An international comparison of the effect of policy shifts to organ donation following cardiocirculatory death (DCD) on donation rates after brain death (DBD) and transplantation rates

Thoracoabdominal normothermic regional perfusion: Is it ethical?

Thoracoabdominal normothermic regional perfusion (TA-NRP), a new method of controlled donation after circulatory death, seems to provide more and better organs for patients on organ transplant waiting lists compared to standard controlled donation after circulatory death. Despite its benefits, the ethical permissibility of TA-NRP is currently a highly debated issue. The recent statement published by the American College of Physicians (ACP) highlights the reasons for these debates. Critics' main concern is that TA-NRP violates the Dead Donor Rule. This paper presents an ethical analysis of the objections raised by the ACP against TA-NRP and argues that TA-NRP is not only morally permissible but also morally required where it is financially and technically feasible. To support this conclusion, the concepts of 'resuscitation,' 'intention,' 'irreversibility,' 'permanence,' 'impossibility,' and 'respect' in the context of TA-NRP are explored. Additionally, the ethical permissibility of this procedure is evaluated through the lenses of Utilitarianism, Kantianism, the core principles of bioethics, and the Doctrine of Double Effect. This ethical analysis demonstrates why the ACP's objection lacks a solid moral foundation and conflates moral and legal considerations. This paper also argues that extra measures are needed to ensure the moral permissibility of TA-NRP, emphasizing the importance of informed consent, additional brain blood flow and activity monitoring, and a contingency plan to abort the organ procurement process if a sign of morally relevant brain activity is detected.

Factors influencing deceased organ donation rates in OECD countries: a panel data analysis

OBJECTIVES

This study aims to investigate factors with a significant influence on deceased organ donation rates in Organisation for Economic Co-operation and Development (OECD) countries and determine their relative importance. It seeks to provide the necessary data to facilitate the development of more efficient strategies for improving deceased organ donation rates.

DESIGN

Retrospective study.

SETTING

Publicly available secondary annual data.

PARTICIPANTS

The study includes 36 OECD countries as panel members for data analysis.

OUTCOME MEASURES

Multivariable panel data regression analysis was employed, encompassing data from 2010 to 2018 for all investigated variables in the included countries.

RESULTS

The following variables had a significant influence on deceased organ donation rates: 'opt-in' system (β=-4.734, p<0.001, ref: 'opt-out' system), only donation after brain death (DBD) donors allowed (β=-4.049, p=0.002, ref: both DBD and donation after circulatory death (DCD) donors allowed), number of hospital beds per million population (pmp) (β=0.002, p<0.001), total healthcare employment pmp (β=-0.00012, p=0.012), World Giving Index (β=0.124, p=0.008), total tax revenue as a percentage of gross domestic product (β=0.312, p=0.009) and percentage of population aged ≥65 years (β=0.801, p<0.001) as well as high education population in percentage (β=0.118, p=0.017).

CONCLUSIONS

Compared with the promotion of socioeconomic factors with a positive significant impact on deceased organ donation rates, the following policies have been shown to significantly increase rates of deceased organ donation, which could be further actively promoted: the adoption of an 'opt-out' system with presumed consent for deceased organ donation and the legal authorisation of both DBD and DCD for transplantation.

Liver transplantation with uncontrolled versus controlled DCD donors using normothermic regional perfusion and ex-situ machine perfusion

In Italy, 20 minutes of continuous, flat-line electrocardiogram are required for death declaration, which significantly increases the risks of donation after circulatory death (DCD) LT. Despite prolonged warm ischemia time, Italian centers reported good outcomes in controlled donation after circulatory death LT by combining normothermic regional and end-ischemic machine perfusion. However, data on uncontrolled DCD (uDCD) LT performed by this approach are lacking. This was a multicenter, retrospective study performed at 3 large-volume centers comparing clinical outcomes of uncontrolled versus controlled DCD LT. The aim of the study was to assess outcomes of sequential normothermic regional perfusion and end-ischemic machine perfusion in uncontrolled DCD liver transplantation (LT). Of 153 DCD donors evaluated during the study period, 40 uDCD and 59 donation after circulatory death grafts were transplanted (utilization rate 52% vs. 78%, p = 0.004). Recipients of uDCD grafts had higher MEAF (4.9 vs. 3.5, p < 0.001) and CCI scores at discharge (24.4 vs. 8.7, p = 0.026), longer ICU stay (5 vs. 4 d, p = 0.047), and a trend toward more severe AKI. At multivariate analysis, 90-day graft loss was associated with recipient BMI and lactate downtrend during normothermic regional perfusion. One-year graft survival was lower in uDCD (75% vs. 90%, p = 0.007) but became comparable when non-liver-related graft losses were treated as censors (77% vs. 90%, p = 0.100). The incidence of ischemic cholangiopathy was 10% in uDCD versus 3% in donation after circulatory death, p = 0.356. uDCD LT with prolonged warm ischemia is feasible by the sequential use of normothermic regional perfusion and end-ischemic machine perfusion. Proper donor and recipient selection are key to achieving good outcomes in this setting.

Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation

AIM OF THE REVIEW

Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries.

METHODS

The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section.

RESULTS

There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness.

CONCLUSIONS

All health systems should develop, implement, and evaluate protocols designed to optimize organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.

Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation

AIM OF THE REVIEW

Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries.

METHODS

The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section.

RESULTS

There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness.

CONCLUSIONS

All health systems should develop, implement, and evaluate protocols designed to optimise organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.

State of the art post-cardiac arrest care: evolution and future of post cardiac arrest care

Out-of-hospital cardiac arrest is a leading cause of mortality. In the pre-hospital setting, bystander response with cardiopulmonary resuscitation and the use of publicly available automated external defibrillators have been associated with improved survival. Early in-hospital treatment still focuses on emergency coronary angiography for selected patients. For patients remaining comatose, temperature control to avoid fever is still recommended, but former hypothermic targets have been abandoned. For patients without spontaneous awakening, the use of a multimodal prognostication model is key. After discharge, follow-up with screening for cognitive and emotional disabilities is recommended. There has been an incredible evolution of research on cardiac arrest. Two decades ago, the largest trials include a few hundred patients. Today, undergoing studies are planning to include 10-20 times as many patients, with improved methodology. This article describes the evolution and perspectives for the future in post-cardiac arrest care.

