• cardiac arrest
• donation after brain death
• ischemic precondition
• liver transplant

• National Natural Science Foundation of China

• Humans
• Kidney Transplantation/adverse effects
• Male
• Heart Arrest/etiology
• Heart Arrest/mortality
• Heart Arrest/diagnosis
• Female
• Middle Aged
• Adult
• Delayed Graft Function/etiology
• Delayed Graft Function/physiopathology
• Australia/epidemiology
• Tissue Donors
• Risk Factors
• Time Factors
• Graft Survival
• Glomerular Filtration Rate
• Risk Assessment
• New Zealand/epidemiology
• Tissue and Organ Procurement
• Donor Selection

• biliary tract complications
• canalicular proliferation
• cholangiography
• interventional endoscopy
• interventional radiology
• liver transplantation

• Calcineurin inhibitor latoxicity
• Chronic renal failure
• Everolimus
• Liver transplantation
• Mycophenolate mofetil

• cardiac arrest
• extended criteria donor
• outcomes
• pediatric liver transplantation

Transplantation of liver grafts from deceased donors who experienced cardiac arrest prior to liver procurement is now common. This single-center study analyzed the impact of pre-donation arrest time on clinical outcomes in liver transplantation.

Records of all orthotopic liver transplants performed at a single center over a 15-year period were reviewed. Donor records were reviewed and total arrest time was calculated as cumulative minutes. Post-transplant liver graft function was assessed using laboratory values. Graft survival was assessed with Cox regression analysis.

Records for 1830 deceased donor transplants were reviewed, and 521 donors experienced pre-procurement cardiac arrest (28%). Median arrest time was 21 min (mean 25 min, range 1–120 min). After transplant, the peak alanine aminotransferase and bilirubin levels for liver grafts from donors with arrest were lower compared to those for donors without arrest (p<0.001). Early allograft dysfunction occurred in 25% (arrest) and 28% (no arrest) of patients (p=0.22). There were no differences in risk of early graft loss (3% vs. 3%, p=0.84), length of hospital stay (10 vs. 10 days, p=0.76), and 1-year graft survival (89% vs. 89%, p=0.94). Cox regression analysis comparing 4 groups (no arrest, <20 min, 20–40 min, and >40 min arrest) demonstrated no statistically significant difference in survival at 10 years. Subgroup analysis of 93 donation after cardiac death grafts showed no significant difference for these same outcomes.

These results support the use of select deceased liver donors who experience pre-donation cardiac arrest. Pre-donation arrest may be associated with less early allograft dysfunction, but had no impact on long-term clinical outcomes. The results for donation after cardiac death donors were similar.

• Hypovolemic shock
• Liver transplantation
• Shock organs
• VSOP

• Animals
• Cryopreservation
• Humans
• Hypovolemia/metabolism
• Hypovolemia/physiopathology
• Liver/metabolism
• Liver/physiopathology
• Liver Transplantation
• Models, Animal
• Oxygen/metabolism
• Portal Vein/metabolism
• Portal Vein/physiopathology
• Rats
• Rats, Wistar
• Reperfusion
• Shock/metabolism
• Shock/physiopathology
• Tissue Donors

• B. Braun-Stiftung

In the past decades liver transplantation (LT) has become the treatment of choice for patients with end stage liver disease (ESLD). The chronic shortage of cadaveric organs for transplantation led to the utilization of a greater number of marginal donors such as older donors or donors after circulatory death (DCD). The improved survival of transplanted patients has increased the frequency of long-term complications, in particular chronic kidney disease (CKD). Acute kidney injury (AKI) post-LT has been recently recognized as an important risk factor for the occurrence of de novo CKD in the long-term outcome. The onset of AKI post-LT is multifactorial, with pre-LT risk factors involved, including higher Model for End-stage Liver Disease score, more sever ESLD and pre-existing renal dysfunction, either with intra-operative conditions, in particular ischaemia reperfusion injury responsible for post-reperfusion syndrome (PRS) that can influence recipient’s morbidity and mortality. Post-reperfusion syndrome-induced AKI is an important complication post-LT that characterizes kidney involvement caused by PRS with mechanisms not clearly understood and implication on graft and patient survival. Since pre-LT risk factors may influence intra-operative events responsible for PRS-induced AKI, we aim to consider all the relevant aspects involved in PRS-induced AKI in the setting of LT and to identify all studies that better clarified the specific mechanisms linking PRS and AKI. A PubMed search was conducted using the terms liver transplantation AND acute kidney injury; liver transplantation AND post-reperfusion syndrome; acute kidney injury AND post-reperfusion syndrome; acute kidney injury AND DCD AND liver transplantation. Five hundred seventy four articles were retrieved on PubMed search. Results were limited to title/abstract of English-language articles published between 2000 and 2015. Twenty-three studies were identified that specifically evaluated incidence, risk factors and outcome for patients developing PRS-induced AKI in liver transplantation. In order to identify intra-operative risk factors/mechanisms specifically involved in PRS-induced AKI, avoiding confounding factors, we have limited our study to “acute kidney injury AND DCD AND liver transplantation”. Accordingly, three out of five studies were selected for our purpose.

• Liver transplantation
• Acute kidney injury
• Post-reperfusion syndrome
• Donation after circulatory death
• Chronic kidney disease

• Acute Kidney Injury/diagnosis
• Acute Kidney Injury/etiology
• Acute Kidney Injury/mortality
• Animals
• Donor Selection
• End Stage Liver Disease/diagnosis
• End Stage Liver Disease/mortality
• End Stage Liver Disease/surgery
• Graft Survival
• Humans
• Liver Transplantation/adverse effects
• Liver Transplantation/mortality
• Reperfusion Injury/diagnosis
• Reperfusion Injury/etiology
• Reperfusion Injury/mortality
• Risk Factors
• Syndrome
• Tissue Donors/supply & distribution
• Treatment Outcome

AIM: To evaluate donation after circulatory death (DCD) orthotopic liver transplant outcomes [hypoxic cholangiopathy (HC) and patient/graft survival] and donor risk-conditions.

