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Meier RPH, Kelly Y, Braun H, Maluf D, Freise C, Ascher N, Roberts J, Roll G. Comparison of Biliary Complications Rates After Brain Death, Donation After Circulatory Death, and Living-Donor Liver Transplantation: A Single-Center Cohort Study. Transpl Int 2022; 35:10855. [PMID: 36568142 PMCID: PMC9780276 DOI: 10.3389/ti.2022.10855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022]
Abstract
Donation-after-circulatory-death (DCD), donation-after-brain-death (DBD), and living-donation (LD) are the three possible options for liver transplantation (LT), each with unique benefits and complication rates. We aimed to compare DCD-, DBD-, and LD-LT-specific graft survival and biliary complications (BC). We collected data on 138 DCD-, 3,027 DBD- and 318 LD-LTs adult recipients from a single center and analyzed patient/graft survival. BC (leak and anastomotic/non-anastomotic stricture (AS/NAS)) were analyzed in a subset of 414 patients. One-/five-year graft survival were 88.6%/70.0% for DCD-LT, 92.6%/79.9% for DBD-LT, and, 91.7%/82.9% for LD-LT. DCD-LTs had a 1.7-/1.3-fold adjusted risk of losing their graft compared to DBD-LT and LD-LT, respectively (p < 0.010/0.403). Bile leaks were present in 10.1% (DCD-LTs), 7.2% (DBD-LTs), and 36.2% (LD-LTs) (ORs, DBD/LD vs. DCD: 0.7/4.2, p = 0.402/<0.001). AS developed in 28.3% DCD-LTs, 18.1% DBD-LTs, and 43.5% LD-LTs (ORs, DBD/LD vs. DCD: 0.5/1.8, p = 0.018/0.006). NAS was present in 15.2% DCD-LTs, 1.4% DBDs-LT, and 4.3% LD-LTs (ORs, DBD/LD vs. DCD: 0.1/0.3, p = 0.001/0.005). LTs w/o BC had better liver graft survival compared to any other groups with BC. DCD-LT and LD-LT had excellent graft survival despite significantly higher BC rates compared to DBD-LT. DCD-LT represents a valid alternative whose importance should increase further with machine/perfusion systems.
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Affiliation(s)
- Raphael Pascal Henri Meier
- University of California, San Francisco, San Francisco, CA, United States,University of Maryland, Baltimore, Baltimore, MD, United States,*Correspondence: Raphael Pascal Henri Meier,
| | - Yvonne Kelly
- University of California, San Francisco, San Francisco, CA, United States
| | - Hillary Braun
- University of California, San Francisco, San Francisco, CA, United States
| | - Daniel Maluf
- University of Maryland, Baltimore, Baltimore, MD, United States
| | - Chris Freise
- University of California, San Francisco, San Francisco, CA, United States
| | - Nancy Ascher
- University of California, San Francisco, San Francisco, CA, United States
| | - John Roberts
- University of California, San Francisco, San Francisco, CA, United States
| | - Garrett Roll
- University of California, San Francisco, San Francisco, CA, United States
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Meier RPH, Kelly Y, Yamaguchi S, Braun HJ, Lunow-Luke T, Adelmann D, Niemann C, Maluf DG, Dietch ZC, Stock PG, Kang SM, Feng S, Posselt AM, Gardner JM, Syed SM, Hirose R, Freise CE, Ascher NL, Roberts JP, Roll GR. Advantages and Limitations of Clinical Scores for Donation After Circulatory Death Liver Transplantation. Front Surg 2022; 8:808733. [PMID: 35071316 PMCID: PMC8766343 DOI: 10.3389/fsurg.2021.808733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/09/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Scoring systems have been proposed to select donation after circulatory death (DCD) donors and recipients for liver transplantation (LT). We hypothesized that complex scoring systems derived in large datasets might not predict outcomes locally. Methods: Based on 1-year DCD-LT graft survival predictors in multivariate logistic regression models, we designed, validated, and compared a simple index using the University of California, San Francisco (UCSF) cohort (n = 136) and a universal-comprehensive (UC)-DCD score using the United Network for Organ Sharing (UNOS) cohort (n = 5,792) to previously published DCD scoring systems. Results: The total warm ischemia time (WIT)-index included donor WIT (dWIT) and hepatectomy time (dHep). The UC-DCD score included dWIT, dHep, recipient on mechanical ventilation, transjugular-intrahepatic-portosystemic-shunt, cause of liver disease, model for end-stage liver disease, body mass index, donor/recipient age, and cold ischemia time. In the UNOS cohort, the UC-score outperformed all previously published scores in predicting DCD-LT graft survival (AUC: 0.635 vs. ≤0.562). In the UCSF cohort, the total WIT index successfully stratified survival and biliary complications, whereas other scores did not. Conclusion: DCD risk scores generated in large cohorts provide general guidance for safe recipient/donor selection, but they must be tailored based on non-/partially-modifiable local circumstances to expand DCD utilization.
