1
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Hann A, Nutu A, Clarke G, Patel I, Sneiders D, Oo YH, Hartog H, Perera MTPR. Normothermic Machine Perfusion—Improving the Supply of Transplantable Livers for High-Risk Recipients. Transpl Int 2022; 35:10460. [PMID: 35711320 PMCID: PMC9192954 DOI: 10.3389/ti.2022.10460] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/04/2022] [Indexed: 11/13/2022]
Abstract
The effectiveness of liver transplantation to cure numerous diseases, alleviate suffering, and improve patient survival has led to an ever increasing demand. Improvements in preoperative management, surgical technique, and postoperative care have allowed increasingly complicated and high-risk patients to be safely transplanted. As a result, many patients are safely transplanted in the modern era that would have been considered untransplantable in times gone by. Despite this, more gains are possible as the science behind transplantation is increasingly understood. Normothermic machine perfusion of liver grafts builds on these gains further by increasing the safe use of grafts with suboptimal features, through objective assessment of both hepatocyte and cholangiocyte function. This technology can minimize cold ischemia, but prolong total preservation time, with particular benefits for suboptimal grafts and surgically challenging recipients. In addition to more physiological and favorable preservation conditions for grafts with risk factors for poor outcome, the extended preservation time benefits operative logistics by allowing a careful explant and complicated vascular reconstruction when presented with challenging surgical scenarios. This technology represents a significant advancement in graft preservation techniques and the transplant community must continue to incorporate this technology to ensure the benefits of liver transplant are maximized.
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Affiliation(s)
- Angus Hann
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Centre for Liver and Gastrointestinal Research and NIHR Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Anisa Nutu
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - George Clarke
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Centre for Liver and Gastrointestinal Research and NIHR Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Ishaan Patel
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Dimitri Sneiders
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Ye H. Oo
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Centre for Liver and Gastrointestinal Research and NIHR Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Hermien Hartog
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - M. Thamara P. R. Perera
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Centre for Liver and Gastrointestinal Research and NIHR Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
- *Correspondence: M. Thamara P. R. Perera,
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2
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Brüggenwirth IMA, van Leeuwen OB, Porte RJ, Martins PN. The Emerging Role of Viability Testing During Liver Machine Perfusion. Liver Transpl 2022; 28:876-886. [PMID: 33963657 DOI: 10.1002/lt.26092] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 04/30/2021] [Indexed: 12/23/2022]
Abstract
The transplant community continues to be challenged by the disparity between the need for liver transplantation and the shortage of suitable donor organs. At the same time, the number of unused donor livers continues to increase, most likely attributed to the worsening quality of these organs. To date, there is no reliable marker of liver graft viability that can predict good posttransplant outcomes. Ex situ machine perfusion offers additional data to assess the viability of donor livers before transplantation. Hence, livers initially considered unsuitable for transplantation can be assessed during machine perfusion in terms of appearance and consistency, hemodynamics, and metabolic and excretory function. In addition, postoperative complications such as primary nonfunction or posttransplant cholangiopathy may be predicted and avoided. A variety of viability criteria have been used in machine perfusion, and to date there is no widely accepted composition of criteria for clinical use. This review discusses potential viability markers for hepatobiliary function during machine perfusion, describes current limitations, and provides future recommendations for the use of viability criteria in clinical liver transplantation.
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Affiliation(s)
- Isabel M A Brüggenwirth
- Department of Surgery, Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.,Division of Organ Transplantation, Department of Surgery, UMass Memorial Medical Center, University of Massachusetts, Worcester, MA
| | - Otto B van Leeuwen
- Department of Surgery, Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Robert J Porte
- Department of Surgery, Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Paulo N Martins
- Division of Organ Transplantation, Department of Surgery, UMass Memorial Medical Center, University of Massachusetts, Worcester, MA
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3
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A Single Center Experience of the Prognosis After Liver Transplantation From Discarded Graft Due to Poor Graft Conditions in Prioritized Centers. Transplant Proc 2022; 54:412-417. [DOI: 10.1016/j.transproceed.2021.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 10/28/2021] [Indexed: 02/07/2023]
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4
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Martins PN, Rizzari MD, Ghinolfi D, Jochmans I, Attia M, Jalan R, Friend PJ. Design, Analysis, and Pitfalls of Clinical Trials Using Ex Situ Liver Machine Perfusion: The International Liver Transplantation Society Consensus Guidelines. Transplantation 2021; 105:796-815. [PMID: 33760791 DOI: 10.1097/tp.0000000000003573] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Recent trials in liver machine perfusion (MP) have revealed unique challenges beyond those seen in most clinical studies. Correct trial design and interpretation of data are essential to avoid drawing conclusions that may compromise patient safety and increase costs. METHODS The International Liver Transplantation Society, through the Special Interest Group "DCD, Preservation and Machine Perfusion," established a working group to write consensus statements and guidelines on how future clinical trials in liver perfusion should be designed, with particular focus on relevant clinical endpoints and how different techniques of liver perfusion should be compared. Protocols, abstracts, and full published papers of clinical trials using liver MP were reviewed. The use of a simplified Grading of Recommendations Assessment, Development, and Evaluation working group (GRADE) system was attempted to assess the level of evidence. The working group presented its conclusions at the International Liver Transplantation Society consensus conference "DCD, Liver Preservation, and Machine Perfusion" held in Venice, Italy, on January 31, 2020. RESULTS Twelve recommendations were proposed with the main conclusions that clinical trials investigating the effect of MP in liver transplantation should (1) make the protocol publicly available before the start of the trial, (2) be adequately powered, and (3) carefully consider timing of randomization in function of the primary outcome. CONCLUSIONS There are issues with using accepted primary outcomes of liver transplantation trials in the context of MP trials, and no ideal endpoint could be defined by the working group. The setup of an international registry was considered vital by the working group.
