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Minimizing liver cold ischemia time protects against mortality, hospital stay

Cold ischemia time in liver transplantation increased the risk for prolonged length of hospital stay with nearly every additional hour of cold ischemia, according to recently published data.

“Cold ischemia time (CIT) has been widely regarded as a donor-related risk factor and is defined as the time from cross clamping of the donor liver to removal of the organ from cold storage solution,” Evelyn T. Pan, MD, from the Baylor College of Medicine, Texas, and colleagues wrote. “Nearly every hour delay in CIT increases the risk for post-transplant [prolonged length of stay (PLOS)], which represents increased morbidity for the recipient and increased cost for the healthcare system.”

Pan and colleagues retrospectively reviewed the United Network for Organ Sharing databased to identify all liver transplants performed between March 2002 — start of the MELD era — and September 2016.

The researchers included 67,426 recipients after excluding pediatric patients and patients who underwent retransplantation, simultaneous multiorgan transplants and living donor transplants. Median cold ischemia time was 6.4 hours and 6 to 7 hours of CIT became the reference group.

CIT between 4 and 5 hours (HR = 0.94; 95% CI, 0.88-0.99) and 5 and 6 hours (HR = 0.94; 95% CI, 0.89-1) against mortality. In contrast, CIT between 11 and 14 hours correlated with significantly increased risk for mortality, particularly between 12 and 13 hours (HR = 1.26; 95% CI, 1.12-1.41).

Multivariate analysis showed that CIT between 2 and 3 hours and 4 and 6 hours was protective against graft loss, whereas CIT between 9 and 16 hours correlated with an increased risk for graft loss. The researchers observed the greatest risk for graft loss with 13 to 14 hours (HR = 1.32; 95% CI, 1.15-1.51) and 15 to 16 hours (HR = 1.33; 95% CI, 1.06-1.68).

In a subgroup analysis for PLOS, including 64,111 transplant recipients and using the same 6 hours to 7 hours reference, multivariate analysis showed that 1 to 6 hours was protective against PLOS, while CIT of 7 hours or more significantly increased the risk for PLOS. The risk for PLOS increased with increasing CIT and the greatest risk was with 13 to 14 hours (OR 2.05; 95% CI, 1.57-2.67) and 15 to 16 hours (OR = 2.06; 95% CI, 1.27-3.33).

“CIT greater than 15 hours was associated with decreased graft survival in the first 14 days of transplant, and CIT greater than 20 hours was associated with increased graft primary non-function,” the researchers wrote. “Transplant centers, therefore, should aim to minimize CIT in order to optimize patient outcomes and minimize costs. Nevertheless, longer CIT should not preclude allocation, and recipients should be counseled regarding the associated risk for post-transplant PLOS.” – by Talitha Bennett

Disclosure: The authors report no relevant financial disclosures.