Brain Stem Death Research Articles

Surgical Resection Followed by Stereotactic Radiosurgery (S+SRS) Versus SRS Alone for Large Posterior Fossa Brain Metastases: A Comparative Analysis of Outcomes and Factors Guiding Treatment Modality Selection

Background/Objectives: Around 20% of cancer patients will develop brain metastases (BrMs), with 15–25% occurring in the posterior fossa (PF). Although the effectiveness of systemic therapies is increasing, surgery followed by stereotactic radiosurgery (S+SRS) versus definitive SRS remains the mainstay of treatment. Given the space restrictions within the PF, patients with BrMs in this location are at higher risk of brainstem compression, hydrocephalus, herniation, coma, and death. However, the criteria for treating large PF BrMs with S+SRS versus definitive SRS remains unclear. Methods: We reviewed a prospective registry database (2009 to 2020) and identified 64 patients with large PF BrMs (≥4 cc) treated with SRS or S+SRS. Clinical and radiological parameters were analyzed. The two endpoints were overall survival (OS) and local failure (LF). Results: Patients in the S+SRS group were more highly symptomatic than patients in the SRS group. Gait imbalance and intracranial pressure symptoms were 97% and 80%, and 47% and 35% for S+SRS and SRS, respectively. Radiologically, there were significant differences in the mean volume of the lesions [6.7 cm3 in SRS vs. 29.8 cm3 in the S+SRS cohort, (p < 0.001)]; compression of the fourth ventricle [47% in SRS vs. 96% in S+SRS cohort, (p < 0.001)]; and hydrocephalus [0% in SRS vs. 29% in S+SRS cohort, (p < 0.001)]. Patients treated with S+SRS had a higher Graded Prognostic Assessment (GPA). LF was 12 and 17 months for SRS and S+SRS, respectively. Moreover, the S+SRS group had improved OS (12 vs. 26 months, p = 0.001). Conclusions: A higher proportion of patients treated with S+SRS presented with hydrocephalus, fourth-ventricle compression, and larger lesion volumes. SRS-alone patients had a lower KPS, a lower GPA, and more brain metastases. S+SRS correlated with improved OS, suggesting that it should be seriously considered for patients with large PF-BrM.

Impact of catastrophic brain injury guidelines on organ donation rates: Results of an EAST multicenter trial.

One third of organ donors suffer catastrophic brain injury (CBI). There are no standard guidelines for the management of traumatic CBI prior to brain death, and not all trauma centers have institutional CBI guidelines. In addition, there is high variability in management between institutions with guidelines. Catastrophic brain injury guidelines vary and may include various combinations of hormone therapy, vasopressors, fluid resuscitation, and other practices. We hypothesized that centers with CBI guidelines have higher organ donation rates than those without. This prospective, observational EAST-sponsored multicenter trial included adult (18+ years old) traumatic-mechanism CBI patients at 33 level I and II trauma centers from January 2022 to May 2023. Catastrophic brain injury was defined as a brain injury causing loss of function above the brain stem and subsequent death. Cluster analysis with linear mixed-effects model including UNOS regions and hospital size by bed count was used to determine whether CBI guidelines are associated with organ donation. A total of 790 CBI patients were included in this analysis. In unadjusted comparison, CBI guideline centers had higher rates of organ donation and use of steroids, whole blood, and hormone therapy. In a linear mixed-effects model, CBI guidelines were not associated with organ donation. Registered organ donor status, steroid hormones, and vasopressin were associated with increased relative risk of donation. There is high variability in management of CBI, even at centers with CBI guidelines in place. While the use of institutional CBI guidelines was not associated with increased organ donation, guidelines in this study were not identical. Hormone replacement with steroids and vasopressin was associated with increased donation. Hormone resuscitation is a common feature of CBI guidelines. Further analysis of individual practices that increase organ donation after CBI may allow for more effective guidelines and an overall increase in donation to decrease the long waiting periods for organ transplant recipients. Prognostic; Level III.

