Liver transplantation (LT) is the best treatment for end-stage
hepatic failure, with an excellent survival rates over the last decade. Biliary complications after LT pose a major challenge especially with the increasing number of procured organs after circulatory death. Ischaemic cholangiopathy (IC) is a set of disorders characterized by multiple diffuse
strictures affecting the graft biliary system in the absence of hepatic artery
thrombosis or
stenosis. It commonly presents with
cholestasis and
cholangitis resulting in higher readmission rates, longer
length of stay, repeated therapeutic interventions, and eventually re-
transplantation with consequent effects on the patient's quality of life and increased health care costs. The pathogenesis of IC is unclear and exhibits a higher prevalence with prolonged ischaemia time, donation after circulatory death (
DCD), rejection, and
cytomegalovirus infection. The majority of IC occurs within 12 mo after LT. Prolonged warm ischaemic times predispose to a profound injury with a subsequently higher prevalence of IC. Biliary complications and IC rates are between 16% and 29% in
DCD grafts compared to between 3% and 17% in donation after
brain death (DBD) grafts. The majority of ischaemic biliary lesions occur within 30 d in
DCD compared to 90 d in DBD grafts following
transplantation. However, there are many other risk factors for IC that should be considered. The benefits of
DCD in expanding the donor pool are hindered by the higher incidence of IC with increased rates of re-
transplantation. Careful
donor selection and procurement might help to optimize the utilization of
DCD grafts.