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Croome KP, Brown TE, Mabrey RL, Sonnenwald SL, Burns JM, Mao SA, Clendenon JN, Nguyen JH, Perry DK, Maddox RG, Taner CB. Development of a portable abdominal normothermic regional perfusion (A-NRP) program in the United States. Liver Transpl 2023; 29:1282-1291. [PMID: 37040930 DOI: 10.1097/lvt.0000000000000156] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 03/26/2023] [Indexed: 04/13/2023]
Abstract
In situ abdominal normothermic regional perfusion (A-NRP) has been used for liver transplantation (LT) with donation after circulatory death (DCD) liver grafts in Europe with excellent results; however, adoption of A-NRP in the United States has been lacking. The current report describes the implementation and results of a portable, self-reliant A-NRP program in the United States. Isolated abdominal in situ perfusion with an extracorporeal circuit was achieved through cannulation in the abdomen or femoral vessels and inflation of a supraceliac aortic balloon and cross-clamp. The Quantum Transport System by Spectrum was used. The decision to use livers for LT was made through an assessment of perfusate lactate (q15min). From May to November 2022, 14 A-NRP donation after circulatory death procurements were performed by our abdominal transplant team (N = 11 LT, N = 20 kidney transplants, and 1 kidney-pancreas transplant). The median A-NRP run time was 68 minutes. None of the LT recipients had post-reperfusion syndrome, nor were there any cases of primary nonfunction. All livers were functioning well at the time of maximal follow-up with zero cases of ischemic cholangiopathy. The current report describes the feasibility of a portable A-NRP program that can be used in the United States. Excellent short-term post-transplant results were achieved with both livers and kidneys procured from A-NRP.
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Affiliation(s)
| | - Thomas E Brown
- Division of Cardiothoracic Surgery, Department of Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Richard L Mabrey
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | | | - Justin M Burns
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Shennen A Mao
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Jacob N Clendenon
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Justin H Nguyen
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Dana K Perry
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Rebecca G Maddox
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
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2
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Glinka J, Sachar Y, Tang E, Brahmania M, Hwang J, Waugh E, Schmerk C, Iansavitchene A, Quan D, Skaro A. Liver transplantation with donation after medical assistance in dying: Case series and systematic review of the literature. Liver Transpl 2023; 29:618-625. [PMID: 36896964 DOI: 10.1097/lvt.0000000000000100] [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: 10/04/2022] [Accepted: 01/17/2023] [Indexed: 03/11/2023]
Abstract
Medical assistance in dying (MAiD) has been a legally approved practice in Canada since 2016. Only recently have patients undergoing MAiD also been considered as donors for liver transplantation (LT). This study aimed to evaluate a case series of LT outcomes for recipients with MAiD donors and was paired with a systematic literature review of studies assessing the efficacy of MAiD-associated liver donation. A retrospective chart review of patients registered within the LT Registry at London Health Sciences Centre (LHSC) in London, Ontario, Canada, that had received MAiD donor LT was conducted to develop a case series. Descriptive statistics were produced based on available patient outcomes information. The systematic review included euthanasia due to MAiD being a term exclusive to Canada. Case series had a 100% 1-year graft survival rate, with 50% of patients experiencing early allograft dysfunction but having no significant clinical outcome. A single case of postoperative biliary complication was reported. Median warm ischemic time ranged from 7.8-13 minutes among case series and literature reviews. Utilization of donation after circulatory death allografts procured after MAiD appears to be promising. Mechanisms associated with potential impact in postoperative outcomes include relatively lower warm ischemic time relative to donation after circulatory death Maastricht III graft recipients.
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Affiliation(s)
- Juan Glinka
- Department of Surgery, London, Ontario, Canada
| | - Yashasavi Sachar
- Division of Gastroenterology, Department of Medicine; London, Ontario, Canada
| | | | - Mayur Brahmania
- Division of Gastroenterology, Department of Medicine; London, Ontario, Canada
- Centre for Quality Improvement, Innovation, and Safety, London, Ontario, Canada
| | | | | | - Crystal Schmerk
- Division of Gastroenterology, Department of Medicine; London, Ontario, Canada
| | - Alla Iansavitchene
- Library Services, London Health Sciences Centre, Western University; London, Canada
| | | | - Anton Skaro
- Department of Surgery, London, Ontario, Canada
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3
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Siddiqui F, Al-Adwan Y, Subramanian J, Henry ML. Contemporary Considerations in Solid Organ Transplantation Utilizing DCD Donors. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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4
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Ohara S, Macdonough E, Egbert L, Brooks A, Lizaola-Mayo B, Mathur AK, Aqel B, Reddy KS, Jadlowiec CC. Decreasing Significance of Early Allograft Dysfunction with Rising Use of Nonconventional Donors. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58060821. [PMID: 35744084 PMCID: PMC9227373 DOI: 10.3390/medicina58060821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/07/2022] [Accepted: 06/13/2022] [Indexed: 11/27/2022]
Abstract
Background and Objectives: Early allograft dysfunction (EAD) is considered a surrogate marker for adverse post-liver transplant (LT) outcomes. With the increasing use of nonconventional donors, EAD has become a more frequent occurrence. Given this background, we aimed to assess the prevalence and impact of EAD in an updated cohort inclusive of both conventional and nonconventional liver allografts. Materials and Methods: Perioperative and one-year outcomes were assessed for a total of 611 LT recipients with and without EAD from Mayo Clinic Arizona. EAD was defined as the presence of one or more of the following: bilirubin > 10 mg/dL on day 7, INR > 1.6 on day 7, or ALT and/or AST > 2000 IU/L within the first 7 days of LT. Results: Within this cohort, 31.8% of grafts (n = 194) came from donation after circulatory death (DCD) donors, 17.7% (n = 108) were nationally shared, 16.4% (n = 100) were allocated as post-cross clamp, and 8.7% contained moderate steatosis. EAD was observed in 52.2% (n = 321) of grafts in the study cohort (79% in DCD grafts and 40% in DBD grafts). EAD grafts had higher donor risk index (DRI) scores (1.9 vs. 1.6, p < 0.0001), were more likely to come from DCD donors (48% vs. 13.8%, p < 0.0001), were regionally allocated (p = 0.003), and had higher cold ischemia times (median 6.0 vs. 5.5 h, p = 0.001). Primary nonfunction events were rare in both groups (1.3% vs. 0.3%, p = 0.22). Post-LT acute kidney injury occurred at a similar frequency in recipients with and without EAD (43.6% vs. 30.3%, p = 0.41), and there were no differences in ICU (median 2 vs. 1 day, p = 0.60) or hospital (6 vs. 5 days, p = 0.24) length of stay. For DCD grafts, the rate of ischemic cholangiopathy was similar in the two groups (14.9% EAD vs. 17.5% no EAD, p = 0.69). One-year patient survival for grafts with and without EAD was 96.0% and 94.1% (HR 1.2, 95% CI 0.7−1.8; p = 0.54); one-year graft survival was 92.5% and 92.1% (HR 1.0, 95% CI 0.7−1.5; p = 0.88). Conclusions: In this cohort, EAD occurred in 52% of grafts. The occurrence of EAD, however, did not portend inferior outcomes. Compared to those without EAD, recipients with EAD had similar post-operative outcomes, as well as one-year patient and graft survival. EAD should be managed supportively and should not be viewed as a deterrent to utilization of non-ideal grafts.
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Affiliation(s)
- Stephanie Ohara
- Division of Surgery, Valleywise Health Medical Center, Creighton University, Phoenix, AZ 85008, USA;
| | - Elizabeth Macdonough
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ 85054, USA; (E.M.); (B.L.-M.); (B.A.)
| | - Lena Egbert
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ 85259, USA;
| | - Abigail Brooks
- School of Medicine, Tel Aviv University, Tel Aviv-Yafo 6997801, Israel;
| | - Blanca Lizaola-Mayo
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ 85054, USA; (E.M.); (B.L.-M.); (B.A.)
| | - Amit K. Mathur
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.); (K.S.R.)
| | - Bashar Aqel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ 85054, USA; (E.M.); (B.L.-M.); (B.A.)
| | - Kunam S. Reddy
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.); (K.S.R.)
| | - Caroline C. Jadlowiec
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, USA; (A.K.M.); (K.S.R.)
- Correspondence: ; Tel.: +1-480-342-0437
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5
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Croome KP, Mathur AK, Aqel B, Yang L, Taner T, Heimbach JK, Rosen CB, Paz-Fumagalli R, Taner CB. Classification of Distinct Patterns of Ischemic Cholangiopathy Following DCD Liver Transplantation: Distinct Clinical Courses and Long-term Outcomes From a Multicenter Cohort. Transplantation 2022; 106:1206-1214. [PMID: 34468429 DOI: 10.1097/tp.0000000000003928] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND As the number of donation after circulatory death (DCD) liver transplants (LTs) performed in the United States continues to increase annually, there has been interest by policy makers to develop a more robust exception point safety net for patients who develop ischemic cholangiopathy (IC) following DCD LT. As such, there is a need for better understanding of the clinical course and long-term outcomes in patients who develop IC, as well as determining if IC can be classified into distinct categories with distinctly different clinical outcomes. METHODS All DCD LT performed at Mayo Clinic Florida, Mayo Clinic Arizona, and Mayo Clinic Rochester from January 1999 to March 2020 were included (N = 770). Outcomes were compared between 4 distinct radiologic patterns of IC: diffuse necrosis, multifocal progressive, confluence dominant, and minor form. RESULTS In total, 88 (11.4%) patients developed IC, of which 42 (5.5%) were listed for retransplantation of liver (ReLT). Patients with diffuse necrosis and multifocal progressive patterns suffered from frequent hospital admissions for cholangitis in the first year following DCD LT (median 3 and 2), were largely stent dependent (100% and 85.7%), and almost universally required ReLT. Patients with confluence dominant disease were managed with multiple stents and frequently recovered, ultimately becoming stent free without need for ReLT. Patients with the minor form IC did well with limited need for stent placement or repeat procedures and did not require ReLT. Graft survival was different between the 4 distinct IC patterns (P < 0.001). CONCLUSIONS The present analysis provides a detailed analysis on the natural history and clinical course of IC. Patients developing IC can be classified into 4 distinct patterns with distinct clinical courses.
