Liver transplantation from donors after cardiac death

Organ shortage limits the applicability of liver transplantation to treat end-stage liver disease, and the use of extended-criteria donors is a necessity in the current era. Donors after cardiac death (DCD) suffer irreversible cardiac arrest prior to donation and represent a potential source of additional organs if properly maintained. DCD undergo an initial period of warm ischemia that provokes cellular alterations. Experimental and clinical studies performed at our center have demonstrated that normothermic extracorporeal membrane oxygenation (NECMO) is effective at maintaining abdominal organs in DCD. NECMO helps stop and even revert some of the changes that occur during warm ischemia and offers the opportunity to evaluate graft viability prior to implantation. Nonetheless, the percentage of organs arising from DCD that are accepted for transplant remains relatively low due to the co-existence of other factors that prohibit their utilization, namely poor perfusion and hepatic steatosis. The use of dual-pump normothermic machine perfusion (NMP) in the ex vivo phase of DCD liver preservation can offer additional benefits over traditional cold storage. In experimental studies, ischemic injury and hepatocellular function are significantly improved in DCD grafts preserved with NMP. Clinical studies on the use of NMP in DCD liver transplantation are under way.