The golden hour: length of total warm ischemia time presages development of severe acute kidney injury after DCD liver transplantation

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M. Kalisvaart, I. Umbro, J.E. de Haan, I. Scalera, A. Schlegel, J.N.M Ijzermans, T. Perera, J. Isaac, A. Mitterhofer, P. Muiesan, J. de Jonge

Chair(s): dr. N.P. van der Kaaij

Thursday 9 march 2017

13:00 - 13:15h

Categories: Poster - Klinisch

Parallel session: Postersessie - Klinisch 3

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Acute kidney injury (AKI) is more frequently observed in DCD liver transplantation (LT). The DCD-specific donor warm ischemia time (DWIT) aggravates hepatic ischemia/reperfusion injury and thereby enhances renal impairment. Our aim was to analyse the impact of all warm ischemia periods on development of AKI after DCD LT. We performed a retrospective two Center study of all DCD LT (2008-2016). AKI was defined following KDIGO criteria. DWIT was divided into two periods: agonal phase (donor treatment withdrawal–circulatory arrest) and asystolic phase (circulatory arrest–cold perfusion). Total warm ischemia time was defined as the sum of DWIT and recipient warm ischemia time (RWIT). Multiple logistic regression was used to identify factors associated with development of severe postoperative AKI (KDIGO stage 2&3). A total of 368 recipients were included. 239 recipients (65%) developed AKI, including 151 recipients (41%) with severe AKI. The relation between all warm ischemia periods and AKI differed between Centers. In Center 1 only RWIT was longer in recipients with severe AKI  (40 minutes) compared to recipients with no or mild AKI (36 minutes) (p=0.003). On the contrary, in Center 2 only agonal phase was longer in the severe AKI group (19 vs 15 minutes; p=0.028). Analysis of the entire cohort showed that the total warm ischemia time increased with severity of AKI: 61 minutes in recipients without AKI up to 69 minutes in recipients with AKI stage 3 (p<0.001). Multiple logistic regression identified length of TOTAL warm ischemia time as a factor associated with severe AKI (OR 1.032; 95%CI 1.014-1.051; p<0.001). In conclusion , the extra DWIT in DCD LT exposes grafts to more hepatic ischemia/reperfusion injury upon the warm ischemia prior to reperfusion. Although the composition of warm ischemia may differ between Centers, the length of total warm ischemia time is associated with development of severe AKI and should ideally not exceed 60 minutes.