Ecstasy-induced brain death and acute hepatocellular failure: multiorgan donor and liver transplantation

Successful Liver Transplantation from a Deceased Donor After Ethylene Glycol Ingestion: A Case Report and Review of the Literature of Organ Donation from Poisoned Donors

Despite the increase in deceased organ donation over the past ten years, the gap between patients awaiting transplant and available organs continues to widen. Deceased donors secondary to acute fatal poisonings represent less than 1% of all organ donors. Organs from poisoned donors have largely been discarded due to concerns of toxin transmission and poor organ function as well as the paucity of data that exists regarding this donor population. Here, we report a case of a 40-year-old male who underwent successful liver re-transplantation from a donor who died following ethylene glycol ingestion. To our knowledge this case report is the first to describe successful re-transplantation from an ethylene glycol-poisoned donor. We also provide a comprehensive review of the literature describing organ donation from poisoned donors.

Intoxicated Donors and Heart Transplant Outcomes: Long-Term Safety

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Background:

The opioid crisis has led to an increase in available donor hearts, although questions remain about the long-term outcomes associated with the use of these organs. Prior studies have relied on historical information without examining the toxicology results at the time of organ offer. The objectives of this study were to examine the long-term survival of heart transplants in the recent era, stratified by results of toxicological testing at the time of organ offer as well as comparing the toxicology at the time of donation with variables based on reported history.

Methods:

The United Network for Organ Sharing database was requested as well as the donor toxicology field. Between 2007 and 2017, 23 748 adult heart transplants were performed. United Network for Organ Sharing historical variables formed a United Network for Organ Sharing Toxicology Score and the measured toxicology results formed a Measured Toxicology Score. Survival was examined by the United Network for Organ Sharing Toxicology Score and Measured Toxicology Score, as well as Cox proportional hazards models incorporating a variety of risk factors.

Results:

The number and percent of donors with drug use has significantly increased over the study period (P<0.0001). Cox proportional hazards modeling of survival including toxicological and historical data did not demonstrate differences in post-transplant mortality. Combinations of drugs identified by toxicology were not associated with differences in survival. Lower donor age and ischemic time were significantly positively associated with survival (P<0.0001).

Conclusions:

Among donors accepted for transplantation, neither history nor toxicological evidence of drug use was associated with significant differences in survival. Increasing use of such donors may help alleviate the chronic donor shortage.

Exogenous Ghrelin Could Not Ameliorate 3,4-methylenedioxymethamphetamine-induced Acute Liver Injury in The Rat: Involved Mechanisms

MDMA (3,4-methylenedioxymethamphetamine, ecstasy) is often abused by youth as a recreational drug. MDMA abuse is a growing problem in different parts of the world. An important adverse consequence of the drug consumption is hepatotoxicity of different intensities. However, the underlying mechanism of this toxicity has not been completely understood. Ghrelin is a gut hormone with growth hormone stimulatory effect. It expresses in liver, albeit at a much lower level than in stomach, and exerts a hepatoprotective effect. In this study, we investigated hepatotoxicity effect of MDMA alone and its combination with ghrelin as a hepatoprotective agent. MDMA and MDMA+ ghrelin could transiently increase serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) followed by tissue necrosis. However, they could significantly decrease liver tumor necrosis factor-a (TNF-±) in both treatment groups. Unexpectedly, in MDMA treated rats, Bax, Bcl-xl, Bcl-2, Fas, Fas ligand (Fas-L), caspase 8, cytochrome c, caspase 3 gene expression, and DNA fragmentation were nearly unchanged. In addition, apoptosis in MDMA+ ghrelin group was significantly reduced when compared with MDMA treated animals. In all, MDMA could transiently increase serum transaminases and induce tissue necrosis and liver toxicity. Ghrelin, however, could not stop liver enzyme rise and MDMA hepatotoxicity. MDMA hepatotoxicity seems to be mediated via tissue necrosis than apoptotic and inflammatory pathways. Conceivably, ghrelin as an anti-inflammatory and anti-apoptotic agent may not protect hepatocytes against MDMA liver toxicity.

Substance Use Disorders in Vulnerable Children

Substance use remains a major challenge in adolescent health. The coexisting use of these substances often creates hurdles for accurate diagnosis of other comorbid psychiatric conditions. It is of critical importance that health care providers be aware of both the isolated presentation of substance use disorder and that with coexisting psychiatric illness in vulnerable children.

