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Haque OJ, Roth EM, Lee DD. Modern-Day Practice of DCD Liver Transplantation: Controversies, Innovations, and Future Directions. Curr Gastroenterol Rep 2023; 25:413-420. [PMID: 37897687 DOI: 10.1007/s11894-023-00902-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE OF REVIEW Over the past decade, donation after circulatory death (DCD) liver transplantation has expanded in the United States due to improved surgical experience and perioperative management. Despite these advances, there remains a reluctance towards broader utilization of DCD liver allografts due to lack of standardized donation process, concern for inferior graft survival, and risk of ischemic cholangiopathy associated with temporary lack of oxygenated perfusion during withdrawal of life-supporting treatment during procurement. RECENT FINDINGS New perfusion technologies offer potential therapeutic options to mitigate biliary complications and expand utilization of marginal DCD grafts. As these modalities enter routine clinical practice, DCD utilization will continue to increase, and liver allocation policies in turn will evolve to reflect this growing practice. This review describes recent progress in DCD LT, current challenges with utilization of DCD liver allografts, and how novel technologies and policies could impact the future of the field.
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Affiliation(s)
- Omar J Haque
- Department of Surgery, Beth Israel Deaconess Medical Center, Lowry Building 7th Floor, 110 Francis St, Boston, MA, 02215, USA
| | - Eve M Roth
- Department of Surgery, Beth Israel Deaconess Medical Center, Lowry Building 7th Floor, 110 Francis St, Boston, MA, 02215, USA
| | - David D Lee
- Department of Surgery, Beth Israel Deaconess Medical Center, Lowry Building 7th Floor, 110 Francis St, Boston, MA, 02215, USA.
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2
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Justo I, Nutu A, García-Conde M, Marcacuzco A, Manrique A, Calvo J, García-Sesma Á, Caso Ó, Martín-Arriscado C, Andrés A, Paz E, Jiménez-Romero C. Incidence and risk factors of primary non-function after liver transplantation using grafts from uncontrolled donors after circulatory death. Clin Transplant 2020; 35:e14134. [PMID: 33128296 DOI: 10.1111/ctr.14134] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/12/2020] [Accepted: 10/24/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Graft primary non-function (PNF) is the most severe complication after orthotopic liver transplantation (OLT) and is frequently associated with livers from uncontrolled circulatory death (uDCD). METHODS We reviewed retrospectively the incidence, risk factors, and outcome of patients showing PNF after receiving uDCD liver grafts. The series comprises 75 OLT performed during 11 years. RESULTS The incidence of PNF using uDCD livers was 8%. We compared patients who developed PNF (n = 6) vs. patients without PNF (n = 69). Mean pump flow of donors during normothermic regional perfusion (NRP) was significantly lower in PNF (p = .032). Day 1 post-OLT levels of transaminases and the incidence of renal complications and postoperative mortality were also significantly higher in the PNF group, but 5-year patient survival was similar in both groups (66.7% in PNF and 68.5% in non-PNF). All PNF patients underwent re-OLT, and 2 died. PNF incidence has decreased in the last 5-years. Binary logistic regression analysis confirmed final ALT value >4 times the normal value as risk factor for PNF, and median donor pump flow >3700 ml/min as protective effect. CONCLUSIONS Adequate donor pump flow during NRP was a protective.
