1
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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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2
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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: 55] [Impact Index Per Article: 18.3] [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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3
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Artiles Medina A, Burgos Revilla FJ, Álvarez Nadal M, Muriel García A, Álvarez Díaz N, Gómez Dos Santos V. Comparison of in situ preservation techniques for kidneys from donors after circulatory death: a systematic review and meta-analysis. Transl Androl Urol 2021; 10:3286-3299. [PMID: 34532253 PMCID: PMC8421834 DOI: 10.21037/tau-21-236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/11/2021] [Indexed: 11/06/2022] Open
Abstract
Background Several techniques have been developed to reduce the warm ischaemic injury of donation after circulatory death (DCD) organs before procurement. There are scarce data about the in situ preservation techniques for kidney graft outcomes. The aim of this systematic review was to evaluate the best in situ preservation method for kidney graft outcomes from organs obtained from controlled and uncontrolled DCD. Methods A systematic review of the PubMed (MEDLINE), Embase, LILACS and Cochrane databases was conducted. Studies that compare two or more in situ preservation techniques were identified and included. Only studies which provided enough data to calculate odds ratio were eligible for meta-analysis. PROSPERO registration: CRD42020179598. Results The search strategy yielded 7,121 studies. Ultimately, 14 retrospective studies were included. Because of heterogeneity, the included studies provided weak evidence that normothermic regional perfusion (NRP) is the best in situ preservation technique in terms of delayed graft function (DGF) rates. Regarding primary nonfunction (PNF), we carried out a meta-analysis of 10 studies with a pooled OR of 0.83 (95% CI: 0.40-1.71), for the NRP. In regard to DGF, pooled OR for NRP was 0.36 (95% CI: 0.25-0.54). Conclusions NRP in the DCD donor could improve kidney graft function and be considered the in situ preservation technique of choice for abdominal organs.
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Affiliation(s)
- Alberto Artiles Medina
- Department of Urology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Francisco Javier Burgos Revilla
- Department of Urology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Marta Álvarez Nadal
- Department of Nephrology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Alfonso Muriel García
- Department of Biostatistics, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBERESP, Universidad de Alcalá de Henares (UAH), Madrid, Spain
| | | | - Victoria Gómez Dos Santos
- Department of Urology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
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4
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Seo HW, Lee S, Lee HY, Park SC, Chung BH, Yang CW, Ban TH. Successful kidney transplantation from an expanded criteria donor with long-term extracorporeal membrane oxygenation treatment: A case report. World J Clin Cases 2020; 8:540-545. [PMID: 32110664 PMCID: PMC7031827 DOI: 10.12998/wjcc.v8.i3.540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 12/30/2019] [Accepted: 01/08/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Due to a shortage of donor kidneys, many centers have utilized graft kidneys from brain-dead donors with expanded criteria. Kidney transplantation (KT) from donors on extracorporeal membrane oxygenation (ECMO) has been identified as a successful way of expanding donor pools. However, there are currently no guidelines or recommendations that guarantee successful KT from donors undergoing ECMO treatment. Therefore, acceptance of appropriate allografts from those donors is solely based on clinician decision.
CASE SUMMARY We report a case of successful KT from a brain-dead donor supported by ECMO for the longest duration to date. A 69-year-old male received a KT from a 63-year-old brain-dead donor who had been on therapeutic ECMO treatment for the previous three weeks. The recipient experienced slow recovery of graft function after surgery but was discharged home on post-operative day 17 free from hemodialysis. Allograft function gradually improved thereafter and was comparatively acceptable up to the 12 mo follow-up, with serum creatinine level of 1.67 mg/dL.
CONCLUSION This case suggests that donation even after long-term ECMO treatment could provide successful KT to suitable candidates.
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Affiliation(s)
- Hye Won Seo
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea
- Transplant Research Center, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea
| | - Sua Lee
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea
- Transplant Research Center, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea
| | - Hwa Young Lee
- Division of Nephrology, Department of Internal Medicine, Jeju National University Hospital, Jeju-do 63241, South Korea
| | - Sun Cheol Park
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seoul 06591, South Korea
| | - Byung Ha Chung
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea
- Transplant Research Center, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea
| | - Chul Woo Yang
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea
- Transplant Research Center, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, South Korea
| | - Tae Hyun Ban
- Division of Nephrology, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Eunpyeong-gu, Seoul 03312, South Korea
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5
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Rijkse E, IJzermans JNM, Minnee RC. Machine perfusion in abdominal organ transplantation: Current use in the Netherlands. World J Transplant 2020; 10:15-28. [PMID: 32110511 PMCID: PMC7031624 DOI: 10.5500/wjt.v10.i1.15] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/03/2019] [Accepted: 12/19/2019] [Indexed: 02/05/2023] Open
Abstract
Scarcity of donor organs and the increment in patients awaiting a transplant increased the use of organs from expanded criteria donors or donation after circulatory death. Due to the suboptimal outcomes of these donor organs, there is an increased interest in better preservation methods, such as ex vivo machine perfusion or abdominal regional perfusion to improve outcomes. This state-of-the-art review aims to discuss the available types of perfusion techniques, its potential benefits and the available evidence in kidney, liver and pancreas transplantation. Additionally, translational steps from animal models towards clinical studies will be described, as well as its application to clinical practice, with the focus on the Netherlands. Despite the lack of evidence from randomized controlled trials, currently available data suggest especially beneficial effects of normothermic regional perfusion on biliary complications and ischemic cholangiopathy after liver transplantation. For ex vivo machine perfusion in kidney transplantation, hypothermic machine perfusion has proven to be beneficial over static cold storage in a randomized controlled trial, while normothermic machine perfusion is currently under investigation. For ex vivo machine perfusion in liver transplantation, normothermic machine perfusion has proven to reduce discard rates and early allograft dysfunction. In response to clinical studies, hypothermic machine perfusion for deceased donor kidneys has already been implemented as standard of care in the Netherlands.
