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Rajsic S, Treml B, Innerhofer N, Eckhardt C, Radovanovic Spurnic A, Breitkopf R. Organ Donation from Patients Receiving Extracorporeal Membrane Oxygenation: A Systematic Review. J Cardiothorac Vasc Anesth 2024; 38:1531-1538. [PMID: 38643059 DOI: 10.1053/j.jvca.2024.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 03/01/2024] [Accepted: 03/17/2024] [Indexed: 04/22/2024]
Abstract
OBJECTIVE The mismatch between the demand for and supply of organs for transplantation is steadily growing. Various strategies have been incorporated to improve the availability of organs, including organ use from patients receiving extracorporeal membrane oxygenation (ECMO) at the time of death. However, there is no systematic evidence of the outcome of grafts from these donors. DESIGN Systematic literature review (Scopus and PubMed, up to October 11, 2023). SETTING All study designs. PARTICIPANTS Organ recipients from patients on ECMO at the time of death. INTERVENTION Outcome of organ donation from ECMO donors. MEASUREMENTS AND MAIN RESULTS The search yielded 1,692 publications, with 20 studies ultimately included, comprising 147 donors and 360 organ donations. The most frequently donated organs were kidneys (68%, 244/360), followed by liver (24%, 85/360). In total, 98% (292/299) of recipients survived with a preserved graft function (92%, 319/347) until follow-up within a variable period of up to 3 years. CONCLUSION Organ transplantation from donors supported with ECMO at the time of death shows high graft and recipient survival. ECMO could be a suitable approach for expanding the donor pool, helping to alleviate the worldwide organ shortage.
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Affiliation(s)
- Sasa Rajsic
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria.
| | - Benedikt Treml
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Nicole Innerhofer
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Christine Eckhardt
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | | | - Robert Breitkopf
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
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Altshuler PJ, Pace DJ, Preston WA, Vincent SA, Shah AP, Glorioso JM, Maley WR, Frank AM, Ramirez CB, West S, Hasz R, Bodzin AS. Assessing Kidney Transplantation Using ECMO-Supported Donors Within a KDPI-Based Allocation System. Transplant Direct 2023; 9:e1521. [PMID: 37829245 PMCID: PMC10566806 DOI: 10.1097/txd.0000000000001521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/16/2023] [Indexed: 10/14/2023] Open
Abstract
Background Organ donors supported by extracorporeal membrane oxygenation (ECMO) have historically been considered high-risk and are judiciously utilized. This study examines transplant outcomes using renal allografts from donors supported on ECMO for nondonation purposes. Methods Retrospective review of the Gift of Life (Pennsylvania, New Jersey, Delaware) organ procurement organization database, cross-referenced to the Organ Procurement and Transplantation Network database, assessed kidney transplants using donors supported on venoarterial (VA) and venovenous (VV) ECMO for nondonation purposes. Transplants using VA- and VV-ECMO donors were compared with Kidney Donor Profile Index (KDPI)-stratified non-ECMO donors. Regression modeling of the entire ECMO and non-ECMO populations assessed ECMO as predictive of graft survival. Additional regression of the ECMO population alone assessed for donor features associated with graft survival. Results Seventy-eight ECMO donors yielded 128 kidney transplants (VA: 80, VV: 48). Comparing outcomes using these donors to kidney transplants using organs from KDPI-stratified non-ECMO donors, VA- and VV-ECMO donor grafts conferred similar rates of delayed graft function and posttransplant renal function to KDPI-matched non-ECMO counterparts. VA-ECMO kidneys demonstrated superior graft survival compared with the lowest-quality (KDPI 86%-100%) non-ECMO kidneys and similar graft survival to KDPI <85% non-ECMO kidneys. VV-ECMO showed inferior graft survival to all but the lowest-quality (KDPI 86%-100%) non-ECMO kidneys. VV-ECMO, but not VA-ECMO, was associated with increased risk of graft loss on multivariable regression (hazard ratios-VA: 1.02, VV: 2.18). Higher KDPI, advanced age, increased body mass index, hypertension, and diabetes were identified as high-risk features of ECMO donors. Conclusions Kidney transplantation using appropriately selected ECMO donors can safely expand the donor pool. Ongoing studies are necessary to determine best practice patterns using kidneys from these donors.
