Donation after circulatory death

A scoping review of the legal and ethical challenges with the use of normothermic regional perfusion in controlled donation after circulatory determination a death from 2005-2023

Use of normothermic regional perfusion (NRP) to enable organ reconditioning and assessment in donation after circulatory determination of death (DCD) is controversial. We conducted a scoping review of peer-reviewed articles, news media, legal literature, and professional society position statements addressing ethical and/or legal issues in use of NRP in controlled DCD from January 1, 2005 to January 5, 2024. Thematic analysis, assessing the four principles of bioethics (autonomy, beneficence, non-maleficence, and justice) and sub-themes identified within each, was conducted for the 112 publications meeting inclusion criteria. More than 30 publications addressed the topic in each of 2022 and 2023, versus ≤6 per year previously. Non-maleficence was the most frequently addressed bioethical principle (111/112 publications), and most varied, with 14 subthemes. Attitudes towards NRP differed by type of NRP: Of 72 publications discussing thoracoabdominal NRP, 22 (30.6%) were 'In Favor', 39 (54.2%) 'Neutral', and 11 (15.3%) 'Against'; of 44 discussing abdominal NRP, 23 (52.3%) were 'In Favor', 20 (45.5%) 'Neutral', and 1 (2.3%) 'Against'. Attitudes differed by authors' country, degree, and affiliation, and by clinical focus of the publishing journal. Overall, our review shows the ethical and legal issues raised by NRP remain unresolved, and debate centered on non-maleficence.

Ethical Issues in Normothermic Regional Perfusion in Controlled Organ Donation After Determination of Death by Circulatory Criteria: A Scoping Review

Normothermic regional perfusion (NRP) is a surgical technique that can improve the quality and number of organs recovered for donation after the determination of death by circulatory criteria. Despite its promise, adoption of NRP has been hindered because of unresolved ethical issues. To inform stakeholders, this scoping review provides an impartial overview of the major ethical controversies surrounding NRP. We undertook this review according to a modified 5-step methodology proposed by Arksey and O'Malley. Publications were retrieved through MEDLINE and Embase. Gray literature was sourced from Canadian organ donation organizations, English-language organ donation organization websites, and through our research networks. Three reviewers independently screened all documents for inclusion, extracted data, and participated in content analysis. Disagreements were resolved through consensus meetings. Seventy-one documents substantively engaging with ethical issues in NRP were included for full-text analysis. We identified 6 major themes encompassing a range of overlapping ethical debates: (1) the compatibility of NRP with the dead donor rule, the injunction that organ recovery cannot cause death, (2) the risk of donor harm posed by NRP, (3) uncertainties regarding consent requirements for NRP, (4) risks to stakeholder trust posed by NRP, (5) the implications of NRP for justice, and (6) NRP's potential to benefits of NRP for stakeholders. We found no agreement on the ethical permissibility of NRP. However, some debates may be resolved through additional empirical study. As decision-makers contemplate the adoption of NRP, it is critical to address the ethical issues facing the technique to ensure stakeholder trust in deceased donation and transplantation systems is preserved.

Extended Criteria Donor Use in Lung Transplants From Donation After Controlled Circulatory Death

BACKGROUND

Most institutions apply the criteria for controlled donation after cardiac death (cDCD) lung retrieval identical to the criteria for donation after brain death (DBD). The availability of extended criteria donor (ECD) in lung transplants from cDCD remains unclear.

METHODS

The United Network for Organ Sharing (UNOS) database was queried for adult lung transplants from cDCD, from May 03, 2005, to March 15, 2022. ECDs were defined by one or more items at variance from standard criteria: age 55 years or more, PaO2:FiO2 300 or less, smoking 20 pack-years or more, diabetes, or purulent secretions upon bronchoscopy. Recipients were divided into the standard criteria donor (SCD) group and the ECD group, and assessed for short- and long-term survival and postoperative events.

RESULTS

Among 827 records, the SCD and ECD group showed no differences in 5-year (P = .56) survival. No significant differences were found in 30-day, 90-day, 1-year mortality and postoperative outcomes before discharge, whether in length of hospital stay, rate of ventilator support for >48 hours or reintubation, incidence of grade 3 PGD 72 hours posttransplant, acute rejection, or dialysis. None of the 5 donor factors used as criteria for lung retrieval was independently associated with cDCD recipient survival.

CONCLUSIONS

Using donor lungs that extend the DBD criteria may be a safe strategy in cDCD lung transplantation. However, the current criteria may not be a perfect fit for cDCD lung retrieval. The specific DCD criteria for standard lung retrieval need to be determined.

Potential for organ donation after controlled circulatory death: a retrospective analysis

Objectives

Despite the discrepancy between demand and availability of organs for transplantation, controlled circulatory death donation has not been implemented in Portugal. This study aimed to estimate the potential increase in organ donation from implementing such a program.

Material and Methods

All deceased patients within the intensive care medicine department at Centro Hospitalar Universitário de São João, throughout the year 2019, were subjected to retrospective analysis. Potential gain was estimated comparing the results with the number of donors and organs collected during the same period at this hospital center. Differences in variables between groups were assessed using t tests for independent samples or Mann-Whitney U tests for continuous variables, and chi-squared tests were used for categorical variables.

Results

During 2019, 152 deaths occurred after withdrawal of life-sustaining therapies, 10 of which would have been potentially eligible for donation after controlled circulatory death. We can anticipate a potential increase of 10 prospective donors, a maximum 21% growth in yearly transplantation activity, with a greater impact on kidney transplantation. For most patients, the time between withdrawal of organ support and death surpassed 120 minutes, an outcome explained by variations in withdrawal of life-sustaining measures and insufficient clinical records, underestimating the potential for controlled circulatory arrest donation.

Conclusion

This study effectively highlights public health benefits of controlled circulatory arrest donation. Legislation allowing donation through this method represents a social gain and enables patients who will never meet brain death criteria to donate organs as part of the end-of-life process in intensive care medicine, within a framework of complete ethical alignment.

