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Hasjim BJ, Sanders JM, Alexander M, Redfield RR, Ichii H. Perfusion Techniques in Kidney Allograft Preservation to Reduce Ischemic Reperfusion Injury: A Systematic Review and Meta-Analysis. Antioxidants (Basel) 2024; 13:642. [PMID: 38929081 PMCID: PMC11200710 DOI: 10.3390/antiox13060642] [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: 03/27/2024] [Revised: 05/16/2024] [Accepted: 05/20/2024] [Indexed: 06/28/2024] Open
Abstract
The limited supply and rising demand for kidney transplantation has led to the use of allografts more susceptible to ischemic reperfusion injury (IRI) and oxidative stress to expand the donor pool. Organ preservation and procurement techniques, such as machine perfusion (MP) and normothermic regional perfusion (NRP), have been developed to preserve allograft function, though their long-term outcomes have been more challenging to investigate. We performed a systematic review and meta-analysis to examine the benefits of MP and NRP compared to traditional preservation techniques. PubMed (MEDLINE), Embase, Cochrane, and Scopus databases were queried, and of 13,794 articles identified, 54 manuscripts were included (n = 41 MP; n = 13 NRP). MP decreased the rates of 12-month graft failure (OR 0.67; 95%CI 0.55, 0.80) and other perioperative outcomes such as delayed graft function (OR 0.65; 95%CI 0.54, 0.79), primary nonfunction (OR 0.63; 95%CI 0.44, 0.90), and hospital length of stay (15.5 days vs. 18.4 days) compared to static cold storage. NRP reduced the rates of acute rejection (OR 0.48; 95%CI 0.35, 0.67) compared to in situ perfusion. Overall, MP and NRP are effective techniques to mitigate IRI and play an important role in safely expanding the donor pool to satisfy the increasing demands of kidney transplantation.
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Affiliation(s)
- Bima J. Hasjim
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery and Islet Cell Transplantation, University of California–Irvine, Orange, CA 92868, USA; (B.J.H.); (M.A.)
| | - Jes M. Sanders
- Department of Surgery, Division of Transplantation, Northwestern Memorial Hospital, Chicago, IL 60611, USA;
| | - Michael Alexander
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery and Islet Cell Transplantation, University of California–Irvine, Orange, CA 92868, USA; (B.J.H.); (M.A.)
| | - Robert R. Redfield
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery and Islet Cell Transplantation, University of California–Irvine, Orange, CA 92868, USA; (B.J.H.); (M.A.)
| | - Hirohito Ichii
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery and Islet Cell Transplantation, University of California–Irvine, Orange, CA 92868, USA; (B.J.H.); (M.A.)
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Moreno P, González-García J, Ruíz-López E, Alvarez A. Lung Transplantation in Controlled Donation after Circulatory-Determination-of-Death Using Normothermic Abdominal Perfusion. Transpl Int 2024; 37:12659. [PMID: 38751771 PMCID: PMC11094278 DOI: 10.3389/ti.2024.12659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 04/15/2024] [Indexed: 05/18/2024]
Abstract
The main limitation to increased rates of lung transplantation (LT) continues to be the availability of suitable donors. At present, the largest source of lung allografts is still donation after the neurologic determination of death (brain-death donors, DBD). However, only 20% of these donors provide acceptable lung allografts for transplantation. One of the proposed strategies to increase the lung donor pool is the use of donors after circulatory-determination-of-death (DCD), which has the potential to significantly alleviate the shortage of transplantable lungs. According to the Maastricht classification, there are five types of DCD donors. The first two categories are uncontrolled DCD donors (uDCD); the other three are controlled DCD donors (cDCD). Clinical experience with uncontrolled DCD donors is scarce and remains limited to small case series. Controlled DCD donation, meanwhile, is the most accepted type of DCD donation for lungs. Although the DCD donor pool has significantly increased, it is still underutilized worldwide. To achieve a high retrieval rate, experience with DCD donation, adequate management of the potential DCD donor at the intensive care unit (ICU), and expertise in combined organ procurement are critical. This review presents a concise update of lung donation after circulatory-determination-of-death and includes a step-by-step protocol of lung procurement using abdominal normothermic regional perfusion.
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Affiliation(s)
- Paula Moreno
- Thoracic Surgery and Lung Transplantation Unit, University Hospital Reina Sofía, Córdoba, Spain
- Group for the Study of Thoracic Neoplasms and Lung Transplantation, IMIBIC (Instituto Maimónides de Investigación Biomédica de Córdoba), University of Córdoba, Córdoba, Spain
| | - Javier González-García
- Thoracic Surgery and Lung Transplantation Unit, University Hospital Reina Sofía, Córdoba, Spain
- Group for the Study of Thoracic Neoplasms and Lung Transplantation, IMIBIC (Instituto Maimónides de Investigación Biomédica de Córdoba), University of Córdoba, Córdoba, Spain
| | - Eloísa Ruíz-López
- Thoracic Surgery and Lung Transplantation Unit, University Hospital Reina Sofía, Córdoba, Spain
- Group for the Study of Thoracic Neoplasms and Lung Transplantation, IMIBIC (Instituto Maimónides de Investigación Biomédica de Córdoba), University of Córdoba, Córdoba, Spain
| | - Antonio Alvarez
- Thoracic Surgery and Lung Transplantation Unit, University Hospital Reina Sofía, Córdoba, Spain
- Group for the Study of Thoracic Neoplasms and Lung Transplantation, IMIBIC (Instituto Maimónides de Investigación Biomédica de Córdoba), University of Córdoba, Córdoba, Spain
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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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Kim DS, Yoon YI, Kim BK, Choudhury A, Kulkarni A, Park JY, Kim J, Sinn DH, Joo DJ, Choi Y, Lee JH, Choi HJ, Yoon KT, Yim SY, Park CS, Kim DG, Lee HW, Choi WM, Chon YE, Kang WH, Rhu J, Lee JG, Cho Y, Sung PS, Lee HA, Kim JH, Bae SH, Yang JM, Suh KS, Al Mahtab M, Tan SS, Abbas Z, Shresta A, Alam S, Arora A, Kumar A, Rathi P, Bhavani R, Panackel C, Lee KC, Li J, Yu ML, George J, Tanwandee T, Hsieh SY, Yong CC, Rela M, Lin HC, Omata M, Sarin SK. Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation. Hepatol Int 2024; 18:299-383. [PMID: 38416312 DOI: 10.1007/s12072-023-10629-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 12/18/2023] [Indexed: 02/29/2024]
Abstract
Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.
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Affiliation(s)
- Dong-Sik Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Pusan National University College of Medicine, Yangsan, Republic of Korea
| | - Sun Young Yim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Cheon-Soo Park
- Department of Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Deok-Gie Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Won-Mook Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Eun Chon
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Woo-Hyoung Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinsoo Rhu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yuri Cho
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Ilsan, Republic of Korea
| | - Pil Soo Sung
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Han Ah Lee
- Department of Internal Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ji Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Si Hyun Bae
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Soek Siam Tan
- Department of Medicine, Hospital Selayang, Batu Caves, Selangor, Malaysia
| | - Zaigham Abbas
- Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Ananta Shresta
- Department of Hepatology, Alka Hospital, Lalitpur, Nepal
| | - Shahinul Alam
- Crescent Gastroliver and General Hospital, Dhaka, Bangladesh
| | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Pravin Rathi
- TN Medical College and BYL Nair Hospital, Mumbai, India
| | - Ruveena Bhavani
- University of Malaya Medical Centre, Petaling Jaya, Selangor, Malaysia
| | | | - Kuei Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jun Li
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Ming-Lung Yu
- Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | | | | | | | | | - H C Lin
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Masao Omata
- Department of Gastroenterology, Yamanashi Central Hospital, Yamanashi, Japan
- University of Tokyo, Bunkyo City, Japan
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Croome KP, Brown TE, Mabrey RL, Sonnenwald SL, Burns JM, Mao SA, Clendenon JN, Nguyen JH, Perry DK, Maddox RG, Taner CB. Development of a portable abdominal normothermic regional perfusion (A-NRP) program in the United States. Liver Transpl 2023; 29:1282-1291. [PMID: 37040930 DOI: 10.1097/lvt.0000000000000156] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 03/26/2023] [Indexed: 04/13/2023]
Abstract
In situ abdominal normothermic regional perfusion (A-NRP) has been used for liver transplantation (LT) with donation after circulatory death (DCD) liver grafts in Europe with excellent results; however, adoption of A-NRP in the United States has been lacking. The current report describes the implementation and results of a portable, self-reliant A-NRP program in the United States. Isolated abdominal in situ perfusion with an extracorporeal circuit was achieved through cannulation in the abdomen or femoral vessels and inflation of a supraceliac aortic balloon and cross-clamp. The Quantum Transport System by Spectrum was used. The decision to use livers for LT was made through an assessment of perfusate lactate (q15min). From May to November 2022, 14 A-NRP donation after circulatory death procurements were performed by our abdominal transplant team (N = 11 LT, N = 20 kidney transplants, and 1 kidney-pancreas transplant). The median A-NRP run time was 68 minutes. None of the LT recipients had post-reperfusion syndrome, nor were there any cases of primary nonfunction. All livers were functioning well at the time of maximal follow-up with zero cases of ischemic cholangiopathy. The current report describes the feasibility of a portable A-NRP program that can be used in the United States. Excellent short-term post-transplant results were achieved with both livers and kidneys procured from A-NRP.
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Affiliation(s)
| | - Thomas E Brown
- Division of Cardiothoracic Surgery, Department of Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Richard L Mabrey
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | | | - Justin M Burns
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Shennen A Mao
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Jacob N Clendenon
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Justin H Nguyen
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Dana K Perry
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Rebecca G Maddox
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, Florida, USA
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Mora-Cuesta VM, Tello-Mena S, Izquierdo-Cuervo S, Iturbe-Fernández D, Sánchez-Moreno L, Ballesteros MA, Alonso-Lecue P, Ortíz-Portal F, Ferrer-Pargada D, Miñambres-García E, Cifrián-Martínez JM, Naranjo-Gozalo S. Bronchial Stenosis After Lung Transplantation From cDCD Donors Using Simultaneous Abdominal Normothermic Regional Perfusion: A Single-center Experience. Transplantation 2023; 107:2415-2423. [PMID: 37389647 DOI: 10.1097/tp.0000000000004698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
BACKGROUND Controlled donation after circulatory death (cDCD) has increased the number of lung donors significantly. The use of abdominal normothermic regional perfusion (A-NRP) during organ procurement is a common practice in some centers due to its benefits on abdominal grafts. This study aimed to assess whether the use of A-NRP in cDCD increases the frequency of bronchial stenosis in lung transplant (LT) recipients. METHODS A single-center, retrospective study including all LTs was performed between January 1, 2015, and August 30, 2022. Airway stenosis was defined as a stricture that leads to clinical/functional worsening requiring the use of invasive monitoring and therapeutic procedures. RESULTS A total of 308 LT recipients were included in the study. Seventy-six LT recipients (24.7%) received lungs from cDCD donors using A-NRP during organ procurement. Forty-seven LT recipients (15.3%) developed airway stenosis, with no differences between lung recipients with grafts from cDCD (17.2%) and donation after brain death donors (13.3%; P = 0.278). A total of 48.9% of recipients showed signs of acute airway ischemia on control bronchoscopy at 2 to 3 wk posttransplant. Acute ischemia was an independent risk factor for airway stenosis development (odds ratio = 2.523 [1.311-4.855], P = 0.006). The median number of bronchoscopies per patient was 5 (2-9), and 25% of patients needed >8 dilatations. Twenty-three patients underwent endobronchial stenting (50.0%) and each patient needed a median of 1 (1-2) stent. CONCLUSIONS Incidence of airway stenosis is not increased in LT recipients with grafts obtained from cDCD donors using A-NRP.
