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Renaudier M, Binois Y, Dumas F, Lamhaut L, Beganton F, Jost D, Charpentier J, Lesieur O, Marijon E, Jouven X, Cariou A, Bougouin W. Controlled donation after circulatory death in post-cardiac arrest patients: Estimates from a large registry. Resuscitation 2024; 199:110202. [PMID: 38582445 DOI: 10.1016/j.resuscitation.2024.110202] [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: 01/18/2024] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Controlled donation after circulatory death (cDCD) in post-anoxic brain injury is a valuable source of organs that is still underused in some countries. We assessed the number of potential cDCD donors after out-of-hospital cardiac arrest (OHCA) in Paris and its suburbs and extrapolated the results to the French population. METHODS Using the large regional registry of the Great Paris area, we prospectively included all consecutive adults with OHCA with a stable return of spontaneous circulation (ROSC) who ultimately died in the intensive care unit (ICU) after withdrawal of life-sustaining treatments (WLST) due to post anoxic brain injury. The primary endpoint was potential for organ donation by cDCD in this population. The number of potential cDCD donors was calculated and extrapolated to the entire French population. RESULTS Between 2011 and 2018, 4638 patients with stable ROSC were admitted to ICUs after OHCA, and 3170 died in ICU, of which 1034 died after WLST due to post-anoxic brain injury. When considering French criteria, 421/1034 patients (41%) would have been potential cDCD donors (55 patients per year in a 4.67 million population). After standardization for age and sex, the potential for cDCD was 515 (95% CI 471-560) patients per year in France corresponding to an annual incidence of 1.18 per 100 000 inhabitants per year. CONCLUSIONS Organ donation by cDCD after cardiac arrest could provide a large pool of donors in France.
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Affiliation(s)
- Marie Renaudier
- Paris Cardiovascular Research Centre (PARCC), INSERM Unit 970, Paris, France; Paris Sudden Death Expertise Centre, Paris, France; Université Paris Cité, Paris, France; Intensive Care Unit, Cochin-Hotel-Dieu Hospital, AP-HP, Paris, France.
| | - Yannick Binois
- Paris Cardiovascular Research Centre (PARCC), INSERM Unit 970, Paris, France; Paris Sudden Death Expertise Centre, Paris, France
| | - Florence Dumas
- Paris Cardiovascular Research Centre (PARCC), INSERM Unit 970, Paris, France; Paris Sudden Death Expertise Centre, Paris, France; Emergency Department, Cochin-Hotel-Dieu Hospital, AP-HP, Paris, France; Université Paris Cité, Paris, France
| | - Lionel Lamhaut
- Paris Cardiovascular Research Centre (PARCC), INSERM Unit 970, Paris, France; Paris Sudden Death Expertise Centre, Paris, France; Université Paris Cité, Paris, France; Intensive Care Unit and SAMU 75, Necker Enfants-Malades Hospital, Paris, France
| | - Frankie Beganton
- Paris Cardiovascular Research Centre (PARCC), INSERM Unit 970, Paris, France; Paris Sudden Death Expertise Centre, Paris, France
| | - Daniel Jost
- Paris Cardiovascular Research Centre (PARCC), INSERM Unit 970, Paris, France; Paris Sudden Death Expertise Centre, Paris, France; Brigade des Sapeurs-Pompiers de Paris (BSPP), Paris, France
| | - Julien Charpentier
- Donor Coordinator Unit, Cochin-Hotel-Dieu Hospital, AP-HP, Paris, France; Intensive Care Unit, Cochin-Hotel-Dieu Hospital, AP-HP, Paris, France
| | - Olivier Lesieur
- Université Paris Cité, Paris, France; Intensive Care Unit, Saint Louis General Hospital, La Rochelle, France
| | - Eloi Marijon
- Paris Cardiovascular Research Centre (PARCC), INSERM Unit 970, Paris, France; Paris Sudden Death Expertise Centre, Paris, France; Université Paris Cité, Paris, France; Cardiology Department, European Georges Pompidou Hospital, AP-HP, Paris, France
| | - Xavier Jouven
- Paris Cardiovascular Research Centre (PARCC), INSERM Unit 970, Paris, France; Paris Sudden Death Expertise Centre, Paris, France; Université Paris Cité, Paris, France; Cardiology Department, European Georges Pompidou Hospital, AP-HP, Paris, France
| | - Alain Cariou
- Paris Cardiovascular Research Centre (PARCC), INSERM Unit 970, Paris, France; Paris Sudden Death Expertise Centre, Paris, France; Université Paris Cité, Paris, France; Intensive Care Unit, Cochin-Hotel-Dieu Hospital, AP-HP, Paris, France
| | - Wulfran Bougouin
- Paris Cardiovascular Research Centre (PARCC), INSERM Unit 970, Paris, France; Paris Sudden Death Expertise Centre, Paris, France; Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, France
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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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3
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Salguero J, Chamorro L, Gómez-Gómez E, Robles JE, Campos JP. Graft survival and delayed graft function with normothermic regional perfusion and rapid recovery after circulatory death in kidney transplantation: a propensity score matching study. Minerva Urol Nephrol 2024; 76:60-67. [PMID: 38015549 DOI: 10.23736/s2724-6051.23.05393-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND A shortage of kidney grafts has led to the implementation of various strategies, including donations after circulatory death. The in situ normothermic regional perfusion technique has been introduced to improve graft quality by reducing warm ischemia times. However, there is limited evidence available on its mid- and long-term outcomes. Therefore, this study aimed to compare the incidence of delayed graft function, graft function, and survival at three years