Donation After Circulatory Death for Liver Transplantation: A Meta-Analysis on the Location of Life Support Withdrawal Affecting Outcomes
Donation After Circulatory Death for Liver Transplantation: A Meta-Analysis on the Location of Life Support Withdrawal Affecting Outcomes
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DOI：
10.1097/tp.0000000000001175
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发表时间：
2016-07-01
期刊：
影响因子：
6.2
通讯作者：
Pleass, Henry
中科院分区：
文献类型：
--
作者：
Cao, Yiming;Shahrestani, Sara;Pleass, Henry
背景与脑死亡（DBD）后捐赠相比，使用循环死亡（DCD）捐赠者的肝移植结局较差。供体热缺血时间延长已被确定为造成这种差异的关键因素。供体生命支持撤回程序的各个方面，包括撤回的位置和生前肝素的给药，被认为在减轻热缺血的影响方面发挥重要作用。然而，系统地探讨这些因素对于更有信心地将这些实践整合到标准DCD协议中非常重要。方法.系统检索Medline、EMBASE和科克伦图书馆，确定了23项相关研究进行分析。根据生命支持撤机的位置（重症监护室或手术室）和生前肝素的使用情况，对循环系统死亡后的献血者进行分层。结果如果生命支持撤出的地点是手术室，则循环死亡后献血者的1年患者生存率与DBD受者相当，但如果地点是重症监护室，则不然。同样地，与DBD受体相比，DCD的1年移植物存活率较低和缺血性胆管病的发生率较高，但在手术室退出后，DCD受体的缺血性胆管病发生率较高，移植物存活率较低。此外，在撤去生命支持前给予肝素可降低同种异体移植物原发性无功能的发生率。结论.我们的证据表明，退出手术室和生前肝素管理改善DCD肝移植的结果，从而允许最有效地利用这些宝贵的器官。
Background. Liver transplantation using donation after circulatory death (DCD) donors is associated with inferior outcomes compared to donation after brain death (DBD). Prolonged donor warm ischemic time has been identified as the key factor responsible for this difference. Various aspects of the donor life support withdrawal procedure, including location of withdrawal and administration of antemortem heparin, are thought to play important roles in mitigating the effects of warm ischemia. However, a systematic exploration of these factors is important for more confident integration of these practices into a standard DCD protocol. Methods. Medline, EMBASE, and Cochrane libraries were systematically searched and 23 relevant studies identified for analysis. Donation after circulatory death recipients were stratified according to location of life support withdrawal (intensive care unit or operating theater) and use of antemortem heparin. Results. Donation after circulatory death recipients had comparable 1-year patient survival to DBD recipients if the location of withdrawal of life support was the operating theater, but not if the location was the intensive care unit. Likewise, the inferior 1-year graft survival and higher incidence of ischemic cholangiopathy of DCD compared with DBD recipients were improved by withdrawal in operating theater, although higher rates of ischemic cholangiopathy and worse graft survival were still observed in DCD recipients. Furthermore, administering heparin before withdrawal of life support reduced the incidence of primary nonfunction of the allograft. Conclusions. Our evidence suggests that withdrawal in the operating theater and premortem heparin administration improve DCD liver transplant outcomes, thus allowing for the most effective usage of these valuable organs.