Cardiac Death Donors Research Articles

Does Assessing Preimplantation Kidney Biopsy and Pump Resistive Index Values Predict Kidney Allograft Survival?

Background The relationship between histological findings of preimplantation kidney biopsies and pump resistive index (RI) values during machine preservation and allograft survival remains unclear due to conflicting results between different studies. Objective To determine the association between histological findings of preimplantation kidney biopsies and pump resistive index values and short-term graft survival (up to 3 years post-transplant). Methods We performed a retrospective review of all patients who received a kidney-only transplant between January 1, 2009, and December 31, 2014, at our center and followed-up until December 1, 2016. Patients who died with a functioning allograft were excluded from analysis. Obsolete glomerulosclerosis was divided into 3 groups (< 10%, 10-20%, and > 20%), intimal arterial narrowing was divided into 3 groups (< 10%, 11-25% and > 25%) and RI was divided into 5 groups (0.00-0.09, 0.10-0.19, 0.20-0.29, 0.30-0.39 and 0.40=0.49). The log-rank test was used to test if there is a significant difference in different RI groups in terms of the probability of survival. Results A total of 662 patients received kidney-only transplants in our study period. 506 of 662 received deceased donor kidneys and were included in our analysis with 21% Caucasian, 47% African American, and 31% Hispanic. The median age was 53.6 (range, 21.1-79.2) and 58% were male. 57% of deceased donors were standard, 31% expanded and 12% donation after cardiac death donors with a median KDPI of 62. During a median follow-up time of 36 months (range, 23-94), 51 patients lost their allografts (death-censored graft survival 90%). There was no difference in terms of patients’ age, sex, race, etiology of kidney disease, type of induction agent, and cold ischemia time when graft loss patients are compared to patients with functioning allograft. The graft loss group had higher KDPI (71 vs. 61, p=0.03) and received more expanded criteria donor (49% vs. 29%, p=0.01). Percent of obsolete glomerulosclerosis and arterial intimal narrowing in preimplantation biopsies showed no association with short-term allograft failure at 1, 2, and 3 years. RI was a strong predictive factor for short-term allograft failure. Kidneys in different RI categories have significantly different survival experiences in 1, 2, and 3 years (p=0.030, p=0.001, p=0.008, respectively). RI > 0.4 performed worse than other RI groups as seen in Figure 1 (Figure 1 shows 3 year Kaplan-Meier graft survival).Conclusions Recipients of higher KDPI score and expanded criteria donor were at higher risk for allograft failure. Percent of obsolete glomerulus and arterial narrowing in preimplantation biopsies did not predict short-term allograft failure. However, RI was a strong predictive factor for short-term allograft failure.

The Effect of Chronic Lesions in Implantation Biopsy on the Function and Survival of Renal Grafts from Donation after Cardiac Death Donors

The Effect of Chronic Lesions in Implantation Biopsy on the Function and Survival of Renal Grafts from Donation after Cardiac Death Donors

