The need for the cadaver organ for liver transplant is increasing. Extended criteria/marginal donors can increase the donor pool significantly as ideal donors are very few. The combination of multiple marginal factors seems to be additive on graft injury. Although the organs from marginal donors may not be optimal, they are a viable alternative to dying while waiting for transplantation. In this review, the utility of various marginal donors in patients requiring liver transplantation will be described. It is inferred that older donors, mild to moderate steatosis, hypernatremia (preferably after correction), high ianotropic requirement, bacteremia, etc. are acceptable. Selected patients with low-grade malignancy may be accepted. Donors with positive viral serologies where transmission to the recipient is possible should be used only if the recipient is already infected with the same agent or the recipient has a critical need. The importance of liver biopsy and the goals of donor maintenance are also described. It is also concluded that the patients with high model for end-stage liver disease (MELD) score (>20) benefit the most with the marginal organs.

1. Selection and maintenance of a cadaver donor for liver
transplantation

2. Apollo Medicine 2012 March
Review Article
Volume 9, Number 1; pp. 9–16
© 2012, Indraprastha Medical Corporation Ltd
Selection and maintenance of a cadaver donor for liver
transplantation
Chirag J Desai*
*Chief Consultant and Program Director, Department of GI, HPB and Liver Transplantation, Apollo Hospital International Ltd.,
Ahmedabad – 380014, Gujarat, India.
ABSTRACT
The need for the cadaver organ for liver transplant is increasing. Extended criteria/marginal donors can increase
the donor pool significantly as ideal donors are very few. The combination of multiple marginal factors seems to
be additive on graft injury. Although the organs from marginal donors may not be optimal, they are a viable alterna-
tive to dying while waiting for transplantation. In this review, the utility of various marginal donors in patients requiring
liver transplantation will be described. It is inferred that older donors, mild to moderate steatosis, hypernatremia
(preferably after correction), high ianotropic requirement, bacteremia, etc. are acceptable. Selected patients with
low-grade malignancy may be accepted. Donors with positive viral serologies where transmission to the recipient
is possible should be used only if the recipient is already infected with the same agent or the recipient has a
critical need. The importance of liver biopsy and the goals of donor maintenance are also described. It is also con-
cluded that the patients with high model for end-stage liver disease (MELD) score (>20) benefit the most with the
marginal organs.
Keywords: Cadaver donor, liver transplant, marginal donor, selection
Correspondence: Dr. Chirag J Desai, E-mail: drchiragdesai@yahoo.com
doi: 10.1016/S0976-0016(12)60114-8
INTRODUCTION
The need for the liver transplant is increasing year by year
as more and more patients are waiting on the cadaver wait-
ing list. To expand the potential donor pool, clinicians are
continually modifying the criteria of an acceptable liver
donor and are looking to marginal or expanded donors to
meet the waiting list demands.1
Donors are generally con-
sidered marginal if there is a risk of initial poor function
(IPF) or primary nonfunction (PNF). The combination of
multiple marginal factors seems to be additive on graft
injury. Although the organs from marginal donors may not
be optimal, they are a viable alternative to dying while wait-
ing for transplantation. In this review, the utility of various
marginal donors in patients requiring liver transplantation
(LT) will be described, including older donors, steatotic
livers, donors with viral hepatitis, hypernatremia, and donors
with malignancies.
Identification of a Potential Cadaver Donor
Before the diagnosis of death, treatments are targeted to maxi-
mize the chances of patient survival rather than to support
individual organs. Brain death may be suspected following
changes in clinical observations. Very active management
may be required to achieve the physiological stability neces-
sary to conduct brain death testing properly.After brain death,
if donation is a possibility, an approach aimed at properly
monitored balanced resuscitation of the donor and mainte-
nance of all their organ systems ensures the greatest number
of organs suitable for transplant.

