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Ruch B, Kumm K, Arias S, Katariya NN, Mathur AK. Donation After Circulatory Death Liver Transplantation: Early Challenges, Clinical Improvement, and Future Directions. Surg Clin North Am 2024; 104:27-44. [PMID: 37953039 DOI: 10.1016/j.suc.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Donation after circulatory death (DCD) liver allografts remain a widely underutilized source of donor organs for transplantation. Although initially linked with inferior outcomes, DCD liver transplant can achieve excellent patient and graft survival with suitable matching of donor and recipient characteristics, rapid donor recovery and precise donor assessment, and appropriate perioperative management. The advent of clinical liver perfusion modalities promises to redefine the viability parameters for DCD liver allografts and hopefully will encourage more widespread usage of this growing source of donor livers.
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Affiliation(s)
- Brianna Ruch
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA. https://twitter.com/BriannaCRuch
| | - Kayla Kumm
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA. https://twitter.com/Kayla_Kumm
| | - Sandra Arias
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Nitin N Katariya
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA. https://twitter.com/nnk_tx_hpb
| | - Amit K Mathur
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA.
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2
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Otero A, Vázquez MA, Suárez F, Pértega S, Rivas JI, Mosteiro F, Gómez M. Results in liver transplantation using grafts from donors after controlled circulatory death: A single‐center experience comparing donor grafts harvested after controlled circulatory death to those harvested after brain death. Clin Transplant 2019; 34:e13763. [DOI: 10.1111/ctr.13763] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 11/16/2019] [Accepted: 11/22/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Alejandra Otero
- Liver Transplant Unit A Coruña University Hospital A Coruña Spain
| | | | - Francisco Suárez
- Liver Transplant Unit A Coruña University Hospital A Coruña Spain
| | - Sonia Pértega
- Epidemiology and Biostatistics Unit A Coruña University Hospital A Coruña Spain
| | | | | | - Manuel Gómez
- Liver Transplant Unit A Coruña University Hospital A Coruña Spain
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3
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Radiologic Characterization of Ischemic Cholangiopathy in Donation-After-Cardiac-Death Liver Transplants and Correlation With Clinical Outcomes. AJR Am J Roentgenol 2016; 205:976-84. [PMID: 26496544 DOI: 10.2214/ajr.14.13383] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The purpose of this study was to define the cholangiographic patterns of ischemic cholangiopathy and clinically silent nonanastomotic biliary strictures in donation-after-cardiac-death (DCD) liver grafts in a large single-institution series. We also examined the correlation of the radiologic findings with laboratory data and clinical outcomes. MATERIALS AND METHODS Data were collected for all DCD liver transplants at one institution from December 1998 to December 2011. Posttransplant cholangiograms were obtained during postoperative weeks 1 and 3 and when clinically indicated. Intrahepatic biliary strictures were classified by anatomic distribution and chronologic development. Radiologic findings were correlated with laboratory data and with 1-, 3-, and 5-year graft and patient survival rates. RESULTS A total of 231 patients received DCD grafts. Cholangiograms were available for 184 of these patients. Postoperative cholangiographic findings were correlated with clinical data and divided into the following three groups: A, normal cholangiographic findings with normal laboratory values; B, radiologic abnormalities and cholangiopathy according to laboratory values; and C, radiologic abnormalities without laboratory abnormalities. Group B had four distinct abnormal cholangiographic patterns that were predictive of graft survival. Group C had mild nonprogressive multifocal stenoses and decreased graft and patient survival rates, although cholangiopathy was not detected in these patients according to laboratory data. CONCLUSION Patterns and severity of nonanastomotic biliary abnormalities in DCD liver transplants can be defined radiologically and correlate with clinical outcomes. Postoperative cholangiography can depict the mild biliary abnormalities that occur in a subclinical manner yet cause a marked decrease in graft and patient survival rates in DCD liver transplants.
