Transplantation Of Discarded Livers After Normothermic Perfusion
Cristiano Quintini, *Luca Del Prete, *Giuseppe D'Amico, *Teresa Diago Uso, *Koji Hashimoto, *Federico Aucejo, *Masato Fujiki, *Bijan Eghtesad, *Kazunari Sasaki, *Choon Hyuck David Kwon, *Charles Miller, *Qiang Liu
Cleveland Clinic, Cleveland, OH
OBJECTIVE(S): The persistent shortage of liver allografts contributes to significant waitlist mortality despite efforts to increase organ donation. Normothermic machine perfusion (NMP) holds the potential to enhance graft preservation, extend viability and allows liver function evaluation in organs previously discarded because considered too high risk for transplant.
Following an FDA and IRB approved protocol, discarded livers from other transplant centers were transplanted after assessment and reconditioning with our institutional developed NMP device. We report here our preliminary results.
RESULTS: Sixteen human livers declined for transplantation were enrolled for assessment with NMP. Discard reasons were high warm ischemia time in donors after circulatory death (DCD), steatosis, hypernatremia, hyperbilirubinemia, hypertransaminasemia due to hypoxia or drug intoxication. Viability criteria for functional assessment included bile production rate, perfusate lactate clearance rate, hemodynamics and liver morphology during NMP. Five livers (31%) were ultimately discarded after NMP because of insufficient lactate clearance (>4.1 mmol/L after 4 hours), limited bile production (<0.5ml/h) or moderate macrosteatosis, whereas eleven (69%) were considered suitable for transplantation. They included seven DCD livers with 13-46 minutes of donor warm ischemia time and 3 hours 41min-7 hours 42min of cold ischemia time. NMP duration was 3 hours 49min-10 hours 29min without technical problems or adverse events. Liver recipients had a MELD score of 15-23 before transplantation. No intraoperative or major early postoperative complications occurred in all transplanted recipients. No primary non-function occurred after transplantation. Five livers had early allograft dysfunction with fast recovery and one patient developed ischemic cholangiopathy after 4 months treated with biliary stents. All other patients had good liver function with a follow-up time of two weeks to nine months.
NMP permitted transplantation of about 70% of discarded livers with good graft and recipient outcomes. The definition of even more selective viability criteria represents a challenge for future studies and a key factor to further reduce the discard rate and waitlist mortality.
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