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Affiliation(s)
| | - Devon J. Pace
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | | | - Sage A. Vincent
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Ashesh P. Shah
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Jaime M. Glorioso
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Warren R. Maley
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Adam M. Frank
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Carlo B. Ramirez
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Sharon West
- Gift of Life Donor Program, Philadelphia, PA
| | | | - Adam S. Bodzin
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
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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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Resch T, Cardini B, Oberhuber R, Weissenbacher A, Dumfarth J, Krapf C, Boesmueller C, Oefner D, Grimm M, Schneeberger S. Transplanting Marginal Organs in the Era of Modern Machine Perfusion and Advanced Organ Monitoring. Front Immunol 2020; 11:631. [PMID: 32477321 PMCID: PMC7235363 DOI: 10.3389/fimmu.2020.00631] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/19/2020] [Indexed: 12/11/2022] Open
Abstract
Organ transplantation is undergoing profound changes. Contraindications for donation have been revised in order to better meet the organ demand. The use of lower-quality organs and organs with greater preoperative damage, including those from donation after cardiac death (DCD), has become an established routine but increases the risk of graft malfunction. This risk is further aggravated by ischemia and reperfusion injury (IRI) in the process of transplantation. These circumstances demand a preservation technology that ameliorates IRI and allows for assessment of viability and function prior to transplantation. Oxygenated hypothermic and normothermic machine perfusion (MP) have emerged as valid novel modalities for advanced organ preservation and conditioning. Ex vivo prolonged lung preservation has resulted in successful transplantation of high-risk donor lungs. Normothermic MP of hearts and livers has displayed safe (heart) and superior (liver) preservation in randomized controlled trials (RCT). Normothermic kidney preservation for 24 h was recently established. Early clinical outcomes beyond the market entry trials indicate bioenergetics reconditioning, improved preservation of structures subject to IRI, and significant prolongation of the preservation time. The monitoring of perfusion parameters, the biochemical investigation of preservation fluids, and the assessment of tissue viability and bioenergetics function now offer a comprehensive assessment of organ quality and function ex situ. Gene and protein expression profiling, investigation of passenger leukocytes, and advanced imaging may further enhance the understanding of the condition of an organ during MP. In addition, MP offers a platform for organ reconditioning and regeneration and hence catalyzes the clinical realization of tissue engineering. Organ modification may include immunological modification and the generation of chimeric organs. While these ideas are not conceptually new, MP now offers a platform for clinical realization. Defatting of steatotic livers, modulation of inflammation during preservation in lungs, vasodilatation of livers, and hepatitis C elimination have been successfully demonstrated in experimental and clinical trials. Targeted treatment of lesions and surgical treatment or graft modification have been attempted. In this review, we address the current state of MP and advanced organ monitoring and speculate about logical future steps and how this evolution of a novel technology can result in a medial revolution.
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Affiliation(s)
- Thomas Resch
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Annemarie Weissenbacher
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Julia Dumfarth
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Christoph Krapf
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudia Boesmueller
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Oefner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Grimm
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Sefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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Seo HW, Lee S, Lee HY, Park SC, Chung BH, Yang CW, Ban TH. Successful kidney transplantation from an expanded criteria donor with long-term extracorporeal membrane oxygenation treatment: A case report. World J Clin Cases 2020; 8:540-545. [PMID: 32110664 PMCID: PMC7031827 DOI: 10.12998/wjcc.v8.i3.540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 12/30/2019] [Accepted: 01/08/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Due to a shortage of donor kidneys, many centers have utilized graft kidneys from brain-dead donors with expanded criteria. Kidney transplantation (KT) from donors on extracorporeal membrane oxygenation (ECMO) has been identified as a successful way of expanding donor pools. However, there are currently no guidelines or recommendations that guarantee successful KT from donors undergoing ECMO treatment. Therefore, acceptance of appropriate allografts from those donors is solely based on clinician decision.
CASE SUMMARY We report a case of successful KT from a brain-dead donor supported by ECMO for the longest duration to date. A 69-year-old male received a KT from a 63-year-old brain-dead donor who had been on therapeutic ECMO treatment for the previous three weeks. The recipient experienced slow recovery of graft function after surgery but was discharged home on post-operative day 17 free from hemodialysis. Allograft function gradually improved thereafter and was comparatively acceptable up to the 12 mo follow-up, with serum creatinine level of 1.67 mg/dL.
CONCLUSION This case suggests that donation even after long-term ECMO treatment could provide successful KT to suitable candidates.