3. 10 Apollo Medicine 2012 March; Vol. 9, No. 1 Desai
© 2012, Indraprastha Medical Corporation Ltd
Ideal (Reference) Donor
Traditionally, the ideal donor is defined as one below the
age of 40 years, head injury as a cause of brain death, hemo-
dynamically stable, no evidence of transmissible disease, no
steatosis or other evidence to suggest chronic liver disease
and short hospital stay without evidence of sepsis. This
implies very low-risk of initial poor graft function. Ideal allo-
graft is different from ideal donor as factors during and after
procurement, like cold ischemia time (CIT), preservation
solution, and technical factors also come in to play.2,3
SELECTION OF CADAVER DONOR
(TABLE 1)
Donor Age
Over the years, the mean age of donors has increased world
over.2
There is no absolute limit of donor age for LT. The
risk related to age also represents a continuum.3
Reports have
shown excellent graft survival with even octogenarian
donors, provided that there are no additional risk factors.4
However, most centers have 65 years as an upper age limit
for the donors.
Studies have shown that aged donors without additional
risk factors have similar outcomes to younger donors, and
age alone should not be a contraindication to liver donation.
However, donor age of >70 years is found to be associated
with lower patient and graft survival.5
The liver is more immune to age compared with other
organs, particularly in the otherwise healthy person. This is
possibly because of the liver’s large functional reserve, regen-
erative capacity, and dual blood supply which exceeds its
metabolic needs.5
Older donor livers tend to be smaller and darker in color
and may have developed fibrous thickening of the capsule.
It has been shown that older donor livers are more suscepti-
ble to endothelial cell injury from cold ischemia and show
decreased adenosine triphosphate (ATP) synthesis after
reperfusion, which may influence the decreased regenerative
capacity and decreased synthetic function seen in these organs.
Although older age may not adversely impact patient and
graft survival, recipients of older donor livers seem to expe-
rience a greater degree of delayed function, with a notable
cholestatic pattern after transplantation. Preperfusion biop-
sies of livers from donors >60 years show higher rates of
moderate to severe microvesicular steatosis compared with
those from <60-year-old donors, as well as higher values of
bilirubin and prothrombin time. Therefore, older livers may
be more susceptible to endothelial cell injury from cold
ischemia. By maintaining CIT to 8 hours or less, long-term
graft function was shown to be equivalent in donors greater
and <50 years of age.
It is observed that fibrosis is more rapid and cirrhosis is
more common in recipients with hepatitis C virus (HCV)
infection who receive organs from older donors6
; donor age
>60 years has even been proposed as a major contributor to
the recent inferior outcome among HCV-positive recipients
compared with other recipient categories.7
Moreover, grafts
from older HCV-positive donors have been reported to cause
significantly more advanced fibrosis compared with HCV-
positive grafts from younger donors.8
For each decade of donor age >50 years, the incidence of
hepatic artery thrombosis (HAT) induced graft loss increases.
Risk of dying on waiting list is far more than graft loss due
to HAT, and hence in the absence of other factors just the
age cannot be the reason to refuse the donor. Additional
studies are required to determine if patients receiving allo-
grafts from donors >50 years may benefit from the institu-
tion of postoperative antiplatelet therapy to help reduce the
risk of graft loss from HAT.9
Table 1 Factors affecting primary nonfunction of the graft.