Law Enforcement in Medical Malpractice Cases in The Protection of Doctors’ Rights: Case Study Tonsil Surgery Causing Brainstem Death in a Child Patient

This study aims to determine the regulations related to the protection of the professional rights of a doctor who is often suspected of committing medical malpractice in carrying out health services. In this study, the author analyzes the rules of malpractice based on positive law in Indonesia, then the author analyzes the liability carried out by the doctor’s profession in suspected malpractice in this study the author takes a case study related to tonsil surgery which caused BA’s child patient to experience brain death at the Kartika Husada, Bekasi Hospital. The method used by the author in this research uses normative or dogmatic research methods, which use documents laws, and regulations related to the issues studied and secondary data sources in the form of books and related journals. The results of the research in this case study conclude that there is no single rule that protects the rights of a doctor who is accused of committing malpractice, neglecting these rules only protects the interests of the patient, then the responsibility for the accusation of malpractice must go through the process of proof first, by the provisions of the elements of malpractice both in terms of criminal and civil law, and based on the case study that has been researched by the author, it is concluded that the efforts in dispute resolution made by the family of BA’s child patient who has died, are appropriate with the family by withdrawing the police report and carrying out peaceful efforts in the form of mediation with the hospital.

SIGNET: protocol for a multicentre, single-blind prospective, group sequential, randomised controlled trial to evaluate the benefits of a single dose of simvastatin given to potential organ donors declared dead by neurological criteria on outcomes in organ recipients

IntroductionSuccessful organ transplantation in patients with end-stage organ failure improves long-term survival, improves quality of life and reduces costs to the NHS. Despite an increase in the number of deceased...

1087 Factors That Impact Cold Ischaemia Time for Deceased Donor Kidney Transplants: Results of a National Transplant Access to Theatre Audit (NTACT)

Abstract Aim Deceased donor kidney utilisation confronts challenges leading to prolonged cold ischemia time (CIT), affecting graft survival. Despite these challenges, an understanding of the obstacles remains unclear. This audit aims to identify the factors that prolong CIT. Method A multicentre, prospective audit of adult deceased donor kidney-only transplants spanned 14 UK transplant centres from February to September 2022. Data, encompassing time intervals between important checkpoints pre-transplantation and perceived reasons for delays, were collected through RedCap. Descriptive statistics was used for analysis. Results Data from 476 kidney-only transplants were gathered (29 excluded for incomplete/incorrect data). Of these, 230 were donations after brainstem death (DBD) organs, and 202 were donations after circulatory death (DCD) organs. Median CIT was 10:55 (IQR:08:11-15:13) for DBD organs and 11:19 (IQR:08:31-15:10) for DCD organs, with 42% of DCD and 15% of DBD organs surpassing national CIT recommendations. Median time from organ arrival to knife to skin was 04:02 (IQR:02:35-07:35). Full and virtual crossmatches constituted 35% and 65%, respectively, with 16% of results arriving after the organ arrives at centre. Anaesthetic time had a median duration of 00:55 (IQR:00:39-01:10) and Knife to skin to organ perfusion was 01:25 (01:10-01:51). Delays reported in 34% of transplant cases, most common causes were the availability of surgical and anaesthetic teams, porters, and the operating theatre. Conclusions This audit allowed us to uncover the factors that prolong CIT at each stage of the transplantation post-arrival. These findings will guide the establishment of realistic targets for optimizing processes in the future.

Echocardiographic surrogate of left ventricular stroke work in a model of brain stem death donors.

The commonest echocardiographic measurement, left ventricular ejection fraction, can not necessarily predict mortality of recipients following heart transplantation potentially due to afterload dependency. Afterload-independent left ventricular stroke work index (LVSWI) is alternatively recommended by the current guideline; however, pulmonary artery catheters are rarely inserted in organ donors in most jurisdictions. We propose a novel non-invasive echocardiographic parameter, Pressure-Strain Product (PSP), as a potential surrogate of catheter-based LVSWI. This study aimed to investigate if PSP could correlate with catheter-based LVSWI in an ovine model of brain stem death (BSD) donors. The association between PSP and myocardial mitochondrial function in the post-transplant hearts was also evaluated. Thirty-one female sheep (weight 47 ± 5 kg) were divided into two groups; BSD (n = 15), and sham neurologic injury (n = 16). Echocardiographic parameters including global circumferential strain (GCS) and global radial strain (GRS) and pulmonary artery catheter-based LVSWI were simultaneously measured at 8-timepoints during 24-h observation. PSP was calculated as a product of GCS or GRS, and mean arterial pressure for PSPcirc or PSPrad, respectively. Myocardial mitochondrial function was evaluated following 6-h observation after heart transplantation. In BSD donor hearts, PSPcirc (n = 96, rho = .547, p < .001) showed the best correlation with LVSWI among other echocardiographic parameters. PSPcirc returned AUC of .825 to distinguish higher values of cardiomyocyte mitochondrial function (cut-off point; mean value of complex 1,2 O2 Flux) in post-transplant hearts, which was greater than other echocardiographic parameters. PSPcirc could be used as a surrogate of catheter-based LVSWI reflecting mitochondrial function.