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Affiliation(s)
- Paulo N Martins
- Division of Organ Transplantation, Department of Surgery, University of Massachusetts Memorial Hospital, University of Massachusetts, Worcester, MA
| | - Michael D Rizzari
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Davide Ghinolfi
- Division of Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Tuscany, Italy
| | - Ina Jochmans
- Transplantation Research Group, Lab of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Belgium
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Magdy Attia
- Department of Hepatobiliary & Transplantation Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, London, United Kingdom
| | - Peter J Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
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5
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Ziogas IA, Martins PN, Alexopoulos SP, Matsuoka LK, Rauf MA, Geevarghese SK, Gorden LD, Karp SJ, Perkins JD, Montenovo MI. Effect of Donor Transaminase Levels on Graft Survival Following Liver Transplant: An Analysis of the Organ Procurement and Transplantation Network Database. EXP CLIN TRANSPLANT 2021; 19:250-258. [PMID: 33605200 DOI: 10.6002/ect.2020.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Despite data showing equivalent outcomes between grafts from marginal versus standard criteria deceased liver donors, elevated donor transaminases constitute a frequent reason to decline potential livers. We assessed the effect of donor transaminase levels and other characteristics on graft survival. MATERIALS AND METHODS We performed a retrospective cohort analysis of adult first deceased donor liver transplant recipients with available transaminase levels registered in the Organ Procurement and Transplantation Network database (2008-2018). We used Cox proportional hazards regression to determine the effects of donor characteristics on graft survival. RESULTS Of 53 913 liver transplants, 52 158 were allografts from donors with low transaminases (≤ 500 U/L; group A) and 1755 were from donors with elevated transaminases (> 500 U/L; group B). Group A recipients were more likely to be hospitalized (P = .01) or in intensive care (P < .001) or to have mechanical assistance (P < .001), portal vein thrombosis (P = .01), diabetes mellitus (P = .003), or dialysis the week before liver transplant (P = .004). Multivariable analysis (controlling for recipient characteristics) showed donor risk factors of graft failure included diabetes mellitus (P < .001), donation after cardiac death (P < .001), total bilirubin > 3.5 mg/dL (P < .001), serum creatinine > 1.5 mg/dL (P = .01), and cold ischemia time > 6 hours (P < .001). Regional organ sharing showed lower risk of graft failure (P = .02). Donor transaminases > 500 U/L were not associated with graft failure (relative risk, 1.02; 95% CI, 0.91-1.14; P = .74). CONCLUSIONS Donor transaminases > 500 U/L should not preclude the use of liver grafts. Instead, donor total bilirubin > 3.5 mg/dL and serum creatinine > 1.5 mg/dL appear to be associated with higher likelihood of graft failure after liver transplant.
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Affiliation(s)
- Ioannis A Ziogas
- From the Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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6
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Bonaccorsi-Riani E, Brüggenwirth IMA, Buchwald JE, Iesari S, Martins PN. Machine Perfusion: Cold versus Warm, versus Neither. Update on Clinical Trials. Semin Liver Dis 2020; 40:264-281. [PMID: 32557478 DOI: 10.1055/s-0040-1713118] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Machine perfusion (MP) preservation is potentially one of the most significant improvements in the field of liver transplantation in the last 20 years, and it has been considered a promising strategy for improved preservation and ex situ evaluation of extended criteria donor (ECD) organs. However, MP preservation adds significant cost and logistical considerations to liver transplantation. MP protocols are mainly classified according to the perfusion temperature with hypothermic machine perfusion (HMP) and normothermic machine perfusion (NMP) being the two categories most studied so far. After extensive preclinical work, MP entered the clinical setting, and there are now several studies that demonstrated feasibility and safety. However, because of the limited quality of clinical trials, there is no compelling evidence of superiority in preservation quality, and liver MP is still considered experimental in most countries. MP preservation is moving to a more mature phase, where ongoing and future studies will bring new evidence in order to confirm their superiority in terms of clinical outcomes, organ utilization, and cost-effectiveness. Here, we present an overview of all preclinical MP studies using discarded human livers and liver MP clinical trials, and discuss their results. We describe the different perfusion protocols, pitfalls in MP study design, and provide future perspectives. Recent trials in liver MP have revealed unique challenges beyond those seen in most clinical studies. Randomized trials, correct trial design, and interpretation of data are essential to generate the data necessary to prove if MP will be the new gold standard method of liver preservation.
