Donation After Brain Death Patients Research Articles

Heart transplantation from donation after circulatory death: a meta-analysis of national registries.

Although it has been widely recognized that heart transplantation (HT) following donation after circulatory death (DCD) can be a successful strategy to expand the donor pool, its clinical outcomes compared to donation after brain death (DBD) are still the subject of intense investigation. We reviewed the clinical characteristics of HT after DCD from the three largest multicenter nationwide registries, highlighting technical aspects, donor and recipient selection, and early outcomes. Moreover, we performed a meta-analysis of survival outcomes of DCD vs. DBD using reconstructed individual patient time-to-event data. The PubMed, Web of Science, and Scopus databases were searched in January 2024 to identify the most recent reports from three large multicenter nationwide registries (United States, United Kingdom, and Australia) of HT after DCD. Clinical characteristics were summarized using descriptive statistics, and survival curves were reconstructed for DBD using individual patient time-to-event data. The pooled hazard ratio (HR) with confidence interval (CI) was calculated via Cox regression. A total of 646 DCD HT patients and 7,253 DBD controls were included in this review. In the majority of cases, donors were young males. The mean age of recipients ranged from 48 to 57 years, and the majority were males with idiopathic dilated cardiomyopathy. Up to 40% of patients required postoperative mechanical circulatory support with extracorporeal membrane oxygenation (ECMO). The meta-analysis estimated a pooled 1-year survival of 91.1% (95% CI: 88.6-93.7%) and 90.1% (95% CI: 89.4-90.8%) for DCD and DBD patients, respectively (P=0.91), with a pooled HR of 0.88 (95% CI: 0.65-1.20). Although the generally more favorable clinical profile of DCD donors and recipients may constitute a potential selection bias, our meta-analysis documented similar early and medium-term survival outcomes for DCD and DBD HT.

Improved Outcomes in Severe Primary Graft Dysfunction After Heart Transplantation Following Donation After Circulatory Death Compared With Donation After Brain Death

Primary graft dysfunction (PGD), the leading cause of early mortality after heart transplantation, is more common following donation after circulatory death (DCD) than donation after brain death (DBD). We conducted a single-center, retrospective cohort study to compare the incidence, severity and outcomes of patients experiencing PGD after DCD compared to DBD heart transplantation. Medical records were reviewed for all adult heart transplant recipients at our institution between March 2016 and December 2021. PGD was diagnosed within 24 hours after transplant according to modified International Society for Heart and Lung Transplant criteria. A total of 459 patients underwent isolated heart transplantation during the study period, 65 (14%) following DCD and 394 (86%) following DBD. The incidence of moderate or severe PGD in DCD and DBD recipients was 34% and 23%, respectively (P = 0.070). DCD recipients were more likely to experience severe biventricular PGD than DBD recipients (19% vs 7.4%; P = 0.004). Among patients with severe PGD, DCD recipients experienced shorter median (Q1, Q3) duration of post-transplant mechanical circulatory support (6 [4, 7] vs 9 [5, 14] days; P = 0.039), shorter median post-transplant hospital length of stay (17 [15, 29] vs 52 [26, 83] days; P = 0.004), and similar 60-day survival rates (100% [95% CI: 76.8%-100%] vs 80.0% [63.1%-91.6%]; P = 0.17) and overall survival (log-rank; P = 0.078) compared with DBD recipients. DCD heart transplant recipients were more likely to experience severe, biventricular PGD than DBD recipients. Despite this, DCD recipients with severe PGD spent fewer days on mechanical circulatory support and in the hospital than similar DBD patients. These findings suggest that patterns of graft dysfunction and recovery may differ between donor types, and they support the expansion of the heart-donor pool with DCD.