Ethical Issues in Donation following Circulatory Death: A Scoping Review Examining Changes over Time from 1993 to 2022

Background: Ethical frameworks for organ donation following circulatory death (DCD) were established >20 years ago. However, considerable variation exists among these, indicating consensus has not been reached on all issues. Additionally, advances such as cardiac DCD transplants and normothermic regional perfusion (NRP) may have reignited old debates.Methods: We reviewed the English-language literature addressing ethical issues in DCD from 1993 to 2022, examining changes in frequency with which ethical principles and their sub-themes identified within each, were addressed.Results: Non-maleficence was the most frequently addressed principle (192 of 199 articles), as well as the most varied, with 9 subthemes (versus 2-4 within each of the other bioethical principles).Conclusions: There were several changes in the terminology used to refer to DCD over time, and substantial interest in cardiac DCD and NRP in recent publications, arising in 11 and 19 of the 30 publications from 2018 to 2022.

Normothermic Regional Perfusion is an Emerging Cost-Effective Alternative in Donation After Circulatory Death (DCD) in Heart Transplantation

In donation after circulatory death (DCD) organ transplantation, normothermic regional perfusion (NRP) restores oxygenated blood flow following cardiac arrest and reverses warm ischemia. Recently, NRP has also been used to help recover DCD hearts in addition to the abdominal organs. While DCD donation has increased the number of abdominal organs and lungs pool, it has not been able to increase the number of heart transplants, despite the fact that it has the potential to increase the number of heart transplants by 15-30%. Thoracoabdominal normothermic regional perfusion makes heart transplantation feasible and permits assessing heart function before an organ procurement without affecting the preservation of abdominal organs. NRP can be used in two ways for DCD donor heart transplants: normothermic regional perfusion followed by machine perfusion (NRP-MP) and normothermic regional perfusion followed by static cold storage (NRP-SCS). Normothermic regional perfusion is an emerging technology, a cost-effective alternative in donation after circulatory death (DCD), and will increase the pool of donors in heart transplantation.

Critical pathways for controlled donation after circulatory death in France

INTRODUCTION

In 2015, France authorised controlled donation after circulatory death (cDCD) according to a nationally approved protocol. The aim of this study is to provide an overview from the perspective of critical care specialists of cDCD. The primary objective is to assess how the organ donation procedure affects the withdrawal of life-sustaining therapies (WLST) process. The secondary objective is to assess the impact of cDCD donors' diagnoses on the whole process.

MATERIAL AND METHODS

This 2015-2019 prospective observational multicentre study evaluated the WLST process in all potential cDCD donors identified nationwide, comparing 2 different sets of subgroups: 1- those whose WLST began after organ donation was ruled out vs. while it was still under consideration; 2- those with a main diagnosis of post-anoxic brain injury (PABI) vs. primary brain injury (PBI) at the time of the WLST decision.

RESULTS

The study analysed 908 potential cDCD donors. Organ donation remained under consideration at WLST initiation for 54.5% of them with longer intervals between their WLST decision and its initiation (2 [1-4] vs. 1 [1-2] days, P < 0.01). Overall, 60% had post-anoxic brain injury. Time from ICU admission to WLST decision was longer for primary brain injury donors (10 [4-21] vs. 6 [4-9] days, P < 0.01). Median time to death (agonal phase) was 15 [15-20] minutes.

CONCLUSIONS

French cDCD donors are mostly related to post-anoxic brain injury. The organ donation process does not accelerate WLST decision but increases the interval between the WLST decision and its initiation.

Physiotherapy in Patients on the Organ Donation Pathway: A Survey of Current Practice

BACKGROUND

The purpose of the survey was to identify the current practices of physiotherapists in the management of patients on the organ donation pathway.

METHODS

The author conducted a cross-sectional telephone survey. Participants were 16 physiotherapists working in intensive care units (ICU) in Queensland, who were involved in the care of patients on the organ donation pathway.

RESULTS

In Queensland ICUs, only 57% of hospitals have formal guidelines for physiotherapy management of patients on the organ donation pathway. When comparing the frequency of interventions with organ donation status, 86% of physiotherapists reported increasing the frequency of interventions once a patient was considered for organ donation. Clinical reasoning was reported as the primary factor affecting intervention choice for 67% of physiotherapists, with no difference in frequency, or choice of intervention in patients for donation after circulatory death, compared with donation after brain death. In hospitals with a level I ICU (with infrequent exposure to organ donation), the use of protocols was supported by 100% of participants, whereas in hospitals with a level II and III ICU (and greater exposure), only 31% of participants supported the use of protocols.

CONCLUSIONS

There are wide variations and a lack of formal guidelines for physiotherapy management of patients on the organ donation pathway; however, clinical reasoning appears to be favored above protocolized management in hospitals with level II and level III ICUs.

Assessing unrealised potential for organ donation after out-of-hospital cardiac arrest

BACKGROUND

Organ donation after brain death is the standard practice in many countries. Rates are low globally. This study explores the potential national number of candidates for uncontrolled donations after cardiac death (uDCD) amongst out-of-hospital cardiac arrest (OHCA) patients and the influence of extracorporeal cardiopulmonary resuscitation (ECPR) on the candidacy of these potential organ donors using Singapore as a case study.

METHODS

Using Singapore data from the Pan-Asian Resuscitation Outcomes Study, we identified all non-traumatic OHCA cases from 2010 to 2016. Four established criteria for identifying uDCD candidates (Madrid, San Carlos Madrid, Maastricht and Paris) were retrospectively applied onto the population. Within these four groups, a condensed ECPR eligibility criteria was employed and thereafter, an estimated ECPR survival rate was applied, extrapolating for possible neurologically intact survivors had ECPR been administered.

RESULTS

12,546 OHCA cases (64.8% male, mean age 65.2 years old) qualified for analysis. The estimated number of OHCA patients who were eligible for uDCD ranged from 4.3 to 19.6%. The final projected percentage of potential uDCD donors readjusted for ECPR survivors was 4.2% (Paris criteria worst-case scenario, n = 532) to 19.4% of all OHCA cases (Maastricht criteria best-case scenario, n = 2428), for an estimated 14.3 to 65.4 uDCD donors per million population per year (pmp/year).

CONCLUSIONS

In Singapore case study, we demonstrated the potential numbers of candidates for uDCD among resuscitated OHCA cases. This sizeable pool of potential donors demonstrates the potential for an uDCD program to expand the organ donor pool. A small proportion of these patients might however survive had they been administered ECPR. Further research into the factors influencing local organ and patient outcomes following uDCD and ECPR is indicated.

European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.

European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.

