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Martinez-Perez S, McCluskey SA, Davierwala PM, Kalra S, Nguyen E, Bhat M, Borosz C, Luzzi C, Jaeckel E, Neethling E. Perioperative Cardiovascular Risk Assessment and Management in Liver Transplant Recipients: A Review of the Literature Merging Guidelines and Interventions. J Cardiothorac Vasc Anesth 2024; 38:1015-1030. [PMID: 38185566 DOI: 10.1053/j.jvca.2023.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/13/2023] [Accepted: 11/26/2023] [Indexed: 01/09/2024]
Abstract
Liver transplantation (LT) is the second most performed solid organ transplant. Coronary artery disease (CAD) is a critical consideration for LT candidacy, particularly in patients with known CAD or risk factors, including metabolic dysfunction associated with steatotic liver disease. The presence of severe CAD may exclude patients from LT; therefore, precise preoperative evaluation and interventions are necessary to achieve transplant candidacy. Cardiovascular complications represent the earliest nongraft-related cause of death post-transplantation. Timely intervention to reduce cardiovascular events depends on adequate CAD screening. Coronary disease screening in end-stage liver disease is challenging because standard noninvasive CAD screening tests have low sensitivity due to hyperdynamic state and vasodilatation. As a result, there is overuse of invasive coronary angiography to exclude severe CAD. Coronary artery calcium scoring using a computed tomography scan is a tool for the prediction of cardiovascular events, and can be used to achieve risk stratification in LT candidates. Recent literature shows that qualitative assessment on both noncontrast- and contrast-enhanced chest computed tomography can be used instead of calcium score to assess the presence of coronary calcium. With increasing prevalence, protocols to address CAD in LT candidates must be reconsidered. Percutaneous coronary intervention could allow a shorter duration of dual-antiplatelet therapy in simple lesions, with safer perioperative outcomes. Hybrid coronary revascularization is an option for high-risk LT candidates with multivessel disease nonamenable to percutaneous coronary intervention. The objective of this review is to evaluate existing methods for preoperative cardiovascular risk stratification, and to describe interventions before surgery to optimize patient outcomes and reduce cardiovascular event risk.
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Affiliation(s)
- Selene Martinez-Perez
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Piroze M Davierwala
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre Toronto, General Hospital, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sanjog Kalra
- Division of Cardiology, Interventional Cardiology Section, Peter Munk Cardiac Center Toronto General Hospital, University Health Network and Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elsie Nguyen
- Department of Medical Imaging, Cardiothoracic Imaging Division Lead, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mamatha Bhat
- Department of Gastroenterology, Hepatology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Cheryl Borosz
- Department of Gastroenterology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Carla Luzzi
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elmar Jaeckel
- Department of Gastroenterology, Ajmera Transplant Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Elmari Neethling
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network and Department of Anesthesiology and Pain Medicine, Temetry Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Ishaque T, Eagleson MA, Bowring MG, Motter JD, Yu S, Luo X, Kernodle AB, Gentry S, Garonzik-Wang JM, King EA, Segev DL, Massie AB. Transplant Candidate Outcomes After Declining a DCD Liver in the United States. Transplantation 2023; 107:e339-e347. [PMID: 37726882 PMCID: PMC11537495 DOI: 10.1097/tp.0000000000004777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND In the context of the organ shortage, donation after circulatory death (DCD) provides an opportunity to expand the donor pool. Although deceased-donor liver transplantation from DCD donors has expanded, DCD livers continue to be discarded at elevated rates; the use of DCD livers from older donors, or donors with comorbidities, is controversial. METHODS Using US registry data from 2009 to 2020, we identified 1564 candidates on whose behalf a DCD liver offer was accepted ("acceptors") and 16 981 candidates on whose behalf the same DCD offers were declined ("decliners"). We characterized outcomes of decliners using a competing risk framework and estimated the survival benefit (adjusted hazard ratio [95% confidence interval]) of accepting DCD livers using Cox regression. RESULTS Within 10 y of DCD offer decline, 50.9% of candidates died or were removed from the waitlist before transplantation with any type of allograft. DCD acceptors had lower mortality compared with decliners at 10 y postoffer (35.4% versus 48.9%, P < 0.001). After adjustment for candidate covariates, DCD offer acceptance was associated with a 46% reduction in mortality (0.54 [0.49-0.61]). Acceptors of older (age ≥50), obese (body mass index ≥30), hypertensive, nonlocal, diabetic, and increased risk DCD livers had 44% (0.56 [0.42-0.73]), 40% (0.60 [0.49-0.74]), 48% (0.52 [0.41-0.66]), 46% (0.54 [0.45-0.65]), 32% (0.68 [0.43-1.05]), and 45% (0.55 [0.42-0.72]) lower mortality risk compared with DCD decliners, respectively. CONCLUSIONS DCD offer acceptance is associated with considerable long-term survival benefits for liver transplant candidates, even with older DCD donors or donors with comorbidities. Increased recovery and utilization of DCD livers should be encouraged.
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Affiliation(s)
- Tanveen Ishaque
- New York University Langone Transplant Institute, New York, New York, USA
| | | | - Mary G. Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jennifer D. Motter
- New York University Langone Transplant Institute, New York, New York, USA
| | - Sile Yu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Xun Luo
- University Hospitals/Case Western Reserve University, Cleveland, Ohio, United States
| | - Amber B. Kernodle
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sommer Gentry
- New York University Langone Transplant Institute, New York, New York, USA
- New York University Grossman School of Medicine, New York, New York, USA
- Scientific Registry of Transplant Recipients, Minneapolis, MN
| | | | - Elizabeth A. King
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- New York University Langone Transplant Institute, New York, New York, USA
- New York University Grossman School of Medicine, New York, New York, USA
- Scientific Registry of Transplant Recipients, Minneapolis, MN
| | - Allan B. Massie
- New York University Langone Transplant Institute, New York, New York, USA
- New York University Grossman School of Medicine, New York, New York, USA
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Karangwa SA, Adelmeijer J, Burgerhof JGM, Lisman T, de Meijer VE, de Kleine RH, Reyntjens KMEM, van den Berg AP, Porte RJ, de Boer MT. Controlled DCD Liver Transplantation Is Not Associated With Increased Hyperfibrinolysis and Blood Loss After Graft Reperfusion. Transplantation 2022; 106:308-317. [PMID: 33606482 DOI: 10.1097/tp.0000000000003698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The specific effect of donation after circulatory death (DCD) liver grafts on fibrinolysis, blood loss, and transfusion requirements after graft reperfusion is not well known. The aim of this study was to determine whether transplantation of controlled DCD livers is associated with an elevated risk of hyperfibrinolysis, increased blood loss, and higher transfusion requirements upon graft reperfusion, compared with livers donated after brain death (DBD). METHODS A retrospective single-center analysis of all adult recipients of primary liver transplantation between 2000 and 2019 was performed (total cohort n = 628). Propensity score matching was used to balance baseline characteristics for DCD and DBD liver recipients (propensity score matching cohort n = 218). Intraoperative and postoperative hemostatic variables between DCD and DBD liver recipients were subsequently compared. Additionally, in vitro plasma analyses were performed to compare the intraoperative fibrinolytic state upon reperfusion. RESULTS No significant differences in median (interquartile range) postreperfusion blood loss (1.2 L [0.5-2.2] versus 1.3 L [0.6-2.2]; P = 0.62), red blood cell transfusion (2 units [0-4] versus 1.1 units [0-3]; P = 0.21), or fresh frozen plasma transfusion requirements (0 unit [0-2.2] versus 0 unit [0-0.9]; P = 0.11) were seen in DCD compared with DBD recipients, respectively. Furthermore, plasma fibrinolytic potential was similar in both groups. CONCLUSIONS Transplantation of controlled DCD liver grafts does not result in higher intraoperative blood loss or more transfusion requirements, compared with DBD liver transplantation. In accordance with this, no evidence for increased hyperfibrinolysis upon reperfusion in DCD compared with DBD liver grafts was found.
