Massimo Malago 1

Marginal Donors in
Liver Transplantation
Massimo Malagò
Klinik für Allgemein- und Transplantationschirurgie

Universitätsklinikum Essen
EUROPEAN LIVER TRANSPLANT REGISTRY ELTR
23 Countries - 131 active Institutions 12/2005
68,776 Transplantations – 61,718 Patients
05/1968 - 12/2005
599
1605
442
548
404
1564
10845
10683 868
3349
440
11823 1098 1902 254
8160 77 82
1147
12421 11 16
440
Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

LTX and Waiting list
Germany
1,800
1,600
1,400
1,200
1,000
800
600
400 855
762 722 757 780 757 756
699
590 586 595
200
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Neuanmeldungen LTX
Quelle: ET, DSO

Organspende in Deutschland

Organ shortage
Maximal organ use
Marginal SPLIT Living donor

donors
Domino
NHBD
Essen: mortality on the list 24,2% in 2004

LIVER TRANSPLANTATION
marginal grafts
Good graft Good patient
Marginal graft High risk patient

Discretional graft allocation: history of transplantation!!
Is it justified to use marginal grafts ?

Inreasing Age of Deceased Donors
Germany -

ELTR
Graft Survival according to Donor 12/2005
Age in Europe
(%)
01/1988 - 12/2005
100
Total Log Rank test p = 0.0001
<55 years : 46061
55-65 years : 7607
80 75 >=65 years : 4763
68
72 64
60 57
57 53
61
48
53
41
40
41
32
20
0
0 1 für Allgemein-
Klinik 2 3 Transplantationschirurgie,
und 4 5 6 Universitätsklinikum
7 8 9
Essen 10 Yrs
Graft Survival according to Donor Age
in Elective Liver Transplantation
01/1988 - 12/2005
(%)
100 Total Log Rank test p = 0.0001 <55 years : 37467
55-65 years : 6405
79
80 ?65 years : 4223
71
75 67
66
60
60 59 56
64
49
55
42
40
42
20
0
0 1 2 3 4 5 6 7 8 9 10 Yrs
Graft Survival according to Donor Age
in Urgent Liver Transplantation
01/1988 - 12/2005
(%)
100 Total Log Rank test p = 0.001 <55 years : 7799
55-65 years : 1108
80 ?
65 years : 493
60
60 54
57 51
47
50 44
50 47
40
40 42
37
34 33
20
0
0 Klinik 1für Allgemein-
2 3 Transplantationschirurgie,
und 4 5 6 7 8 9 Essen
Universitätsklinikum 10 Yrs
The use of marginal donor livers
Ischemia /Reperfusion - Na+
Busuttil & Tanaka Liver Transplantation 2003 9:7, 651-53

Hepatosteatosis
Differenciate not only micro-macrosteatosis

but particularly Steatohepatis (NASH - NAFL)
Graft Survival according to the Type of Graft
01/1988 - 12/2005
Grafts : 56703
(%)
Total Log rank test = 0.0001 Living donor : 1920
100
Reduced liver : 2077
Split liver : 3061
79 Domino : 428
80
76 71
67 67 65
65
59 62
60 63 60 55
63 52
56
54
51
40
20
0
0 1 für Allgemein-
Klinik 2 3und Transplantationschirurgie,
4 5 6 Universitätsklinikum
7 8 9
Essen 10 Yrs
Graft Survival according to the Type of
Graft in Elective Liver Transplantation
01/1988 - 12/2005
(%) Cadaveric Full size : 46675