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Affiliation(s)
- Iago Justo
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Doce de Octubre" Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Anisa Nutu
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Doce de Octubre" Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - María García-Conde
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Doce de Octubre" Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Alberto Marcacuzco
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Doce de Octubre" Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Alejandro Manrique
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Doce de Octubre" Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Jorge Calvo
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Doce de Octubre" Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Álvaro García-Sesma
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Doce de Octubre" Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Óscar Caso
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Doce de Octubre" Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Carmen Martín-Arriscado
- Unit of Statistical Analysis, "Doce de Octubre" Hospital, Complutense University, Madrid, Spain
| | - Amado Andrés
- Service of Nephrology and Kidney Transplantation, "Doce de Octubre" Hospital, Complutense University, Madrid, Spain
| | - Estela Paz
- Service of Immunology, "Doce de Octubre" Hospital, Complutense University, Madrid, Spain
| | - Carlos Jiménez-Romero
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Doce de Octubre" Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
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Excellent Contemporary Graft Survival for Adult Liver Retransplantation: An Australian and New Zealand Registry Analysis From 1986 to 2017. Transplant Direct 2019; 5:e472. [PMID: 31576368 PMCID: PMC6708636 DOI: 10.1097/txd.0000000000000920] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 05/31/2019] [Indexed: 01/10/2023] Open
Abstract
Background. Liver retransplantation is technically challenging, and historical outcomes are significantly worse than for first transplantations. This study aimed to assess graft and patient survival in all Australian and New Zealand liver transplantation units. Methods. A retrospective cohort analysis was performed using data from the Australia and New Zealand Liver Transplant Registry. Graft and patient survival were analyzed according to era. Cox regression was used to determine recipient, donor, or intraoperative variables associated with outcomes. Results. Between 1986 and 2017, Australia and New Zealand performed 4514 adult liver transplants, 302 (6.7%) of which were retransplantations (278 with 2, 22 with 3, 2 with 4). The main causes of graft failure were hepatic artery or portal vein thrombosis (29%), disease recurrence (21%), and graft nonfunction (15%). Patients retransplanted after 2000 had a graft survival of 85% at 1 year, 75% at 5 years, and 64% at 10 years. Patient survival was 89%, 81%, and 74%, respectively. This was higher than retransplantations before 2000 (P < 0.001). Univariate analysis found that increased recipient age (P = 0.001), recipient weight (P = 0.019), and donor age (P = 0.011) were associated with decreased graft survival prior to 2000; however, only increased patient weight was significant after 2000 (P = 0.041). Multivariate analysis found only increased recipient weight (P = 0.042) and donor age (P = 0.025) was significant prior to 2000. There was no difference in survival for second and third retransplants or comparing time to retransplant. Conclusions. Australia and New Zealand have excellent survival following liver retransplantation. These contemporary results should be utilized for transplant waitlist methods.
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Choudhury RA, Prins K, Moore HB, Yoeli D, Kam A, Nydam TL. Uncontrolled deceased cardiac donation: An unutilized source for organ transplantation in the United States. Clin Transplant 2019; 33:e13474. [PMID: 30597670 DOI: 10.1111/ctr.13474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/12/2018] [Accepted: 12/20/2018] [Indexed: 12/15/2022]
Abstract
The practice of uncontrolled donation after cardiac death (uDCD) has been met with tepid interest within the United States transplant community. Hesitancy stems largely from fears of eroding public trust due to complex ethical issues involving consent. Beyond ethical concerns, uDCD creates unique logistic challenges to obtain and to preserve organs within a short time frame. This mandates that organ recovery centers be able to rapidly mobilize, and that traditional cold preservation techniques may be inadequate. Proof of effective uDCD organ recovery comes from several European nations, and the frequency of its use is increasing due to early promising results. These scarce resources provide life-saving organs to desperate transplant candidates who otherwise experience high morbidity and mortality on a transplant waitlist. The objective of this review will be to provide an overview of the European experience with uDCD and discuss the unique ethical and logistic challenges associated with its implementation in the United States. Given existing models for it successful use, uDCD remains a poorly utilized source of donors in the United States at this time.
