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Liver transplantation remains the only curative treatment for patients with end-stage liver disease. Despite a steadily increasing demand for suitable donor livers, the current pool of donor organs fails to meet this demand. To resolve this discrepancy, livers traditionally considered to be of suboptimal quality and function are increasingly utilized. These marginal livers, however, are less tolerant to the current standard cold preservation of donor organs. Therefore, alternative preservation methods have been sought and are progressively applied into clinical practice. Ex situ machine perfusion is a promising alternative preservation modality particularly for suboptimal donor livers as it provides the ability to resuscitate, recondition, and test the viability of an organ prior to transplantation. This review addresses the modalities of machine perfusion currently being applied, and particularly focuses on the hemostatic management employed during machine perfusion. We discuss the anticoagulant agents used, the variation in dosage, and administration, as well as the implications of perfusion for extended periods of time in terms of coagulation activation associated with production of coagulation factors during perfusion. Furthermore, in regard to viability testing of an organ prior to transplantation, we discuss the possibilities and limitations of utilizing the synthesis of liver-derived coagulation factors as potential viability markers. [ABSTRACT FROM AUTHOR]

A decision to withdraw life-sustaining treatment (WLST) is derived by a conclusion that further treatment will not enable a patient to survive or will not produce a functional outcome with acceptable quality of life that the patient and the treating team regard as beneficial. Although many hospitalized patients die under such circumstances, controlled donation after the circulatory determination of death (cDCDD) programs have been developed only in a reduced number of countries. This International Collaborative Statement aims at expanding cDCDD in the world to help countries progress towards self-sufficiency in transplantation and offer more patients the opportunity of organ donation. The Statement addresses three fundamental aspects of the cDCDD pathway. First, it describes the process of determining a prognosis that justifies the WLST, a decision that should be prior to and independent of any consideration of organ donation and in which transplant professionals must not participate. Second, the Statement establishes the permanent cessation of circulation to the brain as the standard to determine death by circulatory criteria. Death may be declared after an elapsed observation period of 5 min without circulation to the brain, which confirms that the absence of circulation to the brain is permanent. Finally, the Statement highlights the value of perfusion repair for increasing the success of cDCDD organ transplantation. cDCDD protocols may utilize either in situ or ex situ perfusion consistent with the practice of each country. Methods to accomplish the in situ normothermic reperfusion of organs must preclude the restoration of brain perfusion to not invalidate the determination of death. [ABSTRACT FROM AUTHOR]

Objectives: To explore whether distinct trajectories of anxiety and depression exist among liver transplant candidates, and to gain insight into demographic, clinical, and individual characteristics related with these trajectories.Design: A multicentre, prospective cohort study among 216 liver transplant candidates. Respondents filled out a questionnaire at study entrance and subsequently every 6 months until transplantation or removal from the waiting list.Methods: Anxiety (STAI6), depression (CES-D), demographic, and individual variables were assessed by questionnaire. Clinical variables were retrieved by medical record review. The SAS PROC TRAJ procedure was used to identify distinct trajectories. Univariate and multiple ordinal logistic regression analyses were used to explore related variables.Results: Regarding anxiety, three stable trajectories were identified as follows: below clinical level (51%), slightly above clinical level (34%), and high above clinical level (15%). Regarding depression, four stable trajectories were identified as follows: below clinical level (23%), slightly below clinical level (34%), slightly above clinical level (28%), and high above clinical level (6%). For anxiety as well as for depression, experiencing more liver disease symptoms, a lower level of personal control, making more use of emotional coping, and making less use of task-oriented coping increased the likelihood of membership in those trajectories with higher symptom levels.Conclusion: Distinct, but stable, trajectories of anxiety and depression were present in liver transplant candidates. The trajectories with symptom levels above clinical relevant levels for anxiety or depression comprised, respectively, 49% and 34% of the respondents. Therefore, psychological screening and subsequently providing appropriate interventions are warranted early in the transplant process. Statement of contribution What is already known on this subject For transplant candidates, the waiting-list period is a period of uncertainty and unpredictability. Psychological problems, such as anxiety and depression, are common among liver transplant candidates. Several demographic, clinical, and individual characteristics are associated with anxiety and depression, but these results remain inconclusive. What does this study add Distinct trajectories of symptoms of anxiety and depression are present among liver transplant candidates. Given the stability of the trajectories over time, the symptom level at baseline is indicative of the symptom level during the waiting-list period. Experiencing more liver disease symptoms, low mastery, more use of emotional coping, and less use of task-oriented coping are associated with trajectories of high symptom levels. [ABSTRACT FROM AUTHOR]

