Combined liver and pancreas procurement from a controlled non-heart-beating donor with aberrant hepatic arterial anatomy

Complications during multiorgan retrieval and pancreas preservation

In pancreas transplantation, complications can arise at each step of the process, from the initial selection of donors and recipients through the surgical technique itself and the post-operative period, when lifelong immunosuppression is required. In the early steps, careful retrieval and preservation of the pancreas are crucial for the viability of the organ and ultimate success of the transplant. The pancreas is a low-flow gland, making it highly sensitive to transplantation conditions and presenting risk of pancreatitis due to periods of ischemia. The two groups of donors - after brain death (DBD) or after cardiac arrest (DCD) - require different strategies of retrieval and preservation to avoid or reduce the risk of complications developing during and after the transplantation. For DBD donor transplantation, multiorgan retrieval and cold preservation is the conventional technique. Asystole donor (DCD) transplantation, in contrast, can benefit from the newest technologies, such as hypothermic and especially normothermic preservation machines (referred to as NECMO), to optimize organ preservation. The latter has led to an increase in the pool of donors by facilitating recuperation of organs for transplantation that would have been discarded otherwise.

Outcomes From Pancreatic Transplantation in Donation After Cardiac Death: A Systematic Review and Meta-Analysis

BACKGROUND

Pancreas transplantation remains the gold standard for treatment for type I diabetes providing an insulin-independent, normoglycemic state. Increasingly, donation after cardiac death (DCD) donors are used in view of the organ donor shortage. We aimed to systematically review recipient outcomes from DCD donors and where possible compared these with donor after brain death (DBD) donors.

METHODS

We searched the databases MEDLINE via PubMed, EMBASE, and The Cochrane Library from inception to March 2015, for studies reporting the outcome of DCD pancreas transplants. We appraised studies using the Newcastle-Ottawa scale and meta-analyzed using a random effects model.

RESULTS

We identified 18 studies, 4 retrospective and 6 prospective cohort studies and 8 case reports. Our bias assessment revealed that although studies were well conducted, some studies had potential confounding factors and absence of comparator groups. Eight of the 18 studies included a DBD comparison group comprising 23 609 transplant recipients. Importantly, there was no significant difference in allograft survival up to 10 years (hazard ratio, 0.98; 95% confidence interval [95% CI], 0.74-1.31; P = 0.92), or patient survival (hazard ratio, 1.31; 95% CI, 0.62-2.78; P = 0.47) between DCD and DBD pancreas transplants. We estimated that the odds of graft thrombosis was 1.67 times higher in DCD organs (95% CI, 1.04-2.67; P = 0.006). However, subgroup analysis found thrombosis was not higher in recipients whose DCD donors were given antemortem heparin (P = 0.62).

CONCLUSIONS

Using current DCD criteria, pancreas transplantation is a viable alternative to DBD transplantation, and antemortem interventions including heparinization may be beneficial. This potential benefit of DCD pancreas donation warrants further study.

ASTS recommended practice guidelines for controlled donation after cardiac death organ procurement and transplantation

The American Society of Transplant Surgeons (ASTS) champions efforts to increase organ donation. Controlled donation after cardiac death (DCD) offers the family and the patient with a hopeless prognosis the option to donate when brain death criteria will not be met. Although DCD is increasing, this endeavor is still in the midst of development. DCD protocols, recovery techniques and organ acceptance criteria vary among organ procurement organizations and transplant centers. Growing enthusiasm for DCD has been tempered by the decreased yield of transplantable organs and less favorable posttransplant outcomes compared with donation after brain death. Logistics and ethics relevant to DCD engender discussion and debate among lay and medical communities. Regulatory oversight of the mandate to increase DCD and a recent lawsuit involving professional behavior during an attempted DCD have fueled scrutiny of this activity. Within this setting, the ASTS Council sought best-practice guidelines for controlled DCD organ donation and transplantation. The proposed guidelines are evidence based when possible. They cover many aspects of DCD kidney, liver and pancreas transplantation, including donor characteristics, consent, withdrawal of ventilatory support, operative technique, ischemia times, machine perfusion, recipient considerations and biliary issues. DCD organ transplantation involves unique challenges that these recommendations seek to address.

