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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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Jia D, Zhao M, Luo J, Li S, Gong J, Cheng M. Dimethyloxalylglycine pretreatment of living donor alleviates both donor and graft liver ischemia-reperfusion injury in rats. Front Pharmacol 2024; 14:1341575. [PMID: 38264531 PMCID: PMC10803591 DOI: 10.3389/fphar.2023.1341575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 12/22/2023] [Indexed: 01/25/2024] Open
Abstract
Background: Under the circumstance of the increasing waiting list for liver transplantation, living donor liver transplantation (LDLT) can alleviate the shortage of liver donors to some extent. However, how to reduce both donor and graft ischemia-reperfusion injury (IRI) is still an unsolved problem in LDLT. Hypoxia-induced transcription factor 1 (HIF1) activation is considered an important mechanism of cellular adaptation to hypoxia, and early activation of HIF1 may be a new way to alleviate liver IRI. Therefore, we aimed to investigate the impact of the HIF1 stabilizer dimethyloxalylglycine (DMOG) on IRI and the survival rate of donors and recipients of rat LDLT. Methods: Seventy percent partial liver resection and 30% partial liver transplantation were used to simulate donor and recipient of clinical LDLT. Rats were treated with DMOG (40 mg/kg) or with an equivalent amount of saline. The expression of HIF1 and downstream targets was analyzed after 2 h of reperfusion. Liver function and histopathology, apoptosis and oxidative stress levels were detected 6 h after reperfusion. At the same time, the 7-day survival rate of rats was calculated. Results: DMOG pretreatment significantly reduced IR-induced injury in the donor and recipient, which was manifested by reducing liver function damage and promoting tissue recovery. Meanwhile, compared with the untreated group, the oxidative stress level and the cell apoptosis rate were decreased in the group pretreated with DMOG. In addition, the transcription and expression of HIF1 target genes in the DMOG group were significantly enhanced. Remarkably, DMOG also increased the survival rate of the recipient. Conclusion: This study provides the first evidence that DMOG pretreatment of donors significantly alleviates liver IRI in both donors and recipients and increases the survival rate of recipients in LDLT. Therefore, DMOG may be a promising strategy for improving LDLT in the future.
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Affiliation(s)
| | | | | | | | | | - Mingxiang Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Shimada S, Yoshida A, Abouljoud M, Miyake K, Ivanics T, Shamaa T, Venkat D, Moonka D, Trudeau S, Reed E, Nagai S. Post-transplant outcomes and financial burden of donation after circulatory death donor liver transplant after the implementation of acuity circle policy. Clin Transplant 2024; 38:e15190. [PMID: 37964683 DOI: 10.1111/ctr.15190] [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] [Received: 05/22/2023] [Revised: 09/30/2023] [Accepted: 10/28/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND After implementation of the Acuity Circles (AC) allocation policy, use of DCD liver grafts has increased in the United States. METHODS We evaluated the impact of AC on rates of DCD-liver transplants (LT), their outcomes, and medical costs in a single practice. Adult LT patients were classified into three eras: Era 1 (pre-AC, 1/01/2015-12/31/2017); Era 2 (late pre-AC era, 1/01/2018-02/03/2020); and Era 3 (AC era, 05/10/2020-09/30/2021). RESULTS A total of 520 eligible LTs were performed; 87 were DCD, and 433 were DBD. With each successive era, the proportion of DCD increased (Era 1: 11%; Era 2: 20%; Era 3: 24%; p < .001). DCD recipients had longer ICU stays, higher re-admission/re-operation rates, and higher incidence of ischemic cholangiopathy compared to those with DBD. Direct, surgical, and ICU costs during first admission were higher with DCD than DBD (+8.0%, p < .001; +4.2%, p < .001; and +33.3%, p = .001). DCD-related costs increased after Era 1 (Direct: +4.9% [Era 2 vs. 1] and +12.4% [Era 3 vs. 1], p = .04; Surgical: +17.7% and +21.7%, p < .001). In the AC era, there was a significantly higher proportion of donors ≥50 years, and more national organ sharing. Compared to DCD from donors <50 years, DCD from donors ≥50 years was associated with significantly higher total direct, surgical, and ICU costs (+12.6%, p = .01; +9.5%, p = .01; +84.6%, p = .03). CONCLUSIONS The proportion of DCD-LT, especially from older donors, has increased after the implementation of AC policies. These changes are likely to be associated with higher costs in the AC era.
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Affiliation(s)
- Shingo Shimada
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Atsushi Yoshida
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Marwan Abouljoud
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Katsunori Miyake
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Tommy Ivanics
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Tayseer Shamaa
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Deepak Venkat
- Division of Gastroenterology and Hepatology, Henry Ford Health, Detroit, Michigan, USA
| | - Dilip Moonka
- Division of Gastroenterology and Hepatology, Henry Ford Health, Detroit, Michigan, USA
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA
| | - Elizabeth Reed
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Shunji Nagai
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health, Detroit, Michigan, USA
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Shen T, Zheng SH, Chen J, Zhou ZS, Yang MF, Liu XY, Chen JL, Zheng SS, Xu X. Older liver grafts from donation after circulatory death are associated with impaired survival and higher incidence of biliary non-anastomotic stricture. Hepatobiliary Pancreat Dis Int 2023; 22:577-583. [PMID: 36775686 DOI: 10.1016/j.hbpd.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 12/29/2022] [Indexed: 02/14/2023]
Abstract
BACKGROUND Grafts from older donors after circulatory death were associated with inferior outcome in liver transplants in the past. But it has seemed to remain controversial in the last decade, as a result of modified clinical protocols, selected recipients, and advanced technology of organ perfusion and preservation. The present study aimed to examine the impact of older donor age on complications and survival of liver transplant using grafts from donation after circulatory death (DCD). METHODS A total of 944 patients who received DCD liver transplantation from 2015 to 2020 were included and divided into two groups: using graft from older donor (aged ≥ 65 years, n = 87) and younger donor (age < 65 years, n = 857). Propensity score matching (PSM) was applied to eliminate selection bias. RESULTS A progressively increased proportion of liver transplants with grafts from older donors was observed from 1.68% to 15.44% during the study period. The well-balanced older donor (n = 79) and younger donor (n = 79) were 1:1 matched. There were significantly more episodes of biliary non-anastomotic stricture (NAS) in the older donor group than the younger donor group [15/79 (19.0%) vs. 6/79 (7.6%); P = 0.017]. The difference did not reach statistical significance regarding early allograft dysfunction (EAD) and primary non-function (PNF). Older livers had a trend toward inferior 1-, 2-, 3-year graft and overall survival compared with younger livers, but these differences were not statistically significant (63.1%, 57.6%, 57.6% vs. 76.9%, 70.2%, 67.7%, P = 0.112; 64.4%, 58.6%, 58.6% vs. 76.9%, 72.2%, 72.2%, P = 0.064). The only risk factor for poor survival was ABO incompatible transplant (P = 0.008) in the older donor group. In the subgroup of ABO incompatible cases, it demonstrated a significant difference in the rate of NAS between the older donor group and the younger donor group [6/8 (75.0%) vs. 3/14 (21.4%); P = 0.014]. CONCLUSIONS Transplants with grafts from older donors (aged ≥ 65 years) after circulatory death are more frequently associated with inferior outcome compared to those from younger donors. Older grafts from DCD are more likely to develop NAS, especially in ABO incompatible cases.
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Affiliation(s)
- Tian Shen
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou 310022, China
| | - Shan-Hua Zheng
- Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jun Chen
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
| | | | - Meng-Fan Yang
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
| | - Xiang-Yan Liu
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou 310022, China
| | - Jun-Li Chen
- China Liver Transplant Registry, Hangzhou 310003, China
| | - Shu-Sen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou 310022, China; Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China; NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China; Institute of Organ Transplantation, Zhejiang University, Hangzhou 310003, China
| | - Xiao Xu
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China; NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China; Institute of Organ Transplantation, Zhejiang University, Hangzhou 310003, China.
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Ray S, Shwaartz C, Sayed BA, Sapisochin G, Ghanekar A, McGilvray I, Cattral M, Lilly L, Selzner N, Tsien C, Bhat M, Jaeckel E, Selzner M, Reichman TW. Should advanced donor age be a deterrent in the utilization of grafts from donation after cardiac death in deceased donor liver transplantation? The Toronto experience. Can J Surg 2023; 66:E561-E571. [PMID: 38016726 DOI: 10.1503/cjs.001123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Advanced donor age paired with donation after cardiac death (DCD) increases the risk of transplantation, precluding widespread use of grafts from such donors worldwide. Our aim was to analyze outcomes of liver transplantation using grafts from older DCD donors and donation after brain death (DBD) donors. METHODS Patients who underwent liver transplantation using grafts from deceased donors between January 2016 and December 2021 were included in the study. Short-and long-term outcomes were analyzed for 4 groups of patients: those who received DCD and DBD grafts from younger (< 50 yr) and older (≥ 50 yr) donors. RESULTS Of the 807 patients included in the analysis, 44.7% (n = 361) of grafts were received from older donors, with grafts for older DCD donors comprising 4.7% of the total cohort (n = 38). Patients who received grafts from older donors had a lower incidence of biliary strictures than those who received grafts from younger donors (7.9% v. 20.0% for DCD donation, p = 0.14, and 4.9% v. 6.8% for DBD donation, p = 0.34), with a significantly lower incidence of ischemic-type biliary strictures in patients who received grafts from older versus younger DCD donors (2.6% v. 18.0%, p = 0.04). There was no difference in 1- and 3-year graft survival rates among patients who received grafts from older and younger DCD donors (92.1% v. 90.8% and 80.2% v. 80.9%, respectively) and those who received grafts from older and younger DBD donors (90.1% v. 93.2% and 85.3% v. 84.4%, respectively) (p = 0.85). Pretransplantation admission to the intensive care unit (hazard ratio [HR] 9.041, p < 0.001) and nonalcoholic steatohepatitis (HR 2.197, p = 0.02) were found to significantly affect survival of grafts from older donors. CONCLUSION Donor age alone should not be the criterion to determine the acceptability of grafts in liver transplantation. With careful selection criteria, older DCD donors could make a valuable contribution to expanding the liver donor pool, with grafts that produce comparable results to those obtained with standard-criteria grafts.
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Affiliation(s)
- Samrat Ray
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Chaya Shwaartz
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Blayne Amir Sayed
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Gonzalo Sapisochin
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Anand Ghanekar
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Ian McGilvray
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Mark Cattral
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Leslie Lilly
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Nazia Selzner
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Cynthia Tsien
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Mamatha Bhat
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Elmar Jaeckel
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Markus Selzner
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
| | - Trevor W Reichman
- From the Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ont. (Ray, Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman); and the Department of Surgery, University of Toronto, Toronto, Ont. (Schwaartz, Sayed, Sapisochin, Ghanekar, McGilvray, Cattral, Lilly, N. Selzner, Tsien, Bhat, Jaeckel, M. Selzner, Reichman)
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Agostini C, Buccianti S, Risaliti M, Fortuna L, Tirloni L, Tucci R, Bartolini I, Grazi GL. Complications in Post-Liver Transplant Patients. J Clin Med 2023; 12:6173. [PMID: 37834818 PMCID: PMC10573382 DOI: 10.3390/jcm12196173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 09/16/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
Liver transplantation (LT) is the treatment of choice for liver failure and selected cases of malignancies. Transplantation activity has increased over the years, and indications for LT have been widened, leading to organ shortage. To face this condition, a high selection of recipients with prioritizing systems and an enlargement of the donor pool were necessary. Several authors published their case series reporting the results obtained with the use of marginal donors, which seem to have progressively improved over the years. The introduction of in situ and ex situ machine perfusion, although still strongly debated, and better knowledge and treatment of the complications may have a role in achieving better results. With longer survival rates, a significant number of patients will suffer from long-term complications. An extensive review of the literature concerning short- and long-term outcomes is reported trying to highlight the most recent findings. The heterogeneity of the behaviors within the different centers is evident, leading to a difficult comparison of the results and making explicit the need to obtain more consent from experts.
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Affiliation(s)
| | | | | | | | | | | | - Ilenia Bartolini
- Department of Experimental and Clinical Medicine, AOU Careggi, 50134 Florence, Italy; (C.A.); (S.B.); (M.R.); (L.F.); (L.T.); (R.T.); (G.L.G.)
