%. Livers were preserved for a total of 14 hours 10 minutes ± 4 hours 46 minutes, which included 6 hours 1 minute ± 1 hour 19 minutes of static cold storage before 8 hours 24 minutes ± 4 hours 4 minutes of NMP. Median peak serum AST in the first 7 days postoperatively was 457 U/L (92-8669 U/L), and 4 (13%) patients developed EAD. PRS was observed in 3 (10%) livers. The median duration of initial critical care stay was 3 days (1-20 days), and median hospital stay was 13 days (7-31 days). There were 7 (23%) patients who developed complications of grade 3b severity or above, and 2 (6%) patients developed biliary complications: 1 bile leak and 1 anastomotic stricture with no cases of ischemic cholangiopathy. The 12-month overall graft survival rate (including death with a functioning graft) was 84%. In conclusion, this study demonstrates that pSCS-NMP was feasible and safe, which may facilitate clinical adoption.
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Affiliation(s)
- Carlo D L Ceresa
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - David Nasralla
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Christopher J E Watson
- Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Andrew J Butler
- Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Constantin C Coussios
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Keziah Crick
- Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Leanne Hodson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, United Kingdom
| | - Charles Imber
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, Royal Free Hospital, London, United Kingdom
| | - Wayel Jassem
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Simon R Knight
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Hynek Mergental
- Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Rutger J Ploeg
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Joerg M Pollok
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, Royal Free Hospital, London, United Kingdom
| | - Alberto Quaglia
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - A M James Shapiro
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Annemarie Weissenbacher
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Peter J Friend
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
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105
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Inflammasome-Mediated Inflammation in Liver Ischemia-Reperfusion Injury. Cells 2019; 8:cells8101131. [PMID: 31547621 PMCID: PMC6829519 DOI: 10.3390/cells8101131] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/19/2019] [Accepted: 09/21/2019] [Indexed: 12/16/2022] Open
Abstract
Ischemia-reperfusion injury is an important cause of liver damage occurring during surgical procedures including hepatic resection and liver transplantation, and represents the main underlying cause of graft dysfunction and liver failure post-transplantation. To date, ischemia-reperfusion injury is an unsolved problem in clinical practice. In this context, inflammasome activation, recently described during ischemia-reperfusion injury, might be a potential therapeutic target to mitigate the clinical problems associated with liver transplantation and hepatic resections. The present review aims to summarize the current knowledge in inflammasome-mediated inflammation, describing the experimental models used to understand the molecular mechanisms of inflammasome in liver ischemia-reperfusion injury. In addition, a clear distinction between steatotic and non-steatotic livers and between warm and cold ischemia-reperfusion injury will be discussed. Finally, the most updated therapeutic strategies, as well as some of the scientific controversies in the field will be described. Such information may be useful to guide the design of better experimental models, as well as the effective therapeutic strategies in liver surgery and transplantation that can succeed in achieving its clinical application.
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106
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Abstract
OBJECTIVE To evaluate the use of elderly donors in liver transplantation (LT) and identify risk factors associated with a worse outcome. SUMMARY BACKGROUND DATA Use of livers from very old donors could expand the donor pool but is not universally implemented. METHODS This is a retrospective, single-center medical record review. From January 2001 to December 2014, 1354 LTs were performed. After exclusion of donors <18 years, ABO-incompatible LT, re-LT and UNOS 1 status patients, LT recipients were stratified into 2 groups based on donor age: 18-69 (n=692) vs. ≥70 years (n=515) then matched using a propensity score approach. Two groups were finally matched (young group = 448 cases; old group = 515 cases). RESULTS The median (interquartile range [IQR]) follow-up was 5.0 (2.0-8.4) years. Comparing the 2 identified groups, no differences were observed regarding early retransplants (1.8 vs. 2.9; P = 0.3), HCV-related death (7.6 vs. 8.7%; P = 0.6), vascular (5.8 vs. 5.0%; P = 0.7), and biliary complications (16.5 vs. 18.6%; P = 0.4). On multivariate analysis, independent risk factors for graft loss were: HCV-positive recipient (HR = 2.1; 95% CI = 1.6-2.7; P < 0.001), donor age (HR = 1.0; 95% CI = 1.0-1.0; P < 0.001), cold ischemia time (HR = 1.0; 95% CI = 1.0-1.0; P = 0.042), and donor history of diabetes mellitus (HR = 1.48; 95% CI = 1.03-2.13; P = 0.036). CONCLUSIONS Use of elderly donors is not associated per se with an increased risk of vascular and biliary complications. In the presence of cold ischemia time and diabetes mellitus, appropriate donor-to-recipient matching is warranted.
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107
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Paterno F, Guarrera JV, Wima K, Diwan T, Cuffy MC, Anwar N, Woodle ES, Shah S. Clinical Implications of Donor Warm and Cold Ischemia Time in Donor After Circulatory Death Liver Transplantation. Liver Transpl 2019; 25:1342-1352. [PMID: 30912253 DOI: 10.1002/lt.25453] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 03/19/2019] [Indexed: 02/07/2023]
Abstract
The use of donation after circulatory death (DCD) liver allografts has been constrained by limitations in the duration of donor warm ischemia time (DWIT), donor agonal time (DAT), and cold ischemia time (CIT). The purpose of this study is to assess the impact of longer DWIT, DAT, and CIT on graft survival and other outcomes in DCD liver transplants. The Scientific Registry of Transplant Recipients was queried for adult liver transplants from DCD donors between 2009 and 2015. Donor, recipient, and center variables were included in the analysis. During the study period, 2107 patients underwent liver transplant with DCD allografts. In most patients, DWIT and DAT were <30 minutes. DWIT was <30 minutes in 1804 donors, between 30 and 40 minutes in 248, and >40 minutes in 37. There was no difference in graft survival, duration of posttransplant hospital length of stay, and readmission rate between DCD liver transplants from donors with DWIT <30 minutes and DWIT between 30 and 40 minutes. Similar outcomes were noted for DAT. In the multivariate analysis, DAT and DWIT were not associated with graft loss. The predictors associated with graft loss were donor age, donor sharing, CIT, recipient admission to the intensive care unit, recipient ventilator dependence, Model for End-Stage Liver Disease score, and low-volume transplant centers. Any CIT cutoff >4 hours was associated with increased risk for graft loss. Longer CIT was also associated with a longer posttransplant hospital stay, higher rate of primary nonfunction, and hyperbilirubinemia. In conclusion, slightly longer DAT and DWIT (up to 40 minutes) were not associated with graft loss, longer posttransplant hospitalization, or hospital readmissions, whereas longer CIT was associated with worse outcomes after DCD liver transplants.
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Affiliation(s)
- Flavio Paterno
- Division of Liver Transplant and Hepatobiliary Surgery, Department of Surgery, Rutgers New Jersey Medical School and University Hospital, Newark, NJ
| | - James V Guarrera
- Division of Liver Transplant and Hepatobiliary Surgery, Department of Surgery, Rutgers New Jersey Medical School and University Hospital, Newark, NJ
| | - Koffi Wima
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Tayyab Diwan
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Madison C Cuffy
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Nadeem Anwar
- Division of Hepatology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - E Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shimul Shah
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
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108
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Croome KP, Lee DD, Croome S, Chadha R, Livingston D, Abader P, Keaveny AP, Taner CB. The impact of postreperfusion syndrome during liver transplantation using livers with significant macrosteatosis. Am J Transplant 2019; 19:2550-2559. [PMID: 30821923 DOI: 10.1111/ajt.15330] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/24/2019] [Accepted: 02/19/2019] [Indexed: 01/25/2023]
Abstract
The impact of postreperfusion syndrome (PRS) during liver transplantation (LT) using donor livers with significant macrosteatosis is largely unknown. Clinical outcomes of all patients undergoing LT with donor livers with moderate macrosteatosis (30%-60%) (N = 96) between 2000 and 2017 were compared to propensity score matched cohorts of patients undergoing LT with donor livers with mild macrosteatosis (10%-29%) (N = 96) and no steatosis (N = 96). Cardiac arrest at the time of reperfusion was seen in eight (8.3%) of the patients in the moderate macrosteatosis group compared to one (1.0%) of the patients in the mild macrosteatosis group (P = .02) and zero (0%) of the patients in the no steatosis group (P = .004). Patients in the moderate macrosteatosis group had a higher rate of PRS (37.5% vs 18.8%; P = .004), early allograft dysfunction (EAD) (76.4% vs 25.8%; P < .001), renal dysfunction requiring continuous renal replacement therapy following transplant (18.8% vs 8.3%; P = .03) and return to the OR within 30 days (24.0% vs 7.3%; P = .002), than the no steatosis group. Both long-term patient (P = .30 and P = .08) and graft survival (P = .15 and P = .12) were not statistically when comparing the moderate macrosteatosis group to the mild macrosteatosis and no steatosis groups. Recipients of LT using livers with moderate macrosteatosis are at a significant increased risk of PRS. If patients are able to overcome the initial increased perioperative risk of using these donor livers, long-term graft survival does not appear to be different than matched recipients receiving grafts with no steatosis.
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Affiliation(s)
| | - David D Lee
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida
| | - Sarah Croome
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida
| | - Ryan Chadha
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida
| | - David Livingston
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida
| | - Peter Abader
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida
| | | | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida
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109
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Cahalane AM, Mojtahed A, Sahani DV, Elias N, Kambadakone AR. Pre-hepatic and pre-pancreatic transplant donor evaluation. Cardiovasc Diagn Ther 2019; 9:S97-S115. [PMID: 31559157 DOI: 10.21037/cdt.2018.09.14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Innovations in surgical techniques coupled with advances in medical and pharmacological management in the past few decades have enabled organ transplantation to become integral to the management of end stage organ failure. In this review article, we will review the role of the radiologist in the work up of liver and pancreas donors during evaluation of their donor candidacy. The critical role of imaging in assessing the parenchymal, biliary and vascular anatomy in liver donor candidates will be reviewed, as well as highlighting the anatomical findings that may pose a contraindication to transplantation. The limited role of imaging in pancreas donor evaluation is also covered, as well as a brief overview of the surgical techniques available and how the radiologist's findings influence operative technique selection.