Critical care specialists, the missing link in organ procurement for transplantation

The procurement process for organ donation begins with the identification of potential organ donors in emergency or critical care units (CCU), followed by their clinical evaluation, diagnostic procedures, and therapeutic interventions, mostly conducted in CCUs. It concludes with the request for organ donation and, if accepted, the retrieval of organs. Despite most interventions occurring in detection units, there has been a neglect of the strategic role played by critical care specialists (CCS) in managing and caring for brain-dead or near-brain-death patients. Questions arise: Are they willing to undertake this responsibility? Do they fully comprehend the nature of organ procurement? Are they aware of the specific interventions required to maintain possible organ donors in optimal physiological condition? Our objective is to examine the role of CCS in organ procurement and propose ways to enhance it, ultimately aiming to increase and enhance organ donation rates.

Delayed Graft Function and the Renin-angiotensin System

Delayed graft function (DGF) is a form of acute kidney injury (AKI) and a common complication following kidney transplantation. It adversely influences patient outcomes increases the financial burden of transplantation, and currently, no specific treatments are available. In developing this form of AKI, activation of the renin-angiotensin system (RAS) has been proposed to play an important role. In this review, we discuss the role of RAS activation and its contribution to the pathophysiology of DGF following the different stages of the transplantation process, from procurement and ischemia to transplantation into the recipient and including data from experimental animal models. Deceased kidney donors, whether during cardiac or brain death, may experience activation of the RAS. That may be continued or further potentiated during procurement and organ preservation. Additional evidence suggests that during implantation of the kidney graft and reperfusion in the recipient, the RAS is activated and may likely remain activated, extrapolating from other forms of AKI where RAS overactivity is well documented. Of particular interest in this setting is the status of angiotensin-converting enzyme 2, a key RAS enzyme essential for the metabolism of angiotensin II and abundantly present in the apical border of the proximal tubules, which is the site of predominant injury in AKI and DGF. Interventions aimed at safely downregulating the RAS using suitable shorter forms of angiotensin-converting enzyme 2 could be a way to offer protection against DGF.

Advancing the Scientific Basis for Determining Death in Controlled Organ Donation After Circulatory Determination of Death

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.

Current Understanding of Marginal Grafts in Liver Transplantation

End-stage liver disease (ESLD), stemming from a spectrum of chronic liver pathologies including chronic liver failure, acute cirrhosis decompensation and hepatocellular carcinoma, imposes a significant global healthcare burden. Liver transplantation (LT) remains the only treatment for ESLD. However, the escalating mortality on transplant waitlists has prompted the utilization of marginal liver grafts in LT procedures. These grafts primarily encompass elderly livers, steatotic livers, livers from donation after circulatory death, split livers and those infected with the hepatitis virus. While the expansion of the donor pool offers promise, it also introduces concomitant risks. These encompass graft failure, biliary and cardiovascular complications, the recurrence of liver disease and reduced patient and graft survival. Consequently, various established strategies, ranging from improved donor-recipient matching to surgical interventions, have emerged to mitigate these risks. This article undertakes a comprehensive assessment of the current landscape, evaluating the viability of diverse marginal liver grafts. Additionally, it synthesizes approaches aimed at enhancing the quality of such marginal liver grafts. The overarching objective is to augment the donor pool and ameliorate the risk factors associated with the shortage of liver grafts.

Cell-specific Extracellular Vesicles and Their miRNA Cargo Released Into the Organ Preservation Solution During Cold Ischemia Storage as Biomarkers for Liver Transplant Outcomes

BACKGROUND

Liver transplantation (LT) is crucial for end-stage liver disease patients, but organ shortages persist. Donation after circulatory death (DCD) aims to broaden the donor pool but presents challenges. Complications like acute rejection, hepatic artery thrombosis, and biliary issues still impact posttransplant prognosis. Biomarkers, including extracellular vesicles (EVs) and microRNAs (miRNAs), show promise in understanding and monitoring posttransplant events. This study explores the role of EVs and their miRNA cargo in LT, including their potential as diagnostic tools.

METHODS

EVs from intrahepatic end-ischemic organ preservation solution (eiOPS) in 79 donated livers were detected using different techniques (nanosight tracking analysis, transmission electron microscopy, and flow cytometry). EV-derived miRNAs were identified by quantitative real time-polymerase chain reaction. Bioinformatics analysis was performed using the R platform.

RESULTS

Different-sized and origin-specific EVs were found in eiOPS, with significantly higher concentrations in DCD compared with donation after brain death organs. Additionally, several EV-associated miRNAs, including let-7d-5p, miR-28-5p, miR-200a-3p, miR-200b-3p, miR-200c-3p, and miR-429, were overexpressed in DCD-derived eiOPS. These miRNAs also exhibited differential expression patterns in liver tissue biopsies. Pathway analysis revealed enrichment in signaling pathways involved in extracellular matrix organization and various cellular processes. Moreover, specific EVs and miRNAs correlated with clinical outcomes, including survival and early allograft dysfunction. A predictive model combining biomarkers and clinical variables showed promise in acute rejection detection after LT.

CONCLUSIONS

These findings provide new insights into the use of EVs and miRNAs as biomarkers and their possible influence on posttransplantation outcomes, potentially contributing to improved diagnostic approaches and personalized treatment strategies in LT.

Ex Vivo Gene Therapy in Organ Transplantation: Considerations and Clinical Translation

Ex vivo machine perfusion (EVMP) is rapidly growing in utility during solid organ transplantation. This form of organ preservation is transforming how organs are allocated and expanding the definition of what is considered a suitable organ for transplantation in comparison with traditional static cold storage. All major organs (heart, lung, liver, kidney) have been influenced by this advanced method of organ preservation. This technology also serves as an unprecedented platform for effective administration of advanced therapeutics, including gene therapies, during organ transplantation to optimize and recondition organs ex vivo in an isolated manner. Applying gene therapy interventions through EVMP introduces different considerations and challenges that are unique from gene therapies designed for systemic administration. Considerations involving vector (choice, dose, toxicity), perfusate composition, and perfusion circuit components should be evaluated when developing a gene therapy to administer in this setting. This review explores these aspects and discusses clinical applications in transplantation where gene therapy interventions can be developed relevant to heart, lung, liver, and kidney donor grafts.

