1
|
Murphy NB, Shemie SD, Capron A, Truog RD, Nakagawa T, Healey A, Gofton T, Bernat JL, Fenton K, Khush KK, Schwartz B, Wall SP. Advancing the Scientific Basis for Determining Death in Controlled Organ Donation After Circulatory Determination of Death. Transplantation 2024:00007890-990000000-00733. [PMID: 38637919 DOI: 10.1097/tp.0000000000005002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
In controlled organ donation after circulatory determination of death (cDCDD), accurate and timely death determination is critical, yet knowledge gaps persist. Further research to improve the science of defining and determining death by circulatory criteria is therefore warranted. In a workshop sponsored by the National Heart, Lung, and Blood Institute, experts identified research opportunities pertaining to scientific, conceptual, and ethical understandings of DCDD and associated technologies. This article identifies a research strategy to inform the biomedical definition of death, the criteria for its determination, and circulatory death determination in cDCDD. Highlighting knowledge gaps, we propose that further research is needed to inform the observation period following cessation of circulation in pediatric and neonatal populations, the temporal relationship between the cessation of brain and circulatory function after the withdrawal of life-sustaining measures in all patient populations, and the minimal pulse pressures that sustain brain blood flow, perfusion, activity, and function. Additionally, accurate predictive tools to estimate time to asystole following the withdrawal of treatment and alternative monitoring modalities to establish the cessation of circulatory, brainstem, and brain function are needed. The physiologic and conceptual implications of postmortem interventions that resume circulation in cDCDD donors likewise demand attention to inform organ recovery practices. Finally, because jurisdictionally variable definitions of death and the criteria for its determination may impede collaborative research efforts, further work is required to achieve consensus on the physiologic and conceptual rationale for defining and determining death after circulatory arrest.
Collapse
Affiliation(s)
- Nicholas B Murphy
- Departments of Medicine and Philosophy, Western University, London, ON, Canada
| | - Sam D Shemie
- Division of Critical Care Medicine, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
- System Development, Canadian Blood Services, Ottawa, ON, Canada
| | - Alex Capron
- Gould School of Law and Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Robert D Truog
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
| | - Thomas Nakagawa
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
| | - Andrew Healey
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
- Divisions of Emergency and Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Teneille Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, NH
| | - Kathleen Fenton
- Advanced Technologies and Surgery Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Bryanna Schwartz
- Heart Development and Structural Diseases Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Division of Cardiology, Children's National Hospital, Washington, DC
| | - Stephen P Wall
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
| |
Collapse
|
2
|
Li Q, Liu Y, Wang Y, Shan X, Liu C, Li Z, Cao J, Dou J, Xu G, Wang Q, Qie X. Bicarbonate ringer's solution could improve the intraoperative acid-base equilibrium and reduce hepatocellular enzyme levels after deceased donor liver transplantation: a randomized controlled study. BMC Anesthesiol 2023; 23:418. [PMID: 38114893 PMCID: PMC10729548 DOI: 10.1186/s12871-023-02383-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 12/12/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Bicarbonate Ringer's (BR) solution is a direct liver and kidney metabolism-independent HCO3- buffering system. We hypothesized that BR solution would be more effective in improving acid-base equilibrium and more conducive to better liver function than Acetate Ringer's (AR) solution in conventional orthotopic liver transplantation (OLT) patients. METHODS Sixty-nine adult patients underwent OLT. Patients in the bicarbonate and acetate groups received BR solution or AR solution as infused crystalloids and graft washing solution, respectively. The primary outcome was the effect on pH and base excess (BE) levels. The secondary outcome measures were the incidence and volume of intraoperative 5% sodium bicarbonate infusion and laboratory indicates of liver and kidney function. RESULTS The pH and absolute BE values changed significantly during the anhepatic phase and immediately after transplanted liver reperfusion in the bicarbonate group compared with the acetate group (all P < 0.05). The incidence and volume of 5% sodium bicarbonate infusion were lower in the bicarbonate group than in the acetate group (all P < 0.05). The aspartate transaminase (AST) level at 7 postoperative days and the creatine level at 30 postoperative days were significantly higher in the acetate group than in the bicarbonate group (all P < 0.05). CONCLUSION Compared with AR solution, BR solution was associated with improved intraoperative acid-base balance and potentially protected early postoperative liver graft function and reduced late-postoperative renal injury.
Collapse
Affiliation(s)
- Qingkai Li
- Department of Aesthesiology, The Third Hospital of Hebei Medical University, Shi Jiazhuang, 050051, China
| | - Ying Liu
- Department of Aesthesiology, The Third Hospital of Hebei Medical University, Shi Jiazhuang, 050051, China
| | - Yanan Wang
- Department of Aesthesiology, The Third Hospital of Hebei Medical University, Shi Jiazhuang, 050051, China
| | - Xin Shan
- Department of Aesthesiology, The Third Hospital of Hebei Medical University, Shi Jiazhuang, 050051, China
| | - Chunxiao Liu
- Department of Aesthesiology, The Third Hospital of Hebei Medical University, Shi Jiazhuang, 050051, China
| | - Zhihua Li
- Department of Aesthesiology, The Third Hospital of Hebei Medical University, Shi Jiazhuang, 050051, China
| | - Jinglin Cao
- Department of Hepatobiliary Surgery, The Third Hospital of Hebei Medical University, Shi Jiazhuang, 050051, China
| | - Jian Dou
- Department of Hepatobiliary Surgery, The Third Hospital of Hebei Medical University, Shi Jiazhuang, 050051, China
| | - Guanjie Xu
- Department of Aesthesiology, The Third Hospital of Hebei Medical University, Shi Jiazhuang, 050051, China
| | - Qiujun Wang
- Department of Aesthesiology, The Third Hospital of Hebei Medical University, Shi Jiazhuang, 050051, China
| | - Xiaojuan Qie
- Department of Aesthesiology, The Third Hospital of Hebei Medical University, Shi Jiazhuang, 050051, China.
