The demand for liver transplantation (LT) exceeds supply, with rising waiting list mortality. Utilization of high‐risk organs is low and a substantial number of procured livers are discarded. We ...report the first series of five transplants with rejected livers following viability assessment by normothermic machine perfusion of the liver (NMP‐L). The evaluation protocol consisted of perfusate lactate, bile production, vascular flows, and liver appearance. All livers were exposed to a variable period of static cold storage prior to commencing NMP‐L. Four organs were recovered from donors after circulatory death and rejected due to prolonged donor warm ischemic times; one liver from a brain‐death donor was declined for high liver function tests (LFTs). The median (range) total graft preservation time was 798 (range 724–951) min. The transplant procedure was uneventful in every recipient, with immediate function in all grafts. The median in‐hospital stay was 10 (range 6–14) days. At present, all recipients are well, with normalized LFTs at median follow‐up of 7 (range 6–19) months. Viability assessment of high‐risk grafts using NMP‐L provides specific information on liver function and can permit their transplantation while minimizing the recipient risk of primary graft nonfunction. This novel approach may increase organ availability for LT.
This pilot study introduces a novel approach to increase availability of livers for transplantation using normothermic machine perfusion to test the function of declined organs, reporting feasibility of this approach in five patients receiving such livers that met predefined viability criteria. See the editorial from Barbas and Knechtle on page 3075.
Organs recovered from donors after circulatory death (DCD) suffer warm ischemia before cold storage which may prejudice graft survival and result in a greater risk of complications after transplant. ...A period of normothermic regional perfusion (NRP) in the donor may reverse these effects and improve organ function. Twenty‐one NRP retrievals from Maastricht category III DCD donors were performed at three UK centers. NRP was established postasystole via aortic and caval cannulation and maintained for 2 h. Blood gases and biochemistry were monitored to assess organ function. Sixty‐three organs were recovered. Forty‐nine patients were transplanted. The median time from asystole to NRP was 16 min (range 10–23 min). Thirty‐two patients received a kidney transplant. The median cold ischemia time was 12 h 30 min (range 5 h 25 min–18 h 22 min). The median creatinine at 3 and 12 months was 107 µmol/L (range 72–222) and 121 µmol/L (range 63–157), respectively. Thirteen (40%) recipients had delayed graft function and four lost the grafts. Eleven patients received a liver transplant. The first week median peak ALT was 389 IU/L (range 58–3043). One patient had primary nonfunction. Two combined pancreas–kidney transplants, one islet transplant and three double lung transplants were performed with primary function. NRP in DCD donation facilitates organ recovery and may improve short‐term outcomes.
This study shows that the use of normothermic regional perfusion for organ recovery from controlled donation after circulatory death leads to an increased organ recovery rate and may improve short‐term transplant outcomes.
The use of livers from donation after circulatory death (DCD) is increasing, but concerns exist regarding outcomes following use of grafts from “marginal” donors. To compare outcomes in transplants ...using DCD and donation after brain death (DBD), propensity score matching was performed for 973 patients with chronic liver disease and/or malignancy who underwent primary whole‐liver transplant between 2004 and 2014 at University Hospitals Birmingham NHS Foundation Trust. Primary end points were overall graft and patient survival. Secondary end points included postoperative, biliary and vascular complications. Over 10 years, 234 transplants were carried out using DCD grafts. Of the 187 matched DCDs, 82.9% were classified as marginal per British Transplantation Society guidelines. Kaplan–Meier analysis of graft and patient survival found no significant differences for either outcome between the paired DCD and DBD patients (p = 0.162 and p = 0.519, respectively). Aspartate aminotransferase was significantly higher in DCD recipients until 48 h after transplant (p < 0.001). The incidences of acute kidney injury and ischemic cholangiopathy were greater in DCD recipients (32.6% vs. 15% p < 0.001 and 9.1% vs. 1.1% p < 0.001, respectively). With appropriate recipient selection, the use of DCDs, including those deemed marginal, can be safe and can produce outcomes comparable to those seen using DBD grafts in similar recipients.
This single‐center study compares outcomes between propensity‐matched recipients of extended criteria liver grafts from circulatory death donors and grafts from brain death donors to explore the different techniques used in the transplantation of these organs.
Between 2003 and 2012, 42 869 first liver transplantations performed in Europe with the use of either University of Wisconsin solution (UW; N = 24 562), histidine‐tryptophan‐ketoglutarate(HTK; N = ...8696), Celsior solution (CE; N = 7756) or Institute Georges Lopez preservation solution (IGL‐1; N = 1855) preserved grafts. Alternative solutions to the UW were increasingly used during the last decade. Overall, 3‐year graft survival was higher with UW, IGL‐1 and CE (75%, 75% and 73%, respectively), compared to the HTK (69%) (p < 0.0001). The same trend was observed with a total ischemia time (TIT) >12 h or grafts used for patients with cancer (p < 0.0001). For partial grafts, 3‐year graft survival was 89% for IGL‐1, 67% for UW, 68% for CE and 64% for HTK (p = 0.009). Multivariate analysis identified HTK as an independent factor of graft loss, with recipient HIV (+), donor age ≥65 years, recipient HCV (+), main disease acute hepatic failure, use of a partial liver graft, recipient age ≥60 years, no identical ABO compatibility, recipient hepatitis B surface antigen (−), TIT ≥ 12 h, male recipient and main disease other than cirrhosis. HTK appears to be an independent risk factor of graft loss. Both UW and IGL‐1, and CE to a lesser extent, provides similar results for full size grafts. For partial deceased donor liver grafts, IGL‐1 tends to offer the best graft outcome.
