Clinical outcomes of donation after circulatory death liver transplantation in primary sclerosing cholangitis

Abstract

Transplantation with DCD (vs. DBD) livers in PSC patients does not impact graft loss or patient survival. In an era of organ shortage, DCD grafts represent a viable therapeutic option for liver transplantation in PSC patients. Lay summary: This study examines the impact of liver transplantation in primary sclerosing cholangitis (PSC) with organs donated after circulatory death (DCD), compared to donation after brainstem death (DBD). We show that in appropriately selected patients, the outcomes for DCD transplantation mirror those using DBD livers, with no significant differences in complication rate, patient survival or transplanted liver survival. In an era of organ shortage and increasing wait-list times, DCD livers represent a potential treatment option for transplantation in PSC.

The impact of ileal pouch‐anal anastomosis on graft survival following liver transplantation for primary sclerosing cholangitis

“…Herein, we identify that any protective effect conferred following colectomy (with regard to recurrent biliary disease) is skewed towards the patient group retaining an end ileostomy, whereas no benefit is evident for patients with an IPAA. As patients with PSC and IPAA often develop pouchitis and poorer pouch function, it is plausible that persistent or recurrent episodes of intestinal inflammation also contribute to an elevated risk of thrombotic injury, akin to that when the colon is retained . Although speculative, evidence to support this hypothesis includes the fact that our ileostomy group experienced the lowest incidence of hepatic artery thrombosis; in addition to findings that show persistent subclinical intestinal inflammation in PSC associated colitis, associations between pouchitis and thrombocytosis, and heightened platelet activation during active IBD…”

“…Whether unique commensal disturbances correlate with risk of allograft recurrence, thromboembolic events or actual graft loss is also an area of ongoing investigation . Given the increased incidence of hepatic artery thrombosis in patients with PSC and IBD, which we now confirm is relevant to those with IPAA, a dedicated evaluation of thrombotic tendency is needed in this at‐risk population …”

“…A similar caution applies to the progressive knowledge that surrounds transplant‐related complications. Consequently, we evaluated the incidence of all recurrent/non‐anastomotic biliary strictures collectively, for attributing more specific labels to lesions that developed in the early 1990s (for instance, differentiating ischaemic‐type biliary lesions from recurrent PSC) may neither be correct nor consistent with contemporary definitions and imaging modalities . In any event, the lack of protocol cholangiographic/angiographic surveillance is caveat across most outcome studies in transplantation including our own, and it is conceivable that the subclinical incidence of vascular events and biliary complications is higher than actually reported.…”

“…Indeed, PSC accounts for >10% of all United Kingdom liver transplant activity, while also being the lead indication for transplantation in Nordic countries . Although transplantation is a proven life‐extending intervention, the incidence of graft loss is significantly greater compared with that observed for non‐PSC aetiologies …”

“…Following liver transplantation, colectomy does not appear protective against graft loss per se, although data from several centres indicate that retention of an intact colon, particularly one associated with ongoing inflammatory activity post‐transplant, increases the risk of developing post‐transplant complications including disease recurrence and hepatic artery thrombosis …”