| |
Collapse
|
3
|
Secanella L, Alconchel F, López-Monclús J, Toledo-Martínez E, Barrios O, Ramírez P, Jiménez-Garrido MC, Rodríguez-Sanjuán JC, Royo-Villanova M, Moreno-González G, Lladó L. Outcomes of liver transplantation with thoracoabdominal normothermic regional perfusion: a matched-controlled initial experience in Spain. FRONTIERS IN TRANSPLANTATION 2023; 2:1280454. [PMID: 38993919 PMCID: PMC11235216 DOI: 10.3389/frtra.2023.1280454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 10/16/2023] [Indexed: 07/13/2024]
Abstract
Thoracoabdominal (TA) normothermic regional perfusion (NRP) should allow the safe recovery of heart and liver grafts simultaneously in the context of controlled donation after circulatory death (cDCD). We present the initial results of cDCD liver transplantation with simultaneous liver and heart procurement in Spain until October 2021. Outcomes were compared with a matched cohort of cDCD with abdominal NRP (A-NRP) from participating institutions. Primary endpoints comprised early allograft dysfunction (EAD) or primary non-function (PNF), and the development of ischemic-type biliary lesions (ITBL). Six transplants were performed using cDCD with TA-NRP during the study period. Donors were significantly younger in the TA-NRP group than in the A-NRP group (median 45.6 years and 62.9 years respectively, p = 0.011), with a median functional warm ischemia time of 12.5 min in the study group and 13 min in the control group. Patient characteristics, procurement times, and surgical baseline characteristics did not differ significantly between groups. No patient in the study group developed EAD or PNF, and over a median follow-up of 9.8 months, none developed ITBL or graft loss. Extending A-NRP to TA-NRP for cardiac procurement may be technically challenging, but it is both feasible and safe, showing comparable postoperative outcomes to A-NRP.
Collapse
Affiliation(s)
- Luis Secanella
- Unidad HPB y Trasplante Hepático, Servicio de Cirugía General y Digestiva, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Felipe Alconchel
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Virgen de la Arrixaca), Murcia, Spain
| | - Javier López-Monclús
- Servicio de Cirugía General y del Aparato Digestivo, Unidad de Trasplante Hepático, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Enrique Toledo-Martínez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Oriana Barrios
- Unidad HPB y Trasplante Hepático, Servicio de Cirugía General y Digestiva, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Pablo Ramírez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Virgen de la Arrixaca), Murcia, Spain
| | - Manuel Cecilio Jiménez-Garrido
- Servicio de Cirugía General y del Aparato Digestivo, Unidad de Trasplante Hepático, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Mario Royo-Villanova
- Servicio de Medicina Intensiva, Coordinación de Trasplantes, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Virgen de la Arrixaca), Murcia, Spain
| | - Gabriel Moreno-González
- Servicio de Medicina Intensiva, Coordinación de Trasplantes, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Laura Lladó
- Unidad HPB y Trasplante Hepático, Servicio de Cirugía General y Digestiva, Hospital Universitari de Bellvitge, Barcelona, Spain
| |
Collapse
|
4
|
Kwon JH, Blanding WM, Shorbaji K, Scalea JR, Gibney BC, Baliga PK, Kilic A. Waitlist and Transplant Outcomes in Organ Donation After Circulatory Death: Trends in the United States. Ann Surg 2023; 278:609-620. [PMID: 37334722 DOI: 10.1097/sla.0000000000005947] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
OBJECTIVES To summarize waitlist and transplant outcomes in kidney, liver, lung, and heart transplantation using organ donation after circulatory death (DCD). BACKGROUND DCD has expanded the donor pool for solid organ transplantation, most recently for heart transplantation. METHODS The United Network for Organ Sharing registry was used to identify adult transplant candidates and recipients in the most recent allocation policy eras for kidney, liver, lung, and heart transplantation. Transplant candidates and recipients were grouped by acceptance criteria for DCD versus brain-dead donors [donation after brain death (DBD)] only and DCD versus DBD transplant, respectively. Propensity matching and competing-risks regression was used to model waitlist outcomes. Survival was modeled using propensity matching and Kaplan-Meier and Cox regression analysis. RESULTS DCD transplant volumes have increased significantly across all organs. Liver candidates listed for DCD organs were more likely to undergo transplantation compared with propensity-matched candidates listed for DBD only, and heart and liver transplant candidates listed for DCD were less likely to experience death or clinical deterioration requiring waitlist inactivation. Propensity-matched DCD recipients demonstrated an increased mortality risk up to 5 years after liver and kidney transplantation and up to 3 years after lung transplantation compared with DBD. There was no difference in 1-year mortality between DCD and DBD heart transplantation. CONCLUSIONS DCD continues to expand access to transplantation and improves waitlist outcomes for liver and heart transplant candidates. Despite an increased risk for mortality with DCD kidney, liver, and lung transplantation, survival with DCD transplant remains acceptable.
Collapse
Affiliation(s)
- Jennie H Kwon
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Walker M Blanding
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Khaled Shorbaji
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Joseph R Scalea
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC
| | - Barry C Gibney
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Prabhakar K Baliga
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| |
Collapse
|
5
|
Brubaker AL, Taj R, Jackson B, Lee A, Tsai C, Berumen J, Parekh JR, Mekeel KL, Gupta AR, Gardner JM, Chaly T, Mathur AK, Jadlowiec C, Reddy S, Nunez R, Bellingham J, Thomas EM, Wellen JR, Pan JH, Kearns M, Pretorius V, Schnickel GT. Early patient and liver allograft outcomes from donation after circulatory death donors using thoracoabdominal normothermic regional: a multi-center observational experience. FRONTIERS IN TRANSPLANTATION 2023; 2:1184620. [PMID: 38993873 PMCID: PMC11235322 DOI: 10.3389/frtra.2023.1184620] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 07/17/2023] [Indexed: 07/13/2024]
Abstract
Background Donation after circulatory death (DCD) liver allografts are associated with higher rates of primary non-function (PNF) and ischemic cholangiopathy (IC). Advanced recovery techniques, including thoracoabdominal normothermic regional perfusion (TA-NRP), may improve organ utilization and patient and allograft outcomes. Given the increasing US experience with TA-NRP DCD recovery, we evaluated outcomes of DCD liver allografts transplanted after TA-NRP. Methods Liver allografts transplanted from DCD donors after TA-NRP were identified from 5/1/2021 to 1/31/2022 across 8 centers. Donor data included demographics, functional warm ischemic time (fWIT), total warm ischemia time (tWIT) and total time on TA-NRP. Recipient data included demographics, model of end stage liver disease (MELD) score, etiology of liver disease, PNF, cold ischemic time (CIT), liver function tests, intensive care unit (ICU) and hospital length of stay (LOS), post-operative transplant related complications. Results The donors' median age was 32 years old and median BMI was 27.4. Median fWIT was 20.5 min; fWIT exceeded 30 min in two donors. Median time to initiation of TA-NRP was 4 min and median time on bypass was 66 min. The median recipient listed MELD and MELD at transplant were 22 and 21, respectively. Median allograft CIT was 292 min. The median length of follow up was 257 days. Median ICU and hospital LOS were 2 and 7 days, respectively. Three recipients required management of anastomotic biliary strictures. No patients demonstrated IC, PNF or required re-transplantation. Conclusion Liver allografts from TA-NRP DCD donors demonstrated good early allograft and recipient outcomes.