Surface-Functionalized Conducting Nanofibers for Electrically Stimulated Neural Cell Function

Strategies involving the inclusion of cell-instructive chemical and topographical cues to smart biomaterials in combination with a suitable physical stimulus may be beneficial to enhance nerve-regeneration rate. In this regard, we investigated the surface functionalization of poly[2-methoxy-5-(2-ethylhexyloxy)-1,4-phenylenevinylene] (MEH-PPV)-based electroconductive electrospun nanofibers coupled with externally applied electrical stimulus for accelerated neuronal growth potential. In addition, the voltage-dependent conductive mechanism of the nanofibers was studied in depth to interlink intrinsic conductive properties with electrically stimulated neuronal expressions. Surface functionalization was accomplished using 3-aminopropyltriethoxysilane (APTES) and 1,6-hexanediamine (HDA) as an alternative to costly biomolecule coating (e.g., collagen) for cell adhesion. The nanofibers were uniform, porous, electrically conductive, mechanically strong, and stable under physiological conditions. Surface amination boosted biocompatibility, 3T3 cell adhesion, and spreading, while the neuronal model rat PC12 cell line showed better differentiation on surface-functionalized mats compared to nonfunctionalized mats. When coupled with electrical stimulation (ES), these mats showed comparable or faster neurite formation and elongation than the collagen-coated mats with no-ES conditions. The findings indicate that surface amination in combination with ES may provide an improved strategy to faster nerve regeneration using MEH-PPV-based neural scaffolds.

Abdominal Normothermic Regional Perfusion in Donation After Circulatory Death: A Systematic Review and Critical Appraisal

BACKGROUND

Abdominal normothermic regional perfusion (aNRP) for donation after circulatory death is an emerging organ preservation technique that might lead to increased organ utilization per donor by facilitating viability testing, improving transplant outcome by early reversal of ischemia, and decreasing the risk of unintentional surgical damage. The aim of the current review is to evaluate the recent literature on the added value of aNRP when compared to local standard perfusion technique.

METHODS

The Preferred Reporting Items for Systematic reviews and Meta-Analyses guideline for systematic reviews was used, and relevant literature databases were searched. Primary outcomes were organ utilization rate and patient and graft survival after 1 year. Secondary outcomes included delayed graft function, primary nonfunction, serum creatinine, and biliary complications.

RESULTS

A total of 24 articles were included in this review. The technique is unanimously reported to be feasible and safe, but the available studies are characterized by considerable heterogeneity and bias.

CONCLUSIONS

Uniform reported outcome measures are needed to draw more definitive conclusions on transplant outcomes and organ utilization. A randomized controlled trial comparing aNRP with standard procurement technique in donation after circulatory death donors would be needed to show the added value of the procedure and determine its place among modern preservation techniques.

Improving outcomes for donation after circulatory death kidney transplantation: Science of the times

The use of kidneys donated after circulatory death (DCD) remains controversial due to concerns with regard to high incidences of early graft loss, delayed graft function (DGF), and impaired graft survival. As these concerns are mainly based on data from historical cohorts, they are prone to time-related effects and may therefore not apply to the current timeframe. To assess the impact of time on outcomes, we performed a time-dependent comparative analysis of outcomes of DCD and donation after brain death (DBD) kidney transplantations. Data of all 11,415 deceased-donor kidney transplantations performed in The Netherlands between 1990–2018 were collected. Based on the incidences of early graft loss, two eras were defined (1998–2008 [n = 3,499] and 2008–2018 [n = 3,781]), and potential time-related effects on outcomes evaluated. Multivariate analyses were applied to examine associations between donor type and outcomes. Interaction tests were used to explore presence of effect modification. Results show clear time-related effects on posttransplant outcomes. The 1998–2008 interval showed compromised outcomes for DCD procedures (higher incidences of DGF and early graft loss, impaired 1-year renal function, and inferior graft survival), whereas DBD and DCD outcome equivalence was observed for the 2008–2018 interval. This occurred despite persistently high incidences of DGF in DCD grafts, and more adverse recipient and donor risk profiles (recipients were 6 years older and the KDRI increased from 1.23 to 1.39 and from 1.35 to 1.49 for DBD and DCD donors). In contrast, the median cold ischaemic period decreased from 20 to 15 hours. This national study shows major improvements in outcomes of transplanted DCD kidneys over time. The time-dependent shift underpins that kidney transplantation has come of age and DCD results are nowadays comparable to DBD transplants. It also calls for careful interpretation of conclusions based on historical cohorts, and emphasises that retrospective studies should correct for time-related effects.

Potential for donation after circulatory death heart transplantation in the United States: Retrospective analysis of a limited UNOS dataset

Donation after Circulatory Death (DCD) is an alternative to Donation after Brain death (DBD), and is a growing strategy for organ procurement in the United States(US). The purpose of this analysis was to review the number and quality of hearts in one United Network for Organ Sharing (UNOS) Region that were not utilized as a potential consequence of nonheart DCD donation. We retrospectively identified all successful US DCD solid organ donors from 1/2011 to 3/1/2017, defined an ideal heart donor by age and left ventricular ejection fraction (LVEF), and then reviewed the donor charts of unused hearts in New York and Vermont (UNOS Region 9). Of 8302 successful DCD donors across the United States, 5033 (61%) were between 18 and 49 years of age, and 872 had a screening echocardiogram, with 573 (66%) measuring an EF >50%. Of these 573 potential donors, 44 (7.7%) were from Region 9. Detailed donor chart review identified 36 ideal heart donors, 24 (66.7%) with anoxic brain injury. Trends in Region 9 DCD donation increased from 4 unused hearts in 2011, to 13 in 2016. In the context of severe organ scarcity, these data indicate that implementation of DCD heart transplantation in the United States would improve overall donation rates and provide a pathway to utilize these ideal donor hearts.

Update of a Systematic Review of Autoresuscitation After Cardiac Arrest

OBJECTIVES

There has been a growth in publications focusing on the phenomena of autoresuscitation in recent years. In 2010, we systematically reviewed the medical literature with the primary objective of summarizing the evidence on the timing of autoresuscitation. Healthcare professionals have continued to voice concerns regarding the potential for autoresuscitation. With this in mind, the objective of this brief report is to update the results of our original review of autoresuscitation.

DATA SOURCES

We applied the same search strategy described in our original article to update our findings to include articles published from January 2009 to September 2016.

STUDY SELECTION AND DATA EXTRACTION

We screened an additional 1,859 citations, after duplicates were removed, and then assessed 46 full-text articles for eligibility, from which 15 studies were included for data extraction.

