1
|
Mohamed Chairi MH, Mogollón González M, Triguero Cabrera J, Segura Jiménez I, Villegas Herrera MT, Villar del Moral JM. Risk scores for allograft failure: Are they still useful in liver recipients from donation after circulatory death? World J Transplant 2024; 14:97612. [DOI: 10.5500/wjt.v14.i4.97612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/17/2024] [Accepted: 08/02/2024] [Indexed: 09/20/2024] Open
Abstract
BACKGROUND Liver grafts from donation after circulatory death (DCD) are associated with a higher risk of early graft dysfunction, determined by the warm ischemia and cold ischemia times. It is essential to have precise criteria to identify this complication in order to guide therapeutic strategies.
AIM To validate different graft and recipient survival scores in patients undergoing liver transplantation (LT) with DCD grafts.
METHODS A retrospective and observational unicentric study was conducted on 65 LT patients with grafts obtained from controlled DCD donors from November 2013 to November 2022. The United Kingdom (UK) risk score, early allograft dysfunction (EAD) Olthoff score, and model for early allograft function (MEAF) score were used to evaluate the risk of graft and recipient survival post-transplant. For survival analysis purposes, we used the Kaplan-Meier method, and the differences between subgroups were compared using the log-rank (Mantel-Cox) test.
RESULTS Sixty-five patients were included in the study. The UK risk score did not demonstrate predictive capacity for recipient or graft survival. However, in donors aged over 70 years old (18.4%), it significantly predicted graft survival (P < 0.05). According to Kaplan-Meier survival curves, graft survival rates at 6 months, 2 years, and 5 years in the futility group dramatically decreased to 50% compared to the other groups (log-rank 8.806, P < 0.05). The EAD Olthoff and MEAF scores did not demonstrate predictive capacity for recipient or graft survival. Based on Kaplan-Meier survival curves, patients with a MEAF score ≥ 7 had a lower graft survival rate at 6 months, 2 years, and 5 years compared to patients with a lower MEAF score (log-rank 4.667, P < 0.05).
CONCLUSION In our series, both UK DCD risk score and MEAF score showed predictive capability for graft survival.
Collapse
Affiliation(s)
- Mohamed H Mohamed Chairi
- Transplant Surgery Division, Department of Surgery, Virgen de las Nieves University Hospital, Granada 18013, Andalusia, Spain
| | - Mónica Mogollón González
- Transplant Surgery Division, Department of Surgery, Virgen de las Nieves University Hospital, Granada 18013, Andalusia, Spain
| | - Jennifer Triguero Cabrera
- Transplant Surgery Division, Department of Surgery, Virgen de las Nieves University Hospital, Granada 18013, Andalusia, Spain
| | - Inmaculada Segura Jiménez
- Transplant Surgery Division, Department of Surgery, Virgen de las Nieves University Hospital, Granada 18013, Andalusia, Spain
| | - Maria T Villegas Herrera
- Transplant Surgery Division, Department of Surgery, Virgen de las Nieves University Hospital, Granada 18013, Andalusia, Spain
| | - Jesús M Villar del Moral
- Transplant Surgery Division, Department of Surgery, Virgen de las Nieves University Hospital, Granada 18013, Andalusia, Spain
| |
Collapse
|
2
|
Ibeabuchi T, Li E, Cywes C, Bittermann T, Mahmud N, Abt PL. The Association Between the Origin of the Donation After Circulatory Death Liver Recovery Team and Graft Survival: A National Study. Transplant Direct 2024; 10:e1699. [PMID: 39301560 PMCID: PMC11410324 DOI: 10.1097/txd.0000000000001699] [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: 07/09/2024] [Accepted: 07/15/2024] [Indexed: 09/22/2024] Open
Abstract
Background Transplant centers have traditionally relied upon procurement teams from their own programs (transplant program procurement team [TPT]) to recover donation after circulatory death (DCD) livers and rarely use surgical procurement teams not affiliated with the recipient center (nontransplant program procurement team [NTPT]). However, in the era of wider geographic organ sharing, greater reliance on NTPTs is often necessary. Methods We used national data to study the association between the origin of the donor procurement team (NTPT versus TPT) and the risk of DCD liver allograft failure. Results Five hundred NTPT and 2257 TPT DCD transplants were identified: 1-y graft survival was 88.9 and 88.6%, respectively (P = 0.962). In a multivariable model, the origin of the procurement team was not associated with graft failure NTPT versus TPT (hazard ratio, 0.92; 95% confidence interval, 0.71-1.22; P = 0.57) but rather with known risks for DCD graft loss including donor age, degree of recipient illness, cold ischemic time, and retransplantation. The overall incidence of retransplantation and ischemic cholangiopathy as an indication for retransplantation were similar between NTPT and TPT. Conclusions This data suggests that transplant centers may be able to safely use DCD livers recovered by local surgical teams.
Collapse
Affiliation(s)
- Tobenna Ibeabuchi
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Eric Li
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Claire Cywes
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Therese Bittermann
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nadim Mahmud
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Peter L Abt
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
3
|
Eggenhofer E, Proneth B. Ferroptosis Inhibition: A Key Opportunity for the Treatment of Ischemia/Reperfusion Injury in Liver Transplantation. Transplantation 2024:00007890-990000000-00874. [PMID: 39294870 DOI: 10.1097/tp.0000000000005199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2024]
Abstract
The outcome after liver transplantation has improved in recent years, which can be attributed to superior storage and transportation conditions of the organs, as well as better peri- and postoperative management and advancements in surgical techniques. Nevertheless, there is an increasing discrepancy between the need for organs and their availability. Consequently, the mortality rate on the waiting list is high and continues to rise. One way of counteracting this trend is to increase the use of "expanded criteria donors." This means that more and more donors will be included, especially those who are older and having additional comorbidities (eg, steatosis). A major complication of any transplantation is the occurrence of ischemia/reperfusion injury (IRI), which often leads to liver dysfunction and failure. However, there have been various promising approaches to minimize IRI in recent years, but an effective and clinically applicable method to achieve a better outcome for patients after liver transplantation is still missing. Thereby, the so-called marginal organs are predominantly affected by IRI; thus, it is crucial to develop suitable and effective treatment options for patients. Recently, regulated cell death mechanisms, particularly ferroptosis, have been implicated to play a major role in IRI, including the liver. Therefore, inhibiting this kind of cell death modality presents a promising therapeutic approach for the management of this yet untreatable condition. Thus, this review provides an overview of the role of ferroptosis in liver IRI and transplantation and discusses possible therapeutic solutions based on ferroptosis inhibition to restrain IRI in marginal organs (especially steatosis and donation after circulatory death organs).
Collapse
Affiliation(s)
- Elke Eggenhofer
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Bettina Proneth
- Institute of Metabolism and Cell Death, Helmholtz Munich, Neuherberg, Germany
| |
Collapse
|
4
|
Schurink IJ, de Goeij FHC, van der Heijden FJ, van Rooden RM, van Dijk MC, Polak WG, van der Laan LJW, Huurman VAL, de Jonge J. Liver function maximum capacity test during normothermic regional perfusion predicts graft function after transplantation. EPMA J 2024; 15:545-558. [PMID: 39239110 PMCID: PMC11372035 DOI: 10.1007/s13167-024-00371-7] [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: 04/04/2024] [Accepted: 06/29/2024] [Indexed: 09/07/2024]
Abstract
Purpose In an effort to reduce waitlist mortality, extended criteria donor organs, including those from donation after circulatory death (DCD), are being used with increasing frequency. These donors carry an increased risk for postoperative complications, and balancing donor-recipient risks is currently based on generalized nomograms. Abdominal normothermic regional perfusion (aNRP) enables individual evaluation of DCD organs, but a gold standard to determine suitability for transplantation is lacking. This study aimed to incorporate individualized and predictive measurements of the liver maximum capacity (LiMAx) test to objectively grade liver function during aNRP and prevent post-op complications. Methods aNRP was performed to salvage 18 DCD liver grafts, otherwise discarded. Continuous variables were presented as the median with the interquartile range. Results The liver function maximum capacity (LiMAx) test was successfully performed within the aNRP circuit in 17 aNRPs (94%). Donor livers with good lactate clearance during aNRP demonstrated significantly higher LiMAx scores (396 (301-451) µg/kg/h versus those who did not 105 (70-158) µg/kg/h; P = 0.006). This was also true for manifesting stress hyperglycemia > 20 mmol/l (P = 0.032). LiMAx score correlated with alanine aminotransferase (ALT; R = - 0.755) and aspartate transaminase (AST; R = - 0.800) levels during perfusion and distinguished livers that were selected for transplantation (397 (346-453) µg/kg/h) from those who were discarded (155 (87-206) µg/kg/h; P < 0.001). Twelve livers were accepted for transplantation, blinded for LiMAx results, and all had LiMAx scores of > 241 µg/kg/h. Postoperatively, LiMAx during aNRP displayed correlation with 24-h lactate levels. Conclusions This study shows for the first time the feasibility to assess liver function during aNRP in individual donor livers. LiMAx presents an objective tool to predict donor liver function and risk of complications in the recipient, thus enabling individualized matching of donor livers for an individual recipient. The LiMAx test may present a valuable test for the prediction of donor liver function, preventing post-transplant complication, and personalizing the selection of donor livers for individual recipients. Supplementary Information The online version contains supplementary material available at 10.1007/s13167-024-00371-7.
Collapse
Affiliation(s)
- Ivo J Schurink
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, Zuid Holland The Netherlands
| | - Femke H C de Goeij
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, Zuid Holland The Netherlands
| | - Fenna J van der Heijden
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, Zuid Holland The Netherlands
| | - Rutger M van Rooden
- LUMC Transplant Center, Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Madeleine C van Dijk
- LUMC Transplant Center, Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Wojciech G Polak
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, Zuid Holland The Netherlands
| | - Luc J W van der Laan
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, Zuid Holland The Netherlands
| | - Volkert A L Huurman
- LUMC Transplant Center, Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen de Jonge
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, Zuid Holland The Netherlands
| |
Collapse
|
5
|
Wehrle CJ, Zhang M, Khalil M, Pita A, Modaresi Esfeh J, Diago-Uso T, Kim J, Aucejo F, Kwon DCH, Ali K, Cazzaniga B, Miyazaki Y, Liu Q, Fares S, Hong H, Tuul M, Jiao C, Sun K, Fairchild RL, Quintini C, Fujiki M, Pinna AD, Miller C, Hashimoto K, Schlegel A. Impact of Back-to-Base Normothermic Machine Perfusion on Complications and Costs: A Multicenter, Real-World Risk-Matched Analysis. Ann Surg 2024; 280:300-310. [PMID: 38557793 DOI: 10.1097/sla.0000000000006291] [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: 04/04/2024]
Abstract
OBJECTIVE Assess cost and complication outcomes after liver transplantation (LT) using normothermic machine perfusion (NMP). BACKGROUND End-ischemic NMP is often used to aid logistics, yet its impact on outcomes after LT remains unclear, as does its true impact on costs associated with transplantation. METHODS Deceased donor liver recipients at 2 centers (January 1, 2019, to June 30, 2023) were included. Retransplants, splits, and combined grafts were excluded. End-ischemic NMP (OrganOx-Metra) was implemented in October 2022 for extended-criteria donation after brain death (DBDs), all donations after circulatory deaths (DCDs), and logistics. NMP cases were matched 1:2 with static cold storage controls (SCS) using the Balance-of-Risk [donation after brain death (DBD)-grafts] and UK-DCD Score (DCD-grafts). RESULTS Overall, 803 transplantations were included, 174 (21.7%) receiving NMP. Matching was achieved between 118 NMP-DBDs with 236 SCS; and 37 NMP-DCD with 74 corresponding SCS. For both graft types, median inpatient comprehensive complications index values were comparable between groups. DCD-NMP grafts experienced reduced cumulative 90-day comprehensive complications index (27.6 vs 41.9, P =0.028). NMP also reduced the need for early relaparotomy and renal replacement therapy, with subsequently less frequent major complications (Clavien-Dindo ≥IVa). This effect was more pronounced in DCD transplants. NMP had no protective effect on early biliary complications. Organ acquisition/preservation costs were higher with NMP, yet NMP-treated grafts had lower 90-day pretransplant costs in the context of shorter waiting list times. Overall costs were comparable for both cohorts. CONCLUSIONS This is the first risk-adjusted outcome and cost analysis comparing NMP and SCS. In addition to logistical benefits, NMP was associated with a reduction in relaparotomy and bleeding in DBD grafts, and overall complications and post-LT renal replacement for DCDs. While organ acquisition/preservation was more costly with NMP, overall 90-day health care costs-per-transplantation were comparable.
Collapse
Affiliation(s)
| | | | | | | | - Jamak Modaresi Esfeh
- Department of Gastroenterology and Transplant Hepatology, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago-Uso
- Department of Liver Transplantation, Cleveland Clinic Abu Dhabi, Cleveland, OH
| | - Jaekeun Kim
- Transplantation Center, Cleveland Clinic, OH
| | | | | | - Khaled Ali
- Transplantation Center, Cleveland Clinic, OH
| | | | | | - Qiang Liu
- Transplantation Center, Cleveland Clinic, OH
| | - Sami Fares
- Transplantation Center, Cleveland Clinic, OH
| | - Hanna Hong
- Transplantation Center, Cleveland Clinic, OH
| | | | - Chunbao Jiao
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Keyue Sun
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Robert L Fairchild
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Cristiano Quintini
- Department of Liver Transplantation, Cleveland Clinic Abu Dhabi, Cleveland, OH
| | | | | | | | - Koji Hashimoto
- Transplantation Center, Cleveland Clinic, OH
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Andrea Schlegel
- Transplantation Center, Cleveland Clinic, OH
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| |
Collapse
|
6
|
Müller PC, Müller BP, Dutkowski P. [Organ donation and organ assessment after primary circulatory death and secondary brain death]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:618-626. [PMID: 38750373 PMCID: PMC11286625 DOI: 10.1007/s00104-024-02094-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/16/2024] [Indexed: 07/26/2024]
Abstract
BACKGROUND The global organ shortage is the biggest obstacle to expand urgently needed liver transplantation activities. In addition to donation after brain death (DBD), donation after primary circulatory death (DCD) has also been introduced in many European countries to increase the number of donated organs. OBJECTIVE This article summarizes the legal and ethical aspects of DCD, the practical donation process of DCD, the clinical results of DCD liver transplantation with a special focus on organ assessment before a planned DCD liver transplantation. RESULTS In Europe 11 countries have active DCD liver transplantation programs and a total of 1230 DCD liver transplantations were performed in Europe in 2023. The highest proportion of DCD liver transplantations were recorded in Belgium (52.8%), the Netherlands (42.8%) and Switzerland (32.1%). The adequate selection of donors and recipients is crucial in DCD transplantation and the use of DCD livers particularly depends on the preparedness of the healthcare system for routine machine perfusion. The leaders are Belgium, France and Italy which implant around 68-74% of DCD organs. With an adequate organ assessment, the long-term results of DBD and DCD liver transplantations are comparable. To assess mitochondrial damage and thus organ quality, hypothermic oxygenated machine perfusion (HOPE) was introduced and has the secondary benefit of mitochondrial protection through oxygenation. The establishment of aerobic metabolism in mitochondria under hypothermia leads to a reduction of toxic metabolites and the restoration of ATP storage, which subsequently leads to a reperfusion light during implantation. CONCLUSION Expanding the donor pool with DCD donors can counteract the global organ shortage. With adequate patient selection and routine organ assessment short-term and also long-term outcomes of DBD and DCD liver transplantation are comparable.
