A More Than 20% Increase in Deceased-Donor Organ Procurement and Transplantation Activity After the Use of Donation After Circulatory Death

Feasibility and performance of a combined extracorporeal assisted cardiac resuscitation and an organ donation program after uncontrolled cardiocirculatory death (Maastricht II)

INTRODUCTION

Approximately 500.000 people in Europe sustain cardiac arrest (CA) every year, being myocardial infarction the main etiology. Interest has been raised in a new approach to refractory cardiac arrest (rCA) using extra-corporeal oxygenation (ECMO). In settings where it can be rapidly implemented, ECMO assisted resuscitation (ECPR) may be considered. Additionally, donation after circulatory death, which seeks to obtain solid organs donation from patients suffering rCA, has increased its role effectively increasing the pool of donors. Combined programs with integration of ECPR and uncontrolled donation after circulatory determination of death (uDCDD) are worldwide limited and experience integrating these two techniques is lacking.

METHODS

We report a 24 months experience of ECPR and uDCDD kidney transplantation based on a management protocol in a university teaching hospital in the urban area of Lisbon.

RESULTS

Over a period of 24 months, 58 patients were admitted to our ICU with rCA, 6 (10%) in the ECPR program and 52 (90%) in the uDCDD. Seventy-eight percent of patients were male, with an average age of 49 year-old. CA was witnessed in 83% of cases and initial rhythm was ventricular fibrillation in 20 cases (35%). 13 (25%) patients were effective organ donors. Refusal for effective donation was mainly due to prior comorbidities.

DISCUSSION

The development of an integrated program for ECPR and uDCDD is feasible and requires a well-established and efficient activation program. In an era of significant organ shortage, it provides a viable option for increasing the organ donation pool, with promising results.

How to improve results after DCD (donation after circulation death)

The shortage of organs for transplantation has led health professionals to look for alternative sources of donors. One of the avenues concerns donors who have died after circulatory arrest. This is a special situation because the organs from these donors are exposed to warm ischaemia-reperfusion lesions that are unavoidable during the journey of the organs from the donor to the moment of transplantation in the recipient. We will address and discuss the key issues from the perspective of team organization, legislation and its evolution, and the ethical framework. In a second part, the avenues to improve the quality of organs will be presented following the itinerary of the organs between the donor and the recipient. The important moments from the point of view of therapeutic strategy will be put into perspective. New connections between key players involved in pathophysiological mechanisms and implications for innate immunity and injury processes are among the avenues to explore. Technological developments to improve the quality of organs from these recipients will be analyzed, such as perfusion techniques with new modalities of temperatures and oxygenation. New molecules are being investigated for their potential role in protecting these organs and an analysis of potential prospects will be proposed. Finally, the important perspectives that seem to be favored will be discussed in order to reposition the use of deceased donors after circulatory arrest. The use of these organs has become a routine procedure and improving their quality and providing the means for their evaluation is absolutely inevitable.

Trauma and donation after circulatory death: a case series from a major trauma center

Even with encouraging recipient outcomes, transplantation using donation after circulatory death (DCD) is still limited. A major barrier to this type of transplantation is the consequences of warm ischemia on graft survival; however, preservation techniques may reduce the consequences of cardiac arrest and provide better organ conservation. Furthermore, DCD in trauma patients could further expand organ donation. We present five cases in which organs were retrieved and transplanted successfully using normothermic regional perfusion (NRP) in trauma patients. Prompt critical care support and surgical treatment allowed us to overcome the acute phase. Unfortunately, owing to the severity of their injuries, all of the donors died. However, the advanced and continuous organ-specific supportive treatment allowed the maintenance of general clinical stability and organ preservation. Consequently, it was possible to retrieve and transplant the donors’ organs. Death was ascertained in accordance with cardio-circulatory criteria, which was followed by NRP. We consider that DCD in trauma patients may represent an important source of organs.

Donation after circulatory death liver transplantation: What are the limits for an acceptable DCD graft?

