1
|
Gallegos EM, Reed T, Deville P, Platt B, Leonardi C, Bellfi L, Dufrene J, Chaudhary S, Hunt J, Stuke L, Greiffenstein P, Schoen J, Marr A, Paramesh A, Smith AA. Does the use of double hormone replacement therapy for trauma patient organ donors improve organ recovery for transplant. World J Transplant 2024; 14:89825. [PMID: 38947973 PMCID: PMC11212584 DOI: 10.5500/wjt.v14.i2.89825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/16/2024] [Accepted: 04/16/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND With an ongoing demand for transplantable organs, optimization of donor management protocols, specifically in trauma populations, is important for obtaining a high yield of viable organs per patient. Endocrine management of brain-dead potential organ donors (BPODs) is controversial, leading to heterogeneous clinical management approaches. Previous studies have shown that when levothyroxine was combined with other treatments, including steroids, vasopressin, and insulin, BPODs had better organ recovery and survival outcomes were increased for transplant recipients. AIM To determine if levothyroxine use in combination with steroids in BPODs increased the number of organs donated in trauma patients. METHODS A retrospective review of adult BPODs from a single level 1 trauma center over ten years was performed. Exclusion criteria included patients who were not solid organ donors, patients who were not declared brain dead (donation after circulatory death), and patients who did not receive steroids in their hospital course. Levothyroxine and steroid administration, the number of organs donated, the types of organs donated, and demographic information were recorded. Univariate analyses were performed with P < 0.05 considered to be statistically significant. RESULTS A total of 88 patients met inclusion criteria, 69 (78%) of whom received levothyroxine and steroids (ST/LT group) vs 19 (22%) receiving steroids without levothyroxine (ST group). No differences were observed between the groups for gender, race, pertinent injury factors, age, or other hormone therapies used (P > 0.05). In the ST/LT group, 68.1% (n = 47) donated a high yield (3-5) of organ types per donor compared to 42.1% (n = 8) in the ST group (P = 0.038). There was no difference in the total number of organ types donated between the groups (P = 0.068). CONCLUSION This study suggests that combining levothyroxine and steroid administration increases high-yield organ donation per donor in BPODs in the trauma patient population. Limitations to this study include the retrospective design and the relatively small number of organ donors who met inclusion criteria. This study is unique in that it mitigates steroid administration as a confounding variable and focuses specifically on the adjunctive use of levothyroxine.
Collapse
Affiliation(s)
- Eden M Gallegos
- Department of Physiology, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA 70124, United States
| | - Tanner Reed
- Department of Medicine, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA 70112, United States
| | - Paige Deville
- Department of Surgery, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA 70112, United States
| | - Blake Platt
- Department of Trauma Surgery, Tacoma General Hospital, Tacoma 98405, United States
| | - Claudia Leonardi
- Department of Public Health, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA 70112, United States
| | - Lillian Bellfi
- Department of Surgery, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA 70112, United States
| | - Jessica Dufrene
- Department of Donation Services, Louisiana Organ Procurement Agency, Covington, LA 70433, United States
| | - Saad Chaudhary
- Department of Medicine, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA 70112, United States
| | - John Hunt
- Department of Surgery, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA 70112, United States
| | - Lance Stuke
- Department of Surgery, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA 70112, United States
| | - Patrick Greiffenstein
- Department of Surgery, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA 70112, United States
| | - Jonathan Schoen
- Department of Surgery, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA 70112, United States
| | - Alan Marr
- Department of Surgery, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA 70112, United States
| | - Anil Paramesh
- Department of Surgery, Tulane Transplant Institute, Tulane University School of Medicine, New Orleans, LA 70112, United States
| | - Alison A Smith
- Department of Surgery, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA 70112, United States
| |
Collapse
|
2
|
Gunst J, Souter MJ. Management of the brain-dead donor in the intensive care unit. Intensive Care Med 2024; 50:964-967. [PMID: 38598128 DOI: 10.1007/s00134-024-07409-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/23/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Michael J Souter
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| |
Collapse
|
3
|
Alvarez B, Balleste Delpierre C. Improvement Gaps to Deal with the Shortage of Lungs for Transplant From a Middle Income Country's Perspective. EXP CLIN TRANSPLANT 2024; 22:207-212. [PMID: 38385399 DOI: 10.6002/ect.mesot2023.p47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
OBJECTIVES Our study aimed to identify the potential causes for the low lung procurement rate in Argentina and to develop strategies to the actual problems in donor management focused on lung retrieval. MATERIALS AND METHODS We performed a crosssectional study in which we analyzed data obtained from digital self-reported surveys conducted on professionals participating in the organ procurement process in Argentina. The surveys included questions on donor management, selection criteria, and resource availability involving increasing lung procurement. RESULTS Among professionals surveyed, 23.7% did not use advanced hemodynamic monitoring in their donor maintenance and limited their use to central venous pressure. Only 35.8% of participants considered maintaining central venous pressure <10 mm Hg during donor maintenance. With regard to donors with severe deterioration of the ejection fraction, 47.4% of participants would not use restrictive fluid, and only 23.2% would use an advanced monitoring of the hemodynamic status to guide fluid management. Only 27.8% of participants routinely would use steroids to improve lung function in donors. With regard to mechanical ventilation, 80.4% of participants used protective ventilation, but only 4.10% used it adequately. Recruitment maneuvers were routinely used by only 3.1% of those surveyed. With regard to expanded selection criteria (age >55 years, smoking habit of >20 packs/year, positive upper airway cultures, unspecific infiltrates in radiography, and >72 hours of mechanical ventilation), 92.8% of surveyed participants would discount patients with some of these expanded selection criteria without considering offering the lungs for donation. CONCLUSIONS Opportunities for improvement may involve training physicians involved in the donor maintenance process and reviewing the donor selection criteria used to increase adherence to expanded selection criteria.
Collapse
Affiliation(s)
- Brian Alvarez
- From the International Cooperation Programs, DTI foundation, Barcelona, Spain
| | | |
Collapse
|
4
|
Tannous LA, Westphal GA, Ioshii SO, de Lima Alves GN, Pigatto RN, Pinto RL, de Carvalho KAT, Francisco JC, Guarita-Souza LC. Histological, Laboratorial, and Clinical Benefits of an Optimized Maintenance Strategy of a Potential Organ Donor-A Rabbit Experimental Model. Life (Basel) 2023; 13:1439. [PMID: 37511814 PMCID: PMC10381703 DOI: 10.3390/life13071439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 07/30/2023] Open
Abstract
INTRODUCTION Most transplanted organs are obtained from brain-dead donors. Inflammation results in a higher rate of rejection. Objectives: The objective of this animal model of brain death (BD) was to evaluate the effect of the progressive institution of volume expansion, norepinephrine, and combined hormone therapy on clinical, laboratory, and histological aspects. Methods: Twenty rabbits were divided: A (control), B (induction of BD + infusion of crystalloid), C (BD + infusion of crystalloid and noradrenaline (NA)), and D (BD + infusion of crystalloid + vasopressin + levothyroxine + methylprednisolone + NA). The animals were monitored for four hours with consecutives analysis of vital signs and blood samples. The organs were evaluated by a pathologist. Results: In Group D, we observed fewer number and lesser volume of infusions (p = 0.032/0.014) when compared with groups B and C. Mean arterial pressure levels were higher in group D when compared with group B (p = 0.008). Group D had better glycemic control when compared with group C (p = 0.016). Sodium values were elevated in group B in relation to groups C and D (p = 0.021). In Group D, the organ perfusion was better. Conclusion: The optimized strategy of management of BD animals is associated with better hemodynamic, glycemic, and natremia control, besides reducing early signs of ischemia.
Collapse
Affiliation(s)
- Luana Alves Tannous
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
| | | | - Sergio Ossamu Ioshii
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
| | | | - Raul Nishi Pigatto
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
| | - Rafael Luiz Pinto
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
| | | | | | - Luiz César Guarita-Souza
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
| |
Collapse
|
5
|
Brown MB, Abramowicz AE, Panzica PJ, Weber G. Anesthetic Considerations of Organ Procurement After Brain and Cardiac Death: A Narrative Review. Cureus 2023; 15:e40629. [PMID: 37476138 PMCID: PMC10355135 DOI: 10.7759/cureus.40629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2023] [Indexed: 07/22/2023] Open
Abstract
Organ donation procedures have become more frequent in the US as the need for transplants is increasing. Defining the anesthesiologist's role in organ donations after brain and cardiac death is important, as is understanding its ethics and practical physiologic and perioperative implications. Despite this, there are few papers specifically addressing the anesthetic management of organ donors. This review summarizes the preoperative, intraoperative, and postmortem considerations for the anesthesiologist involved in organ donation after either brain or cardiac death. A search of the published literature was performed using PubMed, Excerpta Medica dataBASE (EMBASE), and Google Scholar in March of 2022 for articles addressing anesthetic considerations of organ procurement surgeries after brain and cardiac death. This review demonstrates that anesthesiologists play a significant role in the organ procurement process. Their role in the perioperative management of the donor may affect the outcomes of organ transplantation. The gap between the number of organs harvested and the number of patients awaiting organ transplantation remains high despite continued efforts to increase the number of available organs. Perioperative management of organ donors aims at counteracting the associated unique physiologic derangements and targets optimization of oxygenation of the organs intended for procurement. Optimizing care after death can help ensure the viability of organs and the best outcomes for recipients. As organ donation after cardiac death (DCD) becomes more frequent in the US, anesthesiologists should be aware of the DCD classifications of donors and emerging novel perfusion techniques.
