Donation After Brain Death Research Articles

Outcomes of liver transplantation for hepatocellular carcinoma in donation after circulatory death compared with donation after brain death: A systematic review and meta-analysis

Introduction and ObjectivesDue to organ shortages, liver transplantation (LT) using donation-after-circulatory-death (DCD) grafts has become more common. There is limited and conflicting evidence on LT outcomes using DCD grafts compared to those using donation-after-brain death (DBD) grafts for patients with hepatocellular carcinoma (HCC). We aimed to summarize the current evidence on the outcomes of DCD-LT and DBD-LT in patients with HCC. Materials and MethodsOnline databases were searched for studies comparing DCD-LT and DBD-LT outcomes in patients with HCC and a meta-analysis was conducted using fixed- or random-effects models. ResultsFive studies involving 487 (33.4%) HCC DCD-LT patients and 973 (66.6%) DBD-LT patients were included. The meta-analysis showed comparable 1-year [relative risk (RR)=0.99, 95%CI:0.95 to 1.03, p=0.53] and 3-year [RR=0.99, 95%CI:0.89 to 1.09, p=0.79] recurrence-free survival. The corresponding 1-year [RR=0.98, 95%CI:0.93 to 1.03, p=0.35] and 3-year [RR=0.94, 95%CI:0.87 to 1.01, p=0.08] patient survival and 1-year [RR=0.91, 95%CI:0.71 to 1.16, p=0.43] and 3-year [RR=0.92, 95%CI:0.67 to 1.26, p=0.59] graft survival were also comparable. There were no significant differences between the two cohorts regarding the tumor characteristics, donor/recipient risk factors and the incidence of post-operative complications, including acute rejection, primary non-function, biliary complications and retransplantation. ConclusionsBased on the current evidence, it has been found that comparable outcomes can be achieved in HCC patients using DCD-LT compared to DBD-LT, particularly when employing good quality graft, strict donor and recipient selection, and effective surgical management. The decision to utilize DCD-LT for HCC patients should be personalized, taking into consideration the risk of post-LT HCC recurrence. (PROSPERO ID: CRD42023445812).

Old for young kidney transplantation: a responsible option for our patients to reduce waiting time?

PurposeThe Eurotransplant Senior program allocating grafts from donors ≥ 65 years to recipients aged ≥ 65 years has proven good results within the last 20 years. However, “old” grafts are also allocated to younger recipients < 65 years, and this outcome of “old for young” kidney transplantations (KT) still lacks detailed investigations.MethodsAll “old for young” KT performed at four tertiary referral centers were retrospectively compared including a recent follow-up, stratifying for “old for young” (donor ≥ 65 years to recipient < 65 years) vs. “very old for young” KT (donor ≥ 70 years to recipient < 65 years).ResultsOverall, 99 patients were included with 56 (56.6%) “old for young” and 43 (43.4%) “very old for young” KT. The median waiting time did not differ (60.7 vs. 45.8 months, respectively) at comparable living donation rates (57.1% vs. 44.2%) as well as intra- and postoperative results. At a median follow-up of 44 months (range 1; 133), the 3-year graft survival of 91% vs. 87% did not significantly vary. In subgroup analyses assessing living donation or donation after brain death (DBD) KT only, the graft survival was significantly longer for “old for young” KT within the living donation subgroup. In multivariate Cox regression analyses, the presence of panel-reactive antibodies was the only significant impact factor on graft survival (HR 8.32, p = 0.001).ConclusionThis analysis clearly demonstrates the effectiveness of the "old for young" approach, enabling favorable perioperative results as well as comparable data of graft- and overall survival, while reducing waiting time for eligible patients.

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

ObjectivesThis 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...