Donor factors affecting initial allograft function
Age
Steatosis
Hypernatremia
Hemodynamic instability
Cause of brain death (head injury better than hemorrhage)
Heart-beating versus nonheart-beating donor
ABO-incompatibility
Altered liver function test
Duration of intensive care unit stay
Evident sepsis
Affecting long-term results: transmissible infection and
malignancy
Hepatitis C virus-positive donor
Anti-HBc (hepatitis B core)-positive donor
Hepatitis B surface antigen-positive donor
High-risk activity donors
Extrahepatic malignancy in a donor
Factors during procurement
Technical
Split liver transplant
Factors after procurement
Cold ischemia time
Type of solution used

4. Selection and maintenance of a cadaver donor for liver transplantation Review Article 11
© 2012, Indraprastha Medical Corporation Ltd
Steatosis
Steatosis is increasing in the population and is commonly
seen in conjunction with obesity, alcohol use, increased age,
and the presence of type 2 diabetes mellitus. There are two
histological patterns of hepatic steatosis: a diffuse small
droplet vacuolization (microvesicular steatosis) and a com-
bined pattern of large and small vacuole deposits (macrove-
sicular steatosis). Usually both exist together. The use of
grafts with macrovesicular steatosis has been associated with
increased rates of IPF, PNF, and poorer outcome. Proposed
underlying mechanisms include impaired metabolism in the
steatotic hepatocytes, the physical effects of lipid during
cold ischemia, diminished portal blood flow, and increased
sensitivity to oxidative stress on reperfusion. Estimation of
steatosis using hematoxylin and eosin (H&E) stained fro-
zen section liver biopsy or physical inspection of an expert
in assessing the fat content is very subjective. Body mass
index (BMI) and imaging studies also correlate weakly
with the presence and severity of steatosis.8
Although steatosis can regress within weeks after LT,
early functional recovery and regenerative capacity are sig-
nificantly impaired with steatotic allografts, mostly because
of more severe ischemia–reperfusion injury.10
Mild steatosis (<30%) has minimal impact on liver func-
tion post transplantation, provided that CIT is short. When
macrovesicular steatosis exceeds 60%, except in research
protocols employing specific preservation solutions with
very short CIT in highly selected recipients, there is a con-
sensus for discarding allografts because of a high rate of
PNF. The use of grafts with moderate steatosis (30–60%)
remains a challenging issue. In this group, the incidence of
PNF may reach 15%, and the rate of delayed graft function
approaches 35%. Whatever the extent of steatosis is, the exis-
tence of any grade of fibrosis should lead to discarding the
graft. Except when procurement is performed by an experi-
enced transplant surgeon, no graft should be rejected solely on
the basis of inspection. Biopsy should be viewed as a means
for transplanting more organs.2
Even if biopsy is needed, it
should be done and reported quickly to keep CIT short.11
Donor Hypernatremia
Until recently the literature supported the observation that
donor hypernatremia prior to liver procurement negatively
impacts post transplant allograft function.12
Various upper
limits between 155mEq/mL and 170mEq/mL have been
used by various centers. Interestingly, aggressive correction
of donor serum sodium to <155mEq/mL before procure-
ment was shown to be beneficial for post transplant allograft
function. The recipient hyponatremia (serum sodium
<130mEq/mL) has also been shown to reduce 3-months
survival following orthotopic LT (OLT).
From these observations, one can infer that both the
donor sodium level at the time of organ procurement and the
recipient serum sodium level at the time of transplantation
can significantly impact post-OLT outcomes. However, it is
not clear if it is the absolute levels of donor hypernatremia
and recipient hyponatremia per se that impact postoperative
outcomes or whether the difference between these two values
is of greater importance.
Because the osmolality gradient between extracellular
and intracellular compartments determines the magnitude of
intracellular free-water influx (hepatocyte swelling and dys-
function), both donor and recipient sodium levels need to be
considered. It has been postulated that organs procured from
hypernatremic donors may be prone to hepatocyte swelling
upon reperfusion, whereupon the recipient serum sodium
concentration is lower. The translocation of water into the
hepatocytes may be related to increased intracellular osmolar-
ity that develops during the hypernatremic state of the donor.
However, in a retrospective study it was noticed that the
sodium level had no influence on the outcomes such as ini-
tial graft function, length of hospital, and intensive care unit
(ICU) stay or recipient mortality. This observation may be
explained by at least partial correction of the allograft intra-
cellular osmolality concentration via the preservation solu-
tion during the CIT. Both histidine-tryptophan-ketoglutarate
(HTK) and University of Wisconsin (UW) solutions are
slightly hyperosmolar.13
Although, no graft should be rejected
just for hypernatremia,14
if donor is stable, it is desirable to
correct the serum sodium level to <155mEq/mL.
