2017 - CIRTA

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3- Donor Selection and Technical Aspects of Intestine Transplantation

27.1 - Effect of donor vasopressor requirements on recipient outcomes for intestinal and multi-visceral grafts - Is it overrated?

Presenter: Hirak, Pahari, Detroit, United States
Authors: Hirak Pahari, Michael Rizzari, Mohamed Safwan, Hajra Khan, Syed-Mohammed Jafri, Yakir Muszkat, Kelly Collins, Atsushi Yoshida, Marwan Abouljoud, Shunji Nagai

Effect of donor vasopressor requirements on recipient outcomes for intestinal and multi-visceral grafts - Is it overrated?

Hirak Pahari1, Michael Rizzari1, Mohamed Safwan1, Hajra Khan2, Syed-Mohammed Jafri3, Yakir Muszkat3, Kelly Collins1, Atsushi Yoshida1, Marwan Abouljoud1, Shunji Nagai1.

1Transplant and HPB Surgery, Henry Ford Hospital, Detroit, MI, United States; 2Wayne State University School of Medicine, Detroit, MI, United States; 3Department of Gastroenterology, Henry Ford Hospital, Detroit, MI, United States

Introduction: The criteria for donor selection for multi-visceral/intestinal transplant has been varied in literature. Donor prolonged ICU stay, high pressor support, significant CPR duration and hypernatremia are considered to adversely affect quality of intestinal graft, which often leads to organ discard. We do not exclude intestinal donors only based on these factors and aggressively utilize intestinal grafts after good visualization in donor surgeries. Here, we focus on donor vasopressor support and its effect on recipient outcomes.

Methods: This is a retrospective review of 30 patients of multi-visceral/intestinal transplant between Aug 2010 and Jan 2017. High vasopressor requirement in donor was defined as ≥3 vasopressors or any single high dose at any time. Low (or none) vasopressor requirement was defined as ≤2 vasopressors used and none of them at a high dose at any time. The cut off values of high/low for each (epinephrine, norepinephrine, phenylephrine, dopamine and vasopressin) was based on available literature. Graft survival/complications were compared between high and low vasopressor requirement groups. Post-surgical complications were evaluated by Clavien-Dindo classification. A p<0.05 was considered as significant.

Results: There were 12 patients and 18 patients who were categorized into high and low vasopressor requirement groups. No other factor potentially affecting outcome was statistically different between the two groups. Early (<1yr) complications ≥IIIa were no different between the groups. There was no difference in 1 year graft or patient survival. The use of high/low vasopressors did not affect graft/patient survival by log rank test significantly (p=0.32 and 0.45, respectively;

The hazard ratios on Cox regression was 0.54 and 0.59 respectively. We did not find any outcome difference related to duration of pressors or ongoing pressors at donor surgery. In addition, duration of pre-hospitalization or brain death to cross clamp time did not affect survival significantly.

Conclusion: This study indicates that donor pressor requirement did not significantly affect post-transplant outcomes. While high vasopressor requirement often raises concerns about detrimental effect on intestinal graft quality and recipient outcomes, it is worth assessing them by direct visualization, which may increase intestinal donor pool, decrease organ discard rate, and shorten wait time.

[1] Fischer-Fröhlich CL, Königsrainer A, Schaffer R et al. Organ donation: when should we consider intestinal donation. Transpl Int. 2012 Dec;25(12):1229-40.
[2] Matsumoto CS, Kaufman SS, Girlanda R et al. Utilization of donors who have suffered cardiopulmonary arrest and resuscitation in intestinal transplantation. Transplantation. 2008 Oct 15;86(7):941-6.
[3] Zeng G, Chen M, Zhao X et al. Donor Risk Index for Intestinal & Multi-Visceral Transplantation. Am J Transplant. 2016;16 (suppl 3).

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