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Affiliation(s)
- Víctor M Mora-Cuesta
- Lung Transplant Unit, Respiratory Department Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
| | - Sandra Tello-Mena
- Lung Transplant Unit, Respiratory Department Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
| | - Sheila Izquierdo-Cuervo
- Lung Transplant Unit, Respiratory Department Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
| | - David Iturbe-Fernández
- Lung Transplant Unit, Respiratory Department Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
| | - Laura Sánchez-Moreno
- Thoracic Surgery, Lung Transplant Unit, Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
| | - Maria Angeles Ballesteros
- Transplant Coordination Unit and Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, School of Medicine, Universidad de Cantabria, Santander, Cantabria, Spain
| | | | - Felix Ortíz-Portal
- Respiratory Department, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain
| | - Diego Ferrer-Pargada
- Respiratory Department, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain
| | - Eduardo Miñambres-García
- Transplant Coordination Unit and Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, School of Medicine, Universidad de Cantabria, Santander, Cantabria, Spain
| | - José M Cifrián-Martínez
- Lung Transplant Unit, Respiratory Department Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
| | - Sara Naranjo-Gozalo
- Thoracic Surgery, Lung Transplant Unit, Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
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7
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Steinberg I, Patrono D, De Cesaris E, Lucà M, Catalano G, Marro M, Rizza G, Simonato E, Brazzi L, Romagnoli R, Zanierato M. Viability assessment of livers donated after circulatory determination of death during normothermic regional perfusion. Artif Organs 2023; 47:1592-1603. [PMID: 37548353 DOI: 10.1111/aor.14622] [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: 04/28/2023] [Revised: 06/14/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Abdominal normothermic regional perfusion (A-NRP) allows in-situ reperfusion and recovery of abdominal organs metabolism in donors after circulatory death (DCD). Besides improving liver transplantation outcomes, liver injury and function can be assessed during A-NRP. METHODS To refine liver viability assessment during A-NRP, prospectively collected data of controlled DCD donors managed at our Institution between October 2019 and May 2022 were retrospectively analyzed. Baseline characteristics, procedural variables and A-NRP parameters of donors whose liver was successfully transplanted were compared to those of donors whose liver was discarded. RESULTS Twenty-seven donors were included and in 20 (74%) the liver was accepted (positive outcome). No differences between study groups were observed concerning baseline characteristics and warm ischemia times (WIT). Initial lactate levels were positively correlated with functional WIT (r2 = 0.4, p = 0.04), whereas transaminase levels were not. Blood flow during A-NRP was comparable, whereas oxygen consumption (VO2 ) was significantly higher in the positive outcome group after 1 h. Time courses of lactate, AST and ALT were significantly different between study groups (p < 0.001). Donors whose liver was accepted showed faster lactate clearance, a difference which was amplified by normalizing lactate clearance to oxygen delivery (DO2 ) and VO2 . Lactate clearance was correlated to transaminase levels and DO2 -normalized lactate clearance was the parameter best discriminating between study groups. CONCLUSIONS DO2 -normalized lactate clearance may represent an element of liver viability assessment during A-NRP.
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Affiliation(s)
- Irene Steinberg
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Mechanical and Aerospace Engineering, Polytechnic University of Turin, Turin, Italy
| | - Damiano Patrono
- General Surgery 2U - Liver Transplant Center, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Enrico De Cesaris
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Michele Lucà
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Giorgia Catalano
- General Surgery 2U - Liver Transplant Center, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Matteo Marro
- Cardiovascular Surgery, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Giorgia Rizza
- General Surgery 2U - Liver Transplant Center, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Erika Simonato
- Cardiovascular Surgery, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Luca Brazzi
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Renato Romagnoli
- Department of Surgical Sciences, University of Turin, Turin, Italy
- General Surgery 2U - Liver Transplant Center, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Marinella Zanierato
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
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8
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Croome KP, Barbas AS, Whitson B, Zarrinpar A, Taner T, Lo D, MacConmara M, Kim J, Kennealey PT, Bromberg JS, Washburn K, Agopian VG, Stegall M, Quintini C. American Society of Transplant Surgeons recommendations on best practices in donation after circulatory death organ procurement. Am J Transplant 2023; 23:171-179. [PMID: 36695685 DOI: 10.1016/j.ajt.2022.10.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 09/19/2022] [Accepted: 10/14/2022] [Indexed: 01/13/2023]
Abstract
The American Society of Transplant Surgeons supports efforts to increase the number of organs that are critically needed for patients desperately awaiting transplantation. In the United States, transplantation using organs procured from donation after circulatory death (DCD) donors has continued to increase in number. Despite these increases, substantial variability in the utilization and practices of DCD transplantation still exists. To improve DCD organ utilization, it is important to create a set of best practices for DCD recovery. The following recommendations aim to provide guidance on contemporary issues surrounding DCD organ procurement in the United States. A work group was composed of members of the American Society of Transplant Surgeon Scientific Studies Committee and the Thoracic Organ Transplantation Committee. The following topics were identified by the group either as controversial or lacking standardization: prewithdrawal preparation, definition of donor warm ischemia time, DCD surgical technique, combined thoracic and abdominal procurements, and normothermic regional perfusion. The proposed recommendations were classified on the basis of the grade of available evidence and the strength of the recommendation. This information should be valuable for transplant programs as well as for organ procurement organizations and donor hospitals as they develop robust DCD donor procurement protocols.
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Affiliation(s)
| | - Andrew S Barbas
- Division of Abdominal Transplant Surgery,Duke University,Durham,North Carolina,USA
| | - Bryan Whitson
- Division of Cardiac Surgery,Department of Surgery,The Ohio State University Wexner Medical Center,Columbus,Ohio,USA
| | - Ali Zarrinpar
- Department of Surgery,College of Medicine,University of Florida, Gainesville,Florida,USA
| | - Timucin Taner
- Department of Surgery,Mayo Clinic Rochester,Rochester,Minnesota,USA
| | - Denise Lo
- Emory Transplant Center,Emory University,Atlanta, Georgia,USA
| | - Malcolm MacConmara
- Division of Surgical Transplantation,Department of Surgery,University of Texas Southwestern Medical Center,Dallas,Texas,USA
| | - Jim Kim
- Department of Surgery,Keck Medical Center,University of Southern California,Los Angeles,California,USA
| | - Peter T Kennealey
- Department of Surgery,University of Colorado School of Medicine,Aurora,Colorado,USA
| | - Jonathan S Bromberg
- Department of Surgery,University of Maryland School of Medicine,Baltimore,Maryland,USA
| | - Kenneth Washburn
- Department of Surgery,The Ohio State University Wexner Medical Center,Columbus,Ohio,USA
| | - Vatche G Agopian
- Department of Surgery,David Geffen School of Medicine,University of California,Los Angeles,Los Angeles,California,USA
| | - Mark Stegall
- Department of Surgery,Mayo Clinic Rochester,Rochester,Minnesota,USA
| | - Cristiano Quintini
- Department of Surgery,Transplantation Center,Digestive Disease and Surgery Institute,Cleveland Clinic,Cleveland,Ohio,USA
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9
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Croome KP. Introducing Machine Perfusion into Routine Clinical Practice for Liver Transplantation in the United States: The Moment Has Finally Come. J Clin Med 2023; 12:jcm12030909. [PMID: 36769557 PMCID: PMC9918031 DOI: 10.3390/jcm12030909] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/06/2023] [Accepted: 01/17/2023] [Indexed: 01/25/2023] Open
Abstract
While adoption of machine perfusion technologies into clinical practice in the United States has been much slower than in Europe, recent changes in the transplant landscape as well as device availability following FDA approval have paved the way for rapid growth. Machine perfusion may provide one mechanism to maximize the utilization of potential donor liver grafts. Indeed, multiple studies have shown increased organ utilization with the implementation of technologies such as ex-situ normothermic machine perfusion (NMP), ex-situ hypothermic machine perfusion (HMP) and in-situ normothermic regional perfusion (NRP). The current review describes the history and development of machine perfusion utilization in the Unites States along with future directions. It also describes the differences in landscape between Europe and the United States and how this has shaped clinical application of these technologies.
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10
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Where are we today with machine perfusion of liver in donation after circulatory death liver transplantation? TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100111] [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] Open
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11
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Lepoittevin M, Giraud S, Kerforne T, Allain G, Thuillier R, Hauet T. How to improve results after DCD (donation after circulation death). Presse Med 2022; 51:104143. [PMID: 36216034 DOI: 10.1016/j.lpm.2022.104143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/29/2022] [Indexed: 11/09/2022] Open
Abstract
The shortage of organs for transplantation has led health professionals to look for alternative sources of donors. One of the avenues concerns donors who have died after circulatory arrest. This is a special situation because the organs from these donors are exposed to warm ischaemia-reperfusion lesions that are unavoidable during the journey of the organs from the donor to the moment of transplantation in the recipient. We will address and discuss the key issues from the perspective of team organization, legislation and its evolution, and the ethical framework. In a second part, the avenues to improve the quality of organs will be presented following the itinerary of the organs between the donor and the recipient. The important moments from the point of view of therapeutic strategy will be put into perspective. New connections between key players involved in pathophysiological mechanisms and implications for innate immunity and injury processes are among the avenues to explore. Technological developments to improve the quality of organs from these recipients will be analyzed, such as perfusion techniques with new modalities of temperatures and oxygenation. New molecules are being investigated for their potential role in protecting these organs and an analysis of potential prospects will be proposed. Finally, the important perspectives that seem to be favored will be discussed in order to reposition the use of deceased donors after circulatory arrest. The use of these organs has become a routine procedure and improving their quality and providing the means for their evaluation is absolutely inevitable.
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Affiliation(s)
- Maryne Lepoittevin
- Unité UMR U1082, F-86000 Poitiers, France; Faculté de Médecine et de Pharmacie, Université de Poitiers, F-86000 Poitiers, France
| | - Sébastien Giraud
- Unité UMR U1082, F-86000 Poitiers, France; Service de Biochimie, Pôle Biospharm, Centre Hospitalier Universitaire, 2 rue de la Milétrie, CS 90577, 86021 Poitiers Cedex, France
| | - Thomas Kerforne
- Unité UMR U1082, F-86000 Poitiers, France; Faculté de Médecine et de Pharmacie, Université de Poitiers, F-86000 Poitiers, France; CHU Poitiers, Service de Réanimation Chirurgie Cardio-Thoracique et Vasculaire, Coordination des P.M.O., F-86021 Poitiers, France
| | - Géraldine Allain
- Unité UMR U1082, F-86000 Poitiers, France; Faculté de Médecine et de Pharmacie, Université de Poitiers, F-86000 Poitiers, France; CHU Poitiers, Service de Chirurgie Cardiothoracique et Vasculaire, F-86021 Poitiers, France
| | - Raphaël Thuillier
- Unité UMR U1082, F-86000 Poitiers, France; Faculté de Médecine et de Pharmacie, Université de Poitiers, F-86000 Poitiers, France; Service de Biochimie, Pôle Biospharm, Centre Hospitalier Universitaire, 2 rue de la Milétrie, CS 90577, 86021 Poitiers Cedex, France
| | - Thierry Hauet
- Unité UMR U1082, F-86000 Poitiers, France; Faculté de Médecine et de Pharmacie, Université de Poitiers, F-86000 Poitiers, France; Fédération Hospitalo-Universitaire « Survival Optimization in Organ Transplantation », CHU de Poitiers, 2 rue de la Milétrie - CS 90577, 86021 Poitiers Cedex, France.
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12
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Normothermic Regional Perfusion Provides a Great Opportunity to Maximize Organ Procurement in Donation After the Circulatory Determination of Death. Crit Care Med 2022; 50:1649-1653. [PMID: 36227033 DOI: 10.1097/ccm.0000000000005645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Schurink IJ, van de Leemkolk FEM, Fondevila C, De Carlis R, Savier E, Oniscu GC, Huurman VAL, de Jonge J. Donor eligibility criteria and liver graft acceptance criteria during normothermic regional perfusion: A systematic review. Liver Transpl 2022; 28:1563-1575. [PMID: 35603445 PMCID: PMC9796375 DOI: 10.1002/lt.26512] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 04/23/2022] [Accepted: 05/12/2022] [Indexed: 01/01/2023]
Abstract
Acceptance of liver grafts from donations after circulatory death (DCD) largely remains a "black box," particularly due to the unpredictability of the agonal phase. Abdominal normothermic regional perfusion (aNRP) can reverse ischemic injury early during the procurement procedure, and it simultaneously enables graft viability testing to unravel this black box. This review evaluates current protocols for liver viability assessment to decide upon acceptance or decline during aNRP. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was used, and relevant literature databases were searched. The primary outcome consisted of criteria for liver graft viability assessment. Secondary outcomes included survival, primary nonfunction (PNF), early dysfunction, and biliary complications. A total of 14 articles were included in the analysis. In all protocols, a combination of criteria was used to assess suitability of the liver for transplantation. As many as 12 studies (86%) used macroscopic assessment, 12 studies (86%) used alanine transaminase (ALT) levels in perfusate, 9 studies (64%) used microscopic assessment, and 7 studies (50%) used lactate levels as assessment criteria. The organ utilization rate (OUR) was 16% for uncontrolled donation after circulatory death (uDCD) and 64% for controlled donation after circulatory death (cDCD). The most used acceptation criterion in uDCD is ALT level (31%), while in cDCD macroscopic aspect (48%) is most used. Regarding postoperative complications, PNF occurred in 13% (6%-25%) of uDCD livers and 3% (2%-4%) of cDCD livers. In uDCD, the 1-year graft and patient survival rates were 75% (66%-82%) and 82% (75%-88%). In cDCD, the 1-year graft and patient survival rates were 91% (89%-93%) and 93% (91%-94%), respectively. In conclusion, the currently used assessment criteria consist of macroscopic aspect and transaminase levels. The acceptance criteria should be tailored according to donor type to prevent an unacceptable PNF rate in uDCD and to increase the relatively modest OUR in cDCD.