MDMA-Associated Liver Toxicity: Pathophysiology, Management, and Current State of Knowledge

3,4-Methylenedioxymethamphetamine (MDMA, ecstasy) has become a popular recreational drug of abuse among young adults, partly because of the belief that it is relatively safe compared with other drugs with the same stimulant and hallucinogenic effects. However, MDMA use has been associated with a wide spectrum of organ toxicities, with the liver being severely affected by its deleterious effects. This article discusses the essential pharmacology of MDMA and describes the effects MDMA has on various organ systems of the body, with particular focus on the liver. The putative mechanisms by which MDMA can cause liver damage are explored, with emphasis on patient-related factors that explain why some individuals are more susceptible than others to damage from MDMA. The incidence of hepatotoxicity related to MDMA use is presented, and the nursing management of patients who develop acute liver failure due to MDMA overuse is explored in light of current evidence.

Successful Kidney Transplant From a Brain Stem-Dead Donor Due To Lethal Methanol Poisoning

Kidney replacement is the best treatment modality for chronic renal failure; however,the greatest obstacle for transplant is the scarce number of donor organs. In the United States and Europe, less than 1% of organs for transplant are provided from patients with lethal poisoning. In this paper, we present a successful kidney transplant from a donor with methanol poisoning. A 38-year-old-man who had methanol poisoning developed brain stem death after unsuccessful treatment and was a candidate to be a kidney donor for transplant to a 27-year-old male patient with chronic renal failure. Three weeks after kidney transplant, the recipient was discharged with good kidney function. We suggest that it may be possible to consider lethal methanol poisoning for kidney donation.

Effects of drug abuse, smoking and alcohol on donor hearts and lungs

Potential heart and lung donors with a history of illicit drugs and/or smoking and alcohol are frequently offered, though there is no clear guidance on when it is safe to use these organs. A review of the literature on effects of drugs, alcohol and smoking on donor outcomes, and the effects of these on the intact heart and lung was undertaken. There has been a marked increase in deaths from opioid abuse in many developed countries, though recent evidence suggests that outcomes after cardiothoracic transplantation are equivalent to nonopioid donor causes of death. For donor smoking, there is an increased risk with lung transplantation; however, that risk is less when compared to further waiting on the transplant list for a nonsmoking alternative. Heavy alcohol consumption does not adversely affect heart transplantation, and there is no clear evidence of adverse outcomes after lung transplantation. There are no overall effects of cannabis or cocaine on survival after heart or lung transplantation. In all these cases, careful donor assessment can establish if a particular organ can be used. In most cases, use of drugs requires careful assessment, but is not in of itself a contraindication to cardiothoracic transplantation.

Organ and tissue donation from poisoned patients in the emergency department: A Canadian emergency physician survey

OBJECTIVES

Screening for organ and tissue donation is an essential skill for emergency physicians. In 2015, 4,631 Canadians were on a waiting list for a transplant, and 262 died while waiting. Canada’s donation rates are less than half of comparable countries, so it is essential to explore strategies to improve the referral of donors. Poisoned patients may be one such underutilized source for donation. This study explores physician practices and perceptions regarding the referral of poisoned patients as donors.

METHODS

In this cross-sectional unidirectional survey, 1,471 physician members of the Canadian Association of Emergency Physicians were invited to participate. Physicians were presented with 20 scenarios and asked whether they would refer the patient as a potential organ or tissue donor. Results were reported descriptively, and associations between demographics and referral patterns were assessed.

RESULTS

Physicians totalling 208 participated in the organ or tissue donation scenarios (14.1%); 75% of scenarios involving poisoning were referred for organ or tissue donation, compared with 92% in a non-poisoning scenario. Poisons associated with lower referrals included sedatives, acetaminophen, chemical exposure, and organophosphates. A total of 175 physicians completed the demographic survey (11.9%). Characteristics associated with increased referrals included previous referral experience, donation training, donation support, >10 years of service, urban practice, emergency medicine certification, and male gender.

CONCLUSIONS

Scenarios involving poisoning were referred less often when compared with an ideal scenario. Because poisoning is not a contraindication for referral, this represents a potential source of donors. Targeted training and referral support may help improve donation rates in this demographic.

