Extended donor criteria: hemodynamic follow-up of heart transplant recipients receiving a cardiac allograft from donors > or = 60 years of age

Long-term results of organ procurement from burn victims

BACKGROUND

With the increasing success of organ transplantation, many traditional contraindications to organ procurement are being reconsidered. Burn disease has constituted a traditional contraindication to solid organ procurement because of concerns that such organs may have been compromised by ischemia secondary to burn shock and contaminated by bacteremia. With the current shortage of solid organs, the transplant community continues to look for ways to increase the number of organ donors, including the use of marginal donors.

METHODS

Between 1999 and 2009 we have successfully procured 14 organs from four burn patients, who had suffered concurrent anoxic brain injury. There were one male and three female patients with an average age of 43.3 years and a total burned body surface area of 32.5%. Organ transplantation was performed at an average of 4.75days after the injury. Eight kidneys, three livers, two hearts and one pancreas were procured and transplanted into 13 patients.

RESULTS

We were able to follow-up on the organ recipients for an average of 80.5 months. The 5-year survival of the donated organs following transplant was 78.6% and the 5-year organ recipient survival was 92.3%.

CONCLUSIONS

Organ procurement after burns is not contraindicated and transplantation can be performed with good long-term results.

Elevated donor hemoglobin A1c does not impair early survival in cardiac transplant recipients

BACKGROUND

Orthotopic heart transplantation (OHT) is the gold-standard therapy for end-stage heart failure. An increasing deficit between suitable allograft availability and clinical demand for OHT exists. The role of donor diabetes mellitus (DM) on post-transplant recipient outcomes in OHT is controversial. The purpose of this study was to examine donor hemoglobin A1c (HbA1c) levels to identify the impact of donor glycemic control on recipient survival.

METHODS

Adult OHT recipients with donor HbA1c data were identified in the UNOS database from 2010 to 2015. Recipients were stratified on the basis of donor glycemic status: Hyperglycemic-donor and euglycemic-donor cohorts were defined as HbA1c levels ≥6.5% and <6.5%, respectively. Outcomes were compared between unadjusted and propensity-matched hyperglycemic versus euglycemic donors. Primary end point was three-year survival.

RESULTS

Of 5342 OHT recipients, 208 (3.89%) received an allograft from a hyperglycemic donor and 5134 (96.1%) received an allograft from a euglycemic donor. There was no significant difference in survival in the hyperglycemic group before (P=.87) or after (P=.78) propensity matching.

CONCLUSIONS

No difference in four-year survival was noted in recipients who received allografts from hyperglycemic donors. These results suggest that recent cumulative donor glycemic status alone may not be an important predictor of recipient outcomes.

Low incidence of coronary angiography in the evaluation process of the potential heart donor

INTRODUCTION

We investigated the practice of coronary angiography (CA) on donor hearts.

PATIENTS AND METHODS

Between January 1, 2000, and December 31, 2010, all reported organ donors aged <66 years were analyzed retrospectively. Donor charts were evaluated regarding a performed CA, its outcome, the timing of CA during the evaluation process, and reasons for organ refusal. The percentage of positive CA studies in organ donors aged ≥45 years was also evaluated.

RESULTS

Of 292 reported organ donors, 152 organ donor hearts were declined (group 1), and 140 hearts (group 2) were transplanted. Of the 152 declined hearts, 91 hearts were found not suitable for organ offer, and 61 were not successfully allocated or were refused by Eurotransplant. CA was conducted in 17 organ donors (5.8%). In 6 donors, a previous CA was reported (all had pathologic findings), and in 11 donors, a donor CA was performed, indicating 4 pathologic and 7 negative findings (54.5% of the hearts evaluated by donor CA were transplanted). No complication or delay of the donation process was reportedly related to donor CA.

CONCLUSIONS

Special emphasis and implementation of recommendations for CA to be part of the evaluation of donor organs seem necessary.

