心脏死亡后肝脏移植的器官捐献：关于影响结局的生命支持撤除位置的荟萃分析

Donation After Circulatory Death for Liver Transplantation: A Meta-Analysis on the Location of Life Support Withdrawal Affecting Outcomes.

作者信息

Cao Yiming, Shahrestani Sara, Chew Hong Chee, Crawford Michael, Macdonald Peter Simon, Laurence Jerome, Hawthorne Wayne John, Dhital Kumud, Pleass Henry

机构信息

1 Faculty of Medicine, University of New South Wales, NSW, Australia. 2 Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia. 3 Sydney Medical School, University of Sydney, NSW, Australia. 4 Cardiac Transplant Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia. 5 Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia. 6 RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia. 7 Department of Surgery, Westmead Hospital, Westmead, NSW, Australia.

出版信息

Transplantation. 2016 Jul;100(7):1513-24. doi: 10.1097/TP.0000000000001175.

DOI:10.1097/TP.0000000000001175

PMID:27014794

Abstract

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.

摘要

背景

与脑死亡后捐赠（DBD）相比，使用心脏死亡后捐赠（DCD）供体进行肝移植的结果较差。供体热缺血时间延长被认为是造成这种差异的关键因素。供体生命支持撤除程序的各个方面，包括撤除地点和死前肝素的使用，被认为在减轻热缺血的影响方面起着重要作用。然而，对这些因素进行系统探索对于更有信心地将这些做法纳入标准的DCD方案至关重要。

方法

系统检索Medline、EMBASE和Cochrane图书馆，并确定23项相关研究进行分析。根据生命支持撤除的地点（重症监护病房或手术室）和死前肝素的使用情况，对心脏死亡后捐赠受者进行分层。

结果

如果生命支持的撤除地点是手术室，心脏死亡后捐赠受者的1年患者生存率与DBD受者相当，但如果撤除地点是重症监护病房则不然。同样，与DBD受者相比，DCD受者较差的1年移植物生存率和缺血性胆管病的较高发生率在手术室撤除时得到改善，尽管在DCD受者中仍观察到较高的缺血性胆管病发生率和较差的移植物生存率。此外，在撤除生命支持前给予肝素可降低同种异体移植物原发性无功能的发生率。