Collapse
Affiliation(s)
| | - Apolonia E Abramowicz
- Department of Anesthesiology, Westchester Medical Center, Valhalla, USA
- School of Medicine, New York Medical College, Valhalla, USA
| | - Peter J Panzica
- Department of Anesthesiology, Westchester Medical Center, Valhalla, USA
- School of Medicine, New York Medical College, Valhalla, USA
| | - Garret Weber
- Department of Anesthesiology, Westchester Medical Center, Valhalla, USA
- School of Medicine, New York Medical College, Valhalla, USA
| |
Collapse
|
6
|
Copeland H, Knezevic I, Baran DA, Rao V, Pham M, Gustafsson F, Pinney S, Lima B, Masetti M, Ciarka A, Rajagopalan N, Torres A, Hsich E, Patel JK, Goldraich LA, Colvin M, Segovia J, Ross H, Ginwalla M, Sharif-Kashani B, Farr MA, Potena L, Kobashigawa J, Crespo-Leiro MG, Altman N, Wagner F, Cook J, Stosor V, Grossi PA, Khush K, Yagdi T, Restaino S, Tsui S, Absi D, Sokos G, Zuckermann A, Wayda B, Felius J, Hall SA. Donor heart selection: Evidence-based guidelines for providers. J Heart Lung Transplant 2023; 42:7-29. [PMID: 36357275 PMCID: PMC10284152 DOI: 10.1016/j.healun.2022.08.030] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 01/31/2023] Open
Abstract
The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review.
Collapse
Affiliation(s)
- Hannah Copeland
- Department of Cardiovascular and Thoracic Surgery Lutheran Hospital, Fort Wayne, Indiana; Indiana University School of Medicine-Fort Wayne, Fort Wayne, Indiana.
| | - Ivan Knezevic
- Transplantation Centre, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - David A Baran
- Department of Medicine, Division of Cardiology, Sentara Heart Hospital, Norfolk, Virginia
| | - Vivek Rao
- Peter Munk Cardiac Centre Toronto General Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Michael Pham
- Sutter Health California Pacific Medical Center, San Francisco, California
| | - Finn Gustafsson
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Sean Pinney
- University of Chicago Medicine, Chicago, Illinois
| | - Brian Lima
- Medical City Heart Hospital, Dallas, Texas
| | - Marco Masetti
- Heart Failure and Heart Transplant Unit IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Agnieszka Ciarka
- Department of Cardiovascular Diseases, Katholieke Universiteit Leuven, Leuven, Belgium; Institute of Civilisation Diseases and Regenerative Medicine, University of Information Technology and Management, Rzeszow, Poland
| | | | - Adriana Torres
- Los Cobos Medical Center, Universidad El Bosque, Bogota, Colombia
| | | | | | | | | | - Javier Segovia
- Cardiology Department, Hospital Universitario Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Heather Ross
- University of Toronto, Toronto, Ontario, Canada; Sutter Health California Pacific Medical Center, San Francisco, California
| | - Mahazarin Ginwalla
- Cardiovascular Division, Palo Alto Medical Foundation/Sutter Health, Burlingame, California
| | - Babak Sharif-Kashani
- Department of Cardiology, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - MaryJane A Farr
- Department of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Luciano Potena
- Heart Failure and Heart Transplant Unit IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | | | | | | | | | | | - Valentina Stosor
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Kiran Khush
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Tahir Yagdi
- Department of Cardiovascular Surgery, Ege University School of Medicine, Izmir, Turkey
| | - Susan Restaino
- Division of Cardiology Columbia University, New York, New York; New York Presbyterian Hospital, New York, New York
| | - Steven Tsui
- Department of Cardiothoracic Surgery Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Daniel Absi
- Department of Cardiothoracic and Transplant Surgery, University Hospital Favaloro Foundation, Buenos Aires, Argentina
| | - George Sokos
- Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia
| | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Brian Wayda
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Joost Felius
- Baylor Scott & White Research Institute, Dallas, Texas; Texas A&M University Health Science Center, Dallas, Texas
| | - Shelley A Hall
- Texas A&M University Health Science Center, Dallas, Texas; Division of Transplant Cardiology, Mechanical Circulatory Support and Advanced Heart Failure, Baylor University Medical Center, Dallas, Texas
| |
Collapse
|
7
|
Hemodynamic Effects of High-dose Levothyroxine and Methylprednisolone in Brain-dead Potential Organ Donors. Transplantation 2022; 106:1677-1689. [PMID: 35389961 DOI: 10.1097/tp.0000000000004072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hormonal replacement therapy is administered to many brain-dead organ donors to improve hemodynamic stability. Previous clinical studies present conflicting results with several randomized studies reporting no benefit. METHODS Consecutive adult donors (N = 199) were randomized to receive high-dose levothyroxine, high-dose methylprednisolone, both (Combo), or no hormonal therapy (Control). Vasopressor requirements using the vasoactive-inotropic score (VIS) were assessed at baseline, 4 h, and at procurement. Crossover to the Combo group was sufficient to require separate intention-to-treat and per-protocol analyses. RESULTS In the intention-to-treat analysis, the mean (±SD) reduction in VIS from baseline to procurement was 1.6 ± 2.6, 14.9 ± 2.6, 10.9 ± 2.6, and 7.1 ± 2.6 for the levothyroxine, methylprednisolone, Combo, and Control groups, respectively. While controlling for the baseline score, the reduction in VIS was significantly greater in the methylprednisolone and Combo groups and significantly less in the levothyroxine group compared with controls. Results were similar in the per-protocol analysis. CONCLUSION High-dose methylprednisolone alone or in combination with levothyroxine allowed for significant reduction in vasopressor support in organ donors. Levothyroxine alone offered no advantage in reducing vasopressor support. Organ yield, transplantation rates, and recipient outcomes were not adversely affected.
Collapse
|
8
|
Englbrecht JS, Lanckohr C, Ertmer C, Zarbock A. [Perioperative management of the brain-dead organ donor : Anesthesia between ethics and evidence]. Anaesthesist 2021; 71:384-391. [PMID: 34748026 PMCID: PMC9068648 DOI: 10.1007/s00101-021-01065-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
Hintergrund Die Anzahl postmortal gespendeter Organe ist in Deutschland weit geringer als der Bedarf. Dies unterstreicht die Wichtigkeit einer optimalen Versorgung während des gesamten Prozesses der Organspende. Fragestellung Es existieren internationale Leitlinien und nationale Empfehlungen zu intensivmedizinischen organprotektiven Maßnahmen beim Organspender. Für das anästhesiologische Management fehlen evidenzbasierte Empfehlungen. Ziel dieser Übersichtsarbeit ist es, anhand der vorhandenen Evidenz die pathophysiologischen Veränderungen des irreversiblen Hirnfunktionsausfalls zu rekapitulieren und sich kritisch mit den empfohlenen Behandlungsstrategien und therapeutischen Zielgrößen auseinanderzusetzen. Auch auf ethische Aspekte der Betreuung des postmortalen Organspenders wird eingegangen. Methode Diese Übersichtsarbeit basiert auf einer selektiven Literaturrecherche in PubMed (Suchwörter: „brain dead donor“, „organ procurement“, „organ protective therapy“, „donor preconditioning“, „perioperative donor management“, „ethical considerations of brain dead donor“). Internationale Leitlinien und nationale Empfehlungen wurden besonders berücksichtigt. Ergebnisse Insgesamt ist die Evidenz für optimale intensivmedizinische und perioperative organprotektive Maßnahmen beim postmortalen Organspender sehr gering. Nationale und internationale Empfehlungen zu Zielwerten und medikamentösen Behandlungsstrategien unterscheiden sich teilweise erheblich: kontrollierte randomisierte Studien fehlen. Der Stellenwert einer Narkose zur Explantation bleibt sowohl unter pathophysiologischen Gesichtspunkten als auch aus ethischer Sicht ungeklärt. Schlussfolgerungen Die Kenntnisse über die pathophysiologischen Prozesse im Rahmen des irreversiblen Hirnfunktionsausfalls und die organprotektiven Maßnahmen sind ebenso Grundvoraussetzung wie die ethische Auseinandersetzung mit dem Thema postmortale Organspende. Nur dann kann das Behandlungsteam in dieser herausfordernden Situation sowohl dem Organempfänger als auch dem Organspender und seinen Angehörigen gerecht werden.
Collapse
Affiliation(s)
- Jan Sönke Englbrecht
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland.
| | - Christian Lanckohr
- Antibiotic Stewardship (ABS)-Team, Institut für Hygiene, Universitätsklinikum Münster, Münster, Deutschland
| | - Christian Ertmer
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - Alexander Zarbock
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| |
Collapse
|
9
|
Bera KD, Shah A, English MR, Ploeg R. Outcome measures in solid organ donor management research: a systematic review. Br J Anaesth 2021; 127:745-759. [PMID: 34420684 DOI: 10.1016/j.bja.2021.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/24/2021] [Accepted: 07/14/2021] [Indexed: 12/15/2022] Open
Abstract
AIM We systematically reviewed published outcome measures across randomised controlled trials (RCTs) of donor management interventions. METHODS The systematic review was conducted in accordance with recommendations by the Cochrane Handbook and Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We searched MEDLINE, Embase, CENTRAL, Web of Science, and trial databases from 1980 to February 2021 for RCTs of donor management interventions. RESULTS Twenty-two RCTs (n=3432 donors) were included in our analysis. Fourteen RCTs (63.6%) reported a primary outcome relating to a single organ only. Eight RCTs primarily focused on aspects of donor optimisation in critical care. Thyroid hormones and methylprednisolone were the most commonly evaluated interventions (five and four studies, respectively). Only two studies, focusing on single organs (e.g. kidney), evaluated outcomes relating to other organs. The majority of studies evaluated physiological or biomarker-related outcomes. No study evaluated recipient health-related quality of life. Only one study sought consent from potential organ recipients. CONCLUSIONS The majority of RCTs evaluating donor management interventions only assessed single-organ outcomes or effects on donor stability in critical care. There is a need for an evaluation of patient-centred recipient outcomes and standardisation and reporting of outcome measures for future donor management RCTs.