Adult Lung Transplantation from Donation After Circulatory Death Donors: Safety and Outcomes Utilizing the UNOS / OPTN Registry

<h3>Purpose</h3> Donation after circulatory death (DCD) has been described in abdominal transplantation but has not been thoroughly evaluated in lung transplantation. The aim of this retrospective study was to describe and compare DCD utilization with donation after brain death (DBD). <h3>Methods</h3> The United Network for Organ Sharing (UNOS) database was reviewed for all adult patients who underwent lung transplant between 2016 and 2020. Baseline features and post-transplant outcomes were reviewed using descriptive and survival analyses by the Kaplan-Meier and Cox regression method. <h3>Results</h3> A total of 11,837 isolated lung transplant recipients met criteria for analysis. DCD utilization increased over time, from 92/2198 (14.7%) in 2016 to 180/2376 (28.8%) recipients in 2020 (p<0.001 for trend). DCD patients were more likely double lung recipients (79.9 vs 74.6%), had longer ischemia times (7.6 vs. 5.5 h), and were more commonly intubated (42.8 vs. 29.9%) and required extracorporeal support (12.5 vs 7.2%) up to 72 h following surgery (Table 1). Unadjusted overall survival was worse for DCD vs DBD patients (log rank, p<0.001). When stratified by transplant type, there was no survival difference between DCD and DBD single lung recipients (log rank, p=0.322); however, survival among double lung recipients was worse for DCD vs DBD patients (log rank, p<0.001). After adjustment for statistically significant covariates (Table 1), DCD status was not associated with mortality for double lung recipients (HR: 1.189, 95% CI [0.985 - 1.435]; p=0.071). Ischemia time (HR: 1.029, 95% CI [1.007 - 1.052]; p=0.010) and extracorporeal support (HR: 2.862, 95% CI [2.512 - 3.260]; p<0.001) after transplant were more common in DCD patients and strongly associated with mortality up to 5 years. <h3>Conclusion</h3> DCD status was associated with worse survival in double lung transplant recipients, which may be attributed to longer ischemia times. Additional efforts will be required to characterize and mitigate these effects.

Postoperative acute kidney injury and renal replacement therapy after DCD lung transplantation.

Acute kidney injury (AKI) after lung transplantation (LTx) is a common complication. We aimed to assess whether donation after circulatory death (DCD) is associated with an increased risk of AKI and renal replacement therapy (RRT) in the early postoperative period compared to the donation after brain death (DBD). Retrospective data on a cohort (N=95) of LTx patients (DCD n=17, DBD n=78) characterized by no use of ex-vivo lung perfusion were analyzed for the incidence of AKI within 30 postoperative days and incidence of RRT within 7 and 30days. After optimal full matching, an imbalance remained between the DCD and DBD patients in respect to intraoperative use of cardiopulmonary bypass (CPB). Therefore, a further subset (n=77) was defined that excluded CPB patients, and matching was repeated (DCD n=13vs. DBD n=63) resulting in a fair balance on a range of preoperative characteristics and intraoperative use of ECMO. In both matched subsets, DCD was associated with around twice higher risk of AKI and RRT within 7 and 30 postoperative days. In conclusion, data suggest that DCD could be associated with worse early renal outcomes in a subset of LTx patients and justify further studies on the topic in order to refine further renal care pathways perioperatively.

Donation after Circulatory Death Heart Transplantation - The First 5 Years a Successful Leap in Activity

<h3>Purpose</h3> Donation after circulatory death (DCD) heart transplantation was reinstated in response to the critical shortage of donor hearts from donation after brain death (DBD). Promising early results prompted centres in Europe, Australia and United States to adopt this practice. A clinical DCD heart transplant programme was initiated at our centre in March 2015. We aim to review our experience to date. <h3>Methods</h3> The study included recipients of DCD heart transplant from 1^st of March 2015 to 31^st October 2020. Comparison was made with the concurrent group of DBD heart recipients from our centre who were matched on donor and recipient characteristics. DCD hearts were retrieved by one of the three methods practised at our institution: 1. Thoraco-abdominal normothermic regional perfusion followed by <i>ex-situ</i> machine perfusion (TANRP-MP), 2. TANRP followed by cold storage (TANRP-CS) or 3. Direct procurement and perfusion (DPP) utilising <i>ex-situ</i> machine perfusion. All DBD hearts were preserved by cold storage. The 2 primary outcome measures were survival and primary graft dysfunction requiring temporary mechanical circulatory support (MCS). <h3>Results</h3> 85 DCD heart transplants were performed over the studied period. 62 hearts were retrieved by DPP, 20 by TANRP-MP and 3 by TANRP-CS. 30-day patient survival was comparable between groups (p=0.76), with 95% for DCD and 94% for DBD. 90% of DCD patients survived to 1 year vs 91% of their DBD matches. 5-year survival was 87% in the DCD and 83% in the DBDs. 33% of DCD patients required MCS post-transplant vs 24% of DBD patients (p=0.24). Support with V-A ECMO was necessary for 11 DCD and 5 DBD recipients (p=0.21). Early cardiac function appeared better in the DCD group (CI 2.3 vs 1.9, p=0.08). Secondary outcome measures were similar between the groups, table 1. <h3>Conclusion</h3> DCD heart transplantation appears to be equivalent to traditional DBD transplantation. 5-year outcomes of our 85-patient cohort including acute rejection rates support this conclusion.