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Al-Ameri AAM, Zhou Z, Zheng S. Comparative Analysis of Donor Liver Allograft Outcomes in Hepatocellular Carcinoma Patients Who Underwent Liver Transplant. EXP CLIN TRANSPLANT 2023; 21:664-670. [PMID: 37698401 DOI: 10.6002/ect.2023.0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
OBJECTIVES Liver transplant for patients with hepatocellular carcinoma involves 3 main types of donor allografts: donation after brain death, donation after cardiac death, and donation after brain and cardiac death. Data on this topic are limited, and controversies exist regarding liver transplant outcomes in hepatocellular carcinoma patients who have received these allografts. MATERIALS AND METHODS Data from 490 hepatocellular carcinoma patients who received liver transplant from 2015 to 2021 at the Shulan (Hangzhou) Hospital were retrospectively analyzed. Participants were divided into 3 cohorts according to allograft type: donation after brain death, donation after cardiac death, and donation after brain and cardiac death. Kaplan-Meier and Cox regression methods were used to evaluate patient survival, graft survival, and recurrence-free survival rates after liver transplant. RESULTS Kaplan-Meier analysis revealed that 3-year patient survival rates were 69.2% for donations after brain death, 69.2% for donations after cardiac death, and 46.6% for donations after brain and cardiac death (P = .42); the 3-year graft survival rates were 53.3% for donations after brain death, 56.4% for donations after cardiac death, and 46.6% for donations after brain and cardiac death (P = .44); and 3-year recurrence-free survival rates were 55% for donations after brain death, 56.6% for donations after cardiac death, and 39.5% for donations after brain and cardiac death (P = .46). Complications were also similar across the 3 cohorts (P = .36). Multivariable analysis showed that intraoperative red blood cell transfusion (hazard ratio: 1.820; P = .042) and early allograft dysfunction (hazard ratio: 3.240; P = .041) were independent risk factors for graft survival. CONCLUSIONS Similar outcomes can be achieved for hepatocellular carcinoma patients who undergo liver transplant with donations after brain death, donations after cardiac death, or donations after brain and cardiac death allografts, especially when strict donor selection criteria are applied.
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Affiliation(s)
- Abdulahad Abdulrab Mohammed Al-Ameri
- >From the Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; the Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou, China; and the NHC Key Laboratory of Combined Multi-organ Transplantation, the Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Research Unit of Collaborative Diagnosis and Treatment For Hepatobiliary and Pancreatic Cancer, Chinese Academy of Medical Sciences, and the Key Laboratory of Organ Transplantation, Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Zhejiang Province, Hangzhou China
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Shannon AH, Ruff SM, Schenk AD, Washburn K, Pawlik TM. Updates and Expert Opinions on Liver Transplantation for Gastrointestinal Malignancies. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1290. [PMID: 37512101 PMCID: PMC10383519 DOI: 10.3390/medicina59071290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/12/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023]
Abstract
Transplant oncology is a relatively new field in which transplantation is used to treat patients who would otherwise be unresectable. New anticancer treatment paradigms using tumor and transplant immunology and cancer immunogenomics are emerging. In turn, liver transplantation (LT) has become a potential therapy for certain patients with colorectal cancer (CRC) with liver metastasis, hepatocellular (HCC), cholangiocarcinoma (CCA), and metastatic neuroendocrine tumor (NET) of the liver. Although there are established criteria for LT in HCC, evidence regarding LT as a treatment modality for certain gastrointestinal malignancies is still debated. The aim of this review is to highlight updates in the role of LT for certain malignancies, including HCC, metastatic CRC, hilar CCA, and neuroendocrine tumor (NET), as well as contextualize LT use and discuss controversies in transplant oncology.
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Affiliation(s)
- Alexander H Shannon
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH 43210, USA
| | - Samantha M Ruff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH 43210, USA
| | - Austin D Schenk
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH 43210, USA
| | - Kenneth Washburn
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH 43210, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH 43210, USA
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9
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Kathawate RG, Abt PL, Bittermann T. Center expansion of liver transplants using donation after circulatory death organs is associated with reduced overall waitlist mortality. Clin Transplant 2023; 37:e14960. [PMID: 36929662 PMCID: PMC10272092 DOI: 10.1111/ctr.14960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 02/23/2023] [Accepted: 02/25/2023] [Indexed: 03/18/2023]
Abstract
INTRODUCTION Waitlist outcomes in liver transplantation (LT) for individual recipients are improved by use of allografts procured through donation after circulatory death (DCD). However, the impact of increased DCD acceptance on overall center outcomes is unknown. METHODS Using the United Network for Organ Sharing database, 88 centers performing an average of ≥10 LTs/year between 1/2004 and 12/2019 were compared by percent DCD use quartile and categorized into four phenotypes according to temporal usage trends. Overall center median Model for End-stage Liver Disease at LT (MMaT), waitlist mortality, and waiting time were evaluated. RESULTS The overall DCD rate was 6.1% (N = 4906/80,709), ranging from 0% to 25.5%. Centers in the top DCD use quartile had lower MMaT (24 vs. 26; p < .001) and shorter overall waiting times (median 66 days vs. 90 days; p < .001) compared to bottom quartile centers. MMaT increased less over time at centers with increasing DCD use and was lower than at centers with declining DCD use (27 vs. 32; p = .017). Overall waitlist mortality between 2016 and 2019 was lower at increasing DCD use centers (17.8% vs. 22.5%, p = .034), yet did not affect 1-year mortality (p = .747). CONCLUSIONS The improved waitlist outcomes at centers with expanded DCD use extend beyond DCD recipients alone without negative consequences to overall post-LT center metrics.
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Affiliation(s)
| | - Peter L. Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Therese Bittermann
- Department of Medicine, Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
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10
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Durán M, Calleja R, Hann A, Clarke G, Ciria R, Nutu A, Sanabria-Mateos R, Ayllón MD, López-Cillero P, Mergental H, Briceño J, Perera MTPR. Machine perfusion and the prevention of ischemic type biliary lesions following liver transplant: What is the evidence? World J Gastroenterol 2023; 29:3066-3083. [PMID: 37346149 PMCID: PMC10280793 DOI: 10.3748/wjg.v29.i20.3066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/01/2023] [Accepted: 04/28/2023] [Indexed: 05/26/2023] Open
Abstract
The widespread uptake of different machine perfusion (MP) strategies for liver transplant has been driven by an effort to minimize graft injury. Damage to the cholangiocytes during the liver donation, preservation, or early posttransplant period may result in stricturing of the biliary tree and inadequate biliary drainage. This problem continues to trouble clinicians, and may have catastrophic consequences for the graft and patient. Ischemic injury, as a result of compromised hepatic artery flow, is a well-known cause of biliary strictures, sepsis, and graft failure. However, very similar lesions can appear with a patent hepatic artery and these are known as ischemic type biliary lesions (ITBL) that are attributed to microcirculatory dysfunction rather than main hepatic arterial compromise. Both the warm and cold ischemic period duration appear to influence the onset of ITBL. All of the commonly used MP techniques deliver oxygen to the graft cells, and therefore may minimize the cholangiocyte injury and subsequently reduce the incidence of ITBL. As clinical experience and published evidence grows for these modalities, the impact they have on ITBL rates is important to consider. In this review, the evidence for the three commonly used MP strategies (abdominal normothermic regional perfusion [A-NRP], hypothermic oxygenated perfusion [HOPE], and normothermic machine perfusion [NMP] for ITBL prevention has been critically reviewed. Inconsistencies with ITBL definitions used in trials, coupled with variations in techniques of MP, make interpretation challenging. Overall, the evidence suggests that both HOPE and A-NRP prevent ITBL in donated after circulatory death grafts compared to cold storage. The evidence for ITBL prevention in donor after brain death grafts with any MP technique is weak.
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Affiliation(s)
- Manuel Durán
- Department of Liver Transplantation, Reina Sofía University Hospital, Córdoba 14004, Spain
| | - Rafael Calleja
- Department of Liver Transplantation, Reina Sofía University Hospital, Córdoba 14004, Spain
| | - Angus Hann
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TH, United Kingdom
| | - George Clarke
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TH, United Kingdom
| | - Ruben Ciria
- Department of Liver Transplantation, Reina Sofía University Hospital, Córdoba 14004, Spain
| | - Anisa Nutu
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
| | | | - María Dolores Ayllón
- Department of Liver Transplantation, Reina Sofía University Hospital, Córdoba 14004, Spain
| | - Pedro López-Cillero
- Department of Liver Transplantation, Reina Sofía University Hospital, Córdoba 14004, Spain
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TH, United Kingdom
| | - Javier Briceño
- Department of Liver Transplantation, Reina Sofía University Hospital, Córdoba 14004, Spain
| | - M Thamara P R Perera
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TH, United Kingdom
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11
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Ray S, Torres-Hernandez A, Bleszynski MS, Parmentier C, McGilvray I, Sayed BA, Shwaartz C, Cattral M, Ghanekar A, Sapisochin G, Tsien C, Selzner N, Lilly L, Bhat M, Jaeckel E, Selzner M, Reichman TW. Medical Assistance in Dying (MAiD) as a Source of Liver Grafts: Honouring the Ultimate Gift. Ann Surg 2023; 277:713-718. [PMID: 36515405 DOI: 10.1097/sla.0000000000005775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To report the clinical outcomes of liver transplants from donors after medical assistance in dying (MAiD) versus donors after cardiac death (DCD) and deceased brain death (DBD). SUMMARY BACKGROUND DATA In North America, the number of patients needing liver transplants exceeds the number of available donors. In 2016, MAiD was legalized in Canada. METHODS All patients undergoing deceased donor liver transplantation at Toronto General Hospital between 2016 and 2021 were included in the study. Recipient perioperative and postoperative variables and donor physiological variables were compared among 3 groups. RESULTS Eight hundred seven patients underwent deceased donor liver transplantation during the study period, including DBD (n=719; 89%), DCD (n=77; 9.5%), and MAiD (n=11; 1.4%). The overall incidence of biliary complications was 6.9% (n=56), the most common being strictures (n=55;6.8%), highest among the MAiD recipients [5.8% (DBD) vs. 14.2% (DCD) vs. 18.2% (MAiD); P =0.008]. There was no significant difference in 1 year (98.4% vs. 96.4% vs. 100%) and 3-year (89.3% vs. 88.7% vs. 100%) ( P =0.56) patient survival among the 3 groups. The 1- and 3- year graft survival rates were comparable (96.2% vs. 95.2% vs. 100% and 92.5% vs. 91% vs. 100%; P =0.37). CONCLUSION With expected physiological hemodynamic challenges among MAiD and DCD compared with DBD donors, a higher rate of biliary complications was observed in MAiD donors, with no significant difference noted in short-and long-term graft outcomes among the 3 groups. While ethical challenges persist, good initial results suggest that MAiD donors can be safely used in liver transplantation, with results comparable with other established forms of donation.
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Affiliation(s)
- Samrat Ray
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
| | | | | | | | - Ian McGilvray
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Blayne Amir Sayed
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Chaya Shwaartz
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mark Cattral
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Anand Ghanekar
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia Tsien
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nazia Selzner
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Leslie Lilly
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mamatha Bhat
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Elmar Jaeckel
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Markus Selzner
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Trevor W Reichman
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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12
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Long-term outcomes of retransplantation after live donor liver transplantation: A Western experience. Surgery 2023; 173:529-536. [PMID: 36334982 DOI: 10.1016/j.surg.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/12/2022] [Accepted: 09/16/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Despite most liver transplants in North America being from deceased donors, the number of living donor liver transplants has increased over the last decade. Although outcomes of liver retransplantation after deceased donor liver transplantation have been widely published, outcomes of retransplant after living donor liver transplant need to be further elucidated. METHOD We aimed to compare waitlist outcomes and survival post-retransplant in recipients of initial living or deceased donor grafts. Adult liver recipients relisted at University Health Network between April 2000 and October 2020 were retrospectively identified and grouped according to their initial graft: living donor liver transplants or deceased donor liver transplant. A competing risk multivariable model evaluated the association between graft type at first transplant and outcomes after relisting. Survival after retransplant waitlisting (intention-to-treat) and after retransplant (per protocol) were also assessed. Multivariable Cox regression evaluated the effect of initial graft type on survival after retransplant. RESULTS A total of 201 recipients were relisted (living donor liver transplants, n = 67; donor liver transplants, n = 134) and 114 underwent retransplant (living donor liver transplants, n = 48; deceased donor liver transplants, n = 66). The waitlist mortality with an initial living donor liver transplant was not significantly different (hazard ratio = 0.51; 95% confidence interval, 0.23-1.10; P = .08). Both unadjusted and adjusted graft loss risks were similar post-retransplant. The risk-adjusted overall intention-to-treat survival after relisting (hazard ratio = 0.76; 95% confidence interval, 0.44-1.32; P = .30) and per protocol survival after retransplant (hazard ratio:1.51; 95% confidence interval, 0.54-4.19; P = .40) were equivalent in those who initially received a living donor liver transplant. CONCLUSION Patients requiring relisting and retransplant after either living donor liver transplants or deceased donor liver transplantation experience similar waitlist and survival outcomes.
