A systematic review and meta-analysis of cold in situ perfusion and preservation of the hepatic allograft: working towards a unified approach.
Hameed AM, Laurence JM, et al.Liver Transplantation 2017; 22: 22.
Aims
To conduct a systematic review and meta-analysis to determine whether a particular perfusion route (aortic or dual) or perfusion/preservation solution is favourable in donation after brain-death (DBD) liver transplantation.
Interventions
The databases Embase, Medline and Cochrane were searched between January 1980 and February 2017 independently by two researches for both English and non-English language randomized controlled trials and observational studies where University of Wisconsin, histidine- tryptophan-ketoglutarate, Celsior or Institut Georges Lopez-1 solution was utilized as the final perfusion/cold static storage solution, with comparisons either between these perfusion solutions, or between aortic and dual perfusion, pre-flush versus no pre-flush, or variable perfusion volumes.
Participants
22 articles (2294 liver transplants) were included in the systematic review and 14 were used in the meta-analysis.
Outcomes
Primary outcomes measured were peak post-transplant aspartate aminotransferase and alanine aminotransferase, graft loss post-arterial thrombosis, and graft primary non-function.Secondary outcomes included ischemic biliary complications, and graft survival.
Follow-up
Variable with less than 60% of the articles with adequate follow-up.
CET Conclusions
This systematic review was registered as a protocol pre-emptively and searched sufficient databases for RCTs and observational studies in this field. The risk of bias and quality of the individual studies was attended to; a high risk of performance bias was identified. Of the 19 included studies, 14 were used in meta-analysis, although few could be grouped under each parameter analysis. Study quality in those studies comparing aortic with dual aortic and portal flush was very low. There was no significant difference in PNF rate, however peak ALT post-transplantation was significantly lower in the aortic-only perfusion group. The authors explain that this may be due to confounding factors. Study quality was similarly low comparing HTK with UW preservation fluids, and only moderate comparing Celsior with UW. No significant difference was identified between these preservation fluids across outcomes including graft survival, ITBL and thrombotic graft loss. The authors concluded that there was not sufficient evidence to justify dual perfusion over aortic perfusion, given the additional time and complexity associated with the dual approach. Most of the studies using only aortic flush in situ also used portal venous flush on the back-table, so there is a considerable confounding factor there.
Quality notes
Quality assessment not appropriate
Trial registration
PROSPERO - CRD42016038993