201
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Kusaka M, Kubota Y, Sasaki H, Maruyama T, Hayakawa K, Shiroki R, Hoshinaga K. Is Pulsatile Perfusion Necessary for Renal Transplantation Engrafting Kidneys From Cardiac Death Donors? Transplant Proc 2006; 38:3388-9. [PMID: 17175279 DOI: 10.1016/j.transproceed.2006.10.081] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2006] [Indexed: 11/25/2022]
Abstract
BACKGROUND There has been a considerable literature describing the use of pulsatile perfusion (PP) to evaluate the efficacy of organs from deceased donors. Since 1979, we recovered 469 kidneys from deceased donors after cardiac death (DCDs), using an in situ regional cooling technique and preservation by simple cold storage. In this study, the posttransplantation outcomes as well as long-term survivals of renal grafts from DCDs were compared with PP data in the recent literature. MATERIALS AND METHODS We compared our recent data with 176 kidneys recovered between 1993-2002 using an in situ regional cooling technique. Patient and graft survivals were compared with those from the Scientific Registry of Transplant Recipients (SRTR) database. RESULTS Following transplantation, 4.5% of the grafts never recovered; 10.3% of the grafts showed immediate renal function; 85.2% of the grafts had delayed graft function (DGF) with an average acute tubular necrosis (ATN) period of 13.1 days compared with 54.3% DGF from DCD using PP. Graft survival rates at 1, 3, 5, and 10 years were 90.8%, 86.5%, 77.8%, and 69.0%, respectively, compared with 89% at 1 year and 80% at 3 years reported for DCD by the SRTR in which almost 30% of the grafts underwent PP. CONCLUSIONS Although PP seemed to have some advantage to decrease the DGF ratio, an in situ regional cooling technique with simple cold storage may provide excellent graft function and long-term graft survival as well as having benefits in cost and transportation.
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Affiliation(s)
- M Kusaka
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan.
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202
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Koh HK, Jacobson MD, Lyddy AM, O'Connor KJ, Fitzpatrick SM, Krakow M, Judge CM, Alpert HR, Luskin RS. A statewide public health approach to improving organ donation: the Massachusetts Organ Donation Initiative. Am J Public Health 2006; 97:30-6. [PMID: 17138917 PMCID: PMC1716249 DOI: 10.2105/ajph.2005.077701] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Despite the growing disparity between organ supply and demand in the United States, few initiatives have attempted to close the gap through systematic population-based public health endeavors. We examined the evolution, implementation, and outcomes of the Massachusetts Organ Donation Initiative, a statewide effort that included a unique partnership among organ procurement organizations, major teaching hospitals, and the state's department of public health. Lessons from this initiative have contributed to growing national efforts for increasing organ supply and have provided insights for addressing this continuing public health challenge.
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Affiliation(s)
- Howard K Koh
- Division of Public Health Practice, Harvard School of Public Health, Boston, Mass 02115, USA.
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203
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de Vries B, Snoeijs MGJ, von Bonsdorff L, Ernest van Heurn LW, Parkkinen J, Buurman WA. Redox-active iron released during machine perfusion predicts viability of ischemically injured deceased donor kidneys. Am J Transplant 2006; 6:2686-93. [PMID: 16889604 DOI: 10.1111/j.1600-6143.2006.01510.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Redox-active iron, catalyzing the generation of reactive oxygen species, has been implicated in experimental renal ischemia-reperfusion injury. However, in clinical transplantation, it is unknown whether redox-active iron is involved in the pathophysiology of ischemic injury of non-heart-beating (NHB) donor kidneys. We measured redox-active iron concentrations in perfusate samples of 231 deceased donor kidneys that were preserved by machine pulsatile perfusion at our institution between May 1998 and November 2002 using the bleomycin detectable iron assay. During machine pulsatile perfusion, redox-active iron was released into the preservation solution. Ischemically injured NHB donor kidneys had significantly higher perfusate redox-active iron concentrations than heart-beating (HB) donor kidneys that were not subjected to warm ischemia (3.9 +/- 1.1 vs. 2.8 +/- 1.0 micromol/L, p = 0.001). Moreover, redox-active iron concentration was an independent predictor of post-transplant graft viability (odds ratio 1.68, p = 0.01) and added predictive value to currently available donor and graft characteristics. This was particularly evident in uncontrolled NHB donor kidneys for which there is the greatest uncertainty about transplant outcomes. Therefore, perfusate redox-active iron concentration shows promise as a novel viability marker of NHB donor kidneys.
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Affiliation(s)
- B de Vries
- Department of Surgery, Nutrition and Toxicology Research Institute Maastricht (NUTRIM), Academic Hospital Maastricht and Maastricht University, Maastricht, The Netherlands
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204
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Affiliation(s)
- Rahul Deshpande
- Kings College London School of Medicine at Kings College Hospital, Institute of Liver Studies, Denmark Hill, Camberwell, London SE5 9RS, UK
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205
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Abt PL, Fisher CA, Singhal AK. Donation after Cardiac Death in the US: History and Use. J Am Coll Surg 2006; 203:208-25. [PMID: 16864034 DOI: 10.1016/j.jamcollsurg.2006.03.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2005] [Revised: 03/15/2006] [Accepted: 03/20/2006] [Indexed: 01/28/2023]
Affiliation(s)
- Peter L Abt
- Division of Solid Organ Transplantation, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
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206
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Whiting JF, Delmonico F, Morrissey P, Basadonna G, Johnson S, Lewis WD, Rohrer R, O'Connor K, Bradley J, Lovewell TD, Lipkowitz G. Clinical results of an organ procurement organization effort to increase utilization of donors after cardiac death. Transplantation 2006; 81:1368-71. [PMID: 16732170 DOI: 10.1097/01.tp.0000179641.82031.ea] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND To stimulate organ donation, an organ procurement organization (OPO)-wide effort was undertaken to increase donors after cardiac death (DCD) over a 5-year period. This included commonality of protocols, pulsatile perfusion of kidneys, centralization of data and a regional allocation variance designed to minimize cold ischemia times and encourage adoption of DCD protocols at transplant centers. RESULTS In one OPO, eight centers initiated DCD programs in 11 hospitals. A total of 52 DCD donors were procured, increasing from four in 1999 to 21 in 2003. Eleven donors had care withdrawn in the operating room, whereas 41 had care withdrawn in the ICU. In all, 91 patients received renal transplants from these 52 donors (12 kidneys discarded, one double transplant), whereas 5 patients received liver transplants. One-, two-, and three-year kidney graft survival rates were 90%, 90%, and 82%, respectively. Fifty-five percent of patients needed at least one session of hemodialysis postoperatively. Mean recipient hospital length of stay was 11.1+/-6 days. Mean creatinine levels at 3, 6, 12, and 24 months were 1.65, 1.40, 1.41, and 1.40, respectively. CONCLUSIONS DCD donors can be an important source of donor organs and provide excellent overall outcomes. Regional cooperation and a prospectively considered allocation and distribution system are important considerations in stimulating DCD programs.
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Affiliation(s)
- James F Whiting
- Department of Surgery, Maine Medical Center, Portland, 04102, USA.
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207
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Gagandeep S, Matsuoka L, Mateo R, Cho YW, Genyk Y, Sher L, Cicciarelli J, Aswad S, Jabbour N, Selby R. Expanding the donor kidney pool: utility of renal allografts procured in a setting of uncontrolled cardiac death. Am J Transplant 2006; 6:1682-8. [PMID: 16827871 DOI: 10.1111/j.1600-6143.2006.01386.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The chronic shortage of deceased kidney donors has led to increased utilization of donation after cardiac death (DCD) kidneys, the majority of which are procured in a controlled setting. The objective of this study is to evaluate transplantation outcomes from uncontrolled DCD (uDCD) donors and evaluate their utility as a source of donor kidneys. From January 1995 to December 2004, 75,865 kidney-alone transplants from donation after brain death (DBD) donors and 2136 transplants from DCD donors were reported to the United Network for Organ Sharing. Among the DCD transplants, 1814 were from controlled and 216 from uncontrolled DCD donors. The log-rank test was used to compare survival curves. The incidence of delayed graft function in controlled DCD (cDCD) was 42% and in uDCD kidneys was 51%, compared to only 24% in kidneys from DBD donors (p < 0.001). The overall graft and patient survival of DCD donors was similar to that of DBD donor kidneys (p = 0.66; p = 0.88). Despite longer donor warm and cold ischemic times, overall graft and patient survival of uDCD donors was comparable to that of cDCD donors (p = 0.65, p = 0.99). Concerted efforts should be focused on procurement of uDCD donors, which can provide another source of quality deceased donor kidneys.