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Affiliation(s)
- Shanice A Karangwa
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Department of Surgery, Section of HPB Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jelle Adelmeijer
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Johannes G M Burgerhof
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Vincent E de Meijer
- Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Department of Surgery, Section of HPB Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ruben H de Kleine
- Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Department of Surgery, Section of HPB Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Koen M E M Reyntjens
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Aad P van den Berg
- Department of Gastroenterology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Robert J Porte
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Department of Surgery, Section of HPB Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Marieke T de Boer
- Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Department of Surgery, Section of HPB Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Regulations and Procurement Surgery in DCD Liver Transplantation: Expert Consensus Guidance From the International Liver Transplantation Society. Transplantation 2021; 105:945-951. [PMID: 33675315 DOI: 10.1097/tp.0000000000003729] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Donation after circulatory death (DCD) donors are an increasingly more common source of livers for transplantation in many parts of the world. Events that occur during DCD liver recovery have a significant impact on the success of subsequent transplantation. This working group of the International Liver Transplantation Society evaluated current evidence as well as combined experience and created this guidance on DCD liver procurement. Best practices for the recovery and transplantation of livers arising through DCD after euthanasia and organ procurement with super-rapid cold preservation and recovery as well as postmortem normothermic regional perfusion are described, as are the use of adjuncts during DCD liver procurement.
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Lugon Ferreira-Jr AC, Miguel GPS, Moscon I, Abreu IW, Aguiar JBDEOS, Vecci TRDS. Comparison of results on the use of extended criteria liver doners for transplants in Espírito Santo. Rev Col Bras Cir 2021; 48:e20202492. [PMID: 33978120 PMCID: PMC10683471 DOI: 10.1590/0100-6991e-20202492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 09/18/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION liver Transplantation is currently the treatment of choice for several terminal liver diseases. Despite the increase in performed transplants, the waiting lists continue to increase. In order to expand the supply of organs, transplantation teams have started to use previously rejected livers for transplants because of an increased risk of unfavorable outcomes. OBJECTIVE to evaluate the use of livers of expanded criterion donators. METHODS retrospective study of medical records. The livers were classified as normal or expanded criteria. The groups were divided in low and high MELD. A multivariate analysis was performed through logistic regression. RESULTS there was no statistical difference regarding early, late and global mortality between the groups. Decreased survival was observed in patients with high MELD (higher or equal to 20) when they received grafts from expanded criterion donators. The association between the occurrence of cardiorespiratory arrest and presence of elevated total bilirubin in donators was associated with higher mortality rates in expanded criterion livers. CONCLUSION the overall results are similar, but expanded criteria liver donators was associated with higher mortality in patients with high MELD.
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Affiliation(s)
| | - Gustavo Peixoto Soares Miguel
- - Meridional Hospital, Transplant Center - Cariacica - ES - Brasil
- - Federal University of Espírito Santo, Surgycal Clinic - Vitória - ES - Brasil
| | - Iara Moscon
- - Federal University of Espírito Santo, Surgycal Clinic - Vitória - ES - Brasil
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Kahn J, Pregartner G, Avian A, Kniepeiss D, Müller H, Schemmer P. The Graz Liver Allocation Strategy-Impact of Extended Criteria Grafts on Outcome Considering Immunological Aspects. Front Immunol 2020; 11:1584. [PMID: 32849538 PMCID: PMC7427688 DOI: 10.3389/fimmu.2020.01584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 06/15/2020] [Indexed: 12/24/2022] Open
Abstract
Background: Transplant centers are forced to use livers of extended criteria donors for transplantation due to a dramatic organ shortage. The outcome effect of extended donor criteria (EDCs) remains unclear. Thus, this study was designed to assess the impact of EDCs on outcome including immunological aspects after liver transplantation (LT). Patients and Methods: Between November 2016 and March 2018, 49 patients (85.7% male) with a mean age of 57 ± 11 years underwent LT. The impact of EDCs on outcome after LT was assessed retrospectively using both MedOcs and ENIS (Eurotransplant Network Information System). Results: About 80% of grafts derived from extended criteria donors. Alanine aminotransferase/aspartate aminotransferase (AST/ALT) levels elevated more than three times above normal values in organ donors was the only significant risk factor for primary dysfunction (PDF) and primary non-function (PNF)/Re-LT and early non-anastomotic biliary strictures (NAS). Balance of risk (BAR) score did not differ between EDC and non-EDC recipients. PDF (14.3% of all patients) and PNF (6.1% of all patients) occurred in 23.1% of EDC-graft recipients and in 10.0% of non-EDC-graft recipients (RR 2.31, p = 0.663). The 90-day mortality was 3.6%. There was no difference of early non-anastomotic biliary tract complications and biopsy proven rejections (BPR). There was no correlation of PDF/PNF with BPR and NAS, respectively; however, 66.7% of the patients with BPR also developed early NAS (p < 0.001). Conclusion: With the Graz liver allocation strategy, excellent survival can be achieved selecting livers with no more than 2 not outcome-relevant EDCs for patients with MELD >20. Further, BPR is associated with biliary complications.
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Affiliation(s)
- Judith Kahn
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
- Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Gudrun Pregartner
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Daniela Kniepeiss
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
- Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Helmut Müller
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
- Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Peter Schemmer
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
- Transplant Center Graz, Medical University of Graz, Graz, Austria
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Hessheimer AJ, Gastaca M, Miñambres E, Colmenero J, Fondevila C. Donation after circulatory death liver transplantation: consensus statements from the Spanish Liver Transplantation Society. Transpl Int 2020; 33:902-916. [PMID: 32311806 PMCID: PMC7496958 DOI: 10.1111/tri.13619] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/06/2020] [Accepted: 04/14/2020] [Indexed: 02/06/2023]
Abstract
Livers from donation after circulatory death (DCD) donors are an increasingly more common source of organs for transplantation. While there are few high-level studies in the field of DCD liver transplantation, clinical practice has undergone progressive changes during the past decade, in particular due to mounting use of postmortem normothermic regional perfusion (NRP). In Spain, uncontrolled DCD has been performed since the late 1980s/early 1990s, while controlled DCD was implemented nationally in 2012. Since 2012, the rise in DCD liver transplant activity in Spain has been considerable, and the great majority of DCD livers transplanted in Spain today are recovered with NRP. A panel of the Spanish Liver Transplantation Society was convened in 2018 to evaluate current evidence and accumulated experience in DCD liver transplantation, in particular addressing issues related to DCD liver evaluation, acceptance criteria, and recovery as well as recipient selection and postoperative management. This panel has created a series of consensus statements for the standard of practice in Spain and has published these statements with the hope they might help guide other groups interested in implementing new forms of DCD liver transplantation and/or introducing NRP into their clinical practices.
