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Wang S, Lin X, Tang Y, Liang Y, Zhang M, Xie Z, Guo Y, Dong Y, Zhao Q, Guo Z, Wang D, He X, Ju W, Chen M. Ischemia-free liver transplantation improves the prognosis of recipients using functionally marginal liver grafts. Clin Mol Hepatol 2024; 30:421-435. [PMID: 38600871 PMCID: PMC11261232 DOI: 10.3350/cmh.2024.0139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/23/2024] [Accepted: 04/11/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND/AIMS The shortage of donor liver hinders the development of liver transplantation. This study aimed to clarify the poor outcomes of functionally marginal liver grafts (FMLs) and provide evidence for the improvement of ischemia-free liver transplantation (IFLT) after FML transplantation. METHODS Propensity score matching was used to control for confounding factors. The outcomes of the control group and FML group were compared to demonstrate the negative impact of FMLs on liver transplantation patients. We compared the clinical improvements of the different surgical types. To elucidate the underlying mechanism, we conducted bioinformatic analysis based on transcriptome and single-cell profiles. RESULTS FMLs had a significantly greater hazard ratio (HR: 1.969, P=0.018) than did other marginal livers. A worse 90-day survival (Mortality: 12.3% vs. 5.0%, P=0.007) was observed in patients who underwent FML transplantation. Patients who received FMLs had a significant improvement in overall survival after IFLT (Mortality: 10.4% vs 31.3%, P=0.006). Pyroptosis and inflammation were inhibited in patients who underwent IFLT. The infiltration of natural killer cells was lower in liver grafts from these patients. Bulk transcriptome profiles revealed a positive relationship between IL-32 and Caspase 1 (R=0.73, P=0.01) and between IL-32 and Gasdermin D (R=0.84, P=0.0012). CONCLUSION FML is a more important negative prognostic parameter than other marginal liver parameters. IFLT might ameliorate liver injury in FMLs by inhibiting the infiltration of NK cells, consequently leading to the abortion of IL-32, which drives pyroptosis in monocytes and macrophages.
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Affiliation(s)
- Shuai Wang
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Xiaohong Lin
- Department of Thyroid and Breast Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Yunhua Tang
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Yichen Liang
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Min Zhang
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Zhonghao Xie
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Yiwen Guo
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Yuqi Dong
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Qiang Zhao
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Zhiyong Guo
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Dongping Wang
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Xiaoshun He
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Weiqiang Ju
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Maogen Chen
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
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Holmaas G, Hilton E, Foss S, Wathle GK, Kvåle R. Potential organ donors during two years at the second largest hospital in Norway. Acta Anaesthesiol Scand 2024. [PMID: 38801275 DOI: 10.1111/aas.14455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 04/29/2024] [Accepted: 05/10/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Western Norway has the lowest number of actual deceased organ donors per million inhabitants in Norway. We wished to find the total number of potential donors and donor organs during 2 years at Haukeland University Hospital, the largest hospital in the region, and evaluate where and why potential donors were lost. METHODS We evaluated all patients who died at Haukeland University Hospital in 2018-19. We checked if intensive care patients, filling the criteria as organ donors after brain death, became donors, and the reasons why potential donors were lost. We also estimated the number of potential donors after circulatory death. We checked if patients transferred from the intensive care units and patients never admitted to intensive care were potential donors. Location, gender, age, and possible number of organs were registered. RESULTS Of 1453 in-hospital deaths, 20 brain-dead patients became actual donors. One brain-dead and two other potential donors, one of them discharged to a bed ward, were not evaluated at the intensive care units. Relatives refused in five patients. Three fulfilled the Norwegian criteria from 2021 as organ donors after circulatory death. Ten potential donors after brain death were never admitted to intensive care and died on neurological or neurosurgical wards. If all potential organ donors were realised, the number of donors would double. The number of transplanted organs would increase less, as organs used per donor would drop from 3.50 to 2.90. CONCLUSION Our study cannot explain the low number of donors in our region compared with the rest of Norway. If all potential donations were implemented, the number of actual donors would double. Patients dying outside the intensive care units represent the largest potential source for extra donors, maximally increasing the number of donors by 42%, high-quality livers 44% and kidneys 18%. Introducing organ donation after circulatory death may increase the number of donors by 15% and the number of high-quality livers and kidneys by 12%.
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Affiliation(s)
- Gunhild Holmaas
- Department of Surgical Services, Haukeland University Hospital, Bergen, Norway
| | - Edle Hilton
- Medical Faculty, University of Bergen, Bergen, Norway
| | - Stein Foss
- Unit of Transplantation, Oslo University Hospital, Oslo, Norway
| | - Gaute K Wathle
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
| | - Reidar Kvåle
- Department of Surgical Services, Haukeland University Hospital, Bergen, Norway
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Galli AM, Kothari R, Adelmann D, Holm Z, Bokoch MP, De Gasperi A, Niemann CU, Kolodzie K. Lactate concentration at the end of liver transplant: Early predictor of graft function or just one piece of the puzzle? Clin Transplant 2023; 37:e15057. [PMID: 37350743 DOI: 10.1111/ctr.15057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 05/05/2023] [Accepted: 06/11/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND The post-operative course after Liver Transplantation (LT) can be complicated by early allograft dysfunction (EAD), primary nonfunction (PNF) and death. A lactate concentration at the end of transplant of ≥5 mmol/L was recently proposed as a predictive marker of PNF, EAD, and mortality; this study aimed to validate these previous reports in a large single center cohort. METHODS This retrospective cohort study included adult liver transplant recipients who received grafts from deceased donors at our center between June 2012 and May 2021. Receiver operating characteristic (ROC) curves for the lactate concentration at the end of transplantation were computed to determine the AUC for PNF, EAD and mortality at 90 days. RESULTS In our cohort of 1137 cases, the AUCs for lactate to predict EAD, PNF and mortality were respectively .56 (95% confidence interval [CI]: .53-.60), .69 (95% CI: .52-.85), and .74 (95% CI: .63-.84). CONCLUSION The clinical value of lactate concentration at the end of transplantation to predict PNF, EAD and mortality at 90 days was, at best, modest, as shown by the relatively low AUCs. Our findings cannot validate previous reports that the lactate level alone is a good predictor of poor outcomes after liver transplantation.
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Affiliation(s)
- Alessandro M Galli
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
- Department of Critical Care Medicine and Anesthesia, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Rishi Kothari
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Dieter Adelmann
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Zacharias Holm
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
- University of Copenhagen, Copenhagen, Denmark
| | - Michael P Bokoch
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Andrea De Gasperi
- Division of Transplant Surgery, Department of Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Claus U Niemann
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Kerstin Kolodzie
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
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Braga VS, Boteon APCS, Paglione HB, Pecora RAA, Boteon YL. Extended criteria brain-dead organ donors: Prevalence and impact on the utilisation of livers for transplantation in Brazil. World J Hepatol 2023; 15:255-264. [PMID: 36926240 PMCID: PMC10011911 DOI: 10.4254/wjh.v15.i2.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/17/2022] [Accepted: 01/31/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Despite its association with higher postoperative morbidity and mortality, the use of extended criteria donor (ECD) livers for transplantation has increased globally due to the high demand for the procedure.
AIM To investigate the prevalence of ECD in donation after brain death (DBD) and its impact on organ acceptance for transplantation.
METHODS Retrospective analysis of DBD organ offers for liver transplantation between 2017 and 2020 in a high-volume transplant centre. The incidence of the Eurotransplant risk factors to define an ECD (ET-ECD) among DBD donors and the likelihood of organ acceptance over the years were analysed. The relationship between organ refusal for transplantation, the occurrence, and the number of ET-ECD was assessed by simple and multiple logistic regression adjustment.
RESULTS A total of 1619 organ donors were evaluated. Of these, 78.31% (n = 1268) had at least one ET-ECD criterion. There was an increase in the acceptance of ECD DBD organs for transplantation (1 criterion: from 23.40% to 31.60%; 2 criteria: from 13.10% to 27.70%; 3 criteria: From 6.30% to 13.60%). For each addition of one ET-ECD variable, the estimated chance of organ refusal was 64.4% higher (OR 1.644, 95%CI 1.469-1.839, P < 0.001). Except for the donor serum sodium > 165 mmol/L (P = 0.310), all ET-ECD criteria increased the estimated chance of organ refusal for transplantation.
CONCLUSION A high prevalence of ECD DBD was observed. Despite the increase in their utilisation, the presence and the number of extended donor criteria were associated with an increased likelihood of their refusal for transplantation.
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Affiliation(s)
- Victoria S Braga
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
| | - Amanda P C S Boteon
- Transplant Centre, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
| | - Heloisa B Paglione
- Transplant Centre, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
| | - Rafael A A Pecora
- Transplant Centre, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
| | - Yuri L Boteon
- Transplant Centre, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
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Invasive Fungal Breakthrough Infections under Targeted Echinocandin Prophylaxis in High-Risk Liver Transplant Recipients. J Fungi (Basel) 2023; 9:jof9020272. [PMID: 36836384 PMCID: PMC9961099 DOI: 10.3390/jof9020272] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
Invasive fungal infections (IFIs) are frequent and outcome-relevant complications in the early postoperative period after orthotopic liver transplantation (OLT). Recent guidelines recommend targeted antimycotic prophylaxis (TAP) for high-risk liver transplant recipients (HR-LTRs). However, the choice of antimycotic agent is still a subject of discussion. Echinocandins are increasingly being used due to their advantageous safety profile and the increasing number of non-albicans Candida infections. However, the evidence justifying their use remains rather sparse. Recently published data on breakthrough IFI (b-IFI) raise concerns about echinocandin efficacy, especially in the case of intra-abdominal candidiasis (IAC), which is the most common infection site after OLT. In this retrospective study, we analyzed 100 adult HR-LTRs undergoing first-time OLT and receiving echinocandin prophylaxis between 2017 and 2020 in a tertiary university hospital. We found a breakthrough incidence of 16%, having a significant impact on postoperative complications, graft survival, and mortality. The reasons for this may be multifactorial. Among the pathogen-related factors, we identified the breakthrough of Candida parapsilosis in 11% of patients and one case of persistent IFI due to the development of a secondary echinocandin resistance of an IAC caused by Candida glabrata. Consequently, the efficacy of echinocandin prophylaxis in liver transplantation should be questioned. Further studies are necessary to clarify the matter of breakthrough infections under echinocandin prophylaxis.
