DCD for Liver Transplantation

  • Naoto Matsuno
  • Shin Enosawa


A critical shortage of donor liver grafts has promoted the creation of strategies to increase the donor pool. The Institute of Medicine and the Health Resources and Services Administration statement encourages using grafts from higher risk donors in order to decrease the growing waiting list [1–3]. In March 1995, an international workshop on non-heart-beating donation was held in Maastricht. Potential donors after cardiac death (DCDs) are classified using the Maastricht classification [4]. Categories 1, 2, and 4 include uncontrolled DCDs, and Category 3 includes controlled DCDs. DCDs have come to represent the fastest growing proportion of the donor pool, thus increasing from approximately 1 % of all deceased donors in 1996 to 11 % of deceased donors in 2008. In some United Network for Organ Sharing (UNOS) regions with limited standard criteria for donors, DCDs comprise up to 16–21 % of the total donor pool [5]. Recent data regarding kidney transplants show no differences between the long-term outcomes of kidney grafts from DCDs and those from brain-dead donors (DBDs), although the incidence of delayed graft function (DGF) is higher in DCD kidneys [6–8]. Following the successful use of DCD kidney grafts for transplantation, interest has moved toward using extrarenal organs such as the liver, pancreas, and lungs [9]. Recently, a number of transplant programs have begun to use livers from DCDs. Although the use of extrarenal DCD grafts is increasing, this endeavor is still in the midst of development. In the early phase, liver transplantations from DCDs do not always show favorable post-transplant results compared to liver transplantations from DBDs. Livers from DCDs have been found to display diffuse hepatocyte necrosis, increased platelet adhesion, an absence of bile flow, and depletion of ATP. The incidence of DGF in the kidneys is high; however, it can be treated with hemodialysis until the kidneys recover. In contrast, DGF in the liver often requires retransplantation as rescue therapy. For this reason, there has been great caution in using DCD liver grafts. However, in recent years, the incidences of primary nonfunction (PNF) and severe DGF have been remarkably reduced due to the use of selected controlled DCD livers, better selection criteria, and shorter warm and cold ischemic times. Regarding preservation, the introduction of UW solution has improved the quality of cold preserved organ preservation, even for livers. However, the major principle of hypothermic liver preservation is the reduction of metabolic activity. Recently, the Barcelona group has begun to resuscitate uncontrolled DCD donors with the use of normothermic extracorporeal machine perfusion (NECMO) [10]. The use of warm perfusion may provide full metabolic support to DCD livers and establish whether a graft is viable. Again, development for clinical use of DCD liver graft is still midst. Multiple strategies will be required (Table 10.1).


Inferior Vena Cava Liver Graft Delay Graft Function Warm Ischemic Time Graft Survival Rate 
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© Springer Japan 2014

Authors and Affiliations

  1. 1.Division for Innovative Surgery and TransplantationNational Center for Child Health and DevelopmentTokyoJapan
  2. 2.Division for Advanced Medical Sciences, Clinical Research CenterNational Center for Child Health and DevelopmentTokyoJapan

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