Increasing Utilization of Extended Criteria Donor Hearts for Transplantation: The OCS Heart EXPAND Trial

BackgroundExtended criteria donor (ECD) hearts available with donation after brain death (DBD) are underutilized for transplantation due to limitations of cold storage. ObjectivesThis study evaluated use of an extracorporeal perfusion system on donor heart utilization and post-transplant outcomes in ECD DBD hearts. MethodsIn this prospective, single-arm, multicenter study, adult heart transplant recipients received ECD hearts using an extracorporeal perfusion system if hearts met study criteria. The primary outcome was a composite of 30-day survival and absence of severe primary graft dysfunction (PGD). Secondary outcomes were donor heart utilization rate, 30-day survival, and incidence of severe PGD. The safety outcome was the mean number of heart graft–related serious adverse events within 30 days. Additional outcomes included survival through 2 years benchmarked to concurrent nonrandomized control subjects. ResultsA total of 173 ECD DBD hearts were perfused; 150 (87%) were successfully transplanted; 23 (13%) did not meet study transplantation criteria. At 30 days, 92% of patients had survived and had no severe PGD. The 30-day survival was 97%, and the incidence of severe PGD was 6.7%. The mean number of heart graft–related serious adverse events within 30 days was 0.17 (95% CI: 0.11-0.23). Patient survival was 93%, 89%, and 86% at 6, 12, and 24 months, respectively, and was comparable with concurrent nonrandomized control subjects. ConclusionsUse of an extracorporeal perfusion system resulted in successfully transplanting 87% of donor hearts with excellent patient survival to 2 years post-transplant and low rates of severe PGD. The ability to safely use ECD DBD hearts could substantially increase the number of heart transplants and expand access to patients in need. (International EXPAND Heart Pivotal Trial [EXPANDHeart]; NCT02323321; Heart EXPAND Continued Access Protocol; NCT03835754)

Trends in kidney transplantation and living donor nephrectomy in Germany: a total population analysis from 2006 to 2021.

To analyze recent trends of surgical access routes, length of hospital stay (LOS), and mortality in kidney transplantation (KT) and living donor nephrectomy (LDN) in Germany. We studied the nationwide German hospital billing database and the German hospital quality reports from 2006 to 2021. There were a total of 35.898 KTs. In total, 9044 (25%) were living donor transplantations, while 26.854 (75%) were transplantations after donation after brain death (DBD). The share of open LDN decreased from 82% in 2006 to 22% in 2020 (-4%/year; p < 0.001). The share of laparoscopic LDN increased from 18% in 2006 to 70% in 2020 (+ 3%/year; p < 0.001). The share of robotic LDN increased from 0% in 2006 to 8% in 2020 (+ 0.6%/year; p < 0.001). Robotic-assisted KT increased from 5 cases in 2016 to 13 procedures in 2019 (p = 0.2). LOS was shorter after living donor KT, i.e., 18 ± 12.1days versus 21 ± 19.6days for DBD renal transplantation (p < 0.001). Moreover, LOS differed for open versus laparoscopic versus robotic LDN (9 ± 3.1 vs. 8 ± 2.9 vs. 6 ± 2.6; p = 0.031). The overall in-hospital mortality was 0.16% (n = 5) after LDN, 0.47% (n = 42) after living donor KT and 1.8% (n = 475) after DBD KT. There is an increasing trend toward minimal-invasive LDN in recent years. Overall, in-hospital mortality was low after KT. However, 5 deceased healthy donors after LKD caution that the risks of this procedure should also be taken very seriously.

A cost comparison of liver acquisition fees for donation after circulatory death versus donation after brain death donors.

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.

NADPH oxidase overexpression and mitochondrial OxPhos impairment are more profound in human hearts donated after circulatory death than brain death.