Hemodynamic Instability
Hemodynamic instability is common in most donors and
may be sustained in spite of vasoactive support in 20% cases.
The donor may need several ianotropes in combination with
varying doses. Even an episode of cardiac arrest is not
uncommon. Rather than number of ianotropes and its dose,
it is the mean blood pressure (BP) which is most important. It
is very important to maintain mean BP between 60mmHg
and 100mmHg. In case of very high ianotrope requirement,
history of cardiac arrest or persistent low mean BP the liver
biopsy and the trend of the liver enzymes give the fair idea
about the extent of ischemic injury/necrosis and help us
decide the quality of the organ. The presence of acute renal
failure due to hypotension indirectly suggests the extent of
ischemic damage and the quality of liver graft in these
patients is likely to be poor.

5. 12 Apollo Medicine 2012 March; Vol. 9, No. 1 Desai
© 2012, Indraprastha Medical Corporation Ltd
Cause of Brain Death
Although the cause of brain death has no direct influence
on the selection of organ, it is observed that the quality of
the organ is likely to be better in case of head injury. This
is possibly because of the younger age and less incidence
of comorbidity, compared with cases of brain death due to
intracranial hemorrhage.
Heart-beating versus Nonheart-beating
Donors
Nonheart-beating donors (donation after cardiac death
[DCD]) can increase the donor pool by 10–20%. The organs
procured from nonheart-beating donors are inferior to the
brain dead heart-beating donors due to higher incidence of the
ischemic injury during warm ischemia. In view of this fact
the DCD should be very carefully selected (age <40 years, no
steatosis, <15 minutes warm ischemia and <10 hours of CIT).
ABO-incompatibility
ABO-incompatible transplants should be viewed as an impor-
tant therapeutic option in adult patients with acute liver fail-
ure awaiting an emergency procedure. However, routinely
it is advisable to avoid ABO-incompatible graft due to high
rate of complications and wastage of precious organ.
Donors with Abnormal Liver FunctionTests
Abnormal liver function tests (LFT) are commonly seen
in donors as a result of hemodynamic instability, steatosis,
and sepsis. Liver procurement should not be excluded on
the basis of LFTs. There is no clear upper limit in serum
transaminases that contraindicates the use in transplantation.
In cases of markedly increased serum transaminases, donor
hemodynamics is an essential consideration.A rapid decrease
in serum transaminases over time indicates resolving hepa-
tocellular injury, which should promote consideration for
transplantation. Although marked increase in the gamma-
glutamyl transpeptidase (GGT) level (<200IU/L) is a concern,
further consideration for use should be carefully weighted in
light of other donor factors such as alcohol abuse/non-alcoholic
steatohepatitis (NASH), and liver biopsy is warranted. In
addition, if the liver is enlarged or there is hyperechogenicity
on ultrasonography, there should be a high suspicion for sig-
nificant steatosis. A low prothrombin index and increased
international normalized ratio are not contraindications for
transplantation. In deceased donors with major brain injury,
these changes are more likely to be due to disseminated intra-
vascular coagulation than to altered liver function.2
Duration of Intensive Care Unit Stay
The duration of ICU stay before organ procurement used to
be an important factor. However, in view of increasing organ
scarcity the long hospital and ICU stay is not important any
more. The most important aspect is how stable the donor has
been during the entire stay and whether there is infection or not.
Transmissible Infections
Donors with positive viral serologies where transmission
to the recipient is possible (i.e., hepatitis B core [anti-HBc]
antibody positivity, hepatitis B surface antigen [HBsAg] posi-
tivity, HCV antibody positivity and human T-lymphotropic
virus 1) should be used only in certain circumstances (e.g.,
if the recipient is already infected with the same agent or
the recipient has a critical need and is fully informed of the
risk of subsequent donor transmission).2
Hepatitis C Virus
Transplantation because of HCV cirrhosis has increased
because of the greater prevalence of the virus in the past
15 years.15
The HCV-positive donors should only be used in
HCV-negative recipients under exceptional circumstances,
whereas the organs may be implanted in HCV-positive recipi-
ents, as shown by several studies.16,17
Testa et al reported their
findings on the long-term effects of using HCV-positive liver
grafts. Of the 137 patients who underwent transplantation sec-
ondary to HCV, 115 received HCV-negative grafts and 22
received HCV-positive liver grafts. The HCV recurrence rate
was similar in both groups (42% vs 55%; P=not significant).
