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Hessheimer AJ, Flores E, Vengohechea J, Fondevila C. Better liver transplant outcomes by donor interventions? Curr Opin Organ Transplant 2024; 29:219-227. [PMID: 38785132 DOI: 10.1097/mot.0000000000001153] [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: 05/25/2024]
Abstract
PURPOSE OF REVIEW Donor risk factors and events surrounding donation impact the quantity and quality of grafts generated to meet liver transplant waitlist demands. Donor interventions represent an opportunity to mitigate injury and risk factors within donors themselves. The purpose of this review is to describe issues to address among donation after brain death, donation after circulatory determination of death, and living donors directly, for the sake of optimizing relevant outcomes among donors and recipients. RECENT FINDINGS Studies on donor management practices and high-level evidence supporting specific interventions are scarce. Nonetheless, for donation after brain death (DBD), critical care principles are employed to correct cardiocirculatory compromise, impaired tissue oxygenation and perfusion, and neurohormonal deficits. As well, certain treatments as well as marginally prolonging duration of brain death among otherwise stable donors may help improve posttransplant outcomes. In donation after circulatory determination of death (DCD), interventions are performed to limit warm ischemia and reverse its adverse effects. Finally, dietary and exercise programs have improved donation outcomes for both standard as well as overweight living donor (LD) candidates, while minimally invasive surgical techniques may offer improved outcomes among LD themselves. SUMMARY Donor interventions represent means to improve liver transplant yield and outcomes of liver donors and grafts.
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Affiliation(s)
- Amelia J Hessheimer
- General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd
| | - Eva Flores
- Transplant Coordination Unit, Hospital Universitario La Paz, Madrid, Spain
| | - Jordi Vengohechea
- General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd
| | - Constantino Fondevila
- General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd
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Wall A, Monday K, Schwartz G, McKenna GJ, Richards G, Rayle M, Huang Y, Jothidasan A, Lozonschi L, Testa G. First US Cardiac Rapid Recovery With Abdominal Normothermic Regional Perfusion Donation After Circulatory Death Procurement. Prog Transplant 2024; 34:55-56. [PMID: 38449091 DOI: 10.1177/15269248241237818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Affiliation(s)
- Anji Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Kara Monday
- Department of General Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Gary Schwartz
- Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Gregory J McKenna
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Grant Richards
- Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Murphy Rayle
- Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Yi Huang
- TransMedics, Inc, Andover, MA, USA
| | | | - Lucian Lozonschi
- Division of Cardiothoracic Surgery, Tampa General Hospital, Tampa, FL, USA
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
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3
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Wall A, Gupta A, Testa G. Abdominal normothermic regional perfusion in the United States: current state and future directions. Curr Opin Organ Transplant 2024; 29:175-179. [PMID: 38506730 DOI: 10.1097/mot.0000000000001144] [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: 03/21/2024]
Abstract
PURPOSE OF REVIEW Normothermic regional perfusion (NRP) is a novel procurement technique for donation after circulatory death (DCD) in the United States. It was pioneered by cardiothoracic surgery programs and is now being applied to abdominal-only organ donors by abdominal transplant programs. RECENT FINDINGS Liver and kidney transplantation from thoracoabdominal NRP (TA-NRP) donors in the United States was found to have lower rates of delayed kidney graft function and similar graft and patient survival versus recipients of cardiac super rapid recovery (SRR) DCD donors. The excellent outcomes with NRP have prompted the expansion of NRP technology to abdominal transplant programs. SUMMARY Excellent early outcomes with liver and kidney transplantation have prompted the growth of NC-NRP procurement for abdominal-only DCD donors across the US, and now requires standardization of technical and nontechnical aspects of this procedure.
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Silpe S, Martinez E, Wall A. Normothermic regional perfusion procurement for abdominal organ donors: techniques and troubleshooting. Curr Opin Organ Transplant 2024; 29:200-204. [PMID: 38465664 DOI: 10.1097/mot.0000000000001140] [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: 03/12/2024]
Abstract
PURPOSE OF REVIEW Normothermic regional perfusion (NRP) is a novel procurement technique for donation after circulatory death (DCD) in the United States. It was pioneered by cardiothoracic surgery programs and is now being applied to abdominal-only organ donors by abdominal transplant programs. Multiple technical approaches can be used for abdominal-only NRP DCD donors and this review describes these techniques. RECENT FINDINGS NRP has been associated with higher utilization of organs, particularly liver and heart grafts, from DCD donors and with better recipient outcomes. There are lower rates of delayed graft function in kidney transplant recipients and lower rates of ischemic cholangiopathy in liver transplant recipients. These benefits are driving increased interest from abdominal transplant programs in using NRP for DCD procurements. SUMMARY This paper describes the technical aspects of NRP DCD that allow for maximization of its use based on different donor and policy characteristics.