This study investigated cardiac stress and mitochondrial oxidative phosphorylation (OxPhos) in human donation after circulatory death (DCD) hearts regarding warm ischemic time (WIT) and subsequent cold storage and compared them with that of human brain death donor (DBD) hearts. A total of 24 human hearts were procured for the research study-6 in the DBD group and 18 in the DCD group. DCD group was divided into three groups (n = 6) based on different WITs (20, 40, and 60 min). All hearts received del Nido cardioplegia before being placed in normal saline cold storage for 6 h. Left ventricular biopsies were performed at hours 0, 2, 4, and 6. Cardiac stress [nicotinamide adenine dinucleotide phosphate (NADPH) oxidase subunits: 47-kDa protein of phagocyte oxidase (p47phox), 91-kDa glycoprotein of phagocyte oxidase (gp91phox)] and mitochondrial oxidative phosphorylation [OxPhos, complex I (NADH dehydrogenase) subunit of ETC (CI)-complex V (ATP synthase) subunit of ETC (CV)] proteins were measured in cardiac tissue and mitochondria respectively. Modulation of cardiac stress and mitochondrial dysfunction were observed in both DCD and DBD hearts. However, DCD hearts suffered more cardiac stress (overexpressed NADPH oxidase subunits) and diminished mitochondrial OxPhos than DBD hearts. The severity of cardiac stress and impaired oxidative phosphorylation in DCD hearts correlated with the longer WIT and subsequent cold storage time. More drastic changes were evident in DCD hearts with a WIT of 60 min or more. Activation of NADPH oxidase via overproduction of p47phox and gp91phox proteins in cardiac tissue may be responsible for cardiac stress leading to diminished mitochondrial oxidative phosphorylation. These protein changes can be used as biomarkers for myocardium damage and might help assess DCD and DBD heart transplant suitability.NEW & NOTEWORTHY First human DCD heart research studied cardiac stress and mitochondrial dysfunction concerning WIT and the efficacy of del Nido cardioplegia as an organ procurement solution and subsequent cold storage. Mild to moderate cardiac stress and mitochondrial dysfunction were noticed in DCD hearts with WIT 20 and 40 min and cold storage for 4 and 2 h, respectively. These changes can serve as biomarkers, allowing interventions to preserve mitochondria and extend WIT in DCD hearts.

Comparison of Kidney Graft Function and Survival in an Emulated Trial With Living Donors and Brain-Dead Donors.

Living donation (LD) transplantation is the preferred treatment for kidney failure as compared to donation after brain death (DBD), but age may play a role. We compared the 1-year estimated glomerular filtration rate (eGFR) after kidney transplantation for recipients of LD and DBD stratified by recipient and donor age between 2015 and 2018 in a matched cohort. The strength of the association between donation type and 1-year eGFR differed by recipient age (P interaction < 0.0001). For LD recipients aged 40-54years versus same-aged DBD recipients, the adjusted odds ratio (aOR) for eGFR ≥60mL/min/1.73m2 was 1.48 (95% CI: 1.16-1.90). For DBD recipients aged ≥ 60years, the aOR was 0.18 (95% CI: 0.12-0.29) versus DBD recipients aged 40-54years but was 0.91 (95% CI: 0.67-1.24) versus LD recipients aged ≥60years. In the matched cohort, 4-year graft and patient survival differed by donor age and type. As compared with DBD grafts, LD grafts increased the proportion of recipients with 1-year eGFR ≥60mL/min/1.73m2. Recipients aged ≥60years benefited most from LD transplantation, even if the donor was aged ≥60years. For younger recipients, large age differences between donor and recipient could also be addressed with a paired exchange program.

Ex Situ Left Ventricular Pressure-Volume Loop Analyses for Donor Hearts: Proof of Concept in an Ovine Experimental Model.

Ex situ heart perfusion (ESHP) has emerged as an important strategy to preserve donation after brain death (DBD) and donation after circulatory death (DCD) donor hearts. Clinically, both DBD and DCD hearts are successfully preserved using ESHP. Viability assessment is currently based on biochemical values, while a reliable method for graft function assessment in a physiologic working mode is unavailable. As functional assessment during ESHP has demonstrated the highest predictive value of outcome post-transplantation, this is an important area for improvement. In this study, a novel method for ex situ assessment of left ventricular function with pressure-volume loop analyses is evaluated. Ovine hearts were functionally evaluated during normothermic ESHP with the novel pressure-volume loop system. This system provides an afterload and adjustable preload to the left ventricle. By increasing the preload and measuring end-systolic elastance, the system could successfully assess the left ventricular function. End-systolic elastance at 60min and 120min was 2.8 ± 1.8mmHg/mL and 2.7 ± 0.7mmHg/mL, respectively. In this study we show a novel method for functional graft assessment with ex situ pressure-loop analyses during ESHP. When further validated, this method for pressure-volume assessments, could be used for better graft selection in both DBD and DCD donor hearts.

