1
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Rajsic S, Treml B, Rugg C, Innerhofer N, Eckhardt C, Breitkopf R. Organ Utilization From Donors Following Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review of Graft and Recipient Outcome. Transplantation 2024:00007890-990000000-00816. [PMID: 39020459 DOI: 10.1097/tp.0000000000005133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
BACKGROUND The global shortage of solid organs for transplantation is exacerbated by high demand, resulting in organ deficits and steadily growing waiting lists. Diverse strategies have been established to address this issue and enhance organ availability, including the use of organs from individuals who have undergone extracorporeal cardiopulmonary resuscitation (eCPR). The main aim of this work was to examine the outcomes for both graft and recipients of solid organ transplantations sourced from donors who underwent eCPR. METHODS We performed a systematic literature review using a combination of the terms related to extracorporeal life support and organ donation. Using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, PubMed and Scopus databases were searched up to February 2024. RESULTS From 1764 considered publications, 13 studies comprising 130 donors and 322 organ donations were finally analyzed. On average, included patients were 36 y old, and the extracorporeal life support was used for 4 d. Kidneys were the most often transplanted organs (68%; 220/322), followed by liver (22%; 72/322) and heart (5%; 15/322); with a very good short-term graft survival rate (95% for kidneys, 92% for lungs, 88% for liver, and 73% for heart). Four studies with 230 grafts reported functional outcomes at the 1-y follow-up, with graft losses reported for 4 hearts (36%), 8 livers (17%), and 7 kidneys (4%). CONCLUSIONS Following eCPR, organs can be successfully used with very high graft and recipient survival. In terms of meeting demand, the use of organs from patients after eCPR might be a suitable method for expanding the organ donation pool.
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Affiliation(s)
- Sasa Rajsic
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
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2
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Vijayan K, Schroder HJ, Hameed A, Hitos K, Lo W, Laurence JM, Yoon PD, Nahm C, Lim WH, Lee T, Yuen L, Wong G, Pleass H. Kidney Transplantation Outcomes From Uncontrolled Donation After Circulatory Death: A Systematic Review and Meta-analysis. Transplantation 2024; 108:1422-1429. [PMID: 38361237 DOI: 10.1097/tp.0000000000004937] [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: 02/17/2024]
Abstract
BACKGROUND Uncontrolled donation after circulatory death (uDCD) is a potential additional source of donor kidneys. This study reviewed uDCD kidney transplant outcomes to determine if these are comparable to controlled donation after circulatory death (cDCD). METHODS MEDLINE, Cochrane, and Embase databases were searched. Data on demographic information and transplant outcomes were extracted from included studies. Meta-analyses were performed, and risk ratios (RR) were estimated to compare transplant outcomes from uDCD to cDCD. RESULTS Nine cohort studies were included, from 2178 uDCD kidney transplants. There was a moderate degree of bias, as 4 studies did not account for potential confounding factors. The median incidence of primary nonfunction in uDCD was 12.3% versus 5.7% for cDCD (RR, 1.85; 95% confidence intervals, 1.06-3.23; P = 0.03, I 2 = 75). The median rate of delayed graft function was 65.1% for uDCD and 52.0% for cDCD. The median 1-y graft survival for uDCD was 82.7% compared with 87.5% for cDCD (RR, 1.43; 95% confidence intervals, 1.02-2.01; P = 0.04; I 2 = 71%). The median 5-y graft survival for uDCD and cDCD was 70% each. Notably, the use of normothermic regional perfusion improved primary nonfunction rates in uDCD grafts. CONCLUSIONS Although uDCD outcomes may be inferior in the short-term, the long-term outcomes are comparable to cDCD.
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Affiliation(s)
- Keshini Vijayan
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
| | - Hugh J Schroder
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
| | - Ahmer Hameed
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Kerry Hitos
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Warren Lo
- Institute of Urology and Nephrology, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
| | - Jerome M Laurence
- Central Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
| | - Peter D Yoon
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Christopher Nahm
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Taina Lee
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Lawrence Yuen
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Germaine Wong
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
- Department of Renal Medicine, Westmead Hospital, Sydney, NSW, Australia
| | - Henry Pleass
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
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3
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Salgueirinho C, Correia A, Graça I, Oliveira R, Dias J. The Role of Extracorporeal Cardiopulmonary Resuscitation in Pediatric Intraoperative Cardiac Arrest. Cureus 2024; 16:e59940. [PMID: 38854195 PMCID: PMC11162277 DOI: 10.7759/cureus.59940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2024] [Indexed: 06/11/2024] Open
Abstract
Refractory pediatric intraoperative cardiac arrest is a rare but challenging situation for the anesthesiologist. This case describes an intraoperative extracorporeal cardiopulmonary resuscitation (ECPR) in a 16-year-old male who suffered a sudden cardiac arrest during elective thoracolumbar stabilization. The patient recovered to his pre-operative baseline without any neurological sequela secondary to cardiac arrest. Good quality of conventional resuscitation measures, prompt activation of the extracorporeal membrane oxygenation (ECMO) team, and a multidisciplinary coordinated approach were key factors in ECPR success. Despite the lack of robust evidence in pediatrics, case reports like ours outline the life-saving potential of intraoperative ECPR in refractory cardiac arrest scenarios.
