Donation After Brain Death Recipients Research Articles

Single center utilization and post-transplant outcomes of thoracoabdominal normothermic regional perfusion deceased cardiac donor organs.

Thoracoabdominal normothermic regional perfusion (TA-NRP) following cardiac death is an emerging multivisceral organ procurement technique. Recent national studies on outcomes of presumptive TA-NRP-procured organs are limited by potential misclassification since TA-NRP is not differentiated from donation after cardiac death (DCD) in registry data. We studied 22 donors whose designees consented to TA-NRP and organ procurement performed at our institution between January 20, 2020 and July 3, 2022. We identified these donors in SRTR to describe organ utilization and recipient outcomes and compared them to recipients of traditional DCD (tDCD) and donation after brain death (DBD) organs during the same timeframe. All 22 donors progressed to cardiac arrest and underwent TA-NRP followed by heart, lung, kidney, and/or liver procurement. Median donor age was 41 years, 55% had anoxic brain injury, 45% were hypertensive, 0% were diabetic, and median kidney donor profile index was 40%. TA-NRP utilization was high across all organ types (88%-100%), with a higher percentage of kidneys procured via TA-NRP compared to tDCD (88%vs. 72%, p=.02). Recipient and graft survival ranged from 89% to 100% and were comparable to tDCD and DBD recipients (p ≥ .2). Delayed graft function was lower for kidneys procured from TA-NRP compared to tDCD donors (27%vs. 44%, p=.045). Procurement from TA-NRP donors yielded high organ utilization, with outcomes comparable to tDCD and DBD recipients across organ types. Further large-scale study of TA-NRP donors, facilitated by its capture in the national registry, will be critical to fully understand its impact as an organ procurement technique.

Donation after circulatory death significantly reduces waitlist times while not changing post–heart transplant outcomes: A United Network for Organ Sharing Analysis

ObjectiveRecently, several centers in the US have begun performing donation after circulatory death (DCD) heart transplants (HT) in adults. We sought to characterize the recent use of DCD HT, waitlist-time, and outcomes compared to donation after brain death (DBD). MethodsUsing the UNOS database, 10,402 adult (>18yo) HT recipients from January 2019-June 2022 were identified: 425(4%) were DCD and 9,977(96%) were DBD recipients. Post-transplant outcomes in matched and unmatched cohorts, and waitlist-times were compared between groups. ResultsDCD and DBD recipients had similar age [57y for both, p=0.791]. DCD recipients were more likely white (67% vs. 60%,p=0.002), on LVAD (40% vs. 32%,p<0.001) & listed as status 4-6 (60% vs. 24%,p<0.001); however, less likely to require inotropes (22% vs. 40%,p<0.001), & preoperative ECMO (0.9% vs. 6%,p<0.001). DCD donors were younger (29 vs. 32y,p<0.001), had less renal dysfunction (15% vs. 39%,p<0.001), diabetes (1.9% vs. 3.8%,p=0.050) or hypertension (9.9% vs. 16%,p=0.001). In matched & unmatched cohorts, early survival was similar (p=0.22). Adjusted waitlist-time was shorter in DCD group (21d vs. 31d,p<0.001) compared to DBD cohort and 5-fold shorter (DCD-22d vs DBD-115d,p<0.001) for candidates in status 4-6 which was 60% of DCD cohort. ConclusionsThe community is using DCD mostly for those recipients who are expected to have extended wait list times (e.g., Durable LVADs, Status >4). DCD recipients had similar post-transplant early survival, and shorter adjusted waitlist-time compared to DBD group. Given this early success, efforts should be made to expand the donor pool using DCD, especially for traditionally disadvantaged recipients on the waitlist.

