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DCD in liver transplantation

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DCD
in
Liver
Transplanta0on


Pr
Olivier
Detry


Dpt
of
Abdominal
Surgery
and
Transplanta0on
 CHU
Liège,
University
of
Liège,
Belgium


(2)
(3)

DCD in liver transplantation

•  Increased risk of PNF

(4)

DCD in liver transplantation

•  Increased risk of PNF

•  Increased risk of ischemic bile duct lesions (IBDL)

•  Increased risk of post reperfusion syndrome

(5)

DCD in liver transplantation

•  Increased risk of PNF

•  Increased risk of ischemic bile duct lesions (IBDL)

•  Increased risk of post reperfusion syndrome

•  Decreased graft and patient survival

•  Increase risk of retransplantation

(6)

DCD in liver transplantation

•  Increased risk of PNF

•  Increased risk of ischemic bile duct lesions (IBDL)

•  Increased risk of post reperfusion syndrome

•  Decreased graft and patient survival

•  Increase risk of retransplantation

•  Interest?

(7)

Maastricht
DCD
categories


1:
Death
outside
hospital


2:
Failed
resuscita0on
in
hospital


3:
Planned
therapy
withdrawal


4:
Cardiac
arrest
in
a
DBD


“uncontrolled”

“controlled”

Kootstra
et
al.



(8)

Controlled DCD: WI

Withdrawal

Cardiac arrest

Death

Aortic Perfusion

(9)

Controlled DCD: WI

Withdrawal

Cardiac arrest

Death

Aortic Perfusion

2-10 min Surgery

(10)

Controlled DCD: WI

Withdrawal

Cardiac arrest

Death

Aortic Perfusion

2-10 min Surgery

Arterial pressure < 60, 50, 35 mmHg ? pO2 < 70, 65, 35% ?

Acirculatory phase

Withdrawal phase

(11)
(12)

Patients and Methods

-  Retrospective review of the whole Belgian experience in DCD-LT up

to 12/2007

- 58 controlled DCD liver transplantation

(56 Maastricht category III et 2 category IV)

-  All withdrawals in operative rooms

-  Center oriented allocation

-  No patient lost at follow-up

- Mean follow-up: 22 months

(13)

Patients and Methods

-  Retrospective review of the whole Belgian experience in DCD-LT up

to 12/2007

- 58 controlled DCD liver transplantation

(56 Maastricht category III et 2 category IV)

-  All withdrawals in operative rooms

-  Center oriented allocation

-  No patient lost at follow-up

- Mean follow-up: 22 months

(14)

Donors’ characteristics

Data (mean ± SEM) Range

Age (years) 44.6 ± 1.9 13 - 71 Female (%) 32.7 CPR (%) 25.8 Causes of death (n) Anoxia 14 Trauma 23 Cerebrovascular Accident 17 Other (euthanasia) 4 BMI (kg/m2) 24.5 ± 0.5 18 - 38

ICU stay (days) 4.8 ± 0.5 0 - 19

Urinary output (mL/day) 3,002 ± 266 980 - 8,450

Pressors (%) 44.8

Na (mmol/L) 142.3 ± 0.8 129 - 164

Total bilirubin (mg/dL) 0.53 ± 0.04 0.11 - 1.3

AST (U/L) 50.5± 5.7 10 - 300

(15)

Donors’ characteristics

Data (mean ± SEM) Range

Age (years) 44.6 ± 1.9 13 - 71 Female (%) 32.7 CPR (%) 25.8 Causes of death (n) Anoxia 14 Trauma 23 Cerebrovascular Accident 17 Other (euthanasia) 4 BMI (kg/m2) 24.5 ± 0.5 18 - 38

ICU stay (days) 4.8 ± 0.5 0 - 19

Urinary output (mL/day) 3,002 ± 266 980 - 8,450

Pressors (%) 44.8

Na (mmol/L) 142.3 ± 0.8 129 - 164

Total bilirubin (mg/dL) 0.53 ± 0.04 0.11 - 1.3

AST (U/L) 50.5± 5.7 10 - 300

(16)