Collapse
Affiliation(s)
- Aleah L. Brubaker
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, UC San Diego, San Diego, CA, United States
| | - Raeda Taj
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, UC San Diego, San Diego, CA, United States
| | - Brandon Jackson
- Department of Surgery, Division of Cardiothoracic Surgery, UC San Diego, San Diego, CA, United States
| | - Arielle Lee
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, UC San Diego, San Diego, CA, United States
| | - Catherine Tsai
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, UC San Diego, San Diego, CA, United States
| | - Jennifer Berumen
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, UC San Diego, San Diego, CA, United States
| | - Justin R. Parekh
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, UC San Diego, San Diego, CA, United States
| | - Kristin L. Mekeel
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, UC San Diego, San Diego, CA, United States
| | - Alexander R. Gupta
- Department of Surgery, Division of Transplant Surgery, UC San Francisco, San Francisco, CA, United States
| | - James M. Gardner
- Department of Surgery, Division of Transplant Surgery, UC San Francisco, San Francisco, CA, United States
| | - Thomas Chaly
- Arizona Transplant Associates, Phoenix, AZ, United States
| | - Amit K. Mathur
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Caroline Jadlowiec
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Sudhakar Reddy
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Rafael Nunez
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Janet Bellingham
- Department of Transplantation, California Pacific Medical Center, San Francisco, CA, United States
| | - Elizabeth M. Thomas
- Department of Surgery, University Transplant Center, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Jason R. Wellen
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St Louis, MO, United States
| | - Jenny H. Pan
- Department of Surgery, Division of Abdominal Transplantation, Stanford University, Stanford, CA, United States
| | - Mark Kearns
- Department of Surgery, Division of Cardiothoracic Surgery, UC San Diego, San Diego, CA, United States
| | - Victor Pretorius
- Department of Surgery, Division of Cardiothoracic Surgery, UC San Diego, San Diego, CA, United States
| | - Gabriel T. Schnickel
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, UC San Diego, San Diego, CA, United States
| |
Collapse
|
6
|
Lopez-Soler RI, Thorndyke A, Trotter C, Zingraf G, Sorenson J, Samra M. Kidney Transplantation in an Elderly Veteran Population With Hepatitis C Virus Nucleic Acid Test-Positive Donors Results in Improved Outcomes After Prophylactic Glecaprevir/Pibrentasvir Therapy. Transplant Proc 2023; 55:317-324. [PMID: 36801136 DOI: 10.1016/j.transproceed.2022.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/13/2022] [Accepted: 12/19/2022] [Indexed: 02/19/2023]
Abstract
BACKGROUND The average age of waitlisted veterans is 64. Recent data has shown the safety and benefits of using kidneys from hepatitis C virus nucleic acid test (HCV NAT)-positive donors. However, these studies were limited to younger patients with initiation of therapy after transplant. The aim of this study was to determine the safety and efficacy of a preemptive treatment protocol in an elderly veteran population. METHODS This was a prospective, open-label trial with 21 deceased donor kidney transplantations (DDKTs) with HCV NAT-positive kidneys and 32 DDKTs with HCV NAT-negative transplanted between November 2020 and March 2022. The HCV NAT-positive recipients were treated with once-daily glecaprevir/pibrentasvir started preoperatively and continued for 8 weeks. Sustained virologic response (SVR)12 was determined by negative NAT Student's t test. Other endpoints included patient and graft survival as well as graft function. RESULTS There was no major difference between the cohorts other than the increased number of donation after circulatory death kidneys in the non-HCV recipients. Post-transplant graft and patient outcomes were equivalent between the groups. Eight of the 21 HCV NAT-positive recipients had detectable HCV viral loads 1 day after transplant, but all were undetectable by day 7 with 100% SVR12. Calculated estimated glomerular filtration rate was improved in the HCV NAT-positive cohort at week 8 (58.26 vs 47.16 mL/min; P < .05) and continued to be improved over non-HCV recipients 1 year after transplant (71.38 vs 42.15 mL/min; P < .05). Immunologic risk stratification was similar in both cohorts. CONCLUSION The HCV NAT-positive transplants with a preemptive treatment protocol results in improved graft function with minimal to no complications in an elderly veteran population.
Collapse
Affiliation(s)
- Reynold I Lopez-Soler
- Section of Renal Transplantation, Edward Hines VA Jr Hospital, Hines, Illinois; Department of Surgery, Division of Intra-Abdominal Transplantation, Stritch School of Medicine, Maywood, Illinois.
| | - Anne Thorndyke
- Section of Renal Transplantation, Edward Hines VA Jr Hospital, Hines, Illinois
| | - Christine Trotter
- Section of Renal Transplantation, Edward Hines VA Jr Hospital, Hines, Illinois
| | - Gerry Zingraf
- Section of Renal Transplantation, Edward Hines VA Jr Hospital, Hines, Illinois
| | - Jeffrey Sorenson
- Section of Renal Transplantation, Edward Hines VA Jr Hospital, Hines, Illinois
| | - Manpreet Samra
- Section of Renal Transplantation, Edward Hines VA Jr Hospital, Hines, Illinois; Department of Medicine, Division of Transplant Nephrology, Stritch School of Medicine, Maywood, Illinois
| |
Collapse
|
7
|
Cannon RM, Nassel AF, Walker JT, Sheikh SS, Orandi BJ, Lynch RJ, Shah MB, Goldberg DS, Locke JE. Lost potential and missed opportunities for DCD liver transplantation in the United States. Am J Surg 2022; 224:990-998. [PMID: 35589438 PMCID: PMC9940905 DOI: 10.1016/j.amjsurg.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 04/20/2022] [Accepted: 05/03/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Donation after cardiac death(DCD) has been proposed as an avenue to expand the liver donor pool. METHODS We examined factors associated with nonrecovery of DCD livers using UNOS data from 2015 to 2019. RESULTS There 265 non-recovered potential(NRP) DCD livers. Blood type AB (7.8% vs. 1.1%) and B (16.9% vs. 9.8%) were more frequent in the NRP versus actual donors (p < 0.001). The median driving time between donor hospital and transplant center was similar for NRP and actual donors (30.1 min vs. 30.0 min; p = 0.689), as was the percentage located within a transplant hospital (20.8% vs. 20.9%; p = 0.984).The donation service area(DSA) of a donor hospital explained 27.9% (p = 0.001) of the variability in whether a DCD liver was recovered. CONCLUSION A number of potentially high quality DCD donor livers go unrecovered each year, which may be partially explained by donor blood type and variation in regional and DSA level practice patterns.
