Graft utilization after normothermic regional perfusion in controlled donation after circulatory death—a single‐center perspective from France

Muller, Xavier; Rossignol, Guillaume; Damotte, S.; Grégoire, Arnaud; Matillon, X.; Morélon, Emmanuel; Badet, Lionel; Mohkam, Kayvan; Lesurtel, Mickaël; Mabrut, Jean‐Yves

doi:10.1111/tri.13987

Cited by 10 publications

(23 citation statements)

References 34 publications

(60 reference statements)

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“…Of the 14 studies published between 2003 and 2021, 12 studies (86%) were published after 2014 (Table 1). [10][11][12][13][14][15][16][17][18][19][20][21][22][23] All study designs were retrospective cohort studies. No randomized clinical trials were found.…”

Section: Description Of Included Studiesmentioning

confidence: 99%

“…[11] Donor age limitation varied from 65 years up to no limit. [10][11][12][13][14][15][16][17] Compared with uDCD protocols, restrictions…”

Section: Current Criteria For Consideration Of Anrp In Cdcdmentioning

confidence: 99%

“…The ALT level of the donor above three times the ULN before aNRP was a consideration criterion in one study (13%), [16] while the other seven articles (88%) did not select based on pre-aNRP ALT level. [10][11][12][13][14][15]17]…”

Section: Eligible Patients In Whom Anrp Was Performedmentioning

confidence: 99%

“…[10][11][12][13][14]16,17] Four out of eight articles reported ALT levels below 200 U/L or four times the ULN as denominator for acceptance. [10,11,13,16] Three studies accepted higher ALT levels in the blood, with a maximum of 500 [14] and 1000 U/L. [17,18] The protocols that accepted ALT levels to a maximum of 1000 U/L performed additional ex vivo hypothermic or normothermic machine perfusion before transplantation.…”

Section: Protocol Acceptance Criteria Of the Cdcd Liver Grafts During...mentioning

confidence: 99%

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Donor eligibility criteria and liver graft acceptance criteria during normothermic regional perfusion

Schurink

Leemkolk

Fondevila

et al. 2022

Liver Transplantation

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Acceptance of liver grafts from donations after circulatory death (DCD) largely remains a “black box,” particularly due to the unpredictability of the agonal phase. Abdominal normothermic regional perfusion (aNRP) can reverse ischemic injury early during the procurement procedure, and it simultaneously enables graft viability testing to unravel this black box. This review evaluates current protocols for liver viability assessment to decide upon acceptance or decline during aNRP. The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guideline was used, and relevant literature databases were searched. The primary outcome consisted of criteria for liver graft viability assessment. Secondary outcomes included survival, primary nonfunction (PNF), early dysfunction, and biliary complications. A total of 14 articles were included in the analysis. In all protocols, a combination of criteria was used to assess suitability of the liver for transplantation. As many as 12 studies (86%) used macroscopic assessment, 12 studies (86%) used alanine transaminase (ALT) levels in perfusate, 9 studies (64%) used microscopic assessment, and 7 studies (50%) used lactate levels as assessment criteria. The organ utilization rate (OUR) was 16% for uncontrolled donation after circulatory death (uDCD) and 64% for controlled donation after circulatory death (cDCD). The most used acceptation criterion in uDCD is ALT level (31%), while in cDCD macroscopic aspect (48%) is most used. Regarding postoperative complications, PNF occurred in 13% (6%–25%) of uDCD livers and 3% (2%–4%) of cDCD livers. In uDCD, the 1‐year graft and patient survival rates were 75% (66%–82%) and 82% (75%–88%). In cDCD, the 1‐year graft and patient survival rates were 91% (89%–93%) and 93% (91%–94%), respectively. In conclusion, the currently used assessment criteria consist of macroscopic aspect and transaminase levels. The acceptance criteria should be tailored according to donor type to prevent an unacceptable PNF rate in uDCD and to increase the relatively modest OUR in cDCD.

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Section: Description Of Included Studiesmentioning

confidence: 99%

“…[11] Donor age limitation varied from 65 years up to no limit. [10][11][12][13][14][15][16][17] Compared with uDCD protocols, restrictions…”

Section: Current Criteria For Consideration Of Anrp In Cdcdmentioning

confidence: 99%

Section: Eligible Patients In Whom Anrp Was Performedmentioning

confidence: 99%

Section: Protocol Acceptance Criteria Of the Cdcd Liver Grafts During...mentioning

confidence: 99%

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Donor eligibility criteria and liver graft acceptance criteria during normothermic regional perfusion

Schurink

Leemkolk

Fondevila

et al. 2022

Liver Transplantation

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“…In published protocols, 44,45,47–52 they are measured immediately before starting NRP, after 1 h, and at the end of reconditioning. More frequent measurements are also reported 19–53 . Barcelona's team 44,45 adopted a threshold based on a maximum of three times the upper limit of normality at baseline and of four times at the end of NRP.…”

