Sequential normothermic regional and end-ischemic ex-situ machine perfusion allows the safe use of very old DCD donors in liver transplantation (DCDNet trial)
Gabriele Catalano1, Pier Giuseppe Vacca1, Daniele Pezzati1, Jessica Bronzoni1, Caterina Martinelli1, Simona Palladino1, Lorenzo Petagna1, Arianna Trizzino1, Giovanni Tincani1, Emanuele Balzano1, Stefania Petruccelli1, Paola Carrai1, Davide Ghinolfi1.
1Hepatic Surgery and Liver Transplantation, Pisa University Hospital, Pisa, Italy
Background and Aims: In Italy, 20 minutes of continuous, flat-line electrocardiogram are required for death declaration. Despite prolonged warm ischemia time, Italian centers reported good outcomes in controlled DCD (cDCD) liver transplantation by combining normothermic regional and end-ischemic machine perfusion. This study aimed to evaluate the safety and feasibility of the use of septuagenarian and octogenarian cDCD donors with this approach.
Method: All cDCD older than 70 years were evaluated during normothermic regional perfusion (NRP) and then randomly assigned to dual hypothermic (D-HOPE) or normothermic machine perfusion (NMP).
Results: In the period from April 2021 to February 2024, 25 cDCD older than 70 years were considered. In 9 cases (36%) the graft was not considered suitable for liver transplantation: 3 on NRP parameters, 2 on histology, 1 due to hepatic artery thrombosis at procurement, 2 on NMP parameters, and 1 due to machine perfusion technical failure. Sixteen (64%) liver grafts were eventually transplanted. The median donor age was 82 years (IQR: 79-84), being 9 (56%) older than 80. The mean functional warm ischemia was 39 ± 15 minutes. Grafts were randomly assigned to D-HOPE (9 grafts) and NMP (7 grafts).
There were no cases of primary non-function, one of the patients (D-HOPE perfused LT) experienced delayed non-function, treated with retransplantation. Four cases of post-reperfusion syndrome (25%, 50% D-HOPE vs 50% NMP group) and 2 cases (12%) of early allograft dysfunction were observed. At a median follow-up of 12 months, no vascular complications were reported. Three patients experienced biliary complications: 2 anastomotic stenosis and 1 biliary fistula. No patients experienced ischemic cholangiopathy. No major differences were found in terms of post-operative hospitalization or complications based on the type of machine perfusion.
Conclusion: The implementation of sequential normothermic regional and end-ischemic machine perfusion allows the safe use of very old DCD donor grafts in liver transplantation.