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Torri F, Balzano E, Melandro F, Maremmani P, Bertini P, Lo Pane P, Masini M, Rotondo MI, Babboni S, Del Turco S, Antonelli S, De Tata V, Biancofiore G, Guarracino F, Paolicchi A, De Simone P, Basta G, Ghinolfi D. Sequential Normothermic Regional Perfusion and End-ischemic Ex Situ Machine Perfusion Allow the Safe Use of Very Old DCD Donors in Liver Transplantation. Transplantation 2024; 108:1394-1402. [PMID: 38467592 DOI: 10.1097/tp.0000000000004963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
BACKGROUND In Italy, 20 min of continuous, flat-line electrocardiogram are required for death declaration. Despite prolonged warm ischemia time, Italian centers reported good outcomes in controlled donation after circulatory death (cDCD) liver transplantation by combining normothermic regional and end-ischemic machine perfusion (MP). The aim of this study was to evaluate the safety and feasibility of the use of septuagenarian and octogenarian cDCD donors with this approach. METHODS All cDCD older than 70 y were evaluated during normothermic regional perfusion and then randomly assigned to dual hypothermic or normothermic MP. RESULTS In the period from April 2021 to December 2022, 17 cDCD older than 70 y were considered. In 6 cases (35%), the graft was not considered suitable for liver transplantation, whereas 11 (65%) were evaluated and eventually transplanted. The median donor age was 82 y, being 8 (73%) older than 80. Median functional warm ischemia and no-flow time were 36 and 28 min, respectively. Grafts were randomly assigned to ex situ dual hypothermic oxygenated MP in 6 cases (55%) and normothermic MP in 5 (45%). None was discarded during MP. There were no cases of primary nonfunction, 1 case of postreperfusion syndrome (9%) and 2 cases (18%) of early allograft dysfunction. At a median follow-up of 8 mo, no vascular complications or ischemic cholangiopathy were reported. No major differences were found in terms of postoperative hospitalization or complications based on the type of MP. CONCLUSIONS The implementation of sequential normothermic regional and end-ischemic MP allows the safe use of very old donation after circulatory death donors.
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Affiliation(s)
- Francesco Torri
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Hospital, Pisa, Italy
| | - Emanuele Balzano
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Hospital, Pisa, Italy
| | - Fabio Melandro
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Hospital, Pisa, Italy
| | - Paolo Maremmani
- Department of Anesthesia and Critical Care Medicine, University of Pisa Hospital, Pisa, Italy
| | - Pietro Bertini
- Department of Anesthesia and Critical Care Medicine, University of Pisa Hospital, Pisa, Italy
| | - Paolo Lo Pane
- Local Transplant Authority AUSL 6-Area Vasta Nord-Ovest, Livorno, Italy
| | - Matilde Masini
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa Hospital, Pisa, Italy
| | | | - Serena Babboni
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Serena Del Turco
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Stefano Antonelli
- Local Transplant Authority, Gabriele Monasterio Fundation, Del Cuore Hospital, Massa, Italy
| | - Vincenzo De Tata
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa Hospital, Pisa, Italy
| | | | - Fabio Guarracino
- Department of Anesthesia and Critical Care Medicine, University of Pisa Hospital, Pisa, Italy
| | - Aldo Paolicchi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa Hospital, Pisa, Italy
| | - Paolo De Simone
- Department of Endocrine and Metabolic Surgery and Transplantation, University of Pisa, Pisa, Italy
| | - Giuseppina Basta
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Davide Ghinolfi
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Hospital, Pisa, Italy
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Cillo U, Carraro A, Avolio AW, Cescon M, Di Benedetto F, Giannelli V, Magistri P, Nicolini D, Vivarelli M, Lanari J. Immunosuppression in liver transplant oncology: position paper of the Italian Board of Experts in Liver Transplantation (I-BELT). Updates Surg 2024; 76:725-741. [PMID: 38713396 DOI: 10.1007/s13304-024-01845-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 07/31/2023] [Indexed: 05/08/2024]
Abstract
Liver transplant oncology (TO) represents an area of increasing clinical and scientific interest including a heterogeneous group of clinical-pathological settings. Immunosuppressive management after LT is a key factor relevantly impacting result. However, disease-related guidance is still lacking, and many open questions remain in the field. Based on such a substantial lack of solid evidences, the Italian Board of Experts in Liver Transplantation (I-BELT) (a working group including representatives of all national transplant centers), unprecedently promoted a methodologically sound consensus conference on the topic, based on the GRADE approach. The group final recommendations are herein presented and commented. The 18 PICOs and Statements and their levels of evidence and grades of recommendation are reported and grouped into seven areas: (1) risk stratification by histopathological and bio-molecular parameters and role of mTORi post-LT; (2) steroids and HCC recurrence; (3) management of immunosuppression when HCC recurs after LT; (4) mTORi monotherapy; (5) machine perfusion and HCC recurrence after LT; (6) physiopathology of tumor-infiltrating lymphocytes and immunosuppression, the role of inflammation; (7) immunotherapy in liver transplanted patients. The interest in mammalian targets of rapamycin inhibitors (mTORi), for steroid avoidance and the need for a reduction to CNI exposure emerged from the consensus process. A selected list of unmet needs prompting further investigations have also been developed. The so far heterogeneous and granular approach to immunosuppression in oncologic patients deserves greater efforts for a more standardized therapeutic response to the different clinical scenarios. This consensus process makes a first unprecedented step in this direction, to be developed on a larger scale.
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Affiliation(s)
- Umberto Cillo
- Department of Surgical, Oncological and Gastroenterological Sciences, General Surgery 2 Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Padua University Hospital, Via Giustiniani 2, 34128, Padua, PD, Italy.
| | - Amedeo Carraro
- Liver Transplant Unit, Department of Surgery and Oncology, University Hospital Trust of Verona, Verona, Italy
| | - Alfonso W Avolio
- Department of General Surgery and Liver Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Matteo Cescon
- General Surgery and Transplantation Unit, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria-Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Fabrizio Di Benedetto
- Hepatopancreatobiliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Valerio Giannelli
- Liver Unit, Department of Liver Transplant, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Paolo Magistri
- Hepatopancreatobiliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Daniele Nicolini
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Jacopo Lanari
- Department of Surgical, Oncological and Gastroenterological Sciences, General Surgery 2 Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Padua University Hospital, Via Giustiniani 2, 34128, Padua, PD, Italy
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3
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De Goeij FHC, De Meijer V, Mergental H, Guarrera JV, Asthana S, Ghinolfi D, Boteon YL, Selzner N, Kalisvaart M, Pulitano C, Sonnenday C, Martins PN, Berlakovich G, Schlegel A. Challenges With the Implementation of Machine Perfusion in Clinical Liver Transplantation. Transplantation 2024; 108:1296-1307. [PMID: 38057969 DOI: 10.1097/tp.0000000000004872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
Dynamic organ preservation is a relatively old technique which has regained significant interest in the last decade. Machine perfusion (MP) techniques are applied in various fields of solid organ transplantation today. The first clinical series of ex situ MP in liver transplantation was presented in 2010. Since then, the number of research and clinical applications has substantially increased. Despite the notable beneficial effect on organ quality and recipient outcome, MP is still not routinely used in liver transplantation. Based on the enormous need to better preserve organs and the subsequent demand to continuously innovate and develop perfusion equipment further, this technology is also beneficial to test and deliver future therapeutic strategies to livers before implantation. This article summarizes the various challenges observed during the current shift from static to dynamic liver preservation in the clinical setting. The different organ perfusion strategies are discussed first, together with ongoing clinical trials and future study design. The current status of research and the impact of costs and regulations is highlighted next. Factors contributing to costs and other required resources for a worldwide successful implementation and reimbursement are presented third. The impact of research on cost-utility and effectivity to guide the tailored decision-making regarding the optimal perfusion strategy is discussed next. Finally, this article provides potential solutions to the challenging field of innovation in healthcare considering the various social and economic factors and the role of clinical, regulatory, and financial stakeholders worldwide.
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Affiliation(s)
- Femke H C De Goeij
- Department of Surgery, Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Vincent De Meijer
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Surgery, Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth University Hospital, Birmingham, United Kingdom
- The Liver Unit, Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - James V Guarrera
- Division of Abdominal Transplant Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | | | - Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Yuri L Boteon
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil
| | - Nazia Selzner
- Ajmera Transplant Center, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Marit Kalisvaart
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Zurich, Switzerland
| | - Carlo Pulitano
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital and Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | | | - Paulo N Martins
- Division of Organ Transplantation, Department of Surgery, University of Massachusetts Memorial Hospital, University of Massachusetts, Worcester, MA
| | - Gabriela Berlakovich
- Division of Transplantation, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Andrea Schlegel
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
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4
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Hessheimer AJ, Flores E, Vengohechea J, Fondevila C. Better liver transplant outcomes by donor interventions? Curr Opin Organ Transplant 2024:00075200-990000000-00123. [PMID: 38785132 DOI: 10.1097/mot.0000000000001153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
PURPOSE OF REVIEW Donor risk factors and events surrounding donation impact the quantity and quality of grafts generated to meet liver transplant waitlist demands. Donor interventions represent an opportunity to mitigate injury and risk factors within donors themselves. The purpose of this review is to describe issues to address among donation after brain death, donation after circulatory determination of death, and living donors directly, for the sake of optimizing relevant outcomes among donors and recipients. RECENT FINDINGS Studies on donor management practices and high-level evidence supporting specific interventions are scarce. Nonetheless, for donation after brain death (DBD), critical care principles are employed to correct cardiocirculatory compromise, impaired tissue oxygenation and perfusion, and neurohormonal deficits. As well, certain treatments as well as marginally prolonging duration of brain death among otherwise stable donors may help improve posttransplant outcomes. In donation after circulatory determination of death (DCD), interventions are performed to limit warm ischemia and reverse its adverse effects. Finally, dietary and exercise programs have improved donation outcomes for both standard as well as overweight living donor (LD) candidates, while minimally invasive surgical techniques may offer improved outcomes among LD themselves. SUMMARY Donor interventions represent means to improve liver transplant yield and outcomes of liver donors and grafts.
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Affiliation(s)
- Amelia J Hessheimer
- General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd
| | - Eva Flores
- Transplant Coordination Unit, Hospital Universitario La Paz, Madrid, Spain
| | - Jordi Vengohechea
- General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd
| | - Constantino Fondevila
- General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd
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Feng S, Roll GR, Rouhani FJ, Sanchez Fueyo A. The future of liver transplantation. Hepatology 2024:01515467-990000000-00817. [PMID: 38537154 DOI: 10.1097/hep.0000000000000873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/02/2024] [Indexed: 06/15/2024]
Abstract
Over the last 50 years, liver transplantation has evolved into a procedure routinely performed in many countries worldwide. Those able to access this therapy frequently experience a miraculous risk-benefit ratio, particularly if they face the imminently life-threatening disease. Over the decades, the success of liver transplantation, with dramatic improvements in early posttransplant survival, has aggressively driven demand. However, despite the emergence of living donors to augment deceased donors as a source of organs, supply has lagged far behind demand. As a result, rationing has been an unfortunate focus in recent decades. Recent shifts in the epidemiology of liver disease combined with transformative innovations in liver preservation suggest that the underlying premise of organ shortage may erode in the foreseeable future. The focus will sharpen on improving equitable access while mitigating constraints related to workforce training, infrastructure for organ recovery and rehabilitation, and their associated costs. Research efforts in liver preservation will undoubtedly blossom with the aim of optimizing both the timing and conditions of transplantation. Coupled with advances in genetic engineering, regenerative biology, and cellular therapies, the portfolio of innovation, both broad and deep, offers the promise that, in the future, liver transplantation will not only be broadly available to those in need but also represent a highly durable life-saving therapy.
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Affiliation(s)
- Sandy Feng
- Department of Surgery, Division of Transplant Surgery, University of California, San Francisco, California, USA
| | - Garrett R Roll
- Department of Surgery, Division of Transplant Surgery, University of California, San Francisco, California, USA
| | - Foad J Rouhani
- Tissue Regeneration and Clonal Evolution Laboratory, The Francis Crick Institute, London, UK
- Institute of Liver Studies, King's College London, King's College Hospital, NHS Foundation Trust, London, UK
| | - Alberto Sanchez Fueyo
- Institute of Liver Studies, King's College London, King's College Hospital, NHS Foundation Trust, London, UK
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Parente A, Sun K, Dutkowski P, Shapiro AMJ, Schlegel A. Routine utilization of machine perfusion in liver transplantation: Ready for prime time? World J Gastroenterol 2024; 30:1488-1493. [PMID: 38617447 PMCID: PMC11008417 DOI: 10.3748/wjg.v30.i11.1488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/30/2024] [Accepted: 02/28/2024] [Indexed: 03/21/2024] Open
Abstract
The last decade has been notable for increasing high-quality research and dramatic improvement in outcomes with dynamic liver preservation. Robust evidence from numerous randomized controlled trials has been pooled by meta-analyses, providing the highest available evidence on the protective effect of machine perfusion (MP) over static cold storage in liver transplantation (LT). Based on a protective effect with less complications and improved graft survival, the field has seen a paradigm shift in organ preservation. This editorial focuses on the role of MP in LT and how it could become the new "gold standard". Strong collaborative efforts are needed to explore its effects on long-term outcomes.
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Affiliation(s)
- Alessandro Parente
- Department of Surgery, Division of Transplantation, University of Alberta Hospital, Edmonton T6G 2B7, Canada
| | - Keyue Sun
- Immunity and Inflammation, Lerner Research Institute, Cleveland, OH 44195, United States
| | - Philipp Dutkowski
- Swiss Hepato-Pancreato-Biliary Center, Department of Visceral and Transplantation Surgery, University Hospital Zurich, Zurich 8091, Switzerland
| | - AM James Shapiro
- Department of Surgery, Division of Transplantation, University of Alberta Hospital, Edmonton T6G 2B7, Canada
| | - Andrea Schlegel
- Immunity and Inflammation, Digestive Disease and Surgery Institute, Cleveland, OH 44195, United States
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7
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Ghinolfi D, Patrono D, De Carlis R, Melandro F, Buscemi V, Farnesi F, Torri F, Lauterio A, Di Salvo M, Cerchione R, Zanierato M, Morganti R, Romagnoli R, De Simone P, De Carlis L. Liver transplantation with uncontrolled versus controlled DCD donors using normothermic regional perfusion and ex-situ machine perfusion. Liver Transpl 2024; 30:46-60. [PMID: 37450659 DOI: 10.1097/lvt.0000000000000219] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
In Italy, 20 minutes of continuous, flat-line electrocardiogram are required for death declaration, which significantly increases the risks of donation after circulatory death (DCD) LT. Despite prolonged warm ischemia time, Italian centers reported good outcomes in controlled donation after circulatory death LT by combining normothermic regional and end-ischemic machine perfusion. However, data on uncontrolled DCD (uDCD) LT performed by this approach are lacking. This was a multicenter, retrospective study performed at 3 large-volume centers comparing clinical outcomes of uncontrolled versus controlled DCD LT. The aim of the study was to assess outcomes of sequential normothermic regional perfusion and end-ischemic machine perfusion in uncontrolled DCD liver transplantation (LT). Of 153 DCD donors evaluated during the study period, 40 uDCD and 59 donation after circulatory death grafts were transplanted (utilization rate 52% vs. 78%, p = 0.004). Recipients of uDCD grafts had higher MEAF (4.9 vs. 3.5, p < 0.001) and CCI scores at discharge (24.4 vs. 8.7, p = 0.026), longer ICU stay (5 vs. 4 d, p = 0.047), and a trend toward more severe AKI. At multivariate analysis, 90-day graft loss was associated with recipient BMI and lactate downtrend during normothermic regional perfusion. One-year graft survival was lower in uDCD (75% vs. 90%, p = 0.007) but became comparable when non-liver-related graft losses were treated as censors (77% vs. 90%, p = 0.100). The incidence of ischemic cholangiopathy was 10% in uDCD versus 3% in donation after circulatory death, p = 0.356. uDCD LT with prolonged warm ischemia is feasible by the sequential use of normothermic regional perfusion and end-ischemic machine perfusion. Proper donor and recipient selection are key to achieving good outcomes in this setting.
