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Volume: 17 Issue: 1 January 2019 - Supplement - 1

FULL TEXT

Liver Donation From Marginal Donors: To Donate or Not to Donate?

Objectives: Livers from deceased donors compose nearly 30% of all organ transplants, and about 700 liver transplants are carried out per year. Marginal livers (extended-criteria donors), however, are not usually accepted by recipient teams, and there is only one center for these procedures in Iran. The final decision is made according to criteria that are much more conservative than other globally accepted ones.

Materials and Methods: To find significant differences and construct an algorithm to predict the future of marginal livers (before transfer of donors to our organ procurement unit), successfully donated and un-successfully donated livers divided into 2 age groups were compared in terms of age, sex, body mass index, liver function tests, significant medical disorders, and preretrieval liver sonography report.

Results: In the first age group (50-59 years old), there were 88 successful donors and 27 unsuccessful cases (due to 3 reasons: positive virology tests, death before retrieval, and ruled out by surgeons in the operating room). In the second age group (≥ 60 years old), there were 45 successful donors and 11 unsuccessful cases. The results showed that there were no differences between successful and unsuccessful cases regarding age and liver sonography results; however, sex, body mass index, liver function tests, and previous medical disorder were different between groups. Donors in both age groups were mostly male (60% and 73%); however, surprisingly, most unsuccessful cases were female (56.6% and 57%). Donors had generally lower body mass index (2 numerical difference), better liver function tests, and less risk factors (heart disease, diabetes mellitus, fatty liver, and chronic alcohol consumption).

Conclusions: Before transfer of marginal liver donors to the organ procurement unit for further evaluation and organ retrieval, one must consider that age is just a number and the presence of other comorbidities can have more decisive roles on liver quality.


Key words : Brain death, Extended-criteria donors, Organ donation

Introduction

In the past decade, letting go of optimum criteria for selection of deceased-donor organs has pushed liver procurement and transplant numbers to higher levels.1,2 Marginal liver donors have been frequently reported to be effective without significant decreases in survival rates and quality of life of recipients if the cases are well selected and matched.3 However, when marginality has been certainly proved, exact determination of the conditions of whether the neurologically dead person can be a successful donor is another field of concern. The process of brain death and subsequent mechanisms of injury themselves, as well as potential donor characteristics and consi-derations of past medical history on the organ, can affect its rejection.

In Iran, donation after brain death has developed rapidly in the past decade, with donations per million population increasing by 50 times in the 21st century (from 0.2 in 2000 up to 11.4 in 2017).4 Livers from de-ceased donors compose nearly 30% of all organ trans-plants, and about 700 liver transplants are carried out per year. Marginal livers (extended criteria donors), however, are not usually accepted by recipient teams, and there is only one center that considers these livers for further evaluation. The final decision is made ac-cording to some (empirical, self-made) criteria that are much more conservative than globally accepted ones.5

Materials and Methods

To better understand the decision-making process of recipient teams and to prevent wasted time and financial resources on unusable livers, we studied all procured livers from donors of 2 age groups (50-59 year old and ≥ 60 year old) over 2 consecutive Iranian years (March 2016 to March 2018) (Table 1). To find significant differences and to construct an algorithm to predict the future of marginal livers (before donors are transferred to our organ procurement unit), successfully donated livers and unsuccessfully donated livers in both age groups were compared in terms of age, sex, body mass index (BMI), liver function tests, significant medical disorders, and preretrieval liver sonography report.

Results

In the first age group (50-59 years old), there were 88 successful donations and 27 unsuccessful cases (due to 3 reasons: positive virology tests making donation impossible, death before organ retrieval, and ruled out by surgeon in the operating room). In the second group (≥ 60 years old), there were 45 successful donors (80.4%) and 11 unsuccessful cases (19.6%).

We observed no differences between successful donors and unsuccessful cases regarding age and liver sonography results. However, sex, BMI, liver function tests, and previous medical disorders were different between the 2 groups. Donors in both age groups were mostly male (60% and 73%); however, surprisingly, most unsuccessful cases were female (56.6% and 57%; P = .05 and .02). The donor population had generally lower BMI (P = .05), better liver function tests (P = .04), and less risk factors (heart disease, diabetes mellitus, fatty liver, and chronic alcohol consumption; P = .03) (Table 2).

Discussion

The use of marginal donors in liver transplant procedures until now has been questioned in the literature. Among various factors affecting donation are donor age, donor height, donation after cardiac death, split liver donors, black race/ethnicity, vascular accident as cause of death, regional sharing, and cold ischemia time.6 The most controversial criterion is donor age. After a careful overview of related papers, we deduced that donor age alone is not a determining factor regarding organ quality and graft survival.7-10

In their report of characteristics related to graft and patient survival in donors older than 70 years, Alamo and associates11 suggested that such donors can be of similar benefit compared with younger donors if special selection tips are considered. They suggested that prolonged ascites and hepatitis C virus infection were alarming signs. In our center and in accordance with our methodology and results, we suggest the same idea because we have not considered all potential donors greater than 60 years at the same rate as younger donors.

Some researchers have proposed ultrasonography, computed tomography, or even magnetic resonance imaging studies to validate the quality of the liver before retrieval. With the heavy shadow of definitive histology studies like biopsy with frozen section regarding determination of existence and degree of steatosis, fibrosis, and other morphologic consi-derations, the accuracy and fruitfulness of these modalities have faded.12 However, due to the surprising increase in liver steatosis incidence in some populations, performance of at least one of the above modalities seems vital to avoid the subsequent waste of resources.

It is clear that use of liver function tests in a setting like the intensive care unit for prediction of liver quality can be deceptive. In fact, their compatibility with histology studies can explain some pathologies.13 However, we have considered the test results before definitive studies and found a relationship between alanine aminotransferase and aspartate aminotransferase levels versus the final destination of the procured liver.

Conclusions

Before transfer of marginal liver donors to the organ procurement unit for further evaluation and organ retrieval, one must consider that age is just a number and the presence of other comorbidities can have more decisive roles on liver quality. One must be cautious as well with higher BMI and female cases because of their higher liver rejection rates. Liver function tests are also important in predicting liver suitability for donation, but sonography is not an accurate way and we must search for another method for liver evaluation before retrieval.


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Volume : 17
Issue : 1
Pages : 254 - 256
DOI : 10.6002/ect.MESOT2018.P112


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From the Organ Procurement Unit (OPU), Lung Transplantation Research Center (LTRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
Acknowledgements: The authors declare that they have no sources of funding for this study, and they have no conflicts of interest to declare.
Corresponding author: Farahnaz Sadegh Beigee, Organ Procurement Unit (OPU), Lung Transplantation Research Center (LTRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences (SBMU), Darabad, Niavaran, Tehran, Iran 19569-44413
Phone: +98 2127122103
E-mail: Beigeef@hotmail.com