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Affiliation(s)
| | - André Correia
- Department of Anesthesiology, São João University Hospital Center, Porto, PRT
| | - Inês Graça
- Department of Anesthesiology, São João University Hospital Center, Porto, PRT
| | - Raquel Oliveira
- Department of Anesthesiology, São João University Hospital Center, Porto, PRT
| | - José Dias
- Department of Anesthesiology, São João University Hospital Center, Porto, PRT
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Nobre de Jesus G, Neves I, Gouveia J, Ribeiro J. Feasibility and performance of a combined extracorporeal assisted cardiac resuscitation and an organ donation program after uncontrolled cardiocirculatory death (Maastricht II). Perfusion 2024; 39:408-414. [PMID: 36404767 DOI: 10.1177/02676591221140237] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
INTRODUCTION Approximately 500.000 people in Europe sustain cardiac arrest (CA) every year, being myocardial infarction the main etiology. Interest has been raised in a new approach to refractory cardiac arrest (rCA) using extra-corporeal oxygenation (ECMO). In settings where it can be rapidly implemented, ECMO assisted resuscitation (ECPR) may be considered. Additionally, donation after circulatory death, which seeks to obtain solid organs donation from patients suffering rCA, has increased its role effectively increasing the pool of donors. Combined programs with integration of ECPR and uncontrolled donation after circulatory determination of death (uDCDD) are worldwide limited and experience integrating these two techniques is lacking. METHODS We report a 24 months experience of ECPR and uDCDD kidney transplantation based on a management protocol in a university teaching hospital in the urban area of Lisbon. RESULTS Over a period of 24 months, 58 patients were admitted to our ICU with rCA, 6 (10%) in the ECPR program and 52 (90%) in the uDCDD. Seventy-eight percent of patients were male, with an average age of 49 year-old. CA was witnessed in 83% of cases and initial rhythm was ventricular fibrillation in 20 cases (35%). 13 (25%) patients were effective organ donors. Refusal for effective donation was mainly due to prior comorbidities. DISCUSSION The development of an integrated program for ECPR and uDCDD is feasible and requires a well-established and efficient activation program. In an era of significant organ shortage, it provides a viable option for increasing the organ donation pool, with promising results.
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Affiliation(s)
- Gustavo Nobre de Jesus
- Serviço de Medicina Intensiva, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Clínica Universitária de Medicina Intensiva, Lisbon, Portugal
| | - Inês Neves
- Serviço de Medicina Intensiva, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - João Gouveia
- Serviço de Medicina Intensiva, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - João Ribeiro
- Serviço de Medicina Intensiva, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
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5
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Manara A, Rubino A, Tisherman S. ECPR and organ donation: Emerging clarity in decision making. Resuscitation 2023; 193:110035. [PMID: 37944851 DOI: 10.1016/j.resuscitation.2023.110035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Alex Manara
- Consultant in Intensive Care Medicine, Southmead Hospital, Bristol BS10 5NB, United Kingdom.
| | - Antonio Rubino
- Consultant in Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge CB2 0AY, United Kingdom.
| | - Sam Tisherman
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA.
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Rubio-Chacón C, Mateos-Rodríguez A, Neria-Serrano F, Del Rio-Gallegos F, Andrés-Belmonte A. Reply to pre hospital interventions and organ donation in out of hospital cardiac arrest. Resuscitation 2023; 193:110030. [PMID: 37923111 DOI: 10.1016/j.resuscitation.2023.110030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 10/21/2023] [Indexed: 11/07/2023]
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7
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Morrison LJ, Sandroni C, Grunau B, Parr M, Macneil F, Perkins GD, Aibiki M, Censullo E, Lin S, Neumar RW, Brooks SC. Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation. Circulation 2023; 148:e120-e146. [PMID: 37551611 DOI: 10.1161/cir.0000000000001125] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
AIM OF THE REVIEW Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries. METHODS The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section. RESULTS There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness. CONCLUSIONS All health systems should develop, implement, and evaluate protocols designed to optimize organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.
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8
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Drabek T. Where have all the kidneys gone? After ECPR, they are here to stay. Resuscitation 2023; 190:109912. [PMID: 37506815 DOI: 10.1016/j.resuscitation.2023.109912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023]
Affiliation(s)
- Tomas Drabek
- Safar Center for Resuscitation Research, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, UPMC Presbyterian Hospital, 200 Lothrop St., Suite C-200, Pittsburgh, PA 15213, United States.
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9
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Morrison LJ, Sandroni C, Grunau B, Parr M, Macneil F, Perkins GD, Aibiki M, Censullo E, Lin S, Neumar RW, Brooks SC. Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation. Resuscitation 2023; 190:109864. [PMID: 37548950 DOI: 10.1016/j.resuscitation.2023.109864] [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] [Indexed: 08/08/2023]
Abstract
AIM OF THE REVIEW Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries. METHODS The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section. RESULTS There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness. CONCLUSIONS All health systems should develop, implement, and evaluate protocols designed to optimise organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.
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10
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Streit S, Johnston-Webber C, Mah J, Prionas A, Wharton G, Paulino J, Franca A, Mossialos E, Papalois V. Lessons From the Portuguese Solid Organ Donation and Transplantation System: Achieving Success Despite Challenging Conditions. Transpl Int 2023; 36:11008. [PMID: 37305338 PMCID: PMC10249494 DOI: 10.3389/ti.2023.11008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 04/14/2023] [Indexed: 06/13/2023]
Abstract
Over the past two decades, Portugal has become one of the world leaders in organ donation and transplantation despite significant financial constraints. This study highlights how Portugal achieved success in organ donation and transplantation and discusses how this information might be used by other countries that are seeking to reform their national programs. To accomplish this goal, we performed a narrative review of relevant academic and grey literature and revised our results after consultation with two national experts. Our findings were then synthesized according to a conceptual framework for organ donation and transplantation programs. Our results revealed several key strategies used by the Portuguese organ donation and transplantation program, including collaboration with Spain and other European nations, a focus on tertiary prevention, and sustained financial commitment. This report also explores how cooperative efforts were facilitated by geographical, governmental, and cultural proximity to Spain, a world leader in organ donation and transplantation. In conclusion, our review of the Portuguese experience provides insight into the development of organ donation and transplantation systems. However, other countries seeking to reform their national transplant systems will need to adapt these policies and practices to align with their unique cultures and contexts.
