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Preserved 2-y Liver Transplant Outcomes Following Simultaneous Thoracoabdominal DCD Organ Procurement Despite Effects
Steven A Wisel1, Justin A Steggerda1, Carrie Thiessen2
1Department of Surgery, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA.
Insights
Thoracoabdominal donation after circulatory determination of death (TA-DCD) liver transplants show excellent graft survival, comparable to other DCD methods. Normothermic regional perfusion (NRP) procurement minimizes organ discard, optimizing utilization.
Area of Science:
- Transplantation immunology and organ procurement strategies.
- Cardiovascular and hepatobiliary surgery outcomes research.
Background:
- Current donation after circulatory determination of death (DCD) heart procurement methods, including direct procurement and machine perfusion or thoracoabdominal normothermic regional perfusion (NRP), yield excellent heart transplant outcomes.
- The impact of thoracoabdominal DCD (TA-DCD) heart procurement on liver allograft outcomes and utilization remains incompletely understood.
Purpose of the Study:
- To evaluate the impact of TA-DCD heart procurement on liver allograft utilization and outcomes.
- To compare liver transplant outcomes from TA-DCD donors with abdominal-only DCD (A-DCD) and donation after brain death (DBD) donors.
Main Methods:
- Retrospective analysis of 160 simultaneous heart and liver TA-DCD donors from December 2019 to July 2021 using the UNOS/OPTN database.
- Liver outcomes stratified by heart procurement technique (direct procurement/machine perfusion vs. NRP) and compared with A-DCD (n=1332) and DBD (n=12891) liver transplants.
- Kaplan-Meier methods with log-rank testing assessed patient and graft survival; organ discard rates were evaluated.
Main Results:
- 133 of 160 TA-DCD livers were transplanted. TA-DCD donors were younger and had lower BMI than A-DCD and DBD donors.
- TA-DCD livers demonstrated equivalent patient survival (P=.893) and superior graft survival (P=.009) compared to A-DCD.
- TA-DCD livers had higher discard rates due to prolonged warm ischemia time (37.0%) compared to A-DCD (20.5%) and DBD (0.5%). Direct procurement/machine perfusion had higher discard rates (18.5%) than NRP (7.4%).
Conclusions:
- Liver transplantation following TA-DCD donation yields equivalent patient survival and excellent graft survival.
- Normothermic regional perfusion (NRP) procurement is associated with the lowest organ discard rates in TA-DCD, suggesting it as an optimal strategy to maximize organ utilization.
Background:
Current techniques for donation after circulatory determination of death (DCD) heart procurement, through either direct procurement and machine perfusion or thoracoabdominal normothermic regional perfusion (NRP), have demonstrated excellent heart transplant outcomes. However, the impact of thoracoabdominal DCD (TA-DCD) heart procurement on liver allograft outcomes and utilization is poorly understood.
Methods:
One hundred sixty simultaneous heart and liver DCD donors were identified using the United Network for Organ Sharing/Organ Procurement and Transplantation Network database between December 2019 and July 2021. Liver outcomes from TA-DCD donors were stratified by heart procurement technique and evaluated for organ utilization, graft survival, and patient survival. Results were compared with abdominal-only DCD (A-DCD; n = 1332) and donation after brain death (DBD; n = 12 891) liver transplants during the study interval. Kaplan-Meier methods with log-rank testing were used to evaluate patient and graft survival.
Results:
One hundred thirty-three of 160 livers procured from TA-DCD donors proceeded to transplant. TA-DCD donors were younger (mean 28.26 y; P < 0.0001) with lower body mass index (mean 26.61; P < 0.0001) than A-DCD and DBD donors. TA-DCD livers had equivalent patient survival ( P = 0.893) and superior graft survival (P = 0.009) compared with A-DCD. TA-DCD livers had higher rates of organ discard for long warm ischemia time (37.0%) than A-DCD (20.5%) and DBD (0.5%; P < 0.0001), with direct procurement and machine perfusion procurements leading to a higher discard rate (18.5%) than NRP procurements (7.4%).
Conclusions:
Liver transplants after TA-DCD donation demonstrated equivalent patient outcomes and excellent graft outcomes. NRP procurements resulted in the lowest rate of organ discard after DCD donation and may represent an optimal strategy to maximize organ utilization.
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