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Firl DJ, Hashimoto K, O'Rourke C, Diago-Uso T, Fujiki M, Aucejo FN, Quintini C, Kelly DM, Miller CM, Fung JJ, Eghtesad B. Impact of donor age in liver transplantation from donation after circulatory death donors: A decade of experience at Cleveland Clinic. Liver Transpl 2015; 21:1494-503. [PMID: 26334196 DOI: 10.1002/lt.24316] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/23/2015] [Accepted: 08/12/2015] [Indexed: 12/12/2022]
Abstract
The use of liver grafts from donation after circulatory death (DCD) donors remains controversial, particularly with donors of advanced age. This retrospective study investigated the impact of donor age in DCD liver transplantation. We examined 92 recipients who received DCD grafts and 92 matched recipients who received donation after brain death (DBD) grafts at Cleveland Clinic from January 2005 to June 2014. DCD grafts met stringent criteria to minimize risk factors in both donors and recipients. The 1-, 3-, and 5-year graft survival in DCD recipients was significantly inferior to that in DBD recipients (82%, 71%, 66% versus 92%, 87%, 85%, respectively; P = 0.03). Six DCD recipients (7%), but no DBD recipients, experienced ischemic-type biliary stricture (P = 0.01). However, the incidence of biliary stricture was not associated with donor age (P = 0.57). Interestingly, recipients receiving DCD grafts from donors who were <45 years of age (n = 55) showed similar graft survival rates compared to those receiving DCD grafts from donors who were ≥45 years of age (n = 37; 80%, 69%, 66% versus 83%, 72%, 66%, respectively; P = 0.67). Cox proportional hazards modeling in all study populations (n = 184) revealed advanced donor age (P = 0.05) and the use of a DCD graft (P = 0.03) as unfavorable factors for graft survival. Logistic regression analysis showed that the risk of DBD graft failure increased with increasing age, but the risk of DCD graft failure did not increase with increasing age (P = 0.13). In conclusion, these data suggest that stringent donor and recipient selection may ameliorate the negative impact of donor age in DCD liver transplantation. DCD grafts should not be discarded because of donor age, per se, and could help expand the donor pool for liver transplantation.
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Affiliation(s)
- Daniel J Firl
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Koji Hashimoto
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Colin O'Rourke
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago-Uso
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Masato Fujiki
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Federico N Aucejo
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Cristiano Quintini
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Dympna M Kelly
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Charles M Miller
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - John J Fung
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Bijan Eghtesad
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
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O'Neill S, Roebuck A, Khoo E, Wigmore SJ, Harrison EM. A meta-analysis and meta-regression of outcomes including biliary complications in donation after cardiac death liver transplantation. Transpl Int 2015; 27:1159-74. [PMID: 25052036 DOI: 10.1111/tri.12403] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 05/05/2014] [Accepted: 07/12/2014] [Indexed: 12/11/2022]
Abstract
Donation after cardiac death (DCD) liver transplantation is increasingly common but concerns exist over the development of biliary complications and ischemic cholangiopathy (IC). This study aimed to compare outcomes between DCD and donation after brain death (DBD) liver grafts. Studies reporting on post-transplantation outcomes after Maastricht category III DCD liver transplantation were screened for inclusion. Odds ratios (OR) with 95% confidence intervals were produced using random-effects models for the incidence of biliary complications, IC, graft and recipient survival. Meta-regression was undertaken to identify between-study predictors of effect size for biliary complications and IC. PROSPERO Record: CRD42012002113. Twenty-five studies with 62 184 liver transplant recipients (DCD = 2478 and DBD = 59 706) were included. In comparison with DBD, there was a significant increase in biliary complications [OR = 2.4 (1.9, 3.1); P < 0.00001] and IC [OR = 10.5 (5.7, 19.5); P < 0.00001] following DCD liver transplantation. In comparison with DBD, at 1 year [OR = 0.7 (0.5, 0.8); P = 0.0002] and 3 years [OR = 0.6 (0.5, 0.8); P = 0.001], there was a significant decrease in graft survival following DCD liver transplantation. At 1 year, there was also a nonsignificant decrease [OR = 0.8 (0.6, 1.0); P = 0.08] and by 3 years a significant decrease [OR = 0.7 (0.5, 1.0); P = 0.04] found in recipient survival following DCD liver transplantation. Eleven factors were entered into meta-regression models, but none explained the variability in effect size between studies. DCD liver transplantation is associated with an increase in biliary complications, IC, graft loss and mortality. Significant unexplained differences in effect size exist between centers.