DATA SYNTHESIS

During the time period of this review, there have been 1) 10 additional adult and three pediatric case reports of autoresuscitation in patients after cessation of cardiopulmonary resuscitation; in those cases with continuous monitoring and confirmation of circulation, the longest events are reported to be 10 and 2 minutes, respectively for adults and children; 2) six adults (4%, total n = 162) with autoresuscitation events reported from two observational studies and one chart review of patients undergoing withdrawal of life-sustaining therapy; the longest time reported to be 89 seconds with electrocardiogram and invasive arterial blood pressure monitoring and 3 minutes with electrocardiogram monitoring only; 3) 12 pediatric patients studied with vital sign monitoring during withdrawal of life-sustaining therapy without any reports of autoresuscitation.

CONCLUSIONS

Although case reports of autoresuscitation are hampered by variability in observation and monitoring techniques, autoresuscitation has now been reported in adults and children, and there appears to be a distinction in timing between failed cardiopulmonary resuscitation and withdrawal of life-sustaining therapy. Although additional prospective studies are required to clarify the frequency and predisposing factors associated with this phenomenon, clinical decision-making regarding patient management under uncertainty is required nonetheless. Both adult and pediatric healthcare professionals should be aware of the possibility of autoresuscitation and monitor their patients accordingly before diagnosing death.

TAK242 suppresses the TLR4 signaling pathway and ameliorates DCD liver IRI in rats

Ischemia-reperfusion injury (IRI) is a notable cause of tissue damage during surgical procedures and a major risk factor in graft dysfunction in liver transplantation. Livers obtained from donors after circulatory death (DCD) are prone to IRI and toll-like receptor 4 (TLR4) serves a prominent role in the inflammatory response associated with DCD liver IRI. The present study was designed to investigate whether TAK242, a specific TLR4 inhibitor, improves hepatic IRI following a DCD graft and to investigate its underlying protective mechanisms. Male Sprague-Dawley rats were randomized into 4 groups: Control, TAK242, DCD and DCD+TAK242 groups. Rats were pretreated with TAK242 or its vehicle for 30 min, then the livers were harvested without warm ischemia (control group and TAK242 group) or with warm ischemia in situ for 30 min. The livers were stored in cold University of Wisconsin solution for 24 h and subsequently perfused for 60 min with an isolated perfused rat liver system. Rat liver injury was evaluated thereafter. When compared with the DCD group, DCD livers with TAK242 pretreatment displayed significantly improved hepatic tissue injury and less tissue necrosis (P<0.05). Compared with DCD livers, mechanistic experiments revealed that TAK242 pretreatment alleviated mitochondrial dysfunction, reduced reactive oxygen species and malondialdehyde levels and inhibited apoptosis. Additionally, TAK242 significantly inhibited the IRI-associated inflammatory response, indicated by the decreased expression of TLR4, interleukin (IL)-1β, IL-6 and cyclooxygenase 2 at the mRNA and protein levels (P<0.05). TAK242 ameliorates DCD liver IRI via suppressing the TLR4 signaling pathway in rats. The results of the present study have revealed that TAK242 pretreatment harbors a potential benefit for liver transplantation.

Measures influencing post-mortem organ donation rates in Germany, the Netherlands, Spain and the UK : A systematic review

BACKGROUND

German post-mortem organ donation rates have been declining since 2010. Several transplantation scandals led to a negative portrayal of organ donation in the media. Spain, the UK and the Netherlands achieved a rise in organ donation rates while retaining organ donation legislation.

METHODS

A systematic review of publications focusing on (1) organ donation legislation, (2) data on post-mortem organ donation rates and (3) measures to increase post-mortem organ donation rates in Europe was conducted in November 2017 in PubMed, PsycINFO and Web of Science. Quality parameters of the World Bank and the World Health Organization (WHO) were studied to analyze national health services, frequent causes of death and life expectancy.

RESULTS

Quality parameters of national health services were similar in all countries. The Netherlands and Germany have an opt in system. An increase of 37.4% in post-mortem organ donation rates from 2008 to 2015 in the UK was accomplished through the establishment of a donation task force, adopting parts of the Spanish model, while maintaining an opt in system. Spain has the highest organ donation rate worldwide (39.7 per million persons in 2015). The implementation of transplantation coordinators and the change in legislation in Germany in 2012 has so far shown no effect. Public awareness of organ donation in the Netherlands increased following various information campaigns.

CONCLUSION

Donation after cardiac death (DCD), expanded donor criteria, increasing public awareness and introduction of an organ donor register should be discussed as measures to increase organ donation rates in Germany.

Impact of Cold Ischemia Time on Outcomes of Deceased Donor Kidney Transplantation: An Analysis of a National Registry

Background

Cold ischemia time (CIT) is known to impact kidney graft survival rates. We compare the impact of CIT on graft failure and mortality in circulatory death versus brain death donor kidneys and how it relates to donor age.

Methods

We used the prospective Dutch Organ Transplantation Registry to include 2153 adult recipients of brain death (n = 1266) and circulatory death (n = 887) donor kidneys after static cold storage from transplants performed between 2005 and 2012. CIT was modeled nonlinearly with splines. Associations and interactions between CIT, donor type, donor age, 5-year (death-censored) graft survival, and mortality were evaluated.

Results

The median CIT was 16.2 hours (interquartile range 12.8-20), ranging from 3.4 to 44.7 hours for brain death and 4.7 to 46.6 hours for circulatory death donor kidneys. At >12 hours of CIT, we observed an increased risk of graft failure in kidneys donated after circulatory death versus after brain death. This risk rose significantly at >22 hours of CIT (hazard ratio 1.45; 95% confidence interval, 1.01-2.49; P = 0.043). Kidneys that came from 60-year-old circulatory death donors demonstrated elevated hazard risk at 19 hours of CIT, a shorter timeline than that for kidneys that came from brain death donors of the same age (hazard ratio 1.33; 95% confidence interval, 1.00-1.78; P = 0.045). The additional harmful effects of increased CIT in kidneys from circulatory-death donors were also found for death-censored graft failure but did not affect mortality rates in any significant way.

Conclusions

The findings support the hypothesis that prolonged cold ischemia is more harmful for circulatory death donor kidneys that have already been subjected to a permissible period of warm ischemia. Efforts should be made to reduce CIT, especially for older circulatory death donor kidneys.

