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Wall A, Gupta A, Testa G. Abdominal normothermic regional perfusion in the United States: current state and future directions. Curr Opin Organ Transplant 2024; 29:175-179. [PMID: 38506730 DOI: 10.1097/mot.0000000000001144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
PURPOSE OF REVIEW Normothermic regional perfusion (NRP) is a novel procurement technique for donation after circulatory death (DCD) in the United States. It was pioneered by cardiothoracic surgery programs and is now being applied to abdominal-only organ donors by abdominal transplant programs. RECENT FINDINGS Liver and kidney transplantation from thoracoabdominal NRP (TA-NRP) donors in the United States was found to have lower rates of delayed kidney graft function and similar graft and patient survival versus recipients of cardiac super rapid recovery (SRR) DCD donors. The excellent outcomes with NRP have prompted the expansion of NRP technology to abdominal transplant programs. SUMMARY Excellent early outcomes with liver and kidney transplantation have prompted the growth of NC-NRP procurement for abdominal-only DCD donors across the US, and now requires standardization of technical and nontechnical aspects of this procedure.
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Silpe S, Martinez E, Wall A. Normothermic regional perfusion procurement for abdominal organ donors: techniques and troubleshooting. Curr Opin Organ Transplant 2024; 29:200-204. [PMID: 38465664 DOI: 10.1097/mot.0000000000001140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW Normothermic regional perfusion (NRP) is a novel procurement technique for donation after circulatory death (DCD) in the United States. It was pioneered by cardiothoracic surgery programs and is now being applied to abdominal-only organ donors by abdominal transplant programs. Multiple technical approaches can be used for abdominal-only NRP DCD donors and this review describes these techniques. RECENT FINDINGS NRP has been associated with higher utilization of organs, particularly liver and heart grafts, from DCD donors and with better recipient outcomes. There are lower rates of delayed graft function in kidney transplant recipients and lower rates of ischemic cholangiopathy in liver transplant recipients. These benefits are driving increased interest from abdominal transplant programs in using NRP for DCD procurements. SUMMARY This paper describes the technical aspects of NRP DCD that allow for maximization of its use based on different donor and policy characteristics.
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Bommareddi S, Lima B, Shah AS, Trahanas JM. Thoraco-abdominal normothermic regional perfusion for thoracic transplantation in the United States: current state and future directions. Curr Opin Organ Transplant 2024; 29:180-185. [PMID: 38483139 DOI: 10.1097/mot.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2024]
Abstract
PURPOSE OF REVIEW To provide an update regarding the state of thoracoabdominal normothermic regional perfusion (taNRP) when used for thoracic organ recovery. RECENT FINDINGS taNRP is growing in its utilization for thoracic organ recovery from donation after circulatory death donors, partly because of its cost effectiveness. taNRP has been shown to yield cardiac allograft recipient outcomes similar to those of brain-dead donors. Regarding the use of taNRP to recover donor lungs, United Network for Organ Sharing (UNOS) analysis shows that taNRP recovered lungs are noninferior, and taNRP has been used to consistently recover excellent lungs at high volume centers. Despite its growth, ethical debate regarding taNRP continues, though clinical data now supports the notion that there is no meaningful brain perfusion after clamping the aortic arch vessels. SUMMARY taNRP is an excellent method for recovering both heart and lungs from donation after circulatory death donors and yields satisfactory recipient outcomes in a cost-effective manner. taNRP is now endorsed by the American Society of Transplant Surgeons, though ethical debate continues.