among three groups: brain death donors, rapid recovery, and normothermic regional perfusion. METHODS A retrospective analysis of a cohort of kidney transplantations was conducted at a single referral center between January 1, 2015, and December 31, 2019. Univariate and multivariate regression models and propensity score matching analysis were performed to compare recipient-related, transplantation procedure-related, donor-related, and kidney function variables. RESULTS A total of 327 patients were included, with 256 kidneys from brain death donors, 52 kidneys from rapid recovery, and 19 patients from normothermic regional perfusion. After propensity score matching, univariate and multivariate analyses showed a higher incidence of delayed graft function in the rapid recovery group compared to the others (OR: 2.39 CI95%: 1.19, 4.77) with a longer hospital stay (median 11, 15 and 10 days, respectively). However, no differences in 1- and 3-year graft function and survival were found. CONCLUSIONS Normothermic regional perfusion offers advantages over rapid recovery, with a reduced incidence of delayed graft function and a shorter hospital stay. However, no differences in mid-term graft function and survival were found.
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Affiliation(s)
- Joseba Salguero
- Department of Urology, Infanta Margarita Hospital, Cabra, Spain -
| | - Laura Chamorro
- Department of Urology, Reina Sofia University Hospital, IMIBIC, Cordoba, Spain
| | - Enrique Gómez-Gómez
- Department of Urology, Reina Sofia University Hospital IMIBIC UCO, Cordoba, Spain
| | - José E Robles
- Department of Urology, School of Medicine, University of Navarra, Pamplona, Spain
| | - Juan P Campos
- Department of Urology, Reina Sofia University Hospital IMIBIC UCO, Cordoba, Spain
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4
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Thiessen C, Wisel SA, Roll GR. Simultaneous thoracic and abdominal donation after circulatory death organ recovery: the abdominal surgeon's perspective. Curr Opin Organ Transplant 2023; 28:139-144. [PMID: 36603197 PMCID: PMC9994842 DOI: 10.1097/mot.0000000000001045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF THE REVIEW To summarize the international experience with heart-liver (joint) donation after circulatory death (DCD) procurements and to explore the technical challenges in joint abdominal and thoracic DCD procurement. RECENT FINDINGS Following completion of the Donors After Circulatory Death Heart Trial in the US, combined thoracic and abdominal DCD is poised to become the standard of care, expanding access to life-saving heart and lung allografts. DCD heart procurement relies on collection of donor blood for priming of the normothermic perfusion pump, which delays cooling of abdominal organs and increases risk of ischemic injury. We review the effect of donor ischemia time on abdominal organs, with several proposed technical solutions to optimize transplant outcomes for all organs. SUMMARY The strategies reviewed in this manuscript may inform clinical decision-making, preoperative coordination between thoracic and abdominal procurement teams, and surgical technique for joint DCD procurements. Several approaches to organ procurement organization (OPO) and national policy, as well as future areas of focus for research are proposed.
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Affiliation(s)
- Carrie Thiessen
- Division of Transplantation, University of Wisconsin, Madison, Wisconsin
| | - Steven A. Wisel
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles
| | - Garrett R. Roll
- Division of Transplantation, University of California, San Francisco, San Francisco, California, USA
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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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6
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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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7
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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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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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9
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Rand A, Koch T, Ragaller M. [Organ donation-Not only a responsibility of intensive care medicine]. Anaesthesist 2021; 71:311-317. [PMID: 34873631 PMCID: PMC8647959 DOI: 10.1007/s00101-021-01066-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 11/27/2022]
Abstract
Im Jahr 2019 starben in Deutschland 756 Menschen, während sie auf der Warteliste für ein Spenderorgan standen. Sowohl im Eurotransplant-Verbund als auch weltweit gehört Deutschland mit 10,8 Organspendern/Mio. Einwohner im Jahr 2019 zur Schlussgruppe. Sämtliche politischen Versuche, die Spenderzahlen zu steigern, scheinen bislang ohne Effekt geblieben zu sein. Darüber hinaus hat die durch das „severe acute respiratory syndrome coronavirus 2“ (SARS-CoV-2) ausgelöste Pandemie zum weiteren Rückgang der Spenderzahlen geführt. Der Intensivmedizinerin kommt im Prozess der Erkennung möglicher Spender sowie als erste Ansprechpartnerin für die Angehörigen eine zentrale Rolle zu. Jedoch existieren nicht nur in den gesellschaftlichen und medialen Diskussionen um das Thema Organspende viele Unklarheiten, sondern auch bei den intensivmedizinisch tätigen Ärzten. Viele Annahmen und Hypothesen, die mit den niedrigen Spenderzahlen in einen Zusammenhang gebracht werden, lassen sich wissenschaftlich jedoch nicht belegen und sollen in diesem Beitrag diskutiert werden.