Donation after circulatory death hearts recipients compared to donation after brain death heart recipients have comparable systolic left ventricular function and better myocardial strain at 1 year

Abstract Purpose Cardiac transplantation from donation after circulatory death (DCD) has been implemented at our hospital since February 2015. Despite encouraging results some concerns may be raised about the impact of the warm ischemia and reperfusion injury on the myocardium status at longer follow-up. Therefore, we aimed to analyse systolic performance of the left ventricle at 1 year follow in DCD and donation after brain death (DBD) cardiac recipients, as assessed by echocardiography with myocardial deformation imaging. Methods We identified 46 consecutive DCD cardiac recipients who were transplanted from February 2015 to August 2018 and we matched them with 46 DBD cardiac recipients. Six and 7 patients from DCD and DBD group, respectively, died in the first-year post transplant. In the remaining patients we have compared the classical echocardiographic measurements as well as global longitudinal strain (GLS) and global circumferential strain (GCS) at 1-year follow-up. Results DCD and DBD patients did not present with differences in terms of classical echocardiographic parameters of left ventricular (LV) structure and systolic function at one-year follow-up. LVEDV was similar in DCD and DBD patients (101±24 vs. 95±32 ml, p=0.4 respectively), as well as LVESV (42±13 vs. 42±16 ml, p=0.9, respectively), LV ejection fraction (58±6 vs. 56±8%, p=0.22) and LV mass (156±39 vs. 163±38 gr, p=0.2, respectively). In contrast, myocardial deformation parameters, such as GLS and GCS, were better in DCD than in DBD (16.1 vs. −14.5%, p&amp;lt;0.01; and −25.2 vs. 22.3%, p&amp;lt;0.05, respectively). The diastolic LV function parameters were similar in DCD and DBD group, as evidenced by E wave velocity, A wave velocity and deceleration time of mitral inflow, however E over E prime was lower in DCD than in DBD recipients (7.7±8.7, p&amp;lt;0.05). Fractional area change of the right ventricle was higher in DCD in comparison with DBD (46±7 vs. 40±7%, p&amp;lt;0.01) while right atrial volume index was lower in DCD than in DBD (25±8 vs. 29±9 ml/m2, p&amp;lt;0.01). Other parameters of RV function (systolic excursion of the tricuspid annulus, TAPSE) were similar in both groups. Conclusion DCD and DBD heart recipients present with similar systolic LV function at 1-year follow, as assessed by classical echocardiographic parameters. DCD cardiac recipients have better myocardial deformation parameters as assessed by the speckle tracking, better systolic right ventricular function and lower filling pressures of the left ventricle. Funding Acknowledgement Type of funding source: None

DCD Donor Hearts Recipients Compared to DBD Donor Heart Recipients Present with Comparable Systolic Left Ventricular Function and Better Myocardial Strain at 1 Year Follow Up

