Thread by @richlaing

1) Sooooooo.....it’s here. The long awaited D-HOPE ❄️❄️🥶🥶🥶 perfusion paper!! Thanks for the tag @ebtapper. Looked at this last night. Is it the answer we’ve been waiting for???!! A few thoughts follow....#tweetorial @DrDariusMirza

https://twitter.com/nejm/status/1364960848318517250

2) what is D-HOPE?? 🤔
It stands for “dual hypothermic oxygenated machine perfusion”, the “dual” refers to perfusion of both the hepatic artery and portal vein. This is normally performed for 2 hours at the transplanting centre before implantation after a period of cold storage.

3) it has been proposed that D-HOPE helps the liver graft to recharge its 🔋🔋(the mitochondria) before asking it to function at 💯. Perfusing the artery as well as the PV in theory means the bile ducts will get the full benefit (“HOPE” ❤️-ers don’t think this is necessary).

4) DCD grafts (donated following circulatory death) are exposed to a period of warm ischemia 🥵🥵 before preservation. Bile ducts don’t like this 👎. They get damaged at reperfusion and resultant scarring leads to structuring. This is bad. Post reperfusion syndrome & EAD also 👎

5) So what was good??!! a)...#NEJM....very nice 👍 ☺️. Wonderful exposure for the specialty and field. A well run trial from a fantastic group. b) clinically relevant non-anastomotic strictures better 6% vs 18%. [Proponents have previously claimed they see no cholangiopathy].

6) c) 👇🏻 in EAD and post-reperfusion syndrome seen as hoped also. But....does this answer all our problems? Can we take to the streets 🕺 💃🏽 to celebrate and rejoice??!! Well not quite IMO......

7) let’s look at the donors.....these were transplantable grafts. I suspect very few were extended criteria looking at the data. Warm ischemic 🕰 short, CIT 40-60 mjn longer in control group, CIT generally <7 hours. No data at all on steatosis.

8) in spite of these favourable donor characteristics, in the machine perfusion group 43/78 other pts (55%) had radiological evidence of non-anastomotic strictures and 29% had biliary anastomotic strictures. There were no differences in clavien-dindo complications of any grade.

9) So what can we take from this?? D-HOPE is probably beneficial. Is it the panacea? No. It doesn’t prevent the development of non-anastomotic strictures in transplantable DCD grafts. It doesn’t prevent EAD or post reperfusion syndrome, but it is better than the ice box alone.

10) “FANTASTIC! When can I see the HOPE trial results from Zurich and compare it to HOPE (PV perfusion only)?” Unfortunately the HOPE trial is looking at DBDs only and comparing Clavien-Dindo complication rates (which were no diff in this trial). So you won’t be able to. Sorry.

11) “OK does this mean cold perfusion is better than warm perfusion?”

Well, I don’t think it answers that question either. We know end-ischemic NMP isn’t good for extended criteria DCDs. It may be ok for good DCDs (@NasrallaD has lots of experience @RoyalFreeNHS).

12) with complete warm preservation @NasrallaD only had 1 patient in the warm arm with symptomatic biliary strictures and only 11% radiological rate of NAS so actually the results are comparable for transplantable DCDs (if not better on paper in the NMP trial).

13) “So who’s most pleased?”

Probably everyone. The proponents of cold are saying look at the improvements/advantages. The fans of warm are saying our results are as good. And the advocates of normothermic regional perfusion (NRP) are probably shouting NRP is better!!!!

14) “What next?”

We await the HOPE results with anticipation. Then in an ideal world as a community we need to decide on an appropriate end point and compare the different modalities in an RCT.

15) In reality this will be challenging if not impossible. It is likely in the future we will use different MP for different situations and different grafts. Each have logistical and clinical advantages & disadvantages.

I’m looking forward to listening to the debates though!!!

16) very interested to hear anyone else’s thoughts? 👇🏻👇🏻👇🏻👇🏻 🤔 💭

@CholestasisDoc @Drfattyliver @AutoImmuneLiver @shahidfarid @herricksociety @gabriel_oniscu @CFondevila @JHawksworthMD @Paulo_MartinsMD @PatronoDamiano @BAmirSayed @gbonneysurg @chris_nahm @HartogHermien @DrEmamaullee @C_V_M_Brown @HMergental @jfergus75 @hpbsurgeon1 @FionaHand3