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Malik AK, Tingle SJ, Varghese C, Owen R, Mahendran B, Figueiredo R, Amer AO, Currie IS, White SA, Manas DM, Wilson CH. Does Time to Asystole in Donors After Circulatory Death Impact Recipient Outcome in Liver Transplantation? Transplantation 2024:00007890-990000000-00767. [PMID: 38780399 DOI: 10.1097/tp.0000000000005074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND The agonal phase can vary following treatment withdrawal in donor after circulatory death (DCD). There is little evidence to support when procurement teams should stand down in relation to donor time to death (TTD). We assessed what impact TTD had on outcomes following DCD liver transplantation. METHODS Data were extracted from the UK Transplant Registry on DCD liver transplant recipients from 2006 to 2021. TTD was the time from withdrawal of life-sustaining treatment to asystole, and functional warm ischemia time was the time from donor systolic blood pressure and/or oxygen saturation falling below 50 mm Hg and 70%, respectively, to aortic perfusion. The primary endpoint was 1-y graft survival. Potential predictors were fitted into Cox proportional hazards models. Adjusted restricted cubic spline models were generated to further delineate the relationship between TTD and outcome. RESULTS One thousand five hundred fifty-eight recipients of a DCD liver graft were included. Median TTD in the entire cohort was 13 min (interquartile range, 9-17 min). Restricted cubic splines revealed that the risk of graft loss was significantly greater when TTD ≤14 min. After 14 min, there was no impact on graft loss. Prolonged hepatectomy time was significantly associated with graft loss (hazard ratio, 1.87; 95% confidence interval, 1.23-2.83; P = 0.003); however, functional warm ischemia time had no impact (hazard ratio, 1.00; 95% confidence interval, 0.44-2.27; P > 0.9). CONCLUSIONS A very short TTD was associated with increased risk of graft loss, possibly because of such donors being more unstable and/or experiencing brain stem death as well as circulatory death. Expanding the stand down times may increase the utilization of donor livers without significantly impairing graft outcome.
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Affiliation(s)
- Abdullah K Malik
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Samuel J Tingle
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ruth Owen
- Department of Surgery, The Royal Oldham Hospital, Greater Manchester, United Kingdom
| | - Balaji Mahendran
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Rodrigo Figueiredo
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Aimen O Amer
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Ian S Currie
- National Health Service Blood and Transplant, Bristol, United Kingdom
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Steven A White
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Derek M Manas
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle University, Newcastle upon Tyne, United Kingdom
- National Health Service Blood and Transplant, Bristol, United Kingdom
| | - Colin H Wilson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle University, Newcastle upon Tyne, United Kingdom
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Ruck JM, Jackson KR, Motter JD, Massie AB, Philosophe B, Cameron AM, Ottmann SE, Wesson R, Gurakar AO, Segev DL, Garonzik-Wang J. Temporal Trends in Utilization and Outcomes of DCD Livers in the United States. Transplantation 2022; 106:543-551. [PMID: 34259435 DOI: 10.1097/tp.0000000000003878] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Historically, donation after circulatory death (DCD) livers were frequently discarded because of higher mortality and graft loss after liver transplantation (LT). However, the demand for LT continues to outstrip the supply of "acceptable" organs. Additionally, changes in the donor pool, organ allocation, and clinical management of donors and recipients, and improved clinical protocols might have altered post-DCD-LT outcomes. METHODS We studied 5975 recovered DCD livers using US Scientific Registry of Transplant Recipients data from 2005 to 2017, with a comparison group of 78 235 adult donation after brain death (DBD) livers recovered during the same time period. We quantified temporal trends in discard using adjusted multilevel logistic regression and temporal trends in post-LT mortality and graft loss for DCD LT recipients using adjusted Cox regression. RESULTS DCD livers were more likely to be discarded than DBD livers across the entire study period, and the relative likelihood of discard increased over time (adjusted odds ratio [aOR] of discard DCD versus DBD 3.854.455.14 2005-2007, 5.225.876.59 2015-2017) despite improving outcomes after DCD LT. Mortality risk for DCD LTs decreased in each time period (compared with 2005-2007, aHR 2008-2011 0.720.840.97, aHR 2012-2014 0.480.580.70, aHR 2015-2017 0.340.430.55), as did risk of graft loss (compared with 2005-2007, aHR 2008-2011 0.690.810.94, aHR 2012-2014 0.450.550.67, aHR 2015-2017 0.360.450.56). CONCLUSIONS Despite dramatic improvements in outcomes of DCD LT recipients, DCD livers remain substantially more likely to be discarded than DBD livers, and this discrepancy has actually increased over time. DCD livers are underutilized and have the potential to expand the donor pool.