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Affiliation(s)
- Rashikh A Choudhury
- Division of Transplant Surgery, Department of Surgery, University of Colorado Hospital, Aurora, Colorado
| | - Kas Prins
- Division of Transplant Surgery, Department of Surgery, University of Colorado Hospital, Aurora, Colorado
| | - Hunter B Moore
- Division of Transplant Surgery, Department of Surgery, University of Colorado Hospital, Aurora, Colorado
| | - Dor Yoeli
- Division of Transplant Surgery, Department of Surgery, University of Colorado Hospital, Aurora, Colorado
| | - Adi Kam
- Division of Transplant Surgery, Department of Surgery, University of Colorado Hospital, Aurora, Colorado
| | - Trevor L Nydam
- Division of Transplant Surgery, Department of Surgery, University of Colorado Hospital, Aurora, Colorado
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Marked Decrease in Urgent Listing for Liver Transplantation Over Time: Evolution of Characteristics and Outcomes of Status-1 Liver Transplantation. Transplantation 2018; 102:e18-e25. [PMID: 28968354 DOI: 10.1097/tp.0000000000001967] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Approximately 5% of liver transplants annually are performed urgently with "status-1" designation. This study aims to determine if the demand, characteristics, and outcome for status-1 liver transplantation has changed over time. METHODS We used the Scientific Registry of Transplant Patients (2003-2015) to characterize 2352 adult patients who underwent 2408 status-1 liver transplants and compared them between Era1 (2003-6/2009) and Era2 (7/2009-2015). RESULTS Overall, there were fewer liver transplants performed with the status-1 designation in Era2 than Era1 (1099 vs 1309). Although the number of urgent liver transplants was relatively constant with successive years, the proportion transplanted with status-1 designation decreased markedly over time. Era2 patients were older (43.2 years vs 41.7 years, P = 0.01) and less likely be ABO-incompatible (1.1% vs 2.4%, P = 0.01) or retransplant (77 vs 124, P = 0.03). In terms of disease etiology, the largest group was "acute liver failure (ALF), nonspecified" (43.4%). There was no difference in proportion with drug-induced liver injury (DILI), but the subset of herbal/dietary supplements increased in Era2 (1.3% vs 0.46%, P = 0.04). Survival was increased in Era2 in the overall cohort and for patients with autoimmune disease (P < 0.05), despite longer waiting times for this etiology (186 days vs 149 days). DILI or nonspecified ALF had shorter waiting times, and 90% were transplanted within 7 days. CONCLUSIONS Liver transplantation for the most urgent indications (status-1) is decreasing while survival remains excellent. Fewer incidences of ALF are classified as indeterminate, mostly as a result of increasing awareness of autoimmune hepatitis and DILI as causes of the syndrome.
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Sher L, Quintini C, Fayek SA, Abt P, Lo M, Yuk P, Ji L, Groshen S, Case J, Marsh CL. Attitudes and barriers to the use of donation after cardiac death livers: Comparison of a United States transplant center survey to the united network for organ sharing data. Liver Transpl 2017; 23:1372-1383. [PMID: 28834180 DOI: 10.1002/lt.24855] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 08/06/2017] [Indexed: 02/07/2023]
Abstract
Transplantation of liver grafts from donation after cardiac death (DCD) is limited. To identify barriers of DCD liver utilization, all active US liver transplant centers (n = 138) were surveyed, and the responses were compared with the United Network for Organ Sharing (UNOS) data. In total, 74 (54%) centers responded, and diversity in attitudes was observed, with many not using organ and/or recipient prognostic variables defined in prior studies and UNOS data analysis. Most centers (74%) believed lack of a system allowing a timely retransplant is a barrier to utilization. UNOS data demonstrated worse 1- and 5-year patient survival (PS) and graft survival (GS) in DCD (PS, 86% and 64%; GS, 82% and 59%, respectively) versus donation after brain death (DBD) recipients (PS, 90% and 71%; GS, 88% and 69%, respectively). Donor alanine aminotransferase (ALT), recipient Model for End-Stage Liver Disease (MELD), and cold ischemia time (CIT) significantly impacted DCD outcomes to a greater extent than DBD outcomes. At 3 years, relisting and retransplant rates were 7.9% and 4.6% higher in DCD recipients. To optimize outcome, our data support the use of DCD liver grafts with CIT <6-8 hours in patients with MELD ≤ 20. In conclusion, standardization of donor and recipient criteria, defining the impact of ischemic cholangiopathy, addressing donor hospital policies, and developing a strategy for timely retransplant may help to expand the use of these organs. Liver Transplantation 23 1372-1383 2017 AASLD.
