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Hessheimer AJ, Flores E, Vengohechea J, Fondevila C. Better liver transplant outcomes by donor interventions? Curr Opin Organ Transplant 2024; 29:219-227. [PMID: 38785132 DOI: 10.1097/mot.0000000000001153] [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: 05/25/2024]
Abstract
PURPOSE OF REVIEW Donor risk factors and events surrounding donation impact the quantity and quality of grafts generated to meet liver transplant waitlist demands. Donor interventions represent an opportunity to mitigate injury and risk factors within donors themselves. The purpose of this review is to describe issues to address among donation after brain death, donation after circulatory determination of death, and living donors directly, for the sake of optimizing relevant outcomes among donors and recipients. RECENT FINDINGS Studies on donor management practices and high-level evidence supporting specific interventions are scarce. Nonetheless, for donation after brain death (DBD), critical care principles are employed to correct cardiocirculatory compromise, impaired tissue oxygenation and perfusion, and neurohormonal deficits. As well, certain treatments as well as marginally prolonging duration of brain death among otherwise stable donors may help improve posttransplant outcomes. In donation after circulatory determination of death (DCD), interventions are performed to limit warm ischemia and reverse its adverse effects. Finally, dietary and exercise programs have improved donation outcomes for both standard as well as overweight living donor (LD) candidates, while minimally invasive surgical techniques may offer improved outcomes among LD themselves. SUMMARY Donor interventions represent means to improve liver transplant yield and outcomes of liver donors and grafts.
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Affiliation(s)
- Amelia J Hessheimer
- General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd
| | - Eva Flores
- Transplant Coordination Unit, Hospital Universitario La Paz, Madrid, Spain
| | - Jordi Vengohechea
- General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd
| | - Constantino Fondevila
- General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd
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2
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Zirpe K, Pandit R, Gurav S, Mani RK, Prabhakar H, Clerk A, Wanchoo J, Reddy KS, Ramachandran P, Karanth S, George N, Vaity C, Shetty RM, Samavedam S, Dixit S, Kulkarni AP. Management of Potential Organ Donor: Indian Society of Critical Care Medicine-Position Statement. Indian J Crit Care Med 2024; 28:S249-S278. [PMID: 39234232 PMCID: PMC11369920 DOI: 10.5005/jp-journals-10071-24698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 03/18/2024] [Indexed: 09/06/2024] Open
Abstract
This position statement is documented based on the input from all contributing coauthors from the Indian Society of Critical Care Medicine (ISCCM), following a comprehensive literature review and summary of current scientific evidence. Its objective is to provide the standard perspective for the management of potential organ/tissue donors after brain death (BD) in adults only, regardless of the availability of technology. This document should only be used for guidance only and is not a substitute for proper clinical decision making in particular circumstances of any case. Endorsement by the ISCCM does not imply that the statements given in the document are applicable in all or in a particular case; however, they may provide guidance for the users thus facilitating maximum organ availability from brain-dead patients. Thus, the care of potential brain-dead organ donors is "caring for multiple recipients." How to cite this article Zirpe K, Pandit R, Gurav S, Mani RK, Prabhakar H, Clerk A, et al. Management of Potential Organ Donor: Indian Society of Critical Care Medicine-Position Statement. Indian J Crit Care Med 2024;28(S2):S249-278.