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Affiliation(s)
- Swaroop Bommareddi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Brubaker AL, Sellers MT, Abt PL, Croome KP, Merani S, Wall A, Abreu P, Alebrahim M, Baskin R, Bohorquez H, Cannon RM, Cederquist K, Edwards J, Huerter BG, Hobeika MJ, Kautzman L, Langnas AN, Lee DD, Manzi J, Nassar A, Neidlinger N, Nydam TL, Schnickel GT, Siddiqui F, Suah A, Taj R, Taner CB, Testa G, Vianna R, Vyas F, Montenovo MI. US Liver Transplant Outcomes After Normothermic Regional Perfusion vs Standard Super Rapid Recovery. JAMA Surg 2024:2817111. [PMID: 38568597 PMCID: PMC10993160 DOI: 10.1001/jamasurg.2024.0520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/06/2024] [Indexed: 04/06/2024]
Abstract
Importance Normothermic regional perfusion (NRP) is an emerging recovery modality for transplantable allografts from controlled donation after circulatory death (cDCD) donors. In the US, only 11.4% of liver recipients who are transplanted from a deceased donor receive a cDCD liver. NRP has the potential to safely expand the US donor pool with improved transplant outcomes as compared with standard super rapid recovery (SRR). Objective To assess outcomes of US liver transplants using controlled donation after circulatory death livers recovered with normothermic regional perfusion vs standard super rapid recovery. Design, Setting, and Participants This was a retrospective, observational cohort study comparing liver transplant outcomes from cDCD donors recovered by NRP vs SRR. Outcomes of cDCD liver transplant from January 2017 to May 2023 were collated from 17 US transplant centers and included livers recovered by SRR and NRP (thoracoabdominal NRP [TA-NRP] and abdominal NRP [A-NRP]). Seven transplant centers used NRP, allowing for liver allografts to be transplanted at 17 centers; 10 centers imported livers recovered via NRP from other centers. Exposures cDCD livers were recovered by either NRP or SRR. Main Outcomes and Measures The primary outcome was ischemic cholangiopathy (IC). Secondary end points included primary nonfunction (PNF), early allograft dysfunction (EAD), biliary anastomotic strictures, posttransplant length of stay (LOS), and patient and graft survival. Results A total of 242 cDCD livers were included in this study: 136 recovered by SRR and 106 recovered by NRP (TA-NRP, 79 and A-NRP, 27). Median (IQR) NRP and SRR donor age was 30.5 (22-44) years and 36 (27-49) years, respectively. Median (IQR) posttransplant LOS was significantly shorter in the NRP cohort (7 [5-11] days vs 10 [7-16] days; P < .001). PNF occurred only in the SRR allografts group (n = 2). EAD was more common in the SRR cohort (123 of 136 [56.1%] vs 77 of 106 [36.4%]; P = .007). Biliary anastomotic strictures were increased 2.8-fold in SRR recipients (7 of 105 [6.7%] vs 30 of 134 [22.4%]; P = .001). Only SRR recipients had IC (0 vs 12 of 133 [9.0%]; P = .002); IC-free survival by Kaplan-Meier was significantly improved in NRP recipients. Patient and graft survival were comparable between cohorts. Conclusion and Relevance There was comparable patient and graft survival in liver transplant recipients of cDCD donors recovered by NRP vs SRR, with reduced rates of IC, biliary complications, and EAD in NRP recipients. The feasibility of A-NRP and TA-NRP implementation across multiple US transplant centers supports increasing adoption of NRP to improve organ use, access to transplant, and risk of wait-list mortality.