In a retrospective review of over 42,000 liver transplants perf ormed in Europe between 2003 and 2012 examining the use of either University of Wisconsin, histidine‐ tryptophan‐ketoglutarate (HTK), Celsior, or Institut Georges Lopez solution, the authors show that the use of HTK solution is an independent risk factor of graft loss. See editorial by Stewart on page 295.
Donation after cardiac death (DCD) liver transplantation is associated with an increased frequency of hepato‐biliary complications. The implications for renal function have not been explored ...previously. The aims of this single‐center study of 88 consecutive DCD liver transplant recipients were (1) to compare renal outcomes with propensity‐risk‐matched donation after brain death (DBD) patients and (2) in the DCD patients specifically to examine the risk factors for acute kidney injury (AKI; peak creatinine ≥2 times baseline) and chronic kidney disease (CKD; eGFR <60 mL/min/1.73 m2). During the immediate postoperative period DCD liver transplantation was associated with an increased incidence of AKI (DCD, 53.4%; DBD 31.8%, p = 0.004). In DCD patients AKI was a risk factor for CKD (p = 0.035) and mortality (p = 0.017). The cumulative incidence of CKD by 3 years post‐transplant was 53.7% and 42.1% for DCD and DBD patients, respectively (p = 0.774). Importantly, increasing peak perioperative aspartate aminotransferase, a surrogate marker of hepatic ischemia reperfusion injury, was the only consistent predictor of renal dysfunction after DCD transplantation (AKI, p < 0.001; CKD, p = 0.032). In conclusion, DCD liver transplantation is associated with an increased frequency of AKI. The findings suggest that hepatic ischemia reperfusion injury may play a critical role in the pathogenesis of post‐transplant renal dysfunction.
This single center study demonstrates that donation after cardiac death liver transplantation recipients have a greater frequency of postoperative acute kidney injury than propensity risk score matched donation after brain death recipients.
Schlegel et al present their response to the letter of Oniscus et al regarding their use of the UK-DCD-Risk-Score for liver transplantation from donors after circulatory death (DCD). The prediction ...model which was developed from the UK DCD cohort and validated in the UNOS database has classified DCD livers with an overall risk of more than 10 points as futile. The use of the term futile for the highest risk DCD-score roup was criticized and suggested to modify the score based on their experience of the good outcome of using normothermic regional perfusion (NRP) donors.
Background
Preoperative portal vein embolization (PVE) is frequently used to improve future liver remnant volume (FLRV) and to reduce the risk of liver failure after major liver resection.
Objective
...This paper aimed to assess postoperative outcomes after PVE and resection for suspected perihilar cholangiocarcinoma (PHC) in an international, multicentric cohort.
Methods
Patients undergoing resection for suspected PHC across 20 centers worldwide, from the year 2000, were included. Liver failure, biliary leakage, and hemorrhage were classified according to the respective International Study Group of Liver Surgery criteria. Using propensity scoring, two equal cohorts were generated using matching parameters, i.e. age, sex, American Society of Anesthesiologists classification, jaundice, type of biliary drainage, baseline FLRV, resection type, and portal vein resection.
Results
A total of 1667 patients were treated for suspected PHC during the study period. In 298 patients who underwent preoperative PVE, the overall incidence of liver failure and 90-day mortality was 27% and 18%, respectively, as opposed to 14% and 12%, respectively, in patients without PVE (
p
< 0.001 and
p
= 0.005). After propensity score matching, 98 patients were enrolled in each cohort, resulting in similar baseline and operative characteristics. Liver failure was lower in the PVE group (8% vs. 36%,
p
< 0.001), as was biliary leakage (10% vs. 35%,
p
< 0.01), intra-abdominal abscesses (19% vs. 34%,
p
= 0.01), and 90-day mortality (7% vs. 18%,
p
= 0.03).
Conclusion
PVE before major liver resection for PHC is associated with a lower incidence of liver failure, biliary leakage, abscess formation, and mortality. These results demonstrate the importance of PVE as an integral component in the surgical treatment of PHC.
Summary
Background
Liver transplantation is the only life‐extending intervention for primary sclerosing cholangitis (PSC). Given the co‐existence with colitis, patients may also require colectomy; a ...factor potentially conferring improved post‐transplant outcomes.
Aim
To determine the impact of restorative surgery via ileal pouch‐anal anastomosis (IPAA) vs retaining an end ileostomy on liver‐related outcomes post‐transplantation.
Methods
Graft survival was evaluated across a prospectively accrued transplant database, stratified according to colectomy status and type.
Results
Between 1990 and 2016, 240 individuals with PSC/colitis underwent transplantation (cumulative 1870 patient‐years until first graft loss or last follow‐up date), of whom 75 also required colectomy. A heightened incidence of graft loss was observed for the IPAA group vs those retaining an end ileostomy (2.8 vs 0.4 per 100 patient‐years, log‐rank P = 0.005), whereas rates between IPAA vs no colectomy groups were not significantly different (2.8 vs 1.7, P = 0.1). In addition, the ileostomy group experienced significantly lower graft loss rates vs. patients retaining an intact colon (P = 0.044). The risks conferred by IPAA persisted when taking into account timing of colectomy as related to liver transplantation via time‐dependent Cox regression analysis. Hepatic artery thrombosis and biliary strictures were the principal aetiologies of graft loss overall. Incidence rates for both were not significantly different between IPAA and no colectomy groups (P = 0.092 and P = 0.358); however, end ileostomy appeared protective (P = 0.007 and 0.031, respectively).
Conclusion
In PSC, liver transplantation, colectomy + IPAA is associated with similar incidence rates of hepatic artery thrombosis, recurrent biliary strictures and re‐transplantation compared with no colectomy. Colectomy + end ileostomy confers more favourable graft outcomes.
Linked ContentThis article is linked to Weinberg and Reddy paper. To view this article visit https://doi.org/10.1111/apt.14896.
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