Survival following liver transplantation from non-heart-beating donors

The growing disparity between the number of patients awaiting liver transplantation and a limited supply of cadaveric organs has increased waiting times and, consequently, the number of wait list deaths.1 Several methods are available to narrow this gap, including split liver and living donor liver transplantation. Another potential method to increase the supply of organs is the use marginal donors, in particular the use of non-heart-beating donors (NHBDs). These donors are usually individuals with devastating irreversible neurologic injuries but who do not meet formal brain death criteria. Therefore, death is based upon cessation of cardiopulmonary function. Patient and graft survival following liver transplantation with NHBD grafts is not well defined. NHBDs may be classified as controlled or uncontrolled. Controlled donors are hemodynamically stable individuals who are extubated in the operating room or intensive care unit following a decision by the patient’s next of kin to withdraw care and provide consent for organ donation. This is a planned event in which the donor surgical team is present to recover the organs rapidly, therefore limiting warm ischemic time. Uncontrolled donors, as the name implies, are individuals in whom cessation of cardiopulmonary function is an unplanned event. This group consists of individuals who sustain cessation of cardiopulmonary function prior to arriving to a hospital, within the emergency department, or as hospital inpatients. Brain dead donors who sustain cardiopulmonary arrest in the intensive care unit or on the way to the operating room prior to organ donation are also considered uncontrolled NHBDs.2 There may be substantial warm ischemia incurred between the time of the donor’s death and perfusion of the organs during procurement with cold preservation solution. Uncontrolled donors represent the largest pool of potential organ donors and by some estimates could add at least an additional 5000 donors per year.3,4 However, significant ethical, legal, and logistical issues will likely preclude the use of uncontrolled donors to any significant extent in the United States. Controlled NHBDs face few of these problems and have the potential to add about 1000 additional donors per year.4–6 This group is currently underutilized and represents a potential source for a variety of solid organs. The procurement of organs from NHBDs is not a new concept. Prior to the publication of the Harvard neurologic definitions and criteria for death in 1968 and subsequent passage of brain death laws, most retrieved organs were from NHBDs. With acceptance of brain death, issues related to donor warm ischemic time were eliminated. The growing shortage of organs has rekindled interest in the use of NHBDs. Several reports demonstrate that kidneys obtained from controlled NHBDs have similar outcomes as those obtained from heart-beating-donors (HBDs).7–9 However, the renewed interest in hepatic allografts from NHBDs has been approached with trepidation as the liver may be less tolerant of donor warm ischemic time. Several individual centers have published limited and disparate experiences.10–12 The purpose of the present study is to assess patient and graft survival among a large cohort of recipients of hepatic allografts from NHBDs.