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Brubaker AL, Sellers MT, Abt PL, Croome KP, Merani S, Wall A, Abreu P, Alebrahim M, Baskin R, Bohorquez H, Cannon RM, Cederquist K, Edwards J, Huerter BG, Hobeika MJ, Kautzman L, Langnas AN, Lee DD, Manzi J, Nassar A, Neidlinger N, Nydam TL, Schnickel GT, Siddiqui F, Suah A, Taj R, Taner CB, Testa G, Vianna R, Vyas F, Montenovo MI. US Liver Transplant Outcomes After Normothermic Regional Perfusion vs Standard Super Rapid Recovery. JAMA Surg 2024; 159:677-685. [PMID: 38568597 PMCID: PMC10993160 DOI: 10.1001/jamasurg.2024.0520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/06/2024] [Indexed: 04/06/2024]
Abstract
Importance Normothermic regional perfusion (NRP) is an emerging recovery modality for transplantable allografts from controlled donation after circulatory death (cDCD) donors. In the US, only 11.4% of liver recipients who are transplanted from a deceased donor receive a cDCD liver. NRP has the potential to safely expand the US donor pool with improved transplant outcomes as compared with standard super rapid recovery (SRR). Objective To assess outcomes of US liver transplants using controlled donation after circulatory death livers recovered with normothermic regional perfusion vs standard super rapid recovery. Design, Setting, and Participants This was a retrospective, observational cohort study comparing liver transplant outcomes from cDCD donors recovered by NRP vs SRR. Outcomes of cDCD liver transplant from January 2017 to May 2023 were collated from 17 US transplant centers and included livers recovered by SRR and NRP (thoracoabdominal NRP [TA-NRP] and abdominal NRP [A-NRP]). Seven transplant centers used NRP, allowing for liver allografts to be transplanted at 17 centers; 10 centers imported livers recovered via NRP from other centers. Exposures cDCD livers were recovered by either NRP or SRR. Main Outcomes and Measures The primary outcome was ischemic cholangiopathy (IC). Secondary end points included primary nonfunction (PNF), early allograft dysfunction (EAD), biliary anastomotic strictures, posttransplant length of stay (LOS), and patient and graft survival. Results A total of 242 cDCD livers were included in this study: 136 recovered by SRR and 106 recovered by NRP (TA-NRP, 79 and A-NRP, 27). Median (IQR) NRP and SRR donor age was 30.5 (22-44) years and 36 (27-49) years, respectively. Median (IQR) posttransplant LOS was significantly shorter in the NRP cohort (7 [5-11] days vs 10 [7-16] days; P < .001). PNF occurred only in the SRR allografts group (n = 2). EAD was more common in the SRR cohort (123 of 136 [56.1%] vs 77 of 106 [36.4%]; P = .007). Biliary anastomotic strictures were increased 2.8-fold in SRR recipients (7 of 105 [6.7%] vs 30 of 134 [22.4%]; P = .001). Only SRR recipients had IC (0 vs 12 of 133 [9.0%]; P = .002); IC-free survival by Kaplan-Meier was significantly improved in NRP recipients. Patient and graft survival were comparable between cohorts. Conclusion and Relevance There was comparable patient and graft survival in liver transplant recipients of cDCD donors recovered by NRP vs SRR, with reduced rates of IC, biliary complications, and EAD in NRP recipients. The feasibility of A-NRP and TA-NRP implementation across multiple US transplant centers supports increasing adoption of NRP to improve organ use, access to transplant, and risk of wait-list mortality.
