Sequential Use of Normothermic Regional and Ex Situ Machine Perfusion in Donation After Circulatory Death Liver Transplant

Abstract

In Italy, 20 minutes of a continuous flat line on an electrocardiogram are required for declaration of death. In the setting of donation after circulatory death (DCD), prolonged warm ischemia time prompted the introduction of abdominal normothermic regional perfusion (NRP) followed by postprocurement ex situ machine perfusion (MP). This is a retrospective review of DCD liver transplantations (LTs) performed at 2 centers using sequential NRP and ex situ MP. From January 2018 to April 2019, 34 DCD donors were evaluated. Three (8.8%) were discarded before NRP, and 11 (32.4%) were discarded based on NRP parameters (n = 1, 3.0%), liver macroscopic appearance at procurement and/or biopsy results (n = 9, 26.5%), or severe macroangiopathy at back‐table evaluation (n = 1, 3.0%). A total of 20 grafts (58.8%; 11 uncontrolled DCDs, 9 controlled DCDs) were considered eligible for LT, procured and perfused ex situ (9 normothermic and 11 dual hypothermic MPs). In total, 18 (52.9%; 11 uncontrolled) livers were eventually transplanted. Median (interquartile range) no‐flow time was 32.5 (30‐39) minutes, whereas median functional warm ischemia time was 52.5 (47‐74) minutes (controlled DCD), and median low‐flow time was 112 minutes (105‐129 minutes; uncontrolled DCD). There was no primary nonfunction, while postreperfusion syndrome occurred in 8 (44%) recipients. Early allograft dysfunction happened in 5 (28%) patients, while acute kidney injury occurred in 5 (28%). After a median follow‐up of 15.1 (9.5‐22.3) months, 1 case of ischemic‐type biliary lesions and 1 patient death were reported. DCD LT is feasible even with the 20‐minute no‐touch rule. Strict NRP and ex situ MP selection criteria are needed to optimize postoperative results.

The Role of Ex Situ Hypothermic Oxygenated Machine Perfusion and Cold Preservation Time in Extended Criteria Donation After Circulatory Death and Donation After Brain Death

“…In this section, the most frequently used definitions are summarized. For DCD, we refer to the following terminology discussed during the Sixth International Conference on Organ Donation After Circulatory Death ( 30 ) and in the article by Ghinolfi and colleagues ( 13 ) :…”

Continuous Normothermic Machine Perfusion for Renovation of Extended Criteria Donor Livers Without Recooling in Liver Transplantation: A Pilot Experience

“…NMP provides an effective method for salvaging ECD organs. Davide et al retrospectively studied 34 transplantations of DCD donors using NMP and showed that it would be feasible for DCD LT ( 13 ). The prospective clinical trial of Otto et al reported that NMP was a safe option for risky donor livers and increased the number of available donor livers ( 14 ).…”

Graft utilization after normothermic regional perfusion in controlled donation after circulatory death—a single‐center perspective from France

“…Such marginal cDCD liver grafts may benefit from additional ex-vivo perfusion after NRP. Several Italian teams have proposed a sequential strategy with NRP followed by hypothermic oxygenated perfusion (HOPE) to rescue marginal cDCD liver and kidney grafts with FDWI up to 52.5 min for livers and 325 min for kidneys [30][31][32]. In the absence of validated biomarkers during NRP and following the positive results of two recent randomized trials on HOPE in cDCD liver and kidney transplantation, we suggest adding a period of HOPE after NRP in highrisk grafts to assess mitochondrial viability prior to implantation [12,24,[33][34][35][36].…”