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Affiliation(s)
- Amelia J. Hessheimer
- Liver Transplant UnitCIBERehdIDIBAPSHospital ClínicUniversity of BarcelonaBarcelonaSpain
| | - Mikel Gastaca
- Hospital Universitario CrucesBilbaoSpain
- SETH Board of DirectorsSpain
| | - Eduardo Miñambres
- Transplant Coordination Unit & Intensive Care ServiceIDIVALHospital Universitario Marqués de ValdecillaUniversity of CantabriaSantanderSpain
| | - Jordi Colmenero
- Liver Transplant UnitCIBERehdIDIBAPSHospital ClínicUniversity of BarcelonaBarcelonaSpain
- SETH Board of DirectorsSpain
| | - Constantino Fondevila
- Liver Transplant UnitCIBERehdIDIBAPSHospital ClínicUniversity of BarcelonaBarcelonaSpain
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Cascales-Campos PA, Ferreras D, Alconchel F, Febrero B, Royo-Villanova M, Martínez M, Rodríguez JM, Fernández-Hernández JÁ, Ríos A, Pons JA, Sánchez-Bueno F, Robles R, Martínez-Barba E, Martínez-Alarcón L, Parrilla P, Ramírez P. Controlled donation after circulatory death up to 80 years for liver transplantation: Pushing the limit again. Am J Transplant 2020; 20:204-212. [PMID: 31329359 DOI: 10.1111/ajt.15537] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/20/2019] [Accepted: 07/09/2019] [Indexed: 01/25/2023]
Abstract
Our main objective was to compare liver transplant (LT) results between donation after circulatory death (DCD) and donation after brainstem death (DBD) in our hospital and to analyze, within the DCD group, the influence of age on the results obtained with DCD donors aged >70 years and up to 80 years. All DCD-LTs performed were analyzed prospectively. The results of the DCD group were compared with those of a control group who received a DBD-LT immediately after each DCD-LT. Later, the results obtained within the DCD group were analyzed according to the age of the donors, considering 2 subgroups with a cut-off point at 70 years. Survival results for LT with DCD and super rapid recovery were not inferior to those obtained in a similar group of patients transplanted with DBD livers. However, the cost of DCD was a higher rate of biliary complications, including ischemic cholangiopathy. Donor age was not a negative factor.
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Affiliation(s)
- Pedro A Cascales-Campos
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - David Ferreras
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Felipe Alconchel
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Beatriz Febrero
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Mario Royo-Villanova
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
- Intensive Care Unit, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - María Martínez
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
- Intensive Care Unit, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - José M Rodríguez
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Juan Á Fernández-Hernández
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Antonio Ríos
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - José A Pons
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
- Department of Hepatology, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Francisco Sánchez-Bueno
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Ricardo Robles
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Enrique Martínez-Barba
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
- Department of Patholoy, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Laura Martínez-Alarcón
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Pascual Parrilla
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Pablo Ramírez
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
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9
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Pietersen LC, Sarton E, Alwayn I, Lam HD, Putter H, van Hoek B, Braat AE. Impact of Temporary Portocaval Shunting and Initial Arterial Reperfusion in Orthotopic Liver Transplantation. Liver Transpl 2019; 25:1690-1699. [PMID: 31276282 DOI: 10.1002/lt.25592] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 06/06/2019] [Indexed: 01/13/2023]
Abstract
The use of a temporary portocaval shunt (TPCS) as well as the order of reperfusion (initial arterial reperfusion [IAR] versus initial portal reperfusion) in orthotopic liver transplantation (OLT) is controversial and, therefore, still under debate. The aim of this study was to evaluate outcome for the 4 possible combinations (temporary portocaval shunt with initial arterial reperfusion [A+S+], temporary portocaval shunt with initial portal reperfusion, no temporary portocaval shunt with initial arterial reperfusion, and no temporary portocaval shunt with initial portal reperfusion) in a center-based cohort study, including liver transplantations (LTs) from both donation after brain death and donation after circulatory death (DCD) donors. The primary outcome was the perioperative transfusion of red blood cells (RBCs), and the secondary outcomes were operative time and patient and graft survival. Between January 2005 and May 2017, all first OLTs performed in our institution were included in the 4 groups mentioned. With IAR and TPCS, a significantly lower perioperative transfusion of RBCs was seen (P < 0.001) as well as a higher number of recipients without any transfusion of RBCs (P < 0.001). A multivariate analysis showed laboratory Model for End-Stage Liver Disease (MELD) score (P < 0.001) and IAR (P = 0.01) to be independent determinants of the transfusion of RBCs. When comparing all groups, no statistical difference was seen in operative time or in 1-year patient and graft survival rates despite more LTs with a liver from a DCD donor in the A+S+ group (P = 0.005). In conclusion, next to a lower laboratory MELD score, the use of IAR leads to a significantly lower need for perioperative blood transfusion. There was no significant interaction between IAR and TPCS. Furthermore, the use of a TPCS and/or IAR does not lead to increased operative time and is therefore a reasonable alternative surgical strategy.
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Affiliation(s)
- Lars Cornelis Pietersen
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Elise Sarton
- Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ian Alwayn
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Hwai-Ding Lam
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Hein Putter
- Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | - Bart van Hoek
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Andries Erik Braat
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
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Chen W, Yadav DK, Bai X, Lou J, Que R, Gao S, Li G, Ma T, Wang J, Huang B, Liang T. Liver Transplantation from Voluntary Organ Donor System in China: A Comparison between DBD and DCD Liver Transplants. Gastroenterol Res Pract 2019; 2019:5736702. [PMID: 31191649 PMCID: PMC6525890 DOI: 10.1155/2019/5736702] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 04/11/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND In China, the cases of liver transplantation (LT) from donation after citizens' death have rose year by year since the citizen-based voluntary organ donor system was initiated in 2010. The objective of our research was to investigate the early postoperative and late long-term outcomes of LT from donation after brain death (DBD) and donation after circulatory death (DCD) according to the current organ donation system in China. METHODS Sixty-two consecutive cases of LT from donation after citizens' death performed in our hospital between February 2012 and June 2017 were examined retrospectively for short- and long-term outcomes. These included 35 DCD LT and 27 DBD LT. RESULT Subsequent median follow-up time of 19 months and 1- and 3-year graft survival rates were comparative between the DBD group and the DCD group (81.5% and 66.7% versus 67.1% and 59.7%; P = 0.550), as were patient survival rates (85.2% and 68.7% versus 72.2% and 63.9%; P = 0.358). The duration of ICU stay of recipients was significantly shorter in the DBD group, in comparison with that of the DCD group (1 versus 3 days, P = 0.001). Severe complication incidence (≥grade III) after transplantation was identical among the DBD and DCD groups (48.1% versus 60%, P = 0.352). There was no significant difference in postoperative mortality between the DBD and DCD groups (3 of 27 cases versus 5 of 35 cases). Twenty-one grafts (33.8%) were lost and 18 recipients (29.0%) were dead till the time of follow-up. Malignancy recurrence was the most prevalent reason for patient death (38.8%). There was no significant difference in incidence of biliary stenosis between the DBD and DCD groups (5 of 27 cases versus 6 of 35 cases, P = 0.846). CONCLUSION Although the sample size was small to some extent, this single-center study first reported that LT from DCD donors showed similar short- and long-term outcomes with DBD donors and justified the widespread implementation of voluntary citizen-based deceased organ donation in China. However, the results should be verified with a multicenter larger study.
