Retrospective Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 28, 2016; 22(12): 3392-3403
Published online Mar 28, 2016. doi: 10.3748/wjg.v22.i12.3392
Donor preoperative oxygen delivery and post-extubation hypoxia impact donation after circulatory death hypoxic cholangiopathy
Thomas J Chirichella, C Michael Dunham, Michael A Zimmerman, Elise M Phelan, M Susan Mandell, Kendra D Conzen, Stephen E Kelley, Trevor L Nydam, Thomas E Bak, Igal Kam, Michael E Wachs
Thomas J Chirichella, Elise M Phelan, Kendra D Conzen, Trevor L Nydam, Thomas E Bak, Igal Kam, Department of Surgery, Division of Transplant Surgery, University of Colorado, Aurora, CO 80045, United States
C Michael Dunham, Trauma/Critical Care Services, St. Elizabeth Health Center, Youngstown, OH 44501, United States
Michael A Zimmerman, Department of Transplant Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, United States
M Susan Mandell, Department of Anesthesiology, University of Colorado, Aurora, CO 80045, United States
Stephen E Kelley, Donor Alliance Organ Procurement Organization, Denver, CO 80045, United States
Michael E Wachs, Department of Transplant Surgery, Children’s Hospital Colorado, Aurora, CO 80045, United States
Author contributions: Chirichella TJ, Dunham CM, Zimmerman MA, Kam I and Wachs ME conceived and designed the study; Chirichella TJ, Dunham CM, Zimmerman MA, Phelan EM, Mandell MS, Kelley SE, Nydam TL, Bak TE, Kam I and Wachs ME performed the research; Chirichella TJ and Phelan EM acquired the data; Chirichella TJ, Dunham CM, Zimmerman MA, Phelan EM, Mandell MS, Conzen KD, Kelley SE, Nydam TL, Bak TE, Kam I and Wachs ME analysed and interpreted the data; Chirichella TJ, Dunham CM, Mandell MS and Wachs ME drafted the article or revised it critically for important intellectual content.
Conflict-of-interest statement: There are no conflicts of interest to declare.
Data sharing statement: Technical appendix and dataset are available from the corresponding author at tchirichella@gmail.com, after a signed data user agreement is obtained. No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Thomas J Chirichella, MD, Transplantation Fellow, Division of Transplant Surgery, 1635 Aurora Ct., 7th Floor, University of Colorado Hospital, Aurora, CO 80045, United States. tchirichella@gmail.com
Telephone: +1-720-8480878 Fax: +1-720-8480841
Received: May 3, 2015
Peer-review started: May 9, 2015
First decision: September 9, 2015
Revised: October 6, 2015
Accepted: November 30, 2015
Article in press: December 1, 2015
Published online: March 28, 2016
Processing time: 325 Days and 15.2 Hours
Abstract

AIM: To evaluate donation after circulatory death (DCD) orthotopic liver transplant outcomes [hypoxic cholangiopathy (HC) and patient/graft survival] and donor risk-conditions.

METHODS: From 2003-2013, 45 DCD donor transplants were performed. Predonation physiologic data from UNOS DonorNet included preoperative systolic and diastolic blood pressure, heart rate, pH, SpO2, PaO2, FiO2, and hemoglobin. Mean arterial blood pressure was computed from the systolic and diastolic blood pressures. Donor preoperative arterial O2 content was computed as [hemoglobin (gm/dL) × 1.37 (mL O2/gm) × SpO2%) + (0.003 × PaO2)]. The amount of preoperative donor red blood cell transfusions given and vasopressor use during the intensive care unit stay were documented. Donors who were transfused ≥ 1 unit of red-cells or received ≥ 2 vasopressors in the preoperative period were categorized as the red-cell/multi-pressor group. Following withdrawal of life support, donor ischemia time was computed as the number-of-minutes from onset of diastolic blood pressure < 60 mmHg until aortic cross clamping. Donor hypoxemia time was the number-of-minutes from onset of pulse oximetry < 80% until clamping. Donor hypoxia score was (ischemia time + hypoxemia time) ÷ donor preoperative hemoglobin.

RESULTS: The 1, 3, and 5 year graft and patient survival rates were 83%, 77%, 60%; and 92%, 84%, and 72%, respectively. HC occurred in 49% with 16% requiring retransplant. HC occurred in donors with increased age (33.0 ± 10.6 years vs 25.6 ± 8.4 years, P = 0.014), less preoperative multiple vasopressors or red-cell transfusion (9.5% vs 54.6%, P = 0.002), lower preoperative hemoglobin (10.7 ± 2.2 gm/dL vs 12.3 ± 2.1 gm/dL, P = 0.017), lower preoperative arterial oxygen content (14.8 ± 2.8 mL O2/100 mL blood vs 16.8 ± 3.3 mL O2/100 mL blood, P = 0.049), greater hypoxia score >2.0 (69.6% vs 25.0%, P = 0.006), and increased preoperative mean arterial pressure (92.7 ± 16.2 mmHg vs 83.8 ± 18.5 mmHg, P = 0.10). HC was independently associated with age, multi-pressor/red-cell transfusion status, arterial oxygen content, hypoxia score, and mean arterial pressure (r2 = 0.6197). The transplantation rate was greater for the later period with more liberal donor selection [era 2 (7.1/year)], compared to our early experience [era 1 (2.5/year)]. HC occurred in 63.0% during era 2 and in 29.4% during era 1 (P = 0.03). Era 2 donors had longer times for extubation-to-asystole (14.4 ± 4.7 m vs 9.3 ± 4.5 m, P = 0.001), ischemia (13.9 ± 5.9 m vs 9.7 ± 5.6 m, P = 0.03), and hypoxemia (16.0 ± 5.1 m vs 11.1 ± 6.7 m, P = 0.013) and a higher hypoxia score > 2.0 rate (73.1% vs 28.6%, P = 0.006).

CONCLUSION: Easily measured donor indices, including a hypoxia score, provide an objective measure of DCD liver transplantation risk for recipient HC. Donor selection criteria influence HC rates.

Keywords: Orthotopic liver transplantation; Ischemic cholangiopathy; Hypoxic cholangiopathy; Donation after circulatory death; Biliary complications; Reperfusion injury

Core tip: Cholangiopathy is a common and devastating clinical complication developing in recipients following donation after circulatory death liver transplantation. Numerous published investigations have attempted to link the hemodynamic instability and hypoxemia following withdrawal of life support to the development of cholangiopathy, without success. Our research indicates that cholangiopathy is linked to the magnitude of hypoxemic, ischemic, and anemic hypoxia transpiring after life support withdrawal and can be represented by a donor hypoxia score. We recommend that the historically utilized nomenclature of ischemic cholangiopathy be replaced using a more physiologic-based and expansive term, hypoxic cholangiopathy.