Demography of brain stem death and factors leading to successful consent for organ donation

BackgroundThere is a widening gap between the patients requiring transplants in proportion to the availability of organs donated. After brain stem death (BSD), counselling for consent is mandatory and if successful, and viable organs are recovered. A low consent rate for donation results in failed donation in a number of potential donors. Many potential donors fail to make a donation due to various social and familial reasons resulting in a poor consent rate. The aim of this study was to identify the variables that lead to donation denials. MethodsThis retrospective study, carried out from Jan 2009 to Dec 2021 at a tertiary centre with an active transplant and donation programme, analysed BSDs and their counselling outcomes. ResultsA total of 10998 patients were admitted to the intensive care unit, with 2401 (21.8%) deaths. BSD was diagnosed in 8.5% of all deaths, with donor suitability seen in 77.1% (n = 158) cases. After counselling, 55.7% families consented for organ donation. Amongst the families declining consent, most had multiple reasons. The commonest reasons were a difference of opinion among the family members (70%) and unclarity of BSD concept (44.3%). Other reasons included fear of mutilation, religious beliefs, and hope of a miracle. ConclusionAs most reasons of denial are social and related to public awareness, a meticulous transplant program with enthusiastic coordinators coupled with augmentation of public awareness, responsible media reporting, and improved doctor–patient–relative communication would result in enhanced rates of consent.

Establishing targets for goal-directed anesthesia in renal transplantation: A cohort analysis of high-saliency surgical time courses

Delayed graft function (DGF) increases morbidity and mortality in kidney transplant recipients. Operative parameters, including hemodynamic manipulation through vasopressors and fluids, can impact perfusion to the newly transplanted kidney and influence DGF incidence. We analyzed intraoperative time-series data in 5-minute intervals from kidney transplant recipient operations (N = 545) in conjunction with pretransplant characteristics and postsurgical outcomes, including DGF incidence, 60-day creatinine, and graft survival. Of the operations, 127 DGF events were captured in our cohort from a single academic transplant center (57/278 donations after brainstem death [DBDs], 65/150 donations after circulatory/cardiac death [DCDs], 5/117 live donations). In multiple regression, postanastomosis hypotension defined as mean arterial pressure (MAP) <75 mmHg was a risk factor for DGF independent of conventional predictors of DGF in DCD and DBD kidneys. DCD recipients with DGF had lower average postanastomosis MAP (DGF: 80.1 ± 8.1 mmHg vs no DGF: 76.4 ± 6.7 mmHg, P = .004). Interaction analysis demonstrated above-average doses of vasopressors and crystalloids were associated with improved outcomes when used at MAPs ≤75 mmHg, but they were associated with increased DGF at MAPs >75 mmHg, suggesting that the incidence of DGF can be highly influenced by intraoperative hemodynamic controls. This analysis of surgical time courses has identified potential new strategies for goal-directed anesthesia in renal transplantation.

Does Time to Asystole in Donors After Circulatory Death Impact Recipient Outcome in Liver Transplantation?

The agonal phase can vary following treatment withdrawal in donor after circulatory death (DCD). There is little evidence to support when procurement teams should stand down in relation to donor time to death (TTD). We assessed what impact TTD had on outcomes following DCD liver transplantation. Data were extracted from the UK Transplant Registry on DCD liver transplant recipients from 2006 to 2021. TTD was the time from withdrawal of life-sustaining treatment to asystole, and functional warm ischemia time was the time from donor systolic blood pressure and/or oxygen saturation falling below 50 mm Hg and 70%, respectively, to aortic perfusion. The primary endpoint was 1-y graft survival. Potential predictors were fitted into Cox proportional hazards models. Adjusted restricted cubic spline models were generated to further delineate the relationship between TTD and outcome. One thousand five hundred fifty-eight recipients of a DCD liver graft were included. Median TTD in the entire cohort was 13 min (interquartile range, 9-17 min). Restricted cubic splines revealed that the risk of graft loss was significantly greater when TTD ≤14 min. After 14 min, there was no impact on graft loss. Prolonged hepatectomy time was significantly associated with graft loss (hazard ratio, 1.87; 95% confidence interval, 1.23-2.83; P = 0.003); however, functional warm ischemia time had no impact (hazard ratio, 1.00; 95% confidence interval, 0.44-2.27; P > 0.9). A very short TTD was associated with increased risk of graft loss, possibly because of such donors being more unstable and/or experiencing brain stem death as well as circulatory death. Expanding the stand down times may increase the utilization of donor livers without significantly impairing graft outcome.

