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Snyder RA, Moore DR, Moore DE. More donors or more delayed graft function? A cost-effectiveness analysis of DCD kidney transplantation. Clin Transplant 2013; 27:289-96. [PMID: 23350938 DOI: 10.1111/ctr.12073] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2012] [Indexed: 02/04/2023]
Abstract
Expansion of the donor pool with expanded criteria donors and donation after cardiac death (DCD) donors is essential. DCD grafts result in increased rates of primary non-function (PNF) and delayed graft function (DGF). However, long-term patient and graft survival is similar between donation after brain death (DBD) donors and DCD donors. The aim of this study was to evaluate the cost-effectiveness of the use of DCD donors. A Markov-based decision analytic model was created to simulate outcomes for two wait list strategies: (i) wait list composed of only DBD organs and (ii) wait list combining DBD and DCD organs. Baseline values and ranges were determined from the Scientific Registry of Transplant Recipients (SRTR) database and literature review. Sensitivity analyses were conducted to test model strength and parameter variability. The wait list strategy consisting of DBD donors only provided recipients 5.4 Quality-adjusted life years (QALYs) at $65 000/QALY, whereas a wait list strategy combining DBD + DCD donors provided recipients 6.0 QALYs at a cost of $56 000/QALY. Wait lists with DCD donors provide adequate long-term survival despite more DGF. This equates to an improvement in quality of life and decreased cost when compared to remaining on dialysis for any period of time.
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Affiliation(s)
- Rebecca A Snyder
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, TN, USA
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102
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Fieux F, Jacob L. Donneurs décédés après arrêt cardiaque: mise au point. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-012-0624-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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103
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de Vries EE, Hoogland PE, Wind J, Snoeijs MG, van Heurn EL. Transplantation of kidneys from paediatric DCD donors: a comparison with DBD donors. Nephrol Dial Transplant 2012. [DOI: 10.1093/ndt/gfs464] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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104
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Venkataramani AS, Martin EG, Vijayan A, Wellen JR. The impact of tax policies on living organ donations in the United States. Am J Transplant 2012; 12:2133-40. [PMID: 22487077 DOI: 10.1111/j.1600-6143.2012.04044.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In an effort to increase living organ donation, fifteen states passed tax deductions and one a tax credit to help defray potential medical, lodging and wage loss costs between 2004 and 2008. To assess the impact of these policies on living donation rates, we used a differences-in-differences strategy that compares the pre- and postlegislation change in living donations in states that passed legislation against the same change in those states that did not. We found no statistically significant effect of these tax policies on donation rates. Furthermore, we found no evidence of any lagged effects, differential impacts by gender, race or donor relationship, or impacts on deceased donation. Possible hypotheses to explain our findings are: the cash value of the tax deduction may be too low to defray costs faced by donors, lack of public awareness about the existence of these policies, and that states that were proactive enough to pass tax policy laws may have already depleted donor pools with previous interventions.
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Affiliation(s)
- A S Venkataramani
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
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105
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Jochmans I, Darius T, Kuypers D, Monbaliu D, Goffin E, Mourad M, Ledinh H, Weekers L, Peeters P, Randon C, Bosmans JL, Roeyen G, Abramowicz D, Hoang AD, De Pauw L, Rahmel A, Squifflet JP, Pirenne J. Kidney donation after circulatory death in a country with a high number of brain dead donors: 10-year experience in Belgium. Transpl Int 2012; 25:857-66. [DOI: 10.1111/j.1432-2277.2012.01510.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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106
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Reich DJ, Guy SR. Donation After Cardiac Death in Abdominal Organ Transplantation. ACTA ACUST UNITED AC 2012; 79:365-75. [DOI: 10.1002/msj.21309] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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107
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Hanf W, Codas R, Meas-Yedid V, Berthiller J, Buron F, Chauvet C, Brunet M, Giroud A, McGregor BC, Olivo-Marin JC, Hadj-Aissa A, Faure A, Petruzzo P, Martin X, Badet L, Morelon E. Kidney graft outcome and quality (after transplantation) from uncontrolled deceased donors after cardiac arrest. Am J Transplant 2012; 12:1541-50. [PMID: 22390302 DOI: 10.1111/j.1600-6143.2011.03983.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The use of uncontrolled deceased donors after cardiac arrest (uDDCA) has been developed in France to compensate for organ shortage. The quality of these kidneys remains unclear. We analyzed kidney graft function and histology from 27 uDDCA and compared them with kidneys from 30 extended criteria donors (ECD) and from 24 simultaneous pancreas kidney (SPK) donors as a control group of optimal deceased donors. Kidneys from ECD and SPK donors were preserved by static cold storage while kidneys from uDDCA were preserved by pulsatile perfusion. The uDDCA graft function at 3 years posttransplantation (estimated with MDRD and measured with inulin clearance) did not differ from that of the ECD group (eGFR 44.1 vs. 37.4 mL/min/1.73 m(2) , p = 0.13; mGFR 44.6 vs. 36.1 mL/min/1.73 m(2) , p = 0.07 in the uDDCA and ECD groups, respectively). The histological assessment of 3-month and 1-year protocol biopsies did not show differences for interstitial lesions between the uDDCA and ECD grafts (IF score at M3 was 30 vs. 28% and at M12 36 vs. 33%, p = NS). In conclusion, the results at 3 years with carefully selected and machine-perfused uDDCA kidneys have been comparable to ECD kidneys and encourage continuation of this program and development of similar programs.
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Affiliation(s)
- W Hanf
- Service de Néphrologie, Transplantation et Immunologie Clinique, Hôpital Edouard Herriot, Hospices Civils de Lyon, France.
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108
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Thornton SR, Hamilton N, Evans D, Fleming T, Clarke E, Morgan J, Kadi N. Outcome of kidney transplantation from elderly donors after cardiac death. Transplant Proc 2012; 43:3686-9. [PMID: 22172826 DOI: 10.1016/j.transproceed.2011.09.078] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2011] [Accepted: 09/20/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND The rate of renal transplantation is limited by the number of donor organs available. A valuable source of organs is currently supplied by donation after cardiac death (DCD). At the Richard Bright Renal Unit, we have expanded our criteria for DCD, increasing the upper age limit for donation from 65 to 70. METHOD We performed a retrospective analysis of all DCD recipients between 2003 and 2009. We compared outcomes for patients age<60 versus >60 as measured by delayed graft function and estimated glomerular filtration rate (eGFR) and incidence of graft failure. RESULTS One hundred thirty-six DCD transplantations took place. Our early data showed excellent results for non-heart-beating donation. Over the last 7 years, the average age of DCD donors has increased from 43 in 2003 to 50 in 2009. The increase in age has been correlated with a decrease in average recipient eGFR from 59 in 2003 to 32 in 2009. Recipients of kidneys from older DCD donors (>60) have significantly lower eGFRs at 1 month and 1 year compared to kidneys from donors aged <60. The incidence of delayed graft function in recipients of kidneys from donors aged>60 was 71% compared to 40% for <60 age group. Despite this, we have not found any evidence of higher graft failure rates in the recipients of grafts from the >60 donor age group. CONCLUSIONS Expanding the age limits of our DCD donor program has led to an increased average donor age, reduced average eGFR, and increased delayed graft function. There is no evidence of reduced graft survival.
