Extended-criteria donors in liver transplantation Part II: reviewing the impact of extended-criteria donors on the complications and outcomes of liver transplantation

Abstract

Extended criteria donors (ECDs) have an impact on early allograft dysfunction (EAD), biliary complications, relapse of hepatitis C virus (HCV), and survivals. Early allograft dysfunction was frequently seen in grafts with moderate and severe steatosis. Donors after cardiac death (DCD) have been associated with higher rates of graft failure and biliary complications compared to donors after brain death. Extended warm ischemia, reperfusion injury and endothelial activation trigger a cascade, leading to microvascular thrombosis, resulting in biliary necrosis, cholangitis, and graft failure. The risk of HCV recurrence increased by donor age, and associated with using moderately and severely steatotic grafts. With the administration of protease inhibitors sustained virological response was achieved in majority of the patients. Donor risk index and EC donor scores (DS) are reported to be useful, to assess the outcome. The 1-year survival rates were 87% and 40% respectively, for donors with a DS of 0 and 3. Graft survival was excellent up to a DS of 2, however a DS >2 should be avoided in higher-risk recipients. The 1, 3 and 5-year survival of DCD recipients was comparable to optimal donors. However ECDs had minor survival means of 85%, 78.6%, and 72.3%. The graft survival of split liver transplantation (SLT) was comparable to that of whole liver orthotopic liver transplantation. SLT was not regarded as an ECD factor in the MELD era any more. Full-right-full-left split liver transplantation has a significant advantage to extend the high quality donor pool. Hypothermic oxygenated machine perfusion can be applied clinically in DCD liver grafts. Feasibility and safety were confirmed. Reperfusion injury was also rare in machine perfused DCD livers. I) IntroductionAs discussed earlier, extended criteria donors are used widely. In this chapter a review is given about the impact of ECD on the outcome. Living related liver transplantation is discussed shortly, whether the partial grafts can still be regarded as ECD or not. Machine perfusion, as a possible management was also reviewed briefly. Outcome parameters are divided as possible complications, and survival results. Complications are listed as early graft dysfunction, biliary complications, HCV recurrence. Survival rates are summarized separately. Split, and living related LT discussed briefly, and finally the machine perfusion, as a possible future aspect is summarized. Silberhummer et al figured out the recipients' condition by the delta-MELD: as the difference between the MELD at transplantation and the MELD at listing. Patients with a both delta-MELD>1 and an ECD>2 together had a higher chance to develop EAD, and also significantly higher risk for mortality [3]. Others report a similar incidence of EAD, PNF, acute rejection, biliary complication and also that ECD had no significant effect on either ICU stay or duration of postOLT ventilation, and also the postOLT laboratory test, bleeding, biliary and vascular complication rates were similar in ECD and non-...

Curative Intent Treatment of Hepatocellular Carcinoma - 844 Cases Treated in a General Surgery and Liver Transplantation Center

“…In order to expand the donor pool marginal donors could be accepted with good results. The use of marginal donors may be related with an increasing incidence of primary non function, but on long run these organs can led to an outcome similar to the one resulted after transplantation with optimal grafts (32,33). Hypothermic oxygenated machine perfusion can be used for improving marginal grafts, before being transplanted (32).…”

Liver transplantation for unresectable colorectal liver metastases: A systematic review

“…Another tactic that has been proposed involves the use of the split liver technique. Donors with advanced age, hepatic steatosis, prolonged cold ischemia time, donation after cardiac death, and donors with increased risk of infectious disease transmission or cancer have also been used, however the outcomes using these types of donors have been worse . Novel techniques that combine the principles of surgical oncology with transplantation—so called “transplant oncology”—speak to the multidisciplinary nature of this disease and the need for rigorous clinical testing to ensure proper patient selection and ethical distribution of organs …”

Opportunities for Therapeutic Intervention During Machine Perfusion

“…Even moderately steatotic livers are associated with increased acute kidney injury [62] and EAD [63]. Interestingly, even HMP of steatotic rat livers improves bile production, liver ATP and liver oxygen consumption in a simulated reperfusion model, when compared to steatotic livers preserved by SCS [64].…”