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Affiliation(s)
- Aleah L. Brubaker
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, La Jolla, California
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
| | - Marty T. Sellers
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Tennessee Donor Services, Nashville
| | - Peter L. Abt
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | - Kristopher P. Croome
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Transplant, Mayo Clinic Florida, Jacksonville
| | - Shaheed Merani
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, University of Nebraska Medical Center, Omaha
| | - Anji Wall
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Phillipe Abreu
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami, Miami, Florida
| | | | - Roy Baskin
- Methodist Transplant Specialists, Dallas, Texas
| | - Humberto Bohorquez
- Department of Surgery, Ochsner School of Medicine, New Orleans, Louisiana
| | - Robert M. Cannon
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Kelly Cederquist
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | - John Edwards
- Gift of Life Donor Program, Philadelphia, Pennsylvania
| | | | - Mark J. Hobeika
- J.C. Walter Jr Transplant Center, Houston Methodist Hospital, Houston, Texas
| | | | - Alan N. Langnas
- Department of Surgery, University of Nebraska Medical Center, Omaha
| | - David D. Lee
- Department of Surgery, Loyola University, Chicago, Illinois
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Joao Manzi
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami, Miami, Florida
| | - Ahmed Nassar
- Department of Surgery, Emory University, Atlanta, Georgia
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | | | - Trevor L. Nydam
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, Division of Transplant Surgery, University of Colorado, Aurora
| | - Gabriel T. Schnickel
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, La Jolla, California
| | - Farjad Siddiqui
- Department of Surgery, The Ohio State University, Columbus
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Ashley Suah
- Department of Surgery, Emory University, Atlanta, Georgia
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Raeda Taj
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, La Jolla, California
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | | | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Rodrigo Vianna
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami, Miami, Florida
| | - Frederick Vyas
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | - Martin I. Montenovo
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, Vanderbilt University, Nashville, Tennessee
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Zhou AL, Rizaldi AA, Akbar AF, Ruck JM, King EA, Kilic A. Outcomes following concomitant multiorgan heart transplantation from circulatory death donors: The United States experience. J Heart Lung Transplant 2024:S1053-2498(24)01535-3. [PMID: 38548240 DOI: 10.1016/j.healun.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 02/03/2024] [Accepted: 03/16/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Donation after circulatory death (DCD) has reemerged as a method of expanding the donor heart pool. Given the high waitlist mortality of multiorgan heart candidates, we evaluated waitlist outcomes associated with willingness to consider DCD offers and post-transplant outcomes following DCD transplant for these candidates. METHODS We identified adult multiorgan heart candidates and recipients between January 1, 2020 and March 31, 2023 nationally. Among candidates that met inclusion criteria, we compared the cumulative incidence of transplant, with waitlist death/deterioration as a competing risk, by willingness to consider DCD offers. Among recipients of DCD versus brain death (DBD) transplants, we compared perioperative outcomes and post-transplant survival. RESULTS Of 1,802 heart-kidney, 266 heart-liver, and 440 heart-lung candidates, 15.8%, 12.4%, and 31.1%, respectively, were willing to consider DCD offers. On adjusted analysis, willingness to consider DCD offers was associated with higher likelihood of transplant for all multiorgan heart candidates and decreased likelihood of waitlist deterioration for heart-lung candidates. Of 1,100 heart-kidney, 173 heart-liver, and 159 heart-lung recipients, 5.4%, 2.3%, and 2.5%, respectively, received DCD organs. Recipients of DCD and DBD heart-kidney transplants had a similar likelihood of perioperative outcomes and 1-year survival. All other DCD multiorgan heart recipients have survived to the last follow-up. CONCLUSIONS Multiorgan heart candidates who were willing to consider DCD offers had favorable waitlist outcomes, and heart-kidney recipients of DCD transplants had similar post-transplant outcomes to recipients of DBD transplants. We recommend the use of DCD organs to increase the donor pool for these high-risk candidates.
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Affiliation(s)
- Alice L Zhou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Alexandra A Rizaldi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Armaan F Akbar
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Jessica M Ruck
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Elizabeth A King
- Division of Transplant Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland.