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Affiliation(s)
- A Rand
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - T Koch
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - M Ragaller
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
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10
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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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11
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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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12
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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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13
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Regulations and Procurement Surgery in DCD Liver Transplantation: Expert Consensus Guidance From the International Liver Transplantation Society. Transplantation 2021; 105:945-951. [PMID: 33675315 DOI: 10.1097/tp.0000000000003729] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Donation after circulatory death (DCD) donors are an increasingly more common source of livers for transplantation in many parts of the world. Events that occur during DCD liver recovery have a significant impact on the success of subsequent transplantation. This working group of the International Liver Transplantation Society evaluated current evidence as well as combined experience and created this guidance on DCD liver procurement. Best practices for the recovery and transplantation of livers arising through DCD after euthanasia and organ procurement with super-rapid cold preservation and recovery as well as postmortem normothermic regional perfusion are described, as are the use of adjuncts during DCD liver procurement.
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14
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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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15
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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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16
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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] [MESH Headings] [Grants] [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 UnitCIBERehdIDIBAPSHospital ClínicUniversity of BarcelonaBarcelonaSpain
| | - Mikel Gastaca
- Hospital Universitario CrucesBilbaoSpain
- SETH Board of DirectorsSpain
| | - Eduardo Miñambres
- Transplant Coordination Unit & Intensive Care ServiceIDIVALHospital Universitario Marqués de ValdecillaUniversity of CantabriaSantanderSpain
| | - Jordi Colmenero
- Liver Transplant UnitCIBERehdIDIBAPSHospital ClínicUniversity of BarcelonaBarcelonaSpain
- SETH Board of DirectorsSpain
| | - Constantino Fondevila
- Liver Transplant UnitCIBERehdIDIBAPSHospital ClínicUniversity of BarcelonaBarcelonaSpain
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17
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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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18
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Figini MA, Paredes-Zapata D, Juan EO, Chiumello DA. Mobile Extracorporeal Membrane Oxygenation Teams for Organ Donation After Circulatory Death. Transplant Proc 2020; 52:1528-1535. [PMID: 32327262 DOI: 10.1016/j.transproceed.2020.02.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 02/05/2020] [Indexed: 01/25/2023]
Abstract
The shortage of available organ donors is a significant problem worldwide, and various efforts have been carried out to avoid the loss of potential organ donors. Among them, organ donation from cardiocirculatory deceased donors (DCD), in which withdrawal of life-sustaining therapies is ongoing (Maastricht type III donors), is one emerging strategy. Thanks to the latest advances in transplantation and organ preservation, such as normothermic regional perfusion (NRP), ex vivo perfusion techniques, and good organization and communication among prehospital care providers, emergency departments, intensive care units, and transplantation units, DCD is rapidly increasing; it's estimated that it will increase the number of donations of lungs and splanchnic organs by more than 40%. Although Maastricht type II DCD requires a 24/7 available experienced extra corporeal membrane oxygenation (ECMO) team in the institution, Maastricht DCD type III could be organized in secondary care and spoke hospitals without in loco ECMO facilities for NRP. This article analyses a potential mobile team organization based on the hub-and-spoke model, which already exists and functions in Italy, by estimating the dimension of the controlled DCD phenomenon in Italy, coordination requirements, costs, personnel training, and education, and reporting a single center experience in Milan, Italy.
