Solid organ procurement from donors with carbon monoxide poisoning and/or burn--a systematic review

CO as a therapeutic agent: discovery and delivery forms

Carbon monoxide (CO) as one of the three important endogenously produced signaling molecules, termed as "gasotransmitter," has emerged as a promising therapeutic agent for treating various inflammation and cellular-stress related diseases. In this review, we discussed CO's evolution from a well-recognized toxic gas to a signaling molecule, and the effort to develop different approaches to deliver it for therapeutic application. We also summarize recently reported chemistry towards different CO delivery forms.

At the heart of organ donation. Case reports of organ donation after cardiac death in two patients with successfully repaired AAST grade V cardiac injuries

Background

Trauma victims could be an important source of organs. This article presents two cases of successful organ donation and transplant, after Maastricht category III cardiac death in patients with successfully repaired AAST grade V traumatic cardiac injuries.

Case presentation

The first donor was an adult patient with self-inflicted heart stab wound and non-survivable burn injury. The second one was an adult patient with blunt cardiac and abdominal trauma and an anoxic brain injury due to a car accident. The cardiac injury was promptly repaired in both patients. In the first case, adequate organ perfusion ante-mortem was achieved thanks to venoarterial extracorporeal membrane oxygenation and intensive care unit support. The above procedure allowed successful organ donation and transplantation even after Maastricht category III cardiac death. This is the first case reported where, for organ donation purposes, it was made necessary first thing to avoid the immediate death of the patient, due to a rare and frequently not survivable cardiac injury. The challenge of preserving organ perfusion, due to major burn injury effects, was faced afterwards.

Conclusions

The outcomes of these two cases suggest that a repaired heart injury should not be considered as an absolute contraindication to organ donation, even if it is associated with non-survivable major burns. Therefore, cardiac death could provide an opportunity for these kinds of patients to contribute to the pool of potential organ donors.

Carbon monoxide: An emerging therapy for acute kidney injury

Treating acute kidney injury (AKI) represents an important unmet medical need both in terms of the seriousness of this medical problem and the number of patients. There is also a large untapped market opportunity in treating AKI. Over the years, there has been much effort in search of therapeutics with minimal success. However, over the same time period, new understanding of the underlying pathobiology and molecular mechanisms of kidney injury have undoubtedly helped the search for new therapeutics. Along this line, carbon monoxide (CO) has emerged as a promising therapeutic agent because of its demonstrated cytoprotective, and immunomodulatory effects. CO has also been shown to sensitize cancer, but not normal cells, to chemotherapy. This is particularly important in treating cisplatin-induced AKI, a common clinical problem that develops in patients receiving cisplatin therapies for a number of different solid organ malignancies. This review will examine and make the case that CO be developed into a therapeutic agent against AKI.

Liver Procurement from Poisoned Donors: A Survival Study

OBJECTIVES

Although transplant teams understand the effects of donor characteristics on liver transplant outcomes, few studies have investigated the quality of livers obtained from poisoned donors. The aim of this study was to compare livers procured from poisoned donors with a matched control group.

MATERIALS AND METHODS

Liver transplant outcomes from poisoned donors and from donors with trauma-induced death (as the control group) were compared using data of an Organ Procurement Unit from 2000 to 2013. Procured livers were evaluated via histology findings before transplant. Recipient characteristics were assessed in both groups, and immediate and medium-term (up to 5 years after transplant) survival rates were compared with the use of Kaplan-Meier analyses and log-rank tests.

RESULTS

Over a 13-year organ donation program, 1485 livers from brain dead patients were donated. Among them, 115 poisoned donors were evaluated for liver grafts; of these, 74 successful liver transplants were performed. In the poisoned donors, the incidence of reversed cardiac arrest was 54.1%. Likewise, acute kidney injury was detected in 14.9% of the patients, and 16.2% needed urgent dialysis either for clearance of the toxic agents or for treatment of acute kidney injury. No significant differences were observed in 1- to 5-year survival rates, and log-rank test also showed a significance level of 0.83.

CONCLUSIONS

Proper case selection strategies can be implemented to expand the donor pool, including use of poisoned donors. Hence, poisoning is not a contra-indication for a referral, which could lead to decreased mortality for patients requiring a liver transplant.

Poor methodological quality and reporting standards of systematic reviews in burn care management

The methodological and reporting quality of burn-specific systematic reviews has not been established. The aim of this study was to evaluate the methodological quality of systematic reviews in burn care management. Computerised searches were performed in Ovid MEDLINE, Ovid EMBASE and The Cochrane Library through to February 2016 for systematic reviews relevant to burn care using medical subject and free-text terms such as 'burn', 'systematic review' or 'meta-analysis'. Additional studies were identified by hand-searching five discipline-specific journals. Two authors independently screened papers, extracted and evaluated methodological quality using the 11-item A Measurement Tool to Assess Systematic Reviews (AMSTAR) tool and reporting quality using the 27-item Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Characteristics of systematic reviews associated with methodological and reporting quality were identified. Descriptive statistics and linear regression identified features associated with improved methodological quality. A total of 60 systematic reviews met the inclusion criteria. Six of the 11 AMSTAR items reporting on 'a priori' design, duplicate study selection, grey literature, included/excluded studies, publication bias and conflict of interest were reported in less than 50% of the systematic reviews. Of the 27 items listed for PRISMA, 13 items reporting on introduction, methods, results and the discussion were addressed in less than 50% of systematic reviews. Multivariable analyses showed that systematic reviews associated with higher methodological or reporting quality incorporated a meta-analysis (AMSTAR regression coefficient 2.1; 95% CI: 1.1, 3.1; PRISMA regression coefficient 6·3; 95% CI: 3·8, 8·7) were published in the Cochrane library (AMSTAR regression coefficient 2·9; 95% CI: 1·6, 4·2; PRISMA regression coefficient 6·1; 95% CI: 3·1, 9·2) and included a randomised control trial (AMSTAR regression coefficient 1·4; 95%CI: 0·4, 2·4; PRISMA regression coefficient 3·4; 95% CI: 0·9, 5·8). The methodological and reporting quality of systematic reviews in burn care requires further improvement with stricter adherence by authors to the PRISMA checklist and AMSTAR tool.

