THE USE OF mARGINAL DONORS FOR LIVER TRANSPLANTATION A RETROSPECTIVE STUDY OF 365 LIVER DONORS 1,2

InTRODUÇÃOLesão por isquemia e reperfusão é processo inevitável que culmina com morte celular e afeta muito a função do enxerto após o transplante de fígado . Em seguida à restauração do fluxo sangüíneo, o fígado é submetido a lesão adicional mais grave do que a induzida pela isquemia . Disfunção primária e a sua forma mais grave, a falência primária, são conseqüências da lesão de isquemia e reperfusão e representam importante causa no aumento da morbidade e mortalidade após transplante de fígado 3 .O uso de enxertos marginais tem sido solução aceita pela escassez de órgãos para transplante e o seu uso tornou-se muito comum em todo mundo. A literatura vem mostrando efetividade desses órgãos e seus resultados no transplante de fígado 4,5,6 .O objetivo deste estudo é apresentar a experiência com transplante de fígado utilizando órgãos de doadores marginais em um centro hospitalar. ABCDDV/580

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“…A literatura vem mostrando efetividade desses órgãos e seus resultados no transplante de fígado 4,5,6 .…”

Section: Introductionunclassified

O doador marginal: experiência de um centro de transplante de fígado

Fonseca-Neto¹,

Miranda²,

Sabat³

et al. 2008

ABCD, arq. bras. cir. dig.

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“…Insight into the cellular and molecular basis of these injuries will lead to the development of better intervention strategies, which is very important because graft dysfunction results in increased morbidity and enhances mortality rates. 7,8 Moreover, up to 30% of patients with graft dysfunction need retransplantation as early as within the first 3 months after transplantation, 2,7,8 which increases the demand on an already short pool of donor organs.…”

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confidence: 99%

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2001

Liver Transpl

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In liver transplantation, it is currently hypothesized that nonparenchymal cell damage and/or activation is the major cause of preservation-related graft injury. Because parenchymal cells (hepatocytes) appear morphologically well preserved even after extended cold preservation, their injury after warm reperfusion is ascribed to the consequences of nonparenchymal cell damage and/or activation. However, accumulating evidence over the past decade indicated that the current hypothesis cannot fully explain preservation-related liver graft injury. We review data obtained in animal and human liver transplantation and isolated perfused animal livers, as well as isolated cell models to highlight growing evidence of the importance of hepatocyte disturbances in the pathogenesis of normal and fatty graft injury. Particular attention is given to preservation time-dependent decreases in high-energy adenine nucleotide levels in liver cells, a circumstance that (1) sensitizes hepatocytes to various stimuli and insults, (2) correlates well with graft function after liver transplantation, and (3) may also underlie the preservation timedependent increase in endothelial cell damage. We also review damage to bile duct cells, which is increasingly being recognized as important in the long-lasting phase of reperfusion injury. The role of hydrophobic bile salts in that context is particularly assessed. Finally, a number of avenues aimed at preserving hepatocyte and bile duct cell integrity are discussed in the context of liver transplantation therapy as a complement to reducing nonparenchymal cell damage and/or activation. (Liver Transpl 2001;7: 381-400.)A lthough the use of University of Wisconsin (UW) solution has permitted an increase in mean preservation time, the incidence of graft dysfunction still persists, 1,2 contributing significantly to a more than 20% per year mortality rate for patients in liver transplantation centers in the United States. 3 In addition, when storage time exceeds 10 to 12 hours, such late posttransplantation complications as biliary strictures occur in more than 25% of liver transplant recipients. [4][5][6] To prevent or minimize graft dysfunction and posttransplantation complications, it is essential to fully understand the importance of individual liver cell types in graft injury induced by cold storage and reperfusion. Insight into the cellular and molecular basis of these injuries will lead to the development of better intervention strategies, which is very important because graft dysfunction results in increased morbidity and enhances mortality rates. 7,8 Moreover, up to 30% of patients with graft dysfunction need retransplantation as early as within the first 3 months after transplantation, 2,7,8 which increases the demand on an already short pool of donor organs.According to morphological studies, cold preservation leads to injuries of nonparenchymal cells, whereas liver parenchymal cells appear well preserved. It is currently hypothesized that sinusoidal endothelial cell impairment, 9-11 activatio...