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Ibeabuchi T, Li E, Bittermann T, Mahmud N, Abt PL. Reply: How does ex vivo liver perfusion help improve the outcomes of liver transplantation in donation after cardiac death donors? Liver Transpl 2024; 30:E20-E21. [PMID: 37938126 DOI: 10.1097/lvt.0000000000000290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 11/09/2023]
Affiliation(s)
- Tobenna Ibeabuchi
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric Li
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Therese Bittermann
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nadim Mahmud
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter L Abt
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Motter JD, Jaffe IS, Moazami N, Smith DE, Kon ZN, Piper GL, Sommer PM, Reyentovich A, Chang SH, Aljabban I, Montgomery RA, Segev DL, Massie AB, Lonze BE. Single center utilization and post-transplant outcomes of thoracoabdominal normothermic regional perfusion deceased cardiac donor organs. Clin Transplant 2024; 38:e15269. [PMID: 38445531 DOI: 10.1111/ctr.15269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/26/2024] [Accepted: 02/09/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION Thoracoabdominal normothermic regional perfusion (TA-NRP) following cardiac death is an emerging multivisceral organ procurement technique. Recent national studies on outcomes of presumptive TA-NRP-procured organs are limited by potential misclassification since TA-NRP is not differentiated from donation after cardiac death (DCD) in registry data. METHODS We studied 22 donors whose designees consented to TA-NRP and organ procurement performed at our institution between January 20, 2020 and July 3, 2022. We identified these donors in SRTR to describe organ utilization and recipient outcomes and compared them to recipients of traditional DCD (tDCD) and donation after brain death (DBD) organs during the same timeframe. RESULTS All 22 donors progressed to cardiac arrest and underwent TA-NRP followed by heart, lung, kidney, and/or liver procurement. Median donor age was 41 years, 55% had anoxic brain injury, 45% were hypertensive, 0% were diabetic, and median kidney donor profile index was 40%. TA-NRP utilization was high across all organ types (88%-100%), with a higher percentage of kidneys procured via TA-NRP compared to tDCD (88% vs. 72%, p = .02). Recipient and graft survival ranged from 89% to 100% and were comparable to tDCD and DBD recipients (p ≥ .2). Delayed graft function was lower for kidneys procured from TA-NRP compared to tDCD donors (27% vs. 44%, p = .045). CONCLUSION Procurement from TA-NRP donors yielded high organ utilization, with outcomes comparable to tDCD and DBD recipients across organ types. Further large-scale study of TA-NRP donors, facilitated by its capture in the national registry, will be critical to fully understand its impact as an organ procurement technique.
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Affiliation(s)
- Jennifer D Motter
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Ian S Jaffe
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Nader Moazami
- Department of Cardiothoracic Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Deane E Smith
- Department of Cardiothoracic Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Zachary N Kon
- Department of Cardiothoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Greta L Piper
- Department of Cardiothoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Philip M Sommer
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Alex Reyentovich
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Stephanie H Chang
- Department of Cardiothoracic Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Imad Aljabban
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
- Department of Surgery, Columbia University School of Medicine, New York, New York, USA
| | - Robert A Montgomery
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Dorry L Segev
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
- Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
| | - Allan B Massie
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Bonnie E Lonze
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
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Ran G, Wall AE, Narang N, Khush KK, Hoffman JRH, Zhang KC, Parker WF. Post-transplant survival after normothermic regional perfusion versus direct procurement and perfusion in donation after circulatory determination of death in heart transplantation. J Heart Lung Transplant 2024:S1053-2498(24)01500-6. [PMID: 38423416 DOI: 10.1016/j.healun.2024.02.1456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 02/13/2024] [Accepted: 02/20/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Since 2019, the annual transplantation rate of hearts donated following circulatory death (DCD) has increased significantly in the United States. The 2 major heart procurement techniques following circulatory death are direct procurement and perfusion (DPP) and normothermic regional perfusion (NRP). Post-transplant survival for heart recipients has not been compared between these 2 techniques. METHODS This observational study uses data on adult heart transplants from donors after circulatory death from January 1, 2019 to December 31, 2021 in the Scientific Registry of Transplant Recipients. We identified comparable transplant cases across procurement types using propensity-score matching and measured the association between procurement technique and 1-year post-transplant survival using Kaplan-Meier and Cox proportional hazards model stratefied by matching pairs. RESULTS Among 318 DCD heart transplants, 216 (68%) were procured via DPP, and 102 (32%) via NRP. Among 22 transplant centers that accepted circulatory-death donors, 3 used NRP exclusively, and 5 used both procurement techniques. After propensity-score matching on recipient and donor factors, there was no significant difference in 1-year post-transplant survival (93.1% for NRP vs 91.1% for DPP, p = 0.79) between procurement techniques. CONCLUSIONS NRP and DPP procurements are associated with similar 1-year post-transplant survival. If NRP is ethically permissible and improves outcomes for abdominal organs, it should be the preferred procurement technique for DCD hearts.
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Affiliation(s)
- Gege Ran
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Anji E Wall
- Department of Transplant Surgery, Annette C. and Harrold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Nikhil Narang
- Department of Cardiology, Advocate Christ Medical Center, Chicago, Illinois; Department of Medicine, University of Illinois-Chicago, Chicago, Illinois
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Jordan R H Hoffman
- Division of Cardiothoracic Surgery, University of Colorado, Aurora, Colorado
| | - Kevin C Zhang
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - William F Parker
- Department of Medicine, University of Chicago, Chicago, Illinois; Department of Public Health Sciences, University of Chicago, Chicago, Illinois; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois.