Collapse
Affiliation(s)
- Kasia D Bera
- Oxford Transplant Centre, Nuffield Department of Surgical Sciences, Churchill Hospital, Oxford, UK; Vascular Surgery Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Akshay Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M Rex English
- Oxford Medical School, University of Oxford, Oxford, UK
| | - Rutger Ploeg
- Oxford Transplant Centre, Nuffield Department of Surgical Sciences, Churchill Hospital, Oxford, UK
| |
Collapse
|
10
|
van Zanden JE, Leuvenink HGD, Verschuuren EAM, Veldhuis ZJ, Ottens PJ, Erasmus ME, Hottenrott MC. Ex Vivo Perfusion With Methylprednisolone Attenuates Brain Death-induced Lung Injury in Rats. Transplant Direct 2021; 7:e682. [PMID: 33748411 PMCID: PMC7969243 DOI: 10.1097/txd.0000000000001141] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/24/2021] [Accepted: 02/02/2021] [Indexed: 11/25/2022] Open
Abstract
The onset of brain death (BD) leads to the deterioration of potential donor lungs. Methylprednisolone is considered to increase lung oxygenation capacity and enhance the procurement yield of donor lungs, when applied in situ, during donor management. However, whether BD-induced lung damage is ameliorated upon treatment with methylprednisolone during acellular ex vivo lung perfusion (EVLP), remains unknown. We aimed to investigate whether the quality of lungs from brain-dead donors improves upon methylprednisolone treatment during EVLP.
Collapse
Affiliation(s)
- Judith E van Zanden
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Henri G D Leuvenink
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Erik A M Verschuuren
- Department of Pulmonary Diseases, University Medical Center Groningen, Groningen, The Netherlands
| | - Zwanida J Veldhuis
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Petra J Ottens
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel E Erasmus
- Department of Cardiothoracic Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Maximilia C Hottenrott
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands.,Department of Surgery, University of Regensburg, Regensburg, Germany
| |
Collapse
|
11
|
Van Zanden JE, 't Hart NA, Ottens PJ, Liu B, Rebolledo RA, Erasmus ME, Leuvenink HGD. Methylprednisolone Treatment in Brain Death-Induced Lung Inflammation-A Dose Comparative Study in Rats. Front Pharmacol 2021; 12:587003. [PMID: 33692687 PMCID: PMC7937885 DOI: 10.3389/fphar.2021.587003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 01/27/2021] [Indexed: 12/14/2022] Open
Abstract
Background: The process of brain death (BD) leads to a pro-inflammatory state of the donor lung, which deteriorates its quality. In an attempt to preserve lung quality, methylprednisolone is widely recommended in donor lung management. However, clinical treatment doses vary and the dose-effect relation of methylprednisolone on BD-induced lung inflammation remains unknown. The aim of this study was to investigate the effect of three different doses methylprednisolone on the BD-induced inflammatory response. Methods: BD was induced in rats by inflation of a Fogarty balloon catheter in the epidural space. After 60 min of BD, saline or methylprednisolone (low dose (5 mg/kg), intermediate dose (12.5 mg/kg) or high dose (22.5 mg/kg)) was administered intravenously. The lungs were procured and processed after 4 h of BD. Inflammatory gene expressions were analyzed by RT-qPCR and influx of neutrophils and macrophages were quantified with immunohistochemical staining. Results: Methylprednisolone treatment reduced neutrophil chemotaxis as demonstrated by lower IL-8-like CINC-1 and E-selectin levels, which was most evident in rats treated with intermediate and high doses methylprednisolone. Macrophage chemotaxis was attenuated in all methylprednisolone treated rats, as corroborated by lower MCP-1 levels compared to saline treated rats. Thereby, all doses methylprednisolone reduced TNF-α, IL-6 and IL-1β tissue levels. In addition, intermediate and high doses methylprednisolone induced a protective anti-inflammatory response, as reflected by upregulated IL-10 expression when compared to saline treated brain-dead rats. Conclusion: We showed that intermediate and high doses methylprednisolone share most potential to target BD-induced lung inflammation in rats. Considering possible side effects of high doses methylprednisolone, we conclude from this study that an intermediate dose of 12.5 mg/kg methylprednisolone is the optimal treatment dose for BD-induced lung inflammation in rats, which reduces the pro-inflammatory state and additionally promotes a protective, anti-inflammatory response.
Collapse
Affiliation(s)
- Judith E Van Zanden
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Nils A 't Hart
- Department of Pathology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Petra J Ottens
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Bo Liu
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.,Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Rolando A Rebolledo
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.,Institute for Medical and Biological Engineering, Schools of Engineering, Biological Sciences and Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Michiel E Erasmus
- Department of cardiothoracic surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Henri G D Leuvenink
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| |
Collapse
|
12
|
Westphal GA, Robinson CC, Cavalcanti AB, Gonçalves ARR, Guterres CM, Teixeira C, Stein C, Franke CA, da Silva DB, Pontes DFS, Nunes DSL, Abdala E, Dal-Pizzol F, Bozza FA, Machado FR, de Andrade J, Cruz LN, de Azevedo LCP, Machado MCV, Rosa RG, Manfro RC, Nothen RR, Lobo SM, Rech TH, Lisboa T, Colpani V, Falavigna M. Brazilian guidelines for the management of brain-dead potential organ donors. The task force of the AMIB, ABTO, BRICNet, and the General Coordination of the National Transplant System. Ann Intensive Care 2020; 10:169. [PMID: 33315161 PMCID: PMC7736434 DOI: 10.1186/s13613-020-00787-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/01/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To contribute to updating the recommendations for brain-dead potential organ donor management. METHOD A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, joined a task force formed by the General Coordination Office of the National Transplant System/Brazilian Ministry of Health (CGSNT-MS), the Brazilian Association of Intensive Care Medicine (AMIB), the Brazilian Association of Organ Transplantation (ABTO), and the Brazilian Research in Intensive Care Network (BRICNet). The questions were developed within the scope of the 2011 Brazilian Guidelines for Management of Adult Potential Multiple-Organ Deceased Donors. The topics were divided into mechanical ventilation, hemodynamic support, endocrine-metabolic management, infection, body temperature, blood transfusion, and use of checklists. The outcomes considered for decision-making were cardiac arrest, number of organs recovered or transplanted per donor, and graft function/survival. Rapid systematic reviews were conducted, and the quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Two expert panels were held in November 2016 and February 2017 to classify the recommendations. A systematic review update was performed in June 2020, and the recommendations were reviewed through a Delphi process with the panelists between June and July 2020. RESULTS A total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong (lung-protective ventilation strategy, vasopressors and combining arginine vasopressin to control blood pressure, antidiuretic hormones to control polyuria, serum potassium and magnesium control, and antibiotic use), 11 as weak (alveolar recruitment maneuvers, low-dose dopamine, low-dose corticosteroids, thyroid hormones, glycemic and serum sodium control, nutritional support, body temperature control or hypothermia, red blood cell transfusion, and goal-directed protocols), and 1 was considered a good clinical practice (volemic expansion). CONCLUSION Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak. The observed lack of robust evidence on the topic highlights the importance of the present guideline to improve the management of brain-dead potential organ donors.
Collapse
Affiliation(s)
- Glauco Adrieno Westphal
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil. .,Hospital Municipal São José (HMSJ), Joinville, SC, Brazil. .,Centro Hospitalar Unimed, Joinville, SC, Brazil.