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Affiliation(s)
- S R Thornton
- Department of General Surgery, Southmead Hospital, Birstol, UK.
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109
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Affiliation(s)
- Keith Roberts
- liver transplantation at University Hospitals Birmingham
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110
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Maruyama M, Kenmochi T, Saigo K, Naotake A, Iwashita C, Otsuki K, Ito T. Results of Islet Isolation and their Relationship to the Clinical Outcome of Kidney Transplantation in Cases where Both Grafts are Harvested from the Same Non-Heart-Beating Donor. Cell Transplant 2012; 21:559-63. [DOI: 10.3727/096368911x605484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Grafts from non-heart-beating donors (NHBDs) are used because of the limited availability of heart-beating brain-dead donors. These grafts sustain ischemic damage, and the severity of this damage varies among different areas of an organ. This study determined whether the results of islet isolation were correlated with the clinical outcomes of kidney transplantations in cases where both grafts were harvested from the same NHBD. Islets we isolated from the pancreata of 23 NHBDs between February 2004 and March 2007. Forty-six kidneys were also harvested from these NHBDs. The recipients of kidney transplants were divided into the successful isolation ( n = 14) and failed isolation ( n = 32) groups depending on the results of islet isolation. The clinical outcomes of kidney transplantation were compared between the recipients in these two groups. The immediate graft function rate and the 1-year graft survival rate after kidney transplantation in both groups were similar. Hemodialysis after transplantation was required for 6.0 days (SD, 5.2 days) in the successful isolation group and for 12.7 days (13.1 days) in the failed isolation group ( p < 0.05). The serum creatinine concentrations at 1, 3, 6, and 12 months after transplantation were elevated in the failed isolation group ( p < 0.05). The islet yield was inversely correlated with the requirement of hemodialysis (days) and the serum creatinine level at 1 month after transplantation. However, hemodialysis was required for only 7 days in the recipients of six kidneys that were obtained from NHBDs from whom <40,000 IEQ were obtained (extreme failure of islet isolation). The results of islet isolation were found to correlate with the kidney function after transplantation when both grafts are harvested from the same NHBD. However, the marginal conditions of NHBDs affect the results of islet isolation more than they do the posttransplantation kidney function.
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Affiliation(s)
| | - Takashi Kenmochi
- Department of Surgery, Chiba-East National Hospital, Chiba City, Japan
| | - Kenichi Saigo
- Department of Surgery, Chiba-East National Hospital, Chiba City, Japan
| | - Akutsu Naotake
- Department of Surgery, Chiba-East National Hospital, Chiba City, Japan
| | - Chikara Iwashita
- Department of Surgery, Chiba-East National Hospital, Chiba City, Japan
| | - Kazunori Otsuki
- Department of Surgery, Chiba-East National Hospital, Chiba City, Japan
| | - Taihei Ito
- Department of Surgery, Chiba-East National Hospital, Chiba City, Japan
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111
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Manara AR, Murphy PG, O'Callaghan G. Donation after circulatory death. Br J Anaesth 2012; 108 Suppl 1:i108-21. [PMID: 22194426 DOI: 10.1093/bja/aer357] [Citation(s) in RCA: 191] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Donation after circulatory death (DCD) describes the retrieval of organs for the purposes of transplantation that follows death confirmed using circulatory criteria. The persisting shortfall in the availability of organs for transplantation has prompted many countries to re-introduce DCD schemes not only for kidney retrieval but increasingly for other organs with a lower tolerance for warm ischaemia such as the liver, pancreas, and lungs. DCD contrasts in many important respects to the current standard model for deceased donation, namely donation after brain death. The challenge in the practice of DCD includes how to identify patients as suitable potential DCD donors, how to support and maintain the trust of bereaved families, and how to manage the consequences of warm ischaemia in a fashion that is professionally, ethically, and legally acceptable. Many of the concerns about the practice of both controlled and uncontrolled DCD are being addressed by increasing professional consensus on the ethical and legal justification for many of the interventions necessary to facilitate DCD. In some countries, DCD after the withdrawal of active treatment accounts for a substantial proportion of deceased organ donors overall. Where this occurs, there is an increased acceptance that organ and tissue donation should be considered a routine part of end-of-life care in both intensive care unit and emergency department.
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Affiliation(s)
- A R Manara
- The Intensive Care Unit, Frenchay Hospital, Frenchay Park Road, Bristol BS16 1LE, UK.
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112
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Morrissey PE. The case for kidney donation before end-of-life care. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2012; 12:1-8. [PMID: 22650450 DOI: 10.1080/15265161.2012.671886] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Donation after cardiac death (DCD) is associated with many problems, including ischemic injury, high rates of delayed allograft function, and frequent organ discard. Furthermore, many potential DCD donors fail to progress to asystole in a manner that would enable safe organ transplantation and no organs are recovered. DCD protocols are based upon the principle that the donor must be declared dead prior to organ recovery. A new protocol is proposed whereby after a donor family agrees to withdrawal of life-sustaining treatments, premortem nephrectomy is performed in advance of end-of-life management. Since nephrectomy should not cause the donor's death, this approach satisfies the dead donor rule. The donor family's wishes are best met by organ donation, successful outcomes for the recipients, and a dignified death for the deceased. This proposal improves the likelihood of achieving these objectives.
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Affiliation(s)
- Paul E Morrissey
- Alpert Medical School of Brown University, Providence, RI 02903, USA.