Long-term results of organ procurement from burn victims

BACKGROUND

With the increasing success of organ transplantation, many traditional contraindications to organ procurement are being reconsidered. Burn disease has constituted a traditional contraindication to solid organ procurement because of concerns that such organs may have been compromised by ischemia secondary to burn shock and contaminated by bacteremia. With the current shortage of solid organs, the transplant community continues to look for ways to increase the number of organ donors, including the use of marginal donors.

METHODS

Between 1999 and 2009 we have successfully procured 14 organs from four burn patients, who had suffered concurrent anoxic brain injury. There were one male and three female patients with an average age of 43.3 years and a total burned body surface area of 32.5%. Organ transplantation was performed at an average of 4.75days after the injury. Eight kidneys, three livers, two hearts and one pancreas were procured and transplanted into 13 patients.

RESULTS

We were able to follow-up on the organ recipients for an average of 80.5 months. The 5-year survival of the donated organs following transplant was 78.6% and the 5-year organ recipient survival was 92.3%.

CONCLUSIONS

Organ procurement after burns is not contraindicated and transplantation can be performed with good long-term results.

Using drug-intoxicated deaths as potential organ donors: impression of attendees at the American college of medical toxicology 2014 annual scientific meeting

INTRODUCTION

Over the last decade, there has been a reduction of organ donation from intracranial haemorrhage-, stroke- and blunt trauma-related deaths in the USA. There has been a corresponding increase in the use of drug-intoxicated patients as organ donors from 2.1 % in 2003 to 6.8 % in 2013.

METHODS

Questionnaire survey of attendees at the American College of Medical Toxicology 2014 Annual Scientific Meeting breakout session on transplantation from deaths related to poisoning was performed. Participants were asked whether they would recommend the use of solid organs from cocaine- or carbon monoxide-related death before and after the breakout session.

RESULTS

Forty-eight US participants (attending 23, fellow 15, resident 3 and other (including non-medical) 7) completed the survey, and 97.8 and 89.1 % of participants would consider cocaine- and carbon monoxide-related deaths for potential organ donation pre-breakout session, respectively; this increased to 100 % for both post-breakout sessions. There was variability in the consideration of different solid organs (the heart, lungs, liver, pancreas and kidneys)-76.2-95.2 and 76.2-85.7 % for individual solid organs for cocaine- and carbon monoxide-related deaths, respectively. For both scenarios, participants were least likely to consider potential heart donation (76.2 % of participants for both), which increased to 100 % following the breakout session.

CONCLUSIONS

Medical toxicologists have some reservation in recommending solid organs for transplantation from deaths from cocaine and carbon monoxide. Given the decrease in potential organ donors from typical methods of death, further work is needed to promote organ donation in deaths related to acute poisoning.

Organ donation from burn-injured patients--a national perspective

BACKGROUND

There is a discrepancy between publically available data from the United Network for Organ Sharing (UNOS) database and perception of the incidence of mortally burn-injured patients serving as organ donors. In the last 5 y, a single burn center referred several patients who went on to successfully donate multiple organs. However, UNOS data indicate very few referrals of patients with burn injuries nationwide. This discrepancy in UNOS-reported occurrences versus institutional experience prompted this work.

METHODS

UNOS data from 1988-2012 was examined for causes of death related to thermal injury, electrical injury, inhalation injury, or carbon monoxide poisoning. The National Burn Repository was examined for burn center death rates and patient characteristics of those with reported nonsurvivable burn injuries. Finally, a national survey queried the clinical experiences and educated opinions of burn center directors, transplant surgeons, and organ procurement organization (OPO) representatives regarding organ donation in the burn-injured population.

RESULTS

Between 42% and 52% of those surveyed responded. Survey data indicate that at least 61 patients with burn-related injuries have served as organ donors in the past 5 y alone, versus 23 identified in 24 y of UNOS data. Survey data also indicate that inhalation injuries were the most common burn-related injuries seen before successful organ procurement. Kidneys were the most commonly donated organs, but all major organs and tissues were represented in the experiences of surgeon and organ procurement organization respondents. Up to 10% surgeon respondents believe that patients with burn injuries should not be referred for possible organ donation.

CONCLUSIONS

There are more organs donated by patients with mortal burn injuries than currently available UNOS data would suggest. Survey data suggest that these patients should be able to contribute successfully to the supply of organs needed by those on transplant waiting lists, but remain inconsistently recognized as such a resource. Knowledge about long-term organ and tissue viability from burn-injured patients is lacking, and should be the focus of future research.