Hieu Ledinh

Results of Kidney Transplantation From Donors After Cardiac Death

Confronting the organ donor shortage, many transplant centers around the world increasingly use donors after cardiac death (DCD). Over the past 20 years, follow-up studies in kidney recipients comparing DCD and donors after brain death (DBD) have shown comparable long-term graft function and survival. As a consequence, DCD programs should be continued and expanded, for these donors constitute a potential solution to the imbalance between the numbers of end-stage kidney disease patients on waiting lists versus available kidney grafts. DCD kidneys do not necessarily signify suboptimal grafts; they may merit to be allocated the same as DBD grafts.

Results of kidney transplantation from controlled donors after cardio‐circulatory death: a single center experience

The aim of this study was to determine results of kidney transplantation (KT) from controlled donation after cardio‐circulatory death (DCD). Primary end‐points were graft and patient survival, and post‐transplant complications. The influence of delayed graft function (DGF) on graft survival and DGF risk factors were analyzed as secondary end‐points. This is a retrospective mono‐center review of a consecutive series of 59 DCD‐KT performed between 2005 and 2010. Overall graft survival was 96.6%, 94.6%, and 90.7% at 3 months, 1 and 3 years, respectively. Main cause of graft loss was patient’s death with a functioning graft. No primary nonfunction grafts. Renal graft function was suboptimal at hospital discharge, but nearly normalized at 3 months. DGF was observed in 45.6% of all DCD‐KT. DGF significantly increased postoperative length of hospitalization, but had no deleterious impact on graft function or survival. Donor body mass index ≥30 was the only donor factor that was found to significantly increase the risk of DGF (P < 0.05). Despite a higher rate of DGF, controlled DCD‐KT offers a valuable contribution to the pool of deceased donor kidney grafts, with comparable mid‐term results to those procured after brain death.

Contribution of Donors After Cardiac Death to the Deceased Donor Pool: 2002 to 2009 University of Liege Experience

OBJECTIVE In this study, we have evaluated the organ procurement and transplantation activity from donors after cardiac death (DCD) at our institution over an 8-year period. Our aim was to determine whether this program influenced transplantation programs, or donation after brain death (DBD) activity. METHODS We prospectively collected our procurement and transplantation statistics in a database for retrospective review. RESULTS We observed an increasing trend in potential and actual DCD number. The mean conversion rate turning potential into effective donors was 58.1%. DCD accounted for 16.6% of the deceased donor (DD) pool over 8 years. The mean age for effective DCD donors was 53.9 years (range, 3-79). Among the effective donors, 63.3% (n = 31) came from the transplant center and 36.7% (n = 18) were referred from collaborative hospitals. All donors were Maastricht III category. The number of kidney and liver transplants using DCD sources tended to increase. DCD kidney transplants represented 10.8% of the DD kidney pool and DCD liver transplants made up 13.9% of the DD liver pool over 8 years. The DBD program activity increased in the same time period. In 2009, 17 DCD and 33 DBD procurements were performed in a region with a little >1 million inhabitants. CONCLUSION The establishment of a DCD program in our institution enlarged the donor pool and did not compromise the development of the DBD program. In our experience, DCD are a valuable source for abdominal organ transplantation.

Kidney donation after circulatory death in a country with a high number of brain dead donors: 10-year experience in Belgium

Worldwide shortage of standard brain dead donors (DBD) has revived the use of kidneys donated after circulatory death (DCD). We reviewed the Belgian DCD kidney transplant (KT) experience since its reintroduction in 2000. Risk factors for delayed graft function (DGF) were identified using multivariate analysis. Five‐year patient/graft survival was assessed using Kaplan–Meier curves. The evolution of the kidney donor type and the impact of DCDs on the total KT activity in Belgium were compared with the Netherlands. Between 2000 and 2009, 287 DCD KT were performed. Primary nonfunction occurred in 1% and DGF in 31%. Five‐year patient and death‐censored graft survival were 93% and 95%, respectively. In multivariate analysis, cold storage (versus machine perfusion), cold ischemic time, and histidine‐tryptophan‐ketoglutarate solution were independent risk factors for the development of DGF. Despite an increased number of DCD donations and transplantations, the total number of deceased KT did not increase significantly. This could suggest a shift from DBDs to DCDs. To increase KT activity, Belgium should further expand controlled DCD programs while simultaneously improve the identification of all potential DBDs and avoid their referral for donation as DCDs before brain death occurs. Furthermore, living donation remains underused.

