Time needed for removal of the liver after in situ cold perfusion in donation after circulatory death donors is an independent risk factor for the development of biliary strictures and early graft loss after transplantation

O.B. van Leeuwen, M. van Reeven, M. Fujiyoshi, V.E.D.M. de Meijer, R.H.J. de Kleine, M.T. de Boer, J. de Jonge, J.N.M. IJzermans, W.G. Polak, R.J. Porte

Thursday 15 march 2018

11:55 - 12:05h at Willem Burger Zaal

Categories: Clinical, Session (parallel)

Parallel session: Parallel session 3: Clinical

Introduction

Liver transplantation (LT) from donors after circulatory death (DCD) is associated with an increased risk of non-anastomotic biliary strictures (NAS) and early graft loss (EGL). The time between withdrawal of life support and start of in situ cold flush in the donor is an important risk factor for NAS after DCD LT due to warm ischemic injury of the biliary tree. However, even after in situ cold flush, donor livers continue to suffer warm ischemia as the liver temperature stays between 15-20^°C until stored in a box with ice. The aim of this study was to determine whether duration of donor hepatectomy time is associated with an increased risk of NAS and/or EGL after DCD LT.

Methods

A multicenter retrospective study was performed including all adult patients who underwent DCD LT’s between 2004-2017. Baseline donor and recipient characteristics and data on post-transplant outcomes were collected and analyzed. Donor hepatectomy time was defined as time from in situ cold flush until end of hepatectomy, NAS as bile duct stenosis within two years after LT at any location in the biliary tree other than the anastomosis, EGL as graft loss within 3 months, donor warm ischemia time (WIT) as time from cardiac arrest until start of cold flush. Continuous data are expressed as median (IQR).

Results

Of 270 DCD LT’s, 32 patients were excluded because of incomplete donor data. Baseline characteristics in the remaining 238 procedures were as follows: donor age 47 (36-54) years, donor BMI 24 (22-26) kg/m², recipient MELD-score 20 (15-24) and recipient age 55 (48-62) years. Donor WIT was 16 (13-19) min, cold ischemia time 416 (358-461) min. Median donor hepatectomy time was 62 (49-76) min with significant differences among procurement teams. Overall rate of NAS was 22.7% and EGL occurred in 13.4%. Using univariate analysis, donor WIT, donor hepatectomy time and donor age were identified as significant risk factors for NAS and EGL. After multivariate logistic regression analysis donor hepatectomy time (OR 3,17; 95% CI, 1,37-7,33; p=0.007) and donor age (OR 2,24; 95% CI, 1,17-4,29; p=0.015) were identified as significant independent risk factors for the development of NAS and/or EGL.

Conclusion

Donor hepatectomy time is an independent risk factor for the development of NAS and/or EGL after DCD LT. Livers continue to suffer relatively warm ischemic injury during donor hepatectomy and this time period should be kept as short as possible, especially in DCD donors.