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Zhou AL, Leng A, Ruck JM, Akbar AF, Desai NM, King EA. Kidney Donation After Circulatory Death Using Thoracoabdominal Normothermic Regional Perfusion: The Largest Report of the United States Experience. Transplantation 2024; 108:516-523. [PMID: 37691154 PMCID: PMC10840803 DOI: 10.1097/tp.0000000000004801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
BACKGROUND Thoracoabdominal normothermic regional perfusion (TA-NRP) has been increasingly used for donation after circulatory death (DCD) procurements in the United States. We present the largest report of outcomes of kidney transplants performed using DCD donor grafts perfused with TA-NRP. METHODS Adult DCD kidney transplants between 2020 and 2022 in the United Network for Organ Sharing database were included. Donors with ≥50 min between asystole and aortic cross-clamp time in which the heart was also transplanted were considered TA-NRP donors. All other donors were considered direct recovery donors. Multivariable regressions were used to assess delayed graft function, as well as posttransplant survival and all-cause graft failure at 30, 90, and 180 d. A propensity-matched analysis of cohorts matched on donor Kidney Donor Profile Index was performed. RESULTS Of the 16 140 total DCD kidney transplants performed during the study period, 306 (1.9%) used TA-NRP. TA-NRP donors were younger ( P < 0.001) and had lower Kidney Donor Profile Index ( P < 0.001) compared with direct recovery donors. Recipients receiving grafts recovered using TA-NRP were younger ( P < 0.001) and more likely to be blood group O ( P < 0.001). Transplants using TA-NRP had lower likelihood of delayed graft function (adjusted odds ratio 0.22 [95% confidence interval, 0.15-0.31], P < 0.001) but similar 180-d survival ( P = 0.8) and all-cause graft failure ( P = 0.3) as transplants using direct recovery grafts. These inferences were unchanged on propensity-matched analysis. CONCLUSIONS Our results demonstrate that kidney transplants using TA-NRP DCD allografts have positive short-term mortality and graft survival outcomes, with significantly decreased rates of delayed graft function compared with direct recovery DCD grafts.
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Affiliation(s)
- Alice L. Zhou
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Albert Leng
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jessica M. Ruck
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Armaan F. Akbar
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Niraj M. Desai
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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Wall AE, Adams BL, Brubaker A, Chang CWJ, Croome KP, Frontera J, Gordon E, Hoffman J, Kaplan LJ, Kumar D, Levisky J, Miñambres E, Parent B, Watson C, Zemmar A, Pomfret EA. The American Society of Transplant Surgeons Consensus Statement on Normothermic Regional Perfusion. Transplantation 2024; 108:312-318. [PMID: 38254280 DOI: 10.1097/tp.0000000000004894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
On June 3, 2023, the American Society of Transplant Surgeons convened a meeting in San Diego, California to (1) develop a consensus statement with supporting data on the ethical tenets of thoracoabdominal normothermic regional perfusion (NRP) and abdominal NRP; (2) provide guidelines for the standards of practice that should govern thoracoabdominal NRP and abdominal NRP; and (3) develop and implement a central database for the collection of NRP donor and recipient data in the United States. National and international leaders in the fields of neuroscience, transplantation, critical care, NRP, Organ Procurement Organizations, transplant centers, and donor families participated. The conference was designed to focus on the controversial issues of neurological flow and function in donation after circulatory death donors during NRP and propose technical standards necessary to ensure that this procedure is performed safely and effectively. This article discusses major topics and conclusions addressed at the meeting.