| | | | | | - Anderson Ricardo Roman Gonçalves
- Universidade da Região de Joinville (UNIVILLE), R. Paulo Malschitzki, 10, Joinville, SC, 89219710, Brazil.,Clínica de Nefrologia de Joinville, R. Plácido Gomes, 370, Joinville, SC, 89202-050, Brazil
| | - Cátia Moreira Guterres
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Cassiano Teixeira
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Sarmento Leite, 245, Porto Alegre, RS, 90050-170, Brazil
| | - Cinara Stein
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Cristiano Augusto Franke
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Hospital de Pronto de Socorro (HPS), Porto Alegre, RS, Brazil
| | - Daiana Barbosa da Silva
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Daniela Ferreira Salomão Pontes
- General Coordination Office of the National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, DF, 70058900, Brazil
| | - Diego Silva Leite Nunes
- General Coordination Office of the National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, DF, 70058900, Brazil
| | - Edson Abdala
- Faculdade de Medicina, Universidade de São Paulo (USP), Av. Dr, Arnaldo 455, Sala 3206, São Paulo, SP, 01246903, Brazil
| | - Felipe Dal-Pizzol
- Universidade do Extremo Sul Catarinense (UNESC), Av. Universitária, 1105, Criciúma, SC, 88806000, Brazil.,Intensive Care Unit, Hospital São José, R. Cel. Pedro Benedet, 630, Criciúma, SC, 88801-250, Brazil
| | - Fernando Augusto Bozza
- National Institute of Infectious Disease Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Av. Brasil, 4365, Rio de Janeiro, RJ, 21040360, Brazil.,Instituto D'Or de Pesquisa e Ensino (IDOR), R. Diniz Cordeiro, 30, Rio de Janeiro, RJ, 22281100, Brazil
| | - Flávia Ribeiro Machado
- Hospital São Paulo (HU), Universidade Federal de São Paulo (UNIFESP), R. Napoleão de Barros 737, São Paulo, SP, 04024002, Brazil
| | - Joel de Andrade
- Organização de Procura de Órgãos e Tecidos de Santa Catarina (OPO/SC), Rua Esteves Júnior, 390, Florianópolis, SC, 88015130, Brazil
| | - Luciane Nascimento Cruz
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | | | | | - Regis Goulart Rosa
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Roberto Ceratti Manfro
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Universidade Federal do Rio Grande do Sul (UFRGS), Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Rosana Reis Nothen
- Universidade Federal do Rio Grande do Sul (UFRGS), Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Suzana Margareth Lobo
- Faculdade de Medicina de São José do Rio Preto, Av Faria Lima, 5544, São José do Rio Preto, SP, 15090000, Brazil
| | - Tatiana Helena Rech
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Thiago Lisboa
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Verônica Colpani
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Maicon Falavigna
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil.,National Institute for Health Technology Assessment, UFRGS, Rua Ramiro Barcelos, 2350, Porto Alegre, RS, 90035903, Brazil.,Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main St W, Hamilton, ON, Canada
| |
Collapse
|
13
|
Frenette AJ, Williamson D, Weiss MJ, Rochwerg B, Ball I, Brindamour D, Serri K, D'Aragon F, Meade MO, Charbonney E. Worldwide management of donors after neurological death: a systematic review and narrative synthesis of guidelines. Can J Anaesth 2020; 67:1839-1857. [PMID: 32949008 DOI: 10.1007/s12630-020-01815-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/02/2020] [Accepted: 07/02/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE The objectives of this study were to systematically identify and describe guidelines for the care of neurologically deceased donors and to evaluate their methodological quality, with the aim of informing and supporting the new Canadian guidelines for the management of organ donors. METHODOLOGY Following a systematic search, we included any document endorsed by an organ donation organization, a professional society, or a government, that aims to direct the medical management of adult, neurologically deceased, multi-organ donors. We extracted recommendations pertaining to six domains: the autonomic storm, hemodynamic instability, hormone supplementation, ventilation, blood product transfusions, and general intensive care unit (ICU) care. Methodological quality of the guidelines was assessed by the validated AGREE-II tool. MAIN FINDINGS This review includes 27 clinical practice guidelines representing 26 countries published between 1993 and 2019. Using the AGREE-II validated tool for the evaluation of guidelines' quality, documents generally scored well on their scope and clarity of presentation. Nevertheless, quality was limited in terms of the scientific rigor of guideline development. Recommendations varied substantially across the domains of managing the autonomic storm, subsequent management of hemodynamic instability, hormone therapy, mechanical ventilation, blood product transfusion, and general ICU care. We found consistent recommendations for low tidal volume ventilation subsequent to the publication of a landmark clinical trial. CONCLUSION Highly inconsistent recommendations for deceased donor care summarized in this review likely reflect the relatively slow emergence of high-quality clinical research in this field, as well as a late uptake of recent validated guideline methodology. Even in this context of few randomized-controlled trials, our group supported the need for new Canadian guidelines for the management of organ donors that follow rigorous recognized methodology and grading of the evidence. TRIAL REGISTRATION PROSPERO (CRD42018084012); registered 25 February 2016.
Collapse
Affiliation(s)
- Anne Julie Frenette
- Department of Pharmacy, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada.
- Faculté de Pharmacie, Université de Montréal, Montreal, QC, Canada.
- Faculté de Médecine, Université de Montréal, Montreal, QC, Canada.
- Centre de recherche CIUSSSS du Nord de L'Ile, Hôpital du Sacré-Coeur de Montréal, 5400 Gouin Ouest, Montréal, QC, H4J 1C5, Canada.
| | - David Williamson
- Department of Pharmacy, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
- Faculté de Pharmacie, Université de Montréal, Montreal, QC, Canada
- Centre de recherche CIUSSSS du Nord de L'Ile, Hôpital du Sacré-Coeur de Montréal, 5400 Gouin Ouest, Montréal, QC, H4J 1C5, Canada
| | - Matthew-John Weiss
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, CHU de Québec, Université Laval Research Center, Quebec, QC, Canada
- Pediatrics Department, Intensive Care Division, Faculté de Médecine, Université Laval, Quebec, QC, Canada
- Transplant Québec, Montreal, QC, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Ian Ball
- Department of Medicine, Western University, London, ON, Canada
| | - Dave Brindamour
- Department of Pharmacy, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
| | - Karim Serri
- Faculté de Médecine, Université de Montréal, Montreal, QC, Canada
- Centre de recherche CIUSSSS du Nord de L'Ile, Hôpital du Sacré-Coeur de Montréal, 5400 Gouin Ouest, Montréal, QC, H4J 1C5, Canada
- Department of Medicine, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
| | | | - Maureen O Meade
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Emmanuel Charbonney
- Faculté de Médecine, Université de Montréal, Montreal, QC, Canada
- Centre de recherche CIUSSSS du Nord de L'Ile, Hôpital du Sacré-Coeur de Montréal, 5400 Gouin Ouest, Montréal, QC, H4J 1C5, Canada
- Department of Medicine, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
| |
Collapse
|
14
|
|
15
|
Maynes EJ, O'Malley TJ, Austin MA, Deb AK, Choi JH, Weber MP, Khaghani A, Massey HT, Daly RC, Tchantchaleishvili V. Domino heart transplant following heart-lung transplantation: a systematic review and meta-analysis. Ann Cardiothorac Surg 2020; 9:20-28. [PMID: 32175236 DOI: 10.21037/acs.2019.12.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The domino-donor operation occurs when a "conditioned" heart from the heart-lung transplant (HLT) recipient is transplanted into a separate heart transplant (HT) recipient. The purpose of this systematic review was to investigate the indications and outcomes associated with the domino procedure. Methods An electronic search was performed to identify all prospective and retrospective studies on the domino procedure in the English literature. Eight studies reported 183 HLT recipients and 263 HT recipients who were included in the final analysis. Results HLT indications included cystic fibrosis in 58% (95% CI: 27-84%) of recipients, primary pulmonary hypertension (PPH) in 17% (95% CI: 12-24%), bronchiectasis in 5% (95% CI: 3-10%), emphysema in 5% (95% CI: 0-45%), and Eisenmenger's syndrome in 4% (95% CI: 2-8%). HT indications included ischemic heart disease in 40% (95% CI: 33-47%), non-ischemic disease in 39% (95% CI: 25-56%), and re-transplantation in 10% (95% CI: 1-59%). The pooled mean pulmonary vascular resistance (PVR) in HT recipients was 3.05 Woods units (95% CI: 0.14-5.95). The overall mortality in the HLT group was 28% (95% CI: 18-41%) at an average follow-up of 15.68 months (95% CI: 0.82-30.54), and 35% (95% CI: 17-58%) in the HT group at an average follow-up of 37.26 months (95% CI: 6.68-67.84). Freedom from rejection in HT was 94% (95% CI: 75-99%) at 1 month, 77% (95% CI: 30-96%) at 6 months, and 41% (95% CI: 33-50%) at 1 year. Conclusions The domino procedure appears to be a viable option in properly selected patients that can be performed safely with acceptable outcomes.
Collapse
Affiliation(s)
- Elizabeth J Maynes
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Thomas J O'Malley
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Melissa A Austin
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Avijit K Deb
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Jae Hwan Choi
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Matthew P Weber
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - H Todd Massey
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | | |
Collapse
|
16
|
Tavares-da-Silva E, Figueiredo A. Renal Procurement: Techniques for Optimizing the Quality of the Graft in the Cadaveric Setting. Curr Urol Rep 2020; 21:12. [PMID: 32166407 DOI: 10.1007/s11934-020-0963-8] [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] [Indexed: 01/07/2023]
Abstract
PURPOSE OF REVIEW Kidney transplantation is the best treatment for end-stage renal disease. However, due to organ shortage, suboptimal grafts are increasingly being used. RECENT FINDINGS We carried out a review on the methods and techniques of organ optimization in the cadaveric setting. Donor care is the first link in a chain of care. Right after brain death, there is a set of changes, of which hormonal and hemodynamic changes are the most relevant. Several studies have been conducted to determine which drugs to administer, although in most cases, the results are not definitive. The main goal seems rather achieve a set of biochemical and hemodynamic objectives. The ischemia-reperfusion injury is a critical factor for kidney damage in transplantation. One of the ways found to deal with this type of injury is preconditioning. Local and remote ischemic preconditioning has been studied for various organs, but studies on the kidney are scarce. A new promising area is pharmacological preconditioning, which is taking its first steps. Main surgical techniques were established in the late twentieth century. Some minor new features have been introduced to deal with anatomical variations or the emergence of donation after circulatory death. Finally, after harvesting, it is necessary to ensure the best conditions for the kidneys until the time of transplantation. Much has evolved since static cold preservation, but the best preservation conditions are yet to be determined. Conservation in the cold has come to be questioned, and great results have appeared at temperatures closer to physiological.