Collapse
Affiliation(s)
- Philip C Müller
- Klinik für Viszeralchirugie, Clarunis - Universitäres Bauchzentrum, Universitätsspital Basel, Basel, Schweiz
| | - Beat P Müller
- Klinik für Viszeralchirugie, Clarunis - Universitäres Bauchzentrum, Universitätsspital Basel, Basel, Schweiz
| | - Philipp Dutkowski
- Klinik für Viszeralchirugie, Clarunis - Universitäres Bauchzentrum, Universitätsspital Basel, Basel, Schweiz.
- Department of Surgery, Clarunis - University Digestive Health Care Centre Basel, Spitalstr. 21, 4031, Basel, Schweiz.
| |
Collapse
|
7
|
Groen PC, van Leeuwen OB, de Jonge J, Porte RJ. Viability assessment of the liver during ex-situ machine perfusion prior to transplantation. Curr Opin Organ Transplant 2024; 29:239-247. [PMID: 38764406 PMCID: PMC11224566 DOI: 10.1097/mot.0000000000001152] [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: 05/21/2024]
Abstract
PURPOSE OF REVIEW In an attempt to reduce waiting list mortality in liver transplantation, less-than-ideal quality donor livers from extended criteria donors are increasingly accepted. Predicting the outcome of these organs remains a challenge. Machine perfusion provides the unique possibility to assess donor liver viability pretransplantation and predict postreperfusion organ function. RECENT FINDINGS Assessing liver viability during hypothermic machine perfusion remains challenging, as the liver is not metabolically active. Nevertheless, the levels of flavin mononucleotide, transaminases, lactate dehydrogenase, glucose and pH in the perfusate have proven to be predictors of liver viability. During normothermic machine perfusion, the liver is metabolically active and in addition to the perfusate levels of pH, transaminases, glucose and lactate, the production of bile is a crucial criterion for hepatocyte viability. Cholangiocyte viability can be determined by analyzing bile composition. The differences between perfusate and bile levels of pH, bicarbonate and glucose are good predictors of freedom from ischemic cholangiopathy. SUMMARY Although consensus is lacking regarding precise cut-off values during machine perfusion, there is general consensus on the importance of evaluating both hepatocyte and cholangiocyte compartments. The challenge is to reach consensus for increased organ utilization, while at the same time pushing the boundaries by expanding the possibilities for viability testing.
Collapse
Affiliation(s)
- Puck C Groen
- Department of Surgery, Division of Hepato-Pancreato- Biliary and Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | | | | |
Collapse
|
8
|
Nguyen MC, Li X, Reddy KS, Mathur AK. Commentary: DCD liver transplant in patients with a MELD over 35. Front Immunol 2024; 15:1404948. [PMID: 39055702 PMCID: PMC11269119 DOI: 10.3389/fimmu.2024.1404948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 06/24/2024] [Indexed: 07/27/2024] Open
Affiliation(s)
- Michelle C. Nguyen
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | | | | | | |
Collapse
|
9
|
Eden J, Brüggenwirth IMA, Berlakovich G, Buchholz BM, Botea F, Camagni S, Cescon M, Cillo U, Colli F, Compagnon P, De Carlis LG, De Carlis R, Di Benedetto F, Dingfelder J, Diogo D, Dondossola D, Drefs M, Fronek J, Germinario G, Gringeri E, Györi G, Kocik M, Küçükerbil EH, Koliogiannis D, Lam HD, Lurje G, Magistri P, Monbaliu D, Moumni ME, Patrono D, Polak WG, Ravaioli M, Rayar M, Romagnoli R, Sörensen G, Uluk D, Schlegel A, Porte RJ, Dutkowski P, de Meijer VE. Long-term outcomes after hypothermic oxygenated machine perfusion and transplantation of 1,202 donor livers in a real-world setting (HOPE-REAL study). J Hepatol 2024:S0168-8278(24)02341-9. [PMID: 38969242 DOI: 10.1016/j.jhep.2024.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/26/2024] [Accepted: 06/24/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND & AIMS Despite strong evidence for improved preservation of donor livers by machine perfusion, longer post-transplant follow-up data are urgently needed in an unselected patient population. We aimed to assess long-term outcomes after transplantation of hypothermic oxygenated machine perfusion (HOPE)-treated donor livers based on real-world data (i.e., IDEAL-D stage 4). METHODS In this international, multicentre, observational cohort study, we collected data from adult recipients of HOPE-treated livers transplanted between January 2012 and December 2021. Analyses were stratified by donation after brain death (DBD) and donation after circulatory death (DCD), sub-divided by their respective risk categories. The primary outcome was death-censored graft survival. Secondary outcomes included the incidence of primary non-function (PNF) and ischaemic cholangiopathy (IC). RESULTS We report on 1,202 liver transplantations (64% DBD) performed at 22 European centres. For DBD, a total number of 99 benchmark (8%), 176 standard (15%), and 493 extended-criteria (41%) cases were included. For DCD, 117 transplants were classified as low risk (10%), 186 as high risk (16%), and 131 as futile (11%), with significant risk profile variations among centres. Actuarial 1-, 3-, and 5-year death-censored graft survival rates for DBD and DCD livers were 95%, 92%, and 91%, vs. 92%, 87%, and 81%, respectively (log-rank p = 0.003). Within DBD and DCD strata, death-censored graft survival was similar among risk groups (log-rank p = 0.26, p = 0.99). Graft loss due to PNF or IC was 2.3% and 0.4% (DBD), and 5% and 4.1% (DCD). CONCLUSIONS This study shows excellent 5-year survival after transplantation of HOPE-treated DBD and DCD livers with low rates of graft loss due to PNF or IC, irrespective of their individual risk profile. HOPE treatment has now reached IDEAL-D stage 4, which further supports its implementation in routine clinical practice. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05520320. IMPACT AND IMPLICATIONS This study demonstrates the excellent long-term performance of hypothermic oxygenated machine perfusion (HOPE) treatment of donation after circulatory and donation after brain death liver grafts irrespective of their individual risk profile in a real-world setting, outside the evaluation of randomised-controlled trials. While previous studies have established safety, feasibility, and efficacy against the current standard, according to the IDEAL-D evaluation framework, HOPE treatment has now reached the final IDEAL-D stage 4, which further supports its implementation in routine clinical practice.
Collapse
Affiliation(s)
- Janina Eden
- Department of Surgery, Section of HPB Surgery and Liver Transplantation, University of Groningen and University Medical Center Groningen, Groningen, the Netherlands; UMCG Comprehensive Transplant Center, Groningen, the Netherlands
| | - Isabel M A Brüggenwirth
- Department of Surgery, Section of HPB Surgery and Liver Transplantation, University of Groningen and University Medical Center Groningen, Groningen, the Netherlands; UMCG Comprehensive Transplant Center, Groningen, the Netherlands
| | | | - Bettina M Buchholz
- Department of Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florin Botea
- Fundeni Clinical Institute, Center of General Surgery and Liver Transplantation; "Titu Maiorescu" University, Bucharest, Romania
| | - Stefania Camagni
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Matteo Cescon
- Department of General Surgery and Transplantation, IRCCS, Azienda Ospedaliero-Universitaria of Bologna, University of Bologna, Bologna, Italy
| | - Umberto Cillo
- Chirurgia Generale 2, Hepato-Biliary-Pancreatic Unit and Liver Transplant Center, Padova University Hospital, Padova, Italy
| | - Fabio Colli
- General Surgery 2U, Liver Transplant Centre, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Philippe Compagnon
- Department of Transplant Surgery, University of Geneva, Geneva, Switzerland
| | - Luciano G De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Riccardo De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Jule Dingfelder
- Division of Transplantation, Medical University of Vienna, Vienna, Austria
| | - Dulce Diogo
- Adult Liver Transplantation Unit, Department of Surgery and Gastroenterology, Coimbra Hospital and University Center, Coimbra, Portugal
| | - Daniele Dondossola
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, and Department of Pathophysiology and Transplantation Università degli Studi di Milano, Milan, Italy
| | - Moritz Drefs
- Department of Transplant Surgery, University of Munich Grosshaderm, Germany
| | - Jiri Fronek
- Transplant Surgery Department, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Giuliana Germinario
- Department of General Surgery and Transplantation, IRCCS, Azienda Ospedaliero-Universitaria of Bologna, University of Bologna, Bologna, Italy
| | - Enrico Gringeri
- Chirurgia Generale 2, Hepato-Biliary-Pancreatic Unit and Liver Transplant Center, Padova University Hospital, Padova, Italy
| | - Georg Györi
- Division of Transplantation, Medical University of Vienna, Vienna, Austria
| | - Matej Kocik
- Transplant Surgery Department, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Efrayim H Küçükerbil
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Division of HPB and Transplant Surgery, Rotterdam, the Netherlands
| | | | - Hwai-Ding Lam
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Georg Lurje
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Diethard Monbaliu
- Department of Abdominal Transplantation, Leuven Transplant Center, University Hospitals Leuven, Leuven, Belgium
| | - Mostafa El Moumni
- Department of Surgery, Section of Epidemiology and Statistics, University of Groningen and University Medical Center Groningen, Groningen, the Netherlands
| | - Damiano Patrono
- General Surgery 2U, Liver Transplant Centre, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Wojciech G Polak
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Division of HPB and Transplant Surgery, Rotterdam, the Netherlands
| | - Matteo Ravaioli
- Department of General Surgery and Transplantation, IRCCS, Azienda Ospedaliero-Universitaria of Bologna, University of Bologna, Bologna, Italy
| | - Michel Rayar
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France
| | - Renato Romagnoli
- General Surgery 2U, Liver Transplant Centre, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Gustaf Sörensen
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Deniz Uluk
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andrea Schlegel
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, and Department of Pathophysiology and Transplantation Università degli Studi di Milano, Milan, Italy; Transplantation Center and Lerner Research Institute, Cleveland Clinic Ohio, USA
| | - Robert J Porte
- Department of Surgery, Section of HPB Surgery and Liver Transplantation, University of Groningen and University Medical Center Groningen, Groningen, the Netherlands; Erasmus MC Transplant Institute, University Medical Center Rotterdam, Division of HPB and Transplant Surgery, Rotterdam, the Netherlands
| | - Philipp Dutkowski
- Swiss HPB and Transplant Center, Department of Visceral Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Vincent E de Meijer
- Department of Surgery, Section of HPB Surgery and Liver Transplantation, University of Groningen and University Medical Center Groningen, Groningen, the Netherlands; UMCG Comprehensive Transplant Center, Groningen, the Netherlands.
| |
Collapse
|
10
|
Cesaretti M, Izzo A, Pellegrino RA, Galli A, Mavrothalassitis O. Cold ischemia time in liver transplantation: An overview. World J Hepatol 2024; 16:883-890. [PMID: 38948435 PMCID: PMC11212655 DOI: 10.4254/wjh.v16.i6.883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/26/2024] [Accepted: 05/20/2024] [Indexed: 06/20/2024] Open
Abstract
The standard approach to organ preservation in liver transplantation is by static cold storage and the time between the cross-clamping of a graft in a donor and its reperfusion in the recipient is defined as cold ischemia time (CIT). This simple definition reveals a multifactorial time frame that depends on donor hepatectomy time, transit time, and recipient surgery time, and is one of the most important donor-related risk factors which may influence the graft and recipient's survival. Recently, the growing demand for the use of marginal liver grafts has prompted scientific exploration to analyze ischemia time factors and develop different organ preservation strategies. This review details the CIT definition and analyzes its different factors. It also explores the most recent strategies developed to implement each timestamp of CIT and to protect the graft from ischemic injury.