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Affiliation(s)
- Anji E Wall
- Division of Abdominal Transplantation, Baylor Simmons Transplant Institute, Dallas, TX
| | | | - Aleah Brubaker
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Cherylee W J Chang
- Neurocritical Care Division, Department of Neurology, Duke University, Durham, NC
| | | | - Jennifer Frontera
- Department of Neurology, NYU Grossman School of Medicine, New York, NY
| | - Elisa Gordon
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Jordan Hoffman
- Heart and Lung Transplantation and CTEPH Program, University of Colorado School of Medicine, Anschutz Medical Campus, Denver, CO
| | - Lewis J Kaplan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Surgical Critical Care Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Deepali Kumar
- Transplant Infectious Diseases, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Josh Levisky
- Division of Hepatology, Department of Medicine, Northwestern Medicine, Chicago, IL
| | - Eduardo Miñambres
- Donor Transplant Coordination Unit and Intensive Care Service, Hospital Universitario de Marqués de Valdecilla-IDIVAL, Spain
| | - Brendan Parent
- Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY
| | - Christopher Watson
- Department of Surgery, University of Cambridge, Cambridge, United Kingdom
| | - Ajmal Zemmar
- Department of Neurosurgery, University of Louisville, Louisville, KY
| | - Elizabeth A Pomfret
- Division of Transplant Surgery and Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Denver, CO
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Wall AE, Da Graca B, Asrani SK, Ruiz R, Fernandez H, Gupta A, Martinez E, Bayer J, McKenna G, He Lee S, Trotter JF, Testa G. A cost comparison of liver acquisition fees for donation after circulatory death versus donation after brain death donors. Liver Transpl 2024:01445473-990000000-00312. [PMID: 38190240 DOI: 10.1097/lvt.0000000000000328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/14/2023] [Indexed: 01/09/2024]
Abstract
Donation after circulatory death (DCD) donors now represent over 30% of the deceased donor pool in the United States. Compared to donation after brain death, DCD is less likely to result in transplantation. For each potential donor whose organs cannot be utilized for transplantation (ie, dry run), fees are associated with the attempted donation, which add to the overall costs of organ acquisition. To better characterize the true costs of DCD liver acquisition, we performed a cost comparison of the fees associated with organ acquisition for DCD versus donation after brain death at a single transplant institute that comprises 2 liver transplant centers. Cost, recipient, and transportation data for all cases, including fees associated with liver acquisition from July 1, 2019, to October 31, 2021, were collected. We found that the total cost of DCD liver acquisition per liver transplant was $15,029 more than that for donation after brain death donation, with 18% of the costs of the DCD transplant attributed to dry runs. Overall, the costs associated with DCD transplantation accounted for 34.5% of the total organ acquisition costs; however, DCD transplantation accounted for 30.3% of the transplantation volume. Because the expansion of DCD is essential to increasing the availability of liver grafts for transplantation, strategies need to be implemented to decrease the costs associated with dry runs, including using local recovery, transferring donors to hospitals close to transplant centers, and performing more prerecovery organ analysis. Moreover, these strategies are needed to ensure that financial disincentives to DCD procurement and utilization do not reverse the gains made by expanding the organ donor pool using machine perfusion technologies.
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Affiliation(s)
- Anji E Wall
- Baylor Simmons Transplant Institute, Dallas, Texas, USA
| | - Briget Da Graca
- Baylor, Scott and White Research Institute, Dallas, Texas, USA
| | | | - Richard Ruiz
- Baylor Simmons Transplant Institute, Dallas, Texas, USA
| | | | - Amar Gupta
- Baylor Simmons Transplant Institute, Dallas, Texas, USA
| | - Eric Martinez
- Baylor Simmons Transplant Institute, Dallas, Texas, USA
| | - Johanna Bayer
- Baylor Simmons Transplant Institute, Dallas, Texas, USA
| | | | - Seung He Lee
- Baylor Simmons Transplant Institute, Dallas, Texas, USA
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Merani S, Urban M, Westphal SG, Dong J, Miles CD, Maskin A, Hoffman A, Langnas AN. Improved Early Post-Transplant Outcomes and Organ Use in Kidney Transplant Using Normothermic Regional Perfusion for Donation after Circulatory Death: National Experience in the US. J Am Coll Surg 2024; 238:107-118. [PMID: 37772721 DOI: 10.1097/xcs.0000000000000880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
BACKGROUND Normothermic regional perfusion (NRP) is a technique that is intended to enhance organ transplant outcomes from donation circulatory death (DCD) donors. STUDY DESIGN A retrospective analysis of data from the Scientific Registry of Transplant Recipients was performed. DCD donors were screened for inclusion based on date of donation 2020 or later, and whether the heart was also recovered for transplantation. We grouped donors as either donation after brain death or DCD. DCD donors were further divided into groups including those in which the heart was not recovered for transplant (Non-Heart DCD) and those in which it was, based on recovery technique (thoracoabdominal-NRP [TA-NRP] Heart DCD and Super Rapid Recovery Heart DCD). RESULTS A total of 219 kidney transplant recipients receiving organs from TA-NRP Heart DCD donors were compared to 436 SRR Super Rapid Recovery DCD, 10,630 Super Rapid Recovery non-heart DCD, and 27,820 donations after brain death recipients. Kidney transplant recipients of TA-NRP DCD allografts experienced shorter length of stay, lower rates of delayed graft function, and lower serum creatinine at the time of discharge when compared with recipients of other DCD allografts. CONCLUSIONS Our analysis demonstrates superior early kidney allograft function when TA-NRP is used for DCD organ recovery.