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Affiliation(s)
- Kapil Zirpe
- Department of Neurotrauma Unit, Grant Medical Foundation, Pune, Maharashtra, India
| | - Rahul Pandit
- Department of Critical Care, Fortis Hospital, Mumbai, Maharashtra, India
| | - Sushma Gurav
- Department of Neurotrauma Unit, Grant Medical Foundation, Pune, Maharashtra, India
| | - RK Mani
- Department of Critical Care and Pulmonology, Yashoda Super Specialty Hospital, Ghaziabad, Uttar Pradesh, India
| | - Hemanshu Prabhakar
- Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Anuj Clerk
- Department of Intensive Care, Sunshine Global Hospital, Surat, Gujarat, India
| | - Jaya Wanchoo
- Department of Neuroanesthesia and Critical Care, Medanta The Medicity, Gurugram, Haryana, India
| | | | | | - Sunil Karanth
- Department of Critical Care Medicine, Manipal Hospital, Bengaluru, Karnataka, India
| | - Nita George
- Department of Critical Care Medicine, VPS Lakeshore Hospital & Research Center Kochi, Kerala, India
| | - Charudatt Vaity
- Department of Intensive Care, Fortis Hospital, Mumbai, Maharashtra, India
| | - Rajesh Mohan Shetty
- Department of Critical Care Medicine, Manipal Hospital, Bengaluru, Karnataka, India
| | - Srinivas Samavedam
- Department of Critical Care, Ramdev Rao Hospital, Hyderabad, Telangana, India
| | - Subhal Dixit
- Department of Critical Care Medicine, Sanjeevan & MJM Hospital, Pune, Maharashtra, India
| | - Atul P Kulkarni
- Department of Critical Care Medicine, Tata Memorial Centre, Mumbai, Maharashtra, India
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Bera KD, Tabak J, Ploeg RJ. No Evidence of Progressive Proinflammatory Cytokine Storm in Brain-dead Organ Donors-A Time-course Analysis Using Clinical Samples. Transplantation 2024; 108:923-929. [PMID: 38192028 PMCID: PMC10962432 DOI: 10.1097/tp.0000000000004900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 10/04/2023] [Accepted: 10/25/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Solid organ transplantation is a cost-effective treatment for end-stage organ failure. Organ donation after brain death is an important source of transplanted organs. Data are limited on the effects of brain injury or donor management on grafts. The consensus view has been that brain death creates a progressively proinflammatory environment. We aimed to investigate time-course changes across a range of cytokines in a donation after brain death cohort of donors who died of intracranial hemorrhage without any other systemic source of inflammation. METHODS A donor cohort was defined using the UK Quality in Organ Donation biobank. Serum levels of proteins involved in proinflammatory and brain injury pathways (tumor necrosis factor-alpha, interleukin-6, complement C5a, neuron-specific enolase, and glial fibrillary acidic protein) were measured from admission to organ recovery. Moving median analysis was used to combine donor trajectories and delineate a time-course. RESULTS A cohort of 27 donors with brain death duration between 10 and 30 h was created, with 24 donors contributing to the time-course analysis. We observed no increase in tumor necrosis factor-alpha or interleukin-6 throughout the donor management period. Neuronal injury marker and complement C5a remain high from admission to organ recovery, whereas glial fibrillary acidic protein rises around the confirmation of brain death. CONCLUSIONS We found no evidence of a progressive rise of proinflammatory mediators with prolonged duration of brain death, questioning the hypothesis of a progressively proinflammatory environment. Furthermore, the proposed approach allows us to study chronological changes and identify biomarkers or target pathways when logistical or ethical considerations limit sample availability.
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Affiliation(s)
- Katarzyna D. Bera
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Oxford, United Kingdom
- Oxford University NHS Foundation Trust, Oxford, United Kingdom
| | - Joel Tabak
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, United Kingdom
| | - Rutger J. Ploeg
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Oxford, United Kingdom
- Oxford University NHS Foundation Trust, Oxford, United Kingdom
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Montgomery RA, Griesemer AD, Segev DL, Sommer P. The decedent model: A new paradigm for de-risking high stakes clinical trials like xenotransplantation. Am J Transplant 2024; 24:526-532. [PMID: 38341026 DOI: 10.1016/j.ajt.2024.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024]
Abstract
The first 2 living recipients of pig hearts died unexpectedly within 2 months, despite both recipients receiving what over 30 years of nonhuman primate (NHP) research would suggest were the optimal gene edits and immunosuppression to ensure success. These results prompt us to question how faithfully data from the NHP model translate into human outcomes. Before attempting any further heart xenotransplants in living humans, it is highly advisable to gain a more comprehensive understanding of why the promising preclinical NHP data did not accurately predict outcomes in humans. It is also unlikely that additional NHP data will provide more information that would de-risk a xenoheart clinical trial because these cases were based on the best practices from the most successful NHP results to date. Although imperfect, the decedent model offers a complementary avenue to determine appropriate treatment regimens to control the human immune response to xenografts and better understand the biologic differences between humans and NHP that could lead to such starkly contrasting outcomes. Herein, we explore the potential benefits and drawbacks of the decedent model and contrast it to the advantages and disadvantages of the extensive body of data generated in the NHP xenoheart transplantation model.