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Affiliation(s)
- Ivo J. Schurink
- Department of SurgeryErasmus MC Transplant InstituteRotterdamThe Netherlands
| | | | | | - Riccardo De Carlis
- Department of Surgery and TransplantationASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | - Eric Savier
- Department of Hepato‐Biliary and Pancreatic Surgery and Liver TransplantationPitie‐Salpetriere Hospital, Assistance Publique‐Hôpitaux de Paris (AP‐HP), Sorbonne UniversityParisFrance
| | | | - Volkert A. L. Huurman
- Department of Surgery, Transplant CenterLeiden University Medical CenterLeidenThe Netherlands
| | - Jeroen de Jonge
- Department of SurgeryErasmus MC Transplant InstituteRotterdamThe Netherlands
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14
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Fernández-de la Varga M, Del Pozo-Del Valle P, Béjar-Serrano S, López-Andújar R, Berenguer M, Prieto M, Montalvá E, Aguilera V. Good post-transplant outcomes using liver donors after circulatory death when applying strict selection criteria: A propensity-score matched-cohort study. Ann Hepatol 2022; 27:100724. [PMID: 35643260 DOI: 10.1016/j.aohep.2022.100724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/13/2022] [Accepted: 05/12/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Outcomes of liver transplantation (LT) with donors after circulatory death (DCD) have been considered suboptimal due to higher rates of ischemic cholangiopathy, especially when the super-rapid recovery (SRR) technique is used. This study aimed to compare the incidence of complications between recipients receiving DCD vs those receiving donors after brain death (DBD) in a large-volume liver transplant centre. METHODS We performed a retrospective cohort study (LT from January 2015 to December 2018) comparing recipients who underwent a LT with DCD vs. a control group of LT with DBD, matched 1:1 without replacement by propensity score matching that included the following variables: LT indication, recipient sex and age, donor age and MELD score. RESULTS 51 recipients with DCD-LT (29 SRR, 22 normothermic regional perfusion [NRP]) were matched with 51 DBD-LT recipients. Biliary complications were more frequent in DCD, 10% (n=5), all with SRR technique, vs 2% (n=1) in the DBD group, p=0.2. Two patients (4%) suffered primary graft non-function in the DCD group (1 SRR and 1 NRP) versus zero in the DBD group (p=0.49). Postoperative bleeding and reinterventions were also higher in the DCD group: 7 (13.7%) vs 1 (1.95%) and 8 (15.7%) vs 2 (3.9%) respectively (p=0.06 and 0.09). On the 1st postoperative day AST/ALT peak was higher in DCD (p≤0001). The incidence of rejection, vascular complications, renal injury, hospital stay, and readmissions were similar in both groups. Cumulative 1-, 2-, 3- and 4-year graft and patient survival were also similar. CONCLUSIONS DCD donors are an adequate option to increase the donor pool in LT, achieving similar graft and patient survival rates to those achieved with DBD donors, especially when the NRP technique is used.
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Affiliation(s)
| | - Pablo Del Pozo-Del Valle
- Hepatology and Liver Transplantation Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Sergio Béjar-Serrano
- Hepatology and Liver Transplantation Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Rafael López-Andújar
- Department of Hepatobiliopancreatic Surgery and Transplantation Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain; University of Valencia, Valencia, Spain; Liver and Digestive Diseases Networking Biomedical Research Centre (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; IIS La Fe, Valencia, Spain
| | - Marina Berenguer
- Hepatology and Liver Transplantation Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain; University of Valencia, Valencia, Spain; Liver and Digestive Diseases Networking Biomedical Research Centre (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; IIS La Fe, Valencia, Spain
| | - Martín Prieto
- Hepatology and Liver Transplantation Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Liver and Digestive Diseases Networking Biomedical Research Centre (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; IIS La Fe, Valencia, Spain
| | - Eva Montalvá
- Department of Hepatobiliopancreatic Surgery and Transplantation Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain; University of Valencia, Valencia, Spain; Liver and Digestive Diseases Networking Biomedical Research Centre (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; IIS La Fe, Valencia, Spain
| | - Victoria Aguilera
- Hepatology and Liver Transplantation Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain; University of Valencia, Valencia, Spain; Liver and Digestive Diseases Networking Biomedical Research Centre (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; IIS La Fe, Valencia, Spain
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15
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Shields AD, Battistelli JD, Kavanagh LB, Thomson BA, Nielsen PE. A modified Delphi approach to determine current treatment advances for the development of a resuscitation program for maternal cardiac arrest. BMC Emerg Med 2022; 22:149. [PMID: 36028819 PMCID: PMC9419332 DOI: 10.1186/s12873-022-00704-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/30/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Maternal cardiac arrest is a rare and complex process requiring pregnancy-specific responses and techniques. The goals of this study were to (1) identify, evaluate, and determine the most current best practices to treat this patient population and (2) establish a standardized set of guidelines to serve as a foundation for a future educational simulation-based curriculum. STUDY DESIGN We used a three-step modified Delphi process to achieve consensus. Twenty-two healthcare experts from across North America agreed to participate in the expert panel. In round 1, 12 pregnancy-specific best practice statements were distributed to the expert panel. Panelists anonymously ranked these using a 7-point Likert scale and provided feedback. Round 2 consisted of a face-to-face consensus meeting where statements that had not already achieved consensus were discussed and then subsequently voted upon by the panelists. RESULTS Through two rounds, we achieved consensus on nine evidence-based pregnancy-specific techniques to optimize response to maternal cardiac arrest. Round one resulted in one of the 12 best practice statements achieving consensus. Round two resulted in six of the remaining 12 gaining consensus. Best practice techniques involved use of point-of care ultrasound, resuscitative cesarean delivery, cardiopulmonary resuscitation techniques, and the use of extracorporeal cardiopulmonary resuscitation. CONCLUSION The results of this study provide the foundation to develop an optimal, long-term strategy to treat cardiac arrest in pregnancy. We propose these nine priorities for standard practice, curricula, and guidelines to treat maternal cardiac arrest and hope they serve as a foundation for a future educational curriculum.
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Affiliation(s)
- Andrea D. Shields
- Department of Obstetrics and Gynecology, University of Connecticut, Farmington, CT USA
| | - Jacqueline D. Battistelli
- Department of Obstetrics and Gynecology, San Antonio Uniformed Services Health Education Consortium, San Antonio, TX USA
| | - Laurie B. Kavanagh
- Department of Obstetrics and Gynecology, University of Connecticut, Farmington, CT USA
| | - Brook A. Thomson
- Department of Obstetrics and Gynecology, University of Texas Health Sciences Center, San Antonio, TX USA
| | - Peter E. Nielsen
- Department of Obstetrics and Gynecology, University of Connecticut, Farmington, CT USA
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16
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Mora V, Ballesteros MA, Naranjo S, Sánchez L, Suberviola B, Iturbe D, Cimadevilla B, Tello S, Alvarez C, Miñambres E. Lung transplantation from controlled donation after circulatory death using simultaneous abdominal normothermic regional perfusion: A single center experience. Am J Transplant 2022; 22:1852-1860. [PMID: 35390225 DOI: 10.1111/ajt.17057] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/04/2022] [Accepted: 04/04/2022] [Indexed: 01/25/2023]
Abstract
Despite the benefits of abdominal normothermic regional perfusion (A-NRP) for abdominal grafts in controlled donation after circulatory death (cDCD), there is limited information on the effect of A-NRP on the quality of the cDCD lungs. We aimed to study the effect of A-NRP in lungs obtained from cDCD and its impact on recipients´ outcomes. This is a study comparing outcomes of lung transplants (LT) from cDCD donors (September 2014 to December 2021) obtained using A-NRP as the abdominal preservation method. As controls, all lung recipients transplanted from donors after brain death (DBD) were considered. The primary outcomes were lung recipient 3-month, 1-year, and 5-year survival. A total of 269 LT were performed (60 cDCD and 209 DBD). There was no difference in survival at 3 months (98.3% cDCD vs. 93.7% DBD), 1 year (90.9% vs. 87.2%), and 5 years (68.7% vs. 69%). LT from the cDCD group had a higher rate of primary graft dysfunction grade 3 at 72 h (10% vs. 3.4%; p < .001). This is the largest experience ever reported with the use of A-NRP combined with lung retrieval in cDCD donors. This combined method is safe for lung grafts presenting short-term survival outcomes equivalent to those transplanted through DBD.
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Affiliation(s)
- Victor Mora
- Service of Neumology, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Maria Angeles Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Sara Naranjo
- Service of Thoracic Surgery, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Laura Sánchez
- Service of Thoracic Surgery, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Borja Suberviola
- Transplant Coordination Unit & Service of Intensive Care, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - David Iturbe
- Service of Neumology, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Bonifacio Cimadevilla
- Service of Anesthesia, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Sandra Tello
- Service of Neumology, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Carlos Alvarez
- Service of Thoracic Surgery, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain.,School of Medicine, University of Cantabria, Santander, Spain
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17
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Melandro F, Basta G, Torri F, Biancofiore G, Del Turco S, Orlando F, Guarracino F, Maremmani P, Lazzeri C, Peris A, De Simone P, Ghinolfi D. Normothermic regional perfusion in liver transplantation from donation after cardiocirculatory death: Technical, biochemical, and regulatory aspects and review of literature. Artif Organs 2022; 46:1727-1740. [PMID: 35733227 DOI: 10.1111/aor.14330] [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: 01/07/2022] [Revised: 03/21/2022] [Accepted: 05/25/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Organs from donation after circulatory death (DCD) are increasingly used for liver transplantation, due to the persisting organ shortage and waiting list mortality. However, the use of DCD grafts is still limited by the inferior graft survival rate and the increased risk of primary non-function and biliary complications when compared to brain death donors' grafts. METHODS Abdominal normothermic regional perfusion with extracorporeal membrane oxygenation (ECMO) is an in situ preservation strategy. which may mitigate ischemia-reperfusion injuries. and has been proposed to restore blood perfusion after the determination of death thus optimizing liver function before implantation. RESULTS In this systematic review, we highlighted the clinical evidence supporting the use of normothermic regional perfusion in DCD liver underlying the pathophysiological mechanisms, and technical, logistic, and regulatory aspects. CONCLUSIONS Despite the lack of properly designed, prospective, randomized trials, the current available data suggest beneficial effects of normothermic regional perfusion on clinical outcomes after liver transplantation.
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Affiliation(s)
- Fabio Melandro
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Giuseppina Basta
- Institute of Clinical Physiology, CNR San Cataldo Research Area, Pisa, Italy
| | - Francesco Torri
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Giandomenico Biancofiore
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy.,Department of Surgical, Medical, Biochemical Pathology and Intensive Care, University of Pisa, Pisa, Italy
| | - Serena Del Turco
- Institute of Clinical Physiology, CNR San Cataldo Research Area, Pisa, Italy
| | - Francesco Orlando
- Hepatobiliary Surgery and Liver Transplant Center Hospital A. Cardarelli, Naples, Italy
| | - Fabio Guarracino
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Paolo Maremmani
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Chiara Lazzeri
- Tuscany Regional Transplant Authority, Centro Regionale Allocazione Organi e Tessuti (CRAOT), Florence, Italy
| | - Adriano Peris
- Tuscany Regional Transplant Authority, Centro Regionale Allocazione Organi e Tessuti (CRAOT), Florence, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy.,Department of Surgical, Medical, Biochemical Pathology and Intensive Care, University of Pisa, Pisa, Italy
| | - Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
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18
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Gasteiger L, Putzer G, Unterpertinger R, Cardini B, Schneeberger S, Eschertzhuber S, Mair P. Solid Organ Donation From Brain-dead Donors With Cardiorespiratory Arrest After Snow Avalanche Burial: A Retrospective Single-center Study. Transplantation 2022; 106:584-587. [PMID: 33859150 DOI: 10.1097/tp.0000000000003785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Complete snow avalanche burial is associated with high mortality. The aim of this study was to assess the feasibility and incidence of organ retrieval in brain-dead donors following cardiorespiratory arrest due to avalanche burial and to evaluate the function of transplanted organs. METHODS The transplant registry of the Medical University of Innsbruck was searched for organ donors with a history of avalanche burial, and the function and survival of transplanted organs were assessed. RESULTS Thirty-three organs were procured from eight donors and 31 organs (13 kidneys, 6 livers, 3 pancreases, 5 hearts, and 4 lungs) were ultimately transplanted. Allograft and recipient 1-y survival were 100% and both initial and long-term graft function were good. Only one-third of all avalanche victims who died in the intensive care unit with signs of irreversible hypoxic brain injury became organ donors. CONCLUSIONS Initial experience from this retrospective study suggests that organs from brain-dead avalanche victims can be transplanted with good results. Starting a Donation after Circulatory Determination of Death program might be an option for increasing the number of organ donations from avalanche victims with irreversible hypoxic brain injury.