The utilization of donation after circulatory death (DCD) livers has been growing over the last decade. In large-volume centers, survival outcomes have improved and are comparable to outcomes with brain death donor (DBD) liver transplantation (LT). The relatively concentrated success with DCD LT demonstrated by high-volume transplant centers has rekindled international enthusiasm. The combination of increasing expertise in DCD LT and ongoing shortage in transplantable organs has promoted expansion of the DCD donor pool with regards to donor age, body mass index and donor warm ischemia time. In this review, we focused on the practice patterns in DCD liver graft utilization in the last decade, along with the possibilities for further expansion of DCD liver graft utilization and new technologies, such as machine perfusion.

Lysis of cold-storage-induced microvascular obstructions for ex vivo revitalization of marginal human kidneys

Thousands of kidneys from higher-risk donors are discarded annually because of the increased likelihood of complications posttransplant. Given the severe organ shortage, there is a critical need to improve utilization of these organs. To this end, normothermic machine perfusion (NMP) has emerged as a platform for ex vivo assessment and potential repair of marginal organs. In a recent study of 8 transplant-declined human kidneys on NMP, we discovered microvascular obstructions that impaired microvascular blood flow. However, the nature and physiologic impact of these lesions were unknown. Here, in a study of 39 human kidneys, we have identified that prolonged cold storage of human kidneys induces accumulation of fibrinogen within tubular epithelium. Restoration of normoxic conditions-either ex vivo during NMP or in vivo following transplant-triggered intravascular release of fibrinogen correlating with red blood cell aggregation and microvascular plugging. Combined delivery of plasminogen and tissue plasminogen activator during NMP lysed the plugs leading to a significant reduction in markers of renal injury, improvement in indicators of renal function, and improved delivery of vascular-targeted nanoparticles. Our study suggests a new mechanism of cold storage injury in marginal organs and provides a simple treatment with immediate translational potential.

Organ Donation After Circulatory Death and Before Death: Ethical Questions and Nursing Implications

Scientific advances have enabled thousands of individuals to extend their lives through organ donation. Yet, shortfalls of available organs persist, and individuals in the United States die daily before they receive what might have been lifesaving organs. For years, the legal foundation of organ donation in the United States has been known as the Dead Donor Rule, requiring death to be defined for organ donation purposes by either a cardiac standard (termination of the heartbeat) or a neurological one (cessation of all brain function). In this context, one solution used by an increasing number of health care facilities since 2006 is donation after circulatory death, generally defined as when care is withdrawn from individuals who have known residual brain function. Despite its increased use, donation after circulatory death remains ethically controversial. In addition, some ethicists have advocated forgoing the Dead Donor Rule altogether and allowing donation before or near death in certain circumstances. However, nurses and other health professionals must carefully consider the practical and ethical implications of broadening the Dead Donor Rule-as may be already occurring-or removing it entirely. Such changes could harm both the integrity of the health care system as well as efforts to secure organ donation commitments from the public and are outweighed by the moral and pragmatic cost. Nurses should be prepared to confront the challenge posed by the ongoing scarcity of organs and advocate for ethical alternatives including research on effective care pathways and education regarding organ donation.

Solid Organ Transplantation After Retrieval From Deceased Donors With Abdominal Aortic Grafts

INTRODUCTION

Organ procurement from deceased donors has been steadily augmented over the last 20 years. With a more aged donor population, a higher incidence of intraabdominal pathologies, including abdominal aortic aneurysms and atherosclerotic aortic disease, is commonly being encountered. The objective of our study was to report our institutional experience with abdominal aortic grafts during solid organ harvesting.

PATIENTS AND METHODS

Data concerning the presence of aortic grafts in deceased solid organ donors during a 36-month period were retrospectively reviewed.

RESULTS

During the study period, the organ retrieval team of our institution performed 246 multiorgan retrievals from deceased donors. More specifically, we harvested 6 livers and 12 kidneys from 6 donors with abdominal aortic grafts, which were not known/diagnosed to the organ retrieving team prior to the harvesting procedure. Severe atherosclerosis was present in all these donors. All 18 harvested organs were successfully transplanted. Apart of the absence of the aortic patch in 5 kidney grafts, no further special technical difficulties have been reported by the transplant teams. Data analysis of the recipient and graft outcome was performed through the Eurotransplant database.

CONCLUSION

There are so far no literature data on the outcome of recipients and grafts from deceased donors with abdominal aortic grafts. Although retrieval of such organs is very challenging and requires a very experienced team, the transplantation of the corresponding organs can be performed without special technical problems.