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Affiliation(s)
| | - Amit K Mathur
- Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Bashar Aqel
- Division of Gastroenterology and hepatology, Mayo Clinic Arizona, Phoenix, AZ
| | - Liu Yang
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - Timucin Taner
- Department of Surgery, Mayo Clinic Rochester, Rochester, MN
| | | | | | | | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
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6
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Schlegel A. The Long Road to Identify a Reliable Viability Test in Liver Transplantation. Transplantation 2022; 106:702-704. [PMID: 34144553 DOI: 10.1097/tp.0000000000003858] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Andrea Schlegel
- Hepatobiliary Unit, Department of Clinical and Experimental Medicine, University of Florence, AOU Careggi, Florence, Italy
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
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7
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Wadei HM, Burcin Taner C, Keaveny AP, Mai ML, Hodge DO, White LJ, Harnois DM, Mao SA, Jarmi T, Croome KP. The changing impact of pre-liver transplant renal dysfunction on post-transplant survival: results of 2 decades from a single center. Ann Hepatol 2022; 24:100317. [PMID: 33545403 DOI: 10.1016/j.aohep.2021.100317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/27/2020] [Accepted: 01/04/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Renal dysfunction before liver transplantation (LT) is associated with higher post-LT mortality. We aimed to study if this association still persisted in the contemporary transplant era. MATERIALS AND METHODS We retrospectively reviewed data on 2871 primary LT performed at our center from 1998 to 2018. All patients were listed for LT alone and were not considered to be simultaneous liver-kidney (SLK) transplant candidates. SLK recipients and those with previous LT were excluded. Patients were grouped into 4 eras: era-1 (1998-2002, n = 488), era-2 (2003-2007, n = 889), era-3 (2008-2012, n = 703) and era-4 (2013-2018, n = 791). Pre-LT renal dysfunction was defined as creatinine (Cr) >1.5 mg/dl or on dialysis at LT. The effect of pre-LT renal dysfunction on post-LT patient survival in each era was examined using Kaplan Meier estimates and univariate and multivariate Cox proportional hazard analyses. RESULTS Pre-LT renal dysfunction was present in 594 (20%) recipients. Compared to patients in era-1, patients in era-4 had higher Cr, lower eGFR and were more likely to be on dialysis at LT (P < 0.001). Pre-LT renal dysfunction was associated with worse 1, 3 and 5-year survival in era-1 and era-2 (P < 0.005) but not in era-3 or era-4 (P = 0.13 and P = 0.08, respectively). Multivariate analysis demonstrated the lack of independent effect of pre-LT renal dysfunction on post-LT mortality in era-3 and era-4. A separate analysis using eGFR <60 mL/min/1.73 m2 at LT to define renal dysfunction showed similar results. CONCLUSIONS Pre-LT renal dysfunction had less impact on post-LT survival in the contemporary transplant era.
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Affiliation(s)
- Hani M Wadei
- Department of Transplant, Mayo Clinic Florida, United States.
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, United States
| | | | - Martin L Mai
- Department of Transplant, Mayo Clinic Florida, United States
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic Florida, United States
| | - Launia J White
- Department of Health Sciences Research, Mayo Clinic Florida, United States
| | - Denis M Harnois
- Department of Transplant, Mayo Clinic Florida, United States
| | - Shennen A Mao
- Department of Transplant, Mayo Clinic Florida, United States
| | - Tambi Jarmi
- Department of Transplant, Mayo Clinic Florida, United States
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8
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Risk factors of early liver dysfunction after liver transplantation using grafts from donation after citizen death donors. Transpl Immunol 2022; 71:101525. [PMID: 34990790 DOI: 10.1016/j.trim.2021.101525] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 12/29/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND As an early complication after liver transplantation, early allograft dysfunction (EAD) indicates a poor prognosis. This study analyzes the risk factors related to early allograft dysfunction (EAD) after liver transplantation using grafts from donation after citizen death (DCD) to provide a reference for the prevention of EAD after DCD liver transplantation. METHODS A total of 32 patients who underwent DCD liver transplantation in the organ transplantation center of our hospital from September 2013 to January 2021 were enrolled in this study. The patients were divided into the EAD group and non-EAD group according to whether they developed EAD after transplantation. The general data of the donors and recipients before transplantation, intraoperative conditions, and clinical data within one week after transplantation were compared between the two groups, and related complications were statistically analyzed. The follow-up time was one week postoperatively or, if they died within the first week postoperatively, until the patient died. RESULTS The subjects included 10 females and 22 males, and the incidence of postoperative EAD was 25% (8/32). Four patients (12%) had primary malignant tumors (primary liver cancer and cholangiocarcinoma), and five donors (15%) had fatty liver. The univariate analysis revealed that the donor BMI (P = 0.005), degree of fatty liver (P = 0.025), aspartate aminotransferase (P = 0.001), alanine aminotransferase (P < 0.001), and total bilirubin (P = 0.009) were related to the occurrence of EAD after DCD liver transplantation. By analyzing the correlation between the incidence EAD and postoperative complications after liver transplantation using grafts from DCD donors, it was shown that the incidence of primary nonfunction (PNF) is related to EAD (P = 0.024). CONCLUSION Donor BMI, the degree of fatty liver, and preoperative liver function are risk factors for EAD after DCD liver transplantation, and the occurrence of EAD after DCD liver transplantation significantly increases the probability of PNF.
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9
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Sáez de la Fuente I, Sáez de la Fuente J, Molina Collado Z, Chacón Alves S, Sánchez-Bayton Griffith M, Lesmes González de Aledo A, Barea Mendoza J, Sánchez-Izquierdo Riera JÁ, García de Lorenzo A, Montejo González JC. Combination of arterial lactate levels and Cv-aCO2/Da-vO2 ratio to predict early allograft dysfunction after liver transplantation. Clin Transplant 2021; 35:e14482. [PMID: 34545961 DOI: 10.1111/ctr.14482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/30/2021] [Accepted: 09/08/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE We examined the ability of the P(v-a)CO2/Da-vO2 ratio combined with elevated lactate levels to predict early allograft dysfunction (EAD). MATERIALS AND METHODS Patients were classified into four groups according to lactate levels and P(v-a)CO2/Da-vO2 ratio: Group 1; lactate >2.0 mmol/L and P(v-a)CO2/Da-vO2 ratio >1.0; Group 2; lactate >2.0 mmol/L and P(v-a)CO2/Da-vO2 ratio <1.0; group 3; lactate<2.0 mmol/L and P(v-a)CO2/Da-vO2 ratio >1.0; group 4; lactate<2.0 mmol/L and P(v-a)CO2/Da-vO2 ratio <1.0. We defined EAD according to Olthoff criteria. RESULTS One-hundred and fifty patients were included. EAD occurred in 41 patients (27.3%), and was associated with worse graft survival at 1 year (92% vs. 73%; P = ,003) as well as a higher re-transplantation rate (4,6% vs. 17,1%; P = ,019). The multivariate analysis revealed that P(v-a)CO2/Da-vO2 ratio at T6 [OR 7.05(CI95% 2.77-19.01, P<.001)] was an independent predictor for EAD. Belonging to group 1 at 6 h was associated with worse clinical outcomes but no association was found with 1-year graft survival or 1-year patient survival. CONCLUSIONS In this single center, prospective, observational study in patients who received an OLT, we found that elevated lactate levels combined with a high Cv-aCO2/Da-vO2 after 6 h was associated with the development of EAD and worse clinical outcomes in the early postoperative period.
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Affiliation(s)
| | | | | | - Silvia Chacón Alves
- Hospital Universitario 12 de Octubre, Critical Care Department, Madrid, Spain
| | | | | | - Jesús Barea Mendoza
- Hospital Universitario 12 de Octubre, Critical Care Department, Madrid, Spain
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10
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Early Allograft Dysfunction and Complications in DCD Liver Transplantation: Expert Consensus Statements From the International Liver Transplantation Society. Transplantation 2021; 105:1643-1652. [PMID: 34291765 DOI: 10.1097/tp.0000000000003877] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Livers for transplantation from donation after circulatory death donors are relatively more prone to early and ongoing alterations in graft function that might ultimately lead to graft loss and even patient death. In consideration of this fact, this working group of the International Liver Transplantation Society has performed a critical evaluation of the medical literature to create a set of statements regarding the assessment of early allograft function/dysfunction and complications arising in the setting of donation after circulatory death liver transplantation.
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11
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Early Allograft Dysfunction After Liver Transplantation With Donation After Circulatory Death and Brain Death Grafts: Does the Donor Type Matter? Transplant Direct 2021; 7:e727. [PMID: 34291149 PMCID: PMC8288897 DOI: 10.1097/txd.0000000000001182] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/04/2021] [Accepted: 04/29/2021] [Indexed: 11/30/2022] Open
Abstract
Background. Early allograft dysfunction (EAD) after liver transplantation has been associated with long-term reduced graft and patient survival. Methods. In this single-center cohort study, we aimed to compare incidence, risk factors, and outcomes in liver transplant recipients who developed EAD. Patients who received donation after circulatory death (DCD) or donation after brain death (DBD) grafts between January 2007 and December 2017 were included. EAD was defined as bilirubin of ≥10 mg/dL (171 μmol/L) or an international normalized ratio of ≥1.6 on postoperative day 7 or transaminases >2000 U\L in the first-week posttransplantation as previously described. Results. In our cohort of 1068 patients, incidence of EAD was 44%. EAD occurred more frequently in the DCD versus DBD group (71% versus 41%, P < 0.01). Overall, recipients who developed EAD showed a significantly lower graft and patient survival at 1, 3, and 5 y after transplantation (all P < 0.05). This was also the case for recipients of DBD grafts. However, for recipients of DCD grafts, patient and graft survival were not affected by the presence of EAD. For recipients of DBD grafts, donor age, body mass index (BMI) and gender, recipient BMI and model for end-stage liver disease score and warm and cold ischemia time were associated with EAD. For DCD recipients, donor BMI and cold ischemia time were associated with EAD. Conclusions. In our cohort study, EAD resulted in reduced long-term patient and graft survival only for DBD recipients but not for DCD recipients. Predictive markers for EAD were dependent on the donor type.
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12
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Wang K, Lu D, Liu Y, Li W, Zhuang L, Ma Z, Xie Q, Pan B, Wu Y, Chen J, Lin L, Feng X, Wei Q, Wei X, Xie H, Wang Z, Zheng S, Xu X. Severity of early allograft dysfunction following donation after circulatory death liver transplantation: a multicentre study. Hepatobiliary Surg Nutr 2021; 10:9-19. [PMID: 33575286 DOI: 10.21037/hbsn.2019.09.02] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/27/2019] [Indexed: 12/22/2022]
Abstract
Background Early allograft dysfunction (EAD) is associated with decreased graft and patient survival rates. This study aimed to identify the severity of EAD and develop a predictive model for EAD after donation after circulatory death (DCD) liver transplantation (LT). Furthermore, the influence of operative time on EAD incidence was also evaluated. Methods In this retrospective, multicentre cohort study, nomograms were established based on a single-centre training cohort (n=321) and validated in a 3-center validation cohort (n=501). Results The incidence rate of EAD was 46.4% (149/321) in the training cohort and 40.5% (203/501) in the validation cohort. Of the 149 EAD patients in the training cohort, 77 patients with either elevated alanine aminotransferase (ALT) or aspartate aminotransferase (AST) were classified as having EAD type A, and the rest of the EAD patients were classified as having EAD type B. Recipients with EAD type B had lower graft and patient survival rates than recipients with EAD type A (P=0.043 and 0.044, respectively). We further developed a nomogram to predict EAD (graft weight, cold ischemia time, donor age, model for end-stage liver disease (MELD) score) and another nomogram to predict EAD type B (graft weight, cold ischemia time, MELD score). The nomograms for the prediction of EAD and EAD type B had good discrimination [concordance index (C-index) =0.712 (0.666-0.758), 0.707 (0.641-0.773)] and calibration [Hosmer-Lemeshow (HL) P=0.384, P=0.425] in the validation cohort. An increased operative time (>6 h) was associated with increased EAD and EAD type B incidence in the high-risk group (P=0.005, P=0.020, respectively). Conclusions EAD type B was associated with decreased graft and patient survival rates. The novel nomograms effectively predicted the incidence of EAD and EAD type B in DCD LT patients.