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Affiliation(s)
- Lukas Gasteiger
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Gabriel Putzer
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Regina Unterpertinger
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Stephan Eschertzhuber
- Department of Anaesthesiology and Intensive Care Medicine, Hospital Hall in Tirol, Tirol, Austria.,Regional transplant coordinator, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter Mair
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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19
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Ruiz P, Valdivieso A, Palomares I, Prieto M, Ventoso A, Salvador P, Senosiain M, Fernandez JR, Testillano M, Bustamante FJ, Gastaca M. Similar Results in Liver Transplantation From Controlled Donation After Circulatory Death Donors With Normothermic Regional Perfusion and Donation After Brain Death Donors: A Case-Matched Single-Center Study. Liver Transpl 2021; 27:1747-1757. [PMID: 34455694 DOI: 10.1002/lt.26281] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/01/2021] [Accepted: 08/21/2021] [Indexed: 12/13/2022]
Abstract
Although good results have been reported with the use of normothermic regional perfusion (NRP) in controlled donation after circulatory death (cDCD) liver transplantation (LT), there is a lack of evidence to demonstrate similar results to donation after brain death (DBD). We present a single-center retrospective case-matched (1:2) study including 100 NRP cDCD LTs and 200 DBD LTs and a median follow-up of 36 months. Matching was done according to donor age, recipient Model for End-Stage Liver Disease score, and cold ischemia time. The following perioperative results were similar in both groups: alanine transaminase peaks of 909 U/L in the DBD group and 836 U/L in the cDCD group and early allograft disfunction percentages of 21% and 19.2%, respectively. The 1-year and 3-year overall graft survival for cDCD was 99% and 93%, respectively, versus 92% and 87%, respectively, for DBD (P = 0.04). Of note, no cases of primary nonfunction or ischemic-type biliary lesion were observed among the cDCD grafts. Our results confirm that NRP cDCD LT meets the same outcomes as those obtained with DBD LT and provides evidence to support the idea that cDCD donors per se should no longer be considered as "marginal donors" when recovered with NRP.
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Affiliation(s)
- Patricia Ruiz
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Bask Country, Barakaldo, Spain
| | - Andres Valdivieso
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Bask Country, Barakaldo, Spain
| | - Ibone Palomares
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Bask Country, Barakaldo, Spain
| | - Mikel Prieto
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Bask Country, Barakaldo, Spain
| | - Alberto Ventoso
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Bask Country, Barakaldo, Spain
| | - Patricia Salvador
- Hepatology and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Basque Country, Barakaldo, Spain
| | - Maria Senosiain
- Hepatology and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Basque Country, Barakaldo, Spain
| | - Jose Ramon Fernandez
- Hepatology and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Basque Country, Barakaldo, Spain
| | - Milagros Testillano
- Hepatology and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Basque Country, Barakaldo, Spain
| | - Francisco Javier Bustamante
- Hepatology and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Basque Country, Barakaldo, Spain
| | - Mikel Gastaca
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Bask Country, Barakaldo, Spain
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20
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Rubio Muñoz JJ, Dominguez-Gil González B, Miñambres García E, Del Río Gallegos F, Pérez-Villares JM. Role of normothermic perfusion with ECMO in donation after controlled cardiac death in Spain. Med Intensiva 2021; 46:31-41. [PMID: 34794913 DOI: 10.1016/j.medine.2021.11.001] [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: 12/15/2019] [Revised: 01/26/2020] [Accepted: 01/31/2020] [Indexed: 02/07/2023]
Abstract
Spain has become one of the most active countries in donation after controlled cardiac death, using normothermic abdominal perfusion with ECMO in more than 50% of all donors - a situation contributed to by the creation of mobile teams to support hospitals lacking this technology. The donation process must be respectful of the wishes and values of the patients and their relatives, especially if there is pre mortem manipulation, and the absence of cerebral perfusion should be guaranteed. The liver is the most benefited organ by reducing biliary complications as well as the loss of grafts. In renal transplantation, the technique could contribute to reduce the incidence of delayed graft function. In addition, the procedure is compatible with surgical rapid recovery in hypothermia when there is also lung donation. The future lies in the consolidation of cardiac donation by extending normothermic perfusion to the thoracic cavity.
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Affiliation(s)
- J J Rubio Muñoz
- Servicio de Medicina Intensiva, Unidad de Coordinación de Trasplantes, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain.
| | | | - E Miñambres García
- Coordinación Regional de Trasplantes de la Comunidad de Cantabria, Servicio de Medicina Intensiva del Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - F Del Río Gallegos
- Coordinación Regional de Trasplantes de la Comunidad de Madrid, Servicio de Medicina Intensiva del Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - J M Pérez-Villares
- Coordinador Regional de Trasplantes de la Comunidad de Andalucía, Servicio de Medicina Intensiva del Hospital Universitario Virgen de las Nieves, Granada, Spain
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21
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Padilla M, Coll E, Fernández-Pérez C, Pont T, Ruiz Á, Pérez-Redondo M, Oliver E, Atutxa L, Manciño JM, Daga D, Miñambres E, Moya J, Vidal B, Dueñas-Jurado JM, Mosteiro F, Rodríguez-Salgado A, Fernández-García E, Lara R, Hernández-Marrero D, Estébanez B, Rodríguez-Ferrero ML, Barber M, García-López F, Andrés A, Santiago C, Zapatero A, Badenes R, Carrizosa F, Blanco JJ, Bernal JL, Elola FJ, Vidal C, Terrón C, Castro P, Comas J, Domínguez-Gil B. Improved short-term outcomes of kidney transplants in controlled donation after the circulatory determination of death with the use of normothermic regional perfusion. Am J Transplant 2021; 21:3618-3628. [PMID: 33891793 DOI: 10.1111/ajt.16622] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/26/2021] [Accepted: 04/16/2021] [Indexed: 01/25/2023]
Abstract
Normothermic regional perfusion (NRP) allows the in situ perfusion of organs with oxygenated blood in donation after the circulatory determination of death (DCDD). We aimed at evaluating the impact of NRP on the short-term outcomes of kidney transplants in controlled DCDD (cDCDD). This is a multicenter, nationwide, retrospective study comparing cDCDD kidneys obtained with NRP versus the standard rapid recovery (RR) technique. During 2012-2018, 2302 cDCDD adult kidney transplants were performed in Spain using NRP (n = 865) or RR (n = 1437). The study groups differed in donor and recipient age, warm, and cold ischemic time and use of ex situ machine perfusion. Transplants in the NRP group were more frequently performed in high-volume centers (≥90 transplants/year). Through matching by propensity score, two cohorts with a total of 770 patients were obtained. After the matching, no statistically significant differences were observed between the groups in terms of primary nonfunction (p = .261) and mortality at 1 year (p = .111). However, the RR of kidneys was associated with a significantly increased odds of delayed graft function (OR 1.97 [95% CI 1.43-2.72]; p < .001) and 1-year graft loss (OR 1.77 [95% CI 1.01-3.17]; p = .034). In conclusion, compared with RR, NRP appears to improve the short-term outcomes of cDCDD kidney transplants.
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Affiliation(s)
| | | | - Cristina Fernández-Pérez
- Preventive Medicine and Public Health Department, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain.,Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain
| | - Teresa Pont
- Donation and Transplantation Coordination Unit, Hospital Universitario Vall d'Hebrón, Barcelona, Spain.,Vall d'Hebron Barcelona Hospital Campus, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Ángel Ruiz
- Donation and Transplantation Coordination Unit, Hospital Clinic, Barcelona, Spain
| | - Marina Pérez-Redondo
- Donation and Transplantation Coordination Unit, Hospital Universitario Puerta de Hierro- Majadahona, Madrid, Spain
| | - Eva Oliver
- Donation and Transplantation Coordination Unit, Hospital Universitario de Bellvitge, Barcelona, Spain
| | - Lander Atutxa
- Intensive Care Department, Donation and Transplantation Coordination Unit, Hospital Universitario de Donostia, San Sebastián, Spain
| | - José M Manciño
- Intensive Care Department, Hospital Universitario Germans Trias i Pujol, Badalona, Spain
| | - Domingo Daga
- Intensive Care Department, Regional Donor Transplant Coordination, Hospital Universitario Virgen de la Victoria de Málaga, Málaga, Spain
| | - Eduardo Miñambres
- Intensive Care Department, Donation and Transplantation Coordination Unit, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain.,School of Medicine, University of Cantabria, Santander, Spain
| | - José Moya
- Intensive Care Department, Donation and Transplantation Coordination Unit, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Bárbara Vidal
- Intensive Care Department, Donation and Transplantation Coordination Unit, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | | | - Fernando Mosteiro
- Donation and Transplantion Coordination Unit, Complejo Hospitalario Universitario de A Coruña, La Coruña, Spain
| | - Alberto Rodríguez-Salgado
- Intensive Care Department, Donation and Transplantation Coordination Unit, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | | | - Ramón Lara
- Intensive Care Department, Hospital Universitario Virgen de las Nieves, Regional Donor Transplant Coordination in Granada, Granada, Spain
| | - Domingo Hernández-Marrero
- Nephrology Department, Instituto de Investigación Biomédica de Málaga (IBIMA) REDINREN RD16/0009/0006, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Belén Estébanez
- Intensive Care Department, Donation and Transplantation Coordination Unit, Hospital Universitario La Paz, Madrid, Spain
| | | | - María Barber
- Intensive Care Department, Donation and Transplantation Coordination Unit, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Fernando García-López
- Intensive Care Department, Donation and Transplantation Coordination Unit, Hospital General Universitario de Albacete, Albacete, Spain
| | - Amado Andrés
- Nephrology Department, Donation and Transplantation Coordination Unit, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Carlos Santiago
- Nephrology Department, Donation and Transplantation Coordination Unit, Hospital General Universitario de Alicante, Alicante, Spain
| | - Ana Zapatero
- Donation and Transplantation Coordination Unit, Hospital del Mar, Barcelona, Spain
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Department of Surgery, University of Valencia, Valencia, Spain.,INCLIVA, Research Health Institute, Valencia, Spain
| | - Francisco Carrizosa
- Intensive Care Department, Donation and Transplantation Coordination Unit, Hospital Universitario de Jerez de la Frontera, Jerez de la Frontera, Spain
| | - José J Blanco
- Intensive Care Department, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - José L Bernal
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain.,Management Control Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Francisco J Elola
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain
| | | | | | - Pablo Castro
- Coordinación Autonómica de Trasplantes de Andalucía, Sevilla, Spain
| | - Jordi Comas
- Organització Catalana de Trasplantaments, Barcelona, Spain
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22
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Hosgood SA, Brown RJ, Nicholson ML. Advances in Kidney Preservation Techniques and Their Application in Clinical Practice. Transplantation 2021; 105:e202-e214. [PMID: 33982904 PMCID: PMC8549459 DOI: 10.1097/tp.0000000000003679] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/03/2020] [Accepted: 12/15/2020] [Indexed: 11/25/2022]
Abstract
The use of cold preservation solutions to rapidly flush and cool the kidney followed by static cold storage in ice has been the standard kidney preservation technique for the last 50 y. Nonetheless, changing donor demographics that include organs from extended criteria donors and donation after circulatory death donors have led to the adoption of more diverse techniques of preservation. Comparison of hypothermic machine perfusion and static cold storage techniques for deceased donor kidneys has long been debated and is still contested by some. The recent modification of hypothermic machine perfusion techniques with the addition of oxygen or perfusion at subnormothermic or near-normothermic temperatures are promising strategies that are emerging in clinical practice. In addition, the use of normothermic regional perfusion to resuscitate abdominal organs of donation after circulatory death donors in situ before cold flushing is also increasingly being utilized. This review provides a synopsis of the different types of preservation techniques including their mechanistic effects and the outcome of their application in clinical practice for different types of donor kidney.
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Affiliation(s)
- Sarah A. Hosgood
- Department of Surgery, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Rachel J. Brown
- Department of Surgery, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Michael L. Nicholson
- Department of Surgery, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
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23
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De Beule J, Vandendriessche K, Pengel LHM, Bellini MI, Dark JH, Hessheimer AJ, Kimenai HJAN, Knight SR, Neyrinck AP, Paredes D, Watson CJE, Rega F, Jochmans I. A systematic review and meta-analyses of regional perfusion in donation after circulatory death solid organ transplantation. Transpl Int 2021; 34:2046-2060. [PMID: 34570380 DOI: 10.1111/tri.14121] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 12/29/2022]
Abstract
In donation after circulatory death (DCD), (thoraco)abdominal regional perfusion (RP) restores circulation to a region of the body following death declaration. We systematically reviewed outcomes of solid organ transplantation after RP by searching PubMed, Embase, and Cochrane libraries. Eighty-eight articles reporting on outcomes of liver, kidney, pancreas, heart, and lung transplants or donor/organ utilization were identified. Meta-analyses were conducted when possible. Methodological quality was assessed using National Institutes of Health (NIH)-scoring tools. Case reports (13/88), case series (44/88), retrospective cohort studies (35/88), retrospective matched cohort studies (5/88), and case-control studies (2/88) were identified, with overall fair quality. As blood viscosity and rheology change below 20 °C, studies were grouped as hypothermic (HRP, ≤20 °C) or normothermic (NRP, >20 °C) regional perfusion. Data demonstrate that RP is a safe alternative to in situ cold preservation (ISP) in uncontrolled and controlled DCDs. The scarce HRP data are from before 2005. NRP appears to reduce post-transplant complications, especially biliary complications in controlled DCD livers, compared with ISP. Comparisons for kidney and pancreas with ISP are needed but there is no evidence that NRP is detrimental. Additional data on NRP in thoracic organs are needed. Whether RP increases donor or organ utilization needs further research.
