Superior Outcomes Using Normothermic Regional Perfusion in CDCD Liver Transplantation
Amelia Hessheimer1, Elisabeth Coll2, Andrés Valdivieso3, Manuel Gómez4, Julio Santoyo5, Pablo Ramírez6, Miguel Ángel Gómez-Bravo7, Rafael López-Andujar8, Jesús Villar9, Carlos Jiménez10, Félix Lluís11, Laura Lladó12, Daniel Casanova13, Manuel Barrera14, Ramón Charco15, Jose Ángel López-Baena16, Javier Briceño17, Fernando Pardo18, Gerardo Blanco19, David Pacheco20, Beatriz Domínguez-Gil2, Victor Sánchez-Turrión21, Constantino Fondevila1.
1General & Digestive Surgery, Hospital Clínic, Barcelona, Spain; 2Organización Nacional de Trasplantes, Madrid, Spain; 3Hospital Universitario Cruces, Bilbao, Spain; 4Complejo Hospitalario Universitario A Coruña, La Coruña, Spain; 5Hospital Regional Universitario de Málaga, Málaga, Spain; 6Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain; 7Hospital Universitario Virgen del Rocio, Seville, Spain; 8Hospital Universitario y Politécnico de La Fe, Valencia, Spain; 9Hospital Universitario Virgen de las Nieves, Granada, Spain; 10Hospital 12 de Octubre, Madrid, Spain; 11Hospital General Universitario de Alicante, Alicante, Spain; 12Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Spain; 13Hospital Universitario Marqués de Valdecilla, Santander, Spain; 14Hospital Universitario de Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain; 15Hospital Universitario Vall d'Hebrón, Barcelona, Spain; 16Hospital General Universitario Gregorio Marañón, Madrid, Spain; 17Hospital Universitario Reina Sofía, Córdoba, Spain; 18Clínica Universitaria de Navarra, Pamplona, Spain; 19Hospital Universitario Infanta Cristina, Badajoz, Spain; 20Hospital Universitario del Río Hortega, Valladolid, Spain; 21Hospital Universitario Puerta de Hierro, Majadahonda, Spain
While there is increasing interest in its use, definitive evidence demonstrating superiority of normothermic regional perfusion in controlled donation after circulatory death liver transplantation has not been presented. Unlike the rest of the Western world, where use of NRP has been anecdotal, 25% of all cDCD donors that have been performed in Spain since 2012 have included post-mortem NRP.
Aim: Analyze the first years of the Spanish experience with cDCD liver transplantation, in particular regarding the impact post-mortem NRP has had on organ utilization rates and transplant outcomes.
Methods: Data was collected regarding potential cDCD liver donors and transplants that resulted between 2012 and 2016. All transplants had at least 6 mos of follow-up. Each donor hospital determined the process by which organs were recovered: NRP with pre-mortem cannulation, NRP with post-mortem cannulation, or super rapid recovery.
Results: From 2012 to 2016, 370 potential cDCD liver donors were evaluated: 152 with NRP and 218 with SRR. Ultimately, rates of liver transplantation were 64% NRP and 57% SRR (P=0.102). Among livers that were transplanted, median donor age was 57 (46-65 IQR). While there were no differences in terms of relevant donor or recipient characteristics when analyzed according to recovery method, the functional warm ischemia time was shorter when NRP was applied – 12 (10-16) NRP vs. 15 (11-20) SRR – given that in most cases femoral cannulae were placed prior to withdrawal of care. While rates of early allograft dysfunction (22% NRP vs. 29% SRR) and PNF (2% NRP vs. 4% SRR) did not vary, rates of overall biliary complications (9% NRP vs. 24% SRR, P=0.006) and ITBL (2% NRP vs. 12% SRR, P=0.01) were significantly improved among recipients of livers recovered with NRP. One-year graft survival was 87% NRP vs. 78% SRR (P=0.110). On multivariate analysis analyzing risk factors for ITBL (including fWIT), the only significant factor was the organ recovery method used.
Conclusions: This is the first large series describing the application of NRP in cDCD liver transplantation. While results with SRR were acceptable, results using NRP were superior and comparable to those achieved using standard-quality livers, even in spite of advanced donor age.