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Affiliation(s)
- Aleah L. Brubaker
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, La Jolla, California
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
| | - Marty T. Sellers
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Tennessee Donor Services, Nashville
| | - Peter L. Abt
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | - Kristopher P. Croome
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Transplant, Mayo Clinic Florida, Jacksonville
| | - Shaheed Merani
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, University of Nebraska Medical Center, Omaha
| | - Anji Wall
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Phillipe Abreu
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami, Miami, Florida
| | | | - Roy Baskin
- Methodist Transplant Specialists, Dallas, Texas
| | - Humberto Bohorquez
- Department of Surgery, Ochsner School of Medicine, New Orleans, Louisiana
| | - Robert M. Cannon
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Kelly Cederquist
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | - John Edwards
- Gift of Life Donor Program, Philadelphia, Pennsylvania
| | | | - Mark J. Hobeika
- J.C. Walter Jr Transplant Center, Houston Methodist Hospital, Houston, Texas
| | | | - Alan N. Langnas
- Department of Surgery, University of Nebraska Medical Center, Omaha
| | - David D. Lee
- Department of Surgery, Loyola University, Chicago, Illinois
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Joao Manzi
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami, Miami, Florida
| | - Ahmed Nassar
- Department of Surgery, Emory University, Atlanta, Georgia
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | | | - Trevor L. Nydam
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, Division of Transplant Surgery, University of Colorado, Aurora
| | - Gabriel T. Schnickel
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, La Jolla, California
| | - Farjad Siddiqui
- Department of Surgery, The Ohio State University, Columbus
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Ashley Suah
- Department of Surgery, Emory University, Atlanta, Georgia
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Raeda Taj
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, La Jolla, California
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | | | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Rodrigo Vianna
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami, Miami, Florida
| | - Frederick Vyas
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | - Martin I. Montenovo
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, Vanderbilt University, Nashville, Tennessee
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Croome KP. "Age ain't nothing but a number": Advanced perfusion is the key to increasing the usability of older DCD donor livers. Liver Transpl 2024:01445473-990000000-00381. [PMID: 38767450 DOI: 10.1097/lvt.0000000000000405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 05/14/2024] [Indexed: 05/22/2024]
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Taner CB, Croome KP. What is the true cost of DCD liver transplant from a value-based perspective? Liver Transpl 2024:01445473-990000000-00363. [PMID: 38648195 DOI: 10.1097/lvt.0000000000000382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 04/04/2024] [Indexed: 04/25/2024]
Affiliation(s)
- C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
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Akabane M, Melcher ML, Esquivel CO, Imaoka Y, Kim WR, Sasaki K. Enhancing the usability of older DCD donors through strategic approaches in liver transplantation in the United States. Liver Transpl 2024:01445473-990000000-00361. [PMID: 38625836 DOI: 10.1097/lvt.0000000000000376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/17/2024] [Indexed: 04/18/2024]
Abstract
The use of older donors after circulatory death (DCD) for liver transplantation (LT) has increased over the past decade. This study examined whether outcomes of LT using older DCD (≥50 y) have improved with advancements in surgical/perioperative care and normothermic machine perfusion (NMP) technology. A total of 7602 DCD LT cases from the United Network for Organ Sharing database (2003-2022) were reviewed. The impact of older DCD donors on graft survival was assessed using the Kaplan-Meier and HR analyses. In all, 1447 LT cases (19.0%) involved older DCD donors. Although there was a decrease in their use from 2003 to 2014, a resurgence was noted after 2015 and reached 21.9% of all LTs in the last 4 years (2019-2022). Initially, 90-day and 1-year graft survivals for older DCDs were worse than younger DCDs, but this difference decreased over time and there was no statistical difference after 2015. Similarly, HRs for graft loss in older DCD have recently become insignificant. In older DCD LT, NMP usage has increased recently, especially in cases with extended donor-recipient distances, while the median time from asystole to aortic cross-clamp has decreased. Multivariable Cox regression analyses revealed that in the early phase, asystole to cross-clamp time had the highest HR for graft loss in older DCD LT without NMP, while in the later phases, the cold ischemic time (>5.5 h) was a significant predictor. LT outcomes using older DCD donors have become comparable to those from young DCD donors, with recent HRs for graft loss becoming insignificant. The strategic approach in the recent period could mitigate risks, including managing cold ischemic time (≤5.5 h), reducing asystole to cross-clamp time, and adopting NMP for longer distances. Optimal use of older DCD donors may alleviate the donor shortage.
