Evaluation of Liver Graft Donation After Euthanasia

Evaluating Islet Cell Isolation and Transplantation From Donors Following Medical Assistance in Dying

Background

Limited information is available regarding outcomes of islet cell isolation (ICI) and transplantation (ITx) using medical assistance in dying (MAiD) donors. We aimed to assess the feasibility and outcomes of ICI and ITx in MAiD donors.

Methods

ICI and ITx from MAiD were compared with donation after circulatory death (DCD) type III between 2016 and 2023. Differences of isolated islet equivalents (IEQs), numeric viability and other quantitative in vitro metabolic measures were assessed.

Results

Overall, 81 ICIs were available of whom 34 (42%) and 47 (58%) from MAiD and DCD-III, respectively. There were no differences of pancreas and digested tissue weight and islets viability among the 2 groups; however, cold ischemic time was longer in MAiD (11.5 versus 9.1 h; P = 0.021). The IEQ (P < 0.001) and percent trapped (P < 0.001) were higher in the DCD-III; however, MAiD islets demonstrated a higher purity (P = 0.020). Overall, 15 ITx were performed of whom 3 (8.8%) and 12 (25.5%) from MAiD and DCD-III, respectively (P = 0.056). Patients had a median fasting C-peptide of 0.51 ng/mL (interquartile range, 0.30-0.76 nmol/L), with no differences between groups (MAiD = 0.52 versus DCD-III = 0.51; P = 0.718). The median HbA1c was 6.2% (interquartile range, 5.7%-7%) (MAiD = 6.3% versus DCD-III = 6.1%; P = 0.815) and BETA2 scores (MAiD = 7.4 versus DCD-III = 12.8; P = 0.229) did not differ.

Conclusions

ICI from MAiD donor pancreas may be successfully transplanted with comparable outcomes to DCD-III and may be used for research. These results justify additional efforts to consider MAiD as another valuable source of grafts for ITx. Further multicenter studies and larger clinical experience are needed to validate our findings.

The Extent to Which the Wish to Donate One's Organs After Death Contributes to Life-Extension Arguments in Favour of Voluntary Active Euthanasia in the Terminally Ill: An Ethical Analysis

In terminally ill individuals who would otherwise end their own lives, active voluntary euthanasia (AVE) can be seen as life-extending rather than life-shortening. Accordingly, AVE supports key pro-euthanasia arguments (appeals to autonomy and beneficence) and meets certain sanctity of life objections. This paper examines the extent to which a terminally ill individual's wish to donate organs after death contributes to those life-extension arguments. It finds that, in a terminally ill individual who wishes to avoid experiencing life he considers to be not worth living, and who also wishes to donate organs after death, AVE maximizes the likelihood that such donations will occur. The paper finds that the wish to donate organs strengthens the appeals to autonomy and beneficence, and fortifies the meeting of certain sanctity of life objections, achieved by life-extension arguments, and also generates appeals to justice that form novel life-extension arguments in favour of AVE in this context.

The crosstalk between exosomes and ferroptosis: a review

Exosomes are a subtype of extracellular vesicles composed of bioactive molecules, including nucleic acids, proteins, and lipids. Exosomes are generated by the fusion of intracellular multivesicular bodies (MVBs) with the cell membrane and subsequently released into the extracellular space to participate in intercellular communication and diverse biological processes within target cells. As a crucial mediator, exosomes have been implicated in regulating ferroptosis-an iron-dependent programmed cell death characterized by lipid peroxide accumulation induced by reactive oxygen species. The involvement of exosomes in iron, lipid, and amino acid metabolism contributes to their regulatory role in specific mechanisms underlying how exosomes modulate ferroptosis, which remains incompletely understood, and some related studies are still preliminary. Therefore, targeting the regulation of ferroptosis by exosomes holds promise for future clinical treatment strategies across various diseases. This review aims to provide insights into the pathophysiology and mechanisms governing the interaction between exosomes and ferroptosis and their implications in disease development and treatment to serve as a reference for further research.