Outcomes of Heart Transplant Donation After Circulatory Death

BackgroundHeart transplantation using donation after circulatory death (DCD) allografts is increasingly common, expanding the donor pool and reducing transplant wait times. However, data remain limited on clinical outcomes. ObjectivesWe sought to compare 6-month and 1-year clinical outcomes between recipients of DCD hearts, most of them recovered with the use of normothermic regional perfusion (NRP), and recipients of donation after brain death (DBD) hearts. MethodsWe conducted a single-center retrospective observational study of all adult heart-only transplants from January 2020 to January 2023. Recipient and donor data were abstracted from medical records and the United Network for Organ Sharing registry, respectively. Survival analysis and Cox regression were used to compare the groups. ResultsDuring the study period, 385 adults (median age 57.4 years [IQR: 48.0-63.7 years]) underwent heart-only transplantation, including 122 (32%) from DCD donors, 83% of which were recovered with the use of NRP. DCD donors were younger and had fewer comorbidities than DBD donors. DCD recipients were less often hospitalized before transplantation and less likely to require pretransplantation temporary mechanical circulatory support compared with DBD recipients. There were no significant differences between groups in 1-year survival, incidence of severe primary graft dysfunction, treated rejection during the first year, or likelihood of cardiac allograft vasculopathy at 1 year after transplantation. ConclusionsIn the largest single-center comparison of DCD and DBD heart transplantations to date, outcomes among DCD recipients are noninferior to those of DBD recipients. This study adds to the published data supporting DCD donors as a safe means to expand the heart donor pool.

Improved Early Post-Transplant Outcomes and Organ Use in Kidney Transplant Using Normothermic Regional Perfusion for Donation after Circulatory Death: National Experience in the US.

Normothermic regional perfusion (NRP) is a technique that is intended to enhance organ transplant outcomes from donation circulatory death (DCD) donors. A retrospective analysis of data from the Scientific Registry of Transplant Recipients was performed. DCD donors were screened for inclusion based on date of donation 2020 or later, and whether the heart was also recovered for transplantation. We grouped donors as either donation after brain death or DCD. DCD donors were further divided into groups including those in which the heart was not recovered for transplant (Non-Heart DCD) and those in which it was, based on recovery technique (thoracoabdominal-NRP [TA-NRP] Heart DCD and Super Rapid Recovery Heart DCD). A total of 219 kidney transplant recipients receiving organs from TA-NRP Heart DCD donors were compared to 436 SRR Super Rapid Recovery DCD, 10,630 Super Rapid Recovery non-heart DCD, and 27,820 donations after brain death recipients. Kidney transplant recipients of TA-NRP DCD allografts experienced shorter length of stay, lower rates of delayed graft function, and lower serum creatinine at the time of discharge when compared with recipients of other DCD allografts. Our analysis demonstrates superior early kidney allograft function when TA-NRP is used for DCD organ recovery.

Acute rejection in donation after circulatory death (DCD) heart transplants

Donation after circulatory death (DCD) heart transplantation has promising early survival, but the effects on rejection remain unclear. The United Network for Organ Sharing database was queried for adult heart transplants from December 1, 2019, to December 31, 2021. Multiorgan transplants and loss to follow-up were excluded. The primary outcome was acute rejection, comparing DCD and donation after brain death (DBD) transplants. A total of 292 DCD and 5,582 DBD transplants met study criteria. Most DCD transplants were transplanted at status 3-4 (61.0%) compared to 58.6% of DBD recipients at status 1-2. DCD recipients were less likely to be hospitalized at transplant (26.7% vs 58.3%, p<0.001) and to require intra-aortic balloon pumping (IABP; 9.6% vs 28.9%, p<0.001), extracorporeal membrane oxygenation (ECMO; 0.3% vs 5.9%, p<0.001) or temporary left ventricular assist device (LVAD; 1.0% vs 2.7%, p<0.001). DCD recipients were more likely to have acute rejection prior to discharge (23.3% vs 18.4%, p=0.044) and to be hospitalized for rejection (23.4% vs 11.4%, p=0.003) at a median follow-up of 15months; the latter remained significant after propensity matching. On multivariable logistic regression, DCD donation was an independent predictor of acute rejection (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.00-2.15, p=0.048) and hospitalization for rejection (OR 2.03, 95% CI 1.06-3.70, p=0.026). On center-specific subgroup analysis, DCD recipients continued to have higher rates of hospitalization for rejection (23.4% vs 13.8%, p=0.043). DCD recipients are more likely to experience acute rejection. Early survival is similar between DCD and DBD recipients, but long-term implications of increased early rejection in DCD recipients require further investigation.