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Affiliation(s)
- E Bonaccorsi-Riani
- Abdominal Transplant Unit, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium.,Pôle de Chirurgie Expérimentale et Transplantation, Université Catholique de Louvain, Brussels, Belgium
| | - I M A Brüggenwirth
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - J E Buchwald
- Division of Transplant, Department of Surgery, UMass Memorial Medical Center, University of Massachusetts, Worcester, Massachusetts
| | - S Iesari
- Pôle de Chirurgie Expérimentale et Transplantation, Université Catholique de Louvain, Brussels, Belgium.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - P N Martins
- Division of Transplant, Department of Surgery, UMass Memorial Medical Center, University of Massachusetts, Worcester, Massachusetts
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7
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Deceased Brain Dead Donor Liver Transplantation and Utilization in the United States: Nighttime and Weekend Effects. Transplantation 2020; 103:1392-1404. [PMID: 30444802 DOI: 10.1097/tp.0000000000002533] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Understanding factors that contribute to liver discards and nonusage is urgently needed to improve organ utilization. METHODS Using Scientific Registry of Transplant Recipient data, we studied a national cohort of all US adult, deceased brain dead donor, isolated livers available for transplantation from 2003 to 2016, including organ-specific and system-wide factors that may affect organ procurement and discard rates. RESULTS Of 73 686 available livers, 65 316 (88.64%) were recovered for transplant, of which 6454 (9.88%) were ultimately discarded. Livers that were not procured or, on recovery, discarded were more frequently from older, heavier, hepatitis B virus (HCV)+, and more comorbid donors (P < 0.001). However, even after adjustment for organ quality, the odds of liver nonusage were 11% higher on the weekend (defined as donor procurements with cross-clamping occurring from 5:00 PM Friday until 11:59 AM Sunday) compared with weekdays (P < 0.001). Nonuse rates were also higher at night (P < 0.001), defined as donor procurements with cross-clamping occurring from 5:00 PM to 5:00 AM; however, weekend nights had significantly higher nonuse rates compared with weekday nights (P = 0.005). After Share 35, weekend nonusage rates decreased from 21.77% to 19.51% but were still higher than weekday nonusage rates (P = 0.065). Weekend liver nonusage was higher in all 11 United Network of Organ Sharing regions, with an absolute average of 2.00% fewer available livers being used on the weekend compared with weekdays. CONCLUSIONS Although unused livers frequently have unfavorable donor characteristics, there are also systemic and operational factors, including time of day and day of the week a liver becomes available, that impact the chance of liver nonprocurement and discard.
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8
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Goldaracena N, Cullen JM, Kim DS, Ekser B, Halazun KJ. Expanding the donor pool for liver transplantation with marginal donors. Int J Surg 2020; 82S:30-35. [PMID: 32422385 DOI: 10.1016/j.ijsu.2020.05.024] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 05/06/2020] [Accepted: 05/12/2020] [Indexed: 12/16/2022]
Abstract
The current supply of acceptable donor livers is not sufficient to meet the demands of listed patients awaiting transplantation resulting in thousands of deaths each year. Increased utilization of marginal livers may help alleviate this supply/demand mismatch by expanding the donor liver pool. The current status of liver transplantation using marginal donor grafts and efforts to optimize usage are discussed with attention to elderly donors, steatotic livers, donors after circulatory death, and split liver grafts.
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Affiliation(s)
- Nicolas Goldaracena
- Department of Surgery, Division of Transplant Surgery, University of Virginia, Charlottesville, VA, USA.
| | - J Michael Cullen
- Department of Surgery, Division of Transplant Surgery, University of Virginia, Charlottesville, VA, USA.
| | - Dong-Sik Kim
- Division of HBP Surgery & Liver Transplantation, Department of Surgery, Korea University College of Medicine, Seoul, South Korea.
| | - Burcin Ekser
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Karim J Halazun
- Department of Surgery, Division of Liver Transplantation and Hepatobiliary Surgery, Weill Cornell Medical College, New York, NY, USA.
