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Li Y, Nieuwenhuis LM, Werner MJM, Voskuil MD, Gacesa R, Blokzijl H, Lisman T, Weersma RK, Porte RJ, Festen EAM, de Meijer VE. Donor tobacco smoking is associated with postoperative thrombosis after primary liver transplantation. J Thromb Haemost 2020; 18:2590-2600. [PMID: 32614986 PMCID: PMC7590074 DOI: 10.1111/jth.14983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 06/16/2020] [Accepted: 06/22/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Thrombosis after liver transplantation is a leading cause of graft loss, morbidity, and mortality. Several known recipient- and surgery-related characteristics have been associated with increased risk of thrombosis after transplantation. Potential donor-related risk factors, however, remain largely undefined. OBJECTIVES We aimed to identify risk factors for early post-transplantation thrombosis (<90 days) and to determine the impact of early postoperative thrombosis on long-term graft and patient survival. PATIENTS/METHODS A post hoc analysis was performed of an observational cohort study including all primary, adult liver transplantations performed between 1993 and 2018. Donor-, recipient-, and surgery-related characteristics were collected. Competing risk model analyses and multivariable regression analyses were performed to identify risk factors for developing early post-transplant thrombosis and graft failure. RESULTS From a total of 748 adult liver transplantations, 58 recipients (7.8%) developed a thrombosis after a median of 7 days. Post-transplantation thrombotic events included 25 hepatic artery thromboses, 13 portal vein thromboses, and 22 other thrombotic complications. Donor history of smoking was independently associated with early postoperative thrombosis (odds ratio [OR] 2.42; 95% confidence interval [CI], 1.29-4.52). Development of early post-transplant thrombosis was independently associated with patient mortality (hazard ratio [HR] 3.61; 95% CI 1.54-8.46) and graft failure (HR 5.80, 95% CI 3.26-10.33), respectively. CONCLUSION Donor history of smoking conveys a more than two-fold increased risk of thrombosis after liver transplantation, independent of other factors. Post-transplant thrombosis was independently associated with decreased patient and graft survival.
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Affiliation(s)
- Yanni Li
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
- Department of GeneticsUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Lianne M. Nieuwenhuis
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Maureen J. M. Werner
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Michiel D. Voskuil
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
- Department of GeneticsUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Ranko Gacesa
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
- Department of GeneticsUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Hans Blokzijl
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Ton Lisman
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Rinse K. Weersma
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Robert J. Porte
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Eleonora A. M. Festen
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
- Department of GeneticsUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Vincent E. de Meijer
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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Kahn J, Pregartner G, Avian A, Kniepeiss D, Müller H, Schemmer P. The Graz Liver Allocation Strategy-Impact of Extended Criteria Grafts on Outcome Considering Immunological Aspects. Front Immunol 2020; 11:1584. [PMID: 32849538 PMCID: PMC7427688 DOI: 10.3389/fimmu.2020.01584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 06/15/2020] [Indexed: 12/24/2022] Open
Abstract
Background: Transplant centers are forced to use livers of extended criteria donors for transplantation due to a dramatic organ shortage. The outcome effect of extended donor criteria (EDCs) remains unclear. Thus, this study was designed to assess the impact of EDCs on outcome including immunological aspects after liver transplantation (LT). Patients and Methods: Between November 2016 and March 2018, 49 patients (85.7% male) with a mean age of 57 ± 11 years underwent LT. The impact of EDCs on outcome after LT was assessed retrospectively using both MedOcs and ENIS (Eurotransplant Network Information System). Results: About 80% of grafts derived from extended criteria donors. Alanine aminotransferase/aspartate aminotransferase (AST/ALT) levels elevated more than three times above normal values in organ donors was the only significant risk factor for primary dysfunction (PDF) and primary non-function (PNF)/Re-LT and early non-anastomotic biliary strictures (NAS). Balance of risk (BAR) score did not differ between EDC and non-EDC recipients. PDF (14.3% of all patients) and PNF (6.1% of all patients) occurred in 23.1% of EDC-graft recipients and in 10.0% of non-EDC-graft recipients (RR 2.31, p = 0.663). The 90-day mortality was 3.6%. There was no difference of early non-anastomotic biliary tract complications and biopsy proven rejections (BPR). There was no correlation of PDF/PNF with BPR and NAS, respectively; however, 66.7% of the patients with BPR also developed early NAS (p < 0.001). Conclusion: With the Graz liver allocation strategy, excellent survival can be achieved selecting livers with no more than 2 not outcome-relevant EDCs for patients with MELD >20. Further, BPR is associated with biliary complications.
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Affiliation(s)
- Judith Kahn
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Gudrun Pregartner
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Daniela Kniepeiss
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Helmut Müller
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Peter Schemmer
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
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3
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Effects of Smoking on Solid Organ Transplantation Outcomes. Am J Med 2019; 132:413-419. [PMID: 30452885 DOI: 10.1016/j.amjmed.2018.11.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 11/01/2018] [Accepted: 11/02/2018] [Indexed: 01/15/2023]
Abstract
Tobacco smoking is the leading preventable cause of death worldwide. Both donor and recipient smoking have been shown to increase graft loss and mortality in solid organ transplant recipients in many studies. Only in lung transplants is smoking a universal contraindication to transplantation. Transplant centers implement different policies regarding smoking recipients and allografts from smoking donors. Due to scarcity of available allografts, the risks of smoking have to be weighed against the risks of a longer transplant waitlist period. Although transplant centers implement different strategies to encourage smoking cessation pre- and post-transplant, not many studies have been published that validate the efficacy of smoking cessation interventions in this vulnerable population. This article summarizes the results of studies investigating prevalence, impact on outcomes, and cessationinterventions for smoking in the transplant population. We report herein a review of the elevated risks of infection, malignancy, graft loss, cardiovascular events, and mortality in solid organ transplant populations.