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Affiliation(s)
- Wei Chen
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Dipesh Kumar Yadav
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jianying Lou
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Risheng Que
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Shunliang Gao
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Guogang Li
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Tao Ma
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Ji Wang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Bingfeng Huang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
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Milan Z, Katyayani K, Cubas G, Unic‐Stojanovic D, Cooper M, Bras P, Macmillan J. Trends in transfusion practice over 20 years in paediatric liver transplant programme. Vox Sang 2019; 114:355-362. [DOI: 10.1111/vox.12771] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 02/13/2019] [Accepted: 02/18/2019] [Indexed: 12/14/2022]
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12
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Hessheimer AJ, Vendrell M, Muñoz J, Ruíz Á, Díaz A, Sigüenza LF, Lanzilotta JR, Delgado Oliver E, Fuster J, Navasa M, García-Valdecasas JC, Taurá P, Fondevila C. Heparin but not tissue plasminogen activator improves outcomes in donation after circulatory death liver transplantation in a porcine model. Liver Transpl 2018; 24:665-676. [PMID: 29351369 DOI: 10.1002/lt.25013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 12/07/2017] [Accepted: 01/06/2018] [Indexed: 02/07/2023]
Abstract
Ischemic-type biliary lesions (ITBLs) arise most frequently after donation after circulatory death (DCD) liver transplantation and result in high morbidity and graft loss. Many DCD grafts are discarded out of fear for this complication. In theory, microvascular thrombi deposited during donor warm ischemia might be implicated in ITBL pathogenesis. Herein, we aim to evaluate the effects of the administration of either heparin or the fibrinolytic drug tissue plasminogen activator (TPA) as means to improve DCD liver graft quality and potentially avoid ITBL. Donor pigs were subjected to 1 hour of cardiac arrest (CA) and divided among 3 groups: no pre-arrest heparinization nor TPA during postmortem regional perfusion; no pre-arrest heparinization but TPA given during regional perfusion; and pre-arrest heparinization but no TPA during regional perfusion. In liver tissue sampled 1 hour after CA, fibrin deposition was not detected, even when heparin was not given prior to arrest. Although it was not useful to prevent microvascular clot formation, pre-arrest heparin did offer cytoprotective effects during CA and beyond, reflected in improved flows during regional perfusion and better biochemical, functional, and histological parameters during posttransplantation follow-up. In conclusion, this study demonstrates the lack of impact of TPA use in porcine DCD liver transplantation and adds to the controversy over whether the use of TPA in human DCD liver transplantation really offers any protective effect. On the other hand, when it is administered prior to CA, heparin does offer anti-inflammatory and other cytoprotective effects that help improve DCD liver graft quality. Liver Transplantation 24 665-676 2018 AASLD.
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Affiliation(s)
- Amelia J Hessheimer
- Department of Surgery, Institut de Malalties Digestives I Metabòliques, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Marina Vendrell
- Departments of Anesthesia, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Javier Muñoz
- Department of Surgery, Institut de Malalties Digestives I Metabòliques, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Ángel Ruíz
- Department of Hepatobiliary and Liver Transplant Surgery, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Alba Díaz
- Pathology, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Luís Flores Sigüenza
- Department of Surgery, Institut de Malalties Digestives I Metabòliques, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Jorge Rodríguez Lanzilotta
- Department of Surgery, Institut de Malalties Digestives I Metabòliques, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Eduardo Delgado Oliver
- Department of Surgery, Institut de Malalties Digestives I Metabòliques, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Jose Fuster
- Department of Surgery, Institut de Malalties Digestives I Metabòliques, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Miquel Navasa
- Liver Unit, Institut de Malalties Digestives i Metabòliques, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Juan Carlos García-Valdecasas
- Department of Surgery, Institut de Malalties Digestives I Metabòliques, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Pilar Taurá
- Departments of Anesthesia, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Constantino Fondevila
- Department of Surgery, Institut de Malalties Digestives I Metabòliques, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Department of Hepatobiliary and Liver Transplant Surgery, Hospital Clínic, University of Barcelona, Barcelona, Spain
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13
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A literature-based cost analysis of tissue plasminogen activator for prevention of biliary stricture in donation after circulatory death liver transplantation. Am J Surg 2018; 216:959-962. [PMID: 29724406 DOI: 10.1016/j.amjsurg.2018.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/02/2018] [Accepted: 04/11/2018] [Indexed: 01/08/2023]
Abstract
INTRODUCTION This study sought to approximate the cost-effectiveness of tPA utilization for prevention of biliary strictures (PTBS) in donation after circulatory death liver transplantation (DCD-LT). METHODS Previously-reported PTBS rates in DCD-LT with and without tPA were used to calculate the number needed to treat (NNT) for prevention of one PTBS. The incremental cost of PTBS was then used to determine the cost effectiveness of tPA for prevention of PTBS. RESULTS The incidence of PTBS in the setting of tPA administration was 20%, while incidence in patients without tPA use was 43% (p < 0.001). Meta-analysis demonstrated a risk reduction of 15.7%, which translated into a NNT of 6.4. Cost associated with treating 6.4 patients was $50,353. Based on an incremental cost of $81,888 associated with PTBS management, use of tPA in DCD-LT protocols was estimated to save $31,528 per PTBS prevented. CONCLUSION Utilization of tPA in DCD-LT protocols represents one possible cost-effective strategy for prevention of PTBS in DCD-LT.
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14
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Ramirez P, Ferreras D, Febrero B, Royo M, Cascales P, Rodriguez JM, Rios A, Fernandez JA, González MR, Sanchez-Bueno F, Robles R, Parrilla P. Outcomes of Liver Transplantation Using Older Donors After Circulatory Death and the Super-Rapid Technique: 14 Cases. Transplant Proc 2018; 50:601-604. [PMID: 29579864 DOI: 10.1016/j.transproceed.2017.11.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 10/22/2017] [Accepted: 11/11/2017] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Donation after circulatory death (DCD) has increased in the last decade, although a slight increase in surgical complications has been reported in liver transplantation (LT). Therefore, DCD is not recommended with donors aged 60 years or more because it entails an added risk. However, donation after brain death (DBD)-LT with donors aged 70 years or more shows acceptable results. OBJECTIVE The objective was to analyze the characteristics and complications of DCD-LT with donors aged 70 years or more (DCD-70). MATERIALS AND METHODS We included 14 DCD-70-LT and compared them with a control group of 28 DBD-LT aged 70 years or more. STATISTICAL ANALYSIS A descriptive analysis, Mann-Whitney U test, and Pearson chi-square or Fisher test were performed when appropriate. RESULTS Significant differences were found in aminotransferase peak at 24 hours, with an increase in the DCD-70 group (aspartate aminotransferease [AST] 1038 vs 507, P = .013; alanine aminotransferase [ALT] 750 vs 399, P = .014). The cold ischemia time was lower in DCD-70 although without significant differences (4.8 vs 6.7 hours). Biliary complications (28.6% vs 31.7%) and vascular complications (7.1% vs 7.1%) were similar. A single transplant with DCD-70 required a retransplantation due to arterial thrombosis. Mortality was the same in both cases (14.3%). CONCLUSION LT results with DCD-70 are similar to those of DBD-70, so the age criteria could also be extended in this type of donation.
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Affiliation(s)
- P Ramirez
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Murcia, Spain, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
| | - D Ferreras
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Murcia, Spain, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
| | - B Febrero
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Murcia, Spain, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain.