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9
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Resch T, Cardini B, Oberhuber R, Weissenbacher A, Dumfarth J, Krapf C, Boesmueller C, Oefner D, Grimm M, Schneeberger S. Transplanting Marginal Organs in the Era of Modern Machine Perfusion and Advanced Organ Monitoring. Front Immunol 2020; 11:631. [PMID: 32477321 PMCID: PMC7235363 DOI: 10.3389/fimmu.2020.00631] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/19/2020] [Indexed: 12/11/2022] Open
Abstract
Organ transplantation is undergoing profound changes. Contraindications for donation have been revised in order to better meet the organ demand. The use of lower-quality organs and organs with greater preoperative damage, including those from donation after cardiac death (DCD), has become an established routine but increases the risk of graft malfunction. This risk is further aggravated by ischemia and reperfusion injury (IRI) in the process of transplantation. These circumstances demand a preservation technology that ameliorates IRI and allows for assessment of viability and function prior to transplantation. Oxygenated hypothermic and normothermic machine perfusion (MP) have emerged as valid novel modalities for advanced organ preservation and conditioning. Ex vivo prolonged lung preservation has resulted in successful transplantation of high-risk donor lungs. Normothermic MP of hearts and livers has displayed safe (heart) and superior (liver) preservation in randomized controlled trials (RCT). Normothermic kidney preservation for 24 h was recently established. Early clinical outcomes beyond the market entry trials indicate bioenergetics reconditioning, improved preservation of structures subject to IRI, and significant prolongation of the preservation time. The monitoring of perfusion parameters, the biochemical investigation of preservation fluids, and the assessment of tissue viability and bioenergetics function now offer a comprehensive assessment of organ quality and function ex situ. Gene and protein expression profiling, investigation of passenger leukocytes, and advanced imaging may further enhance the understanding of the condition of an organ during MP. In addition, MP offers a platform for organ reconditioning and regeneration and hence catalyzes the clinical realization of tissue engineering. Organ modification may include immunological modification and the generation of chimeric organs. While these ideas are not conceptually new, MP now offers a platform for clinical realization. Defatting of steatotic livers, modulation of inflammation during preservation in lungs, vasodilatation of livers, and hepatitis C elimination have been successfully demonstrated in experimental and clinical trials. Targeted treatment of lesions and surgical treatment or graft modification have been attempted. In this review, we address the current state of MP and advanced organ monitoring and speculate about logical future steps and how this evolution of a novel technology can result in a medial revolution.
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Affiliation(s)
- Thomas Resch
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Annemarie Weissenbacher
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Julia Dumfarth
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Christoph Krapf
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudia Boesmueller
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Oefner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Grimm
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Sefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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10
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Contreras AG, McCormack L, Andraus W, de Souza M Fernandes E. Current status of liver transplantation in Latin America. Int J Surg 2020; 82S:14-21. [PMID: 32247089 DOI: 10.1016/j.ijsu.2020.03.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/06/2020] [Accepted: 03/18/2020] [Indexed: 01/05/2023]
Abstract
The lack of adequate financial coverage, education, and the organization has been the main limiting factor for the development of transplantation in Latin America. As occurred worldwide, the number of patients on liver waiting lists in Latin America grows disproportionately compared to the number of liver transplantations (LTs) performed. Although many law modifications have been made in the last year, most countries lack social awareness about the importance of donation and the irreversibility of brain death. The mechanisms and norms for organ procurement and infrastructure development, capable of supporting this high demand, are still in slow progress in most countries. Access to LT in the region is very heterogeneous. While some countries have no active LT programs so far, others are an international model of a public transplantation system (Brazil) or a national information system (Argentina). While some countries have only a few LT centers, others have too many LT centers performing an inadequate low number of LTs. Disparity to access transplantation remains the major challenge in the region. Cultural and educational efforts have to be accompanied by transparent public policies that will likely increase organ donation and activity in transplantation. The purpose of this article is to review the trends and current activity in LT within Latin America, based on prior publications and the information available in each country of the region.
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Affiliation(s)
- Alan G Contreras
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico.
| | - Lucas McCormack
- Department of Surgery, Hospital Aleman, Buenos Aires, Argentina
| | - Wellington Andraus
- Digestive Organs Transplant Division, Gastroenterology Department, Sao Paulo University School of Medicine, Sao Paulo, Brazil
| | - Eduardo de Souza M Fernandes
- Department of Surgery, Rio de Janeiro Federal University, Department of Surgery and Abdominal Organ Transplant, São Lucas Hospital, Copacabana, Brazil
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11
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Azoulay D, Disabato M, Gomez-Gavara C, Feray C, Salloum C, Ngonggang N, Winter A, Hentati H, Levesque E, Lim C, Compagnon P. Liver Transplantation with "Hors Tour" Allocated Versus Standard MELD Allocated Grafts: Single-Center Audit and Impact on the Liver Pool in France. World J Surg 2019; 44:912-924. [PMID: 31832704 DOI: 10.1007/s00268-019-05271-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The French transplant governing system defined "Rescue" (the so-called "Hors Tour") livers as those livers which were declined for the five top-listed patients. This study compares the outcomes following liver transplantation (LT) in patients who received a donor liver through a rescue allocation (RA) procedure or according to MELD score priority (standard allocation, SA) and evaluates the impact on the graft pool of a proactive policy to accept RA grafts. METHODS Data from all consecutive patients who underwent LT with SA or RA grafts from 2011 to 2015 were compared in terms of short- and long-term outcomes. RESULTS The 249 elective first LTs were performed with 64 (25.7%) RA and 185 (74.3%) SA grafts. RA grafts were obtained from older donors and were associated with a longer cold ischemia time. Recipients of RA livers were older and had lower MELD scores. The rates of delayed graft function, primary nonfunction, retransplantation, complications, and mortality were similar between the RA and SA groups. At 1 and 3 and 5 years, graft and patient survival rates were similar between the groups. These results were maintained after matching on recipient characteristics. Our proactive policy to accept RA grafts increased the liver pool for elective first transplantation by 25%. CONCLUSIONS RA livers can be safely transplanted into selected recipients and significantly expand the liver pool.
