Clinical

UK liver transplant unit reports non-heart beating donation success

Last Updated: 2004-06-09 13:25:57 -0400 (Reuters Health)

By Richard Woodman

LONDON (Agence de Presse Medicale for Reuters Health) - Europe's leading liver transplant centre at King's College Hospital London is reporting high success rates with non-heart beating donation (NHBD).

Paolo Muiesan, consultant surgeon, told APM that 31 patients, including two children, had been transplanted at the unit over the past 3 years using the new technique.

"Twenty-seven out of 31 are still alive today, a survival rate of 87%. Twenty-six out of 31 grafts also survived, a survival rate of 84%," he said in an interview following an international non-heart beating donor conference at the hospital.

The Italian surgeon said this is in line with survival rates using heart-beating donation (HBD) though he admitted his team had been quite selective, transplanting only 31 of 54 organs retrieved.

The success rate appears superior to recent study results from the United States showing 70% one-year graft survival among adult recipients of NHBD hepatic allografts compared with 80% for recipients of HBD livers between 1993 and 2001.

Currently, non-heart beating donors account for a small percentage of the 206 liver transplants performed at King's last year. However, Dr. Muiesan believes the percentage could be increased to 10%, easing the desperate shortage of donor organs. In renal transplantation it could be as high as 25%.

"Previously, families have not been able to donate organs from relatives who have experienced sudden, fatal cardiac arrest or were dying after a decision to withdraw treatment," he said.

The concept of withdrawing life support from patients who have no hope of recovery was accepted by ethical experts, he added. Relatives also found it easier to accept cardiac death, as it was more obvious and less prolonged than brain death.

Non-heart beating donor organs were used in the first transplants in humans in the 1960s but were abandoned in the 1970s because of superior results with HBD donors.

New methods to ensure organs are swiftly retrieved before they deteriorate, improved preservation fluids, and immunosuppression have helped revive the technique.

Dr. Muiesan, who is preparing to publish his results, said his team allowed a 5-minute gap between cardiac death being declared independently by the intensive care team and organ retrieval by the transplant team. This time gap ensured "clarity," he said.

The "super rapid" surgical retrieval procedure at Kings uses Marshall's solution to flush the aorta and University of Wisconsin solution for portal perfusion. Heparin is added to both perfusion solutions.

The aorta is accessed first via a full-length midline laparotomy incision and a large bore cannula is inserted and secured for perfusion with low viscosity Marshall's solution. Topical cooling is achieved with normal saline slush.

A rapid thoracotomy is performed and congestion in the area of the inferior vena cava is relieved by drainage through a large incision in the right atrium. Next a large clamp is applied to the aorta just above the diaphragm.

The superior mesenteric vein is then identified and cannulated and portal perfusion commenced under mild pressure. The procedure then continues in a similar manner to a conventional retrieval though care is taken not to divide possible anomalous hepatic or renal vessels that are more difficult to identify without a pulse.