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Affiliation(s)
- Kun Wang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Di Lu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Yuhui Liu
- Department of Surgery, Dezhou People's Hospital, Dezhou, China
| | - Wangyao Li
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Li Zhuang
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou, China
| | - Zhenyu Ma
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Qinfen Xie
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou, China
| | - Binhua Pan
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Yichao Wu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Junli Chen
- China Liver Transplant Registry, Hangzhou, China
| | - Lidan Lin
- China Liver Transplant Registry, Hangzhou, China
| | - Xiaowen Feng
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Qiang Wei
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Xuyong Wei
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Haiyang Xie
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Zhengxin Wang
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Shusen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China.,Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou, China
| | - Xiao Xu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
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13
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Croome KP, Livingston D, Croome S, Keaveny AP, Taner CB, Nakhleh R. Sequential Protocol Biopsies Post-Liver Transplant From Donors With Moderate Macrosteatosis: What Happens to the Fat? Liver Transpl 2021; 27:248-256. [PMID: 37160014 DOI: 10.1002/lt.25867] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/05/2020] [Accepted: 07/24/2020] [Indexed: 12/28/2022]
Abstract
The number of steatotic deceased donor livers encountered has continued to rise as a result of the obesity epidemic. Little is known about the histological characteristics of moderately macrosteatotic livers over time in the recipient following liver transplantation (LT). All recipients undergoing LT at Mayo Clinic Florida with donor livers with moderate macrosteatosis (30%-60%) from 2000-2017 were identified (n = 96). Routine protocol liver biopsies were performed 1-week and 6-months following LT. All liver donor and protocol biopsies were read by an experienced liver pathologist. Of the 96 moderate macrosteatosis LTs, 70 recipients had post-LT protocol liver biopsies available and comprised the study cohort. Median donor allograft macrosteatosis at the time of transplant was 33% (IQR, 30%-40%) compared with 0% (IQR, 0%-2%) at 1-week (P < 0.001) and 0% (IQR, 0%-0%) at 6-months (P < 0.001) following LT. Biopsies at 1-week post-LT displayed pericentral necrosis in 57.1% of recipients and lipopeliosis in 34.3% of recipients. In the 6-month post-LT biopsies, cholestasis was seen in 3 (4.3%) of the recipients, whereas grade 2 fibrosis was seen in 6 recipients (8.6%). Graft survival at 5 years in the present cohort was 74.0%. Moderate macrosteatosis (30%-60%) in the donor allograft demonstrates complete reversal on liver biopsies performed as early as 7 days following LT and remains absent at 6-months following LT. Both pericentral necrosis and lipopeliosis are common features on day 7 biopsies. Despite these encouraging findings, the perioperative risks of using these livers (postreperfusion cardiac arrest and primary nonfunction) should not be understated. Long-term graft survival is acceptable in patients who are able to overcome the immediate perioperative risk of using moderately steatotic donor livers.
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Affiliation(s)
| | | | - Sarah Croome
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | | | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - Raouf Nakhleh
- Department of Laboratory Medicine and Pathology, Mayo Clinic Florida, Jacksonville, FL
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14
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Ko YC, Tsai HI, Lee CW, Lin JR, Lee WC, Yu HP. A nomogram for prediction of early allograft dysfunction in living donor liver transplantation. Medicine (Baltimore) 2020; 99:e22749. [PMID: 33080739 PMCID: PMC7571974 DOI: 10.1097/md.0000000000022749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Liver transplantation is the treatment of choice for end-stage liver diseases. However, early allograft dysfunction (EAD) is frequently encountered and associated with graft loss or mortality after transplantation. This study aimed to establish a predictive model of EAD after living donor liver transplantation. A total of 77 liver transplants were recruited to the study. Multivariate analysis was utilized to identify significant risk factors for EAD. A nomogram was constructed according to the contributions of the risk factors. The predictive values were determined by discrimination and calibration methods. A cohort of 30 patients was recruited to validate this predictive model. Four independent risk factors, including donor age, intraoperative blood loss, preoperative alanine aminotransferase (ALT), and reperfusion total bilirubin, were identified and used to build the nomogram. The c-statistics of the primary cohort and the validation group were 0.846 and 0.767, respectively. The calibration curves for the probability of EAD presented an acceptable agreement between the prediction by the nomogram and the actual incidence. In conclusion, the study developed a new nomogram for predicting the risk of EAD following living donor liver transplantation. This model may help clinicians to determine individual risk of EAD following living donor liver transplantation.
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Affiliation(s)
- Yu-Chen Ko
- Department of Anesthesiology, Chang Gung Memorial Hospital
| | - Hsin-I Tsai
- Department of Anesthesiology, Chang Gung Memorial Hospital
- College of Medicine, Chang Gung University
| | - Chao-Wei Lee
- College of Medicine, Chang Gung University
- Department of General Surgery, Chang Gung Memorial Hospital
| | - Jr-Rung Lin
- Clinical Informatics and Medical Statistics Research Center and Graduate Institute of Clinical Medicine, Chang Gung University
| | - Wei-Chen Lee
- College of Medicine, Chang Gung University
- Department of General Surgery, Chang Gung Memorial Hospital
- Department of Liver and Transplantation Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Huang-Ping Yu
- Department of Anesthesiology, Chang Gung Memorial Hospital
- College of Medicine, Chang Gung University
- Department of Anesthesiology, Xiamen Chang Gung Hospital, Xiamen, China
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15
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Favorable Outcomes of Liver Transplantation from Controlled Circulatory Death Donors Using Normothermic Regional Perfusion Compared to Brain Death Donors. Transplantation 2020; 104:1943-1951. [PMID: 32639402 DOI: 10.1097/tp.0000000000003372] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Liver transplantation (LT) from controlled donation after circulatory death (cDCD) was initiated in France in 2015 under a protocol based on the use of normothermic regional perfusion (NRP) before organ procurement. The aim was to compare outcomes following cDCD LT with NRP and donation after brain death (DBD) LT. METHODS This is a multicenter retrospective study comparing cDCD LT with NRP and DBD LT. A case-matched study (1:2) was performed using the variables such as recipient and donor age, indication of LT. RESULTS A total of 50 patients from the cDCD group were matched to 100 patients from the DBD group. From postoperative days 1-4, serum transaminase release was significantly lower in the cDCD group compared to the DBD group (P < 0.05). Early allograft dysfunction (cDCD: 18% versus DBD: 32%; P = 0.11), acute kidney injury (26% versus 33%; P = 0.49), 90-d graft loss (2% versus 5%; P = 0.66), and arterial (4% versus 12%; P = 0.19) and biliary (16% versus 17%; P = 0.94) complications were similar between the 2 groups. The 2-y graft survival was 88% for cDCD group and 85% for DBD group (P = 0.91). The 2-y patient survival was 90% for cDCD group and 88% for DBD group (P = 0.68). CONCLUSIONS This study provides evidence that cDCD LT following postmortem NRP can be safely and effectively performed in selected recipients with similar graft and patient survival outcomes, without increased rates of biliary complications and early graft dysfunction compared to DBD LT.
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16
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Protein Profiles of Pretransplant Grafts Predict Early Allograft Dysfunction After Liver Transplantation From Donation After Circulatory Death. Transplantation 2020; 104:79-89. [PMID: 31283675 DOI: 10.1097/tp.0000000000002787] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Predicting the development of early allograft dysfunction (EAD) following liver transplantation (LT) remains challenging for transplant clinicians. The objectives of this study are to investigate the potential relationship between the protein profiles of pretransplant grafts and the onset of EAD, and then combine with clinical parameters to construct a mathematically predictive model. METHODS Clinical data of 121 LT procedures from donation after circulatory death at the authors' center were analyzed. The expression levels of 7 studied proteins were determined by immunohistochemistry. Another independent cohort of 37 subjects was designed for further validation of the predictive model. RESULTS With an incidence of 43.0% (52/121), EAD was linked to significantly increased risk of acute kidney injury and renal replacement therapy, as well as reduced 6-month patient and liver graft survival. Allograft weight and high intrahepatic vascular endothelial growth factor (VEGF) expression were identified as independent risk factors of EAD and survival outcomes. Liver grafts with high VEGF expression exhibited delayed functional recovery within the first postoperative week. The combination of VEGF overexpression and EAD yielded the highest frequency of renal dysfunction and the worst survival. Based on allograft weight and intrahepatic VEGF expression, an EAD risk assessment model was developed. The incidence of EAD differed significantly between grafts with risk scores ≥-1.72 and <-1.72. The model functioned well in the validation cohort. CONCLUSIONS Pretransplant intrahepatic protein profiling contributes to the estimation of early graft performance and recipient outcomes following LT. The predictive model could allow for an accurate prediction of EAD.
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17
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Croome KP, Mathur AK, Mao S, Aqel B, Piatt J, Senada P, Heimbach JK, Moss A, Rosen CB, Taner CB. Perioperative and long-term outcomes of utilizing donation after circulatory death liver grafts with macrosteatosis: A multicenter analysis. Am J Transplant 2020; 20:2449-2456. [PMID: 32216008 DOI: 10.1111/ajt.15877] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 02/04/2020] [Accepted: 03/10/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Given the potentially additive risk from using donor livers that are both steatotic and from a donation after circulatory death (DCD) donor, there is a paucity of data on the outcome of DCD liver transplantation (LT) utilizing livers with macrosteatosis. METHODS All DCD LT performed at Mayo Clinic-Florida, Mayo Clinic-Arizona, and Mayo Clinic-Rochester from 1999 to 2019 were included (N = 714). Recipients of DCD LT were divided into 3 groups: those with moderate macrosteatosis (30%-60%), mild macrosteatosis (5%-30%), and no steatosis (<5%). RESULTS Patients with moderate macrosteatosis had a higher rate of postreperfusion syndrome (PRS; 53.9% vs 26.2%; P = .002), postreperfusion cardiac arrest (7.7% vs 0.3%; P < .001), primary nonfunction (PNF; 7.7% vs 1.0%; P = .003), early allograft dysfunction (EAD; 70.8% vs 45.6% and 8.3%; P = .02), and acute kidney injury (AKI; 39.1% vs 19.4%; P = .02) than patients with no steatosis. No difference in any of the perioperative complications was seen between the mild macrosteatosis and the no steatosis groups except for the rate of EAD (56.8% vs 45.6%; P = .04). No difference in ischemic cholangiopathy (IC), vascular thrombosis/stenosis or graft, and patient survival was seen between the 3 groups. CONCLUSION DCD donors with mild macrosteatosis < 30% can be utilized with no increase in perioperative complications and similar patient and graft survival compared to DCD donors with no steatosis. When utilizing DCD donors with moderate macrosteatosis higher rates of PRS, PNF, postreperfusion cardiac arrest, EAD, and AKI should be anticipated.