Patient and graft survival at 4 years post transplantation was
84% and 72% in the HCV-negative donor grafts, compared
with 79% and 76% in the HCV-positive donor grafts.16,18
The clinical outcome of a large series of HCV-positive
recipients of HCV-positive liver allografts showed that donor
hepatitis C status does not impact on graft or patient survival
after LT for HCV-positive recipients.19
The time to recur-
rence and the course of HCV disease as well as vector of
means of alanine aminotransferase and total bilirubin paral-
lel that in patients who received non-infected organs in a
matched-pair analysis over a 3-years follow-up.20
Empiric evidence indicates most HCV-positive donors
<50 years of age are usable, about one-half of HCV-positive
donors between 50 years and 60 years of age are usable and

6. Selection and maintenance of a cadaver donor for liver transplantation Review Article 13
© 2012, Indraprastha Medical Corporation Ltd
rare HCV-positive donors age >60 years are usable in view
of higher incidence of fibrosis.
Hepatitis B Virus
Small proportion of liver donors are anti-HBc positive. The
proportion of positive anti-HBc livers in donors >60 years
may rise to 25%.21
The transmission rate of hepatitis B virus
(HBV) infection to HBV-negative recipients through this
route has been reported to be 17–94% without prophylaxis.8
Anti-HBc-positive and HBsAg-negative donor livers
must be directed selectively first to HBsAg-positive recipi-
ents, as they will require prophylaxis anyway. Secondly, these
livers should be directed to anti-HBs-positive patients, as they
do not seem to require prophylaxis. Finally, HBV-negative
recipients should only receive these livers in case of critical
conditions where lifelong prophylaxis is mandatory.22
The 5-years patient and graft survival rate in recipients
of anti-HBc-positive livers who received dual HBV prophy-
laxis with hepatitis B immunoglobulin (HBIg) and lamivu-
dine has been reported to be significantly higher than for
patients who received single prophylaxis or no prophylaxis.8
However, prophylaxis with monotherapy or dual therapy and
its dosage remains debatable.
In case series of 10 HBsAg-positive donors, patients
transplanted for HBV-related disease never cleared HBsAg.
Two HBsAg-negative patients never tested positive for
HBsAg, whereas the others experienced an HBsAg appear-
ance, followed by spontaneous production of anti-HBs, allow-
ing HBsAg clearance. No patient ever had any sign of HBV
hepatitis. The HBV replication was effectively controlled by
antiviral therapy.23
High-risk Behavior forTransmissible Infection
Even if the donor has significant history to suggest the pos-
sibility of transmission of infection (e.g., prostitution, drug
abuse, homosexuality, and multiple transfusions) the organs
must be used. However, the recipient should undergo screen-
ing 3 months after transplant.
