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Alarfaj M, Shah Z. Pro: Normothermic Regional Perfusion Should Be Utilized in Orthotopic Heart Transplantation. J Cardiothorac Vasc Anesth 2024; 38:1808-1811. [PMID: 38834444 DOI: 10.1053/j.jvca.2024.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 03/22/2024] [Indexed: 06/06/2024]
Affiliation(s)
- Mohammad Alarfaj
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS; Internal Medicine Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
| | - Zubair Shah
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS
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Royo-Villanova M, Miñambres E, Coll E, Domínguez-Gil B. Normothermic Regional Perfusion in Controlled Donation After the Circulatory Determination of Death: Understanding Where the Benefit Lies. Transplantation 2024:00007890-990000000-00833. [PMID: 39049104 DOI: 10.1097/tp.0000000000005143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Controlled donation after the circulatory determination of death (cDCDD) has emerged as a strategy to increase the availability of organs for clinical use. Traditionally, organs from cDCDD donors have been subject to standard rapid recovery (SRR) with poor posttransplant outcomes of abdominal organs, particularly the liver, and limited organ utilization. Normothermic regional perfusion (NRP), based on the use of extracorporeal membrane oxygenation devices, consists of the in situ perfusion of organs that will be subject to transplantation with oxygenated blood under normothermic conditions after the declaration of death and before organ recovery. NRP is a potential solution to address the limitations of traditional recovery methods. It has become normal practice in several European countries and has been recently introduced in the United States. The increased use of NRP in cDCDD has occurred as a result of a growing body of evidence on its association with improved posttransplant outcomes and organ utilization compared with SRR. However, the expansion of NRP is precluded by obstacles of an organizational, legal, and ethical nature. This article details the technique of both abdominal and thoracoabdominal NRP. Based on the available evidence, it describes its benefits in terms of posttransplant outcomes of abdominal and thoracic organs and organ utilization. It addresses cost-effectiveness aspects of NRP, as well as logistical and ethical obstacles that limit the implementation of this innovative preservation strategy.
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Affiliation(s)
- Mario Royo-Villanova
- Transplant Coordination Unit and Service of Intensive Care, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Eduardo Miñambres
- Transplant Coordination Unit and Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, School of Medicine, Universidad de Cantabria, Santander, Spain
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Klein Nulend R, Hameed A, Singla A, Yuen L, Lee T, Yoon P, Nahm C, Wong G, Laurence J, Lim WH, Hawthorne WJ, Pleass H. Normothermic Machine Perfusion and Normothermic Regional Perfusion of DCD Kidneys Before Transplantation: A Systematic Review. Transplantation 2024:00007890-990000000-00815. [PMID: 39020460 DOI: 10.1097/tp.0000000000005132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
BACKGROUND To overcome organ shortages, donation after circulatory death (DCD) kidneys are being increasingly used for transplantation. Prior research suggests that DCD kidneys have inferior outcomes compared with kidneys donated after brain death. Normothermic machine perfusion (NMP) and normothermic regional perfusion (NRP) may enhance the preservation of DCD kidneys and improve transplant outcomes. This study aimed to review the evidence surrounding NMP and NRP in DCD kidney transplantation. METHODS Two independent reviewers conducted searches for all publications reporting outcomes for NMP and NRP-controlled DCD kidneys, focusing on delayed graft function, primary nonfunction, graft function, graft survival, and graft utilization. Weighted means were calculated for all relevant outcomes and controls. Formal meta-analyses could not be conducted because of significant heterogeneity. RESULTS Twenty studies were included for review (6 NMP studies and 14 NRP studies). Delayed graft function rates seemed to be lower for NRP kidneys (24.6%) compared with NMP kidneys (54.3%). Both modalities yielded similar outcomes with respect to primary nonfunction (NMP 3.3% and NRP 5.6%), graft function (12-mo creatinine 149.3 μmol/L for NMP and 129.9 μmol/L for NRP), and graft utilization (NMP 83.3% and NRP 89%). Although no direct comparisons exist, our evidence suggests that both modalities have good short- and medium-term graft outcomes and high graft survival rates. CONCLUSIONS Current literature demonstrates that both NMP and NRP are feasible strategies that may increase donor organ utilization while maintaining acceptable transplant outcomes and likely improved outcomes compared with cold-stored DCD kidneys. Further research is needed to directly compare NRP and NMP outcomes.
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Affiliation(s)
| | - Ahmer Hameed
- Department of Surgery, Westmead Hospital, Westmead, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Animesh Singla
- Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - Lawrence Yuen
- Department of Surgery, Westmead Hospital, Westmead, NSW, Australia
| | - Taina Lee
- Department of Surgery, Westmead Hospital, Westmead, NSW, Australia
| | - Peter Yoon
- Department of Surgery, Westmead Hospital, Westmead, NSW, Australia
| | - Chris Nahm
- Department of Surgery, Westmead Hospital, Westmead, NSW, Australia
| | - Germaine Wong
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Jerome Laurence
- Department of Surgery, Westmead Hospital, Westmead, NSW, Australia
- RPA Institute of Academic Surgery, University of Sydney, Sydney, NSW, Australia
| | - Wai H Lim
- Faculty of Medicine, University of Western Australia, Crawley, WA, Australia
| | - Wayne J Hawthorne
- Department of Surgery, Westmead Hospital, Westmead, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - Henry Pleass
- Department of Surgery, Westmead Hospital, Westmead, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Benkert AR, Keenan JE, Schroder JN, DeVore AD, Patel CB, Milano C, Jawitz OK. Early U.S. Heart Transplant Experience With Normothermic Regional Perfusion Following Donation After Circulatory Death. JACC. HEART FAILURE 2024:S2213-1779(24)00507-9. [PMID: 39093259 DOI: 10.1016/j.jchf.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 06/12/2024] [Accepted: 06/18/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Heart transplantation following donation after circulatory death (DCD HT) has short-term survival outcomes comparable to donation after brain death and has led to a significant increase in transplantation volume. The U.S. experience with the normothermic regional perfusion (NRP) DCD HT procurement method has not been evaluated. OBJECTIVES The aim of this study was to examine short-term outcomes associated with NRP vs direct procurement and perfusion (DPP) methods used during DCD HT in the United States. METHODS The UNOS (United Network for Organ Sharing) registry was queried for all adult (age ≥18 years) heart recipients and corresponding donors of controlled DCD HT from January 2019-December 2023. Transplantations were stratified by NRP or DPP reperfusion methods. The primary outcome was overall survival. RESULTS A total of 918 heart donors and recipients met inclusion criteria, including 622 (68%) DPP and 296 (32%) NRP transplantations. Unadjusted Kaplan-Meier survival analysis demonstrated improved short-term survival associated with NRP (log-rank P = 0.005). After adjustment, DCD HT with NRP was independently associated with improved survival (HR: 0.39 [95% CI: 0.22-0.70]; P = 0.002). A propensity-matched analysis similarly demonstrated a cumulative survival benefit to NRP (log-rank P = 0.006). CONCLUSIONS In this largest national series of DCD HT procurement perfusion strategies, NRP is associated with improved short-term survival as compared with DPP. This study evaluates the U.S. early experience with DCD HT, and longer-term follow-up data are needed to further assess the impact of DPP and NRP methods on post-heart transplantation outcomes.
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Affiliation(s)
- Abigail R Benkert
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
| | - Jeffrey E Keenan
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jacob N Schroder
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Adam D DeVore
- Duke Clinical Research Institute, Duke University Medical Center, Durham North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Chetan B Patel
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Carmelo Milano
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Oliver K Jawitz
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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5
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Croome KP. Should advanced perfusion be the standard of care for donation after circulatory death liver transplant? Am J Transplant 2024; 24:1127-1131. [PMID: 38514015 DOI: 10.1016/j.ajt.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/06/2024] [Accepted: 03/14/2024] [Indexed: 03/23/2024]
Abstract
As an alternative to static cold storage (SCS), advanced perfusion techniques such as normothermic regional perfusion and ex-situ perfusion (normothermic or hypothermic) have emerged as a way to improve the ischemic injury suffered by donation after circulatory death (DCD) livers. Multiple studies have been published that have demonstrated superior post-DCD liver transplant outcomes when using advanced perfusion compared with SCS. In particular, these studies have shown lower rates of ischemic cholangiopathy with advanced perfusion. In addition to the improved post-liver transplant outcomes, studies have also demonstrated higher rates of liver utilization from DCD donors when advanced perfusion is used compared with SCS. Given the high rates of graft loss in patients who develop ischemic cholangiopathy, the significant reduction seen in DCD donor livers that have undergone advanced perfusion represents a key step in more broad utilization of these livers. With such compelling evidence from multiple trials, it seems reasonable to ask the question: should advanced perfusion be the standard of care for DCD liver transplant?
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Savoye E, Martin-Lefèvre L, Dantal J, Dorez D, Gaudez F, Drouin S, Riou B, Strecker G, Thierry A, Legeai C, Bronchard R, Kerbaul F, Antoine C. Risk Factors for Adverse Outcomes in Kidney Transplants From Donors After Circulatory Death With Normothermic Regional Perfusion: A Systematic Analysis. Transplantation 2024:00007890-990000000-00791. [PMID: 38872246 DOI: 10.1097/tp.0000000000005102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
BACKGROUND This study examined 1071 adult primary kidney transplants from the French-controlled donation after the circulatory determination of death (cDCD) program, which uses normothermic regional perfusion (NRP), and involves short cold ischemia times (CIT) and constrained asystole times differing by donor age. METHODS Logistic regression identified risk factors for primary nonfunction (PNF), delayed graft function (DGF), and graft failure. RESULTS Risk factors for PNF included donor hypertension, admission for ischemic vascular stroke, and HLA DR mismatches. Risk factors for DGF included functional warm ischemia time >40 min, dialysis >2 y, recipient body mass index of 30 kg/m2 or higher, recipient diabetes, and CIT >10 h. Risk factors for 1-y graft failure included donor hypertension, donor lung recovery, ostial calcification, recipient cardiovascular comorbidities, and HLA DR mismatches. A high donor estimated glomerular filtration rate protected against DGF and graft failure at 1-y. After adjustment restricted to recipient and graft factors and donor age, the risks of PNF, DGF, and graft failure increased with donor age up to 65 y and then remained stable. CONCLUSIONS The study suggests that cDCD kidney transplants are highly successful, but also that its outcomes are influenced by lung recovery, poor HLA DR matching, and warm ischemia times differing with donor age. Our study identified several risk factors for kidney transplantation failure after cDCD with systematic use of NRP and some of them seem as modifiable variables associated with cDCD transplant outcome.