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Affiliation(s)
- Davide Ghinolfi
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Hospital, Pisa, Italy
| | - Damiano Patrono
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante, Turin, Italy
| | - Riccardo De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- PhD Course in Clinical and Experimental Sciences, University of Padua, Padua, Italy
| | - Fabio Melandro
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Hospital, Pisa, Italy
| | - Vincenzo Buscemi
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesca Farnesi
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante, Turin, Italy
| | - Francesco Torri
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Hospital, Pisa, Italy
| | - Andrea Lauterio
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Maria Di Salvo
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante, Turin, Italy
| | - Raffaele Cerchione
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marinella Zanierato
- Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante, Turin, Italy
| | | | - Renato Romagnoli
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante, Turin, Italy
| | - Paolo De Simone
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Hospital, Pisa, Italy
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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8
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Tang G, Zhang L, Xia L, Zhang J, Wei Z, Zhou R. Hypothermic oxygenated perfusion in liver transplantation: a meta-analysis of randomized controlled trials and matched studies. Int J Surg 2024; 110:464-477. [PMID: 37738017 PMCID: PMC10793758 DOI: 10.1097/js9.0000000000000784] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/10/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Hypothermic oxygenated machine perfusion (HOPE) is a novel organ-preservation technology designed to optimize organ quality. However, the effects of HOPE on morbidity and mortality after liver transplantation remain unclear. This meta-analysis evaluated the potential benefits of HOPE in liver transplantation. MATERIALS AND METHODS The Embase, Web of Science, PubMed, Cochrane Library, and Scopus databases were searched for articles published up to 15 June 2023 (updated on 12 August 2023). Mean differences (MDs), risk ratios (RRs), and 95% confidence intervals were calculated. RESULTS Eleven studies encompassing five randomized controlled trials and six matched studies were included, with a total of 1000 patients. HOPE did not reduce the incidence of major postoperative complications (RR 0.80), primary non-function (PNF) (RR 0.54), reperfusion syndrome (RR 0.92), hepatic artery thrombosis (RR 0.92), renal replacement therapy (RR 0.98), length of hospital stay (MD, -1.38 days), 1-year recipient death (RR 0.67), or intensive care unit stay (MD, 0.19 days) after liver transplantation. HOPE reduced the incidence of biliary complications (RR 0.74), non-anastomotic biliary strictures (NAS) (RR 0.34), early allograft dysfunction (EAD) (RR 0.54), and acute rejection (RR 0.54). In addition, HOPE improved the retransplantation (RR 0.42) and 1-year graft loss rates (RR 0.38). CONCLUSIONS Compared with static cold storage (SCS), HOPE can reduce the incidence of biliary complications, NAS, EAD, and acute rejection and retransplantation rate after liver transplantation and improve the 1-year graft loss rate. These findings suggest that HOPE, when compared to SCS, can contribute to minimizing complications and enhancing graft survival in liver transplantation. Further research is needed to investigate long-term outcomes and confirm the promising advantages of HOPE in liver transplantation settings.
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Affiliation(s)
- Gang Tang
- Biliary Surgical Department of West China Hospital
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | | | - Lingying Xia
- Biliary Surgical Department of West China Hospital
- Center for Translational Medicine, West China Second University Hospital, Sichuan University, Chengdu, Sichuan
| | - Jie Zhang
- Biliary Surgical Department of West China Hospital
| | - Zhengqiang Wei
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
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9
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Lauterio A, Cillo U, Spada M, Trapani S, De Carlis R, Bottino G, Bernasconi D, Scalamogna C, Pinelli D, Cintorino D, D'Amico FE, Spagnoletti G, Miggino M, Romagnoli R, Centonze L, Caccamo L, Baccarani U, Carraro A, Cescon M, Vivarelli M, Mazaferro V, Ettorre GM, Rossi M, Vennarecci G, De Simone P, Angelico R, Agnes S, Di Benedetto F, Lupo LG, Zamboni F, Zefelippo A, Patrono D, Diviacco P, Laureiro ZL, Gringeri E, Di Francesco F, Lucianetti A, Valsecchi MG, Gruttadauria S, De Feo T, Cardillo M, De Carlis L, Colledan M, Andorno E. Improving outcomes of in situ split liver transplantation in Italy over the last 25 years. J Hepatol 2023; 79:1459-1468. [PMID: 37516203 DOI: 10.1016/j.jhep.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 07/11/2023] [Accepted: 07/13/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND & AIMS Split liver transplant(ation) (SLT) is still considered a challenging procedure that is by no means widely accepted. We aimed to present data on 25-year trends in SLT in Italy, and to investigate if, and to what extent, outcomes have improved nationwide during this time. METHODS The study included all consecutive SLTs performed from May 1993 to December 2019, divided into three consecutive periods: 1993-2005, 2006-2014, and 2015-2019, which match changes in national allocation policies. Primary outcomes were patient and graft survival, and the relative impact of each study period. RESULTS SLT accounted for 8.9% of all liver transplants performed in Italy. A total of 1,715 in situ split liver grafts were included in the analysis: 868 left lateral segments (LLSs) and 847 extended right grafts (ERGs). A significant improvement in patient and graft survival (p <0.001) was observed with ERGs over the three periods. Predictors of graft survival were cold ischaemia time (CIT) <6 h (p = 0.009), UNOS status 2b (p <0.001), UNOS status 3 (p = 0.009), and transplant centre volumes: 25-50 cases vs. <25 cases (p = 0.003). Patient survival was significantly higher with LLS grafts in period 2 vs. period 1 (p = 0.008). No significant improvement in graft survival was seen over the three periods, where predictors of graft survival were CIT <6 h (p = 0.007), CIT <6 h vs. ≥10 h (p = 0.019), UNOS status 2b (p = 0.038), and UNOS status 3 (p = 0.009). Retransplantation was a risk factor in split liver graft recipients, with significantly worse graft and patient survival for both types of graft (p <0.001). CONCLUSIONS Our analysis showed Italian SLT outcomes to have improved over the last 25 years. These results could help to dispel reservations regarding the use of this procedure. IMPACT AND IMPLICATIONS Split liver transplant(ation) (SLT) is still considered a challenging procedure and is by no means widely accepted. This study included all consecutive in situ SLTs performed in Italy from May 1993 to December 2019. With more than 1,700 cases, it is one of the largest series, examining long-term national trends in in situ SLT since its introduction. The data presented indicate that the outcomes of SLT improved during this 25-year period. Improvements are probably due to better recipient selection, refinements in surgical technique, conservative graft-to-recipient matching, and the continuous, yet carefully managed, expansion of donor selection criteria under a strict mandatory split liver allocation policy. These results could help to dispel reservations regarding the use of this procedure.
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Affiliation(s)
- Andrea Lauterio
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplant Unit, Padua University Hospital, Padova, Italy
| | - Marco Spada
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, European Reference Network "TransplantChild", Ospedale Pediatrico Bambino Gesù, IRCCS, Roma, Italy
| | - Silvia Trapani
- Italian National Transplant Center-Istituto Superiore Di Sanità, Rome, Italy
| | - Riccardo De Carlis
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; PhD Course in Clinical and Experimental Sciences, University of Padua, Padua, Italy
| | - Giuliano Bottino
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
| | - Davide Bernasconi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging Centre-B4, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Chiara Scalamogna
- North Italy Transplant Program (NITp), UOC Coordinamento Trapianti, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Domenico Pinelli
- Department of Organ Failure and Transplantation, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Davide Cintorino
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | | | - Gionata Spagnoletti
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, European Reference Network "TransplantChild", Ospedale Pediatrico Bambino Gesù, IRCCS, Roma, Italy
| | - Marco Miggino
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
| | - Renato Romagnoli
- Liver Transplant Center, General Surgery 2U, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Leonardo Centonze
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Lucio Caccamo
- Division of General Surgery and Liver Transplantation, Fondazione Cà Granda IRCCS, Ospedale Maggiore Policlinico di Milano, Milano, Italy
| | - Umberto Baccarani
- Department of Medicine, Liver Transplant Center, University of Udine, Italy
| | - Amedeo Carraro
- Liver Transplant Unit, University and Hospital Trust of Verona, Italy
| | - Matteo Cescon
- Hepatobiliary Surgery and Transplant Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Vivarelli
- HPB Surgery and Transplantation Unit, United Hospital of Ancona, Department of Experimental and Clinical Medicine Polytechnic University of Marche, Ancona, Italy
| | - Vincenzo Mazaferro
- Department of Oncology and Onco-Hematology, University of Milan, Italy; Department of Surgery, Istituto Nazionale Tumori Fondazione IRCCS Milan, Italy
| | - Giuseppe Maria Ettorre
- Division of General Surgery and Liver Transplantation, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | - Massimo Rossi
- General Surgery and Organ Transplantation, Sapienza University of Rome, Umberto I Polyclinic of Rome, Rome, Italy
| | - Giovanni Vennarecci
- Division of Hepatobiliary Surgery and Liver Transplant Center, AORN Cardarelli, Naples, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation AOU Pisana, Pisa, Italy
| | - Roberta Angelico
- Department of Surgical Sciences, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
| | - Salvatore Agnes
- Department of Surgery, Transplantation Service, Catholic University of the Sacred Heart, Foundation A. Gemelli Hospital, Rome, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit Azienda Ospedaliera Policlinico, University of Modena and Reggio Emilia Modena, Italy
| | - Luigi Giovanni Lupo
- General Surgery and Liver Transplantation Unit, University of Bari, Bari, Italy
| | - Fausto Zamboni
- Department of Surgery, General and Hepatic Transplantation Surgery Unit, A.O.B. Brotzu, Cagliari, Italy
| | - Arianna Zefelippo
- Division of General Surgery and Liver Transplantation, Fondazione Cà Granda IRCCS, Ospedale Maggiore Policlinico di Milano, Milano, Italy
| | - Damiano Patrono
- Liver Transplant Center, General Surgery 2U, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Pietro Diviacco
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
| | - Zoe Larghi Laureiro
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, European Reference Network "TransplantChild", Ospedale Pediatrico Bambino Gesù, IRCCS, Roma, Italy
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplant Unit, Padua University Hospital, Padova, Italy
| | - Fabrizio Di Francesco
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | - Alessandro Lucianetti
- First Department of General Surgery, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Maria Grazia Valsecchi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging Centre-B4, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy; Department of Surgery and Medical and Surgical Specialties, University of Catania, 95124, Catania, Italy
| | - Tullia De Feo
- North Italy Transplant Program (NITp), UOC Coordinamento Trapianti, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Cardillo
- Italian National Transplant Center-Istituto Superiore Di Sanità, Rome, Italy
| | - Luciano De Carlis
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Michele Colledan
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Department of Organ Failure and Transplantation, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Enzo Andorno
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
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10
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Panconesi R, Carvalho MF, Eden J, Fazi M, Ansari F, Mancina L, Navari N, Sousa Da Silva RX, Dondossola D, Borrego LB, Pietzke M, Peris A, Meierhofer D, Muiesan P, Galkin A, Marra F, Dutkowski P, Schlegel A. Mitochondrial injury during normothermic regional perfusion (NRP) and hypothermic oxygenated perfusion (HOPE) in a rodent model of DCD liver transplantation. EBioMedicine 2023; 98:104861. [PMID: 37924707 PMCID: PMC10660010 DOI: 10.1016/j.ebiom.2023.104861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 10/15/2023] [Accepted: 10/16/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Normothermic regional perfusion (NRP) and hypothermic-oxygenated-perfusion (HOPE), were both shown to improve outcomes after liver transplantation from donors after circulatory death (DCD). Comparative clinical and mechanistical studies are however lacking. METHODS A rodent model of NRP and HOPE, both in the donor, was developed. Following asystolic donor warm ischemia time (DWIT), the abdominal compartment was perfused either with a donor-blood-based-perfusate at 37 °C (NRP) or with oxygenated Belzer-MPS at 10 °C (donor-HOPE) for 2 h. Livers were then procured and underwent 5 h static cold storage (CS), followed by transplantation. Un-perfused and HOPE-treated DCD-livers (after CS) and healthy livers (DBD) with direct implantation after NRP served as controls. Endpoints included the entire spectrum of ischemia-reperfusion-injury. FINDINGS Healthy control livers (DBD) showed minimal signs of inflammation during 2 h NRP and achieved 100% posttransplant recipient survival. In contrast, DCD livers with 30 and 60 min DWIT suffered from greater mitochondrial injury and inflammation as measured by increased perfusate Lactate, FMN- and HMGB-1-levels with subsequent Toll-like-receptor activation during NRP. In contrast, donor-HOPE (instead of NRP) led to significantly less mitochondrial-complex-I-injury and inflammation. Results after donor-HOPE were comparable to ex-situ HOPE after CS. Most DCD-liver recipients survived when treated with one HOPE-technique (86%), compared to only 40% after NRP (p = 0.0053). Following a reduction of DWIT (15 min), DCD liver recipients achieved comparable survivals with NRP (80%). INTERPRETATION High-risk DCD livers benefit more from HOPE-treatment, either immediately in the donor or after cold storage. Comparative prospective clinical studies are required to translate the results. FUNDING Funding was provided by the Swiss National Science Foundation (grant no: 32003B-140776/1, 3200B-153012/1, 320030-189055/1, and 31IC30-166909) and supported by University Careggi (grant no 32003B-140776/1) and the OTT (grant No.: DRGT641/2019, cod.prog. 19CT03) and the Max Planck Society. Work in the A.G. laboratory was partially supported by the NIH R01NS112381 and R21NS125466 grants.
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Affiliation(s)
- Rebecca Panconesi
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Department of Surgery, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, 10124, Turin, Italy; Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland
| | | | - Janina Eden
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland
| | - Marilena Fazi
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Fariha Ansari
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, 407 East 61st Street, New York, NY, 10065, USA
| | - Leandro Mancina
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland
| | - Nadia Navari
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Richard Xavier Sousa Da Silva
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland
| | - Daniele Dondossola
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan, Centre of Preclinical Research, 20122, Italy
| | - Lucia Bautista Borrego
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland
| | - Matthias Pietzke
- Max Planck Institute for Molecular Genetics, Mass Spectrometry Facility, 14195, Berlin, Germany
| | - Adriano Peris
- Tuscany Regional Transplant Authority, Centro Regionale Allocazione Organi e Tessuti (CRAOT), Florence, Italy
| | - David Meierhofer
- Max Planck Institute for Molecular Genetics, Mass Spectrometry Facility, 14195, Berlin, Germany
| | - Paolo Muiesan
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, 407 East 61st Street, New York, NY, 10065, USA
| | - Alexander Galkin
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, 407 East 61st Street, New York, NY, 10065, USA
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Center for Research, High Education and Transfer DENOThe, University of Florence, Florence, Italy
| | - Philipp Dutkowski
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland
| | - Andrea Schlegel
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland; General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan, Centre of Preclinical Research, 20122, Italy; Transplantation Center, Digestive Disease and Surgery Institute and Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
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11
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Camagni S, Amaduzzi A, Grazioli L, Ghitti D, Pasulo L, Pinelli D, Fagiuoli S, Colledan M. Extended criteria liver donation after circulatory death with prolonged warm ischemia: a pilot experience of normothermic regional perfusion and no subsequent ex-situ machine perfusion. HPB (Oxford) 2023; 25:1494-1501. [PMID: 37659903 DOI: 10.1016/j.hpb.2023.07.902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 07/11/2023] [Accepted: 07/21/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Livers from controlled donation after circulatory death (cDCD) with very prolonged warm ischemic time (WIT) are regularly transplanted after abdominal normothermic regional perfusion (aNRP) plus ex-situ machine perfusion (MP). Considering aNRP as in-situ MP, we investigated whether the results of a pilot experience of extended criteria cDCD liver transplantation (LT) with prolonged WIT, with aNRP alone, were comparable to the best possible outcomes in low-risk cDCD LT. METHODS Prospectively collected data on 24 cDCD LT, with aNRP alone, were analyzed. RESULTS The median total and asystolic WIT were 51 and 25 min. Measures within benchmark cut-offs were: median duration of surgery (5.9 h); median intraoperative transfusions (3 units of red blood cells); need for renal replacement therapy (2/24 patients); median intensive care stay (3 days); key complications; overall morbidity, graft loss, and retransplantation up to 12 months; 12-month mortality (2/21 patients). The median hospital stay (33 days, due to logistics) and mortality up to 6 months (2/24 patients, due to graft-unrelated causes) exceeded benchmark thresholds. CONCLUSIONS This pilot experience suggests that livers from cDCD with very prolonged WIT that appear viable during adequate quality aNRP may be safely transplanted, with no need for ex-situ MP, with considerable resource savings.