Cold Ischemia Time as a Risk Factor for Graft Dysfunction Types in Kidney Transplant Recipients.

Introduction: Cold Ischemia time (CIT) could be informative regarding the possibility of slow graft function (SGF) or delayed graft function (DGF). We aim to determine the incidence of graft dysfunction types and the association with ischemia time. Material and Methods: We performed a prospective study on 54 adults KT recipients, transplanted between 1 of January 2019 and 31 of December 2019. Graft was defined and classified into three categories: immediate graft function (IGF), SGF, and DGF. Cox regression analysis has been used to identify risk factors for graft dysfunction. Results: According to multivariate Cox regression analysis, it was observed that CIT [HR = 1.004, 95%CI = 1.001-1.007, p = 0.007] was an independent risk factor for the occurrence of graft dysfunction, while the brain death donor [HR = 11.94, 95%CI = 0.73-194.94, p = 0.08] and diabetes [HR = 2.71, 95%CI = 0.083-8.80, p = 0.09] had a trend of association with the followed outcome. In two separate models of multivariate we found that CIT was an independent risk factor for DGF [HR = 1.003, 95%CI = 1.001-1.006, p = 0.01], but not for SGF. Conclusion: In conclusion we found that kidney graft dysfunction types are associated with high CIT and CIT was an important risk factor for DGF, but no SGF in KT recipients.

Beating Heart Transplantation: How to Do It.

Heart transplantation utilizing deceased after circulatory death (DCD) donors has expanded the donor pool through the use of ex vivo normothermic perfusion. Compared with brain death donation, the conventional method of performing DCD heart transplantation includes an additional period of warm and cold ischemia. We have developed a beating heart implantation technique that obliviates the need for a second cardioplegic arrest and the associated reperfusion injury. We hypothesize this reproducible method may improve short-term and long-term outcomes to mirror results seen in brain death donors and provide details on how to perform beating heart transplantation.

Pre-recovery biopsy as a tool to optimize liver allocation from brain death donors

Pre-recovery biopsy as a tool to optimize liver allocation from brain death donors

Lung Transplantation in Controlled Donation after Circulatory-Determination-of-Death Using Normothermic Abdominal Perfusion.

The main limitation to increased rates of lung transplantation (LT) continues to be the availability of suitable donors. At present, the largest source of lung allografts is still donation after the neurologic determination of death (brain-death donors, DBD). However, only 20% of these donors provide acceptable lung allografts for transplantation. One of the proposed strategies to increase the lung donor pool is the use of donors after circulatory-determination-of-death (DCD), which has the potential to significantly alleviate the shortage of transplantable lungs. According to the Maastricht classification, there are five types of DCD donors. The first two categories are uncontrolled DCD donors (uDCD); the other three are controlled DCD donors (cDCD). Clinical experience with uncontrolled DCD donors is scarce and remains limited to small case series. Controlled DCD donation, meanwhile, is the most accepted type of DCD donation for lungs. Although the DCD donor pool has significantly increased, it is still underutilized worldwide. To achieve a high retrieval rate, experience with DCD donation, adequate management of the potential DCD donor at the intensive care unit (ICU), and expertise in combined organ procurement are critical. This review presents a concise update of lung donation after circulatory-determination-of-death and includes a step-by-step protocol of lung procurement using abdominal normothermic regional perfusion.

Later Brain Death Declaration Correlates to Favorable Donor Characteristics but Decreased Heart Acceptance.