| | - M Royo
- Transplant Unit, Intensive Care Unit, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
| | - P Cascales
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Murcia, Spain, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
| | - J M Rodriguez
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Murcia, Spain, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
| | - A Rios
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Murcia, Spain, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
| | - J A Fernandez
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Murcia, Spain, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
| | - M R González
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Murcia, Spain, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
| | - F Sanchez-Bueno
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Murcia, Spain, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
| | - R Robles
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Murcia, Spain, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
| | - P Parrilla
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Murcia, Spain, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
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15
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Life Experiences of Hepatitis Patients Waiting for Liver Transplantation. HEPATITIS MONTHLY 2017. [DOI: 10.5812/hepatmon.57775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
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16
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Donation After Circulatory Death for Liver Transplantation: A Meta-Analysis on the Location of Life Support Withdrawal Affecting Outcomes. Transplantation 2017; 100:1513-24. [PMID: 27014794 DOI: 10.1097/tp.0000000000001175] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Liver transplantation using donation after circulatory death (DCD) donors is associated with inferior outcomes compared to donation after brain death (DBD). Prolonged donor warm ischemic time has been identified as the key factor responsible for this difference. Various aspects of the donor life support withdrawal procedure, including location of withdrawal and administration of antemortem heparin, are thought to play important roles in mitigating the effects of warm ischemia. However, a systematic exploration of these factors is important for more confident integration of these practices into a standard DCD protocol. METHODS Medline, EMBASE, and Cochrane libraries were systematically searched and 23 relevant studies identified for analysis. Donation after circulatory death recipients were stratified according to location of life support withdrawal (intensive care unit or operating theater) and use of antemortem heparin. RESULTS Donation after circulatory death recipients had comparable 1-year patient survival to DBD recipients if the location of withdrawal of life support was the operating theater, but not if the location was the intensive care unit. Likewise, the inferior 1-year graft survival and higher incidence of ischemic cholangiopathy of DCD compared with DBD recipients were improved by withdrawal in operating theater, although higher rates of ischemic cholangiopathy and worse graft survival were still observed in DCD recipients. Furthermore, administering heparin before withdrawal of life support reduced the incidence of primary nonfunction of the allograft. CONCLUSIONS Our evidence suggests that withdrawal in the operating theater and premortem heparin administration improve DCD liver transplant outcomes, thus allowing for the most effective usage of these valuable organs.
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17
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Preoperative Thromboelastography as a Sensitive Tool Predicting Those at Risk of Developing Early Hepatic Artery Thrombosis After Adult Liver Transplantation. Transplantation 2017; 100:2382-2390. [PMID: 27780186 DOI: 10.1097/tp.0000000000001395] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Whilst causes of hepatic artery thrombosis (HAT) after liver transplantation (LT) are multifactorial, early HAT (E-HAT) remains pertinent complication impacting on graft and patient survival. Currently there is no screening tool that would identify patients with increased risk of developing E-HAT. METHODS We analyzed the native procoagulant state of LT recipients, identified through pretransplant thromboelastographic (TEG) data among other known risk factors, to identify risk factors for E-HAT. RESULTS The outcomes of 828 adult patients undergoing LT between 2008 and 2013 were analyzed. Overall, 79 (9.5%) patients experienced HAT, E-HAT was diagnosed in 23, and in the remainder this was "late" HAT. The maximum amplitude (MA) on preoperative TEG was significantly higher in patients diagnosed with E-HAT compared with those who did not (71.2 mm vs 57.9 mm; P < 0.0001). Receiver operating characteristic analysis with the cutoff value for MA of 65 mm or greater returned area under the curve of 0.750 (P < 0.001) predicting E-HAT with a sensitivity of 70%. A total of 7% of patients with an MA of 65 mm or greater went on to develop E-HAT (hazard ratio, 5.28; 95% confidence interval, 2.10-12.29; P < 0.001), whereas only 1.2% patients with an MA less than 65 mm experienced E-HAT. CONCLUSIONS Preoperative TEG may reliably identify group of recipients at greater risk of developing E-HAT, and intense surveillance and anticoagulation prophylaxis may avoid this serious complication after LT.
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18
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Abstract
Mortality rates on the liver transplant waiting list are increasing. The shortage of organs has resulted in higher utilization of extended criteria donors (ECDs), with centers pushing the limits of what is acceptable for transplantation. Donor quality is more appropriately represented as a continuum of risk, and careful selection and matching of ECD grafts with recipients may lead to excellent outcomes. Although there is no precise definition for what constitutes an ECD liver, this review focuses on frequently cited characteristics, including donor age, steatosis, donation after cardiac death, and donors with increased risk of disease transmission.
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Affiliation(s)
- Irine Vodkin
- Division of Gastroenterology and Hepatology, University of California, San Diego, 200 West Arbor Drive M/C 8413, San Diego, CA, USA.
| | - Alexander Kuo
- Division of Gastroenterology and Hepatology, University of California, San Diego, 200 West Arbor Drive M/C 8413, San Diego, CA, USA
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19
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Activation of Fibrinolysis, But Not Coagulation, During End-Ischemic Ex Situ Normothermic Machine Perfusion of Human Donor Livers. Transplantation 2017; 101:e42-e48. [DOI: 10.1097/tp.0000000000001562] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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20
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Hessheimer AJ, Cárdenas A, García-Valdecasas JC, Fondevila C. Can we prevent ischemic-type biliary lesions in donation after circulatory determination of death liver transplantation? Liver Transpl 2016; 22:1025-33. [PMID: 27082839 DOI: 10.1002/lt.24460] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 04/02/2016] [Indexed: 12/23/2022]
Abstract
The pool of livers for transplantation consists of an increasingly greater proportion of marginal grafts, in particular those arising through donation after circulatory determination of death (DCD). However, a primary factor limiting the use of marginal livers, and, thereby, the applicability of liver transplantation in general, is concern over the subsequent development of ischemic-type biliary lesion (ITBL). ITBL is a devastating complication of liver transplantation; in its most severe forms, recipients suffer frequent infectious complications that require repeated invasive biliary procedures and ultimately result in either retransplantation or death. In the present review article, we discuss our current understanding of ITBL pathogenesis as it pertains to DCD, in particular. We discuss the most relevant theories regarding its development and provide a comprehensive overview of the most promising strategies we have available today to prevent the appearance of ITBL, strategies that may, furthermore, allow us to transplant a greater proportion of marginal livers in the future. Liver Transplantation 22 1025-1033 2016 AASLD.
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Affiliation(s)
- Amelia J Hessheimer
- General and Digestive Surgery and, University of Barcelona, Barcelona, Spain
| | - Andrés Cárdenas
- Gastrointestinal/Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
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Nemes B, Gámán G, Polak WG, Gelley F, Hara T, Ono S, Baimakhanov Z, Piros L, Eguchi S. Extended criteria donors in liver transplantation Part I: reviewing the impact of determining factors. Expert Rev Gastroenterol Hepatol 2016; 10:827-39. [PMID: 26838962 DOI: 10.1586/17474124.2016.1149061] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The definition and factors of extended criteria donors have already been set; however, details of the various opinions still differ in many respects. In this review, we summarize the impact of these factors and their clinical relevance. Elderly livers must not be allocated for hepatitis C virus (HCV) positives, or patients with acute liver failure. In cases of markedly increased serum transaminases, donor hemodynamics is an essential consideration. A prolonged hypotension of the donor does not always lead to an increase in post-transplantation graft loss if post-OLT care is proper. Hypernatremia of less than 160 mEq/L is not an absolute contraindication to accept a liver graft per se. The presence of steatosis is an independent and determinant risk factor for the outcome. The gold standard of the diagnosis is the biopsy. This is recommended in all doubtful cases. The use of HCV+ grafts for HCV+ recipients is comparable in outcome. The leading risk factor for HCV recurrence is the actual RNA positivity of the donor. The presence of a proper anti-HBs level seems to protect from de novo HBV infection. A favourable outcome can be expected if a donation after cardiac death liver is transplanted in a favourable condition, meaning, a warm ischemia time < 30 minutes, cold ischemia time < 8-10 hours, and donor age 50-60 years. The pathway of organ quality assessment is to obtain the most relevant information (e.g. biopsy), consider the co-existing donor risk factors and the reserve capacity of the recipient, and avoid further technical issues.