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Affiliation(s)
| | - Cristiano Quintini
- Liver Transplantation and HPB Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Sameh Adel Fayek
- Transplant Surgery, Medical City Transplant Institute-Fort Worth, Fort Worth, TX
| | - Peter Abt
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Mary Lo
- Preventive Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Pui Yuk
- Departments of Surgery, Los Angeles, CA
| | - Lingyun Ji
- Preventive Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Susan Groshen
- Preventive Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Jamie Case
- Scripps Center for Organ Transplantation, Scripps Clinic and Green Hospital, La Jolla, CA
| | - Christopher Lee Marsh
- Scripps Center for Organ Transplantation, Scripps Clinic and Green Hospital, La Jolla, CA
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7
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Croome KP, Lee DD, Nguyen JH, Keaveny AP, Taner CB. Waitlist Outcomes for Patients Relisted Following Failed Donation After Cardiac Death Liver Transplant: Implications for Awarding Model for End-Stage Liver Disease Exception Scores. Am J Transplant 2017; 17:2420-2427. [PMID: 28556380 DOI: 10.1111/ajt.14383] [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] [Received: 02/14/2017] [Revised: 05/04/2017] [Accepted: 05/11/2017] [Indexed: 01/25/2023]
Abstract
Understanding of outcomes for patients relisted for ischemic cholangiopathy following a donation after cardiac death (DCD) liver transplant (LT) will help standardization of a Model for End-Stage Liver Disease exception scheme for retransplantation. Early relisting (E-RL) for DCD graft failure caused by primary nonfunction (PNF) or hepatic artery thrombosis (HAT) was defined as relisting ≤14 days after DCD LT, and late relisting (L-RL) due to biliary complications was defined as relisting 14 days to 3 years after DCD LT. Of 3908 DCD LTs performed nationally between 2002 and 2016, 540 (13.8%) patients were relisted within 3 years of transplant (168 [4.3%] in the E-RL group, 372 [9.5%] in the L-RL group). The E-RL and L-RL groups had waitlist mortality rates of 15.4% and 10.5%, respectively, at 3 mo and 16.1% and 14.3%, respectively, at 1 year. Waitlist mortality in the L-RL group was higher than mortality and delisted rates for patients with exception points for both hepatocellular carcinoma (HCC) and hepatopulmonary syndrome (HPS) at 3- to 12-mo time points (p < 0.001). Waitlist outcomes differed in patients with early DCD graft failure caused by PNF or HAT compared with those with late DCD graft failure attributed to biliary complications. In L-RL, higher rates of waitlist mortality were noted compared with patients listed with exception points for HCC or HPS.
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Affiliation(s)
- K P Croome
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - D D Lee
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - J H Nguyen
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - A P Keaveny
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - C B Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
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8
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The Optimal Timing of Hepatitis C Therapy in Transplant Eligible Patients With Child B and C Cirrhosis: A Cost-Effectiveness Analysis. Transplantation 2017; 101:987-995. [PMID: 27495755 DOI: 10.1097/tp.0000000000001400] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Ledipasvir (LDV)/sofosbuvir (SOF) has demonstrated high efficacy, safety, and tolerability in hepatitis C virus (HCV)-infected patients. There is limited data, however, regarding the optimal timing of therapy in the context of possible liver transplantation (LT). METHODS We compared the cost-effectiveness of 12 weeks of HCV therapy before or after LT or nontreatment using a decision analytical microsimulation state-transition model for a simulated cohort of 10 000 patients with HCV Genotype 1 or 4 with Child B or C cirrhosis. All model parameters regarding the efficacy of therapy, adverse events and the effect of therapy on changes in model for end-stage liver disease (MELD) scores were derived from the SOLAR-1 and 2 trials. The simulations were repeated with 10 000 samples from the parameter distributions. The primary outcome was cost (2014 US dollars) per quality adjusted life year. RESULTS Treatment before LT yielded more quality-adjusted life year for less money than treatment after LT or nontreatment. Treatment before LT was cost-effective in 100% of samples at a willingness-to-pay threshold of US $100 000 in the base-case and when the analysis was restricted to Child B alone, Child C, or MELD > 15. Treatment before transplant was not cost-effective when MELD was 6-10. In sensitivity analyses, the MELD after which treatment before transplant was cost-effective was 13 and the maximum cost of LDV/SOF therapy at which treatment before LT is cost-effective is US $177 381. CONCLUSIONS From a societal perspective, HCV therapy using LDV/SOF with ribavirin before LT is the most cost-effective strategy for patients with decompensated cirrhosis and MELD score greater than 13.
