Ashley Limkemann

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Background.: The widespread use of normothermic machine perfusion (NMP) has enabled greater utilization of donation after circulatory death (DCD) liver grafts for transplantation. Use of NMP can cost an additional $40 000–$100 000 The aim of our study was to see whether the use of NMP would lower postoperative costs after DCD liver transplantation (LT). Methods.: Retrospective data of all DCD LTs performed at our center between August 19, 2022, and May 31, 2024, were analyzed. The OrganOx metra device, back-to-base, was used for NMP at our center. United Network for Organ Sharing data were used to present national DCD LT volumes and waitlist outcomes. Results.: Sixty-seven NMP and 44 static cold storage transplants were performed. In the NMP group, donors were older (50 versus 45 y, P = 0.0260), were at increased risk (US donor risk index 2.43 versus 2.12, P = 0.006), incidence of early allograft dysfunction (42% versus 75%, P = 0.0008) and postreperfusion syndrome (25% versus 48%, P = 0.0239) was lower, and recipients had better native kidney function at 3 mo (estimated glomerular filtration rate 73 versus 62 mL/min/1.73 m², P = 0.0205). Use of NMP did not decrease postoperative direct costs. On multivariate analysis, an additional 56 min of cold ischemic time and the presence of postreperfusion syndrome increased postoperative direct costs by $14 700 and $23 100, respectively. Conclusions.: Use of NMP does not decrease postoperative direct costs after DCD LT. However, with the use of NMP, a greater number of DCD liver grafts can be used, from a broader range of donors, wait time to transplant can be reduced, and waitlist survival can be improved while improving relevant clinical outcomes. The overall cost savings achieved by transplanting patients quickly at low Model for End-stage Liver Disease scores and improving waitlist morbidity should be further explored.

Background. Variation in donation after circulatory death (DCD) organ recovery and liver transplant practices exist among transplant centers. This study aimed to evaluate these practices among centers in the United States. Methods. Scientific Registry of Transplant Recipients data were accessed to identify centers that performed liver transplantation in 2021 and 2022. Surveys were sent to transplant centers that consistently performed ≥5 DCD liver transplants per year. Results. DCD liver transplants were performed by 95 centers (65.1%) of the 146 liver transplant centers in the United States. Survey results were recorded from 42 centers that consistently performed ≥5 DCD liver transplants per year, with a 59.5% response rate. Withdrawal-to-asystole and agonal time were used to define donor warm ischemia time (WIT) in 16% and 84% centers, respectively. Fifty-six percent of the centers did not use oxygen saturation to define donor WIT. Systolic blood pressure cutoffs used to define agonal time varied between 50 and 80 mm Hg, donor age cutoffs ranged between 55 and 75 y, and cold ischemia times varied between 4 and 10 h. Seventy-six percent of centers used normothermic machine perfusion for DCD liver transplantation. Conclusions. This study highlights the wide variation in use, recovery, and definition of donor WIT. Using national data to rigorously define best practices will encourage greater utilization of this important donor resource. Export

Background and Objectives: Liver transplantation (LT) is the best strategy for curing several primary and secondary hepatic malignancies. In recent years, growing interest has been observed in the enlargement of the transplant oncology indications. This paper aims to review the most recent developments in the setting of LT oncology, with particular attention to LT for unresectable colorectal liver metastases (CRLM) and cholangiocellular carcinoma (CCA). Materials and Methods: A review of the recently published literature was conducted. Results: Growing evidence exists on the efficacy of LT in curing CRLM and peri-hilar and intrahepatic CCA in well-selected patients when integrating this strategy with (neo)-adjuvant chemotherapy, radiotherapy, or locoregional treatments. Conclusion: For unresectable CCA and CRLM management, several prospective protocols are forthcoming to elucidate LT’s impact relative to alternative therapies. Advances in diagnosis, treatment protocols, and donor-to-recipient matching are needed to better define the oncological indications for transplantation. Prospective, multicenter trials studying these advances and their impact on outcomes are still required.

Objective: To define benchmark values for liver transplantation (LT) in patients with perihilar cholangiocarcinoma (PHC) enabling unbiased comparisons. Background: Transplantation for PHC is used with reluctance in many centers and even contraindicated in several countries. Although benchmark values for LT are available, there is a lack of specific data on LT performed for PHC. Methods: PHC patients considered for LT after Mayo-like protocol were analyzed in 17 reference centers in 2 continents over the recent 5-year period (2014–2018). The minimum follow-up was 1 year. Benchmark patients were defined as operated at high-volume centers (≥50 overall LT/year) after neoadjuvant chemoradiotherapy, with a tumor diameter P<0.001). Conclusion: This multicenter benchmark study demonstrates that LT offers excellent outcomes with superior oncological results in early stage PHC patients, even in candidates for surgery. This provocative observation should lead to a change in available therapeutic algorithms for PHC.