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Affiliation(s)
- Daniel Azoulay
- Centre Hépato-Biliaire, Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Paul Brousse Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Sud, Avenue Paul Vaillant Couturier, 94000, Villejuif, France.
- Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Mara Disabato
- Department of Hepatobiliary Surgery and Transplantation, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France
| | - Concepcion Gomez-Gavara
- Department of Hépato-Pancreato-Biliary and Transplant Surgery, Vall d'Hébron University Hospital, Barcelona, Spain
| | - Cyrille Feray
- Department of Hepatology, Paul Brousse Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Sud, Villejuif, France
| | - Chady Salloum
- Centre Hépato-Biliaire, Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Paul Brousse Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Sud, Avenue Paul Vaillant Couturier, 94000, Villejuif, France
| | - Norbert Ngonggang
- Department of Hepatobiliary Surgery and Transplantation, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France
| | - Audrey Winter
- Laboratoire de Biostatistique, IURC, Montpellier, France
| | - Hassen Hentati
- Department of Hepatobiliary Surgery and Transplantation, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France
| | - Eric Levesque
- Department of Anesthesia and Liver Intensive Care Unit, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France
| | - Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Philippe Compagnon
- Department of Hepatobiliary Surgery and Transplantation, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France
- Service de Transplantation, Hôpitaux Universitaires de Genève, Université de Genève, Faculté de Médecine, Geneva, Switzerland
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12
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Zhang Y, Zhang Y, Zhang M, Ma Z, Wu S. Hypothermic machine perfusion reduces the incidences of early allograft dysfunction and biliary complications and improves 1-year graft survival after human liver transplantation: A meta-analysis. Medicine (Baltimore) 2019; 98:e16033. [PMID: 31169745 PMCID: PMC6571373 DOI: 10.1097/md.0000000000016033] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The worldwide organ shortage continues to be the main limitation of liver transplantation. To bridge the gap between the demand and supply of liver grafts, it becomes necessary to use extended criteria donor livers for transplantation. Hypothermic machine perfusion (HMP) is designed to improve the quality of preserved organs before implantation. In clinical liver transplantation, HMP is still in its infancy. METHODS A systematic search of the PubMed, EMBASE, Springer, and Cochrane Library databases was performed to identify studies comparing the outcomes in patients with HMP versus static cold storage (SCS) of liver grafts. The parameters analyzed included the incidences of primary nonfunction (PNF), early allograft dysfunction (EAD), vascular complications, biliary complications, length of hospital stay, and 1-year graft survival. RESULTS A total of 6 studies qualified for the review, involving 144 and 178 liver grafts with HMP or SCS preservation, respectively. The incidences of EAD and biliary complications were significantly reduced with an odds ratio (OR) of 0.36 (95% confidence interval [CI] 0.17-0.77, P = .008) and 0.47 (95% CI 0.28-0.76, P = .003), respectively, and 1-year graft survival was significantly increased with an OR of 2.19 (95% CI 1.14-4.20, P = .02) in HMP preservation compared to SCS. However, there was no difference in the incidence of PNF (OR 0.30, 95% CI 0.06-1.47, P = .14), vascular complications (OR 0.69, 95% CI 0.29-1.66, P = .41), and the length of hospital stay (mean difference -0.30, 95% CI -4.10 to 3.50, P = .88) between HMP and SCS preservation. CONCLUSIONS HMP was associated with a reduced incidence of EAD and biliary complications, as well as an increased 1-year graft survival, but it was not associated with the incidence of PNF, vascular complications, and the length of hospital stay.