Organ donation following medical assistance in dying, Part II: a scoping review of existing processes and procedures

OBJECTIVE

The objective of this review was to collate and summarize the current literature on what is known about organ donation following medical assistance in dying (MAiD). For this second part of a 2-part scoping review, the focus is on the existing procedures and processes for organ donation following MAiD.

INTRODUCTION

Organ donation following MAiD is a novel and contentious issue worldwide. To give direction for future research and initiatives, a comprehensive understanding of the available evidence of existing procedures and processes for organ donation following MAiD is needed.

INCLUSION CRITERIA

For this review, the population of interest included all individuals who underwent organ donation following MAiD; the concept was defined as procedures and processes involved in organ donation after MAiD; and the context was reports of organ donation following MAiD at home or in any health care setting worldwide. We considered quantitative and qualitative studies, text and opinion papers, gray literature, and unpublished material provided by stakeholders.

METHODS

This scoping review was conducted in line with JBI methodology. Published studies were retrieved from MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), PsycINFO (Ovid), Web of Science Core Collection, and Academic Search Complete (EBSCOhost). Gray and unpublished literature included reports from websites and organ donation organizations in Canada, Belgium, and The Netherlands. Two independent reviewers screened all reports (both title and abstract, and full text) against the predetermined inclusion criteria, extracted data, and completed a content analysis. Any disagreements between the 2 reviewers were resolved through discussion or with another reviewer.

RESULTS

We included 121 documents across parts I and II, and we report on 107 documents in this second part. The majority of the 107 documents were discussion papers, published in English, and in Canada from 2019 to 2021. In the content analysis, we identified 5 major categories regarding existing procedures and processes of organ donation following MAiD: i) clinical pathways for organ donation following MAiD; ii) organ donation following MAiD and the donor; iii) clinical practice tools for organ donation following MAiD; iv) education and support for health care providers involved in organ donation following MAiD; and v) health care providers' roles and perceptions during organ donation following MAiD.

CONCLUSIONS

Findings from this review can be used to provide support and guidance for improvements in procedures and processes, as well as a rich resource for countries currently planning to establish programs for organ donation after MAiD.

Organ donation after medical assistance in dying: a descriptive study from 2018 to 2022 in Quebec

BACKGROUND

Since the implementation of medical assistance in dying (MAiD), deceased organ donation after MAiD has been possible in Quebec. We sought to describe organ donations after MAiD in the first 5 years after this practice was implemented in Quebec.

METHODS

We reviewed all cases referred for donation after MAiD from January 2018 to December 2022. We presented all data descriptively with no comparison statistics.

RESULTS

Transplant Québec received 245 referrals for donation after MAiD, of which 82 were retained (33.5%). Of the 163 nonretained referrals, 152 (93.2%) had a recorded reason, including 91 (55.8%) for medical unsuitability on initial screen (e.g., organ dysfunction, medical history), 34 (20.8%) for patient refusal and 21 (12.9%) instances where patients withdrew from the MAiD process entirely. Six patients died before MAiD. Eighteen of the 82 retained cases were cancelled later in the process, almost all (n = 17, 94.4%) because of medical contraindication discovered during detailed donor evaluation. Sixty-four patients became actual donors after MAiD, increasing from 8 in 2018 to 24 in 2022. The total conversion rate from referral to an actual donor was 26.1% (64/245). A total of 182 organs (116 kidneys, 20 livers and 46 lungs) were transplanted after MAiD. During the study period, MAiD donors represented 8.0% (64/803) of total deceased donors, increasing from 4.9% (8/164) in 2018 to 14.0% (24/171) in 2022.

INTERPRETATION

These data describe a substantial increase in deceased donation after MAiD in the first 5 years of implementation in Quebec. Future studies should focus on how to optimize systems to ensure these requests are treated in the most ethical and medically effective way.