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Affiliation(s)
- Emilie Savoye
- Agence de la biomédecine, Direction Prélèvement Greffe Organes-Tissus, 93212 Saint-Denis-la-Plaine cedex, France
| | - Laurent Martin-Lefèvre
- Organ Donation Service, Service de Médecine Intensive Réanimation, La Roche-Sur-Yon, France
| | - Jacques Dantal
- Nephrology and Transplantation Department, Centre Hospitalier Universitaire, Nantes, France
| | - Didier Dorez
- Organ Donation Service, Centre Hospitalier Annecy-genevois, Epagny Metz-Tessy, France
| | - François Gaudez
- Department of Urology, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sarah Drouin
- Kidney Transplantation, Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Bruno Riou
- Sorbonne Université, UMR 1166, IHU ICAN, Organs and Tissues Harvesting Unit, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Antoine Thierry
- Department of Nephrology, University of Poitiers, Poitiers, France
| | - Camille Legeai
- Agence de la biomédecine, Direction Prélèvement Greffe Organes-Tissus, 93212 Saint-Denis-la-Plaine cedex, France
| | - Régis Bronchard
- Agence de la biomédecine, Direction Prélèvement Greffe Organes-Tissus, 93212 Saint-Denis-la-Plaine cedex, France
| | - François Kerbaul
- Agence de la biomédecine, Direction Prélèvement Greffe Organes-Tissus, 93212 Saint-Denis-la-Plaine cedex, France
| | - Corinne Antoine
- Agence de la biomédecine, Direction Prélèvement Greffe Organes-Tissus, 93212 Saint-Denis-la-Plaine cedex, France
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Sonnenberg EM, Abu-Gazala S, Bittermann T, Abt PL. Following the Flow: Changes in Organ Preservation Methods Require Changes in Our Data Collection. Transplantation 2024; 108:1265-1268. [PMID: 38291568 DOI: 10.1097/tp.0000000000004920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Affiliation(s)
| | - Samir Abu-Gazala
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Therese Bittermann
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA
| | - Peter L Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
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Collins MG, Chadban SJ. Dealing With Delayed Graft Function. Transplantation 2024; 108:1273-1274. [PMID: 38809428 DOI: 10.1097/tp.0000000000004764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Affiliation(s)
- Michael G Collins
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Steven J Chadban
- Department of Renal Medicine, Kidney Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Kidney Node, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
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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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Mella A, Calvetti R, Barreca A, Congiu G, Biancone L. Kidney transplants from elderly donors: what we have learned 20 years after the Crystal City consensus criteria meeting. J Nephrol 2024:10.1007/s40620-024-01888-w. [PMID: 38446386 DOI: 10.1007/s40620-024-01888-w] [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: 05/26/2022] [Accepted: 01/03/2024] [Indexed: 03/07/2024]
Abstract
Based on the current projection of the general population and the combined increase in end-stage kidney disease with age, the number of elderly donors and recipients is increasing, raising crucial questions about how to minimize the discard rate of organs from elderly donors and improve graft and patient outcomes. In 2002, extended criteria donors were the focus of a meeting in Crystal City (VA, USA), with a goal of maximizing the use of organs from deceased donors. Since then, extended criteria donors have progressively contributed to a large number of transplanted grafts worldwide, posing specific issues for allocation systems, recipient management, and therapeutic approaches. This review analyzes what we have learned in the last 20 years about extended criteria donor utilization, the promising innovations in immunosuppressive management, and the molecular pathways involved in the aging process, which constitute potential targets for novel therapies.
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Affiliation(s)
- Alberto Mella
- Renal Transplant Center" A. Vercellone," Nephrology, Dialysis, and Renal Transplant Division, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Corso Bramante, 88, 10126, Turin, Italy
| | - Ruggero Calvetti
- Renal Transplant Center" A. Vercellone," Nephrology, Dialysis, and Renal Transplant Division, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Corso Bramante, 88, 10126, Turin, Italy
| | - Antonella Barreca
- Division of Pathology, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giovanni Congiu
- Renal Transplant Center" A. Vercellone," Nephrology, Dialysis, and Renal Transplant Division, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Corso Bramante, 88, 10126, Turin, Italy
| | - Luigi Biancone
- Renal Transplant Center" A. Vercellone," Nephrology, Dialysis, and Renal Transplant Division, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Corso Bramante, 88, 10126, Turin, Italy.
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Motter JD, Jaffe IS, Moazami N, Smith DE, Kon ZN, Piper GL, Sommer PM, Reyentovich A, Chang SH, Aljabban I, Montgomery RA, Segev DL, Massie AB, Lonze BE. Single center utilization and post-transplant outcomes of thoracoabdominal normothermic regional perfusion deceased cardiac donor organs. Clin Transplant 2024; 38:e15269. [PMID: 38445531 DOI: 10.1111/ctr.15269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/26/2024] [Accepted: 02/09/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION Thoracoabdominal normothermic regional perfusion (TA-NRP) following cardiac death is an emerging multivisceral organ procurement technique. Recent national studies on outcomes of presumptive TA-NRP-procured organs are limited by potential misclassification since TA-NRP is not differentiated from donation after cardiac death (DCD) in registry data. METHODS We studied 22 donors whose designees consented to TA-NRP and organ procurement performed at our institution between January 20, 2020 and July 3, 2022. We identified these donors in SRTR to describe organ utilization and recipient outcomes and compared them to recipients of traditional DCD (tDCD) and donation after brain death (DBD) organs during the same timeframe. RESULTS All 22 donors progressed to cardiac arrest and underwent TA-NRP followed by heart, lung, kidney, and/or liver procurement. Median donor age was 41 years, 55% had anoxic brain injury, 45% were hypertensive, 0% were diabetic, and median kidney donor profile index was 40%. TA-NRP utilization was high across all organ types (88%-100%), with a higher percentage of kidneys procured via TA-NRP compared to tDCD (88% vs. 72%, p = .02). Recipient and graft survival ranged from 89% to 100% and were comparable to tDCD and DBD recipients (p ≥ .2). Delayed graft function was lower for kidneys procured from TA-NRP compared to tDCD donors (27% vs. 44%, p = .045). CONCLUSION Procurement from TA-NRP donors yielded high organ utilization, with outcomes comparable to tDCD and DBD recipients across organ types. Further large-scale study of TA-NRP donors, facilitated by its capture in the national registry, will be critical to fully understand its impact as an organ procurement technique.
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Affiliation(s)
- Jennifer D Motter
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Ian S Jaffe
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Nader Moazami
- Department of Cardiothoracic Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Deane E Smith
- Department of Cardiothoracic Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Zachary N Kon
- Department of Cardiothoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Greta L Piper
- Department of Cardiothoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Philip M Sommer
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Alex Reyentovich
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Stephanie H Chang
- Department of Cardiothoracic Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Imad Aljabban
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
- Department of Surgery, Columbia University School of Medicine, New York, New York, USA
| | - Robert A Montgomery
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Dorry L Segev
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
- Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
| | - Allan B Massie
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Bonnie E Lonze
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
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12
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Zhou AL, Leng A, Ruck JM, Akbar AF, Desai NM, King EA. Kidney Donation After Circulatory Death Using Thoracoabdominal Normothermic Regional Perfusion: The Largest Report of the United States Experience. Transplantation 2024; 108:516-523. [PMID: 37691154 PMCID: PMC10840803 DOI: 10.1097/tp.0000000000004801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
BACKGROUND Thoracoabdominal normothermic regional perfusion (TA-NRP) has been increasingly used for donation after circulatory death (DCD) procurements in the United States. We present the largest report of outcomes of kidney transplants performed using DCD donor grafts perfused with TA-NRP. METHODS Adult DCD kidney transplants between 2020 and 2022 in the United Network for Organ Sharing database were included. Donors with ≥50 min between asystole and aortic cross-clamp time in which the heart was also transplanted were considered TA-NRP donors. All other donors were considered direct recovery donors. Multivariable regressions were used to assess delayed graft function, as well as posttransplant survival and all-cause graft failure at 30, 90, and 180 d. A propensity-matched analysis of cohorts matched on donor Kidney Donor Profile Index was performed. RESULTS Of the 16 140 total DCD kidney transplants performed during the study period, 306 (1.9%) used TA-NRP. TA-NRP donors were younger ( P < 0.001) and had lower Kidney Donor Profile Index ( P < 0.001) compared with direct recovery donors. Recipients receiving grafts recovered using TA-NRP were younger ( P < 0.001) and more likely to be blood group O ( P < 0.001). Transplants using TA-NRP had lower likelihood of delayed graft function (adjusted odds ratio 0.22 [95% confidence interval, 0.15-0.31], P < 0.001) but similar 180-d survival ( P = 0.8) and all-cause graft failure ( P = 0.3) as transplants using direct recovery grafts. These inferences were unchanged on propensity-matched analysis. CONCLUSIONS Our results demonstrate that kidney transplants using TA-NRP DCD allografts have positive short-term mortality and graft survival outcomes, with significantly decreased rates of delayed graft function compared with direct recovery DCD grafts.