Donation after Brain Death and Circulatory Death in Turkey: Current Status

Tissue and organ transplantation is the best treatment option for end-stage organ failure. However, organ shortage still remains to be the greatest challenge facing the field of organ transplantation. Millions of people die and are buried with healthy organs, which could save the lives of many patients who continue to wait on transplant lists. Countries must aim to work towards a system of matching organs as much as possible with the deceased donation to meet the growing demand for organs. This action will not only result in the reduction of organ trafficking activities but shall also make an enormous difference to those patients awaiting transplants where living organ donors are not an option. Donation after circulator death (DCD) has gained much attention over the last decade as one of the accepted practices in order to expand the donor pool. DCD donation takes place after declaration of death using cardio-respiratory criteria in contrast to donation after brain death (DBD) where neurological criteria are used. Although DCD remains a focus of interest and contributes to donor numbers in many countries, it also poses many challenges medically, ethically and legally.

The circulatory death that saves lives-Intensive care nurses' conceptions of participating during 'donation after circulatory death': A phenomenographic study

AIM

To describe intensive care nurses' conceptions of participating during the donation after circulatory death (DCD) process in intensive care units in Sweden.

DESIGN

A qualitative design with a phenomenographic approach.

METHODS

In total, 12 semi-structured interviews were conducted in April 2022 with intensive care nurses from three hospitals. Data were analysed using a phenomenographic approach.

RESULTS

Conceptions of participating during the DCD process varied. Four main themes emerged: DCD as a system; Intensive care nurses' role in the situation; Life to death to life; The essence of DCD. Variations emerged regarding what the informants talked about and how they talked about the what. Variations were based on informants' perspective of their role in relation to the structure and the team, and their conceptions of care for patients and their relatives.

CONCLUSION

The findings illustrated success factors and challenges. Knowledge, experience, distinct structure, and relationship with relatives, among other factors, were described as success factors, while a lack of experience, difficulty in prognosing death, and organisational obstacles emerged as challenges. Furthermore, the findings showed that intensive care nurses play an important role in optimising the outcome of the DCD process. Their work related to DCD was conceived as being meaningful to fulfil more peoples' wishes to donate organs.

IMPACT

People on the waiting list for organ transplantation are dying due to a shortage of organs. The implementation of DCD, as a complement to Donation after Brain Death (DBD), contributed to an increase in the number of organ donors, and intensive care nurses play an important role during the DCD process. Previous research manifests the complexity concerning their role. There is a lack of nursing research regarding intensive care nurses' conceptions of what it means to participate in the DCD process, which emphasises the significance of this study.

REPORTING METHOD

This study is reported using consolidated criteria for reporting qualitative research (SRQR).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

[Legal and forensic medical problems of postmortem donation]

The article is devoted to legal and forensic medical problems of postmortem donation. The substantive provisions of postmortem donation, as well as normative legal documents regulating the processes of organs harvesting from deceased persons for subsequent transplantation and governing the work of transplantologists and forensic medical experts have been considered. The practical examples illustrating the essence and nature of the problem of postmortem forensic medical expertise of persons with absent organs has been given and the importance of the participation of a forensic medical expert involved in the decision-making process on possibility (or impossibility) of the corpse's organs and tissues explantation without prejudice to the further expert examination has been emphasized. The authors pay particular attention to the inadequacy of the legal framework, including the lack of a clear understanding of the legal status of the person holding the position of forensic medical expert, who provides an expert opinion on the organs' explantation.

Impact of Donation After Circulatory Death on Outcomes of Expanded Criteria Donor Kidney Transplants

Expanded criteria donor (ECD) kidneys experience suboptimal outcomes compared with standard criteria donor kidneys. To examine the additional impact of deceased organ category, donation after circulatory death (DCD), and neurologic determination of death (NDD) on ECD outcomes, we examined 1- and 3-year patient and graft survival in all ECD kidney recipients in our institution between January 2008 and December 2017. Of 166 ECD recipients, 49 (29.5%) were DCD and 117 (70.5%) were NDD. Delayed graft function was higher in the DCD/ECD group 61.2 % vs 32.0 % among NDD/ECD recipients. Graft loss was significantly increased among DCD/ECD (hazard ratio for graft loss 4.81 [95% CI1.78-13.01], P = .002 at 1 year and 2.03 [95% CI 1.03-4.0], P = .042 at 3 years). Death-censored graft loss was higher among DCD/ECD (hazard ratio was 10.12 [95% CI, 2.14, 47.92], P = .004 at 1 year and 2.83 [95% CI, 1.24, 6.46], P = .014 at 3 years). There was no statistically significant difference in all-cause mortality. Our study demonstrated that DCD/ECD kidneys have lower graft survival compared with NDD/ECD kidneys. Time on dialysis, waiting time, and panel reactive antibody should be taken into account when offering these organs to patients.

EISOR Delivery: Regional experience with sharing equipe, equipment & expertise to increase cDCD donor pool in time of pandemic

Donation after circulatory death (DCD) programs are expanding in Europe, in the attempt to expand donors pool. Even in controlled DCD donors, however, a protracted warm ischemia time occurring in the perimortem period might damage organs, making these unsuitable for transplantation. Implementing a strategy of extracorporeal interval support for organ retrieval (EISOR), a regional reperfusion with normothermic, oxygenated blood provides a physiologic environment allowing extensive assessment of potential grafts, and potentially promotes recovery of native function. Here we report the results of a multi-center retrospective cohort study including 29 Maastricht Category III controlled DCD donors undergoing extracorporeal support in a regional DCD/EISOR Training Center, and in the network of referring In-Training Centers, under the liaison of the regional Transplant Coordination Center during COVID-19 pandemic, between March 2020 and November 2021. The study aims to understand whether a mobile, experienced EISOR team implementing a consistent technique and sharing its equipe, expertise and equipment in a regional network of hospitals, might be effective and efficient in implementing the regional DCD program activity even in a highly stressed healthcare system.

