Kubal Chandrashekhar, Mangus Richard, Fridell Jonathan, Saxena Romil, Rush Natalia, Wingler Matthew, Ekser Burcin, Tector Joseph
1 Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.2 Department of Pathology, Indiana University School of Medicine, Indianapolis, IN.3 Indiana Donor Network, Indianapolis, IN.
Transplantation. 2016 Aug;100(8):1699-704. doi: 10.1097/TP.0000000000001204.
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).
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.
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).
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.
心脏死亡后器官捐献（DCD）供体库在肝移植（LT）中仍未得到充分利用。我们描述了优化“可改变的风险因素”，如冷缺血时间（CIT）、受体热缺血时间（WIT）以及在获取器官时使用溶栓冲洗，以尽量减少缺血性胆管病（IC）。
从2011年7月（第二阶段）开始，为改善DCD肝移植后的结果，采取了措施以尽量减少CIT、手术时间和受体WIT，并在DCD获取过程中使用组织纤溶酶原激活剂（tPA）冲洗。在第二阶段前瞻性地进行了连续30例DCD肝移植。将结果与61例历史对照（第一阶段）进行比较。对再灌注活检进行坏死和胆管上皮损伤的评估。
第二阶段的中位CIT（4.9[3.5 - 5.9]对6.4[4.3 - 12]；P < 0.001）、肝切除时间（70[42 - 120]对81[58 - 207]；P = 0.02）和受体WIT（16[13 - 31]对24[15 - 40]；P < 0.001）显著缩短。第二阶段的所有患者均接受了tPA冲洗的肝移植。第二阶段的患者均未发生IC（0%对18%；P = 0.013）。第二阶段的胆系并发症较少，且使用tPA未增加出血风险。第二阶段的1年移植物存活率略高（n = 24例患者有1年随访）（88%对80%；P = 0.14）。
优化移植周围条件，如使用溶栓供体冲洗缩短缺血时间，可能预防DCD肝移植后的IC。采用这种方法，DCD供体库可能会扩大。
