Extended Criteria Research Articles

Utilization of hepatitis B surface antigen-positive donors in liver transplantation for recipients with hepatocellular carcinoma: a retrospective and propensity score matching analysis.

The use of extended criteria donor (ECD) grafts such as donor with infection of hepatitis B virus (HBV) is a potential solution for organ shortage. In this study, we aimed to evaluate the safety and long-term survival of utilization of hepatitis B surface antigen-positive (HBsAg+) donor livers in HCC patients using propensity score matching (PSM) analysis. Forty-eight donors with HBsAg-positive and 279 donors with HBsAg-negative were transplanted and enrolled in this study. PSM analysis were used to eliminate selection bias. Perioperative data and survival were collected and analyzed. PSM generated 44 patient pairs. When comparing intra- and post-operative data, no significant difference was found between groups (P>0.05). Patients with a HBsAg-positive donor had significantly worse progression-free survival (1-year: 65.9% vs. 90.9%; 3-year: 18.1% vs. 70.4%, P=0.0060) and overall survival (1-year: 84.1% and 95.4%; 3-year: 27.2% vs. 79.5%, P=0.0039). In multivariate analysis, donor HBsAg-positivity was an independent risk factor for survival and occurrence (P=0.005 and 0.025, respectively). In conclusion, with adequate antiviral prophylaxis and treatment, utilization of HBsAg positive liver grafts did not increase the incidence of early-stage complications. However, patient with an HBsAg-positive graft had poorer progression-free survival and overall survival.

Extracorporeal cytokine adsorption reduces systemic cytokine storm and improves graft function in lung transplantation

ObjectivesIschemia–reperfusion injury often coincides with a cytokine storm, which can result in primary graft dysfunction following lung transplantation. Our previous research has demonstrated allograft improvement by cytokine adsorption during ex vivo lung perfusion. The aim of this study was to investigate the effect of in vivo extracorporeal cytokine adsorption in a large animal model. Materials and MethodsPig left lung transplantation was performed following 24 hours of cold ischemic storage. Observation period after transplantation was 24 hours. In the treatment group (n = 6), extracorporeal CytoSorb adsorption was started 30 minutes before reperfusion and continued for 6 hours. A control group (n = 3) did not receive adsorber treatment. ResultsDuring adsorption, we consistently noticed a significant decrease in plasma proinflammatory interleukin (IL)-2, trends of less proinflammatory, tumor necrosis factor- α, IL-1α, and granulocyte-macrophage colony-stimulating factor as well as significantly reduced systemic neutrophils. In addition, a significantly lower peak airway pressure was detected during the 6 hours of adsorption. After 24 hours of observation, when evaluating the left lung allograft independently, we observed significantly improved CO2 removal, partial pressure of oxygen/inspired oxygen fraction ratio, and less acidosis in the treatment group. At autopsy, bronchoalveolar lavage results exhibited significantly lower recruitment of cells and less pro-inflammatory IL-1α, IL-1β, IL-6, and IL-8 in the treatment group. Histologically, the treatment group had a strong trend, indicating less neutrophil invasion into the alveolar space. ConclusionsBased on our findings, cytokine adsorption during and after reperfusion is a viable approach to reducing posttransplant inflammation following lung transplantation. CytoSorb may increase the acceptance of extended criteria donor lungs, which are more susceptible to ischemia–reperfusion injury.

Fretting fatigue crack propagation under out-of-phase loading conditions using extended maximum tangential stress criterion

In this paper, a numerical crack growth analysis is conducted by using the Maximum Tangential Stress (MTS) criterion and its extension, which considers the contact stress between the crack surfaces. Moreover, fretting fatigue is a multiaxial non-proportional loading problem, and most components are subjected to asynchronous loads. Therefore, this paper mostly focuses on the influence of loading phase difference (Φ) on the crack propagation behavior. Meanwhile, for the fretting fatigue problem, as there is a relationship between the crack initiation and propagation, the effect of initiation characteristics, including crack initiation position and direction is studied under different loading phase differences using Linear Elastic Fracture Mechanics (LEFM) theory. It is observed that the predicted crack path and lifetime by using the extended MTS criterion and Paris’ law is in good agreement with the experimental results in the literature. It is found that the phase difference has a strong effect on the crack propagation behavior. Furthermore, we found that the crack initiation position has a greater influence on crack propagation behavior than the crack initiation direction.