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Affiliation(s)
- Elsaline Rijkse
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam 3015 GD, Netherlands
| | - Jan NM IJzermans
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam 3015 GD, Netherlands
| | - Robert C Minnee
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam 3015 GD, Netherlands
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6
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Novel Organ Perfusion and Preservation Strategies in Transplantation – Where Are We Going in the United Kingdom? Transplantation 2020; 104:1813-1824. [DOI: 10.1097/tp.0000000000003106] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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7
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Shapey IM, Summers A, Augustine T, van Dellen D. Systematic review to assess the possibility of return of cerebral and cardiac activity after normothermic regional perfusion for donors after circulatory death. Br J Surg 2019; 106:174-180. [PMID: 30667536 PMCID: PMC6749564 DOI: 10.1002/bjs.11046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/13/2018] [Accepted: 10/10/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Normothermic regional perfusion (NRP) is a novel technique that aids organ recovery from donors after circulatory death (DCDs). However, ethical concerns exist regarding the potential return of spontaneous cerebral and cardiac activity (ROSCCA). This study aimed to determine the likelihood of ROSCCA in NRP-DCDs of abdominal organs. METHODS Extracorporeal cardiopulmonary resuscitation (ECPR) for refractory out-of-hospital cardiac arrest (OOHCA) was identified as a comparator for NRP-DCDs and as a validation cohort. A systematic search identified all articles relating to NRP-DCDs and ECPR-OOHCA. Rates of ROSCCA and survival outcomes (ECPR-OOHCA only) were recorded and analysed according to the duration of no perfusion. RESULTS In NRP-DCDs, 12 of 410 articles identified by database searching were eligible for inclusion. There were no instances of ROSCCA recorded among 493 donors. In ECPR-OOHCA, eight of 947 screened articles were eligible for inclusion (254 patients). Where the absence of perfusion exceeded 5 min in ECPR-OOHCA, there were no survivors with a favourable neurological outcome. CONCLUSION ROSCCA is unlikely following commencement of NRP and has not occurred to date. Strict observance of the 5-min interval following asystole provides satisfactory assurance that ROSCCA will not occur following NRP.
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Affiliation(s)
- I M Shapey
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Department of Renal and Pancreatic Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - A Summers
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Department of Renal and Pancreatic Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - T Augustine
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Department of Renal and Pancreatic Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - D van Dellen
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Department of Renal and Pancreatic Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
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8
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Angelico R, Perera MTPR, Manzia TM, Parente A, Grimaldi C, Spada M. Donation after Circulatory Death in Paediatric Liver Transplantation: Current Status and Future Perspectives in the Machine Perfusion Era. BIOMED RESEARCH INTERNATIONAL 2018; 2018:1756069. [PMID: 29744353 PMCID: PMC5878911 DOI: 10.1155/2018/1756069] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 02/14/2018] [Indexed: 02/06/2023]
Abstract
Efforts have been made by the transplant community to expand the deceased donor pool in paediatric liver transplantation (LT). The growing experience on donation after circulatory death (DCD) for adult LT has encouraged its use also in children, albeit in selective cases, opening new perspectives for paediatric patients. Even though there has recently been a slight increase in the number of DCD livers transplanted in children, with satisfactory graft and patient outcomes, the use of DCD grafts in paediatric recipients is still controversial due to morbid outcomes associated with DCD grafts. In this context, recent advances in the optimization of donor support by extracorporeal membrane oxygenation and in the graft preservation by liver machine perfusion could find application in order to expand the donor pool in paediatric LT. In the present study we review the current literature on DCD liver grafts transplanted in children and on the use of extracorporeal donor support and liver perfusion machines in paediatrics, with the aim of defining the current status and future perspectives of paediatric LT.
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Affiliation(s)
- Roberta Angelico
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
| | | | - Tommaso Maria Manzia
- Department of Experimental Medicine and Surgery, Liver Unit, Tor Vergata University of Rome, Rome, Italy
| | - Alessandro Parente
- Department of Experimental Medicine and Surgery, Liver Unit, Tor Vergata University of Rome, Rome, Italy
| | - Chiara Grimaldi
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
| | - Marco Spada
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
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9
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Sharma A, Kumar S, Dutta P, Kumar P, Attawar S. Extracorporeal support for donation after cardiac death: a new avatar of ECMO. Indian J Thorac Cardiovasc Surg 2017. [DOI: 10.1007/s12055-017-0519-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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10
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Reeb J, Olland A, Renaud S, Kindo M, Santelmo N, Massard G, Falcoz PE. Principi e indicazioni dell’assistenza circolatoria e respiratoria extracorporea in chirurgia toracica. EMC - TECNICHE CHIRURGICHE - CHIRURGIA GENERALE 2017. [PMCID: PMC7164803 DOI: 10.1016/s1636-5577(17)82113-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In origine, l’extracorporeal membrane oxygenation (ECMO) era una tecnica di assistenza respiratoria che utilizzava uno scambiatore gassoso a membrana. Per estensione, l’ECMO è diventata una tecnica respiratoria e cardiopolmonare utilizzata in caso di deficit respiratorio e/o cardiaco nell’attesa della restaurazione della funzione deficitaria o di un eventuale trapianto. Il supporto emodinamico può essere parziale o totale. Gli accessi vascolari possono essere periferici o centrali. Questo tipo di assistenza utilizza il concetto di circolazione extracorporea (CEC) sanguigna che in epoca moderna si è estesa con l’utilizzo di polmoni artificiali a membrana. Il circuito di base è semplice e comprende una pompa, un ossigenatore (che permette al sangue di caricarsi di O2 e di eliminare CO2) e delle vie d’accesso (una di drenaggio e una di reinfusione). La sua attuazione è facile, veloce e può essere avviata al letto del malato. Il miglioramento delle attrezzature, una migliore conoscenza delle tecniche e delle indicazioni, e le politiche di salute pubblica hanno reso popolare questa tecnica. Alcuni centri di chirurgia toracica la utilizzano di routine come assistenza alla realizzazione di un intervento terapeutico (soprattutto trapianto) assieme a team di rianimazione per il trattamento della sindrome da distress respiratorio acuto. Nel quadro della malattia polmonare dell’adulto, l’idea principale è quella di sviluppare il concetto di strategia minimalista con l’uso di una CEC adiuvante parziale – più che sostitutiva totale – che permetterebbe il recupero metabolico ad integrum del paziente. Nei prossimi anni, i progressi della tecnologia e dell’ingegneria così come le conoscenze approfondite permetteranno il miglioramento della prognosi dei pazienti colpiti da deficit respiratorio sotto assistenza meccanica.
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Affiliation(s)
- J. Reeb
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
- The Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, 200, Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - A. Olland
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - S. Renaud
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - M. Kindo
- Service de chirurgie cardiovasculaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - N. Santelmo
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - G. Massard
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - P.-E. Falcoz
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
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11
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Dalle Ave AL, Bernat JL. Uncontrolled Donation After Circulatory Determination of Death: A Systematic Ethical Analysis. J Intensive Care Med 2016; 33:624-634. [PMID: 28296536 DOI: 10.1177/0885066616682200] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Uncontrolled donation after circulatory determination of death (uDCDD) refers to organ donation after a refractory cardiac arrest. We analyzed ethical issues raised by the uDCDD protocols of France, Madrid, and New York City. We recommend: (1) Termination of resuscitation (TOR) guidelines need refinement, particularly the minimal duration of resuscitation efforts before considering TOR; (2) Before enrolling in an uDCDD protocol, physicians must ascertain that additional resuscitation efforts would be ineffective; (3) Inclusion in an uDCDD protocol should not be made in the outpatient setting to avoid error and conflicts of interest; (4) The patient's condition should be reassessed at the hospital and reversible causes treated; (5) A no-touch period of at least 10 minutes should be respected to avoid the risk of autoresuscitation; (6) Once death has been determined, no procedure that may resume brain circulation should be used, including cardiopulmonary resuscitation, artificial ventilation, and extracorporeal membrane oxygenation; (7) Specific consent is required prior to entry into an uDCDD protocol; (8) Family members should be informed about the goals, risks, and benefits of planned uDCDD procedures; and (9) Public information on uDCDD is desirable because it promotes public trust and confidence in the organ donation system.
