The Authors’ Reply: To NRP or Not to NRP, That Is the Question…
Notice bibliographique
Résumé
We thank Ayorinde et al1 for their interest in our article2 and the editor for giving us the opportunity to clarify concerns. In our manuscript,2 we reported our initial experience with 46 consecutive controlled donors after circulatory death (cDCD) liver transplants (LTs) preserved with normothermic regional perfusion (NRP), presenting an 80% organ recovery rate and an outstanding low rate of complications (no cases of primary nonfunction or ischemic cholangiopathy [IC]). As the authors mentioned,1 it can be argued that the positive results could be partly justified by the short functional warm ischemia time due to premortem interventions or by a highly selected cohort. However, in the UK experience,3 they also presented excellent results with postmortem cannulation, despite a significantly longer functional warm ischemia time. Moreover, our donors cannot be considered highly selected, because our median donor age was 58 years (higher than that reported in other studies)2–4 and almost 30% were over 65 years of age. It is accepted that NRP allows a better evaluation of the graft according to liver function tests and macroscopic aspect. The authors suggest a randomized controlled trial between the rapid recovery (RR) and NRP to achieve evidence. Although it is not completely clear why NRP is beneficial, several experimental studies have demonstrated a replenishment of intracellular ATP that may help organs tolerate the subsequent cold ischemia.2,3 Moreover, RR and NRP have been recently retrospectively compared in 2 studies3,4 that demonstrate an evident benefit of NRP and even present NRP as an independent factor preventing IC. In addition, the use of NRP in Spain has significantly increased during the past years, currently being almost the only preservation system in cDCD. NRP also offers the advantage of being a relatively inexpensive technique that allows the perfusion of not only the liver but also the kidneys and pancreas and even combining with intrathoracic organ retrieval.5 Given the excellent results that we have experienced with NRP, it seems unlikely that any center would abandon NRP to perform RR and expose its recipients to a higher IC rate and graft loss. Therefore, the authors propose1 another trial comparing NRP and RR followed by ex situ machine perfusion (MP). Because NRP has shown superb results from its initial experiences,2 we do not consider NRP cDCD as marginal donors “per se,” rather donors that allow for a safe expansion of the donor pool. So, it seems to have no sense to associate MP. In our opinion, MP must still find its role in LT, although it seems to be useful in discard grafts. Our more extended experience with 83 NRP cDCD LTs has been recently presented in the International Liver Transplantation Society meeting in Toronto; primary nonfunction and IC rates remain 0% with a median follow-up of 24 months. In our opinion, although large trials would be advisable in the interest of evidence-based medicine, the results show that the benefits of NRP are so overwhelming that the adoption of the technique by worldwide active groups involved in cDCD LT is only a matter of time.
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Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,005 | 0,043 |
| Méta-épidémiologie (sens strict) | 0,001 | 0,001 |
| Méta-épidémiologie (sens large) | 0,002 | 0,001 |
| Bibliométrie | 0,001 | 0,001 |
| Études des sciences et des technologies | 0,002 | 0,003 |
| Communication savante | 0,003 | 0,004 |
| Science ouverte | 0,003 | 0,002 |
| Intégrité de la recherche | 0,021 | 0,027 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,006 | 0,006 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».