Developing a donation after cardiac death risk index for adult and pediatric liver transplantation

Abstract

AIMTo identify objective predictive factors for donor after cardiac death (DCD) graft loss and using those factors, develop a donor recipient stratification risk predictive model that could be used to calculate a DCD risk index (DCD-RI) to help in prospective decision making on organ use.METHODSThe model included objective data from a single institute DCD database (2005-2013, n = 261). Univariate survival analysis was followed by adjusted Cox-regressional hazard model. Covariates selected via univariate regression were added to the model via forward selection, significance level P = 0.3. The warm ischemic threshold was clinically set at 30 min. Points were given to each predictor in proportion to their hazard ratio. Using this model, the DCD-RI was calculated. The cohort was stratified to predict graft loss risk and respective graft survival calculated.RESULTSDCD graft survival predictors were primary indication for transplant (P = 0.066), retransplantation (P = 0.176), MELD > 25 (P = 0.05), cold ischemia > 10 h (P = 0.292) and donor hepatectomy time > 60 min (P = 0.028). According to the calculated DCD-RI score three risk classes could be defined of low (DCD-RI < 1), standard (DCD-RI 2-4) and high risk (DCD-RI > 5) with a 5 years graft survival of 86%, 78% and 34%, respectively.CONCLUSIONThe DCD-RI score independently predicted graft loss (P < 0.001) and the DCD-RI class predicted graft survival (P < 0.001).

Normothermic Machine Perfusion (NMP) Inhibits Proinflammatory Responses in the Liver and Promotes Regeneration

“…However, this increase is mainly limited to high-risk, so-called marginal donors, which largely comprise donors deceased after circulatory death 683 (DCD), (2) older donors, and fatty livers. (3) There is evidence that marginal organs have greater vulnerability to ischemia reperfusion injury (IRI), an inevitable process of organ transplantation. (4) A number of experimental and clinical studies have shown that reperfusion of allografts is associated with organ inflammation characterized by the release of inflammatory mediators, up-regulation of adhesion molecules, immune cell infiltration, and increased cell death.…”

Retrieval Practice or Overall Donor and Recipient Risk: What Impacts on Outcomes After Donation After Circulatory Death Liver Transplantation in the United Kingdom?

“…One parameter, recently considered as a risk factor for impaired outcomes, was the duration of donor liver hepatectomy. The team from King’s College Hospital has suggested a threshold of 40 minutes for DCD retrievals and therefore includes this parameter in their DCD risk score . Additionally, another large study based on the ELTR paralleled such reports, although the median hepatectomy time for DCD procurement was 10 minutes longer here (50 versus 39.5 minutes) compared with our analysis .…”

“…In addition to the metabolic status of a particular donor liver at the time of treatment withdrawal, multiple factors contribute to the overall accumulation of graft injury . In contrast to known donor and recipient factors, where thresholds were described, the impact of procurement parameters remains less well defined. Despite the uniform application of the super‐rapid donor cannulation by all retrieval teams in the United Kingdom, such technical improvements throughout recent years could not entirely prevent the occurrence of the most‐feared complications including IC .…”

“…Although retrieval teams in the United Kingdom share the standardized surgical technique of super‐rapid donor cannulation for multiorgan DCD procurement, certain technical differences may exist, including the type and amount of preservation fluid and extra liver flushing prior to packing and transport. In addition to the duration of donor hepatectomy, which has already been proposed to impact on outcomes following DCD liver transplantation (LT) by others, further surgical timings and organ injuries appear of interest with a focus on recipient outcome …”

Simultaneous Liver and Kidney Transplantation Using Organs from Donation After Circulatory Death Donors in the Contemporary Era: We Are Getting Better!

“…More recently, we have become better with matching the right DCD donor liver for the right recipient. Several scoring systems have been developed to help clinicians identify the best DCD liver for an individual recipient to optimize outcomes and avoid transplants that lead to a significantly higher rate of DAC and graft loss …”