Bacterial Infection
Bacterial infections in the donor do not represent by them-
selves a risk factor for liver graft failure. The risk of trans-
mitting a bacterial infection in the case of bacteremia in the
donor is low. Although there is no evidence that a positive
culture of preservation solution requires systematic prescrip-
tion of prophylactic antibiotics, early fever, and positive blood
cultures in the recipient as well the presence of yeast justify
empirical therapy.24,25
Donors with documented bacterial
meningitis do not preclude transplantation, provided that
recipients receive prophylactic antibiotics during the early post
transplantation period. Donors in whom brain death results
from an undefined central nervous system (CNS) infection
are probably at risk of transmitting the infectious disease.2
Donor with Malignancy
The incidence of cancer in donors is about 3% and the risk
of transmitting malignancy by transplantation of an organ is
roughly 0.01%.2
It can be reasonably assumed that the risk
of malignancy increases with donor age. Donors with low-
grade malignancies treated years ago, i.e., skin cancers other
than melanoma or donors with low-grade CNS tumors may
be considered for procurement. The most frequently trans-
mitted malignancies, in the absence of history, originate from
CNS tumors, melanoma, renal cell carcinoma, and lung car-
cinoma. Data on CNS tumors has been varied.8,26
Current
consensus is that certain histological types of CNS tumors
such as glioblastoma multiforme and medulloblastoma, along
with clinical history of ventricular shunting, major craniotomy
and/or extensive radiation increase the risk of metastasis, and
transmission and should be avoided.27
There has been a consensus that melanoma, choriocar-
cinoma, and lung cancer are associated with extremely high
transmission rate, and subsequent mortality, and therefore
should be considered absolute contraindications to organ
donation.27
Tumors that may possess the potential of unpre-
dictable recurrence (breast, colon, lung, melanoma, and renal
cell carcinoma) and any metastatic malignancy in the donor
should exclude donation. Recipients of donors with malig-
nancies should have their immunosuppression modulated
because over-immunosuppression reduces immune surveil-
lance that can accelerate tumor growth.
Cold IschemicTime
There is an evidence which emphasizes the need to shorten
CIT as much as possible in these extended criteria donors.
Recipient survival was shown to be adversely affected by
CIT >12 hours in a European survey and >10 hours in a
US survey.28
There is growing evidence that, independent
of any other risk factor, reducing CIT results in better out-
comes. Several reports have documented that CIT >15 hours
is associated with an increased risk of PNF and reduced
long-term survival.
Liver grafts from elderly donors and/or donors with
steatosis are even more affected by prolonged CIT and

7. 14 Apollo Medicine 2012 March; Vol. 9, No. 1 Desai
© 2012, Indraprastha Medical Corporation Ltd
preservation injury. In this group, optimal liver function can
be best achieved when CITs are kept <8 hours. During the
last decade, CIT has been reduced in European centers from
570 minutes to 470 minutes on average. A similar trend has
been observed in the US.2
Role of Biopsy
In a number of situations, liver biopsy is the reference for
accepting or discarding any liver graft. Frozen section biopsy
permits rapid assessment of liver architecture, fibrosis, stea-
tosis, inflammation, and extent of hepatocyte necrosis.
The biopsy is useful in case of elderly donors, unstable
hemodynamics, nonheart-beating donors or normal looking
liver in an alcoholic. An important goal in use of extended
criteria allografts is short CIT. Unfortunately, frozen section
biopsy may prolong the selection process and increase cold
ischemia. The benefits of biopsy must be balanced against
its consequences in terms of CIT.
Matching Extended Criteria Donors and
Recipients
Traditionally, it was thought that sick recipients with high
model for end-stage liver disease (MELD) score should receive
good-quality organs. However, the current knowledge suggests
that the extended criteria donor impose the same amount of
risk of graft failure irrespective of the MELD score, and the
sick patient benefits after transplant irrespective of the quality
of the organ. Thus, using grafts from extended criteria donors
adds significantly more risk to stable patients than they already
carry but increases the chance for long-term survival for
patients at high-risk of dying of their liver disease.Therefore,
extended criteria donors should be proposed for patients with
higher risks of dying such as those with MELD scores >20.
MAINTENANCE OF A CADAVER DONOR
Brain death is associated with various circulatory, metabolic,
and hormonal changes eventually leading to cardiac death.
In essence, donor management is a continuation of previous
critical care management, but with a shift in goals. There
are no guidelines on the care of donors with respect to opti-
mizing liver allograft function. The aim of donor homoeos-
tasis is listed in Table 2.29
Apart from general ICU care of
a critically ill patient on ventilator, the specific aspect of care
for donor is described here.
