Extracorporeal life support and multiorgan donation in a severe polytrauma patient: A case report

Organ Donation from Patients Receiving Extracorporeal Membrane Oxygenation: A Systematic Review

OBJECTIVE

The mismatch between the demand for and supply of organs for transplantation is steadily growing. Various strategies have been incorporated to improve the availability of organs, including organ use from patients receiving extracorporeal membrane oxygenation (ECMO) at the time of death. However, there is no systematic evidence of the outcome of grafts from these donors.

DESIGN

Systematic literature review (Scopus and PubMed, up to October 11, 2023).

SETTING

All study designs.

PARTICIPANTS

Organ recipients from patients on ECMO at the time of death.

INTERVENTION

Outcome of organ donation from ECMO donors.

MEASUREMENTS AND MAIN RESULTS

The search yielded 1,692 publications, with 20 studies ultimately included, comprising 147 donors and 360 organ donations. The most frequently donated organs were kidneys (68%, 244/360), followed by liver (24%, 85/360). In total, 98% (292/299) of recipients survived with a preserved graft function (92%, 319/347) until follow-up within a variable period of up to 3 years.

CONCLUSION

Organ transplantation from donors supported with ECMO at the time of death shows high graft and recipient survival. ECMO could be a suitable approach for expanding the donor pool, helping to alleviate the worldwide organ shortage.

Ethical considerations in the use of pre-mortem interventions to support deceased organ donation: A scoping review

AIM

Pre-mortem interventions (PMIs) are performed on patients before the determination of death in order to preserve or enhance the possibility of organ donation. These interventions can be ethically controversial, and we thus undertook a scoping review of the ethical issues surrounding diverse PMIs.

METHODS

Using modified scoping review methods, we executed a search strategy created by an information specialist. Screening and iterative coding of each article was done by two researchers using qualitative thematic analysis, and narrative summaries of coded themes were presented.

RESULTS

We identified and screened 5365 references and coded 196 peer-reviewed publications. The most frequently cited issues were related to possible harms to the patient who is a potential donor, and legitimacy of consent. The most controversial issue was that PMIs may place patients at risk for physical harm, yet benefit is accrued mainly to recipients. Some authors argued that lack of direct medical benefit to the still living patient precluded valid consent from surrogate decision makers (SDMs), while many stated that some medical risk could be approved by SDMs if it aligns with non-medical benefits valued by the patient.

CONCLUSION

PMIs require consensus that benefit includes concepts beyond medical benefit to the patient who is a potential donor. Informed consent must be confirmed for each PMI and not assumed to be part of general consent for donation. Risk must be proportionate to the potential benefit and newly proposed interventions should be reviewed carefully for medical efficacy and potential risks.

Ethics in extracorporeal life support: a narrative review

During 50 years of extracorporeal life support (ECLS), this highly invasive technology has left a considerable imprint on modern medicine, and it still confronts researchers, clinicians and policymakers with multifarious ethical challenges. After half a century of academic discussion about the ethics of ECLS, it seems appropriate to review the state of the argument and the trends in it. Through a comprehensive literature search on PubMed, we identified three ethical discourses: (1) trials and evidence accompanying the use of ECLS, (2) ECLS allocation, decision-making and limiting care, and (3) death on ECLS and ECLS in organ donation. All included articles were carefully reviewed, arguments extracted and grouped into the three discourses. This article provides a narrative synthesis of these arguments, evaluates the opportunities for mediation and substantiates the necessity of a shared decision-making approach at the limits of medical care.

Heart Procurement from a Donor on Venovenous ECMO Support

We report the case of a 37-year-old woman with acute respiratory distress syndrome and became a candidate for organ donation after anoxic brain injury and was on a venovenous extracorporeal membrane oxygenation (VV-ECMO) support. On preoperative evaluation and gross examination, the donor's heart was acceptable for heart transplantation to a 62-year-old female patient with a history of nonischemic cardiomyopathy with a HeartMate II mechanical assist device. Orthotopic heart transplantation was successfully performed in the recipient. We report a case that suggests that the procurement of a heart from a donor on ECMO support can potentially expand the donor heart pool in carefully selected patients.

Decellularized Human Liver Is Too Heterogeneous for Designing a Generic Extracellular Matrix Mimic Hepatic Scaffold

Decellularized human livers are considered the perfect extracellular matrix (ECM) surrogate because both three-dimensional architecture and biological features of the hepatic microenvironment are thought to be preserved. However, donor human livers are in chronically short supply, both for transplantation or as decellularized scaffolds, and will become even scarcer as life expectancy increases. It is hence of interest to determine the structural and biochemical properties of human hepatic ECM to derive design criteria for engineering biomimetic scaffolds. The intention of this work was to obtain quantitative design specifications for fabricating scaffolds for hepatic tissue engineering using human livers as a template. To this end, hepatic samples from five patients scheduled for hepatic resection were decellularized using a protocol shown to reproducibly conserve matrix composition and microstructure in porcine livers. The decellularization outcome was evaluated through histological and quantitative image analyses to evaluate cell removal, protein, and glycosaminoglycan content per unit area. Applying the same decellularization protocol to human liver samples obtained from five different patients yielded five different outcomes. Only one liver out of five was completely decellularized, while the other four showed different levels of remaining cells and matrix. Moreover, protein and glycosaminoglycan content per unit area after decellularization were also found to be patient- (or donor-) dependent. This donor-to-donor variability of human livers thus precludes their use as templates for engineering a generic "one-size fits all" ECM-mimic hepatic scaffold.