World J. Surg. 20, 309 –313, 1996 WORLD Journal of SURGERY © 1996 by the Socie ´te ´ Internationale de Chirurgie Reuse of Liver Grafts after Early Death of the First Recipient E. Moreno Gonza ´lez, R. Go ´mez, I. Gonzalez Pinto, C. Loinaz, I. Garcia, V. Maffettone, M. Corral, M. Marcello, A. Gonzalez, C. Jimenez, C. Castellon Department of General and Digestive Surgery, Liver Transplant Unit, Hospital ‘‘12 de Octubre,’’ Universidad Complutense de Madrid, Carretera de Andalucia Km. 5400, 28041 Madrid, Spain Abstract. Three cases are reported of reuse of a transplanted liver graft after early death of the first recipient due to cerebral hemorrhage. The good condition of the donors; the excellent biochemical evolution of the graft in the first recipients; total ABO compatibility and donor-recipient crossmatch; the absence of positivity to hepatitis B virus (HBV), hepatitis C virus (HCV), and bacteriologic cultures; and early death made reuse possible. The shortage of donors in relation to patients on the waiting list and the poor clinical condition of the second recipients made it necessary to adopt the decision to reuse the graft in an attempt to save their lives. The evolution of the patients and the reused grafts was satisfactory, and there were no complications that could be attributed to the fact that the graft had been transplanted before. The first reuse of a liver graft was reported by our group in 1991 [1]; since then another two patients have received transplants due to the reuse of liver grafts. When an urgent transplant for patients with terminal hepatic failure is required and there are no available donors [2, 3], the possibility of reusing liver grafts may be considered but only when that liver had been functioning correctly after the first implant, as this response is the best safety sign; the second implant reproduces the activity shown previously so long as the duration of warm and cold ischemia is minimal and the reperfusion damage is practically nonexistent. Reperfusion with Belzer’s solution preserves the removed grafts better and makes them easier to be reused [4]. Early reuse and total ABO compat- ibility and donor first-recipient crossmatch minimize immunologic implications. The negativity of the first recipients for hepatitis B virus (HBV), hepatitis C virus (HCV), and multiple bacteriologic cultures is a guarantee of the subsequent absence of infection. We present three cases of reuse of liver grafts in critically ill patients following early death of the first recipient. Material and Methods Between April 1986 and April 1995 a total of 421 liver transplants were performed on 353 patients (68 retransplants) at our institu- tion. A total number of 417 donors have been used for 421 transplants: the ‘‘split liver’’ [5] technique was carried out in one case and grafts previously transplanted in another three recipients were reused in three cases. A graft previously transplanted was reused when the donor’s condition and the enzymatic evolution of the graft in the first recipient were good, when the reuse proce- dure could be carried out within the first 48 hours of the death of the first recipient due to cerebral hemorrhage, when the multiple samples for viral and bacteriologic culture and the serology for HBV and HCV were negative, when there was total ABO compatibility and negative donor/first-recipient crossmatch, and finally if there was an available recipient in poor clinical condition who required urgent liver transplantation. Prior to reuse, a biopsy specimen of the graft was examined to rule out pathology. The preservation lesions of the liver graft were classified into three grades according to Demetris et al. [6]. Liver transplantation was performed in accordance with the technique reported else- where [7]. All patients received triple immunosuppressive therapy with prednisone, cyclosporin A, and azathioprine. Patients who underwent retransplantation because of chronic rejection re- ceived quadruple therapy with prophylactic OKT3 during the first 10 to 14 days after the transplant. Table 1 illustrates the features of the cadaveric graft donors and Table 2 the ischemia times and the graft lesions resulting from preservation. Table 3 shows the features of the first and second recipients of the reused grafts. In the first recipients, there were clinical suspicions of brain death during the first 24 hours after orthotopic liver transplantation (OLT), in the intensive care unit (ICU). In all three cases cerebral computed tomography (CT) scans revealed wide areas of intraparenchymal and intraventricu- lar massive hemorrhage as the cause of death. In the first and third cases the hemorrhage may have been caused by, among other problems, severe episodes of arterial hypertension ( 200/100 mmHg) that were difficult to control during the immedi- ate postransplant period. The cause of the cerebral hemorrhage in the remaining case was unknown. An absence of central nervous system (CNS) activity in the first recipients was confirmed by means of clinical examination and two 6-hour intervals between a flat electroencephalogram (EEG) (the management was similar to that of other potential graft donors). These patients with transplants who died within the first 48 hours after their transplant were then considered donors of that graft. The grafts were removed from the first recipients at 22, 43, and 45 hours after OLT, respectively. The three second recipients of the reused grafts presented with Correspondence to: E. Moreno Gonza ´lez.