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Incidence of Invasive Fungal Infections in Liver Transplant Recipients under Targeted Echinocandin Prophylaxis. J Clin Med 2023; 12:jcm12041520. [PMID: 36836055 PMCID: PMC9960065 DOI: 10.3390/jcm12041520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
Invasive fungal infections (IFIs) are one of the most important infectious complications after liver transplantation, determining morbidity and mortality. Antimycotic prophylaxis may impede IFI, but a consensus on indication, agent, or duration is still missing. Therefore, this study aimed to investigate the incidence of IFIs under targeted echinocandin antimycotic prophylaxis in adult high-risk liver transplant recipients. We retrospectively reviewed all patients undergoing a deceased donor liver transplantation at the Medical University of Innsbruck in the period from 2017 to 2020. Of 299 patients, 224 met the inclusion criteria. We defined patients as being at high risk for IFI if they had two or more prespecified risk factors and these patients received prophylaxis. In total, 85% (190/224) of the patients were correctly classified according to the developed algorithm, being able to predict an IFI with a sensitivity of 89%. Although 83% (90/109) so defined high-risk recipients received echinocandin prophylaxis, 21% (23/109) still developed an IFI. The multivariate analysis identified the age of the recipient (hazard ratio-HR = 0.97, p = 0.027), split liver transplantation (HR = 5.18, p = 0.014), massive intraoperative blood transfusion (HR = 24.08, p = 0.004), donor-derived infection (HR = 9.70, p < 0.001), and relaparotomy (HR = 4.62, p = 0.003) as variables with increased hazard ratios for an IFI within 90 days. The fungal colonization at baseline, high-urgency transplantation, posttransplant dialysis, bile leak, and early transplantation showed significance only in a univariate model. Notably, 57% (12/21) of the invasive Candida infections were caused by a non-albicans species, entailing a markedly reduced one-year survival. The attributable 90-day mortality rate of an IFI after a liver transplant was 53% (9/17). None of the patients with invasive aspergillosis survived. Despite targeted echinocandin prophylaxis, there is still a notable risk for IFI. Consequently, the prophylactic use of echinocandins must be critically questioned regarding the high rate of breakthrough infections, the increased occurrence of fluconazole-resistant pathogens, and the higher mortality rate in non-albicans Candida species. Adherence to the internal prophylaxis algorithms is of immense importance, bearing in mind the high IFI rates in case algorithms are not followed.
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Radiomic analysis of liver grafts from brain-dead donors can predict early allograft dysfunction following transplantation: a proof-of-concept study. HPB (Oxford) 2022; 24:1527-1534. [PMID: 35382981 DOI: 10.1016/j.hpb.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 03/04/2022] [Accepted: 03/11/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Selection of liver grafts suitable for transplantation (LT) mainly depends on a surgeon's subjective assessment. This study aimed to investigate the role of radiomic analysis of donor-liver CTs after brain death (DBD) to predict the occurrence of early posttransplant allograft dysfunction (EAD). METHODS We retrospectively extracted and analyzed the left lobe radiomic features from CT scans of DBD livers in training and validation cohorts. Multivariate analysis was performed to identify predictors of EAD. RESULTS From 126 LTs included in the study in the training cohort, 27 (21.4%) had an EAD. For each patient, 279 radiomic features were extracted of which 5 were associated with EAD (AUC = 0.81) (95% CI 0.72-0.89). Among donor and recipient clinical characteristics, cardiac arrest, steatosis on donor's CT, cold ischemic time and age of recipient were also identified as independent risk factors for EAD. Combined radiomic signature and clinical risk factors showed a strong predictive performance for EAD with a C-index of 0.90 (95% CI 0.84-0.96). A validation cohort of 23 patients confirmed these results. CONCLUSION Radiomic signatures extracted from donor CT scan, independently or combined with clinical risk factors is an objective and accurate biomarker for prediction of EAD after LT.
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Liver perfusion strategies: what is best and do ischemia times still matter? Curr Opin Organ Transplant 2022; 27:285-299. [PMID: 35438271 DOI: 10.1097/mot.0000000000000963] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW This review describes recent developments in the field of liver perfusion techniques. RECENT FINDINGS Dynamic preservation techniques are increasingly tested due to the urgent need to improve the overall poor donor utilization. With their exposure to warm ischemia, livers from donors after circulatory death (DCD) transmit additional risk for severe complications after transplantation. Although the superiority of dynamic approaches compared to static-cold-storage is widely accepted, the number of good quality studies remains limited. Most risk factors, particularly donor warm ischemia, and accepted thresholds are inconsistently reported, leading to difficulties to assess the impact of new preservation technologies. Normothermic regional perfusion (NRP) leads to good outcomes after DCD liver transplantation, with however short ischemia times. While randomized controlled trials (RCT) with NRP are lacking, results from the first RCTs with ex-situ perfusion were reported. Hypothermic oxygenated perfusion was shown to protect DCD liver recipients from ischemic cholangiopathy. In contrast, endischemic normothermic perfusion seems to not impact on the development of biliary complications, although this evidence is only available from retrospective studies. SUMMARY Dynamic perfusion strategies impact posttransplant outcomes and are increasingly commissioned in various countries along with more evidence from RCTs. Transparent reporting of risk and utilization with uniform definitions is required to compare the role of different preservation strategies in DCD livers with prolonged ischemia times.
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Chen Z, Wang T, Chen C, Zhao Q, Ma Y, Guo Y, Hong X, Yu J, Huang C, Ju W, Chen M, He X. Transplantation of Extended Criteria Donor Livers Following Continuous Normothermic Machine Perfusion Without Recooling. Transplantation 2022; 106:1193-1200. [PMID: 34495016 PMCID: PMC9128617 DOI: 10.1097/tp.0000000000003945] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 07/10/2021] [Accepted: 07/18/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Traditional liver transplant strategies with cold preservation usually result in ischemia-reperfusion injury (IRI) to the donor liver. Regular normothermic machine perfusion (NMP) donor livers suffer IRI twice. Here, we aimed to introduce a novel technique called continuous NMP without recooling to avoid a second IRI and its application in livers from extended criteria donors. METHODS Seven donor livers transplanted following continuous NMP without recooling, 7 donor livers transplanted following standard NMP, and 14 livers under static cold storage (SCS) were included in this study. Perioperative outcomes were recorded and analyzed between groups. RESULTS During the NMP without a recooling procedure, all livers cleared lactate quickly to normal levels in a median time of 100 min (interquartile range, 60-180) and remained stable until the end of perfusion. In the NMP without recooling and standard NMP groups, posttransplant peak aspartate aminotransferase and alanine aminotransferase levels were both significantly lower than those in the SCS group (P = 0.0015 and 0.016, respectively). The occurrence rate of early allograft dysfunction was significantly lower in the NMP without recooling group than in the SCS group (P = 0.022), whereas there was no difference in the NMP group with or without recooling (P = 0.462). CONCLUSIONS Our pilot study revealed a novel technique designed to avoid secondary IRI. This novel technique is shown to have at least a comparable effect on the standard NMP, although more data are needed to show its superiority in the future.
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Affiliation(s)
- Zhitao Chen
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Tielong Wang
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Chuanbao Chen
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Qiang Zhao
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Yihao Ma
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Yiwen Guo
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Xitao Hong
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Jia Yu
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Changjun Huang
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Weiqiang Ju
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Maogen Chen
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Xiaoshun He
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
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Misar A, McLin VA, Calinescu AM, Wildhaber BE. Impact of length of donor ICU stay on outcome of patients after pediatric liver transplantation with whole and ex situ split liver grafts. Pediatr Transplant 2022; 26:e14186. [PMID: 34738698 DOI: 10.1111/petr.14186] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 09/22/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients who have a prolonged stay in the intensive care unit (ICU) are often excluded for organ donation because of supposed deleterious effects of a lengthy ICU stay. We aimed to determine the effects of a prolonged donor stay in the ICU on the outcome of liver transplantation (LT) in children. METHODS Retrospective review of 89 pediatric LT patients, age 0-18 years, period 2003-2018, including patients having undergone whole organ or in situ split LT. The patients were divided into two groups according to the donor length of stay in the ICU. A prolonged stay was defined as >5 days. Recipient, graft, and donor characteristics were compared; outcome parameters included recipient and graft survival rates and postoperative complications. RESULTS Group short (donor ICU stay <5 days) included 75 patients, group long (donor ICU stay >5 days) 14 patients. Baseline characteristics between recipients did not differ. Donors in group long had significantly more infectious complications and a higher gamma glutamyl transferase (gGT) the day of organ recovery. Incidence of biliary complications post-LT was significantly higher in group long (p = .029). Patient and graft survival rates did not differ significantly between groups. CONCLUSIONS Donors with a prolonged stay in the ICU should still be considered for liver donation if they fulfill most other selection criteria. Recipients from donors having stayed in ICU >5 days may be at increased risk of biliary complications.
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Affiliation(s)
- Aline Misar
- Pediatric Surgery Unit, Department of Pediatrics, Gynecology, and Obstetrics, Swiss Pediatric Liver Center, University Center of Pediatric Surgery of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Valerie A McLin
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Department of Pediatrics, Gynecology, and Obstetrics, Swiss Pediatric Liver Center, University of Geneva, Geneva, Switzerland
| | - Ana M Calinescu
- Pediatric Surgery Unit, Department of Pediatrics, Gynecology, and Obstetrics, Swiss Pediatric Liver Center, University Center of Pediatric Surgery of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Barbara E Wildhaber
- Pediatric Surgery Unit, Department of Pediatrics, Gynecology, and Obstetrics, Swiss Pediatric Liver Center, University Center of Pediatric Surgery of Western Switzerland, University of Geneva, Geneva, Switzerland
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11
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Fuentes-Valenzuela E, Tejedor-Tejada J, García-Pajares F, Rubiales BM, Nájera-Muñoz R, Maroto-Martín C, Sánchez-Delgado L, Alonso-Martín C, Álvarez CA, Sánchez-Antolín G. Postreperfusion Liver Biopsy as Predictor of Early Graft Dysfunction and Survival After Orthotopic Liver Transplantation. J Clin Exp Hepatol 2022; 12:1133-1141. [PMID: 35814514 PMCID: PMC9257905 DOI: 10.1016/j.jceh.2021.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 12/26/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Postreperfusion liver biopsy (PRB) can assess the degree of ischemia/reperfusion injury (IRI) after orthotopic liver transplantation (OLT). The influence of IRI on graft outcomes and overall survival is controversial. AIM To determine the correlation between the severity of IRI in PRB and overall graft and patient survival and, secondarily, to identify factors on PRB that predict poor graft outcomes. METHODS This is a retrospective analysis of all patients who underwent OLT using donation after brain death (DBD) with PRB. The severity of IRI in PRB was graded. Predictors of IRI were assessed using univariate and multivariate analysis and the Kaplan-Meier with log rank test for the graft and overall survival, respectively. RESULTS We included 280 OLTs (64.7%). The histopathological assessment of IRI severity was as follows: no IRI (N = 96, 34.3%), mild IRI (N = 65; 23.2%), moderate IRI (N = 101; 36.1%), and severe IRI (N = 18; 6.4%). The incidence rates of initial good graft function (IGGF), primary nonfunction and early allograft dysfunction (EAD) were 32.5%, 3.9%, and 18.6%, respectively. Severe IRI was associated with a lower incidence of IGGF (OR: 0.34, 95% CI 0.12-0.92; P = 0.03). Patients with severe IRI tended to have a higher incidence of EAD (33.2% vs. 18.6, P = 0.23). The cold ischemia time was an independent predictor of severe IRI on the multivariate analysis. Severe IRI was associated with poor 1- and 5-year overall survival rates (67% and 44%, respectively, compared with 84 and 68% in nonsevere IRI). Patients with severe IRI exhibited worse graft and overall survival. CONCLUSIONS Cold ischemia time predicts the development of severe IRI. Patients with severe IRI show worse graft and overall survival and a lower incidence of IGGF, suggesting that histopathological findings could be useful for identifying patients at high risk of worse outcomes after OLT.