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13
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Meier RPH, Kelly Y, Braun H, Maluf D, Freise C, Ascher N, Roberts J, Roll G. Comparison of Biliary Complications Rates After Brain Death, Donation After Circulatory Death, and Living-Donor Liver Transplantation: A Single-Center Cohort Study. Transpl Int 2022; 35:10855. [PMID: 36568142 PMCID: PMC9780276 DOI: 10.3389/ti.2022.10855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022]
Abstract
Donation-after-circulatory-death (DCD), donation-after-brain-death (DBD), and living-donation (LD) are the three possible options for liver transplantation (LT), each with unique benefits and complication rates. We aimed to compare DCD-, DBD-, and LD-LT-specific graft survival and biliary complications (BC). We collected data on 138 DCD-, 3,027 DBD- and 318 LD-LTs adult recipients from a single center and analyzed patient/graft survival. BC (leak and anastomotic/non-anastomotic stricture (AS/NAS)) were analyzed in a subset of 414 patients. One-/five-year graft survival were 88.6%/70.0% for DCD-LT, 92.6%/79.9% for DBD-LT, and, 91.7%/82.9% for LD-LT. DCD-LTs had a 1.7-/1.3-fold adjusted risk of losing their graft compared to DBD-LT and LD-LT, respectively (p < 0.010/0.403). Bile leaks were present in 10.1% (DCD-LTs), 7.2% (DBD-LTs), and 36.2% (LD-LTs) (ORs, DBD/LD vs. DCD: 0.7/4.2, p = 0.402/<0.001). AS developed in 28.3% DCD-LTs, 18.1% DBD-LTs, and 43.5% LD-LTs (ORs, DBD/LD vs. DCD: 0.5/1.8, p = 0.018/0.006). NAS was present in 15.2% DCD-LTs, 1.4% DBDs-LT, and 4.3% LD-LTs (ORs, DBD/LD vs. DCD: 0.1/0.3, p = 0.001/0.005). LTs w/o BC had better liver graft survival compared to any other groups with BC. DCD-LT and LD-LT had excellent graft survival despite significantly higher BC rates compared to DBD-LT. DCD-LT represents a valid alternative whose importance should increase further with machine/perfusion systems.
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Affiliation(s)
- Raphael Pascal Henri Meier
- University of California, San Francisco, San Francisco, CA, United States,University of Maryland, Baltimore, Baltimore, MD, United States,*Correspondence: Raphael Pascal Henri Meier,
| | - Yvonne Kelly
- University of California, San Francisco, San Francisco, CA, United States
| | - Hillary Braun
- University of California, San Francisco, San Francisco, CA, United States
| | - Daniel Maluf
- University of Maryland, Baltimore, Baltimore, MD, United States
| | - Chris Freise
- University of California, San Francisco, San Francisco, CA, United States
| | - Nancy Ascher
- University of California, San Francisco, San Francisco, CA, United States
| | - John Roberts
- University of California, San Francisco, San Francisco, CA, United States
| | - Garrett Roll
- University of California, San Francisco, San Francisco, CA, United States
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14
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Ivanics T, Wallace D, Claasen MPAW, Patel MS, Brahmbhatt R, Shwaartz C, Prachalias A, Srinivasan P, Jassem W, Heaton N, Cattral MS, Selzner N, Ghanekar A, Morgenshtern G, Mehta N, Massie AB, van der Meulen J, Segev DL, Sapisochin G. Low utilization of adult-to-adult LDLT in Western countries despite excellent outcomes: International multicenter analysis of the US, the UK, and Canada. J Hepatol 2022; 77:1607-1618. [PMID: 36170900 DOI: 10.1016/j.jhep.2022.07.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 06/15/2022] [Accepted: 07/17/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND & AIMS Adult-to-adult living donor liver transplantation (LDLT) offers an opportunity to decrease the liver transplant waitlist and reduce waitlist mortality. We sought to compare donor and recipient characteristics and post-transplant outcomes after LDLT in the US, the UK, and Canada. METHODS This is a retrospective multicenter cohort-study of adults (≥18-years) who underwent primary LDLT between Jan-2008 and Dec-2018 from three national liver transplantation registries: United Network for Organ Sharing (US), National Health Service Blood and Transplantation (UK), and the Canadian Organ Replacement Registry (Canada). Patients undergoing retransplantation or multi-organ transplantation were excluded. Post-transplant survival was evaluated using the Kaplan-Meier method, and multivariable adjustments were performed using Cox proportional-hazards models with mixed-effect modeling. RESULTS A total of 2,954 living donor liver transplants were performed (US: n = 2,328; Canada: n = 529; UK: n = 97). Canada has maintained the highest proportion of LDLT utilization over time (proportion of LDLT in 2008 - US: 3.3%; Canada: 19.5%; UK: 1.7%; p <0.001 - in 2018 - US: 5.0%; Canada: 13.6%; UK: 0.4%; p <0.001). The 1-, 5-, and 10-year patient survival was 92.6%, 82.8%, and 70.0% in the US vs. 96.1%, 89.9%, and 82.2% in Canada vs. 91.4%, 85.4%, and 66.7% in the UK. After adjustment for characteristics of donors, recipients, transplant year, and treating transplant center as a random effect, all countries had a non-statistically significantly different mortality hazard post-LDLT (Ref US: Canada hazard ratio 0.53, 95% CI 0.28-1.01, p = 0.05; UK hazard ratio 1.09, 95% CI 0.59-2.02, p = 0.78). CONCLUSIONS The use of LDLT has remained low in the US, the UK and Canada. Despite this, long-term survival is excellent. Continued efforts to increase LDLT utilization in these countries may be warranted due to the growing waitlist and differences in allocation that may disadvantage patients currently awaiting liver transplantation. LAY SUMMARY This multicenter international comparative analysis of living donor liver transplantation in the United States, the United Kingdom, and Canada demonstrates that despite low use of the procedure, the long-term outcomes are excellent. In addition, the mortality risk is not statistically significantly different between the evaluated countries. However, the incidence and risk of retransplantation differs between the countries, being the highest in the United Kingdom and lowest in the United States.
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Affiliation(s)
- Tommy Ivanics
- Multi-Organ Transplant Program, University Health Network Toronto, Ontario, Canada; Department of Surgery, Henry Ford Hospital, Detroit, Michigan, USA; Department of Surgical Sciences, Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden; Deparment of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - David Wallace
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK; Institute of Liver Studies, Kings College Hospital, Denmark Hill, London, UK
| | - Marco P A W Claasen
- Multi-Organ Transplant Program, University Health Network Toronto, Ontario, Canada; Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Madhukar S Patel
- Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Rushin Brahmbhatt
- Division of General Surgery, University Health Network, Toronto, Ontario, Canada
| | - Chaya Shwaartz
- Multi-Organ Transplant Program, University Health Network Toronto, Ontario, Canada; Division of General Surgery, University Health Network, Toronto, Ontario, Canada
| | - Andreas Prachalias
- Institute of Liver Studies, Kings College Hospital, Denmark Hill, London, UK
| | - Parthi Srinivasan
- Institute of Liver Studies, Kings College Hospital, Denmark Hill, London, UK
| | - Wayel Jassem
- Institute of Liver Studies, Kings College Hospital, Denmark Hill, London, UK
| | - Nigel Heaton
- Institute of Liver Studies, Kings College Hospital, Denmark Hill, London, UK
| | - Mark S Cattral
- Multi-Organ Transplant Program, University Health Network Toronto, Ontario, Canada
| | - Nazia Selzner
- Multi-Organ Transplant Program, University Health Network Toronto, Ontario, Canada
| | - Anand Ghanekar
- Multi-Organ Transplant Program, University Health Network Toronto, Ontario, Canada
| | - Gabriela Morgenshtern
- Department of Computer Science, University of Toronto, Ontario, Canada; Genetics & Genome Biology, The Hospital for Sick Children, Toronto, ON, Canada; Vector Institute, Toronto, Ontario, Canada
| | - Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, CA, USA
| | - Allan B Massie
- Deparment of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Dorry L Segev
- Deparment of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Gonzalo Sapisochin
- Multi-Organ Transplant Program, University Health Network Toronto, Ontario, Canada; Division of General Surgery, University Health Network, Toronto, Ontario, Canada.
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15
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Siddiqui F, Al-Adwan Y, Subramanian J, Henry ML. Contemporary Considerations in Solid Organ Transplantation Utilizing DCD Donors. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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16
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Campsen J, Zimmerman MA. Pancreas transplantation following donation after circulatory death. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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17
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DCD Liver Grafts Can Safely Be Used for Recipients With Grade I–II Portal Vein Thrombosis: A Multicenter Analysis. Transplant Direct 2022; 8:e1392. [PMID: 36246002 PMCID: PMC9553382 DOI: 10.1097/txd.0000000000001392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 11/25/2022] Open
Abstract
With donation after circulatory death (DCD) liver transplantation (LT), the goal of the recipient implantation procedure is to minimize surgical complexity to avoid a tenuous environment for an already marginal graft. The presence of portal vein thrombosis (PVT) at the time of LT adds surgical complexity, yet‚ to date, no studies have investigated the utilization of DCD liver grafts for patients with PVT.
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18
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Cannon RM, Nassel AF, Walker JT, Sheikh SS, Orandi BJ, Lynch RJ, Shah MB, Goldberg DS, Locke JE. Lost potential and missed opportunities for DCD liver transplantation in the United States. Am J Surg 2022; 224:990-998. [PMID: 35589438 PMCID: PMC9940905 DOI: 10.1016/j.amjsurg.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 04/20/2022] [Accepted: 05/03/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Donation after cardiac death(DCD) has been proposed as an avenue to expand the liver donor pool. METHODS We examined factors associated with nonrecovery of DCD livers using UNOS data from 2015 to 2019. RESULTS There 265 non-recovered potential(NRP) DCD livers. Blood type AB (7.8% vs. 1.1%) and B (16.9% vs. 9.8%) were more frequent in the NRP versus actual donors (p < 0.001). The median driving time between donor hospital and transplant center was similar for NRP and actual donors (30.1 min vs. 30.0 min; p = 0.689), as was the percentage located within a transplant hospital (20.8% vs. 20.9%; p = 0.984).The donation service area(DSA) of a donor hospital explained 27.9% (p = 0.001) of the variability in whether a DCD liver was recovered. CONCLUSION A number of potentially high quality DCD donor livers go unrecovered each year, which may be partially explained by donor blood type and variation in regional and DSA level practice patterns.
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Affiliation(s)
- Robert M Cannon
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Ariann F Nassel
- Lister Hill Center for Health Policy, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeffery T Walker
- Center for the Study of Community Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Saulat S Sheikh
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Babak J Orandi
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Raymond J Lynch
- Department of Surgery, Division of Transplantation, Emory University, Atlanta, GA, USA
| | - Malay B Shah
- Department of Surgery, Division of Transplantation, University of Kentucky, Lexington, KY, USA
| | - David S Goldberg
- Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami, Miami, FL, USA
| | - Jayme E Locke
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA
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19
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Characteristics of changes in double positive CD4 +CD8 + T cells in liver transplantation. Int Immunopharmacol 2022; 110:109028. [PMID: 35803130 DOI: 10.1016/j.intimp.2022.109028] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 06/21/2022] [Accepted: 07/01/2022] [Indexed: 11/23/2022]
Abstract
Although double positive CD4+CD8+ T (DPT) cells has been reported to be involved in some diseases, their trajectory and function as associated with liver transplantation (LT) remain unclear. In the present study, we found that the number of DPT cells was increased in the blood and liver tissue of LT patients. Meanwhile, we compared the distribution of DPT cells in peripheral blood samples and in penetrating liver tissue between liver rejection versus non-rejection patients, as well as the proportion of DPT cells as a function of the extent of liver rejection. The number of DPT cells in the rejection group was significantly increased. An analysis of the spatial distance and correlations between DPT and Treg cells, revealed that these cells showed a high degree of contiguity. In a mouse liver transplant model, the number of DPT cells were significantly increased in liver tissue, and the number of CD8+ T cells gradually increased, while CD4+ T cells decreased as a function of time post-transplantation. Expression level of PD-1 in DPT cells also increased in a temporally-dependent manner post liver transplantation and the changes of PD-1+ DPT cells were related to the degree of liver transplant rejection. In DPT cells interacting with Treg, there was an increased expression of PD-1, which enhanced cellular exhaustion. In conclusion, the capacity for DPT cells to induce immune tolerance may represent a new and important protocol for use in targeting treatments for the prevention of liver transplant rejection.