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Affiliation(s)
- Stephen O'Neill
- MRC Centre for Inflammation Research, Tissue Injury and Repair Group, University of Edinburgh, Edinburgh, UK
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Skaro AI, Zhao L, Vanwagner LB, Abecassis MM. Access to retransplantation after failed donation after circulatory death liver transplantation: eo ire itum. Am J Transplant 2014; 14:991-3. [PMID: 24731190 DOI: 10.1111/ajt.12701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 01/14/2014] [Accepted: 01/28/2014] [Indexed: 01/25/2023]
Affiliation(s)
- A I Skaro
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
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7
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Quality of life, risk assessment, and safety research in liver transplantation: new frontiers in health services and outcomes research. Curr Opin Organ Transplant 2013; 17:241-7. [PMID: 22476225 DOI: 10.1097/mot.0b013e32835365c6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW In this review, we briefly summarize three fruitful, emerging areas in liver transplantation research, quality of life; risk assessment; and patient safety. Our goal is to highlight recent findings in these areas, with a call for increased integration of social scientists and transplant clinicians to address how best to shape policy and improve outcomes. RECENT FINDINGS After liver transplantation, recipients generally experience clinically significant, sustained improvement in their physical, social and emotional well being. However, a sizeable minority of patients do experience excess morbidity that may benefit from ongoing surveillance and/or intervention. There is growing body of research that describes risks associated with liver transplantation, which can be useful aids to better inform decision making by patients, clinicians, payers, and policy makers. In contrast, there has been a relative lack of empirical data on transplant patient safety vulnerabilities, placing the field of surgery in stark contrast to other high-risk industries, wherein such assessments inform continuous process improvement. SUMMARY Health services and outcomes research has grown in importance in the liver transplantation literature, but several important questions remain unanswered that merit programmatic, interdisciplinary research.
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Dageforde LA, Feurer ID, Pinson CW, Moore DE. Is liver transplantation using organs donated after cardiac death cost-effective or does it decrease waitlist death by increasing recipient death? HPB (Oxford) 2013; 15:182-9. [PMID: 23374358 PMCID: PMC3572278 DOI: 10.1111/j.1477-2574.2012.00524.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 05/30/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the cost-effectiveness in liver transplantation (LT) of utilizing organs donated after cardiac death (DCD) compared with organs donated after brain death (DBD). METHODS A Markov-based decision analytic model was created to compare two LT waitlist strategies distinguished by organ type: (i) DBD organs only, and (ii) DBD and DCD organs. The model simulated outcomes for patients over 10 years with annual cycles through one of four health states: survival; ischaemic cholangiopathy; retransplantation, and death. Baseline values and ranges were determined from an extensive literature review. Sensitivity analyses tested model strength and parameter variability. RESULTS Overall survival is decreased, and biliary complications and retransplantation are increased in recipients of DCD livers. Recipients of DBD livers gained 5.6 quality-adjusted life years (QALYs) at a cost of US$69 000/QALY, whereas recipients on the DBD + DCD LT waitlist gained 6.0 QALYs at a cost of US$61 000/QALY. The DBD + DCD organ strategy was superior to the DBD organ-only strategy. CONCLUSIONS The extension of life and quality of life provided by DCD LT to patients on the waiting list who might otherwise not receive a liver transplant makes the continued use of DCD livers cost-effective.