Amphetamines, the pregnant woman and her children: a review

The objective of this study is to review and summarize available evidence regarding the impact of amphetamines on pregnancy, the newborn infant and the child. Amphetamines are neurostimulants and neurotoxins that are some of the most widely abused illicit drugs in the world. Users are at high risk of psychiatric co-morbidities, and evidence suggests that perinatal amphetamine exposure is associated with poor pregnancy outcomes, but data is confounded by other adverse factors associated with drug-dependency. Data sources are Government data, published articles, conference abstracts and book chapters. The global incidence of perinatal amphetamine exposure is most likely severely underestimated but acknowledged to be increasing rapidly, whereas exposure to other drugs, for example, heroin, is decreasing. Mothers known to be using amphetamines are at high risk of psychiatric co-morbidity and poorer obstetric outcomes, but their infants may escape detection, because the signs of withdrawal are usually less pronounced than opiate-exposed infants. There is little evidence of amphetamine-induced neurotoxicity and long-term neurodevelopmental impact, as data is scarce and difficult to extricate from the influence of other factors associated with children living in households where one or more parent uses drugs in terms of poverty and neglect. Perinatal amphetamine-exposure is an increasing worldwide concern, but robust research, especially for childhood outcomes, remains scarce. We suggest that exposed children may be at risk of ongoing developmental and behavioral impediment, and recommend that efforts be made to improve early detection of perinatal exposure and to increase provision of early-intervention services for affected children and their families.

Toxicity of amphetamines: an update

Amphetamines represent a class of psychotropic compounds, widely abused for their stimulant, euphoric, anorectic, and, in some cases, emphathogenic, entactogenic, and hallucinogenic properties. These compounds derive from the β-phenylethylamine core structure and are kinetically and dynamically characterized by easily crossing the blood-brain barrier, to resist brain biotransformation and to release monoamine neurotransmitters from nerve endings. Although amphetamines are widely acknowledged as synthetic drugs, of which amphetamine, methamphetamine, and 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) are well-known examples, humans have used natural amphetamines for several millenniums, through the consumption of amphetamines produced in plants, namely cathinone (khat), obtained from the plant Catha edulis and ephedrine, obtained from various plants in the genus Ephedra. More recently, a wave of new amphetamines has emerged in the market, mainly constituted of cathinone derivatives, including mephedrone, methylone, methedrone, and buthylone, among others. Although intoxications by amphetamines continue to be common causes of emergency department and hospital admissions, it is frequent to find the sophism that amphetamine derivatives, namely those appearing more recently, are relatively safe. However, human intoxications by these drugs are increasingly being reported, with similar patterns compared to those previously seen with classical amphetamines. That is not surprising, considering the similar structures and mechanisms of action among the different amphetamines, conferring similar toxicokinetic and toxicological profiles to these compounds. The aim of the present review is to give an insight into the pharmacokinetics, general mechanisms of biological and toxicological actions, and the main target organs for the toxicity of amphetamines. Although there is still scarce knowledge from novel amphetamines to draw mechanistic insights, the long-studied classical amphetamines-amphetamine itself, as well as methamphetamine and MDMA, provide plenty of data that may be useful to predict toxicological outcome to improvident abusers and are for that reason the main focus of this review.

Neuroprotective strategies in drug abuse-evoked encephalopathy

Encephalopathy is evidenced as an altered mental state with various neurological symptoms, such as memory and cognitive problems. The type of a substance-evoked encephalopathy will depend on the drug, substance, or combination being abused. The categories into which we could place the various abused substances could be tentatively divided into stimulants, amphetamines, hallucinogens, narcotics, inhalants, anesthetics, anabolic steroids, and antipsychotics/antidepressants. Other factors that may underlie encephalopathy, such as infectious agents, environmental, and other factors have also to be taken into account. Drugs of abuse can be highly toxic to the CNS following acute, but more so in chronic exposure, and can produce significant damage to other organs, such as the heart, lungs, liver, and kidneys. The damage to these organs may be at least partially reversible when drug abuse is stopped but CNS damage from repeated or prolonged abuse is often irreversible. The major pathways for the organ and CNS toxicity could be related to ischemic events as well as increased cell damage due to metabolic or mitochondrial dysfunction resulting in increased excitotoxicity, reduced energy production, and lowered antioxidant potential. These susceptibilities could be strengthened by the use of antioxidants to combat free radicals (e.g., vitamin E, lipoic acid); trying to improve energy generation by using mitochondriotropic/metabolic compounds (e.g., thiamine, coenzyme Q10, carnitine, riboflavin); by reducing excitotoxicity (e.g., glutamate antagonists) and other possible strategies, such as robust gene response, need to be investigated further. The drug-abuse-evoked encephalopathy still needs to be studied further to enable better preventative and protective strategies.

