Department of General & Digestive Surgery, Institut de Malalties Digestives i Metabòliques (IMDiM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain.
Organización Nacional de Trasplantes, Madrid, Spain.
J Hepatol. 2019 Apr;70(4):658-665. doi: 10.1016/j.jhep.2018.12.013. Epub 2018 Dec 22.
BACKGROUND & AIMS: Although there is increasing interest in its use, definitive evidence demonstrating a benefit for postmortem normothermic regional perfusion (NRP) in controlled donation after circulatory death (cDCD) liver transplantation is lacking. The aim of this study was to compare results of cDCD liver transplants performed with postmortem NRP vs. super-rapid recovery (SRR), the current standard for cDCD.
This was an observational cohort study including all cDCD liver transplants performed in Spain between June 2012 and December 2016, with follow-up ending in December 2017. Each donor hospital determined whether organ recovery was performed using NRP or SRR. The propensity scores technique based on the inverse probability of treatment weighting (IPTW) was used to balance covariates across study groups; logistic and Cox regression models were used for binary and time-to-event outcomes.
During the study period, there were 95 cDCD liver transplants performed with postmortem NRP and 117 with SRR. The median donor age was 56 years (interquartile range 45-65 years). After IPTW analysis, baseline covariates were balanced, with all absolute standardised differences <0.15. IPTW-adjusted risks were significantly improved among NRP livers for overall biliary complications (odds ratio 0.14; 95% CI 0.06-0.35, p <0.001), ischaemic type biliary lesions (odds ratio 0.11; 95% CI 0.02-0.57; p = 0.008), and graft loss (hazard ratio 0.39; 95% CI 0.20-0.78; p = 0.008).
The use of postmortem NRP in cDCD liver transplantation appears to reduce postoperative biliary complications, ischaemic type biliary lesions and graft loss, and allows for the transplantation of livers even from cDCD donors of advanced age.
This is a propensity-matched nationwide observational cohort study performed using livers recovered from donors undergoing cardiac arrest provoked by the intentional withdrawal of life support (controlled donation after circulatory death, cDCD). Approximately half of the livers were recovered after a period of postmortem in situ normothermic regional perfusion, which restored warm oxygenated blood to the abdominal organs, whereas the remainder were recovered after rapid preservation with a cold solution. The study results suggest that the use of postmortem normothermic regional perfusion helps reduce rates of post-transplant biliary complications and graft loss and allows for the successful transplantation of livers from older cDCD donors.
尽管人们对其应用越来越感兴趣，但仍缺乏明确的证据表明在停循环死亡（cDCD）后进行的低温区域性灌注（NRP）对控制捐赠的肝脏移植有益。本研究的目的是比较使用死后 NRP 与超速恢复（SRR）进行 cDCD 肝移植的结果，SRR 是目前 cDCD 的标准。
这是一项观察性队列研究，纳入了 2012 年 6 月至 2016 年 12 月期间在西班牙进行的所有 cDCD 肝移植，随访至 2017 年 12 月结束。每个供体医院决定器官恢复是使用 NRP 还是 SRR 进行。采用基于逆概率治疗加权（IPTW）的倾向评分技术对研究组间的协变量进行平衡；使用逻辑回归和 Cox 回归模型对二项和时间事件结果进行分析。
在研究期间，进行了 95 例使用死后 NRP 的 cDCD 肝移植和 117 例使用 SRR 的肝移植。供体年龄中位数为 56 岁（四分位距 45-65 岁）。在 IPTW 分析后，基线协变量得到平衡，所有绝对标准化差异均<0.15。在 NRP 肝脏中，总体胆道并发症（比值比 0.14；95%可信区间 0.06-0.35，p<0.001）、缺血型胆道病变（比值比 0.11；95%可信区间 0.02-0.57；p=0.008）和移植物丢失（风险比 0.39；95%可信区间 0.20-0.78；p=0.008）的风险显著降低。
在 cDCD 肝移植中使用死后 NRP 似乎可以减少术后胆道并发症、缺血型胆道病变和移植物丢失，并允许对年龄较大的 cDCD 供体的肝脏进行移植。
本研究是一项基于全国范围内的倾向性匹配观察队列研究，研究对象为因主动终止生命支持而发生心脏骤停的供体（控制性循环死亡后供体，cDCD）所捐献的肝脏。大约一半的肝脏是在死后原位低温区域性灌注后恢复的，这种方法可以将含氧的温暖血液重新输送到腹部器官；而其余的肝脏则是在使用冷溶液进行快速保存后恢复的。研究结果表明，使用死后低温区域性灌注有助于降低移植后胆道并发症和移植物丢失的发生率，并允许成功移植来自老年 cDCD 供体的肝脏。