Intraoperative Renal Perfusion in Kidney Transplantation

Aim To explore whether intraoperative direct measurement of renal flows reflect ischemia/reperfusion injury and identify grafts at risk of inferior outcome in kidney transplantation, we conducted an observational retrospective single-center study. Methods Intraoperative direct transit-time flow measurements of renal artery flow (RAF) in mL/min were obtained immediately after graft reperfusion (M1) and prior to skin closure (M2). Patients were divided into the following 4 outcome groups: delayed graft function in patients requiring dialysis within postoperative day 7, non-dialysis requiring delayed graft function in patients with creatinine reduction ratio between postoperative days 1 to 2 (CRR2) ≤30%, immediate graft function (CRR2 >30%), and patients with vascular complications. Median and interquartile ranges are reported. Results 68 kidney transplants were included with a median follow-up of 12.6 (8.1-19.9) months. 16 living donors (LD), 35 donation after brain death donors (DBD) and 17 donation after cardiac death donors (DCD). Renal artery flow was available in 15 patients at M1 and in all 68 included patients at M2. An increase of flow between M1 and M2 was observed in 73% of cases. Living donors showed significantly higher flows than deceased donors (Table 1). A creatinine reduction ratio between postoperative days 1 to 2 ≤30% was observed in all delayed graft function patients requiring dialysis or not and in 3 out of 4 vascular complication patients. Renal artery flow at M2 in these patients was significantly lower compared to immediate graft function patients: 259 (181-344) vs 419.5 (247-551), p=0.0065. Renal artery flow at M2 showed a negative correlation with recipient age (r=-0.28, p=0.002) but not with donor age (r=-0.23, p=0.058). No PNF or irreversible rejection were observed. Graft loss occurred in 3 patients because of 2 renal artery thrombosis and 1 renal vein thrombosis in the early postoperative period. Normal curves with low flow or high resistance were observed at M1 with reduction of resistance at M2 (Table 2). In 2 patients experiencing post-transplant arterial complications initial flows were normal or even high with a reduction of the flows at M2 (M2/M1 ≤1). The patient with postoperative renal vein thrombosis did not show any intraoperative findings in the arterial measurements. Conclusions Our results demonstrates different flows according to graft quality. Patients receiving living donor grafts and with immediate graft function showed significantly higher intraoperative renal artery flows. Intraoperative direct renal artery flow measurement in kidney transplantation identified transplants at risk for worse outcome.

Use of the Capnometry as a Renal Graft Evolution Predictor in Uncontrolled Cardiac Arrest Death Donors

Introduction Capnometry is clearly related to ventilation and tissue perfusion. In several articles it has been postulated that levels of capnometry can indicate the organ grafts evolution of donors after dying by uncontrolled cardiac arrest. Objective To correlate the levels of capnometry during resuscitation and preservation with the evolution of renal grafts. Methodology Retrospective descriptive study from 2013 to 2017 based on the data collection from a series of potential donors transferred by SUMMA112 to Doce de Octubre University Hospital and the post-transplant evolution. Results There have been 60 donors in asystole and 40 patients received a kidney transplant. Donors were mostly males (90%) as well as recipients (79%). The average age was 46 years in donors and 50 in recipients. No patient has presented an acute graft rejection. Conclusion A relationship between lower capnometry figures and, both renal function delay and primary renal failure has been detected; although without statistical significance due to the size of the study sample.

Hemoderivates Transfusion Differences Between Recipients of Liver Grafts from Donors After Uncontrolled Cardiac Death (uDCD) and Brain Death Donors (DBD)

Introduction The scarcity of grafts for liver transplantation (LT) from brain death donors (BDD), as well as the increasing mortality on waiting list have led us to look for other alternatives to achieve more liver grafts, being those from controlled and uncontrolled cardiac death (uDCD) the most attractive sources. However, intraoperative bleeding during LT has been higher when using uDCD donors, also related with higher morbi-mortality and lower patient and graft survival. Our aim is to compare the necessity of hemoderivates in uDCD and DBD groups. Materials and Methods Between January 2006 and December 2016 we performed 783 LT in adult recipients, excluding retransplants or patients undergoing OLT for acute liver failure. Liver grafts from uDCD donors (Group A) were used in 75 patients, and livers from BDD donors (Group B) were used in 708 patients. Results The mean age in group A was 59±8 years vs B 55±10 years in Group B (p=0.000). There were no significant differences in terms of sex, BMI and Child score. HCV cirrhosis was the indication for LT in 60% of cases in Group A vs 50.2% in group B (p=0.541). Hepatocellular carcinoma was present in 54.7% of patients in group A vs 38.9% in Group B (p=0.07). The mean of MELD score was 14.4±5 in Group A vs 14.5±6 in Group B (p=NS).The mean ICU stay was 6.8±7 days in Group A versus 6.3±9 days in group B (p=0.638). The mean transfusion of units of hemoderivates was as follows: 1) Packed red blood cells (PRBC): 12.3±13 units in Group A vs 8.6±10 Group B (p=0.008). 2) Fresh frozen plasma (FFP): 16.2±12 units in group A vs 10.7±8.8 in Group B (p=0.000). 3) Platelets: 2.29±2 units in group A vs 1.7±2 in group B (p=0.014). Using a logistic regression for multiple predictor variables, the only two factors with statistical significance related with MBT (>6 units of RBC) were uDCD condition (OR 2.3; CI 95%: 1.2-4.9; p=0.024), and higher Meld score (OR 2.75; CI 95%: 1.7-4.4; p=0.000) Survival at 1, 3 and 5 years was 81.3%, 70.2% and 68.6%, respectively, in group A vs 89%, 83.7% and 78.8%, respectively, in Group B (p= 0.070) Discussion. Conclusion The use of liver grafts from uDCD donors is associated with increased necessity of transfusion of hemoderivates in comparison with the use of BDD donors.