Pancreas preservation for pancreas and islet transplantation: a minireview

Pancreas preservation by cold storage using University of Wisconsin solution was the mainstay method used for pancreas transplantation during the past 2 decades. Other solutions, such as HTK, Celsior, and SCOT 15, could not demonstrate any advantage for short preservation periods. But the advent of clinical islet transplantation and the larger use of controlled non-heart-beating donors have prompted the transplantation community to develop methods for increasing pancreas graft quality while preventing ischemic reperfusion damages. Oxygenation by 1- or 2-layer methods during pancreas preservation, as well as the use of perfluorocarbons, might increase the islet yield. Based on the former methods, there is a renewed interest in machine perfusion and oxygenation in pancreas preservation for pancreas transplantation and islet preparation.

Belgian experience of DCD kidney transplantation

O-098 – Table 1. LTx in patients with incidental PPHT Indication labMELD mPAP at induction (mmHg) hospital stay (days) Medical treatment post-LTx Outcome Follow-up (months) m/54yr Post-ethyl cirrhosis 32 44 38 Spontaneous resolution Alive and well 15 f/37yr Post-ethyl cirrhosis 26 26 40.6 42 Epoprostenol IV during 13 months Alive and well 13 f/62yr HBV 31 46.7 92 Sildenafil PO during 9 months Alive and well 12 m/61yr Post-ethyl cirrhosis and HCC 12 36.7 6 Extra-corporeal membrane oxygenation †6d post-LTx – f/67yr Sarcoidosis 36 34.3 – Aborted LTx †1d post-LTx – f/54yr Post-ethyl cirrhosis 24 35.3 22 Spontaneous resolution Alive and well 16 f/53yr Postethyl + HBV cirrhosis 19 37.3 19 Spontaneous resolution Alive and well 55 f/53yr PBC 17 51.7 58 Sildenafil PO Alive and well 6 m/42yr HCV 17 53.3 – Listed for combined heart/lung/LTx Alive and well 120 Eleven (9.9%) patients did not even achieve 65% of the predicted target heart rate, and notably all of them were on β-blockers. Thirty (73.1%) of 41 patients who achieved the target heart rate had MELD score ≤15 compared with 11 (26.9%) patients with MELD score > 15 (p < 0.05). Conclusions: Chronotropic incompetence on DSE is frequent in patients with ESLD. In absence of any cardiac symptoms or/and ECG findings during DSE, a lower cut-off for target heart rate may be acceptable when patients are on βblockers or/and MELD score >25 to avoid unnecessary further investigations. Large prospective studies are needed to support these findings. O-098 INCIDENTAL PORTOPULMONARY HYPERTENSION DISCOVERED AT THE START OF LIVER TRANSPLANTATION, “TO GO AHEAD OR TO LET GO...” Filip Gryspeerdt, Marion Dupont, Wim Laleman, Raymond Aerts, Dieter Mesotten, Geert Meyfroidt, Marleen Verhaegen, Arne Neyrinck, Frederik Nevens, Jacques Pirenne, Diethard Monbaliu. Leuven liver Transplant Team, University Hospitals Leuven, Leuven, Belgium Background: Portopulmonary hypertension (PPHT) is the association of pulmonary hypertension (mean pulmonary artery pressure [mPAP] >25 mmHg) and portal hypertension with or without chronic liver disease. Moderate PPHT (mPAP >35 mmHg) is associated with higher morbidity/mortality and severe PPHT (mPAP> 45mmHg) is generally considered a contra-indication for Liver Transplantation (LTx). Moderate to severe PPHT may develop during the waiting time of LTx period. A retrospective analysis was done to review the shortterm outcome of LTx in patients with incidental PPHT (e.g. diagnosed at the start of LTx and unkown at time of listing). Methods: All medical records of patients with incidental PPHT were reviewed. Lab-MELD at time of LTx, mPAP immediately pre-LTx, post-LTx hospital stay, type/length