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Pratschke S, Bender A, Boesch F, Andrassy J, van Rosmalen M, Samuel U, Rogiers X, Meiser B, Küchenhoff H, Driesslein D, Werner J, Guba M, Angele MK. Association between donor age and risk of graft failure after liver transplantation: an analysis of the Eurotransplant database. Transpl Int 2018; 32:270-279. [PMID: 30260509 DOI: 10.1111/tri.13357] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 03/05/2018] [Accepted: 09/20/2018] [Indexed: 12/16/2022]
Abstract
Grafts from elderly donors are increasingly used for liver transplantation. As of yet there is no published systematic data to guide the use of specific age cutoffs the effect of elderly donors on patient outcomes must be clarified. This study analyzed the Eurotransplant database (01/01/2000-31/07/2014; N = 26 294) out of whom 8341 liver transplantations were filtered to identify for this analysis. 2162 of the grafts came from donors >60 including 203 from octogenarians ≥80 years. Primary outcome was the risk of graft failure according to donor age using a confounder adjusted Cox-Regression model with frailty terms (or random effects). The proportion of elderly grafts increased during the study period [i.e., octogenarians 0.1% (n = 1) in 2000 to 3.4% (n = 45) in 2013]. Kaplan-Meier and Cox-analyses revealed a reduced survival and a higher risk for graft failure with increasing donor age. Although the age effect was allowed to vary non-linearly, a linear association hazard ratio (HR = 1.1 for a 10 year increase in donor age) was evident. The linearity of the association suggests that there is no particular age at which the effect increases more rapidly, providing no evidence for a cutoff age. In clinical practice, the combination of high donor age with HU-transplantations, hepatitis C, high MELD-scores and long cold ischemic time should be avoided.
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Affiliation(s)
- Sebastian Pratschke
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
| | - Andreas Bender
- Statistical Consulting Unit StaBLab, Department of Statistics, Ludwig-Maximilians University, Munich, Germany
| | - Florian Boesch
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
| | - Joachim Andrassy
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
| | | | - Undine Samuel
- Eurotransplant International Foundation, Leiden, The Netherlands
| | - Xavier Rogiers
- Transplantatiecentrum, Universitair Ziekenhuis Gent, Gent, Belgium
| | - Bruno Meiser
- Transplant Center, Hospital of the LMU Munich, Munich, Germany
| | - Helmut Küchenhoff
- Statistical Consulting Unit StaBLab, Department of Statistics, Ludwig-Maximilians University, Munich, Germany
| | - David Driesslein
- Statistical Consulting Unit StaBLab, Department of Statistics, Ludwig-Maximilians University, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
| | - Markus Guba
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
| | - Martin K Angele
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
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5
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Lozanovski VJ, Khajeh E, Fonouni H, Pfeiffenberger J, von Haken R, Brenner T, Mieth M, Schirmacher P, Michalski CW, Weiss KH, Büchler MW, Mehrabi A. The impact of major extended donor criteria on graft failure and patient mortality after liver transplantation. Langenbecks Arch Surg 2018; 403:719-731. [PMID: 30112639 DOI: 10.1007/s00423-018-1704-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 08/07/2018] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Numerous extended donor criteria (EDC) have been identified in liver transplantation (LT), but different EDC have different impacts on graft and patient survival. This study aimed to identify major EDC (maEDC) that were best able to predict the outcome after LT and to examine the plausibility of an allocation algorithm based on these criteria. METHODS All consecutive LTs between 12/2006 and 03/2014 were included (n = 611). We analyzed the following EDC: donor age > 65 years, body mass index > 30, malignancy and drug abuse history, intensive care unit stay/ventilation > 7 days, aminotransferases > 3 times normal, serum bilirubin > 3 mg/dL, serum Na+ > 165 mmol/L, positive hepatitis serology, biopsy-proven macrovesicular steatosis (BPS) > 40%, and cold ischemia time (CIT) > 14 h. We analyzed hazard risk ratios of graft failure for each EDC and evaluated primary non-function (PNF). In addition, we analyzed 30-day, 90-day, 1-year, and 3-year graft survival. We established low- and high-risk graft (maEDC 0 vs. ≥ 1) and recipient (labMELD < 20 vs. ≥ 20) groups and compared the post-LT outcomes between these groups. RESULTS BPS > 40%, donor age > 65 years, and CIT > 14 h (all p < 0.05) were independent predictors of graft failure and patient mortality and increased PNF, 30-day, 90-day, 1-year, and 3-year graft failure rates. Three-year graft and patient survival decreased in recipients of ≥ 1 maEDC grafts (all p < 0.05) and LT of high-risk grafts into high-risk recipients yielded worse outcomes compared with other groups. CONCLUSION Donor age > 65 years, BPS > 40%, and CIT > 14 h are major EDC that decrease short and 3-year graft survival, and 3-year patient survival. An allocation algorithm based on maEDC and labMELD is therefore plausible.
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Affiliation(s)
- Vladimir J Lozanovski
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Hamidreza Fonouni
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Jan Pfeiffenberger
- Department of Internal Medicine IV, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Rebecca von Haken
- Department of Anesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thorsten Brenner
- Department of Anesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus Mieth
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Peter Schirmacher
- Institute of Pathology, University Hospital Heidelberg, Im Neuenheimer Feld 220/221, 69120, Heidelberg, Germany
| | - Christoph W Michalski
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Karl Heinz Weiss
- Department of Internal Medicine IV, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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Roullet S, Defaye M, Quinart A, Adam JP, Chiche L, Laurent C, Neau-Cransac M. Liver Transplantation With Old Grafts: A Ten-Year Experience. Transplant Proc 2018; 49:2135-2143. [PMID: 29149974 DOI: 10.1016/j.transproceed.2017.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/18/2017] [Accepted: 07/30/2017] [Indexed: 02/09/2023]
Abstract
BACKGROUND The persistent scarcity of donors has prompted liver transplantation teams to find solutions for increasing graft availability. We report our experience of liver transplantations performed with grafts from older donors, specifically over 70 and 80 years old. PATIENTS AND METHODS We analyzed our prospectively maintained single-center database from January 1, 2005, to December 31, 2014, with 380 liver transplantations performed in 354 patients. Six groups were composed according to donor age: <40 (n = 84), 40 to 49 (n = 67), from 50 to 59 (n = 62), from 60 to 69 (n = 76), from 70 to 79 (n = 64), and ≥80 years (n = 27). RESULTS Donors <40 years of age had a lower body mass index, died more often from trauma, and more often had cardiac arrest and high transaminase levels. In contrast, older donors (≥70 years of age) died more often from stroke. Recipients of grafts from donors <50 years of age were more frequently infected by hepatitis C virus; recipients of oldest grafts more often had hepatocellular carcinoma. Cold ischemia time was the shortest in donors >80 years of age. Patient survival was not significantly different between the groups. In multivariate analysis, factors predicting graft loss were transaminase peak, retransplantation and cold ischemia time but not donor age. CONCLUSIONS Older donors >70 and >80 years of age could provide excellent liver grafts.