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Affiliation(s)
- Simon Streit
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | - Charlotte Johnston-Webber
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | - Jasmine Mah
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Apostolos Prionas
- Department of Surgery, Imperial College, London, United Kingdom
- Department of General Surgery, Whipps Cross Hospital, Barts Health NHS Trust, London, United Kingdom
| | - George Wharton
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | - Jorge Paulino
- Hepato-Biliary-Pancreatic and Transplantation Centre, Curry Cabral Hospital, Lisbon, Portugal
| | - Ana Franca
- Instituto Português do Sangue e da Transplantação, Lisbon, Portugal
| | - Elias Mossialos
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
- Institute of Global Health Innovation, Imperial College, London, United Kingdom
| | - Vassilios Papalois
- Department of Surgery, Imperial College, London, United Kingdom
- Renal and Transplant Unit, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
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11
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Schiff T, Koziatek C, Pomerantz E, Bosson N, Montgomery R, Parent B, Wall SP. Extracorporeal cardiopulmonary resuscitation dissemination and integration with organ preservation in the USA: ethical and logistical considerations. Crit Care 2023; 27:144. [PMID: 37072806 PMCID: PMC10111746 DOI: 10.1186/s13054-023-04432-7] [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: 01/25/2023] [Accepted: 04/05/2023] [Indexed: 04/20/2023] Open
Abstract
Use of extracorporeal membrane oxygenation (ECMO) in cardiopulmonary resuscitation, termed eCPR, offers the prospect of improving survival with good neurological function after cardiac arrest. After death, ECMO can also be used for enhanced preservation of abdominal and thoracic organs, designated normothermic regional perfusion (NRP), before organ recovery for transplantation. To optimize resuscitation and transplantation outcomes, healthcare networks in Portugal and Italy have developed cardiac arrest protocols that integrate use of eCPR with NRP. Similar dissemination of eCPR and its integration with NRP in the USA raise novel ethical issues due to a non-nationalized health system and an opt-in framework for organ donation, as well as other legal and cultural factors. Nonetheless, eCPR investigations are ongoing, and both eCPR and NRP are selectively employed in clinical practice. This paper delineates the most pressing relevant ethical considerations and proposes recommendations for implementation of protocols that aim to promote public trust and reduce conflicts of interest. Transparent policies should rely on protocols that separate lifesaving from organ preservation considerations; robust, centralized eCPR data to inform equitable and evidence-based allocations; uniform practices concerning clinical decision-making and resource utilization; and partnership with community stakeholders, allowing patients to make decisions about emergency care that align with their values. Proactively addressing these ethical and logistical challenges could enable eCPR dissemination and integration with NRP protocols in the USA, with the potential to maximize lives saved through both improved resuscitation with good neurological outcomes and increased organ donation opportunities when resuscitation is unsuccessful or not in accordance with individuals' wishes.
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Affiliation(s)
- Tamar Schiff
- Department of Population Health, NYU Langone Health, 227 E 30th St, New York, NY, 10016, USA
| | - Christian Koziatek
- Ronald O. Perelman Department of Emergency Medicine, NYU Langone Health, New York, NY, USA
| | - Erin Pomerantz
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Nichole Bosson
- Los Angeles County EMS Agency, Santa Fe Springs, CA, USA
- Harbor-UCLA Medical Center and the Lundquist Research Institute, Torrance, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Robert Montgomery
- NYU Langone Transplant Institute, NYU Langone Health, New York, NY, USA
- Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Brendan Parent
- Department of Population Health, NYU Langone Health, 227 E 30th St, New York, NY, 10016, USA
- NYU Langone Transplant Institute, NYU Langone Health, New York, NY, USA
- Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Stephen P Wall
- Department of Population Health, NYU Langone Health, 227 E 30th St, New York, NY, 10016, USA.
- Ronald O. Perelman Department of Emergency Medicine, NYU Langone Health, New York, NY, USA.
- NYU Langone Transplant Institute, NYU Langone Health, New York, NY, USA.
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12
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Reid TD, Kratzke I, Dayal D, Raff L, Serrano P, Kumar A, Boddie O, Zendel A, Gallaher J, Carlson R, Boone J, Charles AG, Desai CS. The role of extracorporeal membrane oxygenation in adult kidney transplant patients: A qualitative systematic review of literature. Artif Organs 2023; 47:24-37. [PMID: 35986612 DOI: 10.1111/aor.14376] [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: 04/20/2022] [Revised: 06/23/2022] [Accepted: 07/26/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND A paucity of evidence exists regarding the risks and benefits of Extracorporeal Membrane Oxygenation (ECMO) in adult kidney transplantation. METHODS This was a systematic review conducted from Jan 1, 2000 to April 24, 2020 of adult kidney transplant recipients (pre- or post- transplant) and donors who underwent veno-arterial or veno-venous ECMO cannulation. Death and graft function were the primary outcomes, with complications as secondary outcomes. RESULTS Twenty-three articles were identified that fit inclusion criteria. 461 donors were placed on ECMO, with an overall recipient 12-month mortality rate of 1.3% and a complication rate of 61.5%, the majority of which was delayed graft function. Fourteen recipients were placed on ECMO intraoperatively or postoperatively, with infection as the most common indication for ECMO. The 90-day mortality rate for recipients on ECMO was 42.9%, with multisystem organ failure and infection as the ubiquitous causes of death. 35.7% of patients experienced rejection within 6 months of decannulation, yet all were successfully treated. CONCLUSIONS ECMO use in adult kidney transplantation is a useful adjunct. Recipient morbidity and mortality from donors placed on ECMO mirrors that of recipients from standard criteria donors. The morbidity and mortality of recipients placed on ECMO are also similar to other patient populations requiring ECMO.
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Affiliation(s)
- Trista D Reid
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ian Kratzke
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Diana Dayal
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lauren Raff
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Pablo Serrano
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Transplant Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Aman Kumar
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Transplant Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Olivia Boddie
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Alex Zendel
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Transplant Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jared Gallaher
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Rebecca Carlson
- Health Sciences Library, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Joshua Boone
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Anthony G Charles
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Trauma and Acute Care Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Chirag S Desai
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Transplant Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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14
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Lazzeri C, Bonizzoli M, Peris A. Uncontrolled donation after circulatory death and SARS-CoV2 pandemia: still feasible? Eur J Emerg Med 2022; 29:241-243. [PMID: 35404312 PMCID: PMC9241561 DOI: 10.1097/mej.0000000000000925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Chiara Lazzeri
- Intensive Care Unit and Regional, ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Manuela Bonizzoli
- Intensive Care Unit and Regional, ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Adriano Peris
- Intensive Care Unit and Regional, ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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15
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Lim WH, Dominguez-Gil B. Ethical Issues Related to Donation and Transplantation of Donation After Circulatory Determination of Death Donors. Semin Nephrol 2022; 42:151269. [PMID: 36577644 DOI: 10.1016/j.semnephrol.2022.07.003] [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] [Indexed: 12/28/2022]
Abstract
With the continuing disparity between organ supply to match the increasing demand for kidney transplants in patients with renal failure, donation after the circulatory determination of death (DCDD) has become an important and increasing global source of kidneys for clinical use. The concern that the outcomes of controlled DCDD donor kidney transplants were inferior to those obtained from donors declared dead by neurologic criteria has largely diminished because large-scale registry and single-center reports consistently have reported favorable outcomes. For uncontrolled DCDD kidney transplants, outcomes are correspondingly acceptable, although there is a greater risk of primary nonfunction. The potential of DCDD remains unrealized in many countries because of the ethical concerns and resource implications in the utilization of these donor kidneys for transplantation. In this review, we discuss the origin and definitions of DCDD donors, and examine the long-term outcomes of transplants from DCDD donor kidneys. We discuss the controversies, challenges, and ethical and legal barriers in the acceptance of DCDD, including the complexities of implementing and sustaining controlled and uncontrolled DCDD donor programs. The lessons learned from global leaders will assist a wider international recognition, acceptance, and development of DCDD transplant programs that will noticeably facilitate and address the global shortages of kidneys for transplantation, and ensure the opportunity for people who had indicated their desires to become organ donors fulfill their final wishes.
