Paola Carrai

DCD (donation after circulatory death) liver transplantation has expanded worldwide but remains associated with an increased risk of complications. Sequential use of normothermic regional perfusion (NRP) followed by ex situ machine perfusion (MP) is increasingly adopted, but the choice of MP technique remains controversial. This randomized controlled trial compares outcomes of dual-hypothermic oxygenated perfusion (D-HOPE) versus normothermic machine perfusion (NMP) following NRP in DCD liver transplantation. After NRP, 50 grafts (44 controlled and 6 uncontrolled DCD) were randomized 1:1 to D-HOPE or NMP using concealed allocation with sequentially numbered sealed envelopes. Ex situ perfusion was not performed for additional assessment. The primary endpoint was 1-year incidence of serious adverse events (SAEs), including graft or patient loss and biliary or vascular complications. Secondary endpoints included other perioperative outcomes. We have also performed an exploratory analysis to identify predictive factors of graft loss and SAEs. No case of primary nonfunction or vascular complication occurred. One-year graft and patient survival were both 88% in the D-HOPE group and 100% in the NMP group ( p =0.07). One-year SAE rate was similar (16% vs. 20%, p =0.31). Biliary leakage and postoperative dialysis rate were comparable between the 2 groups (16% vs. 0%, p =0.12). Blood pH variation, lactate and IL-6 levels during NRP, perfusate lactate trend, portal flow, IL-6, IL-10 and TNF levels during D-HOPE, and perfusate pH variations and IL-10 levels during NMP were related to graft loss. When applied after NRP, D-HOPE and NMP provide comparable mid-term clinical outcomes in DCD liver transplantation. Differences in specific complications may require individualized selection of ex situ MP. The limited sample size and number of events preclude definitive conclusions regarding differences in individual complications or the relative efficacy of either ex situ perfusion strategy. The observed differences in specific complications and exploratory associations with perfusion parameters warrant evaluation in larger prospective studies.

Ischemia–reperfusion injury (IRI) is a mechanism based on inflammatory mediators’ release and activation of effectors of damage. Studies showed a correlation between cytokine, severity of damage, and post-operative outcomes. Ex situ perfusion may work as a platform for the treatment of IRI mechanisms, such as the removal of cytokines using cytokine adsorption (CA). We assessed the safety and benefits of an integrated CA during ex situ dual-oxygenated hypothermic (D-HOPE) and normothermic perfusion (NMP). During the period of July 2021–December 2023, 84 octogenarian liver grafts, suitable for transplantation, were considered: 12 were randomized to D-HOPE or NMP with or without CA (D-HOPE + CA, D-HOPE, NMP + CA, NMP groups, n = 3 each) and compared to 72 performed using grafts preserved in static cold storage (SCS). IL-1, IL-6, IL-10, and TNF-a perfusate concentrations were evaluated together with perfusion parameters and post-operative outcomes. Perfusion procedures were unaffected by CA integration. In NMP, cytokine levels were 10–40 times higher than in healthy subjects and 20–50 times higher than D-HOPE. Cytokines were removed both in D-HOPE and NMP, but the concentration-dependent mechanisms of action of CA led to more remarkable removal in NMP. IL-10 and TNF-a concentrations were significantly lower in NMP + CA than in NMP. The application of CA was associated with significantly higher arterial flows both in D-HOPE and NMP, and reduced neutrophil infiltration in NMP. No differences in post-operative outcomes were found among groups. In conclusion, cytokine adsorption during ex situ machine perfusion of liver grafts from elderly donors is safe and feasible and is associated with modulation of inflammatory mediators and perfusion dynamics. These findings are hypothesis-generating, and larger studies are required to determine the clinical impact of this strategy.