Donation after circulatory death improves probability of heart transplantation in waitlisted candidates and results in post-transplant outcomes similar to those achieved with brain-dead donors

ObjectiveTo quantitate the impact of heart donation after circulatory death (DCD) donor utilization on both waitlist and post-transplant outcomes in the United States. MethodsThe United Network for Organ Sharing database was queried to identify all adult waitlisted and transplanted candidates between October 18, 2018, and December 31, 2022. Waitlisted candidates were stratified according to whether they had been approved for donation after brain death (DBD) offers only or also approved for DCD offers. The cumulative incidence of transplantation was compared between the 2 cohorts. In a post-transplant analysis, 1-year post-transplant survival was compared between unmatched and propensity-score-matched cohorts of DBD and DCD recipients. ResultsA total of 14,803 candidates were waitlisted, including 12,287 approved for DBD donors only and 2516 approved for DCD donors. Overall, DCD approval was associated with an increased sub-hazard ratio (HR) for transplantation and a lower sub-HR for delisting owing to death/deterioration after risk adjustment. In a subgroup analysis, candidates with blood type B and status 4 designation received the greatest benefit from DCD approval. A total of 12,238 recipients underwent transplantation, 11,636 with DBD hearts and 602 with DCD hearts. Median waitlist times were significantly shorter for status 3 and status 4 recipients receiving DCD hearts. One-year post-transplant survival was comparable between unmatched and propensity score–matched cohorts of DBD and DCD recipients. ConclusionsThe use of DCD hearts confers a higher probability of transplantation and a lower incidence of death/deterioration while on the waitlist, particularly among certain subpopulations such as status 4 candidates. Importantly, the use of DCD donors results in similar post-transplant survival as DBD donors.

Pancreas transplantation with grafts obtained from donation after cardiac death or donation after brain death results in comparable outcomes

IntroductionPancreas organ shortages and long recipient waitlist times are critical components that limit recipients from receiving a pancreas transplant. Over the last decade, our center has been using donation after cardiac death (DCD) donors as an adjunct to donation after brain death (DBD) donors to expand the organ pool. The aim of this study was to compare recipient and graft survival between DCD and DBD recipients.MethodsA retrospective single center propensity matched analysis (2011–2020) of 32 DCD vs 96 DBD pancreas transplants was performed.Results8-year recipient survival was similar between DCD and DBD groups (87.4% vs 92.7%, p=0.35) as was simultaneous kidney and pancreas transplant (SPK) 8-year kidney (88.9 vs 96.9%, p=0.219) and pancreas graft survival (77.4% vs 86.7%, p=0.344). There was no difference in vascular thrombosis rate between DCD and DBD pancreas grafts (3.1% vs 7.3%, p=0.73). DCD kidneys had a higher rate of DGF vs DBD kidneys (28.1% vs 6.3%, p=0.004), without any significant difference in long term kidney failure (12.5% vs 8.3%, p=0.5).DiscussionRecipients of DCD grafts demonstrate equivalent long-term patient and graft survival compared to DBD recipients for pancreas transplantation. Increased utilization of well selected DCD donors is a safe strategy to increase the donor pool.

Graft function and incidence of cardiac allograft vasculopathy in donation after circulatory-determined death heart transplant recipients

Experience in donation after circulatory-determined death (DCD) heart transplantation (HTx) is expanding. There is limited information on the functional outcomes of DCD HTx recipients. We sought to evaluate functional outcomes in our cohort of DCD recipients. We performed a single-center, retrospective, observational cohort study comparing outcomes in consecutive DCD and donation after brain death (DBD) HTx recipients between 2015 and 2019. Primary outcome was allograft function by echocardiography at 12 and 24 months. Secondary outcomes included incidence of cardiac allograft vasculopathy, treated rejection, renal function, and survival. Seventy-seven DCD and 153 DBD recipients were included. There was no difference in left ventricular ejection fraction at 12 months (59% vs 59%, P = .57) and 24 months (58% vs 58%, P = .87). There was no significant difference in right ventricular function at 12 and 24 months. Unadjusted survival between DCD and DBD recipients at 5 years (85.7% DCD and 81% DBD recipients; P = .45) was similar. There were no significant differences in incidence of cardiac allograft vasculopathy (odds ratio 1.59, P = .21, 95% confidence interval 0.77-3.3) or treated rejection (odds ratio 0.60, P = .12, 95% confidence interval 0.32-1.15) between DBD and DCD recipients. Post-transplant renal function was similar at 1 and 2 years. In conclusion, cardiac allografts from DCD donors perform similarly to a contemporary population of DBD allografts in the medium term.

