Successful donation after cardiac death liver transplants with prolonged warm ischemia time using normothermic regional perfusion

Abstract

The role of donation after cardiac death (DCD) in expanding the donor pool is mainly limited by the incidence of primary nonfunction (PNF) and ischemia-related complications. Even greater concern exists toward uncontrolled DCD, which represents the largest potential pool of DCD donors. We recently started the first Italian series of DCD liver transplantation, using normothermic regional perfusion (NRP) in 6 uncontrolled donors and in 1 controlled case to deal with the legally required no-touch period of 20 minutes. We examined our first 7 cases for the incidence of PNF, early graft dysfunction, and biliary complications. Acceptance of the graft was based on the trend of serum transaminase and lactate during NRP, the macroscopic appearance, and the liver biopsy. Hypothermic machine perfusion (HMP) was associated in selected cases to improve cold storage. Most notably, no cases of PNF were observed. Median posttransplant transaminase peak was 1014 IU/L (range, 393-3268 IU/L). Patient and graft survival were both 100% after a mean follow-up of 6.1 months (range, 3-9 months). No cases of ischemic cholangiopathy occurred during the follow-up. Only 1 anastomotic stricture completely resolved with endoscopic stenting. In conclusion, DCD liver transplantation is feasible in Italy despite the protracted no-touch period. The use of NRP and HMP seems to earn good graft function and proves safe in these organs. Liver Transplantation 23 166-173 2017 AASLD.

Heparin but not tissue plasminogen activator improves outcomes in donation after circulatory death liver transplantation in a porcine model

“…Mounting clinical evidence suggests that NRP has a significant positive impact on biliary preservation in the setting of DCD liver transplantation because it limits the length of warm ischemia, restores cellular energy stores, and reconditions the graft prior to cold perfusion and storage . There are now several single‐center series that describe excellent posttransplantation survival rates and virtually no ITBL using DCD livers recovered with postmortem NRP . At our own center, postmortem NRP has been used to recover livers from cDCD donors .…”

Machine perfusion for liver transplantation in the era of marginal organs—New kids on the block

“…This should result in less time‐pressure on the retrieval team, easier in situ evaluation of graft quality and expansion of the donor pool with overall improved graft quality . While NRP is a technically feasible approach, it has raised numerous ethical and logistical questions concerning premortem interventions such as administration of heparin, cannulation and including the possibility of resuscitating the donor following declaration of death . These concerns have been partially eliminated by technical innovations (heparin‐coated circuits, initial bypassing the oxygenator to prevent clotting; aortic occlusion balloon to exclude the brain from the perfusion); however, several issues, which have been summarized elsewhere, remain to be elucidated …”

“…102 Most of the teams are currently using the available ECMO devices modified for NRP, but specifically designed devices dedicated to NRP are also available, providing normothermic, regional, pulsatile and oxygenated perfusion during balloon to exclude the brain from the perfusion); however, several issues, which have been summarized elsewhere, remain to be elucidated. 102,[104][105][106][107]109 There are also certain differences in the use of NRP in uncontrolled and controlled DCD donors. 102 In uncontrolled DCD (Maastricht category II-unsuccessful resuscitation), cardiac arrest is unexpected, and death is typically declared before the possibility to consent for organ donation.…”

Perfusion machines and hepatocellular carcinoma: a good match between a marginal organ and an advanced disease?

“…They found HOPE treatment of DCD livers significantly decreased graft injury regarding peak of alanine-aminotransferase (ALT), intrahepatic cholangiopathy, biliary complications, and improved 1-year graft survival, achieving similar results as control DBD livers in all investigated endpoints. De Carlis et al reported a series of 7 HCC patients transplanted with DCDs with extended period of WIT (>20 minutes) where they applied HMP after normothermic regional perfusion achieving 100% graft and patient survival with no incidence of ischemic cholangiopathy (77).…”