Donors’ characteristics

Data (mean ± SEM) Range

Age (years) 44.6 ± 1.9 13 - 71 Female (%) 32.7 CPR (%) 25.8 Causes of death (n) Anoxia 14 Trauma 23 Cerebrovascular Accident 17 Other (euthanasia) 4 BMI (kg/m2) 24.5 ± 0.5 18 - 38

ICU stay (days) 4.8 ± 0.5 0 - 19

Urinary output (mL/day) 3,002 ± 266 980 - 8,450

Pressors (%) 44.8

Na (mmol/L) 142.3 ± 0.8 129 - 164

Total bilirubin (mg/dL) 0.53 ± 0.04 0.11 - 1.3

AST (U/L) 50.5± 5.7 10 - 300

(17)

Donors’ characteristics

Data (mean ± SEM) Range

Age (years) 44.6 ± 1.9 13 - 71 Female (%) 32.7 CPR (%) 25.8 Causes of death (n) Anoxia 14 Trauma 23 Cerebrovascular Accident 17 Other (euthanasia) 4 BMI (kg/m2) 24.5 ± 0.5 18 - 38

ICU stay (days) 4.8 ± 0.5 0 - 19

Urinary output (mL/day) 3,002 ± 266 980 - 8,450

Pressors (%) 44.8

Na (mmol/L) 142.3 ± 0.8 129 - 164

Total bilirubin (mg/dL) 0.53 ± 0.04 0.11 - 1.3

AST (U/L) 50.5± 5.7 10 - 300

(18)

Donors’ characteristics

Data (mean ± SEM) Range

Age (years) 44.6 ± 1.9 13 - 71 Female (%) 32.7 CPR (%) 25.8 Causes of death (n) Anoxia 14 Trauma 23 Cerebrovascular Accident 17 Other (euthanasia) 4 BMI (kg/m2) 24.5 ± 0.5 18 - 38

ICU stay (days) 4.8 ± 0.5 0 - 19

Urinary output (mL/day) 3,002 ± 266 980 - 8,450

Pressors (%) 44.8

Na (mmol/L) 142.3 ± 0.8 129 - 164

Total bilirubin (mg/dL) 0.53 ± 0.04 0.11 - 1.3

AST (U/L) 50.5± 5.7 10 - 300

(19)

Procurements - Transplantations

Data (mean ± SEM) Range

Heparin (%) 82.7

HTK / UW (n) 38 / 20

Graft allocation

Local /National/ International (n) 38 / 15 / 5

Procurement warm ischemia (min) 25.18 ± 2.2 10 - 109

Extubation – cardiac arrest (min) 14.75 ± 2.09 4 - 98 Cardiac arrest– aortic perfusion (min) 10.6 ± 0.84 4 - 38

(20)

Procurements - Transplantations

Data (mean ± SEM) Range

Heparin (%) 82.7

HTK / UW (n) 38 / 20

Graft allocation

Local /National/ International (n) 38 / 15 / 5

Procurement warm ischemia (min) 25.18 ± 2.2 10 - 109

Extubation – cardiac arrest (min) 14.75 ± 2.09 4 - 98 Cardiac arrest– aortic perfusion (min) 10.6 ± 0.84 4 - 38

(21)

Procurements - Transplantations

Data (mean ± SEM) Range

Heparin (%) 82.7

HTK / UW (n) 38 / 20

Graft allocation

Local /National/ International (n) 38 / 15 / 5

Procurement warm ischemia (min) 25.18 ± 2.2 10 - 109

Extubation – cardiac arrest (min) 14.75 ± 2.09 4 - 98 Cardiac arrest– aortic perfusion (min) 10.6 ± 0.84 4 - 38

(22)

Recipients

Data (mean ± SEM) Ranges

Age (years)

54.9 ± 1.5

10 - 70

MELD score

15.4 ± 1

6 - 37

Indications: cirrhosis

26

hepatocarcinoma

22

Status HU

5

Others

5

(23)

Recipients

Data (mean ± SEM) Ranges

Age (years)

54.9 ± 1.5

10 - 70

MELD score

15.4 ± 1

6 - 37

Indications: cirrhosis

26

hepatocarcinoma

22

Status HU

5

Others

5

(24)