Collapse
Affiliation(s)
- Robert M Cannon
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Ariann F Nassel
- Lister Hill Center for Health Policy, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeffery T Walker
- Center for the Study of Community Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Saulat S Sheikh
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Babak J Orandi
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Raymond J Lynch
- Department of Surgery, Division of Transplantation, Emory University, Atlanta, GA, USA
| | - Malay B Shah
- Department of Surgery, Division of Transplantation, University of Kentucky, Lexington, KY, USA
| | - David S Goldberg
- Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami, Miami, FL, USA
| | - Jayme E Locke
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
8
|
Li Y, Shimizu S, Mizumoto M, Iizumi T, Numajiri H, Makishima H, Li G, Sakurai H. Proton Beam Therapy for Multifocal Hepatocellular Carcinoma (HCC) Showing Complete Response in Pathological Anatomy After Liver Transplantation. Cureus 2022; 14:e25744. [PMID: 35812555 PMCID: PMC9264287 DOI: 10.7759/cureus.25744] [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] [Accepted: 06/08/2022] [Indexed: 11/24/2022] Open
Abstract
We describe a patient with multifocal recurrent hepatocellular carcinoma (HCC) who received proton beam therapy (PBT) and then underwent donation after brain dead (DBD) liver transplantation. The anatomy of the explanted diseased liver was examined pathologically post-transplantation. The patient was a 52-year-old male with hepatitis B virus infection and liver cirrhosis of Child-Pugh class B. Right lobe and caudate lobectomy were performed for primary HCC. However, three recurrent tumors appeared in the remnant liver in segments S2 (two sites) and S4, of sizes 23 mm, 10 mm, and 32 mm, respectively. Liver transplantation was required due to these multiple HCCs and liver cirrhosis, but the patient was ineligible for living donor liver transplantation (LDLT) based on Milan criteria. He was registered as a candidate on the waiting list for DBD transplantation. In consideration of the long waiting time for a deceased donor transplant for more than one year, the progression of multiple recurrent HCCs, and the risk of death, the patient had limited treatment options other than PBT for poor liver function and multifocal HCC and eventually received 65 GyE/18 fractions of PBT. Eleven months after the start of PBT, the tumors remained progression-free and liver function did not deteriorate, allowing the patient to wait for liver transplantation. After transplantation, the histopathology of the explanted liver showed that the left lobe of the liver treated by PBT showed no evidence of solid tumors and tumor cells in visual and microscopic examinations. There was also no significant damage to normal liver tissue. This case demonstrates that PBT is a prospective option for patients with HCC with poor liver function, multiple tumors, and no other treatment options. PBT can achieve control or even complete response of HCC while maintaining liver function and may be an effective pre-transplant method for tumor downstaging and prolonging survival. PBT may enable more people to wait for a donor liver or to become eligible for liver transplantation.
Collapse
|
9
|
Baik SM, Park J, Kim TY, Lee JH, Hong KS. The Future Direction of the Organ Donation System After Legislation of the Life-Sustaining Treatment Decision Act. Ann Transplant 2021; 26:e934345. [PMID: 34811342 PMCID: PMC8626983 DOI: 10.12659/aot.934345] [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] [Indexed: 11/09/2022] Open
Abstract
Background The transplant community is seeking ways to encourage organ donation after cardiac arrest to solve the problem of the insufficiency of organs available for the increasing number of people awaiting transplantation. This study aimed to determine whether the life-sustaining treatment (LST) decision system, implemented in Korea on February 4, 2018, can address the shortage of organ donations. Material/Methods We retrospectively analyzed the medical records of the 442 patients who had filled out forms for the LST decision at Ewha Womans University Mokdong Hospital from April 2018 to December 2019, and classified the eligibility of organ and tissue donation according to the Korean Organ Donation Agency criteria. Results We included 442 patients in this study. Among them, 238 (53.8%) were men, and 204 (46.2%) were women. The average age of the patients was 71.8 years (the youngest and oldest were aged 23 years and 103 years, respectively). Of these, 110 patients (24.9%) decided on their own to discontinue LST, whereas 332 (75.1%) decided to discontinue with their family’s consent. This study demonstrated that 50% of patients who were not brain-dead and discontinued LST were eligible for organ donation. However, the patients and caregivers were not aware of this option because the current law does not allow the discussion of such donations. Conclusions A discussion regarding donation after circulatory death is recommended to solve the problem of insufficient organ donation.
Collapse
Affiliation(s)
- Seung Min Baik
- Division of Critical Care Medicine, Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Jin Park
- Division of Critical Care Medicine, Department of Neurology, Ewha Womans University Seoul Hospital, Ewha Women's University College of Medicine, Seoul, South Korea
| | - Tae Yoon Kim
- Division of Critical Care Medicine, Department of Surgery, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Jung Hwa Lee
- Division of Critical Care Medicine, Department of Neurology, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Kyung Sook Hong
- Division of Critical Care Medicine, Department of Surgery, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, South Korea
| |
Collapse
|
10
|
Sneiders D, van Dijk ABRM, Polak WG, Mirza DF, Perera MTPR, Hartog H. Full-left-full-right split liver transplantation for adult recipients: a systematic review and meta-analysis. Transpl Int 2021; 34:2534-2546. [PMID: 34773303 PMCID: PMC9300103 DOI: 10.1111/tri.14160] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/24/2021] [Accepted: 11/07/2021] [Indexed: 12/14/2022]
Abstract
Full-left-full-right split liver transplantation (FSLT) for adult recipients, may increase the availability of liver grafts, reduce waitlist time, and benefit recipients with below-average body weight. However, FSLT may lead to impaired graft and patient survival. This study aims to assess outcomes after FSLT. Five databases were searched to identify studies concerning FSLT. Incidences of complications, graft- and patient survival were assessed. Discrete data were pooled with random-effect models. Graft and patient survival after FSLT were compared with whole liver transplantation (WLT) according to the inverse variance method. Vascular complications were reported in 25/273 patients after FSLT (Pooled proportion: 6.9%, 95%CI: 3.1-10.7%, I2 : 36%). Biliary complications were reported in 84/308 patients after FSLT (Pooled proportion: 25.6%, 95%CI: 19-32%, I2 : 44%). Pooled proportions of graft and patient survival after 3 years follow-up were 72.8% (95%CI: 67.2-78.5, n = 231) and 77.3% (95%CI: 66.7-85.8, n = 331), respectively. Compared with WLT, FSLT was associated with increased graft loss (pooled HR: 2.12, 95%CI: 1.24-3.61, P = 0.006, n = 189) and patient mortality (pooled HR: 1.81, 95%CI: 1.17-2.81, P = 0.008, n = 289). FSLT was associated with high incidences of vascular and biliary complications. Nevertheless, long-term patient and graft survival appear acceptable and justify transplant benefit in selected patients.
