Efficiency of machine perfusion in pediatric liver transplantation

Abstract

Liver transplantation is the only lifesaving procedure for children with end-stage liver disease. The field is however heterogenic with various graft types, recipient age and weight and underlying diseases. Despite recently improved overall outcomes and the expanded use of living donors, waiting list mortality remains unacceptable particularly in small children and infants. Based on the known negative effect of elevated donor age, higher body mass index, and prolonged cold ischemia time, the number of available donors for pediatric recipients is limited. Machine perfusion has regained significant interest in the adult liver transplant population during the last decade. Ten randomized controlled trials are published with an overall advantage of machine perfusion techniques over cold storage regarding post-operative outcomes, including graft survival. The concept of hypothermic oxygenated perfusion (HOPE) was the first and only perfusion technique used for pediatric liver transplantation today. In 2018 the first pediatric candidate received a full-size graft donated after circulatory death with cold storage and HOPE, followed by a few split liver transplants after HOPE with an overall limited case number until today. One series of split procedures during HOPE was recently presented by colleagues from France with excellent results, reduced complications, and better graft survival. Such early experience paves the way for a more systematic use of machine perfusion techniques for different graft types for pediatric recipients. Clinical reports of pediatric liver transplants with other perfusion techniques are awaited. Strong collaborative efforts are needed to explore the effect of perfusion techniques in this vulnerable population impacting not only the immediate posttransplant outcome, but the development and success of an entire life.

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“…Altogether, these data suggest that HOPE-Split could mitigate left partial liver graft IRI similar to the impact of HOPE in whole liver transplantation [8,31]. The presented results demonstrate that HOPE, by replacing CIT during ex-situ liver splitting, may be a promising strategy to expand donor selection criteria especially for split liver grafts [14]. Besides, performing back-table preparation during active perfusion can further improve graft preservation allowing for a CIT <6 h, similar to in-situ split grafts [8,20], which may facilitate logistics.…”

“…PRS is also a major determinant of graft survival in PLT with a reported incidence up to 34%. Therefore, PLT may benefit from the implementation of HOPE to mitigate PRS an IRI [12][13][14]. While the safety and feasibility of HOPE in PSLT have already been established, there is currently no data on the impact of HOPE on early IRI indicators available [9,15,16].…”

HOPE Mitigates Ischemia-Reperfusion Injury in Ex-Situ Split Grafts: A Comparative Study With Living Donation in Pediatric Liver Transplantation

“…Altogether, these data suggest that HOPE-Split could mitigate left partial liver graft IRI similar to the impact of HOPE in whole liver transplantation [ 8 , 31 ]. The presented results demonstrate that HOPE, by replacing CIT during ex-situ liver splitting, may be a promising strategy to expand donor selection criteria especially for split liver grafts [ 14 ]. Besides, performing back-table preparation during active perfusion can further improve graft preservation allowing for a CIT <6 h, similar to in-situ split grafts [ 8 , 20 ], which may facilitate logistics.…”

“…Besides, performing back-table preparation during active perfusion can further improve graft preservation allowing for a CIT <6 h, similar to in-situ split grafts [ 8 , 20 ], which may facilitate logistics. Graft evaluation [ 32 ] and specific scenarios that might benefit the most from HOPE still need to be explored to safely increase the donor pool for pediatric recipients through tailored preservation strategies [ 14 ]. In addition to PLT, HOPE may also facilitate the access to partial grafts for adult recipients with oncological indications in the context of the RAPID procedure (Resection And Partial Liver Segment 2/3 Transplantation with Delayed Total Hepatectomy) [ 33 ].…”

“…PRS is also a major determinant of graft survival in PLT with a reported incidence up to 34%. Therefore, PLT may benefit from the implementation of HOPE to mitigate PRS an IRI [12][13][14]. While the safety and feasibility of HOPE in PSLT have already been established, there is currently no data on the impact of HOPE on early IRI indicators available [9,15,16].…”