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113
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Abboud I, Viglietti D, Antoine C, Gaudez F, Meria P, Tariel E, Mongiat-Artus P, Desgranchamps F, Roussin F, Fieux F, Jacob L, Randoux C, Michel C, Flamant M, Lefaucheur C, Pillebout E, Serrato T, Peraldi MN, Glotz D. Preliminary results of transplantation with kidneys donated after cardiocirculatory determination of death: a French single-centre experience. Nephrol Dial Transplant 2011; 27:2583-7. [DOI: 10.1093/ndt/gfr709] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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114
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de Vries EE, Hoogland ERP, Winkens B, Snoeijs MG, van Heurn LWE. Renovascular resistance of machine-perfused DCD kidneys is associated with primary nonfunction. Am J Transplant 2011; 11:2685-91. [PMID: 21967629 DOI: 10.1111/j.1600-6143.2011.03755.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Donation after cardiac death (DCD) has shown to be a valuable extension of the donor pool despite a higher percentage of primary nonfunction (PNF). Limiting the incidence of PNF is of vital importance. Renovascular resistance is believed to predict graft outcome; however the literature is inconsistent. Therefore, we studied whether renovascular resistance is associated with PNF and whether this parameter should be used to discard donor kidneys. All transplanted DCD kidneys preserved by machine perfusion at our center between 1993 and 2007 were analyzed (n = 440). The effects of renovascular resistance on PNF, delayed graft function (DGF), and graft and patient survival were examined using multivariable analyses; predictive quality by calculating the area under the curve (AUC). We showed that renovascular resistance at the start of machine perfusion was significantly and independently associated with PNF (OR 2.040, 95% CI 1.362-3.056; p = 0.001), and DGF (OR 2.345, 95% CI 1.110-4.955; p = 0.025). Predictive quality was moderate (0.609, 95% CI 0.538-0.681). Graft and patient survival were not associated with renovascular resistance. We conclude that renovascular resistance in DCD kidneys is an independent risk factor for PNF; however, the predictive value is relatively low.
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Affiliation(s)
- E E de Vries
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.
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115
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116
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Van Arendonk KJ, James NT, Locke JE, Montgomery RA, Colombani PM, Segev DL. Late graft loss among pediatric recipients of DCD kidneys. Clin J Am Soc Nephrol 2011; 6:2705-11. [PMID: 21940839 DOI: 10.2215/cjn.03760411] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Kidney transplantation from donors after cardiac death (DCD) provides similar graft survival to donors after brain death (DBD) in adult recipients. However, outcomes of DCD kidneys in pediatric recipients remain unclear, primarily because of limited sample sizes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We identified 137 pediatric (<18 years old) recipients of DCD kidneys between 1994 and 2010 using Scientific Registry of Transplant Recipients data and compared outcomes with 6059 pediatric recipients of DBD kidneys during the same time period, accounting for donor, recipient, and transplant characteristics using time-varying Cox regression and matched controls. Long-term follow-up (4 years or beyond) was available for 31 DCD recipients. RESULTS Pediatric recipients of DCD kidneys experienced a significantly higher rate of delayed graft function (22.0% versus 12.3%; P = 0.001), although lower than reported delayed graft function rates of DCD grafts in adults. Although DCD and DBD graft survival was equal in the early postoperative period, graft loss among pediatric recipients of DCD kidneys exceeded their DBD counterparts starting 4 years after transplantation. This effect was statistically significant in a multivariate Cox model (hazard ratio = 2.03; 95% confidence interval, 1.21 to 3.39; P = 0.007) and matched-controls analysis (hazard ratio = 2.36; 95% confidence interval, 1.11 to 5.03; P = 0.03). CONCLUSIONS A significant increase in DCD graft loss starting 4 years after transplantation motivates a cautious approach to the use of DCD kidneys in children, in whom long-term graft survival is of utmost importance.
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Affiliation(s)
- Kyle J Van Arendonk
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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117
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Abstract
The brain dead patient is the ideal multiorgan donor. Conversely, brain death (BD) is an undesirable outcome of critical care medicine. Conditions that can lead to the state of BD are limited. An analysis showed that a (aneurysmal) subarachnoid hemorrhage, traumatic brain injury, or intracerebral hemorrhage in 83% precede the state of BD. Because of better prevention and treatment options, we should anticipate on an inescapable and desirable decline of BD. In this article, we offer arguments for this statement and discuss alternatives to maintain a necessary level of donor organs for transplantation.
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118
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Abstract
PURPOSE OF REVIEW The purpose of the present review is to describe the techniques currently used to preserve kidneys from donors after cardiac death. RECENT FINDINGS Automated chest compression devices may be used to improve organ perfusion between cardiac death and preservation measures. Normothermic extracorporeal membrane oxygenation reduces warm ischemic injury and has the ability to improve organ viability in donors after cardiac death. SUMMARY Kidneys from donors after cardiac death expand the donor pool but are inevitably subjected to a period of warm ischemia. Reduction of warm ischemic injury to the organs improves transplant outcome. To reduce this injury in organs from donors after cardiac death, different preservation techniques are used. Automated chest compression devices improve organ perfusion between cardiac death and the start of organ preservation. In-situ preservation with double-balloon triple-lumen catheter is an easy technique to preserve organs in uncontrolled donors and is used in many centers to cool and flush the organs. In controlled donors, organs can also be flushed after laparotomy and direct cannulation of the aorta. Extracorporeal membrane oxygenation reduces warm ischemic injury and the use of normothermic perfusion seems promising. Optimal preservation is essential to improve the viability of kidneys from donors after cardiac death, to fully utilize this large donor pool.
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119
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Wind J, Snoeijs MGJ, van der Vliet JA, Winkens B, Christiaans MHL, Hoitsma AJ, van Heurn LWE. Preservation of kidneys from controlled donors after cardiac death. Br J Surg 2011; 98:1260-6. [PMID: 21656512 DOI: 10.1002/bjs.7543] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2011] [Indexed: 01/27/2023]
Abstract
BACKGROUND Donation after cardiac death (DCD) expands the pool of donor kidneys, but is associated with warm ischaemic injury. Two methods are used to preserve kidneys from controlled DCD donors and reduce warm ischaemic injury: in situ preservation using a double-balloon triple-lumen catheter (DBTL) inserted via the femoral artery and direct cannulation of the aorta after rapid laparotomy. The aim of this study was to compare these two techniques. METHODS This was a retrospective cohort study of 165 controlled DCD procedures in two regions in the Netherlands between 2000 and 2006. RESULTS There were 102 donors in the DBTL group and 63 in the aortic group. In the aortic group the kidney discard rate was lower (4·8 versus 28·2 per cent; P < 0·001), and the warm (22 versus 27 min; P < 0·001) and the cold (19 versus 24 h; P < 0·001) ischaemia times were shorter than in the DBTL group. Risk factors for discard included preservation with the DBTL catheter (odds ratio (OR) 5·19, 95 per cent confidence interval 1·88 to 14·36; P = 0·001) and increasing donor age (1·05, 1·02 to 1·07; P < 0·001). Warm ischaemia time had a significant effect on graft failure (hazard ratio 1·04, 1·01 to 1·07; P = 0·009), and consequently graft survival was higher in the aortic cannulation group (86·2 per cent versus 76·8 per cent in the DBTL group at 1 year; P = 0·027). CONCLUSION In this retrospective study, direct aortic cannulation appeared to be a better method to preserve controlled DCD kidneys.