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Affiliation(s)
- Balázs Nemes
- a Department of Organ Transplantation, Faculty of Medicine , Institute of Surgery, University of Debrecen , Debrecen , Hungary
| | - György Gámán
- b Clinic of Transplantation and Surgery , Semmelweis University , Budapest , Hungary
| | - Wojciech G Polak
- c Department of Surgery, Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC , University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Fanni Gelley
- d Department of Internal medicine and Gastroenterology , Polyclinic of Hospitallers Brothers of St. John of God , Budapest , Hungary
| | - Takanobu Hara
- e Department of Surgery , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Shinichiro Ono
- e Department of Surgery , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Zhassulan Baimakhanov
- e Department of Surgery , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Laszlo Piros
- b Clinic of Transplantation and Surgery , Semmelweis University , Budapest , Hungary
| | - Susumu Eguchi
- e Department of Surgery , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
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22
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Blasi A, Hessheimer AJ, Beltrán J, Pereira A, Fernández J, Balust J, Martínez-Palli G, Fuster J, Navasa M, García-Valdecasas JC, Taurá P, Fondevila C. Liver Transplant From Unexpected Donation After Circulatory Determination of Death Donors: A Challenge in Perioperative Management. Am J Transplant 2016; 16:1901-8. [PMID: 26601629 DOI: 10.1111/ajt.13621] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 10/28/2015] [Accepted: 11/03/2015] [Indexed: 01/25/2023]
Abstract
Unexpected donation after circulatory determination of death (uDCD) liver transplantation is a complex procedure, in particular when it comes to perioperative recipient management. However, very little has been published to date regarding intraoperative and immediate postoperative care in this setting. Herein, we compare perioperative events in uDCD liver recipients with those of a matched group of donation after brain death liver recipients. We demonstrate that the former group of recipients suffers significantly greater hemodynamic instability and derangements in coagulation following graft reperfusion. Based on our experience, we recommend a proactive recipient management strategy in uDCD liver transplantation that involves early use of vasopressor support; maintaining adequate intraoperative levels of red cells, platelets, and fibrinogen; and routinely administering tranexamic acid before graft reperfusion.
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Affiliation(s)
- A Blasi
- Anesthesia, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - A J Hessheimer
- General and Digestive Surgery, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - J Beltrán
- Anesthesia, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - A Pereira
- Hemotherapy & Hemostasis, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - J Fernández
- Hepatology, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - J Balust
- Anesthesia, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - G Martínez-Palli
- Anesthesia, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - J Fuster
- General and Digestive Surgery, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - M Navasa
- Hepatology, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - J C García-Valdecasas
- General and Digestive Surgery, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - P Taurá
- Anesthesia, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - C Fondevila
- General and Digestive Surgery, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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23
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Hartmann M, Szalai C, Saner FH. Hemostasis in liver transplantation: Pathophysiology, monitoring, and treatment. World J Gastroenterol 2016; 22:1541-50. [PMID: 26819521 PMCID: PMC4721987 DOI: 10.3748/wjg.v22.i4.1541] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 09/29/2015] [Accepted: 11/13/2015] [Indexed: 02/06/2023] Open
Abstract
Recent findings in the pathophysiology and monitoring of hemostasis in patients with end stage liver disease have major impact on coagulation management during liver transplantation. There is increasing evidence, that the changes in both coagulation factors and platelet count regularly observed in patients with liver cirrhosis cannot be interpreted as a reliable indicator of diffuse bleeding risk. Instead, a differentiated view on hemostasis has led to the concept of a rebalanced coagulation system: While it is important to recognize that procoagulant factors are reduced in liver cirrhosis, it is also evident that synthesis of anticoagulant factors and fibrinolytic proteins produced in the liver is also diminished. Similarly, the decreased platelet count may be counterbalanced by increased platelet aggregability caused by highly active von Willebrand multimeres. The coagulation system is therefor stated to be rebalanced. While under normal "unstressed" conditions diffuse bleeding is rarely observed, however both diffuse bleeding or thrombus formation may occur when compensation mechanisms are exhausted. While most patients presenting for liver transplantation have severe cirrhosis, liver function and thus production of pro- and anticoagulant factors can be preserved especially in cholestatic liver disease. During liver transplantation, profound changes in the hemostasis system can occur. Surgical bleeding can lead to diffuse bleeding as coagulation factors and platelets are already reduced. Ischemia and tissue trauma can lead to alterations of hemostasis comparable to trauma induced coagulopathy. A further common disturbance often starting with the reperfusion of the transplanted organ is hyperfibrinolysis which can eventually precipitate complete consumption of fibrinogen and an endogenous heparinization by glycocalyx shedding. Moreover, thrombotic events in liver transplantations are not uncommon and contribute to increased mortality. Besides conventional laboratory methods, bed-side monitoring of hemostasis (e.g., thrombelastography, thrombelastometry) is often used during liver transplantation to rapidly diagnose decreases in fibrinogen and platelet count as well as hyperfibrinolysis and to guide treatment with blood products, factor concentrates, and antifibrinolytics. There is also evidence which suggests when algorithms based on bed-side hemostasis monitoring are used a reduction of blood loss, blood product use, and eventual mortality are possible. Notably, the bed-side monitoring of anticoagulant pathways and the thrombotic risk is not possible at time and thus a cautious and restrictive use of blood products is recommended.
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24
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Donohue CI, Mallett SV. Reducing transfusion requirements in liver transplantation. World J Transplant 2015; 5:165-182. [PMID: 26722645 PMCID: PMC4689928 DOI: 10.5500/wjt.v5.i4.165] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/10/2015] [Accepted: 11/25/2015] [Indexed: 02/05/2023] Open
Abstract
Liver transplantation (LT) was historically associated with massive blood loss and transfusion. Over the past two decades transfusion requirements have reduced dramatically and increasingly transfusion-free transplantation is a reality. Both bleeding and transfusion are associated with adverse outcomes in LT. Minimising bleeding and reducing unnecessary transfusions are therefore key goals in the perioperative period. As the understanding of the causes of bleeding has evolved so too have techniques to minimize or reduce the impact of blood loss. Surgical “piggyback” techniques, anaesthetic low central venous pressure and haemodilution strategies and the use of autologous cell salvage, point of care monitoring and targeted correction of coagulopathy, particularly through use of factor concentrates, have all contributed to declining reliance on allogenic blood products. Pre-emptive management of preoperative anaemia and adoption of more restrictive transfusion thresholds is increasingly common as patient blood management (PBM) gains momentum. Despite progress, increasing use of marginal grafts and transplantation of sicker recipients will continue to present new challenges in bleeding and transfusion management. Variation in practice across different centres and within the literature demonstrates the current lack of clear transfusion guidance. In this article we summarise the causes and predictors of bleeding and present the evidence for a variety of PBM strategies in LT.
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25
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26
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Parikh ND, Hutton D, Marrero W, Sanghani K, Xu Y, Lavieri M. Projections in donor organs available for liver transplantation in the United States: 2014-2025. Liver Transpl 2015; 21:855-63. [PMID: 25845830 DOI: 10.1002/lt.24136] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 02/26/2015] [Accepted: 03/22/2015] [Indexed: 12/19/2022]
Abstract
With the aging US population, demographic shifts, and obesity epidemic, there is potential for further exacerbation of the current liver donor shortage. We aimed to project the availability of liver grafts in the United States. We performed a secondary analysis of the Organ Procurement and Transplantation Network database of all adult donors from 2000 to 2012 and calculated the total number of donors available and transplanted donor livers stratified by age, race, and body mass index (BMI) group per year. We used National Health and Nutrition Examination Survey and Centers for Disease Control and Prevention historical data to stratify the general population by age, sex, race, and BMI. We then used US population age and race projections provided by the US Census Bureau and the Weldon Cooper Center for Public Service and made national and regional projections of available donors and donor liver utilization from 2014 to 2025. We performed sensitivity analyses and varied the rate of the rise in obesity, proportion of Hispanics, population growth, liver utilization rate, and donation after cardiac death (DCD) utilization. The projected adult population growth in the United States from 2014 to 2025 will be 7.1%. However, we project that there will be a 6.1% increase in the number of used liver grafts. There is marked regional heterogeneity in liver donor growth. Projections were significantly affected by changes in BMI, DCD utilization, and liver utilization rates but not by changes in the Hispanic proportion of the US population or changes in the overall population growth. Overall population growth will outpace the growth of available donor organs and thus potentially exacerbate the existing liver graft shortage. The projected growth in organs is highly heterogeneous across different United Network for Organ Sharing regions. Focused strategies to increase the liver donor pool are warranted.