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Affiliation(s)
- S Gagandeep
- Keck School of Medicine, Division of Hepatobiliary/Pancreatic Surgery and Abdominal Organ Transplantation, University of Southern California, Los Angeles, California, USA
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208
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Dahm F, Weber M, Müller B, Pradel FG, Laube GF, Neuhaus TJ, Cao C, Wüthrich RP, Thiel GT, Clavien PA. Open and laparoscopic living donor nephrectomy in Switzerland: a retrospective assessment of clinical outcomes and the motivation to donate. Nephrol Dial Transplant 2006; 21:2563-8. [PMID: 16702206 DOI: 10.1093/ndt/gfl207] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Laparoscopic living kidney nephrectomy is thought to be associated with reduced morbidity, when compared to open nephrectomy. The purpose of this study was to explore the impact of these techniques on donors' clinical outcomes, satisfaction and motivation to donate. METHODS Clinical outcomes were retrospectively compared in 152 open (n = 71) or laparoscopic (n = 81) donor procedures. Donor satisfaction and motivation were assessed with a self-administered questionnaire. RESULTS The complication rate was the same with both procedures and the majority of complications were mild. Laparoscopy was significantly less painful and resulted in an insignificantly faster return to active life. More than 80% of the donors volunteered to donate without pressure. Worries about future health status, pain or scars were not important in the decision to donate. Similarly, only 15% considered the surgical procedure as instrumental for their decision. Few donors currently worried about their health with one kidney and more than 95% of the donors in both groups stated that they would give their kidney again. CONCLUSIONS Living donor nephrectomy is safe, regardless of the procedure used. Although the laparoscopic nephrectomy offers clear short-term benefits over the open nephrectomy, donors' satisfaction was excellent with both surgical approaches. Moreover, the type of procedure did not seem to influence their decision to donate.
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Affiliation(s)
- Felix Dahm
- Department of Visceral and Transplantation Surgery, University Hospital Zurich, Rämistr. 100, CH-8091 Zurich, Switzerland
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209
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Cohen DJ, St Martin L, Christensen LL, Bloom RD, Sung RS. Kidney and pancreas transplantation in the United States, 1995-2004. Am J Transplant 2006; 6:1153-69. [PMID: 16613593 DOI: 10.1111/j.1600-6143.2006.01272.x] [Citation(s) in RCA: 124] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This article examines OPTN/SRTR data on kidney and pancreas transplantation for 2004 and the previous decade, and discusses recent changes in kidney-pancreas (KP) allocation policy and emerging issues in kidney donation after cardiac death (DCD). Although the number of kidney donors continues to increase, new waiting list registrations again outpaced the number of kidney transplants performed, rising by 11% between 2003 and 2004 and contributing to a 1-year increase of 8% in the number of patients active on the waiting list. DCD has increased steadily since 2000; 39% more DCD transplants were performed in 2004 than 2003. Both deceased donor and living donor kidney graft survival rates remain excellent and are improving. The number of people living with a functioning kidney transplant doubled between 1995 and 2004, to 101,440 with a functioning kidney-alone and 7213 with a functioning KP. Health care providers in all settings are more likely to be exposed to these transplant recipients. Patient survival following simultaneous pancreas-kidney (SPK) transplantation is excellent and has improved incrementally since 1995; death rates in the first year fell from 60 per 1000 patient-years at risk in 2001 to 45 in 2003. The number of solitary pancreas transplants increased dramatically in 2004.
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Affiliation(s)
- D J Cohen
- Columbia University Medical Center, New York, NY, USA.
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210
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Snoeijs MGJ, Schaefer S, Christiaans MH, van Hooff JP, van den Berg-Loonen PM, Peutz-Kootstra CJ, Buurman WA, van Heurn LWE. Kidney transplantation using elderly non-heart-beating donors: a single-center experience. Am J Transplant 2006; 6:1066-71. [PMID: 16611345 DOI: 10.1111/j.1600-6143.2006.01312.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Although acceptable outcomes have been reported in both non-heart-beating (NHB) and elderly donors individually, the large pool of elderly NHB donors has not yet been fully utilized. In 1994, we expanded our transplant protocol to include NHB donors aged over 65 years and this study compares the clinical outcomes with regular NHB transplantations. Up to June 2005, 24 patients were transplanted at our center with kidneys from NHB donors aged 65 years or more, whereas 176 patients received grafts from conventional NHB donors during the same period. Grafts from older donors were associated with inferior glomerular filtration rates (29 vs. 44 mL/min after 1 year, p=0.01) and graft survival (52% vs. 68% after 5 years, p=0.19) compared to younger NHB donor grafts, although the difference in graft survival was not statistically significant. Exclusion of older NHB donor kidneys with severe vascular pathology resulted in similar graft survival of older and younger NHB donor kidneys. We conclude that the use of elderly NHB donors in order to expand the donor pool was associated with unacceptable clinical outcomes and cannot be justified without further refinement in their selection, for example, by histological assessment of pretransplant biopsies.
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Affiliation(s)
- M G J Snoeijs
- Department of Surgery, Nutrition and Toxicology Research Institute Maastricht (NUTRIM), University Hospital Maastricht and Maastricht University. The Netherlands
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211
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Edwards J, Mulvania P, Robertson V, George G, Hasz R, Nathan H, D’Alessandro A. Maximizing Organ Donation Opportunities Through Donation After Cardiac Death. Crit Care Nurse 2006. [DOI: 10.4037/ccn2006.26.2.101] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- John Edwards
- John Edwards is the clinical administrator for Gift of Life Donor Program in Philadelphia, Pa, overseeing all clinical aspects of organ and tissue recovery, and a faculty member for the Gift of Life Institute, Philadelphia, providing training and mentoring for healthcare organizations nationally
| | - Patti Mulvania
- Patti Mulvania oversees the clinical education program for the Gift of Life Donor Program in Philadelphia and is a faculty member of the Gift of Life Institute, specializing in consent and clinical communication
| | - Virginia Robertson
- Virginia Robertson is the associate director of the Gift of Life Institute in Philadelphia. Formerly, she was the director of hospital services for the Gift of Life Donor Program
| | - Gweneth George
- Gweneth George is the director of hospital services for the Gift of Life Donor Program in Philadelphia. She directs a team of nearly 20 hospital development staff accountable for donation performance in 150 acute care hospitals
| | - Richard Hasz
- Richard Hasz is vice president of clinical services for the Gift of Life Donor Program in Philadelphia. He oversees the day-to-day clinical operations, including transplant coordination, hospital development, organ preservation, and tissue recovery
| | - Howard Nathan
- Howard Nathan is president and chief executive officer of the Gift of Life Donor Program in Philadelphia. The program has been involved in coordinating more than 22 000 organ transplantations and tens of thousands of tissue transplantations since 1974
| | - Anthony D’Alessandro
- Anthony D’Alessandro is a professor of surgery at the University of Wisconsin Medical School and the executive director of the University of Wisconsin Hospital and Clinics organ procurement organization, Madison, Wis. He is currently the cochair of the Organ Transplantation Breakthrough Collaborative
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212
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Nuñez JR, Del Rio F, Lopez E, Moreno MA, Soria A, Parra D. Non-heart-beating donors: an excellent choice to increase the donor pool. Transplant Proc 2006; 37:3651-4. [PMID: 16386494 DOI: 10.1016/j.transproceed.2005.09.105] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A specific program was adopted to obtain organs, for transplant purposes from people who die at home or in the street from sudden or unexpected death (type I non-heart-beating donors [NHBD] according to the Maastricht classification). The objective of our program was to increase the donor pool by obtaining organs from well-selected potential donors who die at home, work, or in the street and are maintained on advanced life support (ALS) until hospital arrival. The great number of people who die in a previously healthy situation constitute an excellent source of organs for transplant purposes. Our program includes pre- and in-hospital attendance. Prehospital attendance is based on application of cardiopulmonary resuscitation in situ and ALS until arrival at hospital. In hospital, specific preservation maneuvers must be performed and family assessment and judge permission obtained. In the last 15 years, we developed a kidney transplant program with better results than transplants performed with organs obtained from encephalic death donors (EDD). A specific NHBD subprogram for lung transplant was developed with excellent results as well. We are now improving the liver transplant program. NHBD are an important source of human tissues, including pancreas islets. It is clear that NHBD are a great source of organs and tissues for transplant, and that this kind of program must be established in all countries in which legal regulations allow it.
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Affiliation(s)
- J R Nuñez
- Hospital Clinico San Carlos, Madrid, Spain.
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213
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Fernandez LA, Di Carlo A, Odorico JS, Leverson GE, Shames BD, Becker YT, Chin LT, Pirsch JD, Knechtle SJ, Foley DP, Sollinger HW, D'Alessandro AM. Simultaneous pancreas-kidney transplantation from donation after cardiac death: successful long-term outcomes. Ann Surg 2005; 242:716-23. [PMID: 16244546 PMCID: PMC1409854 DOI: 10.1097/01.sla.0000186175.84788.50] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The outcomes of simultaneous pancreas-kidney (SPK) transplantation with donor organs procured from donation after cardiac death (DCD) are compared with transplants performed with donor organs recovered from donation after brain death (DBD). SUMMARY BACKGROUND DATA Concerns exist regarding the utilization of pancreata obtained from DCD donors. While it is known that DCD kidneys will have a higher rate of DGF, long-term functional graft survival data for DCD pancreata have not been reported. METHODS A retrospective review of all DCD SPK transplants performed at a single center was undertaken. RESULTS Patient, pancreas, and kidney survival at 5 years were similar between DCD and DBD organs. Pancreas function and outcomes were indistinguishable between the 2 modes of procurement. As expected, the DCD kidneys had an elevated rate of DGF, which had no significant long-term clinical impact. CONCLUSION SPK transplantation using selected DCD donors is a safe and viable method to expand the organ pool for transplantation.
