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DCD Liver Transplantation: Is it Worth the Effort?

DCD Liver Transplantation: Is it Worth the Effort?. Sophoclis P. Alexopoulos, M.D. Assistant Professor of Clinical Surgery Department of Hepatobiliary , Pancreatic, and Abdominal Organ Transplant Surgery Keck School of Medicine of USC. Keck Medical Center of USC. Definitions. Definitions.

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DCD Liver Transplantation: Is it Worth the Effort?

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  1. DCD Liver Transplantation:Is it Worth the Effort? Sophoclis P. Alexopoulos, M.D. Assistant Professor of Clinical Surgery Department of Hepatobiliary, Pancreatic, and Abdominal Organ Transplant Surgery Keck School of Medicine of USC Keck Medical Center ofUSC

  2. Definitions Definitions • Donation After Cardiac Death: organ donation after death declared on the basis of cardiopulmonary criteria (irreversible cessation of circulatory and respiratory function) • Donation After Brain Death: organ donation after death declared on the basis of neurologic criteria (irreversible loss of all functions of the entire brain including the brain stem) Keck Medical Center ofUSC N Engl J Med 2007; 357:209-213

  3. Differences Brain Dead Donor Donation After Cardiac Death Patient brought to operating room Heparin administered Patient extubated Await cessation of cardiopulmonary activity Declaration of brain death Dissection performed to insert cannulas Cooling and infusion of organ preservation solution Dissection and removal of organs • Patient brought to operating room with anesthesia • Normal cardiopulmonary hemodynamics maintained to optimize organ perfusion • Dissection performed • Cannulas inserted • Heparinization • Cardiopulmonary arrest instituted simultaneous with cooling and infusion of organ preservation solution Keck Medical Center ofUSC

  4. Variations in Hospital Policy Variations in Hospital Policies Huntington Hospital Antelope Valley Hospital Keck Medical Center ofUSC

  5. Time Points in DCD Liver Transplantation Time Points in DCD Liver Transplantation Keck Medical Center ofUSC Arch Surg. 2011;146(9):1017-1023.

  6. Outcomes Outcomes Keck Medical Center ofUSC

  7. Liver Transplant Outcomes Using DCD Are Inferior To DBD Cox regression estimates of adjusted allograft survival. Keck Medical Center ofUSC Annals of Surgery. 248(4):599-607, October 2008.

  8. Liver Transplant Outcomes Using DCD Are Inferior To DBD Adjusted Allograft Survival at 6-Month Intervals Through the Observation Period Keck Medical Center ofUSC 2 Annals of Surgery. 248(4):599-607, October 2008.

  9. Cumulative Incidence of post-DCD Liver Transplant Outcomes Three years after undergoing DCD liver transplantation, nearly 65% of recipients were alive with a functioning graft. However, more than 20% of these recipients were dead at 3 years, and 13.6% required a subsequent liver transplant. Keck Medical Center ofUSC AJT. 2010;10(11):2512-2519.

  10. Biliary Complication Rates Are Much Higher in DCD Liver Transplantation Keck Medical Center ofUSC Ann Surg. 2011 April; 253(4): 817–825.

  11. Ischemic Cholangiopathy Continues to Develop Over a Prolonged Period in DCD Allografts Keck Medical Center ofUSC Arch Surg. 2011;146(9):1017-1023.

  12. Components of the Liver Parenchyma Keck Medical Center ofUSC

  13. Effect of Donor Warm Ischemia on Graft Failure Following DCD Liver Transplantation Keck Medical Center ofUSC AJT. 2010;10(11):2512-2519.

  14. DCD Donor Determinants of Graft Failure Keck Medical Center ofUSC AJT. 2010;10(11):2512-2519.

  15. DCD Donor Determinants of Recipient Outcome Keck Medical Center ofUSC AJT. 2010;10(11):2512-2519.

  16. Why do DCD Liver Transplant Keck Medical Center ofUSC

  17. Supply-Demand Imbalance In Liver Transplantation Keck Medical Center ofUSC www.unos.org/data

  18. Regional Variation in Liver Transplantation: Location Matters Thirty-day probabilities of receiving a DBD transplant for patients with a MELD score >20 across the 11 UNOS regions. The means and standard deviations are reported for the individual regions. Keck Medical Center ofUSC Liver Transplantation. 2012;18(6):630-640.

  19. Balancing Risk – Reward in DCD Liver Transplantation ↑ Graft Failure ↓ Patient Survival ↑ Ischemic Cholangiopathy Mortality on Wait List Reward Risk Keck Medical Center ofUSC

  20. MELD Score and Probability of 3 Month Mortality without Liver Transplant JAMA. 2006;295:2168-2176. Keck Medical Center ofUSC

  21. Liver Transplantation vs. Delisting Keck Medical Center ofUSC

  22. Waitlist Mortality Exceeds 50% in Patients with MELD ≥ 40 Keck Medical Center ofUSC

  23. Conclusions • A continued shortage of liver allografts necessitates innovative ways of expanding the donor pool • DCD organ donation increases the number of available liver allografts • Outcomes with DCD liver transplantation are significantly inferior to DBD liver transplantation, though a majority of patients do well • The biliary tree is particularly susceptible to ischemic injury inherent in DCD organ donation • Carefully selected DCD liver transplantation should be offered to patients in regions where waitlist mortality exceeds the increased risk of death associated with the use of a DCD organ Keck Medical Center ofUSC

  24. Some Guidelines for the Selection of DCD Liver Allografts • Donor Age ≤ 45 years • Warm Ischemia Time ≤ 30 min • Cold Ischemia Time ≤ 8 hours • Minimal Hepatic Steatosis • Pre-recovery Heparin Administration Keck Medical Center ofUSC

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