Collapse
Affiliation(s)
- Manuela Cesaretti
- Department of HPB and Liver Transplantation, Brotzu Hospital, Cagliari 09122, Italy
- Department of Nanophysic, Istituto Italiano di Tecnologia, Genova 16163, Italy.
| | - Alessandro Izzo
- Department of HPB and Liver Transplantation, Brotzu Hospital, Cagliari 09122, Italy
| | | | - Alessandro Galli
- Department of Critical Care Medicine and Anesthesia, ASST Papa Giovanni XXIII, Bergamo 24100, Italy
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA 94143, United States
| | - Orestes Mavrothalassitis
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA 94143, United States
| |
Collapse
|
11
|
Cortes-Mejia NA, Bejarano-Ramirez DF, Guerra-Londono JJ, Trivino-Alvarez DR, Tabares-Mesa R, Vera-Torres A. Portal vein arterialization in 25 liver transplant recipients: A Latin American single-center experience. World J Transplant 2024; 14:92528. [PMID: 38947972 PMCID: PMC11212596 DOI: 10.5500/wjt.v14.i2.92528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 02/19/2024] [Accepted: 04/28/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Portal vein arterialization (PVA) has been used in liver transplantation (LT) to maximize oxygen delivery when arterial circulation is compromised or has been used as an alternative reperfusion technique for complex portal vein thrombosis (PVT). The effect of PVA on portal perfusion and primary graft dysfunction (PGD) has not been assessed. AIM To examine the outcomes of patients who required PVA in correlation with their LT procedure. METHODS All patients receiving PVA and LT at the Fundacion Santa Fe de Bogota between 2011 and 2022 were analyzed. To account for the time-sensitive effects of graft perfusion, patients were classified into two groups: prereperfusion (pre-PVA), if the arterioportal anastomosis was performed before graft revascularization, and postreperfusion (post-PVA), if PVA was performed afterward. The pre-PVA rationale contemplated poor portal hemodynamics, severe vascular steal, or PVT. Post-PVA was considered if graft hypoperfusion became evident. Conservative interventions were attempted before PVA. RESULTS A total of 25 cases were identified: 15 before and 10 after graft reperfusion. Pre-PVA patients were more affected by diabetes, decompensated cirrhosis, impaired portal vein (PV) hemodynamics, and PVT. PGD was less common after pre-PVA (20.0% vs 60.0%) (P = 0.041). Those who developed PGD had a smaller increase in PV velocity (25.00 cm/s vs 73.42 cm/s) (P = 0.036) and flow (1.31 L/min vs 3.34 L/min) (P = 0.136) after arterialization. Nine patients required PVA closure (median time: 62 d). Pre-PVA and non-PGD cases had better survival rates than their counterparts (56.09 months vs 22.77 months and 54.15 months vs 31.91 months, respectively). CONCLUSION This is the largest report presenting PVA in LT. Results suggest that pre-PVA provides better graft perfusion than post-PVA. Graft hyperperfusion could play a protective role against PGD.
Collapse
Affiliation(s)
- Nicolas Andres Cortes-Mejia
- Division of Anesthesiology, Critical Care Medicine, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
- Transplant and Hepatobiliary Surgery Department, Fundacion Santa Fe de Bogota, Bogota 110111, Colombia
| | | | - Juan Jose Guerra-Londono
- Division of Anesthesiology, Critical Care Medicine, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | | | - Raquel Tabares-Mesa
- General Surgery Department, Fundacion Santa Fe de Bogota, Bogota 110111, Colombia
| | - Alonso Vera-Torres
- Transplant and Hepatobiliary Surgery Department, Fundacion Santa Fe de Bogota, Bogota 110111, Colombia
| |
Collapse
|
12
|
Al-Ameri AAM, Zheng S. Outcomes of liver transplantation for hepatocellular carcinoma in donation after circulatory death compared with donation after brain death: A systematic review and meta-analysis. Ann Hepatol 2024; 29:101484. [PMID: 38417629 DOI: 10.1016/j.aohep.2024.101484] [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: 11/27/2023] [Revised: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 03/01/2024]
Abstract
INTRODUCTION AND OBJECTIVES Due to organ shortages, liver transplantation (LT) using donation-after-circulatory-death (DCD) grafts has become more common. There is limited and conflicting evidence on LT outcomes using DCD grafts compared to those using donation-after-brain death (DBD) grafts for patients with hepatocellular carcinoma (HCC). We aimed to summarize the current evidence on the outcomes of DCD-LT and DBD-LT in patients with HCC. MATERIALS AND METHODS Online databases were searched for studies comparing DCD-LT and DBD-LT outcomes in patients with HCC and a meta-analysis was conducted using fixed- or random-effects models. RESULTS Five studies involving 487 (33.4%) HCC DCD-LT patients and 973 (66.6%) DBD-LT patients were included. The meta-analysis showed comparable 1-year [relative risk (RR)=0.99, 95%CI:0.95 to 1.03, p=0.53] and 3-year [RR=0.99, 95%CI:0.89 to 1.09, p=0.79] recurrence-free survival. The corresponding 1-year [RR=0.98, 95%CI:0.93 to 1.03, p=0.35] and 3-year [RR=0.94, 95%CI:0.87 to 1.01, p=0.08] patient survival and 1-year [RR=0.91, 95%CI:0.71 to 1.16, p=0.43] and 3-year [RR=0.92, 95%CI:0.67 to 1.26, p=0.59] graft survival were also comparable. There were no significant differences between the two cohorts regarding the tumor characteristics, donor/recipient risk factors and the incidence of post-operative complications, including acute rejection, primary non-function, biliary complications and retransplantation. CONCLUSIONS Based on the current evidence, it has been found that comparable outcomes can be achieved in HCC patients using DCD-LT compared to DBD-LT, particularly when employing good quality graft, strict donor and recipient selection, and effective surgical management. The decision to utilize DCD-LT for HCC patients should be personalized, taking into consideration the risk of post-LT HCC recurrence. (PROSPERO ID: CRD42023445812).
Collapse
Affiliation(s)
- Abdulahad Abdulrab Mohammed Al-Ameri
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou, China; NHC Key Laboratory of Combined Multi-Organ Transplantation, China; 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, China; Key Laboratory of Organ Transplantation, Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, Zhejiang 310003, China
| | - Shusen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou, China; NHC Key Laboratory of Combined Multi-Organ Transplantation, China; 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, China; Key Laboratory of Organ Transplantation, Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, Zhejiang 310003, China.
| |
Collapse
|
13
|
Wehrle CJ, Raj R, Maspero M, Satish S, Eghtesad B, Pita A, Kim J, Khalil M, Calderon E, Orabi D, Zervos B, Modaresi Esfeh J, Whitsett Linganna M, Diago-Uso T, Fujiki M, Quintini C, Kwon CD, Miller C, Pinna A, Aucejo F, Hashimoto K, Schlegel A. Risk assessment in liver transplantation for hepatocellular carcinoma: long-term follow-up of a two-centre experience. Int J Surg 2024; 110:2818-2831. [PMID: 38241354 PMCID: PMC11093438 DOI: 10.1097/js9.0000000000001104] [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: 09/02/2023] [Accepted: 01/08/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND Liver transplantation (LT) is a well-established treatment for hepatocellular carcinoma (HCC), but there are ongoing debates regarding outcomes and selection. This study examines the experience of LT for HCC at a high-volume centre. METHODS A prospectively maintained database was used to identify HCC patients undergoing LT from 2000 to 2020 with more than or equal to 3-years follow-up. Data were obtained from the centre database and electronic medical records. The Metroticket 2.0 HCC-specific 5-year survival scale was calculated for each patient. Kaplan-Meier and Cox-regression analyses were employed assessing survival between groups based on Metroticket score and individual donor and recipient risk factors. RESULTS Five hundred sixty-nine patients met criteria. Median follow-up was 96.2 months (8.12 years; interquartile range 59.9-147.8). Three-year recurrence-free (RFS) and overall survival (OS) were 88.6% ( n =504) and 86.6% ( n =493). Five-year RFS and OS were 78.9% ( n =449) and 79.1% ( n =450). Median Metroticket 2.0 score was 0.9 (interquartile range 0.9-0.95). Tumour size greater than 3 cm ( P =0.012), increasing tumour number on imaging ( P =0.001) and explant pathology ( P <0.001) was associated with recurrence. Transplant within Milan ( P <0.001) or UCSF criteria ( P <0.001) had lower recurrence rates. Increasing alpha-fetoprotein (AFP)-values were associated with more HCC recurrence ( P <0.001) and reduced OS ( P =0.008). Chemoembolization was predictive of recurrence in the overall population ( P =0.043) and in those outside-Milan criteria ( P =0.038). A receiver-operator curve using Metroticket 2.0 identified an optimal cut-off of projected survival greater than or equal to 87.5% for predicting recurrence. This cut-off was able to predict RFS ( P <0.001) in the total cohort and predict both, RFS ( P =0.007) and OS ( P =0.016) outside Milan. Receipt of donation after brain death (DBD) grafts (55/478, 13%) or living-donor grafts (3/22, 13.6%) experienced better survival rates compared to donation after cardiac death (DCD) grafts ( n =15/58, 25.6%, P =0.009). Donor age was associated with a higher HCC recurrence ( P =0.006). Both total ischaemia time (TIT) greater than 6hours ( P =0.016) and increasing TIT correlated with higher HCC recurrence ( P =0.027). The use of DCD grafts for outside-Milan candidates was associated with increased recurrence ( P =0.039) and reduced survival ( P =0.033). CONCLUSION This large two-centre analysis confirms favourable outcomes after LT for HCC. Tumour size and number, pre-transplant AFP, and Milan criteria remain important recipient HCC-risk factors. A higher donor risk (i.e. donor age, DCD grafts, ischaemia time) was associated with poorer outcomes.
Collapse
Affiliation(s)
- Chase J. Wehrle
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Roma Raj
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Marianna Maspero
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Sangeeta Satish
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Bijan Eghtesad
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Alejandro Pita
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Jaekeun Kim
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Mazhar Khalil
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Esteban Calderon
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Danny Orabi
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Bobby Zervos
- Cleveland Clinic Weston Hospital, Department of Liver Transplantation, Weston, FL, USA
| | | | | | - Teresa Diago-Uso
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Masato Fujiki
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Cristiano Quintini
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Choon David Kwon
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Charles Miller
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Antonio Pinna
- Cleveland Clinic Weston Hospital, Department of Liver Transplantation, Weston, FL, USA
| | - Federico Aucejo
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Koji Hashimoto
- Transplantation Center, Department of Surgery, Digestive Disease Institute
| | - Andrea Schlegel
- Transplantation Center, Department of Surgery, Digestive Disease Institute
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, OH
| |
Collapse
|
14
|
Akabane M, Melcher ML, Esquivel CO, Imaoka Y, Kim WR, Sasaki K. Enhancing the usability of older DCD donors through strategic approaches in liver transplantation in the United States. Liver Transpl 2024:01445473-990000000-00361. [PMID: 38625836 DOI: 10.1097/lvt.0000000000000376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/17/2024] [Indexed: 04/18/2024]
Abstract
The use of older donors after circulatory death (DCD) for liver transplantation (LT) has increased over the past decade. This study examined whether outcomes of LT using older DCD (≥50 y) have improved with advancements in surgical/perioperative care and normothermic machine perfusion (NMP) technology. A total of 7602 DCD LT cases from the United Network for Organ Sharing database (2003-2022) were reviewed. The impact of older DCD donors on graft survival was assessed using the Kaplan-Meier and HR analyses. In all, 1447 LT cases (19.0%) involved older DCD donors. Although there was a decrease in their use from 2003 to 2014, a resurgence was noted after 2015 and reached 21.9% of all LTs in the last 4 years (2019-2022). Initially, 90-day and 1-year graft survivals for older DCDs were worse than younger DCDs, but this difference decreased over time and there was no statistical difference after 2015. Similarly, HRs for graft loss in older DCD have recently become insignificant. In older DCD LT, NMP usage has increased recently, especially in cases with extended donor-recipient distances, while the median time from asystole to aortic cross-clamp has decreased. Multivariable Cox regression analyses revealed that in the early phase, asystole to cross-clamp time had the highest HR for graft loss in older DCD LT without NMP, while in the later phases, the cold ischemic time (>5.5 h) was a significant predictor. LT outcomes using older DCD donors have become comparable to those from young DCD donors, with recent HRs for graft loss becoming insignificant. The strategic approach in the recent period could mitigate risks, including managing cold ischemic time (≤5.5 h), reducing asystole to cross-clamp time, and adopting NMP for longer distances. Optimal use of older DCD donors may alleviate the donor shortage.
Collapse
Affiliation(s)
- Miho Akabane
- Department of Surgery, Division of Abdominal Transplant, Stanford University Medical Center, Stanford, California, USA
| | - Marc L Melcher
- Department of Surgery, Division of Abdominal Transplant, Stanford University Medical Center, Stanford, California, USA
| | - Carlos O Esquivel
- Department of Surgery, Division of Abdominal Transplant, Stanford University Medical Center, Stanford, California, USA
| | - Yuki Imaoka
- Department of Surgery, Division of Abdominal Transplant, Stanford University Medical Center, Stanford, California, USA
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California, USA
| | - Kazunari Sasaki
- Department of Surgery, Division of Abdominal Transplant, Stanford University Medical Center, Stanford, California, USA
| |
Collapse
|
15
|
Xiang Z, Li J, Zeng H, Xiang X, Gao F, Wang K, Wei X, Zheng S, Xu X. Current Understanding of Marginal Grafts in Liver Transplantation. Aging Dis 2024:AD.2024.0214. [PMID: 38607739 DOI: 10.14336/ad.2024.0214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/14/2024] [Indexed: 04/14/2024] Open
Abstract
End-stage liver disease (ESLD), stemming from a spectrum of chronic liver pathologies including chronic liver failure, acute cirrhosis decompensation and hepatocellular carcinoma, imposes a significant global healthcare burden. Liver transplantation (LT) remains the only treatment for ESLD. However, the escalating mortality on transplant waitlists has prompted the utilization of marginal liver grafts in LT procedures. These grafts primarily encompass elderly livers, steatotic livers, livers from donation after circulatory death, split livers and those infected with the hepatitis virus. While the expansion of the donor pool offers promise, it also introduces concomitant risks. These encompass graft failure, biliary and cardiovascular complications, the recurrence of liver disease and reduced patient and graft survival. Consequently, various established strategies, ranging from improved donor-recipient matching to surgical interventions, have emerged to mitigate these risks. This article undertakes a comprehensive assessment of the current landscape, evaluating the viability of diverse marginal liver grafts. Additionally, it synthesizes approaches aimed at enhancing the quality of such marginal liver grafts. The overarching objective is to augment the donor pool and ameliorate the risk factors associated with the shortage of liver grafts.