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20
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Silverstein J, Yao FY, Grab JD, Braun HJ, Roberts J, Dodge JL, Mehta N. National experience with living donor liver transplantation for hepatocellular carcinoma. Liver Transpl 2022; 28:1144-1157. [PMID: 35226793 DOI: 10.1002/lt.26439] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 01/10/2022] [Accepted: 01/20/2022] [Indexed: 01/13/2023]
Abstract
Living donor liver transplantation (LDLT) is an attractive option to decrease waitlist dropout, particularly for patients with hepatocellular carcinoma (HCC) who face lengthening waiting times. Using the United Network for Organ Sharing (UNOS) national database, trends in LDLT utilization for patients with HCC were evaluated, and post-LT outcomes for LDLT versus deceased donor liver transplantation (DDLT) were compared. From 1998 to 2018, LT was performed in 20,161 patients with HCC including 726 (3.6%) who received LDLT. The highest LDLT utilization was prior to the 2002 HCC Model for End-Stage Liver Disease (MELD) exception policy (17.5%) and dropped thereafter (3.1%) with a slight increase following the 6-month wait policy in 2015 (3.8%). LDLT was more common in patients from long-wait UNOS regions with blood type O, in those with larger total tumor diameter (2.3 vs. 2.1 cm, p = 0.02), and higher alpha-fetoprotein at LT (11.5 vs. 9.0 ng/ml, p = 0.04). The 5-year post-LT survival (LDLT 77% vs. DDLT 75%), graft survival (72% vs. 72%), and HCC recurrence (11% vs. 13%) were similar between groups (all p > 0.20). In conclusion, LDLT utilization for HCC has remained low since 2002 with only a slight increase after the 6-month wait policy introduction in 2015. Given the excellent post-LT survival, LDLT appears to be an underutilized but valuable option for patients with HCC, especially those at high risk for waitlist dropout.
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Affiliation(s)
- Jordyn Silverstein
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Francis Y Yao
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Joshua D Grab
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Hillary J Braun
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - John Roberts
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer L Dodge
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California, USA.,Department of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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21
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Listabarth S, König D, Berlakovich G, Munda P, Ferenci P, Kollmann D, Gyöeri G, Waldhoer T, Groemer M, van Enckevort A, Vyssoki B. Sex Disparities in Outcome of Patients with Alcohol-Related Liver Cirrhosis within the Eurotransplant Network—A Competing Risk Analysis. J Clin Med 2022; 11:jcm11133646. [PMID: 35806931 PMCID: PMC9267400 DOI: 10.3390/jcm11133646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 12/17/2022] Open
Abstract
Alcohol use disorder (AUD) is one of the most important risk factors for the development of alcohol-related liver cirrhosis (ALC). Importantly, psychiatrists are an integral part of the interdisciplinary care for patients with AUD and ALC. The aim of the current study was to investigate whether sex influences the outcome within this group of patients. For this purpose, data of all registrations for liver transplantations due to ALC within the Eurotransplant region from 2010 to 2019 were analyzed for sex disparities using competing risk models and in-between group comparisons. Relevant sex differences in registration numbers (24.8% female) and investigated outcomes were revealed. Risk ratios for a positive outcome, i.e., transplantation (0.74), and those of adverse outcomes, i.e., removal from waiting list (1.44) and death on waiting list (1.10), indicated a relative disadvantage for female patients with ALC. Further, women listed for liver transplantations were significantly younger than their male counterparts. Notably, sex disparities found in registration and outcome parameters were independent of differences found in the prevalence of AUD and liver transplantations. Further research is necessary to identify the underlying mechanisms and establish strategies to ensure equity and utility in liver transplantations due to ALC.
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Affiliation(s)
- Stephan Listabarth
- Clinical Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, 1090 Vienna, Austria; (S.L.); (D.K.); (M.G.); (B.V.)
| | - Daniel König
- Clinical Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, 1090 Vienna, Austria; (S.L.); (D.K.); (M.G.); (B.V.)
| | - Gabriela Berlakovich
- Division of Transplantation, Department of Surgery, Medical University of Vienna, 1090 Vienna, Austria; (G.B.); (D.K.); (G.G.)
| | - Petra Munda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, 1090 Vienna, Austria; (P.M.); (P.F.)
| | - Peter Ferenci
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, 1090 Vienna, Austria; (P.M.); (P.F.)
| | - Dagmar Kollmann
- Division of Transplantation, Department of Surgery, Medical University of Vienna, 1090 Vienna, Austria; (G.B.); (D.K.); (G.G.)
| | - Georg Gyöeri
- Division of Transplantation, Department of Surgery, Medical University of Vienna, 1090 Vienna, Austria; (G.B.); (D.K.); (G.G.)
| | - Thomas Waldhoer
- Center for Public Health, Department of Epidemiology, Medical University of Vienna, 1090 Vienna, Austria
- Correspondence: ; Tel.: +43-(0)1-40160-34720
| | - Magdalena Groemer
- Clinical Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, 1090 Vienna, Austria; (S.L.); (D.K.); (M.G.); (B.V.)
| | | | - Benjamin Vyssoki
- Clinical Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, 1090 Vienna, Austria; (S.L.); (D.K.); (M.G.); (B.V.)
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22
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Okumura K, Misawa R, Ohira S, Dhand A, Kai M, Sogawa H, Veillette G, John D, Diflo T, Nishida S. Does utilization of heart machine perfusion for donation after cardiac death transplantation affect outcomes of other abdominal transplanted organs? Clin Transplant 2022; 36:e14751. [PMID: 35706100 DOI: 10.1111/ctr.14751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 05/15/2022] [Accepted: 06/03/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Machine perfusion of heart for donation after circulatory death (DCD) is being increasingly utilized. Current protocols for utilizing heart DCD's machine perfusion might prolong donor warm ischemic time for nonheart organs. The aim of this study was to analyze the effects of utilizing heart machine perfusion on liver and kidney transplants from the same donor. METHODS We analyzed data of DCD donors from the United Network for Organ Sharing (UNOS) from January-2020 to September-2021 among two groups: donors with heart machine perfusion (HM) and without heart machine perfusion (NHM). Propensity score (PS) matching was performed to compare the short-term outcomes of liver and kidney transplants between two groups. RESULTS Total of 102 liver and 319 kidney transplants were performed using organs from donors with HM. After PS matching, no statistically significant difference was seen in 1-year graft survival (GS) for both liver and kidney transplants between two groups (liver HM 90.6% vs. NHM 90.2%, p = .47; kidney HM 95.2% vs. NHM 92.9%, p = .40). There was no difference in the delayed graft function (DGF) rates in kidney transplantation (KT) (HM 42% vs. NHM 35%, p = .062). CONCLUSION Utilization of heart machine perfusion in DCD donors had no significant impact on 1-year outcomes of liver and kidney transplantation.
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Affiliation(s)
- Kenji Okumura
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Ryosuke Misawa
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Suguru Ohira
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA.,Department of Surgery, Division of Cardiothoracic Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Abhay Dhand
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA.,Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Masashi Kai
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA.,Department of Surgery, Division of Cardiothoracic Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Hiroshi Sogawa
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Gregory Veillette
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Devon John
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Thomas Diflo
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Seigo Nishida
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
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23
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Croome KP, Mathur AK, Aqel B, Yang L, Taner T, Heimbach JK, Rosen CB, Paz-Fumagalli R, Taner CB. Classification of Distinct Patterns of Ischemic Cholangiopathy Following DCD Liver Transplantation: Distinct Clinical Courses and Long-term Outcomes From a Multicenter Cohort. Transplantation 2022; 106:1206-1214. [PMID: 34468429 DOI: 10.1097/tp.0000000000003928] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND As the number of donation after circulatory death (DCD) liver transplants (LTs) performed in the United States continues to increase annually, there has been interest by policy makers to develop a more robust exception point safety net for patients who develop ischemic cholangiopathy (IC) following DCD LT. As such, there is a need for better understanding of the clinical course and long-term outcomes in patients who develop IC, as well as determining if IC can be classified into distinct categories with distinctly different clinical outcomes. METHODS All DCD LT performed at Mayo Clinic Florida, Mayo Clinic Arizona, and Mayo Clinic Rochester from January 1999 to March 2020 were included (N = 770). Outcomes were compared between 4 distinct radiologic patterns of IC: diffuse necrosis, multifocal progressive, confluence dominant, and minor form. RESULTS In total, 88 (11.4%) patients developed IC, of which 42 (5.5%) were listed for retransplantation of liver (ReLT). Patients with diffuse necrosis and multifocal progressive patterns suffered from frequent hospital admissions for cholangitis in the first year following DCD LT (median 3 and 2), were largely stent dependent (100% and 85.7%), and almost universally required ReLT. Patients with confluence dominant disease were managed with multiple stents and frequently recovered, ultimately becoming stent free without need for ReLT. Patients with the minor form IC did well with limited need for stent placement or repeat procedures and did not require ReLT. Graft survival was different between the 4 distinct IC patterns (P < 0.001). CONCLUSIONS The present analysis provides a detailed analysis on the natural history and clinical course of IC. Patients developing IC can be classified into 4 distinct patterns with distinct clinical courses.
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Affiliation(s)
| | - Amit K Mathur
- Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Bashar Aqel
- Division of Gastroenterology and hepatology, Mayo Clinic Arizona, Phoenix, AZ
| | - Liu Yang
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - Timucin Taner
- Department of Surgery, Mayo Clinic Rochester, Rochester, MN
| | | | | | | | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
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24
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Heinemann M, Liwinski T, Adam R, Berenguer M, Mirza D, Malek-Hosseini SA, Heneghan MA, Lodge P, Pratschke J, Boudjema K, Paul A, Zieniewicz K, Fronek J, Mehrabi A, Acarli K, Tokat Y, Coker A, Yilmaz S, Karam V, Duvoux C, Lohse AW, Schramm C. Long-term outcome after living donor liver transplantation compared to donation after brain death in autoimmune liver diseases: Experience from the European Liver Transplant Registry. Am J Transplant 2022; 22:626-633. [PMID: 34605157 DOI: 10.1111/ajt.16864] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/22/2021] [Accepted: 09/20/2021] [Indexed: 01/25/2023]
Abstract
Knowledge of living donor liver transplantation (LDLT) for autoimmune liver diseases (AILDs) is scarce. This study analyzed survival in LDLT recipients registered in the European Liver Transplant Registry with autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis (PSC) and the non-autoimmune disorder alcohol-related cirrhosis. In total, 29 902 individuals enrolled between 1998 and 2017 were analyzed, including 1003 with LDLT. Survival from >90 days after LDLT for AILDs in adults was 85.5%, 74.2%, and 58.0% after 5, 10, and 15 years. Adjusted for recipient age, sex, and liver transplantation era, adult PSC patients receiving LDLT showed increased mortality compared to donation after brain death (DBD) (hazard ratio [HR] = 1.95, 95% confidence interval [CI] = 1.36-2.80, p < .001). Pediatric PSC patients showed also increased mortality >90 days after LDLT compared to DBD (HR = 3.00, 95% CI 1.04-8.70, p = .043). Multivariate analysis identified several risk factors for death in adult PSC patients receiving LDLT including a male donor (HR = 2.49, p = .025). Adult PSC patients with LDLT versus DBD conferred increased mortality from disease recurrence (subdistribution hazard ratio [subHR] = 5.36, p = .001) and biliary complications (subHR = 4.40, p = .006) in multivariate analysis. While long-term outcome following LDLT for AILD is generally favorable, PSC patients with LDLT compared to DBD might be at increased risk of death.
