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Advantages and Limitations of Clinical Scores for Donation After Circulatory Death Liver Transplantation.

ABSTRACT: Background: Scoring systems have been proposed to select donation after circulatory death (DCD) donors and recipients for liver transplantation (LT). We hypothesized that complex scoring systems derived in large datasets might not predict outcomes locally. Methods: Based on 1-year DCD-LT graft survival predictors in multivariate logistic regression models, we designed, validated, and compared a simple index using the University of California, San Francisco (UCSF) cohort (n = 136) and a universal-comprehensive (UC)-DCD score using the United Network for Organ Sharing (UNOS) cohort (n = 5,792) to previously published DCD scoring systems. Results: The total warm ischemia time (WIT)-index included donor WIT (dWIT) and hepatectomy time (dHep). The UC-DCD score included dWIT, dHep, recipient on mechanical ventilation, transjugular-intrahepatic-portosystemic-shunt, cause of liver disease, model for end-stage liver disease, body mass index, donor/recipient age, and cold ischemia time. In the UNOS cohort, the UC-score outperformed all previously published scores in predicting DCD-LT graft survival (AUC: 0.635 vs. ≤0.562). In the UCSF cohort, the total WIT index successfully stratified survival and biliary complications, whereas other scores did not. Conclusion: DCD risk scores generated in large cohorts provide general guidance for safe recipient/donor selection, but they must be tailored based on non-/partially-modifiable local circumstances to expand DCD utilization.

SUBMITTER: Meier RPH

PROVIDER: S-EPMC8766343 | biostudies-literature | 2021

REPOSITORIES: biostudies-literature

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Advantages and Limitations of Clinical Scores for Donation After Circulatory Death Liver Transplantation.

Meier Raphael P H RPH Kelly Yvonne Y Yamaguchi Seiji S Braun Hillary J HJ Lunow-Luke Tyler T Adelmann Dieter D Niemann Claus C Maluf Daniel G DG Dietch Zachary C ZC Stock Peter G PG Kang Sang-Mo SM Feng Sandy S Posselt Andrew M AM Gardner James M JM Syed Shareef M SM Hirose Ryutaro R Freise Chris E CE Ascher Nancy L NL Roberts John P JP Roll Garrett R GR

Frontiers in surgery 20220105

Background: Scoring systems have been proposed to select donation after circulatory death (DCD) donors and recipients for liver transplantation (LT). We hypothesized that complex scoring systems derived in large datasets might not predict outcomes locally. Methods: Based on 1-year DCD-LT graft survival predictors in multivariate logistic regression models, we designed, validated, and compared a simple index using the University of California, San Francisco (UCSF) cohort (n = ...[more]