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Affiliation(s)
| | | | | | - Philip Sommer
- NYU Langone Transplant Institute, New York, NY, USA; NYU Department of Anesthesiology, Perioperative Care and Pain Medicine, New York, NY, USA
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Hessheimer AJ, Flores E, Fondevila C. No Evidence of Progressive Proinflammatory Cytokine Storm in Brain Dead Organ Donors: Should We Avoid the Rush to Flush? Transplantation 2024; 108:839-840. [PMID: 38192013 DOI: 10.1097/tp.0000000000004901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Affiliation(s)
- Amelia J Hessheimer
- General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd, Madrid, Spain
| | - Eva Flores
- Transplant Coordination Unit, Hospital Universitario La Paz, Madrid, Spain
| | - Constantino Fondevila
- General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd, Madrid, Spain
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Eerola V, Sallinen V, Lempinen M, Helanterä I. Association of Procurement Time With Pancreas Transplant Outcomes in Brain-Dead Donors. Transpl Int 2023; 36:11332. [PMID: 37470064 PMCID: PMC10353260 DOI: 10.3389/ti.2023.11332] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/12/2023] [Indexed: 07/21/2023]
Abstract
A brain-death-induced cytokine storm damages organs in an organ donor. However, a longer time period between declaration of brain death and organ procurement (procurement interval) is associated with improved outcomes in kidney, liver, heart, and lung transplantation. The aim of this study was to find the optimal procurement interval for pancreas transplantation. Association of procurement interval with pancreas graft outcomes was analyzed using multivariable models adjusted for variables possibly affecting procurement interval and outcomes. Altogether 10,119 pancreas transplantations were included from the Scientific Registry of Transplant Recipients. The median follow-up was 3.2 (IQR 1.01-6.50) years. During the first year, 832 (9.0%) grafts were lost, including 555 (6.0%) within the first 30 days. Longer procurement interval was associated with increased death-censored graft survival in a multivariable model (HR 0.944 95% CI 0.917-0.972, per 10-h increase, p < 0.001). A decreasing hazard of graft loss was observed also with 1-year, but not with 30-day graft survival. During 1-year follow-up, 953 (12.1%) patients had an acute rejection, and longer procurement interval was also associated with less acute rejections (OR 0.937 95% CI 0.900-0.976, per 10-h increase, p = 0.002) in the multivariable model. In conclusion, longer procurement interval is associated with improved long-term outcomes in pancreas transplantation.
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Jensen CW, Jawitz OK, Benkert AR, Spencer PJ, Bryner BS, Schroder JN, Milano CA. Cardiovascular mechanism of donor brain death and heart recipient survival. J Card Surg 2022; 37:4621-4627. [PMID: 36378929 DOI: 10.1111/jocs.17150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/25/2022] [Accepted: 10/02/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Heart donation after donor brain death from cardiac arrest despite successful resuscitation may be associated with worse recipient outcomes due to potential graft ischemia or underlying rhythmic/structural defects. However, selected grafts from such donors often have normal cardiac function and anatomy. We investigated whether a cardiovascular mechanism of donor brain death (CV-DBD) was associated with worse recipient outcomes. METHODS We queried the United Network for Organ Sharing (UNOS) database for first-time, single-organ, adult (age 18+) heart transplant recipients and their associated donors between January 2005 and March 2021. Recipients were stratified by donor status (CV-DBD vs. non-CV-DBD). We performed multivariable Cox proportional hazards modeling to ascertain whether receiving a CV-DBD graft was independently associated with mortality. RESULTS Of 35,833 included recipients, 2,702 (7.5%) received CV-DBD grafts. The associated donors were significantly more likely to be female, older, and have a history of diabetes, hypertension, and substance use (all p < .001). On unadjusted Kaplan-Meier analysis, CV-DBD recipients had a significantly reduced median survival than non-CV-DBD recipients (12.0 vs. 13.1 years, log-rank p = .04). However, after adjusting for donor/recipient age, recipient comorbidities, annualized center volume, and transplantation era, CV-DBD organ status was not associated with recipient mortality (hazard ratio: 1.05, 95% confidence interval: 0.96-1.13, p = .28). CONCLUSION In this analysis of over 35,000 heart transplants, CV-DBD status was not associated with adjusted recipient survival. Donor brain death due to cardiac arrest should not be an absolute contraindication to heart donation, although graft function should be carefully assessed before transplantation.
