A multicentre outcome analysis to define global benchmarks for donation after circulatory death liver transplantation
Andrea Schlegel, Marjolein van Reeven, Kristopher Croome, Alessandro Parente, Annalisa Dolcet, Jeannette Widmer, Nicolas Meurisse, Riccardo De Carlis, Amelia Hessheimer, Ina Jochmans, Matteo Mueller, Otto B van Leeuwen, Amit Nair, Koji Tomiyama, Ahmed Sherif, Mohamed Elsharif, Philipp Kron, Danny van der Helm, Daniel Borja-Cacho, Humberto Bohorquez, Desislava Germanova, Daniele Dondossola, Tiziana Olivieri, Stefania Camagni, Andre Gorgen, Damiano Patrono, Matteo Cescon, Sarah Croome, Rebecca Panconesi, Mauricio Flores Carvalho, Matteo Ravaioli, Juan Carlos Caicedo, George Loss, Valerio Lucidi, Gonzalo Sapisochin, Renato Romagnoli, Wayel Jassem, Michele Colledan, Luciano De Carlis, Giorgio Rossi, Fabrizio Di Benedetto, Charles M Miller, Bart van Hoek, Magdy Attia, Peter Lodge, Roberto Hernandez-Alejandro, Olivier Detry, Cristiano Quintini, Gabriel C Oniscu, Constantino Fondevila, Massimo Malagó, Jacques Pirenne, Jan N M IJzermans, Robert J Porte, Philipp Dutkowski, C Burcin Taner, Nigel Heaton, Pierre-Alain Clavien, Wojciech G Polak, Paolo Muiesan, DCD Collaborator Group, Ian P J Alwayn, Aad P van der Berg, Margherita Carbonaro, Marco Claasen, Amna Daud, Vincent E de Meijer, Herold J Metselaar, Diethard Monbaliu, Maite Paolucci, Sofie Vets, Erin Winter, Andrea Schlegel, Marjolein van Reeven, Kristopher Croome, Alessandro Parente, Annalisa Dolcet, Jeannette Widmer, Nicolas Meurisse, Riccardo De Carlis, Amelia Hessheimer, Ina Jochmans, Matteo Mueller, Otto B van Leeuwen, Amit Nair, Koji Tomiyama, Ahmed Sherif, Mohamed Elsharif, Philipp Kron, Danny van der Helm, Daniel Borja-Cacho, Humberto Bohorquez, Desislava Germanova, Daniele Dondossola, Tiziana Olivieri, Stefania Camagni, Andre Gorgen, Damiano Patrono, Matteo Cescon, Sarah Croome, Rebecca Panconesi, Mauricio Flores Carvalho, Matteo Ravaioli, Juan Carlos Caicedo, George Loss, Valerio Lucidi, Gonzalo Sapisochin, Renato Romagnoli, Wayel Jassem, Michele Colledan, Luciano De Carlis, Giorgio Rossi, Fabrizio Di Benedetto, Charles M Miller, Bart van Hoek, Magdy Attia, Peter Lodge, Roberto Hernandez-Alejandro, Olivier Detry, Cristiano Quintini, Gabriel C Oniscu, Constantino Fondevila, Massimo Malagó, Jacques Pirenne, Jan N M IJzermans, Robert J Porte, Philipp Dutkowski, C Burcin Taner, Nigel Heaton, Pierre-Alain Clavien, Wojciech G Polak, Paolo Muiesan, DCD Collaborator Group, Ian P J Alwayn, Aad P van der Berg, Margherita Carbonaro, Marco Claasen, Amna Daud, Vincent E de Meijer, Herold J Metselaar, Diethard Monbaliu, Maite Paolucci, Sofie Vets, Erin Winter
Abstract
Background & aims: The concept of benchmarking is established in the field of transplant surgery; however, benchmark values for donation after circulatory death (DCD) liver transplantation are not available. Thus, we aimed to identify the best possible outcomes in DCD liver transplantation and to propose outcome reference values.
Methods: Based on 2,219 controlled DCD liver transplantations, collected from 17 centres in North America and Europe, we identified 1,012 low-risk, primary, adult liver transplantations with a laboratory MELD score of ≤20 points, receiving a DCD liver with a total donor warm ischemia time of ≤30 minutes and asystolic donor warm ischemia time of ≤15 minutes. Clinically relevant outcomes were selected and complications were reported according to the Clavien-Dindo-Grading and the comprehensive complication index (CCI). Corresponding benchmark cut-offs were based on median values of each centre, where the 75th-percentile was considered.
Results: Benchmark cases represented between 19.7% and 75% of DCD transplantations in participating centres. The 1-year retransplant and mortality rates were 4.5% and 8.4% in the benchmark group, respectively. Within the first year of follow-up, 51.1% of recipients developed at least 1 major complication (≥Clavien-Dindo-Grade III). Benchmark cut-offs were ≤3 days and ≤16 days for ICU and hospital stay, ≤66% for severe recipient complications (≥Grade III), ≤16.8% for ischemic cholangiopathy, and ≤38.9 CCI points 1 year after transplant. Comparisons with higher risk groups showed more complications and impaired graft survival outside the benchmark cut-offs. Organ perfusion techniques reduced the complications to values below benchmark cut-offs, despite higher graft risk.
Conclusions: Despite excellent 1-year survival, morbidity in benchmark cases remains high. Benchmark cut-offs targeting morbidity parameters offer a valid tool to assess the protective value of new preservation technologies in higher risk groups and to provide a valid comparator cohort for future clinical trials.
Lay summary: The best possible outcomes after liver transplantation of grafts donated after circulatory death (DCD) were defined using the concept of benchmarking. These were based on 2,219 liver transplantations following controlled DCD donation in 17 centres worldwide. Donor and recipient combinations with higher risk had significantly worse outcomes. However, the use of novel organ perfusion technology helped high-risk patients achieve similar outcomes as the benchmark cohort.
Keywords: Donation after circulatory death; benchmarking; liver transplantation; morbidity; organ perfusion; risk analysis.
Conflict of interest statement
Conflict of interest The authors declare no conflicts of interest that pertain to this work. Please refer to the accompanying ICMJE disclosure forms for further details.
Copyright © 2021 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
Source: PubMed