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Precision monitoring of immunotherapies in solid organ and hematopoietic stem cell transplantation. Adv Drug Deliv Rev 2017. [PMID: 28625828 DOI: 10.1016/j.addr.2017.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Pharmacological immunotherapies are a key component of post-transplant therapy in solid-organ and hematopoietic stem cell transplantation. In current clinical practice, immunotherapies largely follow a one-size fits all approach, leaving a large portion of transplant recipients either over- or under-immunosuppressed, and consequently at risk of infections or immune-mediated complications. Our goal here is to review recent and rapid advances in precision and genomic medicine approaches to monitoring of post-transplant immunotherapies. We will discuss recent advances in precision measurements of pharmacological immunosuppression, measurements of the plasma and gut microbiome, strategies to monitor for allograft injury and post-transplant malignancies via circulating cell-free DNA, and comprehensive measurements of the B and T cell immune cell repertoire.
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Abstract
Hepatic retransplantation has been surgically challenging since the beginning of liver transplant. Outcomes have improved over time, but patient survival with retransplant continues to be significantly worse than that of primary transplant. Many studies have focused on factors to predict outcomes. Models have been developed to help predict risk, but the decision for retransplant must be a multidisciplinary transplant team decision. The question of "when is too much?" can be guided by recipient and donor factors but is an ethical decision that must be made by the liver transplant team.
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Affiliation(s)
- Jennifer Berumen
- Department of Abdominal Transplantation and Hepatobiliary Surgery, University of California, San Diego, La Jolla, CA 92037, USA.
| | - Alan Hemming
- Department of Abdominal Transplantation and Hepatobiliary Surgery, University of California, San Diego, La Jolla, CA 92037, USA
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Xue W, Tian P, Xiang H, Ding X, Pan X, Yan H, Hou J, Feng X, Liu L, Ding C, Tian X, Li Y, Zheng J. Outcomes for primary kidney transplantation from donation after Citizens' death in China: a single center experience of 367 cases. BMC Health Serv Res 2017; 17:250. [PMID: 28376778 PMCID: PMC5379606 DOI: 10.1186/s12913-017-2190-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 03/25/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The cases of donation after brain death followed by circulatory death (DBCD) and donation after cardiac death (DCD) have been increased year by year in China. Further research is needed to understand in the outcomes and risk factors of delayed graft function (DGF) in order to minimize the risk of DGF and ameliorate its potential impact on long-term outcomes. This study was to explore the differences in outcomes between DBCD and DCD transplant and the main risk factors for DGF in DBCD. METHODS Retrospective analysis of the clinical data of 367donations after citizens' death kidney transplant procedures (donors and recipients) between July 2012 and August 2015 at our center. RESULTS During the study period, the donation success rate was 25.3%. 164 cases of DBCD and 35 cases of DCD had been implemented and 367 kidneys were transplanted. The incidence of DGF in DBCD group were significantly lower than that of DCD group (12.0% vs. 27.0%, p = 0.002). The 1-year percent freedom from acute rejection (AR) was significantly higher in DBCD group compared with it of DCD group (94% vs. 82%, p = 0.036). Multivariate logistic regression analysis of the kidney transplants revealed that the high risk factors for DGF after renal transplantation in DBCD were history of hypertension (Odds Ratio [OR] = 5.88, 95% CI: 1.90 to 18.2, p = 0.002), low blood pressure (BP < 80 mmHg) (OR = 4.86, 95% CI: 1.58 to 14.9, p = 0.006) and serum creatinine of donor (OR = 1.09, 95% CI: 1.03 to 1.16, p = 0.003) before donation. CONCLUSIONS The outcomes of DBCD could be better than DCD in DGF and AR. The main risk factors for DGF in DBCD kidney transplants are donors with a history of hypertension, low blood pressure, and serum creatinine of donor before donation.