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Affiliation(s)
- S Roullet
- Department of Anesthesia and Intensive Care and Liver Transplantation Unit, Bordeaux, France; Inserm UMR 12-11, Bordeaux, France.
| | - M Defaye
- Department of Anesthesia and Intensive Care and Liver Transplantation Unit, Bordeaux, France
| | - A Quinart
- Department of Anesthesia and Intensive Care and Liver Transplantation Unit, Bordeaux, France
| | - J-P Adam
- Department of Digestive Surgery and Liver Transplantation Unit, CHU Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | - L Chiche
- Department of Digestive Surgery and Liver Transplantation Unit, CHU Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | - C Laurent
- Department of Digestive Surgery and Liver Transplantation Unit, CHU Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | - M Neau-Cransac
- Department of Hepatology and Liver Transplantation Unit, CHU Bordeaux, Hôpital Haut-Lévêque, Pessac, France
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7
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Essien EOI, Parimi N, Gutwald-Miller J, Nutter T, Scalea TM, Stein DM. Organ Dysfunction and Failure Following Brain Death Do Not Preclude Successful Donation. World J Surg 2018; 41:2933-2939. [PMID: 28620674 DOI: 10.1007/s00268-017-4089-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Organ dysfunction is common after neurologic determination of death (NDD) but before organ collection. Reliable markers for graft success following transplant of these organs would be useful. We sought to determine the relationship between the donor after neurologic determination of death (DNDD) pathophysiology and successful organ donation. METHODS Donor information was obtained through the local organ procurement organization. Donor demographics and clinical data points for cardiovascular, renal, respiratory, hepatic, hematological and neuroendocrine systems were reviewed 12 h before and 12 h after neurologic determination of death was declared. The worst values were utilized for analysis and generation of the organ-specific Sequential Organ Failure Assessment (SOFA) scores. SOFA scores were calculated and used to quantify the degree of organ dysfunction. The NDD non-donors for a specific organ were used as a comparison control group. The control group refers to DNDD patients whose specific organs were not transplanted. Lack of use was mostly due to discard by the transplant team as a result of unsuitability of the organ caused by deterioration or possible donor-specific pathology. RESULTS One hundred and five organ donors were analyzed. Mean age was 35.0 (± 13.6), 78.1% male, median GCS 3, interquartile range (IQR) 3-4 and median injury severity score 32 (IQR 25-43). Of the successful donors, organ-specific severe dysfunction (SOFA 3 or 4) occurred in 96, 27.5 and 3.3% of cardiac, lung and liver donors, respectively. There was no significant difference between the levels of organ dysfunction in donors versus non-donors except lung donors, in which the median lowest partial pressure of arterial oxygen-to-fraction of inspired oxygen (P/F) ratio in the non-donor was 194 (IQR 121.8-308.3) compared to the median lowest P/F ratio in the donor which was 287 (IQR 180-383.5), p = 0.02. In the recipients, graft failure 6 months after transplantation was reported in one kidney recipient (0.74%) (peak donor creatinine = 1 mg/dL) and in five pancreas recipients (11.4%). The median peak glucose of the pancreas donors in failed recipients was 178 mg/dL (IQR 157-213), whereas in the functioning recipients, the median glucose of their donors was not different (185 mg/dL, IQR 157-216), p = 0.394. CONCLUSION Current measures of organ failure and dysfunction do not predict the success of organ donation. Successful donor management in the face of severe organ dysfunction and failure can result in lives saved.
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Affiliation(s)
- Eno-Obong I Essien
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S. Greene St., T1R52, Baltimore, MD, 21201, USA.
| | - Nehu Parimi
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S. Greene St., T1R52, Baltimore, MD, 21201, USA
| | | | - Tyree Nutter
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S. Greene St., T1R52, Baltimore, MD, 21201, USA
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S. Greene St., T1R52, Baltimore, MD, 21201, USA
| | - Deborah M Stein
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S. Greene St., T1R52, Baltimore, MD, 21201, USA
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Zeng C, Hu X, Wang Y, Zeng X, Xiong Y, Li L, Ye Q. A novel hypothermic machine perfusion system using a LifePort Kidney Transporter for the preservation of rat liver. Exp Ther Med 2017; 15:1410-1416. [PMID: 29434725 PMCID: PMC5776655 DOI: 10.3892/etm.2017.5587] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 07/27/2017] [Indexed: 12/23/2022] Open
Abstract
The protective mechanisms for liver preservation associated with hypothermic machine perfusion (HMP) remain unclear. However, the lack of a common and portable HMP system for rat livers limits the study of HMP. The present study aimed to develop a novel, modified HMP system using a LifePort Kidney Transporter for preserving rat livers. A simple ‘Y’ shunt combined with a pressoreceptor for flow and pressure regulation was adapted to perfuse rat livers via the portal vein continuously using a LifePort Kidney Transporter under its ‘prime mode’ setting. An electronic scale was installed under the liver container to calculate the portal inflow according to the association with weight, density and volume of the perfusate. A total of 10 rat livers underwent 6 h of HMP using histidine-tryptophan-ketoglutarate solution enriched with acridine orange (AO) and propidium iodide (PI). The perfusion status of HMP was assessed by comparison of AO+PI-positive cell count in core region (CR) and peripheral region (PR) of rat liver under fluorescence microscopy. The dynamics (inflow, pressure and intrahepatic resistance of perfusion) were assessed to identify whether this system met the demands for HMP of rat livers. Biochemical [alanine transaminase (ALT), lactate dehydrogenase (LDH) and endothelin levels] and histological parameters (sinusoidal dilatation, endothelial cell detachment and vacuolization) were measured to determine cellular damage associated with HMP. No significant difference was observed between the CR and PR according to the comparison of the AO+PI-positive cell count, which indicated that complete perfusion was achieved. Intrahepatic resistance significantly decreased during the initial 3 h of HMP (P<0.01), but remained stable during the final 3 h. ALT and LDH levels significantly increased over the 6 h HMP duration: ALT (0 h, 42.67±5.81 U/l; 3 h, 90.67±6.74 U/l; 6 h, 164.33±7.31 U/l; P<0.01) and LDH (0 h, 492.90±90.20 U/l; 3 h, 973.53±97.4; 6 h, 1,843.40±85.78 U/l; P<0.01) However, the levels of endothelin and oxygen consumption were constant throughout HMP. Furthermore, histological analysis indicated sinusoidal dilation was significantly increased in the post-HMP group compared with the pre-HMP group (P<0.01); however, no other significant differences were observed. Combined with the results of ATP test (640.64±29.46 nmol/l) and bile production (4.88±0.69 µl/h/g of liver) at the end of HMP, the present results demonstrated minimal cellular injury associated with HMP while retaining the dependability and portability of the LifePort Kidney Transporter, which suggests the modified HMP system met the demands required and may be suitable for rat liver preservation.