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Affiliation(s)
- Yili Zhang
- Department of Medical Imaging, The First Affiliated Hospital of Xi’an Jiaotong University
| | - Yangmin Zhang
- Department of Blood Transfusion, Xi’an Central Hospital
| | - Mei Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Zhenhua Ma
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Shengli Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
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13
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Utilization of Declined Liver Grafts Yields Comparable Transplant Outcomes and Previous Decline Should Not Be a Deterrent to Graft Use. Transplantation 2019; 102:e211-e218. [PMID: 29702538 DOI: 10.1097/tp.0000000000002127] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND In the United Kingdom, up to 20% of liver graft offers are not used for transplantation, and the reasons for graft refusal are multifactorial and not consistent among transplant units. METHODS Liver grafts previously declined by other transplant centers in the United Kingdom but transplanted in our unit in Birmingham between 2011 and 2015 were analyzed. According to the indicated reason for previous declines, liver grafts were categorized into 3 refusal groups: "quality," "logistics," and "other reasons." Results were compared with a matched, low-risk cohort of livers primarily accepted and transplanted at our center. RESULTS During the study period, 206 livers (donation after brain death: n = 141 (68.4%); donation after circulatory arrest: n = 65 (31.6%) were transplanted, which were previously discarded by a median of 4 other UK centers. The majority of declines were donor quality (n = 102; 49.5%), refusals followed by logistics (n = 45; 21.8%), and other reasons (n = 59; 28.6%). Transplantation from both graft types (donation after brain death and donation after circulatory arrest) and all 3 refusal groups achieved equally good outcomes with an overall low complication rate. The incidence of primary nonfunction (2.4% vs 1.7%; P = 0.5483), in-hospital mortality (6.3% vs 4.1%; P = 0.2293) and 3-year graft (82.5% vs 84.1%; P = 0.6872) and patient (85.4% vs 87.6%; P = 0.8623) survival was comparable between livers previously declined and livers primarily accepted and transplanted at our center. CONCLUSIONS Transplantation of declined livers can achieve comparable outcomes to primary liver low-risk graft offers. Previous refusal should not be taken as a barrier to use the graft, and with appropriate recipient selection, more lives could be saved.
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14
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Quillin RC, Guarrera JV. Hypothermic machine perfusion in liver transplantation. Liver Transpl 2018; 24:276-281. [PMID: 29278454 DOI: 10.1002/lt.25004] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 12/21/2017] [Indexed: 12/12/2022]
Abstract
A finite supply of donor organs has led many transplant centers to accept marginal liver allografts with increasing frequency. These allografts may be at higher risk of primary nonfunction, early allograft dysfunction, and other recipient complications following liver transplantation. Machine perfusion preservation is an emerging technology that limits ischemia/reperfusion injury associated with preservation and may lead to improved outcomes following transplantation. Increased used of machine perfusion in liver preservation may permit an expansion of the donor pool. In this review, we examine the major clinical experience of hypothermic machine perfusion in human liver transplantation.Liver Transplantation 24 276-281 2018 AASLD.
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Affiliation(s)
- R Cutler Quillin
- From the Center for Liver Disease and Transplantation, Department of Surgery, Columbia University Medical Center, New York, NY
| | - James V Guarrera
- From the Center for Liver Disease and Transplantation, Department of Surgery, Columbia University Medical Center, New York, NY
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15
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Nure E, Lirosi MC, Frongillo F, Bianco G, Silvestrini N, Fiorillo C, Sganga G, Agnes S. Overextended Criteria Donors: Experience of an Italian Transplantation Center. Transplant Proc 2016; 47:2102-5. [PMID: 26361653 DOI: 10.1016/j.transproceed.2014.11.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 11/19/2014] [Indexed: 02/06/2023]
Abstract
The increasing gap between the number of patients who could benefit from liver transplantation and the number of available donors has fueled efforts to maximize the donor pool using marginal grafts that usually were discarded for transplantation. This study included data of all patients who received decreased donor liver grafts between January 2004 and January 2013 (n = 218) with the use of a prospectively collected database. Patients with acute liver failure, retransplantation, pediatric transplantation, and split liver transplantation were excluded. Donors were classified as standard donor (SD), extended criteria donor (ECD), and overextended criteria donor (OECD). The primary endpoints of the study were early allograft primary dysfunction (PDF), primary nonfunction (PNF), and patient survival (PS), whereas incidence of major postoperative complications was the secondary endpoint. In our series we demonstrated that OECD have similar outcome in terms of survival and incidence of complication after liver transplantation as ideal grafts.
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Affiliation(s)
- E Nure
- Department of Surgery-Transplantation Service, Catholic University of the Sacred Heart, Policlinico "A. Gemelli," Rome, Italy
| | - M C Lirosi
- Department of Surgery-Transplantation Service, Catholic University of the Sacred Heart, Policlinico "A. Gemelli," Rome, Italy.