Objective: This study aimed at increasing the understanding of posttraumatic stress disorder (PTSD) in liver transplant patients by describing the course of PTSD, symptom occurrence, psychological co-morbidity, and the nature of re-experiencing symptoms.Methods: A prospective cohort study was performed among 95 liver transplant recipients from before transplantation up until one year post-transplantation. Respondents filled out a questionnaire regarding psychological functioning (PTSD, anxiety, and depression) before, and at 3, 6, and 12months post-transplantation. Both quantitative and qualitative methods were used to analyze the data.Results: Before transplantation, respectively 10.5% and 6.3% of the respondents were identified as possible cases of full or partial PTSD. In all cases, co-morbid conditions of anxiety and/or depression were present. After transplantation, no new onset of full PTSD was found. New onset of possible partial PTSD was found in six respondents. Arousal symptoms were the most frequently reported symptoms, but may not be distinctive for PTSD in transplant patients because of the overlap with disease- and treatment-related symptoms. Re-experiencing symptoms before transplantation were mostly related to waiting for a donor organ and the upcoming surgery; after transplantation this was related to aspects of the hospital stay.Conclusions: In our group of liver transplant patients, PTSD symptomatology was more present before transplantation than after transplantation. Being diagnosed with a life-threatening disease seemed to be the main stressor. However, when a diagnosis of PTSD is suspected, assessment by a clinician is warranted because of the overlap with mood and anxiety disorders, and disease- and treatment-related symptoms. [ABSTRACT FROM AUTHOR]

This study investigates the relationship between blood group and waiting time until transplantation or death on the waiting list. All patients listed for liver transplantation in the Netherlands between 15 December 2006 and 31 December 2012, were included. Study variables were gender, age, year of listing, diagnosis, previous transplantations, blood group, urgency, and MELD score. Using a competing risks analysis, separate cumulative incidence curves were constructed for death on the waiting list and transplantation and used to evaluate outcomes.In 517 listings, the mean death rate per 100 patient-years was 10.4. A total of 375 (72.5% of all listings) were transplanted. Of all transplantations, 352 (93.9%) were ABO-identical and 23 (6.1%) ABO-compatible. The 5-year cumulative incidence of death was 11.2% ( SE 1.4%), and of transplantation 72.5% ( SE 2.0%). Patient blood group had no multivariate significant impact on the hazard of dying on the waiting list nor on transplantation. Age, MELD score, and urgency status were significantly related to the death on the waiting list and transplantation. More recent listing had higher probability of being transplanted. In the MELD era, patient blood group status does not have a significant impact on liver transplant waiting list mortality nor on waiting time for transplantation. [ABSTRACT FROM AUTHOR]

This can enable the determination of death using neurologic criteria and activation of the donation after brain death pathway - allowing more organs to be transplanted and better post-transplant outcomes to be achieved. We agree with Vincent and Creteur that a planned cDCDD that does not proceed because death does not occur within a timeframe that enables successful organ recovery, can cause harm and frustration ("terrible", in their words). [Extracted from the article]

Background: Livers with moderate (30-60%) macrovesicular steatosis have been associated with poor outcome after transplantation. Aim of this study was to examine the outcome after transplantation of livers with moderate macrovesicular steatosis when the cold ischemia time (CIT) is kept very short. Methods: Postoperative outcome of 19 recipients of a moderate steatotic liver were compared with a matched control group of 95 recipients of a nonsteatotic liver graft (1:5 ratio). We studied graft/patient survival rates, incidences of primary nonfunction, postoperative complications (classified according to the Clavien- Dindo classification), first-week postoperative hepatic injury serum markers (AST/ALT), and liver function tests (PT time/bilirubin/lactate). In addition, we studied reversal of graft steatosis in follow-up biopsies. Results: Median CIT in livers with moderate steatosis and in controls was below 8 h in both groups. Although short- and long-term patient/graft survival rates and results of liver function tests were similar, serum markers of hepatic injury and postoperative complications (especially grade IVa) were significantly higher in recipients of a moderate steatotic liver. Reversal of steatosis was seen in 9 of the 11 (82%) recipients with follow-up liver biopsies. Conclusion: Despite the association with severe postoperative complications, moderate macrovesicular steatotic livers can be used successfully for transplantation if the CIT is kept very short. [ABSTRACT FROM AUTHOR]