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Affiliation(s)
- Cheng Zeng
- Transplant Center, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Institute of Hepatobiliary Diseases, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Xiaoyan Hu
- Transplant Center, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Institute of Hepatobiliary Diseases, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Yanfeng Wang
- Transplant Center, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Institute of Hepatobiliary Diseases, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Xianpeng Zeng
- Transplant Center, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Institute of Hepatobiliary Diseases, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Yan Xiong
- Transplant Center, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Institute of Hepatobiliary Diseases, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Ling Li
- Transplant Center, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Institute of Hepatobiliary Diseases, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Qifa Ye
- Transplant Center, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Institute of Hepatobiliary Diseases, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, The Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, P.R. China
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9
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Grąt M, Lewandowski Z, Patkowski W, Grąt K, Wronka KM, Krasnodębski M, Wróblewski T, Nyckowski P, Krawczyk M. Individual Surgeon Experience Yields Bimodal Effects on Patient Outcomes After Deceased-Donor Liver Transplant: Results of a Quantile Regression for Survival Data. EXP CLIN TRANSPLANT 2017; 16:425-433. [PMID: 29108512 DOI: 10.6002/ect.2017.0027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Data on the relevance of surgeon experience in liver transplant procedures are scarce. In this study, we evaluated the effects of individual surgeon experience on survival outcomes after deceased-donor liver transplant. MATERIALS AND METHODS In this retrospective analysis of 1193 liver transplant procedures, quantile regression for survival data was performed to assess the effects of surgeon experience. Conditional quantiles of mortality and graft loss were set as primary and secondary outcome measures, respectively, which were categorized as early, midterm, and late. RESULTS Greater experience of a surgeon performing hepatectomy increased the risk of early mortality (P = .005) and graft loss (P = .025) when the recipient Model for End-Stage Liver Disease was ≤ 25 and the donor Model for End-Stage Liver Disease was ≤ 1600. In conventional transplant procedures, greater experience of surgeon performing hepatectomy additionally increased the risk of midterm mortality (P = .027) and graft loss (P = .046). Conversely, a graft implant procedure performed by a more experienced surgeon was associated with better early, midterm, and late outcomes after conventional transplants (all P < .037) and reduced the risk of early graft loss when the donor Model for End-Stage Liver Disease score was > 1600 (P = .027). CONCLUSIONS Unexpectedly, individual surgeon experience yields bimodal effects on posttransplant outcomes, dependent on the stage of operation, operative technique, severity of recipient status, and transplant risk profile.
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Affiliation(s)
- Michał Grąt
- From the Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
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10
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Ursic-Bedoya J, Donnadieu-Rigole H, Faure S, Pageaux GP. Alcohol use and smoking after liver transplantation; complications and prevention. Best Pract Res Clin Gastroenterol 2017. [PMID: 28624106 DOI: 10.1016/j.bpg.2017.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The last thirty years have been very prosperous in the field of liver transplantation (LT), with great advances in organ conservation, surgical techniques, peri-operative management and long-term immunosuppression, resulting in improved patient and graft survival rates as well as quality of life. However, substance addiction after LT, namely alcohol and tobacco, results in short term morbidity together with medium and long-term mortality. The main consequences can be vascular (increased risk of hepatic artery thrombosis in smokers), hepatic (recurrent alcoholic cirrhosis in alcohol relapsers) and oncological (increased risk of malignancy in patients consuming tobacco and/or alcohol after LT). This issue has thus drawn attention in the field of LT research. The management of these two at-risk behaviors addictions need the implication of hepatologists and addiction specialists, before and after LT. This review will summarize our current knowledge in alcohol use and cigarette smoking in the setting of LT, give practical tools for identification of high risk patients and treatment options.
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Affiliation(s)
- José Ursic-Bedoya
- Liver Transplantation Unit, Digestive Department, Saint Eloi University Hospital, University of Montpellier, 34295, Montpellier Cedex 5, France
| | - Hélène Donnadieu-Rigole
- Addictology Department, Saint Eloi University Hospital, University of Montpellier, 34295, Montpellier Cedex 5, France
| | - Stéphanie Faure
- Liver Transplantation Unit, Digestive Department, Saint Eloi University Hospital, University of Montpellier, 34295, Montpellier Cedex 5, France
| | - Georges-Philippe Pageaux
- Liver Transplantation Unit, Digestive Department, Saint Eloi University Hospital, University of Montpellier, 34295, Montpellier Cedex 5, France.
