Liver transplantation using controlled donation after cardiac death donors: An analysis of a large single-center experience

Abstract

The use of donation after cardiac death (DCD) donors may provide a valuable source of organs for liver transplantation. Concerns regarding primary nonfunction (PNF) and intrahepatic biliary stricture (IHBSs) have limited the enthusiasm for their use. A retrospective analysis of 1436 consecutive deceased donor liver transplants performed between December 1998 and October 2006 was conducted. These included 108 DCD liver transplants, which were compared to 1328 transplants performed with organs from donors meeting the criteria for donation after brain death (DBD). The median follow-up was 48 months. The 1-, 3-, and 5-year patient survival and graft survival for DCD donors were 91.5%, 88.1%, and 88.1% and 79.3%, 74.5%, and 71.0%, respectively. The 1-, 3-, and 5-year patient survival and graft survival for DBD donors were 87.3%, 81.1%, and 77.2% and 81.6%, 74.7%, and 69.1%, respectively. Patient survival and graft survival were not significantly different between DCD donors less than 60 years old, DCD donors greater than 60 years old, and DBD donors. Causes of graft loss included IHBSs (n ϭ 9), PNF (n ϭ 4), recurrent hepatitis C virus (n ϭ 4), hepatic artery thrombosis (n ϭ 1), rejection (n ϭ 2), and patient death (n ϭ 13). Contrary to previously published data, excellent long-term patient survival and graft survival can be obtained with DCD allografts, and in our experience, they are equivalent to those obtained from DBD allografts. This discrepancy between supply and demand has resulted in significant morbidity and mortality for patients awaiting liver transplantation and has in turn resulted in the search for alternatives in order to offer liver transplantation to more patients.Attempts to increase the number of liver transplants using split liver transplantation and LDLT have met with limited success for adults and currently account for only a small percentage of the total number of liver transplants performed annually. LDLT, for example, peaked at 10% of the total number of liver transplants in 2001 and currently has declined to 5% of liver transplants, except in areas in which the average Model for End-Stage Liver Disease (MELD) score at transplant is

Inferior survival in liver transplant recipients with hepatocellular carcinoma receiving donation after cardiac death liver allografts

“…20 It has been shown by previous authors that DCD organs are used more frequently than DBD organs in patients with HCC (20.2% versus 13%). 4,21 The present study examined the effects of the use of DCD allografts in patients with HCC on patient and graft survival. Despite adherence to listing criteria such as the Milan criteria, 22 patients with HCC are known to have slightly inferior long-term survival.…”

“…Recent reports have shown that DCD livers are used more frequently than donation after brain death (DBD) organs in patients with HCC (20.2% versus 13%). 3,4 This may reflect the global tendency to transplant extended criteria organs into recipients with lower unadjusted Model for End-Stage Liver Disease (MELD) scores because of the perception that these patients are better equipped to weather the storm of an extended criteria organ; however, this view has been challenged. 5,6 DCD organs suffer from warm ischemic injury (which is not seen in traditional DBD organs) because of hypoperfusion and hypoxia during the agonal period.…”

Anesthetic considerations in organ procurement surgery: a narrative review

“…44,74 Once mechanical ventilation is re-initiated, tidal volumes should be 6-8 mgÁkg -1 with 8-10 cm H 2 O PEEP in order to decrease the risk of acute lung injury. 6 Liver transplantation Although favourable outcomes have been achieved with the use of DCD liver grafts, 75 there has been a higher rate of biliary complications associated with these organs, and thus, they are considered to represent a higher risk option for the recipient. Factors such as patient weight, total ischemia time, and donor age can affect recipient outcome.…”

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“…To assess the outcomes of patients receiving DCD liver allografts, we analyzed the available previously published literature, including several single-center studies (Table 1) 6,[12][13][14][15][16][17][18][19] and large studies (Table 2) 7,[20][21][22][23][24][25] of national databases, to compare the outcomes of recipients who received DCD versus DBD donor livers and to better understand the risk factors for graft survival, loss, and failure.…”