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Affiliation(s)
- Luis A Fernandez
- Division of Transplantation, University of Wisconsin Medical School, Madison, WI 53792-7375, USA
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214
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Muiesan P, Girlanda R, Jassem W, Melendez HV, O'Grady J, Bowles M, Rela M, Heaton N. Single-center experience with liver transplantation from controlled non-heartbeating donors: a viable source of grafts. Ann Surg 2005; 242:732-8. [PMID: 16244548 PMCID: PMC1409859 DOI: 10.1097/01.sla.0000186177.26112.d2] [Citation(s) in RCA: 143] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND To increase the number of livers available for transplantation a non-heartbeating donor (NHBD) liver transplant program was started after obtaining hospital ethical committee approval. METHODS Controlled donors with a warm ischemia of <30 minutes were considered. A 5-minute stand-off period was observed from asystole to skin incision. A super-rapid technique was used for the retrieval. Methods used to assess the suitability for transplantation included liver function tests, morphologic and histologic assessment, and hepatocyte viability testing. RESULTS Sixty livers were retrieved from NHBDs. Of these, 33 were judged suitable for transplantation. Of these one was exported and transplanted, and one could not be matched to a suitable recipient. A further 27 were not used because of liver appearance in 21, prolonged hypoxia and hypotension in 4, poor perfusion in 1, and donor malignancy in 1. Mean donor age was 39.4 years (range, 0.75-67 years). Causes of death were head trauma in 10 donors, intracranial bleed in 24, and anoxic/ischemic brain injury in 26. Mean warm ischemia time was 14.7 minutes (range, 7-40 minutes). Thirty-two patients were transplanted (one split liver), and the mean age of the recipients was 38.4 years (range, 0.7-72 years). All grafts had good early function except one right lobe split. There were 4 deaths resulting from ischemic brain injury, chronic rejection, biliary sepsis, and multiorgan failure following retransplantation for primary nonfunction. Overall patient and graft survival is 87% and 84%, respectively, at a median follow-up of 15 months. CONCLUSIONS Early results suggest that controlled NHBDs are a significant new source of grafts, but careful donor selection and short cold ischemia are mandatory.
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Affiliation(s)
- Paolo Muiesan
- Department of Liver Transplantation and HPB Surgery, King's College Hospital, London, UK.
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215
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Johnson SR, Pavlakis M, Khwaja K, Karp SJ, Curry M, Curran CC, Monaco AP, Hanto DW. Intensive Care Unit Extubation Does Not Preclude Extrarenal Organ Recovery from Donors after Cardiac Death. Transplantation 2005; 80:1244-50. [PMID: 16314792 DOI: 10.1097/01.tp.0000179643.56257.7f] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND We have sought to increase the utilization of both renal and extrarenal organs from donors after cardiac death (DCD), including DCD donors with ICU extubation. METHODS Extubation occurred in the intensive care unit (ICU; n=15) and operating room (OR; n=5). The charts of donors were reviewed for demographics, cause of death, time of asystole and cold perfusion. Recipient's charts were reviewed for graft function, length of hospitalization, serum creatinine (Cr) at discharge and last follow-up. Peak transaminases, amylase, and lipase for liver and pancreas recipients were also reviewed. Data are presented as means+/-SEM. RESULTS From December 2002 until December 2004, 20 DCD donors were utilized yielding 34 kidney transplants (33 recipients), five liver (1 liver-kidney), and two pancreas (SPK) transplants. Mean follow-up overall is 260 days. ICU extubation occurred in 26/33 (78.8%) kidneys, 3/5(60%) livers and 1/2 (50%) pancreata performed. Time from extubation to asystole was 15.9+/-1.9 min and overall warm ischemia time was 12.5+/-1.0 min. Serum Cr at discharge and at last follow-up for renal grafts are 4.3+/-0.5 and 1.9+/-0.3 mg/dl, respectively. Peak AST and ALT levels after OLTx were 3620+/-951 and 1955+/-266 i.u., respectively. Peak and discharge total bilirubin were 8.1+/-0.9 and 2.5+/-0.5 mg/dl. Length of hospitalization was 9.6+/-1.0 and 15.8+/-2.3 days for kidney and liver recipients, respectively. Both pancreas recipients were insulin free after transplant. CONCLUSIONS ICU extubation should not eliminate extrarenal organs from consideration and may be preferable to OR extubation by improving family support and eliminating OR staff concerns about their role in end-of-life care.
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Affiliation(s)
- Scott R Johnson
- Division of Transplant Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA.
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216
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Alonso A, Fernández-Rivera C, Villaverde P, Oliver J, Cillero S, Lorenzo D, Valdés F. Renal Transplantation From Non–Heart-Beating Donors: A Single-Center 10-Year Experience. Transplant Proc 2005; 37:3658-60. [PMID: 16386496 DOI: 10.1016/j.transproceed.2005.09.104] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Reluctance to accept non-heart-beating donors (NHBD) as a source of kidneys, is due to medical, ethical, and logistical reasons. Evidence suggest that the short-term graft survival is similar to that of kidneys obtained from heart-beating donors (HBD). However, few studies, with long-term follow-up are available. We conducted a single-center study of kidneys obtained from NHBD, in a 14-year period. METHODS We studied 100 patients transplanted with kidneys between 1989 and 2004, using NHBD, supported by heart compression and mechanical ventilation (n = 24), intravascular in situ cooling (n = 59), or cardiorespiratory resuscitation plus manual abdominal counterpulsation without cooling (n = 17), the last technique being used from 1998. The median follow-up was 51 +/- 51 months (range, 1 to 170). The outcomes of these procedures were compared to those of 1025 transplantations of kidneys from HBD performed during the same period. RESULTS The characteristics of the recipients did not differ significantly between the two groups. Kidneys from NHBD showed a significantly higher rate of delayed graft function (DGF; 84% vs 26%; (P < .001), furthermore, the primary nonfunction (PNF) incidence was significantly higher with NHBD vs HBD (16% vs 10%; P < .001). The incidence of acute rejection episodes (ARE) within 3 months and at 1 year did not differ between the groups of donors; however, more NHBD kidneys were lost from ARE. The short-term (3-month and 1 year) and long-term (5 and 10 years) renal function, determined by the serum creatinine levels, and patient and graft survival were not different for kidneys obtained from NHBD. CONCLUSIONS The incidences of PNF and DGF were significantly higher with NHBD, which produced poorer renal function at the time of hospital discharge. One-, 5-, and 10-year graft survivals and renal function did not differ between NHBD and HBD grafts. In our series, PNF was the main barrier to the use of NHBD.
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Affiliation(s)
- A Alonso
- Servicio de Nefrología, CHU Juan Canalejo, A Coruña, Spain.
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217
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Ridley S, Bonner S, Bray K, Falvey S, Mackay J, Manara A. UK guidance for non-heart-beating donation. Br J Anaesth 2005; 95:592-5. [PMID: 16183683 DOI: 10.1093/bja/aei235] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
This guidance offers consensus opinion on the optimum management of non-heart-beating organ donation in adult critical care units. The guidance is not meant to dictate practice but rather to offer suggestions as to what might be considered reasonable practice. The following sections mainly relate to the medical aspects of non-heart-beating organ donation. Fuller guidance on other aspects of organ and tissue donation is available on the Society's website (www.ics.ac.uk). There are a number of parallel areas of work, such as the law on consent, the definition of death and revision of the original Code of Practice describing brainstem testing, which means that many aspects of organ donation are changing rapidly. This guidance is designed to help critical care practitioners while these issues are resolved.
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Affiliation(s)
- S Ridley
- Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7AU, UK.
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Howard RJ, Schold JD, Cornell DL. A 10-year Analysis of Organ Donation after Cardiac Death in the United States. Transplantation 2005; 80:564-8. [PMID: 16177625 DOI: 10.1097/01.tp.0000168156.79847.46] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The greatest challenge facing transplantation today is how to increase the number of organ donors. Patients with severe brain injury who are not brain-dead can donate organs after they are removed from a ventilator and allowed to die, termed donation after cardiac death (DCD). METHODS We analyzed the database of all organs recovered from deceased donors in the United States from 1994 through 2003 to determine DCD trends in the United States. The database was obtained from the United Network for Organ Sharing (UNOS). RESULTS There were 57,681 deceased donors reported from 1994 through 2003. Of these, 1,177 were donors without a heartbeat (DWHB), 55,206 were brain dead donors, and 1,298 were unspecified donors. At least one organ was transplanted from 1010 of the 1177 DWHB. Organ procurement organizations (OPOs) reported 0-212 DWHB accounting for up to 12.3 percent of deceased donors. There was a steady annual increase in the number of DWHB, but in 2003 there were still 19 of 59 OPOs that recovered no DWHB. A total of 2,231 organs were transplanted from the 1,177 DWHB donors, and another 665 organs were recovered for transplantation but not transplanted. The transplanted organs included 1,779 kidneys, 395 livers, 54 pancreata, 2 lungs, and 1 heart. Organs from DWHB can be successfully transplanted. CONCLUSIONS Wider use of DWHB has the potential to greatly increase the number of organ transplants performed each year in the United States.