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Affiliation(s)
- Neehar D Parikh
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI
| | - David Hutton
- School of Public Health, University of Michigan Ann Arbor, MI
| | - Wesley Marrero
- Industrial and Operational Engineering, University of Michigan, Ann Arbor, MI
| | - Kunal Sanghani
- Industrial and Operational Engineering, University of Michigan, Ann Arbor, MI
| | - Yongcai Xu
- Industrial and Operational Engineering, University of Michigan, Ann Arbor, MI
| | - Mariel Lavieri
- Industrial and Operational Engineering, University of Michigan, Ann Arbor, MI
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27
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Xia W, Ke Q, Wang Y, Feng X, Guo H, Wang W, Zhang M, Shen Y, Wu J, Xu X, Yan S, Zheng S. Donation after cardiac death liver transplantation: Graft quality evaluation based on pretransplant liver biopsy. Liver Transpl 2015; 21:838-846. [PMID: 25824672 DOI: 10.1002/lt.24123] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 03/18/2015] [Indexed: 02/05/2023]
Abstract
Donation after cardiac death (DCD) liver grafts are associated with inferior clinical outcomes and high discard rates because of poor graft quality. We investigated the predictive value of DCD liver biopsy for the pretransplant graft quality evaluation. DCD liver transplants that took place between October 2010 and April 2014 were included (n = 127). Histological features of graft biopsy samples were analyzed to assess risk factors for graft survival. Macrovesicular steatosis ≥ 20% [hazard ratio (HR) = 2.973; P = 0.045] and sinusoidal neutrophilic infiltrate (HR = 6.969; P = 0.005) were confirmed as independent risk factors for graft survival; hepatocellular swelling, vacuolation, and necrosis failed to show prognostic value. Additionally, a donor serum total bilirubin level ≥ 34.2 μmol/L was also associated with a lower probability of graft survival. Our analysis indicates that macrovesicular steatosis ≥ 20% and sinusoidal neutrophilic infiltrate are novel and useful histological markers for DCD liver grafts with unacceptable quality. This finding can be used by transplant surgeons to improve DCD liver acceptance protocols.
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Affiliation(s)
- Weiliang Xia
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qinghong Ke
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ye Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaowen Feng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Haijun Guo
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Weilin Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Min Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yan Shen
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jian Wu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiao Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Sheng Yan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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28
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Singhal A, Wima K, Hoehn RS, Quillin RC, Woodle ES, Paquette IM, Paterno F, Abbott DE, Shah SA. Hospital Resource Use with Donation after Cardiac Death Allografts in Liver Transplantation: A Matched Controlled Analysis from 2007 to 2011. J Am Coll Surg 2015; 220:951-8. [DOI: 10.1016/j.jamcollsurg.2015.01.052] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 01/30/2015] [Accepted: 01/31/2015] [Indexed: 01/28/2023]
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29
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National assessment of early biliary complications after liver transplantation: economic implications. Transplantation 2015; 98:1226-35. [PMID: 25119126 DOI: 10.1097/tp.0000000000000197] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite improvement in surgical technique and medical management of liver transplant recipients, biliary complications remain a frequent cause of posttransplant morbidity and graft loss. Biliary complications require potentially expensive interventions including radiologic procedures and surgical revisions. METHODS A national data set linking transplant registry and Medicare claims data for 12,803 liver transplant recipients was developed to capture information on complications, treatments, and associated direct medical costs up to 3 years after transplantation. RESULTS Biliary complications were more common in recipients of donation after cardiac death compared to donation after brain death allografts (23% vs. 19% P<0.001). Among donation after brain death recipients, biliary complications were associated with $54,699 (95% confidence interval [CI], $49,102 to $60,295) of incremental spending in the first year after transplantation and $7,327 in years 2 and 3 (95% CI, $4,419-$10,236). Biliary complications in donation after cardiac death recipients independently increased spending by $94,093 (95% CI, $64,643-$124,542) in the first year and $12,012 (95% CI, $-1,991 to $26,016) in years 2 and 3. CONCLUSION This national study of biliary complications demonstrates the significant economic impact of this common perioperative complication and suggests a potential target for quality of care improvements.
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Pan X, Apinyachon W, Xia W, Hong JC, Busuttil RW, Steadman RH, Xia VW. Perioperative complications in liver transplantation using donation after cardiac death grafts: a propensity-matched study. Liver Transpl 2014; 20:823-30. [PMID: 24711100 DOI: 10.1002/lt.23888] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 03/27/2014] [Indexed: 12/13/2022]
Abstract
Donation after cardiac death (DCD) is an important source for expanding the donor pool for liver transplantation (LT). Although the long-term outcomes of LT using DCD grafts have been extensively studied, perioperative complications related to DCD grafts are rarely reported. The aim of this study was to determine whether DCD grafts were associated with a higher incidence of postreperfusion complications and worse outcomes in adult LT patients. After institutional review board approval, the medical records of all adult patients who underwent LT at our medical center between 2004 and 2011 were reviewed. Postreperfusion complications and posttransplant outcomes were compared between patients receiving DCD grafts and patients receiving donation after brain death (DBD) grafts. In all, 74 patients received DCD grafts during the study period, and 1369 patients received DBD grafts. An initial comparison showed that many preoperative, prereperfusion, and donor variables in the DCD group differed significantly from those in the DBD group. Propensity matching was chosen so that adjustments could be made for the differences. A postmatching analysis showed that the preoperative, prereperfusion, and donor variables no longer differed between the 2 groups. The postreperfusion requirements for blood products and vasopressors, the posttransplant ventilation times, the incidence of posttransplant acute renal injury, and the 30-day and 1-year patient and graft survival rates were comparable between the 2 groups. However, patients receiving DCD grafts experienced significantly higher rates of hyperkalemia (33.8% versus 18.9%, P < 0.05) and postreperfusion syndrome (PRS; 25.7% versus 12.3%, P < 0.05). In conclusion, after adjustments for preoperative and prereperfusion risks via propensity matching, DCD grafts remained a risk factor for postreperfusion hyperkalemia and PRS. A prophylactic regimen aimed at decreasing postreperfusion hyperkalemia and PRS is recommended for the management of LT using DCD grafts.