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Affiliation(s)
- Christopher W Jensen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Oliver K Jawitz
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University Health System, Durham, North Carolina, USA
| | - Abigail R Benkert
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Philip J Spencer
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Benjamin S Bryner
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jacob N Schroder
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Carmelo A Milano
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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8
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Eerola V, Helanterä I, Åberg F, Lempinen M, Mäkisalo H, Nordin A, Isoniemi H, Sallinen V. Timing of Organ Procurement From Brain-Dead Donors Associates With Short- and Long-Term Outcomes After Liver Transplantation. Transpl Int 2022; 35:10364. [PMID: 36118016 PMCID: PMC9472133 DOI: 10.3389/ti.2022.10364] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022]
Abstract
Brain death-induced cytokine storm is thought to harm transplantable organs. However, longer procurement times have been associated with non-inferior or better outcomes in kidney, heart, and lung transplants, while optimal procurement time for liver allografts is unknown. Our aim was to analyze the association of time interval from brain death to organ procurement with liver allograft outcomes in two nationwide cohorts. The association of procurement interval with graft survival and short-term complications was analysed in multivariable models. Altogether 643 and 58,017 orthotopic liver transplantations from brain-dead donors were included from Finland between June 2004 and December 2017 and the US between January 2008 and August 2018, respectively. Median time from brain death to organ procurement was 10.5 h in Finland and 34.6 h in the US. Longer interval associated with better graft survival (non-linearly, p = 0.016) and less acute rejections (OR 0.935 95% CI 0.894–0.978) in the US cohort, and better early allograft function (p = 0.005; Beta −0.048 95% CI −0.085 −(−0.011)) in the Finnish cohort, in multivariable models adjusted with Donor Risk Index, recipient age, Model for End-Stage Liver Disease and indication for transplantation. Progressive liver injury after brain death is unlikely. Rushing to recover seems unnecessary; rest and repair might prove beneficial.
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9
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Brasil S. Mistaken concepts on the use of ancillary testing in brain death diagnosis. Can J Anaesth 2022; 69:405-406. [PMID: 34939138 DOI: 10.1007/s12630-021-02185-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 10/19/2022] Open
Affiliation(s)
- Sérgio Brasil
- Division of Neurosurgery, University of São Paulo, São Paulo, Brazil.
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10
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Mouat MA, Coleman JLJ, Wu J, Dos Remedios CG, Feneley MP, Graham RM, Smith NJ. Involvement of GPR37L1 in murine blood pressure regulation and human cardiac disease pathophysiology. Am J Physiol Heart Circ Physiol 2021; 321:H807-H817. [PMID: 34533400 DOI: 10.1152/ajpheart.00198.2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 09/14/2021] [Indexed: 01/23/2023]
Abstract
Multiple mouse lines lacking the orphan G protein-coupled receptor, GPR37L1, have elicited disparate cardiovascular phenotypes. The first Gpr37l1 knockout mice study to be published reported a marked elevation in systolic blood pressure (SBP; ∼60 mmHg), revealing a potential therapeutic opportunity. The phenotype differed from our own independently generated knockout line, where male mice exhibited equivalent baseline blood pressure to wild type. Here, we attempted to reproduce the first study by characterizing the cardiovascular phenotype of both the original knockout and transgenic lines alongside a C57BL/6J control line, using the same method of blood pressure measurement. The present study supports the findings from our independently developed Gpr37l1 knockout line, finding that SBP and diastolic blood pressure (DBP) are not different in the original Gpr37l1 knockout male mice (SBP: 130.9 ± 5.3 mmHg; DBP: 90.7 ± 3.0 mmHg) compared with C57BL/6J mice (SBP: 123.1 ± 4.1 mmHg; DBP: 87.0 ± 2.7 mmHg). Instead, we attribute the apparent hypertension of the knockout line originally described to comparison with a seemingly hypotensive transgenic line (SBP 103.7 ± 5.0 mmHg; DBP 71.9 ± 3.7 mmHg). Additionally, we quantified myocardial GPR37L1 transcript in humans, which was suggested to be downregulated in cardiovascular disease. We found that GPR37L1 has very low native transcript levels in human myocardium and that expression is not different in tissue samples from patients with heart failure compared with sex-matched healthy control tissue. These findings indicate that cardiac GPR37L1 expression is unlikely to contribute to the pathophysiology of human heart failure.NEW & NOTEWORTHY This study characterizes systolic blood pressure (SBP) in a Gpr37l1 knockout mouse line, which was previously reported to have ∼60 mmHg higher SBP compared with a transgenic line. We observed only a ∼27 mmHg SBP difference between the lines. However, when compared with C57BL/6J mice, knockout mice showed no difference in SBP. We also investigated GPR37L1 mRNA abundance in human hearts and observed no difference between healthy and failing heart samples.