Summary Patients with end-stage isolated polycystic liver disease (PCLD) suffer from incapacitating symptoms because of very large liver volumes. Liver transplantation (LT) is the only curative option. This study assesses the feasibility of LT in PCLD. We used the European Liver Transplant Registry (ELTR) database to extract demographics and outcomes of 58 PCLD patients. We used Kaplan-Meier survival analysis for survival rates. Severe abdominal pain (75%) was the most prominent symptom, while portal hypertension (35%) was the most common complication in PCLD. The explantation of the polycystic liver was extremely difficult in 38% of patients, because of presence of adhesions from prior therapy (17%). Karnofsky score following LT was 90%. The 1- and 5-year graft survival rate was 94.3% and 87.5%, while patient survival rate was 94.8% and 92.3%, respectively. Survival rates after LT for PCLD are good. [ABSTRACT FROM AUTHOR]

Between November 1982 and March 2006, 67 children with body weight ≤10 kg had a primary liver transplantation from deceased donors in our unit. The aim of this study was to analyze the outcome in terms of patient and graft survival and to search for factors affecting this outcome. Overall, one-, three-, five-, and 10-yr primary patient and graft survival rates were 73%, 71%, 66%, 63% and 59%, 56%, 53%, 48%, respectively. Twenty-four of 67 (36%) children died and in the remaining 22 (33%), the first grafts failed and they were retransplanted. Cox regression analysis revealed that a need for retransplantation and urgent transplantation were important predictors for patient survival (p = 0.04 and p = 0.001, respectively). To assess whether the need for retransplantation can be influenced, all study variables were compared between surviving grafts and failed grafts. Cox regression analysis showed that only donor/recipient (D/R) weight ratio proved to be independent predictor for graft survival (p = 0.004). After comparison of graft survival with the long rank test according to different D/R weight ratios (3.0–7.0), the cut-off point for significantly different graft survival approached 4.0. The one-, three-, five-, and 10-yr graft survival for technical variant grafts with a D/R weight ratio <4.0 was 85%, 68%, 68%, and 68% compared with a D/R weight ratio >4.0 was 44%, 38%, 38%, and 30%, respectively (p = 0.02). In summary, patient survival in children with body weight ≤10 kg is determined by urgent transplantation and the need for retransplantation. Graft loss and retransplantation in small children can be prevented by adequate size matching of donor and recipient whereby a D/R weight ratio <4.0 seems to offer the favorable outcome. [ABSTRACT FROM AUTHOR]