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Affiliation(s)
- Alice L. Zhou
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Albert Leng
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jessica M. Ruck
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Armaan F. Akbar
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Niraj M. Desai
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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Royo-Villanova M, Miñambres E, Sánchez JM, Torres E, Manso C, Ballesteros MÁ, Parrilla G, de Paco Tudela G, Coll E, Pérez-Blanco A, Domínguez-Gil B. Maintaining the permanence principle of death during normothermic regional perfusion in controlled donation after the circulatory determination of death: Results of a prospective clinical study. Am J Transplant 2024; 24:213-221. [PMID: 37739346 DOI: 10.1016/j.ajt.2023.09.008] [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: 06/12/2023] [Revised: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 09/24/2023]
Abstract
One concern about the use of normothermic regional perfusion (NRP) in controlled donation after the circulatory determination of death (cDCD) is that the brain may be perfused. We aimed to demonstrate that certain technical maneuvers preclude such brain perfusion. A nonrandomized trial was performed on cDCD donors. In abdominal normothermic regional perfusion (A-NRP), the thoracic aorta was blocked with an intra-aortic occlusion balloon. In thoracoabdominal normothermic regional perfusion (TA-NRP), the arch vessels were clamped and the cephalad ends vented to the atmosphere. The mean intracranial arterial blood pressure (ICBP) was invasively measured at the circle of Willis. Ten cDCD donors subject to A-NRP or TA-NRP were included. Mean ICBP and mean blood pressure at the thoracic and the abdominal aorta during the circulatory arrest were 17 (standard deviation [SD], 3), 17 (SD, 3), and 18 (SD, 4) mmHg, respectively. When A-NRP started, pressure at the abdominal aorta increased to 50 (SD, 13) mmHg, while the ICBP remained unchanged. When TA-NRP was initiated, thoracic aorta pressure increased to 71 (SD, 18) mmHg, but the ICBP remained unmodified. Recorded values of ICBP during NRP were 10 mmHg. In conclusion, appropriate technical measures applied during NRP preclude perfusion of the brain in cDCD. This study might help to expand NRP and increase the number of organs available for transplantation.
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Affiliation(s)
- Mario Royo-Villanova
- Donor Transplant Coordination Unit, Service of Intensive Care, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Eduardo Miñambres
- Donor Transplant Coordination Unit, Service of Intensive Care, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, Universidad de Cantabria, Santander, Spain.
| | - José Moya Sánchez
- Donor Transplant Coordination Unit, Service of Intensive Care, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Eduardo Torres
- Neuro-intervention Unit, Hospital Universitario de Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Clara Manso
- Service of Intensive Care, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - María Ángeles Ballesteros
- Donor Transplant Coordination Unit, Service of Intensive Care, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Guillermo Parrilla
- Interventional Neurovascular Unit, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Gonzalo de Paco Tudela
- Interventional Neurovascular Unit, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
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14
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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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15
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Guo Y, Luke P, Sener A. Organ storage in renal transplantation. Curr Opin Urol 2024; 34:8-13. [PMID: 37916955 DOI: 10.1097/mou.0000000000001139] [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: 11/03/2023]
Abstract
PURPOSE OF REVIEW Kidney transplantation is vital for those with end-stage renal disease, enhancing quality of life and longevity. It is the preferred treatment but is hindered by a global disparity between donor kidney availability and demand. Therefore, optimizing organ storage techniques is crucial to mitigate the effects of ischemia reperfusion injury in available organs. Recent interest has centered on innovative methods like oxygenated normothermic perfusion and abdominal regional perfusion. RECENT FINDINGS Multiple recent metanalyses, including a Cochrane review, confirm the benefits of hypothermic machine perfusion (HMP) for deceased donor kidneys, demonstrating its utility and cost effectiveness. The benefits of oxygenated normothermic perfusion have been seen in retrospective data sets but not in prospective trials. Abdominal regional perfusion (aNRP) is gaining interest, especially for liver transplantation, but kidney specific data are scant. SUMMARY High-quality evidence backs the use of HMP for deceased donor kidneys. Despite interest in other techniques, clinical evidence for their benefits in kidney transplantation is lacking. The gap between innovation and verified success emphasizes the need for continued research and collaboration between medical professionals, researchers, and ethical committees. This review aims to further illuminate the complexities and advancements in the field, bridging the knowledge gap and aiding in the continual pursuit of excellence in transplantation.
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Affiliation(s)
- Yanbo Guo
- Division of Urology, Department of Surgery, McMaster University, Hamilton
| | - Patrick Luke
- Division of Urology, Department of Surgery, Western University, London, ON, Canada
| | - Alp Sener
- Division of Urology, Department of Surgery, Western University, London, ON, Canada
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16
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Merani S, Urban M, Westphal SG, Dong J, Miles CD, Maskin A, Hoffman A, Langnas AN. Improved Early Post-Transplant Outcomes and Organ Use in Kidney Transplant Using Normothermic Regional Perfusion for Donation after Circulatory Death: National Experience in the US. J Am Coll Surg 2024; 238:107-118. [PMID: 37772721 DOI: 10.1097/xcs.0000000000000880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
BACKGROUND Normothermic regional perfusion (NRP) is a technique that is intended to enhance organ transplant outcomes from donation circulatory death (DCD) donors. STUDY DESIGN A retrospective analysis of data from the Scientific Registry of Transplant Recipients was performed. DCD donors were screened for inclusion based on date of donation 2020 or later, and whether the heart was also recovered for transplantation. We grouped donors as either donation after brain death or DCD. DCD donors were further divided into groups including those in which the heart was not recovered for transplant (Non-Heart DCD) and those in which it was, based on recovery technique (thoracoabdominal-NRP [TA-NRP] Heart DCD and Super Rapid Recovery Heart DCD). RESULTS A total of 219 kidney transplant recipients receiving organs from TA-NRP Heart DCD donors were compared to 436 SRR Super Rapid Recovery DCD, 10,630 Super Rapid Recovery non-heart DCD, and 27,820 donations after brain death recipients. Kidney transplant recipients of TA-NRP DCD allografts experienced shorter length of stay, lower rates of delayed graft function, and lower serum creatinine at the time of discharge when compared with recipients of other DCD allografts. CONCLUSIONS Our analysis demonstrates superior early kidney allograft function when TA-NRP is used for DCD organ recovery.
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Affiliation(s)
- Shaheed Merani
- From the Division of Transplant, Department of Surgery (Merani, Maskin, Hoffman, Langnas), University of Nebraska Medical Center, Omaha, NE
| | - Marian Urban
- Division of Cardiothoracic Surgery, Department of Surgery (Urban), University of Nebraska Medical Center, Omaha, NE
| | - Scott G Westphal
- Division of Nephrology Department of Medicine (Westphal, Dong, Miles), University of Nebraska Medical Center, Omaha, NE
| | - James Dong
- Division of Nephrology Department of Medicine (Westphal, Dong, Miles), University of Nebraska Medical Center, Omaha, NE
- Department of Biostatistics (Dong), University of Nebraska Medical Center, Omaha, NE
| | - Clifford D Miles
- Division of Nephrology Department of Medicine (Westphal, Dong, Miles), University of Nebraska Medical Center, Omaha, NE
| | - Alexander Maskin
- From the Division of Transplant, Department of Surgery (Merani, Maskin, Hoffman, Langnas), University of Nebraska Medical Center, Omaha, NE
| | - Arika Hoffman
- From the Division of Transplant, Department of Surgery (Merani, Maskin, Hoffman, Langnas), University of Nebraska Medical Center, Omaha, NE
| | - Alan N Langnas
- From the Division of Transplant, Department of Surgery (Merani, Maskin, Hoffman, Langnas), University of Nebraska Medical Center, Omaha, NE
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17
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Antonini MV, Viola L, Circelli A, Bianchin M, Bolondi G, Nanni A, Agnoletti V. Transesophageal Ultrasound-Guided Normothermic Regional Perfusion in Controlled Donors After Cardiocirculatory Determination of Death. ASAIO J 2024; 70:e1-e5. [PMID: 37549668 DOI: 10.1097/mat.0000000000002024] [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: 08/09/2023] Open
Abstract
Programs of donation after cardiocirculatory determination of death (DCD) are increasingly established in many countries to increase the availability of organs for transplantation. The use of abdominal normothermic regional reperfusion (A-NRP), shortening total warm ischemia time (tWIT), has been recently recommended by the European Society for Organ Transplantation (ESOT) to decrease the risk potentially associated with transplantation of grafts from DCD donors. We aimed to describe our transesophageal ultrasound (TEU)-guided technique to implement A-NRP in controlled DCD (cDCD) donors through femorofemoral venoarterial extracorporeal support, preventing coronary and cerebral reperfusion occluding the aorta with a balloon. After assessment of the central vascular structures, the use of TEU in real time guides the insertion of the guidewires and the balloon. Moreover, TEU allows us to verify the proper positioning of a venous cannula and aortic balloon. The entire procedure may be performed without the need for fluoroscopic or radiographic evaluation, or limiting the need for fluoroscopic or radiology assistance to a selected scenario of difficult or expected difficult cannulation and/or balloon insertion. The distribution of interventions as antemortem and postmortem reflects the scenario imposed by Italian laws regulating organ procurement in DCD donors.
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Affiliation(s)
- Marta Velia Antonini
- From the Anesthesia and Intensive Care Unit, Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Lorenzo Viola
- From the Anesthesia and Intensive Care Unit, Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Alessandro Circelli
- From the Anesthesia and Intensive Care Unit, Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Matteo Bianchin
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Giuliano Bolondi
- From the Anesthesia and Intensive Care Unit, Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Andrea Nanni
- From the Anesthesia and Intensive Care Unit, Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
- Transplant Procurement Management, Transplant Procurement Management-AUSL della Romagna, Cesena, Italy
| | - Vanni Agnoletti
- From the Anesthesia and Intensive Care Unit, Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
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18
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Nwaduru C, Baker E, Buff M, Selim M, Ovalle LA, Baker TB, Zimmerman MA. Assessing Liver Viability: Insights From Mitochondrial Bioenergetics in Ischemia-Reperfusion Injury. Transplant Proc 2024; 56:228-235. [PMID: 38171992 DOI: 10.1016/j.transproceed.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/30/2023] [Indexed: 01/05/2024]
Abstract
Orthotopic liver transplantation remains the definitive treatment for patients with end-stage liver disease. Unfortunately, the increasing demand for donor livers and the limited supply of viable organs have both led to a critical need for innovative strategies to expand the pool of transplantable organs. The mitochondrion, central to hepatic cellular function, plays a pivotal role in hepatic ischemic injury, with impaired mitochondrial function and oxidative stress leading to cell death. Mitochondrial protection strategies have shown promise in mitigating IRI and resuscitating marginal organs for transplant. Machine perfusion (MP) has been proven a valuable tool for reviving marginal organs with very promising results. Evaluation of liver viability during perfusion traditionally relies on parameters including lactate clearance, bile production, and transaminase levels. Nevertheless, the quest for more comprehensive and universally applicable viability markers persists. Normothermic regional perfusion has gained robust attention, offering extended recovery time for organs from donation after cardiac death donors. This approach has shown remarkable success in improving organ quality and reducing ischemic injury using the body's physiological conditions. The current challenge lies in the absence of a reliable assessment tool for predicting graft viability and post-transplant outcomes. To address this, exploring insights from mitochondrial function in the context of ischemia-reperfusion injury could offer a promising path toward better patient outcomes and graft longevity. Indeed, hypoxia-induced mitochondrial injury may serve as a surrogate marker of organ viability following oxygenated resuscitation techniques in the future.