With rates of potential donor heart discard as high as 66% nationally, quality improvement efforts must seek to optimize donor utilization. Whether the timing of donor brain death declaration (BDD) influences organ acceptance is understudied. The authors sought to characterize the impacts of time between donor hospital admission and BDD on heart utilization and posttransplant outcomes. All potential heart donors and recipients in the United Network for Organ Sharing database were identified (2006-2021). Admission-to-BDD cohorts were: 1 to 2 d (n = 52 469), 3 to 4 d (n = 44 033), 5 to 7 d (n = 24 509), and 8 to 10 d (n = 8576). Donor clinical characteristics were compared between cohorts, and donor acceptance was assessed using multivariable binary logistic regression. Recipient posttransplant survival was assessed with the Kaplan-Meier method. Donor demographics and comorbidity profiles (diabetes and hypertension) were comparable across cohorts. Anoxia/overdose deaths were more common (10% > 21% > 24% > 18%, respectively) and cardiopulmonary resuscitation requirements were higher (37% > 52% > 58% > 47%) when BDD occurred longer after admission. Renal dysfunction (44% > 44% > 35% > 29%) and inotrope requirements (52% > 25% > 36% > 29%) were lower in the later BDD cohorts. Proportions of hepatic dysfunction (18%-21%) and left ventricular ejection fraction <50% (13%-16%) were clinically equivalent. Donor acceptance differed by admission-to-BDD cohort (36% [1-2 d], 34% [3-4 d], 30% [5-7 d], and 28% [8-10 d]). Admission-to-BDD >4 d was independently associated with lower odds of acceptance on multivariable analysis (odds ratio 0.79, P < 0.001). Recipients experienced equivalent posttransplant survival for all donor admission-to-BDD cohorts ( P = 0.999 adults and P = 0.260 pediatrics). Heart donors with later BDD were disproportionately discarded despite similar-to-favorable overall clinical profiles, resulting in nearly 3000 fewer transplants during the study. Increased utilization of donors with later BDD and "high-risk" characteristics (eg, anoxia/overdose, cardiopulmonary resuscitation requirement) can improve rates of transplantation without compromising outcomes.

Metabolomic profiling during ex situ normothermic perfusion before heart transplantation defines patterns of substrate utilization and correlates with markers of allograft injury

PURPOSECardiac metabolism is altered in heart failure and ischemia-reperfusion injury states. We hypothesized that metabolomic profiling during ex-situ normothermic perfusion before heart transplantation (HT) would lend insight into myocardial substrate utilization and report on subclinical and clinical allograft dysfunction risk. METHODSMetabolomic profiling was performed on serial samples of ex-situ normothermic perfusate assaying biomarkers of myocardial injury in lactate and cardiac troponin I (TnI) as well as metabolites (66 acylcarnitines, 15 amino acids, non-esterified fatty acids (NEFA), ketones, and 3-hydroxybutyrate). We tested for change over time in injury biomarkers and metabolites, along with differential changes by recovery strategy (donation after circulatory death (DCD) v. donation after brain death (DBD)). We examined associations between metabolites, injury biomarkers, and primary graft dysfunction (PGD). Analyses were performed using linear mixed models adjusted for recovery strategy, assay batch, donor predicted heart mass, and time. RESULTSA total of 176 samples from 92 ex-situ perfusion runs were taken from donors with a mean age of 35 years (SD 11.3) years and a median total ex-situ perfusion time of 234 (IQR 84) minutes. Lactate trends over time differed significantly by recovery strategy, while TnI increased during ex-situ perfusion regardless of DCD v. DBD status. We found fuel substrates were rapidly depleted during ex-situ perfusion, most notably the branched-chain amino acids leucine/isoleucine, as well as ketones, 3-hydroxybutyrate, and NEFA (least squares (LS) mean difference from the first to last timepoint -1.7 - -4.5, FDR q<0.001). Several long-chain acylcarnitines (LCAC), including C16, C18, C18:1, C18:2, C18:3, C20:3, and C20:4 increased during the perfusion run (LS mean difference 0.42 – 0.67, q<0.001). Many LCACs were strongly associated with lactate and TnI. The change over time of many LCACs was significantly different for DCD vs. DBD, suggesting differential trends in fuel substrate utilization by ischemic injury pattern. Changes in leucine/isoleucine, arginine, C12:1-OH/C10:1-DC, and C16-OH/C14-DC were associated with increased odds of moderate-severe PGD. Neither end-of-run nor change in lactate or TnI was associated with PGD. CONCLUSIONMetabolomic profiling of ex-situ normothermic perfusion solution reveals a pattern of fuel substrate utilization that correlates with subclinical and clinical allograft dysfunction. This study highlights a potential role for interventions focused on fuel substrate modification in allograft conditioning during ex-situ perfusion to improve allograft outcomes.

