Normothermic Perfusion in the Assessment and Preservation of Declined Livers Before Transplantation: Hyperoxia and Vasoplegia-Important Lessons From the First 12 Cases.
Normothermic Perfusion in the Assessment and Preservation of Declined Livers Before Transplantation: Hyperoxia and Vasoplegia-Important Lessons From the First 12 Cases.
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DOI：
10.1097/tp.0000000000001661
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发表时间：
2017-05
期刊：
影响因子：
6.2
通讯作者：
Butler AJ
中科院分区：
文献类型：
--
作者：
Watson CJE;Kosmoliaptsis V;Randle LV;Gimson AE;Brais R;Klinck JR;Hamed M;Tsyben A;Butler AJ
开发了常温异位肝脏灌注（NESLiP）程序，以便于更好地评估和使用边缘肝脏，同时最大限度地减少冷缺血。对下降的边缘肝和提供用于研究的边缘肝进行评价。使用基于红细胞的灌注液进行常温异位肝脏灌注。参考灌注液中的生化变化评估活力。12个肝脏（9个循环死亡[DCD]后捐献，3个来自脑死亡供体），供体风险指数中位数2.15，在初始冷藏期427分钟（范围，222-877分钟）后接受NESLiP中位数284分钟（范围，122-530分钟）。前6个肝脏在高灌注氧分压下灌注，随后6个肝脏在接近生理氧分压下灌注。移植后，前6名受体中有5名出现再灌注后综合征，4名出现持续性血管麻痹; 1名受体出现原发性无功能伴难以取出。随后的6例肝移植，肝脏灌注在较低的氧分压，再灌注顺利。三名DCD肝脏接受者发生了胆管病，这与NESLiP期间无法产生碱性胆汁有关。常温异位肝灌注使12个肝脏的评估和移植，否则可能不会被使用。灌注期间避免高氧可预防再灌注后综合征和血管麻痹，监测胆汁pH值，而不是绝对胆汁生成，在确定移植后胆管病的可能性方面可能很重要。常温异位肝脏灌注有可能增加肝脏利用率，但需要更多的工作来确定预测良好结局的因素。这项在储存结束时进行的常温氧合灌注的初步研究确定了与改善器官功能相关的最佳氧合特征。此外，灌注期间的胆汁pH值高度预测DCD供体中胆管病变的发展。这些发现将需要更大的样本量进行验证。补充数字内容可在文本中找到。
A program of normothermic ex situ liver perfusion (NESLiP) was developed to facilitate better assessment and use of marginal livers, while minimizing cold ischemia. Declined marginal livers and those offered for research were evaluated. Normothermic ex situ liver perfusion was performed using an erythrocyte-based perfusate. Viability was assessed with reference to biochemical changes in the perfusate. Twelve livers (9 donation after circulatory death [DCD] and 3 from brain-dead donors), median Donor Risk Index 2.15, were subjected to NESLiP for a median 284 minutes (range, 122-530 minutes) after an initial cold storage period of 427 minutes (range, 222-877 minutes). The first 6 livers were perfused at high perfusate oxygen tensions, and the subsequent 6 at near-physiologic oxygen tensions. After transplantation, 5 of the first 6 recipients developed postreperfusion syndrome and 4 had sustained vasoplegia; 1 recipient experienced primary nonfunction in conjunction with a difficult explant. The subsequent 6 liver transplants, with livers perfused at lower oxygen tensions, reperfused uneventfully. Three DCD liver recipients developed cholangiopathy, and this was associated with an inability to produce an alkali bile during NESLiP. Normothermic ex situ liver perfusion enabled assessment and transplantation of 12 livers that may otherwise not have been used. Avoidance of hyperoxia during perfusion may prevent postreperfusion syndrome and vasoplegia, and monitoring biliary pH, rather than absolute bile production, may be important in determining the likelihood of posttransplant cholangiopathy. Normothermic ex situ liver perfusion has the potential to increase liver utilization, but more work is required to define factors predicting good outcomes. This pilot study of normothermic oxygenated perfusion at the end of storage identified optimal oxygenation characteristics associated with improved organ function. Furthermore, bile pH during perfusion was highly predictive of the development of cholangiopathy in DCD donors. These findings will need to be validated with larger sample sizes. Supplemental digital content is available in the text.