Swedish Intensive Care Nurses' Knowledge, Attitudes, and Views on Donation After Circulatory Death Before a National Implementation

Introduction

An increasing population and a shortage of identified potential organ donors are causing the waiting list for organ transplants to grow continuously. Donation after circulatory death (DCD) is a method aimed at meeting the demand for transplantable organs. However, it presents new challenges in nursing care, and there is a lack of studies investigating nurses' attitudes and knowledge of DCD.

Objective

The objective of this study was to determine and describe intensive care nurses' (ICNs') knowledge, attitudes, and views on DCD before a national implementation in Sweden.

Method

This study utilized a cross-sectional mixed-method design. A convenience sampling method was employed, targeting ICNs working in four intensive care units in Sweden. A study-specific tool comprising fixed and free-text questions was developed. Fifty-one ICNs participated. Data were analyzed descriptively, and correlation analysis was performed using Spearman's correlation. Free-text answers were qualitatively assessed and analyzed. An integrated analysis was conducted to synthesize the quantitative and qualitative findings.

Results

Fifty-three percent reported limited knowledge about DCD. Nurses with previous education on DCD had significantly higher knowledge (r = .380, p = .006), were more engaged with the public debate on organ donation (r = .423, p = .002), and considered the ethical aspects of DCD more thoroughly (r = .386, p = .022). The qualitative analysis identified four key categories: The importance of the team, the need for ethical discussions, increased knowledge of DCD, and unanswered questions and unmet needs. The integrated analysis underscored the need for targeted education, clear guidelines, and ongoing ethical discussions to prepare ICU nurses for DCD.

Conclusion

Nurses educated in organ donor care had better knowledge and a more positive attitude toward DCD implementation. The study also highlights the importance of interprofessional teamwork in DCD implementation. The findings suggest that education on DCD could improve the identification and implementation of DCD donors, addressing the global shortage of transplantable organs.

Circulating exosomes from brain death and cardiac death donors have distinct molecular and immunologic properties: A pilot study

BACKGROUND AND AIMS

Comparison of donation after brain death (DBD) and donation after cardiac death (DCD) lung tissue before transplantation have demonstrated activation of pro-inflammatory cytokine pathway in DBD donors. The molecular and immunological properties of circulating exosomes from DBD and DCD donors were not previously described.

METHODS

We collected plasma from 18 deceased donors (12 DBD and six DCD). Cytokines were analyzed by 30-Plex luminex Panels. Exosomes were analyzed for liver self-antigen (SAg), Transcription Factors and HLA class II (HLA-DR/DQ) using western blot. C57BL/6 animals were immunized with isolated exosomes to determine strength and magnitude of immune responses. Interferon (IFN)-γ and tumor necrosis factor-α producing cells were quantified by ELISPOT, specific antibodies to HLA class II antigens were measured by ELISA RESULTS: We demonstrate increased plasma levels of IFNγ, EGF, EOTAXIN, IP-10, MCP-1, RANTES, MIP-β, VEGF, and interleukins - 6/8 in DBD plasma versus DCD. MiRNA isolated from exosome of DBD donors demonstrated significant increase in miR-421, which has been reported to correlate with higher level of Interleukin-6. Higher levels of liver SAg Collagen III (p = .008), pro-inflammatory transcription factors (NF-κB, p < .05; HIF1α, p = .021), CIITA (p = .011), and HLA class II (HLA-DR, p = .0003 and HLA-DQ, p = .013) were detected in exosomes from DBD versus DCD plasma. The circulating exosomes isolated from DBD donors were immunogenic in mice and led to the development of Abs to HLA-DR/DQ.

CONCLUSIONS

This study provides potential new mechanisms by which DBD organs release exosomes that can activate immune pathways leading to cytokine release and allo-immune response.

Approaching the Families of Potential Deceased Organ Donors: An Overview of Regulations and Practices in Council of Europe Member States

The primary aim of this study was to describe regulations and practices concerning the family approach to discuss donation, specifically after the neurological determination of death, one of the most challenging steps in the donation pathway. A secondary objective was to assess the impact of legislation on consent rates for organ donation. The Council of Europe surveyed 39 member states about national regulations, practices, and consent rates; 34 replied. Opt-out legislation is present in 19, opt-in in 9 and a mixed system in six countries. An opt-out register is kept by 24 countries and an opt-in register by 18 countries, some keeping both. The mean consent rate was 81.2% of all family approaches. Most countries regulate how death using neurological criteria is confirmed (85.3%), while regulation of other aspects of the deceased donation pathway varies: the timing of informing the family about brain death (47.1%) and organ donation (58.8%), the profile of professional who discusses both topics with the family (52.9% and 64.7%, respectively) and the withdrawal of treatment after brain death (47.1%). We also noted a mismatch between what regulations state and what is done in practice in most countries. We suggest possible reasons for this disparity.

Evaluation of functional warm ischemia time during controlled donation after circulatory determination of death using normothermic regional perfusion (ECMO-TT): A prospective multicenter cohort study

BACKGROUND

Controlled donation after circulatory determination of death (cDCD) seems an effective way to mitigate the critical shortage of available organs for transplant worldwide. As a recently developed procedure for organ retrieval, some questions remain unsolved such as the uncertainty regarding the effect of functional warm ischemia time (FWIT) on organs´ viability.

METHODS

We developed a multicenter prospective cohort study collecting all data from evaluated organs during cDCD from 2017 to 2020. All the procedures related to cDCD were performed with normothermic regional perfusion. The analysis included organ retrieval as endpoint and FWIT as exposure of interest. The effect of FWIT on the likelihood for organ retrieval was evaluated with Relative distribution analysis.

RESULTS

A total amount of 507 organs´ related information was analyzed from 95 organ donors. Median donor age was 62 years, and 63% of donors were male. Stroke was the most common diagnosis before withdrawal of life-sustaining therapy (61%), followed by anoxic encephalopathy (21%). This analysis showed that length of FWIT was inversely associated with organ retrieval rates for liver, kidneys, and pancreas. No statistically significant association was found for lungs.