Blood loss during liver transplantation has long been recognized as an important cause of morbidity and, especially in the early days, also mortality. It is well known that blood transfusions are associated with an increased risk of postoperative complications, such as infections, pulmonary complications, protracted recovery, and a higher rate of reoperations. Many studies have been performed during the past decades to elucidate the mechanisms of increased blood loss in liver transplantation. In the late 1980s, primary hyperfibrinolysis was identified as an important mechanism of bleeding during liver transplantation. This has provided the scientific basis for the use of antifibrinolytic drugs in liver transplant recipients. Several randomized, controlled studies have shown the efficacy of these compounds in reducing blood loss and transfusion requirements during liver transplantation. In addition, increasing experience and improvements in surgical technique, anesthesiological care and better graft preservation methods have contributed to a steady decrease in blood transfusion requirements in most liver transplant programs. Several centers are now reporting liver transplantation without any need for blood transfusion in up to 30% of their patients. Despite these improvements, most patients undergoing liver transplantation still require blood transfusions that have a negative impact on outcome, emphasizing the need for further attempts to control blood loss by surgeons and anesthesiologists. This paper provides an overview of the clinical and research developments, which have contributed to a reduction in blood loss and transfusion requirements, resulting in an important reduction in morbidity and mortality after liver transplantation during the last two decades. Copyright © 2005 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Miyamoto S, Polak WG, Geuken E, Peeters PMJG, de Jong KP, Porte RJ, van den Berg AP, Hendriks HG, Slooff MJH. Liver transplantation with preservation of the inferior vena cava. A comparison of conventional and piggyback techniques in adults.Clin Transplant 2004 DOI: 10.1111/j.1399-0012.2004.00278.x© Blackwell Munksgaard, 2004The aim of this study is to analyse a single centre's experience with two techniques of liver transplantation (OLT), conventional (CON-OLT) and piggyback (PB-ES), and to compare outcome in terms of survival, morbidity, mortality and post-operative liver function as well as operative characteristics. A consecutive series (1994–2000) of 167 adult primary OLT were analysed. Ninety-six patients had CON-OLT and 71 patients had PB-ES. In PB-ES group two revascularization protocols were used. In the first protocol reperfusion of the graft was performed first via the portal vein followed by the arterial anastomosis (PB-seq). In the second protocol the graft was reperfused simultaneously via portal vein and hepatic artery (PB-sim). One-, 3- and 5-yr patient survival in the CON-OLT and PB-ES groups were 90, 83 and 80%, and 83, 78 and 78%, respectively (p = ns). Graft survival at the same time points was 81, 73 and 69%, and 78, 69 and 65%, respectively (p = ns). Apart from the higher number of patients with cholangitis and sepsis in CON-OLT group, morbidity, retransplantation rate and post-operative liver and kidney function were not different between the two groups. The total operation time was not different between both groups (9.4 h in PB-ES vs. 10.0 h in CON-OLT), but in PB-ES group cold and warm ischaemia time (CIT and WIT), revascularization time (REVT), functional and anatomic anhepatic phases (FAHP and AAHP) were significantly shorter (8.9 h vs. 10.7 h, 54 min vs. 63 min, 82 min vs. 114 min, 118 min vs. 160 min and 87 min vs. 114 min, respectively, p < 0.05). RBC use in the PB-ES group was lower compared to the CON-OLT group (4.0 min vs. 10.0 units, p < 0.05). Except for WIT and REVT there were no differences in operative characteristics between PB-Sim and PB-Seq groups. The WIT was significantly longer in PB-Sim group compared with PB-Seq group (64 min vs. 50 min, p < 0.05); however REVT was significantly shorter in PB-Sim group (64 min vs. 97 min, p < 0.05). Results of this study show that both techniques are comparable in survival and morbidity; however PB-ES results in shorter AAHP, FAHP, REVT and WIT as well as less RBC use. In the PB-ES group there seems to be no adavantage for any of the revascularization protocols. [ABSTRACT FROM AUTHOR]

One of the main limiting factors in pediatric liver transplantation is donor availability. For adults, DCD liver grafts are increasingly used to expand the donor pool. To improve outcome after DCD liver transplantation, ex situ machine perfusion is used as an alternative organ preservation strategy, with the supplemental value of providing oxygen to the graft during preservation. We here report the first successful transplantation of a pediatric DCD liver graft after hypothermic oxygenated machine perfusion. The full‐size liver graft was derived from a 13‐year‐old, female DCD donor and was end‐ischemic pretreated with dual hypothermic oxygenated machine perfusion. Arterial and portal pressures were set at 18 and 4 mm Hg, slightly lower than protocolized settings for adult livers. During 2 hours of machine perfusion, portal and arterial flows increased from 100 to 210 mL/min and 30 to 63 mL/min, respectively. The pretreated liver graft was implanted in a 16‐year‐old girl with progressive familial intrahepatic cholestasis type 2. Postoperative AST, ALT, and prothrombin time normalized within a week. The recipient quickly recovered and was discharged from the hospital after 18 days. One year after transplantation, she is in excellent condition with a completely normal liver function and histology. This case is the first report of successful transplantation of a pediatric DCD liver graft after hypothermic oxygenated machine perfusion and illustrates the potential role of ex situ machine perfusion in expanding the donor pool and improving outcome after pediatric liver transplantation. [ABSTRACT FROM AUTHOR]