Recipients

Data (mean ± SEM) Ranges

Age (years)

54.9 ± 1.5

10 - 70

MELD score

15.4 ± 1

6 - 37

Indications: cirrhosis

26

hepatocarcinoma

22

Status HU

5

Others

5

(25)

Recipients

Data (mean ± SEM) Ranges

Age (years)

54.9 ± 1.5

10 - 70

MELD score

15.4 ± 1

6 - 37

Indications: cirrhosis

26

hepatocarcinoma

22

Status HU

5

Others

5

(26)
(27)

Survivals


Univariate analysis

p

CIT > 6h Graft 0.04

Withdrawal > 15 min Death 0.02

(28)

Causes of graft loss and patient’s death

Causes of graft loss n Outcome Link to DCD donation

PNF 2 (3.4%) 1 death,

1 reTx

probable

Operative death 2 2 deaths possible

Hepatic artery thrombosis 2 1 death,

1 reTx

possible

ARDS, MOF 2 2 deaths possible

Diffuses intrahepatic stenoses 7 (12%) 1 death,

6 reTx°

highly probable

(29)

Causes of graft loss and patient’s death

Causes of graft loss n Outcome Link to DCD donation

PNF 2 (3.4%) 1 death,

1 reTx

probable

Operative death 2 2 deaths possible

Hepatic artery thrombosis 2 1 death,

1 reTx

possible

ARDS, MOF 2 2 deaths possible

Diffuses intrahepatic stenoses 7 (12%) 1 death,

6 reTx°

highly probable

(30)

Causes of graft loss and patient’s death

Causes of graft loss n Outcome Link to DCD donation

PNF 2 (3.4%) 1 death,

1 reTx

probable

Operative death 2 2 deaths possible

Hepatic artery thrombosis 2 1 death,

1 reTx

possible

ARDS, MOF 2 2 deaths possible

Diffuses intrahepatic stenoses 7 (12%) 1 death,

6 reTx°

highly probable

(31)

Causes of graft loss and patient’s death

Causes of graft loss n Outcome Link to DCD donation

PNF 2 (3.4%) 1 death,

1 reTx

probable

Operative death 2 2 deaths possible

Hepatic artery thrombosis 2 1 death,

1 reTx

possible

ARDS, MOF 2 2 deaths possible

Diffuses intrahepatic stenoses 7 (12%) 1 death,

6 reTx°

highly probable

(32)

Causes of graft loss and patient’s death

Causes of graft loss n Outcome Link to DCD donation

PNF 2 (3.4%) 1 death,

1 reTx

probable

Operative death 2 2 deaths possible

Hepatic artery thrombosis 2 1 death,

1 reTx

possible

ARDS, MOF 2 2 deaths possible

Diffuses intrahepatic stenoses 7 (12%) 1 death,

6 reTx°

highly probable

(33)

Causes of graft loss and patient’s death

Causes of graft loss n Outcome Link to DCD donation

PNF 2 (3.4%) 1 death,

1 reTx

probable

Operative death 2 2 deaths possible

Hepatic artery thrombosis 2 1 death,

1 reTx

possible

ARDS, MOF 2 2 deaths possible

Diffuses intrahepatic stenoses 7 (12%) 1 death,

6 reTx°

highly probable

(34)
(35)

Biliary complications

•  7 (12%) graft losses (1 death, 6 reTx)

•  12 (20%) symptomatic bile duct lesions treated

by endoscopy or surgery

•  Symptomatic biliary lesions in liver grafts that

survived 3 months: 19/50 (39%)

(36)

Conclusions

•  Controlled DCD liver transplantation:

- increased risk of ischemic cholangiopathy

- increased risk of reTx and death

•  Warm ischemia < 30 min

•  Cold ischemia < 6 hr

(37)

RESULTS
OF
LIVER
TRANSPLANTATION
(LT)
FROM


CONTROLLED
DONATION
AFTER
CARDIAC
DEATH
(DCD)


DONORS:
UNIVERSITY
OF
LIEGE
EXPERIENCE


35 DCD liver transplantations (including one combined LKTx)

from 2003 to 1/2010

(38)

