Donation after Circulatory Death in Paediatric Liver Transplantation: Current Status and Future Perspectives in the Machine Perfusion Era.

Roberta Angelico,Tommaso Maria Manzia,Marco Spada,M Thamara P R Perera,Chiara Grimaldi,Alessandro Parente

doi:10.1155/2018/1756069

Abstract

Efforts have been made by the transplant community to expand the deceased donor pool in paediatric liver transplantation (LT). The growing experience on donation after circulatory death (DCD) for adult LT has encouraged its use also in children, albeit in selective cases, opening new perspectives for paediatric patients. Even though there has recently been a slight increase in the number of DCD livers transplanted in children, with satisfactory graft and patient outcomes, the use of DCD grafts in paediatric recipients is still controversial due to morbid outcomes associated with DCD grafts. In this context, recent advances in the optimization of donor support by extracorporeal membrane oxygenation and in the graft preservation by liver machine perfusion could find application in order to expand the donor pool in paediatric LT. In the present study we review the current literature on DCD liver grafts transplanted in children and on the use of extracorporeal donor support and liver perfusion machines in paediatrics, with the aim of defining the current status and future perspectives of paediatric LT.

Highlights

Organ shortage is the main challenge in liver transplantation (LT) and the discrepancy between the number of waiting list patients and potential donor offers is greater in the paediatric field due to the scarcity of size-matched donors/grafts
All papers published in English between January 1995 and October 2017 and focusing on the following topics were retrieved: (1) donation after circulatory death used in paediatric LT; (2) extracorporeal donor support used for paediatric LT; (3) liver perfusion machine used in paediatric LT; (4) splitting liver during perfusion machine
We identified 48 relevant records on the use of donation after circulatory death (DCD) grafts in children, 41 of which were excluded as ineligible for the following reasons: 19 studies included non-LT from DCD donor to paediatric recipients, 18 reports focused on the ethical aspects and the implementation policy of paediatric DCD donation, and 4 studies included LT from paediatric DCD donor to adult recipients; the remaining 7 records, focusing on DCD grafts used in paediatric LT recipients, were included in the review [17,18,19,20,21,22,23,24]

Summary

Introduction

Organ shortage is the main challenge in liver transplantation (LT) and the discrepancy between the number of waiting list patients and potential donor offers is greater in the paediatric field due to the scarcity of size-matched donors/grafts. In recent years a change in donor demographics has resulted in a reduction in the number of brain-dead donor livers suitable for splitting, which represent the major graft pool for children awaiting LT [2]. In the last few decades, there has been a great interest in donation after circulatory death (DCD), the use of which has rapidly increased [3]. Several studies have reported that patient survival after adult DCD LT is equivalent to that of donation after brain death (DBD), while graft survival is slightly inferior [7, 8]. The use of DCD grafts has been associated with higher risks of primary nonfunction (PNF), but the current incidence of PNF appears to be similar to that of DBD grafts due to better understanding and graft selection; but the problems surrounding DCD grafts such as ischaemic cholangiopathy, vascular thrombosis, and posttransplant acute kidney injury remain unsolved [9, 10]

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