100 Living donor : 1764
Total Log rank test = 0.0001
Reduced liver : 1278
Split liver : 2396
79 Domino : 405
80
78 71
70 68 66
75 66
68 67 60
60 64 62
60 56
53
40 p Log rank :
Cadaveric full size vs Living donor : 0.01
Cadaveric full size vs Reduced liver : 0.0001 (Wilcoxon test)
20 Cadaveric full size vs Split liver : NS
Living donor vs Reduced liver : 0.0001
Living donor vs Split liver : 0.001
Reduced liver vs Split liver : NS
0
0 1 für Allgemein-
Klinik 2 3und Transplantationschirurgie,
4 5 6 7 8
Universitätsklinikum9 Essen10 Yrs
Graft Survival according to the Type of
Graft in Urgent Liver Transplantation
01/1988 - 12/2005
(%) Cadaveric Full size : 9068
100 Total Log rank test = 0.0001
Living donor : 134
Reduced liver : 779
80 Split liver : 641
59
64
67 61 59
60
53
50
45 46
50 43 43
41
40 43 42 39
p Log rank : 40 39
Cadaveric full size vs Living donor : NS
Cadaveric full size vs Reduced liver : 0.001
20 Cadaveric full size vs Split liver : 0.0001
Living donor vs Reduced liver : 0.01
Living donor vs Split liver : 0.001
Reduced liver vs Split liver : NS
0
0 1 für Allgemein-
2 3und Transplantationschirurgie,
4 5 6 7 8 9Essen 10 Yrs
Klinik Universitätsklinikum
Liver Transplant Graft Survival
2000 - 2003
U.S.
100
80
Survival Rate (%)
60
40
20
0
0 1 2 3
Years Post Transplant
SCD DCD ECD
2005 UNOS
Marginal liver graft
Donor factors
Graft factors
Associated diseases

Donor factors
Criteria soft hard
Age > 55 (60) > 70 (80)

Hemodynamic stabilty cardiac arrest - y/n
hypotension BP Syst < 60 for > 1h
any Cathecol. > 1γ /kg/min
ICU Stay > 4 days > 10 days

Na+ > 155 160 (165)
any max.
Amylase, lipase abnormal x3

Graft factors
Criteria soft hard
AST, ALT abnormal x 3 (x 5)

Bilirubin abnormal x3
Steatosis Micro , Macro, Mixed

> 30% > 40% (60%)
Fibrosis y/n grade >3
CIT >10 h > 14 h
Technical Vessel injuries Parenchymal injuries

Associated diseases
Criteria soft hard
Malignancies any past history except neurologic
HBV any Anti HBc Ab HBs Ag
HCV HCV Ab RNA +
Other Diseases ....... RABIES !!

Definition of Extended Criteria
Donor (ECD*)
• Donor Age > 65 years
• ICU stay > 7 days
• BMI > 30 kg/m²
• Steatosis (biopsy proven) > 40%
• S - Sodium > 165 mmol/L (at time of organ retrieval)
• S - AST > 3 x normal (at time of organ retrieval) or
• S - ALT > 3 x normal (at time of organ retrieval)
• S - Bilirubin > 3 mg/dL
*According to the Bundesärztekammer Germany BÄK 2004

Patient and Graft survival
with ECD organs
(190)
(152)
(85)
(20)
Pairwise Comparison ECD 1 ECD 2 ECD 3
Non-ECD 0.064 n.s. 0.000 0.189 n.s.
ECD 1 0.049
Becker T., Hanover
Pers. Com. Sept. 06
GSR defined as Patient or Graft Loss

Study on evaluation of the donor / graft

• 30 “marginal livers” transplanted
• Study “a posteriori”: questionnaire to 80 centers Response 60 / 80
• Graft survival ( 1 mo. - 1 yr) 83% 72 %
• Pt survival 80%
• Acceptance yes 38%

add data 20%
emergency 17%
refuse 23 %
undecided 2%
Mirza et al. Lancet 1999 344:1480-83

Evaluation of the donor / graft
accept % refuse %
Abnormal LFT 19 22
Hypotension 17 37
ETOH 22 22
Hidose inotropes 20 24
ICU > 5d 30 35
Age > 55 y. 50 9
Advanced CV disease 60 5
Mirza et al. Lancet 1999 344:1480-83

marginal grafts


Maximal gain for marginal grafts

marginal grafts
Free graft allocation necessary
for the sake of graft and recipent !!
The use marginal grafts is justified
Can the outcome of marginal grafts

be modified??
HOW??