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Affiliation(s)
| | - Amit K Mathur
- Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Shennen Mao
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Bashar Aqel
- Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Jacob Piatt
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Peter Senada
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Julie K Heimbach
- Department of Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Adyr Moss
- Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Charles B Rosen
- Department of Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
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18
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Ig-Izevbekhai K, Goldberg DS, Karp SJ, Foley DP, Abt PL. Immunosuppression in Donation After Circulatory Death Liver Transplantation: Can Induction Modify Graft Survival? Liver Transpl 2020; 26:1154-1166. [PMID: 32583560 DOI: 10.1002/lt.25762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 02/07/2023]
Abstract
Recipients of donation after circulatory death (DCD) LTs historically have an increased risk of graft failure. Antibody induction (AI) with antithymocyte globulin (ATG) or anti-interleukin 2 receptor (anti-IL2R) immunotherapy may decrease the incidence of graft failure by mitigating ischemia/reperfusion injury. A retrospective review of the United Network for Organ Sharing (UNOS) database for LTs between 2002 and 2015 was conducted to determine whether ATG or anti-IL2R AI was associated with graft survival in DCD. A secondary endpoint was postoperative renal function as measured by estimated glomerular filtration rate at 6 and 12 months. Among DCD recipients, ATG (hazard ratio [HR] = 0.71; P = 0.03), but not anti-IL2R (HR = 0.82; P = 0.10), was associated with a decrease in graft failure at 3 years when compared with recipients without AI. ATG (HR = 0.90; P = 0.02) and anti-IL2R (HR = 0.94; P = 0.03) were associated with a decreased risk of graft failure in donation after brain death (DBD) liver recipients at 3 years compared with no AI. When induction regimens were compared between DCD and DBD, only ATG (HR = 1.19; P = 0.19), and not anti-IL2R (HR = 1.49; P < 0.01) or no AI (HR = 1.77; P < 0.01), was associated with similar survival between DCD and DBD. In conclusion, AI therapy with ATG was associated with improved longterm liver allograft survival in DCD compared with no AI. ATG was associated with equivalent graft survival between DCD and DBD, suggesting a beneficial role of immune cell depletion in DCD outcomes.
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Affiliation(s)
| | - David S Goldberg
- Division of Digestive Health and Liver Disease, University of Miami Miller School of Medicine, Miami, FL
| | - Seth J Karp
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - David P Foley
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Peter L Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
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19
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Chang WC, M Yeh B, Chu L, Kim SY, Wen KW, Chiu SH, Ding CKC, Wu EH, Roberts JP, Huang GS, Hsu HH. Post-operative assessment in patients after liver transplantation: imaging parameters associated with 1-year graft failure. Eur Radiol 2020; 31:764-774. [PMID: 32862291 DOI: 10.1007/s00330-020-07124-w] [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: 04/13/2020] [Revised: 06/08/2020] [Accepted: 07/30/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To identify post-liver transplant CT findings which predict graft failure within 1 year. MATERIALS AND METHODS We evaluated the CT scans of 202 adult liver transplants performed in our institution who underwent CT within 3 months after transplantation. We recorded CT findings of liver perfusion defect (LPD), parenchymal homogeneity, and the diameters and attenuations of the hepatic vessels. Findings were correlated to 1-year graft failure, and interobserver variability was assessed. RESULTS Forty-one (20.3%) of the 202 liver grafts failed within 1 year. Graft failure was highly associated with LPD (n = 18/25, or 67%, versus 15/98, or 15%, p < 0.001), parenchymal hypoattenuation (n = 20/41, or 48.8% versus 17/161, or 10.6%, p < 0.001), and smaller diameter of portal veins (right portal vein [RPV], 10.7 ± 2.7 mm versus 14.7 ± 2.2 mm, and left portal vein [LPV], 9.8 ± 3.0 mm versus 12.4 ± 2.2 mm, p < 0.001, respectively). Of these findings, LPD (hazard ratio [HR], 5.43, p < 0.001) and small portal vein diameters (HR, RPV, 3.33, p < 0.001, and LPV, 3.13, p < 0.05) independently predicted graft failure. All the measurements showed fair to moderate interobserver agreement (0.233~0.597). CONCLUSION For patients who have CT scan within the first 3 months of liver transplantation, findings of LPD and small portal vein diameters predict 1-year graft failure. KEY POINTS •Failed grafts are highly associated with liver perfusion defect, hypoattenuation, and small portal vein. •Right portal vein < 11.5 mm and left portal vein < 10.0 mm were associated with poor graft outcome. •Liver perfusion defect and small portal vein diameter independently predicted graft failure.
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Affiliation(s)
- Wei-Chou Chang
- Department of Radiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan.
| | - Benjamin M Yeh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Lisa Chu
- Department of Radiology, Palo Alto Medical Foundation, Palo Alto, CA, USA
| | - So Yeon Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kwun Wah Wen
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Sung-Hua Chiu
- Department of Radiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| | | | - En-Haw Wu
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - John P Roberts
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Guo-Shu Huang
- Department of Radiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| | - Hsian-He Hsu
- Department of Radiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
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20
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Croome KP. Donation after Circulatory Death: Potential Mechanisms of Injury and Preventative Strategies. Semin Liver Dis 2020; 40:256-263. [PMID: 32557479 DOI: 10.1055/s-0040-1709487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Donation after circulatory death (DCD) donors represent a potential means to help address the disparity between the number of patients awaiting liver transplantation (LT) and the availability of donor livers. While initial enthusiasm for DCD LT was high in the early 2000s, early reports of high rates of biliary complications and inferior graft survival resulted in reluctance among many transplant centers to use DCD liver grafts. As with all innovations in transplant practice, there is undoubtedly a learning curve associated with the optimal utilization of liver grafts from DCD donors. More contemporary data has demonstrated that results with DCD LT are improving and the number of DCD LT performed annually has been steadily increasing. In this concise review, potential mechanisms of injury for DCD livers are discussed along with strategies that have been employed in clinical practice to improve DCD LT outcomes.
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21
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Richards JA, Sherif AE, Butler AJ, Hunt F, Allison M, Oniscu GC, Watson CJE. Model for early allograft function is predictive of early graft loss in donation after circulatory death liver transplantation. Clin Transplant 2020; 34:e13982. [PMID: 32441409 DOI: 10.1111/ctr.13982] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/06/2020] [Accepted: 05/16/2020] [Indexed: 12/17/2022]
Abstract
Donation after circulatory death (DCD) liver transplantation is associated with higher rates of graft loss. In this paper, we explored whether the Model for Early Allograft Function (MEAF) predicted outcome in DCD liver transplantation. We performed a retrospective analysis of prospectively collected data from all adult DCD (Maastricht 3) livers transplanted in Cambridge and Edinburgh between 1 January 2011 and 30 June 2017, excluding those undergoing any form of machine perfusion. 187 DCD liver transplants were performed during the study period. DCD liver transplants with a lower MEAF score had a significantly better survival compared to those with a high MEAF score (Mantel-Cox P < .0001); this was largely due to early graft loss. Beyond 28 days post-transplant, there were no significant long-term graft or patient survival differences irrespective of the grade of MEAF (Mantel-Cox P = .64 and P = .43, respectively). The MEAF score correlated with the length of ICU (P = .0011) and hospital stay (P = .0007), but did not predict the requirement for retransplantation for ischemic cholangiopathy (P = .37) or readmission (P = .74). In this study, a high MEAF score predicted early graft loss, but not the subsequent need for re-transplantation or late graft failure as a result of intrahepatic ischemic bile duct pathology.
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Affiliation(s)
- James A Richards
- University of Cambridge Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,The 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.,The National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Ahmed E Sherif
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrew J Butler
- University of Cambridge Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,The 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.,The National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Fiona Hunt
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Michael Allison
- The National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK.,Department of Medicine, Cambridge University Hospitals, Addenbrooke's Hospital, Cambridge, UK
| | - Gabriel C Oniscu
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Christopher J E Watson
- University of Cambridge Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,The 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.,The National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
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22
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Liu WY, Li XX, Fu XY, Wu XD, Wang X, Guo Y, Zang YJ, Wang JH. Combination of liver graft sonographic grading and point shear wave elastography to reduce early allograft dysfunction after liver transplantation. Eur Radiol 2020; 30:5191-5199. [PMID: 32328762 DOI: 10.1007/s00330-020-06842-5] [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: 12/31/2019] [Revised: 03/03/2020] [Accepted: 03/30/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To analyze the performance of a liver graft sonographic grading system and point shear wave elastography (PSWE) in predicting early allograft dysfunction (EAD) after liver transplantation (LT). METHODS Successive brain-dead donors and liver recipients in our hospital from March 2017 to May 2018 were retrospectively recruited. All donors underwent PSWE examination, abdominal ultrasonography, and sonographic grading (grade 0 to grade 5). Donors with ≥ 10 valid PSWE examinations and a failure rate of < 60% were included. For all recipients, abdominal ultrasonography and blood tests for biologic parameters were performed preoperatively and daily postoperatively to screen for EAD. The recipients and their grafts were classified into EAD and non-EAD groups. Statistical analyses were performed to analyze the correlations among liver stiffness (LS), liver graft sonographic grading, and EAD. RESULTS Thirty-two donors and 32 corresponding liver recipients were enrolled (15 cases in the EAD group; 17 in the non-EAD group). There were no grade 0, 1, or 2 cases in the two groups. For prediction of EAD in recipients after LT, the AUC for PSWE was 0.929 and the AUC for combination of PSWE and sonographic grading system was 0.935. CONCLUSIONS Combination of PSWE and sonographic grading system can predict postoperative EAD in LT recipients with high sensitivity. Abnormal results may suggest a need for liver biopsy preoperatively, thus avoiding unnecessary surgical preparation for liver procurement. KEY POINTS • Combination of PSWE with new sonographic grading system is useful for preoperative evaluation of liver grafts from brain-dead donors. • EAD is as a criterion for evaluating the diagnostic value of PSWE and sonographic grading system. • Combination of PSWE and sonographic grading system can predict postoperative EAD in LT recipients with high sensitivity.
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Affiliation(s)
- Wen-Yi Liu
- Organ Transplantation Department, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Southern Distinct, Qingdao, 266003, Shandong, China
| | - Xuan-Xuan Li
- Ultrasound Department, Qingdao Haici Hospital, No. 4, Renmin Road, Qingdao, 266003, Shandong, China
| | - Xiao-Yue Fu
- Organ Transplantation Department, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Southern Distinct, Qingdao, 266003, Shandong, China
| | - Xiao-Dong Wu
- Organ Transplantation Department, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Southern Distinct, Qingdao, 266003, Shandong, China
| | - Xin Wang
- Organ Transplantation Department, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Southern Distinct, Qingdao, 266003, Shandong, China
| | - Yuan Guo
- Organ Transplantation Department, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Southern Distinct, Qingdao, 266003, Shandong, China
| | - Yun-Jin Zang
- Organ Transplantation Department, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Southern Distinct, Qingdao, 266003, Shandong, China.
| | - Jian-Hong Wang
- Organ Transplantation Department, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Southern Distinct, Qingdao, 266003, Shandong, China.