Results of Lung Transplantation for Cystic Fibrosis With Selected Donors Over 65Years Old.

Lung transplantation is limited by the shortage of suitable donors. Many programs have begun to use extended criteria donors. Donors over 65years old are rarely reported, especially for young cystic fibrosis recipients. This monocentric study was conducted for cystic fibrosis recipients from January 2005 to December 2019, comparing two cohorts according to lung donor age (<65years or ≥65years). The primary objective was to assess the survival rate at 3years using a Cox multivariable model. Of the 356 lung recipients, 326 had donors under 65years, and 30 had donors over 65years. Donors' characteristics did not differ significantly in terms of sex, time on mechanical ventilation before retrieval, and partial pressure of arterial oxygen/fraction of inspired oxygen ratio. There were no significant differences in post-operative mechanical ventilation duration and incidence of grade 3 primary graft dysfunction between the two groups. At 1, 3, and 5years, the percentage of predicted forced expiratory volume in 1s (p = 0.767) and survival rate did not differ between groups (p = 0.924). The use of lungs from donors over 65years for cystic fibrosis recipients allows extension of the donor pool without compromising results. Longer follow-up is needed to assess the long-term effects of this practice.

End-ischemic hypothermic oxygenated perfusion for extended criteria donors in liver transplantation: a multicenter, randomized controlled trial—HOPExt

BackgroundGiven the scarce donor supply, an increasing number of so-called marginal or extended criteria donor (ECD) organs are used for liver transplantation. These ECD liver grafts are however known to be associated with a higher rate of early allograft dysfunction and primary non-function because of a greater vulnerability to ischemia–reperfusion injury. The end-ischemic hypothermic oxygenated machine perfusion (HOPE) technique may improve outcomes of liver transplantation with ECD grafts by decreasing reperfusion injury.MethodsHOPExt trial is a comparative open-label, multicenter, national, prospective, randomized, controlled study, in two parallel groups, using static cold storage, the gold standard procedure, as control. The trial will enroll adult patients on the transplant waiting list for liver failure or liver cirrhosis and/or liver malignancy requiring liver transplantation and receiving an ECD liver graft from a brain-dead donor. In the experimental group, ECD liver grafts will first undergo a classical static cold (4 °C) storage followed by a hypothermic oxygenated perfusion (HOPE) for a period of 1 to 4 h. The control group will consist of the classic static cold storage which is the gold standard procedure in liver transplantation. The primary objective of this trial is to study the efficacy of HOPE used before transplantation of ECD liver grafts from brain-dead donors in reducing postoperative early allograft dysfunction within the first 7 postoperative days compared to simple cold static storage.DiscussionWe present in this protocol all study procedures in regard to the achievement of the HOPExt trial, to prevent biased analysis of trial outcomes and improve the transparency of the trial results. Enrollment of patients in the HOPExt trial has started on September 10, 2019, and is ongoing.Trial registrationClinicalTrials.gov NCT03929523. Registered on April 29, 2019, before the start of inclusion.

Outcomes of Lung Transplant Candidates Aged ≥70 Years During the Lung Allocation Score Era

