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Letter to the Editor

First Case of Successful Urgent Liver Retransplantation Using a Graft From a Donor After Uncontrolled Circulatory Death

Justo, Iago MD, PhD1,2; Caso, Óscar MD, PhD1,2; Marcacuzco, Alberto MD, PhD1,2; García-Conde, María MD, PhD1; Jiménez-Romero, Carlos MD, PhD1,2

Author Information
doi: 10.1097/TP.0000000000003796
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To the Editor:

Hepatic arterial thrombosis (HAT) is one of the most common causes of early graft loss (first month) after liver transplantation (LT), usually requiring retransplantation.1 We present here the use of a liver from an uncontrolled donor after circulatory death (uDCD) for retransplantation because liver failure secondary to HAT, to our knowledge an indication no previously reported.

The need for local clinical research ethics committee approval was waived due to retrospective nature of the research.

A 37-y-old man underwent LT because hepatitis C virus cirrhosis and hepatocarcinoma with a model for end-stage liver disease (MELD) score 17, and Child-Pugh B-8. A 32-y-old man, dead from intracranial hemorrhage with absence of cardiac arrest was accepted as donor for splitting technique. Recipient hepatectomy by piggy-back technique was performed following by right lobe graft implantation. Cold ischemia time was 11 h and warm ischemia time was 45 min. Liver implantation elapsed without technical incidents, and the recipient only required 1 unit of packed red blood cells.

Twenty-four hours later, the patient showed liver function impairment and renal failure, requiring renal replacement therapy, norepinephrine and increasing respiratory support. A CT scan showed HAT and multiple liver abscesses/ischemic areas. The patient was placed on urgent retransplantation, observing in the next days a progressive worsening of his clinical condition (Rosen score 11/MELD 26). Five days post-LT, we received an offer of an uDCD liver from a 35-y-old female, with donor risk index of 1.81, 5 min of cardiac arrest, pump flow in normothermic regional perfusion up to 3 L, normal liver function tests, and macrosteatosis <5% at liver biopsy, all characteristics within our acceptance criteria for uDCD livers.2

Retransplantation was performed using that graft with 4 h of cold ischemia time and 45 min of warm ischemia, without observing intraoperative incidents, only requiring a transfusion of 3 units of packed red blood cells. Postretransplant course was uneventful except for initial renal dysfunction resolved on the fifth day. The patient was discharged home on the eighth day of the retransplant with low doses of tacrolimus and mycophenolate mofetil. Twenty-four months later the patient is doing well, without evidence of either biliary or arterial complication (Table 1).

TABLE 1. - Characteristics of the first LT using DBD liver, and re-LT using uDCD liver
First LT Re-LT
Donor characteristics
 Type of graft DBD (split liver [r. lobe]) uDCD (type II)
 Age, y 32 35
 Sex Male Female
 Cause of death Intracranial hemorrhage Cardiac arrhythmia
 Cardiac arrest No 5 min
 Time of basic CPR 10 min
 Time of advanced CPR 60 min
 Total time from arrest to start of NRP 110 min
 Vasopressor use No Epinephrine
 Total bilirubin, mg/dL 0.9 0.8
 AST, IU/L 23 49
 ALT, IU/L 27 17
 GGT, IU/L 46 53
 INR 1.1 1.61
 Cold ischemia time, h 11 4
 Warm ischemia time, min 45 45
 Preservation solution Celsior Celsior
 Pre-LT biopsy Microsteatosis (10%) Macrosteatosis <5%
 Donor risk index 2.02 1.81
Recipient characteristics
 Age, y 37 37
 Sex Male Male
 LT indication HCV – cirrhosis + HCC HAT + L. abscesses
 MELD score 17 26
 Arterial reconstruction Donor RHA with recipient right and left hepatic artery bifurcation Donor patch PHA-GDA with recipient patch of CHA-GDA
Posttransplant evolution
 PRBC transfusion, units 1 3
 First day value of AST, IU/L 4402 1610
 First day value of ALT, IU/L 5371 2424
 First day value of INR 1.8 1.4
 First day value of lactate, mmol/L 5.3 2.7
 Third day AST, IU/L 1446 105
 Third day ALT, IU/L 2509 486
 Third day INR 2.2 0.94
 Third day value of lactate, mmol/L 5.5 1.2
Current status Alive (24 mo)
ALT, alanine transaminase; AST, aspartate transaminase; CHA, common hepatic artery; CPR, cardiopulmonary resuscitation; DBD, donation after brain death; GDA, gastroduodenal artery; GGT, gamma-glutamyl transpeptidase; HAT, hepatic arterial thrombosis; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; INR, international normalized ratio; LT, liver transplantation; MELD, model for end-stage liver disease; NRP, neonatal resuscitation program; PHA, proper hepatic artery; PRBC, packed red blood cells; RHA, right hepatic artery; uDCD, uncontrolled donation after circulatory death.

Liver retransplantation is associated with significantly worse survival than those of primary LT.3 Despite the poor prognosis after retransplantation, these patients still have a better chance of survival accepting a marginal liver than waiting for a standard criteria liver graft.4 Livers from uDCD and controlled (cDCD) are considered marginal grafts.2 There is only 1 report of 10 cases using cDCD livers for retransplantation that do not recommend utilization of these grafts in recipients with MELD score >25 because of high mortality.5 Our patient was waiting for during 5 d an ideally brain dead donor, but because of patient critical condition we had to accept an uDCD liver that fortunately met the criteria to be used according to our experience in patients with chronic liver diseases.2 The decision to use the uDCD liver was based in our good results obtained with these grafts in the last 4 y.2 In an urgent retransplant scenario, an appropriated liver selection from uDCD donation could be used for save the patient’s life.


1. Marudanayagam R, Shanmugam V, Sandhu B, et al. Liver retransplantation in adults: a single-centre, 25-year experience. HPB (Oxford). 2010;12:217–224.
2. Jiménez-Romero C, Manrique A, Calvo J, et al. Liver transplantation using uncontrolled donors after circulatory death: a 10-year single-center experience. Transplantation. 2019;103:2497–2505.
3. Reese PP, Yeh H, Thomasson AM, et al. Transplant center volume and outcomes after liver retransplantation. Am J Transplant. 2009;9:309–317.
4. Amin MG, Wolf MP, TenBrook JA Jr, et al. Expanded criteria donor grafts for deceased donor liver transplantation under the MELD system: a decision analysis. Liver Transpl. 2004;10:1468–1475.
5. Perry DK, Willingham DL, Sibulesky L, et al. Should donation after cardiac death liver grafts be used for retransplantation? Ann Hepatol. 2011;10:482–485.
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