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Affiliation(s)
- Chinedu Nwaduru
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah.
| | - Emma Baker
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Michelle Buff
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Motaz Selim
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Leo Aviles Ovalle
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Talia B Baker
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Michael A Zimmerman
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
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19
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Unes M, Kurashima K, Caliskan Y, Portz E, Jain A, Nazzal M. Normothermic ex vivo perfusion of deceased donor kidneys and its clinical potential in kidney transplantation outcomes. Int J Artif Organs 2023; 46:618-628. [PMID: 37897367 DOI: 10.1177/03913988231207719] [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] [Indexed: 10/30/2023]
Abstract
In recent years, normothermic machine perfusion (NMP) has emerged in conversation surrounding organ preservation and transplantation techniques with the goal of improving patient and clinical outcomes. This is in great attempt to address the rate of non-utilization and the shortage of available organs in kidney transplantation. This focus in mind, normothermic perfusion presents itself as a potential tool to mimic physiological conditions and improve current preservation methods, such as static cold storage. This review serves to improve understanding of the observed connection between the consequences of ischemia and reperfusion injury and traditional preservation techniques as well as how renal NMP may mitigate these issues. Previous studies suggest that reducing time in static cold storage methods by promoting the normothermic perfusion model results in decreased delayed graft function and post-transplant complications. This review also aims to present the immense clinical potential NMP has on future kidney transplantation success and what this means for the fields of nephrology and transplantation. While great strides have been made to evaluate normothermic perfusion's impact on kidney graft viability and transplant success, future research into unified protocol, clinically relevant biomarkers, cost-utility analysis, and use with associated therapeutic and imaging modalities is paramount.
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Affiliation(s)
| | - Kento Kurashima
- Department of Pediatrics, SSM Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Yasar Caliskan
- Division of Nephrology, SSM Saint Louis University Hospital, Saint Louis, MO, USA
| | | | - Ajay Jain
- Department of Pediatrics, SSM Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Mustafa Nazzal
- Department of Surgery, SSM Saint Louis University Hospital, Saint Louis, MO, USA
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20
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Louca JO, Manara A, Messer S, Öchsner M, McGiffin D, Austin I, Bell E, Leboff S, Large S. Getting out of the box: the future of the UK donation after circulatory determination of death heart programme. EClinicalMedicine 2023; 66:102320. [PMID: 38024476 PMCID: PMC10679474 DOI: 10.1016/j.eclinm.2023.102320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 10/28/2023] [Accepted: 11/01/2023] [Indexed: 12/01/2023] Open
Abstract
Heart failure imposes a significant burden on all health care systems and has a 5-year mortality of 50%. Heart transplantation and ventricular assist device (VAD) implantation are the definitive therapies for end stage heart disease, although transplantation appears to offer superior long-term survival and quality of life over VAD implantation. Transplantation is limited by a shortage in donor hearts, resulting in considerable waiting list mortality. Donation after circulatory determination of death (DCD) offers a significant uplift in the number of donors for heart transplantation. The outcomes both from the UK and internationally have been exciting, with outcomes at least as good as conventional donation after brain death (DBD) transplantation. Currently, DCD hearts are reperfused using ex-situ machine perfusion (ESMP). Whilst ESMP has enabled the development of DCD transplantation, it comes at significant cost, with the per run cost of approximately GBP £90,000. In-situ perfusion of the heart, otherwise known as thoraco-abdominal normothermic regional perfusion (taNRP) is cheaper, but there are ethical concerns regarding the potential to restore cerebral perfusion in the donor. We must determine whether there is any cerebral circulation during in-situ perfusion of the heart to ensure that it does not invalidate the diagnosis of death and potentially violate the dead donor rule. Besides this, there is a need for a randomised controlled trial to definitively determine whether taNRP offers any clinical advantages over ex-situ machine perfusion. This viewpoint article explores these issues in more detail.
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Affiliation(s)
- John Onsy Louca
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0SP, UK
| | - Alex Manara
- The Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, BS 10 5NB, UK
| | - Simon Messer
- Golden Jubilee Hospital, Agamermnon Street, Glasgow, G81 4DY, UK
| | - Marco Öchsner
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0SP, UK
| | - David McGiffin
- The Alfred and Monash University, Australia 55 Commercial Rd, Melbourne, VIC, 3004, Australia
| | - Isabel Austin
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0SP, UK
| | - Eliza Bell
- Royal Papworth Hospital Biomedical Campus, Cambridge, CB2 0AY, UK
| | - Savanna Leboff
- Royal Papworth Hospital Biomedical Campus, Cambridge, CB2 0AY, UK
| | - Stephen Large
- Royal Papworth Hospital Biomedical Campus, Cambridge, CB2 0AY, UK
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21
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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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22
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Salguero J, Chamorro L, Gómez-Gómez E, de Benito P, Robles JE, Campos JP. Kidney Survival Impact of Delayed Graft Function Depends on Kidney Donor Risk Index: A Single-Center Cohort Study. J Clin Med 2023; 12:6397. [PMID: 37835040 PMCID: PMC10573826 DOI: 10.3390/jcm12196397] [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: 08/19/2023] [Revised: 09/25/2023] [Accepted: 10/06/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Delayed graft function (DGF) is a significant challenge in renal transplantation, particularly with deceased donors, necessitating early postoperative dialysis. The prolonged effects of medium- and long-term DGF remain uncertain, marked by contradictory graft survival outcomes. This incongruity might arise from the inherent graft resilience and regenerative capacity during transplantation. This study investigates DGF's impact on graft survival, focusing on grafts displaying favorable (KDRI < 1) and unfavorable outcomes (KDRI ≥ 1). METHODS In this retrospective cohort study (January 2015-December 2019), we assessed kidney transplants at our center, excluding multiorgan simultaneous cases, primary non-functioning grafts, and surgical complications causing graft loss. Patients were categorized into DGF presence or absence groups. Univariate and multivariate analyses, alongside propensity score matching (PSM), were performed. RESULTS The study encompassed 322 deceased donor kidneys, with 83 encountering DGF. Grafts with higher KDRI indices (KDRI ≥ 1) and DGF exhibited a notably increased graft loss risk (HR: 4.17, 95% CI: 1.93-9.01). However, lower-KDRI donor grafts displayed no significant disparities between the DGF and non-DGF groups. CONCLUSIONS Delayed graft function (DGF) development significantly contributes to graft loss in kidney transplants, particularly in grafts with KDRI ≥ 1.
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Affiliation(s)
- Joseba Salguero
- Urology Department, Infanta Margarita Hospital, 14940 Cabra, Spain
| | - Laura Chamorro
- Urology Department, Reina Sofía University Hospital, Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba, 14004 Córdoba, Spain; (L.C.); (P.d.B.); (J.P.C.)
| | - Enrique Gómez-Gómez
- Urology Department, Reina Sofía University Hospital, Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba, 14004 Córdoba, Spain; (L.C.); (P.d.B.); (J.P.C.)
| | - Patricia de Benito
- Urology Department, Reina Sofía University Hospital, Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba, 14004 Córdoba, Spain; (L.C.); (P.d.B.); (J.P.C.)
| | - Jose E. Robles
- Urology Department, University of Navarra Clinic, 31009 Pamplona, Spain;
| | - Juan P. Campos
- Urology Department, Reina Sofía University Hospital, Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba, 14004 Córdoba, Spain; (L.C.); (P.d.B.); (J.P.C.)
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23
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Kagawa H, Goodwin M, Stehlik J, Campsen J, Baker T, Selzman CH. A Case Report of Triple Organ Transplantation From a Donor After Circulatory Death Using Thoraco-Abdominal Normothermic Regional Perfusion. Transplant Proc 2023; 55:1883-1887. [PMID: 37612153 DOI: 10.1016/j.transproceed.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/31/2023] [Indexed: 08/25/2023]
Abstract
Organ transplantation with donation after circulatory death can potentially increase the donor pool. Here, we report the rare case of triple-organ (heart/liver/kidney) transplantation from a donor after circulatory death using thoraco-abdominal normothermic regional perfusion. The recipient was a 61-year-old man with end-stage heart failure, liver failure, and kidney failure secondary to arrhythmogenic right ventricular dysplasia. He received a heart/liver/kidney transplantation from a donor after circulatory death. The course was complicated with primary graft dysfunction of the heart that resolved on postoperative day 3. The patient was discharged on postoperative day 39. He has no evidence for rejection on heart biopsy, and all 3 organs exhibit stable function. The use of donation after cardiac death donors greatly increases the donor pool and should be considered for patients requiring multiorgan transplantation. The use of thoraco-abdominal normothermic reperfusion is not only a feasible method for multiorgan procurement but also provides enhanced protection for all transplanted organs.
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Affiliation(s)
- Hiroshi Kagawa
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Matthew Goodwin
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jeffrey Campsen
- Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Talia Baker
- Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah.
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Martínez-Castro S, Navarro R, García-Pérez ML, Segura JM, Carbonell JA, Hornero F, Guijarro J, Zaplana M, Bruño MÁ, Tur A, Martínez-León JB, Zaragoza R, Núñez J, Domínguez-Gil B, Badenes R. Evaluation of functional warm ischemia time during controlled donation after circulatory determination of death using normothermic regional perfusion (ECMO-TT): A prospective multicenter cohort study. Artif Organs 2023; 47:1371-1385. [PMID: 37042612 DOI: 10.1111/aor.14539] [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: 11/08/2022] [Revised: 03/29/2023] [Accepted: 04/06/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Controlled donation after circulatory determination of death (cDCD) seems an effective way to mitigate the critical shortage of available organs for transplant worldwide. As a recently developed procedure for organ retrieval, some questions remain unsolved such as the uncertainty regarding the effect of functional warm ischemia time (FWIT) on organs´ viability. METHODS We developed a multicenter prospective cohort study collecting all data from evaluated organs during cDCD from 2017 to 2020. All the procedures related to cDCD were performed with normothermic regional perfusion. The analysis included organ retrieval as endpoint and FWIT as exposure of interest. The effect of FWIT on the likelihood for organ retrieval was evaluated with Relative distribution analysis. RESULTS A total amount of 507 organs´ related information was analyzed from 95 organ donors. Median donor age was 62 years, and 63% of donors were male. Stroke was the most common diagnosis before withdrawal of life-sustaining therapy (61%), followed by anoxic encephalopathy (21%). This analysis showed that length of FWIT was inversely associated with organ retrieval rates for liver, kidneys, and pancreas. No statistically significant association was found for lungs. CONCLUSIONS Results showed an inverse association between functional warm ischemia time (FWIT) and retrieval rate. We also have postulated optimal FWIT's thresholds for organ retrieval. FWIT for liver retrieval remained between 6 and less than 11 min and in case of kidneys and pancreas, the optimal FWIT for retrieval was 6 to 12 min. These results could be valuable to improve organ utilization and for future analysis.