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Key Words
- ALD, alcohol-related liver disease
- ALF, acute liver failure
- ALT, alanine aminotransferase
- CIHD, chronic ischaemic heart disease
- CNI, calcineurin inhibitors
- COPD, chronic obstructive pulmonary disease
- DBD, donation after brain death
- EAD, early allograft dysfunction
- H&E, hematoxylin and eosin
- HBV, hepatitis B virus
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- IGGF, initial good graft function
- IQR, interquartile range
- IRI, ischaemia/reperfusion injury
- MELD, Model for End-stage Liver Disease
- OLT, orthotopic liver transplantation
- ONT, Organización Nacional de Transplantes
- PBC, primary biliary cholangitis
- PNF, primary nonfunction
- PRB, postreperfusion liver biopsy
- SD, standard deviation
- STROBE, Strengthening the Reporting of Observational studies in Epidemiology
- cold ischemia time
- early allograft dysfunction
- ischemia reperfusion injury
- liver transplantation
- postreperfusion biopsy
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Affiliation(s)
- Esteban Fuentes-Valenzuela
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain,Address for correspondence: Esteban Fuentes-Valenzuela, Department of Gastroenterology and Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, st Dulzaina,2. 47012. Valladolid, Spain.
| | - Javier Tejedor-Tejada
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Félix García-Pajares
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Beatriz M. Rubiales
- Department of Pathology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Rodrigo Nájera-Muñoz
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Carlos Maroto-Martín
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Laura Sánchez-Delgado
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Carmen Alonso-Martín
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Carolina A. Álvarez
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Gloria Sánchez-Antolín
- Department of Gastroenterology, Hepatology and Liver Transplantation Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
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12
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An Update on Usage of High-Risk Donors in Liver Transplantation. J Clin Med 2021; 11:jcm11010215. [PMID: 35011956 PMCID: PMC8746244 DOI: 10.3390/jcm11010215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/01/2021] [Accepted: 12/28/2021] [Indexed: 12/13/2022] Open
Abstract
The ideal management for end stage liver disease, acute liver failure, and hepatocellular carcinoma (HCC), within specific criteria, is liver transplantation (LT). Over the years, there has been a steady increase in the candidates listed for LT, without a corresponding increase in the donor pool. Therefore, due to organ shortage, it has been substantially difficult to reduce waitlist mortality among patients awaiting LT. Thus, marginal donors such as elderly donors, steatotic donors, split liver, and donors after cardiac death (DCD), which were once not commonly used, are now considered. Furthermore, it is encouraging to see the passing of Acts, such as the HIV Organ Policy Equity (HOPE) Act, enabling further research and development in utilizing HIV grafts. Subsequently, the newer antivirals have aided in successful post-transplant period, especially for hepatitis C positive grafts. However, currently, there is no standardization, and protocols are center specific in the usage of marginal donors. Therefore, studies with longer follow ups are required to standardize its use.
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13
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Verhelst X, Geerts A, Colman R, Vanlander A, Degroote H, Abreu de Carvalho L, Meuris L, Berrevoet F, Rogiers X, Callewaert N, Van Vlierberghe H. Serum Glycomics on Postoperative Day 7 Are Associated With Graft Loss Within 3 Months After Liver Transplantation Regardless of Early Allograft Dysfunction. Transplantation 2021; 105:2404-2410. [PMID: 33273318 DOI: 10.1097/tp.0000000000003567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prediction of outcome after liver transplantation (LT) is limited by the lack of robust predictors of graft failure. In this prospective study, we aimed to define a serum glycomic signature in the first week after LT that is associated with graft loss at 3 mo after LT. METHODS Patients were included between January 1, 2011, and February 28, 2017. Glycomic analysis was performed using DNA sequencer-associated fluorophore-associated capillary electrophoresis on a serum sample 1 wk after LT. Making use of Lasso regression, an optimal glycomic signature was identified associated with 3-mo graft survival. RESULTS In this cohort of 131 patients, graft loss at 3 mo occurred in 14 patients (11.9%). The optimal mode, called the GlycoTransplantTest, yielded an area under the curve of 0.95 for association with graft loss at 3 mo. Using an optimized cutoff for this biomarker, sensitivity was 86% and specificity 89%. Negative predictive value was 98%. Odds ratio for graft loss at 3 mo was 70.211 (P < 0.001; 95% confidence interval, 10.876-453.231). CONCLUSIONS A serum glycomic signature is highly associated with graft loss at 3 mo. It could support decision making in early retransplantation.
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Affiliation(s)
- Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
- Hepatology Research Unit, Ghent University, Ghent, Belgium
- European Reference Network, RARE LIVER, Ghent, Belgium
| | - Anja Geerts
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
- Hepatology Research Unit, Ghent University, Ghent, Belgium
- European Reference Network, RARE LIVER, Ghent, Belgium
| | - Roos Colman
- Biostatistical Unit, Ghent University, Ghent, Belgium
| | - Aude Vanlander
- Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University Hospital Medical School, Ghent, Belgium
| | - Helena Degroote
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
- Hepatology Research Unit, Ghent University, Ghent, Belgium
- European Reference Network, RARE LIVER, Ghent, Belgium
| | - Luis Abreu de Carvalho
- Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University Hospital Medical School, Ghent, Belgium
| | - Leander Meuris
- Department for Molecular Biomedical Research, Unit for Medical Biotechnology, VIB, Ghent, Belgium
| | - Frederik Berrevoet
- Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University Hospital Medical School, Ghent, Belgium
| | - Xavier Rogiers
- Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University Hospital Medical School, Ghent, Belgium
| | - Nico Callewaert
- Department for Molecular Biomedical Research, Unit for Medical Biotechnology, VIB, Ghent, Belgium
| | - Hans Van Vlierberghe
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
- Hepatology Research Unit, Ghent University, Ghent, Belgium
- European Reference Network, RARE LIVER, Ghent, Belgium
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14
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Schlegel A, Foley DP, Savier E, Flores Carvalho M, De Carlis L, Heaton N, Taner CB. Recommendations for Donor and Recipient Selection and Risk Prediction: Working Group Report From the ILTS Consensus Conference in DCD Liver Transplantation. Transplantation 2021; 105:1892-1903. [PMID: 34416750 DOI: 10.1097/tp.0000000000003825] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Although the utilization of donation after circulatory death donors (DCDs) for liver transplantation (LT) has increased steadily, much controversy remains, and no common acceptance criteria exist with regard to donor and recipient risk factors and prediction models. A consensus conference was organized by International Liver Transplantation Society on January 31, 2020, in Venice, Italy, to review the current clinical practice worldwide regarding DCD-LT and to develop internationally accepted guidelines. The format of the conference was based on the grade system. International experts in this field were allocated to 6 working groups and prepared evidence-based recommendations to answer-specific questions considering the currently available literature. Working group members and conference attendees served as jury to edit and confirm the final recommendations presented at the end of the conference by each working group separately. This report presents the final statements and recommendations provided by working group 2, covering the entire spectrum of donor and recipient risk factors and prediction models in DCD-LT.
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Affiliation(s)
- Andrea Schlegel
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, United Kingdom
- Hepatobiliary Unit, Department of Clinical and Experimental Medicine, University of Florence, AOU Careggi, Florence, Italy
| | - David P Foley
- University of Wisconsin School of Medicine and Public Health, William S. Middleton VA Medical Center, Madison, WI
| | - Eric Savier
- Department of Hepatobiliary Surgery and Liver Transplantation, Sorbonne Université Pitié-Salpêtrière Hospital, Paris, France
| | - Mauricio Flores Carvalho
- Hepatobiliary Unit, Department of Clinical and Experimental Medicine, University of Florence, AOU Careggi, Florence, Italy
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
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15
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Webb AN, Izquierdo DL, Eurich DT, Shapiro AMJ, Bigam DL. The Actual Operative Costs of Liver Transplantation and Normothermic Machine Perfusion in a Canadian Setting. PHARMACOECONOMICS - OPEN 2021; 5:311-318. [PMID: 33190212 PMCID: PMC8160033 DOI: 10.1007/s41669-020-00241-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/30/2020] [Indexed: 05/25/2023]
Abstract
BACKGROUND Liver transplantation is an effective treatment for end-stage liver disease. However, waiting lists continue to lengthen as demand exceeds supply. Use of extended criteria donors has helped but is associated with increased rates of complications. The application of normothermic machine perfusion (NMP) has been shown to be protective, especially in more marginal grafts. Despite this benefit, no cost-effectiveness studies have been published. OBJECTIVE This study serves as a prelude to a cost-effectiveness analysis of the costs of liver procurement, transplantation, and machine perfusion in a Canadian setting. METHODS The total costs were calculated for 106 in-province procurements, the set cost for 237 out-of-province procurements, and 343 liver transplantations. These costs include overheads, supplies, anaesthesia technologist and nursing salaries, and physician billings. Base and modified costs for all procedures were calculated, with consideration of physician billing modifiers. The total cost per run of NMP was calculated, with a range based on variations in the exchange rates for Great British pounds (₤) to Canadian dollars ($Can), year 2019 values. RESULTS Costs were $Can30,770.22 for in-province and $Can44,636.73 for out-of-province liver procurement and transplantation. These increased to $Can35,659.22 and 48,076.18 when considering modifiers. The minimum cost per NMP run was $Can18,593.02. CONCLUSIONS Although the cost per run is substantial, NMP could potentially lead to cost savings by decreasing night-time salary premiums, complications, and patient length of stay. A formal cost-effectiveness study of NMP in liver transplantation is underway to help clarify the financial benefit or burden of this new technology.
