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Research

Can we reduce ischemic cholangiopathy rates in donation after cardiac death liver transplantation after 10 years of practice? Canadian single-centre experience

Mauro Enrique Tun-Abraham, Kerollos N. Wanis, Carlos Garcia-Ochoa, Nathalie Sela, Hemant Sharma, Ibrahim Al Hasan, Douglas Quan, Bandar Al-Judaibi, Mark Levstik and Roberto Hernandez-Alejandro
CAN J SURG February 01, 2019 62 (1) 44-51; DOI: https://doi.org/10.1503/cjs.012017
Mauro Enrique Tun-Abraham
From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, Garcia-Ochoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
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Kerollos N. Wanis
From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, Garcia-Ochoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
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Carlos Garcia-Ochoa
From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, Garcia-Ochoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
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Nathalie Sela
From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, Garcia-Ochoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
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Hemant Sharma
From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, Garcia-Ochoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
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Ibrahim Al Hasan
From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, Garcia-Ochoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
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Douglas Quan
From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, Garcia-Ochoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
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Bandar Al-Judaibi
From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, Garcia-Ochoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
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Mark Levstik
From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, Garcia-Ochoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
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Roberto Hernandez-Alejandro
From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, Garcia-Ochoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
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    Fig. 1

    Rate of survival free of ischemic cholangiopathy (IC) in patients who received liver grafts from donation after cardiocirculatory death donors, July 2006 to July 2016. All cases of IC occurred within the first 6 months after transplantation. Time to development of ischemic cholangiopathy, d % survival

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    Table 1

    Study population characteristics

    CharacteristicNo. (%) of patients*p value
    Early era
    n = 32
    Late era
    n = 38
    Donors
    Demographic
     Age, yr, median (IQR)44 (18–62)38 (12–59)0.1
     Male sex16 (50)28 (74)0.04
     Height, cm, median (IQR)169 (150–193)175 (152–188)0.1
     Weight, kg, mean ± SD76 ± 5.675 ± 14.60.49
     Body mass index, median (IQR)25 (17–46)24 (17–35)0.2
     Donor Risk Index score, median (IQR)2.46 (1.7–3.2)2.1 (1.6–3.4)0.02
    Location0.04
     Local15 (47)27 (71)
     Regional17 (53)11 (29)
    Cause of death0.049
     Trauma13 (41)15 (39)
     Anoxia6 (19)16 (42)
     Cerebrovascular accident13 (41)7 (18)
    Procurement times
     Warm ischemia time, min, median (IQR)27 (18–121)24 (16–48)0.049
     Cut–cannulation–flush, min, median (IQR)6 (2–12)4 (2–8)0.02
     Skin cut to liver out, min, median (IQR)56 (21–97)52 (28–121)0.2
     Cold ischemia time, h, median (IQR)5.56 (4.45–6.45)5.10 (4.46–6.37)0.4
    Recipients
    Demographic
     Age, yr, median (IQR)54 (26–69)57 (36–66)0.3
     Male sex26 (81)26 (68)0.2
    MELD score, median (IQR)15 (8–40)17 (3–35)0.7
    Diagnosis0.003
     Hepatitis C12 (38)4 (10)
     Hepatocellular carcinoma8 (25)15 (39)
     Alcoholic liver disease5 (16)2 (5)
     Autoimmune3 (9)0 (0)
     Nonalcoholic steatohepatitis0 (0)5 (13)
     Primary biliary cirrhosis0 (0)3 (8)
     Primary sclerosing cholangitis0 (0)3 (8)
     Other4 (12)6 (16)
    • IQR = interquartile range; MELD = Model for End-Stage Liver Disease; SD = standard deviation.

    • ↵* Except where noted otherwise.

    • View popup
    Table 2

    Transplantation outcomes

    VariableNo. (%) of recipients*p value
    Early era
    n = 32
    Late era
    n = 38
    Biliary complications12 (38)7 (18)0.07
    Ischemic cholangiopathy8 (25)1 (3)0.005
    Anastomotic stricture3 (9)4 (10)0.9
    Bile leak0 (0)1 (3)1.0
    Choledocholithiasis1 (3)1 (3)1.0
    Management of biliary complications
     ERCP13 (41)6 (16)0.02
     Total no. of ERCP procedures (range per patient)52 (1–16)7 (1–2)0.008
     No. of patients with stent9 (28)4 (10)0.05
     Total no. of stents (range per patient)20 (1–4)6 (1–2)0.05
    Length of stay, d, median (IQR)12 (8–161)13 (7–115)0.9
    Graft function
     Primary nonfunction2 (6)2 (5)0.9
     Graft failure9 (28)3 (8)0.02
    Survival
     Graft survival, d, mean ± SD2778 ± 2661477 ± 1310.5
     90 d29 (91)35 (92)
     1 yr27 (84)31 (82)0.8
     3 yr24 (75)29 (76)
    Retransplantation3 (9)1 (3)0.2
    Patient survival, d, mean ± SD3016 ± 2511518 ± 1580.3
     90 d29 (91)36 (95)
     1 yr28 (88)31 (82)0.5
     3 yr25 (78)29 (76)
    Death8 (25)9 (24)1.0
    • ERCP = endoscopic retrograde cholangiopancreatography; IQR = interquartile range; SD = standard deviation.

    • ↵* Except where noted otherwise.

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Canadian Journal of Surgery: 62 (1)
CAN J SURG
Vol. 62, Issue 1
1 Feb 2019
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Can we reduce ischemic cholangiopathy rates in donation after cardiac death liver transplantation after 10 years of practice? Canadian single-centre experience
Mauro Enrique Tun-Abraham, Kerollos N. Wanis, Carlos Garcia-Ochoa, Nathalie Sela, Hemant Sharma, Ibrahim Al Hasan, Douglas Quan, Bandar Al-Judaibi, Mark Levstik, Roberto Hernandez-Alejandro
CAN J SURG Feb 2019, 62 (1) 44-51; DOI: 10.1503/cjs.012017

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Can we reduce ischemic cholangiopathy rates in donation after cardiac death liver transplantation after 10 years of practice? Canadian single-centre experience
Mauro Enrique Tun-Abraham, Kerollos N. Wanis, Carlos Garcia-Ochoa, Nathalie Sela, Hemant Sharma, Ibrahim Al Hasan, Douglas Quan, Bandar Al-Judaibi, Mark Levstik, Roberto Hernandez-Alejandro
CAN J SURG Feb 2019, 62 (1) 44-51; DOI: 10.1503/cjs.012017
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