Evaluation of potential liver donors: Limits imposed by donor variables in liver transplantation

Abstract

The aim of this study was to evaluate the predictive value of different donor and recipient parameters that have been recognised previously as proven and to suggest prognostic factors for immediate liver function and final outcome after liver transplantation. We evaluated a total of 228 liver grafts transplanted in the last 3 years in our institution. Parameters were recorded for the donor (age, polytransfusion, atherosclerosis, presence of infection, episodes of hypoxia or hypotension, use of vasoactive drugs, intensive care unit stay, steatosis, and ischemia time) and recipient (red blood cell requirements, immediate liver function [score], incidence of hepatic artery thrombosis, survival, and cause of death or retransplantation). Liver biopsy after reperfusion of the donor liver was performed before closure of the abdomen. Donor age over 65 years and presence of steatosis were associated significantly with initial poor function. The mortality rate at 6 months was related to donor age over 65 years. When donor age over 65 years was combined with transfusion requirement of > 10 U of red blood cells (RBC), the incidence of graft loss increased to 53%. The probability of graft survival at two years decreased when donor age was over 65 years. Moreover, when donor age over 65 years was combined with requirement of >10units RBC the probability of 2-year survival was significantly reduced. This study shows, T he increase in the number of liver transplant candidates has led to a dramatic rise in waiting list mortality. The increased demand for donor organs has resulted in changes in donor characteristics because of the expanded donor selection criteria; this increase was confirmed by a recent report by the Spanish National Organization for Transplantation (ONT). 1 Although in 1992 the mean age for an organ donor was 38 Ϯ 15 years, in 2000 mean age increased to 47 Ϯ 17 years. Moreover, the cause of brain death changed from 43% trauma in 1992 to 55% cerebral hemorrhage. 1 This critical shortage of organ donors is the reason that many transplant centers are accepting lifesaving organs from so-called marginal or suboptimal donors, who would not have been considered suitable for transplantation previously. 2,3 Abnormal liver function tests, long stay in the intensive care unit (ICU), hemodynamic instability (prolonged hypoxia or hypotension), old donor age (over 65), and steatosis are no longer absolute contraindications for organ retrieval. 2,3 Although the outcome of liver transplantation does not seem to have been affected by the use of these donor organs, and real effect remains still to be determined. The current study analyzes several donor and recipient variables associated with liver transplantation, with particular emphasis on immediate graft function and graft survival. Patients and MethodsFrom January, 1997 to December, 1999, 228 consecutive orthotopic liver transplantations (OLTs) were performed in 215 adult patients. Using previously described techniques for multiorgan procurement, 4,5 all donor livers were pr...

D-MELD, a Simple Predictor of Post Liver Transplant Mortality for Optimization of Donor/Recipient Matching

“…The most influential donor risk factor is age (9,12 posttransplant survival and inefficient resource utilization (24). Allocation systems based on 'survival benefit' alone may prevent transplants at low MELD where survival benefit from transplantation is marginal, but do not adequately address inefficient resource utilization in high donor/recipient risk matches (25) demonstrable survival benefit from transplantation to low MELD (6)(7)(8)(9)(10)(11)(12)(13)(14) recipients who derive minimal or no survival benefit from transplantation. Recent studies by Schaubel et al (9) and Maluf et al (27) (28)(29)(30)(31)(32).…”

Variable activation of phosphoinositide 3-kinase influences the response of liver grafts to ischemic preconditioning

“…The frequency and the severity of liver graft reperfusion injury largely depends upon the length of cold ischemia as well as upon the use of marginal livers [2,3]. This latter aspect is a matter of growing concern considering that the shortage of organs increasingly compels the use of marginal livers [4]. This situation has stimulated the development of surgical and pharmacological strategies aimed to reduce reperfusion damage of liver grafts.…”

“…Among the signals activated by ischemic preconditioning, those involving phosphoinositide-3 kinase (PI3K) and the down stream serine-threonine protein kinase B (PKB-Akt) are of particular interest [18,19]. PI3Ks are a family of intracellular signal transducers characterized by the capacity of generating phosphatidylinositol (3,4,5)-triphosphate (PIP3) that in turn acts as a second messenger activating several kinases implicated in the regulation of cell proliferation, survival and metabolism [20]. The importance of PI3K in preventing hepatic injury has emerged from a number of observations showing that PI3K-mediated signals are important in preventing hepatocytes apoptosis as well as in ameliorating liver reperfusion injury [21][22][23].…”

Ischemic Pre-conditioning in Deceased Donor Liver Transplantation: A Prospective Randomized Clinical Trial

“…Some strategies to increase the donor pool have been introduced such as the split procedure, the 'domino' approach, living donor transplantation and the expansion of donor criteria. This latter and most commonly used strategy does not seem to affect overall survival, but even in this setting a number of grafts are still refused because of a high prevalence of primary graft dysfunction (5,6). Despite these livers having a normal or near normal function in the donor, the presence of multiple factors such as steatosis, age, length of time in the intensive care unit (ICU), makes them especially susceptible to ischemic/reperfusion (I/R) injury associated with the transplantation procedure (7,8).…”