Risk factors for graft survival after liver transplantation from donation after cardiac death donors: an analysis of OPTN/UNOS data

Due to increasing use of allografts from donation after cardiac death (DCD) donors, we evaluated DCD liver transplants and impact of recipient and donor factors on graft survival. Liver transplants from DCD donors reported to UNOS were analyzed against donation after brain death (DBD) donor liver transplants performed between 1996 and 2003. We defined a recipient cumulative relative risk (RCRR) using significant risk factors identified from a Cox regression analysis: age; medical condition at transplantation; regraft status; dialysis received and serum creatinine. Graft survival from DCD donors (71% at 1 year and 60% at 3 years) were significantly inferior to DBD donors (80% at 1 year and 72% at 3 years, p < 0.001). Low-risk recipients (RCRR < or = 1.5) with low-risk DCD livers (DWIT < 30 min and CIT < 10 h, n = 226) achieved graft survival rates (81% and 67% at 1 and 3 years, respectively) not significantly different from recipients with DBD allografts (80% and 72% at 1 and 3 years, respectively, log-rank p = 0.23). Liver allografts from DCD donors may be used to increase the cadaveric donor pool, with favorable graft survival rates achieved when low-risk grafts are transplanted in a low-risk setting. Whether transplantation of these organs in low-risk recipients provides a survival benefit compared to the waiting list is unknown.

Retrieval of abdominal organs for transplantation

BACKGROUND

Organ retrieval and donor management are not yet standardized. Different transplant centres apply various techniques, such as single or dual organ perfusion, dissection in the cold or warm, and single or en bloc organ removal. These different approaches may cause inconvenience, especially when more than one organ retrieval team is involved.

METHODS

Cochrane Library, Medline and PubMed were searched for publications on multiorgan donor/donation, retrieval technique and procurement. Levels of evidence and grades of recommendation were evaluated based on current advice from the Oxford Centre for Evidence-Based Medicine.

RESULTS

Multiorgan donation itself does not compromise the outcome of individual organ transplants. Dissection of abdominal organs for transplantation is best performed after cold perfusion. Abdominal organs should be removed rapidly, en bloc, and separated during back-table dissection in the cold, particularly if pancreas or intestine is included. Perfusion itself should be carried out after single cannulation of the aorta with an increased pressure.

CONCLUSION

Although the literature on organ retrieval is extensive, the level of evidence provided is mainly low. Nevertheless, optimized donor treatment and organ retrieval should increase the number and quality of cadaveric donor organs and improve graft function and survival.

Extracorporeal support for organ donation after cardiac death effectively expands the donor pool

BACKGROUND

We sought to evaluate the effect on short-term outcomes of normothermic, extracorporeal perfusion (ECMO) for donation of abdominal organs for transplantation after cardiac death (DCD). Study parameters included increase in number of donors and organs, types of organs procured, and viability of kidneys transplanted.

METHODS

We retrospectively reviewed medical record data for all patients enrolled in our ECMO-supported DCD donor protocol between 10/1/2000 to 2/01/2004. We also reviewed the records for all patients undergoing organ donation after brain-death (DBD) during the study period at our institution. Recipient data were obtained and analyzed for all kidneys procured from both groups.

RESULTS

Twenty patients were enrolled in our DCD protocol and underwent attempted organ donation. Fifteen patients completed the protocol; 3 maintained cardiac function throughout the prescribed 60 minutes after withdrawal of life support, and two patients' organs were deemed unsuitable for transplantation. Fourteen (70%) of the DCD donor patients originated on the trauma service and six (30%) were from other clinical services. The DCD program increased the potential donor pool by 33% (61 versus 81 patients) and the number of kidneys transplanted by 24% (100 versus 124). A total of 24 kidney, 5 liver, and 1 pancreas transplants were performed with these organs. Two of 24 (8.3%) DCD kidneys had delayed graft function. There were no perioperative rejection episodes or deaths.