Directed Organ Donation After Euthanasia

Organ donation after euthanasia is performed in Belgium, the Netherlands, Canada and Spain. Directed deceased organ donation is currently possible under strict conditions in a limited number of countries, while it is currently not possible to opt for directed donation following euthanasia. While organ donation after euthanasia is a deceased donation procedure, directed organ donation after euthanasia could be seen as a deceased donation procedure with a living donation consent process. Therefore, directed organ donation after euthanasia is feasible on medical and ethical grounds. Strict safeguards should be in place, including the requirement of a pre-existing familial or personal relationship with the proposed recipient, without any evidence of coercion or financial gain.

Missed opportunities: saving lives through organ donation following voluntary assisted dying

Organ donation after voluntary assisted dying (VAD) in Australia may potentially increase organ transplant rates. Despite significant international experience with donation after VAD, there has been little discussion of this in Australia. We review potential ethical and practical concerns relating to donation after VAD and advocate action to establish programmes in Australia that ensure safe, ethical and effective donation after VAD.

Medical Assistance in Dying (MAiD) as a Source of Liver Grafts: Honouring the Ultimate Gift

OBJECTIVE

To report the clinical outcomes of liver transplants from donors after medical assistance in dying (MAiD) versus donors after cardiac death (DCD) and deceased brain death (DBD).

SUMMARY BACKGROUND DATA

In North America, the number of patients needing liver transplants exceeds the number of available donors. In 2016, MAiD was legalized in Canada.

METHODS

All patients undergoing deceased donor liver transplantation at Toronto General Hospital between 2016 and 2021 were included in the study. Recipient perioperative and postoperative variables and donor physiological variables were compared among 3 groups.

RESULTS

Eight hundred seven patients underwent deceased donor liver transplantation during the study period, including DBD (n=719; 89%), DCD (n=77; 9.5%), and MAiD (n=11; 1.4%). The overall incidence of biliary complications was 6.9% (n=56), the most common being strictures (n=55;6.8%), highest among the MAiD recipients [5.8% (DBD) vs. 14.2% (DCD) vs. 18.2% (MAiD); P =0.008]. There was no significant difference in 1 year (98.4% vs. 96.4% vs. 100%) and 3-year (89.3% vs. 88.7% vs. 100%) ( P =0.56) patient survival among the 3 groups. The 1- and 3- year graft survival rates were comparable (96.2% vs. 95.2% vs. 100% and 92.5% vs. 91% vs. 100%; P =0.37).

CONCLUSION

With expected physiological hemodynamic challenges among MAiD and DCD compared with DBD donors, a higher rate of biliary complications was observed in MAiD donors, with no significant difference noted in short-and long-term graft outcomes among the 3 groups. While ethical challenges persist, good initial results suggest that MAiD donors can be safely used in liver transplantation, with results comparable with other established forms of donation.

Diagnostic test accuracy for cessation of circulation during death determination: a systematic review

PURPOSE

To synthesize the available evidence comparing noninvasive methods of measuring the cessation of circulation in patients who are potential organ donors undergoing death determination by circulatory criteria (DCC) with the current accepted standard of invasive arterial blood pressure (IAP) monitoring.

SOURCE

We searched (from inception until 27 April 2021) MEDLINE, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials. We screened citations and manuscripts independently and in duplicate for eligible studies that compared noninvasive methodologies assessing circulation in patients who were monitored around a period of cessation of circulation. We performed risk of bias assessment, data abstraction, and quality assessment using Grading of Recommendations, Assessment, Development, and Evaluation in duplicate and independently. We presented findings narratively.