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219
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Affiliation(s)
- Scott R Johnson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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220
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Tolba RH, Yonezawa K, Song S, Burger C, Minor T. Synergistic value of fibrinolysis and hypothermic aerobic preservation with oxygen in the protection of livers from non-heart-beating donors: an experimental model. Transplant Proc 2005; 36:2927-30. [PMID: 15686662 DOI: 10.1016/j.transproceed.2004.11.094] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The chronic organ shortage has led to the reconsideration of marginal donor pools such as non-heart-beating donors (NHBD). The use of these livers is limited due to their minimal tolerance for cold preservation. The aim of this study was to examine the combination of two different therapeutic strategies for the preservation of livers from NHBD. The livers of male Wistar rats were harvested after the induction of cardiac arrest via phrenotomy (30, 90 minutes). Livers were perfused with 10 mL of UW solution (UW), followed by hypothermic preservation with or without insufflation of gaseous oxygen (O2). In one group a fibrinolytic preflush (10 mL of Ringer's containing 7500 IU of streptokinase) was performed with subsequent preservation with O2 (O2+SK). After storage (24 h/4 degrees C/UW) livers were reperfused in vitro. Livers retrieved from heart beating donors served as controls. The results showed that even after only 30 minutes of warm ischemia livers displayed a serious disturbance in vascular perfusion (portal venous pressure, PVP = 7.4 +/- 0.2* versus control: 4.1 +/- 0.5 mmHg), associated with a more than 10-fold increase in enzyme release (ALT: 26819 +/- 513* versus control 683 +/- 152 mU/g/L), which was consistent with a significant depression in bile synthesis (1.21 +/- 0.35* versus 19.36 +/- 2.16 microL/g/45 min). However, these impairments could be prevented with O2. Even after 90 minutes of WI, the function was significant better using aerobic preservation (ALT: 3204 +/- 549 mU/g/L). With a supplementary fibrinolytic preflush, we effectively preserved livers up to 90 minutes of WI with results comparable to livers from heart beating donors with no WI (ALT: 1623 +/- 432 mU/g/L). The combination of these two techniques represents a new therapeutic approach for livers with extended or unclear WI periods in non-heart-beating donors (*P <.05 versus control).
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Affiliation(s)
- R H Tolba
- University of Bonn Medical Center, Bonn, Germany
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221
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Sánchez-Fructuoso AI, Marques M, Conesa J, Ridao N, Rodríguez A, Blanco J, Barrientos A. Use of different immunosuppressive strategies in recipients of kidneys from nonheart-beating donors. Transpl Int 2005; 18:596-603. [PMID: 15819810 DOI: 10.1111/j.1432-2277.2005.00100.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In nonheart-beating donor (NHBD) kidney transplants, immunosuppressive management is difficult mainly because of the high incidence of acute tubular necrosis. This has meant that since the start of our NHBD transplant program, several immunosuppression regimes have been used. The aim of this retrospective study was to evaluate the results obtained over 7 years using different treatment protocols. A total of 172 consecutive NHBD transplants performed between April 1996 and December 2002 were treated as follows: G-I (n = 21), cyclosporine (8 mg/kg/day) plus azathioprine plus steroids; G-II (n = 65), low-dose cyclosporine (5 mg/kg/day) plus mycophenolate plus steroids; G-III (n =17), low-dose tacrolimus (0.1 mg/kg/day) plus mycophenolate plus steroids; and G-IV (n = 69), daclizumab plus low-dose tacrolimus plus mycophenolate plus steroids. Delayed graft function rates were 76.2%, 72.3%, 76.5%, and 42%, respectively, for the four groups (P = 0.000). Rejection-free patient rates were 76.2%, 46.2%, 35.3%, and 71% (P < 0.001). Vascular rejection rates were 19%, 30.8%, 52.9%, and 18.8%, (P = 0.025). Two-year graft survival was 71.4% in group I, 95.4% in group II, 94.1 in group III, and 93.8% in group IV (P =0.004). Patient survival was worse in group I (75.2% in group I, 100% in group II, 100% in group III, and 96.7% in group IV at 2 years; P < 0.001). The use of daclizumab and low-dose tacrolimus could be effective at lowering the incidence of delayed graft function in NHBDT, with no negative repercussions on acute rejection.
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Affiliation(s)
- Ana I Sánchez-Fructuoso
- Department of Nephrology, Hospital Clínico San Carlos, Facultad de Medicina, Universidad Complutense, Madrid, Spain.
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Abstract
Procurement of kidneys and livers from non-heart-beating donors (NHBD) raises ethical and legal issues that need to be considered before wider use of these donors is undertaken. Although NHBDs were used in kidney transplantation as early as the 1960s, retrieval of these organs is not universally accepted today. From a medical point of view, these organs were considered "marginal" because the majority showed delayed or impaired function early after implantation. Legal problems relate to determination of death on cardiopulmonary criteria, the issue of valid consent, and the use of preservation measures. Among ethical issues involved are observance of the dead-donor rule, decisions with respect to resuscitation and withdrawal of life-sustaining treatment, respect for the dying patient and the dead body, and proper guidance of the family. In The Netherlands NHB donation was pioneered by the Maastricht Centre as early as 1981. Today, all seven transplant centers procure and transplant these organs, and NHBDs have become an important source of transplantable kidneys and livers. Recent legislation in The Netherlands also supports NHB donation by allowing the use of organ-preserving measures, even in the absence of family consent. As a result, one of every three kidneys transplanted in The Netherlands in 2004 derives from a NHBD. This article explores Dutch NHBD practice, protocols, and results and compares these data internationally.
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Affiliation(s)
- Michael A Bos
- Health Council of the Netherlands, The Hague, The Netherlands.
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223
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Keizer KM, de Fijter JW, Haase-Kromwijk BJJM, Weimar W. Non???Heart-Beating Donor Kidneys in The Netherlands: Allocation and Outcome of Transplantation. Transplantation 2005; 79:1195-9. [PMID: 15880069 DOI: 10.1097/01.tp.0000160765.66962.0b] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Since February 1, 2001, kidneys from both heart-beating (HB) and non-heart-beating (NHB) donors in The Netherlands have been indiscriminately allocated through the standard renal-allocation system. METHODS Renal function and allograft-survival rate for kidneys from NHB and HB donors were compared at 3 and 12 months. RESULTS The outcomes of 276 renal transplants, 176 from HB donors and 100 from NHB III donors, allocated through the standard renal allocation system, Eurotransplant Kidney Allocation System, and performed between February 1, 2001 and March 1, 2002 were compared. Three months after transplantation, graft survival was 93.7% for HB kidneys and 85.0% for NHB kidneys (P<0.05). At 12 months, graft survival was 92.0% and 83.0%, respectively (P<0.03). Serum creatinine levels in the two groups were comparable at both 3 and 12 months. Multivariate analysis identified previous kidney transplantation (relative risk [RR] 3.33; P<0.005), donor creatinine (RR 1.01; P<0.005), and NHB (RR 2.38; P<0.05) as independent risk factors for transplant failure within 12 months. In multivariate analysis of NHB data, a warm ischemia time (WIT) of 30 minutes or longer (P<0.005; RR 6.16, 95% confidence interval 2.11-18.00) was associated with early graft failure. No difference in 12-month graft survival was seen between HB and NHB kidneys after excluding the kidneys that failed in the first 3 months. CONCLUSION Early graft failure was significantly more likely in recipients of kidneys from NHB donors. A prolonged WIT was strongly associated with this failure. Standard allocation procedures do not have a negative effect on outcome, and there is no reason to allocate NHB kidneys differently from HB kidneys.
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Affiliation(s)
- Karin M Keizer
- Dutch Transplantation Foundation, Leiden, The Netherlands.
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224
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Abstract
This case report outlines the clinical process whereby a patient with severe traumatic brain injury became a non-heartbeating organ donor after a withdrawal-of-care decision. This process raises a series of ethical questions regarding decision-making on grounds of futility, the role of the next of kin, informed consent, the accommodation of manoeuvres directed towards organ retrieval at maximal viability, and the timing and determination of death. Although many aspects of the process can be accommodated within fundamental ethical principles and a broad interpretation of the concept of the 'best interests', the variance with established law requires authoritative clarification if a need for transplantable organs is to be responded to without compromising the reputation of practitioners involved in this area of care. Therefore, this recruitment strategy warrants wide public and professional debate to achieve longer-term sustainability and ensure the protection of all parties.