Donor Blood Tests do Not Predict Pancreas Graft Survival After Simultaneous Pancreas Kidney Transplantation; a National Cohort Study.

Simultaneous pancreas-kidney (SPK) transplantation improves quality of life and limits progression of diabetic complications. There is reluctance to accept pancreata from donors with abnormal blood tests, due to concern of inferior outcomes. We investigated whether donor amylase and liver blood tests (markers of visceral ischaemic injury) predict pancreas graft outcome using the UK Transplant Registry (2016-2021). 857 SPK recipients were included (619 following brainstem death, 238 following circulatory death). Peak donor amylase ranged from 8 to 3300U/L (median = 70), and this had no impact on pancreas graft survival when adjusting for multiple confounders (aHR = 0.944, 95% CI = 0.754-1.81). Peak alanine transaminases also did not influence pancreas graft survival in multivariable models (aHR = 0.967, 95% CI = 0.848-1.102). Restricted cubic splines were used to assess associations between donor blood tests and pancreas graft survival without assuming linear relationships; these confirmed neither amylase, nor transaminases, significantly impact pancreas transplant outcome. This is the largest, most statistically robust study evaluating donor blood tests and transplant outcome. Provided other factors are acceptable, pancreata from donors with mild or moderately raised amylase and transaminases can be accepted with confidence. The use of pancreas grafts from such donors is therefore a safe, immediate, and simple approach to expand the donor pool to reach increasing demands.

Evaluating the Effects of Time From Brain Death and Type of Inotrope Usage on Result of Heart Transplant: Results of 1-Year Follow-Up.

Heart transplant is the most effective treatment in patients with advanced heart failure who are refractory to medical treatment. The brain death interval and type of inotrope We assessed the effects of these parameters on heart transplant outcomes. In this follow-up study, we followed heart transplant recipients for 1 year to study patient survival, ejection fraction, adverse events, and organ rejection. We evaluated follow-up results on time from brainstem death test to the cross-clamp placement, as well as the type of inotrope used. Our study enrolled 54 heart transplant candidates. The inotrope dose was 3.66 ± 0.99 μg/kg/min, and the most used inotrope, with 28 cases (51.9%), was related to dopamine. Six cases (11.1%) of death and 1 case of infection after transplant were observed in recipients. The average ejection fraction of transplanted hearts before transplant, instantly at time of transplant, and 1 month, 6 months, and 1 year after transplant was 54.9 ± 0.68, 52.9 ± 10.4, 51.9 ± 10.7, 50.1 ± 10.9, and 46.8 ± 17, respectively; this decreasing trend over time was significant (P =.001). Furthermore, ejection fraction changes following transplant did not differ significantly in transplanted hearts regarding brain death interval and type of inotrope used. Our study revealed that cardiac output of a transplanted heart may decrease over time and the time elapsed from brain death, and both dopamine and norepinephrine could have negligible effects on cardiac function.

The Fundamental Concept of Death-Controversies and Clinical Relevance: The UDDA Revision Series.