Collapse
Affiliation(s)
- Dimitri Sneiders
- Erasmus MC Transplant Institute, Department of Surgery, Division of HPB and Transplant Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.,Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
| | - Anne-Baue R M van Dijk
- Erasmus MC Transplant Institute, Department of Surgery, Division of HPB and Transplant Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Wojciech G Polak
- Erasmus MC Transplant Institute, Department of Surgery, Division of HPB and Transplant Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Darius F Mirza
- Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
| | | | - Hermien Hartog
- Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
| |
Collapse
|
11
|
Ziogas IA, Kakos CD, Esagian SM, Skarentzos K, Alexopoulos SP, Shingina A, Montenovo MI. Liver transplant after donation from controlled circulatory death versus brain death: A UNOS database analysis and publication bias adjusted meta-analysis. Clin Transplant 2021; 36:e14521. [PMID: 34689372 DOI: 10.1111/ctr.14521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/06/2021] [Accepted: 10/16/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Donation after circulatory death (DCD) is an increasingly utilized alternative to donation after brain death (DBD) to expand the liver donor pool. We compared the outcomes of liver transplant (LT) after DCD versus DBD. METHODS A PRISMA-compliant systematic literature review was performed using the PubMed, Cochrane Library, and Embase databases (end-of-search-date: July 2, 2020). US outcomes were analyzed using the UNOS database (February, 2002-September, 2020). Pooled hazard ratios (HR) for patient and graft survival were obtained through random effect meta-analyses and adjusted for publication bias. RESULTS Thirteen studies reporting on 1426 DCD and 5385 DBD LT recipients were included. 5620 DCD and 87561 DBD LT recipients were analyzed from the UNOS database. Meta-analysis showed increased risk of patient mortality for DCD (HR = 1.36; 95%CI, 1.09-1.70; P = .01; I2 = 53.6%). When adjusted for publication bias, meta-analysis showed no difference in patient survival between DCD and DBD (HR = 1.15; 95%CI, .91-1.45; P = .25; I2 = 61.5%). Meta-analysis showed increased risk of graft loss for DCD (HR = 1.50; 95%CI, 1.20-1.88; P < .001; I2 = 67.8%). When adjusted for publication bias, meta-analysis showed a reduction in effect size (HR = 1.36; 95%CI, 1.06-1.74; P = .02; I2 = 73.5%). CONCLUSION When adjusted for publication bias, no difference was identified between DCD and DBD regarding patient survival, while DCD was associated with an increased risk of graft loss.
Collapse
Affiliation(s)
- Ioannis A Ziogas
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | - Christos D Kakos
- Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | - Stepan M Esagian
- Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | | | - Sophoclis P Alexopoulos
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alexandra Shingina
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Martin I Montenovo
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
12
|
Sasaki K, Nair A, Firl DJ, McVey JC, Moro A, Diago Uso T, Fujiki M, Aucejo FN, Quintini C, Kwon CHD, Eghtesad B, Miller CM, Hashimoto K. Conditional probability of graft survival in liver transplantation using donation after circulatory death grafts - a retrospective study. Transpl Int 2021; 34:1433-1443. [PMID: 33599045 DOI: 10.1111/tri.13846] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/14/2020] [Accepted: 02/15/2021] [Indexed: 01/11/2023]
Abstract
The use of livers from donation after circulatory death (DCD) is historically characterized by increased rates of biliary complications and inferior short-term graft survival (GS) compared to donation after brain death (DBD) allografts. This study aimed to evaluate the dynamic prognostic impact of DCD livers to reveal whether they remain an adverse factor even after patients survive a certain period following liver transplant (LT). This study used 74 961 LT patients including 4065 DCD LT in the scientific registry of transplant recipients from 2002-2017. The actual, 1 and 3-year conditional hazard ratio (HR) of 1-year GS in DCD LT were calculated using a conditional version of Cox regression model. The actual 1-, 3-, and 5-year GS of DCD LT recipients were 83.3%, 73.3%, and 66.3%, which were significantly worse than those of DBD (all P < 0.01). Actual, 1-, and 3-year conditional HR of 1-year GS in DCD compared to DBD livers were 1.87, 1.49, and 1.39, respectively. Graft loss analyses showed that those lost to biliary related complications were significantly higher in the DCD group even 3 years after LT. National registry data demonstrate the protracted higher risks inherent to DCD liver grafts in comparison to their DBD counterparts, despite survival through the early period after LT. These findings underscore the importance of judicious DCD graft selection at individual center level to minimize the risk of long-term biliary complications.