METHODS: From 2003-2013, 45 DCD donor transplants were performed. Predonation physiologic data from UNOS DonorNet included preoperative systolic and diastolic blood pressure, heart rate, pH, SpO₂, PaO₂, FiO₂, and hemoglobin. Mean arterial blood pressure was computed from the systolic and diastolic blood pressures. Donor preoperative arterial O₂ content was computed as [hemoglobin (gm/dL) × 1.37 (mL O₂/gm) × SpO₂%) + (0.003 × PaO₂)]. The amount of preoperative donor red blood cell transfusions given and vasopressor use during the intensive care unit stay were documented. Donors who were transfused ≥ 1 unit of red-cells or received ≥ 2 vasopressors in the preoperative period were categorized as the red-cell/multi-pressor group. Following withdrawal of life support, donor ischemia time was computed as the number-of-minutes from onset of diastolic blood pressure < 60 mmHg until aortic cross clamping. Donor hypoxemia time was the number-of-minutes from onset of pulse oximetry < 80% until clamping. Donor hypoxia score was (ischemia time + hypoxemia time) ÷ donor preoperative hemoglobin.

RESULTS: The 1, 3, and 5 year graft and patient survival rates were 83%, 77%, 60%; and 92%, 84%, and 72%, respectively. HC occurred in 49% with 16% requiring retransplant. HC occurred in donors with increased age (33.0 ± 10.6 years vs 25.6 ± 8.4 years, P = 0.014), less preoperative multiple vasopressors or red-cell transfusion (9.5% vs 54.6%, P = 0.002), lower preoperative hemoglobin (10.7 ± 2.2 gm/dL vs 12.3 ± 2.1 gm/dL, P = 0.017), lower preoperative arterial oxygen content (14.8 ± 2.8 mL O₂/100 mL blood vs 16.8 ± 3.3 mL O₂/100 mL blood, P = 0.049), greater hypoxia score >2.0 (69.6% vs 25.0%, P = 0.006), and increased preoperative mean arterial pressure (92.7 ± 16.2 mmHg vs 83.8 ± 18.5 mmHg, P = 0.10). HC was independently associated with age, multi-pressor/red-cell transfusion status, arterial oxygen content, hypoxia score, and mean arterial pressure (r² = 0.6197). The transplantation rate was greater for the later period with more liberal donor selection [era 2 (7.1/year)], compared to our early experience [era 1 (2.5/year)]. HC occurred in 63.0% during era 2 and in 29.4% during era 1 (P = 0.03). Era 2 donors had longer times for extubation-to-asystole (14.4 ± 4.7 m vs 9.3 ± 4.5 m, P = 0.001), ischemia (13.9 ± 5.9 m vs 9.7 ± 5.6 m, P = 0.03), and hypoxemia (16.0 ± 5.1 m vs 11.1 ± 6.7 m, P = 0.013) and a higher hypoxia score > 2.0 rate (73.1% vs 28.6%, P = 0.006).

CONCLUSION: Easily measured donor indices, including a hypoxia score, provide an objective measure of DCD liver transplantation risk for recipient HC. Donor selection criteria influence HC rates.

• Orthotopic liver transplantation
• Ischemic cholangiopathy
• Hypoxic cholangiopathy
• Donation after circulatory death
• Biliary complications
• Reperfusion injury

• Adolescent
• Adult
• Airway Extubation/adverse effects
• Airway Extubation/mortality
• Biomarkers/metabolism
• Cause of Death
• Child
• Cholestasis/diagnosis
• Cholestasis/etiology
• Cholestasis/mortality
• Cholestasis/surgery
• Donor Selection
• Erythrocyte Transfusion
• Female
• Graft Survival
• Hemoglobins/metabolism
• Humans
• Hypoxia/blood
• Hypoxia/etiology
• Hypoxia/mortality
• Liver Transplantation/adverse effects
• Liver Transplantation/methods
• Liver Transplantation/mortality
• Male
• Middle Aged
• Oxygen Inhalation Therapy/adverse effects
• Oxygen Inhalation Therapy/mortality
• Reoperation
• Retrospective Studies
• Risk Factors
• Shock/blood
• Shock/mortality
• Shock/physiopathology
• Shock/therapy
• Time Factors
• Tissue Donors
• Treatment Outcome
• Young Adult

The scarcity of donor livers has increased the interest in donation after cardiac death (DCD) as an additional pool to expand the availability of organs. However, the initial results of liver transplantation with DCD grafts have been suboptimal due to an increased rate of complications, as well as decreased graft survival. These challenges have led to many developments in DCD donation outcome, as well as basic and translational research. In this article we review the unique characteristics of DCD donors, nuances of DCD organ procurement, the effect of prolonged warm and cold ischemia times, and discuss major studies that compared DCD to donation after brain death liver transplantation, in terms of outcomes and complications. We also review the different methods of donor treatment that has been applied to ameliorate DCD organ outcome, and we discuss the role of machine perfusion techniques in organ reconditioning. We discuss the two major perfusion models, namely, hypothermic machine perfusion and normothermic machine perfusion; we compare both methods, and delineate their major differences.

• Transplant hepatology
• Liver transplantation
• Organ donation
• Extended criteria donors
• Donation after cardiac death
• Ex-vivo liver perfusion
• Normothermic machine perfusion
• Hypothermic machine perfusion