When the Uniform Law Commission (ULC) was recently in the process of revising the Uniform Determination of Death Act (UDDA), Neurology® ran a series of debates over certain controversial issues being deliberated. Omitted was a debate over the fundamental concept underlying brain death. In his introductory article, Bernat offered reasons for this omission: "It is not directly relevant to practicing neurologists who largely accept brain death, do not question its conceptual basis, …." In this article I argue the opposite: the fundamental concept of death is highly relevant to the clinical criteria and tests used to diagnose it. Moreover, most neurologists in fact disagree with the conceptual basis articulated by Bernat. Basically, there are 3 competing concepts of death: (1) biological: cessation of the integrative unity of the organism as a whole (endorsed by Bernat and the 1981 President's Commission), (2) psychological: cessation of the person, equated with a self-conscious mind (endorsed by half of neurologists), and (3) the vital work concept proposed by the 2008 President's Council on Bioethics. The first actually corresponds to a circulatory, not a neurologic, criterion. The second corresponds to a "higher brain" criterion. The third corresponds loosely to the UK's "brainstem death" criterion. In terms of the biological concept, current diagnostic guidelines entail a high rate of false-positive declarations of death, whereas in terms of the psychological concept, the same guidelines entail a high rate of false-negative declarations. Brainstem reflexes have nothing to do with any death concept (their role is putatively to guarantee irreversibility). By shining a spotlight on the deficiencies of the UDDA through attempting to revise it, the ULC may have unwittingly opened a Pandora's box of fresh scrutiny of the concept of death underlying the neurologic criterion-particularly on the part of state legislatures with irreconcilably opposed worldviews.

Decompressive craniectomy: A primer for acute care practitioners.

Decompressive craniectomy (DC) involves surgical removal of the skull that overlies swollen, imperiled, brain. This is done to combat intracranial hypertension and mitigate a vicious cycle of secondary brain injury. If, instead, this pathophysiology goes uninterrupted, it can mean brain herniation and brain stem death. As such, DC can save lives when all else fails. Regardless, it is no panacea and can also "ruin deaths," and leave patients profoundly disabled. DC is not a new procedure; however, this therapy is increasingly noteworthy due to advances in neurocritical care, alongside ethical concerns. We cover the physiological rationale, the surgical basics, the trial data, and focus on secondary decompression (for refractory intracranial pressure (ICP)) rather than primary decompression (i.e. during evacuation of an intracranial mass). Given that DC should not be undertaken indiscriminately, we conclude by introducing ways in which to discuss DC with families and colleagues. Our goal is to provide a primer and common resource for the multidisciplinary team. We aim to increase not only knowledge but wisdom, prudence, collegiality, and family-focused care.

O168: Impact of donor transaminases on liver transplant utilisation and unnecessary organ discard: national registry cohort study

Abstract Background Donor liver transaminases (ALT and AST) have been used to decline livers for transplant, despite evidence that they do not influence transplant outcomes. This study assesses the effect that raised donor transaminases currently have on the unnecessary decline of livers. Methods This retrospective cohort study used the National Health Service registry on adult liver transplantation (2016-2019). Logistic regression models were built to assess the impact of donor transaminases on the utilisation of organs donated following brain stem death (DBD) and circulatory death (DCD). A further model was used to predict the impact on liver decline if raised donor ALT was not used to make utilisation decisions. Results 5424 adult livers were offered for transplant, of which 3605 were utilised (2841 DBD, 764 DCD). In multivariable analysis, adjusted for key factors, increasing peak donor ALT independently increased the odds of liver decline (DBD aOR = 1.396, 1.305-1.494, p&amp;lt;0.001, DCD aOR = 1.162, 1.084-1.246, p&amp;lt;0.001). AST was also a significant predictor of liver decline. 18.5% of livers from DBD donors with ALT&amp;gt;40U/L (n=1683) were declined for transplantation. In this group, our model predicted a 48% (38% - 58%) decrease in decline if donor ALT was excluded from these decisions. This represents an additional 37 (30-45) livers every year that could be safely accepted and transplanted. Conclusions Raised donor ALT increases the likelihood of liver decline, despite previous evidence that it does not influence transplant outcome. Avoiding donor ALT-based organ decline is an immediate and effective way to expand the donor pool.

O172: Donor blood tests and pancreas outcome in simultaneous pancreas kidney transplantation, a national cohort study