CONCLUSIONS

Results showed an inverse association between functional warm ischemia time (FWIT) and retrieval rate. We also have postulated optimal FWIT's thresholds for organ retrieval. FWIT for liver retrieval remained between 6 and less than 11 min and in case of kidneys and pancreas, the optimal FWIT for retrieval was 6 to 12 min. These results could be valuable to improve organ utilization and for future analysis.

Successful transplantation of LUCAS device assisted uncontrolled DCD kidneys with prolonged relative warm ischemia time: An underutilized option in North America

Approximately 25% of deceased donors in the United States are procured in a donation after circulatory death (DCD) setting. Successful transplant outcomes from uncontrolled DCD (uDCD) practices have been reported in multiple European programs. They utilize established protocols for uDCD procurement with normo-thermic or hypothermic regional perfusion to reduce ischemic damage. Further, manual or mechanical chest compressions using extrinsic devices, such as the LUCAS device, are implemented to maintain circulation before organ retrieval. Currently, uDCDs are not a major part of DCD organ utilization in the United States. We report our experience with utilization of kidneys from uDCD with the use of the LUCAS device without normothermic or hypothermic regional perfusion. We transplanted four kidneys from three uDCD donors without utilization of in situ regional perfusion and with prolonged relative warm ischemia time (rWIT) (>100 min). All recipients had functional renal allografts and improved renal function after the transplant. To our knowledge, this is the 1st successful series reported in the United States of the utilization of kidneys from uDCDs without the utilization of in situ perfusion to maintain organ preservation with prolonged rWIT.

Trajectories of systolic blood pressure decline in kidney transplant donors prior to circulatory death and delayed graft function

BACKGROUND

Kidneys donated after circulatory death suffer a period of functional warm ischaemia before death, which may lead to early ischaemic injury. Effects of haemodynamic trajectories during the agonal phase on delayed graft function (DGF) is unknown. We aimed to predict the risk of DGF using patterns of trajectories of systolic blood pressure (SBP) declines in Maastricht category 3 kidney donors.

METHODS

We conducted a cohort study of all kidney transplant recipients in Australia who received kidneys from donation after circulatory death donors, divided into a derivation cohort (transplants between 9 April 2014 and 2 January 2018 [462 donors]) and a validation cohort (transplants between 6 January 2018 and 24 December 2019 [324 donors]). Patterns of SBP decline using latent class models were evaluated against the odds of DGF using a two-stage linear mixed effects model.

RESULTS

In the derivation cohort, 462 donors were included in the latent class analyses and 379 donors in the mixed effects model. Of the 696 eligible transplant recipients, 380 (54.6%) experienced DGF. Ten different trajectories, with distinct patterns of SBP decline were identified. Compared with recipients from donors with the slowest decline in SBP after withdrawal of cardiorespiratory support, the adjusted odds ratio (aOR) for DGF was 5.5 [95% confidence interval (CI) 1.38-28.0] for recipients from donors with a steeper decline and lowest SBP [mean 49.5 mmHg (standard deviation 12.5)] at the time of withdrawal. For every 1 mmHg/min reduction in the rate of decline of SBP, the respective aORs for DGF were 0.95 (95% CI 0.91-0.99) and 0.98 (95% CI 0.93-1.0) in the random forest and least absolute shrinkage and selection operator models. In the validation cohort, the respective aORs were 0.95 (95% CI 0.91-1.0) and 0.99 (95% CI 0.94-1.0).

CONCLUSION

Trajectories of SBP decline and their determinants are predictive of DGF. These results support a trajectory-based assessment of haemodynamic changes in donors after circulatory death during the agonal phase for donor suitability and post-transplant outcomes.

cDCD organ donation pathway of Romagna Local Health Authority: strategic planning, organizational management, and results

The introduction of pathways to enrol deceased donors after cardio-circulatory confirmation of death (donation after circulatory death, DCD) is expanding in many countries to face the shortage of organs for transplantation. The implementation of normothermic regional reperfusion (NRP) with warm oxygenated blood is a strategy to manage in-situ the organs of DCD donors. This approach, an alternative to in-situ cold preservation, and followed by prompt retrieval and cold static storage and/or ex-vivo machine perfusion (EVMP), could be limited to abdominal organs (A-NRP) or extended to the thorax (thoraco-abdominal, TA-NRP. NRP is also referred to as extracorporeal interval support for organ retrieval (EISOR). The use of EISOR is increasing in Europe, even if variably regulated. A-NRP has been demonstrated to be effective in decreasing the risk associated with transplantation of abdominal organs from DCD donors, and was recommended by the European Society for Organ Transplantation (ESOT) in a recent consensus document. We aim to explain how we select the candidates for DCD, to describe our regionalized model for implementing EISOR provision, and to introduce the health care professionals involved in this complex process, with their strictly defined roles, responsibilities, and boundaries. Finally, we report the results of our program, recruiting cDCD donors over a large network of hospitals, all pertaining to a Local Health Authority (Azienda Unità Sanitaria Locale, AUSL) in Romagna, Italy.

Primary graft dysfunction following lung transplantation: From pathogenesis to future frontiers

Lung transplantation is the treatment of choice for patients with end-stage lung disease. Currently, just under 5000 lung transplants are performed worldwide annually. However, a major scourge leading to 90-d and 1-year mortality remains primary graft dysfunction. It is a spectrum of lung injury ranging from mild to severe depending on the level of hypoxaemia and lung injury post-transplant. This review aims to provide an in-depth analysis of the epidemiology, pathophysiology, risk factors, outcomes, and future frontiers involved in mitigating primary graft dysfunction. The current diagnostic criteria are examined alongside changes from the previous definition. We also highlight the issues surrounding chronic lung allograft dysfunction and identify the novel therapies available for ex-vivo lung perfusion. Although primary graft dysfunction remains a significant contributor to 90-d and 1-year mortality, ongoing research and development abreast with current technological advancements have shed some light on the issue in pursuit of future diagnostic and therapeutic tools.