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Affiliation(s)
- Shaheed Merani
- From the Division of Transplant, Department of Surgery (Merani, Maskin, Hoffman, Langnas), University of Nebraska Medical Center, Omaha, NE
| | - Marian Urban
- Division of Cardiothoracic Surgery, Department of Surgery (Urban), University of Nebraska Medical Center, Omaha, NE
| | - Scott G Westphal
- Division of Nephrology Department of Medicine (Westphal, Dong, Miles), University of Nebraska Medical Center, Omaha, NE
| | - James Dong
- Division of Nephrology Department of Medicine (Westphal, Dong, Miles), University of Nebraska Medical Center, Omaha, NE
- Department of Biostatistics (Dong), University of Nebraska Medical Center, Omaha, NE
| | - Clifford D Miles
- Division of Nephrology Department of Medicine (Westphal, Dong, Miles), University of Nebraska Medical Center, Omaha, NE
| | - Alexander Maskin
- From the Division of Transplant, Department of Surgery (Merani, Maskin, Hoffman, Langnas), University of Nebraska Medical Center, Omaha, NE
| | - Arika Hoffman
- From the Division of Transplant, Department of Surgery (Merani, Maskin, Hoffman, Langnas), University of Nebraska Medical Center, Omaha, NE
| | - Alan N Langnas
- From the Division of Transplant, Department of Surgery (Merani, Maskin, Hoffman, Langnas), University of Nebraska Medical Center, Omaha, NE
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13
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Joshi Y, Macdonald PS. Heart Transplantation From DCD Donors Enters the Mainstream. Transplantation 2023; 107:2449-2450. [PMID: 38010153 DOI: 10.1097/tp.0000000000004761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Affiliation(s)
- Yashutosh Joshi
- Heart Transplant Unit, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- Faculty of Medicine, St Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
| | - Peter S Macdonald
- Heart Transplant Unit, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- Faculty of Medicine, St Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
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Wall AE, Rosenzweig M, McKenna GJ, Ma TW, Asrani SK, Testa G. Clarification on the 6-month abdominal transplant recipient outcomes from donation after circulatory death heart donors: A retrospective analysis by procurement technique. Am J Transplant 2023; 23:1817-1818. [PMID: 37604430 DOI: 10.1016/j.ajt.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/04/2023] [Accepted: 08/10/2023] [Indexed: 08/23/2023]
Affiliation(s)
- Anji Elizabeth Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA.
| | - Matthew Rosenzweig
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Gregory J McKenna
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Tsung-Wei Ma
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Sumeet K Asrani
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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Wall AE, Thiessen C, Pomfret EA. Organ Procurement Using Normothermic Regional Perfusion. JAMA 2023; 330:1390. [PMID: 37815571 DOI: 10.1001/jama.2023.16887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Affiliation(s)
- Anji E Wall
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Carrie Thiessen
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Elizabeth Anne Pomfret
- Division of Transplant Surgery, Colorado Center for Transplantation Care, Research, and Education, University of Colorado Anschutz Medical Campus, Aurora
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