Background/Objectives: The rising use of liver grafts from donation after circulatory death (DCD) has been enabled by advances in normothermic regional perfusion (NRP) and machine perfusion (MP) technologies. We aimed to identify predictive biomarkers in DCD grafts subjected to NRP, followed by randomization to either normothermic machine perfusion (NMP) or dual hypothermic oxygenated perfusion (D-HOPE). Methods: Among 57 DCD donors, 32 liver grafts were transplanted, and recipients were monitored for one week post-transplant. Biomarkers linked with oxidative stress, hepatic injury, mitochondrial dysfunction, inflammation, regeneration, and autophagy were measured during NRP, end-ischemic MP, and one week post-transplant. Results: Arginase-1 (ARG-1) levels were consistently higher in discarded grafts and in recipients who later developed early allograft dysfunction (EAD). Specifically, ARG-1 levels at the end of MP correlated with markers of hepatic injury. Receiver operating characteristic analysis indicated that ARG-1 at the end of MP had a good predictive accuracy for EAD (AUC = 0.713; p = 0.02). Lipid peroxidation (TBARS) elevated at the start of NRP, declined over time, with higher levels in D-HOPE than in NMP, suggesting a more oxidative environment in D-HOPE. Metabolites like flavin mononucleotide (FMN) and NADH exhibited significant disparities between perfusion types, due to differences in perfusate compositions. Inflammatory biomarkers rose during NRP and NMP but normalized post-transplantation. Regenerative markers, including osteopontin and hepatocyte growth factor, increased during NRP and NMP and normalized post-transplant. Conclusions: ARG-1 demonstrates strong potential as an early biomarker for assessing liver graft viability during perfusion, supporting timely and effective decision-making in transplantation.

The rising use of liver grafts from donation after circulatory death (DCD) has been enabled by advances in normothermic regional perfusion (NRP) and machine perfusion (MP) technologies. Our study aimed to identify predictive biomarkers in DCD liver grafts subjected to NRP, followed by randomization to either normothermic machine perfusion (NMP) or dual hypothermic oxygenated perfusion (D-HOPE). Among 57 DCD donors, 32 liver grafts were transplanted, and recipients were monitored for one week after transplantation. Biomarkers linked with oxidative stress, hepatic injury, mitochondrial dysfunction, inflammation, regeneration, and autophagy gene expression were measured during NRP, end-ischemic MP, and one week post-transplant. Arginase-1(ARG-1) levels were consistently higher in discarded grafts and recipients who later developed early allograft dysfunction (EAD). Specifically, ARG-1 levels at the end of ex-situ machine perfusion correlated significantly with other markers of hepatic injury. Receiver Operating Characteristic analysis indicated that ARG-1 at the end of MP had good predictive accuracy for EAD (AUC = 0.713 [95% CI: 0.538-1]; p = 0.02). Additionally, lipid peroxidation, measured by TBARS, was elevated at the start of NRP but declined over time, with higher levels in D-HOPE than in NMP, suggesting a more sustained oxidative environment. Metabolites like Flavin mononucleotide (FMN) and NADH exhibited significant disparities between perfusion types, due to differences in perfusate compositions. Inflammatory biomarkers rose during NRP and NMP but normalized post-transplantation. Regenerative markers, including osteopontin and hepatocyte growth factor, also increased during NRP and NMP and normalized after transplantation. In conclusion, ARG-1 demonstrates strong potential as an early biomarker for assessing liver graft viability during perfusion, supporting timely and effective decision-making in transplantation.

A 44-year old man with aortic regurgitation and aneurysm of the ascending aorta underwent an aortic valve-sparing procedure as a durable treatment before liver transplantation. Since patients with chronic liver failure are at high risk of hemorrhagic complications at time of major surgery, while management of warfarin administration may still represent a concern, the choice of a cardiac procedure which avoids any anticoagulant treatment appeared justified.

Toxoplasma gondii (TG) is one of the most widespread intracellular parasites in the world, despite the slight declining trend in industrialized countries. Whilst the infection is often asymptomatic in immunocompetent hosts, in immunocompromised patients such as organ transplant recipients it can have important clinical sequels with even fatal consequences. We retrospectively reviewed 568 primary liver transplants (LT) from deceased donors from 2012 to 2017. Data were analyzed adjusting for year, gender, and age. The study objective was to assess the incidence of post-transplant TG infection and adherence to international guidelines for primary chemoprophylaxis. Prior to transplantation, 42.4% of recipients tested seronegative and 56.5% seropositive, while 36.6% of donors were seropositive and 40.4% showed undetermined serology. Anti-TG antibody titer was higher in patients born abroad (71.4%) versus Italy (54.8%). Among recipients at high risk of post-transplant TG infection, 82.7% of them received chemoprophylaxis, while in 17.3% of cases no prophylaxis was administered. At a mean (SD) follow-up of 21.2 (12.4) months no case of TG infection has been observed. Despite the low rate of adherence to recommendations, prophylaxis of high-risk LT recipients provides control of post-transplant TG infection risk. Review of current guidelines is warranted for low-risk populations.