Cardiac arrest and cardiopulmonary resuscitation in “hostile” environments: Using automated compression devices to minimize the rescuers’ danger

Mechanical automated compression devices are being used in cardiopulmonary resuscitation instead of manual, “hands-on”, rescuer-delivered chest compressions. The -theoretical- advantages include high-quality non-stop compressions, thus freeing the rescuer performing the compressions and additionally the ability of the rescuer to stand reasonably away from a potentially “hazardous” victim, or from hazardous and/or difficult resuscitation conditions. Such circumstances involve cardiopulmonary resuscitation (CPR) in the Cardiac Catheterization Laboratory, especially directly under the fluoroscopy panel, where radiation is well known to cause detrimental effects to the rescuer, and CPR during/after land or air transportation of cardiac arrest victims. Lastly, CPR in a coronavirus disease 2019 patient/ward, where the danger of contamination and further serious illness of the health provider is very existent. The scope of this review is to review and present literature and current guidelines regarding the use of mechanical compressions in these “hostile” and dangerous settings, while comparing them to manual compressions.

Ethical considerations for theatre teams in organ donation after circulatory determination of death

Transplant surgery is an area that gives rise to a number of ethical considerations. As medicine continues to expand the boundaries of what is technically possible, we must consider the ethical implications of our interventions, not solely on patients and society, but also on those asked to provide that care. Here, we consider physician participation in procedures required to provide patient care in the context of the ethical convictions held by the physician, with an emphasis on organ donation after circulatory determination of death. Strategies that can be used to mitigate any potential negative impact on the psychological well-being of members of the patient care team are considered.

Potential of neonatal organ donation and outcome after transplantation

Organ transplantation is limited by access to suitable organs. Infant recipient waitlist mortality is increased due to the scarcity of size-matched organs. Neonatal organ donors have been proposed as an underutilized source of donor organs. However, the literature on the actual prevalence and outcome of neonatal organ donation and transplantation is fragmented and not well analyzed. This literature review aims to summarize the available literature on the potential of neonatal organ donation and to analyze published cases of neonatal organ transplantation. A systematic search of the Medline and Cochrane databases yielded 2964 articles, which were screened for eligibility. In total, 86 articles were considered eligible, of which 34 were included in the literature review: 8 articles describing the potential of neonatal organ donation programs, and 26 articles describing clinical transplantation. Current evidence suggests there is a large pool of potential neonatal organ donors. In contrast, the literature on neonatal organ donor utilization is sparse. However, case series of successful kidney, heart, liver, hepatocyte, and multivisceral transplantation using organs from neonatal donors are summarized. Although good posttransplant organ function was achieved, the use of neonatal organs is associated with increased risk of thrombosis in both kidney and liver transplantation. Neonatal organ donation is a promising alternative for expanding the current donor pool. Experience is limited, but reported patient and graft survival are acceptable and more research on the subject is warranted.

Does Controlled Donation after Circulatory Death Violate the Dead Donor Rule?

The vital status of patients who are a part of controlled donation after circulatory death (cDCD) is widely debated in bioethical literature. Opponents to currently applied cDCD protocols argue that they violate the dead donor rule, while proponents of the protocols advocate compatibility. In this article, we argue that both parties often misinterpret the moral implications of the dead donor rule. The rule as such does not require an assessment of a donor's vital status, we contend, but rather an assessment of whether procurement of organs in cDCD cause the death of the donor or not. We then argue that commonly practiced cDCD protocols do not violate the dead donor rule, since the donation does not trigger or cause the death of the donors.

End-Of-Life Care in the Potential Donor after Circulatory Death: A Systematic Review

Background

Donation after circulatory death (DCD) is becoming increasingly common, yet little is known about the way potential donors receive end-of-life care.

Purpose

The aims of this systematic review are to describe the current practice in end-of-life care for potential donors and identify metrics that are being used to assess discomfort among these patients.

Research design and Study Sample

This review encompasses published literature between June 1, 2000 and June 31, 2020 of end-of-life care received by potential DCD patients. The population of interest was defined as patients eligible for Maastracht classification III donation after circulatory death for a solid organ transplantation. Outcomes examined included: analgesic or palliative protocols, and surrogates of discomfort (eg dyspnea, agitation).

Results

Among 141 unique articles, 27 studies were included for full review. The primary reason for exclusion was lack of protocol description, or lack of reporting on analgesic medications. No primary research studies specifically examined distress in the DCD eligible population. Numerous professional guidelines were identified. Surveys of critical care practitioners identified concerns regarding the impact of symptom management on hastening the dying process in the DCD population as a potential barrier to end-of-life palliative treatment.

Conclusions

There is a paucity of empirical evidence for end-of-life symptom assessment and management for DCD patients. Key evidence gaps identified for DCD include the need for: i) a multidisciplinary structure of treatment teams and preferred environment for DCD, ii) objective tools for monitoring of distress in this patient population, and iii) evidence guiding the administration of analgesic medications following withdrawal of life sustaining therapy.

Review of Postoperative Care for Heart Transplant Recipients

The early postoperative management strategies after heart transplantation include optimizing the function of the denervated heart, correcting the causes of hemodynamic instability, and initiating and maintaining immunosuppressive therapy, allograft rejection surveillance, and prophylaxis against infections caused by immunosuppression. The course of postoperative support is influenced by the quality of allograft myocardial protection prior to implantation and reperfusion, donor-recipient heart size matching, surgical technique of orthotopic heart transplantation, and patient factors (eg, preoperative condition, immunologic compatibility, postoperative vasomotor tone, severity and reversibility of pulmonary vascular hypertension, pulmonary function, mediastinal blood loss, and end-organ perfusion). This review provides an overview of the early postoperative care of recipients and includes a brief description of the surgical techniques for orthotopic heart transplantation.