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Affiliation(s)
- Sara Martínez-Castro
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | - Rosalía Navarro
- Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain
| | - María Luisa García-Pérez
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
- Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain
| | - José Manuel Segura
- Department of Medical Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain
- Transplant Coordination Unit, Hospital Clínic Universitari de Valencia, Valencia, Spain
| | - José A Carbonell
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
- Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain
| | - Fernando Hornero
- Department of Cardiac Surgery, Hospital Clínic Universitari de Valencia, Valencia, Spain
| | - Jorge Guijarro
- Department of Interventional Radiology, Hospital Clínic Universitari de Valencia, Valencia, Spain
| | - Marta Zaplana
- Department of Vascular Surgery, Hospital Clínic Universitari de Valencia, Valencia, Spain
| | - María Ángeles Bruño
- Cardiovascular Perfussion Unit, Hospital Clínic Universitari de Valencia, Valencia, Spain
| | - Ana Tur
- Transplant Coordination Unit, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Juan Bautista Martínez-León
- Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain
- Department of Cardiac Surgery, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Rafael Zaragoza
- Department of Intensive Care Medicine, Hospital Universitario Dr. Peset, Valencia, Spain
| | - Julio Núñez
- INCLIVA Biomedical Research Institute, Valencia, Spain
- Department of Cardiology, Hospital Clínic Universitari de Valencia, Valencia, Spain
- Department of Medicine. School of Medicine, University of Valencia, Valencia, Spain
| | | | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
- Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain
- Transplant Coordination Unit, Hospital Clínic Universitari de Valencia, Valencia, Spain
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25
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Kaffka genaamd Dengler SE, Vervoorn MT, Brouwer M, de Jonge J, van der Kaaij NP. Dilemmas concerning heart procurement in controlled donation after circulatory death. Front Cardiovasc Med 2023; 10:1225543. [PMID: 37583588 PMCID: PMC10424927 DOI: 10.3389/fcvm.2023.1225543] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 07/11/2023] [Indexed: 08/17/2023] Open
Abstract
With an expanding population at risk for heart failure and the resulting increase in patients admitted to the waiting list for heart transplantation, the demand of viable organs exceeds the supply of suitable donor hearts. Use of hearts after circulatory death has reduced this deficit. Two primary techniques for heart procurement in circulatory death donors have been described: direct procurement and perfusion and thoraco-abdominal normothermic regional perfusion. While the former has been accepted as an option for heart procurement in circulatory death donors, the latter technique has raised some ethical questions in relation to the dead donor rule. In this paper we discuss the current dilemmas regarding these heart procurement protocols in circulatory death donors.
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Affiliation(s)
| | - M. T. Vervoorn
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - M. Brouwer
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - J. de Jonge
- Department of Surgery, Erasmus Medical Center Transplant Institute, Rotterdam, Netherlands
| | - N. P. van der Kaaij
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
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26
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Ghoneima AS, Sousa Da Silva RX, Gosteli MA, Barlow AD, Kron P. Outcomes of Kidney Perfusion Techniques in Transplantation from Deceased Donors: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:3871. [PMID: 37373568 DOI: 10.3390/jcm12123871] [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: 03/14/2023] [Revised: 05/03/2023] [Accepted: 05/09/2023] [Indexed: 06/29/2023] Open
Abstract
The high demand for organs in kidney transplantation and the expansion of the donor pool have led to the widespread implementation of machine perfusion technologies. In this study, we aim to provide an up-to-date systematic review of the developments in this expanding field over the past 10 years, with the aim of answering the question: "which perfusion technique is the most promising technique in kidney transplantation?" A systematic review of the literature related to machine perfusion in kidney transplantation was performed. The primary outcome measure was delayed graft function (DGF), and secondary outcomes included rates of rejection, graft survival, and patient survival rates after 1 year. Based on the available data, a meta-analysis was performed. The results were compared with data from static cold storage, which is still the standard of care in many centers worldwide. A total of 56 studies conducted in humans were included, and 43 studies reported outcomes of hypothermic machine perfusion (HMP), with a DGF rate of 26.4%. A meta-analysis of 16 studies showed significantly lower DGF rates in the HMP group compared to those of static cold storage (SCS). Five studies reported outcomes of hypothermic machine perfusion + O2, with an overall DGF rate of 29.7%. Two studies explored normothermic machine perfusion (NMP). These were pilot studies, designed to assess the feasibility of this perfusion approach in the clinical setting. Six studies reported outcomes of normothermic regional perfusion (NRP). The overall incidence of DGF was 71.5%, as it was primarily used in uncontrolled DCD (Maastricht category I-II). Three studies comparing NRP to in situ cold perfusion showed a significantly lower rate of DGF with NRP. The systematic review and meta-analysis provide evidence that dynamic preservation strategies can improve outcomes following kidney transplantation. More recent approaches such as normothermic machine perfusion and hypothermic machine perfusion + O2 do show promising results but need further results from the clinical setting. This study shows that the implementation of perfusion strategies could play an important role in safely expanding the donor pool.
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Affiliation(s)
- Ahmed S Ghoneima
- Department of HPB and Transplant Surgery, St. James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
| | - Richard X Sousa Da Silva
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland
| | | | - Adam D Barlow
- Department of HPB and Transplant Surgery, St. James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
| | - Philipp Kron
- Department of HPB and Transplant Surgery, St. James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland
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27
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Moorlock G, Draper H. Proposal to support making decisions about the organ donation process. JOURNAL OF MEDICAL ETHICS 2023; 49:434-438. [PMID: 35953297 DOI: 10.1136/jme-2022-108323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 08/07/2022] [Indexed: 05/24/2023]
Abstract
In this paper, we propose a novel approach to permit members of the public opportunity to record more nuanced wishes in relation to organ donation. Recent developments in organ donation and procurement have made the associated processes potentially more multistaged and complex than ever. At the same time, opt-out legislation has led to a more simplistic recording of wishes than ever. We argue that in order to be confident that a patient would really wish to go ahead with the various interventions and procedures that now accompany organ donation, more nuanced information than a simple 'yes' or 'no' may be required. This is of particular importance for donation after circulatory death, where some interventions to facilitate donation occur when the patient is still alive. We propose the implementation of an online form to allow people to record more nuanced wishes in relation to donation, including an indication of competing wishes and how these should be weighed into decision-making. We argue that this approach will promote autonomous decision-making for the public, potentially reduce difficulties that family members encounter at the time of organ donation, and should make medical staff more confident that they are truly acting according to the wishes and best interests of their patients.
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Affiliation(s)
- Greg Moorlock
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Heather Draper
- Warwick Medical School, University of Warwick, Coventry, UK
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28
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Salguero J, Chamorro L, Gomez-Gomez E, Robles JE, Campos JP. Midterm Outcomes of Kidney Transplantation from Expanded Criteria Donors After Circulatory Death: A Single-Center Retrospective Cohort Study. EXP CLIN TRANSPLANT 2023; 21:481-486. [PMID: 37455467 DOI: 10.6002/ect.2023.0076] [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: 07/18/2023]
Abstract
OBJECTIVES Kidney transplant is the optimal treatment for end-stage renal disease; however, due to the imbalance between demand and supply, several strategies have been implemented to increase the donor pool. To increase the number of donors, expanded criteria donors after circulatory death have been explored as an acceptable graft source. In this study, we compared graft survival, estimated glomerular filtration rate at 3 and 5 years, and the incidence of delayed graft function between standard and expanded criteria donors after brain death and between standard and expanded criteria donors after circulatory death. MATERIALS AND METHODS A prospective cohort study was conducted between January 1, 2015, and December 31, 2019, at Reina Sofia University Hospital. Variables related to the donor, recipient, and transplant procedure were analyzed, and univariate and multivariate logistic and Cox regression analyses were performed. RESULTS Our study included 308 deceased donor kidneys. The kidneys from standard criteria brain dead donors had higher estimated glomerular filtration rate than the other groups (P < .03).However, no significant differences in estimated glomerular filtration rate were observed among the suboptimal groups (expanded criteria and standard criteria donors after brain death and expanded criteria donors after circulatory death). The incidence of delayed graft function was significantly higher in expanded criteria donors after circulatory death than in the other groups (odds ratio = 6.9; 95% CI, 2.22-21.71; P < .001). Nevertheless, we found no significant differences in death-censored graft loss among the groups. CONCLUSIONS Kidney transplants from expanded criteria donors and donors after cardiac death are comparable, even when both criteria are combined. The use of expanded criteria donor kidneys after cardiac death is therefore a suitable approach to expand the donor pool, despite the higher risk of delayed graft function, as there were no significant differences in death-censored graft loss.