Comparing Cardiac Mechanics and Myocardial Fibrosis in DBD and DCD Heart Transplant Recipients

BackgroundHeart transplantation (HTx) after donation after circulatory death (DCD) is an expanding practice but is associated with increased warm ischemic time. The impact of DCD HTx on cardiac mechanics and myocardial fibrosis has not been reported. We aimed to compare cardiac mechanics and myocardial fibrosis using cardiovascular magnetic resonance (CMR) imaging in donation after brain death (DBD) and DCD HTx recipients and healthy controls. Methods and ResultsConsecutive HTx recipients between March 2015 and March 2021 who underwent routine surveillance CMR imaging were included. Cardiac mechanics were assessed using CMR feature tracking to compute global longitudinal strain, global circumferential strain, and right ventricular free-wall longitudinal myocardial strain. Fibrosis was assessed using late gadolinium enhancement imaging and estimation of extracellular volume. There were 82 (DBD n = 42, DCD n = 40) HTx recipients (aged 53 years, interquartile range 41–59 years, 24% female) who underwent CMR imaging at median of 9 months (interquartile range 6–14 months) after transplantation. HTx recipients had increased extracellular volume (29.7 ± 3.6%) compared with normal ranges (25.9%, interquartile range 25.4–26.5). Myocardial strain was impaired after transplantation compared with controls (global longitudinal strain –12.6 ± 3.1% vs –17.2 ± 1.8%, P < .0001; global circumferential strain –16.9 ± 3.1% vs –19.2 ± 2.0%, P = .002; right ventricular free-wall longitudinal strain –15.7 ± 4.5% vs –21.6 ± 4.7%, P < .0001). There were no differences in fibrosis burden (extracellular volume 30.6 ± 4.4% vs 29.2 ± 3.2%; P = .39) or cardiac mechanics (global longitudinal strain –13.1 ± 3.0% vs –12.1 ± 3.1%, P = .14; global circumferential strain –17.3 ± 2.9% vs –16.6 ± 3.1%, P = .27; right ventricular free-wall longitudinal strain –15.9 ± 4.9% vs –15.5 ± 4.1%, P = .71) between DCD and DBD HTx. ConclusionsHTx recipients have impaired cardiac mechanics compared with controls, with increased myocardial fibrosis. There were no differences in early CMR imaging characteristics between DBD and DCD heart transplants, providing further evidence that DCD and DBD HTx outcomes are comparable.

Abstract 11945: Improved Outcomes in Severe Primary Graft Dysfunction Following Heart Transplantation With Donation After Circulatory Death Compared to Donation After Brain Death

Introduction: Primary graft dysfunction (PGD), the leading cause of early mortality after heart transplant, is more common following heart donation after circulatory death (DCD) than following 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 transplant. Methods: We reviewed the medical records of all adult heart transplant recipients at our institution between March 2016 and December 2021. Patients undergoing multi-organ transplant were excluded. PGD was diagnosed within 24 hours after transplant according to modified ISHLT criteria and was classified by severity and ventricles involved. Results: A total of 459 qualifying patients underwent heart transplant during the study period, of whom 65 (14%) were DCD recipients and 394 (86%) were DBD recipients. The incidence of 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. 7.3%, p = 0.004). Among patients with severe PGD, DCD recipients experienced shorter duration of mechanical circulatory support (ECMO, VAD, or balloon pump; mean 6.0 ± 2.5 vs. 12.1 ± 11.3 days, p = 0.039; Figure), shorter post-transplant hospital length of stay (32.4 ± 41.1 vs. 61.9 ± 47.7 days, p = 0.004), and a trend toward improved 60-day survival (100% vs. 80%, p = 0.170) and one-year survival (92% [95% CI: 76%-100%] vs. 69% [53%-84%]). Conclusions: DCD heart transplant recipients were more likely to experience severe, biventricular PGD than DBD recipients. Despite this, short- and medium-term outcomes among patients with severe PGD were improved in DCD compared to DBD recipients. These data suggest different mechanisms of graft dysfunction and recovery following DCD compared to DBD and support the expansion of the heart donor pool with DCD in most potential recipients.

