Outcomes Using Grafts from Donors after Cardiac Death

Doyle, Maria B. Majella; Collins, Kelly; Vachharajani, Neeta; Lowell, Jeffrey A.; Shenoy, Surendra; Nalbantoglu, ILKe; Byrnes, Kathleen; Garonzik-Wang, Jacqueline; Wellen, Jason; Lin, Yiing; Chapman, William C.

doi:10.1016/j.jamcollsurg.2015.03.053

Cited by 73 publications

(62 citation statements)

References 33 publications

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“…However, our presented data along with other recent reports (21)(22)(23) may suggest otherwise. (23) This prompted us to ask the following questions: how many young DCD livers are discarded annually, and would more frequent acceptance of younger DCD livers increase the number of liver transplants in the United States? If so, this would represent an increase in the donor organ pool, using presently available organs.…”

Section: Scalea Redfield and Foley Liver Transplantation Septembersupporting

confidence: 65%

Liver transplant outcomes using ideal donation after circulatory death livers are superior to using older donation after brain death donor livers

2016

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Multiple reports have demonstrated that liver transplantation following donation after circulatory death (DCD) is associated with poorer outcomes when compared with liver transplantation from donation after brain death (DBD) donors. We hypothesized that carefully selected, underutilized DCD livers recovered from younger donors have excellent outcomes. We performed a retrospective study of the United Network for Organ Sharing database to determine graft survivals for patients who received liver transplants from DBD donors of age 60 years, DBD donors < 60 years, and DCD donors < 50 years of age. Between January 2002 and December 2014, 52,271 liver transplants were performed in the United States. Of these, 41,181 (78.8%) underwent transplantation with livers from DBD donors of age < 60 years, 8905 (17.0%) from DBD donors 60 years old, and 2195 (4.2%) livers from DCD donors < 50 years of age. DCD livers of age < 50 years with < 6 hours of cold ischemia time (CIT) had superior graft survival when compared with DBD livers age 60 years (P < 0.001). In 2014, there were 133 discarded DCD livers; of these, 111 (83.4%) were from donors < age 50 years old. Young DCD donor livers (age < 50 years old) with short CITs yield results better than that seen with DBD livers > 60 years old. Careful donor organ and recipient selection can lead to excellent results, despite previous reports suggesting otherwise. Increased acceptance of these DCD livers would lead to shorter wait list times and increased national liver transplant rates.Liver Transplantation 22 1197-1204 2016 AASLD. There exists a vast disparity between the number of patients on the liver transplant waiting list and the number of available organs.(1-4) One method for increasing the number of transplantable organs has been to use organs from patients who die after circulatory death.(5-9) Accordingly, large increases in the number of transplantable kidneys have resulted from donation after circulatory death (DCD) protocols. However, only modest increases in DCD liver transplantation have been observed. (5,10,11) In fact, only approximately 6% of liver transplants in the United States are performed using DCD livers.(12) This lack of growth in the DCD liver pool is due, in part, to the technical challenges of the operation and concern for postoperative complications such as ischemic cholangiopathy. (5,6) As described by Feng et al., (13) not all donor livers yield equivalent recipient outcomes. Much like livers that are recovered from donation after brain death (DBD) donors, DCD livers carry a spectrum of risk. That is, there are some livers which likely function better than others. It is known that the age of the DCD donor is a risk factor for graft loss when compared with DBD organs, particularly when the DCD donor is >50 years of age. (13,14) In addition, cold ischemia time (CIT) has been shown to have a greater effect on Abbreviations: BMI, body mass index; CIT, cold ischemia time; DBD, donation after brain death; DCD, donation after circulatory death; ICU, intensive ca...

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Section: Scalea Redfield and Foley Liver Transplantation Septembersupporting

confidence: 65%

Liver transplant outcomes using ideal donation after circulatory death livers are superior to using older donation after brain death donor livers

2016

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“…Although LT from DCD donors demonstrates satisfactory long-term outcomes, these are burdened by a higher degree of delayed graft function compared to donation after brain death (DBD) and a higher frequency of AKI as well as CKD[92-95], despite similar pre-LT renal function[96]. In this setting, the damage sustained by the graft during cold preservation following recovery from the donor and during subsequent warm at implantation into the recipient[97] is intensified by the period of warm ischaemia in the donor.…”