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Affiliation(s)
- Joseba Salguero
- From the Urology Department, Infanta Margarita Hospital, Cordoba Spain
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29
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Hosgood SA, Callaghan CJ, Wilson CH, Smith L, Mullings J, Mehew J, Oniscu GC, Phillips BL, Bates L, Nicholson ML. Normothermic machine perfusion versus static cold storage in donation after circulatory death kidney transplantation: a randomized controlled trial. Nat Med 2023; 29:1511-1519. [PMID: 37231075 PMCID: PMC10287561 DOI: 10.1038/s41591-023-02376-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 04/28/2023] [Indexed: 05/27/2023]
Abstract
Kidney transplantation is the optimal treatment for end-stage renal disease, but it is still severely limited by a lack of suitable organ donors. Kidneys from donation after circulatory death (DCD) donors have been used to increase transplant rates, but these organs are susceptible to cold ischemic injury in the storage period before transplantation, the clinical consequence of which is high rates of delayed graft function (DGF). Normothermic machine perfusion (NMP) is an emerging technique that circulates a warmed, oxygenated red-cell-based perfusate through the kidney to maintain near-physiological conditions. We conducted a randomized controlled trial to compare the outcome of DCD kidney transplants after conventional static cold storage (SCS) alone or SCS plus 1-h NMP. A total of 338 kidneys were randomly allocated to SCS (n = 168) or NMP (n = 170), and 277 kidneys were included in the final intention-to-treat analysis. The primary endpoint was DGF, defined as the requirement for dialysis in the first 7 d after transplant. The rate of DGF was 82 of 135 (60.7%) in NMP kidneys versus 83 of 142 (58.5%) in SCS kidneys (adjusted odds ratio (95% confidence interval) 1.13 (0.69-1.84); P = 0.624). NMP was not associated with any increase in transplant thrombosis, infectious complications or any other adverse events. A 1-h period of NMP at the end of SCS did not reduce the rate of DGF in DCD kidneys. NMP was demonstrated to be feasible, safe and suitable for clinical application. Trial registration number: ISRCTN15821205 .
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Affiliation(s)
- Sarah A Hosgood
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.
| | - Christopher J Callaghan
- Department of Nephrology and Transplantation, Guy's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Colin H Wilson
- Freeman Hospital, Institute of Transplantation, Newcastle upon Tyne Hospitals NHS Trust and Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Laura Smith
- NHS Blood and Transplant (NHSBT) Clinical Trials Unit, NHSBT Stoke Gifford, Bristol, UK
| | - Joanne Mullings
- NHS Blood and Transplant (NHSBT) Clinical Trials Unit, NHSBT Stoke Gifford, Bristol, UK
| | - Jennifer Mehew
- NHS Blood and Transplant (NHSBT) Clinical Trials Unit, NHSBT Stoke Gifford, Bristol, UK
| | - Gabriel C Oniscu
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Benedict L Phillips
- Department of Nephrology and Transplantation, Guy's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Lucy Bates
- Freeman Hospital, Institute of Transplantation, Newcastle upon Tyne Hospitals NHS Trust and Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Michael L Nicholson
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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30
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Anwar IJ, Luo X. Research Highlights. Transplantation 2023; 107:1008-1009. [PMID: 37779417 DOI: 10.1097/tp.0000000000004631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Affiliation(s)
| | - Xunrong Luo
- Department of Medicine, Division of Nephrology, Duke University, Durham, NC
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31
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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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Pasrija C, Tipograf Y, Shah AS, Trahanas JM. Normothermic regional perfusion for donation after circulatory death donors. Curr Opin Organ Transplant 2023; 28:71-75. [PMID: 36409266 DOI: 10.1097/mot.0000000000001038] [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: 11/23/2022]
Abstract
PURPOSE OF REVIEW This review is intended to provide an update on the logistics, technique, and outcomes associated with normothermic regional perfusion (NRP), as well as provide a discussion of the associated ethical issues. RECENT FINDINGS There has been renewed interest in utilizing NRP to increase quality and availability of organs from donation after circulatory death (DCD) donors. Our institution has increasing experience with thoraco-abdominal NRP (TA-NRP) in controlled DCD donors (cDCD), whereas abdominal NRP (A-NRP) has been used with success in both cDCD and uncontrolled DCD (uDCD). There is increasing evidence that NRP can be conducted in a practical and cost-efficient manner, and that the organ yield may be of better quality than standard direct procurement and perfusion (DPP). SUMMARY NRP is increasingly successful and will likely prove to be a superior method for cDCD recovery. However, before TA-NRP can be widely accepted the ethical debate surrounding this technique must be settled. VIDEO ABSTRACT http://links.lww.com/COOT/A11.
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Affiliation(s)
- Chetan Pasrija
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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33
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Louca J, Öchsner M, Shah A, Hoffman J, Vilchez FG, Garrido I, Royo-Villanova M, Domínguez-Gil B, Smith D, James L, Moazami N, Rega F, Brouckaert J, Van Cleemput J, Vandendriessche K, Tchana-Sato V, Bandiougou D, Urban M, Manara A, Berman M, Messer S, Large S. The international experience of in-situ recovery of the DCD heart: a multicentre retrospective observational study. EClinicalMedicine 2023; 58:101887. [PMID: 36911270 PMCID: PMC9995283 DOI: 10.1016/j.eclinm.2023.101887] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Heart transplantation is an effective treatment offering the best recovery in both quality and quantity of life in those affected by refractory, severe heart failure. However, transplantation is limited by donor organ availability. The reintroduction of heart donation after the circulatory determination of death (DCD) in 2014 offered an uplift in transplant activity by 30%. Thoraco-abdominal normothermic regional perfusion (taNRP) enables in-situ reperfusion of the DCD heart. The objective of this paper is to assess the clinical outcomes of DCD donor hearts recovered and transplanted from donors undergoing taNRP. METHOD This was a multicentre retrospective observational study. Outcomes included functional warm ischaemic time, use of mechanical support immediately following transplantation, perioperative and long-term actuarial survival and incidence of acute rejection requiring treatment. 157 taNRP DCD heart transplants, performed between February 2, 2015, and July 29, 2022, have been included from 15 major transplant centres worldwide including the UK, Spain, the USA and Belgium. 673 donations after the neurological determination of death (DBD) heart transplantations from the same centres were used as a comparison group for survival. FINDINGS taNRP resulted in a 23% increase in heart transplantation activity. Survival was similar in the taNRP group when compared to DBD. 30-day survival was 96.8% ([92.5%-98.6%] 95% CI, n = 156), 1-year survival was 93.2% ([87.7%-96.3%] 95% CI, n = 72) and 5-year survival was 84.3% ([69.6%-92.2%] 95% CI, n = 13). INTERPRETATION Our study suggests that taNRP provides a significant boost to heart transplantation activity. The survival rates of taNRP are comparable to those obtained for DBD transplantation in this study. The similar survival may in part be related to a short warm ischaemic time or through a possible selection bias of younger donors, this being an uncontrolled observational study. Therefore, our study suggests that taNRP offers an effective method of organ preservation and procurement. This early success of the technique warrants further investigation and use. FUNDING None of the authors have a financial relationship with a commercial entity that has an interest in the subject.
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Affiliation(s)
- John Louca
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Rd, Cambridge CB2 0SP, UK
- Corresponding author.
| | - Marco Öchsner
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Rd, Cambridge CB2 0SP, UK
| | - Ashish Shah
- Vanderbilt Heart Transplant Unit 1215, 21st Ave, Nashville, Tennessee 37232, USA
| | - Jordan Hoffman
- Vanderbilt Heart Transplant Unit 1215, 21st Ave, Nashville, Tennessee 37232, USA
| | | | - Iris Garrido
- Hospital Universitario Virgen de La Arrixaca, Ctra. Madrid-Cartagena, s/n, El Palmar, Murcia 30120, Spain
| | - Mario Royo-Villanova
- Hospital Universitario Virgen de La Arrixaca, Ctra. Madrid-Cartagena, s/n, El Palmar, Murcia 30120, Spain
| | | | - Deane Smith
- Department of Cardiothoracic Surgery, Langone, 1300 Franklin Avenue, Suite ML-2, Garden City, NY, USA
| | - Leslie James
- Department of Cardiothoracic Surgery, Langone, 1300 Franklin Avenue, Suite ML-2, Garden City, NY, USA
| | - Nader Moazami
- Department of Cardiothoracic Surgery, Langone, 1300 Franklin Avenue, Suite ML-2, Garden City, NY, USA
| | - Filip Rega
- Departments of Cardiac Surgery and Cardiology, The University Hospital Leuven, Leuven, Belgium
| | - Janne Brouckaert
- Departments of Cardiac Surgery and Cardiology, The University Hospital Leuven, Leuven, Belgium
| | - Johan Van Cleemput
- Departments of Cardiac Surgery and Cardiology, The University Hospital Leuven, Leuven, Belgium
| | - Katrien Vandendriessche
- Departments of Cardiac Surgery and Cardiology, The University Hospital Leuven, Leuven, Belgium
| | | | | | - Marian Urban
- Department of Cardiothoracic Surgery, University of Nebraska Medical Centre, 2410 Atherholt Road, Omaha, NE, USA
| | - Alex Manara
- The Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol BS 10 5NB, UK
| | - Marius Berman
- Royal Papworth Hospital Biomedical Campus, Cambridge, CB2 0AY, UK
| | - Simon Messer
- Golden Jubilee Hospital, Agamermnon Street, Glasgow G81 4DY, UK
| | - Stephen Large
- Royal Papworth Hospital Biomedical Campus, Cambridge, CB2 0AY, UK
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Farinelli P, Juri J, Varela D, Salome M, Bisigniano L, Raimondi C, Magnate AD, Barone ME, Fernandez MF, Cambariere R, Villavicencio S, Pregno E, Klein F, Villamil A, Schelotto PB, Gondolesi GE. Donation after Cardiocirculatory Death: a program that we must implement. Experts Argentinean meeting report. TRANSPLANTATION REPORTS 2023. [DOI: 10.1016/j.tpr.2023.100132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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Circelli A, Antonini MV, Nanni A, Prugnoli M, Gamberini E, Maitan S, Gecele C, Viola L, Bissoni L, Scognamiglio G, Mezzatesta L, Bergamini C, Gobbi L, Meca MCC, Sangiorgi G, Bisulli M, Spiga M, Pransani V, Liuzzi D, Fantini V, Catena F, Russo E, Agnoletti V. cDCD organ donation pathway of Romagna Local Health Authority: strategic planning, organizational management, and results. DISCOVER HEALTH SYSTEMS 2023; 2:12. [PMID: 37520516 PMCID: PMC10062274 DOI: 10.1007/s44250-023-00022-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 02/03/2023] [Indexed: 04/03/2023]
Abstract
The introduction of pathways to enrol deceased donors after cardio-circulatory confirmation of death (donation after circulatory death, DCD) is expanding in many countries to face the shortage of organs for transplantation. The implementation of normothermic regional reperfusion (NRP) with warm oxygenated blood is a strategy to manage in-situ the organs of DCD donors. This approach, an alternative to in-situ cold preservation, and followed by prompt retrieval and cold static storage and/or ex-vivo machine perfusion (EVMP), could be limited to abdominal organs (A-NRP) or extended to the thorax (thoraco-abdominal, TA-NRP. NRP is also referred to as extracorporeal interval support for organ retrieval (EISOR). The use of EISOR is increasing in Europe, even if variably regulated. A-NRP has been demonstrated to be effective in decreasing the risk associated with transplantation of abdominal organs from DCD donors, and was recommended by the European Society for Organ Transplantation (ESOT) in a recent consensus document. We aim to explain how we select the candidates for DCD, to describe our regionalized model for implementing EISOR provision, and to introduce the health care professionals involved in this complex process, with their strictly defined roles, responsibilities, and boundaries. Finally, we report the results of our program, recruiting cDCD donors over a large network of hospitals, all pertaining to a Local Health Authority (Azienda Unità Sanitaria Locale, AUSL) in Romagna, Italy.
