The Impact of Combined Warm Ischemia Time on Development of Acute Kidney Injury in Donation After Circulatory Death Liver Transplantation

Kalisvaart, Marit; Schlegel, Andrea; Umbro, I.; Haan, Jubi E. de; Scalera, Irene; Polak, Wojciech; IJzermans, Jan N.M.; Mirza, Darius F.; Perera, M. Thamara P. R.; Isaac, J.; Ferguson, James; Mitterhofer, Anna Paola; Jonge, Jeroen de; Muiesan, Paolo

doi:10.1097/tp.0000000000002085

Cited by 41 publications

(50 citation statements)

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“…Because of the center‐based allocation of liver grafts, transplant surgeons have been able to assign high‐risk organs to lower‐risk recipients, and excellent outcomes have been achieved . With this study, we confirm previous reports from our center, where Leithead et al have demonstrated that the development of AKI after liver transplantation is related to the use of ECD (including DCD) grafts . We created stricter criteria for marginal DBD grafts, as the standard for graft quality has been shifting from standard toward marginal grafts since these studies have been published.…”

Section: Discussionsupporting

confidence: 79%

“…Although there is a link between the use of ECD grafts and the posttransplant AKI, which is a risk factor for the development of CKD after liver transplantation, no direct relation between the use of these grafts and CKD has been observed in either this study or in previous studies. As shown in our previous studies, severe AKI (KDIGO stages 2 and 3) has the most significant impact on longterm graft and patient survival rates . In the present study, we highlighted the importance of the severity of AKI and development of CKD.…”

Section: Discussionsupporting

confidence: 70%

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Chronic Kidney Disease After Liver Transplantation: Impact of Extended Criteria Grafts

et al. 2019

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The use of extended criteria donor (ECD) grafts has been associated with acute kidney injury (AKI) after liver transplantation. However, the relation between graft quality and development of chronic kidney disease (CKD) remains unknown. Therefore, the aim of this study was to analyze the impact of ECD grafts for CKD after liver transplantation. All patients (2007‐2015) transplanted for end‐stage liver disease at our center were assessed. Longterm kidney function was divided into 4 groups: no CKD (estimated glomerular filtration rate [eGFR], ≥60 mL/minute/1.73 m2), mild CKD (eGFR, 30‐59 mL/minute/1.73 m2), severe CKD (eGFR, 15‐29 mL/minute/1.73 m2), and end‐stage renal disease (ESRD). Marginal donation after brain death (DBD) grafts (donor age, >70 years; body mass index, >35 kg/m2; cold storage, >12 hours) and donation after circulatory death (DCD) grafts were considered ECD grafts. Overall, 926 patients were included, and 43% received an ECD graft (15% marginal DBD; 28% DCD). After 5 years, 35% developed CKD; severe CKD and ESRD occurred in only 2% and 1%, respectively. CKD rates were comparable for all 3 graft groups (standard group, 36%; marginal DBD group, 29%; DCD group, 35%; standard versus marginal DBD groups, P = 0.16; standard versus DCD group, P = 0.80). None of the ECD criteria were identified as independent risk factors in a Cox regression model for CKD. Risk factors included recipient age, female sex, and preoperative kidney function. Furthermore, recipients who had severe acute kidney injury (AKI; Kidney Disease: Improving Global Outcomes stages 2 and 3) had a 1.8‐fold increased risk for CKD. Longterm kidney function of recipients with severe AKI depended on the recovery of kidney function in the first postoperative week. In conclusion, there is no direct relation between the use of ECD grafts and CKD after liver transplantation. However, caution should be taken in recipients who experience severe AKI, regardless of graft type.

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Section: Discussionsupporting

confidence: 79%

Section: Discussionsupporting

confidence: 70%

Chronic Kidney Disease After Liver Transplantation: Impact of Extended Criteria Grafts

et al. 2019

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“…Interventions include, for example, the use of thrombolytics in the donor or recipient, normothermic perfusion after procurement, and use of extracorporeal membrane oxygenation after cardiac arrest . Additional modifiable recipient risk factors include the following: Hepatectomy time. Recipient WIT. CIT. …”

Section: Discussionmentioning

confidence: 99%

“…In era 2, graft loss was not associated with ECD criteria, unlike in era 1. For instance, in era 2, 16% of ECD DCD livers had a donor f WIT >30 minutes (32,33,33,37, 40, and 41 minutes), and none of these grafts failed. The threshold for f WIT was raised in the latter half of era 2.…”

Section: Ecd Dcd Variablesmentioning

confidence: 99%

“…(8,9,24) The modifiable donor risk factors are as follows: Interventions include, for example, the use of thrombolytics in the donor or recipient, normothermic perfusion after procurement, and use of extracorporeal membrane oxygenation after cardiac arrest. (8,9,13,(25)(26)(27)(28)(29) Additional modifiable recipient risk factors include the following (30)(31)(32) :…”