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Affiliation(s)
| | - Irene D. Feurer
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C. Wright Pinson
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Derek E. Moore
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Jay CL, Skaro AI. Comparative effectiveness research in liver transplantation: crossing the cost and quality chasm. J Comp Eff Res 2013; 2:7-9. [DOI: 10.2217/cer.12.65] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Colleen L Jay
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, 676 St Clair Street, Suite 19-087, Chicago, IL 60611, USA
- Department of Surgery, Division of Transplantation Surgery, Mayo Clinic, Rochester, MN, USA
| | - Anton I Skaro
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, 676 St Clair Street, Suite 19-087, Chicago, IL 60611, USA
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Broomhead RH, Patel S, Fernando B, O'Beirne J, Mallett S. Resource implications of expanding the use of donation after circulatory determination of death in liver transplantation. Liver Transpl 2012; 18:771-8. [PMID: 22315207 DOI: 10.1002/lt.23406] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In the United Kingdom, liver transplantation using donation after circulatory determination of death (DCDD) organs has increased steadily over the last few years and now accounts for 20% of UK transplant activity. The procurement of DCDD livers is actively promoted as a means of increasing the donor pool and bridging the evolving disparity between the wait-list length and the number of transplants performed. The objective of this retrospective study of a cohort of patients who were matched for age, liver disease etiology, and Model for End-Stage Liver Disease score was to determine whether differences in perioperative costs and resource utilization are associated with the use of such organs. Our results showed an increased prevalence of reperfusion syndrome in the DCDD cohort (P < 0.001), a prolonged heparin effect (P = 0.01), a greater incidence of hyperfibrinolysis (P = 0.002), longer periods of postoperative ventilator use (P = 0.03) and vasopressor support (P = 0.002), and a prolonged length of stay in the intensive therapy unit (ITU; P = 0.02). The peak posttransplant aspartate aminotransferase level was higher in the DCDD group (P = 0.007), and there was significantly more graft failure at 12 months (P = 0.03). In conclusion, we have demonstrated different perioperative and early postoperative courses for DCDD and donation after brain death (DBD) liver transplants. The overall quality of DCDD grafts is poorer; as a result, the length of the ITU stay and the need for multiorgan support are increased, and this has significant financial and resource implications. We believe that these implications require a careful real-life consideration of benefits. It is essential for DCDD not to be seen as a like-for-like alternative to DBD and for every effort to be continued to be made to increase the number of donations from brain-dead patients as a first resort.
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Jay CL, Skaro AI, Ladner DP, Wang E, Lyuksemburg V, Chang Y, Xu H, Talakokkla S, Parikh N, Holl JL, Hazen GB, Abecassis MM. Comparative effectiveness of donation after cardiac death versus donation after brain death liver transplantation: Recognizing who can benefit. Liver Transpl 2012; 18:630-40. [PMID: 22645057 PMCID: PMC3365831 DOI: 10.1002/lt.23418] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Due to organ scarcity and wait-list mortality, transplantation of donation after cardiac death (DCD) livers has increased. However, the group of patients benefiting from DCD liver transplantation is unknown. We studied the comparative effectiveness of DCD versus donation after brain death (DBD) liver transplantation. A Markov model was constructed to compare undergoing DCD transplantation with remaining on the wait-list until death or DBD liver transplantation. Differences in life years, quality-adjusted life years (QALYs), and costs according to candidate Model for End-Stage Liver Disease (MELD) score were considered. A separate model for hepatocellular carcinoma (HCC) patients with and without MELD exception points was constructed. For patients with a MELD score <15, DCD transplantation resulted in greater costs and reduced effectiveness. Patients with a MELD score of 15 to 20 experienced an improvement in effectiveness (0.07 QALYs) with DCD liver transplantation, but the incremental cost-effectiveness ratio (ICER) was >$2,000,000/QALY. Patients with MELD scores of 21 to 30 (0.25 QALYs) and >30 (0.83 QALYs) also benefited from DCD transplantation with ICERs of $478,222/QALY and $120,144/QALY, respectively. Sensitivity analyses demonstrated stable results for MELD scores <15 and >20, but the preferred strategy for the MELD 15 to 20 category was uncertain. DCD transplantation was associated with increased costs and reduced survival for HCC patients with exception points but led to improved survival (0.26 QALYs) at a cost of $392,067/QALY for patients without exception points. In conclusion, DCD liver transplantation results in inferior survival for patients with a MELD score <15 and HCC patients receiving MELD exception points, but provides a survival benefit to patients with a MELD score >20 and to HCC patients without MELD exception points.
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Affiliation(s)
- Colleen L. Jay
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago IL
| | - Anton I. Skaro
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago IL
| | - Daniela P Ladner
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago IL
| | - Edward Wang
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago IL
| | - Vadim Lyuksemburg
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago IL
| | - Yaojen Chang
- Institute for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago IL
| | - Hongmei Xu
- McCormick School of Engineering and Applied Science, Northwestern University, Evanston IL
| | - Sandhya Talakokkla
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago IL
| | - Neehar Parikh
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago IL
| | - Jane L. Holl
- Institute for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago IL,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Gordon B Hazen
- McCormick School of Engineering and Applied Science, Northwestern University, Evanston IL
| | - Michael M. Abecassis
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago IL
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