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Affiliation(s)
- M D D Bell
- The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK.
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225
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Gomez del Moral M, Aviles B, Colberger IK, Campos-Martin Y, Suela J, Alvarez J, Perez-Contin MJ, Sánchez-Fructuoso A, Barrientos A, Martinez-Naves E. Expression of adhesion molecules and RANTES in kidney transplant from nonheart-beating donors. Transpl Int 2005; 18:333-40. [PMID: 15730495 DOI: 10.1111/j.1432-2277.2004.00060.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The main difference between cadaveric kidneys from donors with a heartbeat (HBD) and kidneys from nonheart-beating donors (NHBD) is related to warm ischemia/reperfusion time which constitutes an acute inflammatory process. On the contrary, brain death induces in HBD expression of pro-inflammatory adhesion molecules, making it important to evaluate this kind of molecules in both types of donors. Human renal biopsies from NHBD, HBD and normal kidneys (ischemia time = 0) were taken and frozen just before transplant. A semi-quantitative RT-PCR method was used to determine intracellular adhesion molecule 1 (ICAM-1), vascular cell adhesion molecule 1 (VCAM-1), lymphocyte function associated antigen (LFA-1), LFA-3, CD40, CD40 ligand (CD40L) and RANTES (regulated upon activation, normal T-cell expressed and secreted) gene expression. We have detected an elevated relative gene expression of ICAM-1, VCAM-1 and RANTES in NHBD biopsies compared with normal kidneys. In the case of RANTES, the gene expression from NHBD biopsies was higher than observed in HBD biopsies. The rest of genes were not augmented in any group. Preliminary data about early outcome of transplants indicates a correlation between pretransplant RANTES high gene expression levels and early post-transplant acute rejection. The gene expression of pro-inflammatory molecules like adhesion molecules and RANTES is augmented in kidneys from cadaveric NBD just before transplant. The expression is higher probably because of the prolonged warm ischemia period. A larger clinical study is necessary to clarify the effects of these variable expressions on the transplant outcome.
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Affiliation(s)
- Manuel Gomez del Moral
- Department of Cell Biology, Faculty of Medicine, Complutense University, Avda. Complutense S/N 28040 Madrid, Spain
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226
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Rosenberg JC, Beyersdorf T, Pietroski R. Changes in Notification and Demographics of Deceased Donors During the Past Decade in the State of Michigan, USA. Transplant Proc 2005; 37:571-3. [PMID: 15848460 DOI: 10.1016/j.transproceed.2004.12.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
From 1993 to 2003 there have been significant changes in the number and demographics of deceased donors referred to the organ procurement organization (OPO) in the state of Michigan (USA). It was the aim of this study to document the magnitude of these changes and attempt to explain them. There has been a 26-fold increase in the number of reported in-hospital deaths from 1993 to 2003. Most of these calls (96%) concerned patients who were already dead and thus not suitable for organ donation. There has also been a 72% increase in the number of antemortem calls, but there has been only a 30% increase in the number of organ donors, primarily because the majority of the deceased individuals referred for donation (57% in 2003) do not meet the criteria for brain death. The median age of donors over the past 10 years has increased from 31 to 45. The proportion of African-American donors increased from 9.8% in 1993 to 21.3% in 2003. An increase in the age of donors and the increased frequency of cerebrovascular accidents as the cause of death of donors may be a reflection of changes in criteria for donation. Mandatory reporting of hospital deaths has resulted in an increase in notification to the OPO but has not had a major impact on the number of organ donors. On the other hand, increased donation from African-Americans indicates that public information programs may be contributing to the increased donation from this segment of the population.
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Affiliation(s)
- J C Rosenberg
- Gift of Life Michigan, Ann Arbor, Michigan 48104, USA.
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227
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Ramos E, Alonso JC, Durán C, Gómez I, Martínez S, Almoguera I, Bittiini A, Domínguez P, Pérez Vázquez JM. [Graft viability of patients with renal transplantation from non heart beating donors]. ACTA ACUST UNITED AC 2005; 24:32-7. [PMID: 15701344 DOI: 10.1157/13070355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Renal transplantation (RT) is currently the treatment of choice in end-stage renal disease. The Gregorio Marañón hospital performed 65 RT, 97.01 pmp, this year. OBJECTIVE To study the characteristics which RT patients from non-heart beating donors have in the immediate post-transplantation renogram. To know the evolution of the renal function, by renogram. METHODS Ten patients with NHBD graft out of 65 patients with RT were studied in the year 2003. RESULTS The study is made up of 10 patients with RT from NHBD, with an average timing of warm ischemia of 35 min and average timing of cool ischemia 21 h. In the post-transplantation renal function study, 9 of then showed hemodilution and one an acute tubular necrosis (ATN) pattern. In most of the cases, the study was performed the day after the RT except for one that was performed on the 4th day (1.7 +/- 1 days). Renal perfusion was conserved in every case. The renal graft maintained this type of record until post-RT day 7 (6.67 +/- 0.57 days) and evolved towards ATN after day 10 (11.65 +/- 1.5 days) and normal range on day 55 +/- 51.1 post-transplantation. All patients supported the graft, with acceptable renal function, except one of then who was treated with transplantectomy due to a renal venous thrombosis. CONCLUSION The renal function study showed "hemodilution" in the first post-transplantation in 90 % of the RT from NHBD. Evolution went from ATN to normality. The NHBD are adequate for transplantation, significantly shortening the waiting time for RN.
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Affiliation(s)
- E Ramos
- Servicio de Medicina Nuclear, Hospital General Gregorio Marañón, Madrid
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228
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de Vries B, Walter SJ, Peutz-Kootstra CJ, Wolfs TGAM, van Heurn LWE, Buurman WA. The mannose-binding lectin-pathway is involved in complement activation in the course of renal ischemia-reperfusion injury. THE AMERICAN JOURNAL OF PATHOLOGY 2004; 165:1677-88. [PMID: 15509537 PMCID: PMC1618654 DOI: 10.1016/s0002-9440(10)63424-4] [Citation(s) in RCA: 154] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Ischemia-reperfusion (I/R) is an important cause of acute renal failure (ARF). The complement system appears to be essentially involved in I/R injury. However, via which pathway the complement system is activated and in particular whether the mannose-binding lectin (MBL)-pathway is activated is unclear. This tempted us to study the activation and regulation of the MBL-pathway in the course of experimental renal I/R injury and in clinical post-transplant ARF. Mice subjected to renal I/R displayed evident renal MBL-depositions, depending on the duration of warm ischemia, in the early reperfusion phase. Renal deposition of C3, C6 and C9 was observed in the later reperfusion phase. The deposition of MBL-A and -C completely co-localized with the late complement factor C6, showing that MBL is involved in complement activation in the course of renal I/R injury. Moreover, the degree of early MBL-deposition correlated with complement activation, neutrophil-influx, and organ-failure observed in the later reperfusion phase. In serum of mice subjected to renal I/R MBL-A, levels increased in contrast to MBL-C levels, which dropped evidently. In line, liver mRNA levels for MBL-A increased, whereas MBL-C levels decreased. Renal MBL mRNA levels rapidly dropped in the course of renal I/R. Finally, in human biopsies, MBL-depositions were observed early after transplantation of ischemically injured kidneys. In line with our experimental data, in ischemically injured grafts displaying post-transplant organ-failure extensive MBL depositions were observed in peritubular capillaries and tubular epithelial cells. In conclusion, in experimental renal I/R injury and clinical post-transplant ARF the MBL-pathway is activated, followed by activation of the complement system. These data indicate that the MBL-pathway is involved in ischemia-induced complement activation.
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Affiliation(s)
- Bart de Vries
- Department of General Surgery, Maastricht University, P.O. Box 616, Universiteitssingel 50, 6200 MD Maastricht, the Netherlands
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Bains JC, Sandford RM, Brook NR, Hosgood SA, Lewis GRR, Nicholson ML. Comparison of renal allograft fibrosis after transplantation from heart-beating and non-heart-beating donors. Br J Surg 2004; 92:113-8. [PMID: 15593295 DOI: 10.1002/bjs.4777] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Abstract
Background
Renal transplants from non-heart-beating donors (NHBDs) yield acceptable function and allograft survival rates in the medium term. However, the long-term results are less certain and there is a paucity of information relating to the development of chronic allograft nephropathy. The aim of this study was to compare allograft fibrosis in kidneys transplanted from NHBDs and conventional heart-beating donors (HBDs).
Methods
A series of 37 NHBD and 75 HBD renal transplants were studied. Protocol renal transplant biopsies were performed at 6 and 12 months after transplantation. Biopsy sections were stained with Sirius red to demonstrate interstitial extracellular matrix. Renal allograft fibrosis was quantified using a computerized image analysis system.