Normothermic Ex Vivo Allograft Blood Perfusion in Clinical Heart Transplantation

<p><b>Background:</b> Cold ischemia associated with cold static storage is an independent risk factor for primary allograft failure and survival of patients after orthotopic heart transplantation. The effects of normothermic ex vivo allograft blood perfusion on outcomes after orthotopic heart transplantation compared to cold static storage have been studied.</p><p><b>Methods:</b> In this prospective, nonrandomized, single-institutional clinical study, normothermic ex vivo allograft blood perfusion has been performed using an organ care system (OCS) (TransMedics, Andover, MA, USA). Included were consecutive adult transplantation patients who received an orthotopic heart transplantation (oHTx) without a history of any organ transplantation, in the absence of a congenital heart disorder as an underlying disease and not being in need of a combined heart-lung transplantation. Furthermore, patients with fixed pulmonary hypertension, ventilator dependency, chronic renal failure, or panel reactive antibodies >20% and positive T-cell cross-matching were excluded. Inclusion criteria for donor hearts was age of <55 years, systolic blood pressure >85 mmHg at the time of final heart assessment under moderate inotropic support, heart rate of <120 bpm at the time of explantation, and left ventricular ejection fraction >40% assessed by an transcutaneous echo/Doppler study with the absence of gross wall motion abnormalities, absence of left ventricular hypertrophy, and absence of valve abnormalities. Donor hearts which were conventionally cold stored with histidine-tryptophan-ketoglutarate solution (Custodiol; Koehler Chemie, Ansbach, Germany) constituted the control group. The primary end point was the recipients' survival at 30 days and 1 and 2 years after their heart transplantation. Secondary end points were primary and chronic allograft failure, noncardiac complications, and length of hospital stay.</p><p><b>Results:</b> Over a 2-year period (January 2006 to July 2008), 159 adult cardiac allografts were transplanted. Twenty-nine were assigned for normothermic ex vivo allograft blood perfusion and 130 for cold static storage with HTK solution. Cumulative survival rates at 30 days and 1 and 2 years were 96%, 89%, and 89%, respectively, whereas in the cold static storage group survival after oHTx was 95%, 81%, and 79%. Primary graft failure was less frequent in the recipients of an oHTx who received a donor heart which had been preserved with normothermic ex vivo allograft blood perfusion using an OCS (6.89% versus 15.3%; <i>P</i> = .20). Episodes of severe acute rejection (23% versus 17.2%; <i>P</i> = .73), as well as, cases of acute renal failure requiring haemodialysis (25.3% versus 10%; <i>P</i> = .05) were more frequent diagnosed among recipients of a donor heart which had been preserved using the cold static storage. The length of hospital stay did not differ (26 days versus 28 days; <i>P</i> = .80) in both groups.</p><p><b>Conclusions:</b> Normothermic ex vivo allograft blood perfusion in adult clinical orthotopic heart transplantation contributes to better outcomes after transplantation in regard to recipient survival, incidence of primary graft dysfunction, and incidence of acute rejection.</p>

Impact of low donor to recipient weight ratios on cardiac transplantation

BACKGROUND

International Society of Heart and Lung Transplantation guidelines for adult heart transplantation (HT) suggest a donor to recipient body weight ratio (WR) of greater than 0.8. For female to male transplants, a WR of greater than 0.9 is recommended.

METHODS

The United Network for Organ Sharing database was examined for adult HT from 1999 to 2011. Controls with a WR of 0.9 or greater (normal donor to recipient weight ratio) were compared with patients with a WR of 0.6 to 0.89 (WRL) and a WR of less than 0.59 (WRVL). The primary measured outcome was survival.