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Affiliation(s)
- Melina Heinemann
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Timur Liwinski
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network for Hepatological Diseases, Hamburg, Germany
| | - Rene Adam
- Hepato-Biliary Center, AP-HP Paul Brousse Hospital, University of Paris-Sud, Villejuif, France
| | - Marina Berenguer
- Liver Transplantation and Hepatology Unit, La Fe University Hospital, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Valencia, Valencia, Spain
| | - Darius Mirza
- Department of HPB Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Seyed Ali Malek-Hosseini
- Avicenna Center for Medicine and Organ Transplant, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Michael A Heneghan
- King's Liver Transplant Unit, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Peter Lodge
- The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Johann Pratschke
- Department of Surgery, Charité-Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Berlin, Germany
| | - Karim Boudjema
- Department of Hepatobiliary and Digestive Surgery, Pontchaillou University Hospital, Rennes, France
| | - Andreas Paul
- Department of Visceral and Transplant Surgery, University Hospital Essen, Essen, Germany
| | - Krzysztof Zieniewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Jiri Fronek
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Koray Acarli
- Organ Transplantation Center, Memorial Hospital, Istanbul, Turkey
| | - Yaman Tokat
- Liver Transplantation Center, Florence Nightingale Hospital, Istanbul, Turkey
| | - Ahmet Coker
- Department of General Surgery, Ege University Medical School, Izmir, Turkey
| | - Sezai Yilmaz
- Department of Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Vincent Karam
- Hepato-Biliary Center, AP-HP Paul Brousse Hospital, University of Paris-Sud, Villejuif, France
| | - Christophe Duvoux
- Department of Hepatology and Gastroenterology, University Hospital of Henri-Mondor, Creteil, France
| | - Ansgar W Lohse
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network for Hepatological Diseases, Hamburg, Germany.,Martin Zeitz Center for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Schramm
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network for Hepatological Diseases, Hamburg, Germany.,Martin Zeitz Center for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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25
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Safely Expanding the Liver Donor Pool by Utilization of Organs from Donation after Circulatory Death with Comparable Results to Donation After Brain Death, a Large Single-Center Experience. J Gastrointest Surg 2022; 26:1453-1461. [PMID: 35428935 PMCID: PMC9012439 DOI: 10.1007/s11605-022-05313-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/26/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Use of livers donated after circulatory death (DCD) is one way to expand the donor pool. Our center has aggressively incorporated use of DCD liver grafts into practice. We examined our center and national outcomes as well as national DCD liver utilization. METHODS Liver transplants performed at our center and nationally from 11/2016 through 9/2020 were compared. Primary outcomes were patient and graft survival, and national DCD liver utilization. RESULTS For our center, DCD and donation after brain death (DBD) donors were similar except DCD donors were younger (37 vs 40 years; p < 0.05). Recipient Na-MELD (20 vs 24; p < 0.0001) and cold ischemia time (4.63 vs 5.18 h; p < 0.05) were lower in DCD recipients. There were no significant differences in 1-year patient and graft survival between DCD and DBD liver recipients locally. Nationally, there was a difference in 1-year graft survival year (89.4% vs 92.4%, p < 0.0001) but patient survival was similar between groups. The proportion of DCD livers recovered and transplanted widely varied among organ procurement organizations (OPOs) and transplant centers. CONCLUSIONS Similar outcomes for DCD and DBD liver recipients should encourage centers and OPOs nationwide to expand utilization of DCD livers.
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26
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Ischemic Cholangiopathy Postdonation After Circulatory Death Liver Transplantation: Donor Hepatectomy Time Matters. Transplant Direct 2021; 8:e1277. [PMID: 34966844 PMCID: PMC8710320 DOI: 10.1097/txd.0000000000001277] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/28/2021] [Accepted: 11/12/2021] [Indexed: 12/04/2022] Open
Abstract
Background. Outcomes of liver transplantation (LT) from donation after circulatory death (DCD) have been improving; however, ischemic cholangiopathy (IC) continues to be a problem. In 2014, measures to minimize donor hepatectomy time (DHT) and cold ischemic time (CIT) have been adopted to improve DCD LT outcomes. Methods. Retrospective review of all patients who underwent DCD LT between 2005 and 2017 was performed. We compared outcomes of patients who were transplanted before 2014 (historic group) with those who were transplanted between 2014 and 2017 (modern group). Results. We identified 112 patients; 44 were in the historic group and 68 in the modern group. Donors in the historic group were younger (26.5 versus 33, P = 0.007) and had a lower body mass index (26.2 versus 28.2, P = 0.007). DHT (min) and CIT (h) were significantly longer in the historic group (21.5 versus 14, P < 0.001 and 5.3 versus 4.2, P < 0.001, respectively). Fourteen patients (12.5%) developed IC, with a significantly higher incidence in the historic group (23.3% versus 6.1%, P = 0.02). There was no difference in graft and patient survival between both groups. Conclusion. In appropriately selected recipients, minimization of DHT and CIT may decrease the incidence of IC. These changes can potentially expand the DCD donor pool.
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27
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Wu WK, Ziogas IA, Matsuoka LK, Izzy M, Alexopoulos SP. Applicability of the UK DCD Risk Score in the modern era of liver transplantation: a U.S. update. Clin Transplant 2021; 36:e14579. [PMID: 34964989 DOI: 10.1111/ctr.14579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/01/2021] [Accepted: 12/20/2021] [Indexed: 11/29/2022]
Abstract
Careful graft and recipient selection have resulted in improved outcomes in liver transplantation (LT) using donation after cardiac death (DCD) organs. The UK DCD Risk Score was established as a risk stratification tool to guide selection. We evaluated the applicability of the UK DCD Risk Score in a contemporary US cohort of adult DCD LT recipients using the United Network for Organ Sharing registry (2011-2020). 3,899 DCD LTs were included in our study (UK DCD Risk Score 0-5 points: 1,438 [36.9%], 6-9 points: 1,920 [49.2%]; 10-20 points: 541 [13.9%]). Compared to a score of 6-9 points, a score of 0-5 points was associated with decreased risk of graft loss (HR = 0.80, 95%CI: 0.68-0.94, P = 0.006), while a score of 10-20 points was associated with increased risk of graft loss (HR = 1.23, 95%CI: 1.01-1.51, P = 0.04). The 5-year graft survival for patients with risk scores of 0-5, 6-9, and 10-20 were 75.9%, 71.7%, and 67.9%, respectively. The C-statistic for the UK DCD Risk Score in our contemporary cohort was 0.611. The UK DCD Risk Score demonstrates a more limited ability to differentiate recipient outcomes in the modern era of DCD LT in the US. Acceptable long-term outcomes are achievable for patients stratified to the highest-risk group. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- W Kelly Wu
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ioannis A Ziogas
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lea K Matsuoka
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Manhal Izzy
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sophoclis P Alexopoulos
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA
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28
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Honarmand K, Alshamsi F, Foroutan F, Rochwerg B, Belley-Cote E, Mclure G, D'Aragon F, Ball IM, Sener A, Selzner M, Guyatt G, Meade MO. Antemortem Heparin in Organ Donation After Circulatory Death Determination: A Systematic Review of the Literature. Transplantation 2021; 105:e337-e346. [PMID: 33901108 DOI: 10.1097/tp.0000000000003793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Donation after circulatory death determination frequently involves antemortem heparin administration to mitigate peri-arrest microvascular thrombosis. We systematically reviewed the literature to: (1) describe heparin administration practices and (2) explore the effects on transplant outcomes. We searched MEDLINE and EMBASE for studies reporting donation after circulatory death determination heparin practices including use, dosage, and timing (objective 1). To explore associations between antemortem heparin and transplant outcomes (objective 2), we (1) summarized within-study comparisons and (2) used meta-regression analyses to examine associations between proportions of donors that received heparin and transplant outcomes. We assessed risk of bias using the Newcastle Ottawa Scale and applied the GRADE methodology to determine certainty in the evidence. For objective 1, among 55 eligible studies, 48 reported heparin administration to at least some donors (range: 15.8%-100%) at variable doses (up to 1000 units/kg) and times relative to withdrawal of life-sustaining therapy. For objective 2, 7 studies that directly compared liver transplants with and without antemortem heparin reported lower rates of primary nonfunction, hepatic artery thrombosis, graft failure at 5 y, or recipient mortality (low certainty of evidence). In contrast, meta-regression analysis of 32 liver transplant studies detected no associations between the proportion of donors that received heparin and rates of early allograft dysfunction, primary nonfunction, hepatic artery thrombosis, biliary ischemia, graft failure, retransplantation, or patient survival (very low certainty of evidence). In conclusion, antemortem heparin practices vary substantially with an uncertain effect on transplant outcomes. Given the controversies surrounding antemortem heparin, clinical trials may be warranted.
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Farid Foroutan
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Emilie Belley-Cote
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Graham Mclure
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Frederick D'Aragon
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Ian M Ball
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Alp Sener
- Department of Surgery and Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Markus Selzner
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Maureen O Meade
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
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29
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Ziogas IA, Kakos CD, Esagian SM, Skarentzos K, Alexopoulos SP, Shingina A, Montenovo MI. Liver transplant after donation from controlled circulatory death versus brain death: A UNOS database analysis and publication bias adjusted meta-analysis. Clin Transplant 2021; 36:e14521. [PMID: 34689372 DOI: 10.1111/ctr.14521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/06/2021] [Accepted: 10/16/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Donation after circulatory death (DCD) is an increasingly utilized alternative to donation after brain death (DBD) to expand the liver donor pool. We compared the outcomes of liver transplant (LT) after DCD versus DBD. METHODS A PRISMA-compliant systematic literature review was performed using the PubMed, Cochrane Library, and Embase databases (end-of-search-date: July 2, 2020). US outcomes were analyzed using the UNOS database (February, 2002-September, 2020). Pooled hazard ratios (HR) for patient and graft survival were obtained through random effect meta-analyses and adjusted for publication bias. RESULTS Thirteen studies reporting on 1426 DCD and 5385 DBD LT recipients were included. 5620 DCD and 87561 DBD LT recipients were analyzed from the UNOS database. Meta-analysis showed increased risk of patient mortality for DCD (HR = 1.36; 95%CI, 1.09-1.70; P = .01; I2 = 53.6%). When adjusted for publication bias, meta-analysis showed no difference in patient survival between DCD and DBD (HR = 1.15; 95%CI, .91-1.45; P = .25; I2 = 61.5%). Meta-analysis showed increased risk of graft loss for DCD (HR = 1.50; 95%CI, 1.20-1.88; P < .001; I2 = 67.8%). When adjusted for publication bias, meta-analysis showed a reduction in effect size (HR = 1.36; 95%CI, 1.06-1.74; P = .02; I2 = 73.5%). CONCLUSION When adjusted for publication bias, no difference was identified between DCD and DBD regarding patient survival, while DCD was associated with an increased risk of graft loss.
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Affiliation(s)
- Ioannis A Ziogas
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | - Christos D Kakos
- Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | - Stepan M Esagian
- Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | | | - Sophoclis P Alexopoulos
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alexandra Shingina
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Martin I Montenovo
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Early Allograft Dysfunction and Complications in DCD Liver Transplantation: Expert Consensus Statements From the International Liver Transplantation Society. Transplantation 2021; 105:1643-1652. [PMID: 34291765 DOI: 10.1097/tp.0000000000003877] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Livers for transplantation from donation after circulatory death donors are relatively more prone to early and ongoing alterations in graft function that might ultimately lead to graft loss and even patient death. In consideration of this fact, this working group of the International Liver Transplantation Society has performed a critical evaluation of the medical literature to create a set of statements regarding the assessment of early allograft function/dysfunction and complications arising in the setting of donation after circulatory death liver transplantation.