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Affiliation(s)
- Alexis M Cahalane
- Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Amirkasra Mojtahed
- Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Dushyant V Sahani
- Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Nahel Elias
- Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Avinash R Kambadakone
- Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA
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110
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Patrono D, Surra A, Catalano G, Rizza G, Berchialla P, Martini S, Tandoi F, Lupo F, Mirabella S, Stratta C, Salizzoni M, Romagnoli R. Hypothermic Oxygenated Machine Perfusion of Liver Grafts from Brain-Dead Donors. Sci Rep 2019; 9:9337. [PMID: 31249370 PMCID: PMC6597580 DOI: 10.1038/s41598-019-45843-3] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 06/06/2019] [Indexed: 02/08/2023] Open
Abstract
Hypothermic oxygenated machine perfusion (HOPE) was introduced in liver transplantation (LT) to mitigate ischemia-reperfusion injury. Available clinical data mainly concern LT with donors after circulatory-determined death, whereas data on brain-dead donors (DBD) are scarce. To assess the impact of end-ischemic HOPE in DBD LT, data on primary adult LTs performed between March 2016 and June 2018 were analyzed. HOPE was used in selected cases of donor age >80 years, apparent severe graft steatosis, or ischemia time ≥10 hours. Outcomes of HOPE-treated cases were compared with those after static cold storage. Propensity score matching (1:2) and Bayesian model averaging were used to overcome selection bias. During the study period, 25 (8.5%) out of 294 grafts were treated with HOPE. After matching, HOPE was associated with a lower severe post-reperfusion syndrome (PRS) rate (4% versus 20%, p = 0.13) and stage 2–3 acute kidney injury (AKI) (16% versus 42%, p = 0.046). Furthermore, Bayesian model averaging showed lower transaminases peak and a lower early allograft dysfunction (EAD) rate after HOPE. A steeper decline in arterial graft resistance throughout perfusion was associated with lower EAD rate. HOPE determines a significant reduction of ischemia reperfusion injury in DBD LT.
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Affiliation(s)
- Damiano Patrono
- General Surgery 2U - Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Astrid Surra
- General Surgery 2U - Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Giorgia Catalano
- General Surgery 2U - Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Giorgia Rizza
- General Surgery 2U - Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Paola Berchialla
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Silvia Martini
- Gastrohepatology Unit, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Francesco Tandoi
- General Surgery 2U - Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Francesco Lupo
- General Surgery 2U - Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Stefano Mirabella
- General Surgery 2U - Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Chiara Stratta
- Anesthesia Department 2, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Mauro Salizzoni
- General Surgery 2U - Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Renato Romagnoli
- General Surgery 2U - Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy.
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111
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Munsterman ID, van Erp M, Weijers G, Bronkhorst C, de Korte CL, Drenth JPH, van der Laak JAWM, Tjwa ETTL. A Novel Automatic Digital Algorithm that Accurately Quantifies Steatosis in NAFLD on Histopathological Whole-Slide Images. CYTOMETRY PART B-CLINICAL CYTOMETRY 2019; 96:521-528. [PMID: 31173462 PMCID: PMC6899563 DOI: 10.1002/cyto.b.21790] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 04/21/2019] [Accepted: 05/17/2019] [Indexed: 12/14/2022]
Abstract
Background Accurate assessment of hepatic steatosis is a key to grade disease severity in non‐alcoholic fatty liver disease (NAFLD). Methods We developed a digital automated quantification of steatosis on whole‐slide images (WSIs) of liver tissue and performed a validation study. Hematoxylin–eosin stained liver tissue slides were digitally scanned, and steatotic areas were manually annotated. We identified thresholds for size and roundness parameters by logistic regression to discriminate steatosis from surrounding liver tissue. The resulting algorithm produces a steatosis proportionate area (SPA; ratio of steatotic area to total tissue area described as percentage). The software can be implemented as a Java plug‐in in FIJI, in which digital WSI can be processed automatically using the Pathomation extension. Results We obtained liver tissue specimens from 61 NAFLD patients and 18 controls. The area under the curve of correctly classified steatosis by the algorithm was 0.970 (95% CI 0.968–0.973), P < 0.001. Accuracy of the algorithm was 91.9%, with a classification error of 8.1%. SPA correlated significantly with steatosis grade (Rs = 0.845, CI: 0.749–0.902, P < 0.001) and increased significantly with each individual steatosis grade, except between Grade 2 and 3. Conclusions We have developed a novel digital analysis algorithm that accurately quantifies steatosis on WSIs of liver tissue. This algorithm can be incorporated when quantification of steatosis is warranted, such as in clinical trials studying efficacy of new therapeutic interventions in NAFLD. © 2019 The Authors. Cytometry Part B: Clinical Cytometry published by Wiley Periodicals, Inc. on behalf of International Clinical Cytometry Society.
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Affiliation(s)
- Isabelle D Munsterman
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Merijn van Erp
- Department of Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Microscopic Imaging Centre, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Gert Weijers
- Medical UltraSound Imaging Centre (MUSIC), Department of Radiology and Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Carolien Bronkhorst
- Department of Pathology, Jeroen Bosch Ziekenhuis's-Hertogenbosch, The Netherlands
| | - Chris L de Korte
- Medical UltraSound Imaging Centre (MUSIC), Department of Radiology and Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Eric T T L Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
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112
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Abstract
PURPOSE OF REVIEW Normothermic machine perfusion (NMP) is an emerging technology for liver preservation. Early clinical results demonstrate beneficial effects in reconditioning high-risk grafts. This review discusses the role of normothermic perfusion as a tool to assess graft viability and as a platform for graft intervention and modification. RECENT FINDINGS The potential benefits of NMP extend far beyond organ reconditioning. Recent pilot studies have identified clinically relevant viability criteria, which now require validation in large randomized control trials prior to implementation. Furthermore, preclinical studies demonstrate tremendous potential for NMP as a method to extend the preservation period, thus improving transplant logistics as well as serve as a platform for graft-targeted interventions to optimize the preservation period. SUMMARY NMP is a multifunctional tool with potential to transform liver preservation and the field of transplantation. Large clinical trials are necessary to optimize perfusion protocols, clarify indications for NMP therapy and justify use as the standard preservation modality.
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113
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Regional Variation in Utilization and Outcomes of Liver Allografts From Donors With High Body Mass Index and Graft Macrosteatosis: A Role for Liver Biopsy. Transplantation 2019; 103:122-130. [PMID: 30048394 DOI: 10.1097/tp.0000000000002379] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Obesity, defined as a high body mass index (hBMI) of 30 kg/m or greater, is a growing epidemic worldwide and is associated with multiple comorbidities. High BMI individuals account for an increasing portion of potential liver donors. Here we evaluate trends in the utilization and outcomes of hBMI donors on a national and regional level and the potential role of liver biopsy in donor evaluation. METHODS United Network for Organ Sharing Standard Transplant Analysis and Research database was evaluated for deceased donor liver transplants between 2006 and 2016 across 11 Organ Procurement and Transplantation Network regions. High BMI donors were compared with lower BMI counterparts and evaluated for biopsy rates, utilization rates and allograft outcomes. Univariate and multivariable analyses were performed. RESULTS Seventy-seven thousand fifty potential donors were identified and 60 200 transplants were evaluated. Utilization rates for hBMI donors were 66.1% versus 78.1% for lower BMI donors (P < 0.001). Pretransplant biopsy was performed more frequently in hBMI donors (52.1% vs 33.1%, P < 0.001) and macrosteatosis of 30% or greater was identified more often (21.1% vs 12.2%, P < 0.001). Biopsy performance increased utilization rate of hBMI donors in 7 of 11 Organ Procurement and Transplantation Network regions. region 6 showed the highest rate of biopsy performance, high rate of hBMI donor utilization, and highest 5-year estimated graft survival rates of all regions. CONCLUSIONS High BMI donors have not previously been associated with worse graft survival in multivariable analyses; however, they are used much less frequently. Liver biopsy may increase the utilization rate of hBMI donors and improve donor selection. Further evaluation of regions with high rates of utilization and good outcomes is warranted.
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Abstract
PURPOSE OF REVIEW Nonalcoholic fatty liver disease (NAFLD) is a growing cause of chronic liver disease globally and nonalcoholic steatohepatitis is projected to become the most common indication for liver transplantation. The purpose of this review is to highlight key issues surrounding NAFLD as an indication for liver transplantation, including its increasing prevalence, outcomes related to liver transplantation, development of post liver transplant NAFLD and NAFLD in the liver donor pool. RECENT FINDINGS With the advent of direct-acting antiviral therapies, the proportion of patients on the liver transplant list or undergoing liver transplant for chronic hepatitis C infection is steadily decreasing. In contrast, the number transplants performed for NAFLD is increasing. By 2030, it is estimated that the incidence of decompensated cirrhosis and hepatocellular carcinoma will increase by 168 and 137%, respectively, and the number of deaths will increase by 178%. SUMMARY Liver transplantation cures cirrhosis but does not treat the underlying metabolic disease associated with NAFLD. Thus, strategies to control comorbidities in patients with NAFLD prior to transplant are needed to decrease waitlist mortality and the recurrence of NAFLD after liver transplant. NAFLD in the donor pool is also a growing concern. Strategies to minimize steatosis and expand the number of donors are critical to meet the growing demand for liver transplantation.
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115
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Abstract
PURPOSE OF REVIEW Despite high demand, a severe shortage of suitable allografts limits the use of liver transplantation for the treatment of end-stage liver disease. The transplant community is turning to the utilization of high-risk grafts to fill the void. This review summarizes the reemergence of ex-vivo machine perfusion for liver graft preservation, including results of recent clinical trials and its specific role for reconditioning DCD, steatotic and elderly grafts. RECENT FINDINGS Several phase-1 clinical trials demonstrate the safety and feasibility of machine perfusion for liver graft preservation. Machine perfusion has several advantages compared with static cold storage and may provide superior transplantation outcomes, particularly for marginal grafts. Ongoing multicenter trials aim to confirm the results of preclinical and pilot studies and establish the clinical utility of ex-vivo liver machine perfusion. SUMMARY Mounting evidence supports the benefits of machine perfusion for preservation of liver grafts. Thus, machine perfusion is a promising strategy to expand the donor pool by reconditioning and assessing viability of DCD, elderly and steatotic grafts during the preservation period. Additionally, machine perfusion will serve as a platform to facilitate graft intervention and modification to further optimize marginal grafts.