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Affiliation(s)
- Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia; Internal Medicine, University of Western Australia Medical School, Perth, Australia.
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16
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Gottula AL, Neumar RW, Hsu CH. Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest - who, when, and where? Curr Opin Crit Care 2022; 28:276-283. [PMID: 35653248 DOI: 10.1097/mcc.0000000000000944] [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] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Extracorporeal cardiopulmonary resuscitation (ECPR) is an invasive and resource-intensive therapy used to care for patients with refractory cardiac arrest. In this review, we highlight considerations for the establishment of an ECPR system of care for patients suffering refractory out-of-hospital cardiac arrest (OHCA). RECENT FINDINGS ECPR has been shown to improve neurologically favorable outcomes in patients with refractory cardiac arrest in numerous studies, including a single randomized control trial. Successful ECPR programs are typically part of a comprehensive system of care that optimizes all phases of OHCA management. Given the resource-intensive and time-sensitive nature of ECPR, patient selection criteria, timing of ECPR, and location must be well defined. Many knowledge gaps remain within ECPR systems of care, postcardiac arrest management, and neuroprognostication strategies for ECPR patients. SUMMARY To be consistently successful, ECPR must be a part of a comprehensive OHCA system of care that optimizes all phases of cardiac arrest management. Future investigation is needed for the knowledge gaps that remain.
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Affiliation(s)
- Adam L Gottula
- Department of Emergency Medicine
- Department of Anesthesiology
| | - Robert W Neumar
- Department of Emergency Medicine
- Max Harry Weil Institute for Critical Care Research and Innovation
| | - Cindy H Hsu
- Department of Emergency Medicine
- Max Harry Weil Institute for Critical Care Research and Innovation
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
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17
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Gregorini M, Ticozzelli E, Abelli M, Grignano MA, Pattonieri EF, Giacomoni A, De Carlis L, Dell’Acqua A, Caldara R, Socci C, Bottazzi A, Libetta C, Sepe V, Malabarba S, Manzoni F, Klersy C, Piccolo G, Rampino T. Kidney Transplants From Donors on Extracorporeal Membrane Oxygenation Prior to Death Are Associated With Better Long-Term Renal Function Compared to Donors After Circulatory Death. Transpl Int 2022; 35:10179. [PMID: 35210934 PMCID: PMC8862176 DOI: 10.3389/ti.2021.10179] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/28/2021] [Indexed: 01/10/2023]
Abstract
Donation after circulatory death (DCD) allows expansion of the donor pool. We report on 11 years of Italian experience by comparing the outcome of grafts from DCD and extracorporeal membrane oxygenation (ECMO) prior to death donation (EPD), a new donor category. We studied 58 kidney recipients from DCD or EPD and collected donor/recipient clinical characteristics. Primary non function (PNF) and delayed graft function (DGF) rates, dialysis need, hospitalization duration, and patient and graft survival rates were compared. The estimated glomerular filtration rate (eGFR) was measured throughout the follow-up. Better clinical outcomes were achieved with EPD than with DCD despite similar graft and patient survival rates The total warm ischemia time (WIT) was longer in the DCD group than in the EPD group. Pure WIT was the highest in the class II group. The DGF rate was higher in the DCD group than in the EPD group. PNF rate was similar in the groups. Dialysis need was the greatest and hospitalization the longest in the class II DCD group. eGFR was lower in the class II DCD group than in the EPD group. Our results indicate good clinical outcomes of kidney transplants from DCD despite the long “no-touch period” and show that ECMO in the procurement phase improves graft outcome, suggesting EPD as a source for pool expansion.
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Affiliation(s)
- Marilena Gregorini
- Dipartimento di Medicina Interna e Terapia Medica, Università Degli Studi di Pavia, Pavia, Italy
- Unit of Nephrology, Dialysis and Transplant, San Matteo Hospital Foundation (IRCCS), Pavia, Italy
- *Correspondence: Marilena Gregorini,
| | - Elena Ticozzelli
- Unit of General Surgery 2, Department of Surgical Sciences, San Matteo Hospital Foundation (IRCCS), Pavia, Italy
| | - Massimo Abelli
- Transplant Unit, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Maria A. Grignano
- Unit of Nephrology, Dialysis and Transplant, San Matteo Hospital Foundation (IRCCS), Pavia, Italy
| | - Eleonora F. Pattonieri
- Unit of Nephrology, Dialysis and Transplant, San Matteo Hospital Foundation (IRCCS), Pavia, Italy
| | - Alessandro Giacomoni
- Transplant Center, Department of General Surgery and Abdominal Transplantation, Niguarda Cà Granda Hospital, Milan, Italy
| | - Luciano De Carlis
- Transplant Center, Department of General Surgery and Abdominal Transplantation, Niguarda Cà Granda Hospital, Milan, Italy
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
| | - Antonio Dell’Acqua
- Department of Anesthesia and Critical Care, San Raffaele Scientific Institute (IRCCS), Milan, Italy
| | - Rossana Caldara
- Transplant Unit, Department of General Medicine, San Raffaele Scientific Institute, Vita‐Salute San Raffaele University, Milan, Italy
| | - Carlo Socci
- Department of Surgery, San Raffaele Scientific Institute, Vita‐Salute San Raffaele University, Milan, Italy
| | - Andrea Bottazzi
- ICU1 Department of Intensive Medicine, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carmelo Libetta
- Dipartimento di Medicina Interna e Terapia Medica, Università Degli Studi di Pavia, Pavia, Italy
- Unit of Nephrology, Dialysis and Transplant, San Matteo Hospital Foundation (IRCCS), Pavia, Italy
| | - Vincenzo Sepe
- Unit of Nephrology, Dialysis and Transplant, San Matteo Hospital Foundation (IRCCS), Pavia, Italy
| | - Stefano Malabarba
- Unit of General Surgery 2, Department of Surgical Sciences, San Matteo Hospital Foundation (IRCCS), Pavia, Italy
| | - Federica Manzoni
- Health Promotion, Environmental Epidemiology Unit, Hygiene and Health Prevention Department, Health Protection Agency, Pavia, Italy
| | - Catherine Klersy
- Biometry and Clinical Epidemiology Service, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Teresa Rampino
- Unit of Nephrology, Dialysis and Transplant, San Matteo Hospital Foundation (IRCCS), Pavia, Italy
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18
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Survival and Factors Associated with Survival with Extracorporeal Life Support During Cardiac Arrest: A Systematic Review and Meta-Analysis. ASAIO J 2021; 68:987-995. [PMID: 34860714 DOI: 10.1097/mat.0000000000001613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The survival rate after cardiac arrest (CA) remains low. The utilization of extracorporeal life support is proposed to improve management. However, this resource-intensive tool is associated with complications and must be used in selected patients. We performed a meta-analysis to determine predictive factors of survival. Among the 81 studies included, involving 9256 patients, survival was 26.2% at discharge and 20.4% with a good neurologic outcome. Meta-regressions identified an association between survival at discharge and lower lactate values, intrahospital CA, and lower cardio pulmonary resuscitation (CPR) duration. After adjustment for age, intrahospital CA, and mean CPR duration, an initial shockable rhythm was the only remaining factor associated with survival to discharge (β = 0.02, 95% CI: 0.007-0.02; p = 0.0004).