Should Donation after Cardiac Death Donor Organs be Used in the Pediatric Patient Population?

Introduction Multiple strategies exist to increase the organ pool for pediatric recipients, including using high risk donor organs or donation after cardiac death (DCD) organs. Despite the organ shortage, there still remains a relative reluctance to use livers and kidneys from DCD donors. We examined if this reluctance is warranted by evaluating long term patient and allograft outcomes in pediatric liver and kidney transplant recipients. Materials and Methods The United Network for Organ Sharing database was queried to examine outcomes in all liver and kidney transplant recipients from 1996 to 2017. The patients were then divided upon adult and pediatric (under age 18 years) status and donation after brainstem death (DBD) vs. DCD allograft status. Donor and recipient demographic data were examined, and patient and allograft survival were calculated. Categorical differences were compared using the unpaired Student's t-test and nominal variables using either the Chi Square or Fischer's exact test. A p-value of <0.05 was considered to be significant. Results and Discussion 55 pediatric patients received a DCD liver. The donors in the two groups were similar in age (11.5 vs. 12.0 years, p=NS, DCD vs. DBD). The average time from withdrawal to aortic flush was 17 minutes in the DCD group. The cold storage times were 7.9 vs. 7.7 hours, p=NS, in the DCD vs. DBD groups. Those who received DCD organs were older in age (7.9 vs. 5.1 years, p<0.05). The average Pediatric End-Stage Liver Disease score was 18 vs. 14, p=NS in the DCD vs. the DBD group. Patients were of comparable illness in both groups when comparing need for life support at the time of transplant in the DCD vs. DBD groups (12.5% vs. 9.7%, p=NS). There was no significant difference in patient or allograft survival between the two groups. 276 pediatric recipients recieved a DCD kidney. The DCD donors had similar ages (21.7 vs. 22.0 years, p=NS), a higher KDPI (27% vs. 23%, p<0.05), longer cold storage time (15.4 vs. 14.9 hours, p=NS), and had a time from withdrawal to aortic flush of 16.6 minutes. Those who received DCD organs were older (12.9 vs 11.0 years, p<0.05), had a shorter length of stay (10.6 vs. 15.2 days, p<0.05), and no significant difference in rejection within the first year (18.1% vs. 21.7%). There were no significant differences in patient or allograft survival between the two groups. DCD livers and kidneys have similar to if not improved patient and allograft survival, and are an underutilized source of organs in the pediatric population. Conclusion When chosen well, DCD organs can be used safely with good outcomes in the pediatric patient population.