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Affiliation(s)
- Wujun Xue
- Department of Renal Transplant, Center of Nephropathy, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, 277 Yanta West Road, Xi’an, 710061 China
| | - Puxun Tian
- Department of Renal Transplant, Center of Nephropathy, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, 277 Yanta West Road, Xi’an, 710061 China
| | - Heli Xiang
- Department of Renal Transplant, Center of Nephropathy, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, 277 Yanta West Road, Xi’an, 710061 China
| | - Xiaoming Ding
- Department of Renal Transplant, Center of Nephropathy, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, 277 Yanta West Road, Xi’an, 710061 China
| | - Xiaoming Pan
- Department of Renal Transplant, Center of Nephropathy, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, 277 Yanta West Road, Xi’an, 710061 China
| | - Hang Yan
- Department of Renal Transplant, Center of Nephropathy, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, 277 Yanta West Road, Xi’an, 710061 China
| | - Jun Hou
- Department of Renal Transplant, Center of Nephropathy, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, 277 Yanta West Road, Xi’an, 710061 China
| | - Xinshun Feng
- Department of Renal Transplant, Center of Nephropathy, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, 277 Yanta West Road, Xi’an, 710061 China
| | - Linjuan Liu
- Department of Renal Transplant, Center of Nephropathy, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, 277 Yanta West Road, Xi’an, 710061 China
| | - Chenguang Ding
- Department of Renal Transplant, Center of Nephropathy, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, 277 Yanta West Road, Xi’an, 710061 China
| | - Xiaohui Tian
- Department of Renal Transplant, Center of Nephropathy, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, 277 Yanta West Road, Xi’an, 710061 China
| | - Yang Li
- Department of Renal Transplant, Center of Nephropathy, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, 277 Yanta West Road, Xi’an, 710061 China
| | - Jin Zheng
- Department of Renal Transplant, Center of Nephropathy, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, 277 Yanta West Road, Xi’an, 710061 China
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12
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Goldberg DS, French B, Lewis JD, Scott FI, Mamtani R, Gilroy R, Halpern SD, Abt PL. Liver transplant center variability in accepting organ offers and its impact on patient survival. J Hepatol 2016; 64:843-51. [PMID: 26626495 PMCID: PMC4799773 DOI: 10.1016/j.jhep.2015.11.015] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 11/12/2015] [Accepted: 11/15/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Despite an allocation system designed to give deceased-donor livers to the sickest patients, many transplantable livers are declined by U.S. transplant centers. It is unknown whether centers vary in their propensities to decline organs for the highest priority patients, and how these decisions directly impact patient outcomes. METHODS We analyzed Organ Procurement and Transplantation Network (OPTN) data from 5/1/07-6/17/13, and included all adult liver-alone waitlist candidates offered an organ that was ultimately transplanted. We evaluated acceptance rates of liver offers for the highest ranked patients and their subsequent waitlist mortality. RESULTS Of the 23,740 unique organ offers, 8882 (37.4%) were accepted for the first-ranked patient. Despite adjusting for organ quality and recipient severity of illness, transplant centers within and across geographic regions varied strikingly (p<0.001) in the percentage of organ offers they accepted for the highest priority patients. Among all patients ranked first on waitlists, the adjusted center-specific organ acceptance rates ranged from 15.7% to 58.1%. In multivariable models, there was a 27% increased odds of waitlist mortality for every 5% absolute decrease in a center's adjusted organ offer acceptance rate (adjusted OR: 1.27, 95% CI: 1.20-1.32). However, the absolute difference in median 5-year adjusted graft survival was 4% between livers accepted for the first-ranked patient, compared to those declined and transplanted at a lower position. CONCLUSION There is marked variability in center practices regarding accepting livers allocated to the highest priority patients. Center-level decisions to decline organs substantially increased patients' odds of dying on the waitlist without a transplant.