Collapse
Affiliation(s)
- Ze Xiang
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Jiarui Li
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Huixuan Zeng
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Xiaonan Xiang
- Zhejiang University School of Medicine, Hangzhou 310058, China
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, Cambridgeshire, UK
| | - Fengqiang Gao
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Kai Wang
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Xuyong Wei
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China
| | - Shusen Zheng
- Zhejiang University School of Medicine, Hangzhou 310058, China
- Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, Hangzhou 310022, China
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
| | - Xiao Xu
- Zhejiang University School of Medicine, Hangzhou 310058, China
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
| |
Collapse
|
16
|
Rolak S, Elhawary A, Diwan T, Watt KD. Futility and poor outcomes are not the same thing: A clinical perspective of refined outcomes definitions in liver transplantation. Liver Transpl 2024; 30:421-430. [PMID: 38240612 DOI: 10.1097/lvt.0000000000000331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 01/10/2024] [Indexed: 03/16/2024]
Abstract
The term "futility" in liver transplantation is used inappropriately and inaccurately, as it is frequently applied to patient populations with suboptimal outcomes that are often not truly "futile." The term "futile" is used interchangeably with poor outcomes. Not all poor outcomes fulfill a definition of futility when considering all viewpoints. Definitions of "futility" are variable throughout the medical literature. We review futility in the context of liver transplantation, encompassing various viewpoints, with a goal to propose focused outcome definitions, including futility, that encompass broader viewpoints, and improve the utilization of "futility" to truly futile situations, and improve communication between providers and patients/families. Focused, appropriate definitions will help the transplant community develop better models to more accurately predict and avoid futile transplants, and better predict an individual patient's posttransplant outcome.
Collapse
Affiliation(s)
- Stacey Rolak
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ahmed Elhawary
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tayyab Diwan
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kymberly D Watt
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
17
|
Watson CJ, Gaurav R, Butler AJ. Current Techniques and Indications for Machine Perfusion and Regional Perfusion in Deceased Donor Liver Transplantation. J Clin Exp Hepatol 2024; 14:101309. [PMID: 38274508 PMCID: PMC10806097 DOI: 10.1016/j.jceh.2023.101309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/27/2023] [Indexed: 01/27/2024] Open
Abstract
Since the advent of University of Wisconsin preservation solution in the 1980s, clinicians have learned to work within its confines. While affording improved outcomes, considerable limitations still exist and contribute to the large number of livers that go unused each year, often for fear they may never work. The last 10 years have seen the widespread availability of new perfusion modalities which provide an opportunity for assessing organ viability and prolonged organ storage. This review will discuss the role of in situ normothermic regional perfusion for livers donated after circulatory death. It will also describe the different modalities of ex situ perfusion, both normothermic and hypothermic, and discuss how they are thought to work and the opportunities afforded by them.
Collapse
Affiliation(s)
- Christopher J.E. Watson
- University of Cambridge Department of Surgery, Box 210, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
- The Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
| | - Rohit Gaurav
- The Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
| | - Andrew J. Butler
- University of Cambridge Department of Surgery, Box 210, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
- The Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
| |
Collapse
|
18
|
Kim SC, Foley DP. Strategies to Improve the Utilization and Function of DCD Livers. Transplantation 2024; 108:625-633. [PMID: 37496117 DOI: 10.1097/tp.0000000000004739] [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: 07/28/2023]
Abstract
Despite the increased usage of livers from donation after circulatory death (DCD) donors in the last decade, many patients remaining on the waitlist who need a liver transplant. Recent efforts have focused on maximizing the utilization and outcomes of these allografts using advances in machine perfusion technology and other perioperative strategies such as normothermic regional perfusion (NRP). In addition to the standard donor and recipient matching that is required with DCD donation, new data regarding the impact of graft steatosis, extensive European experience with NRP, and the increasing use of normothermic and hypothermic machine perfusion have shown immense potential in increasing DCD organ overall utilization and improved outcomes. These techniques, along with viability testing of extended criteria donors, have generated early promising data to consider the use of higher-risk donor organs and more widespread adoption of these techniques in the United States. This review explores the most recent international literature regarding strategies to optimize the utilization and outcomes of DCD liver allografts, including donor-recipient matching, perioperative strategies including NRP versus rapid controlled DCD recovery, viability assessment of discarded livers, and postoperative strategies including machine perfusion versus pharmacologic interventions.
Collapse
Affiliation(s)
- Steven C Kim
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - David P Foley
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| |
Collapse
|
19
|
Longchamp A, Nakamura T, Uygun K, Markmann JF. Role of Machine Perfusion in Liver Transplantation. Surg Clin North Am 2024; 104:45-65. [PMID: 37953040 DOI: 10.1016/j.suc.2023.07.001] [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
Given the current severe shortage of available livers for transplantation, there is an urgent need to maximize the utilization of donor organs. One of the strategies to increase the number of available livers for transplantation is to improve organ utilization through the use of elderly, overweight, or organs donated after circulatory death. However, the utilization of these "marginal" organs was associated with an increased risk of early allograft dysfunction, primary nonfunction, ischemic biliary complications, or even re-transplantation. Ischemia-reperfusion injury is a key mechanism in the pathogenesis of these complications.
Collapse
Affiliation(s)
- Alban Longchamp
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Tsukasa Nakamura
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Korkut Uygun
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James F Markmann
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
20
|
Wheless WH, Russo MW. Treatment of Primary Sclerosing Cholangitis Including Transplantation. Clin Liver Dis 2024; 28:171-182. [PMID: 37945158 DOI: 10.1016/j.cld.2023.07.008] [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: 11/12/2023]
Abstract
Primary sclerosing cholangitis is a progressive cholestatic liver disease that causes stricturing of the intra and extrahepatic bile ducts that can lead to cirrhosis and end stage liver disease. Effective medical therapy has been elusive, but a course of ursodeoxycholic acid may be prescribed at doses of 17-23 mg/kg/day for up to a year to determine if a reduction in serum alkaline phosphatase is observed. A number of drugs are under investigation, including FXR agonists with choleretic and antimicrobial properties. Liver transplantation for PSC has one of the highest survival rates, but recurrent PSC is seen in up to 25% of recipients.
Collapse
Affiliation(s)
- William H Wheless
- Division of Hepatology, Atrium Health Wake Forest, Charlotte, NC, USA
| | - Mark W Russo
- Division of Hepatology, Atrium Health Wake Forest, Charlotte, NC, USA.
| |
Collapse
|
21
|
Camagni S, Amaduzzi A, Grazioli L, Ghitti D, Pasulo L, Pinelli D, Fagiuoli S, Colledan M. Extended criteria liver donation after circulatory death with prolonged warm ischemia: a pilot experience of normothermic regional perfusion and no subsequent ex-situ machine perfusion. HPB (Oxford) 2023; 25:1494-1501. [PMID: 37659903 DOI: 10.1016/j.hpb.2023.07.902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 07/11/2023] [Accepted: 07/21/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Livers from controlled donation after circulatory death (cDCD) with very prolonged warm ischemic time (WIT) are regularly transplanted after abdominal normothermic regional perfusion (aNRP) plus ex-situ machine perfusion (MP). Considering aNRP as in-situ MP, we investigated whether the results of a pilot experience of extended criteria cDCD liver transplantation (LT) with prolonged WIT, with aNRP alone, were comparable to the best possible outcomes in low-risk cDCD LT. METHODS Prospectively collected data on 24 cDCD LT, with aNRP alone, were analyzed. RESULTS The median total and asystolic WIT were 51 and 25 min. Measures within benchmark cut-offs were: median duration of surgery (5.9 h); median intraoperative transfusions (3 units of red blood cells); need for renal replacement therapy (2/24 patients); median intensive care stay (3 days); key complications; overall morbidity, graft loss, and retransplantation up to 12 months; 12-month mortality (2/21 patients). The median hospital stay (33 days, due to logistics) and mortality up to 6 months (2/24 patients, due to graft-unrelated causes) exceeded benchmark thresholds. CONCLUSIONS This pilot experience suggests that livers from cDCD with very prolonged WIT that appear viable during adequate quality aNRP may be safely transplanted, with no need for ex-situ MP, with considerable resource savings.
Collapse
Affiliation(s)
- Stefania Camagni
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy.
| | - Annalisa Amaduzzi
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy
| | - Lorenzo Grazioli
- Department of Anesthesia and Intensive Care, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy
| | - Davide Ghitti
- Department of Anesthesia and Intensive Care, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy
| | - Luisa Pasulo
- Gastroenterology and Transplant Hepatology, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy
| | - Domenico Pinelli
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy
| | - Stefano Fagiuoli
- Gastroenterology and Transplant Hepatology, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy; Università degli Studi di Milano-Bicocca, Piazza dell'Ateneo Nuovo, 20126 Milano, Italy
| | - Michele Colledan
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy; Università degli Studi di Milano-Bicocca, Piazza dell'Ateneo Nuovo, 20126 Milano, Italy
| |
Collapse
|
22
|
Neri I, Pascale MM, Bianco G, Frongillo F, Agnes S, Giovinazzo F. Age and liver graft: a systematic review with meta-regression. Updates Surg 2023; 75:2075-2083. [PMID: 37695503 PMCID: PMC10710390 DOI: 10.1007/s13304-023-01641-1] [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: 02/14/2023] [Accepted: 08/28/2023] [Indexed: 09/12/2023]
Abstract
Increasing organ shortage results in extended criteria donors (ECD) being used to face the growing demand for liver grafts. The demographic change leads to greater use of elderly donors for liver transplantation, historically considered marginal donors. Age is still considered amongst ECD in liver transplantation as it could affect transplant outcomes. However, what is the cutoff for donor age is still unclear and debated. A search of PubMed, Scopus and Cochrane Library was performed. The primary outcome was 1-year graft survival (GS). The secondary outcome was overall biliary complications and 3-5 years of graft and overall survival. A meta-regression model was used to analyse the temporal trend relation in the survival outcome. The meta-analysis included 11 studies. Hazard ratios for 1-year (age cutoff of 70 and 80,) and 5-year GS (I2:0%) were similar irrespectively of the age group. The meta-regression analysis showed a significant correlation between the 1-year graft survival and the year of publication. (coef. 0.00027, 95% CI - 0.0001 to - 0.0003 p = 0.0009). Advanced-age donors showed an increased risk of overall biliary complications with an odd ratio (OR) of 1.89 (95% CI 1-3.65). Liver grafts potentially discharged because of high-risk failure show encouraging results, and GS in ECD has progressively improved with a temporal trend. Currently, the criteria of marginality vary amongst centres. Age alone cannot be considered amongst the extended criteria. First of all, because of the positive results in terms of septuagenarian graft survival. Moreover, the potential elderly donor-related adjunctive risk can be balanced by reducing other risk factors. A prospective multicentre study should investigate a multi-factorial model based on donor criteria, recipient features and new functional biomarkers to predict graft outcome, as proper donor-recipient matching seems to be the critical point for good outcomes.
Collapse
Affiliation(s)
- Ilaria Neri
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marco Maria Pascale
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giuseppe Bianco
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Frongillo
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Salvatore Agnes
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Giovinazzo
- General Surgery and Liver Transplant Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
| |
Collapse
|
23
|
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.
Collapse
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.
| |
Collapse
|
24
|
O'Neill S, Asgari E, Callaghan C, Gardiner D, Hartog H, Iype S, Manara A, Nasralla D, Oniscu GC, Watson C. The British transplantation society guidelines on organ donation from deceased donors after circulatory death. Transplant Rev (Orlando) 2023; 37:100791. [PMID: 37598591 DOI: 10.1016/j.trre.2023.100791] [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: 08/08/2023] [Revised: 08/11/2023] [Accepted: 08/11/2023] [Indexed: 08/22/2023]
Abstract
Recipient outcomes after transplantation with organs from donation after circulatory death (DCD) donors can compare favourably and even match recipient outcomes after transplantation with organs from donation after brain death donors. Success is dependent upon establishing common practices and accepted protocols that allow the safe sharing of DCD organs and maximise the use of the DCD donor pool. The British Transplantation Society 'Guideline on transplantation from deceased donors after circulatory death' has recently been updated. This manuscript summarises the relevant recommendations from chapters specifically related to organ donation.
Collapse
Affiliation(s)
- Stephen O'Neill
- Consultant Transplant Surgeon, Belfast City Hospital, Belfast, Northern Ireland.
| | - Ellie Asgari
- Consultant Nephrologist, Guy's Hospital, London, England
| | - Chris Callaghan
- Consultant Transplant Surgeon, Guy's Hospital, London, England
| | - Dale Gardiner
- Consultant Intensivist, Queen's Medical Centre, Nottingham, England
| | - Hermien Hartog
- Consultant Transplant Surgeon, Queen Elizabeth Hospital, Birmingham, England
| | - Satheesh Iype
- Consultant Transplant Surgeon, Royal Free Hospital, London, England
| | - Alex Manara
- Consultant Intensivist, Southmead Hospital, Bristol, England
| | - David Nasralla
- Consultant Transplant Surgeon, Royal Free Hospital, London, England
| | - Gabi C Oniscu
- Consultant Transplant Surgeon, Royal Infirmary, Edinburgh, Scotland
| | - Chris Watson
- Consultant Transplant Surgeon, Addenbrooke's Hospital, Cambridge, England
| |
Collapse
|
25
|
Barrett M, Sonnenday CJ. CAQ Corner: Deceased donor selection and management. Liver Transpl 2023; 29:1234-1241. [PMID: 37560989 DOI: 10.1097/lvt.0000000000000242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/31/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Meredith Barrett
- University of Michigan, Department of Surgery, Section of Transplantation
| | | |
Collapse
|
26
|
Secanella L, Alconchel F, López-Monclús J, Toledo-Martínez E, Barrios O, Ramírez P, Jiménez-Garrido MC, Rodríguez-Sanjuán JC, Royo-Villanova M, Moreno-González G, Lladó L. Outcomes of liver transplantation with thoracoabdominal normothermic regional perfusion: a matched-controlled initial experience in Spain. FRONTIERS IN TRANSPLANTATION 2023; 2:1280454. [PMID: 38993919 PMCID: PMC11235216 DOI: 10.3389/frtra.2023.1280454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 10/16/2023] [Indexed: 07/13/2024]
Abstract
Thoracoabdominal (TA) normothermic regional perfusion (NRP) should allow the safe recovery of heart and liver grafts simultaneously in the context of controlled donation after circulatory death (cDCD). We present the initial results of cDCD liver transplantation with simultaneous liver and heart procurement in Spain until October 2021. Outcomes were compared with a matched cohort of cDCD with abdominal NRP (A-NRP) from participating institutions. Primary endpoints comprised early allograft dysfunction (EAD) or primary non-function (PNF), and the development of ischemic-type biliary lesions (ITBL). Six transplants were performed using cDCD with TA-NRP during the study period. Donors were significantly younger in the TA-NRP group than in the A-NRP group (median 45.6 years and 62.9 years respectively, p = 0.011), with a median functional warm ischemia time of 12.5 min in the study group and 13 min in the control group. Patient characteristics, procurement times, and surgical baseline characteristics did not differ significantly between groups. No patient in the study group developed EAD or PNF, and over a median follow-up of 9.8 months, none developed ITBL or graft loss. Extending A-NRP to TA-NRP for cardiac procurement may be technically challenging, but it is both feasible and safe, showing comparable postoperative outcomes to A-NRP.