PRINCIPAL FINDINGS

We included 21 eligible studies (N = 1,177 patients). Meta-analysis was not possible because of study heterogeneity. We identified low quality evidence from four indirect studies (n = 89) showing pulse palpation is less sensitive and specific than IAP (reported sensitivity range, 0.76-0.90; specificity, 0.41-0.79). Isoelectric electrocardiogram (ECG) had excellent specificity for death (two studies; 0% [0/510]), but likely increases the average time to death determination (moderate quality evidence). We are uncertain whether point-of-care ultrasound (POCUS) pulse check, cerebral near-infrared spectroscopy (NIRS), or POCUS cardiac motion assessment are accurate tests for the determination of circulatory cessation (very low-quality evidence).

CONCLUSION

There is insufficient evidence that ECG, POCUS pulse check, cerebral NIRS, or POCUS cardiac motion assessment are superior or equivalent to IAP for DCC in the setting of organ donation. Isoelectric ECG is specific but can increase the time needed to determine death. Point-of-care ultrasound techniques are emerging therapies with promising initial data but are limited by indirectness and imprecision.

STUDY REGISTRATION

PROSPERO (CRD42021258936); first submitted 16 June 2021.

Organ Donation After Euthanasia in Patients Suffering From Psychiatric Disorders: 10-Years of Preliminary Experiences in the Netherlands

Euthanasia based on psychiatric suffering, followed by subsequent organ donation, is considered medically and legally permissible in the Netherlands. Although organ donation after euthanasia (ODE) in patients suffering from unbearable psychiatric illness is performed, it is not specifically addressed in the Dutch guideline on organ donation after euthanasia, and national data on ODE in psychiatric patients have not yet been published. In this article, the preliminary results of the 10-year Dutch case series of psychiatric patients who choose ODE are presented and potential factors influencing opportunities for donation in this population are discussed. We conclude that further future in-depth qualitative exploration of ODE in patients suffering from psychiatric illness and its associated ethical and practical dilemmas, including the consequences for the patient and their family and healthcare professionals, will be important to help make sense of potential barriers to donation for people undergoing euthanasia as a result of psychiatric suffering.

Outcomes of lung transplantation from organ donation after medical assistance in dying: First North American experience

Over 2.5% of deaths in Canada occur as a result from medical assisting in dying (MAID), and a subset of these deaths result in organ donation. However, detailed outcomes of lung transplant recipients using these donors is lacking. This is a retrospective single center cohort study comparing lung transplantation outcomes after donation using MAID donors compared to neurologically determined death and controlled donation after circulatory death (NDD/cDCD) donors from February 2018 to July 2021. Thirty-three patients received lungs from MAID donors, and 560 patients received lungs from NDD/cDCD donors. The donor diagnoses leading to MAID provision were degenerative neurological diseases (n = 33) and end stage organ failure (n = 5). MAID donors were significantly older than NDD/cDCD donors (56 [IQR 49-64] years vs. 48 [32-59]; p = .0009). Median ventilation period and 30 day mortality were not significantly different between MAID and NDD/cDCD lungs recipients (ventilation: 1 day [1-3] vs 2 days [1-3]; p = .37, deaths 0% [0/33] vs. 2% [11/560], p = .99 respectively). Intermediate-term outcomes were also similar. In summary, for lung transplantation using donors after MAID, recipient outcomes were excellent. Therefore, where this practice is permitted, donation after MAID should be strongly considered for lung transplantation as a way to respect donor wishes while substantially improving outcomes for recipients with end-stage lung disease.

Dividing line between organ donation and euthanasia in a combined procedure

In this article, we want to reply to the recent article by Buturovic, to be able to correct some statements and allegations about this combined procedure. Organ donation after euthanasia is an extremely difficult procedure from an ethical point of view. On the one hand, we see a suffering patient who wants to die but who also wants to make an altruistic effort to donate his organs. On the other hand, we visualise a patient in need of an organ but who is wary of the fact that someone else needs to die in order to potentially receive a transplant organ. Healthcare professionals seem to walk a tightrope when balancing between the interests of the patients at these two extremes: while facilitating the dying patient's last wish on the one hand and abiding by all regulations regarding donation and transplantation on the other. Yet, these physicians, nurses and transplant coordinators do their utmost best to keep a strict line between euthanasia and organ donation, to avoid any external pressure on the patient, and to respect his autonomy. They really make an utmost attempt to make the process bearable for the donating patient. However, undeniably the patient who is about to undergo organ donation after euthanasia is nevertheless confronted with dozens of feelings and thoughts. However, this does not imply that procedural safeguards are failing to disentangle organ donation from euthanasia.