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Affiliation(s)
- David S. Goldberg
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania,Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Benjamin French
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania,Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - James D. Lewis
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania,Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Frank I Scott
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania
| | - Ronac Mamtani
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania
| | - Richard Gilroy
- Division of Gastroenterology, Department of Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Scott D. Halpern
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania,Leonard Davis Institute of Health Economics, University of Pennsylvania,Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter L Abt
- Division of Transplantation, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Chirichella TJ, Dunham CM, Zimmerman MA, Phelan EM, Mandell MS, Conzen KD, Kelley SE, Nydam TL, Bak TE, Kam I, Wachs ME. Donor preoperative oxygen delivery and post-extubation hypoxia impact donation after circulatory death hypoxic cholangiopathy. World J Gastroenterol 2016; 22:3392-3403. [PMID: 27022221 PMCID: PMC4806197 DOI: 10.3748/wjg.v22.i12.3392] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 10/06/2015] [Accepted: 12/01/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate donation after circulatory death (DCD) orthotopic liver transplant outcomes [hypoxic cholangiopathy (HC) and patient/graft survival] and donor risk-conditions.
METHODS: From 2003-2013, 45 DCD donor transplants were performed. Predonation physiologic data from UNOS DonorNet included preoperative systolic and diastolic blood pressure, heart rate, pH, SpO2, PaO2, FiO2, and hemoglobin. Mean arterial blood pressure was computed from the systolic and diastolic blood pressures. Donor preoperative arterial O2 content was computed as [hemoglobin (gm/dL) × 1.37 (mL O2/gm) × SpO2%) + (0.003 × PaO2)]. The amount of preoperative donor red blood cell transfusions given and vasopressor use during the intensive care unit stay were documented. Donors who were transfused ≥ 1 unit of red-cells or received ≥ 2 vasopressors in the preoperative period were categorized as the red-cell/multi-pressor group. Following withdrawal of life support, donor ischemia time was computed as the number-of-minutes from onset of diastolic blood pressure < 60 mmHg until aortic cross clamping. Donor hypoxemia time was the number-of-minutes from onset of pulse oximetry < 80% until clamping. Donor hypoxia score was (ischemia time + hypoxemia time) ÷ donor preoperative hemoglobin.
RESULTS: The 1, 3, and 5 year graft and patient survival rates were 83%, 77%, 60%; and 92%, 84%, and 72%, respectively. HC occurred in 49% with 16% requiring retransplant. HC occurred in donors with increased age (33.0 ± 10.6 years vs 25.6 ± 8.4 years, P = 0.014), less preoperative multiple vasopressors or red-cell transfusion (9.5% vs 54.6%, P = 0.002), lower preoperative hemoglobin (10.7 ± 2.2 gm/dL vs 12.3 ± 2.1 gm/dL, P = 0.017), lower preoperative arterial oxygen content (14.8 ± 2.8 mL O2/100 mL blood vs 16.8 ± 3.3 mL O2/100 mL blood, P = 0.049), greater hypoxia score >2.0 (69.6% vs 25.0%, P = 0.006), and increased preoperative mean arterial pressure (92.7 ± 16.2 mmHg vs 83.8 ± 18.5 mmHg, P = 0.10). HC was independently associated with age, multi-pressor/red-cell transfusion status, arterial oxygen content, hypoxia score, and mean arterial pressure (r2 = 0.6197). The transplantation rate was greater for the later period with more liberal donor selection [era 2 (7.1/year)], compared to our early experience [era 1 (2.5/year)]. HC occurred in 63.0% during era 2 and in 29.4% during era 1 (P = 0.03). Era 2 donors had longer times for extubation-to-asystole (14.4 ± 4.7 m vs 9.3 ± 4.5 m, P = 0.001), ischemia (13.9 ± 5.9 m vs 9.7 ± 5.6 m, P = 0.03), and hypoxemia (16.0 ± 5.1 m vs 11.1 ± 6.7 m, P = 0.013) and a higher hypoxia score > 2.0 rate (73.1% vs 28.6%, P = 0.006).
