Extended Criteria Donor Livers Research Articles

Transplantation of a Cadaveric Liver Allograft With Right Lobe Cavernous Hemangioma, Without Back-Table Resection: A Case Report

The use of extended criteria liver donors has become a necessity in an era of organ scarcity for transplantation. We present here a case report of orthotopic liver transplantation using a liver with a giant right lobe hemangioma without backtable resection. Case Report There were no data regarding the liver mass before organ procurement. The donor liver function tests and electrolyte profile were normal. During donor exploration a hemangioma was identified in segments V–VI, occupying approximately 20% of the total liver volume. It was prepared for transplantation on a sterile backtable without performing backtable hemangioma resection. A standard orthotropic liver transplant procedure was performed uneventfully, without veno-veno bypass. There was no bleeding from the hemangioma. The ischemic time was 9 hours and 20 minutes. Postoperative course was uneventful and the patient was discharged at 19 days after the operation. The hemangiomas showed evolution with some decrease in size upon later follow-ups. No clinically important complication was observed. Conclusion Our case and other previous reports show that even large hemangiomas should not be considered to be a contraindication to organ procurement. These benign lesions either could be left in situ and observed or resected.

Waitlist Mortality Decreases with Increased Use of Extended Criteria Donor Liver Grafts at Adult Liver Transplant Centers

Extended criteria donor (ECD) liver allografts are often allocated to less severely ill liver transplant (LT) candidates who are at a relatively lower risk of pretransplant mortality, but it is not clear that the use of ECD allografts will decrease center waitlist mortality (WLM). Individual patient data from the UNOS OPTN database (2002-2005) were aggregated to obtain center-specific data. Deceased donor allografts with any of the following characteristics were defined as ECDs: from a donor with any of the criteria described by the New York State Department of Health Workgroup; or 12+ h of cold ischemia. Multivariate regression was used to examine the relationship between WLM and ECD, non-ECD and LDLT use after adjusting for candidate severity of illness. A total of 3555 ECD transplants, 11,660 standard criteria donor (SCD) transplants, and 717 LDLTs were performed at 100 centers during this period. The model demonstrated that SCD and ECD LTs were inversely correlated with a center's WLM (beta=-0.242 and -0.221, respectively; p <or= 0.003 for each). LDLTs did not significantly reduce WLM (beta=-0.048, p=0.55). In summary, increasing ECD liver allograft use significantly decreased WLM at US centers. Policies encouraging the increase used of ECDs would further reduce WLM.

BILIARY COMPLICATIONS IN STANDARD AND EXTENDED CRITERIA LIVER ALLOGRAFTS IN WHOLE-ORGAN, CADAVERIC LIVER TRANSPLANTATION.

Purpose Although important liver transplant outcomes, such as primary nonfunction, vascular thrombosis, and graft loss, are well reported for marginal grafts in the transplant literature, there are few reports of biliary complications in extended criteria donor (ECD) livers. This study compares ECD and standard donors (SD) for biliary complications in cadaveric, whole-organ liver transplantation. Methods This study is a retrospective review of all liver transplants between 2001 and 2006, with an extensive review of all endoscopic and percutaneous biliary imaging. Our center uses biliary imaging as first evaluation for elevated liver enzymes, prior to biopsy. Outcomes included need for imaging, leak requiring reoperation, intrahepatic strictures, presence of stones or gravel, and first 30-day liver function tests (AST, ALT, alkaline phosphatase, total bilirubin). Results There were 698 orthotopic transplants, including 593 with choledochocholedochostomy (CDC) and 100 Roux-Y reconstructions (RYHJ) (5 OR deaths). Results are presented in the Table. SD and ECD livers do not differ significantly in requirement for biliary imaging, occurrence of biliary leak, or intrahepatic strictures. ECD livers are more likely to have choledocholithiasis. Thirty-day liver enzymes are statistically equivalent. Conclusion ECD livers have been used extensively at our center to decrease median wait time to less than 30 days, with very few wait list deaths and improved post-transplant survival. Results of this analysis demonstrate no increased risk for biliary complications in patients receiving ECD livers.

Utilization of Extended Donor Criteria Liver Allograft: Is the Elevated Risk of Failure Independent of the Model for End-Stage Liver Disease Score of the Recipient?