Section: Expanding the Dcd Donor Poolmentioning

confidence: 99%

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Expanding the Donor Pool With the Use of Extended Criteria Donation After Circulatory Death Livers

et al. 2019

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Use of donation after circulatory death (DCD) donor livers for transplantation has remained cautious in the United States. The aim of this study was to demonstrate the expansion of a DCD liver transplantation (LT) program with the use of extended criteria donor (ECD) DCD livers. After institutional review board approval, 135 consecutive DCD LTs were retrospectively studied. ECD DCD livers were defined as those with 1 of the following factors: donor age >50 years, donor body mass index >35 kg/m2, donor functional warm ischemia time >30 minutes, and donor liver macrosteatosis >30%. An optimization protocol was introduced in July 2011 to improve outcomes of DCD LT, which included thrombolytic donor flush and efforts to minimize ischemia times. The impact of this protocol on outcomes was evaluated in terms of graft loss, ischemic cholangiopathy (IC), and change in DCD LT volume. Of 135 consecutive DCD LTs, 62 were ECD DCDs. In total, 24 ECD DCD LTs were performed before (era 1) and 38 after the institution of optimization protocol (era 2), accounting for an increase in the use of ECD DCD livers from 39% to 52%. Overall outcomes of ECD DCD LT improved in era 2, with a significantly lower incidence of IC (5% versus 17% in era 1; P = 0.03) and better 1‐year graft survival (93% versus 75% in era 1; P = 0.07). Survival outcomes for ECD DCD LT in era 2 were comparable to matched deceased donor LT. With the expansion of the DCD donor pool, the number of DCD LTs performed at our center gradually increased in era 2 to account for >20% of the center's LT volume. In conclusion, with the optimization of perioperative conditions, ECD DCD livers can be successfully transplanted to expand the donor pool for LT.

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Evaluation of Liver Graft Donation After Euthanasia

et al. 2020

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The option of donating organs after euthanasia is not well known. Assessment of the results of organ transplants with grafts donated after euthanasia is essential to justify the use of this type of organ donation.OBJECTIVES To assess the outcomes of liver transplants (LTs) with grafts donated after euthanasia (donation after circulatory death type V [DCD-V]), and to compare them with the results of the more commonly performed LTs with grafts from donors with a circulatory arrest after the withdrawal of life-supporting treatment (type III [DCD-III]). DESIGN, SETTING, AND PARTICIPANTSThis retrospective multicenter cohort study analyzed medical records and LT data for most transplant centers in the Netherlands and Belgium. All LTs with DCD-V grafts performed from the start of the donation after euthanasia program (September 2012 for the Netherlands, and January 2005 for Belgium) through July 1, 2018, were included in the analysis. A comparative cohort of patients who received DCD-III grafts was also analyzed. All patients in both cohorts were followed up for at least 1 year. Data analysis was performed from September 2019 to December 2019.EXPOSURES Liver transplant with either a DCD-V graft or DCD-III graft.MAIN OUTCOMES AND MEASURES Primary outcomes were recipient and graft survival rates at years 1, 3, and 5 after the LT. Secondary outcomes included postoperative complications (early allograft dysfunction, hepatic artery thrombosis, and nonanastomotic biliary strictures) within the first year after the LT. RESULTS Among the cohort of 47 LTs with DCD-V grafts, 25 organ donors (53%) were women and the median (interquartile range [IQR]) age was 51 (44-59) years. Among the cohort of 542 LTs with DCD-III grafts, 335 organ donors (62%) were men and the median (IQR) age was 49 (37-57) years. Median (IQR) follow-up was 3.8 (2.1-6.3) years. In the DCD-V cohort, 30 recipients (64%) were men, and the median (IQR) age was 56 (48-64) years. Recipient survival in the DCD-V cohort was 87% at 1 year, 73% at 3 years, and 66% at 5 years after LT. Graft survival among recipients was 74% at 1 year, 61% at 3 years, and 57% at 5 years after LT. These survival rates did not differ statistically significantly from those in the DCD-III cohort. Incidence of postoperative complications did not differ between the groups. For example, the occurrence of early allograft dysfunction after the LT was found to be 13 (31%) in the DCD-V cohort and 219 (45%) in the DCD-III cohort. The occurrence of nonanastomotic biliary strictures after the LT was found to be 7 (15%) in the DCD-V cohort and 83 (15%) in the DCD-III cohort. CONCLUSIONS AND RELEVANCEThe findings of this cohort study suggest that LTs with DCD-V grafts yield similar outcomes as LTs with DCD-III grafts; therefore, grafts donated after euthanasia may be a justifiable option for increasing the organ donor pool. However, grafts from these donations should be considered high-risk grafts that require an optimal donor selection process and logistics.

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The Impact of Combined Warm Ischemia Time on Development of Acute Kidney Injury in Donation After Circulatory Death Liver Transplantation

Abstract: Combined WIT is a newly defined period of warm ischemia in DCD liver transplantation. Length of combined WIT is associated with severity of postoperative AKI and should ideally not exceed 60 minutes.

Cited by 41 publications

References 41 publications

Chronic Kidney Disease After Liver Transplantation: Impact of Extended Criteria Grafts

Chronic Kidney Disease After Liver Transplantation: Impact of Extended Criteria Grafts

Expanding the Donor Pool With the Use of Extended Criteria Donation After Circulatory Death Livers

Evaluation of Liver Graft Donation After Euthanasia

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