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19
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Hosgood SA, Brown RJ, Nicholson ML. Advances in Kidney Preservation Techniques and Their Application in Clinical Practice. Transplantation 2021; 105:e202-e214. [PMID: 33982904 PMCID: PMC8549459 DOI: 10.1097/tp.0000000000003679] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/03/2020] [Accepted: 12/15/2020] [Indexed: 11/25/2022]
Abstract
The use of cold preservation solutions to rapidly flush and cool the kidney followed by static cold storage in ice has been the standard kidney preservation technique for the last 50 y. Nonetheless, changing donor demographics that include organs from extended criteria donors and donation after circulatory death donors have led to the adoption of more diverse techniques of preservation. Comparison of hypothermic machine perfusion and static cold storage techniques for deceased donor kidneys has long been debated and is still contested by some. The recent modification of hypothermic machine perfusion techniques with the addition of oxygen or perfusion at subnormothermic or near-normothermic temperatures are promising strategies that are emerging in clinical practice. In addition, the use of normothermic regional perfusion to resuscitate abdominal organs of donation after circulatory death donors in situ before cold flushing is also increasingly being utilized. This review provides a synopsis of the different types of preservation techniques including their mechanistic effects and the outcome of their application in clinical practice for different types of donor kidney.
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Affiliation(s)
- Sarah A. Hosgood
- Department of Surgery, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Rachel J. Brown
- Department of Surgery, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Michael L. Nicholson
- Department of Surgery, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
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20
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De Beule J, Vandendriessche K, Pengel LHM, Bellini MI, Dark JH, Hessheimer AJ, Kimenai HJAN, Knight SR, Neyrinck AP, Paredes D, Watson CJE, Rega F, Jochmans I. A systematic review and meta-analyses of regional perfusion in donation after circulatory death solid organ transplantation. Transpl Int 2021; 34:2046-2060. [PMID: 34570380 DOI: 10.1111/tri.14121] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 12/29/2022]
Abstract
In donation after circulatory death (DCD), (thoraco)abdominal regional perfusion (RP) restores circulation to a region of the body following death declaration. We systematically reviewed outcomes of solid organ transplantation after RP by searching PubMed, Embase, and Cochrane libraries. Eighty-eight articles reporting on outcomes of liver, kidney, pancreas, heart, and lung transplants or donor/organ utilization were identified. Meta-analyses were conducted when possible. Methodological quality was assessed using National Institutes of Health (NIH)-scoring tools. Case reports (13/88), case series (44/88), retrospective cohort studies (35/88), retrospective matched cohort studies (5/88), and case-control studies (2/88) were identified, with overall fair quality. As blood viscosity and rheology change below 20 °C, studies were grouped as hypothermic (HRP, ≤20 °C) or normothermic (NRP, >20 °C) regional perfusion. Data demonstrate that RP is a safe alternative to in situ cold preservation (ISP) in uncontrolled and controlled DCDs. The scarce HRP data are from before 2005. NRP appears to reduce post-transplant complications, especially biliary complications in controlled DCD livers, compared with ISP. Comparisons for kidney and pancreas with ISP are needed but there is no evidence that NRP is detrimental. Additional data on NRP in thoracic organs are needed. Whether RP increases donor or organ utilization needs further research.
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Affiliation(s)
- Julie De Beule
- Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | | | - Liset H M Pengel
- Nuffield Department of Surgical Sciences, Centre for Evidence in Transplantation, University of Oxford, Oxford, UK
| | - Maria Irene Bellini
- Department of Emergency Medicine and Surgery, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - John H Dark
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Amelia J Hessheimer
- Department of General & Digestive Surgery, Institut Clínic de Malalties Digestives i Metabòliques (ICMDM), Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Hendrikus J A N Kimenai
- Division of Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Simon R Knight
- Nuffield Department of Surgical Sciences, Centre for Evidence in Transplantation, University of Oxford, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Arne P Neyrinck
- Department of Cardiovascular Sciences, Anesthesiology and Algology, KU Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - David Paredes
- Donation and Transplant Coordination Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Christopher J E Watson
- Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,The NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Filip Rega
- Department of Cardiovascular Sciences, Cardiac Surgery, KU Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Ina Jochmans
- Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
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21
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How effective is extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest? A systematic review and meta-analysis. Am J Emerg Med 2021; 51:127-138. [PMID: 34735971 DOI: 10.1016/j.ajem.2021.08.072] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/17/2021] [Accepted: 08/26/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation (ECPR) has gained increasing as a promising but resource-intensive intervention for out-of-hospital cardiac arrest (OHCA). There is little data to quantify the impact of this intervention and the patients likely to benefit from its use. We conducted a meta-analysis of the literature to assess the survival benefit associated with ECPR for OHCA. METHODS We searched PubMed, Embase, and Scopus databases to identify relevant observational studies and randomized control trials. We used the Newcastle-Ottawa Scale and Cochrane risk-of-bias tool to assess studies' quality. We performed random-effects meta-analysis for the primary outcome of survival to hospital discharge and used meta-regressions to assess heterogeneity. RESULTS We identified 1287 articles, reviewed the full text of 209 and included 44 in our meta-analysis. Our analysis included 3097 patients with OHCA. Patients' mean age was 52, 79% were male, and 60% had primary ventricular fibrillation/ventricular tachycardia arrest. We identified a survival-to-discharge rate of 24%; 18% survived with favorable neurologic function. 30- and 90-days survival rates were both around 18%. The majority of included articles were high quality studies. CONCLUSIONS Extracorporeal cardiopulmonary resuscitation is a promising but resource-intensive intervention that may increase rates of survival to hospital discharge among patients who experience OHCA.
