Hypothermic Oxygenated Machine Perfusion of Liver Grafts from Brain-Dead Donors

Abstract

Hypothermic oxygenated machine perfusion (HOPE) was introduced in liver transplantation (LT) to mitigate ischemia-reperfusion injury. Available clinical data mainly concern LT with donors after circulatory-determined death, whereas data on brain-dead donors (DBD) are scarce. To assess the impact of end-ischemic HOPE in DBD LT, data on primary adult LTs performed between March 2016 and June 2018 were analyzed. HOPE was used in selected cases of donor age >80 years, apparent severe graft steatosis, or ischemia time ≥10 hours. Outcomes of HOPE-treated cases were compared with those after static cold storage. Propensity score matching (1:2) and Bayesian model averaging were used to overcome selection bias. During the study period, 25 (8.5%) out of 294 grafts were treated with HOPE. After matching, HOPE was associated with a lower severe post-reperfusion syndrome (PRS) rate (4% versus 20%, p = 0.13) and stage 2–3 acute kidney injury (AKI) (16% versus 42%, p = 0.046). Furthermore, Bayesian model averaging showed lower transaminases peak and a lower early allograft dysfunction (EAD) rate after HOPE. A steeper decline in arterial graft resistance throughout perfusion was associated with lower EAD rate. HOPE determines a significant reduction of ischemia reperfusion injury in DBD LT.

Machine Perfusions in Liver Transplantation: The Evidence‐Based Position Paper of the Italian Society of Organ and Tissue Transplantation

“…(10,13,15,16) The 1-year patient survival rates ranged from 84% to 100% in the HMP group versus from 42% to 95% in the SCS group. (8,(10)(11)(12)(13)(14)(15)(16) Improved patient survival after HMP was shown in only 1 study in recipients of severely macrosteatotic grafts, showing 100% versus 42% 1-year patient survival in the HMP group versus the SCS group. (13) recOMMenDatiOn We suggest the use of HMP for the improvement of graft survival, especially in the setting of ECD.…”

Use of Dual Hypothermic Oxygenated Machine Perfusion to Recover Extended Criteria Pediatric Liver Grafts

“…During the procedure, the pressure settings were lowered as compared with those usually adopted in adults to avoid damaging the graft from excessive perfusion pressure, which has been observed in the experimental setting. (4) In this case, however, the graft weight was 1500 g, thus not representative of an average pediatric graft.After having gathered experience with D-HOPE for grafts from adult donors, (1) we recently applied this technique in 2 small-sized whole liver grafts from pediatric donors whose liver function tests were consistent with acute liver injury, confirming the safety and feasibility of D-HOPE also in the pediatric LT setting.…”

“…After having gathered experience with D-HOPE for grafts from adult donors, (1) we recently applied this technique in 2 small-sized whole liver grafts from pediatric donors whose liver function tests were consistent with acute liver injury, confirming the safety and feasibility of D-HOPE also in the pediatric LT setting.…”

“…(4) The vascular elasticity as well as the susceptibility to shear stress of pediatric livers during machine perfusion are largely unknown. Yet, our endeavor was not without a background: the cases herein reported were prompted by our previous experience with D-HOPE in adult livers, (1) during which we had perfused 8 grafts weighing between 900 and 1000 g using standard settings, with no case of post-LT graft dysfunction or other adverse events (unpublished data). According to Werner et al (3) we reduced the pressure settings to 4 and 18 mm Hg to further minimize the risk of graft injury.…”

“…Hypothermic oxygenated machine perfusion (HOPE) has been associated with improved outcomes in grafts from donation after circulatory death (DCD) or grafts from extended criteria donation after brain death (DBD) donors. (1,2) As opposed to adult LT, the use of extended criteria donors seems much more limited in pediatric LT. Pediatric recipients are generally allocated whole grafts from pediatric donors or the left lateral segment resulting from the splitting of otherwise optimal grafts or living donation. In these scenarios, static cold storage generally allows satisfactory graft preservation.However, extended criteria donors are not exclusive of adult LT, and HOPE could also find specific indications in pediatric LT.…”