Evolution of Deceased Organ Donation Activity Versus Efficiency Over a 15-year Period: An International Comparison

BACKGROUND

The donation rate (DR) per million population is not ideal for an efficiency comparison of national deceased organ donation programs. The DR does not account for variabilities in the potential for deceased donation which mainly depends on fatalities from causes leading to brain death. In this study, the donation activity was put into relation to the mortality from selected causes. Based on that metric, this study assesses the efficiency of different donation programs.

METHODS

This is a retrospective analysis of 2001 to 2015 deceased organ donation and mortality registry data. Included are 27 Council of Europe countries, as well as the United States. A donor conversion index (DCI) was calculated for assessing donation program efficiency over time and in international comparisons.

RESULTS

According to the DCI and of the countries included in the study, Spain, France, and the United States had the most efficient donation programs in 2015. Even though mortality from the selected causes decreased in most countries during the study period, differences in international comparisons persist. This indicates that the potential for deceased organ donation and its conversion into actual donation is far from being similar internationally.

CONCLUSIONS

Compared with the DR, the DCI takes into account the potential for deceased organ donation, and therefore is a more accurate metric of performance. National donation programs could optimize performance by identifying the areas where most potential is lost, and by implementing measures to tackle these issues.

The need and opportunity for donation after circulatory death worldwide

PURPOSE OF REVIEW

The global shortage of organ donors will not be resolved solely by relying on deceased donation following a brain death determination (DBD). Expansion of deceased donation after circulatory death (DCD) will be needed to address the shortfall of organs for transplantation. Approximately 120 000 organ transplants are performed each year; however, the WHO estimates that this number of transplants only resolves 10% of the annual worldwide transplant need.

RECENT FINDINGS

The report addresses the opportunity of DCD expansion by evaluating the DCD potential that is not being realized, the utility of DCD enabling DBD to emerge in some clinical situations, by the effectiveness of a donor registry in achieving DCD, and by the current clinical research of heart, lung, and liver transplantation from DCD.

SUMMARY

The future of deceased donation must include DCD and ex-vivo organ repair if the organ shortage is to be reconciled even partially to the ongoing demand. Although the religious and legal impediments have been overcome to determine brain death, the possibility of DCD has not been addressed. A program of DCD is feasible in all countries with transplantation services. The excellent results following kidney and lung transplantation suggest opportunities of heart and liver transplantation should be the focus of needed DCD accomplishment in the near future.

Donor referral from outside the intensive care unit: A multidisciplinary cooperation model using communication apps and redefining refereal criteria

OBJECTIVE

We evaluate the impact of a web-based collaborative system on the referral of possible organ donors from outside of the intensive care unit (ICU).

STUDY DESIGN

Cohort prospective study.

SETTINGS

University hospital.

PATIENTS AND INTERVENTION

In 2015 a virtual collaborative system using a cross-platform instant messaging application replaced the previous 2014 protocol for the referral of patients outside of the ICU with a severe brain injury in whom all treatment options were deemed futile by the attending team to the donor coordination (DC). Once the DC evaluated the medical suitability and likelihood of progression to brain death (BD), the option of intensive care to facilitate organ donation (ICOD) was offered to the patient's relatives. This included admission to the ICU and elective non-therapeutic ventilation (ENTV), where appropriate.

RESULTS

A two-fold increase of referrals was noted in 2015 [n=46/74; (62%)] compared to 2014 [n=13/40; (32%)]; p<0.05. Patients were mostly referred from the stroke unit (58.6%) in 2015 and from the emergency department (69.2%) in 2014 (p<0.01). Twenty (2015: 42.5%) and 4 (2014: 30.7%) patients were discarded as donors mostly due to medical unsuitability. Family accepted donation in 16 (2015: 62%) and 6 (2014: 66%) cases, all admitted to the ICU and 10 (2015: 62.5%) and 3 (50%) being subject to ENTV. Ten (2015: 66.6%) and 5 (2014: 83.3%) patients progressed to BD, 60.5±20.2 and 44.4±12.2h after referral respectively. Nine (2015) and 4 (2014) of these patients became utilized donors, representing 29.0% (2015) and 13.0% (2014) of the BD donors in the hospital during the study period (p<0.05).

CONCLUSION

The implementation of a virtual community doubled the number of patients whose families were presented with the option of donation prior to their death.

Barriers and Enablers to Organ Donation After Circulatory Determination of Death: A Qualitative Study Exploring the Beliefs of Frontline Intensive Care Unit Professionals and Organ Donor Coordinators

Background

A shortage of transplantable organs is a global problem. The purpose of this study was to explore frontline intensive care unit professionals' and organ donor coordinators' perceptions and beliefs around the process of, and the barriers and enablers to, donation after circulatory determination death (DCDD).

Methods

This qualitative descriptive study used a semistructured interview guide informed by the Theoretical Domains Framework to interview 55 key informants (physicians, nurses, and organ donation coordinators) in intensive care units (hospitals) and organ donation organizations across Canada.

Results

Interviews were analyzed using a 6-step systematic approach: coding, generation of specific beliefs, identification of themes, aggregation of themes into categories, assignment of barrier or enabler and analysis for shared and unique discipline barriers and enablers. Seven broad categories encompassing 29 themes of barriers (n = 21) and enablers (n = 4) to DCDD use were identified; n = 4 (14%) themes were conflicting, acting as barriers and enablers. Most themes (n = 26) were shared across the 3 key informant groups while n = 3 themes were unique to physicians. The top 3 shared barriers were: (1) DCDD education is needed for healthcare professionals, (2) a standardized and systematic screening process to identify potential DCDD donors is needed, and (3) practice variation across regions with respect to communication about DCDD with families. A limited number of differences were found by region.

Conclusions

Multiple barriers and enablers to DCDD use were identified. These beliefs identify potential individual, team, organization, and system targets for behavior change interventions to increase DCDD rates which, in turn, should lead to more transplantation, reducing patient morbidity and mortality at a population level.

Allogeneic mesenchymal stem cells as induction therapy are safe and feasible in renal allografts: pilot results of a multicenter randomized controlled trial

BACKGROUND

Kidneys from deceased donors are being used to meet the growing need for grafts. However, delayed graft function (DGF) and acute rejection incidences are high, leading to adverse effects on graft outcomes. Optimal induction intervention should include both renal structure injury repair and immune response suppression. Mesenchymal stem cells (MSCs) with potent anti-inflammatory, regenerative, and immune-modulatory properties are considered a candidate to prevent DGF and acute rejection in renal transplantation. Thus, this prospective multicenter paired study aimed to assess the clinical value of allogeneic MSCs as induction therapy to prevent both DGF and acute rejection in deceased donor renal transplantation.