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Affiliation(s)
- Stefania Camagni
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy.
| | - Annalisa Amaduzzi
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy
| | - Lorenzo Grazioli
- Department of Anesthesia and Intensive Care, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy
| | - Davide Ghitti
- Department of Anesthesia and Intensive Care, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy
| | - Luisa Pasulo
- Gastroenterology and Transplant Hepatology, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy
| | - Domenico Pinelli
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy
| | - Stefano Fagiuoli
- Gastroenterology and Transplant Hepatology, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy; Università degli Studi di Milano-Bicocca, Piazza dell'Ateneo Nuovo, 20126 Milano, Italy
| | - Michele Colledan
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy; Università degli Studi di Milano-Bicocca, Piazza dell'Ateneo Nuovo, 20126 Milano, Italy
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12
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Parente A, Tirotta F, Pini A, Eden J, Dondossola D, Manzia TM, Dutkowski P, Schlegel A. Machine perfusion techniques for liver transplantation - A meta-analysis of the first seven randomized-controlled trials. J Hepatol 2023; 79:1201-1213. [PMID: 37302578 DOI: 10.1016/j.jhep.2023.05.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/02/2023] [Accepted: 05/19/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND & AIMS Machine perfusion is increasingly being tested in clinical transplantation. Despite this, the number of large prospective clinical trials remains limited. The aim of this study was to compare the impact of machine perfusion vs. static cold storage (SCS) on outcomes after liver transplantation. METHODS A systematic search of MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL) was conducted to identify randomized-controlled trials (RCTs) comparing "post-transplant" outcomes following machine perfusion vs. SCS. Data were pooled using random effect models. Risk ratios (RRs) were calculated for relevant outcomes. The quality of evidence was rated using the GRADE-framework. RESULTS Seven RCTs were identified (four on hypothermic oxygenated [HOPE] and three on normothermic machine perfusion [NMP]), including a total number of 1,017 patients. Both techniques were associated with significantly lower rates of early allograft dysfunction (NMP: n = 41/282, SCS: n = 74/253, RR 0.50, 95% CI 0.30-0.86, p = 0.01, I2 = 39%; HOPE: n = 45/241, SCS: n = 97/241, RR 0.48, 95% CI 0.35-0.65, p < 0.00001, I2 = 5%). The HOPE approach led to a significant reduction in major complications (Clavien Grade ≥IIIb; HOPE: n = 90/241; SCS: n = 117/241, RR 0.76, 95% CI 0.63-0.93, p = 0.006, I2 = 0%), "re-transplantation" (HOPE: n = 1/163; SCS: n = 11/163; RR 0.21, 95% CI 0.04-0.96, p = 0.04; I2 = 0%) and graft loss (HOPE: n = 7/163; SCS: n = 19/163; RR 0.40, 95% CI 0.17-0.95, p = 0.04; I2 = 0%). Both perfusion techniques were found to 'likely' reduce overall biliary complications and non-anastomotic strictures. CONCLUSIONS Although this study provides the highest current evidence on the role of machine perfusion, outcomes remain limited to a 1-year follow-up after liver transplantation. Comparative RCTs and large real-world cohort studies with longer follow-up are required to enhance the robustness of the data further, thereby supporting the introduction of perfusion technologies into routine clinical practice. PROSPERO-REGISTRATION CRD42022355252. IMPACT AND IMPLICATIONS For a decade, two dynamic perfusion concepts have increasingly been tested in several transplant centres worldwide. We undertook the first systematic review and meta-analysis and identified seven published RCTs, including 1,017 patients, evaluating the effect of machine perfusion (hypothermic and normothermic perfusion techniques) compared to static cold storage in liver transplantation. Both perfusion techniques were associated with lower rates of early allograft dysfunction in the first week after liver transplantation. Hypothermic oxygenated perfusion led to a reduction in major complications, lower "re-transplantation" rates and better graft survival. Both perfusion strategies were found to 'likely' reduce overall biliary complications and non-anastomotic biliary strictures. This study provides the highest current evidence on the role of machine perfusion. Outcomes remain limited to a 1-year post-transplant follow-up. Larger cohort studies with longer follow-up and clinical trials comparing the perfusion techniques are required. This is especially relevant to provide clarity and optimise implementation processes further to support the commissioning of this technology worldwide.
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Affiliation(s)
- Alessandro Parente
- HPB and Transplant Unit, Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - Fabio Tirotta
- Department of Surgery, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Trust, Birmingham, United Kingdom
| | - Alessia Pini
- Department of Statistical Sciences, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Janina Eden
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
| | - Daniele Dondossola
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, General and Liver Transplant Surgery Unit, Milan, 20122, Italy; Department of Pathophysiology and Transplantation Università degli Studi di Milano, Italy
| | - Tommaso M Manzia
- HPB and Transplant Unit, Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
| | - Andrea Schlegel
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, General and Liver Transplant Surgery Unit, Milan, 20122, Italy; Transplantation Center, Digestive Disease and Surgery Institute and Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
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13
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Steinberg I, Patrono D, De Cesaris E, Lucà M, Catalano G, Marro M, Rizza G, Simonato E, Brazzi L, Romagnoli R, Zanierato M. Viability assessment of livers donated after circulatory determination of death during normothermic regional perfusion. Artif Organs 2023; 47:1592-1603. [PMID: 37548353 DOI: 10.1111/aor.14622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/14/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Abdominal normothermic regional perfusion (A-NRP) allows in-situ reperfusion and recovery of abdominal organs metabolism in donors after circulatory death (DCD). Besides improving liver transplantation outcomes, liver injury and function can be assessed during A-NRP. METHODS To refine liver viability assessment during A-NRP, prospectively collected data of controlled DCD donors managed at our Institution between October 2019 and May 2022 were retrospectively analyzed. Baseline characteristics, procedural variables and A-NRP parameters of donors whose liver was successfully transplanted were compared to those of donors whose liver was discarded. RESULTS Twenty-seven donors were included and in 20 (74%) the liver was accepted (positive outcome). No differences between study groups were observed concerning baseline characteristics and warm ischemia times (WIT). Initial lactate levels were positively correlated with functional WIT (r2 = 0.4, p = 0.04), whereas transaminase levels were not. Blood flow during A-NRP was comparable, whereas oxygen consumption (VO2 ) was significantly higher in the positive outcome group after 1 h. Time courses of lactate, AST and ALT were significantly different between study groups (p < 0.001). Donors whose liver was accepted showed faster lactate clearance, a difference which was amplified by normalizing lactate clearance to oxygen delivery (DO2 ) and VO2 . Lactate clearance was correlated to transaminase levels and DO2 -normalized lactate clearance was the parameter best discriminating between study groups. CONCLUSIONS DO2 -normalized lactate clearance may represent an element of liver viability assessment during A-NRP.
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Affiliation(s)
- Irene Steinberg
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Mechanical and Aerospace Engineering, Polytechnic University of Turin, Turin, Italy
| | - Damiano Patrono
- General Surgery 2U - Liver Transplant Center, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Enrico De Cesaris
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Michele Lucà
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Giorgia Catalano
- General Surgery 2U - Liver Transplant Center, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Matteo Marro
- Cardiovascular Surgery, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Giorgia Rizza
- General Surgery 2U - Liver Transplant Center, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Erika Simonato
- Cardiovascular Surgery, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Luca Brazzi
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Renato Romagnoli
- Department of Surgical Sciences, University of Turin, Turin, Italy
- General Surgery 2U - Liver Transplant Center, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Marinella Zanierato
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
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14
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Yilma M, Dalal N, Wadhwani SI, Hirose R, Mehta N. Geographic disparities in access to liver transplantation. Liver Transpl 2023; 29:987-997. [PMID: 37232214 PMCID: PMC10914246 DOI: 10.1097/lvt.0000000000000182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 04/08/2023] [Indexed: 05/27/2023]
Abstract
Since the Final Rule regarding transplantation was published in 1999, organ distribution policies have been implemented to reduce geographic disparity. While a recent change in liver allocation, termed acuity circles, eliminated the donor service area as a unit of distribution to decrease the geographic disparity of waitlisted patients to liver transplantation, recently published results highlight the complexity of addressing geographic disparity. From geographic variation in donor supply, as well as liver disease burden and differing model for end-stage liver disease (MELD) scores of candidates and MELD scores necessary to receive liver transplantation, to the urban-rural disparity in specialty care access, and to neighborhood deprivation (community measure of socioeconomic status) in liver transplant access, addressing disparities of access will require a multipronged approach at the patient, transplant center, and national level. Herein, we review the current knowledge of these disparities-from variation in larger (regional) to smaller (census tract or zip code) levels to the common etiologies of liver disease, which are particularly affected by these geographic boundaries. The geographic disparity in liver transplant access must balance the limited organ supply with the growing demand. We must identify patient-level factors that contribute to their geographic disparity and incorporate these findings at the transplant center level to develop targeted interventions. We must simultaneously work at the national level to standardize and share patient data (including socioeconomic status and geographic social deprivation indices) to better understand the factors that contribute to the geographic disparity. The complex interplay between organ distribution policy, referral patterns, and variable waitlisting practices with the proportion of high MELD patients and differences in potential donor supply must all be considered to create a national policy strategy to address the inequities in the system.
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Affiliation(s)
- Mignote Yilma
- Department of Surgery, University of California San Francisco
- National Clinician Scholars Program, University of California San Francisco
| | - Nicole Dalal
- Department of Medicine, University of California San Francisco
| | | | - Ryutaro Hirose
- Department of Transplant, University of California San Francisco
| | - Neil Mehta
- Department of Medicine, University of California San Francisco
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Patrono D, De Stefano N, Vissio E, Apostu AL, Petronio N, Vitelli G, Catalano G, Rizza G, Catalano S, Colli F, Chiusa L, Romagnoli R. How to Preserve Steatotic Liver Grafts for Transplantation. J Clin Med 2023; 12:3982. [PMID: 37373676 DOI: 10.3390/jcm12123982] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/05/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
Liver allograft steatosis is a significant risk factor for postoperative graft dysfunction and has been associated with inferior patient and graft survival, particularly in the case of moderate or severe macrovesicular steatosis. In recent years, the increasing incidence of obesity and fatty liver disease in the population has led to a higher proportion of steatotic liver grafts being used for transplantation, making the optimization of their preservation an urgent necessity. This review discusses the mechanisms behind the increased susceptibility of fatty livers to ischemia-reperfusion injury and provides an overview of the available strategies to improve their utilization for transplantation, with a focus on preclinical and clinical evidence supporting donor interventions, novel preservation solutions, and machine perfusion techniques.
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Affiliation(s)
- Damiano Patrono
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Nicola De Stefano
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Elena Vissio
- Department of Pathology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Ana Lavinia Apostu
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Nicoletta Petronio
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Giovanni Vitelli
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Giorgia Catalano
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Giorgia Rizza
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Silvia Catalano
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Fabio Colli
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Luigi Chiusa
- Department of Pathology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Renato Romagnoli
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
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16
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De Carlis R, Paolo Muiesan, Taner B. Donation after circulatory death: Novel strategies to improve the liver transplant outcome. J Hepatol 2023; 78:1169-1180. [PMID: 37208104 DOI: 10.1016/j.jhep.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 05/21/2023]
Abstract
In many countries, donation after circulatory death (DCD) liver grafts are used to overcome organ shortages; however, DCD grafts have been associated with an increased risk of complications and even graft loss after liver transplantation. The increased risk of complications is thought to correlate with prolonged functional donor warm ischaemia time. Stringent donor selection criteria and utilisation of in situ and ex situ organ perfusion technologies have led to improved outcomes. Additionally, the increased use of novel organ perfusion strategies has led to the possibility of reconditioning marginal DCD liver grafts. Moreover, these technologies enable the assessment of liver function before implantation, thus providing valuable data that can guide more precise graft-recipient selection. In this review, we first describe the different definitions of functional warm donor ischaemia time and its role as a determinant of outcomes after DCD liver transplantation, with a focus on the thresholds proposed for graft acceptance. Next, organ perfusion strategies, namely normothermic regional perfusion, hypothermic oxygenated perfusion, and normothermic machine perfusion are discussed. For each technique, clinical studies reporting on the transplant outcome are described, together with a discussion on the possible protective mechanisms involved and the functional criteria adopted for graft selection. Finally, we review multimodal preservation protocols involving a combination of more than one perfusion technique and potential future directions in the field.
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Affiliation(s)
- Riccardo De Carlis
- Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Ph.D. Course in Clinical and Experimental Sciences, University of Padua, Padua, Italy
| | - Paolo Muiesan
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan, Centre of Preclinical Research, 20122, Italy
| | - Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, United States.
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17
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Schlegel A, Mergental H, Fondevila C, Porte RJ, Friend PJ, Dutkowski P. Machine perfusion of the liver and bioengineering. J Hepatol 2023; 78:1181-1198. [PMID: 37208105 DOI: 10.1016/j.jhep.2023.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 05/21/2023]
Abstract
With the increasing number of accepted candidates on waiting lists worldwide, there is an urgent need to expand the number and the quality of donor livers. Dynamic preservation approaches have demonstrated various benefits, including improving liver function and graft survival, and reducing liver injury and post-transplant complications. Consequently, organ perfusion techniques are being used in clinical practice in many countries. Despite this success, a proportion of livers do not meet current viability tests required for transplantation, even with the use of modern perfusion techniques. Therefore, devices are needed to further optimise machine liver perfusion - one promising option is to prolong machine liver perfusion for several days, with ex situ treatment of perfused livers. For example, stem cells, senolytics, or molecules targeting mitochondria or downstream signalling can be administered during long-term liver perfusion to modulate repair mechanisms and regeneration. Besides, today's perfusion equipment is also designed to enable the use of various liver bioengineering techniques, to develop scaffolds or for their re-cellularisation. Cells or entire livers can also undergo gene modulation to modify animal livers for xenotransplantation, to directly treat injured organs or to repopulate such scaffolds with "repaired" autologous cells. This review first discusses current strategies to improve the quality of donor livers, and secondly reports on bioengineering techniques to design optimised organs during machine perfusion. Current practice, as well as the benefits and challenges associated with these different perfusion strategies are discussed.
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Affiliation(s)
- Andrea Schlegel
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Centre of Preclinical Research, Milan, 20122, Italy; Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom
| | - Constantino Fondevila
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd, Madrid, Spain
| | - Robert J Porte
- Erasmus MC Transplant Institute, Department of Surgery, Division of HPB & Transplant Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Peter J Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland.
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18
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Durán M, Calleja R, Hann A, Clarke G, Ciria R, Nutu A, Sanabria-Mateos R, Ayllón MD, López-Cillero P, Mergental H, Briceño J, Perera MTPR. Machine perfusion and the prevention of ischemic type biliary lesions following liver transplant: What is the evidence? World J Gastroenterol 2023; 29:3066-3083. [PMID: 37346149 PMCID: PMC10280793 DOI: 10.3748/wjg.v29.i20.3066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/01/2023] [Accepted: 04/28/2023] [Indexed: 05/26/2023] Open
Abstract
The widespread uptake of different machine perfusion (MP) strategies for liver transplant has been driven by an effort to minimize graft injury. Damage to the cholangiocytes during the liver donation, preservation, or early posttransplant period may result in stricturing of the biliary tree and inadequate biliary drainage. This problem continues to trouble clinicians, and may have catastrophic consequences for the graft and patient. Ischemic injury, as a result of compromised hepatic artery flow, is a well-known cause of biliary strictures, sepsis, and graft failure. However, very similar lesions can appear with a patent hepatic artery and these are known as ischemic type biliary lesions (ITBL) that are attributed to microcirculatory dysfunction rather than main hepatic arterial compromise. Both the warm and cold ischemic period duration appear to influence the onset of ITBL. All of the commonly used MP techniques deliver oxygen to the graft cells, and therefore may minimize the cholangiocyte injury and subsequently reduce the incidence of ITBL. As clinical experience and published evidence grows for these modalities, the impact they have on ITBL rates is important to consider. In this review, the evidence for the three commonly used MP strategies (abdominal normothermic regional perfusion [A-NRP], hypothermic oxygenated perfusion [HOPE], and normothermic machine perfusion [NMP] for ITBL prevention has been critically reviewed. Inconsistencies with ITBL definitions used in trials, coupled with variations in techniques of MP, make interpretation challenging. Overall, the evidence suggests that both HOPE and A-NRP prevent ITBL in donated after circulatory death grafts compared to cold storage. The evidence for ITBL prevention in donor after brain death grafts with any MP technique is weak.