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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, Baltimore, MD, United States
| | - Yvonne Kelly
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Seiji Yamaguchi
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Hillary J. Braun
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Tyler Lunow-Luke
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Dieter Adelmann
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, United States
| | - Claus Niemann
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, United States
| | - Daniel G. Maluf
- Department of Surgery, University of Maryland, Baltimore, MD, United States
| | - Zachary C. Dietch
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Peter G. Stock
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Sang-Mo Kang
- 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
| | - Andrew M. Posselt
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - James M. Gardner
- 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
| | - Ryutaro Hirose
- 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
| | - Nancy L. Ascher
- 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
| | - Garrett R. Roll
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
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Pearson R, Geddes C, Mark P, Clancy M, Asher J. Transplantation of kidneys after normothermic perfusion: A single center experience. Clin Transplant 2021; 35:e14431. [PMID: 34288129 DOI: 10.1111/ctr.14431] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/21/2021] [Accepted: 07/07/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND In order to expand the pool of usable donors from circulatory death (DCD) there is increasing interest in normothermic regional perfusion (NRP) to assess and improve liver viability.1,2 NRP may also improve outcomes in kidney transplantation.We present our single center experience of outcomes in imported kidneys following NRP. METHODS Data was obtained from a prospectively maintained database between December 2012 and September 2018. Primary endpoints were incidence of delayed graft function (DGF) and estimated glomerular filtration rate (eGFR). RESULTS Six-hundred and thirty-two decease donor kidneys were transplanted, 229 from DCD donors, 29 of which had NRP. The DGF rate was lower for NRP versus DCD (six of 29, 20.7% vs. 70 of 200, 35.0%) with reduced duration of DGF. Multivariate analysis demonstrated transplant type to be a statistically significant independent predictor of eGFR at 7 and 14 days. Early transplant function in NRP kidneys was comparable to DBD. There were no graft losses within 30 days in the NRP group. One-year graft loss rate was 3.4% for NRP and 6.0% for standard DCD. CONCLUSION This data suggests NRP is safe, and reduces rates of DGF and improves early renal transplant function.
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Affiliation(s)
- Robert Pearson
- Department of Renal Transplantation, Queen Elizabeth University Hospital, Glasgow, UK
| | - Colin Geddes
- Department of Renal Transplantation, Queen Elizabeth University Hospital, Glasgow, UK
| | - Patrick Mark
- Institute of Cardiovascular and Molecular Sciences, University of Glasgow, Glasgow, UK
| | - Marc Clancy
- Department of Renal Transplantation, Queen Elizabeth University Hospital, Glasgow, UK
| | - John Asher
- Department of Renal Transplantation, Queen Elizabeth University Hospital, Glasgow, UK
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Can hypothermic oxygenated perfusion (HOPE) rescue futile DCD liver grafts? HPB (Oxford) 2019; 21:1156-1165. [PMID: 30777695 DOI: 10.1016/j.hpb.2019.01.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 12/21/2018] [Accepted: 01/09/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The new UK-DCD-Risk-Score has been recently developed to predict graft loss in DCD liver transplantation. Donor-recipient combinations with a cumulative risk of >10 points were classified as futile and achieved an impaired one-year graft survival of <40%. The aim of this study was to show, if hypothermic oxygenated perfusion (HOPE) can rescue such extended DCD livers and improve outcomes. METHODS "Futile"-classified donor-recipient combinations were selected from our HOPE-treated human DCD liver cohort (01/2012-5/2017), with a minimum follow-up of one year. Main risk factors, which contribute to the classification "futile" include: elderly donors>60years, prolonged functional donor warm ischemia time (fDWIT > 30min), long cold ischemia time>6hrs, donor BMI>25 kg/m2, advanced recipient age (>60years), MELD-score>25points and retransplantation status. Endpoints included all outcome measures during and after DCD LT. RESULTS Twenty-one donor-recipient combinations were classified futile (median UK-DCD-Risk-Score:11 points). The median donor age and fDWIT were 62 years and 36 min, respectively. After cold storage, livers underwent routine HOPE-treatment for 120 min. All grafts showed immediate function. One-year and 5-year tumor death censored graft survival was 86%. CONCLUSION HOPE-treatment achieved excellent outcomes, despite high-risk donor and recipient combinations. Such easy, endischemic perfusion approach may open the door for an increased utilization of futile DCD livers in other countries.
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Hessheimer AJ, Coll E, Ruíz P, Gastaca M, Rivas JI, Gómez M, Sánchez B, Santoyo J, Ramírez P, Parrilla P, Marín LM, Gómez-Bravo MÁ, García-Valdecasas JC, López-Monclús J, Boscá A, López-Andújar R, Fundora-Suárez Y, Villar J, García-Sesma Á, Jiménez C, Rodríguez-Laíz G, Lladó L, Rodríguez JC, Barrera M, Charco R, López-Baena JÁ, Briceño J, Pardo F, Blanco G, Pacheco D, Domínguez-Gil B, Sánchez Turrión V, Fondevila C. Reply to: "Normothermic regional perfusion - What is the benefit?". J Hepatol 2019; 71:443-445. [PMID: 31130439 DOI: 10.1016/j.jhep.2019.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 04/24/2019] [Accepted: 04/25/2019] [Indexed: 12/04/2022]
Affiliation(s)
- Amelia J Hessheimer
- Department of General & Digestive Surgery, Institut de Malalties Digestives i Metabòliques (IMDiM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain
| | | | | | | | | | - Manuel Gómez
- Complejo Hospitalario Universitario La Coruña, Spain
| | | | | | - Pablo Ramírez
- Hospital Clínico Universitario Virgen de la Arrixaca (IMIB), Murcia, Spain
| | - Pascual Parrilla
- Hospital Clínico Universitario Virgen de la Arrixaca (IMIB), Murcia, Spain
| | | | | | - Juan Carlos García-Valdecasas
- Department of General & Digestive Surgery, Institut de Malalties Digestives i Metabòliques (IMDiM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain
| | | | - Andrea Boscá
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | | | - Jesús Villar
- Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | | | - Gonzalo Rodríguez-Laíz
- Department of General & Digestive Surgery, ISABIAL, Hospital General Universitario de Alicante, Spain
| | - Laura Lladó
- Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Spain
| | | | - Manuel Barrera
- Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Ramón Charco
- Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | | | | | | | | | - David Pacheco
- Hospital Universitario Río Hortega, Valladolid, Spain
| | | | | | - Constantino Fondevila
- Department of General & Digestive Surgery, Institut de Malalties Digestives i Metabòliques (IMDiM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain.
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Boteon APCS, Schlegel A, Kalisvaart M, Boteon YL, Abradelo M, Mergental H, Roberts JK, Mirza DF, Perera MTPR, Isaac JR, Muiesan P. Retrieval Practice or Overall Donor and Recipient Risk: What Impacts on Outcomes After Donation After Circulatory Death Liver Transplantation in the United Kingdom? Liver Transpl 2019; 25:545-558. [PMID: 30919560 DOI: 10.1002/lt.25410] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 12/02/2018] [Indexed: 02/07/2023]
Abstract
Parameters of retrieval surgery are meticulously documented in the United Kingdom, where up to 40% of livers are donation after circulatory death (DCD) donations. This retrospective analysis focuses on outcomes after transplantation of DCD livers, retrieved by different UK centers between 2011 and 2016. Donor and recipient risk factors and the donor retrieval technique were assessed. A total of 236 DCD livers from 9 retrieval centers with a median UK DCD risk score of 5 (low risk) to 7 points (high risk) were compared. The majority used University of Wisconsin solution for aortic flush with a median hepatectomy time of 27-44 minutes. The overall liver injury rate appeared relatively high (27.1%) with an observed tendency toward more retrieval injuries from centers performing a quicker hepatectomy. Among all included risk factors, the UK DCD risk score remained the best predictor for overall graft loss in the multivariate analysis (P < 0.001). In high-risk and futile donor-recipient combinations, the occurrence of liver retrieval injuries had negative impact on graft survival (P = 0.023). Expectedly, more ischemic cholangiopathies (P = 0.003) were found in livers transplanted with a higher cumulative donor-recipient risk. Although more biliary complications with subsequent graft loss were found in high-risk donor-recipient combinations, the impact of the standardized national retrieval practice on outcomes after DCD liver transplantation was minimal.
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Affiliation(s)
- Amanda P C S Boteon
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Andrea Schlegel
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- National Institute for Health Research Birmingham Biomedical Research Centre and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Marit Kalisvaart
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Yuri L Boteon
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- National Institute for Health Research Birmingham Biomedical Research Centre and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Manuel Abradelo
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Hynek Mergental
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- National Institute for Health Research Birmingham Biomedical Research Centre and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - J Keith Roberts
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- National Institute for Health Research Birmingham Biomedical Research Centre and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Darius F Mirza
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- National Institute for Health Research Birmingham Biomedical Research Centre and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
- Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, United Kingdom
| | - M Thamara P R Perera
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, United Kingdom
| | - John R Isaac
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Paolo Muiesan
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- National Institute for Health Research Birmingham Biomedical Research Centre and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
- Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, United Kingdom
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Schlegel A, Kalisvaart M, Isaac J, Dutkowski P, Muiesan P. Reply to: "Redefining futility in DCD liver transplantation in the era of novel perfusion technologies". J Hepatol 2018; 68:1328-1330. [PMID: 29550341 DOI: 10.1016/j.jhep.2018.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 03/05/2018] [Indexed: 12/04/2022]
Affiliation(s)
- A Schlegel
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom; The NIHR Liver Biomedical Research Unit, University Hospitals Birmingham, UK
| | - M Kalisvaart
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom
| | - J Isaac
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom
| | - P Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
| | - P Muiesan
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom.
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