Pushing the limits in DCD donor selection: optimizing graft rehabilitation with ex vivo machine perfusion

BACKGROUND: The use of liver grafts from donors after circulatory death (DCD) is associated with an increased risk of developing severe transplant-related complications. However, a balanced evaluation of risks calculated on both donor's and recipient's specific medical history, may reduce the incidence of post-operative complications avoiding a futile transplant. METHODS: We report a case wherein we transplanted a patient with hepatocellular carcinoma (HCC) outside Milan criteria using a borderline DCD graft. The decision to accept the offered DCD liver was difficult given the extent of injury from severe abdominal trauma, initial blood tests (AST 1782 U/I, ALT 1803 U/I, CPK 12931 mg/dl on procurement day) and technical complexity of Normothermic Regional Perfusion (NRP) due to the amputation of the left lower limb and multiple pelvic fractures. Liver biopsy showed 0% of macro-steatosis and 30% necrosis. We applied our standardized protocol of sequential NRP during graft procurement followed by D-HOPE machine perfusion prior implantation. RESULTS: The graft underwent 130 minutes of cold storage and 192 minutes of D-HOPE machine perfusion before being transplanted and total ischemia time was of 261 minutes. After eleven months, the patient is in good general conditions, no signs of HCC recurrence, AFP 2,7 ng/ml. CONCLUSIONS: The evaluation of the donor should always be based on both pre- and intra-procurement data, taking into-account lactate and transaminase trend during ECMO, liver perfusion and macroscopic appearance of the organ. The use of this grafts may result in a curative chance for patients that demonstrated a favorable HCC biology by pushing the limits of both organ and recipient selection.