Hemodynamic Support
Circulatory changes are the leading cause of organ dysfunc-
tion. The monitoring mandates invasive arterial line and
central venous access. This allows administration of potent
vasoactive drugs. Cardiac output measurement may already
be in use, but if not, is helpful to guide therapy, particularly
if cardiothoracic organ donation is contemplated or ejection
fraction is low. Due to various causes of diuresis and third
spacing most of these patients are volume depleted. The
fluid used for volume resuscitation depends on the serum
sodium level, hematocrit, and coagulation profile. It is imper-
ative to avoid pulmonary edema especially, if intrathoracic
organs are to be used. If in spite of adequate volume resus-
citation hemodynamic instability continues, vasoactive sup-
port is necessary. Although dopamine remains the first line
drug dobutamine, vasopressin, or noradrenalin may be
needed.
Data have demonstrated dysfunction of the hypotha-
lamic–pituitary–adrenal axis during brain death that leads
to a decrease in circulating thyroid hormone and cortico-
steroids. However, no clear evidence exists indicating that
exogenous hormone therapy (vasopressin, thyroid hormones,
and/or corticosteroids) improves outcomes.30,31
However,
the use of thyroid hormone and methylprednisolon is a
routine practice in many centers. Serial reading of serum
lactate levels is a useful guide for the adequacy of the per-
fusion. Bradyarrythmias not responding to atropine (due to
brainstem vagus nerve disruption) may need adrenaline or
isoproterenol.
Respiratory Support
The potential donor is ventilated with a goal to maintain
PaO2 >100mmHg, SaO2 >95%. Positive end-expiratory pres-
sure (PEEP) of 5cm H2O and central venous pressure (CVP)
of 6–8cm H2O while adjusting the ventilation mode. The high
minute ventilation to treat high intracranial pressure (ICP)
Table 2 Goal of donor maintenance therapy.
Mean arterial pressure between 65mmHg and 100mmHg
Urine output between 1mL/Kg/hr and 1.5mL/Kg/hr
Hemoglobin between 7g/dL and 9g/dL
Normal arterial blood lactate
Partial pressure of arterial oxygen >80mmHg
Temperature between 35.5°C and 38°C
Serum sodium <150mmol/L
Blood sugar under control

8. Selection and maintenance of a cadaver donor for liver transplantation Review Article 15
© 2012, Indraprastha Medical Corporation Ltd
can be normalized once the aim of support changes from
patient survival to organ donation.
Renal Support and Diabetes Incipidus
It is desirable to maintain urine output (UO) of >100mL/hr
and creatinine level to <2mg/dL. Diabetes incipidus is very
common in donors and when exists may need use of vaso-
pressin or desmopressin (DDAVP) to keep UO <250mL/hr.
This also helps in maintaining hemodynamics.
Other Specific Supportive Care
Hyperglycemia is common in donors due to volume sup-
port with 5% dextrose solution, use of catecholamines, ster-
oids, and systemic inflammatory response syndrome (SIRS)
response to trauma. Insulin infusion is used to keep it under
control. Identification and correction of infection, coagulo-
pathy, and hypothermia is an on-going process.
CONCLUSION
There is constant increase in the need for cadaver donor liver.
To use the marginal graft is a need of the time. Although it is
desirable to use young, nonsteatotic, hemodynamically stable
donor with normal serum sodium level and the absence of
infection or malignancy, it is not commonly available. Hence,
older donors, mild to moderate steatosis, hypernatremia
(preferably after correction), high ianotropic requirement,
bacteremia, etc. are accepted. However, >1 extended criteria
has an additive effect. Selected patients with low-grade malig-
nancy may be accepted. Donors with positive viral serolo-
gies where transmission to the recipient is possible should be
used only if the recipient is already infected with the same
agent or the recipient has a critical need and is fully informed
of the risk of subsequent donor transmission. It is very impor-
tant to have an informed consent before using a marginal
graft. With improved peri-operative care it is increasingly
safer to use marginal graft. The patients with high MELD
score (>20) benefit the most with the marginal organs.
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