Similar Outcomes of Kidney Transplant Program from Controlled Cardiac Death Donors compared with Kidney Transplant from Brain Dead Donors after 2 Years of Follow Up

REDinREN. REMAR. Material and Methods From October 2014 to October 2016, 45 cDCD kidney transplants (KT) from 30 donors and 68 KT from 52 DBD donors were performed Data regarding donors, recipients, graft and surgical details and one year outcomes were collected from cDCD and DBD, comparing both groups. Results cDCD: Donors: 60 ± 11 years, 50 % men, mean ICU stay 20 ± 11 days, 69% stroke as cause of death, creat 0.5 ± 0.2 mg / dl, proteinuria 514 ± 429 mg / day, 63.3% ECD. Very expanded criteria ( >70 years) 23% Recipients: 58 ± 13 years, 61.9% male, time of RRT 3.5 ± 2.5 years (90% Hemodialysis), 20% hypersensitized, PRA Peak 14 ± 25%, Missmatch 4 ± 1. Very ECD 20%. Total WIT 17± 4 minutes, CIT 7 ± 3 hours. No PGF, delayed graft function (DGF) 40%. BPAR 4.4%. At 1 year: Creat 1.7 ± 0.4 mg / dl, eGFR 42 ± 14 ml / min, proteinuria 467 ± 326 mg / d. At 2 years Creat 1,76 ± 0,5 mg/dl, eGFR 40 ± 14 ml / min, proteinuria 486 ± 462 mg / d. Older and male donor / recipient (ECD and Very ECD) markers of worse renal function at 2 years follow-up. Donor Hypertension and increased ICU stay markers of higher proteinuria at 6 months. cDCD vs. DBD: cDCD donors had lower creatinine (0.5 ± 0.2 vs. 0.9 ± 0.2 mg / dl) and higher proteinuria (464 ± 421 vs. 61± 95 mg / d) cDCD recipients had lower cPRA I + II peak (2.5 ± 7.5 vs. 17 ± 35%). DBD greater CIT (19.6 ± 3.9 vs. 7 ± 3 h). Thymoglobulin induction 44% DBD vs. 84% cDCD. Higher BPAR in DBD vs cDCD ( 10,9 vs. 4,4%) cDCD higher DGF (40% vs. 8.8%), no differences in creatinine, eGFR, proteinuria at 1 year. DBD higher acute rejection (11.3 vs. 4.7%), similar mortality both groups. Conclusions Successful implementation of cDCD program in numerical terms and outcomes at 2 year, similar to DBD, despite higher rate of DGF.

MicroRNAs as Potential Markers for Advantageous Perfusion in a Preclinical Donation after Cardiac Death Animal Model of Oxygenated Hypothermic Machine Perfusion (HOPE)

Background: Extended criteria donors and donation after cardiac death donors provide organs which tend to be more sensitive to the stress of preservation. There is a lack of evidence about the potential role of oxygen in preservation techniques, and literature comparing oxygenated and non-oxygenated techniques is very limited. The aim of the study was to compare HMP with oxygen versus HMP without oxygen in a pig model of kidney auto-transplantation (KT) reproducing conditions of DCD. We have also set up miRNAs expression in preservation solution and kidney biopsies as useful biomarkers for allograft response to perfusion conditions. Methods: A randomized non blinded prospective cohorts study was established in an orthotopic auto-transplantation model mimicking Maastricht type III DCD under hypothermic machine perfusion (Life-port® kidney transporter). Real time PCR detection was performed using SYBR Green and specific commercially available probes for each miRNA of interest in preservation solution and kidney biopsies from non-oxygenated and oxygenated grafts. Sample size calculation was done attending to Mead's resource equation sample for two treatment groups. Data were expressed as median (IQA / Range) and assessed for statistical significance by Mann–Whitney U-test. Results: Somewhat better kidney function and survival results were reached in the oxygenated group. Furthermore, a selection set of miRNAs constituted by miR-29a, miR27a, miR-101, miR-126 and miR-10a, modified its expression most significantly. These miRNAs are related to cell adhesion, intracellular trafficking and kidney fibrosis, and showed a differentially expression between oxygenated and non-oxygenated HMP preservation solution of kidney grafts. Conclusions: miRNAs differential profile in preservation solution during HMP attending to oxygenation reflects a better metabolic state in oxygenated grafts. The descripted miRNAs signature could be a potential predictive biomarker of the cellular metabolic state and kidney function.

