Donation after Circulatory Death: Potential Mechanisms of Injury and Preventative Strategies

Abstract

Donation after circulatory death (DCD) donors represent a potential means to help address the disparity between the number of patients awaiting liver transplantation (LT) and the availability of donor livers. While initial enthusiasm for DCD LT was high in the early 2000s, early reports of high rates of biliary complications and inferior graft survival resulted in reluctance among many transplant centers to use DCD liver grafts. As with all innovations in transplant practice, there is undoubtedly a learning curve associated with the optimal utilization of liver grafts from DCD donors. More contemporary data has demonstrated that results with DCD LT are improving and the number of DCD LT performed annually has been steadily increasing. In this concise review, potential mechanisms of injury for DCD livers are discussed along with strategies that have been employed in clinical practice to improve DCD LT outcomes.

Application of cholecystic duct plasty in the prevention of biliary complications following orthotopic liver transplantation

“…There is a strong correlation between factors such as the presence of warm ischemia-induced damage before cold ischemia during DCD (Donation after Circulatory Death) donor acquisition, blood stasis during warm ischemia, and microthrombosis of the microcirculation around the bile duct (17)(18)(19)(20). The national results of DCD LT are improving with the in-depth study of the mechanisms of DCD LT-related injuries and the practice of prevention strategies including improvement of procurement based (super rapid technique, minimizing warm ischemia time, and so on), minimizing cold ischemia time, machine perfusion, etc (21,22). In this study, 26 patients developed biliary complications during the follow-up period, with an overall incidence of 20.5%.…”

Current Understanding of Marginal Grafts in Liver Transplantation

“…Specifically, for DCD liver recipients, it is necessary to minimize the complexity of the surgery and establish a more resilient environment for marginal grafts. This requires careful selection of recipients who can withstand the challenges of early allograft dysfunction (EAD) [99]. For high-risk donors, they need to be matched with low-risk recipients to shorten the CIT [100].…”

Successfully sharing the sandbox: A perspective on combined DCD liver and heart donor procurement

“…Alternatively, the time from incision until cold perfusion of the organs is almost entirely within the procuring surgeons’ control. While both donor and recipient factors have been correlated with ischemic cholangiopathy (IC) following LT, previous studies have demonstrated that the time from donor asystole until cold perfusion/cross clamp is the most significant predictor of recipient outcome and the development of IC 4,5 . In those studies, on multivariate analysis, each minute increase in asystole‐cross clamp duration was associated with a 16% increase in odds for development of IC.…”