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The Impact of Steatosis on the Outcome of Liver Transplantation: A Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2019; 2019:3962785. [PMID: 31218224 PMCID: PMC6536983 DOI: 10.1155/2019/3962785] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 04/14/2019] [Accepted: 04/22/2019] [Indexed: 12/18/2022]
Abstract
Background and Aims Liver transplantation is one of the most effective treatments for end-stage liver disease as well as for cases of acute liver failure. Facing organ donor shortage, liver transplant teams had to use marginal organs. Thus, increasing availability is a key concern of donor liver grafts including steatotic livers. However, the use of steatotic liver is still controversial. The aim of this systematic review and meta-analysis was to analyze the impact of steatosis on the outcome of liver transplantation. Methods We searched PubMed, Cochrane Library, Embase, Web of knowledge, and so on for studies published through May 31, 2018, in which patients experienced liver transplantation using fatty liver. All studies extracted outcome indicators, and we draw conclusions by contrasting outcome indicators in different groups of steatosis. Odds ratios and 95% confidence intervals were calculated. P<0.05 was considered as statistically significant difference. Results 19 publications were included. There was no significant difference between the group of no steatosis and mild group in primary nonfunction rate (P=0.605) or early graft dysfunction rate (P=0.44). The PNF rate was significantly higher in moderate group (P=0.003) and severe group (P <0.001) compared with that in no steatosis group. The same results were seen in early graft dysfunction rate. However, graft survival rate and patient survival rate did not differ between groups. Conclusions Livers with mild steatosis, even with moderate or severe steatosis, could be suitable donor under strict control of transplant conditions.
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Weissenbacher A, Vrakas G, Nasralla D, Ceresa CDL. The future of organ perfusion and re-conditioning. Transpl Int 2019; 32:586-597. [PMID: 30980772 PMCID: PMC6850430 DOI: 10.1111/tri.13441] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 01/25/2019] [Accepted: 04/09/2019] [Indexed: 12/14/2022]
Abstract
Organ preservation and re‐conditioning using machine perfusion technologies continue to generate promising results in terms of viability assessment, organ utilization and improved initial graft function. Here, we summarize the latest findings and study the results of ex‐vivo/ex‐situ hypothermic (HMP) and normothermic machine perfusion (NMP) in the area of abdominal organ transplantation (kidney, liver, pancreas and intestine). We also consider the potential role of normothermic regional perfusion (NRP) to re‐condition donors after circulatory death organs before retrieval. The findings from clinical studies reported to date suggest that machine perfusion will offer real benefits when compared with conventional cold preservation. Several randomized trials are expected to report their findings within the next 2 years which may shed light on the relative merits of different perfusion methods and could indicate which perfusion parameters may be most useful to predict organ quality and viability. Further work is needed to identify composite endpoints that are relevant for transplanted organs that have undergone machine preservation. Multi‐centre trials to compare and analyse the combinations of NRP followed by HMP and/or NMP, either directly after organ retrieval using transportable devices or when back‐to‐base, are needed. The potential applications of machine preservation technology beyond the field of solid organ transplantation are also considered.
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Affiliation(s)
- Annemarie Weissenbacher
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria.,Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, Oxford University Hospitals, University of Oxford, Oxford, UK
| | - Georgios Vrakas
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, Oxford University Hospitals, University of Oxford, Oxford, UK
| | - David Nasralla
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, Oxford University Hospitals, University of Oxford, Oxford, UK
| | - Carlo D L Ceresa
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, Oxford University Hospitals, University of Oxford, Oxford, UK
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Donor Small-Droplet Macrovesicular Steatosis Affects Liver Transplant Outcome in HCV-Negative Recipients. Can J Gastroenterol Hepatol 2019; 2019:5862985. [PMID: 31187028 PMCID: PMC6521523 DOI: 10.1155/2019/5862985] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 04/03/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND No data are available on liver transplantation (LT) outcome and donor liver steatosis, classified as large droplet macrovesicular (Ld-MaS), small-droplet macrovesicular (Sd-MaS), and true microvesicular (MiS), taking into account the recipient Hepatitis C virus (HCV) status. AIM We investigate the impact of allograft steatosis reclassified according to the Brunt classification on early graft function and survival after LT. METHODS We retrospectively reviewed 204 consecutive preischemia biopsies of grafts transplanted in our center during the period 2001-2011 according to recipient HCV status. RESULTS The median follow-up after LT was 7.5 years (range: 0.0-16.7). In negative recipients (n=122), graft loss was independently associated with graft Sd-MaS, in multivariable Cox regression models comprehending only pre-/intraoperative variables (HR=1.03, 95%CI=1.01-1.05; P=0.003) and when including indexes of early postoperative graft function (HR=1.04, 95%CI=1.02-1.06; P=0.001). Graft Sd-MaS>15% showed a risk for graft loss > 2.5-folds in both the models. Graft Sd-MaS>15% was associated with reduced graft ATP content and, only in HCV- recipients, with higher early post-LT serum AST peaks. CONCLUSIONS In HCV-negative recipients, allografts with >15% Sd-MaS have significantly reduced graft survival and show low ATP and higher AST peaks in the immediate posttransplant period. Donors with >15% Sd-MaS have significantly higher BMI, longer ICU stays, and lower PaO2.
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119
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Dar WA, Sullivan E, Bynon JS, Eltzschig H, Ju C. Ischaemia reperfusion injury in liver transplantation: Cellular and molecular mechanisms. Liver Int 2019; 39:788-801. [PMID: 30843314 PMCID: PMC6483869 DOI: 10.1111/liv.14091] [Citation(s) in RCA: 209] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 02/13/2019] [Accepted: 02/22/2019] [Indexed: 12/11/2022]
Abstract
Liver disease causing end organ failure is a growing cause of mortality. In most cases, the only therapy is liver transplantation. However, liver transplantation is a complex undertaking and its success is dependent on a number of factors. In particular, liver transplantation is subject to the risks of ischaemia-reperfusion injury (IRI). Liver IRI has significant effects on the function of a liver after transplantation. The cellular and molecular mechanisms governing IRI in liver transplantation are numerous. They involve multiple cells types such as liver sinusoidal endothelial cells, hepatocytes, Kupffer cells, neutrophils and platelets acting via an interconnected network of molecular pathways such as activation of toll-like receptor signalling, alterations in micro-RNA expression, production of ROS, regulation of autophagy and activation of hypoxia-inducible factors. Interestingly, the cellular and molecular events in liver IRI can be correlated with clinical risk factors for IRI in liver transplantation such as donor organ steatosis, ischaemic times, donor age, and donor and recipient coagulopathy. Thus, understanding the relationship of the clinical risk factors for liver IRI to the cellular and molecular mechanisms that govern it is critical to higher levels of success after liver transplantation. This in turn will help in the discovery of therapeutics for IRI in liver transplantation - a process that will lead to improved outcomes for patients suffering from end-stage liver disease.
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Affiliation(s)
- Wasim A. Dar
- Department of Surgery, McGovern Medical School at UT Health, Houston, TX
| | - Elise Sullivan
- Department of Anesthesia, McGovern Medical School at UT Health, Houston, TX
| | - John S. Bynon
- Department of Surgery, McGovern Medical School at UT Health, Houston, TX
| | - Holger Eltzschig
- Department of Anesthesia, McGovern Medical School at UT Health, Houston, TX
| | - Cynthia Ju
- Department of Anesthesia, McGovern Medical School at UT Health, Houston, TX
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Álvarez-Mercado AI, Gulfo J, Romero Gómez M, Jiménez-Castro MB, Gracia-Sancho J, Peralta C. Use of Steatotic Grafts in Liver Transplantation: Current Status. Liver Transpl 2019; 25:771-786. [PMID: 30740859 DOI: 10.1002/lt.25430] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 02/02/2019] [Indexed: 12/12/2022]
Abstract
In the field of liver transplantation, the demand for adequate allografts greatly exceeds the supply. Therefore, expanding the donor pool to match the growing demand is mandatory. The present review summarizes current knowledge of the pathophysiology of ischemia/reperfusion injury in steatotic grafts, together with recent pharmacological approaches aimed at maximizing the utilization of these livers for transplantation. We also describe the preclinical models currently available to understand the molecular mechanisms controlling graft viability in this specific type of donor, critically discussing the heterogeneity in animal models, surgical methodology, and therapeutic interventions. This lack of common approaches and interventions makes it difficult to establish the pathways involved and the relevance of isolated discoveries, as well as their transferability to clinical practice. Finally, we discuss how new therapeutic strategies developed from experimental studies are promising but that further studies are warranted to translate them to the bedside.
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Affiliation(s)
- Ana I Álvarez-Mercado
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - José Gulfo
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Manuel Romero Gómez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas (CIBEREHD), Madrid, Spain.,Inter-Centre Unit of Digestive Diseases, Virgen del Rocio University Hospitals, Sevilla, Spain; Institute of Biomedicine of Seville, Seville, Spain.,Institute of Biomedicine of Seville, Seville, Spain
| | | | - Jordi Gracia-Sancho
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas (CIBEREHD), Madrid, Spain.,Hepatology, Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Carmen Peralta
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas (CIBEREHD), Madrid, Spain.,Universidad Internacional de Cataluña, Barcelona, Spain
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121
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Núñez KG, Frank A, Gonzalez-Rosario J, Galliano G, Bridle K, Crawford D, Seal J, Abbruscato F, Vashistha H, Thevenot PT, Cohen AJ. Interleukin-33 / Cyclin D1 imbalance in severe liver steatosis predicts susceptibility to ischemia reperfusion injury. PLoS One 2019; 14:e0216242. [PMID: 31034519 PMCID: PMC6488080 DOI: 10.1371/journal.pone.0216242] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 04/16/2019] [Indexed: 01/01/2023] Open
Abstract
Transplanting donor livers with severe macrosteatosis is associated with increased risk of primary non-function (PNF). The purpose of this study was to identify steatosis-driven biomarkers as a predisposition to severe liver damage and delayed recovery following ischemia reperfusion injury. Wistar rats were fed a methionine- and choline-deficient (MCD) diet for up to three weeks to achieve severe macrosteatosis (>90%). Animals underwent diet withdrawal to control chow and/or underwent ischemia reperfusion and partial hepatectomy injury (I/R-PHx) and reperfused out to 7 days on control chow. For animals with severe macrosteatosis, hepatic levels of IL-33 decreased while Cyclin D1 levels increased in the absence of NF-κB p65 phosphorylation. Animals with high levels of nuclear Cyclin D1 prior to I/R-PHx either did not survive or had persistent macrosteatosis after 7 days on control chow. Survival 7 days after I/R-PHx fell to 57% which correlated with increased Cyclin D1 and decreased liver IL-33 levels. In the absence of I/R-PHx, withdrawing the MCD diet normalized IL-33, Cyclin D1 levels, and I/R-PHx survival back to baseline. In transplanted grafts with macrosteatosis, higher Cyclin D1 mRNA expression was observed. Shifts in Cyclin D1 and IL-33 expression may identify severely macrosteatotic livers with increased failure risk if subjected to I/R injury. Clinical validation of the panel in donor grafts with macrosteatosis revealed increased Cyclin D1 expression corresponding to delayed graft function. This pre-surgical biomarker panel may identify the subset of livers with increased susceptibility to PNF.