Kidney transplantation from brain and cardiac death donors and immunosuppression: a single-center experience

Objective To investigate the experience of kidney transplantation from brain and cardiac death donors(donation after brain plus cardiac death, DBCD)and clinical effect of immunosuppressive regimen. Methods A retrospective analysis of kidney transplantation from DBCD in our hospital from September 2011 to August 2015 was performed. All patients were treated with double doses Basiliximab to inductive immune, and then treated with prednisone(Pre) , mycophenolate mofetil (MMF) , Tacrolimus (FK506). During the follow-up of 1 year, acute rejection, incidence of delayed graft function (DGF), patient's survival and graft survival rates, complication and clinical adverse events and laboratory test results were evaluated. Results In the 80 cases, the actuarial patient and grafts' survival rates at 1, 3, 6 and 12 months after transplantation was 100.0%(100/100), 100.0%(100/100), 98.7%(79/80), 97.5%(78/80) and 97.5%(78/80), 97.5%(78/80), 96.2%(77/80), 95.0%(76/80) respectively.DGF occurred in 13 of 80 (16.3%) , but the occurrence of DGF did not adversely influence patient’s survival (P=0.525) or graft survival (P=0.372). Five cases of acute rejection appeared(6.3%)and the primary non-functioning kidney was not occurred in all patients. Five cases of urinary tract infection during perioperative period, abdominal infection in 2 cases, herpes simplex infection in 2 cases were found. Conclusions DBCD is an important means to solve the shortage of organs in our country, it opens up a new way to expand the source of donor kidney.The combined use of two doses of Basiliximab for inductiving immune combination with Pre, MMF, FK506 immunosuppressive regimen can effctively reduce the incidence of acute rejection, the safety and tolerance are better. Key words: Kidney Transplantation; Brain Death

DCD Liver Transplant: a Meta-review of the Evidence and Current Optimization Strategies

In the current era of liver transplantation (LT), there is a large discrepancy between waiting list demand and organ donor availability. Increased utilization of donation after circulatory death (DCD) donors continues to expand the donor pool and improve access; however, concerns regarding recipient outcomes have limited wider adoption of these donor livers. This review will describe the current evidence regarding recipient outcomes and strategies that may help to optimize them. Historical outcomes of DCD LT are somewhat inferior to the DBD LT, yet new emerging evidence suggests that this outcome disparity may only be marginal at most; however, ischemic cholangiopathy remains a concern. Ideal donor selection criteria and optimizing recipient operative times appear to mitigate some of this risk. Extracorporeal membrane oxygenation (ECMO), hypothermic machine perfusion (HMP), and normothermic machine perfusion (NMP) are promising strategies to further improve graft resilience and performance. Cardiac death donors continue to expand the donor pool but may carry an increased risk of biliary complications. Graft reconditioning techniques, donor selection, and recipient optimization appear to mitigate this risk; however, these strategies need further investigation before generalized adoption.

Impact of Donor Lung Pathogenic Bacteria on Patient Outcomes in the Immediate Post-transplant Period

