Case Studies
Case studies showcase real-world applications of policies and innovations, offering insights into improving outcomes and efficiency. They enhance problem-solving skills, highlight best practices, and engage through storytelling for education and transparency.
Organ Procurement Organization utilization of portable hypothermic oxygenated machine perfusion in liver transplantation: The first US experience
Ralph
Quillin
, MD
, Associate Professor of Surgery, Surgical Director Liver Transplantation
, University of Cincinnati, Department of Surgery
The Challenge
Expansion of advanced machine perfusion techniques has changed the landscape of preservation in liver transplantation and increased the utilization of marginal donors. The majority of machine perfusion for liver allografts in the United States is driven by industry or individual transplant centers. This approach differs markedly from renal allograft machine perfusion, wherein Organ Procurement Organizations (OPO) initiate the perfusion of kidneys. In this study, we describe the first case series of an OPO-initiated hypothermic oxygenated machine perfusion (HMP-O2) for liver transplantation.
The Approach
The LifePort Liver Transporter (LLT) is a portable HMP-O2 platform currently being utilized under a continued access clinical trial (NCT05574361). Indiana Donor Network (IDN) employs both a full-time recovery surgeon and contracts with local transplant surgeons to perform abdominal organ procurements. IDN surgeons and staff were trained to both use and cannulate liver allografts for transplant using the LLT. We examined the characteristics of liver allografts accepted for transplant by the University of Cincinnati (OHUC), then recovered and placed on the LLT by IDN in the donor OR over a one-year period. OHUC acceptance criteria for donation after circulatory death (DCD) donors is functional warm ischemia time (fWIT) is <30 minutes, defined as SBP<50 to flush.
fWIT defined as SBP<80 or SPO2<80 (80/80) is also reported. Data is expressed as median(range) or N,%.
The Results
From 11/21/23 to 11/3/24, 13 livers were transplanted by OHUC using HMP-O2 initiated by IDN. This represents 86.7% of the livers accepted by OHUC from IDN over this period. One recipient died on post-operative day (POD) 1 from technical complications related to a supraceliac aortic conduit and was excluded from the analysis.
Of the 12 recipients, 58.3% were male with median age of 58 (42-74) years. Median MELD at transplant was 16 (11-32), and most common etiologies of liver disease were alcohol (N=6, 50%) and metabolic dysfunction-associated steatohepatitis (N=5, 41.7%). There were 7 DCD donors (58.3%) with a median SBP<50 fWIT of 16 (9-29) minutes and 80/80 fWIT of 29 (17-77) minutes (Table). Median time from cross-clamp to initiation of HMP-O2 was 101 (20-239) minutes. Nearly all liver allografts were perfused with both the arterial and portal circulation (N=11, 91.7%). Median HMP-O2 time was 409 (256-801) minutes and median cold ischemia time was 514 (361-939) minutes.
Most recipients were extubated in the operating room (N= 10, 83.3%). Early allograft dysfunction occurred in 5 recipients (41.7%); however, this seemingly didn’t impact the median length of stay (6 [5-22] days). One recipient had an anastomotic bile leak requiring reoperation on POD 1. No recipient had biliary strictures or ischemic cholangiopathy. The overall patient and graft survival is 100% at a median follow-up time of 213 days.
Age
BMI
Donor Type
fWIT (min)
Cannulation
X-clamp to start HMP (min)
HMP (min)
CIT (min)
WIT (min)
80/80
SBP<50
90
28
DBD
—
—
Portal
123
296
451
21
67
22
DBD
—
—
Dual
109
329
471
29
58
28
DBD
—
—
Dual
86
439
537
25
60
28
DCD
45
16
Dual
79
256
361
23
60
21
DCD
17
9
Dual
117
284
419
23
46
24
DBD
—
—
Dual
117
495
629
30
66
22
DCD
77
29
Dual
97
537
678
37
55
26
DBD
—
—
Dual
63
378
490
16
59
32
DCD
29
15
Dual
20
545
676
27
21
22
DCD
40
13
Dual
69
801
939
28
53
22
DCD
28
22
Dual
239
448
707
33
44
33
DCD
19
17
Dual
105
258
376
20″
Insights & Lessons Learned
This is the first series in the United States describing OPO-initiated portable HMP-O2 for liver transplantation. Time from cross-clamp to initiation of HMP-O2 was under two hours reflecting the simplistic cannulation strategy with this technology. Recipient outcomes were excellent despite donor factors and long preservation times. This report shows proof of concept for adoption of an OPO-driven machine perfusion strategy for liver allografts with HMP-O2. This OPO-driven machine perfusion model would ideally improve utilization of marginal donors and donors with allocation time constraints.