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Affiliation(s)
- Anne L Dalle Ave
- 1 Ethics Unit, University Hospital of Lausanne, Lausanne, Switzerland.,2 Institute for Biomedical Ethics, University Medical Center, Geneva, Switzerland
| | - James L Bernat
- 3 Neurology Department, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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12
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Principi e indicazioni dell’assistenza circolatoria e respiratoria extracorporea in chirurgia toracica. EMC - TECNICHE CHIRURGICHE TORACE 2016. [PMCID: PMC7159017 DOI: 10.1016/s1288-3336(16)79382-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
In origine, l’extracorporeal membrane oxygenation (ECMO) era una tecnica di assistenza respiratoria che utilizzava uno scambiatore gassoso a membrana. Per estensione, l’ECMO è diventata una tecnica respiratoria e cardiopolmonare utilizzata in caso di deficit respiratorio e/o cardiaco nell’attesa della restaurazione della funzione deficitaria o di un eventuale trapianto. Il supporto emodinamico può essere parziale o totale. Gli accessi vascolari possono essere periferici o centrali. Questo tipo di assistenza utilizza il concetto di circolazione extracorporea (CEC) sanguigna che in epoca moderna si è estesa con l’utilizzo di polmoni artificiali a membrana. Il circuito di base è semplice e comprende una pompa, un ossigenatore (che permette al sangue di caricarsi di O2 e di eliminare CO2) e delle vie d’accesso (una di drenaggio e una di reinfusione). La sua attuazione è facile, veloce e può essere avviata al letto del malato. Il miglioramento delle attrezzature, una migliore conoscenza delle tecniche e delle indicazioni, e le politiche di salute pubblica hanno reso popolare questa tecnica. Alcuni centri di chirurgia toracica la utilizzano di routine come assistenza alla realizzazione di un intervento terapeutico (soprattutto trapianto) assieme a team di rianimazione per il trattamento della sindrome da distress respiratorio acuto. Nel quadro della malattia polmonare dell’adulto, l’idea principale è quella di sviluppare il concetto di strategia minimalista con l’uso di una CEC adiuvante parziale – più che sostitutiva totale – che permetterebbe il recupero metabolico ad integrum del paziente. Nei prossimi anni, i progressi della tecnologia e dell’ingegneria così come le conoscenze approfondite permetteranno il miglioramento della prognosi dei pazienti colpiti da deficit respiratorio sotto assistenza meccanica.
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Extracorporeal membrane oxygenation (ECMO) assisted cardiopulmonary resuscitation or uncontrolled donation after the circulatory determination of death following out-of-hospital refractory cardiac arrest—An ethical analysis of an unresolved clinical dilemma. Resuscitation 2016; 108:87-94. [DOI: 10.1016/j.resuscitation.2016.07.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 07/08/2016] [Accepted: 07/12/2016] [Indexed: 11/23/2022]
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Dalle Ave AL, Shaw DM, Bernat JL. Ethical Issues in the Use of Extracorporeal Membrane Oxygenation in Controlled Donation After Circulatory Determination of Death. Am J Transplant 2016; 16:2293-9. [PMID: 26999771 DOI: 10.1111/ajt.13792] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 02/25/2016] [Accepted: 03/03/2016] [Indexed: 01/25/2023]
Abstract
The use of donor extracorporeal membrane oxygenation (ECMO) to improve graft outcomes by some controlled donation after circulatory determination of death (cDCDD) programs raises ethical issues. We reviewed cDCDD protocols using ECMO and the relevant ethics literature to analyze these issues. It is not obvious that ECMO in cDCDD improves graft outcomes. In our opinion, ECMO implemented before death can interfere with end-of-life care and damage bodily integrity. By restoring systemic circulation, ECMO risks invalidating the preceding declaration of death if brain and cardiac perfusion is not adequately excluded because of malfunction or misplacement of the supradiaphragmatic aortic occlusion balloon. The use of ECMO is not compatible with the acronym DCDD because circulation is restored after the determination of death. Because of these deficiencies, we concluded that other techniques are preferable, such as rapid recovery or in situ cold infusion. If ECMO is performed, it requires a specific informed consent and transparency.
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Affiliation(s)
- A L Dalle Ave
- Ethics Unit, University hospital of Lausanne, Lausanne, Switzerland.,Institute for Biomedical Ethics, University Medical Center, Geneva, Switzerland
| | - D M Shaw
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - J L Bernat
- Neurology Department, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Abdominal regional in-situ perfusion in donation after circulatory determination of death donors. Curr Opin Organ Transplant 2016; 21:322-8. [DOI: 10.1097/mot.0000000000000315] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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16
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van Heurn LWE, Talbot D, Nicholson ML, Akhtar MZ, Sanchez-Fructuoso AI, Weekers L, Barrou B. Recommendations for donation after circulatory death kidney transplantation in Europe. Transpl Int 2015; 29:780-9. [PMID: 26340168 DOI: 10.1111/tri.12682] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 06/19/2015] [Accepted: 08/26/2015] [Indexed: 12/29/2022]
Abstract
Donation after circulatory death (DCD) donors provides an invaluable source for kidneys for transplantation. Over the last decade, we have observed a substantial increase in the number of DCD kidneys, particularly within Europe. We provide an overview of risk factors associated with DCD kidney function and survival and formulate recommendations from the sixth international conference on organ donation in Paris, for best-practice guidelines. A systematic review of the literature was performed using Ovid Medline, Embase and Cochrane databases. Topics are discussed, including donor selection, organ procurement, organ preservation, recipient selection and transplant management.
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Affiliation(s)
| | - David Talbot
- Department of Liver/Renal Transplant, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Michael L Nicholson
- Department of Surgery, NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | | | | | - Laurent Weekers
- Department of Nephrology-Dialysis-Transplantation, University of Liège, CHU Sart Tilman, Liège, Belgium
| | - Benoit Barrou
- Department of Urology - Transplantation, GHzu Pitié Salpêtriere, Paris, France
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Donation after circulatory determination of death: the university of michigan experience with extracorporeal support. Transplantation 2014; 98:328-34. [PMID: 24825520 DOI: 10.1097/tp.0000000000000070] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Extracorporeal support (ECS) during organ procurement from donors after circulatory determination of death (DCDD) could increase the number of donor organs and decrease posttransplant complications. This study reports the experience of a large transplant center with controlled DCDD. METHODS A retrospective review of all potential controlled-DCDD cases between October 1, 2000 and July 31, 2013 was performed. We focused on methods, ethical and practical issues, and recipient outcome data of organs procured and transplanted in our institution using ECS-assisted DCDD (E-DCDD). RESULTS ECS was used for organ procurement in 37 controlled DCDD. The number of organs procured per donor was 2.59, and the number of organs transplanted per donor was 1.68. Delayed graft function occurred in 31% of renal grafts. In three donors (8%), organ donation was not completed because of surgeon judgment. Forty-eight renal grafts (65.8%), thirteen livers (61.9%), and one pancreas (50%) were successfully transplanted. CONCLUSIONS ECS can be routinely implemented in controlled DCDD. In our experience, the organs provided per donor was 2.59. Widely applied, EDCDD could result in more donor organs, especially when applied to DCDD in uncontrolled conditions.