METHODS

Forty-two renal allograft recipients were recruited and divided into trial and control groups. The trial group (21 cases) received 2 × 10⁶/kg human umbilical-cord-derived MSCs (UC-MSCs) via the peripheral vein before renal transplantation, and 5 × 10⁶ cells via the renal artery during the surgical procedure. All recipients received standard induction therapy. Incidences of DGF and biopsy-proven acute rejection were recorded postoperatively and severe postoperative complications were assessed. Graft and recipient survivals were also evaluated.

RESULTS

Treatment with UC-MSCs achieved comparable graft and recipient survivals with non-MSC treatment (P = 0.97 and 0.15, respectively). No increase in postoperative complications, including DGF and acute rejection, were observed (incidence of DGF: 9.5% in the MSC group versus 33.3% in the non-MSC group, P = 0.13; Incidence of acute rejection: 14.3% versus 4.8%, P = 0.61). Equal postoperative estimated glomerular filtration rates were found between the two groups (P = 0.88). All patients tolerated the MSCs infusion without adverse clinical effects. Additionally, a multiprobe fluorescence in situ hybridization assay revealed that UC-MSCs administered via the renal artery were absent from the recipient's biopsy sample.

CONCLUSIONS

Umbilical-cord-derived MSCs can be used as clinically feasible and safe induction therapy. Adequate timing and frequency of UC-MSCs administration may have a significant effect on graft and recipient outcomes. Trial registration NCT02490020 . Registered on June 29 2015.

Impact of a National Controlled Donation After Circulatory Death (DCD) Program on Organ Donation in the United Kingdom: A 10-Year Study

Organ transplantation is the most successful treatment for some forms of organ failure, yet a lack of organs means many die on the waiting list. In the United Kingdom, the Organ Donation Taskforce was set up to identify barriers to organ donation and in 2008 released its first report (Organ Donation Taskforce Report; ODTR). This study assesses the success since the ODTR and examines the impact of the United Kingdom's controlled donation after circulatory death (DCD) program and the controversies surrounding it. There were 12 864 intended donation after brain death (DBD) or DCD donors from April 2004 to March 2014. When the 5 years preceding the ODTR was compared to the 5 years following, intended DCD donors increased 292% (1187 to 4652), and intended DBD donors increased 11% (3327 to 3698). Organs retrieved per intended DBD donor remained static (3.30 to 3.26), whereas there was a decrease in DCD (1.54 to 0.99) due to a large rise in donors who did not proceed to donation (325 to 2464). The majority of DCD donors who proceeded did so within 30 min from time of withdrawal. Our study suggests further work on converting eligible referrals to organ donation and exploring methods of converting DCD to DBD donors.

The Implications of the Shift Toward Donation After Circulatory Death in Australia

BACKGROUND

In recent years, an increasing number of donor livers are being declined for transplantation in Australia. The aim of this study was to evaluate the impact of donation after cardiac death and other factors associated with organ quality on liver utilization rates in Australia.

METHODS

Data on organ donors who donated at least 1 organ between 2005 and 2014 were obtained from the Australia and New Zealand organ donation registry. Temporal changes in donor characteristics were assessed and a logistical regression analysis was performed to evaluate their association with liver nonuse.

RESULTS

The number of organ donors increased from 175 in 2005 to 344 in 2014, with overall 19% being donation after cardiac death donors (P < 0.001). The percentage of livers deemed unsuitable for transplantation increased from 24% in 2005 to 41% in 2014 (P < 0.001). Donation after cardiac death was identified as the most important risk factor for nonuse with an odds ratio of 25.88 (95% confidence interval, 18.84-35.56), P < 0.001) followed by donor age, obesity, and diabetes.

DISCUSSION

This study shows that livers donated after circulatory death are an underused resource in Australia. Better use of these currently available organs would be a highly cost-effective way of reducing waiting list mortality in liver transplantation.

Effect of organ donation after circulatory determination of death on number of organ transplants from donors with neurologic determination of death

BACKGROUND

To increase the available pool of organ donors, Ontario introduced donation after circulatory determination of death (DCD) in 2006. Other jurisdictions have reported a decrease in donations involving neurologic determination of death (NDD) after implementation of DCD, with a drop in organ yield and quality. In this study, we examined the effect of DCD on overall transplant activity in Ontario.

METHODS

We examined deceased donor and organ transplant activity during 3 distinct 4-year eras: pre-DCD (2002/03 to 2005/06), early DCD (2006/07 to 2009/10) and recent DCD (2010/11 to 2013/14). We compared these donor groups by categorical characteristics.

RESULTS

Donation increased by 57%, from 578 donors in the pre-DCD era to 905 donors in the recent DCD era, with a 21% proportion (190/905) of DCD donors in the recent DCD era. However, overall NDD donation also increased. The mean length of hospital stay before declaration for NDD was 2.7 days versus 6.0 days before withdrawal of life support and subsequent asystole in cases of DCD. The average organ yield was 3.73 with NDD donation versus 2.58 with DCD (p < 0.001). Apart from hearts, all organs from DCD donors were successfully transplanted. From the pre-DCD era to the recent DCD era, transplant activity in each era increased for all solid-organ recipients, including heart (from 158 to 216), kidney (from 821 to 1321), liver (from 477 to 657) and lung (from 160 to 305).

INTERPRETATION

Implementation of DCD in Ontario led to increased transplant activity for all solid-organ recipients. There was no evidence that the use of DCD was pre-empting potential NDD donation. In contrast to groups receiving other organs, heart transplant candidates have not yet benefited from DCD.

Complement in renal transplantation: The road to translation

Renal transplantation is the treatment of choice for patients with end-stage renal disease. The vital role of the complement system in renal transplantation is widely recognized. This review discusses the role of complement in the different phases of renal transplantation: in the donor, during preservation, in reperfusion and at the time of rejection. Here we examine the current literature to determine the importance of both local and systemic complement production and how complement activation contributes to the pathogenesis of renal transplant injury. In addition, we dissect the complement pathways involved in the different phases of renal transplantation. We also review the therapeutic strategies that have been tested to inhibit complement during the kidney transplantation. Several clinical trials are currently underway to evaluate the therapeutic potential of complement inhibition for the treatment of brain death-induced renal injury, renal ischemia-reperfusion injury and acute rejection. We conclude that it is expected that in the near future, complement-targeted therapeutics will be used clinically in renal transplantation. This will hopefully result in improved renal graft function and increased graft survival.

