Risk assessment in liver transplantation : the impact of donor organ quality on surgical and renal outcomes

Liver transplantation is the only life-saving treatment for patients with end-stage liver disease, but there has always been a disbalance between the number of patients on the waiting list and the availability of donor livers. The worsening organ shortage has led to an increased use of marginal grafts, including donation after circulatory death (DCD) grafts. The aim of this thesis was to analyse the impact of graft quality on the outcomes of patients undergoing liver transplantation, with a focus on surgical and renal outcomes. In Part I of this thesis we present the additional morbidity for recipients of DCD grafts with the novel Comprehensive Complication Index , identify prolonged hypoxia during DCD donation as the driving force of hepatic ischemia/reperfusion injury and present the new UK DCD Risk Score as a tool to assist the transplant surgeon in choosing the best DCD graft and recipient combination. This prediction model can also be used to assess which graft will require additional therapy before implantation, e.g. machine perfusion. The results presented in Part II of this thesis highlight the impact of DCD grafts and other marginal grafts on postoperative acute kidney injury (AKI). Duration of warm ischemia time and severe hypotension after reperfusion of the new liver are correlated with an increased risk to AKI. By combining donor, recipient and surgical risk factors, we developed a new model to predict the risk for postoperative AKI. This AKI Prediction Score can be helpful to assess if a recipient will benefit from renal-sparing immunosuppression. Additional analysis of long-term kidney function after liver transplantation showed that the use of marginal grafts is not directly associated with chronic kidney disease. However, severe AKI (requiring RRT) should be avoided at all costs, as those recipients have an increased risk for long-term renal impairment.

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