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Affiliation(s)
- Miho Akabane
- Department of Surgery, Division of Abdominal Transplant, Stanford University Medical Center, Stanford, California, USA
| | - Marc L Melcher
- Department of Surgery, Division of Abdominal Transplant, Stanford University Medical Center, Stanford, California, USA
| | - Carlos O Esquivel
- Department of Surgery, Division of Abdominal Transplant, Stanford University Medical Center, Stanford, California, USA
| | - Yuki Imaoka
- Department of Surgery, Division of Abdominal Transplant, Stanford University Medical Center, Stanford, California, USA
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California, USA
| | - Kazunari Sasaki
- Department of Surgery, Division of Abdominal Transplant, Stanford University Medical Center, Stanford, California, USA
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Wall A, Arunachalam P, Martinez E, Ruiz R, Fernandez H, Bayer J, Gupta A, McKenna GJ, Lee SH, Adams B, Butler D, Noesges S, Duncan M, Rayle M, Monday K, Schwartz G, Testa G. Stepwise development and expansion of an abdominal normothermic regional perfusion program for donation after circulatory determination of death organ procurement. Clin Transplant 2024; 38:e15297. [PMID: 38545915 DOI: 10.1111/ctr.15297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/12/2024] [Accepted: 03/09/2024] [Indexed: 04/20/2024]
Abstract
INTRODUCTION Normothermic regional perfusion (NRP) represents an innovative technology that improves the outcomes for liver and kidney recipients of donation after circulatory determination of death (DCD) organs but protocols for abdominal-only NRP (A-NRP) DCD are lacking in the US. METHODS We describe the implementation and expansion strategies of a transplant-center-based A-NRP DCD program that has grown in volume, geographical reach, and donor acceptance parameters, presented as four eras. RESULTS In the implementation era, two donors were attempted, and one liver graft was transplanted. In the local expansion era, 33% of attempted donors resulted in transplantation and 42% of liver grafts from donors who died within the functional warm ischemic time (fWIT) limit were transplanted. In the Regional Expansion era, 25% of attempted donors resulted in transplantation and 50% of liver grafts from donors who died within the fWIT limit were transplanted. In the Donor Acceptance Expansion era, 46% of attempted donors resulted in transplantation and 72% of liver grafts from donors who died within the fWIT limit were transplanted. Eight discarded grafts demonstrated a potential opportunity for utilization. CONCLUSION The stepwise approach to building an A-NRP program described here can serve as a model for other transplant centers.
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Affiliation(s)
- Anji Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Priya Arunachalam
- Texas A&M College of Medicine, Dallas Regional Campus, Dallas, Texas, USA
| | - Eric Martinez
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Richard Ruiz
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Hoylan Fernandez
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Johanna Bayer
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Amar Gupta
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Gregory J McKenna
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Seung-Hee Lee
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | | | | | - Scott Noesges
- Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - Michael Duncan
- Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - Murphy Rayle
- Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - Kara Monday
- Department of General Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - Gary Schwartz
- Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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Bakhtiyar SS, Maksimuk TE, Gutowski J, Park SY, Cain MT, Rove JY, Reece TB, Cleveland JC, Pomposelli JJ, Bababekov YJ, Nydam TL, Schold JD, Pomfret EA, Hoffman JRH. Association of procurement technique with organ yield and cost following donation after circulatory death. Am J Transplant 2024:S1600-6135(24)00237-5. [PMID: 38521350 DOI: 10.1016/j.ajt.2024.03.027] [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: 01/13/2024] [Revised: 03/15/2024] [Accepted: 03/15/2024] [Indexed: 03/25/2024]
Abstract
Donation after circulatory death (DCD) could account for the largest expansion of the donor allograft pool in the contemporary era. However, the organ yield and associated costs of normothermic regional perfusion (NRP) compared to super-rapid recovery (SRR) with ex-situ normothermic machine perfusion, remain unreported. The Organ Procurement and Transplantation Network (December 2019 to June 2023) was analyzed to determine the number of organs recovered per donor. A cost analysis was performed based on our institution's experience since 2022. Of 43 502 donors, 30 646 (70%) were donors after brain death (DBD), 12 536 (29%) DCD-SRR and 320 (0.7%) DCD-NRP. The mean number of organs recovered was 3.70 for DBD, 3.71 for DCD-NRP (P < .001), and 2.45 for DCD-SRR (P < .001). Following risk adjustment, DCD-NRP (adjusted odds ratio 1.34, confidence interval 1.04-1.75) and DCD-SRR (adjusted odds ratio 2.11, confidence interval 2.01-2.21; reference: DBD) remained associated with greater odds of allograft nonuse. Including incomplete and completed procurement runs, the total average cost of DCD-NRP was $9463.22 per donor. By conservative estimates, we found that approximately 31 donor allografts could be procured using DCD-NRP for the cost equivalent of 1 allograft procured via DCD-SRR with ex-situ normothermic machine perfusion. In conclusion, DCD-SRR procurements were associated with the lowest organ yield compared to other procurement methods. To facilitate broader adoption of DCD procurement, a comprehensive understanding of the trade-offs inherent in each technique is imperative.