Organ donation protocols

Organ transplantation improves survival and quality of life in patients with end-organ failure. Waiting lists continue to grow across the world despite remarkable advances in the transplantation process, from the creation of public engagement campaigns to the development of critical pathways for the timely identification, referral, approach, and treatment of the potential organ donor. The pathophysiology of dying triggers systemic changes that are intimately related to organ viability. The intensive care management of the potential organ donor optimizes organ function and improves the donation yield, representing a significant step in reducing the mismatch between organ supply and demand. Different beliefs and cultures reflect diverse legislations and donation practices amongst different countries, creating a challenge to standardized practices. Maintaining public trust is necessary for continued progress in organ donation and transplantation, hence the urge for a joint effort in creating uniform protocols that ensure transparent practices within the medical community.

Complement-mediated inflammation and injury in brain dead organ donors

The importance of the complement system in renal ischemia-reperfusion injury and acute rejection is widely recognized, however its contribution to the pathogenesis of tissue damage in the donor remains underexposed. Brain-dead (BD) organ donors are still the primary source of organs for transplantation. Brain death is characterized by hemodynamic changes, hormonal dysregulation, and immunological activation. Recently, the complement system has been shown to be involved. In BD organ donors, complement is activated systemically and locally and is an important mediator of inflammation and graft injury. Furthermore, complement activation can be used as a clinical marker for the prediction of graft function after transplantation. Experimental models of BD have shown that inhibition of the complement cascade is a successful method to reduce inflammation and injury of donor grafts, thereby improving graft function and survival after transplantation. Consequently, complement-targeted therapeutics in BD organ donors form a new opportunity to improve organ quality for transplantation. Future studies should further elucidate the mechanism responsible for complement activation in BD organ donors.

Mechanism of Death after Decompressive Craniectomy in Non-Traumatic Brain Injury

Decompressive craniectomy (DC) after devastating brain injury (DBI) may influence the manner in which patients die, having implications for end-of-life care and organ donation. We performed a retrospective review of deaths following a non-traumatic DBI between 2008 and 2012. 160 patients were reviewed; 26 were treated with DC and 134 received standard care. There was no relationship between DC and mechanism of death, (OR 1.18, 95% CI 0.44-3.17). Prospective studies are required to confirm these preliminary finding. DC studies should report the mechanism of death.

Policy options for increasing the supply of transplantable kidneys in Singapore

Kidney transplantation is the preferred treatment for eligible end-stage renal disease patients. However, the supply of donated kidneys has been consistently insufficient to meet the transplantation requirements of the population. In this paper, I discuss the feasibility of several policy options that engage potential donors or key individuals in a Singapore context, including financial and non-financial incentives for deceased/living organ donors and their families, improving actualisation rates of both donation after brain death, donation after cardiac death through quality improvement programmes and remuneration schemes, and a media platform for directed organ donation. I conclude by highlighting the most feasible policies to be considered.

Recommendations for further improvement of the deceased organ donation process in Belgium

Belgium has achieved high deceased organ donation rates but according to the medical record data in the Donor Action database, deceased potential donors are still missed along the pathway. Between 2010 and 2014, 12.9 ± 3.3% of the potential donors after brain death (DBD) and 24.6 ± 1.8% of the potential donors after circulatory (DCD) death were not identified. Conversion rates of 41.7 ± 2.1% for DBD and 7.9 ± 0.9% for DCD indicate room for further improvement. We identify and discuss different issues in the monitoring of donation activities, practices and outcomes; donor pool; legislation on deceased organ donation; registration; financial reimbursement; educational and training programs; donor detection and practice clinical guidance. The overall aim of this position paper, elaborated by a Belgian expert panel, is to provide recommendations for further improvement of the deceased organ donation process up to organ procurement in Belgium.

ICU Management of the Potential Organ Donor: State of the Art

End-organ failure is associated with high mortality and morbidity, in addition to increased health care costs. Organ transplantation is the only definitive treatment that can improve survival and quality of life in such patients; however, due to the persistent mismatch between organ supply and demand, waiting lists continue to grow across the world. Careful intensive care management of the potential organ donor with goal-directed therapy has the potential to optimize organ function and improve donation yield.

Changing Patterns of Organ Donation: Brain Dead Donors Are Not Being Lost by Donation After Circulatory Death

The clinical characteristics of all New England Organ Bank (NEOB) donors after circulatory death (DCD) donors were analyzed between July 1, 2009, and June 30, 2014. During that 5-year period, there were 494 authorized medically suitable potential DCDs that the NEOB evaluated, constituting more than 30% of deceased donors coordinated annually by the NEOB. From the cohort of 494 authorized potential DCDs, 331 (67%) became actual DCD, 82 (17%) were attempted as a DCD but did not progress to donation, and 81 (16%) transitioned to an actual donor after brain death (DBD). Two hundred seventy-six organs were transplanted from the 81 donors that transitioned from DCD to actual DBD, including 24 heart, 70 liver, 12 single and 14 bilateral lung, and 12 pancreas transplants. When patients with devastating brain injury admitted to the intensive care units are registered donors, the Organ Procurement Organization staff should share the patient's donation decision with the health care team and the patient's family, as early as possible after the comfort measures only discussion has been initiated. The experience of the NEOB becomes an important reference of the successful implementation of DCD that enables an expansion of deceased donation (inclusive of DBD).

Successful Transplantation of Lungs From an Uncontrolled Donor After Circulatory Death Preserved In Situ by Alveolar Recruitment Maneuvers and Assessed by Ex Vivo Lung Perfusion

We developed a protocol to procure lungs from uncontrolled donors after circulatory determination of death (NCT02061462). Subjects with cardiovascular collapse, treated on scene by a resuscitation team and transferred to the emergency room, are considered potential donors once declared dead. Exclusion criteria include unwitnessed collapse, no-flow period of >15 min and low flow >60 min. After death, lung preservation with recruitment maneuvers, continuous positive airway pressure, and protective mechanical ventilation is applied to the donor. After procurement, ex vivo lung perfusion (EVLP) is performed. From November 2014, 10 subjects were considered potential donors; one of these underwent the full process of procurement, EVLP, and transplantation. The donor was a 46-year-old male who died because of thoracic aortic dissection. Lungs were procured 4 h and 48 min after death, and deemed suitable for transplantation after EVLP. Lungs were then offered to a rapidly deteriorating recipient with cystic fibrosis (lung allocation score [LAS] 46) who consented to the transplant in this experimental setting. Six months after transplantation, the recipient is in good condition (forced expiratory volume in 1 s 85%) with no signs of rejection. This protocol allowed procurement of lungs from an uncontrolled donor after circulatory determination of death following an extended period of warm ischemia.