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Affiliation(s)
- Manuel Durán
- Department of Liver Transplantation, Reina Sofía University Hospital, Córdoba 14004, Spain
| | - Rafael Calleja
- Department of Liver Transplantation, Reina Sofía University Hospital, Córdoba 14004, Spain
| | - Angus Hann
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TH, United Kingdom
| | - George Clarke
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TH, United Kingdom
| | - Ruben Ciria
- Department of Liver Transplantation, Reina Sofía University Hospital, Córdoba 14004, Spain
| | - Anisa Nutu
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
| | | | - María Dolores Ayllón
- Department of Liver Transplantation, Reina Sofía University Hospital, Córdoba 14004, Spain
| | - Pedro López-Cillero
- Department of Liver Transplantation, Reina Sofía University Hospital, Córdoba 14004, Spain
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TH, United Kingdom
| | - Javier Briceño
- Department of Liver Transplantation, Reina Sofía University Hospital, Córdoba 14004, Spain
| | - M Thamara P R Perera
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TH, United Kingdom
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19
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Eden J, Sousa Da Silva R, Cortes-Cerisuelo M, Croome K, De Carlis R, Hessheimer AJ, Muller X, de Goeij F, Banz V, Magini G, Compagnon P, Elmer A, Lauterio A, Panconesi R, Widmer J, Dondossola D, Muiesan P, Monbaliu D, de Rosner van Rosmalen M, Detry O, Fondevila C, Jochmans I, Pirenne J, Immer F, Oniscu GC, de Jonge J, Lesurtel M, De Carlis LG, Taner CB, Heaton N, Schlegel A, Dutkowski P. Utilization of livers donated after circulatory death for transplantation - An international comparison. J Hepatol 2023; 78:1007-1016. [PMID: 36740047 DOI: 10.1016/j.jhep.2023.01.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/21/2023] [Accepted: 01/27/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Liver graft utilization rates are a hot topic due to the worldwide organ shortage and the increasing number of transplant candidates on waiting lists. Liver perfusion techniques have been introduced in several countries, and may help to increase the organ supply, as they potentially enable the assessment of livers before use. METHODS Liver offers were counted from donation after circulatory death (DCD) donors (Maastricht type III) arising during the past decade in eight countries, including Belgium, France, Italy, the Netherlands, Spain, Switzerland, the UK, and the US. Initial type-III DCD liver offers were correlated with accepted, recovered and implanted livers. RESULTS A total number of 34,269 DCD livers were offered, resulting in 9,780 liver transplants (28.5%). The discard rates were highest in the UK and US, ranging between 70 and 80%. In contrast, much lower DCD liver discard rates, e.g. between 30-40%, were found in Belgium, France, Italy, Spain and Switzerland. In addition, we observed large differences in the use of various machine perfusion techniques, as well as in graft and donor risk factors. For example, the median donor age and functional donor warm ischemia time were highest in Italy, e.g. >40 min, followed by Switzerland, France, and the Netherlands. Importantly, such varying risk profiles of accepted DCD livers between countries did not translate into large differences in 5-year graft survival rates, which ranged between 60-82% in this analysis. CONCLUSIONS Overall, DCD liver discard rates across the eight countries were high, although this primarily reflects the situation in the Netherlands, the UK and the US. Countries where in situ and ex situ machine perfusion strategies were used routinely had better DCD utilization rates without compromised outcomes. IMPACT AND IMPLICATIONS A significant number of Maastricht type III DCD livers are discarded across Europe and North America today. The overall utilization rate among eight Western countries is 28.5% but varies significantly between 18.9% and 74.2%. For example, the median DCD-III liver utilization in five countries, e.g. Belgium, France, Italy, Switzerland, and Spain is 65%, in contrast to 24% in the Netherlands, UK and US. Despite this, and despite different rules and strategies for organ acceptance and preservation, 1- and 5-year graft survival rates remain fairly similar among all participating countries. A highly varying experience with modern machine perfusion technology was observed. In situ and ex situ liver perfusion concepts, and application of assessment tools for type-III DCD livers before transplantation, may be a key explanation for the observed differences in DCD-III utilization.
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Affiliation(s)
- Janina Eden
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
| | - Richard Sousa Da Silva
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
| | | | - Kristopher Croome
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 United States
| | - Riccardo De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Amelia J Hessheimer
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd, Madrid, Spain
| | - Xavier Muller
- Department of Digestive Surgery & Liver Transplantation, Croix-Rousse Hospital, University of Lyon I, Lyon, France
| | - Femke de Goeij
- Department of Surgery, Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Vanessa Banz
- Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital, University of Berne, Berne, Switzerland
| | - Giulia Magini
- Division of Transplantation, Department of Surgery, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Philippe Compagnon
- Division of Transplantation, Department of Surgery, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Andreas Elmer
- Swisstransplant, The Swiss National Foundation for Organ Donation and Transplantation Effingerstrasse 1, 3011 Bern, Switzerland
| | - Andrea Lauterio
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Rebecca Panconesi
- General Surgery 2U-Liver Transplant Unit, Department of Surgery, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, 10124 Turin, Italy
| | - Jeannette Widmer
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
| | - Daniele Dondossola
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan, Centre of Preclinical Research, 20122, Italy
| | - Paolo Muiesan
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan, Centre of Preclinical Research, 20122, Italy
| | - Diethard Monbaliu
- Department of Microbiology, Immunology and Transplantation, Transplantation Research Group, Lab of Abdominal Transplantation, KU Leuven, Belgium; Department of Abdominal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | | | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, CHU Liege, University of Liege, Liege, Belgium
| | - Constantino Fondevila
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd, Madrid, Spain
| | - Ina Jochmans
- Department of Microbiology, Immunology and Transplantation, Transplantation Research Group, Lab of Abdominal Transplantation, KU Leuven, Belgium; Department of Abdominal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Department of Microbiology, Immunology and Transplantation, Transplantation Research Group, Lab of Abdominal Transplantation, KU Leuven, Belgium; Department of Abdominal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Franz Immer
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Gabriel C Oniscu
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Jeroen de Jonge
- Department of Surgery, Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mickaël Lesurtel
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, University of Paris Cité, 100 Bd du Général Leclerc, 92110, Clichy, France
| | - Luciano G De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 United States
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Andrea Schlegel
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland; General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan, Centre of Preclinical Research, 20122, Italy
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland.
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Rigo F, De Stefano N, Patrono D, De Donato V, Campi L, Turturica D, Doria T, Sciannameo V, Berchialla P, Tandoi F, Romagnoli R. Impact of Hypothermic Oxygenated Machine Perfusion on Hepatocellular Carcinoma Recurrence after Liver Transplantation. J Pers Med 2023; 13:jpm13050703. [PMID: 37240873 DOI: 10.3390/jpm13050703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/16/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Machine perfusion may be able to mitigate ischemia-reperfusion injury (IRI), which increases hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT). This study aimed to investigate the impact of dual-hypothermic oxygenated machine perfusion (D-HOPE) on HCC recurrence in LT. METHODS A single-center retrospective study was conducted from 2016 to 2020. Pre- and postoperative data of HCC patients undergoing LT were analyzed. Recipients of a D-HOPE-treated graft were compared to those of livers preserved using static cold storage (SCS). The primary endpoint was recurrence-free survival (RFS). RESULTS Of 326 patients, 246 received an SCS-preserved liver and 80 received a D-HOPE-treated graft (donation after brain death (DBD), n = 66; donation after circulatory death (DCD), n = 14). Donors of D-HOPE-treated grafts were older and had higher BMI. All DCD donors were treated by normothermic regional perfusion and D-HOPE. The groups were comparable in terms of HCC features and estimated 5-year RFS according to the Metroticket 2.0 model. D-HOPE did not reduce HCC recurrence (D-HOPE 10%; SCS 8.9%; p = 0.95), which was confirmed using Bayesian model averaging and inverse probability of treatment weighting-adjusted RFS analysis. Postoperative outcomes were comparable between groups, except for lower AST and ALT peak in the D-HOPE group. CONCLUSIONS In this single-center study, D-HOPE did not reduce HCC recurrence but allowed utilizing livers from extended criteria donors with comparable outcomes, improving access to LT for patients suffering from HCC.
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Affiliation(s)
- Federica Rigo
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Nicola De Stefano
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Damiano Patrono
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Victor De Donato
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Ludovico Campi
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Diana Turturica
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Teresa Doria
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Veronica Sciannameo
- Centre for Biostatistics, Epidemiology and Public Health (C-BEPH), Department of Clinical and Biological Sciences, University of Torino, 10126 Turin, Italy
| | - Paola Berchialla
- Centre for Biostatistics, Epidemiology and Public Health (C-BEPH), Department of Clinical and Biological Sciences, University of Torino, 10126 Turin, Italy
| | - Francesco Tandoi
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
- HPB and Liver Transplant Unit, Azienda Ospedaliero Universitaria Consorziale Policlinico, 70124 Bari, Italy
| | - Renato Romagnoli
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
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21
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Patrono D, Colli F, Colangelo M, De Stefano N, Apostu AL, Mazza E, Catalano S, Rizza G, Mirabella S, Romagnoli R. How Can Machine Perfusion Change the Paradigm of Liver Transplantation for Patients with Perihilar Cholangiocarcinoma? J Clin Med 2023; 12:jcm12052026. [PMID: 36902813 PMCID: PMC10004136 DOI: 10.3390/jcm12052026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 02/24/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023] Open
Abstract
Perihilar cholangiocarcinomas (pCCA) are rare yet aggressive tumors originating from the bile ducts. While surgery remains the mainstay of treatment, only a minority of patients are amenable to curative resection, and the prognosis of unresectable patients is dismal. The introduction of liver transplantation (LT) after neoadjuvant chemoradiation for unresectable pCCA in 1993 represented a major breakthrough, and it has been associated with 5-year survival rates consistently >50%. Despite these encouraging results, pCCA has remained a niche indication for LT, which is most likely due to the need for stringent candidate selection and the challenges in preoperative and surgical management. Machine perfusion (MP) has recently been reintroduced as an alternative to static cold storage to improve liver preservation from extended criteria donors. Aside from being associated with superior graft preservation, MP technology allows for the safe extension of preservation time and the testing of liver viability prior to implantation, which are characteristics that may be especially useful in the setting of LT for pCCA. This review summarizes current surgical strategies for pCCA treatment, with a focus on unmet needs that have contributed to the limited spread of LT for pCCA and how MP could be used in this setting, with a particular emphasis on the possibility of expanding the donor pool and improving transplant logistics.
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22
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Miñambres E, Estébanez B, Ballesteros MÁ, Coll E, Flores-Cabeza EM, Mosteiro F, Lara R, Domínguez-Gil B. Normothermic Regional Perfusion in Pediatric Controlled Donation After Circulatory Death Can Lead to Optimal Organ Utilization and Posttransplant Outcomes. Transplantation 2023; 107:703-708. [PMID: 36226852 DOI: 10.1097/tp.0000000000004326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The benefits of normothermic regional perfusion (NRP) in posttransplant outcomes after controlled donation after the determination of death by circulatory criteria (cDCD) has been shown in different international adult experiences. However, there is no information on the use of NRP in pediatric cDCD donors. METHODS This is a multicenter, retrospective, observational cohort study describing the pediatric (<18 y) cDCD procedures performed in Spain, using either abdominal NRP or thoracoabdominal NRP and the outcomes of recipients of the obtained organs. RESULTS Thirteen pediatric cDCD donors (age range, 2-17 y) subject to abdominal NRP or thoracoabdominal NRP were included. A total of 46 grafts (24 kidneys, 11 livers, 8 lungs, 2 hearts, and 1 pancreas) were finally transplanted (3.5 grafts per donor). The mean functional warm ischemic time was 15 min (SD 6 min)' and the median duration of NRP was 87 min (interquartile range, 69-101 min). One-year noncensored for death kidney graft survival was 91.3%. The incidence of delayed graft function was 13%. One-year' noncensored-for-death liver graft survival was 90.9%. All lung and pancreas recipients had an excellent evolution. One heart recipient died due to a septic shock. CONCLUSIONS This is the largest experience of pediatric cDCD using NRP as graft preservation method. Although our study has several limitations, such as its retrospective nature and the small sample size, its reveals that NRP may increase the utilization of cDCD pediatric organs and offer optimal recipients' outcomes.
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Affiliation(s)
- Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
- School of Medicine, Universidad de Cantabria, Santander, Spain
| | - Belen Estébanez
- Transplant Coordination Unit & Service of Intensive Care, University Hospital La Paz, Madrid, Spain
| | - Maria Ángeles Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | | | | | - Fernando Mosteiro
- Transplant Coordination Unit & Service of Intensive Care, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Ramón Lara
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Virgen De Las Nieves, Granada, Spain
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In Situ Normothermic Regional Perfusion in Controlled Donation After Circulatory Determination Death: Organ Utilization, Outcomes, and Elusiveness of a Randomized Clinical Trial. Transplantation 2023; 107:311-312. [PMID: 35993669 DOI: 10.1097/tp.0000000000004281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Blondeel J, Monbaliu D, Gilbo N. Dynamic liver preservation: Are we still missing pieces of the puzzle? Artif Organs 2023; 47:248-259. [PMID: 36227006 DOI: 10.1111/aor.14397] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 02/03/2023]
Abstract
To alleviate the persistent shortage of donor livers, high-risk liver grafts are increasingly being considered for liver transplantation. Conventional preservation with static cold storage falls short in protecting these high-risk livers from ischemia-reperfusion injury, as evident from higher rates of post-transplant complications such as early allograft dysfunction and ischemic cholangiopathy. Moreover, static cold storage does not allow for a functional assessment of the liver prior to transplantation. To overcome these limitations, dynamic strategies of liver preservation have been proposed, designed to provide a protective effect while allowing pre-transplant functional assessment. In this review, we discuss how different dynamic preservation strategies exert their effects, where we stand in assessing liver function and what challenges are lying ahead.
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Affiliation(s)
- Joris Blondeel
- Department of Microbiology, Immunology and Transplantation, Laboratory of Abdominal Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Department of Microbiology, Immunology and Transplantation, Laboratory of Abdominal Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Nicholas Gilbo
- Department of Microbiology, Immunology and Transplantation, Laboratory of Abdominal Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium
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Ghinolfi D, Melandro F, Torri F, Esposito M, Bindi M, Biancofiore G, Basta G, Del Turco S, Lazzeri C, Rotondo MI, Peris A, De Simone P. The role of sequential normothermic regional perfusion and end-ischemic normothermic machine perfusion in liver transplantation from very extended uncontrolled donation after cardiocirculatory death. Artif Organs 2023; 47:432-440. [PMID: 36461895 DOI: 10.1111/aor.14468] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/19/2022] [Accepted: 11/09/2022] [Indexed: 12/04/2022]
Abstract
The use of pre-procurement normothermic regional perfusion (NRP) allowed us to implement controlled DCD liver transplantation with results comparable to brain death donors, but the use of uncontrolled DCD is declining due to logistic challenges and the high incidence of post-transplant complications. In Italy, the mandatory stand-off period of 20 min for DCD donors has driven the combined use of NRP and ex-situ machine perfusion with the intent to counterbalance the negative impact of prolonged warm ischemia. Organ viability during NRP is based on duration of warm ischemia, regional perfusion flow, lactate, transaminases values and histology, and those used in Italy are the widest worldwide. However, this evaluation can be difficult, especially when the acute damage is particularly severe. The use of ex-situ NRP could provide a safe organ evaluation. In the period from 06/2020 to 06/2022, all DCD grafts exceeding NRP viability criteria at a single center were eventually evaluated using ex-situ normothermic machine perfusion. Machine perfusion viability criteria were based on lactate clearance, irrespectively to bile production, unless 1-h transaminases perfusate level were not exceeding 5000 IU/L. Three cases of uncontrolled DCD grafts in excess of NRP viability criteria underwent ex-situ graft evaluation. Two matched ex-situ normothermic machine perfusion viability criteria and were successfully transplanted. Both recipients are doing well after 26 and 5 months after surgery with no signs of ischemic cholangiopathy. This experience suggests that the sequential use of NRP and normothermic machine perfusion may further expand the boundaries of organ viability in uncontrolled DCD liver transplantation.