RESULTS

Of the 21,928 patients undergoing HT, 14,592 (66.6%) were performed with a normal donor to recipient weight ratio, 7212 (32.9%) were performed with WRL, and 124 (0.6%) were performed with WRVL. In male donor to male recipient, male donor to female recipient, and female donor to female recipient HT, the use of WRL did not influence median survival (P = .3621) and was not associated with increased mortality (P = .7273). In female donor to male recipient HT, WRL was associated with decreased median survival (435 days, P = .0241) and was associated with increased mortality (hazard ratio, 1.201; P = .0383).

CONCLUSIONS

HT can be safely performed using WRL donors between sex-matched and male to female transplants. However, in female to male transplants, WRL donors are associated with decreased survival. Although clinical circumstances will guide decision making, consensus criteria may be revisited to liberalize the pool of acceptable donors in an era of unprecedented donor shortage.

Cardiac transplantation can be safely performed using selected diabetic donors

OBJECTIVE

Cardiac transplantation (OHT) using diabetic donors (DDs) is thought to adversely influence survival. We attempt to determine if adult OHT can be safely performed using selected DDs.

METHODS

The United Network for Organ Sharing (UNOS) database was examined for adult OHT from 2000 to 2010.

RESULTS

Of the 20,348 patients undergoing OHT, 496 (2.4%) were with DDs. DDs were older (39.6 vs 31.3 years; P < .001), more likely female (41.5% vs 28.3%; P < .001), and had a higher body mass index (BMI) (29.9 vs 26.4; P < .001). Recipients of DD hearts were older (53.4 vs 51.8; P = .004) and more likely to have diabetes (18.9% vs 14.9%; P = .024). The 2 groups were evenly matched with regard to recipient male gender (78.0% vs 76.1%; P = .312), ischemic time (3.3 vs 3.2 hours; P = .191), human leukocyte antigen mismatches (4.7 vs 4.6; P = .483), and requirement of extracorporeal membrane oxygenation (ECMO) as a bridge to transplant (0.8% vs 0.5%; P = .382). Median survival was similar (3799 vs 3798 days; P = .172). On multivariate analysis, DD was not associated with mortality (hazard ratio [HR], 1.155; 95% confidence interval [CI], 0.943-1.415; P = .164). As previously demonstrated, donor age, decreasing donor BMI, ischemic time, recipient creatinine, recipient black race, recipient diabetes, race mismatch, and mechanical ventilation or ECMO as a bridge to transplant were associated with mortality. On multivariate analysis of subgroups, neither insulin-dependent diabetes (1.173; 95% CI, 0.884-1.444; P = .268) nor duration of diabetes for more than 5 years (HR, 1.239; 95% CI, 0.914-1.016; P = .167) was associated with mortality.

CONCLUSIONS

OHT can be safely performed using selected DDs. Consensus criteria for acceptable cardiac donors can likely be revised to include selected DDs.

Solid organ procurement from donors with carbon monoxide poisoning and/or burn--a systematic review

INTRODUCTION

Traditionally, carbon monoxide poisoning and/or burn are considered contraindications to organ procurement. Previously reported cases have shown mixed results and many have been redundantly reported in the literature.

METHODS

We performed a systematic review of all reported cases of organ transplantation procured from donors with carbon monoxide poisoning and/or burn to investigate whether these patients are suitable donors for solid organ transplantations.

RESULTS

Organ survival rates of reported organs were high (86%). All organs procured from donors with carbon monoxide poisoning and burn survived during follow-up. Mean donors' peak carbon monoxide levels were comparable for organs surviving or failing during follow-up (31 ± 2.7 vs. 29 ± 26.8; p=0.95). Eighty-seven per cent of organs procured from donors supported with inotropes or vasopressors prior to organ procurement and 91% of organs procured from donors who were cardiopulmonary resuscitated prior to organ procurement survived during follow-up.

CONCLUSIONS

Burn, carbon monoxide poisoning, high peak carbon monoxide-levels, use of inotropes or vasopressors or cardiopulmonary resuscitation prior to procurement are not contraindications for organ procurement and transplantation. New guidelines for burn units defining the special requirements for organ procurement from donors with carbon monoxide poisoning and/or burn are needed to raise the awareness for potential organ donors and to ultimately increase the donor pool and save patients' lives.