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Affiliation(s)
- Maria Adele Figini
- Department of Anesthesia and Intensive Care Unit, ASST Santi Paolo e Carlo, Milano, Italy.
| | - David Paredes-Zapata
- Donation and Transplantation Coordination Unit, Hospital Clinic, Barcelona, Spain
| | - Eva Oliver Juan
- Transplantation Unit, Hospital de Bellvitge, Barcelona, Spain
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19
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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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20
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Heldal K, Midtvedt K, Lønning K, Iversen T, Hernæs KH, Tsarpali V, Reisæter AV, Bernklev T. Kidney transplantation: an attractive and cost-effective alternative for older patients? A cost-utility study. Clin Kidney J 2019; 12:888-894. [PMID: 31807304 PMCID: PMC6885668 DOI: 10.1093/ckj/sfz018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Indexed: 12/29/2022] Open
Abstract
Background In the elderly, kidney transplantation is associated with increased survival and improved health-related quality of life compared with dialysis treatment. We aimed to study the short-term health economic effects of transplantation in a population of elderly kidney transplant candidates. Methods Self-perceived health, quality-adjusted life years (QALYs) and costs were evaluated and compared 1 year before and 1 year after kidney transplantation in patients included in a single-centre prospective study of 289 transplant candidates ≥65 years of age. Results Self-perceived health and QALYs both significantly improved after transplantation. At 1 year, the costs per QALY were substantially higher for transplantation (€88 100 versus €76 495), but preliminary analyses suggest a favourable long-term health economic effect. Conclusions Kidney transplantation in older kidney transplant recipients is associated with improved health but also with increased costs the first year after engraftment when compared with remaining on the waiting list. Any long-term cost-effectiveness needs to be confirmed in studies with longer observation times.
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Affiliation(s)
- Kristian Heldal
- Clinic of Internal Medicine, Telemark Hospital Trust, Skien, Norway.,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Transplantation Medicine, Section of Nephrology, Oslo University Hospital, Oslo, Norway
| | - Karsten Midtvedt
- Department of Transplantation Medicine, Section of Nephrology, Oslo University Hospital, Oslo, Norway
| | - Kjersti Lønning
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Transplantation Medicine, Section of Nephrology, Oslo University Hospital, Oslo, Norway
| | - Tor Iversen
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | | | - Vasiliki Tsarpali
- Clinic of Internal Medicine, Telemark Hospital Trust, Skien, Norway.,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anna Varberg Reisæter
- Department of Transplantation Medicine, Section of Nephrology, Oslo University Hospital, Oslo, Norway
| | - Tomm Bernklev
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Research and Innovation, Vestfold Hospital Trust, Tonsberg, Norway
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21
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Organ donation after circulatory death: current status and future potential. Intensive Care Med 2019; 45:310-321. [DOI: 10.1007/s00134-019-05533-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/14/2019] [Indexed: 01/26/2023]
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22
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Hagness M, Foss S, Sørensen DW, Syversen T, Bakkan PA, Dahl T, Fiane A, Line P. Liver Transplant After Normothermic Regional Perfusion From Controlled Donors After Circulatory Death: The Norwegian Experience. Transplant Proc 2019; 51:475-478. [PMID: 30879571 DOI: 10.1016/j.transproceed.2019.01.066] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND In order to meet the increasing demand for donor organs, the concept of donation after circulatory death (DCD) was reintroduced in Norway, first as a pilot study, followed by the use of DCD as institutional practice. We report the current Norwegian experience with liver transplant after DCD. METHODS After acceptance from next of kin, life support was withdrawn from patients with devastating brain injury and cardiac arrest observed. After a 5-minute "no-touch" period, extracorporeal membrane oxygenation for post mortem normothermic regional perfusion (NRP) by extracorporeal membrane oxygenator circuit was established. Data from all liver transplant recipients receiving controlled DCD (cDCD) livers in Oslo were analyzed. RESULTS From 2015 to 2017, a total of 8 patients underwent liver transplant with cDCD and NRP liver grafts in Norway. Median Model for End-Stage Liver Disease score was 26 (range, 6-40). There were no cases of delayed graft function or graft loss. Seven patients have reached 1 year of follow-up, and 1 patient has reached 6 months. Two patients have recurrence of primary disease (primary sclerosing cholangitis and steatohepatitis). All patients had normalized liver function at last follow-up. Two patients underwent procedures for biliary complications. In 1 patient, leakage from the cystic duct was successfully handled endoscopically by stenting. In the other patient, a suspected stricture on magnetic resonance imaging led to an endoscopic retrograde cholangiopancreatography, which did not confirm signs of biliary stenosis. There was 1 instance of hepatic artery stenosis, which was managed with endovascular technique. CONCLUSION The results after liver transplant using cDCD with NRP are good. The rate of complications seems to be within the same range as when using conventional donation after brain death grafts.
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Affiliation(s)
- M Hagness
- Department of Transplantation Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, Oslo, Norway.
| | - S Foss
- Department of Transplantation Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, Oslo, Norway
| | - D W Sørensen
- Department of Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - T Syversen
- Department of Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - P A Bakkan
- Department of Transplantation Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, Oslo, Norway
| | - T Dahl
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| | - A Fiane
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - P Line
- Department of Transplantation Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
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