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Affiliation(s)
- Xiongxiong Pan
- Departments of Anesthesiology and David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA; Department of Anesthesiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
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31
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Clevenger B, Mallett SV. Transfusion and coagulation management in liver transplantation. World J Gastroenterol 2014; 20:6146-6158. [PMID: 24876736 PMCID: PMC4033453 DOI: 10.3748/wjg.v20.i20.6146] [Citation(s) in RCA: 121] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 02/10/2014] [Accepted: 03/13/2014] [Indexed: 02/06/2023] Open
Abstract
There is wide variation in the management of coagulation and blood transfusion practice in liver transplantation. The use of blood products intraoperatively is declining and transfusion free transplantations take place ever more frequently. Allogenic blood products have been shown to increase morbidity and mortality. Primary haemostasis, coagulation and fibrinolysis are altered by liver disease. This, combined with intraoperative disturbances of coagulation, increases the risk of bleeding. Meanwhile, the rebalancing of coagulation homeostasis can put patients at risk of hypercoagulability and thrombosis. The application of the principles of patient blood management to transplantation can reduce the risk of transfusion. This includes: preoperative recognition and treatment of anaemia, reduction of perioperative blood loss and the use of restrictive haemoglobin based transfusion triggers. The use of point of care coagulation monitoring using whole blood viscoelastic testing provides a picture of the complete coagulation process by which to guide and direct coagulation management. Pharmacological methods to reduce blood loss include the use of anti-fibrinolytic drugs to reduce fibrinolysis, and rarely, the use of recombinant factor VIIa. Factor concentrates are increasingly used; fibrinogen concentrates to improve clot strength and stability, and prothrombin complex concentrates to improve thrombin generation. Non-pharmacological methods to reduce blood loss include surgical utilisation of the piggyback technique and maintenance of a low central venous pressure. The use of intraoperative cell salvage and normovolaemic haemodilution reduces allogenic blood transfusion. Further research into methods of decreasing blood loss and alternatives to blood transfusion remains necessary to continue to improve outcomes after transplantation.
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32
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Schofield N, Sugavanam A, Thompson K, Mallett SV. No increase in blood transfusions during liver transplantation since the withdrawal of aprotinin. Liver Transpl 2014; 20:584-90. [PMID: 24481770 DOI: 10.1002/lt.23839] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 01/19/2014] [Indexed: 12/13/2022]
Abstract
The aims of this study were to determine whether the withdrawal of aprotinin (APRO) led to an increased bleeding risk in patients undergoing orthotopic liver transplantation (OLT). A retrospective analysis compared consecutive patients undergoing OLT and treated with aprotinin (APRO group; n = 100) with a group in which aprotinin was not used (no-APRO group; n = 100). Propensity score matching was then performed for each group to identify 2 matched cohorts. Patients were matched by their primary diagnoses and Model for End-Stage Liver Disease scores. This resulted in 2 matched cohorts with 55 patients in each group. None of the patients in the APRO group had significant fibrinolysis. In the no-APRO group, 23.6% of the patients developed fibrinolysis (P < 0.003). Tranexamic acid was used in 61.5% of the patients (n = 8) in the no-APRO group in whom lysis was present, and this resolved the fibrinolysis in all but 1 of these patients. There were no differences in red blood cell, fresh frozen plasma, platelet concentrate, or cryoprecipitate transfusions between the 2 groups. In conclusion, we have shown a significant increase in the prevalence of fibrinolysis during OLT since the withdrawal of APRO. However, there has been no increase in transfusion requirements.
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Affiliation(s)
- Nick Schofield
- Department of Anaesthesia, Royal Free Hospital, Hampstead, London, United Kingdom
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33
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[Liver transplant with donated graft after controlled cardiac death. Current situation]. Cir Esp 2013; 91:554-62. [PMID: 24021972 DOI: 10.1016/j.ciresp.2013.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 04/04/2013] [Accepted: 04/08/2013] [Indexed: 02/07/2023]
Abstract
An increasing pressure on the liver transplant waiting list, forces us to explore new sources, in order to expand the donor pool. One of the most interesting and with a promising potential, is donation after cardiac death (DCD). Initially, this activity has developed in Spain by means of the Maastricht type II donation in the uncontrolled setting. For different reasons, donation after controlled cardiac death has been reconsidered in our country. The most outstanding circumstance involved in DCD donation is a potential ischemic stress, that could cause severe liver graft cell damage, resulting in an adverse effect on liver transplant results, in terms of complications and outcomes. The complex and particular issues related to DCD Donation will be discussed in this review.
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34
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Dageforde LA, Feurer ID, Pinson CW, Moore DE. Is liver transplantation using organs donated after cardiac death cost-effective or does it decrease waitlist death by increasing recipient death? HPB (Oxford) 2013; 15:182-9. [PMID: 23374358 PMCID: PMC3572278 DOI: 10.1111/j.1477-2574.2012.00524.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 05/30/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the cost-effectiveness in liver transplantation (LT) of utilizing organs donated after cardiac death (DCD) compared with organs donated after brain death (DBD). METHODS A Markov-based decision analytic model was created to compare two LT waitlist strategies distinguished by organ type: (i) DBD organs only, and (ii) DBD and DCD organs. The model simulated outcomes for patients over 10 years with annual cycles through one of four health states: survival; ischaemic cholangiopathy; retransplantation, and death. Baseline values and ranges were determined from an extensive literature review. Sensitivity analyses tested model strength and parameter variability. RESULTS Overall survival is decreased, and biliary complications and retransplantation are increased in recipients of DCD livers. Recipients of DBD livers gained 5.6 quality-adjusted life years (QALYs) at a cost of US$69 000/QALY, whereas recipients on the DBD + DCD LT waitlist gained 6.0 QALYs at a cost of US$61 000/QALY. The DBD + DCD organ strategy was superior to the DBD organ-only strategy. CONCLUSIONS The extension of life and quality of life provided by DCD LT to patients on the waiting list who might otherwise not receive a liver transplant makes the continued use of DCD livers cost-effective.
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Affiliation(s)
| | - Irene D. Feurer
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C. Wright Pinson
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Derek E. Moore
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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35
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Orman ES, Barritt AS, Wheeler SB, Hayashi PH. Declining liver utilization for transplantation in the United States and the impact of donation after cardiac death. Liver Transpl 2013; 19:59-68. [PMID: 22965893 PMCID: PMC3535500 DOI: 10.1002/lt.23547] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 08/29/2012] [Indexed: 12/21/2022]
Abstract
Worsening donor liver quality resulting in decreased organ utilization may be contributing to the recent decline in liver transplants nationally. We sought to examine trends in donor liver utilization and the relationship between donor characteristics and nonuse. We used the United Network for Organ Sharing database to review all deceased adult organ donors in the United States from whom at least 1 solid organ was transplanted into a recipient. Trends in donor characteristics were examined. Multivariate logistic regression was used to evaluate the association between donor characteristics and liver nonuse between 2004 and 2010. Population attributable risk proportions were determined for donor factors associated with nonuse. We analyzed 107,259 organ donors. The number of unused livers decreased steadily from 1958 (66% of donors) in 1988 to 841 (15%) in 2004 but then gradually increased to 1345 (21%) in 2010. The donor age, the body mass index (BMI), and the prevalence of diabetes and donation after cardiac death (DCD) all increased over time, and all 4 factors were independently associated with liver nonuse. DCD had the highest adjusted odds ratio (OR) for nonuse, and the odds increased nearly 4-fold between 2004 [OR = 5.53, 95% confidence interval (CI) = 4.57-6.70] and 2010 (OR = 21.31, 95% CI = 18.30-24.81). The proportion of nonuse attributable to DCD increased from 9% in 2004 to 28% in 2010. In conclusion, the proportion of donor livers not used has increased since 2004. Older donor age, greater BMI, diabetes, and DCD are all independently associated with nonuse and are on the rise nationally. Current trends may lead to significant declines in liver transplant availability.
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Affiliation(s)
- Eric S. Orman
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill
| | - A. Sidney Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill
| | - Stephanie B. Wheeler
- Department of Health Policy and Management, University of North Carolina, Chapel Hill
| | - Paul H. Hayashi
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill
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36
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Axelrod DA, Reed A. Donation after cardiac death liver transplantation: lose a bit on each one and make it up in volume. Liver Transpl 2012; 18:751-2. [PMID: 22378498 DOI: 10.1002/lt.23421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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