Effects of machine perfusion strategies on different donor types in liver transplantation: a systematic review and meta-analysis

Abstract

Background: Increasing use of extended-criteria donors (ECD) set higher requirements for graft preservation. Machine perfusion (MP) improves orthotopic liver transplantation (OLT) outcomes but its effects on different donor types remains unclear. Our aim was to assess the effects of hypothermic machine perfusion (HMP), normothermic machine perfusion (NMP), or normothermic regional perfusion (NRP) versus static cold storage (SCS) on different donor types. Materials and Methods: A literature search comparing the efficacy of MP versus SCS in PubMed, Cochrane and EMBASE database was conducted. Meta-analysis was performed to obtain pooled effects of MP on extended criteria donors (ECD), donation after circulatory death (DCD), donor after brainstem death. Results: 39 studies were included (9 RCTs and 30 cohort studies). Compared with SCS, HMP significantly reduced the risk of non-anastomotic biliary stricture (NAS) (OR 0.43, 95%CI 0.26-0.72), major complications (OR 0.55, 95%CI 0.39-0.78), early allograft dysfunction (EAD) (OR 0.46, 95%CI 0.32-0.65) and improve one-year graft (OR 2.36, 95%CI 1.55-3.62) in ECD-OLT. HMP also reduced primary nonfunction (PNF) (OR 0.40, 95%CI 0.18-0.92) and acute rejection (OR 0.62, 95%CI 0.40-0.97). NMP only reduced major complications in ECD-OLT (OR 0.56, 95%CI 0.34-0.94), without favorable effects on other complications and survival. NRP lower the overall risk of NAS (OR 0.27, 95%CI 0.11-0.68), PNF (OR 0.43, 95%CI 0.22-0.85), EAD (OR 0.58, 95%CI 0.42-0.80) and meanwhile improved one-year graft survival (OR 2.40, 95%CI 1.65-3.49) in control DCD-OLT. Conclusions: HMP might currently be considered for marginal livers as it comprehensively improves ECD-OLT outcomes. NMP assists some outcomes in ECD-OLT but more evidence regarding NMP-ECD is warrant. NRP significantly improves DCD-OLT outcomes and is recommended where longer non-touch periods exist.

Outcomes using steatotic liver grafts: Will machines score the final goal?

“…Several randomized clinical trials and observational studies have assessed the effects of dynamic machine perfusion techniques when compared with static cold storage in the preservation of grafts from extended-criteria donors. According to recent meta-analyses and systematic reviews, machine perfusion is associated with lower rates of early allograft dysfunction and likely less complications associated with ischemia-reperfusion injury such as nonanastomotic biliary strictures, and hypothermic machine perfusion may also result in better 1-year graft survival 7,8 . On top of that, a novel strategy that leads to defatting the graft during long-term ex situ normothermic machine perfusion has been proposed and may help rescue discarded livers for transplantation 9 .…”

A commentary on ‘Effects of machine perfusion strategies on different donor types in liver transplantation: a systematic review and meta-analysis’

“…With great interest, we read the article entitled ‘Effects of machine perfusion strategies on different donor types in liver transplantation: a systematic review and meta-analysis’ recently published in the International Journal of Surgery by Liang et al . 1 . The authors evaluated the benefits of different machine perfusion strategies for different donor types through a systematic review and meta-analysis.…”