Donation after circulatory death heart transplantation

PURPOSE OF REVIEW

Despite continued expansion in the use of extended-criteria donor hearts following donation after brain death, there remains an unacceptable discrepancy between the supply of suitable donor hearts and the demand from increasing recipient numbers on transplant wait lists. Until recently, the additional approach of utilizing organs following donation after circulatory death (DCD) had not been possible for clinical heart transplantation in the modern era. This review describes relevant advances in translational research and provides an update on the favourable adoption of this donation pathway for clinical heart transplantation.

RECENT FINDINGS

The use of an ex-situ transportable cardiac perfusion platform together with modified cardioplegia, supplemented with postconditioning agents, has allowed three centres to report successful transplantation of distantly procured human DCD hearts. This has been achieved by utilizing either a method of direct procurement and ex-situ perfusion on the device or through an initial in-situ reanimation with extracorporeal normothermic regional perfusion prior to ex-situ perfusion.

SUMMARY

DCD heart transplantation is feasible with excellent early outcomes. In the face of continued and significant donor organ shortage and inevitable wait list attrition, the rejection of suitable DCD hearts, in jurisdictions permitting this donation pathway, is increasingly difficult to justify.

Improving Donor Conversion Rates at a Level One Trauma Center: Impact of Best Practice Guidelines

BACKGROUND

Organ availability is a consistently limiting factor in transplant surgery. A primary driver of this limitation is donor conversion rate, which is defined as the percentage of eligible donors for whom procurement is actually performed. An alternative way to increase organ availability is through improved utilization of organs from donors after cardiac death (DCD). Recently, a concerted, multidisciplinary effort has been made within our system to improve conversion rates and DCD utilization, thus increasing organ availability.

STUDY DESIGN

Retrospective analysis of a prospectively collected database from TransLife, our local organ procurement organization (OPO), as well as the Orlando Regional Medical Center (ORMC) trauma registry, from 2009-2012 (up to 2013 for DCD). During which time, this organization implemented best practice guidelines to improve conversions and DCD utilization. We analyzed yearly conversion rates, DCD donations and population demographics before and after implementation of these policies.

RESULTS

During the study period, donor conversion rates significantly improved from 58% in 2009 to 82% percent in 2012 hospital-wide (P<0.05); and from 50% in 2009 to 81% in 2012 among trauma patients alone (P<0.05). In addition, total organs transplanted increased from 13 to 31 organs (P<0.05) after implementation of best practice guidelines. No significant differences in trauma population demographics were noted during the study period.

CONCLUSIONS

Based on our experience, the establishment of best practice policies for referral of potential donors, coupled with programs to educate hospital staff on the existence and importance of these policies, leads to significant improvement in donor conversion rates and increased utilization of DCD donors.

Suitability of Corneal Tissue for Transplantation Derived From Violent Death: A 10-Year Analysis

Trauma is a leading cause of death and disability worldwide. Corneal tissue donors generally are those who suffered an injury to the brain or fatal trauma caused by stroke, vehicle/motorbike accidents, gunshot wounds, and drowning or cardiovascular death. In Brazil, the Distrito Federal (DF) Eye Bank, located within a trauma center hospital, and the Secretariat of Public Security have collaborated with the aim of increasing the overall number of cornea donations from fatal trauma victims. The purpose of this study was to determine the suitability of cornea tissue for transplantation derived from trauma-related death. The records of eyes donated in the DF Eye Bank were analyzed retrospectively for the period from 2004-2013. We had 3388 cornea donors, the majority of which were between 21 and 30 years old (17.4%), which were derived from violent death (84.1%; P = .00) and were predominately male (73.5%). Among the donated corneas, 54.0% were used for optic purposes. Mechanical trauma caused by gunshot, stabbing or blunt force (23.7%), and road traffic injuries (11%) were the main causes of violent death. Another common cause of death was cardiovascular disease (26.3%). Donor tissue derived from violent death had no statistical interference on tissue suitability for transplantation (P = .06). Because of the large waiting lists, and waiting times for transplants, it is advisable to increase the available tissue from corneas donors derived from violent death through the implementation of this interagency model of collaboration and by the practicing of active tissue donor screening in trauma center hospitals.