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23
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Ningning NMD, Ying TMD, Jingwen ZMD. Real-Time Tissue Elastography: A Noninvasive Technique to Evaluate Liver Damage after Brain Death in Animal Mode. ADVANCED ULTRASOUND IN DIAGNOSIS AND THERAPY 2020. [DOI: 10.37015/audt.2020.190028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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24
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Chadha RM, Croome KP, Aniskevich S, Pai SL, Nguyen J, Burns J, Perry D, Taner CB. Intraoperative Events in Liver Transplantation Using Donation After Circulatory Death Donors. Liver Transpl 2019; 25:1833-1840. [PMID: 31539458 DOI: 10.1002/lt.25643] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/18/2019] [Indexed: 02/07/2023]
Abstract
Liver grafts from donation after circulatory death (DCD) are a source of organs to decrease wait-list mortality. While there have been lower rates of graft loss, there are concerns of an increased incidence of intraoperative events in recipients of DCD grafts. We aim to look at the incidence of intraoperative events between recipients of livers from DCD and donation after brain death (DBD) donors. We collected data for 235 DCD liver recipients between 2006 and 2017. We performed a 1:1 propensity match between these patients and patients with DBD donors. Variables included recipient age, liver disease etiology, biological Model for End-Stage Liver Disease (MELD) score, allocation MELD score, diagnosis of hepatocellular carcinoma, and year of transplantation. DCD and DBD groups had no significant differences in incidence of postreperfusion syndrome (P = 0.75), arrhythmia requiring cardiopulmonary resuscitation (P = 0.66), and treatments for hyperkalemia (P = 0.84). In the DCD group, there was a significant increase in amount of total intraoperative and postreperfusion blood products (with exception of postreperfusion packed red blood cells) utilized (P < 0.05 for all products), significant differences in postreperfusion thromboelastography parameters, as well as inotropes and vasopressors used (P < 0.05 for all infusions). There was no difference in patient (P = 0.49) and graft survival (P = 0.10) at 1, 3, and 5 years. In conclusion, DCD grafts compared with a cohort of DBD grafts have a similar low incidence of major intraoperative events, but increased incidence of transient vasopressor/inotropic usage and increased blood transfusion requirements. This does not result in differences in longterm outcomes. While centers should continue to look at DCD liver donors, they should be cognizant regarding intraoperative care to prevent adverse outcomes.
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Affiliation(s)
- Ryan M Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, Jacksonville, FL
| | | | - Stephen Aniskevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Justin Nguyen
- Department of Transplant Surgery, Mayo Clinic Florida, Jacksonville, FL
| | - Justin Burns
- Department of Transplant Surgery, Mayo Clinic Florida, Jacksonville, FL
| | - Dana Perry
- Department of Transplant Surgery, Mayo Clinic Florida, Jacksonville, FL
| | - C Burcin Taner
- Department of Transplant Surgery, Mayo Clinic Florida, Jacksonville, FL
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Comparison of Supraceliac and Infrarenal Aortic Conduits in Liver Transplantation: Is There a Difference in Patency and Postoperative Renal Dysfunction? Transplant Direct 2019; 5:e499. [PMID: 31773052 PMCID: PMC6831123 DOI: 10.1097/txd.0000000000000949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/17/2019] [Accepted: 09/03/2019] [Indexed: 01/10/2023] Open
Abstract
Aorto-hepatic conduits can provide arterial inflow for liver transplants in cases where the native hepatic artery is unsuitable for use.
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26
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Croome KP, Lee DD, Croome S, Nakhleh RE, Abader Sedki Senada P, Livingston D, Yataco M, Taner CB. Does Donor Allograft Microsteatosis Matter? Comparison of Outcomes in Liver Transplantation With a Propensity-Matched Cohort. Liver Transpl 2019; 25:1533-1540. [PMID: 31187923 DOI: 10.1002/lt.25583] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 06/03/2019] [Indexed: 01/04/2023]
Abstract
It has been suggested that microsteatosis does not negatively impact graft survival following liver transplantation (LT). The present study represents the largest series on donor livers with significant microsteatosis and investigates the impact of microsteatosis on perioperative factors such as postreperfusion syndrome (PRS), early allograft dysfunction (EAD), and postoperative renal dysfunction. Clinical outcomes of all patients undergoing LT with donor livers with isolated microsteatosis (≥30%; n = 239) between 2000 and 2017 were compared with a propensity score-matched cohort of patients undergoing LT with donor livers with no steatosis (n = 239). Patients in the microsteatosis group had a higher rate of PRS (33.1% versus 24.2%; P = 0.03), EAD (38.2% versus 23.0%; P < 0.001), and continuous renal replacement therapy (CRRT) requirement following LT (10.9% versus 3.6%; P = 0.002) than the no steatosis group. No difference in patient (P = 0.33) or graft survival (P = 0.18) was observed between the 2 groups. On multivariate regression, livers with microsteatosis had an increased risk of graft loss with retransplant recipients (hazard ratio [HR], 1.59; P < 0.001), increasing Model for End-Stage Liver Disease (MELD) score (HR, 1.13; P = 0.01), and organs from donation after circulatory death donors (HR, 1.46; P = 0.003). In conclusion, recipients of donor livers with significant microsteatosis are at an increased risk of PRS, EAD, and postoperative renal dysfunction requiring CRRT. Livers with significant microsteatosis should be avoided in retransplant recipients and in recipients with high biological MELD scores. Once appropriately selected recipients of these livers are able to overcome the initial perioperative implications of using these donor livers, longterm patient and graft survival is similar to recipients receiving grafts with no steatosis.
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Affiliation(s)
| | - David D Lee
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - Sarah Croome
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - Raouf E Nakhleh
- Department of Pathology, Mayo Clinic Florida, Jacksonville, FL
| | | | | | - Maria Yataco
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
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27
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Croome KP, Lee DD, Croome S, Chadha R, Livingston D, Abader P, Keaveny AP, Taner CB. The impact of postreperfusion syndrome during liver transplantation using livers with significant macrosteatosis. Am J Transplant 2019; 19:2550-2559. [PMID: 30821923 DOI: 10.1111/ajt.15330] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/24/2019] [Accepted: 02/19/2019] [Indexed: 01/25/2023]
Abstract
The impact of postreperfusion syndrome (PRS) during liver transplantation (LT) using donor livers with significant macrosteatosis is largely unknown. Clinical outcomes of all patients undergoing LT with donor livers with moderate macrosteatosis (30%-60%) (N = 96) between 2000 and 2017 were compared to propensity score matched cohorts of patients undergoing LT with donor livers with mild macrosteatosis (10%-29%) (N = 96) and no steatosis (N = 96). Cardiac arrest at the time of reperfusion was seen in eight (8.3%) of the patients in the moderate macrosteatosis group compared to one (1.0%) of the patients in the mild macrosteatosis group (P = .02) and zero (0%) of the patients in the no steatosis group (P = .004). Patients in the moderate macrosteatosis group had a higher rate of PRS (37.5% vs 18.8%; P = .004), early allograft dysfunction (EAD) (76.4% vs 25.8%; P < .001), renal dysfunction requiring continuous renal replacement therapy following transplant (18.8% vs 8.3%; P = .03) and return to the OR within 30 days (24.0% vs 7.3%; P = .002), than the no steatosis group. Both long-term patient (P = .30 and P = .08) and graft survival (P = .15 and P = .12) were not statistically when comparing the moderate macrosteatosis group to the mild macrosteatosis and no steatosis groups. Recipients of LT using livers with moderate macrosteatosis are at a significant increased risk of PRS. If patients are able to overcome the initial increased perioperative risk of using these donor livers, long-term graft survival does not appear to be different than matched recipients receiving grafts with no steatosis.
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Affiliation(s)
| | - David D Lee
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida
| | - Sarah Croome
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida
| | - Ryan Chadha
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida
| | - David Livingston
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida
| | - Peter Abader
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida
| | | | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida
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Yang J, Yang L, Wu L, Zhao Q, Chen M, He X. Efficacy and Safety of Steroid Therapy for Posttransplant Hyperbilirubinemia Caused by Early Allograft Dysfunction: A Randomized Controlled Trial. Med Sci Monit 2019; 25:1936-1944. [PMID: 30870403 PMCID: PMC6429985 DOI: 10.12659/msm.915128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Hyperbilirubinemia is a common event that occurs after liver transplantation. Hyperbilirubinemia is usually caused by early allograft dysfunction. Glucocorticoid is widely used for immunosuppression, but few studies have analyzed the effects of steroid therapy on posttransplantation hyperbilirubinemia. The aim of this study was to assess whether glucocorticoid was beneficial in treating hyperbilirubinemia caused by early allograft dysfunction. MATERIAL AND METHODS Patients with postoperative hyperbilirubinemia (those with conditions such as biliary complications and rejections were excluded) were randomly assigned, in a 2: 1 ratio, to the steroid and control groups. Patients in the steroid group were treated with glucocorticoid combined with ursodeoxycholic acid, whereas patients in the control group were only treated with ursodeoxycholic acid. The primary endpoint was decrease in bilirubin and the secondary endpoint was safety. RESULTS From 1st June 2016 to 30th April 2018, 40 patients were enrolled into the steroid group, and 20 were enrolled into the control group. Donor, recipient, and operative data were similar between the 2 groups. The decrease in bilirubin levels in the steroid group was significantly greater than that in the control group on the first day after the intervention was finished (9.25±1.30 mg/dL vs. 3.11±1.45 mg/dL, p=0.005), and after 2 weeks (15.01±1.20 mg/dL vs. 8.88±1.98 mg/dL, p=0.007). The steroid group did not have a higher complication rate but it did have a shorter postoperative hospital stay than in the control group. CONCLUSIONS Low-dose steroid therapy was effective and safe for treating hyperbilirubinemia caused by early graft dysfunction, and it improved liver function.