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Affiliation(s)
- Kelley G. Núñez
- Institute of Translational Research, Ochsner Health System, New Orleans, Louisiana, United States of America
| | - Anderson Frank
- Institute of Translational Research, Ochsner Health System, New Orleans, Louisiana, United States of America
| | - Janet Gonzalez-Rosario
- Institute of Translational Research, Ochsner Health System, New Orleans, Louisiana, United States of America
| | - Gretchen Galliano
- Pathology, Ochsner Health System, New Orleans, Louisiana, United States of America
| | - Kim Bridle
- Gallipoli Medical Research Institute and Faculty of Medicine, The University of Queensland School of Medicine, Greenslopes, Brisbane, Australia
| | - Darrell Crawford
- Gallipoli Medical Research Institute and Faculty of Medicine, The University of Queensland School of Medicine, Greenslopes, Brisbane, Australia
| | - John Seal
- Multi-organ Transplant Center, Ochsner Health System, New Orleans, Louisiana, United States of America
| | - Frank Abbruscato
- Institute of Translational Research, Ochsner Health System, New Orleans, Louisiana, United States of America
| | - Himanshu Vashistha
- Institute of Translational Research, Ochsner Health System, New Orleans, Louisiana, United States of America
| | - Paul T. Thevenot
- Institute of Translational Research, Ochsner Health System, New Orleans, Louisiana, United States of America
- * E-mail:
| | - Ari J. Cohen
- Institute of Translational Research, Ochsner Health System, New Orleans, Louisiana, United States of America
- Multi-organ Transplant Center, Ochsner Health System, New Orleans, Louisiana, United States of America
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122
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Liu Z, Jia J, Ning H, Que S, Zhou L, Zheng S. Systematic Evaluation of the Safety Threshold for Allograft Macrovesicular Steatosis in Cadaveric Liver Transplantation. Front Physiol 2019; 10:429. [PMID: 31105577 PMCID: PMC6494939 DOI: 10.3389/fphys.2019.00429] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 03/28/2019] [Indexed: 12/14/2022] Open
Abstract
Background: Currently, 30% macrovesicular steatosis (MaS) content is usually assigned empirically as the boundary between “use” and “refuse” a donor liver for liver transplantation (LT); however, this cut-off is questionable due to the lack of systemic evidence of the efficiency relative to prognosis prediction. Clinicians have tried to identify the threshold for optimized utilization of marginal steatotic allografts, but controversy exists among different studies. Aim: Our study aimed to systematically determine an acceptable donor MaS content cut-off without incurring extra risk in liver transplantation, using meta-analysis. Methods: The relevant literature reporting the relationship between MaS content and post-transplant mortality/morbidity was searched and retrieved in Pubmed, Embase, and ISI Web of Science. Results: Nine studies were enrolled into the final analysis. A categorical comparison revealed that patients who received allografts with moderate steatosis (MaS content >30%) had significantly higher risks of graft failure/dysfunction, but not of mortality. Dose-response analysis showed that donor MaS content affected the graft failure/dysfunction in a non-linear relationship. Risks associated with MaS content in terms of poorer outcomes were independent of other risk covariates for liver transplantation. A non-significant increase in risk of inferior post-transplant outcomes was observed in patients who received allografts with a MaS content <35%. The risks of post-transplant graft failure and dysfunction increased with severe donor MaS content infiltration, without a consistent relationship. Conclusions: The threshold of allograft MaS content can be safely extended to 35% without additional risk burden on post-transplant inferior outcomes. Clarification on “the effects of stratification” for MaS content can provide theoretical evidence for further optimal utilization of marginal steatotic allografts in liver transplantation.
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Affiliation(s)
- Zhengtao Liu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Junjun Jia
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Huaijun Ning
- Department of Pediatrics, Women and Children's Hospital of Guangxi, Nanning, China
| | - Shuping Que
- Science for Life Laboratory, KTH - Royal Institute of Technology, Stockholm, Sweden
| | - Lin Zhou
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
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123
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Living Donor Liver Transplantation: Overview, Imaging Technique, and Diagnostic Considerations. AJR Am J Roentgenol 2019; 213:54-64. [PMID: 30973783 DOI: 10.2214/ajr.18.21034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE. The purpose of this article is to discuss the process of becoming a liver donor, describe the surgical methods used for transplantation, and critically review preoperative and intraoperative imaging techniques. CONCLUSION. Radiologists play a vital role in ensuring the safety of living liver donors; however, consensus guidelines do not exist for imaging protocol or reporting. Standardization would provide more consistent image quality across centers, improve communication with the transplant team, and facilitate data mining for quality assurance and research.
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124
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Indocyanine green fluorescence imaging to evaluate graft perfusion during liver transplantation. HPB (Oxford) 2019; 21:387-392. [PMID: 30297305 DOI: 10.1016/j.hpb.2018.09.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/04/2018] [Accepted: 09/02/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Primary graft dysfunction (PGD) is a leading cause of graft loss after liver transplantation. There is no reliable method to anticipate this complication intraoperatively. Indocyanine green (ICG) fluorescence imaging is a technique used in hepatobiliary surgery for detection of liver malignancies, but has never been reported in the setting of liver transplantation (LT) for function assessment. We hypothesized that there could be an association between the type of fluorescence and the occurrence of PGD. METHODS We retrospectively analyzed 72 patients who underwent LT at our center. An assessment of the liver graft with the ICG fluorescence technique was carried out. A classification comprising 3 types of fluorescence was created after evaluation of the recorded images. We assessed the relationship between the type of fluorescence and the occurrence of PGD. RESULTS Crosstabulation analysis of the fluorescent types and occurrence of PGD yielded a statistically significant association (p = 0.002). Univariate analysis showed that an abnormal ICG fluorescence pattern was a risk factor for the occurrence of PGD after LT. CONCLUSIONS Our findings suggest that there could be an association between ICG fluorescence imaging and graft function. This intraoperative tool could be useful to detect patients at risk of developing PGD after LT.
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125
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Tchilikidi KY. Liver graft preservation methods during cold ischemia phase and normothermic machine perfusion. World J Gastrointest Surg 2019; 11:126-142. [PMID: 31057698 PMCID: PMC6478595 DOI: 10.4240/wjgs.v11.i3.126] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/21/2019] [Accepted: 03/24/2019] [Indexed: 02/06/2023] Open
Abstract
The growing demand for donor organs requires measures to expand donor pool. Those include extended criteria donors, such as elderly people, steatotic livers, donation after cardiac death, etc. Static cold storage to reduce metabolic requirements developed by Collins in late 1960s is the mainstay and the golden standard for donated organ protection. Hypothermic machine perfusion provides dynamic organ preservation at 4°C with protracted infusion of metabolic substrates to the graft during the ex vivo period. It has been used instead of static cold storage or after it as short perfusion in transplant center. Normothermic machine perfusion (NMP) delivers oxygen, and nutrition at physiological temperature mimicking regular environment in order to support cellular function. This would minimize effects of ischemia/reperfusion injury. Potentially, NMP may help to estimate graft functionality before implantation into a recipient. Clinical studies demonstrated at least its non-inferiority or better outcomes vs static cold storage. Regular grafts donated after brain death could be safely preserved with convenient static cold storage. Except for prolonged ischemia time where hypothermic machine perfusion started in transplant center could be estimated to provide possible positive reconditioning effect. Use of hypothermic machine perfusion in regular donation instead of static cold storage or in extended criteria donors requires further investigation. Multicenter randomized clinical trial supposed to be completed in December 2021. Extended criteria donors need additional measures for graft storage and assessment until its implantation. NMP is actively evaluating promising method for this purpose. Future studies are necessary for precise estimation and confirmation to issue clinical practice recommendations.
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126
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Golse N, Cosse C, Allard MA, Laurenzi A, Tedeschi M, Guglielmo N, Fernandez-Sevilla E, Robert M, Tréchot B, Pietrasz D, Pittau G, Ciacio O, Sa Cunha A, Castaing D, Cherqui D, Adam R, Samuel D, Sebagh M, Vibert E. Evaluation of a micro-spectrometer for the real-time assessment of liver graft with mild-to-moderate macrosteatosis: A proof of concept study. J Hepatol 2019; 70:423-430. [PMID: 30399385 DOI: 10.1016/j.jhep.2018.10.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/24/2018] [Accepted: 10/27/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Liver macrosteatosis (MS) is a major predictor of graft dysfunction after transplantation. However, frozen section techniques to quantify steatosis are often unavailable in the context of procurements, and the findings of preoperative imaging techniques correlate poorly with those of permanent sections, so that the surgeon is ultimately responsible for the decision. Our aim was to assess the accuracy of a non-invasive pocket-sized micro-spectrometer (PSM) for the real-time estimation of MS. METHODS We prospectively evaluated a commercial PSM by scanning the liver capsule. A double pathological quantification of MS was performed on permanent sections. Initial calibration (training cohort) was performed on 35 livers (MS ≤60%) and an algorithm was created to correlate the estimated (PSM) and known (pathological) MS values. A second assessment (validation cohort) was then performed on 154 grafts. RESULTS Our algorithm achieved a coefficient of determination R2 = 0.81. Its validation on the second cohort demonstrated a Lin's concordance coefficient of 0.78. Accuracy reached 0.91%, with reproducibility of 86.3%. The sensitivity, specificity, positive and negative predictive values for MS ≥30% were 66.7%, 100%, 100% and 98%, respectively. The PSM could predict the absence (<30%)/presence (≥30%) of MS with a kappa coefficient of 0.79. Neither graft weight nor height, donor body mass index nor the CT-scan liver-to-spleen attenuation ratio could accurately predict MS. CONCLUSION We demonstrated that a PSM can reliably and reproducibly assess mild-to-moderate MS. Its low cost and the immediacy of results may offer considerable added-value decision support for surgeons. This tool could avoid the detrimental and prolonged ischaemia caused by the pathological examination of (potentially) marginal grafts. This device now needs to be assessed in the context of a large-scale multicentre study. LAY SUMMARY Macro-vacuolar liver steatosis is a major prognostic factor for outcomes after liver transplantation. However, it is often difficult for logistical reasons to get this estimation during procurement. Therefore, we developed an algorithm for a commercial, portable and affordable spectrometer to accurately estimate this content in a real-time fashion. This device could be of great interest for clinical decision-making to accept or discard a potential human liver graft.