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.

Post-Kidney Transplantation Results After Circulatory or Brain Death Without Pre-Mortem Heparin Administration.

BackgroundKidney donation after circulatory death (DCD) follows confirmation of death using cardiorespiratory criteria, while donation after brain death (DBD) uses neurological criteria. DBD and DCD donors are the main sources of grafts for transplantation. This retrospective cohort study from a single center in the Czech Republic aimed to compare 5-year post-transplantation outcomes after DCD and DBD transplantation without pre-mortem heparin administration.Material/MethodsA total of 227 recipients with matched donors enrolled in the transplantation program at our institution between 2015 and 2019 were analyzed. Following the application of the inclusion criteria, 99 recipients and 94 matched donors were finally included in the study.ResultsThe duration of cold ischemia (median 961 vs 1100 min, P=0.028) and the perfusion with the preservation solution (median 11 vs 22 min, P<0.001) was statistically significantly shorter in DBD than in DCD grafts. The 1-year survival rates were 97.5% (95% CI 94.1–100.0%) and 90.0% (95% CI: 77.8–100.0%) for DBD and DCD recipients, respectively. The 3-year survival rates were 91.9 (95% CI: 86.0–98.4) and 90.0 (95% CI: 77.8–100.0) for the DBD and DCD groups, respectively. The overall difference in survival between the 2 groups of patients was not statistically significant (P=0.750) nor was disease-free survival (P=0.370).ConclusionsThis retrospective study from a single center showed similar 5-year results after kidney transplantation for DCD and DBD donors without pre-mortem heparin administration, including the time to graft failure and patient survival.

Results of Heart Transplants from Donation After Circulatory Death (DCD) Donors Using Thoraco-Abdominal Normothermic Regional Perfusion (TA-NRP) Compared to Donation After Brain Death (DBD)

<h3>Purpose</h3> In the U.S., heart transplantation from donation after circulatory death (DCD) is increasing. We present our institutional experience of DCD transplantation by using a thoracoabdominal-normothermic regional perfusion (TA-NRP) protocol and compare the results to a cohort concomitantly transplanted, from standard brain death (DBD) donation. <h3>Methods</h3> For TA-NRP protocol, suitable local DCD donors were transferred to our institution and co-located with the recipient in proximate operating rooms. Standard DCD procurement involved resuscitation of the donor on cardiopulmonary bypass after declaration of death and assessment for suitability by echocardiogram and hemodynamic data. Heart transplant from DBD was performed per standard protocol. Immunosuppression and management followed the same standardized protocol for all recipients. <h3>Results</h3> Between January 2020 and October 2021, we performed 10 DCD transplantations with TA-NRP protocol (7 isolated heart, 2 heart-lung and 1 heart-kidney). The median age was 54 years (44-72), and 70% were male. One heart-lung transplant recipient required VA ECMO post-op, for 3 days. During the same period, 70 patients received heart transplant from a DBD donor (71.4% isolated heart, 7.1% heart-lung, 21.4% heart-kidney). The median age was 56 years (24-77) - p=0.916, 84.% were male p=0.27. At mean follow-up of 397.6 days (DCD recipients) and 305.9 days (DBD recipients), there were no significant differences in acute cellular, antibody mediated rejection, cardiac allograft vasculopathy, heart graft function, and survival. Compared to DBD recipients, DCD recipients received transplant at lower listed statuses. <h3>Conclusion</h3> Short-term results suggest that transplant outcomes from DCD TA-NRP are comparable to recipients from DBD. Expanding heart transplantation by using DCD is a viable option for lower-status listed patients and wide adoption should be considered.

