Clinical Report: Evolution and Outcomes of DCD Liver Transplantation in Italy
Overview
This single-center retrospective study from Policlinico Sant’Orsola in Italy evaluates the transition of donation after circulatory death (DCD) liver transplantation from marginal use to standard practice between 2016 and 2023. Despite prolonged donor warm ischemia times inherent to Italian protocols, outcomes have improved with the use of normothermic regional perfusion (NRP) and hypothermic oxygenated perfusion (HOPE), showing comparable graft survival and complication rates to donors after brainstem death (DBD).
Background
Liver transplantation remains the definitive treatment for end-stage liver disease and has expanded through the use of extended criteria donors (ECD), including DCD donors. Historically, DCD grafts were associated with inferior outcomes due to prolonged warm ischemia times, especially in Italy where a 20-minute asystolic period is mandated before death determination. Advances in organ preservation techniques such as NRP and HOPE have improved graft viability and clinical outcomes. This study analyzes trends and outcomes of DCD liver transplantation at a high-volume Italian center over eight years.
Data Highlights
Parameter
2016–2021
2022–2023
Number of DCD Liver Transplants
Initial years (data not specified)
Increased utilization (data not specified)
Donor Warm Ischemia Time (DWIT)
Prolonged due to 20-min asystolic period
Improved with NRP and HOPE
Retransplantation Rates
Higher in early years
Reduced in recent years
Graft Survival
Lower compared to DBD initially
Comparable to DBD in recent years
Biliary Complications
Higher incidence initially
Reduced incidence with improved protocols
Key Findings
DCD liver transplantation in Italy has evolved from marginal use to a more standardized practice with increasing transplant numbers over time.
Italian DCD donors undergo a mandatory 20-minute asystolic period, resulting in prolonged donor warm ischemia time, traditionally considered high risk.
Implementation of normothermic regional perfusion (NRP) and end-ischemic hypothermic oxygenated perfusion (HOPE) has improved graft viability and reduced ischemic injury.
Recent outcomes demonstrate graft survival and biliary complication rates comparable to those from brainstem death donors (DBD), even in extended criteria DCD donors.
Retransplantation rates have decreased with accumulated experience and improved organ preservation techniques.
Careful donor evaluation, metabolic monitoring during NRP, and standardized immunosuppression protocols contribute to improved post-transplant outcomes.
Clinical Implications
The findings support the expanded use of DCD liver grafts in centers with expertise in advanced perfusion techniques such as NRP and HOPE, even in settings with prolonged warm ischemia times like Italy. Clinicians should consider incorporating these organ reconditioning strategies to optimize graft function and reduce complications. This approach may help alleviate organ shortages by safely increasing the donor pool without compromising patient outcomes.
Conclusion
With the integration of advanced perfusion technologies and accumulated clinical experience, DCD liver transplantation in Italy has transitioned from a high-risk marginal practice to a reliable standard procedure yielding outcomes comparable to traditional DBD transplantation. This evolution underscores the potential for broader adoption of DCD grafts in liver transplantation programs.
References
De Carlis et al. 2023 -- From Marginal Use to Standard Practice: Insights from a Single Center on DCD Liver Transplantation in Italy
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