Donor Hemodynamics as a Predictor of Outcomes After Kidney Transplantation From Donors After Cardiac Death

Donation after cardiac death is an important source of transplantable organs, but evidence suggests donor warm ischemia contributes to inferior outcomes. Attempts to predict recipient outcome using donor hemodynamic measurements have not yielded statistically significant results. We evaluated novel measures of donor hemodynamics as predictors of delayed graft function and graft failure in a cohort of 1050 kidneys from 566 donors. Hemodynamics were described using regression line slopes, areas under the curve, and time beyond thresholds for systolic blood pressure, oxygen saturation, and shock index (heart rate divided by systolic blood pressure). A logistic generalized estimation equation model showed that area under the curve for systolic blood pressure was predictive of delayed graft function (above median: odds ratio 1.42, 95% confidence interval [CI] 1.06-1.90). Multivariable Cox regression demonstrated that slope of oxygen saturation during the first 10 minutes after extubation was associated with graft failure (below median: hazard ratio 1.30, 95% CI 1.03-1.64), with 5-year graft survival of 70.0% (95%CI 64.5%-74.8%) for donors above the median versus 61.4% (95%CI 55.5%-66.7%) for those below the median. Among older donors, increased shock index slope was associated with increased hazard of graft failure. Validation of these findings is necessary to determine the utility of characterizing donor warm ischemia to predict recipient outcome.

Donation after circulatory death: the current state and technical approaches to organ procurement

PURPOSE OF REVIEW

In this review, we discuss the current state of donation after circulatory death (DCD). We define the DCD donor and describe the current protocols in management of the DCD patient. We then discuss current techniques in organ procurement of the lung and abdominal organs.

RECENT FINDINGS

Although donation after brain death is preferable to DCD, recent data have demonstrated acceptable early outcomes in both thoracic and abdominal organ transplant. In spite of advancements in surgical techniques and organ preservation, much has yet to be learned to minimize warm ischemia time and reperfusion injury in the DCD population.

SUMMARY

In light of the continually growing disparity between organ supply and demand, DCD has regained traction as a means to increase the donor pool.

Donation after Circulatory Death Renal Allografts--Does Donor Age Greater than 50 Years Affect Recipient Outcomes?

PURPOSE

Donation after circulatory death renal allografts are associated with excellent outcomes. We performed a retrospective chart review to investigate the impact of donor age on postoperative and intermediate term outcomes.

MATERIALS AND METHODS

We compared recipient outcomes of donation after circulatory death allografts from donors older vs younger than 50 years. A total of 118 single donations after circulatory death renal transplants were performed at our institution between July 2006 and September 2013. Outcome variables (creatinine clearance, readmission rate, length of hospital stay, delayed graft function, graft loss and rejection) were compared between the 2 age categories using the Student t-test and the Pearson chi-square test. Independent prognosticators of creatinine clearance at 12 months were assessed with multivariate linear regression modeling.

RESULTS

Mean ± SD recipient age was 53.8 ± 14.7 years and 45.8% of donation after circulatory death donors were older than 50 years. Median followup was 21 months (range 1 to 87). Recipients of kidney transplants from donation after circulatory death donors older than 50 years demonstrated lower creatinine clearance at 1 month (mean 50.3 ± 25.3 vs 72.7 ± 31.7 ml per minute, p <0.001), 3 months (62.5 ± 22.9 vs 87.9 ± 36.4, p <0.001) and 1 year (66.2 ± 26.8 vs 87.8 ± 38.7, p = 0.013). However, the 2 groups did not differ with regard to delayed graft function, graft loss, hospital readmissions or length of hospital stay. Multivariate linear regression demonstrated that donor age, recipient age, recipient gender and cold ischemia time were independent predictors of creatinine clearance at 12 months.

CONCLUSIONS

Recipients of allografts from donors older than 50 years showed inferior renal function at 1 year but the 2 groups had similar graft survival and short-term outcomes. Longer followup is required to determine long-term allograft survival.

Non-therapeutic intensive care for organ donation

Background and Purpose:

Providing non-therapeutic intensive care for some patients in hopeless condition after cerebrovascular stroke in order to protect their organs for possible post-mortem organ donation after brain death is an effective but ethically tricky strategy to increase organ grafting. Finding out the feelings and opinion of the involved healthcare professionals and assessing the training needs before implementing such a strategy is critical to avoid backlash even in a presumed consent system.