Collapse
Affiliation(s)
- Edgar Tavares-da-Silva
- Urology and Renal Transplantation Department, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal.,Centro de Investigação em Meio Ambiente, Genética e Oncobiologia (CIMAGO), Coimbra, Portugal
| | - Arnaldo Figueiredo
- Urology and Renal Transplantation Department, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal. .,Faculty of Medicine, University of Coimbra, Coimbra, Portugal. .,Coimbra Institute for Clinical and Biomedical Research (iCBR), Coimbra, Portugal. .,Centro de Investigação em Meio Ambiente, Genética e Oncobiologia (CIMAGO), Coimbra, Portugal.
| |
Collapse
|
17
|
Meurisse N, Monbaliu D, Berlakovich G, Muiesan P, Oliverius M, Adam R, Pirenne J. Heterogeneity of Bile Duct Management in the Development of Ischemic Cholangiopathy After Liver Transplantation: Results of a European Liver and Intestine Transplant Association Survey. Transplant Proc 2019; 51:1926-1933. [PMID: 31301856 DOI: 10.1016/j.transproceed.2019.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 04/22/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical factors and direct cytotoxicity of bile salts on cholangiocytes may play a role in the development of ischemic cholangiopathy (IC) after liver transplantation (LTx). There is no validated consensus on how to protect the bile ducts during procurement, static preservation, and LTx. Meanwhile, IC remains the most troublesome complication after LTx. AIM To characterize bile duct management techniques during the LTx process among European transplant centers in cases of donation after brain death (DBD) and circulatory death (DCD). METHOD An European Liver and Intestine Transplant Association-European Liver Transplant Registry web survey designed to conceal respondents' personal information was sent to surgeons procuring and/or transplanting livers in Europe. RESULTS Sixty-five percent of responses came from large transplant centers (>50 procurements/y). In 8% of DBDs and 14% of DCDs the bile duct is not rinsed. In 46% of DBDs and 52% of DCDs surgeons prefer to remove the gallbladder after graft reperfusion. Protocols concerning preservation solutions (nature, pressure, volume) are extremely heterogeneous. In 54% of DBDs and 61% of DCDs an arterial back table pressure perfusion is performed. Steroids (20%-10%), heparin (72%-60%), prostacyclin (3%-7%), and fibrinolytics (4%-11%) are used as donor-protective interventions in DBD and DCD cases, respectively. In 2% of DBD and 6% of DCD cases a hepatic artery reperfusion is performed first. In 4% of DBD and 6% of DCD cases, fibrinolytics are administered through the hepatic artery during the bench and/or implantation. CONCLUSION This European web survey shows for the first time the heterogeneity in the management of bile ducts during procurement, preservation, and transplantation in Europe. In the context of sharing more marginal liver grafts, an expert meeting must be organized to formulate guidelines to be applied to protect liver grafts against IC.
Collapse
Affiliation(s)
- Nicolas Meurisse
- Department of Abdominal Transplant Surgery, University of Liege Academic Hospital, ULg CHU, Liege, Belgium; Department of Abdominal Transplant Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Gabriela Berlakovich
- Division of Transplantation, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Paolo Muiesan
- Liver Unit, University of Birmingham, Birmingham, United Kingdom
| | - Martin Oliverius
- Department of Surgery of the 3rd Faculty of Medicine Charles University and Kralovske Vinohrady Hospital, Prague, Czech Republic
| | - René Adam
- APHP Hospital Paul Brousse, Inserm U985, University Paris Sud, Paris, France
| | - Jacques Pirenne
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium.
| |
Collapse
|
18
|
Abstract
Management of the pediatric organ donor necessitates understanding the physiologic changes that occur preceding and after death determination. Recognizing these changes allows application of the therapeutic strategies designed to optimize hemodynamics and metabolic state to allow for preservation of end-organ function for maximal organ recovery and minimal damage to the donor grafts. The pediatric pharmacist serves as the medication expert and may collaborate with the organ procurement organizations for provision of pharmacologic hemodynamic support, hormone replacement therapy, antimicrobials, and nutrition for the pediatric organ donor.
Collapse
|
19
|
Champigneulle B, Neuschwander A, Bronchard R, Favé G, Josserand J, Lebas B, Bastien O, Pirracchio R. Intraoperative management of brain-dead organ donors by anesthesiologists during an organ procurement procedure: results from a French survey. BMC Anesthesiol 2019; 19:108. [PMID: 31202272 PMCID: PMC6570868 DOI: 10.1186/s12871-019-0766-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 05/23/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aimed at describing usual anesthetic practices for brain-dead donors (BDD) during an organ procurement (OP) procedure and to assess the knowledge and self-confidence of French anesthesiologists with this practice. METHODS An electronic and anonymous survey with closed-questions about anesthetic management of BDD was distributed to French anesthesiologists via the mailing list of the French Society of Anesthesiology and Intensive Care Medicine. RESULTS Four hundred fifty-eight responses were analyzed. Respondents were mainly attending physicians with more than 10 years of clinical experience. 78% of them declared being cognizant of guidelines regarding management of BDD. Advanced hemodynamic monitoring and endocrine substitution were rarely considered by respondents (31 and 35% of respondents, respectively). 98% of the respondents used crystalloids for fluid resuscitation. During the procedure, use of neuromuscular blockers, opioids and sedative agents were considered by respectively 84, 61 and 27% of the respondents. A very high level of agreement (10 [8-10], on a ten-points Likert-style scale) was reported concerning the expected impact of intraoperative anesthetic management on the primary function of grafts. CONCLUSIONS Declared anesthetic practice appeared in accordance with guidelines concerning organ donor management in the ICU. Further studies are needed to evaluate the specific impact of intraoperative management during this procedure and thus the need for specific anesthetic guidelines.
Collapse
Affiliation(s)
- Benoit Champigneulle
- Anesthesiology and Intensive Care Department, European Hospital Georges-Pompidou, Assistance Publique - Hôpitaux de Paris (AP-HP), 20 rue Leblanc, 75015, Paris, France.,West francilian network for organ and tissue procurement, Paris, France
| | - Arthur Neuschwander
- Anesthesiology and Intensive Care Department, European Hospital Georges-Pompidou, Assistance Publique - Hôpitaux de Paris (AP-HP), 20 rue Leblanc, 75015, Paris, France
| | - Régis Bronchard
- Agence de la Biomédecine, Direction Prélèvement Greffe Organes-Tissus, Saint-Denis La Plaine, France
| | - Gersende Favé
- Anesthesiology and Intensive Care Department, European Hospital Georges-Pompidou, Assistance Publique - Hôpitaux de Paris (AP-HP), 20 rue Leblanc, 75015, Paris, France.,Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Julien Josserand
- Anesthesiology and Intensive Care Department, European Hospital Georges-Pompidou, Assistance Publique - Hôpitaux de Paris (AP-HP), 20 rue Leblanc, 75015, Paris, France
| | - Benjamin Lebas
- Anesthesiology and Intensive Care Department, Hautepierre Hospital, Strasbourg, France
| | - Olivier Bastien
- Agence de la Biomédecine, Direction Prélèvement Greffe Organes-Tissus, Saint-Denis La Plaine, France
| | - Romain Pirracchio
- Anesthesiology and Intensive Care Department, European Hospital Georges-Pompidou, Assistance Publique - Hôpitaux de Paris (AP-HP), 20 rue Leblanc, 75015, Paris, France. .,Paris Descartes University, Sorbonne Paris Cité, Paris, France. .,Département de biostatistiques et d'informatique médicale, INSERM U-1153, Équipe ECSTRA, Université Paris Diderot; Hôpital Saint-Louis, AP-HP, Paris, France.
| | | |
Collapse
|
20
|
Frenette AJ, Charbonney E, D'Aragon F, Serri K, Marsolais P, Chassé M, Meade M, Williamson D. A Canadian survey of critical care physicians' hemodynamic management of deceased organ donors. Can J Anaesth 2019; 66:1162-1172. [PMID: 31168739 DOI: 10.1007/s12630-019-01388-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/19/2019] [Accepted: 05/01/2019] [Indexed: 12/15/2022] Open
Abstract
PURPOSE We sought to characterize Canadian physicians' perspectives and stated practices regarding their hemodynamic care of deceased organ donors. METHODS We designed a 24-item electronic survey that was independently pretested for relevance, clarity, and intra-rater reliability by ten critical care clinicians. With the help of provincial organ donation organizations (ODO), we identified intensive care units (ICUs) with a high volume of adult deceased donors (defined by the management of five or more donors per year for two consecutive years). Medical directors of these high-volume ICUs helped identify ICU physicians to whom our survey was emailed. RESULTS Of the 448 ICU physicians from 37 centres in nine provinces that were emailed, 184/448 (41.1%) responded to one or more survey questions. Respondents identified specialist nurses from ODOs as their primary source of guidance in donor care (107/165; 60%). They typically diagnosed an autonomic storm according to a rise in blood pressure (159/165; 96.4%) and/or heart rate (135/165; 81.8%); nevertheless, their stated management varied substantially. After termination of the autonomic storm, preferred first-line vasopressors were norepinephrine (93/164; 56.7%) and vasopressin (68/164; 41.5%). Twenty-one respondents (21/162; 13.0%) reported that they never administer inotropes to donors. Corticosteroid and thyroid hormone prescriptions for all donors was reported by 62/161 (37.6%) and 50/161 (31.1%) respondents, respectively. Respondents perceived an influence from ODO nurses or transplant physicians when prescribing corticosteroids (77/161; 47.8%) and/or thyroid hormones (33/161; 20.5%) CONCLUSION: We observed important variability in self-perceived practices of ICU physicians in the hemodynamic management of deceased donors, particularly in the treatment of the autonomic storm, in the prescription of hormone therapy, and in the administration of inotropes.