Collapse
Affiliation(s)
- Kazunari Sasaki
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Amit Nair
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel J Firl
- Department of Surgery, Duke University Hospital, Durham, NC, USA
| | - John C McVey
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Amika Moro
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Teresa Diago Uso
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Masato Fujiki
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Federico N Aucejo
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Cristiano Quintini
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Choon-Hyuck D Kwon
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Bijan Eghtesad
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Charles M Miller
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Koji Hashimoto
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
13
|
Singh N, Helfrich K, Mumtaz K, Washburn K, Logan A, Black S, Schenk A, Limkemann A, Alebrahim M, El-Hinnawi A. Donation After Circulatory Death Yields Survival Rates Similar to Donation After Brain Death Liver Transplant, Which Effectively Expands the Donor Pool. EXP CLIN TRANSPLANT 2021; 19:771-778. [PMID: 33877039 DOI: 10.6002/ect.2021.0013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Liver allograft shortage has necessitated greater use of donations after circulatory death. Limited data are available to compare recipients' health care utilization for donation after circulatory death versus brain death. MATERIALS AND METHODS Liver transplant data for our center from November 2016 until May 2019 were obtained (208 donations after brain death and 39 after circulatory death). We excluded patients <18 years old and multiorgan transplants; for cost data only, we also excluded retransplants. Primary outcome was recipients' health care utilization in donation after circulatory death versus brain death and included index admission length of stay, readmissions, and charges from transplant to 6 months. Secondary outcomes were patient and graft survival. RESULTS Donors from circulatory death were younger than donors from brain death (median age 32 vs 40 years; P < .01). Recipient body mass index (31.23 vs 29.38 kg/m2), Model for End-Stage Liver Disease score (17 vs 19), portal vein thrombosis (15.8% vs 18.0%), length of stay (7 vs 8 days), and 30-, 90-, and 180-day posttransplant index admissions were not significantly different. Charges for index admission were equivalent for donation after circulatory death ($370771) and brain death ($374272) (P = .01). Charges for readmissions at 30 and 180 days were not significantly different (P = .80 and P = .19, respectively). Rates for graft failure (10.3% vs 4.8%; P = .08) and recipient death (10.3% vs 3.8%; P = .17) at 6 months posttransplant were similar. CONCLUSIONS Donation after circulatory death versus brain death liver transplant recipients had similar lengths of stay and equivalent index admission charges. Graft and patient survival and charges from transplant to 6 months were similar. Donation after circulatory death liver allografts provide a safe, costequivalent donor pool expansion after careful donorrecipient selection.
Collapse
Affiliation(s)
- Navdeep Singh
- From the Division of Transplantation, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Navez J, Iesari S, Kourta D, Baami-Mariza K, Nadiri M, Goffette P, Baldin P, Ackenine K, Bonaccorsi-Riani E, Ciccarelli O, Coubeau L, Moreels T, Lerut J. The real incidence of biliary tract complications after adult liver transplantation: the role of the prospective routine use of cholangiography during post-transplant follow-up. Transpl Int 2020; 34:245-258. [PMID: 33188645 DOI: 10.1111/tri.13786] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/13/2020] [Accepted: 11/10/2020] [Indexed: 12/20/2022]
Abstract
Biliary tract complications (BTCs) still burden liver transplantation (LT). The wide reporting variability highlights the absence of systematic screening. From 2000 to 2009, simultaneous liver biopsy and direct biliary visualization were prospectively performed in 242 recipients at 3 and 6 months (n = 212, 87.6%) or earlier when indicated (n = 30, 12.4%). Median follow-up was 148 (107-182) months. Seven patients (2.9%) experienced postprocedural morbidity. BTCs were initially diagnosed in 76 (31.4%) patients; 32 (42.1%) had neither clinical nor biological abnormalities. Acute cellular rejection (ACR) was present in 27 (11.2%) patients and in 6 (22.2%) BTC patients. Nine (3.7%) patients with normal initial cholangiography developed BTCs after 60 (30-135) months post-LT. BTCs directly lead to 7 (2.9%) re-transplantations and 14 (5.8%) deaths resulting in 18 (7.4%) allograft losses. Bile duct proliferation at 12-month biopsy proved an independent risk factor for graft loss (P = 0.005). Systematic biliary tract and allograft evaluation allows the incidence and extent of biliary lesions to be documented more precisely and to avoid erroneous treatment of ACR. The combination 'abnormal biliary tract-canalicular proliferation' is an indicator of worse graft outcome. BTCs are responsible for important delayed allograft and patient losses. These results underline the importance of life-long follow-up and appropriate timing for re-transplantation.
Collapse
Affiliation(s)
- Julie Navez
- Starzl Unit of Abdominal Transplantation, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium.,Medico-Surgical Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Samuele Iesari
- Starzl Unit of Abdominal Transplantation, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium.,Pôle de Chirurgie Expérimentale et Transplantation, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Dhoha Kourta
- Starzl Unit of Abdominal Transplantation, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Kente Baami-Mariza
- Starzl Unit of Abdominal Transplantation, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Marwan Nadiri
- Starzl Unit of Abdominal Transplantation, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Pierre Goffette
- Interventional Radiology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Pamela Baldin
- Pathology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Kevin Ackenine
- Starzl Unit of Abdominal Transplantation, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Eliano Bonaccorsi-Riani
- Starzl Unit of Abdominal Transplantation, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium.,Pôle de Chirurgie Expérimentale et Transplantation, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Olga Ciccarelli
- Starzl Unit of Abdominal Transplantation, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Laurent Coubeau
- Starzl Unit of Abdominal Transplantation, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Tom Moreels
- Hepato-gastroenterology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Jan Lerut
- Pôle de Chirurgie Expérimentale et Transplantation, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| |
Collapse
|
15
|
Little CJ, Dick AAS, Perkins JD, Hsu EK, Reyes JD. Livers From Pediatric Donation After Circulatory Death Donors Represent a Viable and Underutilized Source of Allograft. Liver Transpl 2020; 26:1138-1153. [PMID: 32403205 DOI: 10.1002/lt.25795] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/16/2020] [Accepted: 05/04/2020] [Indexed: 01/13/2023]
Abstract
Despite increased numbers of donation after circulatory death (DCD) donors, pediatric DCD livers are underused. To investigate possible reasons for this discrepancy, we conducted a retrospective cohort study using 2 data sets from the Organ Procurement and Transplantation Network for all deceased liver donors and for all recipients of DCD liver transplants from March 8, 1993, to June 30, 2018. Pediatric (0-12 years) and adolescent (13-17 years) DCD donors were compared with those aged 18-40 years. We found that pediatric DCD allografts are recovered at a significantly lower rate than from 18-to-40-year-old donors (27.3% versus 56.3%; P < 0.001). However, once recovered, these organs are transplanted at a similar rate to those from the 18-to-40-year-old donor cohort (74.7% versus 74.2%). Significantly more pediatric DCD livers (odds ratio [OR], 3.75; confidence interval [CI], 3.14-4.47) were not recovered compared with adult organs, which were most commonly not recovered due to organ quality (10.2% versus 7.1%; P < 0.001). The 10-year relative risks (RRs) for graft failure and patient death were similar between pediatric and adult DCD donors, with adolescent DCD livers demonstrating improved outcomes. DCD livers transplanted into pediatric donors were protective against graft failure (RR, 0.46; 95% confidence interval [CI], 0.21-0.99) and patient death (RR, 0.16; 95% CI, 0.04-0.69). In conclusion, despite lower rates of recovery, pediatric DCD livers represent a viable organ source for certain adults and children.