Section: Specific Intra-operative Risk Factors For Post-lt Prs-inducementioning

confidence: 99%

Acute kidney injury and post-reperfusion syndrome in liver transplantation

Umbro¹,

Tinti²,

Scalera³

et al. 2016

WJG

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In the past decades liver transplantation (LT) has become the treatment of choice for patients with end stage liver disease (ESLD). The chronic shortage of cadaveric organs for transplantation led to the utilization of a greater number of marginal donors such as older donors or donors after circulatory death (DCD). The improved survival of transplanted patients has increased the frequency of long-term complications, in particular chronic kidney disease (CKD). Acute kidney injury (AKI) post-LT has been recently recognized as an important risk factor for the occurrence of de novo CKD in the long-term outcome. The onset of AKI post-LT is multifactorial, with pre-LT risk factors involved, including higher Model for End-stage Liver Disease score, more sever ESLD and pre-existing renal dysfunction, either with intra-operative conditions, in particular ischaemia reperfusion injury responsible for post-reperfusion syndrome (PRS) that can influence recipient’s morbidity and mortality. Post-reperfusion syndrome-induced AKI is an important complication post-LT that characterizes kidney involvement caused by PRS with mechanisms not clearly understood and implication on graft and patient survival. Since pre-LT risk factors may influence intra-operative events responsible for PRS-induced AKI, we aim to consider all the relevant aspects involved in PRS-induced AKI in the setting of LT and to identify all studies that better clarified the specific mechanisms linking PRS and AKI. A PubMed search was conducted using the terms liver transplantation AND acute kidney injury; liver transplantation AND post-reperfusion syndrome; acute kidney injury AND post-reperfusion syndrome; acute kidney injury AND DCD AND liver transplantation. Five hundred seventy four articles were retrieved on PubMed search. Results were limited to title/abstract of English-language articles published between 2000 and 2015. Twenty-three studies were identified that specifically evaluated incidence, risk factors and outcome for patients developing PRS-induced AKI in liver transplantation. In order to identify intra-operative risk factors/mechanisms specifically involved in PRS-induced AKI, avoiding confounding factors, we have limited our study to “acute kidney injury AND DCD AND liver transplantation”. Accordingly, three out of five studies were selected for our purpose.

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“…While our institution, 2,6 King's, 7 and others 8,9 report outcomes in DCD LT comparable to Donation after Brain Death (DBD), DCD LT is still not perfect. In our report, the incidence of IC and hepatic artery thrombosis in late DCD group was significant high than in DBD group (3 vs. 0.5%, P < .05).…”

Section: Response To "Minimization Of Ischemic Cholangiopathy In Donamentioning

confidence: 83%

Response to “Minimization of Ischemic Cholangiopathy in Donation After Cardiac Death Liver Transplantation: Is it Thrombolytic Therapy or Warm Ischemic Time Stringency and Donor Bile Duct Flush?”

Bohórquez

Loss

2018

American Journal of Transplantation

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We thank Giorgakis and colleagues for their interest in our recent published article.1,2 Since the etiology of ischemic cholangiopathy (IC) in Donation after Cardiac Death (DCD) for Liver Transplantation (LT) is not well defined, hypotheses include ischemia-reperfusion injury, microvascular thrombosis, cytotoxic injury, and impaired biliary epithelial regeneration, 3-5 adopting a multifaceted protocol to optimize perioperative conditions is essential. We concur with their observation that fast organ recovery with rapid decompression, in-situ aortic and portal flushing, biliary tree flushing-and in our institution, retrograde venous flushing-keep short ischemic times, careful donorrecipient selection, and pristine technical implantation are imperative to good outcomes.As we mentioned in our paper, we acknowledge the limitations of our retrospective non-randomized study. In the setting of multiple simultaneous changes in our protocol, we cannot, and we do not assume that our graft and patient survival rates are exclusively related to the use of tPA. However, our report shows the safety of tPA utilization after portal reperfusion with no adverse events and no increase in transfusion requirements. Additionally, the early success of this DCD protocol led us to liberalize our thresholds for DCD donor age, hepatic steatosis, and ischemia times with >60% of our last 100 DCD livers originated outside our donor service area and 10% received a donor with functional warm ischemia time (fWIT) >30 minutes.As Giorgakis et al comment, short ischemia times are important in DCD LT and fWIT seem to play an essential role. In our late DCD group, only one patient with fWIT >30 minutes, fWIT of 45 minutes, developed IC indicating that not all factors are mitigated by our protocol. It is worth mentioning that although concept of fWIT is clear to the transplant community, there is a lack of consensus on the level of oxygen saturation and/or systolic blood pressure used to define its beginning.While our institution, 2,6 King's, 7 and others 8,9 report outcomes in DCD LT comparable to Donation after Brain Death (DBD), DCD LT is still not perfect. In our report, the incidence of IC and hepatic artery thrombosis in late DCD group was significant high than in DBD group (3 vs. 0.5%, P < .05). Therefore, efforts should continue to investigate and improve DCD LT outcomes.We look forward to learning more from our colleagues across the Atlantic and propose a faculty exchange to variations in technique. DISCLOSUREThe authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation. Keywordsclinical research/practice, donors and donation: donation after circulatory death (DCD), liver allograft function/dysfunction, liver transplantation/hepatology, organ procurement

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Outcomes Using Grafts from Donors after Cardiac Death

Cited by 73 publications

References 33 publications

Liver transplant outcomes using ideal donation after circulatory death livers are superior to using older donation after brain death donor livers

Liver transplant outcomes using ideal donation after circulatory death livers are superior to using older donation after brain death donor livers

Acute kidney injury and post-reperfusion syndrome in liver transplantation

Response to “Minimization of Ischemic Cholangiopathy in Donation After Cardiac Death Liver Transplantation: Is it Thrombolytic Therapy or Warm Ischemic Time Stringency and Donor Bile Duct Flush?”

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