Liver Donation After Cardiac Death Can Yield Good Outcomes

Daniel M. Keller, PhD

April 20, 2011

April 20, 2011 (Berlin, Germany) — Liver donation after cardiac death appears to be feasible and to result in outcomes equivalent to using donor livers after brain death, but it does present some logistical problems and does not seem to increase the pool of organs for transplantation, according to a study presented here at the European Association for the Study of the Liver (EASL) 46th Annual Meeting.

Wayel Jassem, MD, consultant surgeon in the Institute of Liver Studies at King's College Hospital in London, United Kingdom, presented results of this single-center retrospective analysis of a series of 186 donations after cardiac death (DCD) occurring between May 2001 and October 2010.

The overall actuarial patient survival at 1, 3, and 5 years was 89.9%, 85.6%, and 83.6%, respectively. At the same time points, graft survival was 85.8%, 80.8%, and 76.6%, respectively. Median follow-up was 24 months (range, 1 - 116 months), 21 patients died, and 31 grafts were lost.

Seven patients (3.7%) had primary nonfunction of the graft. Four patients (2.3%) developed diffuse primary ischemic cholangiopathy (2 mild, 2 severe), but none of the 4 required retransplantation. Biopsy-proven rejection occurred in 25.1% of patients, and all responded well to steroids. The median hospital stay was 18 days (range, 7 - 163 days). The International Normalized Ratio and serum bilirubin level on day 5 were associated with the occurrence of primary nonfunction (P ≤ .05).

The median age of the donors was 40 years (range, 8 - 79 years), and donor warm ischemia time was 15 minutes (range, 7 - 31 minutes). The median cold ischemia time was 7.5 hours (range, 4 - 15 hours). Fifty-four of the recipients were women, and 132 were men, with a mean Model for End-Stage Liver Disease score of 15 (range, 4 - 41). Most of the recipients had a diagnosis of noncholestatic cirrhosis and were stable and admitted for transplant from home. Nineteen of the recipients were pediatric patients.

One difference between the use of donor organs from patients after brain death and DCD is the longer warm ischemia time with DCD. A direct association was found between donor warm ischemia time and cholangiopathy (P ≤ .05).

Overall, graft and recipient survival are very similar. "The only thing is, the primary nonfunction is slightly higher [with DCD], so the primary nonfunction is about 4%, and the cadaveric [brain death] liver is about 1[%]," Dr. Jassem said. "And the other new thing about non–heart beating livers is the ischemic cholangiopathy...we had about 2.1%. It is generalized damage to the bile duct, and we don't know why."

He said many centers stopped doing DCD liver transplants because of high rates of ischemic cholangiopathy. Even considering this difference, the complication rate with DCD at his institution was quite low. Patient survival is "very much similar to the [rate] you find in cadaveric transplant," he told Medscape Medical News.

As they gained experience over time, the transplant surgeons at King's College have become more confident in using DCD livers, with a single caveat. "We use them [now] for very, very stable patients, so patients not very, very sick," Dr. Jassem said. In addition, they try to avoid using these organs in recipients who already have bile duct diseases.

The aim of using DCD organs was to increase the supply of donor organs. Unfortunately, so far, it has not worked out. "Nobody showed that these organs can increase the number of donations," Dr. Jassem said. Using DCD organs requires significant effort and resources for mobilizing to prepare the recipient and to harvest the liver immediately after cardiac death, in contrast to the more orderly pace seen when a donor has undergone brain death and is on life support. Dr. Jassem suggested that future efforts go into research in the area of ischemia and organ perfusion to improve outcomes in DCD.

Speaking at a news conference, Patrizia Burra, MD, PhD, head of the Multivisceral Transplant Unit and chief of the Cell Therapy Regional Centre for Metabolic Liver Diseases at Padua University Hospital in Italy, said Dr. Jassem's study is "very important" because the series that is reported is very large, consisting of 186 patients.

Addressing the logistical problems of DCD, she said, "In this case, the difference between [cardiac death and] brain death is that you have really to work...very, very rapidly to get the organs." Even with a warm ischemic time averaging 15 minutes, organ quality diminishes quickly. "That's why this [procedure] is not well developed in all the countries at the present time in Europe," she explained.

With proper systems in place, however, DCD can be feasible. "The present data is that even with the non–heart beating donor, the transplant has a survival rate that was comparable to that with standard donors, so that's really convincing," commented Daniele Prati, MD, director of the Department of Transfusion Medicine and Hematology at the Ospedale Alessandro Manzoni in Lecco, Italy.

Dr. Jassem, Dr. Burra, and Dr. Prati have disclosed no relevant financial relationships. Dr. Jassem's study did not receive any outside support. Dr. Burra and Dr. Prati had no involvement in the study.

European Association for the Study of the Liver (EASL) 46th Annual Meeting. Presented March 31, 2011.

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