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Affiliation(s)
- Alexandria N Webb
- Department of Surgery, University of Alberta, 8440 112 St, Edmonton, AB, T6G 2B7, Canada.
| | - Dayne L Izquierdo
- Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
| | - Dean T Eurich
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - A M James Shapiro
- Department of Surgery, University of Alberta, 8440 112 St, Edmonton, AB, T6G 2B7, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
| | - David L Bigam
- Department of Surgery, University of Alberta, 8440 112 St, Edmonton, AB, T6G 2B7, Canada
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16
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Live Confocal Imaging as a Novel Tool to Assess Liver Quality: Insights From a Murine Model. Transplantation 2021; 104:2528-2537. [PMID: 33215899 DOI: 10.1097/tp.0000000000003405] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In an experimental murine liver clamping model, we aimed to investigate the efficacy of real-time confocal microscopy (RCM) in assessing viability of steatotic livers in comparison to standard assessment tools, including histopathological evaluation. METHODS C57Bl/6 mice were subjected to a methionine-choline-deficient diet causing nonalcoholic fatty liver disease or to Lieber DeCarli diet causing ethanol-induced liver injury. Untreated animals served as controls. Liver biopsies were analyzed following challenge with 45 min of warm ischemia time and either 4 h of reperfusion or 24 h of cold storage. Organ quality assessment was performed at defined time points by RCM, histological staining, measurement of serum alanine aminotransferase activity, and expression analyses of proinflammatory cytokines. Additionally, survival analysis was performed. RESULTS Cold as well as warm ischemia time resulted in a significant decrease in cell viability when compared with naive livers as well as nonischemic-challenged steatotic livers (P < 0.05) as assessed by RCM. Furthermore, RCM revealed the actual cellular damage at early time points, while established methods including H&E-staining and serum transaminase profile failed. CONCLUSIONS In a translational attempt, we demonstrate that RCM is a suitable diagnostic tool to obtain information about functional damage of the liver apart from standard approaches.
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17
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Clinical Implementation of Prolonged Liver Preservation and Monitoring Through Normothermic Machine Perfusion in Liver Transplantation. Transplantation 2020; 104:1917-1928. [PMID: 32371845 DOI: 10.1097/tp.0000000000003296] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Normothermic machine perfusion (NMP) bears the potential for significant prolongation of liver preservation before transplantation. Although safety and feasibility have been recently published, no data are available describing the significant challenges of establishing NMP programs outside clinical studies. We herein present our experience and propose a multidisciplinary approach for liver NMP in the clinical routine. METHODS In February 2018, liver NMP was introduced for routine use in marginal organs, logistic challenges, and complex recipients at our institution. In a multidisciplinary effort among transplant coordinators, perfusionists, transplant surgeons, anesthesia, nurses, blood bank as well as laboratory staff, a clinical routine was established and 34 NMP cases were performed without critical incidents or organ loss. RESULTS Nine livers were discarded due to poor organ quality and function observed during NMP. Twenty-five livers were successfully transplanted after preservation of up to 38 h. The extended criteria donors rate was 100% and 92% in discarded and transplanted livers, respectively. Nighttime procedures and parallel transplantations were eventually omitted. Graft and patient survival was 88% at 20 mo. No cholangiopathy was observed despite the use of extended criteria donor organs in 92% of cases. CONCLUSIONS NMP in a multidisciplinary approach enables a safe prolongation of liver preservation and overnight organ care. A first field test of NMP indicates safety and benefit of this approach.
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18
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Kahn J, Pregartner G, Avian A, Kniepeiss D, Müller H, Schemmer P. The Graz Liver Allocation Strategy-Impact of Extended Criteria Grafts on Outcome Considering Immunological Aspects. Front Immunol 2020; 11:1584. [PMID: 32849538 PMCID: PMC7427688 DOI: 10.3389/fimmu.2020.01584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 06/15/2020] [Indexed: 12/24/2022] Open
Abstract
Background: Transplant centers are forced to use livers of extended criteria donors for transplantation due to a dramatic organ shortage. The outcome effect of extended donor criteria (EDCs) remains unclear. Thus, this study was designed to assess the impact of EDCs on outcome including immunological aspects after liver transplantation (LT). Patients and Methods: Between November 2016 and March 2018, 49 patients (85.7% male) with a mean age of 57 ± 11 years underwent LT. The impact of EDCs on outcome after LT was assessed retrospectively using both MedOcs and ENIS (Eurotransplant Network Information System). Results: About 80% of grafts derived from extended criteria donors. Alanine aminotransferase/aspartate aminotransferase (AST/ALT) levels elevated more than three times above normal values in organ donors was the only significant risk factor for primary dysfunction (PDF) and primary non-function (PNF)/Re-LT and early non-anastomotic biliary strictures (NAS). Balance of risk (BAR) score did not differ between EDC and non-EDC recipients. PDF (14.3% of all patients) and PNF (6.1% of all patients) occurred in 23.1% of EDC-graft recipients and in 10.0% of non-EDC-graft recipients (RR 2.31, p = 0.663). The 90-day mortality was 3.6%. There was no difference of early non-anastomotic biliary tract complications and biopsy proven rejections (BPR). There was no correlation of PDF/PNF with BPR and NAS, respectively; however, 66.7% of the patients with BPR also developed early NAS (p < 0.001). Conclusion: With the Graz liver allocation strategy, excellent survival can be achieved selecting livers with no more than 2 not outcome-relevant EDCs for patients with MELD >20. Further, BPR is associated with biliary complications.
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Affiliation(s)
- Judith Kahn
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Gudrun Pregartner
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Daniela Kniepeiss
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Helmut Müller
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Peter Schemmer
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
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19
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Györi GP, Pereyra D, Rumpf B, Hackl H, Köditz C, Ortmayr G, Reiberger T, Trauner M, Berlakovich GA, Starlinger P. The von Willebrand Factor Facilitates Model for End-Stage Liver Disease-Independent Risk Stratification on the Waiting List for Liver Transplantation. Hepatology 2020; 72:584-594. [PMID: 31773739 PMCID: PMC7497135 DOI: 10.1002/hep.31047] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 11/07/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS The Model for End-Stage Liver Disease (MELD) is used for clinical decision-making and organ allocation for orthotopic liver transplantation (OLT) and was previously upgraded through inclusion of serum sodium (Na) concentrations (MELD-Na). However, MELD-Na may underestimate complications arising from portal hypertension or infection. The von Willebrand factor (vWF) antigen (vWF-Ag) correlates with portal pressure and seems capable of predicting complications in patients with cirrhosis. Accordingly, this study aimed to evaluate vWF-Ag as an adjunct surrogate marker for risk stratification on the waiting list for OLT. APPROACH AND RESULTS Hence, WF-Ag at time of listing was assessed in patients listed for OLT. Clinical characteristics, MELD-Na, and mortality on the waiting list were recorded. Prediction of 3-month waiting-list survival was assessed by receiver operating characteristics and net reclassification improvement. Interestingly, patients dying within 3 months on the waiting list displayed elevated levels of vWF-Ag (P < 0.001). MELD-Na and vWF-Ag were comparable and independent in their predictive potential for 3-month mortality on the waiting list (area under the curve [AUC], vWF-Ag = 0.739; MELD-Na = 0.764). Importantly, a vWF-Ag cutoff at 413% identified patients at risk for death within 3 months of listing with a higher odds ratio (OR) than the previously published cutoff at a MELD-Na of 20 points (vWF-Ag, OR = 10.873, 95% confidence interval [CI], 3.160, 36.084; MELD-Na, OR = 7.594, 95% CI, 2.578, 22.372; P < 0.001, respectively). Ultimately, inclusion of vWF-Ag into the MELD-Na equation significantly improved prediction of 3-month waiting-list mortality (AUC, MELD-Na-vWF = 0.804). CONCLUSIONS A single measurement of vWF-Ag at listing for OLT predicts early mortality. Combining vWF-Ag levels with MELD-Na improves risk stratification and may help to prioritize organ allocation to decrease waiting-list mortality.
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Affiliation(s)
- Georg P. Györi
- Division of TransplantationDepartment of SurgeryMedical University of ViennaGeneral Hospital ViennaViennaAustria
| | - David Pereyra
- Division of General SurgeryDepartment of SurgeryMedical University of ViennaGeneral Hospital ViennaViennaAustria
| | - Benedikt Rumpf
- Division of General SurgeryDepartment of SurgeryMedical University of ViennaGeneral Hospital ViennaViennaAustria
| | - Hubert Hackl
- Division of Bioinformatics, BiocenterMedical University of InnsbruckInnsbruckAustria
| | - Christoph Köditz
- Division of General SurgeryDepartment of SurgeryMedical University of ViennaGeneral Hospital ViennaViennaAustria
| | - Gregor Ortmayr
- Division of General SurgeryDepartment of SurgeryMedical University of ViennaGeneral Hospital ViennaViennaAustria
| | - Thomas Reiberger
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaGeneral Hospital ViennaViennaAustria
| | - Michael Trauner
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaGeneral Hospital ViennaViennaAustria
| | - Gabriela A. Berlakovich
- Division of TransplantationDepartment of SurgeryMedical University of ViennaGeneral Hospital ViennaViennaAustria
| | - Patrick Starlinger
- Division of General SurgeryDepartment of SurgeryMedical University of ViennaGeneral Hospital ViennaViennaAustria
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20
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Liu WY, Li XX, Fu XY, Wu XD, Wang X, Guo Y, Zang YJ, Wang JH. Combination of liver graft sonographic grading and point shear wave elastography to reduce early allograft dysfunction after liver transplantation. Eur Radiol 2020; 30:5191-5199. [PMID: 32328762 DOI: 10.1007/s00330-020-06842-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/03/2020] [Accepted: 03/30/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To analyze the performance of a liver graft sonographic grading system and point shear wave elastography (PSWE) in predicting early allograft dysfunction (EAD) after liver transplantation (LT). METHODS Successive brain-dead donors and liver recipients in our hospital from March 2017 to May 2018 were retrospectively recruited. All donors underwent PSWE examination, abdominal ultrasonography, and sonographic grading (grade 0 to grade 5). Donors with ≥ 10 valid PSWE examinations and a failure rate of < 60% were included. For all recipients, abdominal ultrasonography and blood tests for biologic parameters were performed preoperatively and daily postoperatively to screen for EAD. The recipients and their grafts were classified into EAD and non-EAD groups. Statistical analyses were performed to analyze the correlations among liver stiffness (LS), liver graft sonographic grading, and EAD. RESULTS Thirty-two donors and 32 corresponding liver recipients were enrolled (15 cases in the EAD group; 17 in the non-EAD group). There were no grade 0, 1, or 2 cases in the two groups. For prediction of EAD in recipients after LT, the AUC for PSWE was 0.929 and the AUC for combination of PSWE and sonographic grading system was 0.935. CONCLUSIONS Combination of PSWE and sonographic grading system can predict postoperative EAD in LT recipients with high sensitivity. Abnormal results may suggest a need for liver biopsy preoperatively, thus avoiding unnecessary surgical preparation for liver procurement. KEY POINTS • Combination of PSWE with new sonographic grading system is useful for preoperative evaluation of liver grafts from brain-dead donors. • EAD is as a criterion for evaluating the diagnostic value of PSWE and sonographic grading system. • Combination of PSWE and sonographic grading system can predict postoperative EAD in LT recipients with high sensitivity.