CONCLUSION: Easily measured donor indices, including a hypoxia score, provide an objective measure of DCD liver transplantation risk for recipient HC. Donor selection criteria influence HC rates.
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Goldberg DS, French B, Abt PL, Gilroy RK. Increasing the Number of Organ Transplants in the United States by Optimizing Donor Authorization Rates. Am J Transplant 2015; 15:2117-25. [PMID: 26031323 DOI: 10.1111/ajt.13362] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 02/23/2015] [Accepted: 02/26/2015] [Indexed: 01/25/2023]
Abstract
While recent policies have focused on allocating organs to patients most in need and lessening geographic disparities, the only mechanism to increase the actual number of transplants is to maximize the potential organ supply. We conducted a retrospective cohort study using OPTN data on all "eligible deaths" from 1/1/08 to 11/1/13 to evaluate variability in donor service area (DSA)-level donor authorization rates, and to quantify the potential gains associated with increasing authorization rates. Despite adjustments for donor demographics (age, race/ethnicity, cause of death) and geographic factors (rural/urban status of donor hospital, statewide participation in deceased-donor registries) among 52 571 eligible deaths, there was significant variability (p < 0.001) in donor authorization rates across the 58 DSAs. Overall DSA-level adjusted authorization rates ranged from 63.5% to 89.5% (median: 72.7%). An additional 773-1623 eligible deaths could have been authorized, yielding 2679-5710 total organs, if the DSAs with authorization rates below the median and 75th percentile, respectively, implemented interventions to perform at the level of the corresponding reference DSA. Opportunities exist within the current organ acquisition framework to markedly improve DSA-level donor authorization rates. Such initiatives would mitigate waitlist mortality while increasing the number of transplants.
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Affiliation(s)
- D S Goldberg
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - B French
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - P L Abt
- Division of Transplantation, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - R K Gilroy
- Center for Transplantation and Department of Medicine, University of Kansas Medical Center, Kansas City, KS
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Maduka RC, Abt PL, Goldberg DS. Use of model for end-stage liver disease exceptions for donation after cardiac death graft recipients relisted for liver transplantation. Liver Transpl 2015; 21:554-60. [PMID: 25597393 DOI: 10.1002/lt.24079] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 12/14/2014] [Accepted: 01/07/2015] [Indexed: 12/31/2022]
Abstract
Donation after cardiac death (DCD) liver transplantation is associated with increased biliary complications and graft failure. Yet for unclear reasons, DCD recipients relisted for transplantation have lower wait-list mortality than other retransplant candidates. We used Organ Procurement and Transplantation Network and United Network for Organ Sharing data from 2002 to 2011 to evaluate all DCD recipients relisted for transplantation to evaluate the impact of the utilization of Model for End-Stage Liver Disease (MELD) exception points on wait-list outcomes. Of 262 DCD recipients relisted for liver transplantation >2 weeks after initial transplantation, 82 (31.3%) applied for a nonstandardized MELD exception, and 68 (82.9%) had ≥1 exception approved. Of the relisted DCD recipients, 187 (71.4%) underwent retransplantation; among those with an approved MELD exception, 85.2% underwent retransplantation versus 57.1% of those with an exception denied and 69.4% of those not applying for an exception (P=0.02). In contrast, those receiving MELD exception points were significantly less likely to be removed from the wait list for death or clinical deterioration in comparison with those not applying for an exception (7.1% versus 19.4%, P=0.02). In multivariate models, patients with an approved exception were 3.3 times more likely to undergo retransplantation than those not applying for an exception. Standardized criteria for exception points among DCD recipients should be established to ensure uniform access to retransplantation.
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Affiliation(s)
- Richard C Maduka
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Skaro AI, Zhao L, Vanwagner LB, Abecassis MM. Access to retransplantation after failed donation after circulatory death liver transplantation: eo ire itum. Am J Transplant 2014; 14:991-3. [PMID: 24731190 DOI: 10.1111/ajt.12701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 01/14/2014] [Accepted: 01/28/2014] [Indexed: 01/25/2023]
Affiliation(s)
- A I Skaro
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
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