Collapse
Affiliation(s)
- Anne Julie Frenette
- Hôpital du Sacré-Coeur de Montréal and Centre de recherche de l'Hôpital du Sacré-Coeur de Montréal, 5400 Gouin Ouest, Montréal, QC, H4J 1C5, Canada. .,Faculté de Pharmacie, Université de Montréal, Montréal, QC, Canada.
| | - Emmanuel Charbonney
- Hôpital du Sacré-Coeur de Montréal and Centre de recherche de l'Hôpital du Sacré-Coeur de Montréal, 5400 Gouin Ouest, Montréal, QC, H4J 1C5, Canada.,Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
| | - Frederick D'Aragon
- Anesthesia Department, Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, QC, Canada.,CHUS Research Center, Sherbrooke, QC, Canada
| | - Karim Serri
- Hôpital du Sacré-Coeur de Montréal and Centre de recherche de l'Hôpital du Sacré-Coeur de Montréal, 5400 Gouin Ouest, Montréal, QC, H4J 1C5, Canada.,Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
| | - Pierre Marsolais
- Hôpital du Sacré-Coeur de Montréal and Centre de recherche de l'Hôpital du Sacré-Coeur de Montréal, 5400 Gouin Ouest, Montréal, QC, H4J 1C5, Canada.,Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
| | - Michaël Chassé
- Faculté de Médecine, Université de Montréal, Montréal, QC, Canada.,Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Maureen Meade
- Hamilton Health Sciences Centre, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - David Williamson
- Hôpital du Sacré-Coeur de Montréal and Centre de recherche de l'Hôpital du Sacré-Coeur de Montréal, 5400 Gouin Ouest, Montréal, QC, H4J 1C5, Canada.,Faculté de Pharmacie, Université de Montréal, Montréal, QC, Canada
| | | |
Collapse
|
21
|
Intensive Care Society of Ireland - Guidelines for management of the potential organ donor (2018-2nd edition). Ir J Med Sci 2019; 188:1111-1118. [PMID: 30834487 DOI: 10.1007/s11845-019-01987-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 02/07/2019] [Indexed: 01/07/2023]
|
22
|
Sadegh Beigee F, Daryani EN, Shahryari S, Mojtabaee M. Role of Methylprednisolone in the Management of Hemodynamically Unstable Brain-Dead Cases. EXP CLIN TRANSPLANT 2019; 17:257-259. [PMID: 30777570 DOI: 10.6002/ect.mesot2018.p113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Optimal care of potential donors can lead to successful transplantation. Hemodynamic instability is a common complication in deceased potential donors. The most common underlying causes are hormonal and electrolyte disturbances as well as a hyperinflammatory state, which is rooted in activation of the cytokine cascade. In this study, our aim was to evaluate the efficacy of methylprednisolone injection, an agent introduced for inflammation suppression to achieve more stability in cases of hemodynamic disturbances. MATERIALS AND METHODS This study covered the period from April 2016 to June 2017 and included 45 randomly selected hemodynamically unstable brain-dead cases (mean arterial pressure < 60 mm Hg). For these cases, primary management included trying to achieve stability; however, after many hours, we experienced hemodynamic instability again. Because of no other correctable methods, we decided to use methylprednisolone injection. The potential deceased donors received a total of 1 g methylprednisolone in two 500-mg divided doses after transfer to the organ procurement unit. RESULTS Of 45 patients, 26 were male (58%), and the mean age of patients was 33 years. The most common causes of brain death were trauma (33%) and cerebrovascular accident (22%). Systolic and diastolic blood pressures increased significantly after methylprednisolone use. We observed no significant dif ferences in pulse rate. In addition, methylprednisolone could correct pH from 7.33 ± 0.11 to 7.38 ± 0.12 (P = .007). CONCLUSIONS Use of methylprednisolone in hemodynamically unstable deceased donors could allow better management of these cases. Because there are various factors such as infusion of vasopressor drugs or fluid therapy that could affect the hemodynamic status of these cases, future studies with larger sample sizes are recommended to control these confounding factors.
Collapse
Affiliation(s)
- Farahnaz Sadegh Beigee
- From the Organ Procurement Unit (OPU), Lung Transplantation Research Center (LTRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
| | | | | | | |
Collapse
|
23
|
Management of the brain-dead donor in the ICU: general and specific therapy to improve transplantable organ quality. Intensive Care Med 2019; 45:343-353. [PMID: 30741327 PMCID: PMC7095373 DOI: 10.1007/s00134-019-05551-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 01/28/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE To provide a practical overview of the management of the potential organ donor in the intensive care unit. METHODS Seven areas of donor management were considered for this review: hemodynamic management; fluids and electrolytes; respiratory management; endocrine management; temperature management; anaemia and coagulation; infection management. For each subchapter, a narrative review was conducted. RESULTS AND CONCLUSIONS Most elements in the current recommendations and guidelines are based on pathophysiological reasoning, epidemiological observations, or extrapolations from general ICU management strategies, and not on evidence from randomized controlled trials. The cardiorespiratory management of brain-dead donors is very similar to the management of critically ill patients, and the same applies to the management of anaemia and coagulation. Central diabetes insipidus is of particular concern, and should be diagnosed based on clinical criteria. Depending on the degree of vasopressor dependency, it can be treated with intermittent desmopressin or continuous vasopressin, intravenously. Temperature management of the donor is an area of uncertainty, but it appears reasonable to strive for a core temperature of > 35 °C. The indications and controversies regarding endocrine therapies, in particular thyroid hormone replacement therapy, and corticosteroid therapy, are discussed. The potential donor should be assessed clinically for infections, and screening tests for specific infections are an essential part of donor management. Although the rate of infection transmission from donor to receptor is low, certain infections are still a formal contraindication to organ donation. However, new antiviral drugs and strategies now allow organ donation from certain infected donors to be done safely.
Collapse
|
24
|
Role of biobanks in transplantation. Ann Med Surg (Lond) 2018; 28:30-33. [PMID: 29744049 PMCID: PMC5938524 DOI: 10.1016/j.amsu.2018.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 02/18/2018] [Accepted: 02/20/2018] [Indexed: 01/23/2023] Open
Abstract
The establishment of bio-banks together with high throughput technologies, such as genomics, transcriptomics and proteomics has opened new frontiers in biomarker discovery and the development of systems biology approaches to identifying key pathways that could be exploited to improve outcomes of solid organ transplantation. One of the major challenges in organ donation has been the lack of access to large scale well characterised material to facilitate projects that aim to characterise injury to donor organs and identify biomarkers. This may have hampered research in the field of organ donation by not allowing researchers to materials of high quality and lower pre-analytical variability. We describe in this manuscript the need for bio-banks in organ donation, research opportunities and the particular challenges in establishing such an initiative. We address: The main challenges in transplantation. Underpinning cellular processes of injury and repair. The role of biobanks can be used in transplantation.
Collapse
|
25
|
Ream RS, Armbrecht ES. Variation in Pediatric Organ Donor Management Practices Among US Organ Procurement Organizations. Prog Transplant 2017; 28:4-11. [PMID: 29243536 DOI: 10.1177/1526924817746673] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Reports of actual pediatric organ donor management practice among US organ procurement organizations are sparse, and the use of standardized management guidelines is unknown. A recent consensus statement from the Society of Critical Care Medicine, the American College of Chest Physicians, and the Association of Organ Procurement Organizations offers guidelines for the management of the pediatric organ donor. RESEARCH QUESTION To describe the use of guidelines and routine practices in the management of the pediatric organ donor with respect to hemodynamics, lung and ventilator management, fluid and electrolytes, hormonal replacement therapy, the use of blood products, thermoregulation, and prophylactic antibiotics. DESIGN Cross-sectional observational study using a survey and follow-up telephone interview with respondents from all 58 US organ procurement organizations. RESULTS All 58 US Organ Procurement Organizations participated. A majority employed written guidelines for the management of pediatric donor hemodynamics, thermoregulation, fluids, and electrolytes. Management of blood products, the lung, and mechanical ventilation were less commonly committed to written guidelines, but common practices were described. All used various forms of hormonal replacement therapy and the majority administered empiric antibiotic therapy. Wide variation was observed in the management of the lung, mechanical ventilation, and glycemic control. DISCUSSION Most OPOs used forms of standardized donor management for the pediatric organ donor although variation in the content of that management exists. Barriers to an evidence-based approach to the pediatric donor need to be determined and addressed.
Collapse
Affiliation(s)
- Robert S Ream
- 1 Division of Pediatric Critical Care, Department of Pediatrics, Saint Louis University, St Louis, MO, USA
| | - Eric S Armbrecht
- 2 Center for Outcomes Research, Department of Internal Medicine, Saint Louis University, St Louis, MO, USA
| |
Collapse
|
26
|
Understanding the effect of corticosteroid pretreatment in brain-dead organ donors: new mechanistic insights for improvement of organ quality in liver transplantation. Clin Sci (Lond) 2017; 131:2377-2379. [PMID: 28870982 DOI: 10.1042/cs20170178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/05/2017] [Accepted: 08/02/2017] [Indexed: 11/17/2022]
Abstract
Transplant surgeons are currently faced with the challenge to accept marginal liver transplants due to steatosis or old age. Improving organ quality by implementing a selective organ protective donor management could be the first step towards a graft of enhanced quality. However, the molecular mechanisms of such treatments are still poorly understood. Glucocorticoid medication in donor medicine has been carried out and discussed for a long time. In a recent study published in Clinical Science, Jiménez-Castro et al. [Clin. Sci. (2017) 131, 733-746] demonstrate how liver histology and transplant liver function can be improved by administration of glucocorticoids to brain-dead donor rats with steatotic livers. This work illustrates the need for further trials in order to selectively improve the quality of steatotic livers with a potential for liver transplantation.