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Affiliation(s)
- Alessandro Circelli
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Emilia-Romagna, Italy
| | - Andrea Nanni
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
- Transplant Procurement Management-AUSL della Romagna, Cesena, Italy
| | - Manila Prugnoli
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
- Transplant Procurement Management-AUSL della Romagna, Cesena, Italy
| | - Emiliano Gamberini
- Anesthesia and Intensive Care Unit, Infermi Hospital, AUSL della Romagna, Rimini, Italy
| | - Stefano Maitan
- Intensive Care Unit, Morgagni-Pierantoni Hospital-AUSL della Romagna, Forlì, Italy
| | - Claudio Gecele
- Anesthesia and Intensive Care Unit, Santa Maria delle Croci Hospital, Ravenna, Italy
| | - Lorenzo Viola
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Luca Bissoni
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Giovanni Scognamiglio
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Luca Mezzatesta
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Carlo Bergamini
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Luca Gobbi
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | | | | | - Marcello Bisulli
- Interventional Radiology Department, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Martina Spiga
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Veruska Pransani
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Daria Liuzzi
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Valentina Fantini
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Fausto Catena
- General and Emergency Surgery, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Emanuele Russo
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
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Miñambres E, Estébanez B, Ballesteros MÁ, Coll E, Flores-Cabeza EM, Mosteiro F, Lara R, Domínguez-Gil B. Normothermic Regional Perfusion in Pediatric Controlled Donation After Circulatory Death Can Lead to Optimal Organ Utilization and Posttransplant Outcomes. Transplantation 2023; 107:703-708. [PMID: 36226852 DOI: 10.1097/tp.0000000000004326] [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: 10/17/2022]
Abstract
BACKGROUND The benefits of normothermic regional perfusion (NRP) in posttransplant outcomes after controlled donation after the determination of death by circulatory criteria (cDCD) has been shown in different international adult experiences. However, there is no information on the use of NRP in pediatric cDCD donors. METHODS This is a multicenter, retrospective, observational cohort study describing the pediatric (<18 y) cDCD procedures performed in Spain, using either abdominal NRP or thoracoabdominal NRP and the outcomes of recipients of the obtained organs. RESULTS Thirteen pediatric cDCD donors (age range, 2-17 y) subject to abdominal NRP or thoracoabdominal NRP were included. A total of 46 grafts (24 kidneys, 11 livers, 8 lungs, 2 hearts, and 1 pancreas) were finally transplanted (3.5 grafts per donor). The mean functional warm ischemic time was 15 min (SD 6 min)' and the median duration of NRP was 87 min (interquartile range, 69-101 min). One-year noncensored for death kidney graft survival was 91.3%. The incidence of delayed graft function was 13%. One-year' noncensored-for-death liver graft survival was 90.9%. All lung and pancreas recipients had an excellent evolution. One heart recipient died due to a septic shock. CONCLUSIONS This is the largest experience of pediatric cDCD using NRP as graft preservation method. Although our study has several limitations, such as its retrospective nature and the small sample size, its reveals that NRP may increase the utilization of cDCD pediatric organs and offer optimal recipients' outcomes.
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Affiliation(s)
- Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
- School of Medicine, Universidad de Cantabria, Santander, Spain
| | - Belen Estébanez
- Transplant Coordination Unit & Service of Intensive Care, University Hospital La Paz, Madrid, Spain
| | - Maria Ángeles Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | | | | | - Fernando Mosteiro
- Transplant Coordination Unit & Service of Intensive Care, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Ramón Lara
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Virgen De Las Nieves, Granada, Spain
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Normothermic Regional Perfusion Can Improve Both Utilization and Outcomes in DCD Liver, Kidney, and Pancreas Transplantation. Transplant Direct 2023; 9:e1450. [PMID: 36845854 PMCID: PMC9945290 DOI: 10.1097/txd.0000000000001450] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/12/2022] [Accepted: 01/04/2023] [Indexed: 02/22/2023] Open
Abstract
Normothermic regional perfusion (NRP) has gained widespread adoption in multiple European countries. The aim of this study was to examine the influence of thoracoabdominal-NRP (TA-NRP) on the utilization and outcomes of liver, kidney, and pancreas transplantation in the United States. Methods Using the US national registry data between 2020 and 2021, donation after circulatory death (DCD) donors were separated into 2 groups: DCD with TA-NRP and without TA-NRP. There were 5234 DCD donors; among them 34 donors were with TA-NRP. After 1:4 propensity score matching, the utilization rates were compared between DCD with and without TA-NRP. Results Although the utilization rates of kidney and pancreas were comparable (P = 0.71 and P = 0.06, 94.1% versus 95.6% and 8.8% versus 2.2%, respectively), that of liver in DCD with TA-NRP was significantly higher (P < 0.001; 70.6% versus 39.0%). Among 24 liver transplantations, 62 kidney transplantations, and 3 pancreas transplantations from DCD with TA-NRP, there were 2 liver grafts and 1 kidney graft that failed within 1 y after transplantation. Conclusions TA-NRP in the United States significantly increased the utilization rate of abdominal organs from DCD donors with comparable outcomes after transplantation. Increasing use of NRP may expand the donor pool without compromising transplant outcomes.
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Oniscu GC, Mehew J, Butler AJ, Sutherland A, Gaurav R, Hogg R, Currie I, Jones M, Watson CJE. Improved Organ Utilization and Better Transplant Outcomes With In Situ Normothermic Regional Perfusion in Controlled Donation After Circulatory Death. Transplantation 2023; 107:438-448. [PMID: 35993664 DOI: 10.1097/tp.0000000000004280] [Citation(s) in RCA: 54] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND . We evaluated whether the use of normothermic regional perfusion (NRP) was associated with increased organ recovery and improved transplant outcomes from controlled donation after circulatory death (cDCD). METHODS . This is a retrospective analysis of UK adult cDCD donors' where at least 1 abdominal organ was accepted for transplantation between January 1, 2011, and December 31, 2019. RESULTS . A mean of 3.3 organs was transplanted when NRP was used compared with 2.6 organs per donor when NRP was not used. When adjusting for organ-specific donor risk profiles, the use of NRP increased the odds of all abdominal organs being transplanted by 3-fold for liver ( P < 0.0001; 95% confidence interval [CI], 2.20-4.29), 1.5-fold for kidney ( P = 0.12; 95% CI, 0.87-2.58), and 1.6-fold for pancreas ( P = 0.0611; 95% CI, 0.98-2.64). Twelve-mo liver transplant survival was superior for recipients of a cDCD NRP graft with a 51% lower risk-adjusted hazard of transplant failure (HR = 0.494). In risk-adjusted analyses, NRP kidneys had a 35% lower chance of developing delayed graft function than non-NRP kidneys (odds ratio, 0.65; 95% CI, 0.465-0.901)' and the expected 12-mo estimated glomerular filtration rate was 6.3 mL/min/1.73 m 2 better if abdominal NRP was used ( P < 0.0001). CONCLUSIONS . The use of NRP during DCD organ recovery leads to increased organ utilization and improved transplant outcomes compared with conventional organ recovery.
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Affiliation(s)
- Gabriel C Oniscu
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, United Kingdom
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, United Kingdom
| | - Jennifer Mehew
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, United Kingdom
| | - Andrew J Butler
- University of Cambridge Department of Surgery, Addenbrooke's Hospital, Cambridge, the 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), London, United Kingdom
- Cambridge Transplant Unit, Cambridge University Hospitals NHS Trust, Addenbrooke's Hospital, Bristol, United Kingdom
| | - Andrew Sutherland
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, United Kingdom
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, United Kingdom
| | - Rohit Gaurav
- Cambridge Transplant Unit, Cambridge University Hospitals NHS Trust, Addenbrooke's Hospital, Bristol, United Kingdom
| | - Rachel Hogg
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, United Kingdom
| | - Ian Currie
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, United Kingdom
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, United Kingdom
| | - Mark Jones
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, United Kingdom
| | - Christopher J E Watson
- University of Cambridge Department of Surgery, Addenbrooke's Hospital, Cambridge, the 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), London, United Kingdom
- Cambridge Transplant Unit, Cambridge University Hospitals NHS Trust, Addenbrooke's Hospital, Bristol, United Kingdom
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In Situ Normothermic Regional Perfusion in Controlled Donation After Circulatory Determination Death: Organ Utilization, Outcomes, and Elusiveness of a Randomized Clinical Trial. Transplantation 2023; 107:311-312. [PMID: 35993669 DOI: 10.1097/tp.0000000000004281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Barreda P, Miñambres E, Ballesteros MÁ, Mazón J, Gómez-Román J, Gómez Ortega JM, Belmar L, Valero R, Ruiz JC, Rodrigo E. Controlled Donation After Circulatory Death Using Normothermic Regional Perfusion Does Not Increase Graft Fibrosis in the First Year Posttransplant Surveillance Biopsy. EXP CLIN TRANSPLANT 2022; 20:1069-1075. [PMID: 36718005 DOI: 10.6002/ect.2022.0171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES The number of kidney transplants obtained from controlled donations after circulatory death is increasing, with long-term outcomes similar to those obtained with donations after brain death. Extraction using normothermic regional perfusion can improve results with controlled donors after circulatory death; however, information on the histological impact and extraction procedure is scarce. MATERIALS AND METHODS We retrospectively investigated all kidney transplants performed from October 2014 to December 2019, in which a follow-up kidney biopsy had been performed at 1-year follow-up, comparing controlled procedures with donors after circulatory death and normothermic regional perfusion versus donors after brain death. Interstitial fibrosis/tubular atrophy was assessed by adding the values of interstitial fibrosis and tubular atrophy, according to the Banff classification of renal allograft pathology. RESULTS When we compared histological data from 66 transplants with donations after brain death versus 24 transplants with donations after circulatory death and normothermic regional perfusion, no differences were found in the degree of fibrosis in the 1-year follow-up biopsy (1.7 ± 1.3 vs 1.7 ± 1.1; P = .971) or in the ratio of patients with increased fibrosis calculated as interstitial fibrosis/tubular atrophy >2 (18% vs 13%; P = .522). In our multivariate analysis, which included acute rejection, expanded criteria donation, and the type of donation, no variable was independently related to an increased risk of interstitial fibrosis/tubular atrophy >2. CONCLUSIONS The outcomes of kidney grafts procured in our center using controlled procedures with donors after circulatory death and normothermic regional perfusion were indistinguishable from those obtained from donors after brain death, showing the same degree of fibrosis in the 1-year posttransplant surveillance biopsy. Our data support the conclusion that normothermic regional perfusion should be the method of choice for extraction in donors after circulatory death.