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Hessheimer AJ, Billault C, Barrou B, Fondevila C. Hypothermic or normothermic abdominal regional perfusion in high-risk donors with extended warm ischemia times: impact on outcomes? Transpl Int 2014; 28:700-7. [PMID: 24797796 DOI: 10.1111/tri.12344] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 03/05/2014] [Accepted: 04/25/2014] [Indexed: 12/11/2022]
Abstract
Donation after circulatory determination of death (DCD) has the potential to increase the applicability of transplantation as a treatment for end-stage organ disease; its use is limited, however, by the warm ischemic damage suffered by potential grafts. Abdominal regional perfusion (ARP) has been employed in this setting to not only curtail the deleterious effects of cardiac arrest by re-establishing oxygenated flow but also test and even improve the viability of the kidneys and liver prior to transplantation. In the present review article, we discuss experimental and clinical studies that have been published to date on the use of ARP in DCD, differentiating between its application under hypothermic and normothermic conditions. In addition to describing results that have been achieved thus far, we describe the major obstacles limiting the broader implementation of ARP in this context as well as potential means for improving the effectiveness of this modality in the future.
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Affiliation(s)
- Amelia J Hessheimer
- Department of Surgery, Institut de Malalties Digestives I Metabòliques (IMDiM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Claire Billault
- Department of Urology, Nephrology and Transplantation, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Benoit Barrou
- Department of Urology, Nephrology and Transplantation, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Constantino Fondevila
- Department of Surgery, Institut de Malalties Digestives I Metabòliques (IMDiM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
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IV Reunión de consenso de la Sociedad Española de Trasplante Hepático (SETH) 2012. Trasplante hepático con injertos no convencionales: bipartición hepática (split) y donante en asistolia. Cir Esp 2014; 92:157-67. [DOI: 10.1016/j.ciresp.2013.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 07/31/2013] [Indexed: 02/07/2023]
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Yang JH, Cho YH, Chung CR, Jeon K, Park CM, Suh GY. Use of Extracorporeal Membrane Oxygenation for Optimal Organ Donation. Korean J Crit Care Med 2014. [DOI: 10.4266/kjccm.2014.29.3.194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chi-Min Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Shapey IM, Muiesan P. Regional perfusion by extracorporeal membrane oxygenation of abdominal organs from donors after circulatory death: a systematic review. Liver Transpl 2013; 19:1292-303. [PMID: 24136827 DOI: 10.1002/lt.23771] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Accepted: 09/10/2013] [Indexed: 12/25/2022]
Abstract
Organs from donors after circulatory death (DCDs) are particularly susceptible to the effects of warm ischemia injury. Regional perfusion (RP) by extracorporeal membrane oxygenation (ECMO) is increasingly being advocated as a useful remedy to the effects of ischemia/reperfusion injury, and it has been reported to enable the transplantation of organs from donors previously deemed unsuitable. The MEDLINE, Embase, and Cochrane databases were searched, and articles published between 1997 and 2013 were obtained. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two hundred ten articles were identified, and 11 were eligible for inclusion. Four hundred eighty-two kidneys and 79 livers were transplanted from regional perfusion-supported donor after circulatory death (RP-DCD) sources. One-year graft survival was lower with uncontrolled RP-DCD liver transplantation, whereas 1-year patient survival was similar. Primary nonfunction and ischemic cholangiopathy were significantly more frequent with RP-DCDs versus donors after brain death (DBDs), but there was no difference in postoperative mortality between the 2 groups. The 1-year patient and graft survival rates for RP-DCD kidney transplantation were better than the rates with standard DCDs and were comparable to, if not better than, the rates with DBDs. At experienced centers, delayed graft function (DGF) for kidney transplantation from RP-DCDs was much less frequent in comparison with all other donor types. In conclusion, RP aids the recovery of DCD organs from ischemic injury and enables transplantation with acceptable survival. RP may help to increase the donor pool, but its benefits must still be balanced with the recognition of significantly higher rates of complications in liver transplantation. In kidney transplantation, significant reductions in DGF can be obtained with RP, and there are potentially important implications for long-term outcomes. Significant ethicolegal issues exist, and they are preventing a worldwide consensus on optimum RP protocols and an accurate appreciation of outcomes.
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Affiliation(s)
- Iestyn M Shapey
- Department of Transplantation Surgery, Manchester Royal Infirmary, Manchester, United Kingdom
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The use of extracorporeal membranous oxygenation in donors after cardiac death. Curr Opin Organ Transplant 2013; 18:148-53. [DOI: 10.1097/mot.0b013e32835e29f5] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Gupta P, Blanco C, Madigan M, Dodgen A, Hanson M, Frazier EA, Bhutta AT, Fiser WP. Solid organ donation in a child after extracorporeal membrane oxygenation, orthotopic heart transplantation, and ventricular assist device support. Pediatr Transplant 2012; 16:E368-71. [PMID: 22594304 DOI: 10.1111/j.1399-3046.2012.01720.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Use of high-risk or marginal donors is the most viable short-term means to boost the organ supply and bridge the widening gap between the number of patients on the waiting list for organ transplantation and the insufficient numbers of organ donors. Expansion of the donor pool requires an understanding of the impact on survival likely to result from extending one or more high risk factors. Use of extended donor pool results in shorter waiting list times and limits the morbidity and mortality associated with long-term mechanical support needed to support diseased organs. In this report, we present one such example of expanding donor pool in which a pediatric patient donated a solid organ after two heart transplants and successful use of ECMO and VAD.
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Affiliation(s)
- Punkaj Gupta
- Division of Pediatric Cardiology, Department of Pediatrics, University of Arkansas Medical Center, Little Rock, Arkansas, USA.