Results
The mean first warm ischaemia time for kidneys from NHBDs was 24 min. A significant delay in graft function occurred in eight of 75 recipients in the HBD group and 31 of 37 in the NHBD group (P < 0·001). There were no significant differences in the level of allograft fibrosis between the two groups at any time point.
Conclusion
Despite high rates of delayed graft function secondary to a prolonged warm ischaemia time, NHBD kidneys do not appear to be more susceptible to the development of renal allograft fibrosis. This study supports the growing body of evidence that kidneys from NHBDs are an acceptable alternative to those from HBDs.
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Affiliation(s)
- J C Bains
- University Division of Transplant Surgery, Leicester General Hospital, Leicester LE5 4PW, UK
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230
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Abstract
Kidney transplantation is the treatment of choice for patients with end stage renal disease. Kidney transplantation not only improves the quality of life but also prolongs life. Over the last decade, the short-term allograft survival rate has been improved dramatically. Chronic allograft nephropathy and death from cardiovascular diseases become predominant causes of later graft loss. Prevention and treatment of these disease processes require a comprehensive approach. The ever-increasing shortage of organ supply becomes the greatest challenge for the transplant community and modern medicine. More and more patients are waiting for organs; many of them are dying while waiting. Xenotransplantation and organ engineering and cloning are promising techniques and can potentially provide organs for transplantation in the future.
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Affiliation(s)
- Rubin Zhang
- Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, USA
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231
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Cohen B, Smits JM, Haase B, Persijn G, Vanrenterghem Y, Frei U. Expanding the donor pool to increase renal transplantation. Nephrol Dial Transplant 2004; 20:34-41. [PMID: 15522904 DOI: 10.1093/ndt/gfh506] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION The goal of the Eurotransplant renal allocation scheme is to provide every patient on the waiting list with a reasonably balanced opportunity for a donor offer. New initiatives were taken in order to maximize donor usage while maintaining a successful transplant outcome. METHODS Two Eurotransplant projects were launched in order to accommodate changes in donor and recipient profiles. A re-addressing of the non-heart-beating donor pool was undertaken and an allocation scheme in which organs from donors aged >65 are allocated to recipients aged >65 [the Eurotransplant Senior Programme (ESP)] was introduced. RESULTS Especially in The Netherlands, an enormous increase in the number of non-heart-beating donor kidneys has been observed, however with a pace-keeping reduction in heart-beating donors. The organization-wide implementation of the ESP has been successful. The 3 year graft survival rates for these age-matched transplants were as good as the human leukocyte antigen (HLA)-matched transplants (64 vs 67%) (P = 0.4). CONCLUSION Within the framework of sound research, the utmost flexibility and creativity is needed to keep or even increase the number of renal transplants when faced with a quantitatively stagnating but qualitatively deteriorating donor pool. Both the non-heart-beating donor protocol and the ESP have proven to be quite successful in achieving this goal without compromising the outcome for the individual end-stage renal disease patient.
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Affiliation(s)
- Bernard Cohen
- Eurotransplant International Foundation, Leiden, The Netherlands.
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232
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Reddy S, Zilvetti M, Brockmann J, McLaren A, Friend P. Liver transplantation from non-heart-beating donors: current status and future prospects. Liver Transpl 2004; 10:1223-32. [PMID: 15376341 DOI: 10.1002/lt.20268] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Liver transplantation is the treatment of choice for many patients with acute and chronic liver failure, but its application is limited by a shortage of donor organs. Donor organ shortage is the principal cause of increasing waiting lists, and a number of patients die while awaiting transplantation. Non-heart-beating donor (NHBD) livers are a potential means of expanding the donor pool. This is not a new concept. Prior to the recognition of brainstem death, organs were retrieved from deceased donors only after cardiac arrest. Given the preservation techniques available at that time, this restricted the use of extrarenal organs for transplantation. In conclusion, after establishment of brain death criteria, deceased donor organs were almost exclusively from heart-beating donors (HBDs). To increase organ availability, there is now a resurgence of interest in NHBD liver transplantation. This review explores the basis for this and considers some of the published results.
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Affiliation(s)
- Srikanth Reddy
- Nuffield Department of Surgery, University of Oxford, Oxford, UK
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233
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Cooper JT, Chin LT, Krieger NR, Fernandez LA, Foley DP, Becker YT, Odorico JS, Knechtle SJ, Kalayoglu M, Sollinger HW, D'Alessandro AM. Donation after cardiac death: the university of wisconsin experience with renal transplantation. Am J Transplant 2004; 4:1490-4. [PMID: 15307836 DOI: 10.1111/j.1600-6143.2004.00531.x] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Owing to the shortage of organ donors, there is renewed interest in donation after cardiac death (DCD), formerly referred to as nonheart-beating donation. From January 1984 until August 2000, 382 renal transplants were performed from DCD donors. These were compared with 1089 renal transplants performed from donation after brain death (DBD) donors. The mean warm ischemic time in DCD donors was 16.5 min. There was no statistical difference in cold ischemic time, rate of primary nonfunction, or graft loss in the first 30 days after transplantation. The rate of delayed graft function (DGF) was higher for DCD donors (27.5% vs. 21.3%; p = 0.016) and discharge creatinine was higher in DCD donors (1.92 mg/dL vs. 1.71 mg/dL; p = 0.001). There was no statistical difference in the 5-, 10-, or 15-year allograft survival when DCD donors were compared with DBD donors (64.8%, 44.8%, 27.8% vs. 71.3%, 48.3%, 33.8%; p = 0.054). Likewise, no statistical difference in the rate of technical complications was seen. Our long-term data indicate that the results of renal transplantation from DCD donors are equivalent to long-term allograft survival from DBD donors despite an increase in the rate of DGF. Organ procurement organizations, transplant centers, and hospitals should work to expand the implementation of DCD policies.
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Affiliation(s)
- Jeffrey T Cooper
- Department of Surgery, Tufts University School of Medicine, Boston, MA, USA
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234
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Nishikido M, Noguchi M, Koga S, Kanetake H, Matsuya F, Hayashi M, Hori T, Shindo K. Kidney transplantation from non–heart-beating donors: Analysis of organ procurement and outcome. Transplant Proc 2004; 36:1888-90. [PMID: 15518686 DOI: 10.1016/j.transproceed.2004.06.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Most donors in Japan have been non-heart-beating donors (NHBD), so-called "marginal donors." In Western countries kidney transplants from NHBD have also been increasing. We analyzed 120 kidneys harvested from NHBD with regard to organ procurement, renal function, graft survival, and the donor factors that affected graft survival. METHODS Donors were moved into the operating room after cardiac arrest. A double-balloon catheter was inserted into the abdominal aorta via laparotomy. In situ cooling by Euro-Collins solution was started at 500 mL/min. We did not performed cannulation into the femoral artery or vein prior to cardiac arrest. RESULTS Warm ischemia time (WIT) was 18.6 minutes. Among 108 kidneys (90%) used for transplantation, 102 kidneys functioned. There were no cases of bilateral nonfunctioning kidneys. The delayed graft function (DGF) rate was 86%; however, the death-censored graft survival was 80.0% at 5 years and 62.9% at 10 years. Kidneys implanted after more than 24 hours of total ischemia time required a significantly longer period of hemodialysis. Donor risk factors that affected graft survival included WIT >/= 20 minutes, donor age >/= 50 years, and serum creatinine level at admission > 1.0 mg/dL. CONCLUSIONS Organ procurement without cannulation prior to cardiac arrest entailed a long WIT and a high DGF rate. However, the graft survival was good. It has been necessary to use grafts from NHBD despite the inherent risk factors. It is important to reduce kidney damage both at the organ procurement and during the posttransplant management.
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Affiliation(s)
- M Nishikido
- Department of Urology, Nagasaki University School of Medicine, Nagasaki, Japan.
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Nicholson ML, Hosgood SA, Metcalfe MS, Waller JR, Brook NR. A Comparison of Renal Preservation by Cold Storage and Machine Perfusion Using a Porcine Autotransplant Model. Transplantation 2004; 78:333-7. [PMID: 15316359 DOI: 10.1097/01.tp.0000128634.03233.15] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pulsatile machine perfusion offers theoretical advantages as a method of preserving kidneys before transplantation. This may be particularly the case for organs taken from non-heart-beating donors (NHBD), but there is still a lack of data to support this view. The aim of this study was to compare the effectiveness of static cold storage in ice (CS) and hypothermic pulsatile machine perfusion (MP) as methods of renal transplant preservation. METHODS Groups of large white pigs (n=5) underwent left nephrectomy after warm ischemic times (WIT) of 0 or 30 min. Kidneys were preserved by CS or by cold (3degrees-8degreesC) MP for 24 hr. The left kidney was then autotransplanted into the right iliac fossa and an immediate right nephrectomy was performed. Renal function was assessed daily for 14 days. RESULTS Fourteen-day animal survival rates for 0 and 30 min WIT were four of five and one of five after both CS and MP. In the zero WIT groups, there was improved recovery of renal function after MP (area under the creatinine curve, 4,722+/-2,496 [MP] vs. 8,849+/-2,379 [CS]; P<0.05). MP did not improve renal function after 30 min of WIT (mean daily area under the creatinine curve, 1,077+/-145 [MP] vs. 1,049+/-265 [CS]). CONCLUSIONS In this model, MP improved 24-hr preservation of kidneys not subjected to warm ischemia (heart-beating donor model), but there was no evidence that MP was a better method of preservation than CS for kidneys exposed to 30 min of WIT (NHBD model).
