Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
Clin Mol Hepatol. 2020 Oct;26(4):401-410. doi: 10.3350/cmh.2020.0072. Epub 2020 Jul 10.
Donation after circulatory death (DCD) is an increasing source of liver grafts for transplantation, yet outcomes have been inferior compared to donation after brain death liver transplantation. These worse outcomes are mainly due to the severe graft injury resulting from mandatory warm ischemia during DCD organ recovery. New evidence, however, indicates that improved donor selection and surgical techniques can decrease the risk of graft failure and ischemic cholangiopathy (IC). Under current best practices, DCD organs are retrieved with the super-rapid technique, optimizing timing and protecting the liver graft from detrimental warm ischemia. Graft viability is influenced by both the quantity and quality of warm ischemia, which is unique to each donor and causes various degrees of pathophysiologic consequences. Evidence also shows that the choice of preservation solution and premortem heparin administration influences graft viability. Additionally, although the precise mechanism of IC remains unknown, stasis of blood during donor warm ischemia may cause the formation of microthrombi in the peribiliary vascular plexus and ischemia of the bile duct. Importantly, thrombolytic protocols show a possible preventive modality for IC. Finally, while ex vivo machine perfusion technology has gained an interest in DCD liver transplantation, further studies are necessary to evaluate the effectiveness of this evolving field to improve graft quality and transplant outcomes.
心跳停止后捐献（DCD）是肝移植供体的一个重要来源，但与脑死亡后肝移植相比，其效果较差。这些较差的结果主要是由于在 DCD 器官回收过程中强制性热缺血导致严重的移植物损伤。然而，新的证据表明，改进供者选择和手术技术可以降低移植物失功和缺血性胆管病（IC）的风险。在目前的最佳实践中，使用超速技术获取 DCD 器官，优化时间并保护肝移植物免受有害的热缺血。移植物的活力受到热缺血的数量和质量的影响，这对每个供者都是独特的，并导致不同程度的病理生理后果。证据还表明，保存液和生前肝素给药的选择会影响移植物的活力。此外，尽管 IC 的确切机制尚不清楚，但供者热缺血期间的血液淤滞可能导致胆管周围血管丛中小血栓的形成和胆管的缺血。重要的是，溶栓方案显示出对 IC 的一种可能的预防方式。最后，虽然体外机器灌注技术在 DCD 肝移植中引起了关注，但仍需要进一步的研究来评估该领域的有效性，以改善移植物质量和移植结果。