“Livers that nobody wants” :
The ET Organ Rescue program in Essen
Material and Methods
• Study period 2003 - 2004

• ET-Allocation
• Rescue allocation-Definition
• Results analysis according to recipient outcome
Alive vs.dead
• Survival curves Kaplan Meier Ttest statistics (JMP Utah)
• Parameters analyzed Na, CIT, GOT peak last got etc

Algorithm for Organ Rescue Offer
• The Liver was refused in regular
allocation in more than 3 different centers
because of poor organ or donor quality
• In case a regular allocation is not

possible, donor instability or unfavourable
logistical reasons a rescue allocation is
necessary to save the organ
• Eurotransplant selects the centers by

recipients suitability criteria and by
logistical criteria, according with the MUC
& waiting time
•The accepting center

is not bound to standard recipient
allocation criteria.
Any patient listed
can be transplanted!!
“Livers that nobody wants”:
Prerequisites for participating to the
ET Organ Rescue program
Large waiting list

Consenting patients
“Daring” transplant team
Dedicated transplant center

LTX ESSEN April 1998 – October 2006
n = 881
Reduced Liver (8)
LDLT (185)
Split (115)
Standard-Tx (573)

LTX ESSEN April 1998 – October 2006
n = 881 Pediatric n = 143
Adults n = 738 Le be ndspe nde OLTx re duzie rte Le be r Split
Le be ndspe nde OLTx re duzie rte Le be r Split
37
53
1 61 148
7 46
ALDLT n =148
528 8
Right
Left
140

“Liver that nobody wants” (LNW)
Liver Transplantation in Essen 01/03-12/04
LTx n=241 Cadaver LTx n=169

„LNW“ n=45
32 45
39 CLTX normal CLTx
reduced size
LNW
1 LDTX
169
SLTx
124

marginal grafts


Main reasons for declining offers by other centers
Eurotransplant Database - Klinikum Essen 2001-03
Donor Data Overall recipient alive recipient death
n n n
“Poor organ/donor quality” 7 (21%) 6 1
“Recipient reasons” 3 (9%) 3 -
“Organisational reasons” 5(15%) 5 -
“Combined reasons”
(“Poor organ quality”, “Size-match”,
„Poor donor quality“, “Recipient 19(55%) 15 4
reasons”, “Incompatible age” ,
“Organisational reasons”)
Total n 34 29 5
Overall 159 refusals for 34 livers (5 refusals/graft in median)

Donor - Graft characteristics
ET Organ Rescue - Essen 2003-04 n=45
Donor Data overall recipient alive recipient dead
n n n
Age 41.8 years (1-81) 41.0 years (1-72) 46.3 years (21-81)
Sex 20m/25w 21m/17w 4m/3w
BMI 24.1 (12.3-37.0) 24.0 (12.3-37.0) 25.0(21.9-27.5)
Cause of death
Trauma 21 19 2
ICB 9 8 1
Cerebral Ischemia 13 10 3
Suicide 2 2 -
Cardiac arrest 6/45 6/38 0/7
Vasopressors 27/45 22/38 5/7

Cold ischemic time 528 min (260-900) 513min (260-745) 661 min (388-900)
ICU-stay 5 days (1-15) 5.3 days(1-15) 5.6 days (2-12)

Donor - Graft characteristics
Organ Data overall recipient alive recipient dead

n n n
GOT 87 U/l (9-381) 81 U/l (9-301) 130 U/l (25-381)
GOT-max 175 U/l (16-1055) 175 U/l (16-1055) 118 U/l (32-381)
GPT 88 U/l (4-694) 103 U/l (8-694) 74 U/l (11-176)
GPT-max 162 U/l (11-882) 91 U/l (6-694) 107 U/l (11-231)
Na+ 147.7 mmol/l (127-167) 148.1 mmol/l (127-167) 145.9 mmol/l (141-154)
Na+-max 150,2 mmol// (137-169) 150.7 mmol// (137-169) 147.5 mmol/l (141-156)
Na+ >150mmol/l 16/45 14/38 2/7
Cold ischemic time 528 min (260-900) 513min (260-745) 661 min (388-900)

