Expanded criteria liver donors (ECD): effect of cumulative risks.
The use of ECD in liver donors increases the risk of primary non function (PNF). The German Medical Association (2004) defined an ECD, if one of the following conditions existed: high risk of disease transmission, hemodynamic deterioration, donor age > 65years, BMI > 30kg/m2, bilirubine > 51 mmol/l, ASAT or ALAT > 3*reference, sodium > 165 mmol/l, days on ICU > 7, steatosis > 40% or equivalent liver pathologies. The effect of ECD-criteria was assessed.


METHODS
Out 422 consecutive donors (1992-2004) with 282 liver grafts were transplanted (LTX) the existing ECD criteria were cumulated per donor (sigmaECD), grouped and compared to the number of grafts used and the one year graft function rate (all grafts/censored for grafts lost due to PNF only). Discrimination was determined by Receiver-Operating-Characteristics (ROC).


RESULTS
With increasing sigmaECD the rate of grafts procured declined (sigmaECD = 0: 95% [n = 162], sigmaECD = 1: 62% [n = 146], EECD = 2: 39% [n = 61], sigmaECD = 3: 32% [n = 38], sigmaECD > or = 4: 13% [n = 16], p < 0.0001). Similarly the one year graft function rate diminished (all grafts: sigmaECD = 0: 72%, sigmaECD = 1: 70%, sigmaECD = 2: 75%, sigmaECD = 3: 58%, sigmaECD > or = 4: 0%, p = 0.0801; censored for grafts lost due to PNF: sigmaECD = 0: 99%, sigmaECD = 1: 95%, sigmaECD = 2: 100%, sigmaECD= 3: 67%, sigmaECD > or = 4: 50%, p < 0.0001). The best cut off for prediction of grafts used was a sigmaECD of 0-1 vs. 2-5 (sensitivity 55%, specificity 87%). The one year graft function rate was adversely affected in sigmaECD above 3. All three grafts used for LTX with confirmed severe steatosis at donor operation (n = 3) did not function.


CONCLUSIONS
Grafts from ECD can be used for LTX. Cumulated ECD was associated with an increased risk of PNF requiring retransplantation. Despite this fact not using donors with cumulated ECD will decrease the limited donor pool. Such livers should be ideally allocated regionally to avoid additional ischemic-reperfusion damage.
Fischer-Fröhlich
C L
CL
Stuttgart, Deutsche Stiftung Organtransplantation, Region Baden-Württemberg, Germany. carl-ludwig.fischer-froehlich@dso.de
Lauchart
W
W
D000368:Aged; D004608:Eligibility Determination; D006304:Health Status; D006801:Humans; D016031:Liver Transplantation / Q000009:adverse effects*; D011237:Predictive Value of Tests; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment; D014019:Tissue Donors / Q000706:statistics & numerical data / Q000600:supply & distribution; D016896:Treatment Outcome