Events in procurement as risk factors for ischemic cholangiopathy in liver transplantation using donation after cardiac death donors

Abstract

The use of donation after cardiac death (DCD) liver grafts is controversial because of the overall increased rates of graft loss and morbidity, which are mostly related to the consequences of ischemic cholangiopathy (IC). In this study, we sought to determine the factors leading to graft loss and the development of IC and to compare patient and graft survival rates for recipients of DCD liver grafts and recipients of donation after brain death (DBD) liver grafts in a large series at a single transplant center. Two hundred liver transplants with DCD donors were performed between 1998 and 2010 at Mayo Clinic Florida. Logistic regression models were used in the univariate and multivariate analyses of predictors for the development of IC. Additional analyses using Cox regression models were performed to identify predictors of graft survival and to compare outcomes for DCD and DBD graft recipients. In our series, the patient survival rates for the DCD and DBD groups at 1, 3, and 5 years was 92.6%, 85%, and 80.9% and 89.8%, 83.0%, and 76.6%, respectively (P ¼ not significant). The graft survival rates for the DCD and DBD groups at 1, 3, and 5 years were 80.9%, 72.7%, and 68.9% and 83.3%, 75.1%, and 68.6%, respectively (P ¼ not significant). In the DCD group, 5 patients (2.5%) had primary nonfunction, 7 patients (3.5%) had hepatic artery thrombosis, and 3 patients (1.5%) experienced hepatic necrosis. IC was diagnosed in 24 patients (12%), and 11 of these patients (5.5%) required retransplantation. In the multivariate analysis, the asystole-to-cross clamp duration [odds ratio ¼ 1.161, 95% confidence interval (CI) ¼ 1.021-1.321] and African American recipient race (odds ratio ¼ 5.374, 95% CI ¼ 1.368-21.103) were identified as significant factors for predicting the development of IC (P < 0.05). This study has established a link between the development of IC and the asystole-to-cross clamp duration. Procurement techniques that prolong the nonperfusion period increase the risk for the development of IC in DCD liver grafts. See Editorial on Page 5The large imbalance between the number of available donor liver grafts and the number of patients waiting for liver transplantation (LT) has been the catalyst for identifying new donor sources. Donation after cardiac death (DCD) donors are a significant source that could be used to expand the donor pool. For this type of donor, the declaration of death is based on cardiopulmonary criteria rather than the cessation of brain and brainstem function. The use of liver grafts from DCD

Biliary Complications After Liver Transplantation: Old Problems and New Challenges

“…Since also the peribiliary plexus is involved, the incidence of biliary complications is almost doubled (78). An 'ischemic cholangiopathy' evolves in >20% of recipients (79). The clinical picture is similar to NAS of other etiology, but it manifests regularly within 3 months after LT (78).…”

“…The clinical picture is similar to NAS of other etiology, but it manifests regularly within 3 months after LT (78). Its clinical course is often more severe and retransplantation required in a significant percentage (79,80). Analysis of the UNOS database of 2351 DCD-LT revealed a significantly decreased patient and graft survival with a 5-year graft survival rate of 56% (81).…”

Early allograft dysfunction in liver transplantation using donation after cardiac death donors results in inferior survival

“…17,18 For the DCD organ procurement, a rapid retrieval technique was used in which the abdomen was opened with a cruciate incision. The small bowel was reflected superiorly, and the aorta and portal systems were cannulated for an in situ flush.…”

The Use of Donation After Cardiac Death Allografts Does Not Increase Recurrence of Hepatocellular Carcinoma

“…Overall national and international outcomes as well as reports from individual programs have extensively documented complications related to utilization of these allografts (16,17). More recent reports have shown that comparable outcomes using DBD and DCD liver allografts can be achieved with appropriate donor and recipient selection as well as paying close attention to surgical technique especially during procurement (10,18). A wide range of center experience using DCD allografts likely contributes to the variability of results.…”

“…Survival was calculated from the date of LT to death or last known follow-up. The techniques of DCD at our center have previously been described in detail (9,10).…”