DCD‐LT
at
the
University
of
Liège


0
 2
 4
 6
 8
 10
 12
 14
 2003
 2004
 2005
 2006
 2007
 2008
 2009


(39)
(40)

Procurements - Transplantations

Data (extremes)

Heparin pre withdrawal (%) 92%

HTK/UW (%) 83%

DWIT (min) 20.5 (13 - 39)

Withdrawal phase (min)

11.5 (3 - 30)

Acirculatory phase (min)

8.9 (4 - 15)

Procurement time (min) 24.4 (17 - 75)

CIT (min) 273.5 (105 -576)

(41)

Procurements - Transplantations

Data (extremes)

Heparin pre withdrawal (%) 92%

HTK/UW (%) 83%

DWIT (min) 20.5 (13 - 39)

Withdrawal phase (min)

11.5 (3 - 30)

Acirculatory phase (min)

8.9 (5 - 15)

Procurement time (min) 24.4 (17 - 75)

CIT (min) 273.5 (105 -576)

(42)

Procurements - Transplantations

Data (extremes)

Heparin pre withdrawal (%) 92%

HTK/UW (%) 83%

DWIT (min) 20.5 (13 - 39)

Withdrawal phase (min)

11.5 (3 - 30)

Acirculatory phase (min)

8.9 (5 - 15)

Procurement time (min) 24.4 (17 - 75)

CIT (min) 273.5 (105 -576)

(43)

Procurements - Transplantations

Data (extremes)

Heparin pre withdrawal (%) 92%

HTK/UW (%) 83%

DWIT (min) 20.5 (13 - 39)

Withdrawal phase (min)

11.5 (3 - 30)

Acirculatory phase (min)

8.9 (4 - 15)

Procurement time (min) 24.4 (17 - 75)

CIT (min) 273.5 (105 -576)

(44)

Procurements - Transplantations

Data (extremes)

Heparin pre withdrawal (%) 92%

HTK/UW (%) 83%

DWIT (min) 20.5 (13 - 39)

Withdrawal phase (min)

11.5 (3 - 30)

Acirculatory phase (min)

8.9 (4 - 15)

Procurement time (min) 24.4 (17 - 75)

CIT (min) 273.5 (105 -576)

(45)

Recipients

Mean (extremes) Age (years) 55.5 (25-70) Female (%) 14.2 Liver disease (n) HCC 18 Cirrhosis 16 Other 1 MELD 16.3 (6-40)

(46)

Recipients

Mean (extremes) Age (years) 55.5 (25-70) Female (%) 14.2 Liver disease (n) HCC 18 Cirrhosis 16 Other 1 MELD 16.3 (6-40)

(47)

Post transplant data

Data or mean (extremes)

Peak bilirubin (mg/dL) 53 ( 3.6 - 154.1)

Peak AST (UI/mL) 2,453 (285 - 21,928)

PNF (n) 0 Retransplantation (n) 0 Biliary complications endoscopy 4 hepatico-jejunostomy 3 Recipient’s death 7

Sarcoma 2 (1 transmitted, 1 de novo)

Recurrent HCC 3

(48)

Post transplant data

Data or mean (extremes)

Peak bilirubin (mg/dL) 53 ( 3.6 - 154.1)

Peak AST (UI/mL) 2,453 (285 - 21,928)

PNF (n) 0 Retransplantation (n) 0 Biliary complications endoscopy 4 hepatico-jejunostomy 3 Recipient’s death 7

Sarcoma 2 (1 transmitted, 1 de novo)

Recurrent HCC 3

(49)

Post transplant data

Data or mean (extremes)

Peak bilirubin (mg/dL) 53 ( 3.6 - 154.1)

Peak AST (UI/mL) 2,453 (285 - 21,928)

PNF (n) 0 Retransplantation (n) 0 Biliary complications endoscopy 4 hepatico-jejunostomy 3 Recipient’s death 7

Sarcoma 2 (1 transmitted, 1 de novo)

Recurrent HCC 3

(50)

Post transplant data

Data or mean (extremes)

Peak bilirubin (mg/dL) 53 ( 3.6 - 154.1)

Peak AST (UI/mL) 2,453 (285 - 21,928)