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Moers C, van Rijt G, Ploeg RJ, Leuvenink HGD. The effect of normothermic recirculation before cold preservation on post-transplant injury of ischemically damaged donor kidneys. Transpl Int 2011; 25:210-7. [PMID: 22077364 DOI: 10.1111/j.1432-2277.2011.01383.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Kidneys recovered from donation after cardiac death (DCD) are increasingly used to enlarge the deceased donor pool. Such renal grafts, especially those derived from uncontrolled DCD, have inevitably sustained profound warm ischemic injury, which compromises post-transplant function. Normothermic recirculation (NR) of the deceased donor's body before organ cooling could be an interesting approach to mitigate the detrimental effect of warm ischemia. To date, however, there is no evidence coming from preclinical studies to support the principle of NR in kidney transplantation. In this study, we subjected 48 Lewis rat kidneys to 15 or 30 min of warm ischemia, and subsequently 0, 1, or 2 h of NR. After 24 h cold storage, kidneys were transplanted into a recipient animal and 24 h later we measured the percentage of cortical necrosis, and determined gene expression of heme oxigenase-1, heat shock protein-70, transforming growth factor-β, kidney injury molecule-1, interleukin-6, hypoxia inducible factor-1α, monocyte chemoattractant protein-1, and α-smooth muscle actin in kidney tissue. We found that NR had no significant influence on any of these markers. Therefore, we conclude that this animal study by no means supports the presumed beneficial effect of NR on kidneys that have been severely damaged by warm ischemia.
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Affiliation(s)
- Cyril Moers
- Surgery Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Abstract
Acute kidney injury occurs with kidney transplantation and too frequently progresses to the clinical diagnosis of delayed graft function (DGF). Poor kidney function in the first week of graft life is detrimental to the longevity of the allograft. Challenges to understand the root cause of DGF include several pathologic contributors derived from the donor (ischemic injury, inflammatory signaling) and recipient (reperfusion injury, the innate immune response and the adaptive immune response). Progressive demand for renal allografts has generated new organ categories that continue to carry high risk for DGF for deceased donor organ transplantation. New therapies seek to subdue the inflammatory response in organs with high likelihood to benefit from intervention. Future success in suppressing the development of DGF will require a concerted effort to anticipate and treat tissue injury throughout the arc of the transplantation process.
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Affiliation(s)
- Andrew Siedlecki
- Nephrology Division, Department of Internal Medicine, Washington University in St. Louis School of Medicine, St Louis, MO
| | - William Irish
- CTI, Clinical Trial and Consulting Services, Raleigh, NC
| | - Daniel C. Brennan
- Nephrology Division, Department of Internal Medicine, Washington University in St. Louis School of Medicine, St Louis, MO
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Abstract
PURPOSE OF REVIEW Kidneys from marginal or donation after cardiac death (DCD) donors are particularly susceptible to injury during hypothermic preservation and may benefit from alternative methods of preservation. Normothermic preservation can be adapted to improve the quality of kidneys for transplantation by a variety of techniques. RECENT FINDINGS Extracorporeal membrane support to maintain circulation before cooling and organ retrieval has been used to improve the condition of DCD donor kidneys, with lower rates of delayed graft function (DGF) compared with standard retrieval conditions. Experimentally, normothermic perfusion has been used in conjunction with hypothermic techniques as a resuscitation technique to improve graft outcome. An ex-vivo porcine kidney model showed that energy levels could be replenished to improve tissue perfusion during reperfusion. This technique was translated into a porcine transplant model demonstrating that it was a feasible and safe method of preservation. SUMMARY Normothermic preservation techniques have the potential to be adapted into an improved method of retaining tissue viability compared with hypothermic techniques. Furthermore, they may be used as a device to enhance and assess the condition of the kidney which would be particularly beneficial for kidneys from DCD donors.
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Abstract
PURPOSE OF REVIEW The purpose of the present review is to describe the techniques currently used to preserve kidneys from donors after cardiac death. RECENT FINDINGS Automated chest compression devices may be used to improve organ perfusion between cardiac death and preservation measures. Normothermic extracorporeal membrane oxygenation reduces warm ischemic injury and has the ability to improve organ viability in donors after cardiac death. SUMMARY Kidneys from donors after cardiac death expand the donor pool but are inevitably subjected to a period of warm ischemia. Reduction of warm ischemic injury to the organs improves transplant outcome. To reduce this injury in organs from donors after cardiac death, different preservation techniques are used. Automated chest compression devices improve organ perfusion between cardiac death and the start of organ preservation. In-situ preservation with double-balloon triple-lumen catheter is an easy technique to preserve organs in uncontrolled donors and is used in many centers to cool and flush the organs. In controlled donors, organs can also be flushed after laparotomy and direct cannulation of the aorta. Extracorporeal membrane oxygenation reduces warm ischemic injury and the use of normothermic perfusion seems promising. Optimal preservation is essential to improve the viability of kidneys from donors after cardiac death, to fully utilize this large donor pool.
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Farney AC, Hines MH, al-Geizawi S, Rogers J, Stratta RJ. Lessons learned from a single center's experience with 134 donation after cardiac death donor kidney transplants. J Am Coll Surg 2011; 212:440-51; discussion 451-3. [PMID: 21463765 DOI: 10.1016/j.jamcollsurg.2010.12.033] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 12/15/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND Reports of kidney transplantation from donation after cardiac death (DCD) donors describe high rates of delayed graft function (DGF). STUDY DESIGN From April 1, 2003 to October 17, 2010, we performed 134 kidney transplants from DCD donors including 120 (90%) from standard-criteria donors (SCDs) and 14 (10%) from expanded-criteria donors (ECDs). Nineteen kidneys were recovered from donors managed with extracorporeal interval support for organ retrieval (EISOR) after cardiac arrest to minimize ischemic injury. RESULTS Comparison of donor and recipient characteristics found no differences for cases managed with or without EISOR. Overall actuarial patient survival rates were 93%, 91%, and 89% at 1, 3, and 5 years, respectively, with a mean follow-up of 31 months. Overall actuarial kidney graft survival rates were 89%, 76%, and 76% at 1, 3, and 5 years, respectively. Actuarial graft survival rates of DCD ECD kidneys were 58% and 48% at 1 and 3 years, compared with 90% and 79% at 1 and 3 years for non-ECD grafts (p = 0.013). DGF occurred in 73 patients (54%) overall and was reduced from 55% to 21% (p = 0.016) with the use of EISOR in locally recovered kidneys. The mean resistance value on machine perfusion and the mean estimated glomerular filtration rate 1 month after transplantation were both improved (p < 0.05) in kidneys from donors managed with EISOR. Mean initial hospital stay was reduced from 8.0 to 5.0 days in patients receiving kidneys recovered with EISOR (p = 0.04). CONCLUSIONS EISOR is associated with a lower rate of DGF, lower graft resistance on machine perfusion, and shorter initial hospitalization. Kidneys from DCD SCDs have excellent medium-term outcomes and represent an important means of expanding the donor pool. Kidneys from DCD ECDs have inferior outcomes.
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Affiliation(s)
- Alan C Farney
- Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157–1095, USA.