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Affiliation(s)
- Julie De Beule
- Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | | | - Liset H M Pengel
- Nuffield Department of Surgical Sciences, Centre for Evidence in Transplantation, University of Oxford, Oxford, UK
| | - Maria Irene Bellini
- Department of Emergency Medicine and Surgery, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - John H Dark
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Amelia J Hessheimer
- Department of General & Digestive Surgery, Institut Clínic de Malalties Digestives i Metabòliques (ICMDM), Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Hendrikus J A N Kimenai
- Division of Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Simon R Knight
- Nuffield Department of Surgical Sciences, Centre for Evidence in Transplantation, University of Oxford, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Arne P Neyrinck
- Department of Cardiovascular Sciences, Anesthesiology and Algology, KU Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - David Paredes
- Donation and Transplant Coordination Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Christopher J E Watson
- Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,The NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Filip Rega
- Department of Cardiovascular Sciences, Cardiac Surgery, KU Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Ina Jochmans
- Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
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24
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Early Allograft Dysfunction and Complications in DCD Liver Transplantation: Expert Consensus Statements From the International Liver Transplantation Society. Transplantation 2021; 105:1643-1652. [PMID: 34291765 DOI: 10.1097/tp.0000000000003877] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Livers for transplantation from donation after circulatory death donors are relatively more prone to early and ongoing alterations in graft function that might ultimately lead to graft loss and even patient death. In consideration of this fact, this working group of the International Liver Transplantation Society has performed a critical evaluation of the medical literature to create a set of statements regarding the assessment of early allograft function/dysfunction and complications arising in the setting of donation after circulatory death liver transplantation.
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25
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Kidney Transplants in Controlled Donation Following Circulatory Death, or Maastricht Type III Donors, With Abdominal Normothermic Regional Perfusion, Optimizing Functional Outcomes. Transplant Direct 2021; 7:e725. [PMID: 34291147 PMCID: PMC8288885 DOI: 10.1097/txd.0000000000001174] [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: 11/25/2020] [Revised: 03/31/2021] [Accepted: 04/18/2021] [Indexed: 11/28/2022] Open
Abstract
Supplemental Digital Content is available in the text. Background. Warm ischemia time and ischemia-reperfusion damage result in higher rates of delayed graft function and primary nonfunction in kidney transplants (KTs) from controlled donation after circulatory death (cDCD). This study aimed to assess early and late kidney function and patient and graft survival of KT from cDCD preserved with normothermic regional perfusion (NRP) and to compare with KT from brain death donors (DBDs) and cDCD preserved with rapid recovery (RR). Methods. Patients who received a KT at our institution from 2012 to 2018 were included, with a minimum follow-up period of 1 y. They were categorized by donor type and conditioning methods: DBD, cDCD with NRP, and cDCD with RR. Early and late graft function, along with patient and graft survival were analyzed in all groups. Results. A total of 182 KT recipients were included in the study (98 DBD and 84 cDCD). Out of the cDCDs, 24 kidneys were recovered with the use of NRP and 62 with RR; 22 of the 24 kidneys were ultimately transplanted. The cDCD using NRP group showed lower rates of delayed graft function compared with the cDCD with RR group (36.3% versus 46.7%, P = 0.01). Also, primary nonfunction rates were lower in the cDCD using NRP group (4.5% versus 6.4% cDCD-RR and 10.2% DBD). Patient survival rates were >90% in all groups. No differences were found in graft survival rates at 1 y. Conclusions. The use of abdominal NRP improves early function recovery of KT from cDCD, making their outcomes comparable with those of DBD.
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26
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Transplantation of discarded livers: the complementary role of normothermic regional perfusion. Nat Commun 2021; 12:4471. [PMID: 34294697 PMCID: PMC8298635 DOI: 10.1038/s41467-021-24595-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 06/23/2021] [Indexed: 11/18/2022] Open
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27
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Pearson R, Geddes C, Mark P, Clancy M, Asher J. Transplantation of kidneys after normothermic perfusion: A single center experience. Clin Transplant 2021; 35:e14431. [PMID: 34288129 DOI: 10.1111/ctr.14431] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/21/2021] [Accepted: 07/07/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND In order to expand the pool of usable donors from circulatory death (DCD) there is increasing interest in normothermic regional perfusion (NRP) to assess and improve liver viability.1,2 NRP may also improve outcomes in kidney transplantation.We present our single center experience of outcomes in imported kidneys following NRP. METHODS Data was obtained from a prospectively maintained database between December 2012 and September 2018. Primary endpoints were incidence of delayed graft function (DGF) and estimated glomerular filtration rate (eGFR). RESULTS Six-hundred and thirty-two decease donor kidneys were transplanted, 229 from DCD donors, 29 of which had NRP. The DGF rate was lower for NRP versus DCD (six of 29, 20.7% vs. 70 of 200, 35.0%) with reduced duration of DGF. Multivariate analysis demonstrated transplant type to be a statistically significant independent predictor of eGFR at 7 and 14 days. Early transplant function in NRP kidneys was comparable to DBD. There were no graft losses within 30 days in the NRP group. One-year graft loss rate was 3.4% for NRP and 6.0% for standard DCD. CONCLUSION This data suggests NRP is safe, and reduces rates of DGF and improves early renal transplant function.
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Affiliation(s)
- Robert Pearson
- Department of Renal Transplantation, Queen Elizabeth University Hospital, Glasgow, UK
| | - Colin Geddes
- Department of Renal Transplantation, Queen Elizabeth University Hospital, Glasgow, UK
| | - Patrick Mark
- Institute of Cardiovascular and Molecular Sciences, University of Glasgow, Glasgow, UK
| | - Marc Clancy
- Department of Renal Transplantation, Queen Elizabeth University Hospital, Glasgow, UK
| | - John Asher
- Department of Renal Transplantation, Queen Elizabeth University Hospital, Glasgow, UK
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28
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Jochmans I, Hessheimer AJ, Neyrinck AP, Paredes D, Bellini MI, Dark JH, Kimenai HJAN, Pengel LHM, Watson CJE. Consensus statement on normothermic regional perfusion in donation after circulatory death: report from the European Society for Organ Transplantation's Transplant Learning Journey. Transpl Int 2021; 34:2019-2030. [PMID: 34145644 DOI: 10.1111/tri.13951] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/08/2021] [Accepted: 06/09/2021] [Indexed: 11/27/2022]
Abstract
Normothermic regional perfusion (NRP) in donation after circulatory death (DCD) is a safe alternative to in situ cooling and rapid procurement. An increasing number of countries and centres are performing NRP, a technically and logistically challenging procedure. This consensus document provides evidence-based recommendations on the use of NRP in uncontrolled and controlled DCDs. It also offers minimal ethical, logistical and technical requirements that form the foundation of a safe and effective NRP programme. The present article is based on evidence and opinions formulated by a panel of European experts of Workstream 04 of the Transplantation Learning Journey project, which is part of the European Society for Organ Transplantation.
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Affiliation(s)
- Ina Jochmans
- Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Amelia J Hessheimer
- Department of General & Digestive Surgery, Institut Clínic de Malalties Digestives i Metabòliques (ICMDM), Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Arne P Neyrinck
- Anesthesiology and Algology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - David Paredes
- Donation and Transplant Coordination Unit, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain
| | - Maria Irene Bellini
- Department of Emergency Medicine and Surgery, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - John H Dark
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Hendrikus J A N Kimenai
- Division of Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Liset H M Pengel
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Christopher J E Watson
- University of Cambridge, Department of Surgery, Addenbrooke's Hospital, NIHR Cambridge Biomedical Research Centre, Cambridge, UK
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29
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Ischemia-Reperfusion Injuries Assessment during Pancreas Preservation. Int J Mol Sci 2021; 22:ijms22105172. [PMID: 34068301 PMCID: PMC8153272 DOI: 10.3390/ijms22105172] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 04/25/2021] [Accepted: 05/10/2021] [Indexed: 12/20/2022] Open
Abstract
Maintaining organ viability between donation and transplantation is of critical importance for optimal graft function and survival. To date in pancreas transplantation, static cold storage (SCS) is the most widely practiced method of organ preservation. The first experiments in ex vivo perfusion of the pancreas were performed at the beginning of the 20th century. These perfusions led to organ oedema, hemorrhage, and venous congestion after revascularization. Despite these early hurdles, a number of factors now favor the use of perfusion during preservation: the encouraging results of HMP in kidney transplantation, the development of new perfusion solutions, and the development of organ perfusion machines for the lung, heart, kidneys and liver. This has led to a resurgence of research in machine perfusion for whole organ pancreas preservation. This review highlights the ischemia-reperfusion injuries assessment during ex vivo pancreas perfusion, both for assessment in pre-clinical experimental models as well for future use in the clinic. We evaluated perfusion dynamics, oedema assessment, especially by impedance analysis and MRI, whole organ oxygen consumption, tissue oxygen tension, metabolite concentrations in tissue and perfusate, mitochondrial respiration, cell death, especially by histology, total cell free DNA, caspase activation, and exocrine and endocrine assessment.
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30
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Abstract
PURPOSE OF REVIEW To summarize recently published studies of preservation strategies including machine perfusion in pancreas transplantation. RECENT FINDINGS The shortage of conventional donors is leading units to use extended criteria donors (ECDs) and donors after cardiac death (DCD). Static cold storage (SCS) is still the standard method of preservation for pancreases and University of Wisconsin remains the gold standard preservation solution. In experimental studies, oxygen delivered during preservation reduced tissue injury and improved islet cell yield and function. Hypothermic machine perfusion of discarded human pancreases has been shown to improve adenosine triphosphate levels without adversely effect histology and oedema compared with SCS. Normothermic machine perfusion of discarded human organs has so far been challenging and led to increasing injury, rather than preservation. There are currently no clinical studies in pancreas transplant with the exception of a small number of pancreases being transplanted following normothermic regional perfusion. SUMMARY The storm of new organ preservation methods is now being more widely studied in the pancreas, with some promising results. These new strategies have the potential to allow expansion of the donor pool and greater utilization of ECD and DCD organs.
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31
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Tanaka S, Luis Campo-Cañaveral de la Cruz J, Crowley Carrasco S, Romero Román A, Hoyos Mejía L, Manuel NaranjoGómez J, Córdoba Peláez M, Sánchez Calle Á, Gil Barturen M, Pérez Redondo M, García Fadul C, Varela de Ugarte A, Gómez-de-Antonio D. Effect on the donor lungs of using abdominal normothermic regional perfusion in controlled donation after circulatory death. Eur J Cardiothorac Surg 2020; 59:ezaa398. [PMID: 33225359 DOI: 10.1093/ejcts/ezaa398] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/21/2020] [Accepted: 08/22/2020] [Indexed: 02/24/2024] Open
Abstract
OBJECTIVES Controlled donation after circulatory death (cDCD) donors are becoming a common source of organs for transplantation globally. However, the graft survival rate of cDCD abdominal organs is inferior to that of organs from brain-dead donors. The rapid retrieval (RR) technique is used by most donor organ procurement teams. The abdominal normothermic regional perfusion (A-NRP) technique has been implemented to minimize warm ischaemic damage to the abdominal organs. However, there is limited information on the effect of A-NRP on the quality of the donor lungs. This study aimed to compare lung transplantation outcomes using lungs procured from cDCD donors using the A-NRP and abdominal RR techniques. METHODS A single-centre retrospective analysis of consecutive transplant recipients of cDCD lungs from June 2013 to December 2019 was performed. The recipients were divided into 2 cohorts according to the abdominal procurement technique used. The recipient and donor characteristics (age, sex, cause of brain injury, warm ischaemic time, diagnosis, lung allocation score and other factors), incidence of primary graft dysfunction and early survival were monitored. RESULTS Twenty-eight consecutive lung transplantation recipients were identified (median age 59 years; 61% male); 14 recipients received lungs using the A-NRP and 14 using abdominal RR for abdominal organ retrieval. There were no significant differences in the baseline characteristics, primary graft dysfunction (P = 0.70), hospital mortality (P = 1.0) and 1-year survival rate (P = 1.0) between the 2 groups. CONCLUSIONS No difference was observed in lung transplantation outcomes irrespective of the abdominal organ procurement technique used (A-NRP or abdominal RR).
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Affiliation(s)
- Shin Tanaka
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | | | - Silvana Crowley Carrasco
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Alejandra Romero Román
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Lucas Hoyos Mejía
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Jose Manuel NaranjoGómez
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Mar Córdoba Peláez
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Álvaro Sánchez Calle
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Mariana Gil Barturen
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Marina Pérez Redondo
- Intensive Care Unit, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Christian García Fadul
- Department of Pneumology, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Andrés Varela de Ugarte
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - David Gómez-de-Antonio
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
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Abdominal Normothermic Regional Perfusion in Donation After Circulatory Death: A Systematic Review and Critical Appraisal. Transplantation 2020; 104:1776-1791. [PMID: 32541563 DOI: 10.1097/tp.0000000000003345] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Abdominal normothermic regional perfusion (aNRP) for donation after circulatory death is an emerging organ preservation technique that might lead to increased organ utilization per donor by facilitating viability testing, improving transplant outcome by early reversal of ischemia, and decreasing the risk of unintentional surgical damage. The aim of the current review is to evaluate the recent literature on the added value of aNRP when compared to local standard perfusion technique. METHODS The Preferred Reporting Items for Systematic reviews and Meta-Analyses guideline for systematic reviews was used, and relevant literature databases were searched. Primary outcomes were organ utilization rate and patient and graft survival after 1 year. Secondary outcomes included delayed graft function, primary nonfunction, serum creatinine, and biliary complications. RESULTS A total of 24 articles were included in this review. The technique is unanimously reported to be feasible and safe, but the available studies are characterized by considerable heterogeneity and bias. CONCLUSIONS Uniform reported outcome measures are needed to draw more definitive conclusions on transplant outcomes and organ utilization. A randomized controlled trial comparing aNRP with standard procurement technique in donation after circulatory death donors would be needed to show the added value of the procedure and determine its place among modern preservation techniques.