Section: Methodsmentioning

confidence: 99%

Normothermic regional perfusion in liver transplantation from donation after cardiocirculatory death: Technical, biochemical, and regulatory aspects and review of literature

et al. 2022

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Background Organs from donation after circulatory death (DCD) are increasingly used for liver transplantation, due to the persisting organ shortage and waiting list mortality. However, the use of DCD grafts is still limited by the inferior graft survival rate and the increased risk of primary non‐function and biliary complications when compared to brain death donors’ grafts. Methods Abdominal normothermic regional perfusion with extracorporeal membrane oxygenation (ECMO) is an in situ preservation strategy. which may mitigate ischemia–reperfusion injuries. and has been proposed to restore blood perfusion after the determination of death thus optimizing liver function before implantation. Results In this systematic review, we highlighted the clinical evidence supporting the use of normothermic regional perfusion in DCD liver underlying the pathophysiological mechanisms, and technical, logistic, and regulatory aspects. Conclusions Despite the lack of properly designed, prospective, randomized trials, the current available data suggest beneficial effects of normothermic regional perfusion on clinical outcomes after liver transplantation.

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US Liver Transplant Outcomes After Normothermic Regional Perfusion vs Standard Super Rapid Recovery

Brubaker,

Sellers,

Abt

et al. 2024

JAMA Surg

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ImportanceNormothermic regional perfusion (NRP) is an emerging recovery modality for transplantable allografts from controlled donation after circulatory death (cDCD) donors. In the US, only 11.4% of liver recipients who are transplanted from a deceased donor receive a cDCD liver. NRP has the potential to safely expand the US donor pool with improved transplant outcomes as compared with standard super rapid recovery (SRR).ObjectiveTo assess outcomes of US liver transplants using controlled donation after circulatory death livers recovered with normothermic regional perfusion vs standard super rapid recovery.Design, Setting, and ParticipantsThis was a retrospective, observational cohort study comparing liver transplant outcomes from cDCD donors recovered by NRP vs SRR. Outcomes of cDCD liver transplant from January 2017 to May 2023 were collated from 17 US transplant centers and included livers recovered by SRR and NRP (thoracoabdominal NRP [TA-NRP] and abdominal NRP [A-NRP]). Seven transplant centers used NRP, allowing for liver allografts to be transplanted at 17 centers; 10 centers imported livers recovered via NRP from other centers.ExposurescDCD livers were recovered by either NRP or SRR.Main Outcomes and MeasuresThe primary outcome was ischemic cholangiopathy (IC). Secondary end points included primary nonfunction (PNF), early allograft dysfunction (EAD), biliary anastomotic strictures, posttransplant length of stay (LOS), and patient and graft survival.ResultsA total of 242 cDCD livers were included in this study: 136 recovered by SRR and 106 recovered by NRP (TA-NRP, 79 and A-NRP, 27). Median (IQR) NRP and SRR donor age was 30.5 (22-44) years and 36 (27-49) years, respectively. Median (IQR) posttransplant LOS was significantly shorter in the NRP cohort (7 [5-11] days vs 10 [7-16] days; P &lt; .001). PNF occurred only in the SRR allografts group (n = 2). EAD was more common in the SRR cohort (123 of 136 [56.1%] vs 77 of 106 [36.4%]; P = .007). Biliary anastomotic strictures were increased 2.8-fold in SRR recipients (7 of 105 [6.7%] vs 30 of 134 [22.4%]; P = .001). Only SRR recipients had IC (0 vs 12 of 133 [9.0%]; P = .002); IC-free survival by Kaplan-Meier was significantly improved in NRP recipients. Patient and graft survival were comparable between cohorts.Conclusion and RelevanceThere was comparable patient and graft survival in liver transplant recipients of cDCD donors recovered by NRP vs SRR, with reduced rates of IC, biliary complications, and EAD in NRP recipients. The feasibility of A-NRP and TA-NRP implementation across multiple US transplant centers supports increasing adoption of NRP to improve organ use, access to transplant, and risk of wait-list mortality.

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Graft utilization after normothermic regional perfusion in controlled donation after circulatory death—a single‐center perspective from France

Cited by 10 publications

References 34 publications

Donor eligibility criteria and liver graft acceptance criteria during normothermic regional perfusion

Donor eligibility criteria and liver graft acceptance criteria during normothermic regional perfusion

Normothermic regional perfusion in liver transplantation from donation after cardiocirculatory death: Technical, biochemical, and regulatory aspects and review of literature

US Liver Transplant Outcomes After Normothermic Regional Perfusion vs Standard Super Rapid Recovery

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