Utility of Islet Cell Preparations From Donor Pancreases After Euthanasia

Patients fulfilling criteria for euthanasia can choose to donate their organs after circulatory death [donors after euthanasia (DCD V)]. This study assesses the outcome of islet cell isolation from DCD V pancreases. A procedure for DCD V procurement provided 13 pancreases preserved in Institut Georges Lopez-1 preservation solution and following acirculatory warm ischemia time under 10 minutes. Islet cell isolation outcomes are compared with those from reference donors after brain death (DBD, n = 234) and a cohort of donors after controlled circulatory death (DCD III, n = 29) procured under the same conditions. Islet cell isolation from DCD V organs resulted in better in vitro outcome than for selected DCD III or reference DBD organs. A 50% higher average beta cell number before and after culture and a higher average beta cell purity (35% vs 24% and 25%) was observed, which led to more frequent selection for our clinical protocol (77% of isolates vs 50%). The functional capacity of a DCD V islet cell preparation was illustrated by its in vivo effect following intraportal transplantation in a type 1 diabetes patient: injection of 2 million beta cells/kg body weight (1,900 IEQ/kg body weight) at 39% insulin purity resulted in an implant with functional beta cell mass that represented 30% of that in non-diabetic controls. In conclusion, this study describes procurement and preservation conditions for donor organs after euthanasia, which allow preparation of cultured islet cells, that more frequently meet criteria for clinical use than those from DBD or DCD III organs.

HO-1/BMMSC perfusion using a normothermic machine perfusion system reduces the acute rejection of DCD liver transplantation by regulating NKT cell co-inhibitory receptors in rats

Background

Liver transplantation (LT) is required in many end-stage liver diseases. Donation after cardiac death (DCD) livers are often used, and treatment of acute rejection (ACR) requires the use of immunosuppressive drugs that are associated with complications. Bone marrow mesenchymal stem cells (BMMSCs) are used in treatment following LT; however, they have limitations, including low colonization in the liver. An optimized BMMSC application method is required to suppress ACR.

Methods

BMMSCs were isolated and modified with the heme oxygenase 1 (HO-1) gene. HO-1/BMMSCs were perfused into donor liver in vitro using a normothermic machine perfusion (NMP) system, followed by LT into rats. The severity of ACR was evaluated based on liver histopathology. Gene chip technology was used to detect differential gene expression, and flow cytometry to analyze changes in natural killer (NK) T cells.

Results

NMP induced BMMSCs to colonize the donor liver during in vitro preservation. The survival of HO-1/BMMSCs in liver grafts was significantly longer than that of unmodified BMMSCs. When the donor liver contained HO-1/BMMSCs, the local immunosuppressive effect was improved and prolonged, ACR was controlled, and survival time was significantly prolonged. The application of HO-1/BMMSCs reduced the number of NKT cells in liver grafts, increased the expression of NKT cell co-inhibitory receptors, and reduced NKT cell expression of interferon-γ.

Conclusions

NK cell and CD8⁺ T cell activation was inhibited by application of HO-1/BMMSCs, which reduced ACR of transplanted liver. This approach could be developed to enhance the success rate of LT.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-021-02647-5.

Organ donation after euthanasia starting at home in a patient with multiple system atrophy

Background

A patient who fulfils the due diligence requirements for euthanasia, and is medically suitable, is able to donate his organs after euthanasia in Belgium, the Netherlands and Canada. Since 2012, more than 70 patients have undergone this combined procedure in the Netherlands. Even though all patients who undergo euthanasia are suffering hopelessly and unbearably, some of these patients are nevertheless willing to help others in need of an organ.