BACKGROUND Patient outcomes post-lung transplant remain inferior to other types of solid organ transplantation. We investigated whether the presence of potentially pathogenic bacteria (PPB) in donor lung bronchial cultures was associated with adverse outcomes postoperatively. METHODS All patients who underwent lung transplantation between August 2015 and April 2017 at the University of Kentucky Medical Center were retrospectively reviewed. Retransplants, patients with bronchiectasis (including cystic fibrosis), and individuals who received organs from donation after cardiac death (DCD) donors were excluded. The remaining subjects were separated into two groups: individuals whose donor bronchial cultures grew PPB, and those whose cultures either returned negative for PPB or were sterile. 30-day mortality rates as well as the incidence of grade 3 primary graft dysfunction (PGD) and acute kidney injury (AKI) at both 24 and 72 hours post-transplant were calculated. The duration of mechanical ventilation postoperatively was also recorded. RESULTS Thirty two subjects comprised the study population. 20 patients (63%) had growth of PPB on donor cultures, while 12 (37%) did not. Patients with PPB had a significantly greater number of days on the ventilator postoperatively compared to those with no PPB (mean = 11.3 and median = 5.0 vs mean = 5.8 and median = 3.0, respectively, P = 0.0232). Subsequent regression analysis revealed this association to not be influenced by recipient lung allocation score (LAS), donor age, donor smoking history, recipient mean pulmonary artery pressure (mPAP) value, and/or use of cardiopulmonary bypass at the time of transplantation. Neither 30-day survival nor incidence of Grade 3 PGD and AKI at 24 or 72 hours post-transplant differed between the two groups (P > 0.05). CONCLUSION The recovery of PPB in donor lung cultures was associated with a longer duration of mechanical ventilation postoperatively in lung transplant recipients.

Pediatric Perioperative Nurses and the Ethics of Organ Donation After Cardiac Death.

Pediatric perioperative nurses are experiencing increased opportunities to participate in donations after cardiac death. An increased public awareness regarding transplantation has inspired more people to donate than in previous years. The demand for transplantable organs has led to opportunities that have increased donor candidates including living donors and cardiac death donors. Cardiac death in children is often sudden and unexpected, and is an emotional time not only for the family members but also for the hospital staff members, including perioperative nurses. However, when perioperative nurses adhere to standards and guidelines, they can perform their responsibilities in an ethical and compassionate manner and assist their team in doing so. This article reviews the guiding principles of pediatric organ donation after cardiac death, the phases of the process, and the ethical and moral issues surrounding donation.

Cost Evaluation of a Donation after Cardiac Death Program: How Cost per Organ Compares to Other Donor Types

Donation after cardiac death (DCD) is one method of organ donation. Nationally, more than half of evaluated DCD donors do not yield transplantable organs. There is no algorithm for predicting which DCD donors will be appropriate for organ procurement. Donation after cardiac death program costs from an organ procurement organization (OPO) accounting for all evaluated donors have not been reported. Hospital, transportation, and supply costs of potential DCD donors evaluated at a single OPO from January 2009 to June 2016 were collected. Mean costs per donor and per organ were calculated. Cost of DCD donors that did not yield a transplantable organ were included in cost analyses resulting in total cost of the DCD program. Donation after cardiac death donor costs were compared with costs of in-hospital donation after brain death (DBD) donors. There were 289 organs transplanted from 264 DCD donors evaluated. Mean cost per DCD donor yielding transplantable organs was $9,306. However, 127 donors yielded no organs, at a mean cost of $8,794 per donor. The total cost of the DCD program was $32,020 per donor and $15,179 per organ. Mean cost for an in-hospital DBD donor was $33,546 and $9,478 per organ transplanted. Mean organ yield for DBD donors was 3.54 vs 2.21 for DCD donors (p < 0.0001), making the cost per DBD organ 63% of the cost of a DCD organ. Mean cost per DCD donor is comparable with DBD donors, however, individual cost of DCD organs increases by almost 40% when all costs of an entire DCD program are included.

Long Cold Ischemia Times in Same Hospital Deceased Donor Transplants.