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Affiliation(s)
- Jie Yang
- Department of Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland)
| | - Lei Yang
- Department of Thoracic Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Linwei Wu
- Department of Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland)
| | - Qiang Zhao
- Department of Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland)
| | - Maogen Chen
- Department of Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland)
| | - Xiaoshun He
- Department of Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland)
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29
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Pitarch Martínez M, Sánchez Pérez B, León Díaz F, Fernández Aguilar J, Pérez Daga J, Montiel Casado M, Aranda Narváez J, Suárez Muñoz M, Santoyo Santoyo J. Donation After Cardiac Death in Liver Transplantation: An Additional Source of Organs With Similar Results to Donation After Brain Death. Transplant Proc 2019; 51:4-8. [DOI: 10.1016/j.transproceed.2018.02.208] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 02/07/2018] [Accepted: 02/23/2018] [Indexed: 12/31/2022]
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30
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A Lipidomics Study Reveals Lipid Signatures Associated with Early Allograft Dysfunction in Living Donor Liver Transplantation. J Clin Med 2018; 8:jcm8010030. [PMID: 30597989 PMCID: PMC6352109 DOI: 10.3390/jcm8010030] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 12/24/2018] [Accepted: 12/25/2018] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation has become the ultimate treatment for patients with end stage liver disease. However, early allograft dysfunction (EAD) has been associated with allograft loss or mortality after transplantation. We aim to utilize a metabolomic platform to identify novel biomarkers for more accurate correlation with EAD using blood samples collected from 51 recipients undergoing living donor liver transplantation (LDLT) by 1H-nuclear magnetic resonance spectroscopy (NMR) and liquid chromatography coupled with mass spectrometry (LC-MS). Principal component analysis (PCA) and orthogonal projection to latent structures-discriminant analysis (OPLS-DA) were used to search for a relationship between the metabolomic profiles and the presence of EAD.Cholesteryl esters (CEs), triacylglycerols (TGs), phosphatidylcholines (PCs) and lysophosphatidylcholine (lysoPC) were identified in association with EAD and a combination of cholesterol oleate, PC (16:0/16:0), and lysoPC (16:0) gave an optimal area under the curve (AUC) of 0.9487 and 0.7884 in the prediction of EAD and in-hospital mortality, respectively after LDLT. Such biomarkers may add as a potential clinical panel for the prediction of graft function and mortality after LDLT.
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31
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Wang G, Cheng Y, Liu Y. Comprehensive Evaluation of a Donated After Circulatory Death (DCD) Donor Liver Model in Minipigs. Ann Transplant 2018; 23:758-766. [PMID: 30374013 PMCID: PMC6248047 DOI: 10.12659/aot.911072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background Graft livers from donors after death from circulatory disease (DCD) often suffer injury from severe ischemia or hypoxia before resection. Thus, earlier evaluation of these livers is critical for the survival of recipients. Material/Methods In our study, 18 minipigs, as DCD donor liver models, were evenly divided into a warm ischemia time (WIT) group and a hypoxia plus ischemia group. Another 18 minipigs served as recipients and were implanted with the donor livers of the DCD models. miR-122 levels and hepatic function were examined before and after liver transplantation. Results Results indicated that increased miR-122 levels appeared in the early stages of ischemia and hypoxia. Increases in ALT and GGT levels occurred earlier than changes in TBil. Conclusions The expression levels of miR-122 in donor liver might play a role in the evaluation of organ injury. Changes in donor liver functions were more sensitive to ischemia than hypoxia in this established porcine DCD model.
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Affiliation(s)
- Guang Wang
- Department of Hepatobiliary Surgery and Organ Transplantation, The First Hospital of China Medical University, Shenyang, Liaoning, China (mainland)
| | - Ying Cheng
- Department of Hepatobiliary Surgery and Organ Transplantation, The First Hospital of China Medical University, Shenyang, Liaoning, China (mainland)
| | - Yongfeng Liu
- Department of Hepatobiliary Surgery and Organ Transplantation, The First Hospital of China Medical University, Shenyang, Liaoning, China (mainland)
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32
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Jayant K, Reccia I, Shapiro AMJ. Normothermic ex-vivo liver perfusion: where do we stand and where to reach? Expert Rev Gastroenterol Hepatol 2018; 12:1045-1058. [PMID: 30064278 DOI: 10.1080/17474124.2018.1505499] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Nowadays liver transplantation is considered as the treatment of choice, however, the scarcity of suitable donor organs limits the delivery of care to the end-stage liver disease patients leading to the death while on the waiting list. The advent of ex-situ normothermic machine perfusion (NMP) has emerged as an alternative to the standard organ preservation technique, static cold storage (SCS). The newer technique promises to not only restore the normal metabolic activity but also attempt to recondition the marginal livers back to the pristine state, which are otherwise more susceptible to ischemic injury and foster the poor post-transplant outcomes. Areas covered: An extensive search of all the published literature describing the role of NMP based device in liver transplantation as an alternative to SCS was made on MEDLINE, EMBASE, Cochrane, BIOSIS, Crossref, Scopus databases and clinical trial registry on 10 May 2018. Expert commentary: The main tenet of NMP is the establishment of the physiological milieu, which permits aerobic metabolism to continue through out the period of preservation and limits the effects of ischemia-reperfusion (I/R) injury. In addition, by assessing the various metabolic and synthetic parameters the viability and suitability of donor livers for transplantation can be determined. This important technological advancement has scored satisfactorily on the safety and efficacy parameters in preliminary clinical studies. The present review suggests that NMP can offer the opportunity to assess and safely utilize the marginal donor livers if deemed appropriate for the transplantation. However, ongoing trials will determine its full potential and further adoption.
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Affiliation(s)
- Kumar Jayant
- a Department of Surgery and Cancer , Imperial College London , London , UK
| | - Isabella Reccia
- a Department of Surgery and Cancer , Imperial College London , London , UK
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33
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Yang L, Xin EY, Liao B, Lai LJ, Han M, Wang XP, Ju WQ, Wang DP, Guo ZY, He XS. Development and Validation of a Nomogram for Predicting Incidence of Early Allograft Dysfunction Following Liver Transplantation. Transplant Proc 2018; 49:1357-1363. [PMID: 28736007 DOI: 10.1016/j.transproceed.2017.03.083] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 03/15/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Early allograft dysfunction (EAD) is frequent complication post-liver transplantation and is closely related to recipient's mortality and morbidity. We sought to develop a nomogram for predicting incidence of EAD. METHODS Based on multivariate analysis of donor, recipient, and operation data of 199 liver transplants from deceased donors between 2013 and 2015, we identified 5 significant risk factors for EAD to build a nomogram. The model was subjected to prospective validation with a cohort of 42 patients who was recruited between January and June 2016. The predictive accuracy and discriminative ability were measured by area under the receiver operating characteristic curve (AUC). The agreement between nomogram prediction and actual observation was showed by the calibration curve. RESULTS Incidence rate of EAD in the training set and validation cohort were 55.91% (104/199) and 54.76% (23/42), respectively. In the training set, according to the results of univariable and multivariable analysis, 5 independent risk factors including donor gender, donor serum gamma-glutamyl transpeptidase level, donor serum urea level, donor comorbidities (respiratory, cardiac, and renal dysfunction), and recipient Model for End-stage Liver Disease score were identified and assembled into the nomogram. The AUC of internal validation using bootstrap resampling and prospective validation using the external cohort of 42 patients was 0.74 and 0.60, respectively. The calibration curves for probability of EAD showed acceptable agreement between nomogram prediction and actual observation. According to the score table, the probability of EAD was under 30% when the total point tally was under 72. But when the total was up to 139, the risk of EAD increased to 60%. CONCLUSION We've established and validated a nomogram that can provide individual prediction of EAD for liver transplant recipients. The practical prognostic model may help clinicians to qualify the liver graft accurately, making a more reasonable allocation of organs.
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Affiliation(s)
- L Yang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - E Y Xin
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - B Liao
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China; Pathology Department, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - L J Lai
- Intensive Care Unit, Xin Yi People's Hospital, Xinyi, China
| | - M Han
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - X P Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - W Q Ju
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - D P Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Z Y Guo
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China.
| | - X S He
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China.
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Saidi SA, Meurisse N, Jochmans I, Heedfeld V, Wylin T, Parkkinen J, Pirenne J, Monbaliu D, El Feki A, van Pelt J. Hepatocellular uptake of cyclodextrin-complexed curcumin during liver preservation: A feasibility study. Biopharm Drug Dispos 2017; 39:18-29. [PMID: 28972677 DOI: 10.1002/bdd.2108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 08/03/2017] [Accepted: 09/11/2017] [Indexed: 12/18/2022]
Abstract
The increasing demand for donor organs and the decreasing organ quality is prompting research toward new methods to reduce ischemia reperfusion injury (IRI). Several strategies have been proposed to protect preserved organs from this injury. Before curcumin/dextrin complex (CDC), a potent antioxidant and anti-inflammatory agent, can be used clinically we need to better understand the intracellular uptake under hypothermic conditions on a rat model of liver donation after circulatory death (DCD) and brain death (DBD). To be able to use the fluorescence of CDC for quantification the stability of CDC in different preservation solutions at 4°C or 37°C was investigated. Livers from Wistar rats were procured after being flushed-out through the portal vein using CDC-enriched preservation solutions and stored at 4°C for variable periods. The CDC signal was stable in different preservation solutions over a period of 4 h and allowed the rapid and lasting uptake of curcumin into cells. After 4 h of preservation, CDC was no longer visible microscopically, and HPLC analysis showed very low to non-detectable tissue levels of CDC, proving metabolization during preservation. However, the distribution of CDC was not affected by warm ischemia damage (p = 0.278) nor by flushing the livers before or after 4 h of cold storage and without a warm preflush. Finally, curcumin reduced oxidative stress, lowered histological injury and did not change gene expression after WI/cold storage. Therefore, the use of CDC flush solution for the initial organ flush can offer a promising approach to the enhancement of liver preservation and the maintenance of its quality.
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Affiliation(s)
- Saber Abdelkader Saidi
- Liver Research Facility, Laboratory of Hepatology, Faculty of Medicine, University Hospital Gasthuisberg, Leuven, Belgium.,Laboratory of Animal Ecophysiology/Department of Life Sciences, Sfax, Tunisia.,Faculty of Science and Arts-Khulais, Jeddah University, Saudi Arabia
| | - Nicolas Meurisse
- Department of Abdominal Surgery and Transplantation, CHU Liege, B4000, Liege, Belgium
| | - Ina Jochmans
- Department of Abdominal Transplantation Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Microbiology and Immunology, KU Leuven - University of Leuven, Leuven, Belgium
| | - Veerle Heedfeld
- Department of Abdominal Transplantation Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Tine Wylin
- Department of Abdominal Transplantation Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jaakko Parkkinen
- Department of Biomedicine/Biochemistry, University of Helsinki, Helsinki, Finland
| | - Jacques Pirenne
- Department of Abdominal Transplantation Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Department of Abdominal Transplantation Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Abdelfattah El Feki
- Laboratory of Animal Ecophysiology/Department of Life Sciences, Sfax, Tunisia
| | - Jos van Pelt
- Liver Research Facility, Laboratory of Hepatology, Faculty of Medicine, University Hospital Gasthuisberg, Leuven, Belgium
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Nicolau-Raducu R, Cohen AJ, Bokhari A, Bohorquez H, Bruce D, Carmody I, Bugeaud E, Seal J, Sonnier D, Nossaman B, Loss G. Predictive model and risk factors associated with a revised definition of early allograft dysfunction in liver transplant recipients. Clin Transplant 2017; 31. [PMID: 28856732 DOI: 10.1111/ctr.13097] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2017] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Early allograft dysfunction (EAD) is a well-defined clinical syndrome that reflects overall graft function within the first week after transplant. The aim of this study was to further refine the definition for EAD. METHOD In this study, 1124 patients were included for analysis. Logistic regression was performed to identify markers of liver injury associated with 6-month patient and graft failure. RESULTS Recursive partitioning identified cut-points for ALT/AST > 3000/6000 IU/dL observed within first week, with bilirubin ≥ 10 mg/dL and INR ≥ 1.6 on postoperative day 7 for the revised EAD model. The incidence of updated EAD was 15% (164/1124). Multivariable analysis identified eight risk factors associated with EAD: % macrosteatosis, donor location, donor weight, nonheart beating donors, type of organ transplanted, recipient-associated hepatocellular carcinoma, severity of postreperfusion syndrome, and the amount of transfused fresh frozen plasma. In the presence of EAD, the incidence of post-transplant renal replacement therapy and dialysis dependence increases. There was a significant association of the presence of EAD with 6-month mortality (12% vs 3%) and 6-month graft failure (8% vs 1%). CONCLUSION Higher AST/ALT level needed as cutoff in comparison with the old EAD definition.
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Affiliation(s)
| | - Ari J Cohen
- Department of Surgery/Transplantation, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Amjad Bokhari
- Department of Surgery/Transplantation, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Humberto Bohorquez
- Department of Surgery/Transplantation, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - David Bruce
- Department of Surgery/Transplantation, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Ian Carmody
- Department of Surgery/Transplantation, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Emily Bugeaud
- Department of Surgery/Transplantation, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - John Seal
- Department of Surgery/Transplantation, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Dennis Sonnier
- Department of Surgery/Transplantation, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Bobby Nossaman
- Department of Anesthesiology, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - George Loss
- Department of Surgery/Transplantation, Ochsner Clinic Foundation, New Orleans, LA, USA
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36
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Does Donation After Cardiac Death Utilization Adversely Affect Hepatocellular Cancer Survival? Transplantation 2016; 100:1916-24. [DOI: 10.1097/tp.0000000000001150] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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37
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Nemes B, Gámán G, Polak WG, Gelley F, Hara T, Ono S, Baimakhanov Z, Piros L, Eguchi S. Extended-criteria donors in liver transplantation Part II: reviewing the impact of extended-criteria donors on the complications and outcomes of liver transplantation. Expert Rev Gastroenterol Hepatol 2016; 10:841-59. [PMID: 26831547 DOI: 10.1586/17474124.2016.1149062] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Extended-criteria donors (ECDs) have an impact on early allograft dysfunction (EAD), biliary complications, relapse of hepatitis C virus (HCV), and survivals. Early allograft dysfunction was frequently seen in grafts with moderate and severe steatosis. Donors after cardiac death (DCD) have been associated with higher rates of graft failure and biliary complications compared to donors after brain death. Extended warm ischemia, reperfusion injury and endothelial activation trigger a cascade, leading to microvascular thrombosis, resulting in biliary necrosis, cholangitis, and graft failure. The risk of HCV recurrence increased by donor age, and associated with using moderately and severely steatotic grafts. With the administration of protease inhibitors sustained virological response was achieved in majority of the patients. Donor risk index and EC donor scores (DS) are reported to be useful, to assess the outcome. The 1-year survival rates were 87% and 40% respectively, for donors with a DS of 0 and 3. Graft survival was excellent up to a DS of 2, however a DS >2 should be avoided in higher-risk recipients. The 1, 3 and 5-year survival of DCD recipients was comparable to optimal donors. However ECDs had minor survival means of 85%, 78.6%, and 72.3%. The graft survival of split liver transplantation (SLT) was comparable to that of whole liver orthotopic liver transplantation. SLT was not regarded as an ECD factor in the MELD era any more. Full-right-full-left split liver transplantation has a significant advantage to extend the high quality donor pool. Hypothermic oxygenated machine perfusion can be applied clinically in DCD liver grafts. Feasibility and safety were confirmed. Reperfusion injury was also rare in machine perfused DCD livers.
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Affiliation(s)
- Balázs Nemes
- a Department of Organ Transplantation, Faculty of Medicine, Institute of Surgery , University of Debrecen , Debrecen , Hungary
| | - György Gámán
- b Clinic of Transplantation and Surgery , Semmelweis University , Budapest , Hungary
| | - Wojciech G Polak
- c Department of Surgery, Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC , University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Fanni Gelley
- d Dept of Internal medicine and Gastroenterology , Polyclinic of Hospitallers Brothers of St. John of God , Budapest , Hungary
| | - Takanobu Hara
- e Department of Surgery , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Shinichiro Ono
- e Department of Surgery , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Zhassulan Baimakhanov
- e Department of Surgery , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Laszlo Piros
- b Clinic of Transplantation and Surgery , Semmelweis University , Budapest , Hungary
| | - Susumu Eguchi
- e Department of Surgery , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
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Lipidomics comparing DCD and DBD liver allografts uncovers lysophospholipids elevated in recipients undergoing early allograft dysfunction. Sci Rep 2015; 5:17737. [PMID: 26635289 PMCID: PMC4669413 DOI: 10.1038/srep17737] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 11/05/2015] [Indexed: 12/14/2022] Open
Abstract
Finding specific biomarkers of liver damage in clinical evaluations could increase the pool of available organs for transplantation. Lipids are key regulators in cell necrosis and hence this study hypothesised that lipid levels could be altered in organs suffering severe ischemia. Matched pre- and post-transplant biopsies from donation after circulatory death (DCD, n = 36, mean warm ischemia time = 2 min) and donation after brain death (DBD, n = 76, warm ischemia time = none) were collected. Lipidomic discovery and multivariate analysis (MVA) were applied. Afterwards, univariate analysis and clinical associations were conducted for selected lipids differentiating between these two groups. MVA grouped DCD vs. DBD (p = 6.20 × 10(-12)) and 12 phospholipids were selected for intact lipid measurements. Two lysophosphatidylcholines, LysoPC (16:0) and LysoPC (18:0), showed higher levels in DCD at pre-transplantation (q < 0.01). Lysophosphatidylcholines were associated with aspartate aminotransferase (AST) 14-day post-transplantation (q < 0.05) and were more abundant in recipients undergoing early allograft dysfunction (EAD) (p < 0.05). A receiver-operating characteristics (ROC) curve combining both lipid levels predicted EAD with 82% accuracy. These findings suggest that LysoPC (16:0) and LysoPC (18:0) might have a role in signalling liver tissue damage due to warm ischemia before transplantation.
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Croome KP, Lee DD, Saucedo-Crespo H, Burns JM, Nguyen JH, Perry DK, Taner CB. A novel objective method for deceased donor and recipient size matching in liver transplantation. Liver Transpl 2015; 21:1471-7. [PMID: 26358746 DOI: 10.1002/lt.24333] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 07/14/2015] [Accepted: 08/20/2015] [Indexed: 12/12/2022]
Abstract
Although the consequences of implantation of a large whole liver graft into a small recipient such as compression and compromise of graft perfusion are well known, no accepted measure to aid in donor-to-recipient size matching exists. Donor liver graft and recipient native liver weights as well as donor and recipient size and amount of ascites were investigated in 1953 patients who underwent liver transplantation using deceased donor grafts between January 2002 and July 2013. We used a previously described formula for liver resections (standardized total liver volume [sTLV] = -794.41 + 1267.28 × body surface area [m(2)]) for calculating sTLV, in the current cohort of deceased liver donors. Early allograft dysfunction (EAD) and graft survival were the primary outcome measures. The formula for calculating sTLV for liver resections was validated as an accurate predictor of liver volume in the current cohort of deceased liver donors (r(2) = 0.45; P < 0.001). A cutoff point of sTLV ratio ≥ 1.25 was determined through receiver operating characteristic curves, and patients were dichotomized into 2 groups. In the sTLV ratio ≥ 1.25 group, 50% of patients developed EAD compared to 25% of patients in the sTLV ratio < 1.25 group (P < 0.001). The proportion of patients developing graft failure within 90 days was 9.6% in the sTLV ratio ≥ 1.25 group and 5.4% in the sTLV ratio < 1.25 group (P = 0.045). This study validates the use of the sTLV for prediction of actual donor liver weight in the transplant setting. Using this formula, donors with a calculated sTLV size ratio ≥ 1.25 have an increased risk of EAD and therefore caution should be used when that value is exceeded. This adjusted size ratio can be used as a decision aid when considering donor and recipient matching with potential liver organ offers.
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Affiliation(s)
- Kristopher P Croome
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | - David D Lee
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | - Hector Saucedo-Crespo
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | - Justin M Burns
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | - Justin H Nguyen
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | - Dana K Perry
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | - C Burcin Taner
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
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Croome KP, Lee DD, Burns JM, Musto K, Paz D, Nguyen JH, Perry DK, Harnois DM, Taner CB. The Use of Donation After Cardiac Death Allografts Does Not Increase Recurrence of Hepatocellular Carcinoma. Am J Transplant 2015; 15:2704-11. [PMID: 25968609 DOI: 10.1111/ajt.13306] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 02/12/2015] [Accepted: 03/08/2015] [Indexed: 01/25/2023]
Abstract
Hepatocellular carcinoma (HCC) recurrence in patients undergoing liver transplantation (LT) with donation after brain death (DBD) and donation after cardiac death (DCD) allografts has not previously been investigated. Rates and patterns of HCC recurrences were investigated in patients undergoing DBD (N = 1633) and DCD (N = 243) LT between 2003 and 2012. LT for HCC was identified in 397 patients (340 DBD and 57 DCD). No difference in tumor number (p = 0.26), tumor volume (p = 0.34) and serum alphafetoprotein (AFP) (p = 0.47) was seen between the groups. HCC recurrence was identified in 41 (12.1%) patients in the DBD group and 7 (12.3%) patients in the DCD group. There was no difference in recurrence-free survival (p = 0.29) or cumulative incidence of HCC recurrence (p = 0.91) between the groups. Liver allograft was the first site of recurrence in 22 (65%) patients in the DBD group and two (37%) patients in the DCD group (p = 0.39). LT for HCC with DBD and DCD allografts demonstrate no difference in the rate of HCC recurrence. Previously published differences in survival demonstrated between recipients with HCC receiving DBD and DCD allografts despite statistical adjustment can likely be explained by practice patterns not captured by variables contained in the SRTR database.