Recipient demographics
Recipient Data overall alive dead
n n n
Age 53.0 years (20-69) 52.8 years (20-69) 54.2 years (28-65)
Sex 30m/15w 24m/14w 6m/1w
MELD-Score 16 15 18
T-Status
HU (1) 1 0 1
T2 (<2A) 8 8 -
T3 (<2B) 26 21 5
T4 (3) 10 9 1
Indication
HBV-cirrhosis 3 2 1
HCV-cirrhosis 14 11 3
Alcoholic-cirrhosis 6 5 1
HCC in cirrhosis 7 7 -
PSC/PBC 4 4 -
SBC 3 3 -
Cryptogenic 5 4 1
Biliary atresia 2 2 -
AcuteKlinik für Allgemein- und Transplantationschirurgie,
liver failure 1 Universitätsklinikum
- Essen1
Postoperative liver function
1400
GOT (U/l) Standard
1200 GPT (U/l) deviation
GOT GPT
1000
(U/l) (U/l)
800 1. post-LTx 1556 834
600 2. post-LTx 1557 933
400 3. post-LTx 749 758
4. post-LTx 571 658

200
5. post-LTx 607 708
0
1. post- 2. post- 3. post- 4. post- 5. post-
LTx LTx LTx LTx LTx
GOT/GPT>1000U/l in 16 patients (36%)

3000 GOT (U/l)
3000 GOT (U/l)
GPT (U/l)
GPT (U/l)
2500 2500
2000 2000
1500 1500
1000 1000
500 500
0 0
1. post- 2. post- 3. post- 4. post- 5. post- 1. post- 2. post- 3. post- 4. post- 5. post-
LTx LTx LTx LTx LTx LTx LTx LTx LTx LTx
Patients expired Patients survived

6,00 Bilirubin (mg/dl)

Standard
5,00 deviation
Bilirubin
4,00 (mg/dl)
1. post-LTx 3.91
3,00
2. post-LTx 2.37
2,00 3. post-LTx 2.67
4. post-LTx 2.63
1,00
5. post-LTx 2.81
0,00
1. post- 2 .post- 3. post- 4. post- 5 .post-
LTx LTx LTx LTx LTx

Bilirubin (mg/dl) 8,00

8,00 Bilirubin (mg/dl)
7,00
7,00
6,00 6,00
5,00 5,00
4,00 4,00
3,00 3,00
2,00 2,00
1,00 1,00
0,00 0,00
1. post- 2 .post- 3. post- 4. post- 5 .post- 1. post- 2 .post- 3. post- 4. post- 5 .post-
LTx LTx LTx LTx LTx LTx LTx LTx LTx LTx
Patients expired Patients survived

Morbidity and mortality
Morbidity Patients Re-LTx
n n
Primary dysfunction/non-function 8 3
Myocardial ischemia 1 -
Arterial thrombosis 4 1
Re-operations 7 -
Acute cellular rejection 2 -
4/45 (9%)
Mortality Patients
7/45 (16%) n
MOF in PNF 2
MOF in IPF 1
Pulmonary embolism 1
ICB 1
Heart failure 2
Graft survival: 9/45 (80%)

Patient survival: 7/45 (84%)

Marginal donors / organs - Risk analysis
Organ Rescue - Essen 2003-04 n=45
Donor Data overall recipient alive recipient dead Pearson
n n n test
Age > 70 3/45 2/38 1/7 0.379
BMI > 30 1/45 1/38 0/7 0.664
GOT > 200 4/45 3/38 1/7 0.585
GOTmax > 200 7/45 5/38 2/7 0.334
GPT > 200 5/45 5/38 0/7 0.315
GPTmax > 200 7/45 6/38 1/7 0.912
Amylase > 95 9/45 6/38 3/7 0.099
Liver acceptable 12/45 9/38 3/7 0.117
Steatosis >30 % 5/45 5/38 2/7 0.109
CIT > 600 min 9/45 7/38 2/7 0.537
Na+ > 160 4/45 4/38 0/7 0.368
Na+Max > 160 4/45 4/38 0/7 0.368
Cardiac arrest 6/45 6/38 0/7 0.258
Vasopressors 27/45 22/38 5/7 0.502
Cold ischemic 528 min (260-900) 513min (260-745) 661 min (388-900)
time