Purpose Cardiac transplantation from donation after circulatory death (DCD) has been implemented at Papworth hospital since February 2015. Despite encouraging results some concerns may be raised about the impact of the warm ischemia and reperfusion injury on the myocardium status at longer follow-up. Therefore, we aimed to analyse systolic performance of the left ventricle at 1 year follow in DCD and donation after brain death (DBD) cardiac recipients, as assessed by echocardiography with myocardial deformation imaging. Methods We identified 26 DCD cardiac recipients who were transplanted from February 2015 to February 2017 and we matched them with 26 DBD cardiac recipients. Three and 2 patients from DCD and DBD group, respectively, died in the first-year post transplant. In the remaining patients we have compared the classical echocardiographic measurements as well as global longitudinal strain (GLS) and global circumferential strain (GCS) at 1-year follow-up. Results DCD and DBD patients did not present with differences in terms of classical echocardiographic parameters of left ventricular (LV) structure and systolic function. LVEDV was similar in DCD and DBD patients (102+/-37 vs. 99+/-21 ml, respectively), as well as LVESV (44+/-12 vs. 43 +/- 18 ml, respectively) and LV mass (157+/-36 vs. 169+/-44 gr). LV ejection fraction was similar in two groups (57+/- 7 vs. 58+/-8 %), as well as GLS (-15.9+/-2.3 vs. 14.8+/- 1.9%, p=0.1) and GCS (-23.7+/-5.7 vs. -20.3+/-4.1, p=0.05). In both groups 3 patients presented with left ventricular dysfunction secondary either to primary graft dysfunction or cellular rejection. When we limited analysis to the patients who presented at 1 year follow up with LVEF>=50%, DCD and DBD cardiac recipients presented with similar LVEF (60+/-5 vs. 58+/-4%), but DCD cardiac recipients in comparison to DBD recipients had better GLS (-16.5+/-1.7% vs. -15.1+/-1.4%, p=0.04) and better GCS (-25.2+/-4% vs. 20.9+/-3.25, p=0.02). Conclusion DCD and DBD cardiac recipients present with similar systolic LV function at 1-year follow, as assessed by classical echocardiographic parameters. DCD cardiac recipients have better myocardial deformation parameters as assessed by the speckle tracking in comparison to DBD cardiac recipients. Cardiac transplantation from donation after circulatory death (DCD) has been implemented at Papworth hospital since February 2015. Despite encouraging results some concerns may be raised about the impact of the warm ischemia and reperfusion injury on the myocardium status at longer follow-up. Therefore, we aimed to analyse systolic performance of the left ventricle at 1 year follow in DCD and donation after brain death (DBD) cardiac recipients, as assessed by echocardiography with myocardial deformation imaging. We identified 26 DCD cardiac recipients who were transplanted from February 2015 to February 2017 and we matched them with 26 DBD cardiac recipients. Three and 2 patients from DCD and DBD group, respectively, died in the first-year post transplant. In the remaining patients we have compared the classical echocardiographic measurements as well as global longitudinal strain (GLS) and global circumferential strain (GCS) at 1-year follow-up. DCD and DBD patients did not present with differences in terms of classical echocardiographic parameters of left ventricular (LV) structure and systolic function. LVEDV was similar in DCD and DBD patients (102+/-37 vs. 99+/-21 ml, respectively), as well as LVESV (44+/-12 vs. 43 +/- 18 ml, respectively) and LV mass (157+/-36 vs. 169+/-44 gr). LV ejection fraction was similar in two groups (57+/- 7 vs. 58+/-8 %), as well as GLS (-15.9+/-2.3 vs. 14.8+/- 1.9%, p=0.1) and GCS (-23.7+/-5.7 vs. -20.3+/-4.1, p=0.05). In both groups 3 patients presented with left ventricular dysfunction secondary either to primary graft dysfunction or cellular rejection. When we limited analysis to the patients who presented at 1 year follow up with LVEF>=50%, DCD and DBD cardiac recipients presented with similar LVEF (60+/-5 vs. 58+/-4%), but DCD cardiac recipients in comparison to DBD recipients had better GLS (-16.5+/-1.7% vs. -15.1+/-1.4%, p=0.04) and better GCS (-25.2+/-4% vs. 20.9+/-3.25, p=0.02). DCD and DBD cardiac recipients present with similar systolic LV function at 1-year follow, as assessed by classical echocardiographic parameters. DCD cardiac recipients have better myocardial deformation parameters as assessed by the speckle tracking in comparison to DBD cardiac recipients.