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11
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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 I: reviewing the impact of determining factors. Expert Rev Gastroenterol Hepatol 2016; 10:827-39. [PMID: 26838962 DOI: 10.1586/17474124.2016.1149061] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The definition and factors of extended criteria donors have already been set; however, details of the various opinions still differ in many respects. In this review, we summarize the impact of these factors and their clinical relevance. Elderly livers must not be allocated for hepatitis C virus (HCV) positives, or patients with acute liver failure. In cases of markedly increased serum transaminases, donor hemodynamics is an essential consideration. A prolonged hypotension of the donor does not always lead to an increase in post-transplantation graft loss if post-OLT care is proper. Hypernatremia of less than 160 mEq/L is not an absolute contraindication to accept a liver graft per se. The presence of steatosis is an independent and determinant risk factor for the outcome. The gold standard of the diagnosis is the biopsy. This is recommended in all doubtful cases. The use of HCV+ grafts for HCV+ recipients is comparable in outcome. The leading risk factor for HCV recurrence is the actual RNA positivity of the donor. The presence of a proper anti-HBs level seems to protect from de novo HBV infection. A favourable outcome can be expected if a donation after cardiac death liver is transplanted in a favourable condition, meaning, a warm ischemia time < 30 minutes, cold ischemia time < 8-10 hours, and donor age 50-60 years. The pathway of organ quality assessment is to obtain the most relevant information (e.g. biopsy), consider the co-existing donor risk factors and the reserve capacity of the recipient, and avoid further technical issues.
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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 Department 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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12
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Brandl A, Stolzlechner P, Eschertzhuber S, Aigner F, Weiss S, Vogel W, Krannich A, Neururer S, Pratschke J, Graziadei I, Öllinger R. Inferior graft survival of hepatitis B core positive grafts is not influenced by post-transplant hepatitis B infection in liver recipients--5-year single-center experience. Transpl Int 2016; 29:471-82. [PMID: 26716608 DOI: 10.1111/tri.12741] [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: 01/20/2015] [Revised: 02/11/2015] [Accepted: 12/23/2015] [Indexed: 12/21/2022]
Abstract
Nonoptimal liver grafts, and among them organs from anti-HBc+ donors, are increasingly used for liver transplantation. In this retrospective study including 1065 adult liver transplantations performed between 1977 and 2012, we analyzed long-term patient and graft survival and occurrence of HBV infection. A total of 52 (5.1%) patients received an anti-HBc+ graft. The 10-year graft and patient survival of these recipients were 50.9% and 59.0% compared to 72.0% and 76.5% (P = 0.001; P = 0.004) of patients receiving anti-HBc- grafts, respectively. Cox regression model showed that high urgency allocation (P = 0.003), recipient age (P = 0.027), anti-HCV+ recipients (P = 0.005), and anti-HBc+ organs (P = 0.048) are associated with decreased graft survival. Thirteen of 52 (25.0%) patients receiving anti-HBc+ grafts developed post-transplant HBV infection within a mean of 2.8 years. In this study, antiviral prophylaxis did not have significant impact on HBV infection, but long-term survival (P = 0.008). Development of post-transplant HBV infection did not affect adjusted 10-year graft survival (100% vs. 100%; P = 1). Anti-HBc+ liver grafts can be transplanted with reasonable but inferior long-term patient and graft survival. The inferior graft survival is not, however, related with post-transplant HBV infection as long as early diagnosis and treatment take place.
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Affiliation(s)
- Andreas Brandl
- Department of Visceral-, Transplant-, and Thoracic Surgery, Medical University, Innsbruck, Austria.,Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany
| | - Philipp Stolzlechner
- Department of Visceral-, Transplant-, and Thoracic Surgery, Medical University, Innsbruck, Austria
| | - Stephan Eschertzhuber
- Department of Anaesthesia and Intensive Care Medicine, Medical University, Innsbruck, Austria
| | - Felix Aigner
- Department of Visceral-, Transplant-, and Thoracic Surgery, Medical University, Innsbruck, Austria.,Department of Anaesthesia and Intensive Care Medicine, Medical University, Innsbruck, Austria
| | - Sascha Weiss
- Department of Visceral-, Transplant-, and Thoracic Surgery, Medical University, Innsbruck, Austria.,Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany
| | - Wolfgang Vogel
- Department of Internal Medicine II, Gastroenterology & Hepatology, Medical University, Innsbruck, Austria
| | - Alexander Krannich
- Department of Biostatistics, Coordination Center for Clinical Trials, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Sabrina Neururer
- Department of Medical Statistics, Medical University, Innsbruck, Austria
| | - Johann Pratschke
- Department of Visceral-, Transplant-, and Thoracic Surgery, Medical University, Innsbruck, Austria.,Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany
| | - Ivo Graziadei
- Department of Internal Medicine II, Gastroenterology & Hepatology, Medical University, Innsbruck, Austria.,Department of Internal Medicine, District Hospital Hall, Innsbruck, Austria
| | - Robert Öllinger
- Department of Visceral-, Transplant-, and Thoracic Surgery, Medical University, Innsbruck, Austria.,Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany
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13
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Fischer-Fröhlich CL, Kutschmann M, Feindt J, Schmidtmann I, Kirste G, Frühauf NR, Wirges U, Rahmel A, Schleicher C. Influence of Deceased Donor and Pretransplant Recipient Parameters on Early Overall Kidney Graft-Survival in Germany. J Transplant 2015; 2015:307230. [PMID: 26539298 PMCID: PMC4619958 DOI: 10.1155/2015/307230] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 09/03/2015] [Indexed: 12/02/2022] Open
Abstract
Background. Scarcity of grafts for kidney transplantation (KTX) caused an increased consideration of deceased donors with substantial risk factors. There is no agreement on which ones are detrimental for overall graft-survival. Therefore, we investigated in a nationwide multicentre study the impact of donor and recipient related risks known before KTX on graft-survival based on the original data used for allocation and graft acceptance. Methods. A nationwide deidentified multicenter study-database was created of data concerning kidneys donated and transplanted in Germany between 2006 and 2008 as provided by the national organ procurement organization (Deutsche Stiftung Organtransplantation) and BQS Institute. Multiple Cox regression (significance level 5%, hazard ratio [95% CI]) was conducted (n = 4411, isolated KTX). Results. Risk factors associated with graft-survival were donor age (1.020 [1.013-1.027] per year), donor size (0.985 [0.977-0.993] per cm), donor's creatinine at admission (1.002 [1.001-1.004] per µmol/L), donor treatment with catecholamine (0.757 [0.635-0.901]), and reduced graft-quality at procurement (1.549 [1.217-1.973]), as well as recipient age (1.012 [1.003-1.021] per year), actual panel reactive antibodies (1.007 [1.002-1.011] per percent), retransplantation (1.850 [1.484-2.306]), recipient's cardiovascular comorbidity (1.436 [1.212-1.701]), and use of IL2-receptor antibodies for induction (0.741 [0.619-0.887]). Conclusion. Some donor characteristics persist to impact graft-survival (e.g., age) while the effect of others could be mitigated by elaborate donor-recipient match and care.