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Affiliation(s)
- J Wind
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.
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120
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Roberts KJ, Muiesan P. Abdominal organ donation after death. Br J Surg 2011; 98:1185-7. [PMID: 21607938 DOI: 10.1002/bjs.7570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
New approaches to increase donor organ supply
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Affiliation(s)
- K J Roberts
- The Liver Unit, Third Floor Nuffield House, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK
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121
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Cantafio AW, Dick AAS, Halldorson JB, Bakthavatsalam R, Reyes JD, Perkins JD. Risk stratification of kidneys from donation after cardiac death donors and the utility of machine perfusion. Clin Transplant 2011; 25:E530-40. [PMID: 21585547 DOI: 10.1111/j.1399-0012.2011.01477.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- A W Cantafio
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA 98195, USA.
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122
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Reid AWN, Harper S, Jackson CH, Wells AC, Summers DM, Gjorgjimajkoska O, Sharples LD, Bradley JA, Pettigrew GJ. Expansion of the kidney donor pool by using cardiac death donors with prolonged time to cardiorespiratory arrest. Am J Transplant 2011; 11:995-1005. [PMID: 21449941 DOI: 10.1111/j.1600-6143.2011.03474.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Donation after Cardiac Death (DCD) is an increasingly important source of kidney transplants, but because of concerns of ischemic injury during the agonal phase, many centers abandon donation if cardiorespiratory arrest has not occurred within 1 h of controlled withdrawal of life-supporting treatment (WLST). We report the impact on donor numbers and transplant function using instead a minimum 'cut-off' time of 4 h. The agonal phase of 173 potential DCD donors was characterized according to the presence or absence of: acidemia; lactic acidosis; prolonged (>30 min) hypotension, hypoxia or oliguria, and the impact of these characteristics on 3- and 12-month transplant outcome evaluated by multivariable regression analysis. Of the 117 referrals who became donors, 27 (23.1%) arrested more than 1 h after WLST. Longer agonal-phase times were associated with greater donor instability, but surprisingly neither agonal-phase instability nor its duration influenced transplant outcome. In contrast, 3- and 12-month eGFR in the 190 transplanted kidneys was influenced independently by donor age, and 3-month eGFR by cold ischemic time. DCD kidney numbers are increased by 30%, without compromising transplant outcome, by lengthening the minimum waiting time after WLST from 1 to 4 h.
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Affiliation(s)
- A W N Reid
- Cambridge Transplant Unit, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK.
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123
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124
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Abstract
BACKGROUND The shortage of organ donors presents a major obstacle for adequate treatment of patients with end-stage renal disease. Donation after cardiac death (DCD) has been shown to increase the number of kidneys available for transplantation. The present article reports on the first 25 years of our experience with DCD kidney transplantation. METHODS This observational cohort study included all DCD kidney transplantations recovered in our procurement area from January 1, 1981 until December 31, 2005 (n=297). Patients were followed up until the earliest of death or December 31, 2006. Clinical outcomes were compared with matched kidney transplantations from brain dead donors (DBD, n=594), using multivariable regression models to adjust for potential confounders. RESULTS DCD activity resulted in a 44% increase in the number of deceased donor kidneys from our organ procurement area. After adjustment for potential confounders, the odds of primary nonfunction and delayed graft function were 7.5 (95% CI, 4.0-14.1; P<0.001) and 10.3 (95% CI, 6.7-15.9; P<0.001) times greater, respectively, for DCD kidneys compared with DBD kidneys. The high incidence of primary nonfunction of DCD kidneys resulted in an increased rate of graft loss (HR, 1.82; 95% CI, 1.37-2.42; P<0.001). However, DCD kidneys that did not experience primary nonfunction functioned as long as DBD kidneys (HR, 1.05; 95% CI, 0.73-1.51; P=0.79). Patient survival of DCD and DBD kidney recipients was equivalent (HR, 1.16; 95% CI, 0.87-1.54; P=0.32). CONCLUSIONS The benefits of DCD kidney transplantation outweigh the increased risk of early graft loss. Expansion of the supply of DCD kidneys is likely to improve the treatment of wait-listed dialysis patients.
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125
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Perfusion storage reduces apoptosis in a porcine kidney model of donation after cardiac death. Transplantation 2011; 91:169-75. [PMID: 21200363 DOI: 10.1097/tp.0b013e3182013753] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Donation after cardiac death (DCD) kidneys suffer a high incidence of delayed graft function attributable to warm ischemia and cold ischemia (CI). Neither the mechanism of injury nor type of cell death has been described. Clinical studies suggest that perfusion storage (PS) of DCD kidneys may reduce injury although the mechanism of protection is unknown. In a porcine model of DCD, we hypothesized that DCD kidneys have increased caspase-1 due to warm ischemia (WI) and increased caspase-3 and apoptosis due to CI. METHODS Male Yorkshire pigs subjected to cardiac death were perfused with cold University of Wisconsin solution. The perfused kidneys were removed and stored in cold University of Wisconsin solution for 24 hr. Kidney biopsies were obtained before cardiac death and at 0 and 24 hr of CI. RESULTS There was an increase in caspase-1 activity due to WI before cold preservation. CI was associated with a massive increase in apoptosis, caspase-3/7 activity, and caspase-3 protein expression. Next, we hypothesized that PS would protect against apoptosis. We compared DCD kidneys subjected to static versus PS for 24 hr. PS significantly reduced proximal tubular apoptosis and was associated with increased B-cell lymphoma-extra large, and hypoxia-inducible transcription factor-1α. CONCLUSIONS These findings suggest that in DCD kidneys, WI preferentially activates caspase-1, whereas CI activates caspase-3 and causes apoptosis. PS may protect DCD kidneys through activation of antiapoptotic pathways involving B-cell lymphoma-extra large and hypoxia-inducible transcription factor-1α.
