Andrea Schlegel1, Marjolein van Reeven2, Kristopher Croome3, Alessandro Parente4, Annalisa Dolcet5, Jeannette Widmer6, Nicolas Meurisse7, Riccardo De Carlis8, Amelia Hessheimer9, Ina Jochmans10, Matteo Mueller11, Otto B van Leeuwen12, Amit Nair13, Koji Tomiyama14, Ahmed Sherif15, Mohamed Elsharif16, Philipp Kron17, Danny van der Helm18, Daniel Borja-Cacho19, Humberto Bohorquez20, Desislava Germanova21, Daniele Dondossola22, Tiziana Olivieri23, Stefania Camagni24, Andre Gorgen25, Damiano Patrono26, Matteo Cescon27, Sarah Croome3, Rebecca Panconesi28, Mauricio Flores Carvalho29, Matteo Ravaioli27, Juan Carlos Caicedo19, George Loss20, Valerio Lucidi21, Gonzalo Sapisochin30, Renato Romagnoli26, Wayel Jassem5, Michele Colledan31, Luciano De Carlis32, Giorgio Rossi22, Fabrizio Di Benedetto23, Charles M Miller33, Bart van Hoek18, Magdy Attia16, Peter Lodge16, Roberto Hernandez-Alejandro14, Olivier Detry7, Cristiano Quintini33, Gabriel C Oniscu15, Constantino Fondevila9, Massimo Malagó34, Jacques Pirenne10, Jan N M IJzermans2, Robert J Porte12, Philipp Dutkowski11, C Burcin Taner3, Nigel Heaton5, Pierre-Alain Clavien11, Wojciech G Polak2, Paolo Muiesan35. 1. The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom; Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland; Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy. 2. Erasmus MC Transplant Institute, University Medical Center Rotterdam, Department of Surgery, Division of Hepato-Pancreato-Biliary and Transplant Surgery, Rotterdam, the Netherlands. 3. Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 United States. 4. The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom. 5. Institute of Liver Studies, King's College Hospital, London, United Kingdom. 6. Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland; HPB Surgery and Liver Transplantation, Royal Free Hospital London, United Kingdom. 7. Department of Abdominal Surgery and Transplantation, CHU Liege, University of Liege, Liege, Belgium. 8. Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy. 9. General & Digestive Surgery, Hospital Clínic Barcelona, Barcelona, Spain; CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain. 10. Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium; Abdominal Transplant Surgery, Department of Surgery, University Hospitals Leuven, Leuven, Belgium. 11. Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland. 12. Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands. 13. Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA; Division of Transplantation/Hepatobiliary Surgery, Department of Surgery, University of Rochester, NY, USA. 14. Division of Transplantation/Hepatobiliary Surgery, Department of Surgery, University of Rochester, NY, USA. 15. Department of Transplant Surgery, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, United Kingdom. 16. HPB and Transplant Unit, St James's University Hospital, Leeds LS9 7TF, United Kingdom. 17. Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland; HPB and Transplant Unit, St James's University Hospital, Leeds LS9 7TF, United Kingdom. 18. Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands. 19. Division of Transplantation, Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA. 20. Multi-Organ Transplant Institute, University of Queensland School and the Ochsner Clinical School, Ochsner Clinic Foundation, New Orleans, Louisiana, USA. 21. Department of abdominal surgery, Unit of hepato-biliary surgery and abdominal transplantation, CUB Erasme Hospital, Free University of Brussels (ULB), Brussels, Belgium. 22. General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan 20122, Italy. 23. Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy. 24. Department of Organ Failure and Transplantation, Papa Giovanni XXIII Hospital, Bergamo, Italy. 25. Multi-Organ Transplant Program, Division of General Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada. 26. General Surgery 2U-Liver Transplant Unit, Department of Surgery, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy. 27. Department of Medical and Surgical Sciences (DIMEC), University of Bologna, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy. 28. Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy; General Surgery 2U-Liver Transplant Unit, Department of Surgery, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy. 29. Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy. 30. Università di Milano-Bicocca, Milano, Italy. 31. Department of Organ Failure and Transplantation, Papa Giovanni XXIII Hospital, Bergamo, Italy; Università di Milano-Bicocca, Milano, Italy. 32. Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy. 33. Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA. 34. HPB Surgery and Liver Transplantation, Royal Free Hospital London, United Kingdom. 35. The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom; Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy; General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan 20122, Italy. Electronic address: paolo.muiesan@unimi.it.