Predictors of Early Repeat Endoscopic Retrograde Cholangiopancreatography After Liver Transplantation by Organ Donor Type

Background and AimsEndoscopic retrograde cholangiopancreatography (ERCP) is the first-line therapy for management of post-transplant biliary complications. We assess ERCP frequency and rate of early repeat ERCP and anastomotic stricture development across, living donor (LD), donation after cardiac death (DCD) and donation after brain death (DBD) liver transplant (LT) donor types. MethodsWe performed a single-center retrospective study of patients who underwent LT from January 2014 to December 2019. Proportion of patients requiring ERCP and number of ERCPs per patient were compared across donor types using analysis of variance and chi-squared methods. Logistic regression was used to assess the risk of early repeat ERCP, defined as ERCP within 28 days of preceding ERCP and anastomotic stricture development. ResultsA total of 509 LTs, 352 (69.2%) DBD, 101 (19.8%) DCD, and 56 (11.0%) LD were performed during the study period. A greater proportion of LD (51.8%) recipients required ERCP compared with DBD (28.7%) recipients (P ≤ 0.01). LD and DCD recipients required significantly greater number of median (interquartile range [IQR]) ERCPs compared with DBD recipients (8 [4, 12] vs 3 [2, 5], P < 0.01 and 4 [2, 6] vs 3 [2, 5], P = 0.05). Risk of early repeat ERCP was significantly higher in LD (odds ratio 9.2; 95% confidence interval 4.6-18.5) and DCD (OR 2.3; 95% confidence interval 1.2-4.5) recipients compared with DBD recipients. ConclusionLD and DCD recipients experience higher ERCP frequency and greater risk of early repeat ERCP compared with DBD recipients. Our results suggest the need to tailor ERCP management protocols for post-LT biliary complications based on donor type.

Long-term outcomes of transplant kidneys donated after circulatory death.

Donation after circulatory death (DCD) represents up to 40% of used kidney grafts. While studies have shown similar outcomes compared with donation after brain death (DBD) in the short term and mid-term, no data on long-term outcomes exist. We retrospectively analysed patients transplanted at our institution between January 1985 and March 2000. All DCD recipients were matched one-to-one with patients transplanted with DBD grafts during this period according to sex, age and year of transplantation and followed up until December 2020. During this period, 1133 kidney transplantations were performed, of which 122 were with a DCD graft. The median graft survival after 35 years of follow-up was 23 years [277 months {95% confidence interval (CI) 182-372}] in DBD recipients and 24.5 years [289 months (95% CI 245-333)] in DCD recipients (P = 0.65; hazard ratio 0.91). Delayed graft function occurred in 47 patients in the DCD group compared with 23 in the DBD group (P < 0.001), albeit without a significant long-term outcome difference in graft or patient survival. We could not show any difference in graft function in terms of creatinine levels (133 versus 119 µmol/L), proteinuria (370 versus 240 mg/24 h) and glomerular filtration rate slope (-0.6 versus -0.3 mL/min/year) between the two groups for graft survival >20 years. This is the first study to show similar graft survival and function in DCD kidneys compared with DBD kidneys after 35 years of follow-up. DCD grafts are a valuable resource and can be utilized in the same way as DBD grafts.

Early Allograft Dysfunction After Liver Transplantation With Donation After Circulatory Death and Brain Death Grafts: Does the Donor Type Matter?

Background.Early allograft dysfunction (EAD) after liver transplantation has been associated with long-term reduced graft and patient survival.Methods.In this single-center cohort study, we aimed to compare incidence, risk factors, and outcomes in liver transplant recipients who developed EAD. Patients who received donation after circulatory death (DCD) or donation after brain death (DBD) grafts between January 2007 and December 2017 were included. EAD was defined as bilirubin of ≥10 mg/dL (171 μmol/L) or an international normalized ratio of ≥1.6 on postoperative day 7 or transaminases >2000 U\\L in the first-week posttransplantation as previously described.Results.In our cohort of 1068 patients, incidence of EAD was 44%. EAD occurred more frequently in the DCD versus DBD group (71% versus 41%, P < 0.01). Overall, recipients who developed EAD showed a significantly lower graft and patient survival at 1, 3, and 5 y after transplantation (all P < 0.05). This was also the case for recipients of DBD grafts. However, for recipients of DCD grafts, patient and graft survival were not affected by the presence of EAD. For recipients of DBD grafts, donor age, body mass index (BMI) and gender, recipient BMI and model for end-stage liver disease score and warm and cold ischemia time were associated with EAD. For DCD recipients, donor BMI and cold ischemia time were associated with EAD.Conclusions.In our cohort study, EAD resulted in reduced long-term patient and graft survival only for DBD recipients but not for DCD recipients. Predictive markers for EAD were dependent on the donor type.