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Ghinolfi D, Lai Q, Dondossola D, De Carlis R, Zanierato M, Patrono D, Baroni S, Bassi D, Ferla F, Lauterio A, Lazzeri C, Magistri P, Melandro F, Pagano D, Pezzati D, Ravaioli M, Rreka E, Toti L, Zanella A, Burra P, Petta S, Rossi M, Dutkowski P, Jassem W, Muiesan P, Quintini C, Selzner M, Cillo U. Machine Perfusions in Liver Transplantation: The Evidence-Based Position Paper of the Italian Society of Organ and Tissue Transplantation. Liver Transpl 2020; 26:1298-1315. [PMID: 32519459 DOI: 10.1002/lt.25817] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 05/26/2020] [Accepted: 05/08/2020] [Indexed: 02/05/2023]
Abstract
The use of machine perfusion (MP) in liver transplantation (LT) is spreading worldwide. However, its efficacy has not been demonstrated, and its proper clinical use has far to go to be widely implemented. The Società Italiana Trapianti d'Organo (SITO) promoted the development of an evidence-based position paper. A 3-step approach has been adopted to develop this position paper. First, SITO appointed a chair and a cochair who then assembled a working group with specific experience of MP in LT. The Guideline Development Group framed the clinical questions into a patient, intervention, control, and outcome (PICO) format, extracted and analyzed the available literature, ranked the quality of the evidence, and prepared and graded the recommendations. Recommendations were then discussed by all the members of the SITO and were voted on via the Delphi method by an institutional review board. Finally, they were evaluated and scored by a panel of external reviewers. All available literature was analyzed, and its quality was ranked. A total of 18 recommendations regarding the use and the efficacy of ex situ hypothermic and normothermic machine perfusion and sequential normothermic regional perfusion and ex situ MP were prepared and graded according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. A critical and scientific approach is required for the safe implementation of this new technology.
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Affiliation(s)
- Davide Ghinolfi
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Quirino Lai
- Hepatobiliary and Organ Transplantation Unit, Sapienza University of Rome, Rome, Italy
| | - Daniele Dondossola
- General and Liver Transplantation Unit, Fondazione IRCCS Ca'Granda, University of Milan Medical School Hospital, Milan, Italy
| | - Riccardo De Carlis
- Department of General Surgery and Abdominal Transplantation, Niguarda Hospital, Milan, Italy
| | - Marinella Zanierato
- General Surgery and Liver Transplantation, University of Turin Medical School Hospital, Turin, Italy
| | - Damiano Patrono
- Department of Anesthesiology, University of Turin Medical School Hospital, Turin, Italy
| | - Stefano Baroni
- Department of Anesthesiology, University of Modena Medical School Hospital, Modena, Italy
| | - Domenico Bassi
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Padua Medical School Hospital, Padua, Italy
| | - Fabio Ferla
- Department of General Surgery and Abdominal Transplantation, Niguarda Hospital, Milan, Italy
| | - Andrea Lauterio
- Department of General Surgery and Abdominal Transplantation, Niguarda Hospital, Milan, Italy
| | - Chiara Lazzeri
- Intensive Care Unit and Regional ECMO Referral Centre, University of Florence Medical School Hospital, Florence, Italy
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver, Transplantation Unit, University of Modena Medical School Hospital, Modena, Italy
| | - Fabio Melandro
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Duilio Pagano
- Department for the Treatment and the Study of Abdominal Diseases and Abdominal Transplantation, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione and University of Pittsburgh Medical Center, Palermo, Italy
| | - Daniele Pezzati
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Matteo Ravaioli
- Department of Organ Insufficiency and Transplantation, General Surgery and Transplantation, University of Bologna Medical School Hospital, Bologna, Italy
| | - Erion Rreka
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Luca Toti
- HPB and Transplant Unit, Department of Surgery, University of Tor Vergata, Rome, Italy
| | - Alberto Zanella
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, University of Milan Medical School Hospital, Milan, Italy
| | - Patrizia Burra
- Department of Surgery, Oncology, and Gastroenterology, University of Padua Medical School Hospital, Padua, Italy
| | - Salvatore Petta
- Division of Gastroenterology and Hepatology, University of Palermo Medical School Hospital, Palermo, Italy
| | - Massimo Rossi
- Hepatobiliary and Organ Transplantation Unit, Sapienza University of Rome, Rome, Italy
| | - Philippe Dutkowski
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Wayel Jassem
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Paolo Muiesan
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | | | - Markus Selzner
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Padua Medical School Hospital, Padua, Italy
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Kidney Transplant From Uncontrolled Donation After Circulatory Death: Contribution of Normothermic Regional Perfusion. Transplantation 2020; 104:130-136. [PMID: 30985577 DOI: 10.1097/tp.0000000000002753] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The French uncontrolled donors after circulatory death (DCD) protocol restricts donor age to <55 years, no-flow time to <30 minutes, and functional warm ischemia time to <150 minutes. In situ kidney perfusion can be performed at either 4°C (in situ cooling [ISC]) or 33-36°C (normothermic regional perfusion [NRP]). Hypothermic machine perfusion is systematically used. Only nonimmunized first transplant recipients were eligible. To improve the management of uncontrolled DCD, we tried to identify factors predictive of outcome. METHODS We identified all kidney transplants from uncontrolled DCD between 2007 and 2014 from the French Transplant Registry. Risk factors for primary nonfunction (PNF; n = 37) and poor renal function (estimated glomerular filtration rate < 30 mL/min or graft loss at 1 y, n = 66) were analyzed by using a multivariate logistic model. RESULTS This study analyzed 499 kidney transplantations, 50% of which were performed with NRP. Mean functional warm ischemia time was 135 minutes. Mean cold ischemia time was 14 hours. The principal PNF risk factor was young donor age (odds ratio [OR] = 0.95; P = 0.002). A sensitivity analysis showed a higher risk of PNF with ISC than with NRP (OR = 4.5; P = 0.015). Risk factors for poor renal function were donor body mass index (OR = 1.2; P < 0.001) and ISC versus NRP. Univariate analysis of uncontrolled DCD-specific risk factors showed no-flow time, functional warm time, and cold ischemia time did not affect the risk of PNF or poor renal function. CONCLUSIONS Uncontrolled DCD kidneys are an additional source of valuable transplants. NRP appears to decrease graft failure by restoring oxygenated blood as the first step of preconditioning.
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35
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Croome KP. Donation after Circulatory Death: Potential Mechanisms of Injury and Preventative Strategies. Semin Liver Dis 2020; 40:256-263. [PMID: 32557479 DOI: 10.1055/s-0040-1709487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Donation after circulatory death (DCD) donors represent a potential means to help address the disparity between the number of patients awaiting liver transplantation (LT) and the availability of donor livers. While initial enthusiasm for DCD LT was high in the early 2000s, early reports of high rates of biliary complications and inferior graft survival resulted in reluctance among many transplant centers to use DCD liver grafts. As with all innovations in transplant practice, there is undoubtedly a learning curve associated with the optimal utilization of liver grafts from DCD donors. More contemporary data has demonstrated that results with DCD LT are improving and the number of DCD LT performed annually has been steadily increasing. In this concise review, potential mechanisms of injury for DCD livers are discussed along with strategies that have been employed in clinical practice to improve DCD LT outcomes.
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36
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Abstract
Purpose of Review The transplant community continues to look for ways to help address the discordance between donor liver graft availability and patients on the liver transplant waiting list. Donation after circulatory death (DCD) donor livers represents one potential means to help address this discordance. The present review describes the changing landscape of DCD liver transplantation (LT). Recent Findings The number of DCD LTs performed annually within the USA has continued to grow on an annual basis. Importantly, national data has demonstrated that outcomes with DCD LT have been improving. This improvement has been driven by better understanding of how to successfully utilize these organs through better donor and recipient matching and careful evaluation of both hemodynamics during withdrawal of life support and the refinement of the procurement operation. Summary Despite these improvements in outcome, ischemic cholangiopathy (IC) continues to be the Achilles heel of DCD LT. Emerging technologies such as various forms of machine perfusion may allow for reduction of complications and better prognostication of the risk associated with DCD liver grafts.
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Affiliation(s)
- Kristopher P Croome
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
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37
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Rubio Muñoz JJ, Dominguez-Gil González B, Miñambres García E, Del Río Gallegos F, Pérez-Villares JM. Role of normothermic perfusión with ECMO in donation after controlled cardiac death in Spain. Med Intensiva 2020; 46:S0210-5691(20)30066-8. [PMID: 32564985 DOI: 10.1016/j.medin.2020.01.017] [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: 12/15/2019] [Revised: 01/26/2020] [Accepted: 01/31/2020] [Indexed: 02/07/2023]
Abstract
Spain has become one of the most active countries in donation after controlled cardiac death, using normothermic abdominal perfusion with ECMO in more than 50% of all donors - a situation contributed to by the creation of mobile teams to support hospitals lacking this technology. The donation process must be respectful of the wishes and values of the patients and their relatives, especially if there is pre mortem manipulation, and the absence of cerebral perfusion should be guaranteed. The liver is the most benefited organ by reducing biliary complications as well as the loss of grafts. In renal transplantation, the technique could contribute to reduce the incidence of delayed graft function. In addition, the procedure is compatible with surgical rapid recovery in hypothermia when there is also lung donation. The future lies in the consolidation of cardiac donation by extending normothermic perfusion to the thoracic cavity.
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Affiliation(s)
- J J Rubio Muñoz
- Servicio de Medicina Intensiva, Unidad de Coordinación de Trasplantes, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España.
| | | | - E Miñambres García
- Coordinación Regional de Trasplantes de la Comunidad de Cantabria, Servicio de Medicina Intensiva del Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, España
| | - F Del Río Gallegos
- Coordinación Regional de Trasplantes de la Comunidad de Madrid, Servicio de Medicina Intensiva del Hospital Universitario Clínico San Carlos, Madrid, España
| | - J M Pérez-Villares
- Coordinador Regional de Trasplantes de la Comunidad de Andalucía, Servicio de Medicina Intensiva del Hospital Universitario Virgen de las Nieves, Granada, España
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38
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Parent B, Moazami N, Wall S, Carillo J, Kon Z, Smith D, Walsh BC, Caplan A. Ethical and logistical concerns for establishing NRP-cDCD heart transplantation in the United States. Am J Transplant 2020; 20:1508-1512. [PMID: 31913567 DOI: 10.1111/ajt.15772] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/12/2019] [Accepted: 12/31/2019] [Indexed: 01/25/2023]
Abstract
Controlled heart donation after circulatory determination of death (cDCD) is well established internationally with good outcomes and could be adopted in the United States to increase heart supply if ethical and logistical challenges are comprehensively addressed. The most effective and resource-efficient method for mitigating warm ischemia after circulatory arrest is normothermic regional perfusion (NRP) in situ. This strategy requires restarting circulation after declaration of death according to circulatory criteria, which appears to challenge the legal circulatory death definition requiring irreversible cessation. Permanent cessation for life-saving efforts must be achieved to assuage this concern and ligating principal vessels maintains no blood flow to the brain, which ensures natural progression to cessation of brain function. This practice-standard in some countries-raises unique concerns about prioritizing life-saving efforts, informed authorization from decision-makers, and the clinician's role in the patient's death. To preserve public trust, medical integrity, and respect for the donor, the donation conversation must not take place until after an un-coerced decision to withdraw life-sustaining treatment made in accordance with the patient's treatment goals. The decision-maker(s) must understand cDCD procedure well enough to provide genuine authorization and the preservation/procurement teams must be kept separate from the clinical care team.