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Affiliation(s)
- Syed Shahyan Bakhtiyar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA.
| | - Tiffany E Maksimuk
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - John Gutowski
- University of Colorado Hospital Transplant Center, Aurora, Colorado, USA
| | - Sarah Y Park
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Michael T Cain
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA; University of Colorado Hospital Transplant Center, Aurora, Colorado, USA
| | - Jessica Y Rove
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA; University of Colorado Hospital Transplant Center, Aurora, Colorado, USA
| | - T Brett Reece
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA; University of Colorado Hospital Transplant Center, Aurora, Colorado, USA
| | - Joseph C Cleveland
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA; University of Colorado Hospital Transplant Center, Aurora, Colorado, USA
| | - James J Pomposelli
- University of Colorado Hospital Transplant Center, Aurora, Colorado, USA; Division of Transplant Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Yanik J Bababekov
- University of Colorado Hospital Transplant Center, Aurora, Colorado, USA; Division of Transplant Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Trevor L Nydam
- University of Colorado Hospital Transplant Center, Aurora, Colorado, USA; Division of Transplant Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Jesse D Schold
- Division of Transplant Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA; Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, USA
| | - Elizabeth A Pomfret
- University of Colorado Hospital Transplant Center, Aurora, Colorado, USA; Division of Transplant Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Jordan R H Hoffman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA; University of Colorado Hospital Transplant Center, Aurora, Colorado, USA
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11
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Croome KP. Should advanced perfusion be the standard of care for donation after circulatory death liver transplant? Am J Transplant 2024:S1600-6135(24)00217-X. [PMID: 38514015 DOI: 10.1016/j.ajt.2024.03.021] [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: 12/04/2023] [Revised: 03/06/2024] [Accepted: 03/14/2024] [Indexed: 03/23/2024]
Abstract
As an alternative to static cold storage (SCS), advanced perfusion techniques such as normothermic regional perfusion and ex-situ perfusion (normothermic or hypothermic) have emerged as a way to improve the ischemic injury suffered by donation after circulatory death (DCD) livers. Multiple studies have been published that have demonstrated superior post-DCD liver transplant outcomes when using advanced perfusion compared with SCS. In particular, these studies have shown lower rates of ischemic cholangiopathy with advanced perfusion. In addition to the improved post-liver transplant outcomes, studies have also demonstrated higher rates of liver utilization from DCD donors when advanced perfusion is used compared with SCS. Given the high rates of graft loss in patients who develop ischemic cholangiopathy, the significant reduction seen in DCD donor livers that have undergone advanced perfusion represents a key step in more broad utilization of these livers. With such compelling evidence from multiple trials, it seems reasonable to ask the question: should advanced perfusion be the standard of care for DCD liver transplant?