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Are we ready to expand donation after cardiac death to the newborn population? J Pediatr 2011; 158:6-8. [PMID: 20869726 DOI: 10.1016/j.jpeds.2010.08.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 08/25/2010] [Indexed: 11/20/2022]
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Metzger JC, Eastman AL, Pepe PE. Year in review 2009: Critical Care--cardiac arrest, trauma and disasters. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:242. [PMID: 21122166 PMCID: PMC3220035 DOI: 10.1186/cc9302] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
During 2009, Critical Care published nine papers on various aspects of resuscitation, prehospital medicine, trauma care and disaster response. One article demonstrated that children as young as 9 years of age can learn cardiopulmonary resuscitation (CPR) effectively, although, depending on their size, some may have difficulty performing it. Another paper showed that while there was a trend toward mild therapeutic hypothermia reducing S-100 levels, there was no statistically significant change. Another predictor study also showed a strong link between acute kidney injury and neurologic outcome while another article described a program in which kidneys were harvested from cardiac arrest patients and showed an 89% graft survival rate. One experimental investigation indicated that when a pump-less interventional lung assist device is present, leaving the device open (unclamped) while performing CPR has no harmful effects on mean arterial pressures and it may have positive effects on blood oxygenation and CO2 clearance. One other study, conducted in the prehospital environment, found that end-tidal CO2 could be useful in diagnosing pulmonary embolism. Three articles addressed disaster medicine, the first of which described a triage system for use during pandemic influenza that demonstrated high reliability in delineating patients with a good chance of survival from those likely to die. The other two studies, both drawn from the 2008 Sichuan earthquake experience, showed success in treating crush injured patients in an on-site tent ICU and, in the second case, how the epidemiology of earthquake injuries and related factors predicted mortality.
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Affiliation(s)
- Jeffery C Metzger
- Department of Surgery/Emergency Medicine, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd, Mail Code 8579, Dallas, TX 75390-8579, USA.
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Irish WD, Ilsley JN, Schnitzler MA, Feng S, Brennan DC. A risk prediction model for delayed graft function in the current era of deceased donor renal transplantation. Am J Transplant 2010; 10:2279-86. [PMID: 20883559 DOI: 10.1111/j.1600-6143.2010.03179.x] [Citation(s) in RCA: 290] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Delayed graft function (DGF) impacts short- and long-term outcomes. We present a model for predicting DGF after renal transplantation. A multivariable logistic regression analysis of 24,337 deceased donor renal transplant recipients (2003-2006) was performed. We developed a nomogram, depicting relative contribution of risk factors, and a novel web-based calculator (http://www.transplantcalculator.com/DGF) as an easily accessible tool for predicting DGF. Risk factors in the modern era were compared with their relative impact in an earlier era (1995-1998). Although the impact of many risk factors remained similar over time, weight of immunological factors attenuated, while impact of donor renal function increased by 2-fold. This may reflect advances in immunosuppression and increased utilization of kidneys from expanded criteria donors (ECDs) in the modern era. The most significant factors associated with DGF were cold ischemia time, donor creatinine, body mass index, donation after cardiac death and donor age. In addition to predicting DGF, the model predicted graft failure. A 25-50% probability of DGF was associated with a 50% increased risk of graft failure relative to a DGF risk < 25%, whereas a > 50% DGF risk was associated with a 2-fold increased risk of graft failure. This tool is useful for predicting DGF and long-term outcomes at the time of transplant.
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Affiliation(s)
- W D Irish
- Biostatistics and Health Outcomes Research, CTI Clinical Trial and Consulting Services, Cincinnati, OH, USA.
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Kim JM, Kim SJ. The Use of Non-Heart Beating Donors to Expand the Donor Pool. KOREAN JOURNAL OF TRANSPLANTATION 2010. [DOI: 10.4285/jkstn.2010.24.3.165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Joo Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Kusaka M, Kuroyanagi Y, Ichino M, Sasaki H, Maruyama T, Hayakawa K, Shiroki R, Sugitani A, Kurahashi H, Hoshinaga K. Serum tissue inhibitor of metalloproteinases 1 (TIMP-1) predicts organ recovery from delayed graft function after kidney transplantation from donors after cardiac death. Cell Transplant 2010; 19:723-9. [PMID: 20525436 DOI: 10.3727/096368910x508825] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Donors after cardiac death (DCD) have recently become an important source of renal transplants to alleviate the shortage of renal grafts in kidney transplantation (KTx), although DCD kidneys often have complications associated with a delayed graft function (DGF). A microarray-based approach using renal biopsy samples obtained at 1 h after KTx from DCD identified the tissue inhibitor of metalloproteinases 1 (TIMP-1) gene as a potential predictive marker for DGF. The current study measured serum TIMP-1 in patients undergoing KTx and analyzed the time course after KTx. The average serum TIMP-1 level before KTx was 240 ± 10 ng/ml (n = 34). In patients undergoing KTx from a living donor (n = 23), the serum TIMP-1 levels showed no increase after KTx (POD1: 226 ± 12, POD2: 211 ± 12, and POD3: 195 ± 10 ng/ml), but in one case, the only patient who required post-KTx HD due to DGF, the level on POD1 was the highest among subjects (361 ng/ml). In contrast, patients undergoing KTx from DCDs (n = 11), the serum TIMP-1 levels increased rapidly after a KTx (POD1: 418 ± 32, POD2: 385 ± 42, and POD3: 278 ± 25 ng/ml). However, two patients who avoided post-KTx HD due to the immediate function of the graft did not show increased levels (<370 ng/ml) on either POD1 or POD2. The peak serum TIMP-1 values appeared to correlate to the post-KTx dialysis period. Furthermore, the increment of serum TIMP-1 on the early POD was found to be predictive of immediate or delayed function of the grafts. These data suggest that monitoring of serum TIMP-1 levels allow the prediction of graft recovery and the need for HD after a KTx from a DCD.
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Affiliation(s)
- Mamoru Kusaka
- Department of Urology, Division of Molecular Genetics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan.