BackgroundWith the increasing age of lung transplant candidates, we studied waitlist and posttransplantation outcomes of candidates ≥70 years during the Lung Allocation Score era. MethodsAdult lung transplant candidates from 2005 to 2020 in the United Network for Organ Sharing database were included and stratified on the basis of age at listing into 18 to 59 years old, 60 to 69 years old, and ≥70 years old. Baseline characteristics, waitlist outcomes, and posttransplantation outcomes were assessed. ResultsA total of 37,623 candidates were included (52.3% aged 18-59 years, 40.6% aged 60-69 years, 7.1% aged ≥70 years). Candidates ≥70 years were more likely than younger candidates to receive a transplant (81.9% vs 72.7% [aged 60-69 years] vs 61.6% [aged 18-59 years]) and less likely to die or to deteriorate on the waitlist within 1 year (9.1% vs 10.1% [aged 60-69 years] vs 12.2% [aged 18-59 years]; P < .001). Donors for older recipients were more likely to be extended criteria (75.7% vs 70.1% [aged 60-69 years] vs 65.7% [aged 18-59 years]; P < .001). Recipients ≥70 years were found to have lower rates of acute rejection (6.7% vs 7.4% [aged 60-69 years] vs 9.2% [aged 18-59 years]; P < .001) and prolonged intubation (21.7% vs 27.4% [aged 60-69 years] vs 34.5% [aged 18-59 years]; P < .001). Recipients aged ≥70 years had increased 1-year (adjusted hazard ratio [aHR], 1.19 [95% CI, 1.06-1.33]; P < .001), 3-year (aHR, 1.28 [95% CI, 1.18-1.39]; P < .001), and 5-year mortality (aHR, 1.29 [95% CI, 1.21-1.38]; P < .001) compared with recipients aged 60 to 69 years. ConclusionsCandidates ≥70 years had favorable waitlist and perioperative outcomes despite increased use of extended criteria donors. Careful selection of candidates and postoperative surveillance may improve posttransplantation survival in this population.

A Spectrofluorometric Method for Real-Time Graft Assessment and Patient Monitoring.

Biomarkers are powerful clinical diagnostics and predictors of patient outcome. However, robust measurements often require time and expensive laboratory equipment, which is insufficient to track rapid changes and limits direct use in the operating room. Here, this study presents a portable spectrophotometric device for continuous real-time measurements of fluorescent and non-fluorescent biomarkers at the point of care. This study measures the mitochondrial damage biomarker flavin mononucleotide (FMN) in 26 extended criteria human liver grafts undergoing hypothermic oxygenated perfusion to guide clinical graft assessment. Real-time data identified seven organs unsuitable for transplant that are discarded. The remaining grafts are transplanted and FMN values correlated with post-transplant indicators of liver function and patient recovery. Further, this study shows how this device can be used to monitor dialysis patients by measuring creatinine in real-time. Ourapproach provides a simple method to monitor biomarkers directly within biological fluids to improve organ assessment, patient care, and biomarkerdiscovery.

Secondary Cold Ischemia After Normothermic Machine Perfusion: A Drawback to Centralized Organ Perfusion Centers?

Secondary Cold Ischemia After Normothermic Machine Perfusion: A Drawback to Centralized Organ Perfusion Centers?

Prolonged Normothermic Machine Perfusion: Buying More Time for Liver Graft Assessment and Repair.

Prolonged Normothermic Machine Perfusion: Buying More Time for Liver Graft Assessment and Repair.

Expanding Heart Donor Pool With a Broken Heart: Cardiac Transplant From Donor Following Circulatory Death With Takotsubo Syndrome.

Owing to the growth of patients with advanced heart failure and limited potential for donation after brain death, expanding donor source with hearts from controlled donation after circulatory death (cDCD) and meeting extended criteria are essential strategies. We present the first case of a patient who successfully underwent cardiac transplant (CT) from cDCD with Takotsubo syndrome (TTS). The donor was a 49-y-old man without risk factors for coronary artery disease (CAD) and terminal amyotrophic lateral sclerosis with respiratory failure and mechanical ventilation support. A decision was made with patient’s family to withdraw life-sustaining therapies (WLSTs). Organ donation option was presented and consented, and cDCD Maastricht Classification III1 was considered suitable. He presented normal blood tests, electrocardiogram, and echocardiogram. The cDCD process was performed using an extracorporeal membrane oxygenation circuit to perform thoracoabdominal normothermic regional perfusion.2 During intraoperative evaluation, transesophageal echocardiography revealed normal left ventricular ejection fraction (LVEF). However, after WLST, moderate dysfunction (LVEF 37%) and apical ballooning suggestive of TTS were observed (Figure 1A), continuing present after thoracoabdominal normothermic regional perfusion withdrawal and organ extraction. Epicardial coronary arteries palpation did not reveal pathology.FIGURE 1.: A, Intraoperative transesophageal echocardiography evaluation that shows the left ventricle in diastole and systole with apical akinesia and preserved contractility of basal segments. B, The 12-lead electrocardiogram reveals T wave inversion and prolonged QT interval. C, A graph of heart recovery timeline based on the high-sensitivity troponin T levels, left ventricular ejection fraction, and inotrope support, correlated with the d after cardiac transplant. D, Normal right and left coronary arteries in the post cardiac transplant protocol–based coronary angiography. LVEF, left ventricular ejection fraction.The heart recipient was a 52-y-old man with severe, irreversible ischemic cardiomyopathy and 10 d with a ventricular assist device, listed for CT after excluding severe comorbidities and a multidisciplinary team discussion. An orthotopic transplant was performed using the bicaval technique, with spontaneous heartbeat and cold ischemia time of 86 min. He required minimal vasoactive support, withdrawn 48 h after CT. The electrocardiogram showed diffuse negative T waves and prolonged QTc interval (Figure 1B), and peak level of high-sensitivity troponin T was 2115 ng/L. Six days after CT, LVEF normalized. The timeline of heart recovery is represented in Figure 1C. The coronary angiography ruled out donor CAD (Figure 1D). The patient was discharged 30 d after CT and is doing well 43 wk after. Serial echocardiograms reveal normal wall motion and function. DISCUSSION Although TTS and CT have been indirectly associated, few cases have been published on donor hearts with TTS, these with no compromised survival3; none in cDCD. Similar pathophysiological aspects, present in TTS and cDCD, could be responsible for the phenomenon that occurred during CT. In the cDCD, the heart experiences a warm ischemia period during the WLST, cardiac arrest, and CT. This implies ischemia–reperfusion injury: activation of inflammatory and coagulation cascades and release of catecholamines.4 The mechanisms behind TTS, clinical condition characterized by acute transient left ventricular dysfunction, remain unknown. The most widely accepted theory is catecholamine-induced cardiotoxicity, and growing evidence is arising for myocardial inflammation, endothelial and microcirculation dysfunction, and neurohormonal alterations.5 Because of donor’s age, low-risk profile of CAD, and echocardiographic abnormalities, TTS was suspected. The post-CT protocol–based coronary angiography ruled out obstructive CAD or atherosclerotic plaque rupture. There was a rapid normalization of LVEF, negative T waves in the electrocardiogram, and elevated cardiac enzymes. This fulfilled the most widely used TTS diagnostic criteria.5 A pre-CT coronary angiography in patients >40 y or at risk of CAD could avoid ruling out hearts with left ventricular dysfunction. CONCLUSION The pathophysiological knowledge of cDCD and TTS could increase CT rates. This first experience in cDCD should be cautiously interpreted and analyzed individually in future cases.

Nanoparticle-Based Interventions for Liver Transplantation.

Liver transplantation is the only treatment for hepatic insufficiency as a result of acute and chronic liver injuries/pathologies that fail to recover. Unfortunately, there remains an enormous and growing gap between organ supply and demand. Although recipients on the liver transplantation waitlist have significantly higher mortality, livers are often not allocated because they are (i) classified as extended criteria or marginal livers and (ii) subjected to longer cold preservation time (>6 h) with a direct correlation of poor outcomes with longer cold ischemia. Downregulating the recipient's innate immune response to successfully tolerate a graft having longer cold ischemia times or ischemia-reperfusion injury through induction of immune tolerance in the graft and the host would significantly improve organ utilization and post-transplant outcomes. Broadly, technologies proposed for development aim to extend the life of the transplanted liver through post-transplant or recipient conditioning. In this review, we focus on the potential benefits of nanotechnology to provide unique pre-transplant grafting and recipient conditioning of extended criteria donor livers using immune tolerance induction and hyperthermic pre-conditioning.

Mechanical thrombectomy for acute large vessel occlusion stroke beyond 24h.

Multiple trials have shown that mechanical thrombectomy (MT) is superior to medical therapy. However, no robust evidence is available regarding MT beyond 24h. In this study, we aimed to determine the safety and efficacy of endovascular stroke therapy in this late window. We conducted a retrospective study of prospectively collected data of patients who met extended window trial criteria, but underwent MT beyond 24h. Safety and efficacy outcomes included symptomatic intracerebral hemorrhage (sICH), procedural complications, number of passes, successful recanalization (mTICI 2b-3), delta (Δ) NIHSS (baseline-discharge), and favorable outcomes (mRS 0-2 at 90days). A total of 39 patients were included with a median age of 69years (IQR 61.5, 73.5); 54% were females. Hypertension was present in 76% of patients; 23% were smokers. Half of the patients had M1 occlusion (48.7%). Median preprocedural NIHSS was 11 (IQR 7.0, 19.5). Successful revascularization was achieved in 87%; median number of passes was 2 (IQR 1.0, 3.0). Median ΔNIHSS was 3.0 (IQR -1.5, 8.0). Favorable outcome was achieved in 49% (95% CI: 34%-64%), and 95% were free of complications. A total of 3 patients (7.7%) had sICH. In an exploratory analysis, posterior circulation occlusion was associated with higher mRS at 90days (OR: 14.7, p=0.016). Favorable discharge facility was associated with lower mRS at 90days (OR: 0.11, p=0.004). Our study showed comparable clinical outcomes of MT beyond 24h compared to MT trials within 24h in patients with favorable imaging profile, especially in anterior circulation occlusions.

Comment on "Salvage of Declined Extended Criteria DCD Livers Using In-Situ Normothermic Regional Perfusion".

We have read the excellent article written by Schurink et al1 with great interest and much appreciation. The authors show that abdominal normothermic regional perfusion is powerful in protecting extended criteria controlled donation after circulatory death (DCD) liver grafts that could be eventually transplanted with results comparable to donation after brain death liver graft transplantation. The conclusions drawn from this study are of great importance for improving the utilization rate of DCD livers. However, there are still some considerations needing further clarification. First, because each country has different standards for the use of DCD donor livers, whether the authors collect the specific reasons for the declined extended criteria DCD livers and the liver biochemical indicators at the time of decline, and if this part is included in the study, we can also see the liver protective potential of NRP more specifically. This will serve as a reference for other countries and may save a part of the liver that should be declined. Second, because of the powerful effect of abdominal normothermic regional perfusion, it can be seen that a large amount of the donor’s liver is wasted; it is time to unify the standard to reduce the declined rate of extended criteria DCD livers. It is possible to appropriately expand the criteria for liver selection during perfusion; however, this procedure must be performed with great caution to prevent severe postoperative complications. Furthermore, increasing evidence has shown that Hypothermic Oxygenated Machine Perfusion (HOPE) plays an excellent role in protecting the donor liver.2 We also suggest that the authors should actively include HOPE in the study to observe whether HOPE can protect the DCD liver and whether NRP + HOPE has a more positive effect, which will significantly improve the utilization rate of the DCD liver and minimize postoperative complications.

Input-to-State Stability of Time-Delay Systems With Hybrid Impulses and Continuous Subdynamics Based on Vector Lyapunov Function

This article focuses on input-to-state stability (ISS) of impulsive time-delay systems where the hybrid effect of impulses with time-dependent multiple jump maps in different subsystems is fully considered. By virtue of M-matrix and vector Lyapunov function, some theorems for ISS are established for Krasovskii-type conditions which avoid the common threshold of impulses in subsystems and allow the simultaneous existence of stable and unstable continuous subdynamics. If the time intervals between impulses are bounded, the ISS of time-delay systems can be ensured even though hybrid impulses exist in each subsystem, which determines the robustness of stable time-delay systems with respect to hybrid impulses. The unstable time-delay systems with different subdynamics can be stabilized in input-to-state-stability sense by involving hybrid impulses. In addition, several extended criteria are presented to bridge the results derived via vector Lyapunov function, scalar Lyapunov function, and comparison principle. At last, the theoretical results are validated by numerical example and a simplified model of sewage treatment tank.

Introduction: Pushing the boundaries in liver transplantation

Liver disease is a major cause of mortality worldwide and liver transplantation remains the most effective therapeutic modality for the treatment of decompensated cirrhosis, acute liver failure, and small HCC. The field of liver transplantation has dramatically evolved over the past 50 years from an experimental endeavor to a highly successful life-saving procedure for patients with sustained irreversible liver injury. Advances in surgical technique, perioperative and postoperative management, and immunosuppression provided for increased application of liver transplantation with excellent 1-year survival rates reaching 90%. However, the ubiquity of liver transplantation has created its own unique challenges including determining patient eligibility and the shortage of deceased donor organs. The allocation of organs is predicated upon the fine balance between utility and justice. Applying these principles shapes public policy related to patient selection and organ allocation. Candidate selection is increasingly important when optimizing the selection of the recipients who would derive the most benefit from liver transplantation given the scarcity of organs. The trend toward viable organ donation scarcity continues while there has been exponential growth in the number of transplant candidates over the same period of time. The ever-expanding wait list registry reflects the rising tide of NAFLD, specifically the more advanced form, NASH, and alcohol-associated liver disease. Furthermore, ground-breaking success in liver transplantation for hepatic and biliary malignancies paved a path for reaching even more candidates. As perioperative and postoperative management continues to improve, those being considered for liver transplantation have more comorbidities including obesity, diabetes mellitus, and cardiovascular disease. Despite the growing number of potential recipients, the pool of donor organs is failing to keep pace and poses a highly challenging global problem. The mismatch between supply and demand requires the transplant community to ration already limited liver allografts and continually reassess allocation policies based on need versus survival benefit. Efforts were made to expand the pool of potential donors, including utilization of extended criteria donors and donation after cardiac death. Nevertheless, there remains a scarcity of organs. In recent years, the increasing application of living donor liver transplantation has helped mitigate the organ shortage. But this practice is still fraught with contentious elements that have hindered extensive implementation. We are in a new era of liver transplantation. As a transplant community, we must pioneer not only the rising obesity and alcohol epidemics but also successfully manage our aging population while minimizing waitlist mortality. The need for more innovative practices is upon us. In this Clinical Liver Disease series, “Pushing the Boundaries in Liver Transplantation,” the authors review select challenging indications for liver transplantation, the currently accepted practices, and innovative ways that endeavor to expand the reach of liver transplantation.

Predictive value of portal fibrosis and inflammation in transplanted liver grafts treated with hypothermic oxygenated perfusion.

Hypothermic oxygenated perfusion (HOPE) has become widespread for the preservation of liver grafts, making tangled the relationship among the use of extended criteria donors (ECD), graft histology and transplant outcome. To prospectively validate the impact of the graft histology on transplant outcome in recipient receiving liver grafts from ECD after HOPE. Ninety-three ECD grafts were prospectively enrolled; 49 (52.7 %) were perfused with HOPE according to our protocols. All clinical, histological and follow-up data were collected. Grafts with portal fibrosis stage ≥3 according to Ishak's (evaluated with Reticulin stain) had a significantly higher incidence of early allograft dysfunction (EAD) and 6-month-dysfunction (p=0.026 and p=0.049), with more days in Intensive Care Unit (p=0.050). Lobular fibrosis correlated with post-liver transplant kidney function (p=0.019). Moderate-to-severe chronic portal inflammation was correlated with graft survival on both multivariate and univariate analyses (p<0.001), but this risk factor is sensibly reduced by the execution of HOPE. The use of liver grafts with portal fibrosis stage ≥3 implies a higher risk of post-transplant complications. Portal inflammation represents an important prognostic factor as well, but the execution of HOPE represents a valid tool to improve graft survival.

Extended criteria brain-dead organ donors: Prevalence and impact on the utilisation of livers for transplantation in Brazil.

Despite its association with higher postoperative morbidity and mortality, the use of extended criteria donor (ECD) livers for transplantation has increased globally due to the high demand for the procedure. To investigate the prevalence of ECD in donation after brain death (DBD) and its impact on organ acceptance for transplantation. Retrospective analysis of DBD organ offers for liver transplantation between 2017 and 2020 in a high-volume transplant centre. The incidence of the Eurotransplant risk factors to define an ECD (ET-ECD) among DBD donors and the likelihood of organ acceptance over the years were analysed. The relationship between organ refusal for transplantation, the occurrence, and the number of ET-ECD was assessed by simple and multiple logistic regression adjustment. A total of 1619 organ donors were evaluated. Of these, 78.31% (n = 1268) had at least one ET-ECD criterion. There was an increase in the acceptance of ECD DBD organs for transplantation (1 criterion: from 23.40% to 31.60%; 2 criteria: from 13.10% to 27.70%; 3 criteria: From 6.30% to 13.60%). For each addition of one ET-ECD variable, the estimated chance of organ refusal was 64.4% higher (OR 1.644, 95%CI 1.469-1.839, P < 0.001). Except for the donor serum sodium > 165 mmol/L (P = 0.310), all ET-ECD criteria increased the estimated chance of organ refusal for transplantation. A high prevalence of ECD DBD was observed. Despite the increase in their utilisation, the presence and the number of extended donor criteria were associated with an increased likelihood of their refusal for transplantation.