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Affiliation(s)
- Wen-Yi Liu
- Organ Transplantation Department, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Southern Distinct, Qingdao, 266003, Shandong, China
| | - Xuan-Xuan Li
- Ultrasound Department, Qingdao Haici Hospital, No. 4, Renmin Road, Qingdao, 266003, Shandong, China
| | - Xiao-Yue Fu
- Organ Transplantation Department, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Southern Distinct, Qingdao, 266003, Shandong, China
| | - Xiao-Dong Wu
- Organ Transplantation Department, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Southern Distinct, Qingdao, 266003, Shandong, China
| | - Xin Wang
- Organ Transplantation Department, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Southern Distinct, Qingdao, 266003, Shandong, China
| | - Yuan Guo
- Organ Transplantation Department, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Southern Distinct, Qingdao, 266003, Shandong, China
| | - Yun-Jin Zang
- Organ Transplantation Department, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Southern Distinct, Qingdao, 266003, Shandong, China.
| | - Jian-Hong Wang
- Organ Transplantation Department, The Affiliated Hospital of Qingdao University, No. 16, Jiangsu Road, Southern Distinct, Qingdao, 266003, Shandong, China.
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21
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Prevalence and Profile of Discarded Liver Donors in a Tertiary Health Service in Brazil From 2015 to 2018. Transplant Proc 2020; 52:1251-1255. [PMID: 32224015 DOI: 10.1016/j.transproceed.2020.01.078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 01/25/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Little has changed in donor management and liver utilization rates in Brazil over the last decade. With a growing demand for liver donations, organ waste is an important obstacle toward better patient care. The study of discarded donors helps to shed light on the possibilities of increasing organ usage, including by using extended criteria donors. METHODS We retrospectively analyzed all discarded liver donors in a high-volume Brazilian transplant center from January 2015 to December 2018. Pertinent clinical and laboratorial data were collected from the donors' electronic health records. RESULTS In our study period, there were 248 liver harvests, of which 67 (27.0%) were discarded. Most discarded donors were male (65.7%). More than three-quarters of donors were Caucasian (79.1%). Median donor body mass index was 26.27 kg/m2, and most discarded donors presented no comorbidities. Donor liver injury tests were abnormal in 56 (83.5%) out of 67 discarded donors. Forty-three (64.1%) donors presented elevated transaminases. Alanine aminotransferase levels were elevated in 35 (52.2%) discarded donors, with a median value of 38 U/L. Half of all discarded livers were due to graft-related issues. Twenty-eight organs (41.79%) presented external pathologic alterations. Organ refusal due to donor clinical and laboratorial condition was reported in 24 cases. CONCLUSION It is clear there is a considerable issue of organ waste in Brazil, with the subjective judgment of graft quality and inadequate interpretation of donor's laboratorial exams leading to excessive denial of organs that could be fitted into extended criteria for donation.
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22
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van Reeven M, van Leeuwen OB, van der Helm D, Darwish Murad S, van den Berg AP, van Hoek B, Alwayn IPJ, Polak WG, Porte RJ. Selected liver grafts from donation after circulatory death can be safely used for retransplantation - a multicenter retrospective study. Transpl Int 2020; 33:667-674. [PMID: 32065433 PMCID: PMC7318636 DOI: 10.1111/tri.13596] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/15/2019] [Accepted: 02/13/2020] [Indexed: 12/14/2022]
Abstract
Due to the growing number of liver transplantations (LTs), there is an increasing number of patients requiring retransplantation (reLT). Data on the use of grafts from extended criteria donors (ECD), especially donation after circulatory death (DCD), for reLT are lacking. We aimed to assess the outcome of patients undergoing reLT using a DCD graft in the Netherlands between 2001 and July 2018. Propensity score matching was used to match each DCD-reLT with three DBD-reLT cases. Primary outcomes were patient and graft survival. Secondary outcome was the incidence of biliary complications, especially nonanastomotic strictures (NAS). 21 DCD-reLT were compared with 63 matched DBD-reLTs. Donors in the DCD-reLT group had a significantly lower BMI (22.4 vs. 24.7 kg/m2 , P-value = 0.02). Comparison of recipient demographics and ischemia times yielded no significant differences. Patient and graft survival rates were comparable between the two groups. However, the occurrence of nonanastomotic strictures after DCD-reLT was significantly higher (38.1% vs. 12.7%, P-value = 0.02). ReLT with DCD grafts does not result in inferior patient and graft survival compared with DBD grafts in selected patients. Therefore, DCD liver grafts should not routinely be declined for patients awaiting reLT.
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Affiliation(s)
- Marjolein van Reeven
- Department of Surgery, Section of HPB Surgery and Liver Transplantation, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Otto B van Leeuwen
- Department of Surgery, Section of HPB Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
| | - Danny van der Helm
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Aad P van den Berg
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ian P J Alwayn
- Department of Surgery, Section of Transplantation Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Wojciech G Polak
- Department of Surgery, Section of HPB Surgery and Liver Transplantation, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert J Porte
- Department of Surgery, Section of HPB Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
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23
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Winter A, Féray C, Antoine C, Azoulay D, Daurès JP, Landais P. Matching Graft Quality to Recipient's Disease Severity Based on the Survival Benefit in Liver Transplantation. Sci Rep 2020; 10:4111. [PMID: 32139780 PMCID: PMC7057972 DOI: 10.1038/s41598-020-60973-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 02/14/2020] [Indexed: 01/04/2023] Open
Abstract
Persistent shortage and heterogeneous quality of liver grafts encourages the optimization of donor-recipient matching in liver transplantation (LT). We explored whether or not there was a survival benefit (SB) of LT according to the quality of grafts assessed by the Donor Quality Index (DQI) and recipients' disease severity, using the Model for End-Stage Liver Disease (MELD) in 8387 French patients wait-listed between 2009 and 2014. SB associated with LT was estimated using the sequential stratification method in different categories of MELD and DQI. For each transplantation, a stratum was created that matched one transplanted patient with all eligible control candidates. Strata were thereafter combined, and a stratified Cox model, adjusted for covariates, was fitted in order to estimate hazard ratios that qualified the SB according to each MELD and DQI sub-group. A significant SB was observed for all MELD and DQI sub-groups, with the exception of high MELD patients transplanted with "high-risk" grafts. More specifically, in decompensated-cirrhosis patients, "high-risk" grafts did not appear to be detrimental in medium MELD patients. Interestingly, in hepatocellular-carcinoma (HCC) patients, a significant SB was found for all MELD-DQI combinations. For MELD exceptions no SB was found. In terms of SB, "low-risk" grafts appeared appropriate for most severe patients (MELD > 30). Conversely, low/medium MELD and HCC patients presented an SB while allocated "high-risk" grafts. Thus, SB based matching rules for LT candidates might improve the survival of the LT population as a whole.
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Affiliation(s)
- Audrey Winter
- University of Montpellier, Department of Biostatistics, UPRES EA2415, Clinical Reasearch University Institute, Montpellier, France. .,Beau Soleil Clinic, Languedoc Mutualité, Montpellier, France. .,Department of Radiological Sciences, Medical Imaging & Informatics, University of California, Los Angeles, CA, USA.
| | - Cyrille Féray
- Centre Hépato-Biliaire, INSERM 1193, Paul Brousse Hospital, Villejuif, France
| | | | - Daniel Azoulay
- Centre Hépato-Biliaire, INSERM 1193, Paul Brousse Hospital, Villejuif, France
| | - Jean-Pierre Daurès
- University of Montpellier, Department of Biostatistics, UPRES EA2415, Clinical Reasearch University Institute, Montpellier, France.,Beau Soleil Clinic, Languedoc Mutualité, Montpellier, France
| | - Paul Landais
- University of Montpellier, Department of Biostatistics, UPRES EA2415, Clinical Reasearch University Institute, Montpellier, France
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24
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Abstract
Machine perfusion is a hot topic in liver transplantation and several new perfusion concepts are currently developed. Prior to introduction into routine clinical practice, however, such perfusion approaches need to demonstrate their impact on liver function, post-transplant complications, utilization rates of high-risk organs, and cost benefits. Therefore, based on results of experimental and clinical studies, the community has to recognize the limitations of this technology. In this review, we summarize current perfusion concepts and differences between protective mechanisms of ex- and in-situ perfusion techniques. Next, we discuss which graft types may benefit most from perfusion techniques, and highlight the current understanding of liver viability testing. Finally, we present results from recent clinical trials involving machine liver perfusion, and analyze the value of different outcome parameters, currently used as endpoints for randomized controlled trials in the field.