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Affiliation(s)
- Margaret A Mouat
- Molecular Pharmacology Laboratory, Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
- St Vincent's Clinical School, UNSW Sydney, Sydney, New South Wales, Australia
- Molecular Cardiology and Biophysics Division, Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
| | - James L J Coleman
- Molecular Pharmacology Laboratory, Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
- St Vincent's Clinical School, UNSW Sydney, Sydney, New South Wales, Australia
- Molecular Cardiology and Biophysics Division, Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
| | - Jianxin Wu
- Molecular Cardiology and Biophysics Division, Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
- Cardiac Physiology and Transplantation Division, Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
| | - Cristobal G Dos Remedios
- Molecular Cardiology and Biophysics Division, Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
| | - Michael P Feneley
- Cardiac Physiology and Transplantation Division, Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
| | - Robert M Graham
- St Vincent's Clinical School, UNSW Sydney, Sydney, New South Wales, Australia
- Molecular Cardiology and Biophysics Division, Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
| | - Nicola J Smith
- Molecular Pharmacology Laboratory, Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
- St Vincent's Clinical School, UNSW Sydney, Sydney, New South Wales, Australia
- Molecular Cardiology and Biophysics Division, Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
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11
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Eerola V, Helanterä I, But A, Lempinen M, Mäkisalo H, Nordin A, Isoniemi H, Sallinen V. The Association of Time to Organ Procurement on Short- and Long-Term Outcomes in Kidney Transplantation. Clin J Am Soc Nephrol 2021; 16:427-436. [PMID: 33637606 PMCID: PMC8011019 DOI: 10.2215/cjn.11420720] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/08/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Transplant centers in Europe aim to minimize the time from brain death to organ procurement (procurement delay), but evidence to justify this is scarce. In the United States, procurement times are significantly longer. Our objective was to analyze how procurement delay associates with kidney allograft outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Kidney transplantations from brain-dead donors were retrospectively analyzed from the Finnish Kidney Transplant Registry and the Scientific Registry of Transplant Recipients in the United States. Multivariable models were adjusted with donor and recipient characteristics, and the relationship between procurement delay and outcomes was modeled with cubic spline functions. RESULTS In total, 2388 and 101,474 kidney transplantations in Finland and the United States were included, respectively. The median procurement delay was 9.8 hours (interquartile range, 7.8-12.4) in Finland and 34.8 hours (interquartile range, 26.3-46.3) in the United States. A nonlinear association was observed between procurement delay and the risk of delayed graft function, with highest risk seen in short and very long procurement delays. In multivariable models, the lowest risk of delayed graft function was associated with procurement delay between 20 and 50 hours. In multivariable models, longer procurement delay was linearly associated with lower risk of graft loss (hazard ratio, 0.90/1 h longer; 95% confidence interval, 0.88 to 0.92; P<0.001). Acute rejection rates, for which data were only available from Finland, were not associated with procurement delay. CONCLUSIONS Longer procurement delay was associated with noninferior or even better kidney allograft outcomes.
