循环死亡后的捐赠可能对LT有积极的结果

StephenW

Donation after circulatory death may have positive outcomes for LT

Firl DJ, et al. Liver Transpl. 2016;doi:10.1002/lt.24633.
October 24, 2016



Liver donations after circulatory death may experience long warm ischemia time; however, these organs may still lead to positive outcomes for liver transplant recipients, per published findings in Liver Transplantation.


“Donation after circulatory death donors are one of the solutions to expand the donor pool for liver transplantation,” Koji Hashimoto, MD, PhD, department of general surgery, Digestive Disease Institute at Cleveland Clinic, told Healio.com/Hepatology. “Compared to liver transplantation from brain dead donors, [donation after circulatory death] organs are generally considered to have poor quality due to mandatory warm ischemic time during organ recovery.”

To determine if this is a safe organ pool for surgery, Hashimoto and colleagues conducted a retrospective study testing whether hemodynamic trajectories were associated with transplant outcomes in donation after circulatory (DCD) liver transplantation. They phenotyped 87 DCD donors based on hemodynamic trajectory for mean arterial pressure and peripheral oxygen saturation after withdrawing from life support. Donors were divided into three groups: those who gradually declined after withdrawal of life support (group 1), those who maintained stable hemodynamics followed by rapid decline (group 2) and those who declined rapidly (group 3).

“We looked at our data of DCD liver transplant, which showed no correlation between donor warm ischemia time and transplant outcomes. Therefore, we carefully looked at how donors expired from withdrawal of life support to expiration,” Hashimoto said.

Hashimoto said it is a common assumption in many centers that if DCD livers reach a warm ischemia time of more than 30 minutes, they shouldn’t be used.

“[We tend to] believe that if donors don’t expire within 30 minutes, the quality of donor liver is not good enough to maintain liver function after transplantation,” Hashimoto said. “I believe there are many DCD livers that have been discarded because of ‘long’ ischemia time.”

Through the study, Hashimoto said they found that some donors experienced shorter warm ischemia and others had longer; however, one group had different outcomes from these two.

“There was a group of donors who maintained their blood pressure and oxygenation after withdrawal for some time then rapidly declined to asystole,” Hashimoto said. “This category of donors had long warm ischemia time, but transplant outcome was excellent, which we have never known.”

Hashimoto further explained that donor warm ischemia time is not always a good surrogate marker of donor organ quality.

“Even donor warm ischemia time is long, if donors are hemodynamically stable after withdrawal, donor organ quality can be good,” he said. “Therefore, we should not discard DCD livers just because of long warm ischemia time,” adding that the way donors expire should be carefully considered before giving up livers.

Further analyses using Cox proportional modeling showed that hepatocellular carcinoma (HR = 2.53), cold ischemia time (HR = 1.5 per hour) and mean arterial pressure among group 1 were associated with increased risk for graft loss (P = .021). However, it was not with peripheral oxygen saturation (P = .172) or donor warm ischemia time (P = .154).

Despite longer donor ischemia time, the mean arterial pressure and peripheral oxygen saturation in group 2 had similar graft survival compared with the mean arterial pressure and peripheral oxygen saturation in group 3.

“I hope this study helps increase available donor organs to save more patients who need life-saving liver transplantation,” Hashimoto said. – by Melinda Stevens

Disclosure: The researchers report no relevant financial disclosures.

StephenW

循环死亡后的捐赠可能对LT有积极的结果

Firl DJ，et al。肝转移。 2016; doi：10.1002 / lt.24633。
2016年10月24日



循环死亡后肝脏捐赠可能经历长时间的温热缺血时间;然而，这些器官可能仍然导致肝移植受者的积极结果，根据在肝移植中发表的发现。


克里夫兰诊所消化疾病研究所普通外科部门Koji Hashimoto博士说：“循环死亡捐赠者捐赠是扩大肝移植供体库的解决方案之一。” “与来自脑死亡捐赠者的肝移植相比，[循环死亡后的捐赠]器官通常被认为具有差的质量，因为器官恢复期间强制性缺血时间。

为了确定这是否是一个安全的手术室器官池，桥本和同事进行了一项回顾性研究，测试血液动力学轨迹是否与循环系统（DCD）肝移植后捐赠的移植结果相关。他们根据平均动脉压的血流动力学轨迹和撤回生命支持后的外周血氧饱和度表型化87 DCD供体。捐赠者分为三组：在撤回生命支持（组1）后逐渐下降的组，维持稳定的血液动力学，随后快速下降（组2）和那些快速下降（组3）的那些组。

“我们观察了我们的DCD肝移植数据，其显示供体热缺血时间与移植结果之间没有相关性。因此，我们仔细研究了捐赠者从生命支持的提取过期到过期，“Hashimoto说。

桥本说，这是许多中心的一个共同的假设，如果DCD肝脏达到超过30分钟的热缺血时间，他们不应该使用。

“我们倾向于认为，如果捐赠者在30分钟内不到期，那么捐赠肝脏的质量不足以在移植后维持肝功能，”Hashimoto说。 “我相信有很多DCD肝脏因为”长时间“缺血时间而被丢弃。

通过这项研究，桥本表示，他们发现一些捐赠者经历较短的热缺血，而其他捐赠者则更长;然而，一组与这两组有不同的结果。

“有一组捐赠者在停药一段时间后保持血压和氧合，然后迅速下降到心搏停止，”桥本说。 “这类捐赠者有长时间的缺血时间，但移植结果非常好，我们从来不知道。

桥本进一步解释捐赠者温暖缺血时间并不总是一个良好的替代标志物的供体器官质量。

“即使捐赠者热缺血时间很长，如果捐赠者在退出后血液动力学稳定，捐赠器官的质量可以很好，”他说。 “因此，我们不应该仅仅因为长时间的缺血时间而丢弃DCD肝脏，”补充说，在放弃肝脏之前，应该仔细考虑捐献者过期的方式。

使用Cox比例模型的进一步分析显示，组1中的肝细胞癌（HR = 2.53），冷缺血时间（HR = 1.5 /小时）和平均动脉压与移植物损失的风险增加相关（P = 0.021）。然而，它不与外周血氧饱和度（P = .172）或捐助者热缺血时间（P = .154）。

尽管较长的供体缺血时间，组2中的平均动脉压和外周氧饱和度与组3中的平均动脉压和外周氧饱和度相比具有相似的移植存活。

Hashimoto说：“我希望这项研究有助于增加可用的捐赠器官，以节省更多需要挽救生命的肝移植的患者。 - 由梅琳达·史蒂文斯

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