Regulations and Procurement Surgery in DCD Liver Transplantation: The Custodial Role of Professional Societies in the DCD and Liver Perfusion Revolution

Abstract

We thank Dr Choubey and Dr Ortiz for their interest in and insightful commentary regarding our International Liver Transplantation Society (ILTS) consensus guidelines on regulations and procurement surgery in controlled donation after circulatory death (cDCD) liver transplantation.1,2 Based on logistical and technical as well as ethical complexities associated with cDCD, we agree it is essential to have clear, consistent language describing the cDCD process and organ recovery. This is important to achieving our goals as transplant professionals of not only optimizing graft utilization rates and outcomes but also maintaining a high degree of confidence in our work among the remainder of the medical community and population at large. In their letter, Choubey and Ortiz highlight the importance of limiting donor warm ischemia in recovering organs for transplantation and achieving adequate posttransplantation outcomes. In this regard, we refer the authors to the thorough work performed by our colleagues from the ILTS Working Group on definitions and evaluation of donor warm ischemia times in cDCD.3 With respect to providing more explicit guidance on the minimum no-touch period of electrical or mechanical asystole required for declaring death, we necessarily defer to the directives of our colleagues in anesthesia and critical care. As transplant professionals, our role is to be at the ready but not to influence let alone manage decisions or care at the end of a patient’s life. Coinciding with the focus of the 2020 ILTS Consensus Conference on DCD, Liver Preservation, and Machine Perfusion, Choubey and Ortiz also describe in their letter the fact that greater use of DCD organs will be accompanied by increased use of perfusion technologies. These include not only ex situ modalities hypothermic and normothermic machine perfusion but also in situ normothermic regional perfusion (NRP). While at present, ex situ machine perfusion treats a single organ after a variable length of cold ischemia, NRP restores oxygenated blood flow to the kidneys, liver, and pancreas (abdominal NRP) or all aforementioned organs plus the heart and lungs (thoracoabdominal NRP) immediately following donor cardiac arrest and declaration of death. As such, it effectively converts the period of donor hypoperfusion and arrests into one of ischemic preconditioning, restoring energy substrates, removing metabolic waste products, and increasing levels of endogenous antioxidants before cold preservation and recovery. For the liver, these benefits have translated into the successful transplantation of cDCD livers from older donors or with prolonged donor warm ischemia times, with graft and patient survival rates comparable with those seen with donation after brain death livers and minimal to no ischemic biliary injury observed in published multicenter experiences.4,5 Given current trends, clinical application of cDCD liver transplantation will continue to expand in the coming years. We, as professionals and societies, have an important role as custodians in this process, and we must continue to provide experience-, evidence-, and value-based directives to help guide the DCD and liver perfusion revolution.