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Affiliation(s)
- Nicolas Golse
- Department of Surgery, Paul-Brousse Hospital Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif 94800, France; DHU Hepatinov, Villejuif 94800, France; INSERM, Unit 1193, Villejuif 94800, France; Univ Paris-Sud, UMR-S 1193, Villejuif 94800, France.
| | - Cyril Cosse
- Faculty of Medicine Paris V, Paris 75020, France
| | - Marc-Antoine Allard
- Department of Surgery, Paul-Brousse Hospital Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif 94800, France
| | - Andrea Laurenzi
- Department of Surgery, Paul-Brousse Hospital Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif 94800, France
| | - Michele Tedeschi
- Department of Surgery, Paul-Brousse Hospital Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif 94800, France
| | - Nicola Guglielmo
- Department of Surgery, Paul-Brousse Hospital Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif 94800, France
| | - Elena Fernandez-Sevilla
- Department of Surgery, Paul-Brousse Hospital Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif 94800, France
| | - Maud Robert
- Department of General Surgery and Bariatric Surgery, Edouard Herriot Hospital, Hospices Civils de Lyon-Claude Bernard Lyon 1 University, France
| | - Boris Tréchot
- Department of Surgery, Paul-Brousse Hospital Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif 94800, France
| | - Daniel Pietrasz
- Department of Surgery, Paul-Brousse Hospital Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif 94800, France
| | - Gabriella Pittau
- Department of Surgery, Paul-Brousse Hospital Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif 94800, France
| | - Oriana Ciacio
- Department of Surgery, Paul-Brousse Hospital Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif 94800, France
| | - Antonio Sa Cunha
- Department of Surgery, Paul-Brousse Hospital Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif 94800, France; DHU Hepatinov, Villejuif 94800, France; INSERM, Unit 1193, Villejuif 94800, France; Univ Paris-Sud, UMR-S 1193, Villejuif 94800, France
| | - Denis Castaing
- Department of Surgery, Paul-Brousse Hospital Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif 94800, France; DHU Hepatinov, Villejuif 94800, France; INSERM, Unit 1193, Villejuif 94800, France; Univ Paris-Sud, UMR-S 1193, Villejuif 94800, France
| | - Daniel Cherqui
- Department of Surgery, Paul-Brousse Hospital Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif 94800, France; DHU Hepatinov, Villejuif 94800, France; INSERM, Unit 1193, Villejuif 94800, France; Univ Paris-Sud, UMR-S 1193, Villejuif 94800, France
| | - René Adam
- Department of Surgery, Paul-Brousse Hospital Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif 94800, France; DHU Hepatinov, Villejuif 94800, France; INSERM, Unit 776, Villejuif F-94800, France; Univ Paris-Sud, UMR-S 776, Villejuif 94800, France
| | - Didier Samuel
- DHU Hepatinov, Villejuif 94800, France; INSERM, Unit 1193, Villejuif 94800, France; Univ Paris-Sud, UMR-S 1193, Villejuif 94800, France; Department of Hepatology, Paul-Brousse Hospital Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif 94800, France
| | - Mylene Sebagh
- Department of Pathology, Paul-Brousse Hospital Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif 94800, France
| | - Eric Vibert
- Department of Surgery, Paul-Brousse Hospital Assistance Publique Hôpitaux de Paris, Centre Hépato-Biliaire, Villejuif 94800, France; DHU Hepatinov, Villejuif 94800, France; INSERM, Unit 1193, Villejuif 94800, France; Univ Paris-Sud, UMR-S 1193, Villejuif 94800, France
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127
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Croome KP, Lee DD, Taner CB. The "Skinny" on Assessment and Utilization of Steatotic Liver Grafts: A Systematic Review. Liver Transpl 2019; 25:488-499. [PMID: 30817859 DOI: 10.1002/lt.25408] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 12/25/2018] [Indexed: 02/07/2023]
Abstract
The frequency at which steatotic deceased donor liver grafts are encountered will likely continue to increase. Utilization of liver grafts with moderate-to-severe steatosis for liver transplantation (LT) has been previously shown to be associated with increased rates of primary nonfunction and decreased recipient survival. In order to better inform clinical decision making and guide future research, critical evaluation of the literature on donor liver steatosis and posttransplantation outcome is needed. This literature review aims to provide the "skinny" on using deceased donor steatotic livers for LT.
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Affiliation(s)
| | - David D Lee
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
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128
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Lynch RJ. Backing Into Benefit: What Fringe Donors Can Teach the Mainstream. Liver Transpl 2019; 25:205-206. [PMID: 30586219 DOI: 10.1002/lt.25404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 12/20/2018] [Indexed: 01/13/2023]
Affiliation(s)
- Raymond J Lynch
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
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129
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Czigany Z, Lurje I, Tolba RH, Neumann UP, Tacke F, Lurje G. Machine perfusion for liver transplantation in the era of marginal organs-New kids on the block. Liver Int 2019; 39:228-249. [PMID: 30129192 DOI: 10.1111/liv.13946] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/26/2018] [Accepted: 08/16/2018] [Indexed: 12/12/2022]
Abstract
In the face of a critical organ shortage in the Western world, various strategies are employed to expand the donor pool for orthotopic liver transplantation (OLT). Among them is the transplantation of organs from extended criteria donors, a valuable source of liver allografts, however, characterized by potential risks for post-OLT complications and inferior outcomes. In recent years, machine perfusion (MP) of the explanted donor liver as well as regional perfusion techniques has witnessed significant advancements. Here, we aim to discuss different modes of dynamic organ preservation in OLT. These include hypothermic and normothermic MP, hypothermic oxygenated machine perfusion (HOPE), controlled oxygenated rewarming as well as regional perfusion protocols. Over recent years, multiple feasibility trials have demonstrated the clinical prospects of MP. In the context of OLT using organs from extended criteria donors, MP has numerous advantages compared to conventional cold storage, some of which include the preservation and reconditioning of borderline transplantable organs and the viability assessment of high-risk donor allografts. This review aims to address the topic of liver allograft MP, highlighting particularly the current trends in clinical applications and future perspectives. Furthermore, different approaches of liver storage and reconditioning are reviewed in the context of ongoing research.
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Affiliation(s)
- Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Isabella Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Rene H Tolba
- Institute for Laboratory Animal Science, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulf P Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany.,Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Frank Tacke
- Department of Gastroenterology, Metabolic Disorders and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Georg Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
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130
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Otto G. Donor Shortage in Germany: Impact on Short- and Long-Term Results in Liver Transplantation. Visc Med 2019; 34:449-452. [PMID: 30675492 DOI: 10.1159/000493891] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
With slightly more than 10 donors per million inhabitants, Germany belongs to the underdeveloped countries in Europe with regard to organ donation. Organ shortage is supposed to promote the usage of organs which are declined in case of less pronounced scarcity. This may result in deteriorated graft and patient survival. In the light of this situation, data on the centers' procedures and outcome of liver transplantation in Germany is presented based upon reports of Eurotransplant, the German Institutions for Quality Assessment, and the Deutsche Stiftung Organtransplantation. Surprisingly, along with an increasing organ scarcity, the outcome during waiting time and after transplantation has been improved. The 1- and 3-year patient survival improved by 7 and 9%, respectively. Reasons for this unexpected development are discussed.
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Affiliation(s)
- Gerd Otto
- Dir. em. of the Department of Hepatobiliary and Transplant Surgery, University Medical Center Mainz, Mainz, Germany
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131
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132
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Rampes S, Ma D. Hepatic ischemia-reperfusion injury in liver transplant setting: mechanisms and protective strategies. J Biomed Res 2019; 33:221-234. [PMID: 32383437 DOI: 10.7555/jbr.32.20180087] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Hepatic ischemia-reperfusion injury is a major cause of liver transplant failure, and is of increasing significance due to increased use of expanded criteria livers for transplantation. This review summarizes the mechanisms and protective strategies for hepatic ischemia-reperfusion injury in the context of liver transplantation. Pharmacological therapies, the use of pre-and post-conditioning and machine perfusion are discussed as protective strategies. The use of machine perfusion offers significant potential in the reconditioning of liver grafts and the prevention of hepatic ischemia-reperfusion injury, and is an exciting and active area of research, which needs more study clinically.