[Evaluation of the potential organ donor with special regards to heart donation]

Angesichts der auch in Österreich vorherrschenden Knappheit an verfügbaren Organspendern für Herztransplantationen erscheint es dringlich notwendig, eine Optimierung von Spenderevaluierung und Management zu diskutieren. In der vorliegenden Arbeit werden allgemeine Spenderkriterien und herzspezifische Parameter detailliert diskutiert und im Zusammenhang mit der internationalen Literatur dargestellt. Es wird der "marginale" und im Gegensatz dazu der "optimale" Organspender definiert. Das Spendermanagement wird besprochen, wobei neben der hämodynamischen Optimierung auch auf zusätzliche intensivmedizinische Aspekte eingegangen wird. Erst die exakte Evaluierung erlaubt die individuelle Zuteilung des Organs zum passenden Empfänger und stellt somit insbesondere bei marginalen Spendern die Grundlage eines Therapieerfolgs dar.

Outcomes in cardiac transplant recipients using allografts from older donors versus mortality on the transplant waiting list

OBJECTIVES

This study investigates the outcomes of cardiac transplantation using older donors.

BACKGROUND

Despite high mortality rates on waiting lists, transplanting hearts from older donors remains a relative contraindication.

METHODS

We retrospectively reviewed data on 479 adult heart transplant recipients, 352 status I patients, and 534 status II patients enrolled on a waiting list between 1992 and 1999. The Cox proportional hazards model was used for statistical analysis.

RESULTS

Of all donors, 20% were 40 to 50 years old and 8% were > or =50 years old. The risk of six-month mortality on the waiting list for patients who were not transplanted (status I: relative risk [RR] 8.5; status II: RR 3.7) significantly outweighed the risk of transplanting patients with a heart from donors >40 years old (status I: RR 1.6; status II: RR 2.1). Recipients of cardiac allografts from donors <40 years old had a one-month mortality rate of 5%, in contrast to 13% and 22% in those receiving allografts from donors 40 to 50 years old and > or =50 years old, respectively. Donor age did not influence long-term survival or frequency of rejections; however, it did correlate with the early presence of transplant-related coronary artery disease (TCAD). By the first annual angiogram, only 17% of recipients with donors <20 years old developed TCAD, in contrast to 26% to 30% and 34% of recipients who received allografts from donors age 20 to 40 years and >40 years, respectively.

CONCLUSIONS

Despite a strong association between older donor age and increased post-operative mortality and TCAD, it is more beneficial in terms of patient survival to receive an allograft from a donor >40 years old than to remain on the waiting list.

Extended criteria for organ acceptance. Strategies for achieving organ safety and for increasing organ pool

The terms extended donor or expanded donor mean changes in donor acceptability criteria. In almost all cases, the negative connotations of these terms cannot be justified. Factors considered to affect donor or organ acceptability have changed with time, after showing that they did not negatively affect graft or patient survival per se or when the adequate measures had been adopted. There is no age limit to be an organ donor. Kidney and liver transplantation from donors older than 65 years can have excellent graft and patient actuarial survival and graft function. Using these donors can be from an epidemiological point of view the most important factor to esablish the final number of cadaveric liver and kidney transplantations. Organs with broad structural parenchyma lesion with preserved functional reserve and organs with reversible functional impairment can be safely transplanted. Bacterial and fungal donor infection with the adequate antibiotic treatment of donor and/or recipient prevents infection in the latter. The organs, including the liver, from donors with infection by the hepatitis B and C viruses can be safely transplanted to recipients with infection by the same viruses, respectively. Poisoned donors and non-heart-beating donors, grafts from transplant recipients, reuse of grafts, domino transplant and splitting of one liver for two recipients can be an important and safe source of organs for transplantation.