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Snoeijs MG, Schaubel DE, Hené R, Hoitsma AJ, Idu MM, Ijzermans JN, Ploeg RJ, Ringers J, Christiaans MH, Buurman WA, van Heurn LWE. Kidneys from donors after cardiac death provide survival benefit. J Am Soc Nephrol 2010; 21:1015-21. [PMID: 20488954 DOI: 10.1681/asn.2009121203] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The continuing shortage of kidneys for transplantation requires major efforts to expand the donor pool. Donation after cardiac death (DCD) increases the number of available kidneys, but it is unknown whether patients who receive a DCD kidney live longer than patients who remain on dialysis and wait for a conventional kidney from a brain-dead donor (DBD). This observational cohort study included all 2575 patients who were registered on the Dutch waiting list for a first kidney transplant between January 1, 1999, and December 31, 2004. From listing until the earliest of death, living-donor kidney transplantation, or December 31, 2005, 459 patients received a DCD transplant and 680 patients received a DBD transplant. Graft failure during the first 3 months after transplantation was twice as likely for DCD kidneys than DBD kidneys (12 versus 6.3%; P=0.001). Standard-criteria DCD transplantation associated with a 56% reduced risk for mortality (hazard ratio 0.44; 95% confidence interval 0.24 to 0.80) compared with continuing on dialysis and awaiting a standard-criteria DBD kidney. This reduction in mortality translates into 2.4-month additional expected lifetime during the first 4 years after transplantation for recipients of DCD kidneys compared with patients who await a DBD kidney. In summary, standard-criteria DCD kidney transplantation associates with increased survival of patients who have ESRD and are on the transplant waiting list.
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Affiliation(s)
- Maarten G Snoeijs
- Department of Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, Netherlands.
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Abstract
Pediatric organ donation and organ transplantation can have a significant life-extending benefit to the young recipients of these organs and a high emotional impact on donor and recipient families. Pediatricians, pediatric medical specialists, and pediatric transplant surgeons need to be better acquainted with evolving national strategies that involve organ procurement and organ transplantation to help acquaint families with the benefits and risks of organ donation and transplantation. Efforts of pediatric professionals are needed to shape public policies to provide a system in which procurement, distribution, and cost are fair and equitable to children and adults. Major issues of concern are availability of and access to donor organs; oversight and control of the process; pediatric medical and surgical consultation and continued care throughout the organ-donation and transplantation process; ethical, social, financial, and follow-up issues; insurance-coverage issues; and public awareness of the need for organ donors of all ages.
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Halpern SD, Raz A, Kohn R, Rey M, Asch DA, Reese P. Regulated payments for living kidney donation: an empirical assessment of the ethical concerns. Ann Intern Med 2010; 152:358-65. [PMID: 20231566 PMCID: PMC2865248 DOI: 10.7326/0003-4819-152-6-201003160-00005] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Although regulated payments to encourage living kidney donation could reduce morbidity and mortality among patients waiting for a kidney transplant, doing so raises several ethical concerns. OBJECTIVE To determine the extent to which the 3 main concerns with paying kidney donors might manifest if a regulated market were created. DESIGN Cross-sectional study of participants' willingness to donate a kidney in 12 scenarios. SETTING Regional rail and urban trolley lines in Philadelphia County, Philadelphia, Pennsylvania. PARTICIPANTS Of 550 potential participants, 409 completed the questionnaire (response rate, 74.4%); 342 of these participants were medically eligible to donate. INTERVENTION Across scenarios, researchers experimentally manipulated the amount of money that participants would receive, the participants' risk for subsequently developing kidney failure themselves, and who would receive the donated kidney. MEASUREMENTS The researchers determined whether payment represents an undue inducement by evaluating participants' sensitivity to risk in relation to the payment offered or an unjust inducement by evaluating participants' sensitivity to payment as a function of their annual income. The researchers also evaluated whether introducing payment would hinder altruistic donations by comparing participants' willingness to donate altruistically before versus after the introduction of payments. RESULTS Generalized estimating equation models revealed that participants' willingness to donate increased significantly as their risk for kidney failure decreased, as the payment offered increased, and when the kidney recipient was a family member rather than a patient on a public waiting list (P < 0.001 for each). No statistical interactions were identified between payment and risk (odds ratio, 1.00 [95% CI, 0.96 to 1.03]) or between payment and income (odds ratio, 1.01 [CI, 0.99 to 1.03]). The proximity of these estimates to 1.0 and narrowness of the CIs suggest that payment is neither an undue nor an unjust inducement, respectively. Alerting participants to the possibility of payment did not alter their willingness to donate for altruistic reasons (P = 0.40). LIMITATION Choices revealed in hypothetical scenarios may not reflect real-world behaviors. CONCLUSION Theoretical concerns about paying persons for living kidney donation are not corroborated by empirical evidence. A real-world test of regulated payments for kidney donation is needed to definitively show whether payment provides a viable and ethical method to increase the supply of kidneys available for transplantation. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Scott D Halpern
- University of Pennsylvania School of Medicine and Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania 19104-6021, USA.
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137
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Halpern SD, Truog RD. Organ donors after circulatory determination of death: Not necessarily dead, and it does not necessarily matter*. Crit Care Med 2010; 38:1011-2. [DOI: 10.1097/ccm.0b013e3181cc1228] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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138
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Death and Donation in Critical Care: Management of Deceased Organ Donation. Neurocrit Care 2010. [DOI: 10.1007/978-1-84882-070-8_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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139
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140
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Chudzinski RE, Khwaja K, Teune P, Miller J, Tang H, Pavlakis M, Rogers C, Johnson S, Karp S, Hanto D, Mandelbrot D. Successful DCD kidney transplantation using early corticosteroid withdrawal. Am J Transplant 2010; 10:115-23. [PMID: 19958332 DOI: 10.1111/j.1600-6143.2009.02922.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Organs from donors after cardiac death (DCD) are being increasingly utilized. Prior reports of DCD kidney transplantation involve the use of prednisone-based immunosuppression. We report our experience with early corticosteroid withdrawal (ECSW). Data on 63 DCD kidney transplants performed between 2002 and 2007 were analyzed. We compared outcomes in 28 recipients maintained on long-term corticosteroids (LTCSs) with 35 recipients that underwent ECSW. DGF occurred in 49% of patients on ECSW and 46% on LTCS (p=0.8). There was no difference between groups for serum creatinine or estimated GFR between 1 and 36 months posttransplant. Acute rejection rates at 1 year were 11.4% and 21.4% for the ECSW and LTCS group (p=0.2). Graft survival at 1 and 3 years was 94% and 91% for the ECSW group versus 82% and 78% for the LTCS group (p>or=0.1). Death censored graft survival was significantly better at last follow-up for the ECSW group (p=0.02). Multivariate analysis revealed no correlation between the use of corticosteroids and survival outcomes. In conclusion, ECSW can be used successfully in DCD kidney transplantation with no worse outcomes in DGF, rejection, graft loss or the combined outcome of death and graft loss compared to patients receiving LTCS.