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Early Allograft Dysfunction After Liver Transplantation With Donation After Circulatory Death and Brain Death Grafts: Does the Donor Type Matter? Transplant Direct 2021; 7:e727. [PMID: 34291149 PMCID: PMC8288897 DOI: 10.1097/txd.0000000000001182] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/04/2021] [Accepted: 04/29/2021] [Indexed: 11/30/2022] Open
Abstract
Background. Early allograft dysfunction (EAD) after liver transplantation has been associated with long-term reduced graft and patient survival. Methods. In this single-center cohort study, we aimed to compare incidence, risk factors, and outcomes in liver transplant recipients who developed EAD. Patients who received donation after circulatory death (DCD) or donation after brain death (DBD) grafts between January 2007 and December 2017 were included. EAD was defined as bilirubin of ≥10 mg/dL (171 μmol/L) or an international normalized ratio of ≥1.6 on postoperative day 7 or transaminases >2000 U\L in the first-week posttransplantation as previously described. Results. In our cohort of 1068 patients, incidence of EAD was 44%. EAD occurred more frequently in the DCD versus DBD group (71% versus 41%, P < 0.01). Overall, recipients who developed EAD showed a significantly lower graft and patient survival at 1, 3, and 5 y after transplantation (all P < 0.05). This was also the case for recipients of DBD grafts. However, for recipients of DCD grafts, patient and graft survival were not affected by the presence of EAD. For recipients of DBD grafts, donor age, body mass index (BMI) and gender, recipient BMI and model for end-stage liver disease score and warm and cold ischemia time were associated with EAD. For DCD recipients, donor BMI and cold ischemia time were associated with EAD. Conclusions. In our cohort study, EAD resulted in reduced long-term patient and graft survival only for DBD recipients but not for DCD recipients. Predictive markers for EAD were dependent on the donor type.
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Halpern SE, Rush CK, Edwards RW, Brennan TV, Barbas AS, Pollara J. Systemic Complement Activation in Donation After Brain Death Versus Donation After Circulatory Death Organ Donors. EXP CLIN TRANSPLANT 2021; 19:635-644. [PMID: 33877036 DOI: 10.6002/ect.2020.0425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Complement activation in organs from deceased donors is associated with allograft injury and acute rejection. Because use of organs from donors after circulatory death is increasing, we characterized relative levels of complement activation in organs from donors after brain death and after circulatory death and examined associations between donor complement factor levels and outcomes after kidney and liver transplant. MATERIALS AND METHODS Serum samples from 65 donors (55 donations after brain death, 10 donations after circulatory death) were analyzed for classical, lectin, alternative, and terminal pathway components by Luminex multiplex assays. Complement factor levels were compared between groups, and associations with posttransplant outcomes were explored. RESULTS Serum levels of the downstream complement activation product C5a were similar in organs from donors after circulatory death versus donors after brain death. In organs from donors after circulatory death, complement activation occurred primarily via the alternative pathway; the classical, lectin, and alternative pathways all contributed in organs from donors after brain death. Donor complement levels were not associated with outcomes after kidney transplant. Lower donor complement levels were associated with need for transfusion, reintervention, hospital readmission, and acute rejection after liver transplant. CONCLUSIONS Complement activation occurs at similar levels in organs donated from donors after circulatory death versus those after brain death. Lower donor complement levels may contribute to adverse outcomes after liver transplant. Further study is warranted to better understand how donor complement activation contributes to posttransplant outcomes.
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Affiliation(s)
- Samantha E Halpern
- From the School of Medicine, Duke University, Durham, North Carolina, USA
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Singh N, Helfrich K, Mumtaz K, Washburn K, Logan A, Black S, Schenk A, Limkemann A, Alebrahim M, El-Hinnawi A. Donation After Circulatory Death Yields Survival Rates Similar to Donation After Brain Death Liver Transplant, Which Effectively Expands the Donor Pool. EXP CLIN TRANSPLANT 2021; 19:771-778. [PMID: 33877039 DOI: 10.6002/ect.2021.0013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Liver allograft shortage has necessitated greater use of donations after circulatory death. Limited data are available to compare recipients' health care utilization for donation after circulatory death versus brain death. MATERIALS AND METHODS Liver transplant data for our center from November 2016 until May 2019 were obtained (208 donations after brain death and 39 after circulatory death). We excluded patients <18 years old and multiorgan transplants; for cost data only, we also excluded retransplants. Primary outcome was recipients' health care utilization in donation after circulatory death versus brain death and included index admission length of stay, readmissions, and charges from transplant to 6 months. Secondary outcomes were patient and graft survival. RESULTS Donors from circulatory death were younger than donors from brain death (median age 32 vs 40 years; P < .01). Recipient body mass index (31.23 vs 29.38 kg/m2), Model for End-Stage Liver Disease score (17 vs 19), portal vein thrombosis (15.8% vs 18.0%), length of stay (7 vs 8 days), and 30-, 90-, and 180-day posttransplant index admissions were not significantly different. Charges for index admission were equivalent for donation after circulatory death ($370771) and brain death ($374272) (P = .01). Charges for readmissions at 30 and 180 days were not significantly different (P = .80 and P = .19, respectively). Rates for graft failure (10.3% vs 4.8%; P = .08) and recipient death (10.3% vs 3.8%; P = .17) at 6 months posttransplant were similar. CONCLUSIONS Donation after circulatory death versus brain death liver transplant recipients had similar lengths of stay and equivalent index admission charges. Graft and patient survival and charges from transplant to 6 months were similar. Donation after circulatory death liver allografts provide a safe, costequivalent donor pool expansion after careful donorrecipient selection.
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Affiliation(s)
- Navdeep Singh
- From the Division of Transplantation, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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34
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Oldhafer F, Beetz O, Cammann S, Richter N, Klempnauer J, Vondran FWR. [Machine Perfusion for Liver Transplantation - What is Possible and Where Do We Stand in Germany? Review of the Literature and Results of a National Survey]. Zentralbl Chir 2021; 146:382-391. [PMID: 33761573 DOI: 10.1055/a-1363-2520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Machine perfusion of donor livers is currently regarded as the most important innovation in transplant surgery to address the continuing shortage of organs in liver transplantation. Hypothermic machine perfusion (HMP) is safe to use and appears to reduce the risk of biliary complications and improve the long-term survival of transplanted organs following preservation by cold static storage - even in donors after cardiac death. A potential functional test of donor organs during HMP uses flavin mononucleotide and is still under clinical investigation. Normothermic machine perfusion (NMP) has a greater risk of technical problems, but functional testing using conventional laboratory parameters during NMP allows significant expansion of the donor pool, even though no prospective randomised study has been able to demonstrate a survival advantage for transplanted organs after NMP. In addition, the preservation time of the donor organs can be significantly extended with the help of NMP, which is particularly advantageous for complex recipient operations and/or logistics. Both methods could be applied for various scenarios in transplantation medicine - theoretically also in combination. The majority of German transplant centres regard machine perfusion as an important innovation and already actively perform perfusions or are in preparation for doing so. However, the overall practical experience in Germany is still relatively low, with only 2 centres having performed more than 20 perfusions. In the coming years, multi-centre efforts to conduct clinical trials and to develop national guidelines on machine perfusion will therefore be indispensable in order to define the potential of these technological developments objectively and to exploit it optimally for the field of transplantation medicine.
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Affiliation(s)
- Felix Oldhafer
- Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Deutschland
| | - Oliver Beetz
- Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Deutschland
| | - Sebastian Cammann
- Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Deutschland
| | - Nicolas Richter
- Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Deutschland
| | - Juergen Klempnauer
- Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Deutschland
| | - Florian W R Vondran
- Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Deutschland
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35
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Zhang T, Hickner B, Cotton R, Nguyen Galvan NT, Vierling JM, O'Mahony C, Goss JA, Rana A. Donor Gamma-Glutamyl Transferase Is Associated With Liver Allograft Discard and Failure. Prog Transplant 2021; 31:101-107. [PMID: 33729047 DOI: 10.1177/15269248211002800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The disparity between the number of individuals on the wait list and available liver allografts creates the need for a system that maximizes donor liver utilization and predicts graft failure. RESEARCH QUESTION This study aimed to determine the relationship between donor Gamma-Glutamyl Transferase (GGT), liver discard, and graft failure. DESIGN Through multivariate analysis from 53 966 deceased liver donors, we adjusted for donor clinical and demographic characteristics and compared donor GGT with allograft discard. We compared donor GGT ranges with graft failure and analyzed data from 47 269 liver recipients. RESULTS After adjusting for other factors, donor GGT was significantly associated with liver discard, with GGT over 200 U/L being most significant (OR 2.74, CI 2.51-2.99). Donor GGT under 20 U/L was also found to be a protective factor for post-transplant graft failure (HR 0.91, CI 0.83 - 1.00). CONCLUSION Going forward, GGT should be included among other characteristics associated with allograft discard considered during the procurement process.
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Affiliation(s)
- Theodore Zhang
- School of Medicine, 3989Baylor College of Medicine, Houston, TX, USA
| | - Brian Hickner
- School of Medicine, 3989Baylor College of Medicine, Houston, TX, USA
| | - Ronald Cotton
- Division of Abdominal Transplantation, Michael E DeBakey, Department of General Surgery, 3989Baylor College of Medicine, Houston, TX, USA
| | - Nhu Thao Nguyen Galvan
- Division of Abdominal Transplantation, Michael E DeBakey, Department of General Surgery, 3989Baylor College of Medicine, Houston, TX, USA
| | - John M Vierling
- Division of Gastroenterology, Nutrition & Hepatology, 3989Baylor College of Medicine, Houston, TX, USA
| | - Christine O'Mahony
- Division of Abdominal Transplantation, Department of General Surgery, 3989Baylor College of Medicine, Houston, TX, USA
| | - John A Goss
- Division of Abdominal Transplantation, Department of General Surgery, 3989Baylor College of Medicine, Houston, TX, USA
| | - Abbas Rana
- Division of Abdominal Transplantation, Michael E DeBakey, Department of General Surgery, 3989Baylor College of Medicine, Houston, TX, USA
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36
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Panconesi R, Flores Carvalho M, Mueller M, Meierhofer D, Dutkowski P, Muiesan P, Schlegel A. Viability Assessment in Liver Transplantation-What Is the Impact of Dynamic Organ Preservation? Biomedicines 2021; 9:biomedicines9020161. [PMID: 33562406 PMCID: PMC7915925 DOI: 10.3390/biomedicines9020161] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 02/07/2023] Open
Abstract
Based on the continuous increase of donor risk, with a majority of organs classified as marginal, quality assessment and prediction of liver function is of utmost importance. This is also caused by the notoriously lack of effective replacement of a failing liver by a device or intensive care treatment. While various parameters of liver function and injury are well-known from clinical practice, the majority of specific tests require prolonged diagnostic time and are more difficult to assess ex situ. In addition, viability assessment of procured organs needs time, because the development of the full picture of cellular injury and the initiation of repair processes depends on metabolic active tissue and reoxygenation with full blood over several hours or days. Measuring injury during cold storage preservation is therefore unlikely to predict the viability after transplantation. In contrast, dynamic organ preservation strategies offer a great opportunity to assess organs before implantation through analysis of recirculating perfusates, bile and perfused liver tissue. Accordingly, several parameters targeting hepatocyte or cholangiocyte function or metabolism have been recently suggested as potential viability tests before organ transplantation. We summarize here a current status of respective machine perfusion tests, and report their clinical relevance.
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Affiliation(s)
- Rebecca Panconesi
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, 50134 Florence, Italy; (R.P.); (M.F.C.); (P.M.)
| | - Mauricio Flores Carvalho
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, 50134 Florence, Italy; (R.P.); (M.F.C.); (P.M.)
| | - Matteo Mueller
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, 8091 Zurich, Switzerland; (M.M.); (P.D.)
| | - David Meierhofer
- Max Planck Institute for Molecular Genetics, Mass Spectrometry Facility, 14195 Berlin, Germany;
| | - Philipp Dutkowski
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, 8091 Zurich, Switzerland; (M.M.); (P.D.)
| | - Paolo Muiesan
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, 50134 Florence, Italy; (R.P.); (M.F.C.); (P.M.)
| | - Andrea Schlegel
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, 50134 Florence, Italy; (R.P.); (M.F.C.); (P.M.)
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, 8091 Zurich, Switzerland; (M.M.); (P.D.)