Abstract Introduction Simultaneous pancreas-kidney (SPK) transplantation improves quality of life in people with diabetes and end-stage renal disease, and limits the progression of diabetes related complications. Many surgeons are reluctant to accept the pancreas of a donor with raised amylase, due to concern of potentially inferior outcomes. We aim to ascertain whether donor amylase and liver blood tests (a marker of visceral ischaemic injury) predict pancreas transplant outcome. Methods This retrospective cohort study used the NHS registry on adult SPK transplantation (2016-2021). Adjusted regressions models assessed the effect of donor amylase and liver blood tests on pancreas transplant outcome. Results 857 SPK recipients were included (619 following brainstem death, 238 following circulatory death). Peak donor amylase ranged from 8-3300U/L (median=70). Donor peak amylase had no significant impact on pancreas graft survival when adjusting for multiple confounders (aHR=0.944, 95% CI=0.754-1.81). Median peak alanine transaminase and aspartate transaminase was 67U/L and 72U/L (range 8-5930 and 0-7910U/L). Neither of these influenced pancreas graft survival in multivariable models (aHR=0.967, 95% CI=0.848-1.102 and aHR=0.908, 95% CI=0.771-1.070, respectively). Restricted cubic splines were used to assess the relationship between donor blood tests and pancreas graft survival without assuming linear relationships; these confirmed neither amylase, nor transaminases, significantly impact on pancreas transplant outcome. Conclusions Donor amylase and transaminases do not predict transplant outcomes. Therefore, raised donor amylase or transaminases should not be considered a barrier to organ utilisation. The use of pancreas grafts from donors with hyperamylasaemia is a safe, immediate, and simple approach to expand the donor pool.

O91: The Negative Impact of Transplant Liver Steatosis is Significantly Exaggerated in Donation Following Circulatory Death: A National Cohort Study

Abstract Introduction The demand for liver transplantation is rising, as is the prevalence of steatotic liver disease. Steatotic grafts have inferior outcomes post-transplantation, perhaps related to increased sensitivity to ischaemia-reperfusion injury. We aimed to formally evaluate whether the impact of steatosis differs in grafts donated following brainstem (DBD) versus circulatory death (DCD). Methods The NHS registry on adult liver transplantation was reviewed retrospectively (2006-2019). We used multiple-imputation for missing data, and adjusted regression models with interaction terms to compare the impact of donor graft steatosis (visually-assessed) on transplant outcome in DCD versus DBD. Results 9217 adult recipients of deceased donor grafts were included (DBD=7349; DCD=1868). Multivariable cox regression revealed that the negative effects of moderate or severe steatosis on graft survival were significantly different in DCD and DBD livers (interaction P=0.011 and P=0.043). The largest impact was in DCD livers (aHR=1.851, 1.296-2.645, P=0.001 for moderate and aHR=5.426, 1.723-17.090, P=0.004 for severe steatosis). In contrast, steatotic livers did not suffer inferior longer-term graft survival in the DBD cohort, despite inferior early outcomes. Conclusion The impact of steatosis on transplant outcome differs significantly based on donor type, with a much larger negative impact in DCD, proving that steatotic livers are specifically sensitive to the DCD process. This highlights a high-risk group which should be the target of novel therapeutics to allow this growing sector of the donor pool to be safely utilised. In contrast, moderate-severe steatosis does not impact longer term outcome in DBDs, and such grafts can be transplanted with excellent outcome.

Knowledge, Attitudes and Intention to Donate Organs among the Public, Health Sciences Students and Health Personnel: A Scoping Review with a Systematic Review of Malaysian Studies.

Various barriers lead to a shortage of organs for transplantation in Malaysia. One drive to improve the organ donation rate operates through future healthcare practitioners and practitioner advocacy. This scoping review was carried out to establish and summarise findings about organ donation-related articles among the public, health sciences students and health personnel. A further aim was to synthesise the latest data on knowledge and attitudes towards organ donation in the Malaysian population. PubMed, Scopus, Google Scholar and the Malaysian Medical Repository (MyMedR) were used for a search conducted up to May 2022. Relevant search terms included 'Organ donation' and 'Malaysia'. Journal articles related to knowledge, attitudes and intention were grouped under the general public and health science. Students and health personnel were included. Eligible studies were reviewed by two independent reviewers. Any disagreements were resolved by consensus with a third reviewer. The 31 included articles revealed an increased level of awareness among the public regarding organ donation. The analysis identified that nonrecognition of brainstem death (38.5%), no knowledge of how to contact the Organ Transplant Coordinator (82.3%) and never approaching the families of a potential donor (63.9%) led to a lack of confidence among healthcare practitioners to promote organ donation. The shortage of organ donors is the result of the failure to identify the expected donor, obtain consent and procure the organs due to the passivity of Malaysian health professionals in promoting the organ donation process.

