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Reuse of liver allografts from brain‐dead liver transplant recipients

Sirs, A unique method of expanding the donor pool is to reuse allograft from recipients. Although there are case reports documenting retransplantation of livers, the concept has not been routinely adopted [1–7]. From June 2007, we implemented a policy of reusing liver allografts. We present three cases and extrapolate from our experience the potential for liver reprocurement. The first of our recipients was a 17-year-old girl with acute liver failure (ALF) after acetaminophen overdose. The patient progressed to grade 4 encephalopathy, severe coagulopathy, and renal failure. The intracranial pressure (ICP) ranged from 15 to 20 mmHg and the cerebral perfusion pressure ranged from 50 to 60 mmHg. A liver graft (Table 1) was procured in a standard fashion and the piggyback technique with a lateral cavoplasty was used to perform the recipient operation. The anastomosis involved the donor proper hepatic artery to the recipient common hepatic artery; 5 units of packed red blood cells (PRBC) and 8 units of fresh frozen plasma (FFP) were necessary. Postoperatively, the recipient progressed to brain-death. The family consented to organ donation. The second recipient of this liver was a 61-year-old white man with hepatitis C virus (HCV) and hepatocellular carcinoma (HCC – within Milan criteria) [United Network of Organ Sharing (UNOS) Model for End-Stage Liver Disease (MELD) score – 25 and the laboratory MELD score – 16]. After liver procurement, the inferior vena cava at the site of lateral cavoplasty was over-sewn. The recipient operation was done with the standard caval replacement technique. The hepatic artery was anastomosed without a conduit and the bile duct anastomosis was performed with a T-tube. No blood products were necessary. The patient was discharged from hospital on postoperative day 8. The first recipient in our second case was a 17-yearold boy (Table 1), with ALF from acetaminophen toxicity. He developed grade 4 encephalopathy; however, severe coagulopathy precluded ICP monitoring. A CT scan revealed mild cerebral edema and brainstem reflexes were intact. A liver allograft (Table 1) was transplanted with vena caval replacement. The hepatic artery was anastomosed without a conduit. The biliary anastomosis was end-to-end without a T-tube; 14 units of PRBC, 23 units of FFP, 10 units of cryoprecipitate, and factor VII were transfused. The patient, however, progressed to brain-death. The family consented for donation. The second recipient of this liver was a 57-year-old AfricanAmerican man with HCV cirrhosis and HCC within Milan criteria [UNOS MELD score – 25 and laboratory MELD score – 9]. The transplant was done with a standard caval replacement technique. The hepatic artery was anastomosed without a conduit and the biliary anastomosis was performed end-to-end without a T-tube. Two units of PRBC and FFP were transfused. Liver enzymes normalized on day 20 (Table 1). The patient was discharged 10 days after surgery. He had one episode of acute cellular rejection after 14 months, treated with steroids. The first recipient in our third case was a 16-year-old African-American boy with ALF after an overdose of an unknown drug, presenting with severe acidosis and coagulopathy. The donor liver (Table 1) had completely replaced right and left hepatic arteries, which were reconstructed on the back table. The transplant involved the piggyback technique; the suprahepatic vena cava was anastomosed to the ostia of the hepatic veins. The patient made an uneventful recovery. Fifty-two months following transplantation, the patient was declared brain-dead from a gunshot to the head. The family consented to donation. The second recipient of this liver was a 34-year-old African-American woman with cirrhosis from autoimmune hepatitis [MELD score of 40]. She had type 1 diabetes mellitus and renal failure requiring dialysis. The liver was procured with careful hilar dissection to avoid disturbance to the blood supply of the bile duct. The liver was transplanted using a standard technique with anastomoses of supra and infrahepatic vena cava. The donor’s common hepatic artery (without disturbing the reconstructed replaced vessels) was anastomosed to the recipient’s common hepatic artery and the bile duct was anastomosed in an end-to-end fashion. The right kid-