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Affiliation(s)
- Davide Ghinolfi
- Division of Hepatic Surgery and Liver Transplantation, University Hospital of Pisa, Pisa, Italy
| | - Fabio Melandro
- Division of Hepatic Surgery and Liver Transplantation, University Hospital of Pisa, Pisa, Italy
| | - Francesco Torri
- Division of Hepatic Surgery and Liver Transplantation, University Hospital of Pisa, Pisa, Italy
| | - Massimo Esposito
- Department of Anesthesia, University Hospital of Pisa, Pisa, Italy
| | - Maria Bindi
- Department of Anesthesia, University Hospital of Pisa, Pisa, Italy
| | | | - Giuseppina Basta
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Serena Del Turco
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Chiara Lazzeri
- CRAOT, Regional Authority for Organ and Tissue Allocation, Careggi Hospital (Centro Regionale per l'Allocazione di Organi e Tessuti), Florence, Italy
| | | | - Adriano Peris
- OTT, Regional Transplant Authority of Tuscany (Organizzazione Toscana Trapianti), Florence, Italy
| | - Paolo De Simone
- Division of Hepatic Surgery and Liver Transplantation, University Hospital of Pisa, Pisa, Italy
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A Meta-Analysis and Systematic Review of Normothermic and Hypothermic Machine Perfusion in Liver Transplantation. J Clin Med 2022; 12:jcm12010235. [PMID: 36615037 PMCID: PMC9820958 DOI: 10.3390/jcm12010235] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/02/2022] [Accepted: 12/05/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The gap between the demand and supply of donor livers is still a considerable challenge. Since static cold storage is not sufficient in marginal livers, machine perfusion is being explored as an alternative. The objective of this study was to assess (dual) hypothermic oxygenated machine perfusion (HOPE/D-HOPE) and normothermic machine perfusion (NMP) in contrast to static cold storage (SCS). METHODS Three databases were searched to identify studies about machine perfusion. Graft and patient survival and postoperative complications were evaluated using the random effects model. RESULTS the incidence of biliary complications was lower in HOPE vs. SCS (OR: 0.59, 95% CI: 0.36-0.98, p = 0.04, I2: 0%). There was no significant difference in biliary complications between NMP and SCS (OR: 0.76, 95% CI: 0.41-1.40, p = 0.38, I2: 55%). Graft and patient survival were significantly better in HOPE than in SCS (HR: 0.40, 95% CI: 0.23-0.71, p = 0.002, I2: 0%) and (pooled HR: 0.43, 95% CI: 0.20-0.93, p = 0.03, I2: 0%). Graft and patient survival were not significantly different between NMP and SCS. CONCLUSION HOPE/D-HOPE and NMP are promising alternatives to SCS for donor liver preservation. They may help address the widening gap between the demand for and availability of donor livers by enabling the rescue and transplantation of marginal livers.
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De Stefano N, Calleri A, Navarro-Tableros V, Rigo F, Patrono D, Romagnoli R. State-of-the-Art and Future Directions in Organ Regeneration with Mesenchymal Stem Cells and Derived Products during Dynamic Liver Preservation. Medicina (B Aires) 2022; 58:medicina58121826. [PMID: 36557029 PMCID: PMC9785426 DOI: 10.3390/medicina58121826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/29/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
Transplantation is currently the treatment of choice for end-stage liver diseases but is burdened by the shortage of donor organs. Livers from so-called extended-criteria donors represent a valid option to overcome organ shortage, but they are at risk for severe post-operative complications, especially when preserved with conventional static cold storage. Machine perfusion technology reduces ischemia-reperfusion injury and allows viability assessment of these organs, limiting their discard rate and improving short- and long-term outcomes after transplantation. Moreover, by keeping the graft metabolically active, the normothermic preservation technique guarantees a unique platform to administer regenerative therapies ex vivo. With their anti-inflammatory and immunomodulatory properties, mesenchymal stem cells are among the most promising sources of therapies for acute and chronic liver failure, but their routine clinical application is limited by several biosafety concerns. It is emerging that dynamic preservation and stem cell therapy may supplement each other if combined, as machine perfusion can be used to deliver stem cells to highly injured grafts, avoiding potential systemic side effects. The aim of this narrative review is to provide a comprehensive overview on liver preservation techniques and mesenchymal stem cell-based therapies, focusing on their application in liver graft reconditioning.
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Affiliation(s)
- Nicola De Stefano
- General Surgery 2U—Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, 10126 Turin, Italy
| | - Alberto Calleri
- Gastrohepatology Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, 10126 Turin, Italy
| | - Victor Navarro-Tableros
- 2i3T, Società per la Gestione dell’incubatore di Imprese e per il Trasferimento Tecnologico, University of Torino, 10126 Turin, Italy
| | - Federica Rigo
- General Surgery 2U—Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, 10126 Turin, Italy
| | - Damiano Patrono
- General Surgery 2U—Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, 10126 Turin, Italy
| | - Renato Romagnoli
- General Surgery 2U—Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, 10126 Turin, Italy
- Correspondence: ; Tel.: +39-011-6334364
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Where are we today with machine perfusion of liver in donation after circulatory death liver transplantation? TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Mohkam K, Nasralla D, Mergental H, Muller X, Butler A, Jassem W, Imber C, Monbaliu D, Perera MTPR, Laing RW, García‐Valdecasas JC, Paul A, Dondero F, Cauchy F, Savier E, Scatton O, Robin F, Sulpice L, Bucur P, Salamé E, Pittau G, Allard M, Pradat P, Rossignol G, Mabrut J, Ploeg RJ, Friend PJ, Mirza DF, Lesurtel M. In situ normothermic regional perfusion versus ex situ normothermic machine perfusion in liver transplantation from donation after circulatory death. Liver Transpl 2022; 28:1716-1725. [PMID: 35662403 PMCID: PMC9796010 DOI: 10.1002/lt.26522] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 03/14/2022] [Accepted: 03/19/2022] [Indexed: 12/30/2022]
Abstract
In situ normothermic regional perfusion (NRP) and ex situ normothermic machine perfusion (NMP) aim to improve the outcomes of liver transplantation (LT) using controlled donation after circulatory death (cDCD). NRP and NMP have not yet been compared directly. In this international observational study, outcomes of LT performed between 2015 and 2019 for organs procured from cDCD donors subjected to NRP or NMP commenced at the donor center were compared using propensity score matching (PSM). Of the 224 cDCD donations in the NRP cohort that proceeded to asystole, 193 livers were procured, resulting in 157 transplants. In the NMP cohort, perfusion was commenced in all 40 cases and resulted in 34 transplants (use rates: 70% vs. 85% [p = 0.052], respectively). After PSM, 34 NMP liver recipients were matched with 68 NRP liver recipients. The two cohorts were similar for donor functional warm ischemia time (21 min after NRP vs. 20 min after NMP; p = 0.17), UK-Donation After Circulatory Death risk score (5 vs. 5 points; p = 0.38), and laboratory Model for End-Stage Liver Disease scores (12 vs. 12 points; p = 0.83). The incidence of nonanastomotic biliary strictures (1.5% vs. 2.9%; p > 0.99), early allograft dysfunction (20.6% vs. 8.8%; p = 0.13), and 30-day graft loss (4.4% vs. 8.8%; p = 0.40) were similar, although peak posttransplant aspartate aminotransferase levels were higher in the NRP cohort (872 vs. 344 IU/L; p < 0.001). NRP livers were more frequently allocated to recipients suffering from hepatocellular carcinoma (HCC; 60.3% vs. 20.6%; p < 0.001). HCC-censored 2-year graft and patient survival rates were 91.5% versus 88.2% (p = 0.52) and 97.9% versus 94.1% (p = 0.25) after NRP and NMP, respectively. Both perfusion techniques achieved similar outcomes and appeared to match benchmarks expected for donation after brain death livers. This study may inform the design of a definitive trial.
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Affiliation(s)
- Kayvan Mohkam
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - David Nasralla
- Department of Hepatopancreatobiliary and Liver Transplant SurgeryRoyal Free HospitalLondonUK
| | - Hynek Mergental
- Liver Unit, Queen Elizabeth HospitalUniversity Hospitals BirminghamBirminghamUK
| | - Xavier Muller
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - Andrew Butler
- Department of Surgery, Addenbrooke's HospitalUniversity of CambridgeCambridgeUK
| | - Wayel Jassem
- Institute of Liver StudiesKing's College HospitalLondonUK
| | - Charles Imber
- Department of Hepatopancreatobiliary and Liver Transplant SurgeryRoyal Free HospitalLondonUK
| | - Diethard Monbaliu
- Abdominal Transplant Surgery Unit, Department of SurgeryUniversity Hospitals LeuvenLeuvenBelgium
| | | | - Richard W. Laing
- Liver Unit, Queen Elizabeth HospitalUniversity Hospitals BirminghamBirminghamUK
| | | | - Andreas Paul
- Department of General, Visceral and Transplantation SurgeryUniversity Hospital EssenEssenGermany
| | - Federica Dondero
- Department of Hepatobiliopancreatic SurgeryDepartment of Hepatopancreatobiliary Surgery and Liver TransplantationBeaujon Hospital, Assitance Publique‐Hôpitaux de Paris (AP‐HP), University Paris CitéClichyFrance
| | - François Cauchy
- Department of Hepatobiliopancreatic SurgeryDepartment of Hepatopancreatobiliary Surgery and Liver TransplantationBeaujon Hospital, Assitance Publique‐Hôpitaux de Paris (AP‐HP), University Paris CitéClichyFrance
| | - Eric Savier
- Department of Hepatobiliary Surgery and Liver Transplantation, Pitié‐Salpêtrière HospitalSorbonne UniversityParisFrance
| | - Olivier Scatton
- Department of Hepatobiliary Surgery and Liver Transplantation, Pitié‐Salpêtrière HospitalSorbonne UniversityParisFrance
| | - Fabien Robin
- Department of Hepatobiliary and Digestive SurgeryPontchaillou University HospitalRennesFrance
| | - Laurent Sulpice
- Department of Hepatobiliary and Digestive SurgeryPontchaillou University HospitalRennesFrance
| | - Petru Bucur
- Department of Digestive, Oncological, Endocrine, Hepato‐Biliary, Pancreatic and Liver Transplant SurgeryTrousseau HospitalToursFrance
| | - Ephrem Salamé
- Department of Digestive, Oncological, Endocrine, Hepato‐Biliary, Pancreatic and Liver Transplant SurgeryTrousseau HospitalToursFrance
| | - Gabriella Pittau
- Centre Hépato‐Biliaire, Hôpital Paul Brousse, Assistance Publique‐Hôpitaux de Paris (AP‐HP)Université Paris SudVillejuifFrance
| | - Marc‐Antoine Allard
- Centre Hépato‐Biliaire, Hôpital Paul Brousse, Assistance Publique‐Hôpitaux de Paris (AP‐HP)Université Paris SudVillejuifFrance
| | - Pierre Pradat
- Clinical Research Centre, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - Guillaume Rossignol
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - Jean‐Yves Mabrut
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - Rutger J. Ploeg
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Peter J. Friend
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Darius F. Mirza
- Liver Unit, Queen Elizabeth HospitalUniversity Hospitals BirminghamBirminghamUK
| | - Mickaël Lesurtel
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
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Professor Paolo Muiesan (1961-2022) Surgical Master, Educator, Mentor, and Gentleman. Transplantation 2022; 106:1892-1896. [PMID: 36173655 DOI: 10.1097/tp.0000000000004242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ravaioli M, Germinario G, Dajti G, Sessa M, Vasuri F, Siniscalchi A, Morelli MC, Serenari M, Del Gaudio M, Zanfi C, Odaldi F, Bertuzzo VR, Maroni L, Laurenzi A, Cescon M. Hypothermic oxygenated perfusion in extended criteria donor liver transplantation-A randomized clinical trial. Am J Transplant 2022; 22:2401-2408. [PMID: 35671067 PMCID: PMC9796786 DOI: 10.1111/ajt.17115] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/12/2022] [Accepted: 06/03/2022] [Indexed: 01/25/2023]
Abstract
Hypothermic Oxygenated Perfusion (HOPE) of the liver can reduce the incidence of early allograft dysfunction (EAD) and failure in extended criteria donors (ECD) grafts, although data from prospective studies are very limited. In this monocentric, open-label study, from December 2018 to January 2021, 110 patients undergoing transplantation of an ECD liver graft were randomized to receive a liver after HOPE or after static cold storage (SCS) alone. The primary endpoint was the incidence of EAD. The secondary endpoints included graft and patient survival, the EASE risk score, and the rate of graft or other graft-related complications. Patients in the HOPE group had a significantly lower rate of EAD (13% vs. 35%, p = .007) and were more frequently allocated to the intermediate or higher risk group according to the EASE score (2% vs. 11%, p = .05). The survival analysis confirmed that patients in the HOPE group were associated with higher graft survival one year after LT (p = .03, log-rank test). In addition, patients in the SCS group had a higher re-admission and overall complication rate at six months, in particular cardio-vascular adverse events (p = .04 and p = .03, respectively). HOPE of ECD grafts compared to the traditional SCS preservation method is associated with lower dysfunction rates and better graft survival.
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Affiliation(s)
- Matteo Ravaioli
- Department of General Surgery and TransplantationIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly,Department of Medical and Surgical Sciences (DIMEC)University of BolognaBolognaItaly
| | - Giuliana Germinario
- Department of General Surgery and TransplantationIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly,Department of Medical and Surgical Sciences (DIMEC)University of BolognaBolognaItaly
| | - Gerti Dajti
- Department of Medical and Surgical Sciences (DIMEC)University of BolognaBolognaItaly
| | - Maurizio Sessa
- Department of Drug Design and PharmacologyUniversity of CopenhagenCopenhagenDenmark
| | - Francesco Vasuri
- Department of Specialized, Experimental and Diagnostic Medicine, Pathology UnitIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
| | - Antonio Siniscalchi
- Department of General Surgery and TransplantationIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
| | - Maria Cristina Morelli
- Department of General Surgery and TransplantationIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
| | - Matteo Serenari
- Department of General Surgery and TransplantationIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
| | - Massimo Del Gaudio
- Department of General Surgery and TransplantationIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
| | - Chiara Zanfi
- Department of General Surgery and TransplantationIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
| | - Federica Odaldi
- Department of General Surgery and TransplantationIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
| | - Valentina Rosa Bertuzzo
- Department of General Surgery and TransplantationIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
| | - Lorenzo Maroni
- Department of General Surgery and TransplantationIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly,Department of Medical and Surgical Sciences (DIMEC)University of BolognaBolognaItaly
| | - Andrea Laurenzi
- Department of General Surgery and TransplantationIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly
| | - Matteo Cescon
- Department of General Surgery and TransplantationIRCCS Azienda Ospedaliero‐Universitaria di BolognaBolognaItaly,Department of Medical and Surgical Sciences (DIMEC)University of BolognaBolognaItaly
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Schurink IJ, van de Leemkolk FEM, Fondevila C, De Carlis R, Savier E, Oniscu GC, Huurman VAL, de Jonge J. Donor eligibility criteria and liver graft acceptance criteria during normothermic regional perfusion: A systematic review. Liver Transpl 2022; 28:1563-1575. [PMID: 35603445 PMCID: PMC9796375 DOI: 10.1002/lt.26512] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 04/23/2022] [Accepted: 05/12/2022] [Indexed: 01/01/2023]
Abstract
Acceptance of liver grafts from donations after circulatory death (DCD) largely remains a "black box," particularly due to the unpredictability of the agonal phase. Abdominal normothermic regional perfusion (aNRP) can reverse ischemic injury early during the procurement procedure, and it simultaneously enables graft viability testing to unravel this black box. This review evaluates current protocols for liver viability assessment to decide upon acceptance or decline during aNRP. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was used, and relevant literature databases were searched. The primary outcome consisted of criteria for liver graft viability assessment. Secondary outcomes included survival, primary nonfunction (PNF), early dysfunction, and biliary complications. A total of 14 articles were included in the analysis. In all protocols, a combination of criteria was used to assess suitability of the liver for transplantation. As many as 12 studies (86%) used macroscopic assessment, 12 studies (86%) used alanine transaminase (ALT) levels in perfusate, 9 studies (64%) used microscopic assessment, and 7 studies (50%) used lactate levels as assessment criteria. The organ utilization rate (OUR) was 16% for uncontrolled donation after circulatory death (uDCD) and 64% for controlled donation after circulatory death (cDCD). The most used acceptation criterion in uDCD is ALT level (31%), while in cDCD macroscopic aspect (48%) is most used. Regarding postoperative complications, PNF occurred in 13% (6%-25%) of uDCD livers and 3% (2%-4%) of cDCD livers. In uDCD, the 1-year graft and patient survival rates were 75% (66%-82%) and 82% (75%-88%). In cDCD, the 1-year graft and patient survival rates were 91% (89%-93%) and 93% (91%-94%), respectively. In conclusion, the currently used assessment criteria consist of macroscopic aspect and transaminase levels. The acceptance criteria should be tailored according to donor type to prevent an unacceptable PNF rate in uDCD and to increase the relatively modest OUR in cDCD.