Collapse
Affiliation(s)
| | - Andre A S Dick
- Division of Transplantation, University of Washington Medical Center, Seattle, WA.,Seattle Children's Hospital, Section of Pediatric Transplantation, Seattle, WA
| | - James D Perkins
- Division of Transplantation, University of Washington Medical Center, Seattle, WA
| | - Evelyn K Hsu
- Division of Gastroenterology, Department of Pediatrics, University of Washington Medical Center, Seattle, WA
| | - Jorge D Reyes
- Division of Transplantation, University of Washington Medical Center, Seattle, WA.,Seattle Children's Hospital, Section of Pediatric Transplantation, Seattle, WA
| |
Collapse
|
16
|
Does Normothermic Regional Perfusion Improve the Results of Donation After Circulatory Death Liver Transplantation? Transplant Proc 2020; 52:1477-1480. [PMID: 32252997 DOI: 10.1016/j.transproceed.2020.01.088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 01/10/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND The so-called grafts or donors with extended criteria are a risk factor for the development of liver transplant activity. One source comes from controlled donation after circulatory death (cDCD). The hypothesis was to verify the improvement in results by comparing DCD liver transplants performed with postmortem normothermic regional perfusion (NRP) vs super-rapid recovery (SRR), the current standard for cDCD. A prospective study comparing both techniques was carried out. METHODS A total of 42 transplants were performed with cDCD, 22 of which were with SRR and 23 with NRP from April 2014 to September 2019. RESULTS Differences were found in early allograft dysfunction (68.1% in the SRR group vs 25% in the NRP group; P < .01) and biliary complications (22.7% vs 5%, respectively; P = .04). Differences were also found, although not statistically significant, in ischemic cholangiopathy (13.6% in the SRR group vs 5% in the NRP group; P = .09), and retransplant rate (9.1% vs 0%, respectively; P = .3). CONCLUSIONS With the use of NRP machines, results are similar to the standard donation with donors in brain death in terms of rate of early allograft dysfunction and survival of the patient and graft attempted, reducing the rate of ischemic cholangiopathy compared with SRR.
Collapse
|
17
|
Nostedt JJ, Shapiro J, Freed DH, Bigam DL. Addressing organ shortages: progress in donation after circulatory death for liver transplantation. Can J Surg 2020; 63:E135-E141. [PMID: 32195556 DOI: 10.1503/cjs.005519] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Reducing wait list mortality among patients awaiting liver transplantation remains a substantial challenge because of organ shortage. In efforts to expand the donor pool there has been a trend toward increased use of donation after circulatory death (DCD) liver grafts. However, these marginal grafts are prone to higher complication rates, particularly biliary complications. In addition, many procured DCD livers are then deemed unsuitable for transplant. Despite these limitations, DCD grafts represent an important resource to address the current organ shortage, and as such there are research efforts directed toward improving the use of and outcomes for transplantation of these grafts. We review the current progress in DCD liver transplantation.
Collapse
Affiliation(s)
- Jordan J. Nostedt
- From the Department of Surgery, Division of General Surgery, University of Alberta Hospital, Edmonton, Alta. (Nostedt, Shapiro, Bigam); the Department of Physiology, University of Alberta, Edmonton, Alta. (Freed); and the Department of Surgery, Division of Cardiac Surgery, University of Alberta, Alberta Heart Institute, Edmonton, Alta. (Freed)
| | - James Shapiro
- From the Department of Surgery, Division of General Surgery, University of Alberta Hospital, Edmonton, Alta. (Nostedt, Shapiro, Bigam); the Department of Physiology, University of Alberta, Edmonton, Alta. (Freed); and the Department of Surgery, Division of Cardiac Surgery, University of Alberta, Alberta Heart Institute, Edmonton, Alta. (Freed)
| | - Darren H. Freed
- From the Department of Surgery, Division of General Surgery, University of Alberta Hospital, Edmonton, Alta. (Nostedt, Shapiro, Bigam); the Department of Physiology, University of Alberta, Edmonton, Alta. (Freed); and the Department of Surgery, Division of Cardiac Surgery, University of Alberta, Alberta Heart Institute, Edmonton, Alta. (Freed)
| | - David L. Bigam
- From the Department of Surgery, Division of General Surgery, University of Alberta Hospital, Edmonton, Alta. (Nostedt, Shapiro, Bigam); the Department of Physiology, University of Alberta, Edmonton, Alta. (Freed); and the Department of Surgery, Division of Cardiac Surgery, University of Alberta, Alberta Heart Institute, Edmonton, Alta. (Freed)
| |
Collapse
|
18
|
Gottin L, Taiana M. Uncontrolled donation after circulatory death and liver transplantation: much still remains to be done. Minerva Anestesiol 2020; 86:129-131. [DOI: 10.23736/s0375-9393.19.14095-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
19
|
Inflammasome-Mediated Inflammation in Liver Ischemia-Reperfusion Injury. Cells 2019; 8:cells8101131. [PMID: 31547621 PMCID: PMC6829519 DOI: 10.3390/cells8101131] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/19/2019] [Accepted: 09/21/2019] [Indexed: 12/16/2022] Open
Abstract
Ischemia-reperfusion injury is an important cause of liver damage occurring during surgical procedures including hepatic resection and liver transplantation, and represents the main underlying cause of graft dysfunction and liver failure post-transplantation. To date, ischemia-reperfusion injury is an unsolved problem in clinical practice. In this context, inflammasome activation, recently described during ischemia-reperfusion injury, might be a potential therapeutic target to mitigate the clinical problems associated with liver transplantation and hepatic resections. The present review aims to summarize the current knowledge in inflammasome-mediated inflammation, describing the experimental models used to understand the molecular mechanisms of inflammasome in liver ischemia-reperfusion injury. In addition, a clear distinction between steatotic and non-steatotic livers and between warm and cold ischemia-reperfusion injury will be discussed. Finally, the most updated therapeutic strategies, as well as some of the scientific controversies in the field will be described. Such information may be useful to guide the design of better experimental models, as well as the effective therapeutic strategies in liver surgery and transplantation that can succeed in achieving its clinical application.
