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Liver transplantation following donation after cardiac death: an analysis using matched pairs
James K Pine1, Amer Aldouri, Alistair L Young
1Department of Hepatobiliary/Transplant Surgery, St. James's University Hospital, Beckett Street, United Kingdom.
Insights
Grafts from donation after cardiac death (DCD) donors show higher complication rates like biliary strictures and hepatic artery stenosis compared to donation after brain death (DBD) donors. Despite poorer outcomes, DCD grafts are valuable with careful management.
Area of Science:
- Transplantation Surgery
- Organ Donation
- Hepatology
Background:
- Donation after cardiac death (DCD) liver grafts are crucial for increasing organ availability.
- Concerns exist regarding potential graft dysfunction due to warm ischemia in DCD donors.
- Comparing DCD and donation after brain death (DBD) outcomes is essential for optimizing liver transplantation.
Purpose of the Study:
- To compare the outcomes of liver transplantation using DCD grafts versus DBD grafts.
- To evaluate graft survival, primary non-function (PNF), and complication rates between DCD and DBD recipients.
- To assess the impact of warm ischemia on DCD graft function and patient outcomes.
Main Methods:
- A retrospective comparison of 39 DCD liver grafts with 39 case-matched DBD grafts.
- Matching was based on variables significantly impacting mortality to ensure similar predictive risk.
- Key outcomes analyzed included patient/graft survival, PNF, nonanastomotic biliary strictures (NABS), and hepatic artery stenosis (HAS).
Main Results:
- DCD grafts constituted 6.1% of all liver transplants in the study period.
- Higher incidences of NABS (20.5%) and HAS (12.8%) were observed in the DCD group compared to the DBD group (0% for both).
- One-year (79.5% vs. 97.4%) and three-year (63.6% vs. 97.4%) graft survival, and three-year patient survival (68.2% vs. 100%) were significantly lower in the DCD group.
Conclusions:
- DCD liver grafts are associated with significantly poorer graft and patient survival rates and increased complications like NABS and HAS.
- NABS and HAS in DCD recipients are likely attributable to warm ischemia and potential arterial injury during retrieval.
- Despite challenges, DCD grafts remain a valuable resource, with acceptable outcomes achievable through careful donor/recipient selection, ischemia minimization, and postoperative care.
Abstract:
Grafts from donation after cardiac death (DCD) donors are used to increase the number of organs available for liver transplantation. There is concern that warm ischemia may impair graft function. We compared our DCD recipients with a case-matched group of donation after brain death (DBD) recipients. Between January 2002 and April 2008, 39 DCD grafts were transplanted. These were matched with 39 DBD recipients on the basis of identified variables that had a significant impact on mortality. These were used to individually match DCD and DBD patients with similar predictive mortality. We compared patient/graft survival, primary non-function (PNF), and rates of complications. Of all liver transplants, 6.1% were DCD grafts. PNF occurred twice in the DCD group. The incidence of nonanastomotic biliary strictures (NABS; 20.5% versus 0%, P = 0.005) and hepatic artery stenosis (HAS; 12.8% versus 0%, P = 0.027) in the DCD group was higher. One-year (79.5% versus 97.4%, P = 0.029) and 3-year (63.6% versus 97.4%, P = 0.001) graft survival was lower in the DCD group. Three-year patient survival was also lower (68.2% versus 100%, P < 0.0001). Our study is the first to use case-matched patients and compare groups with similar predictive mortality. There was a higher incidence of NABS and HAS in the DCD group. NABS were likely a result of warm ischemia. HAS may have been due to ischemia or arterial injury during retrieval. The DCD group had significantly poorer outcomes, but DCD grafts remain a valuable resource. With careful donor/recipient selection, minimization of ischemia, and good postoperative care, acceptable results can be achieved.
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