Diagnosis of brain death

Brain death (BD) should be understood as the ultimate clinical expression of a brain catastrophe characterized by a complete and irreversible neurological stoppage, recognized by irreversible coma, absent brainstem reflexes, and apnea. The most common pattern is manifested by an elevation of intracranial pressure to a point beyond the mean arterial pressure, and hence cerebral perfusion pressure falls and, as a result, no net cerebral blood flow is present, in due course leading to permanent cytotoxic injury of the intracranial neuronal tissue. A second mechanism is an intrinsic injury affecting the nervous tissue at a cellular level which, if extensive and unremitting, can also lead to BD. We review here the methodology of diagnosing death, based on finding any of the signs of death. The irreversible loss of cardio-circulatory and respiratory functions can cause death only when ischemia and anoxia are prolonged enough to produce an irreversible destruction of the brain. The sign of such loss of brain functions, that is to say BD diagnosis, is fully reviewed.

Marginal Lung Donors: A Diminishing Margin of Safety?

Lung donor shortages have resulted in the critical appraisal of cadaveric donor acceptability criteria and the gradual relaxation of once strict guidelines. Many centers have reported their results with these "extended criteria" donors and an increasing number of multicenter registry studies have also been published. The results have been contradictory and leave many questions unanswered. Important new data has however come to light since the last review of the subject by the International Society for Heart and Lung Transplantation Pulmonary Council. We review the current literature focusing on recent developments in the pursuit of an expanded lung donor pool with acceptable outcomes.

Clinical Management of the Organ Donor

There is a critical mismatch between available organs for transplant and acutely or critically ill patients with end-stage organ disease. Patients who may benefit from organ transplantation far outnumber available organs. The causes for this imbalance are multiple. One cause is family refusal to donate. A second cause is nonrecognition or delay in determination of brain death. A third cause is donor loss due to profound cardiopulmonary and metabolic instability consequent to brain-stem herniation and brain death. Family refusal may be addressed by education, public awareness, as well as close attention to social, cultural and ethical issues, and optimal communication with donor families. Brain death may be consequent to traumatic brain injury, ischemic versus hemorrhagic stroke, as well as massive cerebral anoxia/ischemic following cardiac arrest. Nonrecognition or delay in brain death determination may be addressed by clinician education and frequent clinical assessment to detect early stages of brain-stem herniation refractory to aggressive measures for control of intracranial pressure. Donor loss due to profound cardiopulmonary and metabolic instability may be addressed by aggressive, mechanism-based treatment for clinical instability based on affected body system, as well as measures to support metabolic activity at the cellular and tissue level in the brain-dead organ donor. This article explores cerebral physiology related to impending brain death and catastrophic intracranial pressure elevations. In addition, physiologic consequences of brain death are correlated with affected body systems and mechanism-based therapies to support organ function pending transplantation. Ethical/legal issues are explored as related to patient autonomy and optimal family outcomes. Effective family communication, astute clinical assessment, and optimal clinical management of the organ donor are illustrated using a case study approach, highlighting the role of the advanced practice nurse in donor management.

[Biochemical, pharmacological and toxic effects of n-metil 3,4-methylenedioxyamphetamine--"ecstasy"]

<zakljucak> Navedeni podaci ukazuju da ?ekstazi? nije, kako se to posebno medju omladinom smatra, laka, bezopasna i zabavna droga. Obilje nezeljenih psihickih, neuroloskih, hepatickih, bubreznih, kardiovaskularnih i drugih toksicnih efekata pokazuje samo da oni nisu dobro procenjeni, a najopasnije je sto se desavaju pri upotrebi uobicajenih prosecnih doza ove droge. Uzivaoci u vecini slucajeva prelaze preko nezeljenih efekata MDMA i veoma lako se vracaju omiljenoj piluli, ali vremenom nezeljeni efekti postaju naglaseniji. U pokusaju da savladaju depresivnost, anksioznost i bezrazlozni zamor uzivaoci "ekstazija" obicno posezu za alkoholom ili drugim tezim narkoticima, cime posle privremenog "poboljsanja" stanje postaje jos teze, a put u tesku narkomaniju postaje sasvim izvestan. Usled nepoznavanja stvarne toksicnosti "ekstazija" zdravstveni radnici svih profila moraju uloziti napor i javnost upoznati sa stvarnim cinjenicama, posebno mlade koji iz neznanja i pomodarstva koriste "ekstazi".

