Chapter 46: Expanded-Criteria Donors in Liver Transplantation

GENERAL PRINCIPLES

• It is common sense that one of the major problems for liver transplantation (LT)—and transplantation in general—is the discrepancy between the donor and recipient numbers, with far fewer donors than recipients. As a consequence, patients with liver failure have to wait for a long time before they can be offered an allograft.

• In this frame of universal shortage of organs, as well as the risk and cost of the LT, efforts have been made to overcome it by exploring new sources of grafts along with measures to improve and prolong graft function and survival.

• The use of expanded-criteria donors has been utilized to increase the donor pool.

• Expanded liver donor criteria are not strictly defined.

• A combination of different donor characteristics could create the profile of an expanded liver donor.

EXPANDED LIVER DONOR CRITERIA

• Age >50 to 60 years

• Obesity (weight >100 kg or body mass index [BMI] >27)

• Macrovesicular steatosis >30% to 50%

• Intensive care unit stay >5 days

• Prolonged hypotensive episodes >1 hour, with mean blood pressure <60 mm Hg

• High inotropic drug use

• Cardiac arrest, cardiopulmonary resuscitation

• Cold ischemia time >12 to 14 hours

• Peak serum sodium >150 to 155 mEq/L

• Sepsis

• Hepatitis infection

• Alcoholism

• Bilirubin level >2 mg/dL

• Alanine aminotransferase (ALT) >170 U/L

• Aspartate aminotransferase (AST) >150 U/L

• Extrahepatic neoplasia

SPECIAL CATEGORIES

• Donors after cardiac death

• Pediatric donors for adult recipients

  • Only if denied for pediatric recipients is the use of pediatric livers for adult recipients a possible option

• Domino liver transplantation donors (prolonged cold ischemia time)

• Split-liver donors for adult recipients (prolonged cold ischemia time)

• Donors beyond lifespan-expanded criteria

  • Donors ≥75 years of age

• “Rescue offer” organs

DONORS AFTER CARDIAC DEATH

• Donor who has suffered devastating and irreversible brain injury and may be near death but does not meet formal brain death criteria.

• Treatment withdrawal and circulatory arrest.

• The surgeons involved in transplantation cannot be part of the end-of-life care or in the declaration of death.

• Quality end-of-life care for a potential organ donor remains the priority and must not be compromised by the donation process.

• Liver transplantation with a donor-after-cardiac-death (DCD) liver may be associated with lower patient and graft survival at 1 year.

“RESCUE OFFER” ORGANS

• Applicable in some transplant organizations such as Eurotransplant.

• When a liver graft is rejected by at least 3 centers, it is allocated either to the geographically closest center or to the first center to accept it (multiple-refusal/competitive rescue offer procedure).

• When donor instability or unfavorable logistical reasons prevent a regular allocation, Eurotransplant selects centers based on recipient suitability, logistic criteria, and Model for End-Stage Liver Disease (MELD) score (unfavorable grafting situation/single-recipient rescue offer procedure).

FURTHER READING