| | - F Frongillo
- Department of Surgery-Transplantation Service, Catholic University of the Sacred Heart, Policlinico "A. Gemelli," Rome, Italy
| | - G Bianco
- Department of Surgery-Transplantation Service, Catholic University of the Sacred Heart, Policlinico "A. Gemelli," Rome, Italy
| | - N Silvestrini
- Department of Surgery-Transplantation Service, Catholic University of the Sacred Heart, Policlinico "A. Gemelli," Rome, Italy
| | - C Fiorillo
- Department of Surgery-Transplantation Service, Catholic University of the Sacred Heart, Policlinico "A. Gemelli," Rome, Italy
| | - G Sganga
- Department of Surgery-Transplantation Service, Catholic University of the Sacred Heart, Policlinico "A. Gemelli," Rome, Italy
| | - S Agnes
- Department of Surgery-Transplantation Service, Catholic University of the Sacred Heart, Policlinico "A. Gemelli," Rome, Italy
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16
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Mas VR. Ischemia/reperfusion, does temperature matter? Laboratory perspective. Liver Transpl 2015; 21 Suppl 1:S1-5. [PMID: 26334928 DOI: 10.1002/lt.24322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 08/24/2015] [Accepted: 09/01/2015] [Indexed: 01/13/2023]
Affiliation(s)
- Valeria R Mas
- Translational Genomics Transplant Laboratory, Transplant Division, Department of Surgery, University of Virginia, Charlottesville, VA
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17
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Guarrera JV, Henry SD, Samstein B, Reznik E, Musat C, Lukose TI, Ratner LE, Brown RS, Kato T, Emond JC. Hypothermic machine preservation facilitates successful transplantation of "orphan" extended criteria donor livers. Am J Transplant 2015; 15:161-9. [PMID: 25521639 DOI: 10.1111/ajt.12958] [Citation(s) in RCA: 233] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/21/2014] [Accepted: 07/22/2014] [Indexed: 02/06/2023]
Abstract
Hypothermic machine preservation (HMP) remains investigational in clinical liver transplantation. It is widely used to preserve kidneys for transplantation with improved results over static cold storage (SCS). At our center, we have used HMP in 31 adults receiving extended criteria donor (ECD) livers declined by the originating United Network for Organ Sharing region ("orphan livers"). These cases were compared to ECD SCS cases in a matched cohort study design. Livers were matched for donor age, recipient age, cold ischemic time, donor risk index and Model for End-Stage Liver Disease (MELD) score. HMP was performed for 3-7 h at 4-8 °C using our previously published protocol. Early allograft dysfunction rates were 19% in the HMP group versus 30% in the control group (p = 0.384). One-year patient survival was 84% in the HMP group versus 80% in the SCS group (p = NS). Post hoc analysis revealed significantly less biliary complications in the HMP group versus the SCS group (4 vs. 13, p = 0.016). Mean hospital stay was significantly shorter in the HMP group (13.64 ± 10.9 vs. 20.14 ± 11.12 days in the SCS group, p = 0.001). HMP provided safe and reliable preservation in orphan livers transplanted at our center.
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Affiliation(s)
- J V Guarrera
- Center for Liver Disease and Transplantation, Department of Surgery, Columbia University Medical Center, New York, NY
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18
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Maggi U, Nita G, Gatti S, Antonelli B, Paolo R, Como G, Messa P, Rossi G. Hyperbilirubinemia after liver transplantation: the role of coupled plasma filtration adsorption. Transplant Proc 2014; 45:2715-7. [PMID: 24034030 DOI: 10.1016/j.transproceed.2013.07.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Hyperbilirubinemia often accompanies liver failure; therefore, artificial liver support devices are currently used as a bridge to more definitive treatments to eliminate water-soluble and albumin-bound toxins. We report 2 patients, of which, after liver transplantation, the first experienced early allograft dysfunction and the other hyperbilirubinemia linked to chronic rejection. After 3 cycles of coupled plasma filtration adsorption (CPFA), the bilirubin promptly decreased in both cases. CPFA is an extracorporeal therapy that uses plasma filtration associated with an adsorbent cartridge and hemofiltration to remove cytokines and inflammatory mediators associated with septic shock, severe sepsis, and multiple organ dysfunction syndrome. Each cycle of treatment lowered the bilirubin of our patients by ∼40%. CPFA deserves attention as a potential inexpensive short-lasting device to treat hyperbilirubinemia after liver surgery or transplantation. Moreover, the effects of CPFA should be further studied to address inflammatory mediators in chronic rejection after liver transplantation or other immunologic disorders.
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Affiliation(s)
- U Maggi
- UO Chirurgia Generale e Trapianti di Fegato, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Milano, Italy; Department of Digestive and Hepatobiliary Surgery, AP-HP, UFR de Médecine de 1'Université Paris XII-Créteil, France.