Collapse
|
27
|
Martens A, Boada M, Vanaudenaerde BM, Verleden SE, Vos R, Verleden GM, Verbeken EK, Van Raemdonck D, Schols D, Claes S, Neyrinck AP. Steroids can reduce warm ischemic reperfusion injury in a porcine donation after circulatory death model with ex vivo lung perfusion evaluation. Transpl Int 2017; 29:1237-1246. [PMID: 27514498 DOI: 10.1111/tri.12823] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 04/27/2016] [Accepted: 07/28/2016] [Indexed: 02/05/2023]
Abstract
Donation after circulatory death (DCD) is being used to increase the number of transplantable organs. The role and timing of steroids in DCD donation and ex vivo lung perfusion (EVLP) has not been thoroughly investigated. In this study, we investigated the effect of steroids on warm ischemic injury in a porcine model (n = 6/group). Following cardiac arrest, grafts were left untouched in the donor (90-min warm ischemia). Graft function was assessed after 6 h of EVLP. In the MP group, 500 mg methylprednisolone was given prior to cardiac arrest and during EVLP. In the CONTR group, no steroids were added. Median lung compliance (13 ml/cmH2 0) was significantly better preserved in the CONTR group than in the MP group (30.5 ml/cmH2 0). Also, median wet-to-dry weight (6.11 vs. 6.94) and CT density (182.5 vs. 352.9 g/l) were significantly better in the MP group than in the CONTR group, respectively. There was no difference in oxygenation and pulmonary vascular resistance. Perfusate cytokine analysis showed a significant reduction in IL-1β, IL-8, IFN-α, IL-10, TNF-α, and IFN-γ in MP. Cytokines in bronchoalveolar lavage were not decreased except for IFN-gamma. We demonstrated that warm ischemic injury in DCD donation can be attenuated by steroids when given prior to warm ischemia and during EVLP. Ethical context of donor preconditioning should be discussed further.
Collapse
Affiliation(s)
- An Martens
- Laboratory of Anesthesiology and Algology, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven and University Hospitals, Leuven, Belgium.,Leuven Lung Transplant Unit, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Marc Boada
- Laboratory of Experimental Thoracic Surgery, Department of Clinical and Experimental Medicine, Katholieke Universiteit Leuven and University Hospitals, Leuven, Belgium
| | - Bart M Vanaudenaerde
- Leuven Lung Transplant Unit, Katholieke Universiteit Leuven, Leuven, Belgium.,Lung Transplant Unit, Laboratory of Pneumology, Department of Clinical and Experimental Medicine, Katholieke Universiteit Leuven and University Hospitals, Leuven, Belgium
| | - Stijn E Verleden
- Leuven Lung Transplant Unit, Katholieke Universiteit Leuven, Leuven, Belgium.,Lung Transplant Unit, Laboratory of Pneumology, Department of Clinical and Experimental Medicine, Katholieke Universiteit Leuven and University Hospitals, Leuven, Belgium
| | - Robin Vos
- Leuven Lung Transplant Unit, Katholieke Universiteit Leuven, Leuven, Belgium.,Lung Transplant Unit, Laboratory of Pneumology, Department of Clinical and Experimental Medicine, Katholieke Universiteit Leuven and University Hospitals, Leuven, Belgium
| | - Geert M Verleden
- Leuven Lung Transplant Unit, Katholieke Universiteit Leuven, Leuven, Belgium.,Lung Transplant Unit, Laboratory of Pneumology, Department of Clinical and Experimental Medicine, Katholieke Universiteit Leuven and University Hospitals, Leuven, Belgium
| | - Eric K Verbeken
- Department of Histopathology, University Hospitals Leuven, Leuven, Belgium
| | - Dirk Van Raemdonck
- Leuven Lung Transplant Unit, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Experimental Thoracic Surgery, Department of Clinical and Experimental Medicine, Katholieke Universiteit Leuven and University Hospitals, Leuven, Belgium
| | - Dominique Schols
- Laboratory of Virology and Chemotherapy (Rega Institute), Department of Microbiology and Immunology, Katholieke University Leuven, Leuven, Belgium
| | - Sandra Claes
- Laboratory of Virology and Chemotherapy (Rega Institute), Department of Microbiology and Immunology, Katholieke University Leuven, Leuven, Belgium
| | - Arne P Neyrinck
- Laboratory of Anesthesiology and Algology, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven and University Hospitals, Leuven, Belgium. .,Leuven Lung Transplant Unit, Katholieke Universiteit Leuven, Leuven, Belgium.
| |
Collapse
|
28
|
D'Aragon F, Belley-Cote E, Agarwal A, Frenette AJ, Lamontagne F, Guyatt G, Dhanani S, Meade MO. Effect of corticosteroid administration on neurologically deceased organ donors and transplant recipients: a systematic review and meta-analysis. BMJ Open 2017; 7:e014436. [PMID: 28667204 PMCID: PMC5734295 DOI: 10.1136/bmjopen-2016-014436] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES This review investigates the impact of corticosteroids on donation rates and transplant outcomes in light of findings from randomised controlled trials (RCTs) and to highlight the sources of uncertainty in this unresolved donor management issue. DATA SOURCES We searched electronic databases, trial registries and conference proceedings for RCTs evaluating corticosteroid therapy in neurologically deceased donors. STUDY SELECTION AND DATA EXTRACTION Independent reviewers assessed eligibility, evaluated risk of bias and abstracted data, including donor haemodynamic data, number of organs recovered and transplant outcomes. Where possible, we pooled results. For each outcome, we assessed the overall quality of evidence using The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. DATA SYNTHESIS Eleven RCTs with different corticosteroid regimens were included. Most trials assessed a once-daily infusion of methylprednisolone. Aside from one study showing improved liver graft function, no individual study or pooled analysis showed benefit of corticosteroids for any outcome: vasopressor use (three trials; relative risk (RR) 0.96; 95% CI 0.89 to 1.05), multiple organs recovered (two trials; RR 0.82; 95% CI 0.61 to 1.11), acute graft rejection (three trials; RR 0.91; 95% CI 0.60 to 1.39) or graft dysfunction (eight trials; RR 1.01; 95% CI 0.83 to 1.24). Two trials investigated adverse effects and found similar rates between groups. Quality of evidence was moderate or low for all outcomes. CONCLUSION Current clinical trials are limited in numbers and size to identify benefits or harms of corticosteroid therapy for deceased organ donors. In the face of these results, administering or withholding steroids both appear reasonable courses of action.
Collapse
Affiliation(s)
- Frédérick D'Aragon
- Department of Cinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke et Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Canada
| | - Emilie Belley-Cote
- Department of Cinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Arnav Agarwal
- Department of Cinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Anne-Julie Frenette
- Hopital Sacre Cœur de Montreal, Faculty of Pharmacy, University of Montreal, Montreal, Canada
| | - Francois Lamontagne
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke et Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Canada
| | - Gordon Guyatt
- Department of Cinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Sonny Dhanani
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Pediatric Critical Care, Children’s Hospital of Eastern Ontario, Ottawa, Canada
| | - Maureen O Meade
- Department of Cinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
| |
Collapse
|
29
|
|
30
|
|
31
|
Organ donor management: Eight common recommendations and actions that deserve reflection. Med Intensiva 2017; 41:559-568. [PMID: 28318674 DOI: 10.1016/j.medin.2017.01.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/11/2017] [Accepted: 01/13/2017] [Indexed: 01/18/2023]
Abstract
Despite major advances in our understanding of the physiopathology of brain death (BD), there are important controversies as to which protocol is the most appropriate for organ donor management. Many recent reviews on this subject offer recommendations that are sometimes contradictory and in some cases are not applied to other critically ill patients. This article offers a review of the publications (many of them recent) with an impact upon these controversial measures and which can help to confirm, refute or open new areas of research into the most appropriate measures for the management of organ donors in BD, and which should contribute to discard certain established recommendations based on preconceived ideas, that lead to actions lacking a physiopathological basis. Aspects such as catecholamine storm management, use of vasoactive drugs, hemodynamic objectives and monitoring, assessment of the heart for donation, and general care of the donor in BD are reviewed.
Collapse
|
32
|
The effect of cortisol in rat steatotic and non-steatotic liver transplantation from brain-dead donors. Clin Sci (Lond) 2017; 131:733-746. [PMID: 28246131 DOI: 10.1042/cs20160676] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 02/13/2017] [Accepted: 02/27/2017] [Indexed: 12/22/2022]
Abstract
In the present study, we examined the effects of cortisol on steatotic and non-steatotic liver grafts from brain-dead donors and characterized the underlying mechanisms involved. Non-steatotic liver grafts showed reduced cortisol and increased cortisone levels in association with up-regulation of enzymes that inactivate cortisol. Conversely, steatotic liver grafts exhibited increased cortisol and reduced cortisone levels. The enzymes involved in cortisol generation were overexpressed, and those involved in cortisol inactivation or clearance were down-regulated in steatotic liver grafts. Exogenous administration of cortisol negatively affected hepatic damage and survival rate in non-steatotic liver transplantation (LT); however, cortisol treatment up-regulated the phosphoinositide 3-kinase (PI3K)-protein kinase C (PKC) pathway, resulting in protection against the deleterious effects of brain-dead donors on damage and inflammatory response in steatotic LT as well as in increased survival of recipients. The present study highlights the differences in the role of cortisol and hepatic mechanisms that regulate cortisol levels based on the type of liver. Our findings suggest that cortisol treatment is a feasible and highly protective strategy to reduce the adverse effects of brain-dead donor livers in order to ultimately improve liver graft quality in the presence of steatosis, whereas cortisol treatment would not be recommended for non-steatotic liver grafts.
