First report of successful transplantation of a pediatric donor liver graft after hypothermic machine perfusion

Abstract

One of the main limiting factors in pediatric liver transplantation is donor availability. For adults, DCD liver grafts are increasingly used to expand the donor pool. To improve outcome after DCD liver transplantation, ex situ machine perfusion is used as an alternative organ preservation strategy, with the supplemental value of providing oxygen to the graft during preservation. We here report the first successful transplantation of a pediatric DCD liver graft after hypothermic oxygenated machine perfusion. The full‐size liver graft was derived from a 13‐year‐old, female DCD donor and was end‐ischemic pretreated with dual hypothermic oxygenated machine perfusion. Arterial and portal pressures were set at 18 and 4 mm Hg, slightly lower than protocolized settings for adult livers. During 2 hours of machine perfusion, portal and arterial flows increased from 100 to 210 mL/min and 30 to 63 mL/min, respectively. The pretreated liver graft was implanted in a 16‐year‐old girl with progressive familial intrahepatic cholestasis type 2. Postoperative AST, ALT, and prothrombin time normalized within a week. The recipient quickly recovered and was discharged from the hospital after 18 days. One year after transplantation, she is in excellent condition with a completely normal liver function and histology. This case is the first report of successful transplantation of a pediatric DCD liver graft after hypothermic oxygenated machine perfusion and illustrates the potential role of ex situ machine perfusion in expanding the donor pool and improving outcome after pediatric liver transplantation.

Use of Dual Hypothermic Oxygenated Machine Perfusion to Recover Extended Criteria Pediatric Liver Grafts

“…From a technical point of view, the celiac trunk was used for arterial cannulation using an 8-Fr cannula, according to our usual technique in adults. This is in contrast with the report from the Groningen group, (3) in which a supratruncal aorta was used for arterial cannulation, leaving the celiac trunk untouched and potentially suitable for subsequent arterial reconstruction. In our patients, favorable recipient anatomies allowed for using the celiac artery for cannulation without any particular problem.…”

“…To our knowledge, D-HOPE for pediatric livers weighing ~800 g has not been reported so far. Following the case reported by Werner et al, (3) this report suggests that D-HOPE may represent a valuable adjunct to expand the donor pool and improve outcomes in pediatric LT as in adults. In the present series, D-HOPE allowed successful transplantation of 2 pediatric whole grafts from donors showing signs of acute liver injury, which could otherwise have been discarded.…”

“…Yet, our endeavor was not without a background: the cases herein reported were prompted by our previous experience with D-HOPE in adult livers, (1) during which we had perfused 8 grafts weighing between 900 and 1000 g using standard settings, with no case of post-LT graft dysfunction or other adverse events (unpublished data). According to Werner et al (3) we reduced the pressure settings to 4 and 18 mm Hg to further minimize the risk of graft injury. Despite reduced pressure settings, satisfactory flow characterized by the usual incremental pattern was achieved in both cases.…”

“…However, extended criteria donors are not exclusive of adult LT, and HOPE could also find specific indications in pediatric LT. Recently, the Groningen group (3) reported the successful transplantation of a graft from a pediatric DCD donor after dual hypothermic oxygenated machine perfusion (D-HOPE; ie, perfusion from both the portal vein and hepatic artery). During the procedure, the pressure settings were lowered as compared with those usually adopted in adults to avoid damaging the graft from excessive perfusion pressure, which has been observed in the experimental setting.…”

Machine Perfusions in Liver Transplantation: The Evidence‐Based Position Paper of the Italian Society of Organ and Tissue Transplantation

“…Furthermore, no studies analyzed patient or graft survival as primary endpoints, and survival often needed to be extrapolated from Kaplan-Meier curves because it was not clearly reported in the text. The 1-year graft survival rates ranged from 80% to 100% (8,10,11,13,(15)(16)(17) in the HMP group versus 69%-90% in the SCS group. Considering case-control studies, graft loss was 0%-14% in the HMP group versus 0%-45% in the SCS group.…”