Use of preprocurement biopsy in donation after circulatory death liver transplantation

Abstract

We perform routine preprocurement image‐guided percutaneous liver biopsies on potential donation after circulatory death (DCD) liver donors. The purpose of this study was to examine the impact of preprocurement liver biopsy on the use of livers from DCD donors. We retrospectively reviewed demographics, liver histology, and disposition of DCD liver donors within a single organ procurement organization (OPO) who underwent preprocurement liver biopsy from January 2000 through December 2019. A total of 212 potential donors underwent prerecovery biopsy. No donors were lost as a result of complications of biopsy. Of these, 183 (86.3%) had acceptable biopsies: 146 (79.8%) were successfully transplanted and 37 (20.2%) were deemed not suitable for transplant. In contrast, of 120 DCD livers recovered with the intent to transplant that were not biopsied prior to recovery, 59 (49.2%) were successfully transplanted, and 61 (50.8%) were deemed not suitable for transplant. A total of 14 donors were ruled out for transplant based on prerecovery histology. Successfully transplanted livers that underwent preprocurement biopsy were more likely to come from donors aged older than 50 years or with body mass index more than 30 kg/m2 compared with successfully transplanted livers without a prerecovery biopsy. Biopsy excluded 6.6% of DCD donor livers for transplant prior to recovery and facilitated the successful recovery and transplant of two‐thirds of potential DCD donor livers. Livers intended for transplant at the time of recovery that did not undergo preprocurement biopsy were more likely to not be recovered or to be discarded. Preprocurement biopsy provides additional histologic information prior to deploying resources and helps to identify usable livers that might otherwise be declined for transplant. Consideration of liver biopsy in this group benefits OPOs and transplant centers by maximizing organ use and optimizing resource deployment.

DCD Hepatitis C Virus–positive Donor Livers Can Achieve Favorable Outcomes With Liver Transplantation and Are Underutilized

“…Recently, an OPO reported their practice of premortem biopsies for DCD donors. 12 They found that premortem biopsy excluded 6.6% of DCD donors from liver donors. However, several points may warrant emphasis before premortem biopsies are considered for HCV-positive DCD donors.…”

“…Second, to use premortem biopsies, a long-standing collaborative relationship is required among the OPO, donor hospitals within donor service area, and transplant centers. 12 Therefore, with the more widespread sharing of DCD liver grafts outside of those transplant centers, the complexity of decision-making on whether liver grafts are warranted for biopsy and their allocation may increase. Finally, although the study suggests that premortem biopsy can help optimize human and equipment resources from an OPO standpoint, 12 premortem biopsy requires donor support specialists in working with families of potential donors, qualified local practitioners to perform the biopsy, and pathologists to evaluate it.…”

“…12 Therefore, with the more widespread sharing of DCD liver grafts outside of those transplant centers, the complexity of decision-making on whether liver grafts are warranted for biopsy and their allocation may increase. Finally, although the study suggests that premortem biopsy can help optimize human and equipment resources from an OPO standpoint, 12 premortem biopsy requires donor support specialists in working with families of potential donors, qualified local practitioners to perform the biopsy, and pathologists to evaluate it. Although premortem biopsy for DCD donors allows transplant centers to identify usable liver grafts for transplantation, further studies may be warranted to clarify its applicability and the indication criteria.…”

“…However, assessment of fibrosis among HCV-positive DCD donors is more challenging because intraoperative liver biopsy cannot commence until after the patient is pronounced dead, with a few exceptions. 12 Because biopsies are usually not performed until cross-clamp is achieved in DCD LT, the time allotted for obtaining a biopsy and awaiting its results prolongs cold ischemia time (CIT). Recently, Narasimman et al 13 reported that, although liver fibrosis on donor biopsy increased the rate of graft discard, it did not compromise transplant outcomes.…”

Improving DCD liver utilization by challenging the status quo

“…In this issue of Liver Transplantation , Bolognese et al [ 6 ] describe a novel method for potentially improving DCD liver utilization. This article details a single organ procurement organization (OPO) experience with pre‐recovery liver biopsy in potential DCD donors, and the central finding of the study is that the availability of biopsy data promoted improved utilization of DCD livers.…”