CONCLUSION

The implementation of a DCD protocol using extracorporeal perfusion increased the potential organ donor pool at our institution by 33%. This was accomplished without short term adverse effect on organ function compared with kidneys transplanted from DBD donors.

Personal experience with the procurement of 32 liver allografts

AIM: To introduce the American Pittsburgh’s method of rapid liver procurement under the condition of brain death and factors influencing the quality of donor liver.

METHODS: To analyze 32 cases of allograft liver procurement retrospectively and observe the clinical outcome of orthotopic liver transplantation.

RESULTS: Average age of donors was 38.24 ± 12.78 years, with a male:female ratio of 23:9. The causes of brain death included 21 cases of trauma (65.63%) and nine cases of cerebrovascular accident (28.13%). Fourteen grafts (43.75%) had hepatic arterial anomalies, seven cases only right hepatic arterial anomalies (21.88%), five cases only left hepatic arterial anomalies (15.63%) and two cases of both right and left hepatic arterial anomalies (6.25%) among them. Eight cases (57.14%) of hepatic arterial anomalies required arterial reconstruction prior to transplantation. Of the 32 grafts evaluated for early function, 27 (84.38%) functioned well, whereas three (9.38%) functioned poorly and two (6.25%) failed to function at all. Only one recipient died after transplantation and thirty-one recipients recovered. Four recipients needed retransplantation. The variables associated with less than optimal function of the graft consisted of donor age (35.6 ± 12.9 years vs 54.1 ± 4.3 years, P < 0.05), duration of donor’s stay in the intensive care unit (ICU) (3.5 ± 2.4 d vs 7.4 ± 2.1 d, P < 0.005), abnormal graft appearance (19.0% vs 100%, P < 0.05), and such recipient problems as vascular thromboses during or immediately following transplantation (89.3% vs 50.0%, P < 0.005).

CONCLUSION: During liver procurement, complete heparization, perfusion in situ with localized low temperature and standard technique procedures are the basis ensuring the quality of the graft. The hepatic arterial anomalies should be taken care of to avoid injury. The donor age, duration of donor’s staying in ICU, abnormal graft appearance and recipient problem are important factors influencing the quality of the liver graft.

Long-term outcome of controlled, non-heart-beating donor liver transplantation

BACKGROUND

Previous reports have established the feasibility of using livers from controlled, non-heart-beating donors (CNHBD) with good immediate graft function. This has been largely borne out of necessity because of the donor shortage.

METHODS

Retrospective database review for the last 7 years (1995-2002), encompassing 19 patients receiving CNHBD, with follow-up period of 1,000 +/- 694 days, median 762 days. Detailed review of recipient characteristics, operative and clinical course, immunosuppression, complications, survival rates, and comparison with the results obtained in patients receiving transplants of allografts procured in standard fashion, from heart-beating donors

RESULTS

Kaplan-Meier patient survival rates were 100%, 89.5%, and 83.5% at 30 days, 1, and 2 years, respectively, which is not different from recipients of livers procured from heart-beating cadaveric donors (P=0.74, log-rank test). Five patients died at a mean follow-up time of 492 (range 46-1,103) days. The causes of death were related to secondary sclerosing cholangitis (n=1), cardiac failure (n=1), and sepsis (n=3). Two (10.5%) recipients underwent retransplantation, one for primary graft nonfunction and one because of biliary cast syndrome with cholangitis. Significant preservation damage (ALT>2,000) developed in five patients, but this did not affect survival. The incidence of vascular (15.6% vs. 9.6%, P=0.34) and biliary complications (10.55 vs. 13.8%, P=0.68) was no different than for those recipients receiving standard cadaveric donors.

CONCLUSIONS

CNHBD safely expands the donor pool with similar long-term results as those obtained in patients receiving organs from brain-dead donors under standard procurement techniques.