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Affiliation(s)
- Brendan Parent
- Department of Population Health, Division of Medical Ethics, NYU Langone Health, New York, New York
| | - Nader Moazami
- NYU Langone Transplant Institute, New York, New York
| | - Stephen Wall
- Ronald O. Perelman Department of Emergency Medicine, NYU Langone Health, New York, New York.,Department of Population Health, Division of Health and Behavior, NYU Langone Health, New York, New York
| | - Julius Carillo
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Zachary Kon
- NYU Langone Transplant Institute, New York, New York
| | - Deane Smith
- NYU Langone Transplant Institute, New York, New York.,Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - B Corbett Walsh
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, NYU Langone Health, New York, New York
| | - Arthur Caplan
- Department of Population Health, Division of Medical Ethics, NYU Langone Health, New York, New York
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Pérez Redondo M, Alcántara Carmona S, Fernández Simón I, Villanueva Fernández H, Ortega López A, Pardo Rey C, Duerto Álvarez J, Lipperheide Vallhonrat I, González Romero M, Ballesteros Ortega D, Río Gallegos F, Rubio Muñoz JJ. Implementation of a mobile team to provide normothermic regional perfusion in controlled donation after circulatory death: Pilot study and first results. Clin Transplant 2020; 34:e13899. [DOI: 10.1111/ctr.13899] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 04/11/2020] [Accepted: 05/02/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Marina Pérez Redondo
- Department of Intensive Care MedicineHospital Universitario Puerta de Hierro Majadahonda Madrid Spain
| | - Sara Alcántara Carmona
- Department of Intensive Care MedicineHospital Universitario Puerta de Hierro Majadahonda Madrid Spain
| | | | | | - Alfonso Ortega López
- Department of Intensive Care MedicineHospital Universitario Puerta de Hierro Majadahonda Madrid Spain
| | - Cándido Pardo Rey
- Department of Intensive Care Medicine and Transplant Coordinator. HospitalUniversitario Clínico San Carlos Madrid Spain
| | - Jorge Duerto Álvarez
- Department of Intensive Care Medicine and Transplant Coordinator. HospitalUniversitario Clínico San Carlos Madrid Spain
| | | | - Manuel González Romero
- Department of Intensive Care Medicine and Transplant Coordinator. HospitalUniversitario Clínico San Carlos Madrid Spain
| | - Daniel Ballesteros Ortega
- Department of Intensive Care MedicineHospital Universitario Puerta de Hierro Majadahonda Madrid Spain
| | - Francisco Río Gallegos
- Department of Intensive Care Medicine and Transplant Coordinator. HospitalUniversitario Clínico San Carlos Madrid Spain
| | - Juan José Rubio Muñoz
- Department of Intensive Care MedicineHospital Universitario Puerta de Hierro Majadahonda Madrid Spain
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40
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Hessheimer AJ, Gastaca M, Miñambres E, Colmenero J, Fondevila C. Donation after circulatory death liver transplantation: consensus statements from the Spanish Liver Transplantation Society. Transpl Int 2020; 33:902-916. [PMID: 32311806 PMCID: PMC7496958 DOI: 10.1111/tri.13619] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/06/2020] [Accepted: 04/14/2020] [Indexed: 02/06/2023]
Abstract
Livers from donation after circulatory death (DCD) donors are an increasingly more common source of organs for transplantation. While there are few high-level studies in the field of DCD liver transplantation, clinical practice has undergone progressive changes during the past decade, in particular due to mounting use of postmortem normothermic regional perfusion (NRP). In Spain, uncontrolled DCD has been performed since the late 1980s/early 1990s, while controlled DCD was implemented nationally in 2012. Since 2012, the rise in DCD liver transplant activity in Spain has been considerable, and the great majority of DCD livers transplanted in Spain today are recovered with NRP. A panel of the Spanish Liver Transplantation Society was convened in 2018 to evaluate current evidence and accumulated experience in DCD liver transplantation, in particular addressing issues related to DCD liver evaluation, acceptance criteria, and recovery as well as recipient selection and postoperative management. This panel has created a series of consensus statements for the standard of practice in Spain and has published these statements with the hope they might help guide other groups interested in implementing new forms of DCD liver transplantation and/or introducing NRP into their clinical practices.
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Affiliation(s)
- Amelia J Hessheimer
- Liver Transplant Unit, CIBERehd, IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Mikel Gastaca
- Hospital Universitario Cruces, Bilbao, Spain.,SETH Board of Directors, Spain
| | - Eduardo Miñambres
- Transplant Coordination Unit & Intensive Care Service, IDIVAL, Hospital Universitario Marqués de Valdecilla, University of Cantabria, Santander, Spain
| | - Jordi Colmenero
- Liver Transplant Unit, CIBERehd, IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain.,SETH Board of Directors, Spain
| | - Constantino Fondevila
- Liver Transplant Unit, CIBERehd, IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
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41
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Rijkse E, IJzermans JNM, Minnee RC. Machine perfusion in abdominal organ transplantation: Current use in the Netherlands. World J Transplant 2020; 10:15-28. [PMID: 32110511 PMCID: PMC7031624 DOI: 10.5500/wjt.v10.i1.15] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/03/2019] [Accepted: 12/19/2019] [Indexed: 02/05/2023] Open
Abstract
Scarcity of donor organs and the increment in patients awaiting a transplant increased the use of organs from expanded criteria donors or donation after circulatory death. Due to the suboptimal outcomes of these donor organs, there is an increased interest in better preservation methods, such as ex vivo machine perfusion or abdominal regional perfusion to improve outcomes. This state-of-the-art review aims to discuss the available types of perfusion techniques, its potential benefits and the available evidence in kidney, liver and pancreas transplantation. Additionally, translational steps from animal models towards clinical studies will be described, as well as its application to clinical practice, with the focus on the Netherlands. Despite the lack of evidence from randomized controlled trials, currently available data suggest especially beneficial effects of normothermic regional perfusion on biliary complications and ischemic cholangiopathy after liver transplantation. For ex vivo machine perfusion in kidney transplantation, hypothermic machine perfusion has proven to be beneficial over static cold storage in a randomized controlled trial, while normothermic machine perfusion is currently under investigation. For ex vivo machine perfusion in liver transplantation, normothermic machine perfusion has proven to reduce discard rates and early allograft dysfunction. In response to clinical studies, hypothermic machine perfusion for deceased donor kidneys has already been implemented as standard of care in the Netherlands.
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Affiliation(s)
- Elsaline Rijkse
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam 3015 GD, Netherlands
| | - Jan NM IJzermans
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam 3015 GD, Netherlands
| | - Robert C Minnee
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam 3015 GD, Netherlands
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42
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Novel Organ Perfusion and Preservation Strategies in Transplantation – Where Are We Going in the United Kingdom? Transplantation 2020; 104:1813-1824. [DOI: 10.1097/tp.0000000000003106] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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43
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Miñambres E, Ruiz P, Ballesteros MA, Álvarez C, Cifrián JM, Atutxa L, Ventoso A, Castillo F, Gastaca M. Combined lung and liver procurement in controlled donation after circulatory death using normothermic abdominal perfusion. Initial experience in two Spanish centers. Am J Transplant 2020; 20:231-240. [PMID: 31265753 DOI: 10.1111/ajt.15520] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 06/01/2019] [Accepted: 06/21/2019] [Indexed: 01/25/2023]
Abstract
Combining simultaneously lung and liver procurement in controlled donation after circulatory death (cDCD) using normothermic abdominal perfusion (NRP) for abdominal grafts and cooling and rapid recovery technique (RR) for the lungs increases the complexity of the procurement procedure and might injure the grafts. A total of 19 cDCDs from two centers using this combined procedure were evaluated, and 16 liver and 21 lung transplantations were performed. As controls, 34 donors after brain death (DBDs) were included (29 liver and 41 lung transplantations were performed). Two cDCD liver recipients developed primary nonfunction (12.5%). No cases of ischemic cholangiopathy were observed among cDCD recipients. The 1-year and 2-year liver recipients survival was 87.5% and 87.5% for the cDCD group, and 96% and 84.5% for the DBD group, respectively (P = .496). The 1-year and 2-year lung recipients survival was 84% and 84% for the cDCD group and 90% and 90% for the DBD group, respectively (P = .577). This is the largest experience ever reported in cDCD with the use of NRP combined with RR of the lungs. This combined method offers an outstanding recovery rate and liver and lung recipients survival comparable with those transplanted with DBDs. Further studies are needed to confirm our findings.
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Affiliation(s)
- Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, University of Cantabria, Santander, Spain
| | - Patricia Ruiz
- Hepatobiliary Surgery and Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bilbao, Spain
| | - Maria Angeles Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Carlos Álvarez
- Service of Thoracic Surgery, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Jose Manuel Cifrián
- Service of Neumology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Lander Atutxa
- Transplant Coordination Unit & Service of Intensive Care, Donostia University Hospital, San Sebastian, Spain
| | - Alberto Ventoso
- Hepatobiliary Surgery and Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bilbao, Spain
| | - Federico Castillo
- Hepatobiliary Surgery and Liver Transplantation Unit, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Mikel Gastaca
- Hepatobiliary Surgery and Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bilbao, Spain
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Favorable Outcomes After Liver Transplantation With Normothermic Regional Perfusion From Donors After Circulatory Death: A Single-center Experience. Transplantation 2019; 103:938-943. [PMID: 30063694 DOI: 10.1097/tp.0000000000002391] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Controlled donation after circulatory death (cDCD) has been associated with a high incidence of ischemic cholangiopathy and other perioperative complications. In an attempt to avoid these complications, we implemented an active protocol of cDCD liver transplant (LT) with normothermic regional perfusion (NRP) preservation. METHODS This is a descriptive analysis of data collected from a prospective date base of cDCD LT preserved with NRP from January 2015 to June 2017 with a minimum follow up of 9 months. RESULTS Fifty-seven potential cDCD donors were connected to the NRP system. Of these, 46 livers were transplanted over a 30-month period (80% liver recovery rate). The median posttransplant peak in alanine transaminase was 1136 U/L (220-6683 U/L). Seven (15%) patients presented postreperfusion syndrome and 11 (23%) showed early allograft dysfunction. No cases of ischemic cholangiopathy were diagnosed, and no graft loss was observed over a medium follow-up period of 19 months. Of note, 13 donors were older than 65 years, achieving comparable perioperative and midterm results to younger donors. CONCLUSIONS As far as we know, this represents the largest published series of cDCD LT with NRP preservation. Our results demonstrate that cDCD liver grafts preserved with NRP appear far superior to those obtained by the conventional rapid recovery technique.
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Ding GY, Zhao Y, Wu W, Zhong M, Fu PY, Xu M, Zhou J, Fan J, Huang XW, Song K. In Situ Normothermic Regional Perfusion for Liver Donation From China Category III (Organ Donation After Brain Death Followed by Circulatory Death): A Single-Center Cohort Study. EXP CLIN TRANSPLANT 2019; 18:83-88. [PMID: 31617836 DOI: 10.6002/ect.2019.0200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Organ donation after brain death followed by circulatory death is practiced in China. This study evaluated the application of normothermic regional perfusion to protect the liver grafts from these donors from warm ischemia in a large transplant center in China. MATERIALS AND METHODS This prospective study involved 19 liver transplants from brain death followed by circulatory death donors that were conducted between December 2014 and June 2017. We evaluated the baseline characteristics of the donors and recipients and compared outcomes of both groups. Graft and recipient survival and postoperative complications were also analyzed. RESULTS Although the normothermic regional perfusion group consisted of marginal donors with prolonged warm ischemia and recipients with higher Model for End-Stage Liver Disease scores (P < .05), postoperative tests indicated no differences in liverfunction recovery in both groups. Furthermore, total bilirubin decreased significantly faster in the normothermic regional perfusion group than in the control group (P < .05). Both groups showed similar 1-year recipient survival rates. No recipients in the normothermic regional perfusion group had any biliary complications, whereas 2 recipients in the control group developed ischemic cholangiopathy and received invasive treatment during follow-up. CONCLUSIONS In situ normothermic regional perfusion demonstrated a significant benefit in grafts from brain death followed by circulatory death donors and could potentially increase both the number and quality of donated organs.
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Affiliation(s)
- Guang-Yu Ding
- From the Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Shanghai, China
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46
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47
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Hessheimer AJ, Riquelme F, Fundora-Suárez Y, García Pérez R, Fondevila C. Normothermic perfusion and outcomes after liver transplantation. Transplant Rev (Orlando) 2019; 33:200-208. [PMID: 31239189 DOI: 10.1016/j.trre.2019.06.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 06/04/2019] [Accepted: 06/09/2019] [Indexed: 01/04/2023]
Abstract
Ischemia has been a persistent and largely unavoidable element in solid organ transplantation, contributing to graft deterioration and adverse post-transplant outcomes. In liver transplantation, where available organs arise with greater frequency from marginal donors (i.e., ones that are older, obese, and/or declared dead following cardiac arrest through the donation after circulatory death process), there is increasing interest using dynamic perfusion strategies to limit, assess, and even reverse the adverse effects of ischemia in these grafts. Normothermic perfusion, in particular, is used to restore the flow of oxygen and other metabolic substrates at physiological temperatures. It may be used in liver transplantation both in situ following cardiac arrest in donation after circulatory death donors or during part or all of the ex situ preservation phase. This review article addresses issues relevant to use of normothermic perfusion strategies in liver transplantation, including technical and logistical aspects associated with establishing and maintaining normothermic perfusion in its different forms and clinical outcomes that have been reported to date.