The goal of this analysis was to determine if outcomes from the use of extended criteria donor (ECD) livers were dependent upon the Model for End-Stage Liver Disease (MELD) score of the recipient. The Organ Procurement and Transplantation Network (OPTN) database as of March 4, 2006 was used for the analysis. Data from 12,056 adult liver transplant (LTx) recipients between June 1, 2002 and June 30, 2005 was analyzed. The donor risk index (DRI) was calculated as previously reported. A DRI of > or =1.7 was classified as ECD. Relative risk (RR) estimates were derived from Cox regression models adjusted for DRI, recipient MELD, age, sex, ethnicity, diagnosis, and year of transplant. Data from 2,873 grafts falling in the ECD category (23.8%) and their recipients were analyzed. Recipients with low MELD scores (<15) received the highest proportion of ECD livers (33%). ECD livers were associated with a significant increase in the RR of graft failure within each MELD category. However, this effect held within each of the three MELD categories. The use of ECD grafts expands the organ pool at expense of increased RR of liver failure. Our analysis showed no significant interaction between DRI and MELD score of the recipient. The fact that there is no additional impact of ECD livers in recipients with high MELD scores suggests that this group of patients may benefit from this pool of grafts.

Use of Extended Criteria Livers Decreases Wait Time for Liver Transplantation Without Adversely Impacting Posttransplant Survival

The use of extended criteria donors (ECDs) could minimize shortage of suitable donor livers for transplantation. In 3 years, the aggressive use of ECD livers has reduced the wait list at our center from 257 to 30 patients with a median wait time of 18 days without using living donors. This study compares the graft/patient survival from standard (SD) and ECD for our transplant population between 2001 and 2005. Records of all adult liver transplant recipients over 4 years were reviewed (n = 571). ECD criteria included: age >59 years, BMI >34.9, maximum AST/ALT >500, maximum bilirubin >2.0, peak serum sodium >170, HBV/HCV/HTLV reactive, donation after cardiac death, cold ischemia time >12 hours, ICU stay >5 days, 3 or more pressors simultaneously, extensive alcohol abuse, cancer history (nonskin), active meningitis/bacteremia, or significant donor liver trauma. Outcomes included graft and patient survival at 90 days, 1 year, and 2 years. Sixty-eight percent of recipients (n = 388) received ECD livers. Primary factors accounting for ECD-liver status included: elevated liver function tests (20%), hypernatremia (12.6%), and extensive alcohol abuse (11.4%). Graft survival was (SD, ECD): 90-day 91%, 88%; 1-year 84%, 80%; 2-year 78%, 77%; patient survival was: 90-day 93%, 90%; 1-year 87%, 82%; 2-year 83%, 79%. Kaplan-Meier survival analysis failed to demonstrate an overall difference in graft or patient survival at any time point. Only donor age >60 years was associated with decreased graft and patient survival. Liver grafts from ECD can be used to dramatically reduce wait list time with outcomes comparable to those for SD without resorting to living donor liver transplantation.

OUTCOMES OF ORTHOTOPIC LIVER TRANSPLANTS USING EXTENDED CRITERIA DONOR LIVERS

P570 Aims: Extended criteria donor (ECD) liver utilization has expanded the limited donor pool for patients awaiting orthotopic liver transplant (OLT). Many centers approach ECD livers with caution as the outcomes following their use remains unclear. The goal of this review was to analyze outcomes of OLT using ECD livers compared to a control group of standard criteria donor (SCD) liver allografts. Methods: All OLT recipients at our center between Jan 2002-Oct 2003 were categorized as having received an ECD or SCD liver. ECD allografts were defined as having any one or more of the following: donor age > 60 yrs, biopsy exhibiting >40% macrovesicular and/or >75% microvesicular steatosis, any donor down time (±CPR), use of 2 or more pressors within 12 hrs of procurement, or liver function studies > 5 × upper limit of normal. Parameters that were reviewed included: recipient demographics (age, sex, MELD, mean follow-up, length of stay), graft ischemic times (total and warm), laboratory data, and clinical outcomes (death, biliary complications, rejections). Results: 90 OLTs (42 ECD and 48 SCD) were performed during the study period. No statistical differences were observed in laboratory data including: serum creatinine, transaminases (AST/ALT), total bilirubin, and albumin at discharge, day 30, 90, and 180 for both groups. The two groups were similar with respect to rejection episodes per patient ECD (1.1) vs. SCD (1.3) [p=ns]. Five instances of vascular complications were identified (3 ECD vs. 2 SCD), although only one of those was a hepatic artery thrombosis. Conclusions: Clinical outcomes following OLT using ECD livers are identical to those using SCD livers. No differences were noted insofar as early or mid laboratory values, LOS, biliary or vascular complications. With intelligent recipient selection, the aggressive use of ECD liver allografts can become an important component of any transplant program.Figure