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Affiliation(s)
| | - Marcus Kutschmann
- BQS Institute for Quality and Patient Safety, Kanzlerstraße 4, 40472 Düsseldorf, Germany
| | - Johanna Feindt
- MVZ Anaesthesio Nordrhein, Hans-Günther-Sohl-Straße 6-10, 40235 Düsseldorf, Germany
| | - Irene Schmidtmann
- Institut für Medizinische Biometrie, Epidemiologie und Informatik (IMBEI), Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Obere Zahlbacher Straße 69, 55131 Mainz, Germany
| | - Günter Kirste
- Medizinische Fakultät, Albert Ludwigs Universität Freiburg, Hebelstraße 29, 79104 Freiburg, Germany
| | - Nils R. Frühauf
- Landesärztekammer Niedersachsen, Berliner Allee 20, 30175 Hannover, Germany
| | - Ulrike Wirges
- Deutsche Stiftung Organtransplantation, Region Nordrhein-Westfalen, Lindenallee 29-41, 45127 Essen, Germany
| | - Axel Rahmel
- Deutsche Stiftung Organtransplantation, Deutschherrnufer 52, 60594 Frankfurt am Main, Germany
| | - Christina Schleicher
- Deutsche Stiftung Organtransplantation, Region Baden-Württemberg, Kriegerstraße 6, 70192 Stuttgart, Germany
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14
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Westerkamp AC, Korkmaz KS, Bottema JT, Ringers J, Polak WG, van den Berg A, van Hoek B, Metselaar HJ, Porte RJ. Elderly donor liver grafts are not associated with a higher incidence of biliary complications after liver transplantation: results of a national multicenter study. Clin Transplant 2015; 29:636-43. [PMID: 25997000 DOI: 10.1111/ctr.12569] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Liver transplantation with livers grafts from elderly donors has been associated with a higher risk of biliary complications. The aim of this study was to examine whether our national protocol could contribute to a lower incidence of biliary complications. METHODS All adult recipients in the Netherlands transplanted with a liver from an elderly donor (≥ 65 yrs; n = 68) in the period January 2000-July 2011 were matched with recipients of a liver from a donor <65 yr (n = 136). Outcome parameters were 90-d, one-yr, and three-yr patient/graft survival rates, biliary complications (non-anastomotic stricture, anastomotic stricture, biliary leakage, and post-transplant cholangitis), and postoperative hepatic ischemic injury serum markers (AST/ALT). RESULTS The median cold ischemia time (CIT) was 7:25 (h:min) in the group recipients of an elderly donor liver graft. Ninety-day, one-yr, and three-yr patient/graft survival rates were similar between the group with an elderly donor liver and their younger controls. Moreover, no differences were found in the incidence of biliary complications and postoperative levels of AST/ALT between the two groups. CONCLUSION Transplantation of livers from elderly donors (≥ 65 yr) is not associated with a higher incidence of biliary complications, in a national policy wherein the CIT is kept short.
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Affiliation(s)
- Andrie C Westerkamp
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Kerem S Korkmaz
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan T Bottema
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan Ringers
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Wojciech G Polak
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Aad van den Berg
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Herold J Metselaar
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, 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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15
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Coers Byram S, L. Ault M. Con: The Challenges of Utilizing Expanded-Criteria Donors for Orthotopic Heart Transplantation. J Cardiothorac Vasc Anesth 2014; 28:1688-90. [DOI: 10.1053/j.jvca.2014.06.009] [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: 05/12/2014] [Indexed: 11/11/2022]
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16
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Mataya L, Aronsohn A, Thistlethwaite R, Ross LF. Decision making in liver transplantation--limited application of the liver donor risk index. Liver Transpl 2014; 20:831-7. [PMID: 24692309 PMCID: PMC4072766 DOI: 10.1002/lt.23879] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 03/28/2014] [Indexed: 02/06/2023]
Abstract
The liver donor risk index (LDRI), originally developed in 2006 by Feng et al. and since modified, is a method of evaluating liver grafts from deceased donors through the determination of the relative risk of graft failure after transplantation. Online and paper surveys about attitudes and practices regarding decision making in liver transplantation and the role of the LDRI were sent to liver transplant physicians. One hundred forty-seven of 401 eligible respondents (37%) returned partial or complete surveys. The majority of the respondents were male (116/134 or 87%) and practiced in academic medical centers (128/138 or 93%). Transplant coordinators initially contacted the candidate with an offer in 81% of the programs. Eighty-eight of 143 respondents (62%) reported that they were very familiar with the LDRI, but the vast majority (114/137 or 83%) rarely or never discussed the concept of the LDRI with their patients. A majority of the respondents (96/132 or 73%) believed that the LDRI does not adequately describe a liver's relative risk of graft failure and that there are factors making the LDRI potentially misleading (122/138 or 88%). Nevertheless, 60 of 130 respondents (46%) believed that the LDRI would increase/improve shared decision making. The LDRI has not been widely adopted because of concerns that (1) it does not accurately reflect posttransplant survival, (2) it excludes relevant donor and recipient factors, and (3) it is too complicated for candidates to grasp. There is a need to improve it or to develop other decision-making tools to help promote shared decision making. There is also great diversity in how liver offers are made to ambulatory candidates and in how transplant programs address a candidate's refusal. Research is needed to determine evidence-based best practice.