Donation After Circulatory Death: A New Frontier

PURPOSE OF REVIEW

To highlight the current global experience with DCD heart transplantation and explore the evolution of, and compare preservation strategies; examine early clinical outcomes, and discuss the growing use of DCD donors as a new frontier in heart transplantation.

RECENT FINDINGS

The two strategies of DCD heart preservation include NMP using the OCS Heart and TA-NRP followed by either: NMP or CSS. Better understanding the limits of cold ischaemia following TA-NRP will aid in distant procurement. Asystolic warm ischaemia plays an important role in determining immediate post-operative graft function and potential need for mechanical support. Large volume DCD heart transplant units show no difference in survival between DCD and DBD donor heart transplants. In a previously non-utilised source of donor hearts, often viewed as an "unknown frontier" in heart transplantation, DCD hearts are a suitable alternative to brain-dead donor hearts and are likely to remain a permanent part of the heart transplantation landscape. Global uptake is currently increasing, and as understanding of preservation strategies and tolerable ischaemic times improve, utilisation of DCD hearts will continue to grow.

In vitro and In vivo assessment of a novel organ perfusion stent for successful flow separation in donation after cardiac death

Shortage of healthy donors' organs has appeared as one of the main challenges for organ transplantation. This study focuses on the novel endovascular device development to increase the number of available organs from cardiac death donors. The primary objective of this study is the design validation of a newly developed stent graft for the abdominal organ perfusion with cardiac blood flow isolation. In this paper, the effectiveness of the device design has been validated via the assessment of the device performance both in vitro and in vivo. The radial force of stent structure was first numerically analyzed using finite element method, then was quantified experimentally. The blood perfusion parameters were investigated to demonstrate their effect on the blood delivered to the abdominal organs, maintaining the organs healthy for donation. In vitro flow leakage was measured using a 3-D printing-based silicone aortic model to evaluate the isolation between cardiac flow and perfusion flow with minimum values. Following the design validation process, a functional prototype stent graft has been successfully fabricated using optimized laser welding conditions and subsequent joining processes. In vivo porcine study results have demonstrated smooth delivery and successful placement of the device showing complete cardiac flow separation isolating abdominal regions only with the oxygenated blood flow.

Donation after Circulatory Death in Lung Transplantation

The shortage of donor lungs has become a serious obstacle to implementing lung transplantation (LTx). Donation after circulatory death (DCD) donors are among the several donor pools utilized to overcome the problem posed by the shortage of donation after brain death (DBD) donors. The active use of DCD donors is expected to significantly reduce mortality on the waiting list for LTx, as LTx from DCD donors has comparable outcomes to LTx from DBD donors. Further studies on efforts to shorten the warm ischemic time and use uncontrolled DCD are required.

Modulation of Mitochondrial Respiration During Early Reperfusion Reduces Cardiac Injury in Donation After Circulatory Death Hearts

ABSTRACT

Donation after circulatory death (DCD) donors are a potential source for heart transplantation. The DCD process has unavoidable ischemia and reperfusion (I/R) injury, primarily mediated through mitochondria, which limits routine utilization of hearts for transplantation. Amobarbital (AMO), a transient inhibitor of the electron transport chain, is known to decrease cardiac injury following ex vivo I/R. We studied whether AMO treatment during reperfusion can decrease injury in DCD hearts. Sprague Dawley rat hearts subjected to 25 minutes of in vivo ischemia (DCD hearts), or control beating donor hearts, were treated with AMO or vehicle for the first 5 minutes of reperfusion, followed by Krebs-Henseleit buffer reperfusion for 55 minutes (for mitochondrial isolation) or 85 minutes (for infarct size determination). Compared with vehicle, AMO treatment led to decreased infarct size (25.2% ± 1.5% vs. 31.5% ± 1.5%; P ≤ 0.05) and troponin I release (4.5 ± 0.05 ng/mL vs. 9.3 ± 0.24 ng/mL, P ≤ 0.05). AMO treatment decreased H 2 O 2 generation with glutamate as complex I substrate in both subsarcolemmal mitochondria (SSM) (37 ± 3.7 pmol·mg -1 ·min -1 vs. 56.9 ± 4.1 pmol·mg -1 ·min -1 ; P ≤ 0.05), and interfibrillar mitochondria (IFM) (31.8 ± 2.8 pmol·mg -1 ·min -1 vs. 46 ± 4.8 pmol·mg -1 ·min -1 ; P ≤ 0.05) and improved calcium retention capacity in SSM (360 ±17.2 nmol/mg vs. 277 ± 13 nmol/mg; P ≤ 0.05), and IFM (483 ± 20 nmol/mg vs. 377± 19 nmol/mg; P ≤ 0.05) compared with vehicle treatment. SSM and IFM retained more cytochrome c with AMO treatment compared with vehicle. In conclusion, brief inhibition of mitochondrial respiration during reperfusion using amobarbital is a promising approach to decrease injury in DCD hearts.

Ethical Issues Related to Donation and Transplantation of Donation After Circulatory Determination of Death Donors

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.

Donation After Cardiac Death in Children

The wait list for organ transplant exceeds the rate of organ donation, especially in children. The solid-organ transplant rate has remained stable over time, despite increased demand. Although donation after cardiac death has helped to expand the donor organ pool for the adult population, this option remains scarce for children in need of transplant. Because long-term graft survival is more important in the pediatric group than in adults, we should reconsider the common notion that donation after cardiac death is inferior to donation after brain death. Herein, we review the literature to extract and analyze data regarding donation after cardiac death for solid-organ transplant in children.