Collapse
|
20
|
Wanis KN, Madenci AL, Dokus MK, Tomiyama K, Al-Judaibi BM, Hernán MA, Hernandez-Alejandro R. The Effect of the Opioid Epidemic on Donation After Circulatory Death Transplantation Outcomes. Transplantation 2019; 103:973-979. [DOI: 10.1097/tp.0000000000002467] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
|
21
|
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]
|
22
|
Jayant K, Reccia I, Virdis F, Shapiro AMJ. Systematic Review and Meta-Analysis on the Impact of Thrombolytic Therapy in Liver Transplantation Following Donation after Circulatory Death. J Clin Med 2018; 7:jcm7110425. [PMID: 30413051 PMCID: PMC6262573 DOI: 10.3390/jcm7110425] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/02/2018] [Accepted: 11/06/2018] [Indexed: 02/06/2023] Open
Abstract
Aim: The livers from DCD (donation after cardiac death) donations are often envisaged as a possible option to bridge the gap between the availability and increasing demand of organs for liver transplantation. However, DCD livers possess a heightened risk for complications and represent a formidable management challenge. The aim of this study was to evaluate the effects of thrombolytic flush in DCD liver transplantation. Methods: An extensive search of the literature database was made on MEDLINE, EMBASE, Cochrane, Crossref, Scopus databases, and clinical trial registry on 20 September 2018 to assess the role of thrombolytic tissue plasminogen activator (tPA) flush in DCD liver transplantation. Results: A total of four studies with 249 patients in the tPA group and 178 patients in the non-tPA group were included. The pooled data revealed a significant decrease in ischemic-type biliary lesions (ITBLs) (P = 0.04), re-transplantation rate (P = 0.0001), and no increased requirement of blood transfusion (P = 0.16) with a better one year graft survival (P = 0.02). Conclusions: To recapitulate, tPA in DCD liver transplantation decreased the incidence of ITBLs, re-transplantation and markedly improved 1-year graft survival, without any increased risk for blood transfusion, hence it has potential to expand the boundaries of DCD liver transplantation.
Collapse
Affiliation(s)
- Kumar Jayant
- Department of Surgery and Cancer, Imperial College London, London W12 OHS, UK.
| | - Isabella Reccia
- Department of Surgery and Cancer, Imperial College London, London W12 OHS, UK.
| | | | - A M James Shapiro
- Department of Surgery, University of Alberta, Edmonton, AB T6G 2B7, Canada.
| |
Collapse
|
23
|
Jayant K, Reccia I, Shapiro AMJ. Normothermic ex-vivo liver perfusion: where do we stand and where to reach? Expert Rev Gastroenterol Hepatol 2018; 12:1045-1058. [PMID: 30064278 DOI: 10.1080/17474124.2018.1505499] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Nowadays liver transplantation is considered as the treatment of choice, however, the scarcity of suitable donor organs limits the delivery of care to the end-stage liver disease patients leading to the death while on the waiting list. The advent of ex-situ normothermic machine perfusion (NMP) has emerged as an alternative to the standard organ preservation technique, static cold storage (SCS). The newer technique promises to not only restore the normal metabolic activity but also attempt to recondition the marginal livers back to the pristine state, which are otherwise more susceptible to ischemic injury and foster the poor post-transplant outcomes. Areas covered: An extensive search of all the published literature describing the role of NMP based device in liver transplantation as an alternative to SCS was made on MEDLINE, EMBASE, Cochrane, BIOSIS, Crossref, Scopus databases and clinical trial registry on 10 May 2018. Expert commentary: The main tenet of NMP is the establishment of the physiological milieu, which permits aerobic metabolism to continue through out the period of preservation and limits the effects of ischemia-reperfusion (I/R) injury. In addition, by assessing the various metabolic and synthetic parameters the viability and suitability of donor livers for transplantation can be determined. This important technological advancement has scored satisfactorily on the safety and efficacy parameters in preliminary clinical studies. The present review suggests that NMP can offer the opportunity to assess and safely utilize the marginal donor livers if deemed appropriate for the transplantation. However, ongoing trials will determine its full potential and further adoption.
Collapse
Affiliation(s)
- Kumar Jayant
- a Department of Surgery and Cancer , Imperial College London , London , UK
| | - Isabella Reccia
- a Department of Surgery and Cancer , Imperial College London , London , UK
| | | |
Collapse
|
24
|
First Scandinavian Protocol for Controlled Donation After Circulatory Death Using Normothermic Regional Perfusion. Transplant Direct 2018; 4:e366. [PMID: 30046656 PMCID: PMC6056274 DOI: 10.1097/txd.0000000000000802] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 01/25/2023] Open
Abstract
Background Donation after circulatory death (DCD) can increase the pool of available organs for transplantation. This pilot study evaluates the implementation of a controlled DCD (cDCD) protocol using normothermic regional perfusion in Norway. Methods Patients aged 16 to 60 years that are in coma with documented devastating brain injury in need of mechanical ventilation, who would most likely attain cardiac arrest within 60 minutes after extubation, were eligible. With the acceptance from the next of kin and their wish for organ donation, life support was withdrawn and cardiac arrest observed. After a 5-minute no-touch period, extracorporeal membrane oxygenation for post mortem regional normothermic regional perfusion was established. Cerebral and cardiac reperfusion was prevented by an aortic occlusion catheter. Measured glomerular filtration rates 1 year postengraftment were compared between cDCD grafts and age-matched grafts donated after brain death (DBD). Results Eight cDCD were performed from 2014 to 2015. Circulation ceased median 12 (range, 6-24) minutes after withdrawal of life-sustaining treatment. Fourteen kidneys and 2 livers were retrieved and subsequently transplanted. Functional warm ischemic time was 26 (20-51) minutes. Regional perfusion was applied for 97 minutes (54-106 minutes). Measured glomerular filtration rate 1 year postengraftment was not significantly different between cDCD and donation after brain death organs, 75 (65-76) vs 60 (37-112) mL/min per 1.73 m2 (P = 0.23). No complications have been observed in the 2 cDCD livers. Conclusion A protocol for cDCD is successfully established in Norway. Excellent transplant outcomes have encouraged us to continue this work addressing the shortage of organs for transplantation.
Collapse
|