Single-center experience with liver transplantation from controlled non-heartbeating donors: a viable source of grafts.

The demand for liver transplantation (OLT) has led to an increasing discrepancy between the number of potential candidates and organ availability. Diverse strategies have been successfully implemented to try to improve organ supply including the use of marginal, split, living, and domino donor grafts. Following the successful use of kidney grafts from non-heartbeating donors (NHBDs) for transplantation,1 interest has extended to include the liver, pancreas, and lung.2,3 NHBDs are patients with brain injury incompatible with recovery whose condition does not meet formal criteria for brainstem death and whose cardiopulmonary function ceases before organs are retrieved. In the 1960s, NHBDs were the main source of allografts until the Harvard neurologic definition and criteria for brain death were published in 1968. Following the introduction of brainstem death criteria, interest in NHBD declined because of the better results obtained with heartbeating donor organs. Renewed interest in NHBDs as a source of organs has occurred because of organ shortage and improvements in organ preservation, immunosuppression, and surgical techniques. NHBD can be categorized into 2 groups: controlled and uncontrolled donors. Controlled donation takes place when the death occurs within an intensive care unit (ICU)/hospital setting and there is planned withdrawal of therapy by the patient's medical team. Uncontrolled donation takes place when death occurs outside the hospital or within the emergency room and resuscitation is continuing and is unpredictable. The ethics, assessment, techniques of retrieval, and outcome of transplant are very different between these 2 groups. NHBDs have been further categorized into 4 groups4 according to the location and modality of death. Experience of NHBD kidney transplants has shown no difference in the long-term outcome of kidney grafts from NHBD and brain dead donors, although the incidence of delayed function is significantly higher in the former.5–7 Whereas these patients can be managed with dialysis, this is not possible with the liver recipients and if primary nonfunction (PNF) or severe dysfunction occur, emergency retransplantation is the only rescue therapy. There have been relatively few reports regarding OLT from NHBDs, but these have shown a progressive reduction in the incidence of PNF in recent years due to a shift towards controlled donation and restriction of donor selection criteria with shorter warm and cold ischemic times.8,9 In 2001, a NHBD liver transplant program was started on the background of a long-standing non-heartbeating kidney transplantation program based in our region since 1988. A protocol for liver retrieval and evaluation of controlled NHBD livers was developed, and hospital ethical committee approval was obtained in our institution and in prospective donor hospitals in our retrieval zone.