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Affiliation(s)
- Michael L Nicholson
- Division of Transplant Surgery, University of Leicester, Leicester General Hospital, Leicester, United Kingdom.
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Nishikido M, Noguchi M, Koga S, Kanetake H, Harada T, Taguchi T, Watanabe J, Matsuya F, Hayashi M. Different clinicopathological courses of two recipients of kidneys retrieved from the same non-heart beating donor. Clin Transplant 2004; 18 Suppl 11:54-60. [PMID: 15191375 DOI: 10.1111/j.1399-0012.2004.00249.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report the clinicopathological courses of two recipients of kidneys retrieved from the same non-heart beating donor (NHBD). A 52-year-old man received a renal transplant from an NHBD. The donor was a 66-year-old woman who died of subarachnoid haemorrhage. The recipient was immunosuppressed by basiliximab, tacrolimus (TAC), mycophenolate mofetil (MMF), methyl prednisolone (MP), and antilymphocyte globulin (ALG). On post-operative day (POD) 21, haemodialysis therapy was withdrawn, however, their serum creatinine (s-Cr) level failed to improve. Four transplant biopsies were performed (1 h and POD 46, 74, and 114). The biopsy showed tubular degeneration but no evidence of TAC nephrotoxicity. The last biopsy after discontinuation of TAC demonstrated acute rejection of borderline grade. The s-Cr level at discharge was 5.0 mg/dL. The contra-lateral kidney was transplanted into a 31-year-old female and showed early functioning, with an s-Cr level at discharge of 1.8 mg/dL. Biopsy examination on POD 38 showed a recovery of tubular degeneration. The causes of delayed graft function and persistently high level of s-Cr in Case 1 remain unclear. Various factors, including donor-related factors, recipient-related factors, TAC nephrotoxicity, acute rejection, and urinary tract infection could all be associated with this condition.
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Affiliation(s)
- M Nishikido
- Department of Urology, Nagasaki University School of Medicine, Sakamoto, Nagasaki City, Japan.
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de Vries B, Walter SJ, von Bonsdorff L, Wolfs TGAM, van Heurn LWE, Parkkinen J, Buurman WA. Reduction of circulating redox-active iron by apotransferrin protects against renal ischemia-reperfusion injury. Transplantation 2004; 77:669-75. [PMID: 15021827 DOI: 10.1097/01.tp.0000115002.28575.e7] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Warm ischemia-reperfusion (I/R) injury plays an important role in posttransplant organ failure. In particular, organs from marginal donors suffer I/R injury. Although iron has been implicated in the pathophysiology of renal I/R injury, the mechanism of iron-mediated injury remains to be established. The authors therefore investigated the role of circulating redox-active iron in an experimental model for renal I/R injury. METHODS Male Swiss mice were subjected to unilateral renal ischemia for 45 min, followed by contralateral nephrectomy and reperfusion. To investigate the role of circulating iron, mice were treated with apotransferrin, an endogenous iron-binding protein, or iron-saturated apotransferrin (holotransferrin). RESULTS Renal ischemia induced a significant increase in circulating redox-active iron levels during reperfusion. Apotransferrin, in contrast to holotransferrin, reduced the amount of circulating redox-active iron and abrogated renal superoxide formation. Apotransferrin treatment did not affect I/R-induced renal apoptosis, whereas holotransferrin aggravated apoptotic cell death. Apotransferrin, in contrast to holotransferrin, inhibited the influx of neutrophils. Both apo- and holotransferrin reduced I/R-induced complement deposition, indicating that the effects of transferrin are differentially mediated by its iron and protein moiety. Finally, apotransferrin, in contrast to holotransferrin, dose-dependently inhibited the loss of renal function induced by ischemia. CONCLUSIONS Redox-active iron is released into the circulation in the course of renal I/R. Reducing the amount of circulating redox-active iron by treatment with apotransferrin protects against renal I/R injury, inhibiting oxidative stress, inflammation, and loss of function. Apotransferrin could be used in the treatment of acute renal failure, as seen after transplantation of ischemically damaged organs.
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Affiliation(s)
- Bart de Vries
- Department of Surgery, Nutrition and Toxicology Research Institute Maastricht, Academic Hospital Maastricht, Maastricht, The Netherlands
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238
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Fischer JH, Funcke C, Yotsumoto G, Jeschkeit-Schubbert S, Kuhn-Régnier F. Maintenance of physiological coronary endothelial function after 3.3 h of hypothermic oxygen persufflation preservation and orthotopic transplantation of non-heart-beating donor hearts. Eur J Cardiothorac Surg 2004; 25:98-104. [PMID: 14690739 DOI: 10.1016/s1010-7940(03)00673-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The use of non-heart-beating donors (NHBD) might increase the number of grafts available for transplantation. Experiments on heart transplantation from NHBDs demonstrated the necessity for oxygenation during preservation to allow sufficient myocardial recovery. It has been shown that, after 16 min normothermic ischemia followed by 3.3-h hypothermic preservation, excellent myocardial and cardiovascular recovery is attained, if coronary oxygen persufflation (COP) is included in the preservation protocol. Here tests are presented on the recovery of coronary endothelium derived relaxation (EDR) of NHBD hearts after preservation including COP. METHODS After 16 min normothermic ischemia, pig hearts were stored for 3.3 h at 0-1 degrees C in modified HTK plus COP (mBHTK+COP, n=6) or in two control groups without COP: (1) with mBHTK (n=6); and (2) with HTK (n=4). Following orthotopic transplantation and 3 h of reperfusion with full blood, coronary EDR was tested in vitro using Substance P (SP) under indomethacin for prostaglandin blockage. Additional tests were performed adding L-NIL to block the NO-production by iNOS or L-NNA to block total NO production. RESULTS The EDR in percent of precontraction was 78 +/- 7% after mBHTK+COP and 77 +/- 20% (mBHTK) or 72 +/- 7% (HTK) in the controls without significant differences between the groups. Physiologic values of normal coronaries were 75 +/- 9%. L-NIL for blockage of NO-production by iNOS resulted in unchanged relaxations. After blockage of total NO production by L-NNA, the SP-induced dilation was significantly reduced to 58 +/- 8% (mBHTK+COP) and to 48 +/- 8% (mBHTK) or 55 +/- 13% (HTK) in the controls. CONCLUSIONS Even after 16 min of warm ischemia followed by 3.3 h of preservation with gaseous oxygen persufflation, orthotopic transplantation, and reperfusion the endothelium derived coronary dilatation was unchanged from physiologic values and similar to the controls without COP. Blockage of NO production by L-NNA resulted in equal values of EDR with or without COP, while blockage of NO production by iNOS did not influence the EDR reaction. Thus COP preservation, which has been shown to allow excellent recovery of preserved NHBD hearts, caused no damage to the coronary EDR mechanisms.
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Affiliation(s)
- Jürgen H Fischer
- Institute of Experimental Medicine, University of Cologne, Robert-Koch-Str 10, 50931 Cologne, Germany.
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Ojo AO, Heinrichs D, Emond JC, McGowan JJ, Guidinger MK, Delmonico FL, Metzger RA. Organ donation and utilization in the USA. Am J Transplant 2004; 4 Suppl 9:27-37. [PMID: 15113353 DOI: 10.1111/j.1600-6135.2004.00396.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The processes leading to donor identification, consent, organ procurement, and allocation continue to dominate debates and efforts in the field of transplantation. A considerable shortage of donors remains while the number of patients needing organ transplantation increases. This article reviews the main trends in organ donation practices and procurement patterns from both deceased and living sources in the USA. Although there have been increases in living donation in recent years, 2002 witnessed a much more modest growth of 1%. Absolute declines in living liver and lung donation were also noted in 2002. In 2002, the number of deceased donors increased by only 1.6% (101 donors). Increased donation from deceased donors provides more organs for transplantation than a comparable increase in living donation, because on average 3.6 organs are recovered from each deceased donor. The total number of organs recovered from deceased donors increased by 2.1% (462 organs). Poor organ quality continued to be the major reason given for nonrecovery of consented organs from deceased donors. The kidney is the organ most likely to be discarded after recovery. Over the past decade the discard rate of recovered kidneys has increased from 6% to 11%. Many of these are expanded criteria donor kidneys.
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Affiliation(s)
- Akinlolu O Ojo
- Scientific Registry of Transplant Recipients/University of Michigan, Ann Arbor, MI, USA.
