Liver transplantation remains the standard treatment for patients with end-stage liver disease. Over the years there have been significant improvements in liver transplant outcomes due to improved surgical techniques, organ preservation, immunosuppression, and anti-infective therapies. This success has resulted in more patients being listed for transplantation out of proportion to the number of available organs. Thus, the donor organ shortage remains a significant obstacle to increasing the number of liver transplants. In an attempt to combat the donor organ shortage, more liver transplant centers are using livers from donation after cardiac death (DCD) donors. Based on the Scientific Registry of Transplant Recipients (SRTR) 2007 Annual Report, there has been a seven-fold increase in the number of liver transplant programs performing DCD liver transplants over the last seven years. In addition the number of DCD liver transplants performed at centers in the United States increased from 39 in 2000 to 277 in 2007 (2007 OPTN/SRTR Annual Report. HHS/HRSA/HSB/DOT; UNOS; Arbor Research Collaborative for Health).

Despite this increase in DCD liver utilization, there remains reluctance among many centers to aggressively use these organs. This unwillingness is based on both national database and single-center studies reporting inferior patient and graft survival rates when compared to liver transplants from donation after brain death donors (DBD).1,2,3,4 Another important concern with the use of DCD livers is the development of biliary complications. The incidence of biliary complications after DCD liver transplantation ranges between 25–60%, 3,5,6,7,8 compared to 10–30% seen in DBD whole liver transplantation.9,10,11,12 The most critical biliary complication that frequently requires retransplantation is the development of ischemic-type biliary strictures or ischemic cholangiopathy. Ischemic cholangiopathy (IC) is defined as intra-hepatic or non-anastomotic, extra-hepatic biliary strictures in the presence of a patent hepatic artery. The incidence of IC in DCD liver transplantation ranges between 10–50% in published series.13,5,6,8,14 Although not all patients with IC require retransplantation, this complication can result in considerable patient morbidity including biliary sepsis, prolonged antibiotic therapy, and the requirement for multiple endoscopic or percutaneous biliary procedures. In addition, most patients with IC maintain excellent hepatocellular function despite biliary damage and dysfunction and therefore have relatively low Model for End-Stage Liver Disease (MELD) scores when being considered for retransplantation. In many cases requests for a MELD exception are made to the regional review boards in order to obtain a sufficient MELD score for re transplantation. The granting of these exceptions is quite variable across the country and not standardized in the current liver allocation process. This prolonged waiting time may result in recurrent biliary sepsis, the development of multi-resistant organisms, and patient debilitation that could potentially exclude them from retransplantation.

Previous analyses utilizing the United Network for Organ Sharing/Organ Procurement and Transplantation Network Liver Transplantation Registry have identified potential risk factors that are predictive of graft survival after DCD liver transplantation.15,16 However, the risk factors for the development biliary complications were not analyzed in these studies. The objectives of this analysis were (1) to compare the long-term outcomes of DCD and DBD liver transplants with 15 year follow-up, (2) to compare the incidence of biliary complications between DCD and DBD liver transplant recipients, and (3) to identify potential risk factors for the development of biliary complications in DCD liver transplant recipients at the University of Wisconsin.

/pdf/biliary-complications-after-liver-transplantation-from-5escv3anu5.pdf

Biliary complications after liver transplantation from donation after cardiac death donors: an analysis of risk factors and long-term outcomes from a single center.

BACKGROUND: Exposure of donor liver grafts to prolonged periods of warm ischemia before procurement causes injuries including intrahepatic cholangiopathy, which may lead to graft loss. Due to unavoidable prolonged ischemic time before procurement in donation after cardiac death (DCD) donation in 1 participating center, each liver graft of this center was pretreated with the new machine perfusion "Hypothermic Oxygenated PErfusion" (HOPE) in an attempt to improve graft quality before implantation.
METHODS: HOPE-treated DCD livers (n = 25) were matched and compared with normally preserved (static cold preservation) DCD liver grafts (n = 50) from 2 well-established European programs. Criteria for matching included duration of warm ischemia and key confounders summarized in the balance of risk score. In a second step, perfused and unperfused DCD livers were compared with liver grafts from standard brain dead donors (n = 50), also matched to the balance of risk score, serving as baseline controls.
RESULTS: HOPE treatment of DCD livers significantly decreased graft injury compared with matched cold-stored DCD livers regarding peak alanine-aminotransferase (1239 vs 2065 U/L, P = 0.02), intrahepatic cholangiopathy (0% vs 22%, P = 0.015), biliary complications (20% vs 46%, P = 0.042), and 1-year graft survival (90% vs 69%, P = 0.035). No graft failure due to intrahepatic cholangiopathy or nonfunction occurred in HOPE-treated livers, whereas 18% of unperfused DCD livers needed retransplantation. In addition, HOPE-perfused DCD livers achieved similar results as control donation after brain death livers in all investigated endpoints.
CONCLUSIONS: HOPE seems to offer important benefits in preserving higher-risk DCD liver grafts.

/pdf/first-comparison-of-hypothermic-oxygenated-perfusion-versus-1uyi4a699d.pdf

First Comparison of Hypothermic Oxygenated PErfusion Versus Static Cold Storage of Human Donation After Cardiac Death Liver Transplants: An International-matched Case Analysis.

HOPE for human liver grafts obtained from donors after cardiac death.

US: United StatesDCD: Donation after Cardiac DeathHRSA: Health Resources and Services AdministrationCMS: Centers for Medicare and Medicaid ServicesDBD: Donation after Brain DeathIC: Ischemic CholangiopathyLOS: Length of StayUNOS: United Network for Organ SharingSRTR: Scientific Registry of Transplan

Ischemic cholangiopathy after controlled donation after cardiac death liver transplantation: a meta-analysis.

Background:

The outcome of orthotopic liver transplantation (OLT) with controlled graft donation after cardiac death (DCD) is usually inferior to that with graft donation after brain death (DBD). This study compared outcomes from OLT with DBD versus controlled DCD donors with predefined restrictive acceptance criteria.



Methods:

All adult recipients in the Netherlands in 2001–2006 with full-size OLT from DCD (n = 55) and DBD (n = 471) donors were included. Kaplan–Meier, log rank and Cox regression analyses were used.



Results:

One- and 3-year patient survival rates were similar for DCD (85 and 80 per cent) and DBD (86·3 and 80·8 per cent) transplants (P = 0·763), as were graft survival rates (74 and 68 per cent versus 80·4 and 74·5 per cent; P = 0·212). The 3-year cumulative percentage of surviving grafts developing non-anastomotic biliary strictures was 31 per cent after DCD and 9·7 per cent after DBD transplantation (P < 0·001). The retransplantation rate was similar overall (P = 0·081), but that for biliary stricture was higher in the DCD group (P < 0·001). Risk factors for 1-year graft loss after DBD OLT were transplant centre, recipient warm ischaemia time and donor with severe head trauma. After DCD OLT they were transplant centre, donor warm ischaemia time and cold ischaemia time. DCD graft was a risk factor for non-anastomotic biliary stricture.



Conclusion:

OLT using controlled DCD grafts and restrictive criteria can result in patient and graft survival rates similar to those of DBD OLT, despite a higher risk of biliary stricture. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

https://bjssjournals.onlinelibrary.wiley.com/doi/pdf/10.1002/bjs.7043

Similar liver transplantation survival with selected cardiac death donors and brain death donors

http://www.custodiol.com/hansjb/wp-content/uploads/2014/12/LiverTransplantationDeVera.pdf

R Lopez-Solis

Papers

Liver Transplantation Using Donation After Cardiac Death Donors: Long-Term Follow-Up from a Single Center