Collapse
Affiliation(s)
- Luis Secanella
- Unidad HPB y Trasplante Hepático, Servicio de Cirugía General y Digestiva, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Felipe Alconchel
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Virgen de la Arrixaca), Murcia, Spain
| | - Javier López-Monclús
- Servicio de Cirugía General y del Aparato Digestivo, Unidad de Trasplante Hepático, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Enrique Toledo-Martínez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Oriana Barrios
- Unidad HPB y Trasplante Hepático, Servicio de Cirugía General y Digestiva, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Pablo Ramírez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Virgen de la Arrixaca), Murcia, Spain
| | - Manuel Cecilio Jiménez-Garrido
- Servicio de Cirugía General y del Aparato Digestivo, Unidad de Trasplante Hepático, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Mario Royo-Villanova
- Servicio de Medicina Intensiva, Coordinación de Trasplantes, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Virgen de la Arrixaca), Murcia, Spain
| | - Gabriel Moreno-González
- Servicio de Medicina Intensiva, Coordinación de Trasplantes, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Laura Lladó
- Unidad HPB y Trasplante Hepático, Servicio de Cirugía General y Digestiva, Hospital Universitari de Bellvitge, Barcelona, Spain
| |
Collapse
|
27
|
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: 3] [Impact Index Per Article: 3.0] [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.
Collapse
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.)
| | | |
Collapse
|
28
|
Brubaker AL, Taj R, Jackson B, Lee A, Tsai C, Berumen J, Parekh JR, Mekeel KL, Gupta AR, Gardner JM, Chaly T, Mathur AK, Jadlowiec C, Reddy S, Nunez R, Bellingham J, Thomas EM, Wellen JR, Pan JH, Kearns M, Pretorius V, Schnickel GT. Early patient and liver allograft outcomes from donation after circulatory death donors using thoracoabdominal normothermic regional: a multi-center observational experience. FRONTIERS IN TRANSPLANTATION 2023; 2:1184620. [PMID: 38993873 PMCID: PMC11235322 DOI: 10.3389/frtra.2023.1184620] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 07/17/2023] [Indexed: 07/13/2024]
Abstract
Background Donation after circulatory death (DCD) liver allografts are associated with higher rates of primary non-function (PNF) and ischemic cholangiopathy (IC). Advanced recovery techniques, including thoracoabdominal normothermic regional perfusion (TA-NRP), may improve organ utilization and patient and allograft outcomes. Given the increasing US experience with TA-NRP DCD recovery, we evaluated outcomes of DCD liver allografts transplanted after TA-NRP. Methods Liver allografts transplanted from DCD donors after TA-NRP were identified from 5/1/2021 to 1/31/2022 across 8 centers. Donor data included demographics, functional warm ischemic time (fWIT), total warm ischemia time (tWIT) and total time on TA-NRP. Recipient data included demographics, model of end stage liver disease (MELD) score, etiology of liver disease, PNF, cold ischemic time (CIT), liver function tests, intensive care unit (ICU) and hospital length of stay (LOS), post-operative transplant related complications. Results The donors' median age was 32 years old and median BMI was 27.4. Median fWIT was 20.5 min; fWIT exceeded 30 min in two donors. Median time to initiation of TA-NRP was 4 min and median time on bypass was 66 min. The median recipient listed MELD and MELD at transplant were 22 and 21, respectively. Median allograft CIT was 292 min. The median length of follow up was 257 days. Median ICU and hospital LOS were 2 and 7 days, respectively. Three recipients required management of anastomotic biliary strictures. No patients demonstrated IC, PNF or required re-transplantation. Conclusion Liver allografts from TA-NRP DCD donors demonstrated good early allograft and recipient outcomes.
Collapse
Affiliation(s)
- Aleah L. Brubaker
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, UC San Diego, San Diego, CA, United States
| | - Raeda Taj
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, UC San Diego, San Diego, CA, United States
| | - Brandon Jackson
- Department of Surgery, Division of Cardiothoracic Surgery, UC San Diego, San Diego, CA, United States
| | - Arielle Lee
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, UC San Diego, San Diego, CA, United States
| | - Catherine Tsai
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, UC San Diego, San Diego, CA, United States
| | - Jennifer Berumen
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, UC San Diego, San Diego, CA, United States
| | - Justin R. Parekh
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, UC San Diego, San Diego, CA, United States
| | - Kristin L. Mekeel
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, UC San Diego, San Diego, CA, United States
| | - Alexander R. Gupta
- Department of Surgery, Division of Transplant Surgery, UC San Francisco, San Francisco, CA, United States
| | - James M. Gardner
- Department of Surgery, Division of Transplant Surgery, UC San Francisco, San Francisco, CA, United States
| | - Thomas Chaly
- Arizona Transplant Associates, Phoenix, AZ, United States
| | - Amit K. Mathur
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Caroline Jadlowiec
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Sudhakar Reddy
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Rafael Nunez
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Janet Bellingham
- Department of Transplantation, California Pacific Medical Center, San Francisco, CA, United States
| | - Elizabeth M. Thomas
- Department of Surgery, University Transplant Center, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Jason R. Wellen
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St Louis, MO, United States
| | - Jenny H. Pan
- Department of Surgery, Division of Abdominal Transplantation, Stanford University, Stanford, CA, United States
| | - Mark Kearns
- Department of Surgery, Division of Cardiothoracic Surgery, UC San Diego, San Diego, CA, United States
| | - Victor Pretorius
- Department of Surgery, Division of Cardiothoracic Surgery, UC San Diego, San Diego, CA, United States
| | - Gabriel T. Schnickel
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, UC San Diego, San Diego, CA, United States
| |
Collapse
|
29
|
Fallani G, Stocco A, Siniscalchi A, Antonini MV, Stella AP, Amato A, Prosperi E, Turco L, Morelli MC, Cescon M, Ravaioli M. Beyond the Concepts of Elder and Marginal in DCD Liver Transplantation: A Prospective Observational Matched-Cohort Study in the Italian Clinical Setting. Transpl Int 2023; 36:11697. [PMID: 37736400 PMCID: PMC10511003 DOI: 10.3389/ti.2023.11697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/21/2023] [Indexed: 09/23/2023]
Abstract
Donation after circulatory determination of death (DCD) is a valuable strategy to increase the availability of grafts for liver transplantation (LT). As the average age of populations rises, the donor pool is likely to be affected by a potential increase in DCD donor age in the near future. We conducted a prospective cohort study to evaluate post-transplantation outcomes in recipients of grafts from elderly DCD donors compared with younger DCD donors, and elderly donors after brainstem determination of death (DBD). From August 2020 to May 2022, consecutive recipients of deceased donor liver-only transplants were enrolled in the study. DCD recipients were propensity score matched 1:3 to DBD recipients. One-hundred fifty-seven patients were included, 26 of whom (16.6%) were transplanted with a DCD liver graft. After propensity score matching and stratification, three groups were obtained: 15 recipients of DCD donors ≥75 years, 11 recipients of DCD donors <75 years, and 28 recipients of DBD donors ≥75 years. Short-term outcomes, as well as 12 months graft survival rates (93.3%, 100%, and 89.3% respectively), were comparable among the groups. LT involving grafts retrieved from very elderly DCD donors was feasible and safe in an experienced high-volume center, with outcomes comparable to LTs from younger DCD donors and age-matched DBD donors.
Collapse
Affiliation(s)
- Guido Fallani
- Department of Hepatobiliary Surgery and Transplantation, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alberto Stocco
- Department of Hepatobiliary Surgery and Transplantation, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Antonio Siniscalchi
- Department of Transplant Intensive Care Unit, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marta Velia Antonini
- Ospedale “Maurizio Bufalini”—Azienda Unità Sanitaria Locale Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Adriano Pasquale Stella
- Department of Hepatobiliary Surgery and Transplantation, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessio Amato
- Department of Hepatobiliary Surgery and Transplantation, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Enrico Prosperi
- Department of Hepatobiliary Surgery and Transplantation, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Laura Turco
- Department of Internal Medicine for the Treatment of Severe Organ Failure, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maria Cristina Morelli
- Department of Internal Medicine for the Treatment of Severe Organ Failure, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Cescon
- Department of Hepatobiliary Surgery and Transplantation, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Matteo Ravaioli
- Department of Hepatobiliary Surgery and Transplantation, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| |
Collapse
|
30
|
Meier RPH, Nunez M, Syed SM, Feng S, Tavakol M, Freise CE, Roberts JP, Ascher NL, Hirose R, Roll GR. DCD liver transplant in patients with a MELD over 35. Front Immunol 2023; 14:1246867. [PMID: 37731493 PMCID: PMC10507358 DOI: 10.3389/fimmu.2023.1246867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 08/17/2023] [Indexed: 09/22/2023] Open
Abstract
Introduction Donation after circulatory death (DCD) liver transplantation (LT) makes up well less than 1% of all LTs with a Model for End-Stage Liver Disease (MELD)≥35 in the United States. We hypothesized DCD-LT yields acceptable ischemia-reperfusion and reasonable outcomes for recipients with MELD≥35. Methods We analyzed recipients with lab-MELD≥35 at transplant within the UCSF (n=41) and the UNOS (n=375) cohorts using multivariate Cox regression and propensity score matching. Results In the UCSF cohort, five-year patient survival was 85% for DCD-LTs and 86% for matched-Donation after Brain Death donors-(DBD) LTs (p=0.843). Multivariate analyses showed that younger donor/recipient age and more recent transplants (2011-2021 versus 1999-2010) were associated with better survival. DCD vs. DBD graft use did not significantly impact survival (HR: 1.2, 95%CI 0.6-2.7). The transaminase peak was approximately doubled, indicating suggesting an increased ischemia-reperfusion hit. DCD-LTs had a median post-LT length of stay of 11 days, and 34% (14/41) were on dialysis at discharge versus 12 days and 22% (9/41) for DBD-LTs. 27% (11/41) DCD-LTs versus 12% (5/41) DBD-LTs developed a biliary complication (p=0.095). UNOS cohort analysis confirmed patient survival predictors, but DCD graft emerged as a risk factor (HR: 1.5, 95%CI 1.3-1.9) with five-year patient survival of 65% versus 75% for DBD-LTs (p=0.016). This difference became non-significant in a sub-analysis focusing on MELD 35-36 recipients. Analysis of MELD≥35 DCD recipients showed that donor age of <30yo independently reduced the risk of graft loss by 30% (HR, 95%CI: 0.7 (0.9-0.5), p=0.019). Retransplant status was associated with a doubled risk of adverse event (HR, 95%CI: 2.1 (1.4-3.3), p=0.001). The rejection rates at 1y were similar between DCD- and DBD-LTs, (9.3% (35/375) versus 1,541 (8.7% (1,541/17,677), respectively). Discussion In highly selected recipient/donor pair, DCD transplantation is feasible and can achieve comparable survival to DBD transplantation. Biliary complications occurred at the expected rates. In the absence of selection, DCD-LTs outcomes remain worse than those of DBD-LTs.
Collapse
Affiliation(s)
- Raphael P. H. Meier
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Miguel Nunez
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Shareef M. Syed
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Sandy Feng
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Mehdi Tavakol
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Chris E. Freise
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - John P. Roberts
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Nancy L. Ascher
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Ryutaro Hirose
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Garrett R. Roll
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| |
Collapse
|
31
|
Wu WK, Ukita R, Patel YJ, Cortelli M, Trinh VQ, Ziogas IA, Francois SA, Mentz M, Cardwell NL, Talackine JR, Grogan WM, Stokes JW, Lee YA, Kim J, Alexopoulos SP, Bacchetta M. Xenogeneic cross-circulation for physiological support and recovery of ex vivo human livers. Hepatology 2023; 78:820-834. [PMID: 36988383 PMCID: PMC10440302 DOI: 10.1097/hep.0000000000000357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 01/25/2023] [Accepted: 02/10/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND AND AIMS The scarcity of suitable donor livers highlights a continuing need for innovation to recover organs with reversible injuries in liver transplantation. APPROACH AND RESULTS Explanted human donor livers (n = 5) declined for transplantation were supported using xenogeneic cross-circulation of whole blood between livers and xeno-support swine. Livers and swine were assessed over 24 hours of xeno-support. Livers maintained normal global appearance, uniform perfusion, and preservation of histologic and subcellular architecture. Oxygen consumption increased by 75% ( p = 0.16). Lactate clearance increased from -0.4 ± 15.5% to 31.4 ± 19.0% ( p = 0.02). Blinded histopathologic assessment demonstrated improved injury scores at 24 hours compared with 12 hours. Vascular integrity and vasoconstrictive function were preserved. Bile volume and cholangiocellular viability markers improved for all livers. Biliary structural integrity was maintained. CONCLUSIONS Xenogeneic cross-circulation provided multisystem physiological regulation of ex vivo human livers that enabled functional rehabilitation, histopathologic recovery, and improvement of viability markers. We envision xenogeneic cross-circulation as a complementary technique to other organ-preservation technologies in the recovery of marginal donor livers or as a research tool in the development of advanced bioengineering and pharmacologic strategies for organ recovery and rehabilitation.
Collapse
Affiliation(s)
- Wei Kelly Wu
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rei Ukita
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Yatrik J. Patel
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael Cortelli
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Vincent Q. Trinh
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ioannis A. Ziogas
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sean A. Francois
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Meredith Mentz
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nancy L. Cardwell
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jennifer R. Talackine
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William M. Grogan
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John W. Stokes
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Youngmin A. Lee
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jinho Kim
- Department of Biomedical Engineering, Stevens Institute of Technology, Hoboken, New Jersey, USA
| | - Sophoclis P. Alexopoulos
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew Bacchetta
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Engineering, Vanderbilt University; Nashville, Tennessee, USA
| |
Collapse
|
32
|
Richards JA, Gaurav R, Upponi SS, Swift L, Fear C, Webb GJ, Allison MED, Watson CJE, Butler AJ. Outcomes of livers from donation after circulatory death donors with extended agonal phase and the adjunct of normothermic regional perfusion. Br J Surg 2023; 110:1112-1115. [PMID: 37079886 PMCID: PMC10416677 DOI: 10.1093/bjs/znad099] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/18/2023] [Accepted: 03/27/2023] [Indexed: 04/22/2023]
Abstract
The liver performs important functions that are essential for life. If the liver fails, patients will die unless they receive a new liver from a donor (transplant). Unfortunately, there are not enough livers for everyone and some patients die while waiting for a suitable organ. This article describes a novel technique that allows resuscitation and testing of a potential donor liver so that more patients can safely receive a transplant.