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Roberts KJ, Muiesan P. Abdominal organ donation after death. Br J Surg 2011; 98:1185-7. [PMID: 21607938 DOI: 10.1002/bjs.7570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
New approaches to increase donor organ supply
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Affiliation(s)
- K J Roberts
- The Liver Unit, Third Floor Nuffield House, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK
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Morozumi J, Matsuno N, Sakurai E, Nakamura Y, Arai T, Ohta S. Application of an automated cardiopulmonary resuscitation device for kidney transplantation from uncontrolled donation after cardiac death donors in the emergency department. Clin Transplant 2011; 24:620-5. [PMID: 19888995 DOI: 10.1111/j.1399-0012.2009.01140.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Vital-organ transplantation has become acceptable as the treatment of choice for end-stage organ failure. If the patient, facing the end of life, wishes to donate organs after cardiac arrest (CA), donation after cardiac death (DCD) is increasingly important for the realization of the patient's desires after CA. In Japan, kidney transplantation from uncontrolled DCD donors, who are identified in modified Maastricht categories II or V, is one of the critical factors in expanding the donor pool. However, according to the forensic code for post-mortems and the requirement of legal consent for transplantation, the time required to meet all procedural requirements has sometimes prohibited organ procurement from uncontrolled DCD donors. We have therefore attempted to use an automated cardiopulmonary resuscitation (CPR) device and maintain arterial pressure for uncontrolled DCD donors during all interim procedures after sudden CA. Comparing kidneys procured from standard DCD donors (n = 10) and uncontrolled DCD donors (n = 4), significant differences were seen in warm ischemic time (WIT), defined as the time from CA to initiation of cooling in situ. However, our early experience showed good tolerance and viability of uncontrolled DCD kidneys. Immediate availability of an automated CPR device might provide a bridge to kidney procurement from uncontrolled DCD donors.
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Affiliation(s)
- Junya Morozumi
- Department of Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Hachioji-shi, Tokyo Japan.
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Reznik O, Bagnenko S, Skvortsov A, Ananyev A, Senchik K, Loginov I, Moysyuk Y. Rehabilitation of ischemically damaged human kidneys by normothermic extracorporal hemoperfusion in situ with oxygenation and leukocyte depletion. Transplant Proc 2010; 42:1536-8. [PMID: 20620470 DOI: 10.1016/j.transproceed.2010.01.071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Accepted: 01/26/2010] [Indexed: 11/28/2022]
Abstract
The potential use of donors after cardiac death is an important issue. The crucial point in uncontrolled donors after cardiac death is the warm ischemic time. Definition of the limit of warm ischemic time was 1 of our tasks; an other was to develop a preservation protocol. Five uncontrolled donors kidneys with warm ischemia times up to 80 minutes were exposed to an extracorporal perfusion device for preservation after ischemic damage. We sought to eliminate leukocytes as the main damaging factor in modified donor blood circulating in the device. Recipients of 8 kidneys from this protocol displayed immediate graft function with an average serum creatinine value of 140 +/- 37.9 mmol/L at the end of the second month. Treatment of ischemically damaged kidneys by normothermic extracorporal perfusion with leukocyte depletion before procurement demands further study.
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Affiliation(s)
- O Reznik
- Department of Transplantation, Saint-Petersburg State Research Institute for Emergency named after I.I. Djanelidze.
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Reznik O, Skvortsov A, Loginov I, Ananyev A, Bagnenko S, Moysyuk Y. Kidney from uncontrolled donors after cardiac death with one hour warm ischemic time: resuscitation by extracorporal normothermic abdominal perfusion "in situ" by leukocytes-free oxygenated blood. Clin Transplant 2010; 25:511-6. [PMID: 20973824 DOI: 10.1111/j.1399-0012.2010.01333.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The availability of brain death donors is restricted by many factors. Use of uncontrolled donors after cardiac death could be a promising perspective, but the limiting factor in uncontrolled donation after cardiac death is the warm ischemic time. The purpose of our work was to develop an in situ kidney preservation protocol with application of the extracorporal normothermic abdominal perfusion for organ resuscitation in uncontrolled donors after cardiac death. The main attention was paid to the elimination of leukocytes as the key damaging factor from modified donor oxygenated blood circulating in the device. In 2009, we had 10 uncontrolled donors with warm ischemic time from 45 to 92 min; a normothermic extracorporal perfusion device was applied, providing preservation and restoration of kidney after ischemic damage. In 6 out of 20 kidney recipients, graft function was recovered immediately. All kidney grafts are functioning, and to the end of the third month, the average creatinine was 118.5 ± 19.9 mM. Treatment of ischemically damaged kidney by normothermic extracorporal perfusion with leukocyte depletion before procurement seems to be a challenging protocol for expanding donors' pool and demands further study.
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Affiliation(s)
- Oleg Reznik
- Transplant Department, St. Petersburg State Research Institute for Emergency, St. Petersburg, Russia.
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Reznik O, Bagnenko S, Scvortsov A, Loginov I, Ananyev A, Senchik K, Moysyuk Y. The use of in-situ normothermic extracorporeal perfusion and leukocyte depletion for resuscitation of human donor kidneys. Perfusion 2010; 25:343-8. [DOI: 10.1177/0267659110377817] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The unexploited potential of donors after cardiac death is an actual issue for all countries where organ transplantation is performed. The crucial point in uncontrolled donation after cardiac death is the warm ischemic time. The primary purpose of our work was to define the limits of warm ischemic time. Another purpose was the development of an in situ kidney preservation protocol. In 8 uncontrolled donors with warm ischemic time from 45 to 91 minutes, a normothermic extracorporeal perfusion device was applied, providing preservation and restoration of the kidney after ischemic damage. Main attention was paid to the elimination of leukocytes as the key damaging factor from modified donor blood circulating in the device. In 6 out of 16 kidney recipients, graft function was recovered immediately and, by the end of the third month, the average creatinine was 117.9±21.9 mmol/L. Treatment of ischemically damaged kidneys by normothermic extracorporeal perfusion, with leukocyte depletion before procurement, seems to be a challenging protocol and demands further study. Implementation of perfusion systems in organ procurement practice could lead to a partial solution in the organ deficit problem.
