strategies for maximizing outcomes in liver transplantation james d. eason, m.d. chief of...
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Strategies for Maximizing Outcomes in Liver Transplantation
James D. Eason, M.D.Chief of Transplantation / Professor of
SurgeryUniversity of Tennessee / Methodist
Transplant Institute
Recent Publications
(HTK) is associated with reduced graft survival in deceased donor livers, especially those donated after cardiac death.
Stewart ZA, Cameron AM, Singer AL, Montgomery RA, Segev DL. Am J Transplant. 2009 Feb;9(2):286-93.
Results
All deceased donor transplants (n = 4755 HTK and 12 673 UW)HR 1.14 (1.05–1.23) p = 0.002
Donor after cardiac death (n = 254 HTK and 575 UW) HR1.44 (1.05–1.97) p = 0.025
ProblemsExtended Criteria donors
AgeSteatosisDCD
Ischemia Reperfusion InjuryCold and warm ischemiaCell Death over time
ImmunosupressionMinimizing adverse events
UT Experience120 Liver Transplants in 2008
9th Largest in US401 Cadaveric OLT over 40 months
24 DCDHTK perfusion in 90% of donorsRATG induction
Steroid-free immunosuppression
National ResultsPatient Graft
United States 88.34 84.31
University of TN/Methodist
91.0 86.51
Cleveland Clinic 90.09 83.94
Indiana- Clarian 88.33 86.62
Johns Hopkins 79.81 72.41
Ischemia-Reperfusion
HTK - Low viscosityBuffered- minimize drop in pHBiliary protectiveEndothelial protective
Timing is Everything!Cold Ischemic Time
Usually under 6 hoursAnastomotic time
ReperfusionArterialization
Warm Ischemic time in DCDRapid Cannulation
ImmunosuppressionRATG Induction
May decrease immune contribution to ischemia-reperfusion
Results9th largest program in 2008401 adult OLT over 40 months
20 combined liver/kidney
Age at Transplant 52.8 ± 9.42 years
Male Recipient 73.3%Caucasian Recipient 72.4% MELD Score 22 ± 4.89
A Matter of TimeWarm Ischemic Time (anastomotic) 36.8 ±
11.9 minutesCold Ischemic Time 5.7 ± 2.2 hoursArterialization - 60 minutesMean operative time 4 hours (2.1 – 6)
DCD results24 DCD OLT over 3 years
Mean F/U – 450 days20 patients > 1 year
91% one -year patient survival2 deaths within one year1sepsis, 1 PNF
1 death at 13 months - heart failure2 patients with intrahepatic strictures two
years post-transplant
DCDMELD -median 18 (15-22)Donor age mean- 35years (15-52)Cannulation time – 2minutes Warm Ischemic time - (7-42 minutes)pressure
/ O2 sat < 80Cold ischemic time - 5.47 hours (2.3 - 8.3)Anastomotic time - mean 32 minutes
DCD deathsPATIENT CIT
(hours) Anastomotic Time
WIT (minutes)
Other factors
#1 PNF Day 12
6.27 68 minutes 15.24 Recipient 66, multiple surgery
#2 Sepsis Day 40
6.0 28 24 61
#3 Biliary strictures heart failure Day 450
8.0 52 20.44 73 y/o CABG
DCD protocol
Staff surgeon – experience mattersHTKMinimize times
WITCannulationCIT arterialization
Donor selectionProper recipient selection
Immunosuppression ProtocolRATG 1.5 mg/kg in anhepatic phase and
POD 2 – total 3mg/kgPremedication -500 mg methylprednisolone,
500 mg acetominophen and 25mg diphenhydramine
MMF 1gram BID on Day 1Tacrolimus begun on day 2 or when
serum creatinine fell below 2mg/dlPrimary sirolimus if serum creatinine >
2.5 or oliguric by Day 7
Immunosuppression (continued)
Tacrolimus target level
Day 7-12 weeks 6-812-24 weeks 3-56-12 months 3After 12 months 1-3
Tacrolimus InitiationMean 3.5+ 1.8 daysRange 2 – 12 days27 patients started day 4 – 12
7 subsequently converted to sirolimusMean tacrolimus levels
Day 7- 4.5Day 30 - 6
Serum Creatinine Liver Transplant Recipients only (n= 101)
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
Pre-transplant Day 3 Month 1 Month 3 Month 6
Time Post-Transplant p< .001 for all time points from pretransplant
P < 0.001 (for all time points)
Tacrolimus levels
Day 7 1 month 3 months 6 months One year
6.4 7.2 7.4 7.1 5.8
Sirolimus
40 patients started on primary sirolimus therapy within 15 days
25 additional patients converted after 30 days
Minimal Immunosuppression
Single agentTacrolimusSirolimus
Continue weaning to lowest levels
Maximizing Outcomes
Control controllable factorsIschemic time
Preservation solution- HTKProper selection/ matching ofdonor –
recipientMinimize immunosuppression to
avoid complications
Conclusion
Excellent outcomes that exceed expected survival can be achieved
with HTK preservation when performed by experienced surgeons
under controlled circumstances