Critical recipients - Risk analysis
Organ Rescue - Essen 2003-04 n=45
Recipient Data overall alive dead pearson

n n n
Age >60 14/45 11/38 3/7 0.465
MELD >20 10/45 7/38 3/7 0.212
T2 4/45 4/38 0/7 0.339

“Livers that nobody wants”:
The ET Organ Rescue program in Essen
Survival
1,0
0,9
0,8
0,7
• 1-year-survival: 84%
Survival rate
0,6
0,5 • 2-years-survival: 84%
0,4
0,3
• Median follow-up: 12.4 months
0,2 (range 0-31 months)
0,1
0,0
0 6 12 18 24
survival [months]

Definition of Extended Criteria
Donor (ECD*)
• Donor Age > 65 years
• ICU stay > 7 days
• BMI > 30 kg/m²
• Steatosis (biopsy proven) > 40%
• S - Sodium > 165 mmol/L (at time of organ retrieval)
• S - AST > 3 x normal (at time of organ retrieval) or
• S - ALT > 3 x normal (at time of organ retrieval)
• S - Bilirubin > 3 mg/dL
*According to the Bundesärztekammer Germany BÄK 2004

Recipient Demographics - “LNW”
LNW/non ECD ECD p-value
n=19 n=26
Age (years) 47 ± 19 47 ± 18 n.s.
Sex (m / f) 9/10 21/5 n.s.
Urgency (Status 1 excluded)
T2 (Eurotransplant) 4 (21%) 4 (16%)
T3/4 (Eurotransplant) 14 (74%) 22 (84%)
MELD >25 1 (5%) 2 (7%)
MELD 19-24 5 (26%) 3 (11%) n.s.
MELD 11-18 7 (14%) 12 (46%)
MELD < 10 3 (16%) 7 (27%)
Mean MELD 16.4 ± 6.8 15.0 ± 5.4 n.s.
Diagnosis Groups
Cholestatic 2 (11%) 4 (15%)
Cirrhotic 15 (78%) 15 (58%)
HCC 2 (11%) 6 (23%) n.s.
Metabolic and others 0 (0%) 1 (4%)
Cold Ischemia Time (min) 595.4 ± 166 497.1 ± 133 n.s.

Frequency of ECD
in „Livers that Nobody Wants“
56%-87%
LFTs >3x 53.85% 20

18 17
Sodium >165 7.69%
16
Steatosis >40% 15.38% 14
12
BMI > 30 3.85%
10
8 7
ICU > 7 d 46.15%
6
Donor Age >65 yrs 15.38% 4
2
2
0% 10% 20% 30% 40% 50% 60% 0
1 2 3

Objective evaluation: scoring systems

Cumulative risk factors
Essen 2003 -2004 n=45
Scoring Criterium: 1- 3 vs > 4 risk factors
Risk factors N= Graft Patient

1-3 28 76 % 82 %
>4 17 60 % 76 %

Cumulative risk factors Essen 2003 -2004 n=45
ECD liver to “sick recipient” (Age> 60 MELD > 20)
0
1,0 1
0,9
Test
Log-Rank
ChiSquare
24,4945
DF Prob>ChiSq
3 <.0001 2
0,8
Wilcoxon 23,8246 3 <.0001
3
0,7
Surviving
0,6
0,5
0,4
0,3
0,2
0,1
0,0
0 10 20 30 40 50
Follow-up (months)