Kidney Transplantation From Donors After Brain or Cardiac Death in China—A Clinical Analysis of 94 Cases

BackgroundWe analyzed outcomes of kidney transplantation (KTx) from donation after brain death (DBD) or cardiac death (DCD) in China under the current level of the health care system. MethodsAmong 94 KTx performed from February 2007 to March 2012 in two organ transplant centers in the south of China, 50 KTx were used DBD and 44 DCD donors. We retrospectively analyzed the clinical outcomes. ResultsAt a mean follow-up of 25.5 months, the 1-year and 2-year graft survival rates were 96.8% and 95.2% respectively. Delayed graft function (DGF) occurred in 27.7% recipients, three of whom lost graft function. Among six observed acute rejection episodes, five were reversed. When compared to the DCD group in DBD patients were apt to recover from DGF. Serum creatinine decreased more promptly in the DBD than in DCD group. Serum creatinine in the DCD group increased after months 12, when it was significantly higher than that in the DBD group (P < .05). ConclusionsKidney transplantation from DBD donors showed good outcomes with few complications. Although KTx from DCD donors showed a higher DGF rate and longer duration of graft recovery, we achieved favorable short-term clinical outcome using this source.

Donation After Cardiac Death Liver Transplant Recipients Have an Increased Frequency of Acute Kidney Injury

Donation after cardiac death (DCD) liver transplantation is associated with an increased frequency of hepato-biliary complications. The implications for renal function have not been explored previously. The aims of this single-center study of 88 consecutive DCD liver transplant recipients were (1) to compare renal outcomes with propensity-risk-matched donation after brain death (DBD) patients and (2) in the DCD patients specifically to examine the risk factors for acute kidney injury (AKI; peak creatinine ≥2 times baseline) and chronic kidney disease (CKD; eGFR <60 mL/min/1.73 m(2) ). During the immediate postoperative period DCD liver transplantation was associated with an increased incidence of AKI (DCD, 53.4%; DBD 31.8%, p = 0.004). In DCD patients AKI was a risk factor for CKD (p = 0.035) and mortality (p = 0.017). The cumulative incidence of CKD by 3 years post-transplant was 53.7% and 42.1% for DCD and DBD patients, respectively (p = 0.774). Importantly, increasing peak perioperative aspartate aminotransferase, a surrogate marker of hepatic ischemia reperfusion injury, was the only consistent predictor of renal dysfunction after DCD transplantation (AKI, p < 0.001; CKD, p = 0.032). In conclusion, DCD liver transplantation is associated with an increased frequency of AKI. The findings suggest that hepatic ischemia reperfusion injury may play a critical role in the pathogenesis of post-transplant renal dysfunction.

Transcriptional signatures in donor lungs from donation after cardiac death vs after brain death: A functional pathway analysis

Lung donation after cardiac death (DCD), in contrast to donation after brain death (DBD), is a promising and increasingly common method to help relieve the shortage of donor organs. We aimed to study the differential gene expression profiles in lungs of DCD and DBD patients and interpreted the differences using functional pathway analysis. We performed microarray studies on pre- and post-transplant lung tissues from 7 DCD and 12 matched DBD patients. Gene profiling was performed by Affymetrix human gene U-133 plus 2 GeneChip on 35 lung tissues. Principal Component Analysis (PCA), Significance Analysis of Microarray (SAM) and Hierarchical Clustering were performed to identify gross gene expression features and the lists of significantly regulated genes. We used Gene Set Enrichment Analysis (GSEA) and Ingenuity Pathway Analysis (IPA) to determine functional significance and the genomic network relationship. Gene expression profiles between DCD and DBD demonstrated a clear distinction by PCA, especially in the pre-transplant period. The gene sets enriched in DBD mapped to innate immunity, intracellular signaling, cytokine interaction, cell communication and apoptosis pathways. The networks produced by IPA showed that pro-inflammatory nodes played major role in pre-transplant DBD networks. However, the number of differentially regulated transcripts or gene sets decreased markedly after transplantation between DBD and DCD. Analysis of gene expression profiles in donor lungs showed significant differences in pathway activation between DBD and DCD lungs. The observation of fewer inflammatory features of DCD donor lungs suggests safe application of lung transplantation in properly preserved DCD donor lungs.