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Affiliation(s)
- Andrea Schlegel
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Xavier Muller
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
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25
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Ruffolo LI, Levstik MA, Hernandez-Alejandro R. Watching the Clock in Donation After Circulatory Death Liver Transplantation. Liver Transpl 2019; 25:1305-1307. [PMID: 31365774 DOI: 10.1002/lt.25617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 07/29/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Luis I Ruffolo
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Mark A Levstik
- Division of Transplant Hepatology and Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Roberto Hernandez-Alejandro
- Department of Hepatobiliary Surgery and Abdominal Transplantation, University of Rochester Medical Center, Rochester, NY
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26
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Nemes B, Barta A, Ivádi G, Kárai B, Szánthó E, Hevessy Z, Szabó RP, Szilvási A, Sipka S, Baráth S. T Cell Subset Profile and Appearance of Donor-specific Antibodies in Primary and Retransplanted Kidney Recipients. Transplant Proc 2019; 51:1215-1225. [DOI: 10.1016/j.transproceed.2019.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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27
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Mazaheri M, Mojtabaee M, Mohsenzadeh M, Shahryari S, Sadegh Beigee F. Liver Donation From Marginal Donors: To Donate or Not to Donate? EXP CLIN TRANSPLANT 2019; 17:254-256. [PMID: 30777569 DOI: 10.6002/ect.mesot2018.p112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Livers from deceased donors compose nearly 30% of all organ transplants, and about 700 liver transplants are carried out per year. Marginal livers (extended-criteria donors), however, are not usually accepted by recipient teams, and there is only one center for these procedures in Iran. The final decision is made according to criteria that are much more conservative than other globally accepted ones. MATERIALS AND METHODS To find significant differences and construct an algorithm to predict the future of marginal livers (before transfer of donors to our organ procurement unit), successfully donated and unsuccessfully donated livers divided into 2 age groups were compared in terms of age, sex, body mass index, liver function tests, significant medical disorders, and preretrieval liver sonography report. RESULTS In the first age group (50-59 years old), there were 88 successful donors and 27 unsuccessful cases (due to 3 reasons: positive virology tests, death before retrieval, and ruled out by surgeons in the operating room). In the second age group (? 60 years old), there were 45 successful donors and 11 unsuccessful cases. The results showed that there were no differences between successful and unsuccessful cases regarding age and liver sonography results; however, sex, body mass index, liver function tests, and previous medical disorder were different between groups. Donors in both age groups were mostly male (60% and 73%); however, surprisingly, most unsuccessful cases were female (56.6% and 57%). Donors had generally lower body mass index (2 numerical difference), better liver function tests, and less risk factors (heart disease, diabetes mellitus, fatty liver, and chronic alcohol consumption). CONCLUSIONS Before transfer of marginal liver donors to the organ procurement unit for further evaluation and organ retrieval, one must consider that age is just a number and the presence of other comorbidities can have more decisive roles on liver quality.
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Affiliation(s)
- Masoud Mazaheri
- From the Organ Procurement Unit (OPU), Lung Transplantation Research Center (LTRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
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28
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Schlegel A, Dutkowski P. Impact of Machine Perfusion on Biliary Complications after Liver Transplantation. Int J Mol Sci 2018; 19:ijms19113567. [PMID: 30424553 PMCID: PMC6274934 DOI: 10.3390/ijms19113567] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/01/2018] [Accepted: 11/05/2018] [Indexed: 12/13/2022] Open
Abstract
We describe in this review the different types of injuries caused to the biliary tree after liver transplantation. Furthermore, we explain underlying mechanisms and why oxygenated perfusion concepts could not only protect livers, but also repair high-risk grafts to prevent severe biliary complications and graft loss. Accordingly, we summarize experimental studies and clinical applications of machine liver perfusion with a focus on biliary complications after liver transplantation. Key points: (1) Acute inflammation with subsequent chronic ongoing liver inflammation and injury are the main triggers for cholangiocyte injury and biliary tree transformation, including non-anastomotic strictures; (2) Hypothermic oxygenated perfusion (HOPE) protects livers from initial oxidative injury at normothermic reperfusion after liver transplantation. This is a unique feature of a cold oxygenation approach, which is effective also end-ischemically, e.g., after cold storage, due to mitochondrial repair mechanisms. In contrast, normothermic oxygenated perfusion concepts protect by reducing cold ischemia, and are therefore most beneficial when applied instead of cold storage; (3) Due to less downstream activation of cholangiocytes, hypothermic oxygenated perfusion also significantly reduces the development of biliary strictures after liver transplantation.
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Affiliation(s)
- Andrea Schlegel
- Department of Surgery & Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland.
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham B15 2TH, UK.
- NIHR Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham B15 2TH, UK.
| | - Philipp Dutkowski
- Department of Surgery & Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland.
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29
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Pratschke S, Bender A, Boesch F, Andrassy J, van Rosmalen M, Samuel U, Rogiers X, Meiser B, Küchenhoff H, Driesslein D, Werner J, Guba M, Angele MK. Association between donor age and risk of graft failure after liver transplantation: an analysis of the Eurotransplant database. Transpl Int 2018; 32:270-279. [PMID: 30260509 DOI: 10.1111/tri.13357] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 03/05/2018] [Accepted: 09/20/2018] [Indexed: 12/16/2022]
Abstract
Grafts from elderly donors are increasingly used for liver transplantation. As of yet there is no published systematic data to guide the use of specific age cutoffs the effect of elderly donors on patient outcomes must be clarified. This study analyzed the Eurotransplant database (01/01/2000-31/07/2014; N = 26 294) out of whom 8341 liver transplantations were filtered to identify for this analysis. 2162 of the grafts came from donors >60 including 203 from octogenarians ≥80 years. Primary outcome was the risk of graft failure according to donor age using a confounder adjusted Cox-Regression model with frailty terms (or random effects). The proportion of elderly grafts increased during the study period [i.e., octogenarians 0.1% (n = 1) in 2000 to 3.4% (n = 45) in 2013]. Kaplan-Meier and Cox-analyses revealed a reduced survival and a higher risk for graft failure with increasing donor age. Although the age effect was allowed to vary non-linearly, a linear association hazard ratio (HR = 1.1 for a 10 year increase in donor age) was evident. The linearity of the association suggests that there is no particular age at which the effect increases more rapidly, providing no evidence for a cutoff age. In clinical practice, the combination of high donor age with HU-transplantations, hepatitis C, high MELD-scores and long cold ischemic time should be avoided.
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Affiliation(s)
- Sebastian Pratschke
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
| | - Andreas Bender
- Statistical Consulting Unit StaBLab, Department of Statistics, Ludwig-Maximilians University, Munich, Germany
| | - Florian Boesch
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
| | - Joachim Andrassy
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
| | | | - Undine Samuel
- Eurotransplant International Foundation, Leiden, The Netherlands
| | - Xavier Rogiers
- Transplantatiecentrum, Universitair Ziekenhuis Gent, Gent, Belgium
| | - Bruno Meiser
- Transplant Center, Hospital of the LMU Munich, Munich, Germany
| | - Helmut Küchenhoff
- Statistical Consulting Unit StaBLab, Department of Statistics, Ludwig-Maximilians University, Munich, Germany
| | - David Driesslein
- Statistical Consulting Unit StaBLab, Department of Statistics, Ludwig-Maximilians University, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
| | - Markus Guba
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
| | - Martin K Angele
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the LMU Munich, Munich, Germany
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30
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Beal EW, Dumond C, Kim JL, Akateh C, Eren E, Maynard K, Sen CK, Zweier JL, Washburn K, Whitson BA, Black SM. A Small Animal Model of Ex Vivo Normothermic Liver Perfusion. J Vis Exp 2018. [PMID: 30010635 DOI: 10.3791/57541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
There is a significant shortage of liver allografts available for transplantation, and in response the donor criteria have been expanded. As a result, normothermic ex vivo liver perfusion (NEVLP) has been introduced as a method to evaluate and modify organ function. NEVLP has many advantages in comparison to hypothermic and subnormothermic perfusion including reduced preservation injury, restoration of normal organ function under physiologic conditions, assessment of organ performance, and as a platform for organ repair, remodeling, and modification. Both murine and porcine NEVLP models have been described. We demonstrate a rat model of NEVLP and use this model to show one of its important applications - the use of a therapeutic molecule added to liver perfusate. Catalase is an endogenous reactive oxygen species (ROS) scavenger and has been demonstrated to decrease ischemia-reperfusion in the eye, brain, and lung. Pegylation has been shown to target catalase to the endothelium. Here, we added pegylated-catalase (PEG-CAT) to the base perfusate and demonstrated its ability to mitigate liver preservation injury. An advantage of our rodent NEVLP model is that it is inexpensive in comparison to larger animal models. A limitation of this study is that it does not currently include post-perfusion liver transplantation. Therefore, prediction of the function of the organ post-transplantation cannot be made with certainty. However, the rat liver transplant model is well established and certainly could be used in conjunction with this model. In conclusion, we have demonstrated an inexpensive, simple, easily replicable NEVLP model using rats. Applications of this model can include testing novel perfusates and perfusate additives, testing software designed for organ evaluation, and experiments designed to repair organs.
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Affiliation(s)
- Eliza W Beal
- Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Lab, Division of Transplant, Department of Surgery, Comprehensive Transplant Center, Ohio State University Wexner Medical Center; Department of Surgery, Division of Transplant, Ohio State University Wexner Medical Center
| | - Curtis Dumond
- Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Lab, Division of Transplant, Department of Surgery, Comprehensive Transplant Center, Ohio State University Wexner Medical Center
| | - Jung-Lye Kim
- Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Lab, Division of Transplant, Department of Surgery, Comprehensive Transplant Center, Ohio State University Wexner Medical Center; Department of Surgery, Division of Transplant, Ohio State University Wexner Medical Center
| | - Clifford Akateh
- Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Lab, Division of Transplant, Department of Surgery, Comprehensive Transplant Center, Ohio State University Wexner Medical Center; Department of Surgery, Division of Transplant, Ohio State University Wexner Medical Center
| | - Emre Eren
- Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Lab, Division of Transplant, Department of Surgery, Comprehensive Transplant Center, Ohio State University Wexner Medical Center
| | - Katelyn Maynard
- Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Lab, Division of Transplant, Department of Surgery, Comprehensive Transplant Center, Ohio State University Wexner Medical Center
| | - Chandan K Sen
- Department of Surgery, Division of CardioThoracic Surgery, Ohio State University Wexner Medical Center
| | - Jay L Zweier
- Department of Medicine, Ohio State University Wexner Medical Center
| | - Kenneth Washburn
- Department of Surgery, Division of Transplant, Ohio State University Wexner Medical Center
| | - Bryan A Whitson
- Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Lab, Division of Transplant, Department of Surgery, Comprehensive Transplant Center, Ohio State University Wexner Medical Center; Department of Surgery, Division of CardioThoracic Surgery, Ohio State University Wexner Medical Center
| | - Sylvester M Black
- Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Lab, Division of Transplant, Department of Surgery, Comprehensive Transplant Center, Ohio State University Wexner Medical Center; Department of Surgery, Division of Transplant, Ohio State University Wexner Medical Center;
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31
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Kisu I, Umene K, Adachi M, Emoto K, Nogami Y, Banno K, Itagaki I, Kawamoto I, Nakagawa T, Narita H, Yoshida A, Tsuchiya H, Ogasawara K, Aoki D. Allowable warm ischemic time and morphological and biochemical changes in uterine ischemia/reperfusion injury in cynomolgus macaque: a basic study for uterus transplantation. Hum Reprod 2018; 32:2026-2035. [PMID: 28938750 DOI: 10.1093/humrep/dex250] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 07/11/2017] [Indexed: 12/16/2022] Open
Abstract
STUDY QUESTION How long is the allowable warm ischemic time of the uterus and what morphological and biochemical changes are caused by uterine ischemia/reperfusion injury in cynomolgus macaques? SUMMARY ANSWER Warm ischemia in the uterus of cynomolgus macaques is tolerated for up to 4 h and reperfusion after uterine ischemia caused no further morphological and biochemical changes. WHAT IS KNOWN ALREADY Uterus transplantation is a potential option for women with uterine factor infertility. The allowable warm ischemic time and ischemia/reperfusion injury of the uterus in humans and non-human primates is unknown. STUDY DESIGN, SIZE, DURATION This experimental study included 18 female cynomolgus macaques with periodic menstruation. PARTICIPANTS/MATERIALS, SETTING, METHODS Animals were divided into six groups of three monkeys each: a control group and groups with uterine ischemia for 0.5, 1, 2, 4 and 8 h. Biopsies of uterine tissues were performed before blood flow blockage, after each blockage time, and after reperfusion for 3 h. Blood sampling was performed after each blockage time, and after reperfusion for 5, 15 and 30 min for measurement of biochemical data. Resumption of menstruation was monitored after the surgical procedure. Morphological, physiological and biochemical changes after ischemia and reperfusion were evaluated. MAIN RESULTS AND THE ROLE OF CHANCE Mild muscle degeneration and zonal degeneration were observed in all animals subjected to warm ischemia for 4 or 8 h, but there were no marked differences in the appearance of specimens immediately after ischemia and after reperfusion for 3 h in animals subjected to 4 or 8 h of warm ischemia. There were no significant changes in any biochemical parameters at any time point in each group. Periodical menstruation resumed in all animals with warm ischemia up to 4 h, but did not recover in animals with warm ischemia for 8 h with atrophic uteri. LIMITATIONS, REASON FOR CAUTION Warm ischemia in actual transplantation was not exactly mimicked in this study because uteri were not perfused, cooled, transplanted or reanastomosed with vessels. Results in non-human primates cannot always be extrapolated to humans. WIDER IMPLICATIONS OF THE FINDINGS The findings suggest that the tolerable warm ischemia time in the uterus is expected to be longer than that in other vital organs. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by the Japan Society for the Promotion of Science (JSPS) KAKENHI Grant Number 26713050. None of the authors has a conflict of interest to declare.