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Affiliation(s)
- Leslie Mataya
- second year medical student at the University of Chicago Pritzker School of Medicine
| | | | | | - Lainie Friedman Ross
- Carolyn and Matthew Bucksbaum Professor of Clinical Medical Ethics, Professor in the Departments of Medicine, Pediatrics and Surgery; and Associate Director of the MacLean Center for Clinical Medical Ethics, University of Chicago
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17
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Shin M, Moon HH, Kim JM, Park JB, Kwon CHD, Kim SJ, Joh JW. Importance of donor-recipient age gradient to the prediction of graft outcome after living donor liver transplantation. Transplant Proc 2014; 45:3005-12. [PMID: 24157024 DOI: 10.1016/j.transproceed.2013.08.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE Advanced donor age is a well-known risk factor for poor graft function after living donor liver transplantation (LDLT). In addition, advanced recipient age has a significant impact because of the high prevalence of comorbidities. We investigated the relationship between donor-recipient age gradient (DRAG) and the posttransplant outcomes in LDLT. METHODS We included 821 consecutive adult recipients who underwent LDLT from June 1997 to May 2011. According to the value of DRAG, they were divided into 2 groups: Negative years (the donor was younger than the recipient) and positive years (the donor was older than the recipient). These groups were further divided into subgroups (≤-21, -20 to -1, 0 to 20, and ≥21 years). We collected retrospectively patient characteristics, laboratory results, medical and surgical complications, and graft loss. RESULTS The positive DRAG group had higher level of posttransplant alkaline phosphatase, but a lower incidence of biliary complications. The negative DRAG group, particularly DRAG ≤ -21 years was associated with the superior 1-, 3-, 5-, and 10-year graft survivals. Recipients with DRAG ≥ 21 showed persistently inferior graft survival during the observation period. In cases of young donors, transplants utilizing lower DRAG seen between young donors and older recipients showed more favorable graft survival than that of young-to-young transplants. CONCLUSION This study demonstrated that DRAG and a fixed donor age limit could be significant factors to predict graft survival after LDLT. Patients should carefully consider the worse graft survival if the donor is older than the recipient by ≥20.
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Affiliation(s)
- M Shin
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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18
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Kutschmann M, Fischer-Fröhlich CL, Schmidtmann I, Bungard S, Zeissig SR, Polster F, Kirste G, Frühauf NR. The joint impact of donor and recipient parameters on the outcome of heart transplantation in Germany after graft allocation. Transpl Int 2013; 27:152-61. [DOI: 10.1111/tri.12221] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 07/21/2013] [Accepted: 10/20/2013] [Indexed: 02/06/2023]
Affiliation(s)
| | | | - Irene Schmidtmann
- Institute for Medical Biometrics, Epidemiology and Informatics (IMBEI); Universitätsmedizin der Johannes Gutenberg; Universität Mainz; Mainz Germany
| | - Sven Bungard
- BQS Institute for Quality and Patient Safety; Düsseldorf Germany
| | - Sylke R. Zeissig
- Institute for Medical Biometrics, Epidemiology and Informatics (IMBEI); Universitätsmedizin der Johannes Gutenberg; Universität Mainz; Mainz Germany
| | - Frank Polster
- Deutsche Gesellschaft für Gewebespende gGmbH; Hannover Germany
| | - Günter Kirste
- Deutsche Stiftung Organtransplantation (DSO); Frankfurt Germany
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19
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Shin M, Kim J, Park J, Kwon C, Kim SJ, Joh JW. Effect of Donor–Recipient Age Gradient on Graft Outcomes in Deceased Donor Liver Transplantation. Transplant Proc 2013; 45:3013-8. [DOI: 10.1016/j.transproceed.2013.08.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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20
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Abstract
Smoking, both by donors and by recipients, has a major impact on outcomes after organ transplantation. Recipients of smokers' organs are at greater risk of death (lungs hazard ratio [HR], 1.36; heart HR, 1.8; and liver HR, 1.25), extended intensive care stays, and greater need for ventilation. Kidney function is significantly worse at 1 year after transplantation in recipients of grafts from smokers compared with nonsmokers. Clinicians must balance the use of such higher-risk organs with the consequences on waiting list mortality if the donor pool is reduced further by exclusion of such donors. Smoking by kidney transplant recipients significantly increases the risk of cardiovascular events (29.2% vs. 15.4%), renal fibrosis, rejection, and malignancy (HR, 2.56). Furthermore, liver recipients who smoke have higher rates of hepatic artery thrombosis, biliary complications, and malignancy (13% vs. 2%). Heart recipients with a smoking history have increased risk of developing coronary atherosclerosis (21.2% vs. 12.3%), graft dysfunction, and loss after transplantation. Self-reporting of smoking is commonplace but unreliable, which limits its use as a tool for selection of transplant candidates. Despite effective counseling and pharmacotherapy, recidivism rates after transplantation remain high (10-40%). Transplant services need to be more proactive in educating and implementing effective smoking cessation strategies to reduce rates of recidivism and the posttransplantation complications associated with smoking. The adverse impact of smoking by the recipient supports the requirement for a 6-month period of abstinence in lung recipients and cessation before other solid organs.
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21
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Hong SH, Kwak JA, Jeon JY, Park CS. Prediction of early allograft dysfunction using serum phosphorus level in living donor liver transplantation. Transpl Int 2013; 26:402-10. [DOI: 10.1111/tri.12058] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Revised: 08/26/2012] [Accepted: 12/23/2012] [Indexed: 02/07/2023]
Affiliation(s)
- Sang Hyun Hong
- Department of Anaesthesiology and Pain Medicine; Seoul St. Mary's Hospital; College of Medicine; The Catholic University of Korea; Seoul; Korea
| | - Jung Ah Kwak
- Department of Anaesthesiology and Pain Medicine; Seoul St. Mary's Hospital; College of Medicine; The Catholic University of Korea; Seoul; Korea
| | - Jin Yeong Jeon
- Department of Anaesthesiology and Pain Medicine; Yeouido St. Mary's Hospital; College of Medicine; The Catholic University of Korea; Seoul; Korea
| | - Chul Soo Park
- Department of Anaesthesiology and Pain Medicine; Seoul St. Mary's Hospital; College of Medicine; The Catholic University of Korea; Seoul; Korea
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22
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Schrem H, Reichert B, Frühauf N, Kleine M, Zachau L, Becker T, Lehner F, Bektas H, Klempnauer J. [Extended donor criteria defined by the German Medical Association : study on their usefulness as prognostic model for early outcome after liver transplantation]. Chirurg 2012; 83:980-8. [PMID: 22810545 PMCID: PMC7095839 DOI: 10.1007/s00104-012-2325-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
INTRODUCTION Expansion of the donor pool by the use of grafts with extended donor criteria reduces waiting list mortality with an increased risk for graft and patient survival after liver transplantation. The ability of the number of fulfilled extended donor criteria as currently defined by the German Medical Association (BÄK-Score) to predict early outcome is unclear. PATIENTS A total of 291 consecutive adult liver transplantations (01.01.2007-31.12.2010) in 257 adult recipients were analyzed. METHODS Primary study endpoints were 30 day mortality, 3 month mortality, 3 month patient and graft survival and the necessity of acute retransplantation within 30 days. For primary study endpoints a ROC curve analysis was performed to calculate sensitivity, specificity and overall model correctness of the BÄK score as a predictive model. Further methods included Kaplan-Meier estimates, log-rank tests, Cox regression analysis, logistic regression analysis and χ(2)-tests. RESULTS The number of extended donor criteria fulfilled had no statistically significant influence on the primary study endpoints (p > 0.05) or on patient survival (p > 0.05). ROC curve analysis revealed areas under the curve ≤ 0.561 for the prediction of primary study endpoints (overall model correctness < 58%, sensitivity < 52%). CONCLUSIONS The number of fulfilled extended donor criteria as currently defined by the German Medical Association is unable to predict early outcome after liver transplantation.