Recent changes in deceased donor organ allocation for livers (Share-35) and kidneys (kidney allocation system) have resulted in broader sharing of organs and increased cold ischemia time (CIT). Broader organ sharing however is not the only cause of increased CIT. This was a retrospective registry study of CIT in same-hospital liver transplants (SHLT, n = 4347) and same-hospital kidney transplants (SHKT, n = 9707) between 2004 and 2014. In SHLT, median (interquartile range) CIT was 5.0 (3.5-6.5) hours versus 6.6 (5.1-8.4) hours in other-hospital LT. donation after circulatory death donors, donor biopsy, male recipient, recipient obesity, and previous transplant were associated with increased CIT. Model for End-Stage Liver Disease at transplant of 29+ or status 1a was associated with decreased CIT. SHLT CIT varied by Organ Procurement Organization and transplant-center (P < 0.01), with center median CIT ranging from 2.0 to 7.8 hours across 118 centers. In SHKT, CIT was 13.0 (8.5-19.0) hours versus 16.5 (11.3-22.6) hours in other-hospital KT. Overweight donors, donation after cardiac death donors, right-kidney, donor biopsy, recipient obesity, use of mechanical perfusion, additional KT procedures on the same day, and transplant center annual volume were associated with increased CIT. Older donor age, extended criteria donors, and underweight recipients were associated with decreased CIT. SHKT CIT varied by Organ Procurement Organization and transplant-center (P < 0.001), with center median CIT ranging from 3.3 to 29 hours across 206 centers. Transplant centers with longer SHKT also had longer SHLT (P = 0.01). Same-hospital transplants already have a significant amount of CIT, even without transporting the organ to another hospital.

Successful kidney transplantation from a cardiac death donor after 164 hours of anuria: A case report

Successful kidney transplantation from a cardiac death donor after 164 hours of anuria: A case report

The future of cardiac transplantation.

The first human-to-human heart transplant was performed 50 years ago in 1967. Heart transplantation has now entered an era of tremendous growth and innovation. The future of heart transplantation is bright with the advent of newer immunosuppressive medications and strategies that may even result in tolerance. Much of this progress in heart transplant medicine is predicated on a better understanding of acute and chronic rejection pathways through basic science studies. The future will also include personalized medicine where genomics and molecular science will dictate customized treatment for optimal outcomes. The introduction of mechanical circulatory support (MCS) devices has changed the landscape for patients with severe heart failure to stabilize the most ill patient and make them better candidates for heart transplant. As ex vivo preservation takes hold, we may witness an expansion of the donor pool through the use of donation after cardiac death (DCD) donors. In addition, further geographical donor heart sharing through ex vivo preservation may further decrease waitlist mortality by enabling longer distance donor hearts to be allocated for the sickest waitlist patient. It is no doubt an exciting time to be involved in the field of heart transplantation. In this perspective, we will summarize the present state of heart transplantation and discuss various innovations that are being pursued.

Liver Transplant Recipients With End-Stage Renal Disease Largely Benefit From Kidney Transplantation

BackgroundThe incidence of end-stage renal disease (ESRD) after liver transplant (LT) has increased. The actual benefit of kidney transplantation (KT) is not completely understood in LT recipients with ESRD. MethodsWe analyzed Scientific Registry of Transplant Recipients data for all KT candidates with prior LT from 1998 to 2014; the benefits of KT relative to remaining on dialysis were compared by means of multivariate Cox proportional hazards regression analysis. ResultsThe number of these KT candidates with prior LT has tripled from 98 in 1998 to 323 in 2015; LT recipients with ESRD remaining on dialysis have a 2.5-times increase in the risk of liver graft failure and a 3.6-times increase in the risk of patient death compared with these patients receiving KT. The adjusted liver graft and patient survival rates after donors from donation after cardiac death or expanded-criteria donor kidney transplantation were significantly higher than in patients remaining on dialysis in LT recipients with ESRD. ConclusionsThe number of referrals to KT with prior LT is increasing at a rapid rate. Remaining on dialysis in LT recipients with ESRD has profound increased risks of liver graft failure and patient death in comparison to receiving a KT. LT recipients with ESRD can benefit from expanded-criteria donor and donation after cardiac death kidney transplantation.

