Biliary Complications After Liver Transplantation From Donation After Cardiac Death Donors

Abstract

Objective This study evaluates the long-term outcomes, biliary complication rates, and risk factors for biliary complications after liver transplantation from donation after cardiac death (DCD) donors. Summary Background Data Recent enthusiasm toward increased use of DCD donor livers is mitigated by high biliary complication rates. Predictive risk factors for the development of biliary complications after DCD liver transplantation remain incompletely defined. Methods We performed a retrospective review of 1157 donation after brain death (DBD) and 87 DCD liver transplants performed between January 1, 1993 and December 31, 2008. Patient and graft survivals, and complication rates within the first year of transplantation were compared between DBD and DCD groups. Cox proportional hazards models were used to assess the influence of potential risk factors. Results Patient survival was significantly lower in the DCD group compared to the DBD group at 1, 5, 10 and 15 years (DCD: 84%, 68%, 54%, 54% vs. DBD: 91%, 81%, 67%, 58%, p<0.01). Graft survival was also significantly lower in the DCD group compared to the DBD group at 1, 5, 10 and 15 years (DCD: 69%, 56%, 43%, 43% vs. DBD: 86%, 76%, 60%, 51%, p<0.001). Rates of overall biliary complications (OBC) (DCD: 47% vs. DBD: 26%, p<0.01) and ischemic cholangiopathy (IC) (DCD: 34% vs. DBD: 1%, p<0.01) were significantly higher in the DCD group. Donor age (HR: 1.04, p<0.01) and donor age >40 years (HR: 3.13, p < 0.01) were significant risk factors for the development of OBC. Multivariate analysis revealed cold ischemic time (CIT) >8 hours (HR: 2.46, p=0.05), donor age >40 (HR: 2.90, p< 0.01) significantly increased the risk of IC. Conclusions Long-term patient and graft survival after DCD liver transplantation remain significantly lower but acceptable when compared to DBD liver transplants. Donor age and CIT >8 hours are the strongest predictors for the development of ischemic cholangiopathy. Careful selection of younger DCD donors and minimizing CIT may limit the incidence of severe biliary complications and improve the successful utilization of DCD donor livers.

Biliary Complications After Liver Transplantation: Old Problems and New Challenges

“…However, Serran found no differences in the rate of AS in donors > = 60 but a markedly higher rate of nonanastomotic strictures (NAS) in older donors (21). Foley detected a donor BMI of more than 25 kg/m 2 or a donor weight > 82 kg as risk factors for AS (22). Likewise, a multivariate analysis revealed a >25% macrovacuolar steatosis of the graft as only risk factor for biliary complications (23).…”

Liver Transplantation After Ex Vivo Normothermic Machine Preservation: A Phase 1 (First-in-Man) Clinical Trial

“…Also, organ donation is increasingly offered following cardiovascular/circulatory, rather than neurological, determination of death: this inevitably implies a period of warm ischemic injury prior to preservation (3). The use of these marginal organs is associated with a much higher risk of immediate graft failure and later complications (4,5). Notably, while 87% of all donation after brain death (DBD) livers in the United Kingdom were utilized, only 28% of donation after circulatory death (DCD) livers were transplanted (3).…”

Risk factors for cytomegalovirus reactivation after liver transplantation: Can pre‐transplant cytomegalovirus antibody titers predict outcome?

“…21,22 The secretion of cytokines from adipose tissue in obese patients may dysregulate the immune system, although the true mechanism remains unclear. 23,24 A prolonged cold ischemia time has been shown to increase the risk of ischemic cholangiopathy and subsequent allograft rejection. 22 This event may predispose these patients to more aggressive immunosuppression and thus lead to an increased risk of CMV infection.…”

“…The median age was 57 years (IQR, 47-62 years), and the sex distribution was almost equal. The median MELD score was 25 (IQR, [18][19][20][21][22][23][24][25][26][27][28][29]. The majority of patients were Caucasian (85%).…”