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Affiliation(s)
- Iori Kisu
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Kiyoko Umene
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Masataka Adachi
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Katsura Emoto
- Department of Pathology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Yuya Nogami
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Kouji Banno
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Iori Itagaki
- Research Center for Animal Life Science, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga 520-2192, Japan.,The Corporation for Production and Research of Laboratory Primates, Sakura, Tsukuba, Ibaraki 305-0003, Japan
| | - Ikuo Kawamoto
- Research Center for Animal Life Science, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga 520-2192, Japan
| | - Takahiro Nakagawa
- Research Center for Animal Life Science, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga 520-2192, Japan
| | - Hayato Narita
- Research Center for Animal Life Science, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga 520-2192, Japan
| | - Atsushi Yoshida
- Research Center for Animal Life Science, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga 520-2192, Japan
| | - Hideaki Tsuchiya
- Research Center for Animal Life Science, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga 520-2192, Japan
| | - Kazumasa Ogasawara
- Research Center for Animal Life Science, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga 520-2192, Japan.,Division of Pathology and Disease Regulation, Department of Pathology, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga 520-2192, Japan
| | - Daisuke Aoki
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
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Roullet S, Defaye M, Quinart A, Adam JP, Chiche L, Laurent C, Neau-Cransac M. Liver Transplantation With Old Grafts: A Ten-Year Experience. Transplant Proc 2018; 49:2135-2143. [PMID: 29149974 DOI: 10.1016/j.transproceed.2017.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/18/2017] [Accepted: 07/30/2017] [Indexed: 02/09/2023]
Abstract
BACKGROUND The persistent scarcity of donors has prompted liver transplantation teams to find solutions for increasing graft availability. We report our experience of liver transplantations performed with grafts from older donors, specifically over 70 and 80 years old. PATIENTS AND METHODS We analyzed our prospectively maintained single-center database from January 1, 2005, to December 31, 2014, with 380 liver transplantations performed in 354 patients. Six groups were composed according to donor age: <40 (n = 84), 40 to 49 (n = 67), from 50 to 59 (n = 62), from 60 to 69 (n = 76), from 70 to 79 (n = 64), and ≥80 years (n = 27). RESULTS Donors <40 years of age had a lower body mass index, died more often from trauma, and more often had cardiac arrest and high transaminase levels. In contrast, older donors (≥70 years of age) died more often from stroke. Recipients of grafts from donors <50 years of age were more frequently infected by hepatitis C virus; recipients of oldest grafts more often had hepatocellular carcinoma. Cold ischemia time was the shortest in donors >80 years of age. Patient survival was not significantly different between the groups. In multivariate analysis, factors predicting graft loss were transaminase peak, retransplantation and cold ischemia time but not donor age. CONCLUSIONS Older donors >70 and >80 years of age could provide excellent liver grafts.
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Affiliation(s)
- S Roullet
- Department of Anesthesia and Intensive Care and Liver Transplantation Unit, Bordeaux, France; Inserm UMR 12-11, Bordeaux, France.
| | - M Defaye
- Department of Anesthesia and Intensive Care and Liver Transplantation Unit, Bordeaux, France
| | - A Quinart
- Department of Anesthesia and Intensive Care and Liver Transplantation Unit, Bordeaux, France
| | - J-P Adam
- Department of Digestive Surgery and Liver Transplantation Unit, CHU Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | - L Chiche
- Department of Digestive Surgery and Liver Transplantation Unit, CHU Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | - C Laurent
- Department of Digestive Surgery and Liver Transplantation Unit, CHU Bordeaux, Hôpital Haut-Lévêque, Pessac, France
| | - M Neau-Cransac
- Department of Hepatology and Liver Transplantation Unit, CHU Bordeaux, Hôpital Haut-Lévêque, Pessac, France
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DCD Liver Transplant: a Meta-review of the Evidence and Current Optimization Strategies. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0193-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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34
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Schlegel A, Scalera I, Perera MTPR, Kalisvaart M, Mergental H, Mirza DF, Isaac J, Muiesan P. Impact of donor age in donation after circulatory death liver transplantation: Is the cutoff "60" still of relevance? Liver Transpl 2018; 24:352-362. [PMID: 28885771 DOI: 10.1002/lt.24865] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/19/2017] [Accepted: 08/24/2017] [Indexed: 02/07/2023]
Abstract
Advanced donor age has been identified as a risk factor when combined with donor warm ischemia time (WIT), eg, in donation after circulatory death (DCD). In several countries, DCD livers older than 60 years are not considered suitable due to concerns related to poor graft function and development of ischemic cholangiopathy. In this study, we evaluate outcomes after DCD liver transplantation using grafts from donors older than 60 years. We analyzed outcomes after DCD liver transplantation (n = 315), comparing donors > 60 years (n = 93) and donors ≤ 60 years (n = 222) from our center between 2005 and 2015. End points included graft function and complications and patient and graft survival. Multivariate risk analysis was performed to define further key factors that predicted inferior outcome. Donor age at the cutoff 60 years failed to stratify patient and graft survival. The rate of vascular, biliary, and overall complications was comparably low in both cohorts, and the median comprehensive complication index was 42.7 points, independent from the donor age. Second, donor body mass index (BMI) above a threshold of 25 kg/m2 significantly impacted on graft and patient survival at any donor age, whereas donor WIT and cold ischemia times were not predictive for graft loss. In conclusion, older DCD donors can be successfully used for liver transplantation with good longterm outcomes when further risk factors are limited. Additional risk is transmitted by an increased donor BMI regardless of donor age. Liver Transplantation 24 352-362 2018 AASLD.
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Affiliation(s)
- Andrea Schlegel
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK
| | - Irene Scalera
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - M Thamara P R Perera
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, UK
| | - Marit Kalisvaart
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK
| | - Darius F Mirza
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, UK
| | - John Isaac
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, UK
| | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, UK
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35
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Schlegel A, Muller X, Dutkowski P. Hypothermic Machine Preservation of the Liver: State of the Art. CURRENT TRANSPLANTATION REPORTS 2018; 5:93-102. [PMID: 29564206 PMCID: PMC5843682 DOI: 10.1007/s40472-018-0183-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW In this review, we highlight which livers may benefit from additional treatment before implantation and describe the concept of hypothermic machine liver perfusion. Furthermore, we explain why cold oxygenated perfusion concepts could potentially lead to a breakthrough in this challenging field of transplantation. Accordingly, we summarize recent clinical applications of different hypothermic perfusion approaches. RECENT FINDINGS The impact of end-ischemic, hypothermic liver perfusion in liver transplantation is currently assessed by two multicenter, randomized controlled trials. Recently, new applications of hypothermic perfusion showed promising results and recipients were protected from severe intrahepatic biliary complications, despite the use of very extended criteria grafts including donation after circulatory death livers. SUMMARY Hypothermic machine liver perfusion is beneficial for high-risk livers and protects recipients from most feared complications. Importantly, such easy approach is currently implemented in several European centers and new markers obtained from perfusate may improve the prediction of liver function in the future.
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Affiliation(s)
- Andrea Schlegel
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
- NIHR Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK
| | - Xavier Muller
- Department of Surgery & Transplantation, Swiss HPB and Transplant Center, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery & Transplantation, Swiss HPB and Transplant Center, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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36
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Chela H, Yousef MH, Albarrak AA, Romana BS, Hudhud DN, Tahan V. Elderly donor graft for liver transplantation: Never too late. World J Transplant 2017; 7:324-328. [PMID: 29312861 PMCID: PMC5743869 DOI: 10.5500/wjt.v7.i6.324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 11/27/2017] [Accepted: 12/05/2017] [Indexed: 02/05/2023] Open
Abstract
The definitive treatment for end stage liver disease remains a liver transplant and hence livers are needed for these patients along with cases of acute fulminant liver failure. Hence livers are a scarce and highly valuable commodity in the current time. By extending the pool of donors to include the elderly livers, it allows for increased availability of donors and reduces the mortality that is associated with the waiting list itself. There is an increasing prevalence of end stage liver disease due to conditions like chronic hepatitis B and C, non-alcoholic steatohepatitis, alcoholic liver disease. Many studies show non-inferior outcomes when elderly livers are used as a vigorous selection process is implemented. The process takes into account the characteristics of the donor, graft and recipient allowing for appropriate donor-recipient coupling. To meet the increasing demands of livers, elderly donors should be utilized for liver transplantation. The aim of this review article is to describe the aging process of the liver and the outcomes associated with use of elderly livers for transplantation.
