Optimization of Perioperative Conditions to Prevent Ischemic Cholangiopathy in Donation After Circulatory Death Donor Liver Transplantation

Chandrashekhar Kubal, Richard Mangus, Jonathan Fridell, Romil Saxena, Natalia Rush, Matthew Wingler, Burcin Ekser, Joseph Tector

Research output: Contribution to journalArticle

17 Citations (Scopus)

Abstract

BACKGROUND: Donation after circulatory death (DCD) donor pool remains underutilized for liver transplantation (LT). We describe optimizing “modifiable risk factors,” such as cold ischemia time (CIT) recipient warm ischemia time (WIT) and the use of thrombolytic flush at the time of procurement to minimize ischemic cholangiopathy (IC). METHODS: From July 2011 (era II), to improve outcomes after DCD LT, measures were taken to minimize CIT, operative time and recipient WIT along with the use of tissue plasminogen activator (tPA) flush during DCD procurements. Thirty consecutive DCD LTs were performed prospectively in era II. Outcomes were compared with 61 historic controls (era I). Reperfusion biopsies were evaluated for the presence of necrosis and biliary epithelial damage. RESULTS: Median CIT (4.9 [3.5-5.9] vs 6.4 [4.3-12]; P <0.001), hepatectomy time (70 [42-120] vs 81 [58-207]; P = 0.02), and recipient WIT (16 [13-31] vs 24[15-40]; P <0.001) were significantly shorter in era II. All patients in era II received tPA flushed liver grafts. None of the patients in era II developed IC (0% vs 18%; P = 0.013). There were fewer biliary complications in era II, and there was no increased risk of bleeding associated with the use of tPA. One-year graft survival was slightly better in era II (n = 24 patients with 1 year follow-up) (88% vs 80%; P = 0.14). CONCLUSIONS: Optimizing peritransplant conditions, such as shortening ischemic times with the use of thrombolytic donor flush, may prevent IC after DCD LT. With this approach, the DCD donor pool may be expanded.

Original languageEnglish (US)
JournalTransplantation
DOIs
StateAccepted/In press - Apr 29 2016

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Liver Transplantation
Tissue Donors
Cold Ischemia
Warm Ischemia
Tissue Plasminogen Activator
Hepatectomy
Graft Survival
Operative Time
Reperfusion
Necrosis
Hemorrhage
Transplants
Biopsy
Liver

ASJC Scopus subject areas

  • Transplantation

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Optimization of Perioperative Conditions to Prevent Ischemic Cholangiopathy in Donation After Circulatory Death Donor Liver Transplantation. / Kubal, Chandrashekhar; Mangus, Richard; Fridell, Jonathan; Saxena, Romil; Rush, Natalia; Wingler, Matthew; Ekser, Burcin; Tector, Joseph.

In: Transplantation, 29.04.2016.

Research output: Contribution to journalArticle

Kubal, Chandrashekhar ; Mangus, Richard ; Fridell, Jonathan ; Saxena, Romil ; Rush, Natalia ; Wingler, Matthew ; Ekser, Burcin ; Tector, Joseph. / Optimization of Perioperative Conditions to Prevent Ischemic Cholangiopathy in Donation After Circulatory Death Donor Liver Transplantation. In: Transplantation. 2016.
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abstract = "BACKGROUND: Donation after circulatory death (DCD) donor pool remains underutilized for liver transplantation (LT). We describe optimizing “modifiable risk factors,” such as cold ischemia time (CIT) recipient warm ischemia time (WIT) and the use of thrombolytic flush at the time of procurement to minimize ischemic cholangiopathy (IC). METHODS: From July 2011 (era II), to improve outcomes after DCD LT, measures were taken to minimize CIT, operative time and recipient WIT along with the use of tissue plasminogen activator (tPA) flush during DCD procurements. Thirty consecutive DCD LTs were performed prospectively in era II. Outcomes were compared with 61 historic controls (era I). Reperfusion biopsies were evaluated for the presence of necrosis and biliary epithelial damage. RESULTS: Median CIT (4.9 [3.5-5.9] vs 6.4 [4.3-12]; P <0.001), hepatectomy time (70 [42-120] vs 81 [58-207]; P = 0.02), and recipient WIT (16 [13-31] vs 24[15-40]; P <0.001) were significantly shorter in era II. All patients in era II received tPA flushed liver grafts. None of the patients in era II developed IC (0{\%} vs 18{\%}; P = 0.013). There were fewer biliary complications in era II, and there was no increased risk of bleeding associated with the use of tPA. One-year graft survival was slightly better in era II (n = 24 patients with 1 year follow-up) (88{\%} vs 80{\%}; P = 0.14). CONCLUSIONS: Optimizing peritransplant conditions, such as shortening ischemic times with the use of thrombolytic donor flush, may prevent IC after DCD LT. With this approach, the DCD donor pool may be expanded.",
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T1 - Optimization of Perioperative Conditions to Prevent Ischemic Cholangiopathy in Donation After Circulatory Death Donor Liver Transplantation

