Risk Factors and Consequences of Ischemic Cholangiopathy in Liver Transplantation from DCD Maastricht IIA

Introduction Although donors after cardiac death (DCD) Maastricht type IIA have been established as an acceptable source of grafts in the current setting of organ shortage, biliary complications, especially ischemic cholangiopathy (IC), remain a considerable difficulty in the management of these patients, with a significant impact in long term results and quality of life. Objectives To study the incidence and impact of ischemic cholangiopathy among DCD IIA liver transplant recipients, and identify risk factors related to this complication. Materials and Methods Retrospective analysis of the DCD Maastricht type IIA liver transplantation series in University Hospital 12 de Octubre, registered from January 2006 to December 2016. Results 75 LT from DCD type IIA were performed during the study period, with 23 cases of IC diagnosed (30.7%). Comparing patients who suffered this complication (IC) with those who did not (no-IC), there were no significant differences found in recipient age (no-IC 58.4+7.7, IC 59.5+7.7 years), MELD score (no-IC 13.9+4.8 vs IC 15.6+4.8), donor age, HCV infection or hepatocellular carcinoma prevalence. Mean MELD-Na was 19+7 in those patients who developed IC, and 15.9+5.8 in those who did not, although the difference was not significant. Ischemia times and ECMO flow rates were similar in both groups. Retransplantation rate was higher in the no-IC group (11.5% vs. 13%, NS). No differences were achieved comparing liver function tests. Median time from transplantation to development of ischemic cholangiopathy was 5.8 months (range 1.2-70.3). Multivariate analysis shows an increased risk of IC in those grafts with AST levels over four times the upper limit of the normal range in the last blood sample obtained during NECMO (OR, 5.93; 95% CI, 1.001-35.208; p 0.05). No other statistically relevant risk factors were identified in this analysis. Differences found when comparing actuarial survival at 1, 3 and 5 years in recipients who did not develop IC (76.5%, 70.3% and 70.3%) with those who did (91.3%, 69.6% and 65.2%) were not statistically significant (p 0.915). Similar results were obtained when studying graft survival (no IC 70.6%, 64.3%, 64.3% vs. IC 78.3%, 60.9%, 56.5%; p 0.958). Conclusions AST levels 4 times above the usual laboratory range have been identified as a significant risk factor in the developement of ischemic cholangiopathy, suggesting that grafts with this characteristic should be discarded to minimize said complication.