Collapse
|
33
|
Serri K, Marsolais P. End-of-Life Issues in Cardiac Critical Care: The Option of Organ Donation. Can J Cardiol 2016; 33:128-134. [PMID: 28024551 DOI: 10.1016/j.cjca.2016.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 10/17/2016] [Accepted: 10/19/2016] [Indexed: 12/13/2022] Open
Abstract
Despite important advances in the care of postcardiac arrest patients, severe brain injury remains one of the major causes of death in the cardiac intensive care unit. Neurological prognostication after cardiac arrest has evolved significantly since the introduction of therapeutic hypothermia. It now relies on a multimodal approach and a minimal observation period of 72 hours is usually advocated. However, when brain injury is severe and the prognosis considered dismal, patients become eligible for organ donation. Patients with severe anoxic encephalopathy might evolve toward brain death and be candidates for donation after brain death. In the presence of severe brain injury without brain death criteria, when withdrawal of life-sustaining therapy is considered, patients might be eligible for donation after cardiocirculatory death. The diagnosis of brain death, the differences between donation after brain death and donation after cardiocirculatory death, family approach, and donor management in the intensive care unit are discussed. Because these are increasingly encountered situations in the cardiac intensive care unit, it is essential that physicians involved in cardiac critical care be familiar with these concepts.
Collapse
Affiliation(s)
- Karim Serri
- Hôpital du Sacré-Coeur de Montréal, Service de soins intensifs, Département de médecine, and Centre de recherche Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Pierre Marsolais
- Hôpital du Sacré-Coeur de Montréal, Service de soins intensifs, Département de médecine, and Centre de recherche Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Québec, Canada
| |
Collapse
|
34
|
Levin K, Kotecha S, Westall G, Snell G. How can we improve the quality of transplantable lungs? Expert Rev Respir Med 2016; 10:1155-1161. [PMID: 27656957 DOI: 10.1080/17476348.2016.1240035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Optimization of lungs for organ donation is becoming increasingly important as donation rates stagnate despite growing waiting lists. Improving procurement and utilization of donated lungs has the ability to reduce mortality and time on the lung transplantation (LTx) waiting list. Additionally, assessment and optimization of donor lungs can reduce both early and late post-LTx morbidity and mortality, as well as reduce overall costs and resource utility. Areas covered: Strategies that we will discuss in detail include intensive care management practices, such as targeted ventilation protocols and therapeutic bronchoscopy, as well as the ever expanding possibilities within the arena of ex vivo lung perfusion (EVLP). Expert commentary: Donor lung quality is currently optimized both in vivo prior to organ procurement, and also via EVLP circuits. Despite good evidence demonstrating the utility of both approaches, data remain elusive as to whether EVLP is beneficial for all donor lungs prior to implantation, or instead as a tool by which we can evaluate and recondition sub-optimal donor lungs.
Collapse
Affiliation(s)
- Kovi Levin
- a Alfred Hospital - Lung Transplant Service , Department of Respiratory Medicine , Melbourne , Australia
| | - Sakhee Kotecha
- a Alfred Hospital - Lung Transplant Service , Department of Respiratory Medicine , Melbourne , Australia
| | - Glen Westall
- a Alfred Hospital - Lung Transplant Service , Department of Respiratory Medicine , Melbourne , Australia
| | - Gregory Snell
- a Alfred Hospital - Lung Transplant Service , Department of Respiratory Medicine , Melbourne , Australia
| |
Collapse
|
35
|
Gupta R, Dhanani S. Endocrine Considerations of the Pediatric Organ Donor. J Pediatr Intensive Care 2016; 5:205-212. [PMID: 31110906 DOI: 10.1055/s-0036-1583286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 11/25/2015] [Indexed: 10/21/2022] Open
Abstract
Patients determined to be neurologically deceased exhibit potentially harmful changes in various endocrine pathways due to disruptions of the body's neurohormonal control mechanisms. These deviations from endocrine homeostasis lead to hemodynamic, metabolic, and immunologic aberrations that are associated with reduced graft procurement and function for the purposes of organ donation. Existing literature has attempted to describe the pathophysiology that associates disruptions in endocrine pathways with organ dysfunction, both to increase understanding and to identify strategies to support the donor. For example, diabetes insipidus due to arginine vasopressin deficiency is commonly encountered, and should be anticipated. The significance of abnormalities in other pathways such as those involving cortisol and thyroid hormone is less established; however, there is increasing support for treating potential organ donors with combined hormonal therapies. While there are published documents aimed at guiding management of organ donors in general, many controversies exist and pediatric-specific literature is scarce. This article aims to review several of the important endocrine-specific aspects of managing the neurologically deceased organ donor, with an emphasis on pediatrics where information is available.
Collapse
Affiliation(s)
- Ronish Gupta
- Division of Critical Care, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Sonny Dhanani
- Division of Critical Care, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| |
Collapse
|
36
|
Organ donation in adults: a critical care perspective. Intensive Care Med 2016; 42:305-315. [DOI: 10.1007/s00134-015-4191-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 12/13/2015] [Indexed: 10/22/2022]
|
37
|
Steroid Anti-Inflammatory Effects Did Not Improve Organ Quality in Brain-Dead Rats. BIOMED RESEARCH INTERNATIONAL 2015; 2015:207534. [PMID: 26090389 PMCID: PMC4452233 DOI: 10.1155/2015/207534] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 04/08/2015] [Indexed: 01/02/2023]
Abstract
Effect of glucocorticoid administration on improving the outcomes of kidney and liver allografts has not been clearly elucidated. This study investigated the effect of prednisolone administration after onset of brain death (BD) on kidney and liver in a controlled rat model of BD. BD was induced in rats by inflating an epidurally placed balloon catheter. Animals were treated with saline or prednisolone (5, 12.5, or 22.5 mg/kg) one hour after the onset of BD. After 4 hours of BD, experiments were terminated and serum and tissues were collected. Tissue gene and protein expression were measured for markers of inflammation, apoptosis, and cellular stress response markers. Prednisolone caused a reduction of plasma levels of IL-6, while the tissue expression of IL-6, IL-1β, and MCP-1 in both kidney and liver were also reduced. Creatinine plasma levels, complement (C3) expression, HSP-70, HO-1, Bcl2/BAX ratio, and PMN influx did not significantly change in kidney nor liver. Plasma AST and LDH levels were increased in the prednisolone treated group. Our results demonstrate prednisolone can has an anti-inflammatory effect mediated through reducing serum circulating cytokines. However, this anti-inflammatory effect does not translate into improved kidney function and indeed was associated with increased liver injury markers.
Collapse
|
38
|
Champigneulle B, Charpentier J. Conséquences cardiovasculaires de la mort cérébrale et prise en charge pour prélèvement d’organe(s). MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1055-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
39
|
Anesthetic considerations in organ procurement surgery: a narrative review. Can J Anaesth 2015; 62:529-39. [PMID: 25715847 DOI: 10.1007/s12630-015-0345-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 02/13/2015] [Indexed: 12/28/2022] Open
Abstract
PURPOSE While a few publications specify the anesthetic implications of either brain or cardiac death, they lack detail on how to provide anesthesia during organ donation surgery. We provide a thorough description of important anesthetic considerations during organ donation surgery in patients with either brain or cardiac death. SOURCE A thorough literature review was undertaken to locate all relevant articles that describe systemic effects of brain and cardiac death and their anesthetic implications. We searched PubMed, Pubget, and EMBASE™ for relevant articles using the following search terms: anesthesia, management, donation cardiac death, donation brain death. In addition, we reviewed the relevant protocols at our own institution. PRINCIPAL FINDINGS Highly specific intraoperative management by an anesthesiologist is required during organ procurement after brain death. To manage the heart-beating brain-dead donor, the anesthesiologist must incorporate knowledge of the effects of brain death on each organ system as well as the effects of the preoperative measures that the donor required in the intensive care unit. It is also important to know which organs are going to be procured in order to establish specific goals and implement strategies (e.g., lung-protective ventilation or intraoperative glycemic control) to optimize donor outcome. During organ procurement after cardiac death, an anesthesiologist's direct involvement is particularly important for lung donors. CONCLUSION Anesthesiologist-guided physiological optimization of the brain-dead donor may be a factor in determining the outcome of the organ recipient. Additionally, anesthesiologists have an important role in helping to ensure that the highest quality and most appropriate care are rendered to non-heart-beating donors. This is achieved through establishing protocols in their hospitals for donation after cardiac death that maximize the number of available organs with the best chance for long-term graft viability.
Collapse
|
40
|
Dhanani S, Shemie SD. Advancing the science of organ donor management. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:612. [PMID: 25672523 PMCID: PMC4331331 DOI: 10.1186/s13054-014-0612-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
There is an increasing burden of responsibility for intensivists to optimize donation potential after the declaration of brain death in patients with catastrophic brain injury. Best practice for donor management, if present, has been formed on low quality and mainly observational studies or consensus. In particular, research into the use of corticosteroids has shown varied benefit. The specific and limited results of the CORTICOME study are less important than the systematic methodology and the development of rigour in the study of deceased organ donation. Donor management would benefit from continued systematic analysis of current literature, understanding of the physiologic basis for therapy, and further prospective controlled trials. Worldwide collaboration partnerships and funding are needed to optimize the management of deceased organ donation.
Collapse
|