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Affiliation(s)
- Sanketh Rampes
- Faculty of Life Sciences & Medicine, King's College London, London SE1 1U, UK
| | - Daqing Ma
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London SW10 9NH, UK
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133
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Prevalence of Steatosis Hepatis in the Eurotransplant Region: Impact on Graft Acceptance Rates. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2018; 2018:6094936. [PMID: 30515073 PMCID: PMC6236971 DOI: 10.1155/2018/6094936] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/17/2018] [Indexed: 12/11/2022]
Abstract
Due to the shortage of liver allografts and the rising prevalence of fatty liver disease in the general population, steatotic liver grafts are considered for transplantation. This condition is an important risk factor for the outcome after transplantation. We here analyze the characteristics of the donor pool offered to the Charité – Universitätsmedizin Berlin from 2010 to 2016 with respect to liver allograft nonacceptance and steatosis hepatis. Of the 2653 organs offered to our center, 19.9% (n=527) were accepted for transplantation, 58.8% (n=1561) were allocated to other centers, and 21.3% (n = 565) were eventually discarded from transplantation. In parallel to an increase of the incidence of steatosis hepatis in the donor pool from 20% in 2010 to 30% in 2016, the acceptance rates for steatotic organs increased in our center from 22.3% to 51.5% in 2016 (p < 0.001), with the majority (86.9%; p > 0.001) having less than 30% macrovesicular steatosis hepatis. However, by 2016, the number of canceled transplantations due to higher grades of steatosis hepatis had significantly increased from 14.7% (n = 15) to 63.6% (42; p < 0.001). The rising prevalence of steatosis hepatis in the donor pool has led to higher acceptance rates of steatotic allografts. Nonetheless, steatosis hepatis remains a predominant phenomenon in discarded organs necessitating future concepts such as organ reconditioning to increase graft utilization.
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134
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De Carlis R, Di Sandro S, Lauterio A, Botta F, Ferla F, Andorno E, Bagnardi V, De Carlis L. Liver Grafts From Donors After Circulatory Death on Regional Perfusion With Extended Warm Ischemia Compared With Donors After Brain Death. Liver Transpl 2018; 24:1523-1535. [PMID: 30022597 DOI: 10.1002/lt.25312] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/19/2018] [Accepted: 07/11/2018] [Indexed: 02/07/2023]
Abstract
Donation after circulatory death (DCD) in Italy constitutes a relatively unique population because of the requirement of a no-touch period of 20 minutes. The first aim of this study was to compare liver transplantations from donors who were maintained on normothermic regional perfusion after circulatory death and suffered extended warm ischemia (DCD group, n = 20) with those from donors who were maintained on extracorporeal membrane oxygenation (ECMO) and succumbed to brain death (ECMO group, n = 17) and those from standard donors after brain death (donation after brain death [DBD] group, n = 52). Second, we conducted an explorative analysis on the DCD group to identify relationships between the donor characteristics and the transplant outcomes. The 1-year patient survival for the DCD group (95%) was not significantly different from that of the ECMO group (87%; P = 0.47) or the DBD group (94%; P = 0.94). Graft survival was slightly inferior in the DCD group (85%) because of a high rate of primary nonfunction (10%) and retransplantation (15%) but was not significantly different from the ECMO group (87%; P = 0.76) or the DBD group (91%; P = 0.20). Although ischemic cholangiopathy was more frequent in the DCD group (10%), this issue did not adversely impact graft survival because none of the recipients underwent retransplantation due to biliary complications. Moreover, the DCD recipients were more likely to develop posttransplant renal dysfunction with the need for renal replacement therapy. Further analysis of the DCD group showed that warm ischemia >125 minutes and an Ishak fibrosis score of 1 at liver biopsy negatively impacted serum creatinine and alanine transaminase levels in the first posttransplant week, respectively. In conclusion, our findings encourage the use of liver grafts from DCD donors maintained by regional perfusion after proper selection.
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Affiliation(s)
- Riccardo De Carlis
- Department of General Surgery and Transplantation, Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Surgical Sciences, University of Pavia, Pavia, Italy
| | - Stefano Di Sandro
- Department of General Surgery and Transplantation, Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Andrea Lauterio
- Department of General Surgery and Transplantation, Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesca Botta
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Fabio Ferla
- Department of General Surgery and Transplantation, Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Enzo Andorno
- Department of General Surgery, Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliera Universitaria San Martino, Genoa, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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135
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The Transplant Index: A Novel Method to Predict Adult Liver Transplant Waitlist Outcomes. Transplantation 2018; 103:1152-1158. [PMID: 30300288 DOI: 10.1097/tp.0000000000002479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The field of transplantation is shifting outcome priorities from 1-year survival to more comprehensive metrics including transplant rate and waitlist mortality. Identifying disenfranchised candidates (high waitlist death risk, low transplantation chance) can be a focus to improve outcomes. METHODS Given the waitlist outcomes (continued waiting, death, and transplantation), we aimed to identify factors predicting the likelihood candidates would undergo transplant or death by performing multivariate competing risk analyses of 121 198 candidates in the United Network for Organ Sharing database. We incorporated these probabilities (likelihood of transplantation and waitlist death) into the Transplant Index (TI) to identify disenfranchised candidates (high likelihood of death, low likelihood of transplantation). RESULTS Half of the patients had low incidences of death and transplantation within 90 days (TI-inactive). The remaining were stratified into 10 groups within a predictive index, the TI. Low TI groups (TI 10, 20, 30) had 90-day transplant rates of 50.8%, 41.6%, and 39.8% respectively, and their respective 90-day death rates were 22.8%, 15.1%, and 10.9%. High TI groups (TI 80, 90, >90) had 90-day transplantation rates of 53.7%, 64.3%, and 73.9%, respectively, and 90-day death rates of 5.9%, 6.5%, and 6.7% respectively. As TI increased, the likelihood of transplantation increased and that of death decreased. Low-TI groups represent the disenfranchised candidates. CONCLUSIONS The TI identifies disenfranchised candidates on the adult liver transplant waitlist. This is the subgroup that would benefit the most from efforts to increase access to transplantation.
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136
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Boteon YL, Boteon APCS, Attard J, Mergental H, Mirza DF, Bhogal RH, Afford SC. Ex situ machine perfusion as a tool to recondition steatotic donor livers: Troublesome features of fatty livers and the role of defatting therapies. A systematic review. Am J Transplant 2018; 18:2384-2399. [PMID: 29947472 DOI: 10.1111/ajt.14992] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/13/2018] [Accepted: 06/18/2018] [Indexed: 02/06/2023]
Abstract
Long-standing research has shown that increased lipid content in donor livers is associated with inferior graft outcomes posttransplant. The global epidemic that is obesity has increased the prevalence of steatosis in organ donors, to the extent that it has become one of the main reasons for declining livers for transplantation. Consequently, it is one of the major culprits behind the discrepancy between the number of donor livers offered for transplantation and those that go on to be transplanted. Steatotic livers are characterized by poor microcirculation, depleted energy stores because of an impaired capacity for mitochondrial recovery, and a propensity for an exaggerated inflammatory response following reperfusion injury culminating in poorer graft function postoperatively. Ex situ machine perfusion, currently a novel method in graft preservation, is showing great promise in providing a tool for the recovery and reconditioning of marginal livers. Hence, reconditioning these steatotic livers using machine perfusion has the potential to increase the number of liver transplants performed. In this review, we consider the problematic issues associated with fatty livers in the realm of transplantation and discuss pharmacological and nonpharmacological options that are being developed to enhance recovery of these organs using machine perfusion and defatting strategies.
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Affiliation(s)
- Yuri L Boteon
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Amanda P C S Boteon
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Joseph Attard
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Darius F Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ricky H Bhogal
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon C Afford
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, UK
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137
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Jayant K, Reccia I, Shapiro AMJ. Normothermic ex-vivo liver perfusion: where do we stand and where to reach? Expert Rev Gastroenterol Hepatol 2018; 12:1045-1058. [PMID: 30064278 DOI: 10.1080/17474124.2018.1505499] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Nowadays liver transplantation is considered as the treatment of choice, however, the scarcity of suitable donor organs limits the delivery of care to the end-stage liver disease patients leading to the death while on the waiting list. The advent of ex-situ normothermic machine perfusion (NMP) has emerged as an alternative to the standard organ preservation technique, static cold storage (SCS). The newer technique promises to not only restore the normal metabolic activity but also attempt to recondition the marginal livers back to the pristine state, which are otherwise more susceptible to ischemic injury and foster the poor post-transplant outcomes. Areas covered: An extensive search of all the published literature describing the role of NMP based device in liver transplantation as an alternative to SCS was made on MEDLINE, EMBASE, Cochrane, BIOSIS, Crossref, Scopus databases and clinical trial registry on 10 May 2018. Expert commentary: The main tenet of NMP is the establishment of the physiological milieu, which permits aerobic metabolism to continue through out the period of preservation and limits the effects of ischemia-reperfusion (I/R) injury. In addition, by assessing the various metabolic and synthetic parameters the viability and suitability of donor livers for transplantation can be determined. This important technological advancement has scored satisfactorily on the safety and efficacy parameters in preliminary clinical studies. The present review suggests that NMP can offer the opportunity to assess and safely utilize the marginal donor livers if deemed appropriate for the transplantation. However, ongoing trials will determine its full potential and further adoption.
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Affiliation(s)
- Kumar Jayant
- a Department of Surgery and Cancer , Imperial College London , London , UK
| | - Isabella Reccia
- a Department of Surgery and Cancer , Imperial College London , London , UK
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138
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Singanayagam A, Bernal W. Transplantation for the Very Sick Patient—Donor and Recipient Factors. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0197-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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139
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Boteon YL, Wallace L, Boteon APCS, Mirza DF, Mergental H, Bhogal RH, Afford S. An effective protocol for pharmacological defatting of primary human hepatocytes which is non-toxic to cholangiocytes or intrahepatic endothelial cells. PLoS One 2018; 13:e0201419. [PMID: 30044872 PMCID: PMC6059478 DOI: 10.1371/journal.pone.0201419] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/14/2018] [Indexed: 12/14/2022] Open
Abstract
Introduction Pharmacological defatting of rat hepatocytes and hepatoma cell lines suggests that the same method could be used to ameliorate macrovesicular steatosis in moderate to severely fatty livers. However there is no data assessing the effects of those drugs on primary human liver cells. We aimed to determine the effectiveness of a pharmacological cocktail in reducing the in vitro lipid content of primary human hepatocytes (PHH). In addition we sought to determine the cytotoxicity of the cocktail towards non-parenchymal liver cells. Methods Steatosis was induced in PHH by supplementation with a combination of saturated and unsaturated free fatty acids. This was followed by addition of a defatting drug cocktail for up to 48 hours. The same experimental method was used with human intra-hepatic endothelial cells (HIEC) and human cholangiocytes. MTT assay was used to assess cell viability, triglyceride quantification and oil red O staining were used to determine intracellular lipids content whilst ketone bodies were measured in the supernatants following experimentation. Results Incubation of fat loaded PHH with the drugs over 48 hours reduced the intracellular lipid area by 54%, from 12.85% to 5.99% (p = 0.002) (percentage of total oil red O area), and intracellular triglyceride by 35%, from 28.24 to 18.30 nmol/million of cells (p<0.001). Total supernatant ketone bodies increased 1.4-fold over 48 hours in the defatted PHH compared with vehicle controls (p = 0.002). Moreover incubation with the drugs for 48 hours increased the viability of PHH by 11%, cholangiocytes by 25% whilst having no cytotoxic effects on HIEC. Conclusion These data demonstrate that pharmacological intervention can significantly decrease intracellular lipid content of PHH, increase fatty acids β-oxidation whilst being non-toxic to PHH, HIEC or cholangiocytes.
