Liver Preservation by Aortic Perfusion Alone Compared With Preservation by Aortic Perfusion and Additional Arterial Ex Situ Back-Table Perfusion With Histidine-Tryptophan-Ketoglutarate Solution: A Prospective, Randomized, Controlled, Multicenter Study

Abstract

BackgroundArterial ex situ back-table perfusion (BP) reportedly reduces ischemic-type biliary lesion after liver transplantation. We aimed to verify these findings in a prospective investigation.MethodsOur prospective, randomized, controlled, multicenter study involved livers retrieved from patients in 2 German regions, and compared the outcomes of standard aortic perfusion to those of aortic perfusion combined with arterial ex situ BP. The primary endpoint was the incidence of ischemic-type biliary lesions over a follow-up of 2 years after liver transplantation, whereas secondary endpoints included 2-year graft survival, initial graft damage as reflected by transaminase levels, and functional biliary parameters at 6 months after transplantation.ResultsA total of 75 livers preserved via standard aortic perfusion and 75 preserved via standard aortic perfusion plus arterial BP were treated using a standardized protocol. The incidence of clinically apparent biliary lesions after liver transplantation (n = 9 for both groups; P = 0.947), the 2-year graft survival rate (standard aortic perfusion, 74%; standard aortic perfusion plus arterial BP, 68%; P = 0.34), and incidence of initial graft injury did not differ between the 2 perfusion modes. Although 33 of the 77 patients with cholangiography workups exhibited injured bile ducts, only 10 had clinical symptoms.ConclusionsContrary to previous findings, the present study indicated that additional ex situ BP did not prevent ischemic-type biliary lesions or ischemia-reperfusion injury after liver transplantation. Moreover, there was considerable discrepancy between cholangiography findings regarding bile duct changes and clinically apparent cholangiopathy after transplantation, which should be considered when assessing ischemic-type biliary lesions.

Donor hepatectomy time influences ischemia-reperfusion injury of the biliary tree in donation after circulatory death liver transplantation

“…28 However, a randomized controlled trial comparing aortic flush only and combined aortic and portal flush in DBD-LT, showed no difference in the incidence of post-transplant cholangiopathy. 29 Since DCD grafts could also be considered as high-risk grafts, it would be justifiable to evaluate the effect of dual perfusion versus aortic only perfusion in the DCD-LT population. Another method to potentially minimize the detrimental effect of both dWIT and hepatectomy time on the outcomes after LT is the use of normothermic regional perfusion.…”

Heterogeneity of Bile Duct Management in the Development of Ischemic Cholangiopathy After Liver Transplantation: Results of a European Liver and Intestine Transplant Association Survey

“…Based on the hypothesis that perfusion of the peribiliary capillary plexus is of paramount importance, an arterial back table pressure perfusion (150 mm Hg) of 300 cc UW through the hepatic artery has been identified as an independent protective factor to prevent the development of IC [24]. However, these findings were not confirmed in a recent powered multicenter RCT using ex situ perfusion through HA with 300 cc HTK at a pressure of 100 cm H 2 O [25].…”

Donor Shortage in Germany: Impact on Short- and Long-Term Results in Liver Transplantation

“…The DRI, including graft features such as donor age, cause of death, cold ischemia time etc., has turned out to be a reliable predictor of graft survival [3,14]. In addition, steatotic livers, which are not considered in the DRI calculation, proved to be an important indicator of subsequent graft function [15].…”

“…Organ shortage is supposed to promote the usage of organs which are discarded in case of less pronounced scarcity. In a recently published German multicenter study [3], the median donor risk index (ET-DRI) in the years around 2010 was 2.0 (1.22-3.6) [4]. At that time, the donation rate was comparatively high in Germany.…”