Hepatitis C recurrence is not adversely affected by the use of donation after cardiac death liver allografts

Many factors can worsen a recurrent hepatitis C virus (HCV) infection after liver transplantation (LT). We sought to determine whether the use of donation after cardiac death (DCD) livers affects HCV recurrence. From January 2000 to June 2008, 37 HCV patients underwent LT with DCD allografts. The outcomes and severity of HCV recurrence were analyzed along with those for 74 matched control patients with HCV who received donation after brain death (DBD) livers. The 2 groups had similar donor and recipient characteristics, immunosuppression regimens, rates of acute cellular rejection (ACR), and HCV profiles. DCD patients had a higher incidence of primary nonfunction (19% versus 3%, P = 0.006) and significantly higher peak aspartate aminotransferase levels in comparison with DBD subjects, suggesting a greater degree of ischemia/reperfusion injury. Although the survival rates were not significantly different, DCD recipients had lower 1- and 5-year patient survival rates (83% and 69% versus 84% and 78%, respectively, P = 0.75) and graft survival rates (70% and 61% versus 82% and 74%, respectively, P = 0.24). Three hundred fourteen protocol and clinically indicated liver biopsy procedures were performed within 6 years after transplantation, and mixed modeling analysis showed that fibrosis progression rates were similar for the 2 groups (0.6 fibrosis units/year according to the Ishak modified staging system). The rates of severe HCV recurrence (retransplantation or death due to recurrent hepatitis C and/or the development of stage 4/6 fibrosis or worse within 2 years) were similar [3 DCD patients (8%) versus 11 DBD patients (15%), P = 0.38], and cytomegalovirus infection (hazard ratio = 7.9, P = 0.002, 95% confidence interval = 2.1-28.9) and ACR (hazard ratio = 6.2, P = 0.002, 95% confidence interval = 2.0-19.7) were the only independent risk factors for severe recurrence. In summary, although there was a trend of poorer overall outcomes in DCD patients, the use of DCD livers did not appear to adversely affect HCV recurrence after LT.

Liver transplantation following donation after cardiac death: An analysis using matched pairs

Grafts from donation after cardiac death (DCD) donors are used to increase the number of organs available for liver transplantation. There is concern that warm ischemia may impair graft function. We compared our DCD recipients with a case-matched group of donation after brain death (DBD) recipients. Between January 2002 and April 2008, 39 DCD grafts were transplanted. These were matched with 39 DBD recipients on the basis of identified variables that had a significant impact on mortality. These were used to individually match DCD and DBD patients with similar predictive mortality. We compared patient/graft survival, primary non-function (PNF), and rates of complications. Of all liver transplants, 6.1% were DCD grafts. PNF occurred twice in the DCD group. The incidence of nonanastomotic biliary strictures (NABS; 20.5% versus 0%, P = 0.005) and hepatic artery stenosis (HAS; 12.8% versus 0%, P = 0.027) in the DCD group was higher. One-year (79.5% versus 97.4%, P = 0.029) and 3-year (63.6% versus 97.4%, P = 0.001) graft survival was lower in the DCD group. Three-year patient survival was also lower (68.2% versus 100%, P < 0.0001). Our study is the first to use case-matched patients and compare groups with similar predictive mortality. There was a higher incidence of NABS and HAS in the DCD group. NABS were likely a result of warm ischemia. HAS may have been due to ischemia or arterial injury during retrieval. The DCD group had significantly poorer outcomes, but DCD grafts remain a valuable resource. With careful donor/recipient selection, minimization of ischemia, and good postoperative care, acceptable results can be achieved.

Liver Transplantation Using Donation After Cardiac Death Donors: Long-Term Follow-Up from a Single Center

There is a lack of universally accepted clinical parameters to guide the utilization of donation after cardiac death (DCD) donor livers and it is unclear as to which patients would benefit most from these organs. We reviewed our experience in 141 patients who underwent liver transplantation using DCD allografts from 1993 to 2007. Patient outcomes were analyzed in comparison to a matched cohort of 282 patients who received livers from donation after brain death (DBD) donors. Patient survival was similar, but 1-, 5- and 10-year graft survival was significantly lower in DCD (69%, 56%, 44%) versus DBD (82%, 73%, 63%) subjects (p < 0.0001). Primary nonfunction and biliary complications were more common in DCD patients, accounting for 67% of early graft failures. A donor warm ischemia time >20 min, cold ischemia time >8 h and donor age >60 were associated with poorer DCD outcomes. There was a lack of survival benefit in DCD livers utilized in patients with model for end-stage liver disease (MELD) < or =30 or those not on organ-perfusion support, as graft survival was significantly lower compared to DBD patients. However, DCD and DBD subjects transplanted with MELD >30 or on organ-perfusion support had similar graft survival, suggesting a potentially greater benefit of DCD livers in critically ill patients.