Ischemic Cholangiopathy Postdonation After Circulatory Death Liver Transplantation: Donor Hepatectomy Time Matters

Abstract

Background. Outcomes of liver transplantation (LT) from donation after circulatory death (DCD) have been improving; however, ischemic cholangiopathy (IC) continues to be a problem. In 2014, measures to minimize donor hepatectomy time (DHT) and cold ischemic time (CIT) have been adopted to improve DCD LT outcomes. Methods. Retrospective review of all patients who underwent DCD LT between 2005 and 2017 was performed. We compared outcomes of patients who were transplanted before 2014 (historic group) with those who were transplanted between 2014 and 2017 (modern group). Results. We identified 112 patients; 44 were in the historic group and 68 in the modern group. Donors in the historic group were younger (26.5 versus 33, P = 0.007) and had a lower body mass index (26.2 versus 28.2, P = 0.007). DHT (min) and CIT (h) were significantly longer in the historic group (21.5 versus 14, P < 0.001 and 5.3 versus 4.2, P < 0.001, respectively). Fourteen patients (12.5%) developed IC, with a significantly higher incidence in the historic group (23.3% versus 6.1%, P = 0.02). There was no difference in graft and patient survival between both groups. Conclusion. In appropriately selected recipients, minimization of DHT and CIT may decrease the incidence of IC. These changes can potentially expand the DCD donor pool.

Comparison of Biliary Complications Rates After Brain Death, Donation After Circulatory Death, and Living-Donor Liver Transplantation: A Single-Center Cohort Study

“…The nature and frequency of biliary complications are what differentiate most long-term outcomes in DCD-LT versus DBD-LT or LD-LT. A focused analysis led us to study biliary complications in 414 recipients, including one-third of each donor type. Non-anastomotic biliary stricture developed in 15.2% of DCD recipients, which aligns with what is reported in the literature [7,8,11]. This complication was exceptional in DBD-LT or LD-LT in the absence of an arterial supply problem.…”

“…It is well recognized that DCD livers expose the recipient to increased risk from the inevitably longer donor warm ischemia time (dWIT). Aside from primary nonfunction [4], the most feared complication, and one of the main reasons for graft loss, is ischemic cholangiopathy (IC), defined as the appearance of intrahepatic non-anastomotic biliary strictures (NAS), which occurs in 10%-50% of cases [5][6][7][8][9]. The increasing use of normothermic preservation machines (NMP) might significantly modify these complication rates [10].…”

“…In this regard, we and others have developed scores to select donors/recipients in order to optimize outcomes with a special emphasis on minimizing biliary complications [11][12][13][14]. Known risk factors for IC are donor age (>40 years) [6,15], prolonged cold ischemic time (CIT) (>8 h) [6], prolonged dWIT (>20 min), low venous oxygen saturation (SvO 2 ≤ 60) [15], and donor liver extraction time [8,13]. Besides IC, other relevant ischemic complications include anastomotic biliary strictures (AS) and bile leaks which were previously shown to range between 10% and 15% in DCD cases, and not be significantly different from DBD rates [6].…”

Structural and Temporal Dynamics of Mesenchymal Stem Cells in Liver Diseases From 2001 to 2021: A Bibliometric Analysis

“…The emergence and application of (donation after circulatory death) DCD provide the possibility to solve the shortage of clinical liver supply ( 124 ). However, the long-term hepatic ischemia-reperfusion injury (IRI) and intracellular reactive oxygen species (ROS) injury lead to the damage of DCD donor liver structure and function, which may lead to complications such as primary non-function after liver transplantation ( 125 ). Machine perfusion has become a novel strategy for liver graft preservation, and the treatment with MSCs has unique advantages in the clinical application during perfusion in recent years ( 126 , 127 ).…”

From Haphazard to a Sustainable Normothermic Regional Perfusion Service: A Blueprint for the Introduction of Novel Perfusion Technologies

“…These range in ambition and complexity from optimisation of the retrieval process (7), through the use of novel perfusion and preservation technology, in the form of ex situ machine perfusion [hypothermic (8,9), oxygenated hypothermic (10,11), or normothermic (12)], or by re-establishing an oxygenated blood supply to donor organs in situ after donor asystole with Normothermic Regional Perfusion (NRP) (4,13) or a combination of these strategies (14). Ex situ technologies have shown a variable degree of benefit in DCD transplantation in terms of either prolonged preservation, a reduction in the rate of complications, immunomodulation, and improved graft outcomes.…”