Abstract
Predicting organ viability before transplantation remains one of the most challenging and ambitious objectives in transplant surgery. Waitlist mortality is high while transplantable organs are discarded. Currently, around 20% of deceased donor kidneys and livers are discarded because of “poor organ quality”, Decisions to discard are still mainly a subjective judgement since there are only limited reliable tools predictive of outcome available. Organ perfusion technology has been posed as a platform for pre-transplant organ viability assessment. Markers of graft injury and function as well as perfusion parameters have been investigated as possible viability markers during ex-situ hypothermic and normothermic perfusion. We provide an overview of the available evidence for the use of kidney and liver perfusion as a tool to predict posttransplant outcomes. Although evidence shows post-transplant outcomes can be predicted by both injury markers and perfusion parameters during hypothermic kidney perfusion, the predictive accuracy is too low to warrant clinical decision making based upon these parameters alone. In liver, further evidence on the usefulness of hypothermic perfusion as a predictive tool is needed. Normothermic perfusion, during which the organ remains fully metabolically active, seems a more promising platform for true viability assessment. Although we do not yet fully understand “on-pump” organ behaviour at normothermia, initial data in kidney and liver are promising. Besides the need for well-designed (registry) studies to advance the field, the catch-22 of selection bias in clinical studies needs addressing.
Highlights
One of the underlying causes of the perpetuating organ shortage is the discarding of transplantable organs based on “poor organ quality”
Kidney and Liver Viability Assessment after circulatory death (DCD) compared to those donated after brain death (DBD) [2]
Organ perfusion has demonstrated it can serve as a viability assessment tool with current evidence suggesting normothermic perfusion is better suited
Summary
One of the underlying causes of the perpetuating organ shortage is the discarding of transplantable organs based on “poor organ quality”. With the increasing use of DCD kidneys and livers, the need for reliable pre-transplant viability assessment has become even more important. During hypothermic perfusion an acellular perfusion solution is used, in normothermic conditions an oxygen carrier is needed and this are often red blood cells. In this dynamic environment, the organ can be assessed realtime by evaluating perfusion parameters and injury markers (Figure 1). This review provides an overview of the available clinical evidence on the use of organ perfusion as a platform to predict kidney and liver viability before transplantation. Hypothermic kidney perfusion has been reintroduced in clinical settings after it was shown to reduce the risk of DGF compared to static cold storage [13]. Normothermic perfusion is being investigated in research settings with a first randomised trial underway [14]
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