Liver Donation After Cardiac Death Still A Work in Progress

From the annual meeting of the Central Surgical Association, Sarasota, Fla.:
Surgeons transplanted more than 6,000 donor livers into recipients in the United States in 2007, but that number may not seem so impressive when you consider that more than 16,000 patients remained on the Organ Procurement and Transplantation Network‘s waiting list and more than 2,000 people died waiting on it in that year.
Most of those livers have been procured from donation after brain death (DBD) donors, but the percentage of livers that have been obtained from donation after cardiac death (DCD) donors has increased more than 10-fold in the past decade to 5.8% in 2006. And although recipient survival is now frequently reported in studies to be similar with either type of donation, the rates of re-listing, re-transplant, and resource utilization are higher in DCD recipients than in DBD recipients, according to Dr. Anton Skaro.
Dr. Anton Skaro

Dr. Anton Skaro

“Beyond survival metrics and basic complication rates, the impact of ischemic cholangiopathy and biliary complications in general have not been studied with regard to their impact on patients and society,” said Dr. Skaro of the division of organ transplantation at Northwestern University, Chicago.

In a study of 32 DCD and 237 DBD recipients of primary liver transplants at the university during 2003-2008, he and his colleagues found that DCD recipients had signficantly higher rates of biliary complications (53% vs. 22%) and ischemic cholangiopathy (38% vs. 2%) than did DBD recipients. Biliary complications were the cause of nearly 70% of all re-transplantations among the DCD recipients.

Hospital readmissions and invasive biliary tract procedures also occurred significantly more often among patients who had ischemic cholangiopathy than in those who did not. After adjusting for recipient confounding variables, the risk of ischemic cholangiopathy was independently associated with DCD donor age greater than 40 years and the ratio of donor-to-recipient heights.

In an interview, Dr. Skaro said that finding additional predictors for poor outcomes, particularly biliary complications and ischemic cholangiopathy, should help centers to match recipients with appropriate donor livers. This may require organ allocators to design ways of detecting patients with these complications that will then address whether they need an ‘upgrade’ in their Model for End-Stage Liver Disease (MELD) score in order to give them better access to re-transplantation.

“I think transplant centers need to have the ability go further down the list to preferantially transplant recipients who are ‘desperate’–those that have a low MELD score but are affected by significant disease burden that isn’t reflected in that MELD score,” he said.

—Jeff Evans

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Filed under Gastroenterology, Surgery, Transplant Medicine and Surgery

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