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Affiliation(s)
- R E Chudzinski
- Transplant Institute, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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141
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Successful Kidney Transplantation from a Donation After Cardiac Death Donor With an Ileal Conduit. Transplant Proc 2009; 41:4420-1. [DOI: 10.1016/j.transproceed.2009.09.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Revised: 05/21/2009] [Accepted: 09/02/2009] [Indexed: 11/20/2022]
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142
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Donación tras la muerte cardíaca. Parada cardíaca en el mantenimiento del donante en muerte encefálica. Med Intensiva 2009; 33:327-35. [DOI: 10.1016/j.medin.2008.12.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Accepted: 12/20/2008] [Indexed: 11/18/2022]
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143
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Muñoz Camargo JC. [Review of knowledge of nursing care in organ and tissue transplantation (Test answer Vol. 20-number 2)]. ENFERMERIA INTENSIVA 2009; 20:122-6. [PMID: 19775570 DOI: 10.1016/s1130-2399(09)72593-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- J C Muñoz Camargo
- Unidad de Cuidados Intensivos, Hospital General de Ciudad Real, Ciudad Real, España
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144
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Reich DJ, Mulligan DC, Abt PL, Pruett TL, Abecassis MMI, D'Alessandro A, Pomfret EA, Freeman RB, Markmann JF, Hanto DW, Matas AJ, Roberts JP, Merion RM, Klintmalm GBG. ASTS recommended practice guidelines for controlled donation after cardiac death organ procurement and transplantation. Am J Transplant 2009; 9:2004-11. [PMID: 19624569 DOI: 10.1111/j.1600-6143.2009.02739.x] [Citation(s) in RCA: 253] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The American Society of Transplant Surgeons (ASTS) champions efforts to increase organ donation. Controlled donation after cardiac death (DCD) offers the family and the patient with a hopeless prognosis the option to donate when brain death criteria will not be met. Although DCD is increasing, this endeavor is still in the midst of development. DCD protocols, recovery techniques and organ acceptance criteria vary among organ procurement organizations and transplant centers. Growing enthusiasm for DCD has been tempered by the decreased yield of transplantable organs and less favorable posttransplant outcomes compared with donation after brain death. Logistics and ethics relevant to DCD engender discussion and debate among lay and medical communities. Regulatory oversight of the mandate to increase DCD and a recent lawsuit involving professional behavior during an attempted DCD have fueled scrutiny of this activity. Within this setting, the ASTS Council sought best-practice guidelines for controlled DCD organ donation and transplantation. The proposed guidelines are evidence based when possible. They cover many aspects of DCD kidney, liver and pancreas transplantation, including donor characteristics, consent, withdrawal of ventilatory support, operative technique, ischemia times, machine perfusion, recipient considerations and biliary issues. DCD organ transplantation involves unique challenges that these recommendations seek to address.
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Affiliation(s)
- D J Reich
- Drexel University College of Medicine, Philadelphia, PA, USA.
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Fieux F, Losser MR, Bourgeois E, Bonnet F, Marie O, Gaudez F, Abboud I, Donay JL, Roussin F, Mourey F, Adnet F, Jacob L. Kidney retrieval after sudden out of hospital refractory cardiac arrest: a cohort of uncontrolled non heart beating donors. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R141. [PMID: 19715564 PMCID: PMC2750199 DOI: 10.1186/cc8022] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Revised: 07/01/2009] [Accepted: 08/28/2009] [Indexed: 12/02/2022]
Abstract
Introduction To counter the shortage of kidney grafts in France, a non heart beating donor (NHBD) program has recently been implemented. The aim of this study was to describe this pilot program for kidney retrieval from "uncontrolled" NHBD meaning those for whom attempts of resuscitation after a witnessed out-of-hospital cardiac arrest (CA) have failed (Maastricht 1 and 2), in a centre previously trained for retrieval from brain dead donors. Methods A prospective, monocentric, descriptive study concerning NHBD referred to our institution from February 2007 to June 2008. The protocol includes medical transport of refractory CA under mechanical ventilation and external cardiac massage, kidney protection by insertion of an intraaortic double-balloon catheter (DBC) with perfusion of a hypothermic solution, kidney retrieval and kidney preservation in a hypothermic pulsatile perfusion machine. Results 122 potential NHBD were referred to our institution after a mean resuscitation attempt of 35 minutes (20–95). Regarding the contraindications, 63 were finally accepted and 56 had the DBC inserted. Organ retrieval was performed in 27 patients (43%) and 31 kidneys out of the 54 procured (57%) have been transplanted. Kidney transplantation exclusion was related to family refusal (n = 15), past medical history, time constraints, viral serology, high vascular ex vivo resistance of the graft and macroscopic abnormalities. The 31 kidneys exhibited an expected high delayed graft function rate (92%). Despite these initial results transplanted kidney had good creatinine clearance at six months (66 ± 24 ml/min) with a 89% graft survival rate at six months. Conclusions This study shows the feasibility and efficacy of an organ procurement program targeting NHBD allowing a 10% increase in the kidney transplantation rate over 17 months. With a six months follow-up period, the results of transplanted kidney function were excellent.
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Affiliation(s)
- Fabienne Fieux
- Department of Anesthesia and Critical Care, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris-7 Diderot, 1 Avenue Claude Vellefaux, 75010 Paris, France.
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146
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Sharp TA. The Impact of Trust Study Days on Organ and Tissue Donation among Critical Care Staff. J Intensive Care Soc 2009. [DOI: 10.1177/175114370901000308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
The UK has one of the lowest rates of organ donation in Western Europe. Several barriers to the donation process have been identified. Among these are lack of knowledge, failure of staff to identify potential donors and feeling that it is someone else's responsibility to request for donation. Evidence suggests that educational programmes covering issues regarding organ and tissue donation enhance knowledge and confidence in the organ donation process and ultimately increase the number of potential donors. In 2002, Bolton NHS trust made changes aiming to increase donor rates. Trust study days were introduced, aiming to educate staff about aspects of donation. Since then, Bolton has had a significant increase in donor rates. The purposes of this audit were to assess present levels of knowledge and attitudes about organ and tissue donation and to see whether the introduction of trust study days has made a positive impact amongst critical care staff. The findings of this audit are encouraging, showing a positive impact on both staff knowledge and attitudes towards donation and reflecting a change in culture within the trust.