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Affiliation(s)
- Ivo J. Schurink
- Department of SurgeryErasmus MC Transplant InstituteRotterdamThe Netherlands
| | | | | | - Riccardo De Carlis
- Department of Surgery and TransplantationASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | - Eric Savier
- Department of Hepato‐Biliary and Pancreatic Surgery and Liver TransplantationPitie‐Salpetriere Hospital, Assistance Publique‐Hôpitaux de Paris (AP‐HP), Sorbonne UniversityParisFrance
| | | | - Volkert A. L. Huurman
- Department of Surgery, Transplant CenterLeiden University Medical CenterLeidenThe Netherlands
| | - Jeroen de Jonge
- Department of SurgeryErasmus MC Transplant InstituteRotterdamThe Netherlands
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Widmer J, Eden J, Carvalho MF, Dutkowski P, Schlegel A. Machine Perfusion for Extended Criteria Donor Livers: What Challenges Remain? J Clin Med 2022; 11:jcm11175218. [PMID: 36079148 PMCID: PMC9457017 DOI: 10.3390/jcm11175218] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 08/30/2022] [Indexed: 11/28/2022] Open
Abstract
Based on the renaissance of dynamic preservation techniques, extended criteria donor (ECD) livers reclaimed a valuable eligibility in the transplantable organ pool. Being more vulnerable to ischemia, ECD livers carry an increased risk of early allograft dysfunction, primary non-function and biliary complications and, hence, unveiled the limitations of static cold storage (SCS). There is growing evidence that dynamic preservation techniques—dissimilar to SCS—mitigate reperfusion injury by reconditioning organs prior transplantation and therefore represent a useful platform to assess viability. Yet, a debate is ongoing about the advantages and disadvantages of different perfusion strategies and their best possible applications for specific categories of marginal livers, including organs from donors after circulatory death (DCD) and brain death (DBD) with extended criteria, split livers and steatotic grafts. This review critically discusses the current clinical spectrum of livers from ECD donors together with the various challenges and posttransplant outcomes in the context of standard cold storage preservation. Based on this, the potential role of machine perfusion techniques is highlighted next. Finally, future perspectives focusing on how to achieve higher utilization rates of the available donor pool are highlighted.
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Affiliation(s)
- Jeannette Widmer
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zürich, Switzerland
| | - Janina Eden
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zürich, Switzerland
| | - Mauricio Flores Carvalho
- Hepatobiliary Unit, Department of Clinical and Experimental Medicine, University of Florence, AOU Careggi, 50139 Florence, Italy
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zürich, Switzerland
| | - Andrea Schlegel
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zürich, Switzerland
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Centre of Preclinical Research, 20122 Milan, Italy
- Correspondence:
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Liver perfusion strategies: what is best and do ischemia times still matter? Curr Opin Organ Transplant 2022; 27:285-299. [PMID: 35438271 DOI: 10.1097/mot.0000000000000963] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW This review describes recent developments in the field of liver perfusion techniques. RECENT FINDINGS Dynamic preservation techniques are increasingly tested due to the urgent need to improve the overall poor donor utilization. With their exposure to warm ischemia, livers from donors after circulatory death (DCD) transmit additional risk for severe complications after transplantation. Although the superiority of dynamic approaches compared to static-cold-storage is widely accepted, the number of good quality studies remains limited. Most risk factors, particularly donor warm ischemia, and accepted thresholds are inconsistently reported, leading to difficulties to assess the impact of new preservation technologies. Normothermic regional perfusion (NRP) leads to good outcomes after DCD liver transplantation, with however short ischemia times. While randomized controlled trials (RCT) with NRP are lacking, results from the first RCTs with ex-situ perfusion were reported. Hypothermic oxygenated perfusion was shown to protect DCD liver recipients from ischemic cholangiopathy. In contrast, endischemic normothermic perfusion seems to not impact on the development of biliary complications, although this evidence is only available from retrospective studies. SUMMARY Dynamic perfusion strategies impact posttransplant outcomes and are increasingly commissioned in various countries along with more evidence from RCTs. Transparent reporting of risk and utilization with uniform definitions is required to compare the role of different preservation strategies in DCD livers with prolonged ischemia times.
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Andrijevic D, Vrselja Z, Lysyy T, Zhang S, Skarica M, Spajic A, Dellal D, Thorn SL, Duckrow RB, Ma S, Duy PQ, Isiktas AU, Liang D, Li M, Kim SK, Daniele SG, Banu K, Perincheri S, Menon MC, Huttner A, Sheth KN, Gobeske KT, Tietjen GT, Zaveri HP, Latham SR, Sinusas AJ, Sestan N. Cellular recovery after prolonged warm ischaemia of the whole body. Nature 2022; 608:405-412. [PMID: 35922506 PMCID: PMC9518831 DOI: 10.1038/s41586-022-05016-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 06/23/2022] [Indexed: 02/05/2023]
Abstract
After cessation of blood flow or similar ischaemic exposures, deleterious molecular cascades commence in mammalian cells, eventually leading to their death1,2. Yet with targeted interventions, these processes can be mitigated or reversed, even minutes or hours post mortem, as also reported in the isolated porcine brain using BrainEx technology3. To date, translating single-organ interventions to intact, whole-body applications remains hampered by circulatory and multisystem physiological challenges. Here we describe OrganEx, an adaptation of the BrainEx extracorporeal pulsatile-perfusion system and cytoprotective perfusate for porcine whole-body settings. After 1 h of warm ischaemia, OrganEx application preserved tissue integrity, decreased cell death and restored selected molecular and cellular processes across multiple vital organs. Commensurately, single-nucleus transcriptomic analysis revealed organ- and cell-type-specific gene expression patterns that are reflective of specific molecular and cellular repair processes. Our analysis comprises a comprehensive resource of cell-type-specific changes during defined ischaemic intervals and perfusion interventions spanning multiple organs, and it reveals an underappreciated potential for cellular recovery after prolonged whole-body warm ischaemia in a large mammal.
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Affiliation(s)
- David Andrijevic
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,These authors contributed equally: David Andrijevic, Zvonimir Vrselja, Taras Lysyy, Shupei Zhang
| | - Zvonimir Vrselja
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,These authors contributed equally: David Andrijevic, Zvonimir Vrselja, Taras Lysyy, Shupei Zhang
| | - Taras Lysyy
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,Department of Surgery, Yale School of Medicine New Haven, New Haven, CT, USA.,These authors contributed equally: David Andrijevic, Zvonimir Vrselja, Taras Lysyy, Shupei Zhang
| | - Shupei Zhang
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,Department of Genetics, Yale School of Medicine, New Haven, CT, USA.,These authors contributed equally: David Andrijevic, Zvonimir Vrselja, Taras Lysyy, Shupei Zhang
| | - Mario Skarica
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Ana Spajic
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - David Dellal
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Stephanie L. Thorn
- Yale Translational Research Imaging Center, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Robert B. Duckrow
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Shaojie Ma
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Phan Q. Duy
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA.,Medical Scientist Training Program (MD-PhD), Yale School of Medicine, New Haven, CT, USA
| | - Atagun U. Isiktas
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Dan Liang
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Mingfeng Li
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Suel-Kee Kim
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Stefano G. Daniele
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,Medical Scientist Training Program (MD-PhD), Yale School of Medicine, New Haven, CT, USA
| | - Khadija Banu
- Department of Nephrology, Yale School of Medicine, New Haven, CT, USA
| | - Sudhir Perincheri
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Madhav C. Menon
- Department of Nephrology, Yale School of Medicine, New Haven, CT, USA
| | - Anita Huttner
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Kevin N. Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.,Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Kevin T. Gobeske
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Gregory T. Tietjen
- Department of Surgery, Yale School of Medicine New Haven, New Haven, CT, USA.,Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Hitten P. Zaveri
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Stephen R. Latham
- Interdisciplinary Center for Bioethics, Yale University, New Haven, CT, USA
| | - Albert J. Sinusas
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA.,Department of Biomedical Engineering, Yale University, New Haven, CT, USA.,Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, USA.,Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Nenad Sestan
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA. .,Department of Genetics, Yale School of Medicine, New Haven, CT, USA. .,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA. .,Department of Comparative Medicine, Yale School of Medicine, New Haven, CT, USA. .,Program in Cellular Neuroscience, Neurodegeneration and Repair, Yale School of Medicine, New Haven, CT, USA. .,Yale Child Study Center, New Haven, CT, USA.
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Salvage of Declined Extended Criteria DCD Livers Using in-situ Normothermic Regional Perfusion. Ann Surg 2022; 276:e223-e230. [PMID: 35861530 DOI: 10.1097/sla.0000000000005611] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study investigates whether liver grafts donated after circulatory death (DCD) that are declined by the entire Euro-transplant region can be salvaged with abdominal normothermic regional perfusion (aNRP). SUMMARY BACKGROUND DATA aNRP is increasingly used for DCD liver grafts because it prevents typical complications. However, it is unclear whether aNRP is capable to rescue pre-transplant declined liver grafts, by providing the opportunity to test function during donation. METHODS Donor livers from DCD donors, declined by all centers in the Euro-transplant region, were included for this study. The comparator cohort included standard DCD livers and livers donated after brain death, transplanted in the same time period. RESULTS After withdrawal of life-sustaining treatment, 28 from the 43 donors had a circulatory death within 2 hours, in which case aNRP was initiated. Out of these 28 cases, in 3 cases perfusion problems occurred, 5 grafts were declined based on liver assessment, and 20 liver grafts were transplanted. The main differences during aNRP between the transplanted grafts and the assessed non-transplanted grafts were ALT levels of 53 (34-68) versus 367 (318-488; P=0.001) U/l and bile production in 100% versus 50% of the grafts (P=0.024). The 12-month graft and patient survival were both 95%, similar to the comparator cohort. The incidence of ischemic cholangiopathy was 11%, which was lower than in the standard DCD cohort (18%). CONCLUSIONS aNRP can safely select and thus is able to rescue DCD liver grafts that were deemed unsuitable for transplantation, while preventing primary non-function and minimizing ischemic cholangiopathy.
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Panconesi R, Flores Carvalho M, Dondossola D, Muiesan P, Dutkowski P, Schlegel A. Impact of Machine Perfusion on the Immune Response After Liver Transplantation – A Primary Treatment or Just a Delivery Tool. Front Immunol 2022; 13:855263. [PMID: 35874758 PMCID: PMC9304705 DOI: 10.3389/fimmu.2022.855263] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 05/31/2022] [Indexed: 12/12/2022] Open
Abstract
The frequent use of marginal livers forces transplant centres to explore novel technologies to improve organ quality and outcomes after implantation. Organ perfusion techniques are therefore frequently discussed with an ever-increasing number of experimental and clinical studies. Two main approaches, hypothermic and normothermic perfusion, are the leading strategies to be introduced in clinical practice in many western countries today. Despite this success, the number of studies, which provide robust data on the underlying mechanisms of protection conveyed through this technology remains scarce, particularly in context of different stages of ischemia-reperfusion-injury (IRI). Prior to a successful clinical implementation of machine perfusion, the concept of IRI and potential key molecules, which should be addressed to reduce IRI-associated inflammation, requires a better exploration. During ischemia, Krebs cycle metabolites, including succinate play a crucial role with their direct impact on the production of reactive oxygen species (ROS) at mitochondrial complex I upon reperfusion. Such features are even more pronounced under normothermic conditions and lead to even higher levels of downstream inflammation. The direct consequence appears with an activation of the innate immune system. The number of articles, which focus on the impact of machine perfusion with and without the use of specific perfusate additives to modulate the inflammatory cascade after transplantation is very small. This review describes first, the subcellular processes found in mitochondria, which instigate the IRI cascade together with proinflammatory downstream effects and their link to the innate immune system. Next, the impact of currently established machine perfusion strategies is described with a focus on protective mechanisms known for the different perfusion approaches. Finally, the role of such dynamic preservation techniques to deliver specific agents, which appear currently of interest to modulate this posttransplant inflammation, is discussed together with future aspects in this field.
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Affiliation(s)
- Rebecca Panconesi
- Department of Clinical and Experimental Medicine, Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy
- General Surgery 2U-Liver Transplant Unit, Department of Surgery, A.O.U. Città della Salute e della, Scienza di Torino, University of Turin, Turin, Italy
| | - Mauricio Flores Carvalho
- Department of Clinical and Experimental Medicine, Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Daniele Dondossola
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore, Policlinico and University of Milan, Milan, Italy
| | - Paolo Muiesan
- Department of Clinical and Experimental Medicine, Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore, Policlinico and University of Milan, Milan, Italy
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland
| | - Andrea Schlegel
- Department of Clinical and Experimental Medicine, Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore, Policlinico and University of Milan, Milan, Italy
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland
- *Correspondence: Andrea Schlegel,
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Brüggenwirth IMA, Mueller M, Lantinga VA, Camagni S, De Carlis R, De Carlis L, Colledan M, Dondossola D, Drefs M, Eden J, Ghinolfi D, Koliogiannis D, Lurje G, Manzia TM, Monbaliu D, Muiesan P, Patrono D, Pratschke J, Romagnoli R, Rayar M, Roma F, Schlegel A, Dutkowski P, Porte RJ, de Meijer VE. Prolonged preservation by hypothermic machine perfusion facilitates logistics in liver transplantation: A European observational cohort study. Am J Transplant 2022; 22:1842-1851. [PMID: 35315202 PMCID: PMC9540892 DOI: 10.1111/ajt.17037] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 02/14/2022] [Accepted: 03/11/2022] [Indexed: 01/25/2023]
Abstract
A short period (1-2 h) of hypothermic oxygenated machine perfusion (HOPE) after static cold storage is safe and reduces ischemia-reperfusion injury-related complications after liver transplantation. Machine perfusion time is occasionally prolonged for logistical reasons, but it is unknown if prolonged HOPE is safe and compromises outcomes. We conducted a multicenter, observational cohort study of patients transplanted with a liver preserved by prolonged (≥4 h) HOPE. Postoperative biochemistry, complications, and survival were evaluated. The cohort included 93 recipients from 12 European transplant centers between 2014-2021. The most common reason to prolong HOPE was the lack of an available operating room to start the transplant procedure. Grafts underwent HOPE for a median (range) of 4:42 h (4:00-8:35 h) with a total preservation time of 10:50 h (5:50-20:50 h). Postoperative peak ALT was 675 IU/L (interquartile range 419-1378 IU/L). The incidence of postoperative complications was low, and 1-year graft and patient survival were 94% and 88%, respectively. To conclude, good outcomes are achieved after transplantation of donor livers preserved with prolonged (median 4:42 h) HOPE, leading to a total preservation time of almost 21 h. These results suggest that simple, end-ischemic HOPE may be utilized for safe extension of the preservation time to ease transplantation logistics.
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Affiliation(s)
- Isabel M. A. Brüggenwirth
- Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands
| | - Matteo Mueller
- Department of Surgery and TransplantationUniversity Hospital ZurichZurichSwitzerland
| | - Veerle A. Lantinga
- Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands
| | - Stefania Camagni
- Department of Organ Failure and TransplantationASST Papa Giovanni XXIIIBergamoItaly
| | - Riccardo De Carlis
- Department of General Surgery and TransplantationASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | - Luciano De Carlis
- Department of General Surgery and TransplantationASST Grande Ospedale Metropolitano NiguardaMilanItaly,School of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | - Michele Colledan
- Department of Organ Failure and TransplantationASST Papa Giovanni XXIIIBergamoItaly,School of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | - Daniele Dondossola
- General and Liver Transplant Surgery UnitFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan and Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
| | - Moritz Drefs
- Department of General, Visceral, and Transplant SurgeryUniversity Hospital of MunichMunichGermany
| | - Janina Eden
- Department of Surgery and TransplantationUniversity Hospital ZurichZurichSwitzerland
| | - Davide Ghinolfi
- Division of Hepatic Surgery and Liver TransplantationUniversity of Pisa Medical School HospitalPisaItaly
| | - Dionysios Koliogiannis
- Department of General, Visceral, and Transplant SurgeryUniversity Hospital of MunichMunichGermany
| | - Georg Lurje
- Department of SurgeryCharité—Universitätsmedizin BerlinBerlinGermany
| | - Tommaso M. Manzia
- Hepato‐Pancreato‐Biliary and Transplant UnitUniversity of Rome Tor VergataRomeItaly
| | - Diethard Monbaliu
- Department of Abdominal Transplant Surgery and Transplant CoordinationUniversity Hospitals LeuvenCatholic University LeuvenLeuvenBelgium
| | - Paolo Muiesan
- General and Liver Transplant Surgery UnitFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan and Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
| | - Damiano Patrono
- AOU Città della Salute e della Scienza di TorinoUniversity of TurinTurinItaly
| | - Johann Pratschke
- Department of SurgeryCharité—Universitätsmedizin BerlinBerlinGermany
| | - Renato Romagnoli
- AOU Città della Salute e della Scienza di TorinoUniversity of TurinTurinItaly
| | - Michel Rayar
- CHU Rennes, Service de Chirurgie Hépatobiliaire et DigestiveRennesFrance
| | - Federico Roma
- General and Liver Transplant Surgery UnitFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan and Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
| | - Andrea Schlegel
- Department of Surgery and TransplantationUniversity Hospital ZurichZurichSwitzerland,General and Liver Transplant Surgery UnitFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan and Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
| | - Philipp Dutkowski
- Department of Surgery and TransplantationUniversity Hospital ZurichZurichSwitzerland
| | - Robert J. Porte
- Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands
| | - Vincent E. de Meijer
- Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands
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Melandro F, Basta G, Torri F, Biancofiore G, Del Turco S, Orlando F, Guarracino F, Maremmani P, Lazzeri C, Peris A, De Simone P, Ghinolfi D. Normothermic regional perfusion in liver transplantation from donation after cardiocirculatory death: Technical, biochemical, and regulatory aspects and review of literature. Artif Organs 2022; 46:1727-1740. [PMID: 35733227 DOI: 10.1111/aor.14330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/21/2022] [Accepted: 05/25/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Organs from donation after circulatory death (DCD) are increasingly used for liver transplantation, due to the persisting organ shortage and waiting list mortality. However, the use of DCD grafts is still limited by the inferior graft survival rate and the increased risk of primary non-function and biliary complications when compared to brain death donors' grafts. METHODS Abdominal normothermic regional perfusion with extracorporeal membrane oxygenation (ECMO) is an in situ preservation strategy. which may mitigate ischemia-reperfusion injuries. and has been proposed to restore blood perfusion after the determination of death thus optimizing liver function before implantation. RESULTS In this systematic review, we highlighted the clinical evidence supporting the use of normothermic regional perfusion in DCD liver underlying the pathophysiological mechanisms, and technical, logistic, and regulatory aspects. CONCLUSIONS Despite the lack of properly designed, prospective, randomized trials, the current available data suggest beneficial effects of normothermic regional perfusion on clinical outcomes after liver transplantation.
