DCD liver transplant in patients with a MELD over 35

Frontiers in Immunology

Immunology

Ryutaro Hirose¹  Shareef M. Syed¹  Chris E. Freise¹  Miguel Nunez¹  Sandy Feng¹  Garrett R. Roll¹  Mehdi Tavakol¹  John P. Roberts¹  Nancy L. Ascher¹  Raphael P. H. Meier² 

[1] Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States;Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States;Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, United States;

关键词: liver transplantation;    high model for end-stage liver disease score;    donation after circulatory death;    donation after brain death;    ischemia-reperfusion;    acute rejection;    chronic rejection;    renal failure;   

DOI  :  10.3389/fimmu.2023.1246867

 received in 2023-06-24, accepted in 2023-08-17,  发布年份 2023

来源: Frontiers

【 摘 要 】

IntroductionDonation after circulatory death (DCD) liver transplantation (LT) makes up well less than 1% of all LTs with a Model for End-Stage Liver Disease (MELD)≥35 in the United States. We hypothesized DCD-LT yields acceptable ischemia-reperfusion and reasonable outcomes for recipients with MELD≥35.MethodsWe analyzed recipients with lab-MELD≥35 at transplant within the UCSF (n=41) and the UNOS (n=375) cohorts using multivariate Cox regression and propensity score matching.ResultsIn the UCSF cohort, five-year patient survival was 85% for DCD-LTs and 86% for matched-Donation after Brain Death donors-(DBD) LTs (p=0.843). Multivariate analyses showed that younger donor/recipient age and more recent transplants (2011-2021 versus 1999-2010) were associated with better survival. DCD vs. DBD graft use did not significantly impact survival (HR: 1.2, 95%CI 0.6-2.7). The transaminase peak was approximately doubled, indicating suggesting an increased ischemia-reperfusion hit. DCD-LTs had a median post-LT length of stay of 11 days, and 34% (14/41) were on dialysis at discharge versus 12 days and 22% (9/41) for DBD-LTs. 27% (11/41) DCD-LTs versus 12% (5/41) DBD-LTs developed a biliary complication (p=0.095). UNOS cohort analysis confirmed patient survival predictors, but DCD graft emerged as a risk factor (HR: 1.5, 95%CI 1.3-1.9) with five-year patient survival of 65% versus 75% for DBD-LTs (p=0.016). This difference became non-significant in a sub-analysis focusing on MELD 35-36 recipients. Analysis of MELD≥35 DCD recipients showed that donor age of <30yo independently reduced the risk of graft loss by 30% (HR, 95%CI: 0.7 (0.9-0.5), p=0.019). Retransplant status was associated with a doubled risk of adverse event (HR, 95%CI: 2.1 (1.4-3.3), p=0.001). The rejection rates at 1y were similar between DCD- and DBD-LTs, (9.3% (35/375) versus 1,541 (8.7% (1,541/17,677), respectively).DiscussionIn highly selected recipient/donor pair, DCD transplantation is feasible and can achieve comparable survival to DBD transplantation. Biliary complications occurred at the expected rates. In the absence of selection, DCD-LTs outcomes remain worse than those of DBD-LTs.

【 授权许可】

Unknown   
Copyright © 2023 Meier, Nunez, Syed, Feng, Tavakol, Freise, Roberts, Ascher, Hirose and Roll