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Affiliation(s)
- Oleg Reznik
- Saint-Petersburg Russian Federation Saint-Petersburg State Research Institute for Emergency, Saint-Petersburg, Russia,
| | - Sergey Bagnenko
- Saint-Petersburg Russian Federation Saint-Petersburg State Research Institute for Emergency, Saint-Petersburg, Russia
| | - Andrei Scvortsov
- Saint-Petersburg Russian Federation Saint-Petersburg State Research Institute for Emergency, Saint-Petersburg, Russia
| | - Igor Loginov
- Saint-Petersburg Russian Federation Saint-Petersburg State Research Institute for Emergency, Saint-Petersburg, Russia
| | - Alexei Ananyev
- Saint-Petersburg Russian Federation Saint-Petersburg State Research Institute for Emergency, Saint-Petersburg, Russia
| | - Konstantin Senchik
- Saint-Petersburg Russian Federation Saint-Petersburg State Research Institute for Emergency, Saint-Petersburg, Russia
| | - Yan Moysyuk
- Shumakov Research Center of Transplantology, Moscow, Russia
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Rojas-Pena, Reoma J, Krause E, Boothman E, Padiyar N, Cook K, Bartlett R, Punch J. Extracorporeal support: improves donor renal graft function after cardiac death. Am J Transplant 2010; 10:1365-74. [PMID: 20553447 PMCID: PMC3876456 DOI: 10.1111/j.1600-6143.2010.03063.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Donors after cardiac death (DCD) could increase the organ pool. Data supports good long-term renal graft survival. However, DCDs are <10% of deceased donors in the United States, due to delayed graft function, and primary nonfunction. These complications are minimized by extracorporeal support after cardiac death (ECS-DCD). This study assesses immediate and acute renal function from different donor types. DCDs kidneys were recovered by conventional rapid recovery or by ECS, and transplanted into nephrectomized healthy swine. Warm ischemia of 10 and 30 min were evaluated. Swine living donors were controls (LVD). ECS-DCDs were treated with 90 min of perfusion until organ recovery. After procurement, kidneys were cold storage 4-6 h. Renal vascular resistance (RVR), urine output (UO), urine protein concentration (UrPr) and creatinine clearance (CrCl), were collected during 4 h posttransplantation. All grafts functioned with adequate renal blood flow for 4 h. RVR at 4 h posttransplant returned to baseline only in the LVD group (0.36 mmHg/mL/min +/- 0.03). RVR was higher in all DCDs (0.66 mmHg/mL/min +/- 0.13), without differences between them. UO was >50 mL/h in all DCDs, except in DCD-30 (6.8 mL/h +/- 1.7). DCD-30 had lower CrCl (0.9 mL/min +/- 0.2) and higher UrPr >200 mg/dL, compared to other DCDs >10 mL/min and <160 mg/dL, respectively. Normothermic ECS can resuscitate kidneys to transplantable status after 30 min of cardiac arrest/WI.
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Affiliation(s)
- Rojas-Pena
- Section of General Surgery, Division of Transplantation, University of Michigan, Ann Arbor MI,Extracorporeal Life Support (ECS) Laboratory, University of Michigan, Ann Arbor MI
| | - J.L. Reoma
- Extracorporeal Life Support (ECS) Laboratory, University of Michigan, Ann Arbor MI
| | - E. Krause
- Extracorporeal Life Support (ECS) Laboratory, University of Michigan, Ann Arbor MI
| | - E.L. Boothman
- Extracorporeal Life Support (ECS) Laboratory, University of Michigan, Ann Arbor MI
| | - N.P. Padiyar
- Extracorporeal Life Support (ECS) Laboratory, University of Michigan, Ann Arbor MI
| | - K.E. Cook
- Extracorporeal Life Support (ECS) Laboratory, University of Michigan, Ann Arbor MI
| | - R.H. Bartlett
- Extracorporeal Life Support (ECS) Laboratory, University of Michigan, Ann Arbor MI
| | - J.D Punch
- Section of General Surgery, Division of Transplantation, University of Michigan, Ann Arbor MI
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Lung physiology during ECS resuscitation of DCD donors followed by in situ assessment of lung function. ASAIO J 2009; 55:388-94. [PMID: 19506464 DOI: 10.1097/mat.0b013e3181a8fd98] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Extracorporeal cardiopulmonary support (ECS) of donors after cardiac death (DCD) has been shown to improve abdominal organs for transplantation. This study assesses whether pulmonary congestion occurs during ECS with the heart arrested and describes an in vivo method to assess if lungs are suitable for transplantation from DCD donors after ECS resuscitation. Cardiac arrest was induced in 30 kg pigs, followed by 10 min of warm ischemia. Cannulae were placed into the right atrium (RA) and iliac artery, and veno-arterial ECS was initiated for 90 min with lungs inflated, group 1 (n = 5) or deflated, group 2 (n = 3). Left atrial pressures were measured as a marker for pulmonary congestion. After 90 min of ECS, lung function was evaluated. Cannulae were placed into the pulmonary artery (PA) and left ventricle (LV). A second pump was included, and ECS was converted to a bi-ventricular (bi-VAD) system. The RVAD drained from the RA and pumped into the PA, and the LVAD drained the LV and pumped into the iliac. This brought the lungs back into circulation for a 1-hr assessment period. The oxygenator was turned off, and ventilation was restarted. Flows, blood gases, PA and left atrial pressures, and compliance were recorded. In both the groups, LA pressure was <15 mm Hg during ECS. During the lung assessment period, PA flows were 1.4-2.2 L/min. PO2 was >300 mm Hg, with normal PCO2. Extracorporeal cardiopulmonary support resuscitation of DCD donors is feasible and allows for assessment of function before procurement. Extracorporeal cardiopulmonary support does not cause pulmonary congestion, and the lungs retain adequate function for transplantation. Compliance correlated with lung function.
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Jousset N, Jacob JP, Gaudin A, Mauillon D, Penneau M, Rougé-Maillart C. [Recovery of transportable organs after cardiac arrest]. Presse Med 2009; 38:740-4. [PMID: 19171457 DOI: 10.1016/j.lpm.2008.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Revised: 10/13/2008] [Accepted: 10/20/2008] [Indexed: 11/25/2022] Open
Abstract
The transplant of an allograft after cardiac arrest has been allowed in France since 2005 (decree of 2 august 2005: art R.1232-4-1, 2 and 3 of the public health code). Recently, according to the international scale, 4 situations that could lead to the realization of transplantable organs after cardiac arrest were identified according to a classification called "Maastricht" which describes the potential donors. In France the donors of class III (cessation of all medical care) were excluded. Ethical questions concerning this new practice come up. Are criteria adopted to define death enough sure? What is the place of non-heart beating donor transplantation with new technical resuscitation as extracorporeal life support for prolonged cardiac arrest? How does family and medical staff live this protocol? Despite this, non heart-beating donor kidney transplants offer the opportunity to compensate for the growing discrepancy between supply and demand for donor kidneys. Results from foreign studies have shown that they have the same survival and long term function as kidneys from traditional brain-stem dead donors. This practice is defined by legislation and supervised by the "Agence de la biomédecine" which guarantees technical efficiency and respect of ethics.
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Affiliation(s)
- Nathalie Jousset
- Service de médecine légale, CHU Angers, F-49933 Angers cedex 9, France.
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Thomas S, Terrier N, Padilla M, Durand M, Chavanon O. [Kidney allograft harvesting on a donor patient under cardiopulmonary bypass]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2008; 27:166-168. [PMID: 18162360 DOI: 10.1016/j.annfar.2007.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Accepted: 11/07/2007] [Indexed: 05/25/2023]
Abstract
We report the case of a kidney allograft harvesting on a donor patient under cardiopulmonary bypass (CPB) after a cardiac arrest. The two kidneys were successfully transplanted with immediate graft function. CPB may provide an option to expand the number of harvested grafts.