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Affiliation(s)
- Fabio Melandro
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Giuseppina Basta
- Institute of Clinical Physiology, CNR San Cataldo Research Area, Pisa, Italy
| | - Francesco Torri
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Giandomenico Biancofiore
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy.,Department of Surgical, Medical, Biochemical Pathology and Intensive Care, University of Pisa, Pisa, Italy
| | - Serena Del Turco
- Institute of Clinical Physiology, CNR San Cataldo Research Area, Pisa, Italy
| | - Francesco Orlando
- Hepatobiliary Surgery and Liver Transplant Center Hospital A. Cardarelli, Naples, Italy
| | - Fabio Guarracino
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Paolo Maremmani
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Chiara Lazzeri
- Tuscany Regional Transplant Authority, Centro Regionale Allocazione Organi e Tessuti (CRAOT), Florence, Italy
| | - Adriano Peris
- Tuscany Regional Transplant Authority, Centro Regionale Allocazione Organi e Tessuti (CRAOT), Florence, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy.,Department of Surgical, Medical, Biochemical Pathology and Intensive Care, University of Pisa, Pisa, Italy
| | - Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
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40
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Schlegel A, Porte R, Dutkowski P. Protective mechanisms and current clinical evidence of hypothermic oxygenated machine perfusion (HOPE) in preventing post-transplant cholangiopathy. J Hepatol 2022; 76:1330-1347. [PMID: 35589254 DOI: 10.1016/j.jhep.2022.01.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/10/2022] [Accepted: 01/31/2022] [Indexed: 12/12/2022]
Abstract
The development of cholangiopathies after liver transplantation impacts on the quality and duration of graft and patient survival, contributing to higher costs as numerous interventions are required to treat strictures and infections at the biliary tree. Prolonged donor warm ischaemia time in combination with additional cold storage are key risk factors for the development of biliary strictures. Based on this, the clinical implementation of dynamic preservation strategies is a current hot topic in the field of donation after circulatory death (DCD) liver transplantation. Despite various retrospective studies reporting promising results, also regarding biliary complications, there are only a few randomised-controlled trials on machine perfusion. Recently, the group from Groningen has published the first randomised-controlled trial on hypothermic oxygenated perfusion (HOPE), demonstrating a significant reduction of symptomatic ischaemic cholangiopathies with the use of a short period of HOPE before DCD liver implantation. The most likely mechanism for this important effect, also shown in several experimental studies, is based on mitochondrial reprogramming under hypothermic aerobic conditions, e.g. exposure to oxygen in the cold, with a controlled and slow metabolism of ischaemically accumulated succinate and simultaneous ATP replenishment. This unique feature prevents mitochondrial oxidative injury and further downstream tissue inflammation. HOPE treatment therefore supports livers by protecting them from ischaemia-reperfusion injury (IRI), and thereby also prevents the development of post-transplant biliary injury. With reduced IRI-associated inflammation, recipients are also protected from activation of the innate immune system, with less acute rejections seen after HOPE.
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Affiliation(s)
- Andrea Schlegel
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland; General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20100 Milan, Italy
| | - Robert Porte
- Department of Surgery, Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Philipp Dutkowski
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland.
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41
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Croome KP, Mathur AK, Aqel B, Yang L, Taner T, Heimbach JK, Rosen CB, Paz-Fumagalli R, Taner CB. Classification of Distinct Patterns of Ischemic Cholangiopathy Following DCD Liver Transplantation: Distinct Clinical Courses and Long-term Outcomes From a Multicenter Cohort. Transplantation 2022; 106:1206-1214. [PMID: 34468429 DOI: 10.1097/tp.0000000000003928] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND As the number of donation after circulatory death (DCD) liver transplants (LTs) performed in the United States continues to increase annually, there has been interest by policy makers to develop a more robust exception point safety net for patients who develop ischemic cholangiopathy (IC) following DCD LT. As such, there is a need for better understanding of the clinical course and long-term outcomes in patients who develop IC, as well as determining if IC can be classified into distinct categories with distinctly different clinical outcomes. METHODS All DCD LT performed at Mayo Clinic Florida, Mayo Clinic Arizona, and Mayo Clinic Rochester from January 1999 to March 2020 were included (N = 770). Outcomes were compared between 4 distinct radiologic patterns of IC: diffuse necrosis, multifocal progressive, confluence dominant, and minor form. RESULTS In total, 88 (11.4%) patients developed IC, of which 42 (5.5%) were listed for retransplantation of liver (ReLT). Patients with diffuse necrosis and multifocal progressive patterns suffered from frequent hospital admissions for cholangitis in the first year following DCD LT (median 3 and 2), were largely stent dependent (100% and 85.7%), and almost universally required ReLT. Patients with confluence dominant disease were managed with multiple stents and frequently recovered, ultimately becoming stent free without need for ReLT. Patients with the minor form IC did well with limited need for stent placement or repeat procedures and did not require ReLT. Graft survival was different between the 4 distinct IC patterns (P < 0.001). CONCLUSIONS The present analysis provides a detailed analysis on the natural history and clinical course of IC. Patients developing IC can be classified into 4 distinct patterns with distinct clinical courses.
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Affiliation(s)
| | - Amit K Mathur
- Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Bashar Aqel
- Division of Gastroenterology and hepatology, Mayo Clinic Arizona, Phoenix, AZ
| | - Liu Yang
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - Timucin Taner
- Department of Surgery, Mayo Clinic Rochester, Rochester, MN
| | | | | | | | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
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De Simone P, Ghinolfi D. Hospital-Based Health Technology Assessment of Machine Perfusion Systems for Human Liver Transplantation. Transpl Int 2022; 35:10405. [PMID: 35692735 PMCID: PMC9184439 DOI: 10.3389/ti.2022.10405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/05/2022] [Indexed: 01/14/2023]
Abstract
Based on published data, we have carried out a hospital-based health technology assessment of machine perfusion in adult liver transplantation using cold storage as a comparator, and within the perspective of a national health system-based hospital practice and disease-related group reimbursement policy. A systematic literature review on machine perfusion for adult liver transplantation was conducted exploring the Pubmed, CINAHL, Scopus, Embase, and Cochrane databases. The literature was analyzed with the intent to provide information on 6 dimensions and 19 items of the hospital-based health technology assessment framework derived from previous studies. Out of 705 references, 47 (6.7%) were retained for current analysis. Use of machine perfusion was associated with advantages over cold storage, i.e., a 10%–50% reduced risk for early allograft dysfunction, 7%–15% less ischemia reperfusion injury; 7%–50% fewer ischemic biliary complications, comparable or improved 1-year graft and patient survival, and up to a 50% lower graft discard rate. Hospital stay was not longer, and technical failures were anecdotal. Information on costs of machine perfusion is limited, but this technology is projected to increase hospital costs while cost-effectiveness analysis requires data over the transplant patient lifetime. No hospital-based health technology assessment study on machine perfusion in liver transplantation was previously conducted. From the hospital perspective, there is evidence of the clinical advantages of this novel technology, but strategies to counterbalance the increased costs of liver transplantation are urgently needed. Further studies should focus on the ethical, social, and organizational issues related to machine perfusion.
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Affiliation(s)
- Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
- Department of Surgical, Medical, Biomolecular Pathology and Intensive Care Unit, University of Pisa, Pisa, Italy
- *Correspondence: Paolo De Simone,
| | - Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
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43
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Patrono D, Zanierato M, Vergano M, Magaton C, Diale E, Rizza G, Catalano S, Mirabella S, Cocchis D, Potenza R, Livigni S, Balagna R, Romagnoli R. Normothermic Regional Perfusion and Hypothermic Oxygenated Machine Perfusion for Livers Donated After Controlled Circulatory Death With Prolonged Warm Ischemia Time: A Matched Comparison With Livers From Brain-Dead Donors. Transpl Int 2022; 35:10390. [PMID: 35529593 PMCID: PMC9072630 DOI: 10.3389/ti.2022.10390] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/31/2022] [Indexed: 12/29/2022]
Abstract
Prolonged warm ischemia time (WIT) has a negative prognostic value in liver transplantation (LT) using grafts procured after circulatory death (DCD). To assess the value of abdominal normothermic regional perfusion (A-NRP) associated with dual hypothermic oxygenated machine perfusion (D-HOPE) in controlled DCD LT, prospectively collected data on LTs performed between January 2016 and July 2021 were analyzed. Outcome of controlled DCD LTs performed using A-NRP + D-HOPE (n = 20) were compared to those performed with grafts procured after brain death (DBD) (n = 40), selected using propensity-score matching. DCD utilization rate was 59.5%. In the DCD group, median functional WIT, A-NRP and D-HOPE time was 43, 246, and 205 min, respectively. Early outcomes of DCD grafts recipients were comparable to those of matched DBD LTs. In DCD and DBD group, incidence of anastomotic biliary complications and ischemic cholangiopathy was 15% versus 22% (p = 0.73) and 5% versus 2% (p = 1), respectively. One-year patient and graft survival was 100% versus 95% (p = 0.18) and 90% versus 95% (p = 0.82). In conclusion, the association of A-NRP + D-HOPE in DCD LT with prolonged WIT allows achieving comparable outcomes to DBD LT.
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Affiliation(s)
- Damiano Patrono
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Marinella Zanierato
- Department of Anesthesia and Critical Care, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Marco Vergano
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Turin, Italy
| | - Chiara Magaton
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Enrico Diale
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Giorgia Rizza
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Silvia Catalano
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Stefano Mirabella
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Donatella Cocchis
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Raffaele Potenza
- Regional Procurement Organization, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Sergio Livigni
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Turin, Italy
| | - Roberto Balagna
- Anesthesia Department 2, A.O.U. Città Della Salute e Della Scienza di Torino, Turin, Italy
| | - Renato Romagnoli
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
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44
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Patrono D, Cussa D, Sciannameo V, Montanari E, Panconesi R, Berchialla P, Lepore M, Gambella A, Rizza G, Catalano G, Mirabella S, Tandoi F, Lupo F, Balagna R, Salizzoni M, Romagnoli R. Outcome of liver transplantation with grafts from brain-dead donors treated with dual hypothermic oxygenated machine perfusion, with particular reference to elderly donors. Am J Transplant 2022; 22:1382-1395. [PMID: 35150050 PMCID: PMC9303789 DOI: 10.1111/ajt.16996] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/21/2021] [Accepted: 01/12/2022] [Indexed: 01/25/2023]
Abstract
Prompted by the utilization of extended criteria donors, dual hypothermic oxygenated machine perfusion (D-HOPE) was introduced in liver transplantation to improve preservation. When donors after neurological determination of death (DBD) are used, D-HOPE effect on graft outcomes is unclear. To assess D-HOPE value in this setting and to identify ideal scenarios for its use, data on primary adult liver transplant recipients from January 2014 to April 2021 were analyzed using inverse probability of treatment weighting, comparing outcomes of D-HOPE-treated grafts (n = 121) with those preserved by static cold storage (n = 723). End-ischemic D-HOPE was systematically applied since November 2017 based on donor and recipient characteristics and transplant logistics. D-HOPE use was associated with a significant reduction of early allograft failure (OR: 0.24; 0.83; p = .024), grade ≥3 complications (OR: 0.57; p = .046), comprehensive complication index (-7.20 points; p = .003), and improved patient and graft survival. These results were confirmed in the subset of elderly donors (>75-year-old). Although D-HOPE did not reduce the incidence of biliary complications, its use was associated with a reduced severity of ischemic cholangiopathy. In conclusion, D-HOPE improves postoperative outcomes and reduces early allograft loss in extended criteria DBD grafts.
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Affiliation(s)
- Damiano Patrono
- General Surgery 2U ‐ Liver Transplant UnitA.O.U. Città della Salute e della Scienza di TorinoUniversity of TurinTurinItaly
| | - Davide Cussa
- General Surgery 2U ‐ Liver Transplant UnitA.O.U. Città della Salute e della Scienza di TorinoUniversity of TurinTurinItaly
| | | | - Elena Montanari
- General Surgery 2U ‐ Liver Transplant UnitA.O.U. Città della Salute e della Scienza di TorinoUniversity of TurinTurinItaly
| | - Rebecca Panconesi
- General Surgery 2U ‐ Liver Transplant UnitA.O.U. Città della Salute e della Scienza di TorinoUniversity of TurinTurinItaly
| | - Paola Berchialla
- Department of Clinical and Biological SciencesUniversity of TurinTurinItaly
| | - Mirella Lepore
- General Surgery 2U ‐ Liver Transplant UnitA.O.U. Città della Salute e della Scienza di TorinoUniversity of TurinTurinItaly
| | | | - Giorgia Rizza
- General Surgery 2U ‐ Liver Transplant UnitA.O.U. Città della Salute e della Scienza di TorinoUniversity of TurinTurinItaly
| | - Giorgia Catalano
- General Surgery 2U ‐ Liver Transplant UnitA.O.U. Città della Salute e della Scienza di TorinoUniversity of TurinTurinItaly
| | - Stefano Mirabella
- General Surgery 2U ‐ Liver Transplant UnitA.O.U. Città della Salute e della Scienza di TorinoUniversity of TurinTurinItaly
| | - Francesco Tandoi
- General Surgery 2U ‐ Liver Transplant UnitA.O.U. Città della Salute e della Scienza di TorinoUniversity of TurinTurinItaly
| | - Francesco Lupo
- General Surgery 2U ‐ Liver Transplant UnitA.O.U. Città della Salute e della Scienza di TorinoUniversity of TurinTurinItaly
| | - Roberto Balagna
- Anesthesia Department 2A.O.U. Città della Salute e della Scienza di TorinoTurinItaly
| | - Mauro Salizzoni
- General Surgery 2U ‐ Liver Transplant UnitA.O.U. Città della Salute e della Scienza di TorinoUniversity of TurinTurinItaly
| | - Renato Romagnoli
- General Surgery 2U ‐ Liver Transplant UnitA.O.U. Città della Salute e della Scienza di TorinoUniversity of TurinTurinItaly
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45
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Hessheimer AJ, de la Rosa G, Gastaca M, Ruíz P, Otero A, Gómez M, Alconchel F, Ramírez P, Bosca A, López-Andújar R, Atutxa L, Royo-Villanova M, Sánchez B, Santoyo J, Marín LM, Gómez-Bravo MÁ, Mosteiro F, Villegas Herrera MT, Villar Del Moral J, González-Abos C, Vidal B, López-Domínguez J, Lladó L, Roldán J, Justo I, Jiménez C, López-Monclús J, Sánchez-Turrión V, Rodríguez-Laíz G, Velasco Sánchez E, López-Baena JÁ, Caralt M, Charco R, Tomé S, Varo E, Martí-Cruchaga P, Rotellar F, Varona MA, Barrera M, Rodríguez-Sanjuan JC, Briceño J, López D, Blanco G, Nuño J, Pacheco D, Coll E, Domínguez-Gil B, Fondevila C. Abdominal normothermic regional perfusion in controlled donation after circulatory determination of death liver transplantation: Outcomes and risk factors for graft loss. Am J Transplant 2022; 22:1169-1181. [PMID: 34856070 DOI: 10.1111/ajt.16899] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/11/2021] [Accepted: 11/11/2021] [Indexed: 01/25/2023]
Abstract
Postmortem normothermic regional perfusion (NRP) is a rising preservation strategy in controlled donation after circulatory determination of death (cDCD). Herein, we present results for cDCD liver transplants performed in Spain 2012-2019, with outcomes evaluated through December 31, 2020. Results were analyzed retrospectively and according to recovery technique (abdominal NRP [A-NRP] or standard rapid recovery [SRR]). During the study period, 545 cDCD liver transplants were performed with A-NRP and 258 with SRR. Median donor age was 59 years (interquartile range 49-67 years). Adjusted risk estimates were improved with A-NRP for overall biliary complications (OR 0.300, 95% CI 0.197-0.459, p < .001), ischemic type biliary lesions (OR 0.112, 95% CI 0.042-0.299, p < .001), graft loss (HR 0.371, 95% CI 0.267-0.516, p < .001), and patient death (HR 0.540, 95% CI 0.373-0.781, p = .001). Cold ischemia time (HR 1.004, 95% CI 1.001-1.007, p = .021) and re-transplantation indication (HR 9.552, 95% CI 3.519-25.930, p < .001) were significant independent predictors for graft loss among cDCD livers with A-NRP. While use of A-NRP helps overcome traditional limitations in cDCD liver transplantation, opportunity for improvement remains for cases with prolonged cold ischemia and/or technically complex recipients, indicating a potential role for complimentary ex situ perfusion preservation techniques.
