Influence of Ischemic Agonal Phase on Hepatic Ischemia / Reperfusion Injury and Postoperative Outcomes in DCD Liver Transplantation

M. Kalisvaart, J.E. de Haan, W.G. Polak, J.N.M Ijzermans, D.A.M.P.J. Gommers, H.J. Metselaar, J. de Jonge

Chair(s): dr. D.E. Braat & dr. N.C. van der Weerd

Thursday 9 march 2017

9:48 - 10:00h at Johan de Meesterzaal

Categories: Parallel - Klinisch

Parallel session: Parallelsessie XII – Klinisch 4 - Pretransplantatie en donatie

Donation after circulatory death (DCD) grafts are increasingly used in liver transplantation, but the use of these marginal grafts is associated with biliary complications and impaired graft survival rates. The DCD-specific extra donor warm ischemia time (DWIT) exposes the graft to a longer period of warm ischemia, which potentially aggravates hepatic ischemia/reperfusion injury. Our aim was to analyse the impact of DWIT on the severity of hepatic ischemia/reperfusion injury and subsequent recipient outcomes in DCD liver transplantation. We performed a retrospective single centre cohort study of all DCD liver transplantation from 2008 until 2016. DWIT was divided into two periods: ischemic agonal phase (time after treatment withdrawal that saturation drops below 80% or MAP below 50 mmHg to circulatory arrest) and asystolic phase (time from circulatory arrest to start of cold perfusion). Postoperative peak serum AST levels (72h) were used to quantify the severity of hepatic ischemia/reperfusion injury. A total of 93 recipients were included in this study. The mean length of ischemic agonal phase and asystolic phase was 13 and 16 minutes, respectively. Only the length of ischemic agonal phase was correlated with hepatic ischemia/reperfusion injury (Spearmans’ rho 0.399; p<0.001) and multilinear modelling identified length of ischemic agonal phase (p<0.001), but not asystolic phase, as a factor associated with postoperative peak serum AST levels. Further analysis of the impact of ischemic agonal phase on recipient outcomes showed higher in-hospital severe complication (p=0.001) and mortality rates (p=0.030) in recipients with a ischemic agonal phase longer than 13 minutes. The 1-year graft survival was also inferior for recipients with a longer agonal phase (<=13 minutes, 92%; >13 minutes, 74%; p=0.016).

In conclusion, this study provides new insight on the relation between ischemic agonal phase and hepatic ischemia/reperfusion injury. Furthermore, the impact on recipient outcomes are significant and further studies are required to identify poor DCD liver grafts.