Participants and methods:

A single-centre opinion survey of healthcare professionals was conducted in 2013 in the potentially involved wards of a French University Hospital: the Neurosurgical, Surgical and Medical Intensive Care Units, the Stroke Unit and the Emergency Department. A questionnaire with multiple-choice questions and one open-ended question was made available in the different wards between February and May 2013.

Ethical considerations:

The project was approved by the board of the Lorraine University Diploma in Medical Ethics.

Results:

Of a total of 340 healthcare professionals, 51% filled the form. Only 21.8% received a specific education on brain death, and only 18% on potential donor’s family approach and support. Most healthcare professionals (93%) think that non-therapeutic intensive care is the continuity of patient’s care. But more than 75% of respondents think that the advance patient’s consent and the consent of the family must be obtained despite the presumed consent rule regarding post-mortem organ donation in France.

Conclusion:

The acceptance by healthcare professionals of non-therapeutic intensive care for brain death organ donation seems fairly good, despite a suboptimal education regarding brain death, non-therapeutic intensive care and families’ support. But they ask to require previously expressed patient’s consent and family’s approval. So, it seems that non-therapeutic intensive care should only remain an ethically sound mean of empowerment of organ donors and their families to make post-mortem donation happen as a full respect of individual autonomy.

[Eligibility to a Maastricht III - type organ donation according to the protocol proposed by the French organ procurement organization (Agence de la biomedicine) among patients in a medico surgical intensive care unit]

OBJECTIVE

Because of graft shortages, an experimental programme of organ donation after Maastricht 3-type circulatory death (M3) has been proposed by the French organ procurement organization (Agence de la biomedicine: ABM). The aim of the study was to estimate how many potential patients were eligible for an M3-type organ donation, amongst deceased patients who have had life-support withdrawn.

PATIENTS AND METHODS

We conducted a retrospective study looking at the notes of deceased patients in a French general intensive care unit (ICU), where organ donation is arranged in DBD donors.

RESULTS

Over the year 2013, 1475 patients were admitted in ICU and 215 died. One hundred and one patients were brain-injured and 26 of them died following a decision to withdrawn life-support and without contraindication to organ donation. Among them, 2 patients (8%) met the criteria for the French M3-type organ donation protocol. A 12.5% increase in organ donation activity of our team and five organ transplantations could have been considered.

CONCLUSION

If M3 organ donation is considered, a significant increase in transplantation would be expected.

Donor age as a risk factor in donation after circulatory death liver transplantation in a controlled withdrawal protocol programme

BACKGROUND

Results of donation after circulatory death (DCD) liver transplantation are impaired by graft loss, resulting mainly from non-anastomotic biliary stricture. Donor age is a risk factor in deceased donor liver transplantation, and particularly in DCD liver transplantation. At the authors' institute, age is not an absolute exclusion criterion for discarding DCD liver grafts, DCD donors receive comfort therapy before withdrawal, and cold ischaemia is minimized.

METHODS

All consecutive DCD liver transplantations performed from 2003 to 2012 were studied retrospectively. Three age groups were compared in terms of donor and recipient demographics, procurement and transplantation conditions, peak laboratory values during the first post-transplant 72 h, and results at 1 and 3 years.

RESULTS

A total of 70 DCD liver transplants were performed, including 32 liver grafts from donors aged 55 years or less, 20 aged 56-69 years, and 18 aged 70 years or more. The overall graft survival rate at 1 month, 1 and 3 years was 99, 91 and 72 per cent respectively, with no graft lost secondary to non-anastomotic stricture. No difference other than age was noted between the three groups for donor or recipient characteristics, or procurement conditions. No primary non-function occurred, but one patient needed retransplantation for artery thrombosis. Biliary complications were similar in the three groups. Graft and patient survival rates were no different at 1 and 3 years between the three groups (P = 0.605).

CONCLUSION

Results for DCD liver transplantation from younger and older donors were similar. Donor age above 50 years should not be a contraindication to DCD liver transplantation if other donor risk factors (such as warm and cold ischaemia time) are minimized.