Klinik für Allgemein- und Transplantationschirurgie, UniversitätsklinikumJ Belghiti
Essen ILTS ‘03
Essen ILTS ‘03
Graft Survival according to the number of the
Liver Transplantation in Urgent Cases
01/1988 - 12/2005
(%)
100 p Log Rank :
1st LT vs 2nd LT : 0.0001 2nd LT vs 3rd LT : 0.0001
1st LT vs 3rd LT : 0.0001 2nd LT vs 4th LT : NS
80
1st LT vs4th LT : 0.04 3rd LT vs 4th LT : NS
63
57
60 54
50
49 47
43 40
40 35
33 32
34
31 31 29
20
0
0 1 2 3 4 5 6 7 8 9 10 Yrs
1st liver transplantations : 2nd liver transplantations : 3151
3rd liver transplantations : 342 4th liver transplantations : 39
Essen ILTS ‘03
Donor / Recipient Analysis -
“LNW”
Donors Recipient
Donor Age n.s. Recipient Age n.s.
ICU Stay n.s. Diagnosis Group n.s.
BMI n.s. MELD Score 0.0253
Sodium n.s. CIT n.s.
LFTs n.s.
Cox Regression, Backward Stepwise (Likelihood Ratio)

Donor Criteria Analysis - “LNW”
Appropriate “allocation buffer”
Donor Age n.s.

ICU Stay 0.0009
BMI n.s.
Sodium n.s.
ASAT 0.005
ALAT n.s.
Cox Regression, Backward Stepwise (Likelihood Ratio)

Log-Rank (Mantel-Cox)
Marginale Spenderlebern
Summary
• The use of marginal livers has entered the clinical practice
• “Critcal” liver grafts evaluated differently by experienced, high volume
centers - Key for success is the free allocation of graft-recipient
• The use of true marginal livers can be dangerous
• Appropriate recipient, center, surgeon selection is imperative
• Objective criteria to define the true marginal organs are needed
• A multifactorial score system seems a promising approach
different strategies needed

Summary
• Match ECD livers to patients not too sick !!!
• Reduce cold ischemia time
• Retransplant early in PPF/PNF
• Accept ECD livers with judgment

• Allow «rescue allocation» of ECD livers: flexible allocation rules
• Time for a match program for ECDs to appropriate risk recipients

Massimo Malago 1

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Marginal Donors in

Klinik für Allgemein- und Transplantationschirurgie

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

Quelle: ET, DSO

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

Marginal SPLIT Living donor

Essen: mortality on the list 24,2% in 2004

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

Marginal graft High risk patient

Is it justified to use marginal grafts ?

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

Busuttil & Tanaka Liver Transplantation 2003 9:7, 651-53

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

Differenciate not only micro-macrosteatosis

(%) Cadaveric Full size : 46675

SCD DCD ECD

Marginal liver graft

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

Criteria soft hard

Age > 55 (60) > 70 (80)

ICU Stay > 4 days > 10 days

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

Criteria soft hard

AST, ALT abnormal x 3 (x 5)

Steatosis Micro , Macro, Mixed

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

Criteria soft hard

Malignancies any past history except neurologic

HBV any Anti HBc Ab HBs Ag

HCV HCV Ab RNA +

Other Diseases ....... RABIES !!

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

*According to the Bundesärztekammer Germany BÄK 2004

Pairwise Comparison ECD 1 ECD 2 ECD 3

Non-ECD 0.064 n.s. 0.000 0.189 n.s.

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

Study on evaluation of the donor / graft

• Acceptance yes 38%

Mirza et al. Lancet 1999 344:1480-83

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

Evaluation of the donor / graft

Mirza et al. Lancet 1999 344:1480-83

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

Marginal graft High risk patient

Is it justified to use marginal grafts ?

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

The use marginal grafts is justified

Can the outcome of marginal grafts

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

Material and Methods

• Study period 2003 - 2004

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

• In case a regular allocation is not

• Eurotransplant selects the centers by

•The accepting center

Large waiting list

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen

LTx n=241 Cadaver LTx n=169

Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen