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Donation After Circulatory Death for Liver Transplantation

2016; Wolters Kluwer; Volume: 100; Issue: 7 Linguagem: Inglês

10.1097/tp.0000000000001175

1534-6080

Yiming Cao, Sara Shahrestani, H. Chew, Michael Crawford, Peter S. Macdonald, Jerome Laurence, Wayne J. Hawthorne, K. Dhital, Henry Pleass,

Liver Disease and Transplantation

In Brief Background Liver transplantation using donation after circulatory death (DCD) donors is associated with inferior outcomes compared to donation after brain death (DBD). Prolonged donor warm ischemic time has been identified as the key factor responsible for this difference. Various aspects of the donor life support withdrawal procedure, including location of withdrawal and administration of antemortem heparin, are thought to play important roles in mitigating the effects of warm ischemia. However, a systematic exploration of these factors is important for more confident integration of these practices into a standard DCD protocol. Methods Medline, EMBASE, and Cochrane libraries were systematically searched and 23 relevant studies identified for analysis. Donation after circulatory death recipients were stratified according to location of life support withdrawal (intensive care unit or operating theater) and use of antemortem heparin. Results Donation after circulatory death recipients had comparable 1-year patient survival to DBD recipients if the location of withdrawal of life support was the operating theater, but not if the location was the intensive care unit. Likewise, the inferior 1-year graft survival and higher incidence of ischemic cholangiopathy of DCD compared with DBD recipients were improved by withdrawal in operating theater, although higher rates of ischemic cholangiopathy and worse graft survival were still observed in DCD recipients. Furthermore, administering heparin before withdrawal of life support reduced the incidence of primary nonfunction of the allograft. Conclusions Our evidence suggests that withdrawal in the operating theater and premortem heparin administration improve DCD liver transplant outcomes, thus allowing for the most effective usage of these valuable organs. This meta-analysis identified 23 evaluable studies regarding optimal use of DCD for liver transplantation. Extubation in the operating room emerges as a highly significant predictor of acceptable outcomes. The role of heparinization and the incidence of biliary complications is carefully examined.