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Affiliation(s)
- Yuri L. Boteon
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Lorraine Wallace
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Amanda P. C. S. Boteon
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Darius F. Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Ricky H. Bhogal
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Simon Afford
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- * E-mail:
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140
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Vinaixa C, Selzner N, Berenguer M. Fat and liver transplantation: clinical implications. Transpl Int 2018; 31:828-837. [DOI: 10.1111/tri.13288] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/14/2018] [Accepted: 06/01/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Carmen Vinaixa
- Hepatology and Liver Transplantation Unit; Hospital Universitario y Politécnico La Fe; Valencia Spain
| | - Nazia Selzner
- Multi Organ Transplant Program; Liver Transplant Unit; University Health Network; University of Toronto; Toronto ON Canada
| | - Marina Berenguer
- Hepatology and Liver Transplantation Unit; Hospital Universitario y Politécnico La Fe; Valencia Spain
- CIBERehd; Instituto Carlos III; Madrid Spain
- Faculty of Medicine; University of Valencia; Valencia Spain
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141
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Jayant K, Reccia I, Virdis F, Shapiro AMJ. The Role of Normothermic Perfusion in Liver Transplantation (TRaNsIT Study): A Systematic Review of Preliminary Studies. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2018; 2018:6360423. [PMID: 29887782 PMCID: PMC5985064 DOI: 10.1155/2018/6360423] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/18/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The success of liver transplantation has been limited by the unavailability of suitable donor livers. The current organ preservation technique, i.e., static cold storage (SCS), is not suitable for marginal organs. Alternatively, normothermic machine perfusion (NMP) promises to recreate the physiological environment and hence holds promise for the better organ preservation. The objective of this systematic review is to provide an overview of the safety, benefits, and insight into the other potential useful parameters of NMP in the liver preservation. MATERIAL AND METHODS We searched the current literature following registration in the International Prospective Register of Systematic Reviews (PROSPERO) with registration number CRD42018086034 for prospective trials comparing the role of NMP device to SCS in liver transplant by searching the PubMed, EMBASE, Cochrane, BIOSIS, Crossref, and Scopus databases and clinical trial registry. RESULTS The literature search identified five prospective clinical trials (four being early phase single institutional and single randomized multi-institutional) comparing 187 donor livers on NMP device to 273 donor livers on SCS. The primary outcome of interest was to assess the safety and graft survival at day 30 after transplant following NMP of the donor liver. Secondary outcomes included were early allograft dysfunction (EAD) in the first seven days; serum measures of liver functions as bilirubin, aspartate aminotransferase (AST), alanine amino transferase (ALT), alkaline phosphatase (ALP), and international normalized ratio (INR) on days 1-7; major complications as defined by a Clavien-Dindo score ≥ 3; and patient and graft survival and biliary complications at six months. The peaked median AST level between days 1 and 7 in the five trials was 417-1252 U/L (range 84-15009 U/L) while on NMP and 839-1474 U/L (range 153-8786 U/L) in SCS group. The median bilirubin level on day 7 ranged within 25-79 µmol/L (range 8-344 µmol/l) and 30-47.53 µmol/l (range 9-340 µmol/l) in NMP and SCS groups, respectively. A single case of PNF was reported in NMP group in the randomized trial while none of the other preliminary studies reported any in either group. There was intertrial variability in EAD which ranged within 15-56% in NMP group while being within 23-37% in SCS group. Biliary complications observed in NMP group ranged from 0 to 20%. Single device malfunction was reported in randomized controlled trial leading to renouncement of transplant while none of the other trials reported any machine failure, although two user related device errors inadvertent were reported. CONCLUSION This review outlines that NMP not only demonstrated safety and efficacy but also provided the favourable environment of organ preservation, repair, and viability assessment to donor liver prior to the transplantation with low rate of posttransplantation complication as PNF, EAD, and biliary complication; however further studies are needed to broaden our horizon.
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Affiliation(s)
- Kumar Jayant
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Isabella Reccia
- Department of Surgery and Cancer, Imperial College London, London, UK
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Allard MA, Castro-Benitez C, Imai K, Selten J, Lopez A, Sebagh M, Lemoine A, Sa Cunha A, Cherqui D, Castaing D, Vibert E, Adam R. Suitability of livers for transplantation when treated by normothermic machine perfusion. Clin Transplant 2018; 32:e13256. [DOI: 10.1111/ctr.13256] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2018] [Indexed: 01/27/2023]
Affiliation(s)
- Marc-Antoine Allard
- Centre Hépatobiliaire; Paul Brousse Hospital; Villejuif France
- Institut National de la Santé et de la Recherche (INSERM) Unité 935; Villejuif France
| | - Carlos Castro-Benitez
- Centre Hépatobiliaire; Paul Brousse Hospital; Villejuif France
- Institut National de la Santé et de la Recherche (INSERM) Unité 935; Villejuif France
| | - Katsunori Imai
- Centre Hépatobiliaire; Paul Brousse Hospital; Villejuif France
| | - Jasmijn Selten
- Centre Hépatobiliaire; Paul Brousse Hospital; Villejuif France
| | - Alexandre Lopez
- Institut National de la Santé et de la Recherche (INSERM) Unité 935; Villejuif France
| | - Mylène Sebagh
- INSERM Unité 1193; Villejuif France
- Department of Pathology; Paul Brousse Hospital; Villejuif France
| | - Antoinette Lemoine
- Department of Pathology; Paul Brousse Hospital; Villejuif France
- Department of Biochemistry and Molecular Biology; Paul Brousse Hospital; Villejuif France
| | - Antonio Sa Cunha
- Centre Hépatobiliaire; Paul Brousse Hospital; Villejuif France
- Institut National de la Santé et de la Recherche (INSERM) Unité 935; Villejuif France
| | - Daniel Cherqui
- Centre Hépatobiliaire; Paul Brousse Hospital; Villejuif France
- Department of Pathology; Paul Brousse Hospital; Villejuif France
| | - Denis Castaing
- Centre Hépatobiliaire; Paul Brousse Hospital; Villejuif France
- Department of Pathology; Paul Brousse Hospital; Villejuif France
| | - Eric Vibert
- Centre Hépatobiliaire; Paul Brousse Hospital; Villejuif France
- Department of Pathology; Paul Brousse Hospital; Villejuif France
| | - René Adam
- Centre Hépatobiliaire; Paul Brousse Hospital; Villejuif France
- Institut National de la Santé et de la Recherche (INSERM) Unité 935; Villejuif France
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143
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Zhang J, Ren H, Sun Y, Li Z, Wang H, Liu Z, Zhou S. Outcomes of Adult Liver Transplantation from Donation After Brain Death Followed by Circulatory Death in China. Ann Transplant 2018; 23:285-291. [PMID: 29712886 PMCID: PMC6248057 DOI: 10.12659/aot.907790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background Organ donation from a deceased donor, which is donation after brain death followed by circulatory death, is a unique transplantation practice in China. Pathological features of grafts help guide the utilization of grafts. Material/Methods We retrospectively reviewed our experiences in 188 DBCD allografts from May 2014 to April 2017. We divided 183 transplanted allografts into 3 groups according to pretransplant histology: the good quality graft group (n=62), the preservation injury group (n=27), and the steatotic graft group (n=94). Univariate and multivariate analyses were performed to identify factors in the steatotic graft group predicting the prognoses. Results The prevalence rates of allografts in the good quality, steatotic liver, and preservation injury groups were 33.0% (62/188), 50.0% (94/188), and 14.4%(27/188), respectively, and the discarded rate was 2.7% (5/188). The 1- and 3-year overall survival rates were 92.1% and 88.1%, respectively. There were no differences in 1- and 3-year patient survival among the 3 groups (p=0.615). Some complications occurred: acute rejection in 7 cases, lung infection in 11 recipients, biliary stricture and bile leak in 9 patients, and portal thrombosis in 1 recipient; 17 recipients died of various causes. Cox multivariate analysis revealed that longer cold storage time was associated with worse outcome in the steatotic graft group. Conclusions Clinical outcomes of adult liver transplantation from deceased donation in China are acceptable.