Collapse
Affiliation(s)
- James A Richards
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
- University of Cambridge Department of Surgery, Addenbrooke’s Hospital, Cambridge, UK
- NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK
- National Institute for Health and Care Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
- HPB and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | - Rohit Gaurav
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
- National Institute for Health and Care Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Sara S Upponi
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
- National Institute for Health and Care Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
| | - Lisa Swift
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
| | - Corrina Fear
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
| | - Gwilym J Webb
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
- Department of Medicine, Cambridge University Hospitals, Addenbrooke’s Hospital, Cambridge, UK
| | - Michael E D Allison
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
- National Institute for Health and Care Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
- Department of Medicine, Cambridge University Hospitals, Addenbrooke’s Hospital, Cambridge, UK
| | - Christopher J E Watson
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
- University of Cambridge Department of Surgery, Addenbrooke’s Hospital, Cambridge, UK
- NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK
- National Institute for Health and Care Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Andrew J Butler
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
- University of Cambridge Department of Surgery, Addenbrooke’s Hospital, Cambridge, UK
- NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK
- National Institute for Health and Care Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| |
Collapse
|
33
|
Agrawal D, Saigal S. Early allograft dysfunction after living donor liver transplantation-current concepts and future directions. Liver Transpl 2023; 29:871-884. [PMID: 37162155 DOI: 10.1097/lvt.0000000000000173] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/03/2023] [Indexed: 05/11/2023]
Abstract
Early allograft dysfunction (EAD) after liver transplantation is a significant clinical problem that negatively impacts graft and patient outcomes. The rising incidence of EAD and what it means concerning living donor liver transplantation (LDLT) is an area of great interest. However, EAD after LDLT is a complex research topic yet to be reviewed comprehensively. Most of the literature on EAD is based on experience in deceased donor liver transplantation, and limited information is available in the context of LDLT. Thus, in this review, we present an overview of EAD after LDLT and have attempted to present balanced points of view on all its aspects, such as definitions, pathogenesis, risk factors, predictive markers, and management. The review aims to broadly overview the nature and extent of ongoing research evidence on this complex topic and inform practice in the field by identifying key concepts and knowledge gaps and highlighting areas that require further inquiry.
Collapse
Affiliation(s)
- Dhiraj Agrawal
- Department of Gastroenterology and Hepatology, PACE Hospitals, Hitec City, Hyderabad, India
| | - Sanjiv Saigal
- Hepatology and Liver Transplant, Centre for Liver & Biliary Sciences, Centre of Gastroenterology, Hepatology & Endoscopy, Max Super Speciality Hospital, Saket, New Delhi, India
| |
Collapse
|
34
|
De Carlis R, Paolo Muiesan, Taner B. Donation after circulatory death: Novel strategies to improve the liver transplant outcome. J Hepatol 2023; 78:1169-1180. [PMID: 37208104 DOI: 10.1016/j.jhep.2023.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 05/21/2023]
Abstract
In many countries, donation after circulatory death (DCD) liver grafts are used to overcome organ shortages; however, DCD grafts have been associated with an increased risk of complications and even graft loss after liver transplantation. The increased risk of complications is thought to correlate with prolonged functional donor warm ischaemia time. Stringent donor selection criteria and utilisation of in situ and ex situ organ perfusion technologies have led to improved outcomes. Additionally, the increased use of novel organ perfusion strategies has led to the possibility of reconditioning marginal DCD liver grafts. Moreover, these technologies enable the assessment of liver function before implantation, thus providing valuable data that can guide more precise graft-recipient selection. In this review, we first describe the different definitions of functional warm donor ischaemia time and its role as a determinant of outcomes after DCD liver transplantation, with a focus on the thresholds proposed for graft acceptance. Next, organ perfusion strategies, namely normothermic regional perfusion, hypothermic oxygenated perfusion, and normothermic machine perfusion are discussed. For each technique, clinical studies reporting on the transplant outcome are described, together with a discussion on the possible protective mechanisms involved and the functional criteria adopted for graft selection. Finally, we review multimodal preservation protocols involving a combination of more than one perfusion technique and potential future directions in the field.
Collapse
Affiliation(s)
- Riccardo De Carlis
- Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Ph.D. Course in Clinical and Experimental Sciences, University of Padua, Padua, Italy
| | - Paolo Muiesan
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan, Centre of Preclinical Research, 20122, Italy
| | - Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, United States.
| |
Collapse
|
35
|
Campo-Cañaveral de la Cruz JL, Miñambres E, Coll E, Padilla M, Sánchez Antolín G, de la Rosa G, Rosado J, González García FJ, Crowley Carrasco S, Sales Badía G, María Fieria Costa E, Alberto García Salcedo J, Mora V, de la Torre C, Badenes R, Atutxa Bizkarguenaga L, Domínguez-Gil B. Outcomes Of Lung And Liver Transplantation After Simultaneous Recovery Using Abdominal Normothermic Regional Perfusion In Donors After The Circulatory Determination Of Death Versus Donors After Brain Death. Am J Transplant 2023:S1600-6135(23)00414-8. [PMID: 37100392 DOI: 10.1016/j.ajt.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 04/28/2023]
Abstract
Normothermic regional perfusion (NRP) in controlled donation after the circulatory determination of death (cDCD) is a growing preservation technique for abdominal organs that coexists with the rapid recovery of lungs. We aim at describing the outcomes of lung transplants (LuTx) and liver transplants (LiTx) when both grafts are simultaneously recovered from cDCD donors using NRP, and compare them to donation after brain death (DBD). All LuTx and LiTx meeting these criteria during January-2015 to December-2020 in Spain were included in the study. Simultaneous recovery of lungs and livers was undertaken in 227 (17%) cDCD with NRP and 1,879 (21%) DBD donors (p<0.001). Primary graft dysfunction grade-3 within the first 72hours was similar in both LuTx groups (14.7% cDCD vs. 10.5% DBD;p=0.139). LuTx survival at 1 and 3years was 79.9% and 66.4% in cDCD, vs. 81.9% and 69.7% in DBD (p=0.403). The incidence of primary non-function and ischemic cholangiopathy was similar in both LiTx groups. Graft survival at 1 and 3years was 89.7% and 80.8% in cDCD vs. 88.2% and 82.1% in DBD LiTx (p=0.669). In conclusion, the simultaneous rapid recovery of lungs and preservation of abdominal organs with NRP in cDCD donors is feasible, and offers similar outcomes in both LuTx and LiTx recipients to transplants using DBD grafts.
Collapse
Affiliation(s)
| | - Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL. School of Medicine, Universidad de Cantabria, Santander, Spain
| | | | | | | | | | - Joel Rosado
- Thoracic Surgery and Lung Transplantation. Vall d'Hebrón University Hospital. Barcelona, Spain
| | | | - Silvana Crowley Carrasco
- Thoracic Surgery and Lung Transplantation Department. Hospital Universitario Puerta de Hierro-Majadahonda. Madrid, Spain
| | - Gabriel Sales Badía
- Thoracic Surgery and Lung Transplantation. Hospital Universitari i Politècnic La Fe. Valencia, Spain
| | - Eva María Fieria Costa
- Thoracic Surgery and Lung Transplantation. Complejo Hospitalario Universitario A Coruña. A Coruña, Spain
| | | | - Victor Mora
- Pneumology Department, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Carlos de la Torre
- Pediatric Surgery and Lung Transplantation. La Paz University Hospital. Madrid, Spain
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, Valencia, Spain
| | | | | |
Collapse
|
36
|
Thiessen C, Wisel SA, Roll GR. Simultaneous thoracic and abdominal donation after circulatory death organ recovery: the abdominal surgeon's perspective. Curr Opin Organ Transplant 2023; 28:139-144. [PMID: 36603197 PMCID: PMC9994842 DOI: 10.1097/mot.0000000000001045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF THE REVIEW To summarize the international experience with heart-liver (joint) donation after circulatory death (DCD) procurements and to explore the technical challenges in joint abdominal and thoracic DCD procurement. RECENT FINDINGS Following completion of the Donors After Circulatory Death Heart Trial in the US, combined thoracic and abdominal DCD is poised to become the standard of care, expanding access to life-saving heart and lung allografts. DCD heart procurement relies on collection of donor blood for priming of the normothermic perfusion pump, which delays cooling of abdominal organs and increases risk of ischemic injury. We review the effect of donor ischemia time on abdominal organs, with several proposed technical solutions to optimize transplant outcomes for all organs. SUMMARY The strategies reviewed in this manuscript may inform clinical decision-making, preoperative coordination between thoracic and abdominal procurement teams, and surgical technique for joint DCD procurements. Several approaches to organ procurement organization (OPO) and national policy, as well as future areas of focus for research are proposed.
Collapse
Affiliation(s)
- Carrie Thiessen
- Division of Transplantation, University of Wisconsin, Madison, Wisconsin
| | - Steven A. Wisel
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles
| | - Garrett R. Roll
- Division of Transplantation, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
37
|
Ganni S, Handing G, Anand A, Barrett S, Galvan NTN, O’Mahony C, Goss JA, Cotton RT, Rana A. Selecting DCD Recipients Using Predictive Indices. Transplant Direct 2023; 9:e1467. [PMID: 37009165 PMCID: PMC10065835 DOI: 10.1097/txd.0000000000001467] [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: 12/30/2021] [Revised: 01/27/2023] [Accepted: 01/28/2023] [Indexed: 04/04/2023] Open
Abstract
Donation after circulatory death (DCD) allografts might represent one of the largest untapped sources of liver allografts. Our aim was to identify independent recipient risk factors that predict mortality in DCD allograft recipients to preselect optimal candidates for successful transplantation. Furthermore, we compared the application of our newly constructed DCD Recipient Selector Index (RSI) score to previously developed models to determine superiority in predicting recipient survival. Methods Using the Organ Procurement and Transplantation Network database, we performed univariate and multivariate retrospective analyses on 4228 DCD liver allograft recipients. Results We identified 8 significant factors and incorporated them into the weighted RSI to predict 3-mo survival following DCD liver transplantation with a C-statistic of 0.6971. The most significant recipient risk factors were recipient serum sodium levels >150 mEq/L at transplant, recipient albumin <2.0 g/dL at transplant, and a history of portal vein thrombosis. Because Model for End-Stage Liver Disease (MELD) score components were included as individual predictors, the DCD RSI predicts survival independently of MELD. Upon comparison with 3 previous recipient risk scores-Balance of Risk, Renal Risk Index, Patient-Survival Outcomes Following Liver Transplantation-the DCD RSI was determined to be superior at selecting optimal candidates pre-DCD transplantation, yielding a C-statistic of 0.6971. Conclusions After verifying the performance of predictive indices for selection of DCD recipients, the DCD RSI is best used to preselect patients for optimized outcomes after DCD transplantation. This can increase utilization of DCD donors by improving outcomes.
Collapse
Affiliation(s)
- Saif Ganni
- Division of Abdominal Transplant, Department of Surgery, Michael E DeBakey, Houston, TX
| | - Greta Handing
- Department of Student Affairs, Baylor College of Medicine, Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Adrish Anand
- Department of Student Affairs, Baylor College of Medicine, Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Spencer Barrett
- Department of Student Affairs, Baylor College of Medicine, Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | | | - Christine O’Mahony
- Division of Abdominal Transplant, Department of Surgery, Michael E DeBakey, Houston, TX
| | - John A. Goss
- Division of Abdominal Transplant, Department of Surgery, Michael E DeBakey, Houston, TX
| | - Ronald T. Cotton
- Division of Abdominal Transplant, Department of Surgery, Michael E DeBakey, Houston, TX
| | - Abbas Rana
- Division of Abdominal Transplant, Department of Surgery, Michael E DeBakey, Houston, TX
| |
Collapse
|
38
|
Normothermic Regional Perfusion Can Improve Both Utilization and Outcomes in DCD Liver, Kidney, and Pancreas Transplantation. Transplant Direct 2023; 9:e1450. [PMID: 36845854 PMCID: PMC9945290 DOI: 10.1097/txd.0000000000001450] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/12/2022] [Accepted: 01/04/2023] [Indexed: 02/22/2023] Open
Abstract
Normothermic regional perfusion (NRP) has gained widespread adoption in multiple European countries. The aim of this study was to examine the influence of thoracoabdominal-NRP (TA-NRP) on the utilization and outcomes of liver, kidney, and pancreas transplantation in the United States. Methods Using the US national registry data between 2020 and 2021, donation after circulatory death (DCD) donors were separated into 2 groups: DCD with TA-NRP and without TA-NRP. There were 5234 DCD donors; among them 34 donors were with TA-NRP. After 1:4 propensity score matching, the utilization rates were compared between DCD with and without TA-NRP. Results Although the utilization rates of kidney and pancreas were comparable (P = 0.71 and P = 0.06, 94.1% versus 95.6% and 8.8% versus 2.2%, respectively), that of liver in DCD with TA-NRP was significantly higher (P < 0.001; 70.6% versus 39.0%). Among 24 liver transplantations, 62 kidney transplantations, and 3 pancreas transplantations from DCD with TA-NRP, there were 2 liver grafts and 1 kidney graft that failed within 1 y after transplantation. Conclusions TA-NRP in the United States significantly increased the utilization rate of abdominal organs from DCD donors with comparable outcomes after transplantation. Increasing use of NRP may expand the donor pool without compromising transplant outcomes.