Ex vivo lung perfusion moderates gene expression differences between cardiac death and brain death donor lungs

Donation after cardiac death (DCD) donor lungs have been shown to express less pro-inflammatory genes than donation after brain death (DBD) lungs, likely due to the absence of brain-death related inflammatory physiology. However, it is unclear whether this difference is clinically significant following reperfusion. To avoid confounding by the recipient immune system and activation state, we utilized ex vivo lung perfusion (EVLP) as a reperfusion-like event and examined the effect of EVLP on the transcriptome of DCD (n=39) and DBD (n=49) lungs. To validate our RNA results, banked EVLP perfusates from a separate cohort of DCD (n=24) and DBD (n=24) cases were assayed for IL-6, IL-8, IL-10, IL-1β, sTNFR1, and sTREM1 protein levels at 15 min intervals for three hours. While DCD lungs demonstrated lower levels of pro-inflammatory transcripts and perfusate cytokine protein levels than DBD lungs prior to EVLP, after EVLP there were no significant gene expression differences or cytokine protein levels between groups. Therefore, while DCD and DBD lungs differ by the amounts of pro-inflammatory cytokines following procurement, the propagation of inflammation becomes limited during EVLP, and DBD and DCD lungs reach a similar plateau of transcript expression, including pro-inflammatory cytokines at the end of perfusion. EVLP may therefore play a pre-conditioning role by dampening the pro-inflammatory state prior to transplant reperfusion.

Should advanced donor age be a deterrent in the utilization of grafts from donation after cardiac death in deceased donor liver transplantation? The Toronto experience.

Advanced donor age paired with donation after cardiac death (DCD) increases the risk of transplantation, precluding widespread use of grafts from such donors worldwide. Our aim was to analyze outcomes of liver transplantation using grafts from older DCD donors and donation after brain death (DBD) donors. Patients who underwent liver transplantation using grafts from deceased donors between January 2016 and December 2021 were included in the study. Short-and long-term outcomes were analyzed for 4 groups of patients: those who received DCD and DBD grafts from younger (< 50 yr) and older (≥ 50 yr) donors. Of the 807 patients included in the analysis, 44.7% (n = 361) of grafts were received from older donors, with grafts for older DCD donors comprising 4.7% of the total cohort (n = 38). Patients who received grafts from older donors had a lower incidence of biliary strictures than those who received grafts from younger donors (7.9% v. 20.0% for DCD donation, p = 0.14, and 4.9% v. 6.8% for DBD donation, p = 0.34), with a significantly lower incidence of ischemic-type biliary strictures in patients who received grafts from older versus younger DCD donors (2.6% v. 18.0%, p = 0.04). There was no difference in 1- and 3-year graft survival rates among patients who received grafts from older and younger DCD donors (92.1% v. 90.8% and 80.2% v. 80.9%, respectively) and those who received grafts from older and younger DBD donors (90.1% v. 93.2% and 85.3% v. 84.4%, respectively) (p = 0.85). Pretransplantation admission to the intensive care unit (hazard ratio [HR] 9.041, p < 0.001) and nonalcoholic steatohepatitis (HR 2.197, p = 0.02) were found to significantly affect survival of grafts from older donors. Donor age alone should not be the criterion to determine the acceptability of grafts in liver transplantation. With careful selection criteria, older DCD donors could make a valuable contribution to expanding the liver donor pool, with grafts that produce comparable results to those obtained with standard-criteria grafts.

A Single-center Exploration of Attitudes to Deceased Organ Donation Over Time Among Healthcare Staff in Intensive Care.