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Affiliation(s)
- H Schrem
- Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland.
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Martin EF, Huang J, Xiang Q, Klein JP, Bajaj J, Saeian K. Recipient survival and graft survival are not diminished by simultaneous liver-kidney transplantation: an analysis of the united network for organ sharing database. Liver Transpl 2012; 18:914-29. [PMID: 22467623 PMCID: PMC3405201 DOI: 10.1002/lt.23440] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Recipients of solitary liver and kidney transplants are living longer, and this increases their risk of long-term complications such as recurrent hepatitis C virus (HCV) and drug-induced nephrotoxicity. These complications may require retransplantation. Since the adoption of the Model for End-Stage Liver Disease, the number of simultaneous liver-kidney transplantation (SLK) procedures has increased. However, there are no standardized criteria for organ allocation to SLK candidates. The aims of this study were to retrospectively compare recipient and graft survival with liver transplantation alone (LTA), SLK, kidney after liver transplantation (KALT), and liver after kidney transplantation (LAKT) and to identify independent risk factors affecting recipient and graft survival. The United Network for Organ Sharing/Organ Procurement and Transplantation Network database (1988-2007) was queried for adult LTA (66,026), SLK (2327), KALT (1738), and LAKT procedures (242). After adjustments for potential confounding demographic and clinical variables, there was no difference in recipient mortality rates with LTA and SLK (P = 0.02). However, there was a 15% decreased risk of graft loss with SLK versus LTA (hazard ratio = 0.85, P < 0.001). The recipient and graft survival rates with SLK were higher than the rates with both KALT (P <0.001 and P <0.001) and LAKT (P = 0.003 and P < 0.001). The following were all identified as independent negative predictors of recipient mortality and graft loss: recipient age ≥ 65 years, male sex, black race, HCV/diabetes mellitus status, donor age ≥ 60 years, serum creatinine level ≥2.0 mg/dL, cold ischemia time > 12 hours, and warm ischemia time > 60 minutes. Although the recent increase in the number of SLK procedures performed each year has effectively decreased the number of potential donor kidneys available to patients with end-stage renal disease (ESRD) awaiting kidney transplantation, SLK in patients with end-stage liver disease and ESRD is justified because of the lower risk of graft loss with SLK versus LTA as well as the superior recipient and graft survival with SLK versus serial liver-kidney transplantation.
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Affiliation(s)
- Eric F Martin
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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Amatschek S, Wilflingseder J, Pones M, Kainz A, Bodingbauer M, Mühlbacher F, Langer RM, Gerlei Z, Oberbauer R. The effect of steroid pretreatment of deceased organ donors on liver allograft function: a blinded randomized placebo-controlled trial. J Hepatol 2012; 56:1305-9. [PMID: 22326464 PMCID: PMC3355301 DOI: 10.1016/j.jhep.2012.01.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 01/12/2012] [Accepted: 01/23/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Brain death-associated inflammatory response contributes to increased risk of impaired early liver allograft function, which might be counterbalanced by steroid pretreatment of the organ donor. The aim of this randomized controlled trial was to elucidate whether steroid pretreatment of liver donors improves early liver allograft function, prevents rejection and prolongs survival. METHODS A placebo-controlled blinded randomized clinical trial was performed in three different centers in Austria and Hungary between 2006 and 2008. Ninety deceased organ donors received either 1000 mg of methylprednisolone or placebo 6h before recovery of organs. The primary end point was the concentration slope of transaminases within the first week. The secondary end point included survival and biopsy-confirmed acute rejection (BCAR) within 3 years after transplantation. RESULTS Of the 90 randomized donors, 83 recipients were eligible for study. The trajectories of ALT and AST were not different between treatments (p=0.40 and p=0.13, respectively). Eight subjects died in the steroid and 13 in the placebo group within 3 years after engraftment (RR=0.63 95% CI [0.29,1.36], p=0.31). Eleven recipients experienced biopsy-confirmed rejection (BCAR) in the steroid and 11 in the placebo group (RR=1.02 95% CI [0.50,2.10], p=1.00). No effect modification could be identified in the predefined strata of donor age, sex, cold ischemic time, and cause of donor death. CONCLUSIONS Steroid pretreatment of organ donors did not improve outcomes after liver transplantation.
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Affiliation(s)
- Stefan Amatschek
- KH Elisabethinen, Linz, Austria,Department of Internal Medicine 3, Medical University of Vienna, Austria
| | - Julia Wilflingseder
- KH Elisabethinen, Linz, Austria,Department of Internal Medicine 3, Medical University of Vienna, Austria
| | - Mario Pones
- Department of Transplantation, Medical University of Vienna, Austria
| | - Alexander Kainz
- KH Elisabethinen, Linz, Austria,Department of Internal Medicine 3, Medical University of Vienna, Austria
| | | | | | - Robert M. Langer
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Zsuzsanna Gerlei
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Rainer Oberbauer
- KH Elisabethinen, Linz, Austria,Department of Internal Medicine 3, Medical University of Vienna, Austria,Corresponding author. Address: Department of Internal Medicine 3, Medical University of Vienna, Währinger Gürtel 18–20, 1090 Vienna, Austria. Tel.: +43 1 40400 4390; fax: +43 1 40400 4392.
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