Collapse
|
39
|
Croome KP, Barbas AS, Whitson B, Zarrinpar A, Taner T, Lo D, MacConmara M, Kim J, Kennealey PT, Bromberg JS, Washburn K, Agopian VG, Stegall M, Quintini C. American Society of Transplant Surgeons recommendations on best practices in donation after circulatory death organ procurement. Am J Transplant 2023; 23:171-179. [PMID: 36695685 DOI: 10.1016/j.ajt.2022.10.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 09/19/2022] [Accepted: 10/14/2022] [Indexed: 01/13/2023]
Abstract
The American Society of Transplant Surgeons supports efforts to increase the number of organs that are critically needed for patients desperately awaiting transplantation. In the United States, transplantation using organs procured from donation after circulatory death (DCD) donors has continued to increase in number. Despite these increases, substantial variability in the utilization and practices of DCD transplantation still exists. To improve DCD organ utilization, it is important to create a set of best practices for DCD recovery. The following recommendations aim to provide guidance on contemporary issues surrounding DCD organ procurement in the United States. A work group was composed of members of the American Society of Transplant Surgeon Scientific Studies Committee and the Thoracic Organ Transplantation Committee. The following topics were identified by the group either as controversial or lacking standardization: prewithdrawal preparation, definition of donor warm ischemia time, DCD surgical technique, combined thoracic and abdominal procurements, and normothermic regional perfusion. The proposed recommendations were classified on the basis of the grade of available evidence and the strength of the recommendation. This information should be valuable for transplant programs as well as for organ procurement organizations and donor hospitals as they develop robust DCD donor procurement protocols.
Collapse
Affiliation(s)
| | - Andrew S Barbas
- Division of Abdominal Transplant Surgery,Duke University,Durham,North Carolina,USA
| | - Bryan Whitson
- Division of Cardiac Surgery,Department of Surgery,The Ohio State University Wexner Medical Center,Columbus,Ohio,USA
| | - Ali Zarrinpar
- Department of Surgery,College of Medicine,University of Florida, Gainesville,Florida,USA
| | - Timucin Taner
- Department of Surgery,Mayo Clinic Rochester,Rochester,Minnesota,USA
| | - Denise Lo
- Emory Transplant Center,Emory University,Atlanta, Georgia,USA
| | - Malcolm MacConmara
- Division of Surgical Transplantation,Department of Surgery,University of Texas Southwestern Medical Center,Dallas,Texas,USA
| | - Jim Kim
- Department of Surgery,Keck Medical Center,University of Southern California,Los Angeles,California,USA
| | - Peter T Kennealey
- Department of Surgery,University of Colorado School of Medicine,Aurora,Colorado,USA
| | - Jonathan S Bromberg
- Department of Surgery,University of Maryland School of Medicine,Baltimore,Maryland,USA
| | - Kenneth Washburn
- Department of Surgery,The Ohio State University Wexner Medical Center,Columbus,Ohio,USA
| | - Vatche G Agopian
- Department of Surgery,David Geffen School of Medicine,University of California,Los Angeles,Los Angeles,California,USA
| | - Mark Stegall
- Department of Surgery,Mayo Clinic Rochester,Rochester,Minnesota,USA
| | - Cristiano Quintini
- Department of Surgery,Transplantation Center,Digestive Disease and Surgery Institute,Cleveland Clinic,Cleveland,Ohio,USA
| | | |
Collapse
|
40
|
Dirchwolf M, Becchetti C, Stampf S, Haldimann C, Immer F, Beyeler F, Toso C, Dutkowski P, Candinas D, Dufour JF, Banz V. The impact of perceived donor liver quality on post-transplant outcome. ANZ J Surg 2023; 93:918-925. [PMID: 36708059 DOI: 10.1111/ans.18217] [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: 08/30/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND We analysed the impact of perceived liver donor quality on transplant recipient outcomes. METHODS this prospective cohort study included all deceased liver donors during 2008-2018 in the Swiss Transplant Cohort Study. Perceived low-quality liver donors were defined when refused for ≥5 top listed recipients or for all recipients in at least one centre before being transplanted. The effect of liver donor quality on relisting or recipient death at 1 week and 1 year after transplantation was analysed using Kaplan-Meier and Cox proportional hazard models. A 1:3 matching was also performed using a recipient score. RESULTS Of 973 liver donors, 187 (19.2%) had perceived poor-quality. Males, obesity, donation after circulatory death and alanine aminotransferase values were significantly associated with perceived poor-quality, with no significant effect of the perceived quality on re-listing or death within the first week and first year post-transplant [(aHR) = 1.45, 95% CI: (0.6, 3.5), P = 0.41 and aHR = 1.52 (95% CI 0.98-2.35), P = 0.06], adjusting by recipient age and gender, obesity, diabetes, prior liver transplantation and model for end-stage liver disease (MELD) score. At 1 year, prior liver transplantation and higher MELD score associated with higher risk of re-listing or death. CONCLUSION Comparable post-transplant outcomes with different perceived quality liver donors stresses the need to improve donor selection in liver transplantation.
Collapse
Affiliation(s)
- Melisa Dirchwolf
- Novartis Fellowship in Hepatology, Department of Biomedical Research, University of Bern, Bern, Switzerland.,Liver Unit, Hospital Privado de Rosario, Santa Fe, Argentina
| | - Chiara Becchetti
- Hepatology, Department of Biomedical Research, University of Bern, Bern, Switzerland.,Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Susanne Stampf
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Christa Haldimann
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Franz Immer
- Swisstransplant, The Swiss National Foundation for Organ Donation and Transplantation, Bern, Switzerland
| | - Franziska Beyeler
- Swisstransplant, The Swiss National Foundation for Organ Donation and Transplantation, Bern, Switzerland
| | - Christian Toso
- Abdominal Surgery, Geneva University Hospital of Geneva, Geneva, Switzerland
| | - Philipp Dutkowski
- Abdominal Transplant Surgery, University Hospital of Zürich, Zürich, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Jean-Francois Dufour
- Hepatology, Department of Biomedical Research, University of Bern, Bern, Switzerland.,Centre des Maladies Digestives, Lausanne, Switzerland
| | - Vanessa Banz
- Department of Visceral Surgery and Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | | |
Collapse
|
41
|
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.
Collapse
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
| |
Collapse
|
42
|
Where are we today with machine perfusion of liver in donation after circulatory death liver transplantation? TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
43
|
Watson CJ, Gaurav R, Fear C, Swift L, Selves L, Ceresa CD, Upponi SS, Brais R, Allison M, Macdonald-Wallis C, Taylor R, Butler AJ. Predicting Early Allograft Function After Normothermic Machine Perfusion. Transplantation 2022; 106:2391-2398. [PMID: 36044364 PMCID: PMC9698137 DOI: 10.1097/tp.0000000000004263] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 04/14/2022] [Accepted: 04/25/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Normothermic ex situ liver perfusion is increasingly used to assess donor livers, but there remains a paucity of evidence regarding criteria upon which to base a viability assessment or criteria predicting early allograft function. METHODS Perfusate variables from livers undergoing normothermic ex situ liver perfusion were analyzed to see which best predicted the Model for Early Allograft Function score. RESULTS One hundred fifty-four of 203 perfused livers were transplanted following our previously defined criteria. These comprised 84/123 donation after circulatory death livers and 70/80 donation after brain death livers. Multivariable analysis suggested that 2-h alanine transaminase, 2-h lactate, 11 to 29 mmol supplementary bicarbonate in the first 4 h, and peak bile pH were associated with early allograft function as defined by the Model for Early Allograft Function score. Nonanastomotic biliary strictures occurred in 11% of transplants, predominantly affected first- and second-order ducts, despite selection based on bile glucose and pH. CONCLUSIONS This work confirms the importance of perfusate alanine transaminase and lactate at 2-h, as well as the amount of supplementary bicarbonate required to keep the perfusate pH > 7.2, in the assessment of livers undergoing perfusion. It cautions against the use of lactate as a sole indicator of viability and also suggests a role for cholangiocyte function markers in predicting early allograft function.
Collapse
Affiliation(s)
- Christopher J.E. Watson
- Department of Surgery, University of Cambridge, Level E9, Addenbrooke’s Hospital, Cambridge, United Kingdom
- The National Institute of Health Research, Cambridge Biomedical Research Centre (BRC 1215 20014), Cambridge, United Kingdom
- The National Institute for Health Research Blood and Transplant Research Unit, University of Cambridge in collaboration with Newcastle University and in partnership with National Health Service Blood and Transplant, Cambridge, United Kingdom
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Rohit Gaurav
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Corrina Fear
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Lisa Swift
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Linda Selves
- Department of Surgery, University of Cambridge, Level E9, Addenbrooke’s Hospital, Cambridge, United Kingdom
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Carlo D.L. Ceresa
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Sara S. Upponi
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Rebecca Brais
- Department of Pathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Michael Allison
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Corrie Macdonald-Wallis
- Statistics and Clinical Research, National Health Service Blood and Transplant, Bristol, United Kingdom
| | - Rhiannon Taylor
- Statistics and Clinical Research, National Health Service Blood and Transplant, Bristol, United Kingdom
| | - Andrew J. Butler
- Department of Surgery, University of Cambridge, Level E9, Addenbrooke’s Hospital, Cambridge, United Kingdom
- The National Institute of Health Research, Cambridge Biomedical Research Centre (BRC 1215 20014), Cambridge, United Kingdom
- The National Institute for Health Research Blood and Transplant Research Unit, University of Cambridge in collaboration with Newcastle University and in partnership with National Health Service Blood and Transplant, Cambridge, United Kingdom
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| |
Collapse
|
44
|
Jadlowiec CC, Macdonough E, Pont K, Valenti K, Lizaola‐Mayo B, Brooks A, Das D, Heilman R, Mathur AK, Hewitt W, Moss A, Aqel B, Reddy KS. Donation after circulatory death transplant outcomes using livers recovered by local surgeons. Liver Transpl 2022; 28:1726-1734. [PMID: 35332655 PMCID: PMC9790574 DOI: 10.1002/lt.26461] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/26/2022] [Accepted: 03/19/2022] [Indexed: 12/30/2022]
Abstract
Donation after circulatory death (DCD) liver transplantation (LT) outcomes have been attributed to multiple variables, including procurement surgeon recovery techniques. Outcomes of 196 DCD LTs at Mayo Clinic Arizona were analyzed based on graft recovery by a surgeon from our center (transplant procurement team [TPT]) versus a local procurement surgeon (non-TPT [NTPT]). A standard recovery technique was used for all TPT livers. The recovery technique used by the NTPT was left to the discretion of that surgeon. A total of 129 (65.8%) grafts were recovered by our TPT, 67 (34.2%) by the NTPT. Recipient age (p = 0.43), Model for End-Stage Liver Disease score (median 17 vs. 18; p = 0.22), and donor warm ischemia time (median 21.0 vs. 21.5; p = 0.86) were similar between the TPT and NTPT groups. NTPT livers had longer cold ischemia times (6.5 vs. 5.0 median hours; p < 0.001). Early allograft dysfunction (80.6% vs. 76.1%; p = 0.42) and primary nonfunction (0.8% vs. 0.0%; p = 0.47) were similar. Ischemic cholangiopathy (IC) treated with endoscopy occurred in 18.6% and 11.9% of TPT and NTPT grafts (p = 0.23). At last follow-up, approximately half of those requiring endoscopy were undergoing a stent-free trial (58.3% TPT; 50.0% NTPT; p = 0.68). IC requiring re-LT in the first year occurred in 0.8% (n = 1) of TPT and 3.0% (n = 2) of NTPT grafts (p = 0.23). There were no differences in patient (hazard ratio [HR], 1.95; 95% confidence interval [CI], 0.76-5.03; p = 0.23) or graft (HR, 1.99; 95% CI, 0.98-4.09; p = 0.10) survival rates. Graft survival at 1 year was 91.5% for TPT grafts and 95.5% for NTPT grafts. Excellent outcomes can be achieved using NTPT for the recovery of DCD livers. There may be an opportunity to expand the use of DCD livers in the United States by increasing the use of NTPT.
Collapse
Affiliation(s)
| | | | - Kylie Pont
- Division of Transplant SurgeryDepartment of SurgeryMayo ClinicPhoenixArizonaUSA
| | - Kristi Valenti
- Division of Transplant SurgeryDepartment of SurgeryMayo ClinicPhoenixArizonaUSA
| | | | - Abigail Brooks
- Tel Aviv University School of MedicineTel Aviv‐YafoIsrael
| | - Devika Das
- Division of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | | | - Amit K. Mathur
- Division of Transplant SurgeryDepartment of SurgeryMayo ClinicPhoenixArizonaUSA
| | - Winston Hewitt
- Division of Transplant SurgeryDepartment of SurgeryMayo ClinicPhoenixArizonaUSA
| | - Adyr Moss
- Division of Transplant SurgeryDepartment of SurgeryMayo ClinicPhoenixArizonaUSA
| | - Bashar Aqel
- Division of Gastroenterology and HepatologyMayo ClinicPhoenixArizonaUSA
| | - Kunam S. Reddy
- Division of Transplant SurgeryDepartment of SurgeryMayo ClinicPhoenixArizonaUSA
| |
Collapse
|
45
|
Mohkam K, Nasralla D, Mergental H, Muller X, Butler A, Jassem W, Imber C, Monbaliu D, Perera MTPR, Laing RW, García‐Valdecasas JC, Paul A, Dondero F, Cauchy F, Savier E, Scatton O, Robin F, Sulpice L, Bucur P, Salamé E, Pittau G, Allard M, Pradat P, Rossignol G, Mabrut J, Ploeg RJ, Friend PJ, Mirza DF, Lesurtel M. In situ normothermic regional perfusion versus ex situ normothermic machine perfusion in liver transplantation from donation after circulatory death. Liver Transpl 2022; 28:1716-1725. [PMID: 35662403 PMCID: PMC9796010 DOI: 10.1002/lt.26522] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 03/14/2022] [Accepted: 03/19/2022] [Indexed: 12/30/2022]
Abstract
In situ normothermic regional perfusion (NRP) and ex situ normothermic machine perfusion (NMP) aim to improve the outcomes of liver transplantation (LT) using controlled donation after circulatory death (cDCD). NRP and NMP have not yet been compared directly. In this international observational study, outcomes of LT performed between 2015 and 2019 for organs procured from cDCD donors subjected to NRP or NMP commenced at the donor center were compared using propensity score matching (PSM). Of the 224 cDCD donations in the NRP cohort that proceeded to asystole, 193 livers were procured, resulting in 157 transplants. In the NMP cohort, perfusion was commenced in all 40 cases and resulted in 34 transplants (use rates: 70% vs. 85% [p = 0.052], respectively). After PSM, 34 NMP liver recipients were matched with 68 NRP liver recipients. The two cohorts were similar for donor functional warm ischemia time (21 min after NRP vs. 20 min after NMP; p = 0.17), UK-Donation After Circulatory Death risk score (5 vs. 5 points; p = 0.38), and laboratory Model for End-Stage Liver Disease scores (12 vs. 12 points; p = 0.83). The incidence of nonanastomotic biliary strictures (1.5% vs. 2.9%; p > 0.99), early allograft dysfunction (20.6% vs. 8.8%; p = 0.13), and 30-day graft loss (4.4% vs. 8.8%; p = 0.40) were similar, although peak posttransplant aspartate aminotransferase levels were higher in the NRP cohort (872 vs. 344 IU/L; p < 0.001). NRP livers were more frequently allocated to recipients suffering from hepatocellular carcinoma (HCC; 60.3% vs. 20.6%; p < 0.001). HCC-censored 2-year graft and patient survival rates were 91.5% versus 88.2% (p = 0.52) and 97.9% versus 94.1% (p = 0.25) after NRP and NMP, respectively. Both perfusion techniques achieved similar outcomes and appeared to match benchmarks expected for donation after brain death livers. This study may inform the design of a definitive trial.