- Correspondence:
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37
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Wang K, Lu D, Liu Y, Li W, Zhuang L, Ma Z, Xie Q, Pan B, Wu Y, Chen J, Lin L, Feng X, Wei Q, Wei X, Xie H, Wang Z, Zheng S, Xu X. Severity of early allograft dysfunction following donation after circulatory death liver transplantation: a multicentre study. Hepatobiliary Surg Nutr 2021; 10:9-19. [PMID: 33575286 DOI: 10.21037/hbsn.2019.09.02] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/27/2019] [Indexed: 12/22/2022]
Abstract
Background Early allograft dysfunction (EAD) is associated with decreased graft and patient survival rates. This study aimed to identify the severity of EAD and develop a predictive model for EAD after donation after circulatory death (DCD) liver transplantation (LT). Furthermore, the influence of operative time on EAD incidence was also evaluated. Methods In this retrospective, multicentre cohort study, nomograms were established based on a single-centre training cohort (n=321) and validated in a 3-center validation cohort (n=501). Results The incidence rate of EAD was 46.4% (149/321) in the training cohort and 40.5% (203/501) in the validation cohort. Of the 149 EAD patients in the training cohort, 77 patients with either elevated alanine aminotransferase (ALT) or aspartate aminotransferase (AST) were classified as having EAD type A, and the rest of the EAD patients were classified as having EAD type B. Recipients with EAD type B had lower graft and patient survival rates than recipients with EAD type A (P=0.043 and 0.044, respectively). We further developed a nomogram to predict EAD (graft weight, cold ischemia time, donor age, model for end-stage liver disease (MELD) score) and another nomogram to predict EAD type B (graft weight, cold ischemia time, MELD score). The nomograms for the prediction of EAD and EAD type B had good discrimination [concordance index (C-index) =0.712 (0.666-0.758), 0.707 (0.641-0.773)] and calibration [Hosmer-Lemeshow (HL) P=0.384, P=0.425] in the validation cohort. An increased operative time (>6 h) was associated with increased EAD and EAD type B incidence in the high-risk group (P=0.005, P=0.020, respectively). Conclusions EAD type B was associated with decreased graft and patient survival rates. The novel nomograms effectively predicted the incidence of EAD and EAD type B in DCD LT patients.
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Affiliation(s)
- Kun Wang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Di Lu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Yuhui Liu
- Department of Surgery, Dezhou People's Hospital, Dezhou, China
| | - Wangyao Li
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Li Zhuang
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou, China
| | - Zhenyu Ma
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Qinfen Xie
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou, China
| | - Binhua Pan
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Yichao Wu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Junli Chen
- China Liver Transplant Registry, Hangzhou, China
| | - Lidan Lin
- China Liver Transplant Registry, Hangzhou, China
| | - Xiaowen Feng
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Qiang Wei
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Xuyong Wei
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Haiyang Xie
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Zhengxin Wang
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Shusen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China.,Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou, China
| | - Xiao Xu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
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Croome KP, Taner CB. Expanding Role of Donation After Circulatory Death Donors in Liver Transplantation. Clin Liver Dis 2021; 25:73-88. [PMID: 33978584 DOI: 10.1016/j.cld.2020.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Better understanding of how to utilize donation after circulatory death (DCD) liver grafts has resulted in improved national outcomes and expansion in the number of DCD liver transplants (LTs). This improvement has been driven by better donor and recipient matching, careful evaluation of hemodynamics during withdrawal of life support, and refinement of the procurement operation. Changes to liver allocation likely will result in increased utilization of DCD liver grafts. Ischemic cholangiopathy remains the Achilles heel of DCD LTs and, although rates have fallen with improved protocols, a certain rate likely is unavoidable. This review discusses contemporary issues with DCD LTs.
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Affiliation(s)
- Kristopher P Croome
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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39
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Pandya K, Sastry V, Panlilio MT, Yip TCF, Salimi S, West C, Virtue S, Wells M, Crawford M, Pulitano C, Strasser SI, McCaughan GW, Majumdar A, Liu K. Differential Impact of Extended Criteria Donors After Brain Death or Circulatory Death in Adult Liver Transplantation. Liver Transpl 2020; 26:1603-1617. [PMID: 32750732 DOI: 10.1002/lt.25859] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/30/2020] [Accepted: 07/18/2020] [Indexed: 01/01/2023]
Abstract
Using grafts from extended criteria donors (ECDs) and donation after circulatory death (DCD) donors is a strategy to address organ shortage in liver transplantation (LT). We studied the characteristics and outcomes of ECD and DCD grafts. We retrospectively studied consecutive adults who underwent deceased donor LT between 2006 and 2019. ECD was defined using modified Eurotransplant criteria. Our primary outcomes were graft and patient survival. A total of 798 grafts were used for LT, of which 93.1% were donation after brain death (DBD; 59.9% were also ECD) and 6.9% were DCD grafts (49.1% were also ECD). Among DBD graft recipients, donors having >33% liver steatosis or 3 ECD criteria resulted in poorer graft survival. Otherwise ECD graft recipients had similar graft and patient survival compared with non-ECD graft recipients. DCD graft recipients also had similar patient survival compared with DBD recipients. However, DCD grafts from an ECD appeared to have worse outcomes. DCD graft recipients experienced higher rates of early allograft dysfunction (50.9% versus 24.7%; P < 0.001) and ischemic biliopathy (16.4% versus 1.5%; P < 0.001) compared with DBD graft recipients. Use of DBD grafts from ECDs did not impact outcomes unless there was significant donor steatosis or 3 Eurotransplant criteria were met. DCD graft recipients have similar patient survival compared with DBD graft recipients as long as the donor was not an ECD. We recommend that DBD donors with 3 or more ECD features or >33% steatosis and DCD donors with any ECD features be used with caution in adult LT.
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Affiliation(s)
- Keval Pandya
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Vinay Sastry
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Mara T Panlilio
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Terry C F Yip
- Department of Medicine and Therapeutics, Medical Data Analytic Centre, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Shirin Salimi
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Claire West
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Susan Virtue
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Mark Wells
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Michael Crawford
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
| | - Carlo Pulitano
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
| | - Simone I Strasser
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
| | - Geoffrey W McCaughan
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia.,Liver Injury and Cancer Program, The Centenary Institute, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Avik Majumdar
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
| | - Ken Liu
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia.,Liver Injury and Cancer Program, The Centenary Institute, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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40
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Favorable Outcomes of Liver Transplantation from Controlled Circulatory Death Donors Using Normothermic Regional Perfusion Compared to Brain Death Donors. Transplantation 2020; 104:1943-1951. [PMID: 32639402 DOI: 10.1097/tp.0000000000003372] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Liver transplantation (LT) from controlled donation after circulatory death (cDCD) was initiated in France in 2015 under a protocol based on the use of normothermic regional perfusion (NRP) before organ procurement. The aim was to compare outcomes following cDCD LT with NRP and donation after brain death (DBD) LT. METHODS This is a multicenter retrospective study comparing cDCD LT with NRP and DBD LT. A case-matched study (1:2) was performed using the variables such as recipient and donor age, indication of LT. RESULTS A total of 50 patients from the cDCD group were matched to 100 patients from the DBD group. From postoperative days 1-4, serum transaminase release was significantly lower in the cDCD group compared to the DBD group (P < 0.05). Early allograft dysfunction (cDCD: 18% versus DBD: 32%; P = 0.11), acute kidney injury (26% versus 33%; P = 0.49), 90-d graft loss (2% versus 5%; P = 0.66), and arterial (4% versus 12%; P = 0.19) and biliary (16% versus 17%; P = 0.94) complications were similar between the 2 groups. The 2-y graft survival was 88% for cDCD group and 85% for DBD group (P = 0.91). The 2-y patient survival was 90% for cDCD group and 88% for DBD group (P = 0.68). CONCLUSIONS This study provides evidence that cDCD LT following postmortem NRP can be safely and effectively performed in selected recipients with similar graft and patient survival outcomes, without increased rates of biliary complications and early graft dysfunction compared to DBD LT.
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41
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Ly M, Crawford M, Verran D. Biliary complications in donation after circulatory death liver transplantation: the Australian National Liver Transplantation Unit's experience. ANZ J Surg 2020; 91:445-450. [PMID: 32985774 DOI: 10.1111/ans.16304] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 08/19/2020] [Accepted: 08/24/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Biliary complications are the most common complications of donation after circulatory death (DCD) liver transplantation and the international experience with DCD transplants suggests increased rates of biliary complications compared to donation after brain death transplants. Therefore, it is important to understand factors that are associated with the development of biliary complications within the Australian DCD context in order to inform future practice. The aim of this study is to determine the incidence of biliary complications after DCD liver transplantation at the Australian National Liver Transplantation Unit and identify factors associated with this outcome. METHODS A retrospective analysis of all adult DCD liver transplants at the Australian National Liver Transplantation Unit from 2007 to 2015 was undertaken. The primary outcome measure was the incidence of biliary complications and was censored on 31 December 2016. Recipients were then stratified into groups based on the development of biliary complications and risk factor analysis was performed. RESULTS Biliary complications occurred in 35% of DCD transplants, including seven anastomotic strictures and 10 non-anastomotic strictures. Higher donor risk index scores (P = 0.03), post-transplant portal vein complications (P = 0.042) and peak gamma-glutamyl transferase levels within 7 days post-transplant (P = 0.047) were associated with biliary complications. CONCLUSION Findings from this study demonstrate that biliary complications remain common in DCD liver recipients. Recipients who developed a biliary complication tended to have higher donor risk index, elevated peak gamma-glutamyl transferase levels within 7 days post-transplant or a portal vein complication. The presence of any of these factors should prompt close monitoring for post-transplant biliary complications.
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Affiliation(s)
- Mark Ly
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Michael Crawford
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Deborah Verran
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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42
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Croome KP, Mathur AK, Mao S, Aqel B, Piatt J, Senada P, Heimbach JK, Moss A, Rosen CB, Taner CB. Perioperative and long-term outcomes of utilizing donation after circulatory death liver grafts with macrosteatosis: A multicenter analysis. Am J Transplant 2020; 20:2449-2456. [PMID: 32216008 DOI: 10.1111/ajt.15877] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 02/04/2020] [Accepted: 03/10/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Given the potentially additive risk from using donor livers that are both steatotic and from a donation after circulatory death (DCD) donor, there is a paucity of data on the outcome of DCD liver transplantation (LT) utilizing livers with macrosteatosis. METHODS All DCD LT performed at Mayo Clinic-Florida, Mayo Clinic-Arizona, and Mayo Clinic-Rochester from 1999 to 2019 were included (N = 714). Recipients of DCD LT were divided into 3 groups: those with moderate macrosteatosis (30%-60%), mild macrosteatosis (5%-30%), and no steatosis (<5%). RESULTS Patients with moderate macrosteatosis had a higher rate of postreperfusion syndrome (PRS; 53.9% vs 26.2%; P = .002), postreperfusion cardiac arrest (7.7% vs 0.3%; P < .001), primary nonfunction (PNF; 7.7% vs 1.0%; P = .003), early allograft dysfunction (EAD; 70.8% vs 45.6% and 8.3%; P = .02), and acute kidney injury (AKI; 39.1% vs 19.4%; P = .02) than patients with no steatosis. No difference in any of the perioperative complications was seen between the mild macrosteatosis and the no steatosis groups except for the rate of EAD (56.8% vs 45.6%; P = .04). No difference in ischemic cholangiopathy (IC), vascular thrombosis/stenosis or graft, and patient survival was seen between the 3 groups. CONCLUSION DCD donors with mild macrosteatosis < 30% can be utilized with no increase in perioperative complications and similar patient and graft survival compared to DCD donors with no steatosis. When utilizing DCD donors with moderate macrosteatosis higher rates of PRS, PNF, postreperfusion cardiac arrest, EAD, and AKI should be anticipated.
