Incidence of and risk factors for ischemic-type biliary lesions following orthotopic liver transplantation

Abstract

Summary Ischemic‐type biliary lesions (ITBL) account for a major part of patients’ morbidity and mortality after orthotopic liver transplantation (OLT). The exact origin of this type of biliary complication remains unknown. This study retrospectively evaluated 1843 patients. Patients with primary sclerosing cholangitis were excluded from this study. The diagnosis of ITBL was established only when all other causes of destruction of the biliary tree were ruled out. Donor age (P = 0.028) and cold ischemic time (CIT) (P = 0.002) were found to be significant risk factors for the development of ITBL. Organs that were perfused with University of Wisconsin (UW) solution developed ITBL significantly more often than Histidine–Tryptophan–Ketoglutarate (HTK)‐perfused organs (P = 0.036). The same applied to organs harvested externally and shipped to our center versus those that were procured locally by our harvest teams (P < 0.001). Pressure perfusion via the hepatic artery significantly reduced the risk of ITBL (P = 0.001). The only recipient factor that showed a significant influence was Child‐Pugh score status C (P = 0.021). Immunologic factors had no significant impact on ITBL. The clinical consequences of this study for our institution have been the strict limitation of CIT to <10 h and the exclusive use of HTK solution. We further advocate that all organ procurement teams perform pressure perfusion on harvested organs.

Ischemic Type Biliary Lesions

“…Finally, graft atrophy and the reduction of functional reserve may develop, compromising the result of an initially successful LT. Significant morphological similarities are observed in a non-transplant setting as well: in patients with HIV-associated cholangiopathy as vanishing bile duct-syndrome, sclerosing cholangitis and shock-liver [1,26]. In summary, chronic inflammation caused by any noxious effectors may lead to the uniform picture described above.…”

“…Frequently, significant difficulties arise in the attempt of differentiation between recurrent PSC and ITBL in the graft. Morphologically these entities may present identical pictures [1]. …”

“…Hereby, ischemic injury seems to be the most important factor including cold and warm ischemia during transplantation, disturbed blood flow in the peribiliary plexus resulting from an inappropriate procurement of the donor liver with little periductal tissue, and hypoxemia during the postoperative period [12,27]. Immunological injury including ABO-incompatibility, rejection, pre-existing liver disease with autoimmune component, CMV-Infection, immunosuppressive medication and chronic rejection also seem to play a role in the development of the non-anastomotic strictures [1,27,28]. Moreover, bile fluid has been shown to be toxic for the vulnerable biliary epithelium of the graft [29].…”

“…ITBL seems to be a polygenic disease, influenced by a whole variety of confounders. Currently identified risk factors may be divided into four major pathogenetic columns: peri-operative ischemia (including preserving solution), immunologic damage, toxicity of bile salts and epidemiological confounders [1,27]. The degree and relation of the functional impact among risk factors are not fully investigated.…”

“…ductopenic rejection) [1]. As a diagnosis of exclusion, ITBL is regarded as a serious transplant complication and a notable graft disease, undeniably deserving scientific attention.…”