LIVER DONATION AFTER CIRCULATORY DEATH WITH VERY PROLONGED WARM ISCHEMIA: A PILOT EXPERIENCE OF ABDOMINAL NORMOTHERMIC REGIONAL PERFUSION ALONE

Objectives: Over the last two decades, liver donors from controlled donation after circulatory death (cDCD) have become a precious resource to face organ shortage in many countries. In Italy, a legally obliged stand-off period of 20 minutes necessarily leads to very prolonged warm ischemia. In this particular national context, the use of abdominal normothermic regional perfusion (aNRP) is systematic; the addition of ex-situ machine perfusion (MP) is almost systematic, but not supported by evidence. We report a pilot experience of extended criteria cDCD liver transplantation (LT) with very prolonged warm ischemic time (WIT), with aNRP alone, at our high-volume transplant center. We investigated whether our results were comparable to the best possible outcomes in low-risk cDCD LT. Methods: Prospectively collected data on 24 cDCD LT, with aNRP alone, were analyzed. Results: The median total and asystolic WIT were of 51 and 25 minutes, respectively. Measures within benchmark cut-offs were: median duration of surgery (5.9 hours); median intraoperative transfusions (3 units of red blood cells); need for renal replacement therapy (8.3%); intensive care unit stay (3 days); incidence of primary nonfunction, ischemic cholangiopathy, bile leak, and vascular thrombosis (0%); incidence of bleeding (8.3%) and anastomotic strictures (25%); overall morbidity up to 12 months (the median comprehensive complication index was of 16.6 points at discharge and at 3 months, of 24.4 points at 6 months, and of 27.2 points at 12 months); the rate of graft loss (8.3%) and retransplantation (0%) up to 6 months; 12-month mortality (9.5%). Hospital stay (33 days, due to logistics) and mortality up to 6 months (8.3%, due to graft-unrelated causes) exceeded benchmark thresholds. Conclusions: This pilot experience suggests that livers from cDCD with very prolonged WIT that appear viable during adequate quality aNRP may be safely transplanted, with no need for ex-situ MP, with considerable resource savings.