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22
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Ehrsam JP, Benden C, Immer FF, Inci I. Current status and further potential of lung donation after circulatory death. Clin Transplant 2021; 35:e14335. [PMID: 33948997 DOI: 10.1111/ctr.14335] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 04/22/2021] [Accepted: 04/27/2021] [Indexed: 12/13/2022]
Abstract
Chronic organ shortage remains the most limiting factor in lung transplantation. To overcome this shortage, a minority of centers have started with efforts to reintroduce donation after circulatory death (DCD). This review aims to evaluate the experimental background, the current international clinical experience, and the further potential and challenges of the different DCD categories. Successful strategies have been implemented to reduce the problems of warm ischemic time, thrombosis after circulatory arrest, and difficulties in organ assessment, which come with DCD donation. From the currently reported results, controlled-DCD lungs are an effective and safe method with good mid-term and even long-term survival outcomes comparable to donation after brain death (DBD). Primary graft dysfunction and onset of chronic allograft dysfunction seem also comparable. Thus, controlled-DCD lungs should be ceased to be treated as marginal and instead be promoted as an equivalent alternative to DBD. A wide implementation of controlled-DCD-lung donation would significantly decrease the mortality on the waiting list. Therefore, further efforts in establishment of legislation and logistics are crucial. With regard to uncontrolled DCD, more data are needed analyzing long-term outcomes. To help with the detailed assessment and improvement of uncontrolled or otherwise questionable grafts after retrieval, ex-vivo lung perfusion is promising.
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Affiliation(s)
- Jonas P Ehrsam
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland.,Department of Thoracic Surgery, Cantonal Hospital Aarau, Zurich, Switzerland
| | | | | | - Ilhan Inci
- Department of Thoracic Surgery, Cantonal Hospital Aarau, Zurich, Switzerland.,University of Zurich Faculty of Medicine, Zurich, Switzerland
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23
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Coll E, Miñambres E, Sánchez-Fructuoso A, Fondevila C, Campo-Cañaveral de la Cruz JL, Domínguez-Gil B. Uncontrolled Donation After Circulatory Death: A Unique Opportunity. Transplantation 2020; 104:1542-1552. [PMID: 32732830 DOI: 10.1097/tp.0000000000003139] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Uncontrolled donation after circulatory death (uDCD) refers to donation from persons who die following an unexpected and unsuccessfully resuscitated cardiac arrest. Despite the large potential for uDCD, programs of this kind only exist in a reduced number of countries with a limited activity. Barriers to uDCD are of a logistical and ethical-legal nature, as well as arising from the lack of confidence in the results of transplants from uDCD donors. The procedure needs to be designed to reduce and limit the impact of the prolonged warm ischemia inherent to the uDCD process, and to deal with the ethical issues that this practice poses: termination of advanced cardiopulmonary resuscitation, extension of advanced cardiopulmonary resuscitation beyond futility for organ preservation, moment to approach families to discuss donation opportunities, criteria for the determination of death, or the use of normothermic regional perfusion for the in situ preservation of organs. Although the incidence of primary nonfunction and delayed graft function is higher with organs obtained from uDCD donors, overall patient and graft survival is acceptable in kidney, liver, and lung transplantation, with a proper selection and management of both donors and recipients. Normothermic regional perfusion has shown to be critical to achieve optimal outcomes in uDCD kidney and liver transplantation. However, the role of ex situ preservation with machine perfusion is still to be elucidated. uDCD is a unique opportunity to improve patient access to transplantation therapies and to offer more patients the chance to donate organs after death, if this is consistent with their wishes and values.