Collapse
Affiliation(s)
- Kayvan Mohkam
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - David Nasralla
- Department of Hepatopancreatobiliary and Liver Transplant SurgeryRoyal Free HospitalLondonUK
| | - Hynek Mergental
- Liver Unit, Queen Elizabeth HospitalUniversity Hospitals BirminghamBirminghamUK
| | - Xavier Muller
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - Andrew Butler
- Department of Surgery, Addenbrooke's HospitalUniversity of CambridgeCambridgeUK
| | - Wayel Jassem
- Institute of Liver StudiesKing's College HospitalLondonUK
| | - Charles Imber
- Department of Hepatopancreatobiliary and Liver Transplant SurgeryRoyal Free HospitalLondonUK
| | - Diethard Monbaliu
- Abdominal Transplant Surgery Unit, Department of SurgeryUniversity Hospitals LeuvenLeuvenBelgium
| | | | - Richard W. Laing
- Liver Unit, Queen Elizabeth HospitalUniversity Hospitals BirminghamBirminghamUK
| | | | - Andreas Paul
- Department of General, Visceral and Transplantation SurgeryUniversity Hospital EssenEssenGermany
| | - Federica Dondero
- Department of Hepatobiliopancreatic SurgeryDepartment of Hepatopancreatobiliary Surgery and Liver TransplantationBeaujon Hospital, Assitance Publique‐Hôpitaux de Paris (AP‐HP), University Paris CitéClichyFrance
| | - François Cauchy
- Department of Hepatobiliopancreatic SurgeryDepartment of Hepatopancreatobiliary Surgery and Liver TransplantationBeaujon Hospital, Assitance Publique‐Hôpitaux de Paris (AP‐HP), University Paris CitéClichyFrance
| | - Eric Savier
- Department of Hepatobiliary Surgery and Liver Transplantation, Pitié‐Salpêtrière HospitalSorbonne UniversityParisFrance
| | - Olivier Scatton
- Department of Hepatobiliary Surgery and Liver Transplantation, Pitié‐Salpêtrière HospitalSorbonne UniversityParisFrance
| | - Fabien Robin
- Department of Hepatobiliary and Digestive SurgeryPontchaillou University HospitalRennesFrance
| | - Laurent Sulpice
- Department of Hepatobiliary and Digestive SurgeryPontchaillou University HospitalRennesFrance
| | - Petru Bucur
- Department of Digestive, Oncological, Endocrine, Hepato‐Biliary, Pancreatic and Liver Transplant SurgeryTrousseau HospitalToursFrance
| | - Ephrem Salamé
- Department of Digestive, Oncological, Endocrine, Hepato‐Biliary, Pancreatic and Liver Transplant SurgeryTrousseau HospitalToursFrance
| | - Gabriella Pittau
- Centre Hépato‐Biliaire, Hôpital Paul Brousse, Assistance Publique‐Hôpitaux de Paris (AP‐HP)Université Paris SudVillejuifFrance
| | - Marc‐Antoine Allard
- Centre Hépato‐Biliaire, Hôpital Paul Brousse, Assistance Publique‐Hôpitaux de Paris (AP‐HP)Université Paris SudVillejuifFrance
| | - Pierre Pradat
- Clinical Research Centre, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - Guillaume Rossignol
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - Jean‐Yves Mabrut
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - Rutger J. Ploeg
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Peter J. Friend
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Darius F. Mirza
- Liver Unit, Queen Elizabeth HospitalUniversity Hospitals BirminghamBirminghamUK
| | - Mickaël Lesurtel
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | | |
Collapse
|
46
|
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
|
47
|
Clavien PA, Dutkowski P, Mueller M, Eshmuminov D, Bautista Borrego L, Weber A, Muellhaupt B, Sousa Da Silva RX, Burg BR, Rudolf von Rohr P, Schuler MJ, Becker D, Hefti M, Tibbitt MW. Transplantation of a human liver following 3 days of ex situ normothermic preservation. Nat Biotechnol 2022; 40:1610-1616. [PMID: 35641829 DOI: 10.1038/s41587-022-01354-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 05/09/2022] [Indexed: 01/13/2023]
Abstract
Current organ preservation methods provide a narrow window (usually <12 hours) to assess, transport and implant donor grafts for human transplantation. Here we report the transplantation of a human liver discarded by all centers, which could be preserved for several days using ex situ normothermic machine perfusion. The transplanted liver exhibited normal function, with minimal reperfusion injury and the need for only a minimal immunosuppressive regimen. The patient rapidly recovered a normal quality of life without any signs of liver damage, such as rejection or injury to the bile ducts, according to a 1-year follow up. This inaugural clinical success opens new horizons in clinical research and promises an extended time window of up to 10 days for assessment of viability of donor organs as well as converting an urgent and highly demanding surgery into an elective procedure.
Collapse
Affiliation(s)
- Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) and Transplant Center, University Hospital Zurich, Zurich, Switzerland. .,Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland.
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) and Transplant Center, University Hospital Zurich, Zurich, Switzerland
| | - Matteo Mueller
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) and Transplant Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Dilmurodjon Eshmuminov
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) and Transplant Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Lucia Bautista Borrego
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) and Transplant Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Achim Weber
- Department of Pathology and Molecular Pathology, and Institute of Molecular Cancer Research, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Beat Muellhaupt
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Richard X Sousa Da Silva
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) and Transplant Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Brian R Burg
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland.,Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland.,Pixium Vision, Paris, France
| | - Philipp Rudolf von Rohr
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland.,Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Martin J Schuler
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland.,Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Dustin Becker
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland.,Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Max Hefti
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland.,Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Mark W Tibbitt
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland.,Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| |
Collapse
|
48
|
Bolognese AC, Foley DP, Sparks CJ, Schneider A, D'Alessandro AM, Neidlinger NA. Use of preprocurement biopsy in donation after circulatory death liver transplantation. Liver Transpl 2022; 28:1709-1715. [PMID: 35596660 PMCID: PMC9796628 DOI: 10.1002/lt.26510] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/08/2022] [Accepted: 05/10/2022] [Indexed: 01/01/2023]
Abstract
We perform routine preprocurement image-guided percutaneous liver biopsies on potential donation after circulatory death (DCD) liver donors. The purpose of this study was to examine the impact of preprocurement liver biopsy on the use of livers from DCD donors. We retrospectively reviewed demographics, liver histology, and disposition of DCD liver donors within a single organ procurement organization (OPO) who underwent preprocurement liver biopsy from January 2000 through December 2019. A total of 212 potential donors underwent prerecovery biopsy. No donors were lost as a result of complications of biopsy. Of these, 183 (86.3%) had acceptable biopsies: 146 (79.8%) were successfully transplanted and 37 (20.2%) were deemed not suitable for transplant. In contrast, of 120 DCD livers recovered with the intent to transplant that were not biopsied prior to recovery, 59 (49.2%) were successfully transplanted, and 61 (50.8%) were deemed not suitable for transplant. A total of 14 donors were ruled out for transplant based on prerecovery histology. Successfully transplanted livers that underwent preprocurement biopsy were more likely to come from donors aged older than 50 years or with body mass index more than 30 kg/m2 compared with successfully transplanted livers without a prerecovery biopsy. Biopsy excluded 6.6% of DCD donor livers for transplant prior to recovery and facilitated the successful recovery and transplant of two-thirds of potential DCD donor livers. Livers intended for transplant at the time of recovery that did not undergo preprocurement biopsy were more likely to not be recovered or to be discarded. Preprocurement biopsy provides additional histologic information prior to deploying resources and helps to identify usable livers that might otherwise be declined for transplant. Consideration of liver biopsy in this group benefits OPOs and transplant centers by maximizing organ use and optimizing resource deployment.
Collapse
Affiliation(s)
- Alexandra C. Bolognese
- Division of Transplantation, Department of SurgeryUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - David P. Foley
- Division of Transplantation, Department of SurgeryUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | | | | | - Anthony M. D'Alessandro
- Division of Transplantation, Department of SurgeryUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA,UW Organ and Tissue DonationMadisonWisconsinUSA
| | - Nikole A. Neidlinger
- Division of Transplantation, Department of SurgeryUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA,UW Organ and Tissue DonationMadisonWisconsinUSA
| |
Collapse
|
49
|
Nagai S, Ivanics T, Kitajima T, Shimada S, Shamaa TM, Collins K, Rizzari M, Yoshida A, Moonka D, Abouljoud M. Disparities in the Effects of Acuity Circle-based Liver Allocation on Waitlist and Transplant Practice Between Centers. Transplant Direct 2022; 8:e1356. [PMID: 36176726 PMCID: PMC9514831 DOI: 10.1097/txd.0000000000001356] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/12/2022] [Accepted: 06/05/2022] [Indexed: 11/26/2022] Open
Abstract
Liver allocation in the United States was updated on February 4, 2020, by introducing the acuity circle (AC)-based model. This study evaluated the early effects of the AC-based allocation on waitlist outcomes. Methods Adult liver transplant (LT) candidates listed between January 1, 2019, and September 30, 2021, were assessed. Two periods were defined according to listing date (pre- and post-AC), and 90-d waitlist outcomes were compared. Median transplant Model for End-stage Liver Disease (MELD) score of each transplant center was calculated, with centers categorized as low- (<25 percentile), mid- (25-75 percentile), and high-MELD (>75 percentile) centers. Results A total of 12 421 and 17 078 LT candidates in the pre- and post-AC eras were identified. Overall, the post-AC era was associated with higher cause-specific 90-d hazards of transplant (csHR, 1.32; 95% confidence interval [CI], 1.27-1.38; P < 0.001) and waitlist mortality (cause-specific hazard ratio [csHR], 1.20; 95% CI, 1.09-1.32; P < 0.001). The latter effect was primarily driven by high-MELD centers. Low-MELD centers had a higher proportion of donations after circulatory death (DCDs) used. Compared with low-MELD centers, mid-MELD and high-MELD centers had significantly lower cause-specific hazards of DCD-LT in both eras (mid-MELD: csHR, 0.47; 95% CI, 0.38-0.59 in pre-AC and csHR, 0.56; 95% CI, 0.46-0.67 in post-AC and high-MELD: csHR, 0.11; 95% CI, 0.07-0.17 in pre-AC and csHR, 0.14; 95% CI, 0.10-0.20 in post-AC; all P < 0.001). Using a structural Bayesian time-series model, the AC policy was associated with an increase in the actual monthly DCD-LTs in low-, mid-, and high-MELD centers (actual/predicted: low-MELD: 19/16; mid-MELD: 21/14; high-MELD: 4/3), whereas the increase in monthly donation after brain death-LTs were only present in mid- and high-MELD centers. Conclusions Although AC-based allocation may improve waitlist outcomes, regional variation exists in the drivers of such outcomes between centers.
Collapse
Affiliation(s)
- Shunji Nagai
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Tommy Ivanics
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Toshihiro Kitajima
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Shingo Shimada
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Tayseer M. Shamaa
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Kelly Collins
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Michael Rizzari
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Atsushi Yoshida
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Dilip Moonka
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, MI
| | - Marwan Abouljoud
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| |
Collapse
|
50
|
Widmer J, Eden J, Carvalho MF, Dutkowski P, Schlegel A. Machine Perfusion for Extended Criteria Donor Livers: What Challenges Remain? J Clin Med 2022; 11:jcm11175218. [PMID: 36079148 PMCID: PMC9457017 DOI: 10.3390/jcm11175218] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 08/30/2022] [Indexed: 11/28/2022] Open
Abstract
Based on the renaissance of dynamic preservation techniques, extended criteria donor (ECD) livers reclaimed a valuable eligibility in the transplantable organ pool. Being more vulnerable to ischemia, ECD livers carry an increased risk of early allograft dysfunction, primary non-function and biliary complications and, hence, unveiled the limitations of static cold storage (SCS). There is growing evidence that dynamic preservation techniques—dissimilar to SCS—mitigate reperfusion injury by reconditioning organs prior transplantation and therefore represent a useful platform to assess viability. Yet, a debate is ongoing about the advantages and disadvantages of different perfusion strategies and their best possible applications for specific categories of marginal livers, including organs from donors after circulatory death (DCD) and brain death (DBD) with extended criteria, split livers and steatotic grafts. This review critically discusses the current clinical spectrum of livers from ECD donors together with the various challenges and posttransplant outcomes in the context of standard cold storage preservation. Based on this, the potential role of machine perfusion techniques is highlighted next. Finally, future perspectives focusing on how to achieve higher utilization rates of the available donor pool are highlighted.
Collapse
Affiliation(s)
- Jeannette Widmer
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zürich, Switzerland
| | - Janina Eden
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zürich, Switzerland
| | - Mauricio Flores Carvalho
- Hepatobiliary Unit, Department of Clinical and Experimental Medicine, University of Florence, AOU Careggi, 50139 Florence, Italy
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zürich, Switzerland
| | - Andrea Schlegel
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zürich, Switzerland
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Centre of Preclinical Research, 20122 Milan, Italy
- Correspondence:
| |
Collapse
|