Examination of the Brain Stem Death Approach to Defining Death in an Organ Transplant Context and its Credibility with ‘Nigerian’ Values and Beliefs

Organ donation generally consists of two modes - living (largely less-problematic), and cadaveric (largely problematic). Cadaveric donation of solid organs is simply the process of solid organ transplant after the demise of its owner (deceased). Consequently, many approaches to death have evolved in order to procure more solid organs in the medical sphere today as a result of science and technology. However, these approaches to death are not without controversies such as the credibility of the approach with the Nigerian values and beliefs. To this end, this paper, examines the some key controversies surrounding the adoption of the brain stem death approach to defining death and its credibility with the Nigerian values and beliefs with a bid to chart a way-forward for the country. In gathering and analysing data, the writer used doctrinal method of data collection relying on local statutes, cases laws, textbooks, journal articles, international treaties, conventions and covenants. The writer found that although it may appear unrealistic to have an approach to organ donation that will be devoid of criticisms, a holistic adherence to the recommendations herein may significantly address fears of critics and possibly reduce controversies and tensions surrounding the approaches to death. More so, robust sensitization of the citizenry should be done to turn the rather, organ transplantation apathy to an enviable one.

Breaking distance barriers in liver transplantation: Risk factors and outcomes of long-distance liver grafts

BackgroundLong-distance-traveling liver grafts in liver transplantation present challenges due to prolonged cold ischemic time and increased risk of ischemia–reperfusion injury. We identified long-distance-traveling liver graft donor and recipient characteristics and risk factors associated with long-distance-traveling liver graft use. MethodsWe conducted a retrospective analysis of data from donor liver transplantation patients registered from 2014 to 2020 in the United Network for Organ Sharing registry database. Donor, recipient, and transplant factors of graft survival were compared between short-travel grafts and long-distance-traveling liver grafts (traveled >500 miles). ResultsDuring the study period, 28,265 patients received a donation after brainstem death liver transplantation and 3,250 a donation after circulatory death liver transplantation. The long-distance-traveling liver graft rate was 6.2% in donation after brainstem death liver transplantation and 7.1% in donation after circulatory death liver transplantation. The 90-day graft survival rates were significantly worse for long-distance-traveling liver grafts (donation after brainstem death: 95.7% vs 94.5%, donation after circulatory death: 94.5% vs 93.9%). The 3-year graft survival rates were similar for long-distance-traveling liver grafts (donation after brainstem death: 85.5% vs 85.1%, donation after circulatory death: 81.0% vs 80.4%). Cubic spline regression analyses revealed that travel distance did not linearly worsen the prognosis of 3-year graft survival. On the other hand, younger donor age, lower donor body mass index, and shorter cold ischemic time mitigated the negative impact of 90-day graft survival in long-distance-traveling liver grafts. ConclusionThe use of long-distance-traveling liver grafts negatively impacts 90-day graft survival but not 3-year graft survival. Moreover, long-distance-traveling liver grafts are more feasible with appropriate donor and recipient factors offsetting the extended cold ischemic time. Mechanical perfusion can improve long-distance-traveling liver graft use. Enhanced collaboration between organ procurement organizations and transplant centers and optimized transportation systems are essential for increasing long-distance-traveling liver graft use, ultimately expanding the donor pool.

Heart graft preservation technics and limits: an update and perspectives.

Heart transplantation, the gold standard treatment for end-stage heart failure, is limited by heart graft shortage, justifying expansion of the donor pool. Currently, static cold storage (SCS) of hearts from donations after brainstem death remains the standard practice, but it is usually limited to 240 min. Prolonged cold ischemia and ischemia-reperfusion injury (IRI) have been recognized as major causes of post-transplant graft failure. Continuous ex situ perfusion is a new approach for donor organ management to expand the donor pool and/or increase the utilization rate. Continuous ex situ machine perfusion (MP) can satisfy the metabolic needs of the myocardium, minimizing irreversible ischemic cell damage and cell death. Several hypothermic or normothermic MP methods have been developed and studied, particularly in the preclinical setting, but whether MP is superior to SCS remains controversial. Other approaches seem to be interesting for extending the pool of heart graft donors, such as blocking the paths of apoptosis and necrosis, extracellular vesicle therapy, or donor heart-specific gene therapy. In this systematic review, we summarize the mechanisms involved in IRI during heart transplantation and existing targeting therapies. We also critically evaluate all available data on continuous ex situ perfusion devices for adult donor hearts, highlighting its therapeutic potential and current limitations and shortcomings.