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147
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Barlow AD, Metcalfe MS, Johari Y, Elwell R, Veitch PS, Nicholson ML. Case-matched comparison of long-term results of non-heart beating and heart-beating donor renal transplants. Br J Surg 2009; 96:685-91. [PMID: 19434702 DOI: 10.1002/bjs.6607] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Function and survival of non-heart-beating donor (NHBD) renal transplants have been shown to be comparable to those from heart-beating donors (HBDs) up to 10 years after transplantation. However, there are few data on outcome after 10 years, particularly from uncontrolled NHBD donors. METHODS All NHBD renal transplants (predominantly uncontrolled) performed between April 1992 and January 2002 were retrospectively matched with HBD renal transplants performed over the same period. RESULTS Some 112 NHBD renal transplants were compared with 164 HBD renal transplants. Delayed graft function was significantly higher in the NHBD group (83.9 versus 22.0 per cent respectively; P < 0.001). Primary non-function rates were similar (5.4 versus 1.8 per cent respectively; P = 0.164). Overall serum creatinine was significantly higher in NHBDs (P < 0.001). Median graft and patient survival was 126 months for NHBD and 159 months for HBD kidneys. Death-censored graft survival at 1, 5, 10 and 15 years was respectively 91.8, 77.5, 61.0 and 44.2 per cent for NHBD, and 91.1, 86.3, 71.7 and 58.5 per cent for HBD kidneys (P = 0.108). CONCLUSION Despite increased delayed graft function rates and serum creatinine levels, the long-term survival of NHBD renal transplants was similar to those from HBDs. However, there was a trend to poorer function and survival from 10 years after transplant.
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Affiliation(s)
- A D Barlow
- Department of Transplant Surgery, Leicester General Hospital, Leicester, UK.
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148
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Revisión de conocimientos sobre atención de Enfermería en el trasplante de órganos y tejidos. ENFERMERIA INTENSIVA 2009. [DOI: 10.1016/s1130-2399(09)71149-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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149
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Kusaka M, Kuroyanagi Y, Mori T, Nagaoka K, Sasaki H, Maruyama T, Hayakawa K, Shiroki R, Kurahashi H, Hoshinaga K. Global Expression Profiles in 1-Hour Biopsy Specimens of Human Kidney Transplantation from Donors after Cardiac Death. Cell Transplant 2009; 18:647-56. [DOI: 10.1177/096368970901805-621] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Because of the worldwide shortage of renal grafts, kidney transplantation (KTx) from donors after cardiac death (DCD) is an alternative way to obtain KTx from brain-dead donors. Although the prognosis of DCD KTx is gradually improving, the graft often undergoes delayed graft function (DGF), rendering the control of DGF essential for post-KTx patient care. In an attempt to characterize etiology of DGF, genome-wide gene expression profiling was performed using renal biopsy samples performed at 1 h after KTx from DCD and the data were compared with those of KTx from living donors (LD). A total of 526 genes were differentially expressed between them. Genes involved in acute inflammation were activated, while metabolic pathways were consistently downregulated in DCD. These findings imply the inferior performance of the DCD grafts relative to LD grafts. Several genes were identified where the expression levels were correlated well with parameters indicating short- and long-term prognosis of the DCD patients. In addition, several genes encoding secretory proteins were identified that might reflect the performance of the graft and be potential noninvasive biomarkers. These data provide a good source for candidates of biomarkers that are potentially useful for the control of DGF.
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Affiliation(s)
- Mamoru Kusaka
- Department of Urology, Division of Molecular Genetics, Institute for Comprehensive Medical Science and 21st Century COE Program, Development Center for Targeted and Minimally Invasive Diagnosis and Treatment, Fujita Health University School of Medicine, Aichi 470-1192, Japan
| | - Yoko Kuroyanagi
- Department of Urology, Division of Molecular Genetics, Institute for Comprehensive Medical Science and 21st Century COE Program, Development Center for Targeted and Minimally Invasive Diagnosis and Treatment, Fujita Health University School of Medicine, Aichi 470-1192, Japan
| | - Terumi Mori
- Department of Urology, Division of Molecular Genetics, Institute for Comprehensive Medical Science and 21st Century COE Program, Development Center for Targeted and Minimally Invasive Diagnosis and Treatment, Fujita Health University School of Medicine, Aichi 470-1192, Japan
| | - Kayuri Nagaoka
- Department of Urology, Division of Molecular Genetics, Institute for Comprehensive Medical Science and 21st Century COE Program, Development Center for Targeted and Minimally Invasive Diagnosis and Treatment, Fujita Health University School of Medicine, Aichi 470-1192, Japan
| | - Hitomi Sasaki
- Department of Urology, Division of Molecular Genetics, Institute for Comprehensive Medical Science and 21st Century COE Program, Development Center for Targeted and Minimally Invasive Diagnosis and Treatment, Fujita Health University School of Medicine, Aichi 470-1192, Japan
| | - Takahiro Maruyama
- Department of Urology, Division of Molecular Genetics, Institute for Comprehensive Medical Science and 21st Century COE Program, Development Center for Targeted and Minimally Invasive Diagnosis and Treatment, Fujita Health University School of Medicine, Aichi 470-1192, Japan
| | - Kunihiro Hayakawa
- Department of Urology, Division of Molecular Genetics, Institute for Comprehensive Medical Science and 21st Century COE Program, Development Center for Targeted and Minimally Invasive Diagnosis and Treatment, Fujita Health University School of Medicine, Aichi 470-1192, Japan
| | - Ryoichi Shiroki
- Department of Urology, Division of Molecular Genetics, Institute for Comprehensive Medical Science and 21st Century COE Program, Development Center for Targeted and Minimally Invasive Diagnosis and Treatment, Fujita Health University School of Medicine, Aichi 470-1192, Japan
| | - Hiroki Kurahashi
- Department of Urology, Division of Molecular Genetics, Institute for Comprehensive Medical Science and 21st Century COE Program, Development Center for Targeted and Minimally Invasive Diagnosis and Treatment, Fujita Health University School of Medicine, Aichi 470-1192, Japan
| | - Kiyotaka Hoshinaga
- Department of Urology, Division of Molecular Genetics, Institute for Comprehensive Medical Science and 21st Century COE Program, Development Center for Targeted and Minimally Invasive Diagnosis and Treatment, Fujita Health University School of Medicine, Aichi 470-1192, Japan
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