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Affiliation(s)
- K P Croome
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | - D D Lee
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | - J M Burns
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | | | - D Paz
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | - J H Nguyen
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | - D K Perry
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | - D M Harnois
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | - C B Taner
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
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O'Neill S, Roebuck A, Khoo E, Wigmore SJ, Harrison EM. A meta-analysis and meta-regression of outcomes including biliary complications in donation after cardiac death liver transplantation. Transpl Int 2015; 27:1159-74. [PMID: 25052036 DOI: 10.1111/tri.12403] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 05/05/2014] [Accepted: 07/12/2014] [Indexed: 12/11/2022]
Abstract
Donation after cardiac death (DCD) liver transplantation is increasingly common but concerns exist over the development of biliary complications and ischemic cholangiopathy (IC). This study aimed to compare outcomes between DCD and donation after brain death (DBD) liver grafts. Studies reporting on post-transplantation outcomes after Maastricht category III DCD liver transplantation were screened for inclusion. Odds ratios (OR) with 95% confidence intervals were produced using random-effects models for the incidence of biliary complications, IC, graft and recipient survival. Meta-regression was undertaken to identify between-study predictors of effect size for biliary complications and IC. PROSPERO Record: CRD42012002113. Twenty-five studies with 62 184 liver transplant recipients (DCD = 2478 and DBD = 59 706) were included. In comparison with DBD, there was a significant increase in biliary complications [OR = 2.4 (1.9, 3.1); P < 0.00001] and IC [OR = 10.5 (5.7, 19.5); P < 0.00001] following DCD liver transplantation. In comparison with DBD, at 1 year [OR = 0.7 (0.5, 0.8); P = 0.0002] and 3 years [OR = 0.6 (0.5, 0.8); P = 0.001], there was a significant decrease in graft survival following DCD liver transplantation. At 1 year, there was also a nonsignificant decrease [OR = 0.8 (0.6, 1.0); P = 0.08] and by 3 years a significant decrease [OR = 0.7 (0.5, 1.0); P = 0.04] found in recipient survival following DCD liver transplantation. Eleven factors were entered into meta-regression models, but none explained the variability in effect size between studies. DCD liver transplantation is associated with an increase in biliary complications, IC, graft loss and mortality. Significant unexplained differences in effect size exist between centers.
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Affiliation(s)
- Stephen O'Neill
- MRC Centre for Inflammation Research, Tissue Injury and Repair Group, University of Edinburgh, Edinburgh, UK
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43
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Kurian SM, Fouraschen SMG, Langfelder P, Horvath S, Shaked A, Salomon DR, Olthoff KM. Genomic profiles and predictors of early allograft dysfunction after human liver transplantation. Am J Transplant 2015; 15:1605-14. [PMID: 25828101 DOI: 10.1111/ajt.13145] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 11/09/2014] [Accepted: 12/03/2014] [Indexed: 02/06/2023]
Abstract
Early hepatic allograft dysfunction (EAD) manifests posttransplantation with high serum transaminases, persistent cholestasis, and coagulopathy. The biological mechanisms are poorly understood. This study investigates the molecular mechanisms involved in EAD and defines a gene expression signature revealing different biological pathways in subjects with EAD from those without EAD, a potential first step in developing a molecular classifier as a potential clinical diagnostic. Global gene expression profiles of 30 liver transplant recipients of deceased donor grafts with EAD and 26 recipients without graft dysfunction were investigated using microarrays of liver biopsies performed at the end of cold storage and after graft reperfusion prior to closure. Results reveal a shift in inflammatory and metabolic responses between the two time points and differences between EAD and non-EAD. We identified relevant pathways (PPARα and NF-κB) and targets (such as CXCL1, IL1, TRAF6, TIPARP, and TNFRSF1B) associated with the phenotype of EAD. Preliminary proof of concept gene expression classifiers that distinguish EAD from non-EAD patients, with Area Under the Curve (AUC) >0.80 were also identified. This data may have mechanistic and diagnostic implications for EAD.
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Affiliation(s)
- S M Kurian
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - S M G Fouraschen
- Penn Transplant Institute, Department of Surgery, University of Pennsylvania, Philadelphia, PA.,Department of Surgery and Laboratory of Experimental Transplantation and Intestinal Surgery, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - P Langfelder
- Department of Human Genetics, University of California, Los Angeles, CA
| | - S Horvath
- Department of Human Genetics, University of California, Los Angeles, CA
| | - A Shaked
- Penn Transplant Institute, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - D R Salomon
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - K M Olthoff
- Penn Transplant Institute, Department of Surgery, University of Pennsylvania, Philadelphia, PA
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Pareja E, Cortes M, Hervás D, Mir J, Valdivieso A, Castell JV, Lahoz A. A score model for the continuous grading of early allograft dysfunction severity. Liver Transpl 2015; 21:38-46. [PMID: 25204890 DOI: 10.1002/lt.23990] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 07/10/2014] [Accepted: 09/02/2014] [Indexed: 01/12/2023]
Abstract
Early allograft dysfunction (EAD) dramatically influences graft and patient outcomes. A lack of consensus on an EAD definition hinders comparisons of liver transplant outcomes and management of recipients among and within centers. We sought to develop a model for the quantitative assessment of early allograft function [Model for Early Allograft Function Scoring (MEAF)] after transplantation. A retrospective study including 1026 consecutive liver transplants was performed for MEAF score development. Multivariate data analysis was used to select a small number of postoperative variables that adequately describe EAD. Then, the distribution of these variables was mathematically modeled to assign a score for each actual variable value. A model, based on easily obtainable clinical parameters (ie, alanine aminotransferase, international normalized ratio, and bilirubin) and scoring liver function from 0 to 10, was built. The MEAF score showed a significant association with patient and graft survival at 3-, 6- and 12-month follow-ups. Hepatic steatosis and age for donors; cold/warm ischemia times and postreperfusion syndrome for surgery; and intensive care unit and hospital stays, Model for End-Stage Liver Disease and Child-Pugh scores, body mass index, and fresh frozen plasma transfusions for recipients were factors associated significantly with EAD. The model was satisfactorily validated by its application to an independent set of 200 patients who underwent liver transplantation at a different center. In conclusion, a model for the quantitative assessment of EAD severity has been developed and validated for the first time. The MEAF provides a more accurate graft function assessment than current categorical classifications and may help clinicians to make early enough decisions on retransplantation benefits. Furthermore, the MEAF score is a predictor of recipient and graft survival. The standardization of the criteria used to define EAD may allow reliable comparisons of recipients' treatments and transplant outcomes among and within centers.
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Affiliation(s)
- Eugenia Pareja
- Unidad de Hepatología Experimental, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
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Verhoeven CJ, Farid WRR, de Jonge J, Metselaar HJ, Kazemier G, van der Laan LJW. Biomarkers to assess graft quality during conventional and machine preservation in liver transplantation. J Hepatol 2014; 61:672-84. [PMID: 24798616 DOI: 10.1016/j.jhep.2014.04.031] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 04/11/2014] [Accepted: 04/24/2014] [Indexed: 02/08/2023]
Abstract
A global rising organ shortage necessitates the use of extended criteria donors (ECD) for liver transplantation (LT). However, poor preservation and extensive ischemic injury of ECD grafts have been recognized as important factors associated with primary non-function, early allograft dysfunction, and biliary complications after LT. In order to prevent for these ischemia-related complications, machine perfusion (MP) has gained interest as a technique to optimize preservation of grafts and to provide the opportunity to assess graft quality by screening for extensive ischemic injury. For this purpose, however, objective surrogate biomarkers are required which can be easily determined at time of graft preservation and the various techniques of MP. This review provides an overview and evaluation of biomarkers that have been investigated for the assessment of graft quality and viability testing during different types of MP. Moreover, studies regarding conventional graft preservation by static cold storage (SCS) were screened to identify biomarkers that correlated with either allograft dysfunction or biliary complications after LT and which could potentially be applied as predictive markers during MP. The pros and cons of the different biomaterials that are available for biomarker research during graft preservation are discussed, accompanied with suggestions for future research. Though many studies are currently still in the experimental setting or of low evidence level due to small cohort sizes, the biomarkers presented in this review provide a useful handle to monitor recovery of ECD grafts during clinical MP in the near future.
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Affiliation(s)
- Cornelia J Verhoeven
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | - Waqar R R Farid
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | - Jeroen de Jonge
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | - Herold J Metselaar
- Department of Gastroenterology & Hepatology, Erasmus MC - University Medical Center, Rotterdam, The Netherlands.
| | - Geert Kazemier
- Department of Surgery, VU University Medical Center Amsterdam, The Netherlands
| | - Luc J W van der Laan
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
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Han M, Guo ZY, Zhao Q, Wang XP, Yuan XP, Jiao XY, Yang CH, Wang DP, Ju WQ, Wu LW, Hu AB, Tai Q, Ma Y, Zhu XF, He XS. Liver transplantation using organs from deceased organ donors: a single organ transplant center experience. Hepatobiliary Pancreat Dis Int 2014; 13:409-15. [PMID: 25100126 DOI: 10.1016/s1499-3872(14)60274-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND In 2011, a pilot program for deceased organ donation was initiated in China. We describe the first successful series of liver transplants in the pilot program. METHODS From July 2011 to August 2012, our center performed 26 liver transplants from a pool of 29 deceased donors. All organ donation and allograft procurement were conducted according to the national protocol. The clinical data of donors and recipients were collected and summarized retrospectively. RESULTS Among the 29 donors, 24 were China Category II donors (organ donation after cardiac death), and five were China Category III donors (organ donation after brain death followed by cardiac death). The recipients were mainly the patients with hepatocellular carcinoma. The one-year patient survival rate was 80.8% with a median follow-up of 422 (2-696) days. Among the five mortalities during the follow-up, three died of tumor recurrence. In terms of post-transplant complications, 9 recipients (34.6%) experienced early allograft dysfunction, 1 (3.8%) had non-anastomotic biliary stricture, and 1 (3.8%) was complicated with hepatic arterial thrombosis. None of these complications resulted in patient death. Notably, primary non-function was not observed in any of the grafts. CONCLUSION With careful donor selection, liver transplant from deceased donors can be performed safely and plays a critical role in overcoming the extreme organ shortage in China.
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Affiliation(s)
- Ming Han
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510080, China.
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Croome KP, Hernandez-Alejandro R, Chandok N. Early allograft dysfunction is associated with excess resource utilization after liver transplantation. Transplant Proc 2013; 45:259-64. [PMID: 23375312 DOI: 10.1016/j.transproceed.2012.07.147] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 07/19/2012] [Indexed: 12/27/2022]
Abstract
BACKGROUND There are limited data on length of stay (LOS) following liver transplantation (LT), yet this is an important health services metric that directly correlates with early post-LT health care costs. The primary objective of this study was to examine the relationship between early allograft dysfunction (EAD) and LOS after LT. The secondary objective was to identify additional recipient, donor, and operative factors associated with LOS. METHODS Adult patients undergoing primary LT over a 32-month period were prospectively examined at a single center. Subjects fulfilling standard criteria for EAD were compared with those not meeting the definition. Variables associated with increased LOS on ordinal logistic regression were identified. RESULTS Subjects with EAD had longer mean hospital LOS than those without (42.5 ± 38.9 days vs 27.4 ± 31 days; P = .003). Subjects with EAD also had longer mean intensive care LOS (8.61 ± 10.28 days vs 5.45 ± 11.6 days; P = .048). Additional factors significantly associated with LOS included Model for End-Stage Liver Disease (MELD) score, recipient location before LT, and postoperative surgical complications. CONCLUSIONS EAD is associated with longer hospitalization after LT. MELD score, preoperative recipient location, and postoperative complications were significantly associated with LOS. From a cost-containment perspective, these findings have implications on resource allocation.
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Affiliation(s)
- K P Croome
- Multi-Organ Transplant Program, London Health Sciences Centre, Western University, London, Ontario, Canada
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