Clinical and Functional Outcomes after Lung Transplantation with Grafts from Donation after Circulatory (DCD) Donors. Preliminary Results of a Clinical Trial

<h3>Purpose</h3> We present the results of a clinical trial (NCT02061462) comparing outcomes after lung transplantation (LT) of subjects receiving lungs from donation after brain death (DBD) donors with that of subjects receiving lungs from donation after circulatory death (DCD) donors, procured using our original open lung strategy. Briefly, our protocol consists of a non-rapid normothermic open-lung procurement using recruitment manoeuvres, protective ventilation and CPAP without topical cooling. <h3>Methods</h3> We evaluated patients undergoing bilateral LT from 11/2014 to 07/2019; exclusion criteria: recipients ≤14 years, re-LT, donors ≥65 years, DCD category I and IV. Variables were prospectively recorded as well as respiratory functional parameters in the first year. <h3>Results</h3> We performed 143 LT; 22 cases were excluded, 121 were enrolled: 11 recipients received lungs from DCD donors (5 and 6 from DCD category II and III, respectively). The two groups had similar features. Most of the subjects had cystic fibrosis (72,7% and 61,9% of DCD and DBD, respectively). DCD donors' BMI was significantly higher (p=0.022); 15,5% of DBD grafts underwent machine perfusion. Duration of postoperative mechanical ventilation was higher in the DCD group (DCD vs DBD=2 vs 1 day, p=0.011). Incidence of grade 3 primary graft dysfunction was 27,3% in the DCD group and 18,2% in the DBD group (p=0.742). Cold ischemia and preservation times were significantly higher in the DCD group (p<0.001). Airway complications occurred in 18,2% and 6,4% in DCD and DBD recipients, respectively (Table 1). Mean FEV1 was significantly higher in the DBD group at 6 months (83,5% vs 78,5%) but not at 1 year (86,0% vs 81,7%). FVC and Tiffenau did not significantly differ. <h3>Conclusion</h3> Regardless of the small study population, our results are encouraging. Our data show the feasibility of LT from DCD donors using our original protocol, with adequate grafts function and survival.

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.

Long-Term Outcomes of Early Experience in Donation After Circulatory Death Liver Transplantation: Outcomes at 10 Years.

BackgroundDonation after circulatory death (DCD) livers remain an underutilized pool of transplantable organs due to concerns of inferior long-term patient survival (PS) and graft survival (GS), which factors greatly into clinician decision-making and patient expectations.Material/MethodsThis retrospective study used SRTR data to assess 33 429 deceased-donor liver transplants (LT) and compared outcomes between DCD and donation after brain death (DBD) LT recipients in the United States. Data were collected from 2002 to 2008 to obtain 10 years of follow-up (2012–2018) in the era of MELD implementation. Propensity scores for donor type (DCD vs DBD) were estimated using logistic regression, and the association of donor type with 10-year outcomes was evaluated after adjustment using stabilized inverse probability of treatment weights.ResultsAfter adjusting for confounders, patient survival for DBD recipients at 10 years was 60.7% versus 57.5% for DCD recipients (P=0.24). Incorporating retransplants, 10-year adjusted patient survival was 60.2% for DBD recipients versus 55.5% for DCD recipients (P=0.07). Adjusted 10-year graft survival for DBD recipients was 56.4% versus 45.4% for DCD recipients (P<0.001). Surprisingly, however, 1 year after LT, DBD and DCD graft failure rates converged to 7.5% over the remaining 9 years.ConclusionsThese data reveal inferior 10-year DCD graft survival, but only in the first year after LT, and similar 10-year patient survival in DCD LT recipients compared to DBD recipients. Our results show the stability and longevity of DCD grafts, which should encourage the increased utilization of these livers for transplantation.

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