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19
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Liver Transplantation without Perioperative Transfusions Single-Center Experience Showing Better Early Outcome and Shorter Hospital Stay. J Transplant 2013; 2013:649209. [PMID: 24455193 PMCID: PMC3876589 DOI: 10.1155/2013/649209] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 11/17/2013] [Indexed: 12/14/2022] Open
Abstract
Background. Significant amounts of red blood cells (RBCs) transfusions are associated with poor outcome after liver transplantation (LT). We report our series of LT without perioperative RBC (P-RBC) transfusions to evaluate its influence on early and long-term outcomes following LT. Methods. A consecutive series of LT between 2006 and 2011 was analyzed. P-RBC transfusion was defined as one or more RBC units administrated during or ≤48 hours after LT. We divided the cohort in “No-Transfusion” and “Yes-Transfusion.” Preoperative status, graft quality, and intra- and postoperative variables were compared to assess P-RBC transfusion risk factors and postoperative outcome. Results. LT was performed in 127 patients (“No-Transfusion” = 39 versus “Yes-Transfusion” = 88). While median MELD was significantly higher in Yes-Transfusion (11 versus 21; P = 0.0001) group, platelet count, prothrombin time, and hemoglobin were significantly lower. On multivariate analysis, the unique independent risk factor associated with P-RBC transfusions was preoperative hemoglobin (P < 0.001). Incidence of postoperative bacterial infections (10 versus 27%; P = 0.03), median ICU (2 versus 3 days; P = 0.03), and hospital stay (7.5 versus 9 days; P = 0.01) were negatively influenced by P-RBC transfusions. However, 30-day mortality (10 versus 15%) and one- (86 versus 70%) and 3-year (77 versus 66%) survival were equivalent in both groups. Conclusions. Recipient MELD score was not a predictive factor for P-RBC transfusion. Patients requiring P-RBC transfusions had worse postoperative outcome. Therefore, maximum efforts must be focused on improving hemoglobin levels during waiting list time to prevent using P-RBC in LT recipients.
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20
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McCormack L, Quiñónez E, Goldaracena N, Anders M, Rodríguez V, Orozco Ganem F, Mastai RC. Liver transplantation using Chagas-infected donors in uninfected recipients: a single-center experience without prophylactic therapy. Am J Transplant 2012; 12:2832-7. [PMID: 22813351 DOI: 10.1111/j.1600-6143.2012.04160.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Organ shortage is the first cause of death on liver transplant waiting lists. As a consequence, we recently decided to expand liver acceptance to those organs that could potentially transmit infectious diseases to their recipients. On January 2010, we initiated a prospective protocol using livers from Chagas-infected donors for transplanting uninfected recipients without using prophylactic therapy. During a 13-month period, 9 of 37 (24%) liver transplants were performed within this protocol. After transplant, each recipient was sequentially and strictly monitored for infection transmission using the Strout method and promptly treated with benznidazole if this occurs. During follow-up, two patients died without Chagas infection and only two (donor-derived T. cruzi transmission rate: 2/9; 22%) patients developed donor-derived Chagas transmission without clinical symptoms. The median follow-up time of the seven live patients was 15 months (range: 13-20). At present, all are symptoms-free with excellent allograft function and without evidence of Chagas disease. In conclusion, we consider that Chagas-infected donors are a promising source of liver grafts that could reduce the growing mortality on liver waiting lists in America. Relevant data from larger prospective studies are required to confirm these preliminary excellent results.
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Affiliation(s)
- L McCormack
- Liver Surgery and Transplantation Unit, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina.
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21
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Goldaracena N, Quiñonez E, Méndez P, Anders M, Orozco Ganem F, Mastai R, McCormack L. Extremely Marginal Liver Grafts From Deceased Donors Have Outcome Similar to Ideal Grafts. Transplant Proc 2012; 44:2219-22. [DOI: 10.1016/j.transproceed.2012.07.113] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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22
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Goldaracena N, Wolf MM, Quiñonez E, Anders M, Mastai R, McCormack L. Is it safe to use a liver graft from a Chagas disease-seropositive donor in a human immunodeficiency virus-positive recipient? A case report addressing a novel challenge in liver transplantation. Liver Transpl 2012; 18:979-83. [PMID: 22508549 DOI: 10.1002/lt.23452] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This is the first report presenting a human immunodeficiency virus (HIV)-positive patient with fulminant hepatic failure receiving a liver graft from a Chagas disease-seropositive deceased donor. We describe the history of a 38-year-old HIV-positive female patient who developed fulminant hepatic failure of an autoimmune etiology with rapid deterioration of her clinical status and secondary multiorgan failure and, therefore, needed emergency liver transplantation (LT) as a lifesaving procedure. Because of the scarcity of organs and the high mortality rate for emergency status patients on the LT waiting list, we decided to accept a Chagas disease-seropositive deceased donor liver graft for this immunocompromised Chagas disease-seronegative patient. The recipient had a rapid postoperative recovery and was discharged on postoperative day 9 without prophylactic treatment for Chagas disease. Fifteen months after LT, she was still alive and had never experienced seroconversion on periodic screening tests for Chagas detection. Although there is an inherent risk of acute Chagas disease developing in seronegative recipients, our report suggests that these infected organs can be safely used as a lifesaving strategy for HIV patients with a high need for LT.
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Affiliation(s)
- Nicolás Goldaracena
- Liver Surgery and Transplantation Unit, Hospital Alemán, Buenos Aires, Argentina
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