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Affiliation(s)
- Hye Won Seo
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea
- Transplant Research Center, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea
| | - Sua Lee
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea
- Transplant Research Center, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea
| | - Hwa Young Lee
- Division of Nephrology, Department of Internal Medicine, Jeju National University Hospital, Jeju-do 63241, South Korea
| | - Sun Cheol Park
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seoul 06591, South Korea
| | - Byung Ha Chung
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea
- Transplant Research Center, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea
| | - Chul Woo Yang
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea
- Transplant Research Center, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea
| | - Tae Hyun Ban
- Division of Nephrology, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Eunpyeong-gu, Seoul 03312, South Korea
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Chiang PJ, Tang SH, Li CC, Chou MH, Lin YC, Wu ST. Kidney Transplantation from an extracorporeal membrane oxygenation-supported brain-dead donor: A case report. Medicine (Baltimore) 2018; 97:e11106. [PMID: 29952950 PMCID: PMC6039615 DOI: 10.1097/md.0000000000011106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Extracorporeal membrane oxygenation (ECMO) can deliver effective respiratory and circulatory maintenance to organ donors, improve organ function, and shorten warm ischemic time before harvesting. However, ECMO-supported brain-dead donors (DBDs) still have a high risk of acute kidney injury related to decreased renal oxygen delivery and inflammatory damage, which may cause early graft failure. PATIENT CONCERNS Kidney transplantation from an ECMO-supported DBD. DIAGNOSES We found an extremely abnormal "very dark blue" appearance of the graft kidneys from an ECMO-supported DBD during kidney procurement. INTERVENTIONS Rather than discarding the graft kidneys, we performed an on-table biopsy. Pretransplant biopsy results revealed minimal interstitial fibrosis in the section of these graft kidneys. OUTCOMES Two candidates received graft kidneys, and the two grafts remained functional until the 8-month follow-up. LESSONS Currently, there is no standard method for evaluating graft kidney function of ECMO-supported DBDs. Regardless of the donors' preoperative serum creatinine (SCr) level, estimated glomerular filtration rate (eGFR), or gross appearance of the graft kidney, we believe that it is more reliable to include pretransplant biopsy as a criterion in clinical practice to safely accept kidneys from ECMO-supported DBDs.
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Affiliation(s)
| | | | | | | | - Yu-Chun Lin
- Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Nei-Hu, Taipei, Taiwan
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Fan X, Chen Z, Nasralla D, Zeng X, Yang J, Ye S, Zhang Y, Peng G, Wang Y, Ye Q. The organ preservation and enhancement of donation success ratio effect of extracorporeal membrane oxygenation in circulatory unstable brain death donor. Clin Transplant 2016; 30:1306-1313. [PMID: 27460305 DOI: 10.1111/ctr.12823] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2016] [Indexed: 12/22/2022]
Affiliation(s)
- Xiaoli Fan
- Zhongnan Hospital of Wuhan University; Transplant Center of Wuhan University; Wuhan China
| | - Zhiquan Chen
- Zhongnan Hospital of Wuhan University; Transplant Center of Wuhan University; Wuhan China
| | - David Nasralla
- Transplant Center; Nuffield Department of Surgical Sciences; Oxford University; Oxford UK
| | - Xianpeng Zeng
- Zhongnan Hospital of Wuhan University; Transplant Center of Wuhan University; Wuhan China
| | - Jing Yang
- Zhongnan Hospital of Wuhan University; Transplant Center of Wuhan University; Wuhan China
| | - Shaojun Ye
- Zhongnan Hospital of Wuhan University; Transplant Center of Wuhan University; Wuhan China
| | - Yi Zhang
- Zhongnan Hospital of Wuhan University; Transplant Center of Wuhan University; Wuhan China
| | - Guizhu Peng
- Zhongnan Hospital of Wuhan University; Transplant Center of Wuhan University; Wuhan China
| | - Yanfeng Wang
- Zhongnan Hospital of Wuhan University; Transplant Center of Wuhan University; Wuhan China
| | - Qifa Ye
- Zhongnan Hospital of Wuhan University; Transplant Center of Wuhan University; Wuhan China
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Kang J, Choi B, Moon K, Park Y, Yang K, Ryu J, Chu C. Beneficial Effect of Extracorporeal Membrane Oxygenation on Organ Perfusion During Management of the Unstable Brain-dead Donor: A Case Series. Transplant Proc 2016; 48:2458-2460. [DOI: 10.1016/j.transproceed.2016.02.093] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 02/02/2016] [Indexed: 01/06/2023]
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Dalle Ave AL, Gardiner D, Shaw DM. The ethics of extracorporeal membrane oxygenation in brain-dead potential organ donors. Transpl Int 2016; 29:612-8. [DOI: 10.1111/tri.12772] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 01/20/2016] [Accepted: 03/01/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Anne L. Dalle Ave
- Ethics Unit; University Hospital of Lausanne; Lausanne Switzerland
- Institute for Biomedical Ethics; University Medical Center; Geneva Switzerland
| | - Dale Gardiner
- Nottingham University Hospitals NHS Trust; Nottingham UK
| | - David M. Shaw
- Institute for Biomedical Ethics; University of Basel; Basel Switzerland
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