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

BackgroundIn recent years, an increasing number of donor livers are being declined for transplantation in Australia. The aim of this study was to evaluate the impact of donation after cardiac death and other factors associated with organ quality on liver utilization rates in Australia.MethodsData on organ donors who donated at least 1 organ between 2005 and 2014 were obtained from the Australia and New Zealand organ donation registry. Temporal changes in donor characteristics were assessed and a logistical regression analysis was performed to evaluate their association with liver nonuse.ResultsThe number of organ donors increased from 175 in 2005 to 344 in 2014, with overall 19% being donation after cardiac death donors (P < 0.001). The percentage of livers deemed unsuitable for transplantation increased from 24% in 2005 to 41% in 2014 (P < 0.001). Donation after cardiac death was identified as the most important risk factor for nonuse with an odds ratio of 25.88 (95% confidence interval, 18.84-35.56), P < 0.001) followed by donor age, obesity, and diabetes.DiscussionThis study shows that livers donated after circulatory death are an underused resource in Australia. Better use of these currently available organs would be a highly cost-effective way of reducing waiting list mortality in liver transplantation.

Outcomes of red blood cell transfusions prescribed in organ donors by the Digital Intern, an electronic decision support algorithm.

The Digital Intern (DI) is an electronic decision support tool for the management of organ donors. One algorithm determines the dose, in units of red blood cells to be transfused, based on hematocrit (Hct) thresholds and targets. The effectiveness of the transfusion dose calculated by the DI in terms of achieving the selected Hct target and the duration of the targeted dose is not known. This was a retrospective study to describe the outcomes of transfusions prescribed by the DI. Pre- and posttransfusion Hct levels were compared to define response and all posttransfusion Hct values were plotted to evaluate the duration of the prescribed dose. A total of 120 organ donors were studied and 22 donors had 28 transfusions (six were transfused twice). The transfused donors were a mix of trauma and medical admissions and brain death and cardiac death donors. The transfusion target of 24% Hct was attained in 96% of transfusions. The mean number of units transfused was 1.4 and the mean time from transfusion to procurement was 19.8 hours. There was a decline in Hct over time after transfusion in all but one case with a mean decline of 1.9% Hct over 13 hours. Six donors were transfused twice, likely due to a longer donor time period (41.7 hr vs. 27 hr). The DI provided transfusion dosing that achieved the desired threshold in the majority of organ donors transfused. Ongoing work focuses on application of this technology to transfusions in general patient populations.

Use of Lung Allografts From Donation After Cardiac Death Donors: A Single-Center Experience

Lung transplantation remains the only treatment for end-stage lung disease. Availability of suitable lungs does not parallel this growing trend. Centers using donation after cardiac death (DCD) donor lungs report comparable outcomes with those from brain-dead donors. Donor assessment protocols and consistent surgical teams have been advocated when considering using the use of DCD donors. We present our experience using lungs from Maastricht category III DCD donors. Starting 2007 to July 2016, 73 DCD donors were assessed, 44 provided suitable lungs that resulted in 46 transplants. A 2012 to October 2016 comparative cohort of 379 brain-dead donors were assessed. Recipient and donor characteristics and primary graft dysfunction (PGD) and survival were monitored. Seventy-three DCD (40% dry run rate) donors assessed yielded 46 transplants (23 double, 6 right, and 17 left). Comparative cohort of 379 brain-dead donors yielded 237 transplants (112 double, 43 right, and 82 left). One- and 3-year recipient survival was 91% and 78% for recipients of DCD lungs and 91% and 75% for recipients of lungs from brain-dead donors, respectively. PGD 2 and 3 in DCD recipients at 72 hours was 4 of 46 (9%) and 6 of 46 (13%), respectively. Comparatively, brain-dead donor recipient cohort at 72 hours with PGD 2 and 3 was 23 of 237 (10%) and 41 of 237 (17%), respectively. Our experience reaffirms the use of lungs from DCD donors as a viable source with favorable outcomes. Recipients from DCD donors showed equivalent PGD rate at 72 hours and survival compared with recipients from brain-dead donors.