Prerecovery liver biopsy in the brain-dead donor: A case-control study of logistics, safety, precision, and utility

Abstract

Prerecovery liver biopsy (PLB) can potentially to decrease futile recovery and increase utilization of marginal brain-dead donor (BDD) livers. A case-control study was conducted to examine the logistics, safety, histological precision, and liver utilization associated with PLB in BDDs. Twenty-three cases between January 2008 and January 2013 were compared to 2 groups: 48 sequential and 69 clinically matched controls. Compared to the sequential controls, the cases were older (53 versus 46 years), heavier (30.2 versus 25.8 kg/m 2 ), had higher prevalences of hypertension (78.3% versus 44.7%) and alcohol use (56.5% versus 23.4%), and a lower United Network for Organ Sharing expected organ yield (0.73 versus 0.81 livers/donor; P < 0.05 for all). Baseline characteristics were similar between cases and clinical controls. Donor management time was longer for the cases (22.4 hours) versus sequential controls (16.5 hours, P 5 0.01) and clinical controls (15.9 hours, P 5 0.01). Complications for cases (8.7%) were not different from either group of controls (18.8% for sequential controls, P 5 0.46; 17.4% for clinical controls, P 5 0.50). The agreement between the donor hospital and study pathologists was substantial regarding evaluation of steatosis (j 5 0.623) and fibrosis (j 5 0.627) and moderate regarding inflammation (j 5 0.495). The proportions of livers that were transplanted were similar for the cases and the clinical controls (60.9% versus 59.4%). In contrast, the proportion of donors for whom liver recovery was not attempted was higher (30.4% versus 8.7%), and the proportion of attempted liver recoveries that did not result in transplantation was lower (8.7% versus 31.9%). These differences were significant at P 5 0.009. Overall, PLB is logistically feasible with only a minimal delay and is safe, its interpretation at donor hospitals is reproducible, and it appears to decrease futile liver recovery. Liver Transpl 20:237-244, 2014. V C 2013 AASLD.Received July 5, 2013; accepted October 27, 2013.With the continued scarcity of livers, the transplantation of marginal livers from brain-dead donors (BDDs) and livers from cardiac death donors has increased. Concurrently, the proportion of unused livers has increased during the past decade. Data from the Scientific Registry of Transplant Recipients show that 21% of available livers were not used in 2010, whereas 15% were not used in 2004. 1 Although no uniform definition of a marginal liver BDD exists, typically older donors (age > 60 years), very obese donors, donors with positive hepatitis serologies or other highrisk behaviors, and donors with intracranial malignancies are considered marginal. 2-4 Usually, when a liver is not considered optimal on the basis of clinical, Abbreviations: BDD, brain-dead donor; DHP, donor hospital pathologist; EtOH, ethanol; O/E, observed yield per expected yield; O-E/100, observed yield minus expected yield per 100 donors; OPO, organ procurement organization; PLB, prerecovery liver biopsy; SP, study pathologist; UNOS,

The role of deceased donor liver biopsy: An analysis of 5449 liver transplant recipients

“…These reports represent the largest study of rates of graft biopsy with variability in graft utilization seeming to be largely transplant center and OPO dependent . With regard to outcome, Oliver et al have demonstrated that liver biopsy is safe in deceased donors and our data expand upon their work to show that there are no long‐term adverse effects of procurement biopsy on patient or graft survival …”

“…Liver biopsy has been demonstrated to be a method of identifying occult liver disease which may be indiscernible from clinical parameters alone . Additionally, the use of pre‐recovery liver biopsies has been shown to decrease futile liver recovery, though it has been suggested that this practice may also lead to exclusion of livers that might have been deemed useable at time of recovery, for the appropriate recipient . The determination of which donors require a biopsy and the impact of biopsy findings remains surgeon and transplant center dependent …”

Liver biopsy in assessment of extended criteria donors

“…Despite the use of PLB in brain death donors in many OPOs in the United States, the existing literature on this topic is sparse. Our large study provides substantially more information on the important issues of safety, futile liver recovery, and liver utilization than the existing 3 single‐center–based publications . The multifaceted diversity in the OPOs and their donor population allow for greater generalizability of our findings.…”

“…That is in contrast to an almost 30% rate of intraoperative biopsy . Evidence from 3 single OPO studies suggests that PLB decreases futile liver recovery and may be cost‐effective, particularly in liver‐only donors . There are no large studies confirming this and the safety of PLB.…”

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“…Liver biopsy before organ recovery has been demonstrated to be "logistically feasible" for decreasing futile organ retrieval. 9 This method has significantly decreased the proportion of attempted liver recoveries that did not end in transplant (from 31.9% to 8.7%; P = .009).…”