PNF (n) 0 Retransplantation (n) 0 Biliary complications endoscopy 4 hepatico-jejunostomy 3 Recipient’s death 7

Sarcoma 2 (1 transmitted, 1 de novo)

Recurrent HCC 3

(51)

Post transplant data

Data or mean (extremes)

Peak bilirubin (mg/dL) 53 ( 3.6 - 154.1)

Peak AST (UI/mL) 2,453 (285 - 21,928)

PNF (n) 0 Retransplantation (n) 0 Biliary complications endoscopy 4 hepatico-jejunostomy 3 Recipient’s death 7

Sarcoma 2 (1 transmitted, 1 de novo)

Recurrent HCC 3

(52)
(53)

Correlations: AST - CI

p < 0.001 Linear Regression 95% Confidence Interval 104.00 232.00 360.00 488.00 616.00 CI (min) 0.00 1024.00 2048.00 3072.00 4096.00 5120.00 6144.00 7168.00 8192.00 9216.00 10240.00 11264.00 12288.00 13312.00 14336.00 15360.00 16384.00 17408.00 18432.00 19456.00 20480.00 21504.00

(54)

Correlations: AST - Donor’s age

Linear Regression 95% Confidence Interval 25.00 33.00 41.00 49.00 57.00 65.00 73.00 81.00 Age 0.00 2048.00 4096.00 6144.00 8192.00 10240.00 12288.00 14336.00 16384.00 18432.00 20480.00 22528.00 p = NS

(55)

Age – peak AST

Mean donor age: 56.6 years (27 – 79 )

0
 500
 1000
 1500
 2000
 2500
 3000
 3500
 4000
 4500
 <59
 >60
 Age Peak AST

p = NS

(56)

Age – peak AST

p = 0.056

Age CI (min) 0
 60
 120
 180
 240
 300
 360
 <
59
 >
60


(57)

DCD‐LT
at
the
University
of
Liège


0
 2
 4
 6
 8
 10
 12
 14
 2003
 2004
 2005
 2006
 2007
 2008
 2009


(58)

LT
at
the
University
of
Liège


0
 5
 10
 15
 20
 25
 30
 35
 40
 DBD‐LT
 LD‐LT
 DCD‐LT


(59)

Organ
dona0on
at
the
University
of
Liège


21
 22
 26
 33
 25
 30
 27
 43
 29
 33
 1
 3
 2
 7
 8
 12
 17
 0
 10
 20
 30
 40
 50
 60
 DCD
 DBD


(60)

Conclusions

•  DCD-LT may provide a significant increase of

liver grafts, with good results if:

(61)

Conclusions

•  DCD-LT may provide a significant increase of

liver grafts, with good results if:

- procurement warm ischemia < 45 min

- cold ischemia < 6 h

(62)

Conclusions

•  DCD-LT may provide a significant increase of

liver grafts, with good results if:

- procurement warm ischemia < 45 min

- cold ischemia < 6 h

(63)

Conclusions

•  DCD-LT may provide a significant increase of

liver grafts, with good results if:

- procurement warm ischemia < 45 min

- cold ischemia < 6 h

- stable patient (reperfusion syndrome)

- easy case

(64)

Conclusions

•  DCD-LT may provide a significant increase of

liver grafts, with good results if:

- procurement warm ischemia < 45 min

- cold ischemia < 6 h

- stable patient (reperfusion syndrome)

- easy case

(65)

Conclusions

•  DCD-LT may provide a significant increase of

liver grafts, with good results if:

- procurement warm ischemia < 45 min

- cold ischemia < 6 h

- stable patient (reperfusion syndrome)

- easy case

- experienced procurement and transplant surgeon

•  DCD does not decrease the rate of cadaveric

procurement

(66)

Conclusions

•  DCD-LT may provide a significant increase of

liver grafts, with good results if:

- procurement warm ischemia < 45 min

- cold ischemia < 6 h

- stable patient (reperfusion syndrome)

- easy case

- experienced procurement and transplant surgeon

•  DCD does not decrease the rate of cadaveric

procurement

•  DCD donors > 60 y of age should be considered

with a very short CI (4 hours)

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