of post-LTx medical treatment for PPHT and patient survival were analyzed (see Table 1). Results: Between 2000-2011, 9/653 patients were diagnosed with moderate to severe PPHT at time of LTx induction. LTx was pursued in 7 patients. Of those, 6 had uneventful post-LTx recovery with spontaneous or medically assisted (vasodilators) resolution of PPHT; and 1 succumbed to complications of extra-corporeal membrane oxygenation. LTx was started but aborted in 1 due to hemodynamic unstability. LTx was not started in 1 who later received combined heart/lung/LTx. Conclusion: The incidental discovery of a previously unknown moderate to severe PPHT at the start of LTX is a possibility that LTx teams should be aware of. PPHT has usually been seen as a contra-indication for LTx. However, favorable outcome in 6/7 recipients suggests that LTx should not necessarily be aborted in case of incidental PPHT. 28 Oral Sessions Oral Session 13: Liver / intestine miscellaneous O-099 LIVER INMUNOPROTECTIVE EFFECT ON THE KIDNEY ALLOGRAFT IN SIMULTANEOUS LIVER AND KIDNEY TRANSPLANTATION Nuria N. Esforzado 1, Ana Yurena A.Y. Sánchez 1, José Vicente J.V. Torregosa 1, Nuria N. Serra 1, Rafael R. Pascualin 1, Jaume J. Martorell 2 , Federico F. Oppenheimer 1 , Josep Maria J.M. Campistol 1 . 1Renal Transplant Unit, 2Inmunology Unit, Hospital Clinic, Barcelona, Spain Background: Simultaneous liver-kidney transplantation (SLK) has less incidence of renal graft rejection and inmunological graft lost against the receptors of an isolated renal transplantation (RT). In addition, a low rejection incidence and a good renal graft evolution have ben reported in cross-match (CM) positive (+) SLK patients. The low prevalence of immunological complications in high-risk immune (“HRI”) SLK patients, suggests a liver’s inmunoprotective effect on the kidney graft. Material and methods: We present our experience in “HRI” SLK patients, defined as CM by cytotoxicity (CDC) post DTT + and/or “HRI” + pre transplantion (Tx). From May 1993 until December 2010, 58 SLK Tx were made (27 retransplanted patients), and eight patients had CM + pre Tx and other four patients had negative CM but positive “HRI”. Results: Of 12 “HRI” patients, 3 (25%) patients had graft dysfunction related to humoral acute rejection (HAR) during the first month after SLK Tx. Only one of these patients (33%) received Apheresis and Rituximab treatment with a good response. In the other two patients, HAR was resolved without specific treatment. None of 12 patients after 45±40 months follow-up, loss graft related to inmunological etiology. Six of 8 CM + pre Tx patients became negative post Tx. Conclusion: High-risk inmune SLK patients have a low prevalence of immunological complications which suggests an inmunoprotector role of the liver on the kidney allograft in these patients. O-100 EVOLUTION OF KIDNEY FUNCTION AFTER LIVER TRANSPLANTATION FOR ADULT POLYCYSTIC LIVER DISEASE AND INDICATIONS FOR COMBINED LIVER AND KIDNEY TRANSPLANTATION Tom Darius 1, Alexander Patris 1, Ziad Hassoun 1, Diethard Monbaliu 2, Tania Roskams 2, Olga Ciccarelli 1, Yves Pirson 1, Yves Vanrenterghem 2 , Frederik Nevens 2, Jacques Pirenne 2, Jan Lerut 1 . 