Ischemic cholangiopathy in liver transplantation using donation after cardiac death donors: analysis of a matched control study in a single large volume center.

Background: Shortage of available organs is a limiting factor in liver transplantation (LT). The use of donors after cardiac death (DCD) offers potentials to increase the organ pool. The early results with DCD liver grafts were associated with a greater incidence of non-anastomotic biliary complications, leading to several programs to abandoning this source of organs. The UNOS data also raise concerns regarding DCD-LT results and the incidence of cholangiopathy. Aim: To assess the impact of cholangiopathy and biliary complications in DCD recipients at a single institution. Methods: A retrospective analysis from April 2001 to 2010 was undertaken focusing on 167 consecutive DCD-LT. Each DCD transplant was matched with two DBD (brain death donors) grafts (n=333) according to the period of transplantation. Primary outcome measures were biliary complications and ischemic cholangiopathy including the severity of complications, graft survival and patient survival. Results: The most common type among biliary complication was anastomotic stricture (DCD=30, 19% vs. DBD=41, 13%). Most of them were treated endocoscopically (grade IIIa=72%), while hepatico-jejunostomy (grade IIIb) was performed in 22%. Primary ischemic cholangiopathy occurred in 4 (2.5%) recipients from the DCD group, while such complication were absent in the DBD group (p=0.005). However, none of these patients required re-transplantation. Patient and graft survival at 1-, 3- and 5- years were similar between DCD and DBD groups (p=0.106, p=0.138, p=0.113 respectively). Conclusions: In contrast to previous reports, the incidence of ischemic cholangiopathy in DCD recipients was low, and has had no impact on graft or patient survival to-date. These encouraging results of DCD-LT are likely due to a stringent selection of DCD grafts and clear definition of warm ischemia.