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Affiliation(s)
- Harleen Chela
- Department of Internal Medicine, University of Missouri, Columbia, MO 65212, United States
| | - Mohamad H Yousef
- Division of Gastroenterology and Hepatology, Missouri University, Columbia, MO 65212, United States
| | - Abdelmajeed A Albarrak
- Division of Gastroenterology and Hepatology, Missouri University, Columbia, MO 65212, United States
| | - Bhupinder S Romana
- Division of Gastroenterology and Hepatology, Missouri University, Columbia, MO 65212, United States
| | - Dania N Hudhud
- Department of Internal Medicine, University of Missouri, Columbia, MO 65212, United States
| | - Veysel Tahan
- Division of Gastroenterology and Hepatology, Missouri University, Columbia, MO 65212, United States
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37
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Zeng C, Hu X, Wang Y, Zeng X, Xiong Y, Li L, Ye Q. A novel hypothermic machine perfusion system using a LifePort Kidney Transporter for the preservation of rat liver. Exp Ther Med 2017; 15:1410-1416. [PMID: 29434725 PMCID: PMC5776655 DOI: 10.3892/etm.2017.5587] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 07/27/2017] [Indexed: 12/23/2022] Open
Abstract
The protective mechanisms for liver preservation associated with hypothermic machine perfusion (HMP) remain unclear. However, the lack of a common and portable HMP system for rat livers limits the study of HMP. The present study aimed to develop a novel, modified HMP system using a LifePort Kidney Transporter for preserving rat livers. A simple ‘Y’ shunt combined with a pressoreceptor for flow and pressure regulation was adapted to perfuse rat livers via the portal vein continuously using a LifePort Kidney Transporter under its ‘prime mode’ setting. An electronic scale was installed under the liver container to calculate the portal inflow according to the association with weight, density and volume of the perfusate. A total of 10 rat livers underwent 6 h of HMP using histidine-tryptophan-ketoglutarate solution enriched with acridine orange (AO) and propidium iodide (PI). The perfusion status of HMP was assessed by comparison of AO+PI-positive cell count in core region (CR) and peripheral region (PR) of rat liver under fluorescence microscopy. The dynamics (inflow, pressure and intrahepatic resistance of perfusion) were assessed to identify whether this system met the demands for HMP of rat livers. Biochemical [alanine transaminase (ALT), lactate dehydrogenase (LDH) and endothelin levels] and histological parameters (sinusoidal dilatation, endothelial cell detachment and vacuolization) were measured to determine cellular damage associated with HMP. No significant difference was observed between the CR and PR according to the comparison of the AO+PI-positive cell count, which indicated that complete perfusion was achieved. Intrahepatic resistance significantly decreased during the initial 3 h of HMP (P<0.01), but remained stable during the final 3 h. ALT and LDH levels significantly increased over the 6 h HMP duration: ALT (0 h, 42.67±5.81 U/l; 3 h, 90.67±6.74 U/l; 6 h, 164.33±7.31 U/l; P<0.01) and LDH (0 h, 492.90±90.20 U/l; 3 h, 973.53±97.4; 6 h, 1,843.40±85.78 U/l; P<0.01) However, the levels of endothelin and oxygen consumption were constant throughout HMP. Furthermore, histological analysis indicated sinusoidal dilation was significantly increased in the post-HMP group compared with the pre-HMP group (P<0.01); however, no other significant differences were observed. Combined with the results of ATP test (640.64±29.46 nmol/l) and bile production (4.88±0.69 µl/h/g of liver) at the end of HMP, the present results demonstrated minimal cellular injury associated with HMP while retaining the dependability and portability of the LifePort Kidney Transporter, which suggests the modified HMP system met the demands required and may be suitable for rat liver preservation.
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Affiliation(s)
- Cheng Zeng
- Transplant Center, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Institute of Hepatobiliary Diseases, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Xiaoyan Hu
- Transplant Center, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Institute of Hepatobiliary Diseases, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Yanfeng Wang
- Transplant Center, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Institute of Hepatobiliary Diseases, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Xianpeng Zeng
- Transplant Center, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Institute of Hepatobiliary Diseases, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Yan Xiong
- Transplant Center, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Institute of Hepatobiliary Diseases, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Ling Li
- Transplant Center, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Institute of Hepatobiliary Diseases, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Qifa Ye
- Transplant Center, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Institute of Hepatobiliary Diseases, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, P.R. China.,Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, The Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, P.R. China
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38
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39
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Practical Recommendations for Long-term Management of Modifiable Risks in Kidney and Liver Transplant Recipients: A Guidance Report and Clinical Checklist by the Consensus on Managing Modifiable Risk in Transplantation (COMMIT) Group. Transplantation 2017; 101:S1-S56. [PMID: 28328734 DOI: 10.1097/tp.0000000000001651] [Citation(s) in RCA: 181] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Short-term patient and graft outcomes continue to improve after kidney and liver transplantation, with 1-year survival rates over 80%; however, improving longer-term outcomes remains a challenge. Improving the function of grafts and health of recipients would not only enhance quality and length of life, but would also reduce the need for retransplantation, and thus increase the number of organs available for transplant. The clinical transplant community needs to identify and manage those patient modifiable factors, to decrease the risk of graft failure, and improve longer-term outcomes.COMMIT was formed in 2015 and is composed of 20 leading kidney and liver transplant specialists from 9 countries across Europe. The group's remit is to provide expert guidance for the long-term management of kidney and liver transplant patients, with the aim of improving outcomes by minimizing modifiable risks associated with poor graft and patient survival posttransplant.The objective of this supplement is to provide specific, practical recommendations, through the discussion of current evidence and best practice, for the management of modifiable risks in those kidney and liver transplant patients who have survived the first postoperative year. In addition, the provision of a checklist increases the clinical utility and accessibility of these recommendations, by offering a systematic and efficient way to implement screening and monitoring of modifiable risks in the clinical setting.
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40
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Schlegel A, Linecker M, Kron P, Györi G, De Oliveira ML, Müllhaupt B, Clavien PA, Dutkowski P. Risk Assessment in High- and Low-MELD Liver Transplantation. Am J Transplant 2017; 17:1050-1063. [PMID: 27676319 DOI: 10.1111/ajt.14065] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 08/23/2016] [Accepted: 09/21/2016] [Indexed: 01/25/2023]
Abstract
Allocation of liver grafts triggers emotional debates, as those patients, not receiving an organ, are prone to death. We analyzed a high-Model of End-stage Liver Disease (MELD) cohort (laboratory MELD score ≥30, n = 100, median laboratory MELD score of 35; interquartile range 31-37) of liver transplant recipients at our center during the past 10 years and compared results with a low-MELD group, matched by propensity scoring for donor age, recipient age, and cold ischemia time. End points of our study were cumulative posttransplantation morbidity, cost, and survival. Six different prediction models, including donor age x recipient MELD (D-MELD), Difference between listing MELD and MELD at transplant (Delta MELD), donor-risk index (DRI), Survival Outcomes Following Liver Transplant (SOFT), balance-of-risk (BAR), and University of California Los Angeles-Futility Risk Score (UCLA-FRS), were applied in both cohorts to identify risk for poor outcome and high cost. All score models were compared with a clinical-oriented decision, based on the combination of hemofiltration plus ventilation. Median intensive care unit and hospital stays were 8 and 26 days, respectively, after liver transplantation of high-MELD patients, with a significantly increased morbidity compared with low-MELD patients (median comprehensive complication index 56 vs. 36 points [maximum points 100] and double cost [median US$179 631 vs. US$80 229]). Five-year survival, however, was only 8% less than that of low-MELD patients (70% vs. 78%). Most prediction scores showed disappointing low positive predictive values for posttransplantation mortality, such as mortality above thresholds, despite good specificity. The clinical observation of hemofiltration plus ventilation in high-MELD patients was even superior in this respect compared with D-MELD, DRI, Delta MELD, and UCLA-FRS but inferior to SOFT and BAR models. Of all models tested, only the BAR score was linearly associated with complications. In conclusion, the BAR score was most useful for risk classification in liver transplantation, based on expected posttransplantation mortality and morbidity. Difficult decisions to accept liver grafts in high-risk recipients may thus be guided by additional BAR score calculation, to increase the safe use of scarce organs.
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Affiliation(s)
- A Schlegel
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| | - M Linecker
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| | - P Kron
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| | - G Györi
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| | - M L De Oliveira
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| | - B Müllhaupt
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - P-A Clavien
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
| | - P Dutkowski
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
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41
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Report of the 22nd Annual Congress of the International Liver Transplantation Society. Transplantation 2016; 101:252-259. [PMID: 27941439 DOI: 10.1097/tp.0000000000001566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The 2016 Annual Congress of the International Liver Transplantation Society was held in Seoul, South Korea in May. The 22nd Congress marked the largest multidisciplinary liver transplantation meeting in Asia since 2010. The principal themes were living donation, allocation, immunosuppression, machine preservation, novel treatment of hepatitis C, and expansion of the deceased-donor allograft pool. This report presents select abstracts from the scientific sessions within the context of the published literature to serve as a quick reference.
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42
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Loggi E, Conti F, Cucchetti A, Ercolani G, Pinna AD, Andreone P. Liver grafts from hepatitis B surface antigen-positive donors: A review of the literature. World J Gastroenterol 2016; 22:8010-8016. [PMID: 27672295 PMCID: PMC5028814 DOI: 10.3748/wjg.v22.i35.8010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 06/06/2016] [Accepted: 07/21/2016] [Indexed: 02/06/2023] Open
Abstract
The scarcity of available organs and the gap between supply and demand continue to be the main limitations of liver transplantation. To relieve the organ shortage, current transplant strategies have implemented extended criteria, which include the use of liver from patients with signs of past or present hepatitis B virus (HBV) infection. While the use of liver grafts from donors with evidence of past HBV infection is quite limited, some data have been collected regarding the feasibility of transplanting a liver graft from a hepatitis B surface antigen (HBsAg) positive donor. The aim of the present work was to review the literature regarding liver transplants from HBsAg-positive donors. A total of 17 studies were identified by a search in Medline. To date, HBsAg positive grafts have preferentially been allocated to HBsAg positive recipients. The large majority of these patients continue to be HBsAg positive despite the use of immunoglobulin, and infection prevention can only be guaranteed by using antiviral prophylaxis. Although serological persistence is evident, no significant HBV-related disease has been observed, except in patients coinfected with delta virus. Consistently less data are available for HBsAg negative recipients, although they are mostly promising. HBsAg-positive grafts could be an additional organ source for liver transplantation, provided that the risk of reinfection/reactivation is properly prevented.
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