First experience of liver transplantation with type 2 donation after cardiac death in France

Abstract

Organ donation after unexpected cardiac death [type 2 donation after cardiac death (DCD)] is currently authorized in France and has been since 2006. Following the Spanish experience, a national protocol was established to perform liver transplantation (LT) with type 2 DCD donors. After the declaration of death, abdominal normothermic oxygenated recirculation was used to perfuse and oxygenate the abdominal organs until harvesting and cold storage. Such grafts were proposed to consenting patients < 65 years old with liver cancer and without any hepatic insufficiency. Between 2010 and 2013, 13 LTs were performed in 3 French centers. Six patients had a rapid and uneventful postoperative recovery. However, primary nonfunction occurred in 3 patients, with each requiring urgent retransplantation, and 4 early allograft dysfunctions were observed. One patient developed a nonanastomotic biliary stricture after 3 months, whereas 8 patients showed no sign of ischemic cholangiopathy at their 1-year follow-up. In comparison with a control group of patients receiving grafts from braindead donors (n 5 41), donor age and cold ischemia time were significantly lower in the type 2 DCD group. Time spent on Additional Supporting Information may be found in the online version of this article.

Liver Grafts From Donors After Circulatory Death on Regional Perfusion With Extended Warm Ischemia Compared With Donors After Brain Death

“…The use of liver grafts from donors suffering CA is expanding as a result of extracorporeal perfusion systems. Fondevila et al and Savier et al have successfully used NRP in 34 and 13 uncontrolled DCD LTs, respectively, with a no‐touch period of 5 minutes . On the other hand, Carter et al have reported 15 LTs from ECMO‐supported DBD donors with a 1‐year graft survival of 93%, and several other studies report similar results .…”

“…For ALT, a cutoff of 4‐fold of the upper limit of normal has been adopted by Fondevila et al, whereas Savier et al have defined this limit at 200 IU/L . Although serum lactate is considered to be a marker of adequate perfusion and hepatic clearance, these groups have placed little importance on this factor, probably because its concentration during NRP may be altered by reflux from extra‐abdominal regions . Recent studies on normothermic machine perfusion have used serum lactate levels for ex situ evaluation .…”

“…Extracorporeal membrane oxygenation (ECMO) is increasingly used for support of patients with overwhelming cardiac failure, and some investigators have reported successful liver transplantations (LTs) from donation after brain death (DBD) during ECMO . In DCD, normothermic regional perfusion (NRP) based on ECMO technology has proven effective for improving transplant outcomes and allowing use of uncontrolled donors . In addition to its reconditioning properties, NRP also offers the possibility to assess graft function after warm ischemia.…”

Heparin but not tissue plasminogen activator improves outcomes in donation after circulatory death liver transplantation in a porcine model

“…In the present model, CA is sudden, as is the case in human uDCD. In uDCD, given the abrupt and unexpected nature of arrest, the donor and liver undergo a very prolonged period of warm ischemia, and the risk for the development of ischemic biliary complications in the posttransplant period is very high if aggressive donor recovery and maintenance and strict organ selection criteria are not employed . Although this model lacks the “agonal phase” seen in the other clinical scenario of cDCD, it is unlikely that the addition of an agonal phase would have changed anything with regard to fibrin deposition (or, in this case, the lack thereof).…”

Liver Transplantation in France

“…A protocol of uncontrolled (Maastricht 2) DCD donation was launched in LT in French pilot centers in 2010 with a standardized national protocol. To date, only 20 LTs with uncontrolled DCD donors have been performed with a substantial rate of graft loss . Procurement of controlled DCD organs (Maastricht 3) was authorized in France in 2014.…”