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Affiliation(s)
| | - Eduardo Miñambres
- Intensive Care Unit and Donor Coordination Unit, Hospital Universitario Marqués de Valdecilla-IDIVAL, Universidad de Cantabria, Santander, Spain
| | - Ana Sánchez-Fructuoso
- Nephrology Department, Hospital Universitario Clínico San Carlos, Facultad de Medicina, Universidad Complutense, Madrid, Spain
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24
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Lazzeri C, Bonizzoli M, Fulceri GE, Guetti C, Ghinolfi D, Li Marzi V, Migliaccio ML, Peris A. Utilization rate of uncontrolled donors after circulatory death‐a 3‐year single‐center investigation. Clin Transplant 2020; 34. [DOI: 10.1111/ctr.13896] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/23/2020] [Indexed: 08/30/2023]
Affiliation(s)
- Chiara Lazzeri
- Intensive Care Unit and Regional ECMO Referral centre Azienda Ospedaliero‐Universitaria Careggi Florence Italy
| | - Manuela Bonizzoli
- Intensive Care Unit and Regional ECMO Referral centre Azienda Ospedaliero‐Universitaria Careggi Florence Italy
| | - Giorgio Enzo Fulceri
- Intensive Care Unit and Regional ECMO Referral centre Azienda Ospedaliero‐Universitaria Careggi Florence Italy
| | - Cristiana Guetti
- Intensive Care Unit and Regional ECMO Referral centre Azienda Ospedaliero‐Universitaria Careggi Florence Italy
| | - Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation Unit University of Pisa Medical School Hospital Pisa Italy
| | - Vincenzo Li Marzi
- Renal Transplantation Unit Azienda Ospedaliero‐Universitaria Careggi Florence Italy
| | - Maria Luisa Migliaccio
- Tuscany Authority for Transplantation (Centro Regionale Allocazione Organi e Tessuti CRAOT) Florence Italy
| | - Adriano Peris
- Intensive Care Unit and Regional ECMO Referral centre Azienda Ospedaliero‐Universitaria Careggi Florence Italy
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25
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Miñambres E, Rodrigo E, Suberviola B, Valero R, Quintana A, Campos F, Ruiz-San Millán JC, Ballesteros MÁ. Strict selection criteria in uncontrolled donation after circulatory death provide excellent long-term kidney graft survival. Clin Transplant 2020; 34:e14010. [PMID: 32573027 DOI: 10.1111/ctr.14010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/29/2020] [Accepted: 06/04/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND We aimed to report our experience in uncontrolled donation after circulatory death (uDCD) kidney transplantation applying a strict donor selection and preservation criteria. METHODS All kidney recipients received a graft from a local uDCD. As controls, we included all renal transplants from local standard criteria donation after brain death (SDBD) donors. Normothermic regional perfusion was the preservation method in all cases. RESULTS A total of 19 kidneys from uDCD donors were included and 67 controls. Delayed graft function (DGF) was higher in the uDCD group (42.1% vs 17.9%; P = .033), whereas no differences were observed in primary nonfunction (0% cases vs 3% controls; P = .605). The estimated glomerular filtration rate was identical in both groups. No differences were observed in graft survival censored for death between the uDCD and the SDBD groups at 1-year (100% vs 95%) or 5-year follow-up (92% vs 91%). uDCD kidney recipients did not have higher risk of graft loss in the multivariate analysis adjusted by recipient age, cold ischemic time, presence of DGF, and second kidney transplant (HR: 0.4; 95% CI 0.02-6; P = .509). CONCLUSIONS Obtaining renal grafts from uDCD is feasible in a small city and provides similar outcomes compared to standard DBD donors.
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Affiliation(s)
- Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain.,School of Medicine, University of Cantabria, Santander, Spain
| | - Emilio Rodrigo
- School of Medicine, University of Cantabria, Santander, Spain.,Service of Nephrology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Borja Suberviola
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Rosalía Valero
- Service of Nephrology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Alfredo Quintana
- Extrahospitalary Emergency, Gerencia de Atención Primaria-061, Santander, Spain
| | - Félix Campos
- Service of Urology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Juan Carlos Ruiz-San Millán
- School of Medicine, University of Cantabria, Santander, Spain.,Service of Nephrology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - María Á Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
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26
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Kidney transplantation following uncontrolled donation after circulatory death. Curr Opin Organ Transplant 2020; 25:144-150. [DOI: 10.1097/mot.0000000000000742] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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27
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Chonde M, Escajeda J, Elmer J, Callaway CW, Guyette FX, Boujoukos A, Sappington PL, Smith AJ, Schmidhofer M, Sciortino C, Kormos RL. Challenges in the development and implementation of a healthcare system based extracorporeal cardiopulmonary resuscitation (ECPR) program for the treatment of out of hospital cardiac arrest. Resuscitation 2019; 148:259-265. [PMID: 31887368 DOI: 10.1016/j.resuscitation.2019.12.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 12/12/2019] [Accepted: 12/17/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Extracorporeal cardiopulmonary resuscitation (ECPR) can treat cardiac arrest refractory to conventional therapies. Many institutions are interested in developing their own ECPR program. However, there may be challenges in logistics and implementation. AIMS The aim of our protocol was to demonstrate that an ECPR team was feasible within our healthcare system and that the identification of UPMC Presbyterian as a receiving center allowed for successful treatment within 30 min from EMS dispatch. METHODS We developed out of hospital cardiac arrest (OHCA) ECPR protocols for Emergency Medical Services (EMS), EMS communications, and our in-hospital ECPR team. Inclusion criteria indentified patients with a potentially reversible arrest etiology and high probability of recoverable brain injury using a simple checklist: witnessed collapse, layperson CPR, initial shockable rhythm, and age 18-60 years. We trained local EMS crews to screen patients and reviewed the criteria with a Medic Command Physician prior to transport to our hospital. RESULTS From October 2015 to March 31st 2018, EMS treated 1165 EMS OHCA cases, transported 664 (57%) to a local hospital, and transported 120 (10%) to our institution. Of these, five (4.1%) patients underwent ECPR. Among excluded cases, 64 (53%) had nonshockable rhythms, 48 (40%) were unwitnessed arrests, 50 (42%) were over age 60 and the remaining 20 (17%) had no documented reasons for exclusion. For ECPR cases, median pre-hospital CPR duration was 26 [IQR 25-40] min. Four patients (80%) received mechanical CPR. Interval from arrest to arrival on scene was 5 [IQR 4-6] min and interval from radio call to activation of ECPR was 13 [IQR 7-21] min. Interval from EMS dispatch to departure from scene was 20 [IQR 19-21] min. Time from EMS dispatch to initiation of ECPR was 63 [IQR 59-69] min. CONCLUSIONS ECPR is an infrequent occurrence in EMS practice. Most apparently eligible patients did not get ECPR, highlighting the need for ongoing programmatic development, provider education, and qualitative work exploring barriers to implementation.
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Affiliation(s)
- Meshe Chonde
- University of Pittsburgh, Department of Medicine, Divison of Cardiology, United States.