Pediatric Donation After Circulatory Determination of Death: A Scoping Review

OBJECTIVE

Although pediatric donation after circulatory determination of death is increasing in frequency, there are no national or international donation after circulatory determination of death guidelines specific to pediatrics. This scoping review was performed to map the pediatric donation after circulatory determination of death literature, identify pediatric donation after circulatory determination of death knowledge gaps, and inform the development of national or regional pediatric donation after circulatory determination of death guidelines.

DATA SOURCES

Terms related to pediatric donation after circulatory determination of death were searched in Embase and MEDLINE, as well as the non-MEDLINE sources in PubMed from 1980 to May 2014.

STUDY SELECTION

Seven thousand five hundred ninety-seven references were discovered and 85 retained for analysis. All references addressing pediatric donation after circulatory determination of death were considered. Exclusion criteria were articles that did not address pediatric patients, animal or laboratory studies, surgical techniques, and local pediatric donation after circulatory determination of death protocols. Narrative reviews and opinion articles were the most frequently discovered reference (25/85) and the few discovered studies were observational or qualitative and almost exclusively retrospective.

DATA EXTRACTION

Retained references were divided into themes and analyzed using qualitative methodology.

DATA SYNTHESIS

The main discovered themes were 1) studies estimating the number of potential pediatric donation after circulatory determination of death donors and their impact on donation; 2) ethical issues in pediatric donation after circulatory determination of death; 3) physiology of the dying process after withdrawal of life-sustaining therapy; 4) cardiac pediatric donation after circulatory determination of death; and 5) neonatal pediatric donation after circulatory determination of death. Donor estimates suggest that pediatric donation after circulatory determination of death will remain an event less common than brain death, albeit with the potential to substantially expand the existing organ donation pool. Limited data suggest outcomes comparable with organs donated after neurologic determination of death. Although there is continued debate around ethical aspects of pediatric donation after circulatory determination of death, all pediatric donation after circulatory determination of death publications from professional societies contend that pediatric donation after circulatory determination of death can be practiced ethically.

CONCLUSIONS

This review provides a comprehensive overview of the published literature related to pediatric donation after circulatory determination of death. In addition to informing the development of pediatric-specific guidelines, this review serves to highlight several important knowledge gaps in this topic.

Declining liver graft quality threatens the future of liver transplantation in the United States

National liver transplantation (LT) volume has declined since 2006, in part because of worsening donor organ quality. Trends that degrade organ quality are expected to continue over the next 2 decades. We used the United Network for Organ Sharing (UNOS) database to inform a 20-year discrete event simulation estimating LT volume from 2010 to 2030. Data to inform the model were obtained from deceased organ donors between 2000 and 2009. If donor liver utilization practices remain constant, utilization will fall from 78% to 44% by 2030, resulting in 2230 fewer LTs. If transplant centers increase their risk tolerance for marginal grafts, utilization would decrease to 48%. The institution of "opt-out" organ donation policies to increase the donor pool would still result in 1380 to 1866 fewer transplants. Ex vivo perfusion techniques that increase the use of marginal donor livers may stabilize LT volume. Otherwise, the number of LTs in the United States will decrease substantially over the next 15 years. In conclusion, the transplant community will need to accept inferior grafts and potentially worse posttransplant outcomes and/or develop new strategies for increasing organ donation and utilization in order to maintain the number of LTs at the current level.

[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.

The marginal kidney donor

PURPOSE OF REVIEW

The current era of organ shortage has necessitated a widening of criteria for donation, considering donors who would have been considered unsuitable before. This review summarizes the recent advances in strategies to maximize the use of marginal kidneys without compromising the outcomes.

RECENT FINDINGS

Various strategies have been studied and implemented to optimize procurement and allocation of marginal kidneys, and to preserve their function. In particular, a growing number of transplant centers are using donors after circulatory death. Whereas normothermic ex-vivo and postmortem perfusion are promising procedures to improve the outcomes of marginal grafts in the future, dual-kidney transplantation is a viable approach which is at present potentially underutilized. Despite active research on new strategies to evaluate organ quality, pretransplant biopsy assessment currently remains the most reliable method. The practice of using living donors with advanced age is supported by available evidence, whereas the use of young living donors with minor medical abnormalities needs further investigation.

SUMMARY

Progress has been made in the recent years, clarifying the best criteria for evaluating, recovering, and allocating marginal kidney donors. However, further research is needed, with special regards to the criteria for using marginal living-kidney donors.

Design, implementation, and evaluation of a knowledge translation intervention to increase organ donation after cardiocirculatory death in Canada: a study protocol

Background

A shortage of transplantable organs is a global problem. There are two types of organ donation: living and deceased. Deceased organ donation can occur following neurological determination of death (NDD) or cardiocirculatory death. Donation after cardiocirculatory death (DCD) accounts for the largest increments in deceased organ donation worldwide. Variations in the use of DCD exist, however, within Canada and worldwide. Reasons for these discrepancies are largely unknown. The purpose of this study is to develop, implement, and evaluate a theory-based knowledge translation intervention to provide practical guidance about how to increase the numbers of DCD organ donors without reducing the numbers of standard NDD donors.

Methods

We will use a mixed method three-step approach. In step one, we will conduct semi-structured interviews, informed by the Theoretical Domains Framework, to identify and describe stakeholders’ beliefs and attitudes about DCD and their perceptions of the multi-level factors that influence DCD. We will identify: determinants of the evidence-practice gap; specific behavioural changes and/or process changes needed to increase DCD; specific group(s) of clinicians or organizations (e.g., provincial donor organizations) in need of behaviour change; and specific targets for interventions. In step two, using the principles of intervention mapping, we will develop a theory-based knowledge translation intervention that encompasses behavior change techniques to overcome the identified barriers and enhance the enablers to DCD. In step three, we will roll out the intervention in hospitals across the 10 Canadian provinces and evaluate its effectiveness using a multiple interrupted time series design.

Discussion

We will adopt a behavioural approach to define and test novel, theory-based, and ethically-acceptable knowledge translation strategies to increase the numbers of available DCD organ donors in Canada. If successful, this study will ultimately lead to more transplantations, reducing patient morbidity and mortality at a population-level.