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Affiliation(s)
- S Thomas
- Pôle d'anesthésie réanimation, hôpital Michallon, B.P. 217, 38043 Grenoble cedex 09, France
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Le prélèvement sur donneurs à cœur arrêté dans le cadre de la greffe rénale. Nephrol Ther 2008; 4:5-14. [DOI: 10.1016/j.nephro.2007.07.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Revised: 07/24/2007] [Accepted: 07/24/2007] [Indexed: 11/23/2022]
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Snoeijs MG, van Heurn LE, van Mook WN, Christiaans MH, van Hooff JP. Controlled donation after cardiac death: a European perspective. Transplant Rev (Orlando) 2007. [DOI: 10.1016/j.trre.2007.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Kokkinos C, Antcliffe D, Nanidis T, Darzi AW, Tekkis P, Papalois V. Outcome of Kidney Transplantation From Nonheart-Beating Versus Heart-Beating Cadaveric Donors. Transplantation 2007; 83:1193-9. [PMID: 17496535 DOI: 10.1097/01.tp.0000261710.53848.51] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to assess outcomes of kidney transplants from nonheart-beating (NHB) compared with heart-beating (HB) cadaveric donors with meta-analytical techniques. METHODS A literature search was performed for studies comparing kidney transplants from NHB vs. HB cadaveric donors between 1992 and 2005. The following outcomes were evaluated: warm and cold ischemia times, primary nonfunction, delayed graft function, length of hospital stay, acute graft rejection, patient and graft survival, and post-transplant serum creatinine. RESULTS Eighteen comparative studies of 114,081 patients matched the selection criteria; 1,858 received kidney from NHB and 112,223 from HB donor. Warm ischemia time was significantly longer for the NHB group by 24 min (P<0.001). Cold ischemia time was similar for the two groups (P=0.97). The incidence of primary nonfunction and delayed graft function was 2.4 times (P<0.001) and 3.6 times (P<0.001) greater, respectively, in the NHB group. Length of hospital stay was longer for the NHB group by 4.6 days (P<0.001). The 6-month, 2-year, and 5-year patient survival were similar between the two groups. The incidence of acute rejection was similar between the two groups whereas the initial graft survival advantage in favor of the HB group diminished gradually over the course of time. There was no statistically significant difference between the two groups for the recipient serum creatinine levels at 3 and 12 months after transplantation. CONCLUSION NHB donors carry the potential of expanding the cadaveric kidney pool. Although, transplants from NHB donors are associated with a greater incidence of early adverse events, long-term outcomes appear comparable with those of transplants from HB donors.
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Affiliation(s)
- Constantinos Kokkinos
- Imperial College London, Department of Biosurgery and Surgical Technology, St Mary's Hospital, London, United Kingdom
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Kootstra G, van Heurn E. Non-heartbeating donation of kidneys for transplantation. ACTA ACUST UNITED AC 2007; 3:154-63. [PMID: 17322927 DOI: 10.1038/ncpneph0426] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2006] [Accepted: 12/15/2006] [Indexed: 01/01/2023]
Abstract
There is a persistent shortage of kidneys available for transplantation. In the early 1980s, therefore, we published the concept of non-heartbeating (NHB) donation; that is, procurement of kidneys from donors whose death has been accompanied by irreversible circulatory arrest. NHB donors are generally categorized using four definitions; category III (awaiting cardiac arrest) and category IV (cardiac arrest while braindead)--or 'controlled'--donors are the most suitable for initiating NHB donation programs. Delayed graft function is associated with use of kidneys from such donors, but has no effect on graft survival in the short or long term. Use of kidneys from category I (dead upon arrival at hospital) and category II (unsuccessfully resuscitated), or 'uncontrolled', donors is likewise associated with delayed graft function, but also with an increased risk of primary nonfunction. Viability testing of donated organs from these sources is a prerequisite for transplantation. Machine preservation parameters and enzyme release measurements help to distinguish viable from nonviable kidneys. The proportion of NHB donor kidneys in the total pool of postmortem kidneys differs considerably between countries. In The Netherlands, the proportion is nearly 50%. This figure is markedly higher than that in the US and Canada, where national programs have now been initiated to increase rates of NHB donation. In the future, warm preservation techniques might facilitate better viability testing, thereby increasing NHB donation from category I and II donors and further reducing the shortage of kidneys available for transplantation.
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Stratta RJ, Rohr MS, Sundberg AK, Farney AC, Hartmann EL, Moore PS, Rogers J, Iskandar SS, Gautreaux MD, Kiger DF, Doares W, Anderson TK, Hairston G, Adams PL. Intermediate-term outcomes with expanded criteria deceased donors in kidney transplantation: a spectrum or specter of quality? Ann Surg 2006; 243:594-601; discussion 601-3. [PMID: 16632993 PMCID: PMC1570560 DOI: 10.1097/01.sla.0000216302.43776.1a] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To compare intermediate-term outcomes in adult recipients of expanded criteria (ECD) versus concurrent standard criteria (SCD) deceased donor kidney transplants at a single center using a standardized approach. SUMMARY BACKGROUND DATA Expanded criteria donors (ECDs) are a source of kidneys that increase the donor organ pool, but the value of transplanting these kidneys has been questioned because of concerns regarding diminished survival and predicted poorer intermediate-term outcomes. METHODS Over a 47-month period, we performed 244 deceased donor kidney transplants into adult recipients, including 143 from SCDs and 101 from ECDs. Management algorithms were implemented to preserve nephron function, and recipient selection for an ECD kidney transplant was based on low immunologic risk. All patients received depleting antibody induction in combination with tacrolimus and mycophenolate mofetil. A total of 188 patients (77%) had at least a 1-year follow-up. RESULTS ECDs were older, had a higher BMI, had an increased incidence of cerebrovascular brain death and preexisting donor hypertension, and had a lower estimated creatinine clearance (CrCl, all P < 0.01) compared with SCDs. Cold ischemic times were similar between groups, but more ECD kidneys were preserved with pulsatile perfusion (P < 0.01). ECD kidney recipients were older, less sensitized, had a lower BMI, had fewer 0-antigen mismatches, and had a shorter waiting time (all P < 0.01) compared with SCD kidney recipients. Actual patient (93%) and kidney graft (83%) survival rates were similar between groups with a mean follow-up of 24 months. The rates of delayed graft function (DGF), acute rejection, readmissions, operative complications, major infections, and resource utilization were comparable between groups. Renal function followed longitudinally was consistently better in SCD patients (P < 0.05). Black recipients had higher rates of DGF, acute rejection, and graft loss (P < 0.05), but the effects were less pronounced in the ECD group. CONCLUSIONS By appropriate donor and recipient profiling and the use of management algorithms to project and protect renal function, excellent intermediate-term outcomes can be achieved with ECD kidney transplants that are comparable to SCD kidney transplants.
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Affiliation(s)
- Robert J Stratta
- Department of General Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC 27157, USA.
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