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Evaluation of Liver Graft Donation After Euthanasia

Educational Objective
To review the outcomes of liver transplant with grafts donated after euthanasia and compare these outcomes with those after withdrawal of life-sustaining therapy.

1 Credit CME

JAMA Surgery

October 1, 2020

Original Investigation

Article Information and Disclosures

Marjolein van Reeven, MD¹;

Nicholas Gilbo, MD^2,3;

Diethard Monbaliu, MD, PhD^2,3;

et al

Otto B. van Leeuwen, BSc⁴;

Robert J. Porte, MD, PhD⁴;

Dirk Ysebaert, MD, PhD⁵;

Bart van Hoek, MD, PhD⁶;

Ian P. J. Alwayn, MD, PhD⁷;

Nicolas Meurisse, MD, PhD⁸;

Olivier Detry, MD, PhD⁸;

Laurent Coubeau, MD⁹;

Olga Cicarelli, MD, PhD⁹;

Frederik Berrevoet, MD, PhD¹⁰;

Aude Vanlander, MD, PhD¹⁰;

Jan N. M. IJzermans, MD, PhD¹;

Wojciech G. Polak, MD, PhD¹

Author Affiliations

¹Division of Hepato-Pancreato-Biliary and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
²Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
³Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
⁴Department of Surgery, Section of Hepato-Pancreato-Biliary and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
⁵Department of Hepatobiliary, Transplantation and Endocrine Surgery, Antwerp University Hospital, Antwerp, Belgium
⁶Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
⁷Division of Transplant Surgery, Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
⁸Department of Abdominal Surgery and Transplantation, Centre Hospitalier Universitaire de Liège, Liège, Belgium
⁹Department of Abdominal Surgery and Transplantation, University Hospitals Saint-Luc, Brussels, Belgium
¹⁰Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University Hospital, Ghent, Belgium

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Key Points

Question What are the outcomes of liver transplants with grafts donated after euthanasia?

Findings In this cohort study of 47 liver transplants with grafts donated after euthanasia in the Netherlands and Belgium, recipient and graft survival rates were comparable with the survival rates in a comparative cohort of 542 recipients of liver grafts from donors with a circulatory arrest after the withdrawal of life-supporting treatment. The use of liver grafts donated after euthanasia can expand the pool of grafts donated after circulatory death by approximately 7%.

Meaning Findings from this study suggest that the use of liver grafts donated after euthanasia is justifiable and can expand the existing liver donor pool.

Abstract

Importance The option of donating organs after euthanasia is not well known. Assessment of the results of organ transplants with grafts donated after euthanasia is essential to justify the use of this type of organ donation.

Objectives To assess the outcomes of liver transplants (LTs) with grafts donated after euthanasia (donation after circulatory death type V [DCD-V]), and to compare them with the results of the more commonly performed LTs with grafts from donors with a circulatory arrest after the withdrawal of life-supporting treatment (type III [DCD-III]).

Design, Setting, and Participants This retrospective multicenter cohort study analyzed medical records and LT data for most transplant centers in the Netherlands and Belgium. All LTs with DCD-V grafts performed from the start of the donation after euthanasia program (September 2012 for the Netherlands, and January 2005 for Belgium) through July 1, 2018, were included in the analysis. A comparative cohort of patients who received DCD-III grafts was also analyzed. All patients in both cohorts were followed up for at least 1 year. Data analysis was performed from September 2019 to December 2019.

Exposures Liver transplant with either a DCD-V graft or DCD-III graft.

Main Outcomes and Measures Primary outcomes were recipient and graft survival rates at years 1, 3, and 5 after the LT. Secondary outcomes included postoperative complications (early allograft dysfunction, hepatic artery thrombosis, and nonanastomotic biliary strictures) within the first year after the LT.

Results Among the cohort of 47 LTs with DCD-V grafts, 25 organ donors (53%) were women and the median (interquartile range [IQR]) age was 51 (44-59) years. Among the cohort of 542 LTs with DCD-III grafts, 335 organ donors (62%) were men and the median (IQR) age was 49 (37-57) years. Median (IQR) follow-up was 3.8 (2.1-6.3) years. In the DCD-V cohort, 30 recipients (64%) were men, and the median (IQR) age was 56 (48-64) years. Recipient survival in the DCD-V cohort was 87% at 1 year, 73% at 3 years, and 66% at 5 years after LT. Graft survival among recipients was 74% at 1 year, 61% at 3 years, and 57% at 5 years after LT. These survival rates did not differ statistically significantly from those in the DCD-III cohort. Incidence of postoperative complications did not differ between the groups. For example, the occurrence of early allograft dysfunction after the LT was found to be 13 (31%) in the DCD-V cohort and 219 (45%) in the DCD-III cohort. The occurrence of nonanastomotic biliary strictures after the LT was found to be 7 (15%) in the DCD-V cohort and 83 (15%) in the DCD-III cohort.

Conclusions and Relevance The findings of this cohort study suggest that LTs with DCD-V grafts yield similar outcomes as LTs with DCD-III grafts; therefore, grafts donated after euthanasia may be a justifiable option for increasing the organ donor pool. However, grafts from these donations should be considered high-risk grafts that require an optimal donor selection process and logistics.

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Article Information

Accepted for Publication: April 16, 2020.

Corresponding Author: Wojciech G. Polak, MD, PhD, Division of Hepato-Pancreato-Biliary and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands (w.polak@erasmusmc.nl).

Published Online: August 5, 2020. doi:10.1001/jamasurg.2020.2479

Author Contributions: Drs van Reeven and Polak had full access to all data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: van Reeven, Ysebaert, Alwayn, IJzermans, Polak.

Acquisition, analysis, or interpretation of data: van Reeven, Gilbo, Monbaliu, van Leeuwen, Porte, van Hoek, Meurisse, Detry, Coubeau, Ciccarelli, Berrevoet, Vanlander, IJzermans, Polak.

Drafting of the manuscript: van Reeven, IJzermans, Polak.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: van Reeven, Gilbo, van Leeuwen.

Administrative, technical, or material support: van Reeven, Monbaliu, Porte, Ysebaert, van Hoek, Meurisse, Ciccarelli.

Supervision: van Leeuwen, Porte, Ysebaert, Alwayn, Detry, Berrevoet, Vanlander, IJzermans, Polak.

Other—coordinator of the study: van Reeven.

Conflict of Interest Disclosures: Dr van Hoek reported receiving grants from Zambon Pharma, Astellas Pharma, and Chiesi Pharma and personal fees from Norgine outside the submitted work. No other disclosures were reported.

Additional Contributions: Xavier Rogiers, MD, Ghent University Hospital, assisted in data collection and manuscript revision. Jacques Pirenne, PhD, University Hospitals Leuven, provided additional survival rate data on liver transplants with donation after brain death in Belgium. The Landelijk Overleg Levertransplantatie Dutch Liver Transplant Committee and the Belgian Liver and Intestinal Advisory Committee endorsed this project. Eurotransplant provided required data. None of the named individuals and groups received financial compensation for their contributions.

Additional Information: Xavier Rogiers, MD, died November 20, 2019.

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