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240
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Kidney transplantation; retained foreign objects; perceptions of quality of care; older nurses' experiences. AORN J 2004. [DOI: 10.1016/s0001-2092(06)60922-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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241
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Gok MA, Shenton BK, Buckley PE, Peaston R, Cornell C, Soomro N, Jaques BC, Manas DM, Talbot D. How to improve the quality of kidneys from non-heart-beating donors: a randomised controlled trial of thrombolysis in non-heart-beating donors. Transplantation 2004; 76:1714-9. [PMID: 14688521 DOI: 10.1097/01.tp.0000093834.05766.fd] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The growth in the prevalence of end-stage renal failure has been accompanied with a rise in the waiting list for renal transplantation, which has not been matched by an increase in the kidney donor pool. Non-heart-beating donors (NHBD) offer a potential source of kidneys that are not currently being significantly used. Cardiac arrest for a protracted period of time leads to in situ thrombosis, and, as a consequence, the discard rates for harvested kidneys is higher than brain-stem-dead donors. METHODS A double-blinded, randomised, controlled trial of streptokinase preflush or placebo for NHBD was performed. An initial 30 donors were entered into the study. After routine nephrectomy, NHBD kidneys were machine perfused as part of viability screening before transplantation. Kidneys were then transplanted within 24 hours of cardiac arrest. The primary objectives were the improvements of viability parameters (perfusion, enzyme levels, and histopathology) of the kidneys. The secondary objective was to increase the number of kidneys passing the viability tests and thus transplanted. RESULTS The two groups of NHBD donors and their kidneys were similar in their descriptive epidemiologic characteristics. The NHBD kidneys from the streptokinase-treated donors had a better appearance at procurement (P<0.001) and performed better during machine preservation (P<0.001). Enzyme biomarkers present in the kidney perfusate were all significantly reduced by the use of streptokinase. These included glutathione S-transferase (P<0.001), fatty acid binding protein (P<0.001), and alanine aminopeptidase (P<0.001). However, although there was a higher proportion of kidneys transplanted through the use of streptokinase (63.6% with streptokinase vs. 42.6% with placebo), this did not achieve significance. There was no difference with respect to postoperative bleeding and transfusion requirements in the recipient whether streptokinase preflush or placebo was used. CONCLUSION This study using streptokinase preflush in the NHBD was found to improve the condition of the kidneys retrieved. The improvement in the quality of the donor kidneys was not associated with an increased morbidity in the recipient.
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Affiliation(s)
- Muhammad A Gok
- Department of Surgery, The Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne NE4 6BE, England, UK
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242
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Nuñez JR, Varela A, del Río F, Gámez P, Calatayud J, Córdoba M, Hernando F, Ussetti P, Gómez A, Carreño MC, Torres A, Gómez J, Balibrea JL, López A. Bipulmonary transplants with lungs obtained from two non–heart-beating donors who died out of hospital. J Thorac Cardiovasc Surg 2004; 127:297-9. [PMID: 14752457 DOI: 10.1016/j.jtcvs.2003.07.025] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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243
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Iwata H, Mori Y, Takagi H, Shirahashi K, Fukumoto Y, Umeda Y, Mizuno Y, Yoshikawa S, Hirose H, Ito S, Takahashi Y, Deguchi T, Iwaki Y. A clinical renal-transplant case from a non-heart-beating donor using percutaneous cardiopulmonary support. Transplantation 2003; 76:1772-3. [PMID: 14688533 DOI: 10.1097/01.tp.0000088666.48340.4f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The use of non heart-beating donor (NHBD) kidneys to expand transplant programmes offers an answer to the problem of donor shortage. This source of kidneys is utilised by very few renal transplant units despite longstanding and growing evidence of equivalent graft function and survival, compared with cadaveric donor organs. This article reviews the selection criteria, technical approaches and logistical organisation involved in NHBD kidney retrieval and transplantation and outlines the evidence for graft function and survival, and patient outcome. The ethical and legal implications of running a NHBD programme are discussed, and some areas of current and likely future research are covered.
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Affiliation(s)
- N R Brook
- The University Division of Transplant Surgery, Leicester General Hospital, Gwendolen Road, Leicester, LE1 6GF.
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246
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Otero A, Gómez-Gutiérrez M, Suárez F, Arnal F, Fernández-García A, Aguirrezabalaga J, García-Buitrón J, Alvarez J, Máñez R. Liver transplantation from Maastricht category 2 non-heart-beating donors. Transplantation 2003; 76:1068-73. [PMID: 14557754 DOI: 10.1097/01.tp.0000085043.78445.53] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The demand for liver transplantation has increasingly exceeded the supply of cadaver donor organs. Non-heart-beating donors (NHBDs) may be an alternative to increase the cadaver donor pool. METHODS The outcome of 20 liver transplants from Maastricht category 2 NHBDs is compared with 40 liver transplants from heart-beating donors (HBDs). After unsuccessful cardiopulmonary resuscitation (CPR), cardiopulmonary support (CPS) with simultaneous application of chest and abdominal compression (n=6), and cardiopulmonary bypass (CPB; n=14), which was hypothermic (n=7) or normothermic (n=7), were used to preserve the organs from NHBDs. Factors that may influence the outcome of livers from Maastricht category 2 NHBDs were also investigated. RESULTS With a minimum follow-up of 2 years, actuarial patient and graft survivals with livers from Maastricht category 2 NHBDs were 80% and 55%, respectively. Transplantation of organs from these donors was associated with a significantly higher incidence of primary nonfunction, biliary complications, and more severe initial liver dysfunction compared with livers from HBDs. Graft survival was 83% in livers from NHBDs preserved with CPS and 42% in those maintained with CPB. No graft failed if the duration of warm ischemia did not exceed 130 min with CPR or CPS, and if the period of CPB did not surpass 150 min when this method was used after CPR, regardless if it was hypothermic or normothermic. CONCLUSION Livers from Maastricht type 2 NHBDs may be used for transplantation if the period of warm ischemia during CPR or CPS does not exceed 130 min. Hypothermic or normothermic CPB after CPR preserves liver viability for an additional 150 min.
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Affiliation(s)
- Alejandra Otero
- Liver Transplant Unit, Hospital Juan Canalejo, La Coruña, Spain
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Krishnamurthi V. RE: Long-term results of renal transplantation using kidneys harvested from non-heartbeating donors: a 15-year experience. J Urol 2003; 170:927. [PMID: 12913739 DOI: 10.1097/01.ju.0000080840.52494.dd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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López-Navidad A, Caballero F. Extended criteria for organ acceptance. Strategies for achieving organ safety and for increasing organ pool. Clin Transplant 2003; 17:308-24. [PMID: 12868987 DOI: 10.1034/j.1399-0012.2003.00119.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The terms extended donor or expanded donor mean changes in donor acceptability criteria. In almost all cases, the negative connotations of these terms cannot be justified. Factors considered to affect donor or organ acceptability have changed with time, after showing that they did not negatively affect graft or patient survival per se or when the adequate measures had been adopted. There is no age limit to be an organ donor. Kidney and liver transplantation from donors older than 65 years can have excellent graft and patient actuarial survival and graft function. Using these donors can be from an epidemiological point of view the most important factor to esablish the final number of cadaveric liver and kidney transplantations. Organs with broad structural parenchyma lesion with preserved functional reserve and organs with reversible functional impairment can be safely transplanted. Bacterial and fungal donor infection with the adequate antibiotic treatment of donor and/or recipient prevents infection in the latter. The organs, including the liver, from donors with infection by the hepatitis B and C viruses can be safely transplanted to recipients with infection by the same viruses, respectively. Poisoned donors and non-heart-beating donors, grafts from transplant recipients, reuse of grafts, domino transplant and splitting of one liver for two recipients can be an important and safe source of organs for transplantation.
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Affiliation(s)
- Antonio López-Navidad
- Department of Organ & Tissue Procurement for Transplantation, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.
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249
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Affiliation(s)
- Paolo Muiesan
- Department of Liver Transplantation, Institute of Liver Studies, King's College Hospital, Denmark Hill, Camberwell, London, UK
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250
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Abstract
If I have to answer the question in the title, the answer will be yes and no. No, there is no future for transplantation, as we know it today. The practices and policies are constantly changing. I hope that in the near future the number of cadaveric donors will increase in most countries owing to improvements in procurement organizations and better medical management of donors. I doubt, however, that it is possible to attain the number of cadaveric donors realized in Spain. Some of us may live to see that the cadaveric donor pool has decreased. Maximized donation without financial incentives for donors or their surviving families will go a long way to meet the demand, but I fear that in the future there will be some financial incentives involved in donation. Yes, there is a future for transplantation and there always will be, but not for transplantation as we know it today The question is whether xenotransplantation or stem cell therapy will be there to take over as the number of allotransplants fail to meet the increasing demand for organ allografts, a demand that cannot be met by a judicious combination of organs from living and deceased donors.
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Affiliation(s)
- H Gäbel
- National Board of Health and Welfare, 10630 Stockholm, Sweden.
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