Abstract
BACKGROUND & AIMS: The concept of benchmarking is established in the field of transplant surgery; however, benchmark values for donation after circulatory death (DCD) liver transplantation are not available. Thus, we aimed to identify the best possible outcomes in DCD liver transplantation and to propose outcome reference values. METHODS: Based on 2,219 controlled DCD liver transplantations, collected from 17 centres in North America and Europe, we identified 1,012 low-risk, primary, adult liver transplantations with a laboratory MELD score of ≤20 points, receiving a DCD liver with a total donor warm ischemia time of ≤30 minutes and asystolic donor warm ischemia time of ≤15 minutes. Clinically relevant outcomes were selected and complications were reported according to the Clavien-Dindo-Grading and the comprehensive complication index (CCI). Corresponding benchmark cut-offs were based on median values of each centre, where the 75th-percentile was considered. RESULTS: Benchmark cases represented between 19.7% and 75% of DCD transplantations in participating centres. The 1-year retransplant and mortality rates were 4.5% and 8.4% in the benchmark group, respectively. Within the first year of follow-up, 51.1% of recipients developed at least 1 major complication (≥Clavien-Dindo-Grade III). Benchmark cut-offs were ≤3 days and ≤16 days for ICU and hospital stay, ≤66% for severe recipient complications (≥Grade III), ≤16.8% for ischemic cholangiopathy, and ≤38.9 CCI points 1 year after transplant. Comparisons with higher risk groups showed more complications and impaired graft survival outside the benchmark cut-offs. Organ perfusion techniques reduced the complications to values below benchmark cut-offs, despite higher graft risk. CONCLUSIONS: Despite excellent 1-year survival, morbidity in benchmark cases remains high. Benchmark cut-offs targeting morbidity parameters offer a valid tool to assess the protective value of new preservation technologies in higher risk groups and to provide a valid comparator cohort for future clinical trials. LAY SUMMARY: The best possible outcomes after liver transplantation of grafts donated after circulatory death (DCD) were defined using the concept of benchmarking. These were based on 2,219 liver transplantations following controlled DCD donation in 17 centres worldwide. Donor and recipient combinations with higher risk had significantly worse outcomes. However, the use of novel organ perfusion technology helped high-risk patients achieve similar outcomes as the benchmark cohort.
BACKGROUND & AIMS: The concept of benchmarking is established in the field of transplant surgery; however, benchmark values for donation after circulatory death (DCD) liver transplantation are not available. Thus, we aimed to identify the best possible outcomes in DCD liver transplantation and to propose outcome reference values. METHODS: Based on 2,219 controlled DCD liver transplantations, collected from 17 centres in North America and Europe, we identified 1,012 low-risk, primary, adult liver transplantations with a laboratory MELD score of ≤20 points, receiving a DCD liver with a total donor warm ischemia time of ≤30 minutes and asystolic donor warm ischemia time of ≤15 minutes. Clinically relevant outcomes were selected and complications were reported according to the Clavien-Dindo-Grading and the comprehensive complication index (CCI). Corresponding benchmark cut-offs were based on median values of each centre, where the 75th-percentile was considered. RESULTS: Benchmark cases represented between 19.7% and 75% of DCD transplantations in participating centres. The 1-year retransplant and mortality rates were 4.5% and 8.4% in the benchmark group, respectively. Within the first year of follow-up, 51.1% of recipients developed at least 1 major complication (≥Clavien-Dindo-Grade III). Benchmark cut-offs were ≤3 days and ≤16 days for ICU and hospital stay, ≤66% for severe recipient complications (≥Grade III), ≤16.8% for ischemic cholangiopathy, and ≤38.9 CCI points 1 year after transplant. Comparisons with higher risk groups showed more complications and impaired graft survival outside the benchmark cut-offs. Organ perfusion techniques reduced the complications to values below benchmark cut-offs, despite higher graft risk. CONCLUSIONS: Despite excellent 1-year survival, morbidity in benchmark cases remains high. Benchmark cut-offs targeting morbidity parameters offer a valid tool to assess the protective value of new preservation technologies in higher risk groups and to provide a valid comparator cohort for future clinical trials. LAY SUMMARY: The best possible outcomes after liver transplantation of grafts donated after circulatory death (DCD) were defined using the concept of benchmarking. These were based on 2,219 liver transplantations following controlled DCD donation in 17 centres worldwide. Donor and recipient combinations with higher risk had significantly worse outcomes. However, the use of novel organ perfusion technology helped high-risk patients achieve similar outcomes as the benchmark cohort.
Authors: Otto B van Leeuwen; Silke B Bodewes; Veerle A Lantinga; Martijn P D Haring; Adam M Thorne; Isabel M A Brüggenwirth; Aad P van den Berg; Marieke T de Boer; Iris E M de Jong; Ruben H J de Kleine; Bianca Lascaris; Maarten W N Nijsten; Koen M E M Reyntjens; Vincent E de Meijer; Robert J Porte Journal: Am J Transplant Date: 2022-04-18 Impact factor: 9.369
Authors: Isabel M A Brüggenwirth; Matteo Mueller; Veerle A Lantinga; Stefania Camagni; Riccardo De Carlis; Luciano De Carlis; Michele Colledan; Daniele Dondossola; Moritz Drefs; Janina Eden; Davide Ghinolfi; Dionysios Koliogiannis; Georg Lurje; Tommaso M Manzia; Diethard Monbaliu; Paolo Muiesan; Damiano Patrono; Johann Pratschke; Renato Romagnoli; Michel Rayar; Federico Roma; Andrea Schlegel; Philipp Dutkowski; Robert J Porte; Vincent E de Meijer Journal: Am J Transplant Date: 2022-04-05 Impact factor: 9.369