AU - Kubal, Chandrashekhar

AU - Mangus, Richard

AU - Fridell, Jonathan

AU - Saxena, Romil

AU - Rush, Natalia

AU - Wingler, Matthew

AU - Ekser, Burcin

AU - Tector, Joseph

PY - 2016/4/29

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N2 - BACKGROUND: Donation after circulatory death (DCD) donor pool remains underutilized for liver transplantation (LT). We describe optimizing “modifiable risk factors,” such as cold ischemia time (CIT) recipient warm ischemia time (WIT) and the use of thrombolytic flush at the time of procurement to minimize ischemic cholangiopathy (IC). METHODS: From July 2011 (era II), to improve outcomes after DCD LT, measures were taken to minimize CIT, operative time and recipient WIT along with the use of tissue plasminogen activator (tPA) flush during DCD procurements. Thirty consecutive DCD LTs were performed prospectively in era II. Outcomes were compared with 61 historic controls (era I). Reperfusion biopsies were evaluated for the presence of necrosis and biliary epithelial damage. RESULTS: Median CIT (4.9 [3.5-5.9] vs 6.4 [4.3-12]; P <0.001), hepatectomy time (70 [42-120] vs 81 [58-207]; P = 0.02), and recipient WIT (16 [13-31] vs 24[15-40]; P <0.001) were significantly shorter in era II. All patients in era II received tPA flushed liver grafts. None of the patients in era II developed IC (0% vs 18%; P = 0.013). There were fewer biliary complications in era II, and there was no increased risk of bleeding associated with the use of tPA. One-year graft survival was slightly better in era II (n = 24 patients with 1 year follow-up) (88% vs 80%; P = 0.14). CONCLUSIONS: Optimizing peritransplant conditions, such as shortening ischemic times with the use of thrombolytic donor flush, may prevent IC after DCD LT. With this approach, the DCD donor pool may be expanded.

AB - BACKGROUND: Donation after circulatory death (DCD) donor pool remains underutilized for liver transplantation (LT). We describe optimizing “modifiable risk factors,” such as cold ischemia time (CIT) recipient warm ischemia time (WIT) and the use of thrombolytic flush at the time of procurement to minimize ischemic cholangiopathy (IC). METHODS: From July 2011 (era II), to improve outcomes after DCD LT, measures were taken to minimize CIT, operative time and recipient WIT along with the use of tissue plasminogen activator (tPA) flush during DCD procurements. Thirty consecutive DCD LTs were performed prospectively in era II. Outcomes were compared with 61 historic controls (era I). Reperfusion biopsies were evaluated for the presence of necrosis and biliary epithelial damage. RESULTS: Median CIT (4.9 [3.5-5.9] vs 6.4 [4.3-12]; P <0.001), hepatectomy time (70 [42-120] vs 81 [58-207]; P = 0.02), and recipient WIT (16 [13-31] vs 24[15-40]; P <0.001) were significantly shorter in era II. All patients in era II received tPA flushed liver grafts. None of the patients in era II developed IC (0% vs 18%; P = 0.013). There were fewer biliary complications in era II, and there was no increased risk of bleeding associated with the use of tPA. One-year graft survival was slightly better in era II (n = 24 patients with 1 year follow-up) (88% vs 80%; P = 0.14). CONCLUSIONS: Optimizing peritransplant conditions, such as shortening ischemic times with the use of thrombolytic donor flush, may prevent IC after DCD LT. With this approach, the DCD donor pool may be expanded.

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