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Affiliation(s)
| | - Amit K Mathur
- Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Shennen Mao
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Bashar Aqel
- Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Jacob Piatt
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Peter Senada
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Julie K Heimbach
- Department of Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Adyr Moss
- Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Charles B Rosen
- Department of Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
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43
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Kahn J, Pregartner G, Avian A, Kniepeiss D, Müller H, Schemmer P. The Graz Liver Allocation Strategy-Impact of Extended Criteria Grafts on Outcome Considering Immunological Aspects. Front Immunol 2020; 11:1584. [PMID: 32849538 PMCID: PMC7427688 DOI: 10.3389/fimmu.2020.01584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 06/15/2020] [Indexed: 12/24/2022] Open
Abstract
Background: Transplant centers are forced to use livers of extended criteria donors for transplantation due to a dramatic organ shortage. The outcome effect of extended donor criteria (EDCs) remains unclear. Thus, this study was designed to assess the impact of EDCs on outcome including immunological aspects after liver transplantation (LT). Patients and Methods: Between November 2016 and March 2018, 49 patients (85.7% male) with a mean age of 57 ± 11 years underwent LT. The impact of EDCs on outcome after LT was assessed retrospectively using both MedOcs and ENIS (Eurotransplant Network Information System). Results: About 80% of grafts derived from extended criteria donors. Alanine aminotransferase/aspartate aminotransferase (AST/ALT) levels elevated more than three times above normal values in organ donors was the only significant risk factor for primary dysfunction (PDF) and primary non-function (PNF)/Re-LT and early non-anastomotic biliary strictures (NAS). Balance of risk (BAR) score did not differ between EDC and non-EDC recipients. PDF (14.3% of all patients) and PNF (6.1% of all patients) occurred in 23.1% of EDC-graft recipients and in 10.0% of non-EDC-graft recipients (RR 2.31, p = 0.663). The 90-day mortality was 3.6%. There was no difference of early non-anastomotic biliary tract complications and biopsy proven rejections (BPR). There was no correlation of PDF/PNF with BPR and NAS, respectively; however, 66.7% of the patients with BPR also developed early NAS (p < 0.001). Conclusion: With the Graz liver allocation strategy, excellent survival can be achieved selecting livers with no more than 2 not outcome-relevant EDCs for patients with MELD >20. Further, BPR is associated with biliary complications.
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Affiliation(s)
- Judith Kahn
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Gudrun Pregartner
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Daniela Kniepeiss
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Helmut Müller
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Peter Schemmer
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
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44
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Croome KP. Donation after Circulatory Death: Potential Mechanisms of Injury and Preventative Strategies. Semin Liver Dis 2020; 40:256-263. [PMID: 32557479 DOI: 10.1055/s-0040-1709487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Donation after circulatory death (DCD) donors represent a potential means to help address the disparity between the number of patients awaiting liver transplantation (LT) and the availability of donor livers. While initial enthusiasm for DCD LT was high in the early 2000s, early reports of high rates of biliary complications and inferior graft survival resulted in reluctance among many transplant centers to use DCD liver grafts. As with all innovations in transplant practice, there is undoubtedly a learning curve associated with the optimal utilization of liver grafts from DCD donors. More contemporary data has demonstrated that results with DCD LT are improving and the number of DCD LT performed annually has been steadily increasing. In this concise review, potential mechanisms of injury for DCD livers are discussed along with strategies that have been employed in clinical practice to improve DCD LT outcomes.
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45
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Ziogas IA, Alexopoulos SP, Matsuoka LK, Geevarghese SK, Gorden LD, Karp SJ, Perkins JD, Montenovo MI. Living vs deceased donor liver transplantation in cholestatic liver disease: An analysis of the OPTN database. Clin Transplant 2020; 34:e14031. [PMID: 33427333 DOI: 10.1111/ctr.14031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/11/2020] [Accepted: 06/28/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Living donor liver transplantation (LDLT) and donation after circulatory death (DCD) can expand the donor pool for cholestatic liver disease (CLD) patients. We sought to compare the outcomes of deceased donor liver transplant (DDLT) vs LDLT in CLD patients. METHODS Retrospective cohort analysis of adult CLD recipients registered in the OPTN database who received primary LT between 2002 and 2018. Cox proportional hazards regression models with mixed effects were used to determine the impact of graft type on patient and graft survival. RESULTS Five thousand, nine hundred ninety-nine DDLT (5730 donation after brain death [DBD], 269 DCD) and 912 LDLT recipients were identified. Ten-year patient/graft survival rates were DBD: 73.8%/67.9%, DCD: 74.7%/60.7%, and LDLT: 82.5%/73.9%. Higher rates of biliary complications as a cause of graft failure were seen in DCD (56.8%) than LDLT (30.5%) or DBD (18.7%) recipients. On multivariable analysis, graft type was not associated with patient mortality, while DCD was independently associated with graft failure (P = .046). CONCLUSION DBD, DCD, and LDLT were associated with comparable overall patient survival. No difference in the risk of graft failure could be observed between LDLT and DBD. DCD can be an acceptable alternative to DBD with equivalent patient survival, but inferior graft survival likely related to the high rate of biliary complications.
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Affiliation(s)
- Ioannis A Ziogas
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sophoclis P Alexopoulos
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lea K Matsuoka
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sunil K Geevarghese
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lee D Gorden
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Seth J Karp
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James D Perkins
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA, USA.,Clinical and Bio-Analytics Transplant Laboratory (CBATL), University of Washington, Seattle, WA, USA
| | - Martin I Montenovo
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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46
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Abstract
Purpose of Review The transplant community continues to look for ways to help address the discordance between donor liver graft availability and patients on the liver transplant waiting list. Donation after circulatory death (DCD) donor livers represents one potential means to help address this discordance. The present review describes the changing landscape of DCD liver transplantation (LT). Recent Findings The number of DCD LTs performed annually within the USA has continued to grow on an annual basis. Importantly, national data has demonstrated that outcomes with DCD LT have been improving. This improvement has been driven by better understanding of how to successfully utilize these organs through better donor and recipient matching and careful evaluation of both hemodynamics during withdrawal of life support and the refinement of the procurement operation. Summary Despite these improvements in outcome, ischemic cholangiopathy (IC) continues to be the Achilles heel of DCD LT. Emerging technologies such as various forms of machine perfusion may allow for reduction of complications and better prognostication of the risk associated with DCD liver grafts.
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Affiliation(s)
- Kristopher P Croome
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
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47
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Kollmann D, Neong SF, Rosales R, Hansen BE, Sapisochin G, McCluskey S, Bhat M, Cattral MS, Lilly L, McGilvray ID, Ghanekar A, Grant DR, Selzner M, Wong FSH, Selzner N. Renal Dysfunction After Liver Transplantation: Effect of Donor Type. Liver Transpl 2020; 26:799-810. [PMID: 32189415 PMCID: PMC7317208 DOI: 10.1002/lt.25755] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 01/27/2020] [Accepted: 02/10/2020] [Indexed: 12/15/2022]
Abstract
Recipients of donation after circulatory death (DCD) grafts are reportedly at higher risk of developing renal dysfunction after liver transplantation (LT). We compared the development of acute kidney injury (AKI) and chronic kidney disease (CKD) after LT in recipients of DCD versus donation after brain death (DBD) or living donor liver transplantation (LDLT) livers. Adult recipients of DBD, LDLT, and DCD between 2012 and 2016 at Toronto General Hospital were included. AKI was defined as a post-LT increase of serum creatinine (sCr) ≥26.5 µmol/L within 48 hours or a ≥50% increase from baseline, and CKD was defined as an estimated glomerular filtration rate <60 mL/minute for >3 months. A total of 681 patients (DCD, n = 57; DBD, n = 446; and LDLT, n = 178) with similar baseline comorbidities were included. Perioperative AKI (within the first 7 postoperative days) was observed more frequently in the DCD group (61%; DBD, 40%; and LDLT, 44%; P = 0.01) and was associated with significantly higher peak AST levels (P < 0.001). Additionally, patients in the DCD group had a significantly higher peak sCr (P < 0.001) and a trend toward higher rates of AKI stage 3 (DCD, 33%; DBD, 21%; LDLT, 21%; P = 0.11). The proportions of recovery from AKI (DCD, 77%; DBD, 72%; LDLT, 78%; P = 0.45) and patients developing CKD (DCD, 33%; DBD, 32%; LDLT, 32%; P = 0.99) were similar. Nevertheless, patients who received DCD or DBD LT and required perioperative renal replacement therapy showed significantly lower patient survival in multivariate analysis (hazard ratio, 7.90; 95% confidence interval, 4.51-13.83; P < 0.001). In conclusion, recipients of DCD liver grafts experience higher rates of short-term post-LT renal dysfunction compared with DBD or LDLT. Additional risk factors for the development of severe kidney injury, such as high Model for End-Stage Liver Disease score, massive transfusions, or donor age ≥60 years should be avoided.
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Affiliation(s)
- Dagmar Kollmann
- Multi‐Organ Transplant ProgramToronto General HospitalTorontoONCanada,Department of SurgeryMedical University of ViennaViennaAustria
| | - Shuet Fong Neong
- Multi‐Organ Transplant ProgramToronto General HospitalTorontoONCanada
| | - Roizar Rosales
- Multi‐Organ Transplant ProgramToronto General HospitalTorontoONCanada
| | - Bettina E. Hansen
- Institute of Health PolicyManagement and EvaluationUniversity of TorontoTorontoONCanada,Toronto Centre for Liver DiseaseToronto General HospitalTorontoONCanada
| | | | - Stuart McCluskey
- Department of Anesthesia and Pain ManagementToronto General HospitalTorontoONCanada
| | - Mamatha Bhat
- Multi‐Organ Transplant ProgramToronto General HospitalTorontoONCanada
| | - Mark S. Cattral
- Multi‐Organ Transplant ProgramToronto General HospitalTorontoONCanada
| | - Les Lilly
- Multi‐Organ Transplant ProgramToronto General HospitalTorontoONCanada
| | - Ian D. McGilvray
- Multi‐Organ Transplant ProgramToronto General HospitalTorontoONCanada
| | - Anand Ghanekar
- Multi‐Organ Transplant ProgramToronto General HospitalTorontoONCanada
| | - David R. Grant
- Multi‐Organ Transplant ProgramToronto General HospitalTorontoONCanada
| | - Markus Selzner
- Multi‐Organ Transplant ProgramToronto General HospitalTorontoONCanada
| | - Florence S. H. Wong
- Division of GastroenterologyToronto General HospitalUniversity Health NetworkToronto General HospitalTorontoONCanada
| | - Nazia Selzner
- Multi‐Organ Transplant ProgramToronto General HospitalTorontoONCanada
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48
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49
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Pérez Redondo M, Alcántara Carmona S, Fernández Simón I, Villanueva Fernández H, Ortega López A, Pardo Rey C, Duerto Álvarez J, Lipperheide Vallhonrat I, González Romero M, Ballesteros Ortega D, Río Gallegos F, Rubio Muñoz JJ. Implementation of a mobile team to provide normothermic regional perfusion in controlled donation after circulatory death: Pilot study and first results. Clin Transplant 2020; 34:e13899. [DOI: 10.1111/ctr.13899] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 04/11/2020] [Accepted: 05/02/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Marina Pérez Redondo
- Department of Intensive Care MedicineHospital Universitario Puerta de Hierro Majadahonda Madrid Spain
| | - Sara Alcántara Carmona
- Department of Intensive Care MedicineHospital Universitario Puerta de Hierro Majadahonda Madrid Spain
| | | | | | - Alfonso Ortega López
- Department of Intensive Care MedicineHospital Universitario Puerta de Hierro Majadahonda Madrid Spain
| | - Cándido Pardo Rey
- Department of Intensive Care Medicine and Transplant Coordinator. HospitalUniversitario Clínico San Carlos Madrid Spain
| | - Jorge Duerto Álvarez
- Department of Intensive Care Medicine and Transplant Coordinator. HospitalUniversitario Clínico San Carlos Madrid Spain
| | | | - Manuel González Romero
- Department of Intensive Care Medicine and Transplant Coordinator. HospitalUniversitario Clínico San Carlos Madrid Spain
| | - Daniel Ballesteros Ortega
- Department of Intensive Care MedicineHospital Universitario Puerta de Hierro Majadahonda Madrid Spain
| | - Francisco Río Gallegos
- Department of Intensive Care Medicine and Transplant Coordinator. HospitalUniversitario Clínico San Carlos Madrid Spain
| | - Juan José Rubio Muñoz
- Department of Intensive Care MedicineHospital Universitario Puerta de Hierro Majadahonda Madrid Spain
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50
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Choubey AP, Siskind EJ, Ortiz AC, Nayebpour M, Koizumi N, Wiederhold P, Ortiz J. Disparities in DCD organ procurement policy from a national OPO survey: A call for standardization. Clin Transplant 2020; 34:e13826. [DOI: 10.1111/ctr.13826] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/19/2020] [Accepted: 02/12/2020] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | - Mehdi Nayebpour
- Schar School of Policy and Government George Mason University Fairfax VA USA
| | - Naoru Koizumi
- Schar School of Policy and Government George Mason University Fairfax VA USA
| | | | - Jorge Ortiz
- Department of Surgery University of Toledo Medical Center Toledo OH USA
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