Liver Transplant From Unexpected Donation After Circulatory Determination of Death Donors: A Challenge in Perioperative Management

Abstract

Unexpected donation after circulatory determination of death (uDCD) liver transplantation is a complex procedure, in particular when it comes to perioperative recipient management. However, very little has been published to date regarding intraoperative and immediate postoperative care in this setting. Herein, we compare perioperative events in uDCD liver recipients with those of a matched group of donation after brain death liver recipients. We demonstrate that the former group of recipients suffers significantly greater hemodynamic instability and derangements in coagulation following graft reperfusion. Based on our experience, we recommend a proactive recipient management strategy in uDCD liver transplantation that involves early use of vasopressor support; maintaining adequate intraoperative levels of red cells, platelets, and fibrinogen; and routinely administering tranexamic acid before graft reperfusion.

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

“…Apart from the fact that it is not beneficial, the administration of a fibrinolytic drug to a graft, which may have ongoing effects even after washout due to binding to the vascular endothelium, is an intervention that could pose substantial risk for the development of uncontrollable hemorrhage in the recipient. This issue is particularly relevant in the setting of DCD liver transplantation, where postreperfusion coagulopathy is not uncommon . Nonetheless, there are clinical reports that allege benefit for the use of fibrinolytic therapy in this setting.…”

“…This issue is particularly relevant in the setting of DCD liver transplantation, where postreperfusion coagulopathy is not uncommon. (49,50) Nonetheless, there are clinical reports that allege benefit for the use of fibrinolytic therapy in this setting. The Cleveland Clinic Group described a series of 22 transplants performed with cDCD grafts treated with TPA injected into the donor hepatic artery on the back table, with or without heparin administered systemically prior to ventilator withdrawal.…”

Can we prevent ischemic‐type biliary lesions in donation after circulatory determination of death liver transplantation?

“…The administration of a fibrinolytic drug to a graft, even with subsequent washout, is an intervention that could pose substantial risk for the development of uncontrollable hemorrhage in the recipient, in particular in the context of DCD liver transplantation, where postreperfusion coagulopathy is common. (66,67) On the basis of the body of evidence that we have outlined, the use of fibrinolytic therapy to prevent ITBL in DCD liver transplantation is a practice that should be regarded with extreme caution.…”

Controlled Donation After Circulatory Determination of Death in Spain

“…We read with interest Magliocca's editorial regarding our recent publication on the perioperative management of liver recipients of uncontrolled or unexpected donation after circulatory determination of death (uDCD) (1,2). One comment in particular, that "the ethical and legal environment of transplantation in Spain preclude[s] the use of [controlled donation after circulatory determination of death (cDCD)] transplants as an option," drew our attention.…”