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12
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Das I, Pham SM, Perry DK, Croome KP. The Use of Ex Situ Normothermic Machine Perfusion in Combined Cardiac and Liver Transplantation Procedures. Transplant Direct 2024; 10:e1574. [PMID: 38274474 PMCID: PMC10810592 DOI: 10.1097/txd.0000000000001574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/05/2023] [Accepted: 10/24/2023] [Indexed: 01/27/2024] Open
Affiliation(s)
- Ian Das
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - Si M. Pham
- Division of Cardiothoracic Surgery, Mayo Clinic Florida, Jacksonville, FL
| | - Dana K. Perry
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
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13
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Wall AE, Da Graca B, Asrani SK, Ruiz R, Fernandez H, Gupta A, Martinez E, Bayer J, McKenna G, He Lee S, Trotter JF, Testa G. A cost comparison of liver acquisition fees for donation after circulatory death versus donation after brain death donors. Liver Transpl 2024:01445473-990000000-00312. [PMID: 38190240 DOI: 10.1097/lvt.0000000000000328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/14/2023] [Indexed: 01/09/2024]
Abstract
Donation after circulatory death (DCD) donors now represent over 30% of the deceased donor pool in the United States. Compared to donation after brain death, DCD is less likely to result in transplantation. For each potential donor whose organs cannot be utilized for transplantation (ie, dry run), fees are associated with the attempted donation, which add to the overall costs of organ acquisition. To better characterize the true costs of DCD liver acquisition, we performed a cost comparison of the fees associated with organ acquisition for DCD versus donation after brain death at a single transplant institute that comprises 2 liver transplant centers. Cost, recipient, and transportation data for all cases, including fees associated with liver acquisition from July 1, 2019, to October 31, 2021, were collected. We found that the total cost of DCD liver acquisition per liver transplant was $15,029 more than that for donation after brain death donation, with 18% of the costs of the DCD transplant attributed to dry runs. Overall, the costs associated with DCD transplantation accounted for 34.5% of the total organ acquisition costs; however, DCD transplantation accounted for 30.3% of the transplantation volume. Because the expansion of DCD is essential to increasing the availability of liver grafts for transplantation, strategies need to be implemented to decrease the costs associated with dry runs, including using local recovery, transferring donors to hospitals close to transplant centers, and performing more prerecovery organ analysis. Moreover, these strategies are needed to ensure that financial disincentives to DCD procurement and utilization do not reverse the gains made by expanding the organ donor pool using machine perfusion technologies.
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Affiliation(s)
- Anji E Wall
- Baylor Simmons Transplant Institute, Dallas, Texas, USA
| | - Briget Da Graca
- Baylor, Scott and White Research Institute, Dallas, Texas, USA
| | | | - Richard Ruiz
- Baylor Simmons Transplant Institute, Dallas, Texas, USA
| | | | - Amar Gupta
- Baylor Simmons Transplant Institute, Dallas, Texas, USA
| | - Eric Martinez
- Baylor Simmons Transplant Institute, Dallas, Texas, USA
| | - Johanna Bayer
- Baylor Simmons Transplant Institute, Dallas, Texas, USA
| | | | - Seung He Lee
- Baylor Simmons Transplant Institute, Dallas, Texas, USA
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14
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Jia ZX, Guo SS, Yang JM, Li HY. Letter to the Editor: Development of a portable abdominal normothermic regional perfusion (A-NRP) program in the United States. Liver Transpl 2024; 30:E4-E5. [PMID: 37204174 DOI: 10.1097/lvt.0000000000000179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/20/2023]
Affiliation(s)
- Zhi-Xing Jia
- Department of Surgery, Wen County People's Hospital, Jiaozuo, Henan, China
| | - Shan-Shan Guo
- Department of Nephrology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ji-Ming Yang
- Department of Surgery, Wen County People's Hospital, Jiaozuo, Henan, China
| | - Hui-Yuan Li
- Department of Surgery, Wen County People's Hospital, Jiaozuo, Henan, China
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15
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Croome KP, Perry DK, Taner CB. Reply: Development of a portable abdominal normothermic regional perfusion (A-NRP) program in the United States. Liver Transpl 2024; 30:E6-E7. [PMID: 37204167 DOI: 10.1097/lvt.0000000000000178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 05/20/2023]
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16
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Fondevila C, Estébanez B, Hessheimer AJ. Practical considerations for implementation of abdominal normothermic regional perfusion. Liver Transpl 2023; 29:1255-1257. [PMID: 37540165 DOI: 10.1097/lvt.0000000000000236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 07/31/2023] [Indexed: 08/05/2023]
Affiliation(s)
- Constantino Fondevila
- General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd, Madrid, Spain
| | - Belén Estébanez
- Transplant Coordination, Hospital Universitario La Paz, Madrid, Spain
| | - Amelia J Hessheimer
- General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd, Madrid, Spain
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