Clinical Scorecard: From Marginal Use to Standard Practice: Insights from a Single Center on DCD Liver Transplantation in Italy

At a Glance

Key Highlights

• DCD liver transplantation outcomes have improved with experience and organ reconditioning strategies, approaching those of donors after brainstem death (DBD).
• Italian DCD donors have a prolonged asystolic period (20 minutes) before death determination, leading to long donor warm ischemia time (DWIT), traditionally considered high-risk.
• Use of normothermic regional perfusion (NRP) and end-ischemic hypothermic oxygenated perfusion (HOPE) protocols enable evaluation and reconditioning of DCD grafts, improving transplant outcomes.

Guideline-Based Recommendations

Diagnosis

• Confirm donor death by continuous electrocardiographic monitoring for 20 minutes ensuring absence of cardiac electrical activity.
• Evaluate graft viability during NRP by monitoring lactate clearance, pH normalization, and liver function.

Management

• Initiate normothermic regional perfusion (NRP) immediately after death confirmation to assess and preserve organ function.
• Perform surgical retrieval after satisfactory metabolic and functional assessment during NRP.
• Apply end-ischemic hypothermic oxygenated perfusion (HOPE) through the portal vein during back-table preparation and until implantation to reduce ischemic injury.
• Manage immunosuppression post-transplant with steroids and tacrolimus according to center protocols.

Monitoring & Follow-up

• Monitor recipients for biliary complications using magnetic resonance cholangiopancreatography when clinically indicated or upon liver function test alterations.
• Classify biliary complications according to established criteria (Esser et al.).

Risks

• Prolonged donor warm ischemia time (DWIT) inherent to DCD donors increases risk of graft dysfunction and biliary complications.
• DCD donors with extended criteria stigmata (EC-DCD) may carry additional risk but can achieve comparable outcomes with appropriate perfusion strategies.

Patient & Prescribing Data

Adult liver transplant recipients receiving grafts from Maastricht III-controlled DCD donors

Use of NRP and HOPE protocols in DCD grafts is associated with improved graft survival and reduced retransplantation rates, enabling expansion of donor pool without compromising outcomes.

Clinical Best Practices

• Strict adherence to Italian legislation for death determination with 20-minute asystolic period.
• Prompt initiation of NRP after death confirmation to evaluate and preserve graft function.
• Use of end-ischemic HOPE to recondition grafts prior to implantation.
• Comprehensive metabolic and functional assessment during NRP to guide organ retrieval decisions.
• Standardized immunosuppression protocols post-transplant to optimize graft survival.
• Routine imaging and laboratory surveillance for early detection of biliary complications.

References

• Extended criteria donors and liver transplantation outcomes
• Comparison of DCD and DBD liver transplant outcomes
• Normothermic regional perfusion and hypothermic oxygenated perfusion in DCD liver transplantation
• Italian DCD donor management protocols
• STROBE guidelines for observational studies