| | - Jeremiah Escajeda
- University of Pittsburgh, Department of Emergency Medicine, United States
| | - Jonathan Elmer
- University of Pittsburgh, Department of Emergency Medicine, United States; University of Pittsburgh, Department of Critical Care Medicine, United States
| | - Clifton W Callaway
- University of Pittsburgh, Department of Emergency Medicine, United States
| | - Frank X Guyette
- University of Pittsburgh, Department of Emergency Medicine, United States
| | - Arthur Boujoukos
- University of Pittsburgh, Department of Critical Care Medicine, United States
| | - Penny L Sappington
- University of Pittsburgh, Department of Critical Care Medicine, United States
| | - Anson J Smith
- University of Pittsburgh, Department of Medicine, Divison of Cardiology, United States
| | - Mark Schmidhofer
- University of Pittsburgh, Department of Medicine, Divison of Cardiology, United States
| | | | - Robert L Kormos
- University of Pittsburgh, Department of Cardiothoracic Surgery, United States
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28
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Azeli Y, Lorente Olazabal JV, Monge García MI, Bardají A. Understanding the Adverse Hemodynamic Effects of Serious Thoracic Injuries During Cardiopulmonary Resuscitation: A Review and Approach Based on the Campbell Diagram. Front Physiol 2019; 10:1475. [PMID: 31849717 PMCID: PMC6901598 DOI: 10.3389/fphys.2019.01475] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 11/15/2019] [Indexed: 01/29/2023] Open
Abstract
Chest compressions during cardiopulmonary resuscitation (CPR) generate cardiac output during cardiac arrest. Their quality performance is key to achieving the return of spontaneous circulation. Serious thoracic injuries (STIs) are common during CPR, and they can change the shape and mechanics of the thorax. Little is known about their hemodynamic effects, so a review of this emerging concept is necessary. The Campbell diagram (CD) is a theoretical framework that integrates the lung and chest wall pressure-volume curves, allowing us to assess the consequences of STIs on respiratory mechanics and hemodynamics. STIs produce a decrease in the compliance of the chest wall and lung. The representation of STIs on the CD shows a decrease in the intrathoracic negative pressure and a functional residual capacity decrease during the thoracic decompression, leading to a venous return impairment. The thorax with STIs is more vulnerable to the adverse hemodynamic effects of leaning, hyperventilation, and left ventricular outflow tract obstruction during CPR. A better understanding of the effects of STIs during CPR, and the study of avoidable injuries, can help to improve the effectiveness of chest compressions and the survival in cardiac arrest.
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Affiliation(s)
- Youcef Azeli
- Sistema d’Emergències Mèdiques de Catalunya, Barcelona, Spain
- Emergency Department, Sant Joan University Hospital, Reus, Spain
- Institut d’Investigació Sanitari Pere Virgili, Tarragona, Spain
| | - Juan Víctor Lorente Olazabal
- Clinical Management Anaesthesiology Unit, Resuscitation and Pain Therapy, Juan Ramón Jiménez Hospital, Huelva, Spain
- School of Medicine and Health Sciences, International University of Catalonia (IUC), Barcelona, Spain
| | | | - Alfredo Bardají
- Department of Cardiology, Joan XXIII University Hospital, Tarragona, Spain
- School of Medicine, Rovira i Virgili University, Tarragona, Spain
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29
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Reed MJ, Currie I, Forsythe J, Young I, Stirling J, Logan L, Clegg GR, Oniscu GC. Lessons from a pilot for uncontrolled donation after circulatory death in the ED in the UK. Emerg Med J 2019; 37:155-161. [PMID: 31757833 DOI: 10.1136/emermed-2019-208650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 10/07/2019] [Accepted: 10/25/2019] [Indexed: 11/03/2022]
Abstract
Worldwide there is a shortage of available organs for patients requiring transplants. However, some countries such as France, Italy and Spain have had greater success by allowing donations from patients with unexpected and unrecoverable circulatory arrest who arrive in the ED. Significant advances in the surgical approach to organ recovery from donation after circulatory death (DCD) led to the establishment of a pilot programme for uncontrolled DCD in the ED of the Royal Infirmary of Edinburgh. This paper describes the programme and discusses the lessons learnt.
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Affiliation(s)
- Matthew James Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Ian Currie
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - John Forsythe
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
- NHS Blood and Transplant, The Courtyard Callendar Business Park, Falkirk, UK
| | - Irene Young
- NHS Blood and Transplant, The Courtyard Callendar Business Park, Falkirk, UK
| | - John Stirling
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Lesley Logan
- NHS Blood and Transplant, The Courtyard Callendar Business Park, Falkirk, UK
| | - Gareth R Clegg
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Gabriel C Oniscu
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
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30
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Molina M, Domínguez-Gil B, Pérez-Villares JM, Andrés A. Uncontrolled donation after circulatory death: ethics of implementation. Curr Opin Organ Transplant 2019; 24:358-363. [PMID: 31090649 DOI: 10.1097/mot.0000000000000648] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Despite its potential to increase the donor pool, uncontrolled donation after circulatory death (uDCD) is available in a limited number of countries. Ethical concerns may preclude the expansion of this program. This article addresses the ethical concerns that arise in the implementation of uDCD. RECENT FINDINGS The first ethical concern is that associated with the determination of an irreversible cardiac arrest. Professionals must strictly adhere to local protocols and international standards on advanced cardiopulmonary resuscitation, independent of their participation in an uDCD program. Cardiac compression and mechanical ventilation are extended beyond futility during the transportation of potential uDCD donors to the hospital with the sole purpose of preserving organs. Importantly, potential donors remain monitored while being transferred to the hospital, which allows the identification of any return of spontaneous circulation. Moreover, this procedure allows the determination of death to be undertaken in the hospital by an independent health care provider who reassesses that no other therapeutic interventions are indicated and observes a period of the complete absence of circulation and respiration. Extracorporeal-assisted cardiopulmonary resuscitation programs can successfully coexist with uDCD programs. The use of normothermic regional perfusion with ECMO devices for the in-situ preservation of organs is considered appropriate in a setting in which the brain is subject to profound and prolonged ischemic damage. Finally, communication with relatives must be transparent and accurate, and the information should be provided respecting the time imposed by the family's needs and emotions. SUMMARY uDCD can help increase the availability of organs for transplantation while giving more patients the opportunity to donate organs after death. The procedures should be designed to confront the ethical challenges that this practice poses and respect the values of all those involved.
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Affiliation(s)
- María Molina
- Department of Nephrology, Hospital Universitario '12 de Octubre'
- Department of Nephrology, Hospital Universitario Arnau de Vilanova
- Institut de Recerca Biomèdica, Lleida
| | | | - José M Pérez-Villares
- Coordinación Sectorial de Trasplantes de Granada, Servicio de Medicina Intensiva Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Amado Andrés
- Department of Nephrology, Hospital Universitario '12 de Octubre'
- Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid
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31
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Organ donation after circulatory death: current status and future potential. Intensive Care Med 2019; 45:310-321. [DOI: 10.1007/s00134-019-05533-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/14/2019] [Indexed: 01/26/2023]
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