Transplantation of Declined Liver Allografts Following Normothermic Ex-Situ Evaluation

Abstract

These authors contributed equally to the study.This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.The demand for liver transplantation (LT) exceeds supply, with rising waiting list mortality. Utilization of high-risk organs is low and a substantial number of procured livers are discarded. We report the first series of five transplants with rejected livers following viability assessment by normothermic machine perfusion of the liver (NMP-L). The evaluation protocol consisted of perfusate lactate, bile production, vascular flows, and liver appearance. All livers were exposed to a variable period of static cold storage prior to commencing NMP-L. Four organs were recovered from donors after circulatory death and rejected due to prolonged donor warm ischemic times; one liver from a brain-death donor was declined for high liver function tests (LFTs). The median (range) total graft preservation time was 798 (range 724-951) min. The transplant procedure was uneventful in every recipient, with immediate function in all grafts. The median inhospital stay was 10 (range 6-14) days. At present, all recipients are well, with normalized LFTs at median follow-up of 7 (range 6-19) months. Viability assessment of high-risk grafts using NMP-L provides specific information on liver function and can permit their transplantation while minimizing the recipient risk of primary graft nonfunction. This novel approach may increase organ availability for LT.

Normothermic machine perfusion of donor livers without the need for human blood products

“…Normothermic machine perfusion (NMP) is a technique whereby human donor livers are perfused ex situ at 37°C. This technique can be used for the entire period of preservation, as is currently being evaluated in a clinical trial by Friend et al in Oxford, and for viability assessment of the organ prior to transplantation . In this manner, only well‐functioning organs are transplanted, including those that initially may have been declined for transplantation.…”

Liver Grafts From Donors After Circulatory Death on Regional Perfusion With Extended Warm Ischemia Compared With Donors After Brain Death

“…Although serum lactate is considered to be a marker of adequate perfusion and hepatic clearance, these groups have placed little importance on this factor, probably because its concentration during NRP may be altered by reflux from extra‐abdominal regions . Recent studies on normothermic machine perfusion have used serum lactate levels for ex situ evaluation . In our study, although levels exceeded the above‐mentioned limits, ALT did not exhibit a clear relationship to the transplant outcomes.…”

Organ Preservation into the 2020s: The Era of Dynamic Intervention

“…There was also no advantage to be gained from using normothermic perfusion in terms of any major outcome measure, such as graft or patient survival or frequency of biliary complications. Mergental et al [137] reported liver transplants after a period of normothermic perfusion to assess the viability of the rejected livers. They used these livers after a variable period of cold storage and reported encouraging results, with an average hospital stay of 10 days and graft survival in all recipients.…”