Early Loss of Two Renal Grafts Obtained from the Same Donor: Role of Ecstasy?

Early loss of renal grafts is generally caused by vascular or immunologic complications. We describe two patients who received a kidney transplant from the same donor and lost their grafts during the first posttransplant week. Both cases presented necrotizing graft vasculopathy without inflammatory element. The donor was a 21-year-old woman who regularly used "ecstasy" over a 2-year period. After an extensive work-up to investigate the potential causes of graft loss, we considered the possibility of ecstasy being the cause of these two renal-graft losses.

Prélèvements d’organes après intoxication

BACKGROUND

There is an increasing gap between the number of patients on the waiting list and the number of transplanted patients. In France, more than 10000 patients waited for an organ transplantation in 2002. Due to the graft shortage, "marginal" donors are now considered. The patients who present brain death after accidental or voluntary poisoning belong to this category.

EPIDEMIOLOGY

The data available from European or North American organ procurement organisations show that poisoned donors represent about 1% of all organ donors. It seems likely that a significant number of poisoned patients are not referred because poisoning is regarded as a contraindication to organ donation. When organ procurement can be achieved, the results expressed as recipient survival or graft survival are quite encouraging.

TOXIC PRODUCTS

The most frequently involved toxins are either drugs (psychotropic agents, analgesics...), illicit substances, or environmental agents (gases, alcohols...). The literature data are discussed; some issues remain controversial.

PRACTICAL APPROACH

Several criteria have to be applied when poisoned patients are considered as potential organ donors. Besides a firm diagnosis of "brain death", the knowledge of the "target organs" of poisoning is of paramount importance, together with careful analysis of the toxicokinetics and toxicodynamics. In most cases, routine biological and morphological data are sufficient to assess graft function.

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.

Successful transplantation of organs from a donor who died from acute cocaine intoxication

One to two percent of the general population of western countries are regular consumers of cocaine, 10% being sporadic consumers. This proportion increases considerably in the population age groups which are most frequently organ donors. Cocaine may directly cause brain death, or be present in those with brain death who died from other causes, especially head trauma. We present a 30-yr-old female donor, a regular consumer of inhaled cocaine, who died of brain anoxia after cocaine inhalation. Twenty-five hours after cocaine inhalation, the liver and kidneys were removed for transplantation. The liver was transplanted to a patient with acute hepatocellular failure caused by isoniazids, and the kidneys to two recipients with renal polycystosis. Toxicity attributable to the cocaine was not observed in any of the three recipients. All three grafts presented immediate function, and the clinical evolution of all three recipients and the function of all three grafts were excellent during the 5 yr of follow-up. The serum creatinines of the two kidney recipients 5 yr from transplantation were 76 and 72 micro mol/L, respectively.

Poisoned patients as potential organ donors: postal survey of transplant centres and intensive care units

BACKGROUND

The number of patients awaiting allograft transplantation in the UK exceeds the number of organs offered for transplantation each year. Most organ donors tend to be young, fit and healthy individuals who die because of trauma or sudden cardiac arrest. Patients who die from drug and poison intoxication tend to have similar characteristics but are less frequently offered as potential organ donors.

METHODS

A postal questionnaire survey of all transplantation centres and an equal number of intensive care units in the UK was undertaken. The use of kidney, heart, lung, liver and pancreas transplants from poisoned patients following deliberate methanol ingestion, cardiac arrest presumed secondary to cocaine overdose, accidental domestic carbon monoxide inhalation and industrial cyanide exposure were used as case scenarios.

RESULTS

Response rates were 70% for transplantation centres and 50% for intensive care unit directors. Over 80% of organs would be offered or discussed with transplant coordinators by intensive care unit directors. Transplantation physicians/surgeons would consider transplanting organs in up to 100% of case scenarios, depending on the organ and poisoning or intoxication involved.

DISCUSSION

The postal survey presented here shows that most transplantation physicians and surgeons and intensive care unit directors would consider those who die following acute drug intoxication and poisoning as potential organ donors. The previously reported literature shows in general that transplanted organs from poisoned patients have good long-term survival, although the number of reports is small. Poisoned patients are another pool of organ donors who at present are probably underused by transplantation services.