PMID: 35071316

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Project description:BackgroundDuring orthotopic liver transplantation, allograft reperfusion is a dynamic point in the operation and often requires vasoactive medications and blood transfusions. Normothermic machine perfusion (NMP) of liver allografts has emerged to increase the number of transplantable organs and may have utility during donation after circulatory death (DCD) liver transplantation in reducing transfusion burden and vasoactive medication requirements.MethodsThis is a single-center retrospective study involving 226 DCD liver transplant recipients who received an allograft transported with NMP (DCD-NMP group) or with static cold storage (DCD-SCS group). Veno-venous bypass was not used in any patients. Infusion doses of norepinephrine, epinephrine, and vasopressin as well as bolus doses of vasoactive medications during reperfusion were recorded. Blood component therapy was recorded according to phase of liver transplantation and during the first 24 hours postprocedure.ResultsA total of 103 recipients in the DCD-NMP group and 123 patients in the DCD-SCS group were included. Post-reperfusion syndrome (PRS) incidence was reduced in the DCD-NMP group compared to the DCD-SCS group (10.7% [95% confidence interval, CI, 5.5%-18.3%] vs 42.3% [95% CI, 33.4%-51.5%]; P < .001). During the reperfusion period, patients in the DCD-SCS group required increased bolus doses of epinephrine and vasopressin compared to the DCD-NMP group (24.6 vs 7.5 µg; P < .001) and (5.4 vs 2.4 units; P < .001), respectively. The DCD-SCS group received a higher infusion dose of epinephrine during anhepatic phase, at reperfusion, and up to 90 minutes after reperfusion. In the postreperfusion period, there were significant increases in the transfusion of red blood cells (RBCs; 5.3 vs 3.7 units; P = .006), fresh frozen plasma (FFP; 3.4 vs 1.9 units; P < .001), cryoprecipitate (2.7 vs 1.8 pooled units; P = .015) and platelets (0.9 vs 0.4 units; P = .008) in the DCD-SCS group compared to the DCD-NMP group. During the first 24 hours postprocedure, transfusion of RBCs, FFP, and cryoprecipitate in the DCD-SCS group was increased compared to the DCD-NMP group ([2.6 vs 1.7 units; P = .028], [1.6 vs 0.8 units; P < .001], [1.5 vs 0.9 pooled units; P = .031]) respectively. Administration of tranexamic acid was more frequent in the DCD-SCS group during the post-reperfusion period compared to the DCD-NMP group (13% [95% CI, 5.7%-17.4%] vs 3.9% [95% CI, 1.1%-9.6% 95%]; P = .018).ConclusionsIn DCD liver transplantation, use of NMP was associated with reduced incidence of PRS and decreased vasopressor and inotrope requirements at the time of allograft reperfusion compared to using SCS. Additionally, NMP was associated with reduced transfusion of all blood product components as well as antifibrinolytic agent administration in the post-reperfusion period. Reduced transfusion burden in the DCD-NMP group also occurred during the first 24 hours posttransplant.

Project description:BackgroundHeart failure remains a significant cause of morbidity and mortality internationally. With significant disparities in supply and demand for donor organs and recipients, there has been a growing need to expand the donor pool. Donation after circulatory death (DCD) heart transplantation offers such a method, with ex-situ machine perfusion (ESMP) and thoracoabdominal normothermic reperfusion (NRP) offering two potential methods of procuring DCD organs. This systematic review and meta-analysis aims to evaluate the current literature and compare DCD with donation after brain death (DBD) as well as DCD methods of transplantation.MethodsA systematic literature review was performed according to PRISMA guidelines. Primary outcomes were 30-day, 6- and 12-month survival, as well as primary graft dysfunction (PGD) and acute rejection. Secondary outcomes were length of stay (LOS), intensive care unit (ICU) LOS and temporary dialysis. Weighted averages were utilised to summarise data with funnel plots utilised for comparisons. Reconstructed Kaplan-Meier curves were utilised to evaluate mid-term survival.ResultsA total of 10 studies were included evaluating 923 DCD recipients and 7,236 DBD recipients. Survival for DCD and DBD patients at 6 months was 93% and 91% respectively [odds ratio (OR), 1.5; 95% confidence interval (CI): 1.0-2.2; P<0.05] and at 12 months 93% and 91% for DCD and DBD respectively (OR 0.77, 95% CI: 0.1-5.3, P=0.8). Acute rejection was 15% and 19% in DCD and DBD patients respectively (OR, 1.0; 95% CI: 0.6-1.8; P=0.9). Thirty-day survival was similar between NRP (96.9%) and direct procurement and perfusion (DPP) (97%) (OR, 0.8; 95% CI: 0.2-3.9; P=0.8). PGD was higher in DCD (17%) compared with DBD (8%) patients (OR, 1.9; 95% CI: 0.98-3.7; P=0.06) whilst PGD for DPP and NRP was 21% and 14% respectively.ConclusionsDCD may offer comparable outcomes to DBD in short and mid-term outcomes, although PGD remains a concern. Further comparative research is required to delineate the role of both techniques in the current transplant landscape.

Dataset Information

Advantages and Limitations of Clinical Scores for Donation After Circulatory Death Liver Transplantation.

Publications

Advantages and Limitations of Clinical Scores for Donation After Circulatory Death Liver Transplantation.

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