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Affiliation(s)
- Paloma Barreda
- From the Nephrology Department/Transplantation and Autoimmunity Groupt, University Hospital Marqués de Valdecilla/IDIVAL, University of Cantabria, Cantabria, Spain
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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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42
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Lim WH, Dominguez-Gil B. Ethical Issues Related to Donation and Transplantation of Donation After Circulatory Determination of Death Donors. Semin Nephrol 2022; 42:151269. [PMID: 36577644 DOI: 10.1016/j.semnephrol.2022.07.003] [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] [Indexed: 12/28/2022]
Abstract
With the continuing disparity between organ supply to match the increasing demand for kidney transplants in patients with renal failure, donation after the circulatory determination of death (DCDD) has become an important and increasing global source of kidneys for clinical use. The concern that the outcomes of controlled DCDD donor kidney transplants were inferior to those obtained from donors declared dead by neurologic criteria has largely diminished because large-scale registry and single-center reports consistently have reported favorable outcomes. For uncontrolled DCDD kidney transplants, outcomes are correspondingly acceptable, although there is a greater risk of primary nonfunction. The potential of DCDD remains unrealized in many countries because of the ethical concerns and resource implications in the utilization of these donor kidneys for transplantation. In this review, we discuss the origin and definitions of DCDD donors, and examine the long-term outcomes of transplants from DCDD donor kidneys. We discuss the controversies, challenges, and ethical and legal barriers in the acceptance of DCDD, including the complexities of implementing and sustaining controlled and uncontrolled DCDD donor programs. The lessons learned from global leaders will assist a wider international recognition, acceptance, and development of DCDD transplant programs that will noticeably facilitate and address the global shortages of kidneys for transplantation, and ensure the opportunity for people who had indicated their desires to become organ donors fulfill their final wishes.
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Affiliation(s)
- Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia; Internal Medicine, University of Western Australia Medical School, Perth, Australia.
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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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Hessheimer AJ, de la Rosa G, Gastaca M, Ruíz P, Otero A, Gómez M, Alconchel F, Ramírez P, Bosca A, López-Andújar R, Atutxa L, Royo-Villanova M, Sánchez B, Santoyo J, Marín LM, Gómez-Bravo MÁ, Mosteiro F, Villegas Herrera MT, Villar Del Moral J, González-Abos C, Vidal B, López-Domínguez J, Lladó L, Roldán J, Justo I, Jiménez C, López-Monclús J, Sánchez-Turrión V, Rodríguez-Laíz G, Velasco Sánchez E, López-Baena JÁ, Caralt M, Charco R, Tomé S, Varo E, Martí-Cruchaga P, Rotellar F, Varona MA, Barrera M, Rodríguez-Sanjuan JC, Briceño J, López D, Blanco G, Nuño J, Pacheco D, Coll E, Domínguez-Gil B, Fondevila C. Abdominal normothermic regional perfusion in controlled donation after circulatory determination of death liver transplantation: Outcomes and risk factors for graft loss. Am J Transplant 2022; 22:1169-1181. [PMID: 34856070 DOI: 10.1111/ajt.16899] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/11/2021] [Accepted: 11/11/2021] [Indexed: 01/25/2023]
Abstract
Postmortem normothermic regional perfusion (NRP) is a rising preservation strategy in controlled donation after circulatory determination of death (cDCD). Herein, we present results for cDCD liver transplants performed in Spain 2012-2019, with outcomes evaluated through December 31, 2020. Results were analyzed retrospectively and according to recovery technique (abdominal NRP [A-NRP] or standard rapid recovery [SRR]). During the study period, 545 cDCD liver transplants were performed with A-NRP and 258 with SRR. Median donor age was 59 years (interquartile range 49-67 years). Adjusted risk estimates were improved with A-NRP for overall biliary complications (OR 0.300, 95% CI 0.197-0.459, p < .001), ischemic type biliary lesions (OR 0.112, 95% CI 0.042-0.299, p < .001), graft loss (HR 0.371, 95% CI 0.267-0.516, p < .001), and patient death (HR 0.540, 95% CI 0.373-0.781, p = .001). Cold ischemia time (HR 1.004, 95% CI 1.001-1.007, p = .021) and re-transplantation indication (HR 9.552, 95% CI 3.519-25.930, p < .001) were significant independent predictors for graft loss among cDCD livers with A-NRP. While use of A-NRP helps overcome traditional limitations in cDCD liver transplantation, opportunity for improvement remains for cases with prolonged cold ischemia and/or technically complex recipients, indicating a potential role for complimentary ex situ perfusion preservation techniques.
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Affiliation(s)
- Amelia J Hessheimer
- General & Digestive Surgery, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain.,General & Digestive Surgery Service, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Barcelona, Spain.,IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | | | | | | | - Alejandra Otero
- Complejo Hospitalario Universitario La Coruña, A Coruna, Spain
| | - Manuel Gómez
- Complejo Hospitalario Universitario La Coruña, A Coruna, Spain
| | - Felipe Alconchel
- Hospital Clínico Universitario Virgen de la Arrixaca, IMIB, El Palmar, Spain
| | - Pablo Ramírez
- Hospital Clínico Universitario Virgen de la Arrixaca, IMIB, El Palmar, Spain
| | - Andrea Bosca
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Rafael López-Andújar
- Hospital Universitario y Politécnico La Fe, Valencia, Spain.,CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Lánder Atutxa
- Hospital Universitario Donostia, San Sebastián, Spain
| | | | | | | | - Luís M Marín
- Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | | | | | | | - Carolina González-Abos
- General & Digestive Surgery Service, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Barcelona, Spain
| | - Bárbara Vidal
- Hospital General Universitario de Castellón, Castellón, Spain
| | | | - Laura Lladó
- Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Spain
| | - José Roldán
- Hospital Universitario de Navarra, Pamplona, Spain
| | - Iago Justo
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | | | - Gonzalo Rodríguez-Laíz
- Department of General & Digestive Surgery, ISABIAL, Hospital General Universitario de Alicante, Alicante, Spain
| | | | | | - Mireia Caralt
- Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | - Ramón Charco
- Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | - Santiago Tomé
- Complejo Hospitalario Universitario Santiago, Santiago de Compostela, Spain
| | - Evaristo Varo
- Complejo Hospitalario Universitario Santiago, Santiago de Compostela, Spain
| | - Pablo Martí-Cruchaga
- HPB and Liver Transplant Unit, General & Digestive Surgery, Clínica Universitaria de Navarra, Pamplona, Spain
| | - Fernando Rotellar
- HPB and Liver Transplant Unit, General & Digestive Surgery, Clínica Universitaria de Navarra, Pamplona, Spain
| | - María A Varona
- Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Manuel Barrera
- Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | | | | | - Diego López
- Hospital Universitario Infanta Cristina, Badajoz, Spain
| | | | - Javier Nuño
- Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - David Pacheco
- Hospital Universitario Río Hortega, Valladolid, Spain
| | | | | | - Constantino Fondevila
- General & Digestive Surgery, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain.,General & Digestive Surgery Service, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Barcelona, Spain.,IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
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Boteon YL, Hessheimer AJ, Brüggenwirth IMA, Boteon APCS, Padilla M, de Meijer VE, Domínguez-Gil B, Porte RJ, Perera MTPR, Martins PN. The economic impact of machine perfusion technology in liver transplantation. Artif Organs 2021; 46:191-200. [PMID: 34878658 DOI: 10.1111/aor.14131] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/03/2021] [Accepted: 11/14/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Several clinical studies have demonstrated the safety, feasibility, and efficacy of machine perfusion in liver transplantation, although its economic outcomes are still underexplored. This review aimed to examine the costs related to machine perfusion and its associated outcomes. METHODS Expert opinion of several groups representing different machine perfusion modalities. Critical analysis of the published literature reporting the economic outcomes of the most used techniques of machine perfusion in liver transplantation (normothermic and hypothermic ex situ machine perfusion and in situ normothermic regional perfusion). RESULTS Machine perfusion costs include disposable components of the perfusion device, perfusate components, personnel and facility fees, and depreciation of the perfusion device or device lease fee. The limited current literature suggests that although this upfront cost varies between perfusion modalities, its use is highly likely to be cost-effective. Optimization of the donor liver utilization rate, local conditions of transplant programs (long waiting list times and higher MELD scores), a decreased rate of complications, changes in logistics, and length of hospital stay are potential cost savings points that must highlight the expected benefits of this intervention. An additional unaccounted factor is that machine perfusion optimizing donor organ utilization allows patients to be transplanted earlier, avoiding clinical deterioration while on the waiting list and the costs associated with hospital admissions and other required procedures. CONCLUSION So far, the clinical benefits have guided machine perfusion implementation in liver transplantation. Albeit there is data suggesting the economic benefit of the technique, further investigation of its costs to healthcare systems and society and associated outcomes is needed.
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Affiliation(s)
- Yuri L Boteon
- Liver Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Amelia J Hessheimer
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Hospital Universitario La Paz, Madrid, Spain
| | - Isabel M A Brüggenwirth
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - María Padilla
- Organización Nacional de Trasplantes, Ministerio de Sanidad, Madrid, Spain
| | - Vincent E de Meijer
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Robert J Porte
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M Thamara P R Perera
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paulo N Martins
- Department of Surgery, Transplant Division, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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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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47
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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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