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Affiliation(s)
- Verner Eerola
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ilkka Helanterä
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anna But
- Biostatistics Consulting, Department of Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marko Lempinen
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Heikki Mäkisalo
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Arno Nordin
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Helena Isoniemi
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ville Sallinen
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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12
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Dark JH, Mehew J, Venkateswaran R. Prolongation of time from brain death to retrieval is beneficial to the donor heart. J Thorac Cardiovasc Surg 2020; 161:e311-e312. [PMID: 33218762 DOI: 10.1016/j.jtcvs.2020.06.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 06/21/2020] [Accepted: 06/23/2020] [Indexed: 01/19/2023]
Affiliation(s)
- John H Dark
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Jenny Mehew
- Statistics and Clinical Studies, National Health System Blood and Transplant, Bristol, United Kingdom
| | - Rajamiyer Venkateswaran
- Transplant Unit, Manchester University Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
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13
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Jawitz OK, Raman V. Reply from authors: Heart donor brain death duration-external validation from across the pond. J Thorac Cardiovasc Surg 2020; 161:e313. [PMID: 32868053 DOI: 10.1016/j.jtcvs.2020.06.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 06/25/2020] [Accepted: 06/26/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Oliver K Jawitz
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Vignesh Raman
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
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Le AT, Mokadam NA. Reply: Riding out the storm. J Thorac Cardiovasc Surg 2020; 161:e312-e313. [PMID: 32859421 DOI: 10.1016/j.jtcvs.2020.07.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Anh-Thu Le
- Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Nahush A Mokadam
- Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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15
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Bera KD, Shah A, English MR, Harvey D, Ploeg RJ. Optimisation of the organ donor and effects on transplanted organs: a narrative review on current practice and future directions. Anaesthesia 2020; 75:1191-1204. [PMID: 32430910 DOI: 10.1111/anae.15037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 12/16/2022]
Abstract
Mortality remains high for patients on the waiting list for organ transplantation. A marked imbalance between the number of available organs and recipients that need to be transplanted persists. Organs from deceased donors are often declined due to perceived and actual suboptimal quality. Adequate donor management offers an opportunity to reduce organ injury and maximise the number of organs than can be offered in order to respect the donor's altruistic gift. The cornerstones of management include: correction of hypovolaemia; maintenance of organ perfusion; prompt treatment of diabetes insipidus; corticosteroid therapy; and lung protective ventilation. The interventions used to deliver these goals are largely based on pathophysiological rationale or extrapolations from general critical care patients. There is currently insufficient high-quality evidence that has assessed whether any interventions in the donor after brain death may actually improve immediate post-transplant function and long-term graft survival or recipient survival after transplantation. Improvements in our understanding of the underlying mechanisms following brain death, in particular the role of immunological and metabolic changes in donors, offer promising future therapeutic opportunities to increase organ utilisation. Establishing a UK donor management research programme involves consideration of ethical, logistical and legal issues that will benefit transplanted patients while respecting the wishes of donors and their families.
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Affiliation(s)
- K D Bera
- Oxford Biomedical Research Centre and Oxford University Hospital NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - A Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK
| | - M R English
- University of Oxford Medical School, Oxford, UK
| | - D Harvey
- Department of Intensive Care Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R J Ploeg
- Nuffield Department of Surgical Sciences and Oxford Biomedical Research Centre, University of Oxford, UK
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Stadlan N. Patients who are dead by neurologic criteria (brain dead) are not homogeneous. J Thorac Cardiovasc Surg 2019; 159:e213. [PMID: 31669025 DOI: 10.1016/j.jtcvs.2019.07.143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 07/17/2019] [Accepted: 07/18/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Noam Stadlan
- Division of Neurosurgery, University of Chicago, Pritzker School of Medicine, Chicago, Ill; Division of Neurosurgery, NorthShore University HealthSystem, Evanston, Ill
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Lee PHU, Mokadam NA. Reply: Worth the wait. J Thorac Cardiovasc Surg 2019; 159:e213-e214. [PMID: 31627946 DOI: 10.1016/j.jtcvs.2019.08.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 08/02/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Peter H U Lee
- Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Nahush A Mokadam
- Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Kilic A. Commentary: Duration of brain death and heart transplant outcomes: The devil is in the detail. J Thorac Cardiovasc Surg 2019; 159:1356. [PMID: 31255347 DOI: 10.1016/j.jtcvs.2019.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 05/21/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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