Declined Organs for Liver Transplantation: A Right Decision or a Missed Opportunity for Patients with Hepatocellular Carcinoma?

Liver transplantation is the only promising treatment for end-stage liver disease and patients with hepatocellular carcinoma. However, too many organs are rejected for transplantation. We analyzed the factors involved in organ allocation in our transplant center and reviewed all livers that were declined for transplantation. Reasons for declining organs for transplantation were categorized as major extended donor criteria (maEDC), size mismatch and vascular problems, medical reasons and risk of disease transmission, and other reasons. The fate of the declined organs was analyzed. 1086 declined organs were offered 1200 times. A total of 31% of the livers were declined because of maEDC, 35.5% because of size mismatch and vascular problems, 15.8% because of medical reasons and risk of disease transmission, and 20.7% because of other reasons. A total of 40% of the declined organs were allocated and transplanted. A total of 50% of the organs were completely discarded, and significantly more of these grafts had maEDC than grafts that were eventually allocated (37.5% vs. 17.7%, p < 0.001). Most organs were declined because of poor organ quality. Donor-recipient matching at time of allocation and organ preservation must be improved by allocating maEDC grafts using individualized algorithms that avoid high-risk donor-recipient combinations and unnecessary organ declination.

Use of extended criteria donor hearts in combined heart-kidney transplant confers greater risk of mortality

Extended criteria donors (ECD) hearts have demonstrated acceptable outcomes in select populations. However, their use in patients undergoing simultaneous heart-kidney transplantation (SHKT) has not been explored. This study is assessed the effect of ECD hearts in patients undergoing SHKT vs isolated heart transplants (IHT). The United Network for Organ Sharing (UNOS) database was queried for all adult patients undergoing IHT and SHKT. Patients were stratified by receipt of ECD heart, defined as donor hearts failing to meet established acceptable use criteria. Interaction effects between ECDs and simultaneous kidney transplants were generated. Postoperative outcomes, risk factors, and patient/graft survival were compared across cohorts using Fine-Gray, Kaplan Meier, and Cox Proportional Hazards analyses. Among 26,207 patients included, 1,766 (7%) underwent SHKT. ECD hearts were used in 25% of both IHT and SHKT cohorts. Five-year survival among SHKT/ECD patients (67.3%) was reduced (p < 0.01) compared to SHKT/SDC (80.3%), IHT/ECD (78.1%) and IHT/SCD (80.0%) groups. Among SHKT patients, use of ECD hearts was associated with increased risk (SHR: 1.48; p < 0.01) of renal graft failure compared to SCD hearts. Among SHKT patients, receipt of an ECD heart, and individual ECD criteria (coronary disease and size mismatch >20%), predicted mortality. The interaction effect of receiving both ECD and SHKT predicted mortality and graft failure (HR 1.43; p < 0.01). Patients undergoing SHKT with an ECD heart face greater risks of mortality and graft failure in comparison to those undergoing IHT with ECD hearts. Careful selection of donor organs should be applied to this high-risk cohort.

Ascending aorta cannulation for isolated liver procurement in extended criteria donors: a safe option in case of massive infrarenal aortic atherosclerosis.

The chronic organ shortage and the increased number of patients on the waiting list for liver transplantation have led to a progressive increase in the use of extended criteria donors. Nowadays more and more overweight donors with several comorbidities are selected for donation providing acceptable patient and liver graft survival. These donors have often aortic atherosclerosis which can spare the hepatic artery making suitable the liver for procurement. Massive aortic atherosclerosis localized to infrarenal aorta can challenge aortic cannulation for organ cooling. We herein describe in a stepwise approach the aortic cannulation realized at the ascending aorta level in case of massive infrarenal aortic atherosclerosis in ECD donors. This technique represents a safe option when abdominal aorta is not suitable for cannulation and it should be included into the surgical armamentarium of liver transplant surgeon.