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Affiliation(s)
- Amelia J Hessheimer
- General & Digestive Surgery, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain.,General & Digestive Surgery Service, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Barcelona, Spain.,IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | | | | | | | - Alejandra Otero
- Complejo Hospitalario Universitario La Coruña, A Coruna, Spain
| | - Manuel Gómez
- Complejo Hospitalario Universitario La Coruña, A Coruna, Spain
| | - Felipe Alconchel
- Hospital Clínico Universitario Virgen de la Arrixaca, IMIB, El Palmar, Spain
| | - Pablo Ramírez
- Hospital Clínico Universitario Virgen de la Arrixaca, IMIB, El Palmar, Spain
| | - Andrea Bosca
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Rafael López-Andújar
- Hospital Universitario y Politécnico La Fe, Valencia, Spain.,CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Lánder Atutxa
- Hospital Universitario Donostia, San Sebastián, Spain
| | | | | | | | - Luís M Marín
- Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | | | | | | | - Carolina González-Abos
- General & Digestive Surgery Service, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Barcelona, Spain
| | - Bárbara Vidal
- Hospital General Universitario de Castellón, Castellón, Spain
| | | | - Laura Lladó
- Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Spain
| | - José Roldán
- Hospital Universitario de Navarra, Pamplona, Spain
| | - Iago Justo
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | | | - Gonzalo Rodríguez-Laíz
- Department of General & Digestive Surgery, ISABIAL, Hospital General Universitario de Alicante, Alicante, Spain
| | | | | | - Mireia Caralt
- Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | - Ramón Charco
- Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | - Santiago Tomé
- Complejo Hospitalario Universitario Santiago, Santiago de Compostela, Spain
| | - Evaristo Varo
- Complejo Hospitalario Universitario Santiago, Santiago de Compostela, Spain
| | - Pablo Martí-Cruchaga
- HPB and Liver Transplant Unit, General & Digestive Surgery, Clínica Universitaria de Navarra, Pamplona, Spain
| | - Fernando Rotellar
- HPB and Liver Transplant Unit, General & Digestive Surgery, Clínica Universitaria de Navarra, Pamplona, Spain
| | - María A Varona
- Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Manuel Barrera
- Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | | | | | - Diego López
- Hospital Universitario Infanta Cristina, Badajoz, Spain
| | | | - Javier Nuño
- Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - David Pacheco
- Hospital Universitario Río Hortega, Valladolid, Spain
| | | | | | - Constantino Fondevila
- General & Digestive Surgery, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain.,General & Digestive Surgery Service, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Barcelona, Spain.,IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
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46
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De Carlis R, Lauterio A, Centonze L, Buscemi V, Schlegel A, Muiesan P, De Carlis L, Carraro A, Ghinolfi D, De Simone P, Ravaioli M, Cescon M, Dondossola D, Bongini M, Mazzaferro V, Pagano D, Gruttadauria S, Gringeri E, Cillo U, Patrono D, Romagnoli R, Camagni S, Colledan M, Olivieri T, Di Benedetto F, Vennarecci G, Baccarani U, Lai Q, Rossi M, Manzia TM, Tisone G, Vivarelli M, Scalera I, Lupo LG, Andorno E, Meniconi RL, Ettorre GM, Avolio AW, Agnes S, Pellegrino RA, Zamboni F. Current practice of normothermic regional perfusion and machine perfusion in donation after circulatory death liver transplants in Italy. Updates Surg 2022; 74:501-510. [PMID: 35226307 DOI: 10.1007/s13304-022-01259-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 02/15/2022] [Indexed: 12/21/2022]
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47
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Schlegel A, van Reeven M, Croome K, Parente A, Dolcet A, Widmer J, Meurisse N, De Carlis R, Hessheimer A, Jochmans I, Mueller M, van Leeuwen OB, Nair A, Tomiyama K, Sherif A, Elsharif M, Kron P, van der Helm D, Borja-Cacho D, Bohorquez H, Germanova D, Dondossola D, Olivieri T, Camagni S, Gorgen A, Patrono D, Cescon M, Croome S, Panconesi R, Carvalho MF, Ravaioli M, Caicedo JC, Loss G, Lucidi V, Sapisochin G, Romagnoli R, Jassem W, Colledan M, De Carlis L, Rossi G, Di Benedetto F, Miller CM, van Hoek B, Attia M, Lodge P, Hernandez-Alejandro R, Detry O, Quintini C, Oniscu GC, Fondevila C, Malagó M, Pirenne J, IJzermans JNM, Porte RJ, Dutkowski P, Taner CB, Heaton N, Clavien PA, Polak WG, Muiesan P. A multicentre outcome analysis to define global benchmarks for donation after circulatory death liver transplantation. J Hepatol 2022; 76:371-382. [PMID: 34655663 DOI: 10.1016/j.jhep.2021.10.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 09/17/2021] [Accepted: 10/04/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS The concept of benchmarking is established in the field of transplant surgery; however, benchmark values for donation after circulatory death (DCD) liver transplantation are not available. Thus, we aimed to identify the best possible outcomes in DCD liver transplantation and to propose outcome reference values. METHODS Based on 2,219 controlled DCD liver transplantations, collected from 17 centres in North America and Europe, we identified 1,012 low-risk, primary, adult liver transplantations with a laboratory MELD score of ≤20 points, receiving a DCD liver with a total donor warm ischemia time of ≤30 minutes and asystolic donor warm ischemia time of ≤15 minutes. Clinically relevant outcomes were selected and complications were reported according to the Clavien-Dindo-Grading and the comprehensive complication index (CCI). Corresponding benchmark cut-offs were based on median values of each centre, where the 75th-percentile was considered. RESULTS Benchmark cases represented between 19.7% and 75% of DCD transplantations in participating centres. The 1-year retransplant and mortality rates were 4.5% and 8.4% in the benchmark group, respectively. Within the first year of follow-up, 51.1% of recipients developed at least 1 major complication (≥Clavien-Dindo-Grade III). Benchmark cut-offs were ≤3 days and ≤16 days for ICU and hospital stay, ≤66% for severe recipient complications (≥Grade III), ≤16.8% for ischemic cholangiopathy, and ≤38.9 CCI points 1 year after transplant. Comparisons with higher risk groups showed more complications and impaired graft survival outside the benchmark cut-offs. Organ perfusion techniques reduced the complications to values below benchmark cut-offs, despite higher graft risk. CONCLUSIONS Despite excellent 1-year survival, morbidity in benchmark cases remains high. Benchmark cut-offs targeting morbidity parameters offer a valid tool to assess the protective value of new preservation technologies in higher risk groups and to provide a valid comparator cohort for future clinical trials. LAY SUMMARY The best possible outcomes after liver transplantation of grafts donated after circulatory death (DCD) were defined using the concept of benchmarking. These were based on 2,219 liver transplantations following controlled DCD donation in 17 centres worldwide. Donor and recipient combinations with higher risk had significantly worse outcomes. However, the use of novel organ perfusion technology helped high-risk patients achieve similar outcomes as the benchmark cohort.
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Affiliation(s)
- Andrea Schlegel
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom; Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland; Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Marjolein van Reeven
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Department of Surgery, Division of Hepato-Pancreato-Biliary and Transplant Surgery, Rotterdam, the Netherlands
| | - Kristopher Croome
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 United States
| | - Alessandro Parente
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom
| | - Annalisa Dolcet
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Jeannette Widmer
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland; HPB Surgery and Liver Transplantation, Royal Free Hospital London, United Kingdom
| | - Nicolas Meurisse
- Department of Abdominal Surgery and Transplantation, CHU Liege, University of Liege, Liege, Belgium
| | - Riccardo De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Amelia Hessheimer
- General & Digestive Surgery, Hospital Clínic Barcelona, Barcelona, Spain; CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Ina Jochmans
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium; Abdominal Transplant Surgery, Department of Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Matteo Mueller
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
| | - Otto B van Leeuwen
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Amit Nair
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA; Division of Transplantation/Hepatobiliary Surgery, Department of Surgery, University of Rochester, NY, USA
| | - Koji Tomiyama
- Division of Transplantation/Hepatobiliary Surgery, Department of Surgery, University of Rochester, NY, USA
| | - Ahmed Sherif
- Department of Transplant Surgery, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, United Kingdom
| | - Mohamed Elsharif
- HPB and Transplant Unit, St James's University Hospital, Leeds LS9 7TF, United Kingdom
| | - Philipp Kron
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland; HPB and Transplant Unit, St James's University Hospital, Leeds LS9 7TF, United Kingdom
| | - Danny van der Helm
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Daniel Borja-Cacho
- Division of Transplantation, Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Humberto Bohorquez
- Multi-Organ Transplant Institute, University of Queensland School and the Ochsner Clinical School, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - Desislava Germanova
- Department of abdominal surgery, Unit of hepato-biliary surgery and abdominal transplantation, CUB Erasme Hospital, Free University of Brussels (ULB), Brussels, Belgium
| | - Daniele Dondossola
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan 20122, Italy
| | - Tiziana Olivieri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefania Camagni
- Department of Organ Failure and Transplantation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Andre Gorgen
- Multi-Organ Transplant Program, Division of General Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Damiano Patrono
- General Surgery 2U-Liver Transplant Unit, Department of Surgery, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Matteo Cescon
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sarah Croome
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 United States
| | - Rebecca Panconesi
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy; General Surgery 2U-Liver Transplant Unit, Department of Surgery, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | | | - Matteo Ravaioli
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Juan Carlos Caicedo
- Division of Transplantation, Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - George Loss
- Multi-Organ Transplant Institute, University of Queensland School and the Ochsner Clinical School, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - Valerio Lucidi
- Department of abdominal surgery, Unit of hepato-biliary surgery and abdominal transplantation, CUB Erasme Hospital, Free University of Brussels (ULB), Brussels, Belgium
| | | | - Renato Romagnoli
- General Surgery 2U-Liver Transplant Unit, Department of Surgery, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Wayel Jassem
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Michele Colledan
- Department of Organ Failure and Transplantation, Papa Giovanni XXIII Hospital, Bergamo, Italy; Università di Milano-Bicocca, Milano, Italy
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Giorgio Rossi
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan 20122, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Charles M Miller
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Magdy Attia
- HPB and Transplant Unit, St James's University Hospital, Leeds LS9 7TF, United Kingdom
| | - Peter Lodge
- HPB and Transplant Unit, St James's University Hospital, Leeds LS9 7TF, United Kingdom
| | | | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, CHU Liege, University of Liege, Liege, Belgium
| | - Cristiano Quintini
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gabriel C Oniscu
- Department of Transplant Surgery, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, United Kingdom
| | - Constantino Fondevila
- General & Digestive Surgery, Hospital Clínic Barcelona, Barcelona, Spain; CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Massimo Malagó
- HPB Surgery and Liver Transplantation, Royal Free Hospital London, United Kingdom
| | - Jacques Pirenne
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium; Abdominal Transplant Surgery, Department of Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jan N M IJzermans
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Department of Surgery, Division of Hepato-Pancreato-Biliary and Transplant Surgery, Rotterdam, the Netherlands
| | - Robert J Porte
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 United States
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
| | - Wojciech G Polak
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Department of Surgery, Division of Hepato-Pancreato-Biliary and Transplant Surgery, Rotterdam, the Netherlands
| | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom; Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy; General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan 20122, Italy.
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Boteon YL, Hessheimer AJ, Brüggenwirth IMA, Boteon APCS, Padilla M, de Meijer VE, Domínguez-Gil B, Porte RJ, Perera MTPR, Martins PN. The economic impact of machine perfusion technology in liver transplantation. Artif Organs 2021; 46:191-200. [PMID: 34878658 DOI: 10.1111/aor.14131] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/03/2021] [Accepted: 11/14/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Several clinical studies have demonstrated the safety, feasibility, and efficacy of machine perfusion in liver transplantation, although its economic outcomes are still underexplored. This review aimed to examine the costs related to machine perfusion and its associated outcomes. METHODS Expert opinion of several groups representing different machine perfusion modalities. Critical analysis of the published literature reporting the economic outcomes of the most used techniques of machine perfusion in liver transplantation (normothermic and hypothermic ex situ machine perfusion and in situ normothermic regional perfusion). RESULTS Machine perfusion costs include disposable components of the perfusion device, perfusate components, personnel and facility fees, and depreciation of the perfusion device or device lease fee. The limited current literature suggests that although this upfront cost varies between perfusion modalities, its use is highly likely to be cost-effective. Optimization of the donor liver utilization rate, local conditions of transplant programs (long waiting list times and higher MELD scores), a decreased rate of complications, changes in logistics, and length of hospital stay are potential cost savings points that must highlight the expected benefits of this intervention. An additional unaccounted factor is that machine perfusion optimizing donor organ utilization allows patients to be transplanted earlier, avoiding clinical deterioration while on the waiting list and the costs associated with hospital admissions and other required procedures. CONCLUSION So far, the clinical benefits have guided machine perfusion implementation in liver transplantation. Albeit there is data suggesting the economic benefit of the technique, further investigation of its costs to healthcare systems and society and associated outcomes is needed.
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Affiliation(s)
- Yuri L Boteon
- Liver Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Amelia J Hessheimer
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Hospital Universitario La Paz, Madrid, Spain
| | - Isabel M A Brüggenwirth
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - María Padilla
- Organización Nacional de Trasplantes, Ministerio de Sanidad, Madrid, Spain
| | - Vincent E de Meijer
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Robert J Porte
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M Thamara P R Perera
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paulo N Martins
- Department of Surgery, Transplant Division, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Dondossola D, Ravaioli M, Germinario G, Cescon M, Rossi G. Reply. Liver Transpl 2021; 27:1684-1685. [PMID: 34137157 DOI: 10.1002/lt.26211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/03/2021] [Indexed: 01/13/2023]
Affiliation(s)
- Daniele Dondossola
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Matteo Ravaioli
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy.,Department of General Surgery and Transplantation, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giuliana Germinario
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy.,Department of General Surgery and Transplantation, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Cescon
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy.,Department of General Surgery and Transplantation, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giorgio Rossi
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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50
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Patrono D, Potenza R, Zanierato M, Romagnoli R. The Role of Ex Situ Hypothermic Oxygenated Machine Perfusion and Cold Preservation Time in Extended Criteria Donation After Circulatory Death and Donation After Brain Death. Liver Transpl 2021; 27:1682-1683. [PMID: 34118110 DOI: 10.1002/lt.26204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/04/2021] [Indexed: 01/13/2023]
Affiliation(s)
- Damiano Patrono
- General Surgery 2U - Liver Transplant Center, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Raffaele Potenza
- Regional Procurement Organization, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Marinella Zanierato
- Department of Anesthesia and Critical Care, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Renato Romagnoli
- General Surgery 2U - Liver Transplant Center, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
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