Aim: Donation after cardiac death (DCD) is a valuable source of liver grafts Little is known about the impact of severe hypoxemia and hypotension before asystole on patient outcome. We analyzed different patterns of donor ischemia and outcomes in DCD liver transplantation (LTx).

Patients-Methods: 27 DCD LTx (20M, 7F, median age 58 years [range 37-73] were performed at our center between 2008-2012. DCD selection criteria were: age ≤ 60y, BMI ≤30 and warm ischemia time (WIT, extubation to cold perfusion) ≤30min. Patients were divided in 2 groups based on duration of hypoxemia (SpO2 <80%) and hypotension (MAP <50 mmHg) for >50% (group A) or ≤50% (group B) of the interval between extubation and asystole. Biliary complications (BC) and survival rates of DCD were compared to 330 adult LTx from brain dead donors (DBD) during the same period. Indications for LTx and allocation criteria were comparable with the exclusion of re-transplants and recipients with prior complex abdominal surgery from DCD offers.

Results: Median DCD donor age was 35y [12-59], time to asystole 13 min [4-20], WIT 20min [10-30], CIT 6:02hrs [2:51-9:27]. Median DCD recipient age was 58y [37-73] and MELD score 25. In DBD recipients median age was 55y [19-73] and MELD score 18. 5 DCD patients (19%) developed BC (3 anastomotic stricture, 1 diffuse cholangiopathy, 1 sludge/stone) compared to 54 (16%) in the DBD group (p=0.79). BC developed in 3 pts in hypoxemia group A (n=20) and 2 pts in group B (n=6) (p=0.56), as well as in 1 pt in hypotension group A (n=8) and 4 pts in group B (n=19) (p>0.99). The only pt with ischemic cholangiopathy had the longest period of hypotension (82% of time from extubation-asystole) and hypoxemia (94%). There was no graft loss due to BC among DCD LTx. 5 DCD recipients died at median follow-up of 485 days (CHF, GVHD, ICH, sudden death at home and cardiac arrest).Actuarial patient survival of DCD and DBD recipients was 87% and 92% at 1y and 61% and 85% at 3y, (p=0.18). Actuarial graft survival was 87% and 92% at 1y and 61% and 84% at 3y (p=0.19). Conclusion: the incidence of BC and survival rates of DCD and DBD LTx were comparable at 3y. Careful donor and recipient selection and minimization of WIT/CIT are key factors in optimizing DCD LTx. Severe and prolonged donor hypoxemia and hypotension do not appear to increase the risk of BC. Further studies are needed to determine risk factors for ischemic cholangiopathy in the long term.

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