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Affiliation(s)
- Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kyle R Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jennifer D Motter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Benjamin Philosophe
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew M Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shane E Ottmann
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Russell Wesson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ahmet O Gurakar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.,Scientific Registry of Transplant Recipients, Minneapolis, MN
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Pérez Redondo M, Alcántara Carmona S, Fernández Simón I, Villanueva Fernández H, Ortega López A, Pardo Rey C, Duerto Álvarez J, Lipperheide Vallhonrat I, González Romero M, Ballesteros Ortega D, Río Gallegos F, Rubio Muñoz JJ. Implementation of a mobile team to provide normothermic regional perfusion in controlled donation after circulatory death: Pilot study and first results. Clin Transplant 2020; 34:e13899. [DOI: 10.1111/ctr.13899] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 04/11/2020] [Accepted: 05/02/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Marina Pérez Redondo
- Department of Intensive Care MedicineHospital Universitario Puerta de Hierro Majadahonda Madrid Spain
| | - Sara Alcántara Carmona
- Department of Intensive Care MedicineHospital Universitario Puerta de Hierro Majadahonda Madrid Spain
| | | | | | - Alfonso Ortega López
- Department of Intensive Care MedicineHospital Universitario Puerta de Hierro Majadahonda Madrid Spain
| | - Cándido Pardo Rey
- Department of Intensive Care Medicine and Transplant Coordinator. HospitalUniversitario Clínico San Carlos Madrid Spain
| | - Jorge Duerto Álvarez
- Department of Intensive Care Medicine and Transplant Coordinator. HospitalUniversitario Clínico San Carlos Madrid Spain
| | | | - Manuel González Romero
- Department of Intensive Care Medicine and Transplant Coordinator. HospitalUniversitario Clínico San Carlos Madrid Spain
| | - Daniel Ballesteros Ortega
- Department of Intensive Care MedicineHospital Universitario Puerta de Hierro Majadahonda Madrid Spain
| | - Francisco Río Gallegos
- Department of Intensive Care Medicine and Transplant Coordinator. HospitalUniversitario Clínico San Carlos Madrid Spain
| | - Juan José Rubio Muñoz
- Department of Intensive Care MedicineHospital Universitario Puerta de Hierro Majadahonda Madrid Spain
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4
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Vivalda S, Zhengbin H, Xiong Y, Liu Z, Wang Z, Ye Q. Vascular and Biliary Complications Following Deceased Donor Liver Transplantation: A Meta-analysis. Transplant Proc 2019; 51:823-832. [PMID: 30979471 DOI: 10.1016/j.transproceed.2018.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 11/15/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess biliary and vascular complications after liver transplantations (LTs) sourced from deceased donors. METHODS This study reviewed potentially relevant English-language articles gathered from PubMed and Medline published from 2012 to 2017. One additional study was carried out using our institution's database for articles published from 2013 to 2017. Biliary and vascular complications from adult patients receiving their first deceased-donor LT were included. This meta-analysis was performed using Review Manager version 5.2 (Cochrane Collaboration, Copenhagen, Denmark) and the study quality was evaluated using the Newcastle-Ottawa Scale. RESULTS Ten studies met our inclusion criteria. Heterogeneity in donation after cardiac death (DCD) and donation after brain death (DBD) recipients was observed and minimized after pooling a subgroup analysis. This latter analysis focused on biliary stricture, biliary leaks and stones, and vascular thrombosis and stenosis. Meta-analyses showed that patients receiving DCD organs have a greatly increased risk of biliary complications compared to those receiving DBD organs, particularly the following: biliary leaks and stones (odds ratio [OR] = 1.69, 95% confidence interval [CI] 1.22-2.34); and biliary stricture (OR = 1.58, 95% CI 1.21-2.06). DCD grafts tended to be but were not significantly associated with DBD regarding vascular thrombosis (OR = 1.62, 95% CI 1.05-2.50), and the risk of vascular stenosis in DCD grafts was not statistically significant (OR = 1.25, 95% CI, .70-2.25). CONCLUSION DCD was associated with an increased risk of biliary complications after LT, tended to indicate an increased risk of vascular thrombosis versus, and was not associated with an increased risk of vascular stenosis compared to DBD. There was no significant difference between the grafts.
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Affiliation(s)
- S Vivalda
- Institute of Hepatobiliary Diseases, Transplant Center, Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - H Zhengbin
- Institute of Hepatobiliary Diseases, Transplant Center, Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Y Xiong
- Institute of Hepatobiliary Diseases, Transplant Center, Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Z Liu
- Institute of Hepatobiliary Diseases, Transplant Center, Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Z Wang
- Institute of Hepatobiliary Diseases, Transplant Center, Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Q Ye
- Institute of Hepatobiliary Diseases, Transplant Center, Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, China; Transplantation Medicine Engineering and Technology Research Center, National Health Commission, the 3rd Xiangya Hospital of Central South University, Changsha, China.
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5
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Lerut J. Biliary tract complications and its prevention. Liver Transpl 2015; 21 Suppl 1:S20-3. [PMID: 26332162 DOI: 10.1002/lt.24311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 08/26/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Jan Lerut
- Starzl Unit Abdominal Transplantation, University Hospitals Saint Luc, Université Catholique Louvain, Brussels, Belgium
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6
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Weeder PD, van Rijn R, Porte RJ. Machine perfusion in liver transplantation as a tool to prevent non-anastomotic biliary strictures: Rationale, current evidence and future directions. J Hepatol 2015; 63:265-75. [PMID: 25770660 DOI: 10.1016/j.jhep.2015.03.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 02/25/2015] [Accepted: 03/02/2015] [Indexed: 02/08/2023]
Abstract
The high incidence of non-anastomotic biliary strictures (NAS) after transplantation of livers from extended criteria donors is currently a major barrier to widespread use of these organs. This review provides an update on the most recent advances in the understanding of the etiology of NAS. These new insights give reason to believe that machine perfusion can reduce the incidence of NAS after transplantation by providing more protective effects on the biliary tree during preservation of the donor liver. An overview is presented regarding the different endpoints that have been used for assessment of biliary injury and function before and after transplantation, emphasizing on methods used during machine perfusion. The wide spectrum of different approaches to machine perfusion is discussed, including the many different combinations of techniques, temperatures and perfusates at varying time points. In addition, the current understanding of the effect of machine perfusion in relation to biliary injury is reviewed. Finally, we explore directions for future research such as the application of (pharmacological) strategies during machine perfusion to further improve preservation. We stress the great potential of machine perfusion to possibly expand the donor pool by reducing the incidence of NAS in extended criteria organs.
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Affiliation(s)
- Pepijn D Weeder
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Rianne van Rijn
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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