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“…The limited supply of organ donors has increasingly influenced the selection of candidates for liver transplantation, and is used at some institutions to justify restricting the availability of the procedure. 1 Although the exact magnitude of the organ deficit is not yet known, 2,3 the obvious gap between supply and need has stimulated the development of bioartificial liver assist devices, 4 utilization of living related liver donors, 5,6 use of non-heart beating donors, 7-9 and 18,19 or beyond 20 was followed by a flurry of confirmatory reports, 13,14,21,22 countered by descriptions of degraded results using geriatric livers. [23][24][25][26] Less has been written about the effect of donor sex on outcome after liver transplantation, although there is an extensive literature, recently summarized by Neugarten and Silbiger, 27 showing poorer results with kidney allografts from female donors.…”

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confidence: 99%

“…10 A more immediate impact on organ shortage already has come from the widespread use of livers from "marginal donors," as first documented by Makowka et al 11 and Pruim et al 12 The definition of a marginal donor has varied in different reports, and recently has included obesity. 13,14 Two potential risk factors-age and gender-are relevant with all donors, no matter what the other circumstances of death. Although it has long been thought that the liver is less affected than other organs by senescence, 15,16 poor experience with older donors in the original Denver series (including two who were 73 years of age) resulted in an upper donor age limitation of 45 years.…”

mentioning

confidence: 99%

“…Although it has long been thought that the liver is less affected than other organs by senescence, 15,16 poor experience with older donors in the original Denver series (including two who were 73 years of age) resulted in an upper donor age limitation of 45 years. 17 The demonstration that satisfactory livers could be obtained from donors well into the seventh decade of life 18,19 or beyond 20 was followed by a flurry of confirmatory reports, 13,14,21,22 countered by descriptions of degraded results using geriatric livers. [23][24][25][26] Less has been written about the effect of donor sex on outcome after liver transplantation, although there is an extensive literature, recently summarized by Neugarten and Silbiger, 27 showing poorer results with kidney allografts from female donors.…”

mentioning

confidence: 99%

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Effect of donor age and sex on the outcome of liver transplantation*1

et al. 1995

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We correlated donor and recipient factors with graft outcome in 436 adult patients who underwent 462 liver transplants. Donor variables analyzed were age, gender, ABO blood group, cause of death, length of stay in the intensive care unit, use of pressors or pitressin, need for cardiopulmonary resuscitation, terminal serum transaminases, and ischemia time. Recipient variables analyzed were age, gender, primary diagnosis, history of previous liver transplant, ABO blood group, cytotoxic antibody crossmatch, United Network for Organ Sharing (UNOS) status, and waiting time (except for the cross-match results, they were all known at the time of the operation). The endpoint of the analysis was graft failure, defined as patient death or retransplantation. Using multivariate analysis, graft failure was significantly associated with donor age, donor gender, previous liver transplantation, and UNOS 4 status of the recipient. The effect of donor age became evident only when they were older than 45 years. Livers from female donors yielded significantly poorer results, with 2-year graft survival of female to male 55% (95% CI, 45% to 67%); female to female, 64% (95% CI, 54% to 77%); male to male, 72% (95% CI, 66% to 78%); and male to female, 78% (95% CI, 70% to 88%). The only donors identified as questionable for liver procurement were old (≥60 years) women in whom the adverse age and gender factors were at least additive. However, rather than discard even these livers, in the face of an organ shortage crisis, their individualized use is suggested with case reporting in a special category.As of January 4, 1995, 37,751 transplant candidates were registered on the national waiting list operated by the United Network for Organ Sharing (UNOS), the agency that coordinates organ allocation in the United States. This was a 391% increase from the 9,632 waiting in December 1986. Of the 37,751 in 1995, 4,039 were liver candidates, up from 449 in 1987 (a 900% increase). The supply of all organ donors had undergone a marginal increase between 1988 and 1990 (from 4,085 to 4,514), but has remained relatively stable since then: 4,531 in 1991, 4,521 in 1992, 4,849 in 1993, and 4,891 in 1994. The limited supply of organ donors has increasingly influenced the selection of candidates for liver transplantation, and is used at some institutions to justify restricting the availability of the procedure. 1 Although the exact magnitude of the organ deficit is not yet known, 2,3 the obvious gap between supply and need has stimulated the development of bioartificial liver assist devices, 4 utilization of living related liver donors, 5,6 use of non-heart beating donors, 7-9 and 18,19 or beyond 20 was followed by a flurry of confirmatory reports, 13,14,21,22 countered by descriptions of degraded results using geriatric livers. [23][24][25][26] Less has been written about the effect of donor sex on outcome after liver transplantation, although there is an extensive literature, recently summarized by Neugarten and Silbiger, 27 showing poorer re...

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THE USE OF mARGINAL DONORS FOR LIVER TRANSPLANTATION A RETROSPECTIVE STUDY OF 365 LIVER DONORS 1,2

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O doador marginal: experiência de um centro de transplante de fígado

O doador marginal: experiência de um centro de transplante de fígado

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Effect of donor age and sex on the outcome of liver transplantation*1

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