Organ donation after euthanasia is a so-called donation after circulatory death (DCD), Maastricht category III procedure, which takes place following cardiac arrest, comparable to donation after withdrawal of life sustaining therapy in critically ill patients. To minimize the period of organ ischemia, the patient is transported to the operating room immediately after the legally mandated no-touch period of 5 min following circulatory arrest. This means that the organ donation procedure following euthanasia must take place in the hospital, which appears to be insurmountable to many patients who are willing to donate, since they already spent a lot of time in the hospital.

Case presentation

This article describes the procedure of organ donation after euthanasia starting at home (ODAEH) following anesthesia in a former health care professional suffering from multiple system atrophy. This case is unique for at least two reasons. He spent his last conscious hours surrounded by his family at home, after which he underwent general anaesthesia and was intubated, before being transported to the hospital for euthanasia and organ donation. In addition, the patient explicitly requested the euthanasia to be performed in the preparation room, next to the operating room, in order to limit the period of organ ischemia due to transport time from the intensive care unit to the operating room. The medical, legal and ethical considerations related to this illustrative case are subsequently discussed.

Conclusions

Organ donation after euthanasia is a pure act of altruism. This combined procedure can also be performed after the patient has been anesthetized at home and during transportation to the hospital.

Regulations and Procurement Surgery in DCD Liver Transplantation: Expert Consensus Guidance From the International Liver Transplantation Society

Donation after circulatory death (DCD) donors are an increasingly more common source of livers for transplantation in many parts of the world. Events that occur during DCD liver recovery have a significant impact on the success of subsequent transplantation. This working group of the International Liver Transplantation Society evaluated current evidence as well as combined experience and created this guidance on DCD liver procurement. Best practices for the recovery and transplantation of livers arising through DCD after euthanasia and organ procurement with super-rapid cold preservation and recovery as well as postmortem normothermic regional perfusion are described, as are the use of adjuncts during DCD liver procurement.

Ex Situ Perfusion of Hearts Donated After Euthanasia: A Promising Contribution to Heart Transplantation

Organ donation after euthanasia is performed in an increasing number of countries. In this donation after circulatory death procedure, it has not been possible to donate the heart. Recent literature, however, reports positive results of heart donation after circulatory death. Therefore, patients who donate organs following euthanasia might be suitable candidates for heart donation. We want to confirm this assumption by sharing the results of 2 cases of heart donation following euthanasia with ex situ subnormothermic heart preservation. Our aim is to raise awareness of the potential of heart donation following euthanasia for both clinical transplantation and research.

Methods

The data of 2 consecutive heart donations following euthanasia were collected prospectively. Informed consent was obtained from the patients themselves for heart donation for research purposes. An acellular oxygenated subnormothermic machine perfusion strategy was used to preserve both donor hearts. Subsequently, the hearts were evaluated on a normothermic perfusion machine using a balloon in the left ventricle.

Results

Heart donation following euthanasia was feasible without significant changes in existing retrieval protocols. Duration of machine perfusion preservation was 408 and 432 minutes, for heart 1 and 2, respectively. For heart 1, developed pressure (P_dev) was 119 mm Hg, maximal rate of pressure rise (dP/dt_max), and fall (dP/dt_min) were 1524 mm Hg/s and -1057 mm Hg/s, respectively. For heart 2, P_dev was 142 mm Hg, dP/dt_max was 1098 mm Hg/s, and dP/dt_min was -802 mm Hg/s.

Conclusions

Hearts donated following euthanasia are highly valuable for research purposes and can have sufficient quality to be transplanted. With the implementation of ex situ heart perfusion, patients who are to donate their organs following euthanasia should also be able to donate their hearts. The complex combination of euthanasia and heart donation is ethically sound and surgically feasible and can contribute to shortening the heart transplant waiting list.