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Affiliation(s)
- Amelia J Hessheimer
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Digestive & Metabolic Disease Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain.
| | - Francisco Riquelme
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Digestive & Metabolic Disease Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain
| | - Yiliam Fundora-Suárez
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Digestive & Metabolic Disease Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain
| | - Rocío García Pérez
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Digestive & Metabolic Disease Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain
| | - Constantino Fondevila
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Digestive & Metabolic Disease Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain
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Watson CJE, Hunt F, Messer S, Currie I, Large S, Sutherland A, Crick K, Wigmore SJ, Fear C, Cornateanu S, Randle LV, Terrace JD, Upponi S, Taylor R, Allen E, Butler AJ, Oniscu GC. In situ normothermic perfusion of livers in controlled circulatory death donation may prevent ischemic cholangiopathy and improve graft survival. Am J Transplant 2019; 19:1745-1758. [PMID: 30589499 DOI: 10.1111/ajt.15241] [Citation(s) in RCA: 160] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 11/09/2018] [Accepted: 12/16/2018] [Indexed: 01/25/2023]
Abstract
Livers from controlled donation after circulatory death (DCD) donors suffer a higher incidence of nonfunction, poor function, and ischemic cholangiopathy. In situ normothermic regional perfusion (NRP) restores a blood supply to the abdominal organs after death using an extracorporeal circulation for a limited period before organ recovery. We undertook a retrospective analysis to evaluate whether NRP was associated with improved outcomes of livers from DCD donors. NRP was performed on 70 DCD donors from whom 43 livers were transplanted. These were compared with 187 non-NRP DCD donor livers transplanted at the same two UK centers in the same period. The use of NRP was associated with a reduction in early allograft dysfunction (12% for NRP vs. 32% for non-NRP livers, P = .0076), 30-day graft loss (2% NRP livers vs. 12% non-NRP livers, P = .0559), freedom from ischemic cholangiopathy (0% vs. 27% for non-NRP livers, P < .0001), and fewer anastomotic strictures (7% vs. 27% non-NRP, P = .0041). After adjusting for other factors in a multivariable analysis, NRP remained significantly associated with freedom from ischemic cholangiopathy (P < .0001). These data suggest that NRP during organ recovery from DCD donors leads to superior liver outcomes compared to conventional organ recovery.
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Affiliation(s)
- Christopher J E Watson
- University of Cambridge Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK.,Cambridge Transplant Unit, Cambridge University Hospitals NHS Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Fiona Hunt
- The Scottish Liver Transplant Unit, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Simon Messer
- Royal Papworth Hospital, Papworth Everard, Cambridge, UK
| | - Ian Currie
- The Scottish Liver Transplant Unit, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Stephen Large
- Royal Papworth Hospital, Papworth Everard, Cambridge, UK
| | - Andrew Sutherland
- The Scottish Liver Transplant Unit, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Keziah Crick
- Cambridge Transplant Unit, Cambridge University Hospitals NHS Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Stephen J Wigmore
- The Scottish Liver Transplant Unit, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK.,Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Corrina Fear
- Cambridge Transplant Unit, Cambridge University Hospitals NHS Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Sorina Cornateanu
- The Scottish Liver Transplant Unit, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | | | - John D Terrace
- The Scottish Liver Transplant Unit, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Sara Upponi
- Department of Radiology, Cambridge University Hospitals NHS Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Rhiannon Taylor
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
| | - Elisa Allen
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
| | - Andrew J Butler
- University of Cambridge Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK.,Cambridge Transplant Unit, Cambridge University Hospitals NHS Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Gabriel C Oniscu
- The Scottish Liver Transplant Unit, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK.,Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
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49
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Hessheimer AJ, Coll E, Torres F, Ruíz P, Gastaca M, Rivas JI, Gómez M, Sánchez B, Santoyo J, Ramírez P, Parrilla P, Marín LM, Gómez-Bravo MÁ, García-Valdecasas JC, López-Monclús J, Boscá A, López-Andújar R, Fundora-Suárez J, Villar J, García-Sesma Á, Jiménez C, Rodríguez-Laíz G, Lladó L, Rodríguez JC, Barrera M, Charco R, López-Baena JÁ, Briceño J, Pardo F, Blanco G, Pacheco D, Domínguez-Gil B, Sánchez Turrión V, Fondevila C. Normothermic regional perfusion vs. super-rapid recovery in controlled donation after circulatory death liver transplantation. J Hepatol 2019; 70:658-665. [PMID: 30582980 DOI: 10.1016/j.jhep.2018.12.013] [Citation(s) in RCA: 177] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/14/2018] [Accepted: 12/08/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although there is increasing interest in its use, definitive evidence demonstrating a benefit for postmortem normothermic regional perfusion (NRP) in controlled donation after circulatory death (cDCD) liver transplantation is lacking. The aim of this study was to compare results of cDCD liver transplants performed with postmortem NRP vs. super-rapid recovery (SRR), the current standard for cDCD. METHODS This was an observational cohort study including all cDCD liver transplants performed in Spain between June 2012 and December 2016, with follow-up ending in December 2017. Each donor hospital determined whether organ recovery was performed using NRP or SRR. The propensity scores technique based on the inverse probability of treatment weighting (IPTW) was used to balance covariates across study groups; logistic and Cox regression models were used for binary and time-to-event outcomes. RESULTS During the study period, there were 95 cDCD liver transplants performed with postmortem NRP and 117 with SRR. The median donor age was 56 years (interquartile range 45-65 years). After IPTW analysis, baseline covariates were balanced, with all absolute standardised differences <0.15. IPTW-adjusted risks were significantly improved among NRP livers for overall biliary complications (odds ratio 0.14; 95% CI 0.06-0.35, p <0.001), ischaemic type biliary lesions (odds ratio 0.11; 95% CI 0.02-0.57; p = 0.008), and graft loss (hazard ratio 0.39; 95% CI 0.20-0.78; p = 0.008). CONCLUSIONS The use of postmortem NRP in cDCD liver transplantation appears to reduce postoperative biliary complications, ischaemic type biliary lesions and graft loss, and allows for the transplantation of livers even from cDCD donors of advanced age. LAY SUMMARY This is a propensity-matched nationwide observational cohort study performed using livers recovered from donors undergoing cardiac arrest provoked by the intentional withdrawal of life support (controlled donation after circulatory death, cDCD). Approximately half of the livers were recovered after a period of postmortem in situ normothermic regional perfusion, which restored warm oxygenated blood to the abdominal organs, whereas the remainder were recovered after rapid preservation with a cold solution. The study results suggest that the use of postmortem normothermic regional perfusion helps reduce rates of post-transplant biliary complications and graft loss and allows for the successful transplantation of livers from older cDCD donors.
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Affiliation(s)
- Amelia J Hessheimer
- Department of General & Digestive Surgery, Institut de Malalties Digestives i Metabòliques (IMDiM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Ferrán Torres
- Medical Statistics Core Facility, IDIBAPS, Hospital Clínic Barcelona & Biostatistics Unit, Faculty of Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | | | | | - Manuel Gómez
- Complejo Hospitalario Universitario La Coruña, La Coruña, Spain
| | | | - Julio Santoyo
- Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Pablo Ramírez
- Hospital Clínico Universitario Virgen de la Arrixaca (IMIB), Murcia, Spain
| | - Pascual Parrilla
- Hospital Clínico Universitario Virgen de la Arrixaca (IMIB), Murcia, Spain
| | | | | | - Juan Carlos García-Valdecasas
- Department of General & Digestive Surgery, Institut de Malalties Digestives i Metabòliques (IMDiM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Andrea Boscá
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | | | - Jesús Villar
- Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | | | - Gonzalo Rodríguez-Laíz
- Department of General & Digestive Surgery, ISABIAL, Hospital General Universitario de Alicante, Alicante, Spain
| | - Laura Lladó
- Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Spain
| | | | - Manuel Barrera
- Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Ramón Charco
- Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | | | | | | | | | - David Pacheco
- Hospital Universitario Río Hortega, Valladolid, Spain
| | | | | | - Constantino Fondevila
- Department of General & Digestive Surgery, Institut de Malalties Digestives i Metabòliques (IMDiM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain.
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50
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Kerforne T, Allain G, Giraud S, Bon D, Ameteau V, Couturier P, Hebrard W, Danion J, Goujon JM, Thuillier R, Hauet T, Barrou B, Jayle C. Defining the optimal duration for normothermic regional perfusion in the kidney donor: A porcine preclinical study. Am J Transplant 2019; 19:737-751. [PMID: 30091857 DOI: 10.1111/ajt.15063] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/02/2018] [Accepted: 08/03/2018] [Indexed: 01/25/2023]
Abstract
Kidneys from donation after circulatory death (DCD) are highly sensitive to ischemia-reperfusion injury and thus require careful reconditioning, such as normothermic regional perfusion (NRP). However, the optimal NRP protocol remains to be characterized. NRP was modeled in a DCD porcine model (30 minutes of cardiac arrest) for 2, 4, or 6 hours compared to a control group (No-NRP); kidneys were machine-preserved and allotransplanted. NRP appeared to permit recovery from warm ischemia, possibly due to an increased expression of HIF1α-dependent survival pathway. At 2 hours, blood levels of ischemic injury biomarkers increased: creatinine, lactate/pyruvate ratio, LDH, AST, NGAL, KIM-1, CD40 ligand, and soluble-tissue-factor. All these markers then decreased with time; however, AST, NGAL, and KIM-1 increased again at 6 hours. Hemoglobin and platelets decreased at 6 hours, after which the procedure became difficult to maintain. Regarding inflammation, active tissue-factor, cleaved PAR-2 and MCP-1 increased by 4-6 hours, but not TNF-α and iNOS. Compared to No-NRP, NRP kidneys showed lower resistance during hypothermic machine perfusion (HMP), likely associated with pe-NRP eNOS activation. Kidneys transplanted after 4 and 6 hours of NRP showed better function and outcome, compared to No-NRP. In conclusion, our results confirm the mechanistic benefits of NRP and highlight 4 hours as its optimal duration, after which injury markers appear.
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Affiliation(s)
- Thomas Kerforne
- INSERM U1082, (IRTOMIT), Poitiers, France.,Faculty of Medicine and Pharmacy, University of Poitiers, Poitiers, France.,Anesthesia and Intensive Care Department, Poitiers Regional and Academic Teaching Hospital Center, Poitiers, France
| | - Geraldine Allain
- INSERM U1082, (IRTOMIT), Poitiers, France.,Faculty of Medicine and Pharmacy, University of Poitiers, Poitiers, France.,CardioVascular Surgery Division, Poitiers Regional and Academic Teaching Hospital Center, Poitiers, France
| | - Sebastien Giraud
- INSERM U1082, (IRTOMIT), Poitiers, France.,Faculty of Medicine and Pharmacy, University of Poitiers, Poitiers, France.,Biochemistry Department, Poitiers Regional and Academic Teaching Hospital Center, Poitiers, France
| | - Delphine Bon
- INSERM U1082, (IRTOMIT), Poitiers, France.,Faculty of Medicine and Pharmacy, University of Poitiers, Poitiers, France
| | - Virginie Ameteau
- INSERM U1082, (IRTOMIT), Poitiers, France.,Faculty of Medicine and Pharmacy, University of Poitiers, Poitiers, France
| | - Pierre Couturier
- INSERM U1082, (IRTOMIT), Poitiers, France.,Biochemistry Department, Poitiers Regional and Academic Teaching Hospital Center, Poitiers, France.,IBiSA 'plate-forme MOdélisation Préclinique - Innovations Chirurgicale et Technologique (MOPICT)', Domaine Expérimental du Magneraud, Surgères, France
| | - William Hebrard
- Unité expérimentale Génétique, Expérimentations et systèmes innovants (GENESI), INRA, Domaine Expérimental du Magneraud, Surgères, France
| | - Jerome Danion
- INSERM U1082, (IRTOMIT), Poitiers, France.,Visceral Surgery Department, Poitiers Regional and Academic Teaching Hospital Center, Poitiers, France
| | - Jean-Michel Goujon
- INSERM U1082, (IRTOMIT), Poitiers, France.,Faculty of Medicine and Pharmacy, University of Poitiers, Poitiers, France.,Pathology Department, Poitiers Regional and Academic Teaching Hospital Center, Poitiers, France
| | - Raphael Thuillier
- INSERM U1082, (IRTOMIT), Poitiers, France.,Faculty of Medicine and Pharmacy, University of Poitiers, Poitiers, France.,Biochemistry Department, Poitiers Regional and Academic Teaching Hospital Center, Poitiers, France
| | - Thierry Hauet
- INSERM U1082, (IRTOMIT), Poitiers, France.,Faculty of Medicine and Pharmacy, University of Poitiers, Poitiers, France.,Biochemistry Department, Poitiers Regional and Academic Teaching Hospital Center, Poitiers, France.,IBiSA 'plate-forme MOdélisation Préclinique - Innovations Chirurgicale et Technologique (MOPICT)', Domaine Expérimental du Magneraud, Surgères, France.,FHU SUPORT 'SUrvival oPtimization in ORgan Transplantation', Poitiers, France
| | - Benoit Barrou
- INSERM U1082, (IRTOMIT), Poitiers, France.,Service d'Urologie et de transplantation rénale, AP-HP, GH Pitié-Salpêtrière, Paris, France.,Pierre and Marie Curie Paris VI University, Paris, France
| | - Christophe Jayle
- INSERM U1082, (IRTOMIT), Poitiers, France.,Faculty of Medicine and Pharmacy, University of Poitiers, Poitiers, France.,CardioVascular Surgery Division, Poitiers Regional and Academic Teaching Hospital Center, Poitiers, France.,IBiSA 'plate-forme MOdélisation Préclinique - Innovations Chirurgicale et Technologique (MOPICT)', Domaine Expérimental du Magneraud, Surgères, France
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