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Affiliation(s)
- Jiabin Zhang
- Center of Hepatopancreatobiliary Surgery and Liver Transplantation, 302 Hospital, Beijing, China (mainland)
| | - Hui Ren
- Center of Hepatopancreatobiliary Surgery and Liver Transplantation, 302 Hospital, Beijing, China (mainland)
| | - Yanling Sun
- Center of Hepatopancreatobiliary Surgery and Liver Transplantation, 302 Hospital, Beijing, China (mainland)
| | - Zhijie Li
- Center of Hepatopancreatobiliary Surgery and Liver Transplantation, 302 Hospital, Beijing, China (mainland)
| | - Hongbo Wang
- Center of Hepatopancreatobiliary Surgery and Liver Transplantation, 302 Hospital, Beijing, China (mainland)
| | - Zhenwen Liu
- Center of Hepatopancreatobiliary Surgery and Liver Transplantation, 302 Hospital, Beijing, China (mainland)
| | - Shaotang Zhou
- Center of Hepatopancreaticobiliary Surgery and Liver Transplantation, 302 Hospital, Beijing, China (mainland)
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144
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Endothelial Dysfunction in Steatotic Human Donor Livers: A Pilot Study of the Underlying Mechanism During Subnormothermic Machine Perfusion. Transplant Direct 2018; 4:e345. [PMID: 29796416 PMCID: PMC5959347 DOI: 10.1097/txd.0000000000000779] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 01/20/2018] [Indexed: 02/06/2023] Open
Abstract
Supplemental digital content is available in the text. Background Steatosis is a major risk factor for primary nonfunction in liver transplantations. Steatotic livers recover poorly from ischemia reperfusion injury, in part due to alterations in the microcirculation, although the exact mechanism is unclear. In this study, we tested if there were any alterations in the shear stress sensing Kruppel-like factor 2 (KLF2) and its likely downstream consequences in the ex vivo perfused human liver endothelium, which would imply perturbations in microcirculatory flow in macrosteatotic livers disrupts laminar flow to evaluate if this is a potential therapeutic target for steatotic livers. Methods Using a subnormothermic machine perfusion system, 5 macrosteatotic and 4 nonsteatotic human livers were perfused for 3 hours. Flow, resistance, and biochemical profile were monitored. Gene expression levels of nitric oxide synthase 3 (eNOS), KLF2, and thrombomodulin were determined. Nitric oxide (NO) was measured in the perfusion fluid and activation of eNOS was measured with Western blotting. Results Flow dynamics, injury markers, and bile production were similar in both groups. Kruppel-like factor 2 expression was significantly higher in nonsteatotic livers. Western blotting analyses showed significantly higher levels of activated eNOS in nonsteatotic livers, consistent with an increase in NO production over time. Macrosteatotic livers showed decreased KLF2 upregulation, eNOS activity, and NO production during machine perfusion. Conclusions These results indicate a perturbed KLF2 sensing in steatotic livers, which aligns with perturbed microcirculatory state. This may indicate endothelial dysfunction and contribute to poor posttransplantation outcomes in fatty livers, and further studies to confirm by evaluation of flow and testing treatments are warranted.
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145
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Mikolasevic I, Filipec-Kanizaj T, Mijic M, Jakopcic I, Milic S, Hrstic I, Sobocan N, Stimac D, Burra P. Nonalcoholic fatty liver disease and liver transplantation - Where do we stand? World J Gastroenterol 2018; 24:1491-1506. [PMID: 29662288 PMCID: PMC5897854 DOI: 10.3748/wjg.v24.i14.1491] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/19/2018] [Accepted: 03/25/2018] [Indexed: 02/06/2023] Open
Abstract
Nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH) is a challenging and multisystem disease that has a high socioeconomic impact. NAFLD/NASH is a main cause of macrovesicular steatosis and has multiple impacts on liver transplantation (LT), on patients on the waiting list for transplant, on post-transplant setting as well as on organ donors. Current data indicate new trends in the area of chronic liver disease. Due to the increased incidence of metabolic syndrome (MetS) and its components, NASH cirrhosis and hepatocellular carcinoma caused by NASH will soon become a major indication for LT. Furthermore, due to an increasing incidence of MetS and, consequently, NAFLD, there will be more steatotic donor livers and less high quality organs available for LT, in addition to a lack of available liver allografts. Patients who have NASH and are candidates for LT have multiple comorbidities and are unique LT candidates. Finally, we discuss long-term grafts and patient survival after LT, the recurrence of NASH and NASH appearing de novo after transplantation. In addition, we suggest topics and areas that require more research for improving the health care of this increasing patient population.
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Affiliation(s)
- Ivana Mikolasevic
- Department of Gastroenterology, UHC Rijeka, School of Medicine, University of Rijeka, Rijeka 51000, Croatia
| | - Tajana Filipec-Kanizaj
- Department of Gastroenterology, University Hospital Merkur, School of Medicine, University of Zagreb, Zagreb 10000, Croatia
| | - Maja Mijic
- Department of Gastroenterology, University Hospital Merkur, School of Medicine, University of Zagreb, Zagreb 10000, Croatia
| | - Ivan Jakopcic
- Department of Gastroenterology, UHC Rijeka, School of Medicine, University of Rijeka, Rijeka 51000, Croatia
| | - Sandra Milic
- Department of Gastroenterology, UHC Rijeka, School of Medicine, University of Rijeka, Rijeka 51000, Croatia
| | - Irena Hrstic
- Department of Internal medicine, General Hospital Pula, Pula, School of Medicine, University of Rijeka and Zagreb, Pula 52100, Croatia
| | - Nikola Sobocan
- Department of Gastroenterology, University Hospital Merkur, School of Medicine, University of Zagreb, Zagreb 10000, Croatia
| | - Davor Stimac
- Department of Gastroenterology, UHC Rijeka, School of Medicine, University of Rijeka, Rijeka 51000, Croatia
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
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146
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Linecker M, Krones T, Berg T, Niemann CU, Steadman RH, Dutkowski P, Clavien PA, Busuttil RW, Truog RD, Petrowsky H. Potentially inappropriate liver transplantation in the era of the "sickest first" policy - A search for the upper limits. J Hepatol 2018; 68:798-813. [PMID: 29133246 DOI: 10.1016/j.jhep.2017.11.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/11/2017] [Accepted: 11/06/2017] [Indexed: 12/11/2022]
Abstract
Liver transplantation has emerged as a highly efficient treatment for a variety of acute and chronic liver diseases. However, organ shortage is becoming an increasing problem globally, limiting the applicability of liver transplantation. In addition, potential recipients are becoming sicker, thereby increasing the risk of losing the graft during transplantation or in the initial postoperative period after liver transplantation (three months). This trend is challenging the model for end-stage liver disease allocation system, where the sickest candidates are prioritised and no delisting criteria are given. The weighting of the deontological demand for "equity", trying to save every patient, regardless of the overall utility; and "efficiency", rooted in utilitarianism, trying to save as many patients as possible and increase the overall quality of life of patients facing the same problem, has to be reconsidered. In this article we are aiming to overcome the widespread concept of futility in liver transplantation, providing a definition of potentially inappropriate liver transplantation and giving guidance on situations where it is best not to proceed with liver transplantation, to decrease the mortality rate in the first three months after transplantation. We propose "absolute" and "relative" conditions, where early post-transplant mortality is highly probable, which are not usually captured in risk scores predicting post-transplant survival. Withholding liver transplantation for listed patients in cases where liver transplant is not deemed clearly futile, but is potentially inappropriate, is a far-reaching decision. Until now, this decision had to be discussed extensively on an individual basis, applying explicit communication and conflict resolution processes, since the model for end-stage liver disease score and most international allocation systems do not include explicit delisting criteria to support a fair delisting process. More work is needed to better identify cases where transplantation is potentially inappropriate and to integrate and discuss these delisting criteria in allocation systems, following a societal debate on what we owe to all liver transplant candidates.
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Affiliation(s)
- Michael Linecker
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Tanja Krones
- Division of Clinical Ethics, University Hospital Zurich, Switzerland; Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland
| | - Thomas Berg
- Division of Hepatology, University of Leipzig, Germany
| | - Claus U Niemann
- Department of Anesthesiology, University of California, San Francisco, USA; Department of Surgery, University of California San Francisco, USA
| | - Randolph H Steadman
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, USA
| | - Philipp Dutkowski
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Pierre-Alain Clavien
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Ronald W Busuttil
- Dumont-UCLA Transplant Center, Ronald Reagan Medical Center, University of California Los Angeles, USA
| | - Robert D Truog
- Center for Bioethics, Harvard Medical School, Boston, USA; Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, USA
| | - Henrik Petrowsky
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland.
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147
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Ceresa CDL, Nasralla D, Jassem W. Normothermic Machine Preservation of the Liver: State of the Art. CURRENT TRANSPLANTATION REPORTS 2018; 5:104-110. [PMID: 29564207 PMCID: PMC5843699 DOI: 10.1007/s40472-018-0186-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Purpose of Review This review aims to introduce the concept of normothermic machine perfusion (NMP) and its role in liver transplantation. By discussing results from recent clinical studies and highlighting the potential opportunities provided by this technology, we aim to provide a greater insight into NMP and the role it can play to enhance liver transplantation. Recent Findings NMP has recently been shown to be both safe and feasible in liver transplantation and has also demonstrated its superiority to traditional cold storage in terms of early biochemical liver function. Through the ability to perform a viability assessment during preservation and extend preservation times, it is likely that an increase in organ utilisation will follow. NMP may facilitate the enhanced preservation with improved outcomes from donors after cardiac death and steatotic livers. Furthermore, it provides the exciting potential for liver-directed therapeutic interventions. Summary Evidence to date suggests that NMP facilitates the enhanced preservation of liver grafts with improved early post-transplant outcomes. The key role for this technology is to increase the number and quality of liver grafts available for transplantation and to reduce waiting list deaths.
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Affiliation(s)
- Carlo D L Ceresa
- 1Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - David Nasralla
- 1Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Wayel Jassem
- 2Institute of Liver Studies, King's College Hospital, London, UK
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148
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Kwong AJ, Asrani SK. Artificial neural networks and liver transplantation: Are we ready for self-driving cars? Liver Transpl 2018; 24:161-163. [PMID: 29211925 DOI: 10.1002/lt.24993] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 12/05/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Allison J Kwong
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
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Shingina A, Montenovo MI. Go/No-Go decision in donor liver utilization: The value of preretrieval liver biopsy. Liver Transpl 2018; 24:159-160. [PMID: 29266828 DOI: 10.1002/lt.24997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 12/18/2017] [Indexed: 01/13/2023]
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150
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Cold storage or normothermic perfusion for liver transplantation: probable application and indications. Curr Opin Organ Transplant 2017; 22:300-305. [PMID: 28301388 DOI: 10.1097/mot.0000000000000410] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW Preservation of the liver via normothermic machine perfusion (NMP) is rapidly becoming an area of great academic and clinical interest. This review focuses on the benefits and limitations of NMP and where the role for static cold storage may lie. RECENT FINDINGS Clinical studies have recently been published reporting the use of NMP in liver preservation for transplantation. They have described the technology to be well tolerated and feasible with potentially improved posttransplant outcomes. NMP facilitates extended preservation times as well as the potential to increase organ utilization through viability assessment and regeneration. However, this technology is considerably more costly than cold storage and carries significant logistical challenges. Cold storage remains the gold standard preservation for standard criteria livers with good long-term patient and graft survival. SUMMARY NMP is an exciting new technological advancement in liver preservation, which is likely to have a positive impact in liver transplantation. However, randomized controlled trials are required to justify its inclusion into standard practice and provide evidence to support its efficacy.
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