Changes to deceased organ donation in the United Kingdom, including establishment of the specialist nurse for organ donation (SNOD) role, have resulted in increased numbers of donations. Have increasing numbers of donations altered attitudes among intensive care unit (ICU) healthcare professionals (ICU staff) to organ donation over time? A written survey of ICU staff at Nottingham University Hospitals National Health Service Trust was conducted across 2 wk in 2015, 2018, and 2020 (pre-COVID-19). Participants were asked to submit descriptors (words/phrases) they associated with 3 aspects of donation: donation after brain death (DBD), donation after circulatory death (DCD), and SNOD role. Three independent and blinded assessors categorized the descriptors as positive or negative in favorability. Thematic analysis was used to identify trends within each group of descriptors. Across the 3 surveys, 281 responses were returned, containing a total of 2095 descriptors. Positive descriptors were found in 65% of DBD responses, 46% of DCD responses, and 92% of SNOD role. Over time, there was some evidence of increased polarization of opinion for DCD and to a smaller degree DBD. Attitude toward the SNOD role remained consistently highly favorable over time. Thematic analysis was correlated with the assessor favorability ratings to identify specific factors for positive or negative attitudes; this demonstrated the themes that were the most common causes of positive or negative attributions for each aspect of organ donation. ICU staff were found to be highly favorably positive toward the SNOD role, positive toward DBD, and negative toward DCD. Although we found broadly positive perceptions of the benefits of deceased organ donation, negative attitudes toward DCD centered on timescale and complexity of the donation process. Measurement of staff attitudes to organ donation may allow targeted interventions that support staff and improve patient and family care through the organ donation process.

Organ Donation Awareness among Family Members of ICU Patients.

Background and Objectives: With one of the lowest donation rates in the European Union, Romania faces challenges in organ donation from brain death donors, within an opt-in system. This study aims to measure the attitudes and knowledge of ICU patient's relatives toward organ donation. Materials and Methods: A descriptive cross-sectional study was conducted in the intensive care unit of the Emergency Clinical County Hospital of Oradea, Romania. A 24-item self-administered questionnaire (N = 251) was used to collect data on knowledge about organ and tissue donation and transplantation, as well as the willingness to donate. Results: A high degree of awareness and willingness for organ donation and transplantation was recorded. The main positive predictor of willingness to donate was the perception of helping others by donating their organs after brain death (β = 0.537, OR = 1.711, p < 0.05), and the main negative predictor was the idea that the whole body should be buried intact (β = -0.979, OR = 0.376, p < 0.01). Conclusions: A basic understanding of organ donation and transplantation and favorable attitudes toward organ donation were registered. Families' interviews for organ donation consent may be affected due to extreme emotional distress.

Application of extended criteria donor grafts in liver transplantation for acute-on-chronic liver failure: A retrospective cohort study.

There is no consensus on the usage of extended criteria donor (ECD) grafts in liver transplantation (LT) for acute-on-chronic liver failure (ACLF) patients. To summarize the experience of using ECD livers in ACLF-LT. A retrospective cohort study was conducted, enrolling patients who underwent LT at the First Affiliated Hospital of Sun Yat-Sen University from January 2015 to November 2021. The patients were divided into ECD and non-ECD groups for analysis. A total of 145 recipients were enrolled in this study, of which ECD and non-ECD recipients accounted for 53.8% and 46.2%, respectively. Donation after cardiac death (DCD) recipients accounted for the minority compared with donation after brain death (DBD) recipients (16.6% vs 83.4%). Neither overall survival nor graft survival significantly differed between ECD and non-ECD and DCD and DBD recipients. ECD grafts were associated with a significantly higher incidence of early allograft dysfunction (EAD) than non-ECD grafts (67.9% vs 41.8%, P = 0.002). Postoperative outcomes between DCD and DBD recipients were comparable (P > 0.05). ECD graft (P = 0.009), anhepatic phase (P = 0.034) and recipient gamma glutamyltransferase (P = 0.016) were independent risk factors for EAD. Recipient preoperative number of extrahepatic organ failures > 2 (P = 0.015) and intraoperative blood loss (P = 0.000) were independent predictors of poor post-LT survival. Although related to a higher risk of EAD, ECD grafts can be safely used in ACLF-LT. The main factors affecting post-LT survival in ACLF patients are their own severe preoperative disease and intraoperative blood loss.