1Abdominal Transplant Unit, University Hospitals Saint Luc, Brussels, Belgium; 2Liver Transplant programme, University Hospitals Gasthuisberg, Leuven, Belgium Background: Adult polycystic liver disease (PLD) is frequently associated with autosomal dominant polycystic kidney disease (ADPKD). Established indication for combined liver and kidney transplantation (CLKTx) is end stage renal failure. If renal insufficiency is less advanced, indications for combined kidney transplantation (KTx) are controversial. We reviewed our experience with isolated liver transplantation (LTx) and CLKTx in patients with PLD. Methods: Between 1995-2008, 56 patients originating from 2 collaborating centers underwent LTx for PLD. 7 patients with isolated PLD received LTx alone. Of 49 patients with combined PLD and ADPKD, 31 underwent isolated LTx and 18 CLKTx. Among the 18 CLKTx recipients, 11 were dialysisdependent pre-transplant whereas 7 had a creatinine clearance (CrCl) between 15 and 38 mL/min. Results: Median follow up is 34 months (range, 26-167). 1 and 5-year patient and liver graft survival were 96% and 94%, and 96% and 90%, respectively. The 1 and 5-year kidney graft survival (death censored) is 100%. Of the 31 patients who underwent isolated LTx for combined PLD and ADPKD, 29% (n=9) developed terminal renal failure post-LTx. Their mean pre-LTx CrCl was 76 mL/min (range, 48-110). The mean pre-LTx CrCl in the 71% patients who display stable kidney function post-LTx was 78 mL/min (range, 47-153). Pre-LTx CrCl was not a significant factor for the development of renal failure after isolated LTx for combined PLD and ADPKD (p=0,835). Conclusion: This series demonstrates that short& long-term survival after LTx and CLKTx for PLD is excellent. In patients with clearly-proven & evolving renal impairment pre-transplant, CLKTx is the preferred option, anticipating the need for later KTx. In patients with preserved/mildly disturbed renal function, nephron sparing strategies are essential since evolution towards renal failure is seen in 29%, without clear prognosis factors. O-101 LIVER TRANSPLANTATION (LTx) FOR TRANSTHYRETIN SYSTEMIC AMYLOIDOSIS DISORDERS: ANALYSIS FROM THE FAMILIAL AMYLOIDOTIC POLYNEUROPATHY WORLD TRANSPLANT REGISTER (FAPWTR) Bo-Göran Ericzon. Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden Background: Transthyretin (TTR) systemic amyloidosis disorders are treatable with Ltx. The FAPWTR was established in 1993 to assemble data on such patients. Methods/Results: By December 2009, 1798 patients/1953 liver transplantations were reported to the FAPWTR from 72 centers in 19 different countries. Most transplantations were done in Portugal (n=866), France (n=216), Sweden (n=130) and Brazil (n=91). More than 45 different TTR-variants have been reported, the commonest being Val30Met (85%) followed by Ser77Tyr, Thr60Ala and Tyr114Cys. Gastrointestinal, cardiovascular and extraneurological manifestations appear more often in non-Val30Met than in Val30Met patients. 15% of the non-Val30Met patients underwent liver and heart transplantation compared to 0.1% of the Val30Met patients. Different countries show varying age at onset in Val30Met patients, with Brazil having the youngest patients and Sweden the oldest (32 years and 45 years, respectively). After Ltx, 80-90% of the ValMet30 patients reported stable or improved clinical symptoms compared to 60-65% in non-Val30Met patients. The overall 5-, 10and 15-year patient survival is 79%, 70% and 64%, respectively. Most common cause of death is cardiac. Val30Met patients with a disease duration >7 years disclose inferior 5-year survival than patients with a duration ≤7 years (58.2% and 84.7%, respectively p<0.001). Results improve when analyzing patients transplanted in the last 5 years, but the 5-year survival still remains significantly better in patients with less than 7 years disease duration (72.1% and 88.7%, respectively p<0.05). Conclusion: LTx is lifesaving in patients with TTR amyloidosis. Val30Met and non-Val30Met TTR mutations differ clinically. Cardiac related post transplant death i