Comparing Deceased Organ Donation Performance in Two Countries that Use Different Metrics: Comparing Apples With Apples

Organ donation networks audit and report on national or regional organ donation performance, however there are inconsistencies in the metrics and definitions used, rendering comparisons difficult or inappropriate. This is despite multiple attempts exploring the possibility for convergently evolving audits so that collectives of donation networks might transparently share data and practice and then target system interventions. This paper represents a collaboration between the United Kingdom and Australian organ donation organisations which aimed to understand the intricacies of our respective auditing systems, compare the metrics and definitions they employ and ultimately assess their level of comparability. This point of view outlines the historical context underlying the development of the auditing tools, demonstrates their differences to the Critical Pathway proposed as a common tool a decade ago and presents a side-by-side comparison of donation definitions, metrics and data for the 2019 calendar year. There were significant differences in donation definition terminology, metrics and overall structure of the audits. Fitting the audits to a tiered scaffold allowed for reasonable comparisons however this required substantial effort and understanding of nuance. Direct comparison of international and inter-regional donation performance is challenging and would benefit from consistent auditing processes across organisations.

Cytokine mass balance levels in donation after circulatory death donors using hemoadsorption: Case series report

The use of hemadsorption has been purposed to reduce cytokine levels during the reperfusion phase during donation after circulatory death (DCD) programs. This paper aims to describe a cases series of the inflammatory cytokine levels before and after hemadsorption during normothermic reperfusion in DCD donors of liver and kidneys. In this observational pilot paper, we describe 8 DCD donors of liver or kidneys in our center from the year 2018 to 2019. All DCD donor subjects had similar age, were younger than 60 years, without evident critical conditions, no liver or kidney dysfunction known, and they presented with poor neurological outcomes instrumentally and clinically documented. We observed in our patients an interesting reduction of IL-10 and TNF-α levels during the normothermic reperfusion with hemadsorption. We transplanted all livers and kidneys from DCD donors without significant compliances.

Risk Assessment and Management for Potential Living Kidney Donors: The Role of “Third-Party” Commission

Living kidney donation is the most common type of living-donor transplant. Italian guidelines allow the living donations from emotionally related donors only after clear and voluntary consent expressed by both the donor and the recipient involved. Living donation raises ethical and legal issues because donors voluntarily undergo a surgical procedure to remove a healthy kidney in order to help another person. According to the Italian standards, the assessment of living donor-recipient pair has to be conducted by a medical “third party”, completely independent from both the patients involved and the medical team treating the recipient. Starting from the Hospital “Città della Salute e della Scienza” of Turin (Italy) experience, including 116 living kidney donations, the Authors divided the evaluation process performed by the “Third-Party” Commission into four stages, with a particular attention to the potential donor. Living donation procedures should reflect fiduciary duties that healthcare providers have toward their patients, originating from the relationship of trust between physician and patient. In addition to that, the social implications are enormous if one considers the worldwide campaigns to promote public awareness about organ donation and transplantation, and to encourage people to register their organ donation decisions. The systematic process proposed here can be a tool that proactively reduces and controls the risks of coercion, organ trafficking, vitiated consent, insufficient weighting of donative choice, that could arise especially in donors involved in living kidney donation.

Does prolonged cold ischemia affect outcomes in donation after cardiac death donor kidney transplants?

    : The purpose of this study was to analyze the combined effect of cold ischemia time (CIT) and donation after cardiac death (DCD, with requisite warm ischemia time, WIT) on kidney transplant (KT) outcomes.

METHODS

Single center retrospective review of DCD KT recipients stratified by CIT.

RESULTS

From 6/08 to 10/20, we performed 446 DCD KTs (115 CIT ≤20, 205 CIT 20-30, 88 CIT 30-40, 38 CIT ≥40 hours). Mean WITs (26/25/27/23 minutes) and KDPI values (59%/55%/55%/59%) were similar while mean CITs (16.4/23.6/33.4/42.5 hours) and pump times (10.3/13.6/16.1/20.4 hours) differed across groups (p < 0.05). With a mean 6-year follow-up, patient survival (84%/84%/74%/84%) was similar. Kidney graft survival (GS) (72%/72%/56%/58%) and death censored GS (DCGS) (82%/80%/63%/67%) rates decreased whereas rates of primary nonfunction (PNF, 0.9%/2.4%/9.1%/7.9%) and delayed graft function (DGF) (36%/48%/50%/69%) increased with longer CIT (≥30 hours, p<0.05). Meaningful years free of dialysis, which we refer to as Allograft Life Years, were achieved in all cohorts (4.5/4.3/3.9/4.3 years per patient transplanted).

CONCLUSION

DCD donor kidneys with prolonged CIT (≥30 hours) are associated with increased rates of DGF and PNF, along with decreased GS and DCGS. Despite this, Allograft Life Years were gained even with longer CITs, demonstrating the utility of using these allografts. This article is protected by copyright. All rights reserved.

Knowledge and Attitude of People With or Without a Medical Education Regarding Organ Donation and Transplant: A Sample From the City of Baghdad

OBJECTIVES

Organ donation is the driving force for transplant. Awareness about donation and transplant is invaluable for improved transplant services in any country. Our objective was to assess the knowledge and attitude toward organ donation and transplant among medically educated adult Iraqis versus adult Iraqis who were not medically educated, in Baghdad, Iraq.

MATERIALS AND METHODS

For this study, we recruited 400 Iraqi residents of Baghdad city from December 1, 2018, to March 1, 2019. We used an interviewer-adm-inistered questionnaire to survey 200 health care professionals and 200 adults who lacked medical education, and then we analyzed the responses from the 2 groups.

RESULTS

The study included 165 males and 235 females (mean age 33.73 ± 10.38 years). Most participants (60%) were aware of organ donation, and a health care provider was the main source of their knowledge. Only 11.25% were aware of Iraqi legislation that permits donation after brain death. Nearly 50% of the participants volunteered to be living donors, and 229/400 (57.25%%) volunteered to donate after death. About 50% accepted the idea of organ donation as an act to save life, whomever the donor. The most important barrier was the fear of future risks to health after living donation and body disfigurement after death. There was a statistically significant difference in the knowledge and attitude scores between the 2 groups. From the study sample, 46.5% accepted the concept of incenting living donors or families of deceased donors.

CONCLUSIONS

Iraqi people are moderately informed about organ donation and transplant. Medically educated people demonstrated an attitude of greater acceptance. Religion and social beliefs were not barriers to organ donation in the study sample. Regulated governmental application of incentive programs may be a useful strategy at present.