Donation After Cardiac Death Donors Research Articles

Results from an International Survey of Donor and Recipient Eligibility for Solid Organ Pancreas Transplantation.

BackgroundCurrent solid organ pancreas transplantation protocols have differing donor criteria for donor pancreas acceptance and recipient eligibility criteria for transplant workup. We quantified this variation and compared current Australia and New Zealand (ANZ) solid pancreas transplant eligibility criteria with current international practice.Material/MethodsA survey of donor and recipient eligibility criteria for solid pancreas transplantation was disseminated to 85 transplant units in 23 countries. Responses were grouped by regions (ANZ, North America, Eurotransplant, Europe, United Kingdom) and analyzed for significant differences between regions and for ANZ compared to all other regions.ResultsResponding UK pancreas transplant units reported the highest mean donor upper age limit (61 years old) and the highest mean donation after cardiac death donor (DCD) age limit (55 years old). All responding UK and USA units utilized DCD pancreas donors and accepted suitable type 2 diabetes (T2DM) recipients for pancreas transplantation; however, this was less common among responding European or Eurotransplant units. ANZ mean standard and DCD pancreas donor upper age limits (47 and 35 years old, respectively) were lower compared to all other regions (54 years old and 48 years old, respectively).ConclusionsPancreas donor age limits, DCD pancreas donor utilization, and transplanting T2DM recipients differ between responding pancreas transplant units. ANZ units have more conservative donor upper age limits compared to other responding units. Increased utilization of DCD pancreas donors and T2DM recipients while standardizing pancreas donor age limits might increase donor numbers and improve access to solid pancreas transplantation both locally and abroad.

Donor type and 3-month hospital readmission following kidney transplantation: results from the Netherlands organ transplant registry

BackgroundHospital readmission after transplantation is common in kidney transplant recipients (KTRs). In this study, we aim to compare the risk of 3-month hospital readmission after kidney transplantation with different donor types in the overall population and in both young (< 65 years) and elderly (≥65 years) KTRs.MethodsWe included all first-time adult KTRs from 2016 to 2018 in the Netherlands Organ Transplant Registry. Multivariable logistic regression models were used to estimate the effect while adjusting for baseline confounders.ResultsAmong 1917 KTRs, 615 (32.1%) had at least one hospital readmission. Living donor kidney transplantation (LDKT) recipients had an adjusted OR of 0.76 (95%CI, 0.61 to 0.96; p = 0.02) for hospital readmission compared to deceased donor kidney transplantation (DDKT) recipients. In the young and elderly, the adjusted ORs were 0.69 (95%CI, 0.52 to 0.90, p = 0.01) and 0.93 (95%CI, 0.62 to 1.39, p = 0.73) and did not differ significantly from each other (p-value for interaction = 0.38). In DDKT, the risk of hospital readmission is similar between recipients with donation after cardiac death (DCD) or brain death (DBD) and the risk was similar between the young and elderly.ConclusionA lower risk of post-transplant 3-month hospital readmission was found in recipients after LDKT compared to DDKT, and this benefit of LDKT might be less dominant in elderly patients. In DDKT, having either DCD or DBD donors is not associated with post-transplant 3-month hospital readmission, regardless of age. Tailored patient management is needed for recipients with DDKT and elderly KTRs.

Rupture of the Ascending Aorta in a Donor Heart during Ex-Vivo Transport: A Case Report

<h3>Purpose</h3> Problems encountered during transport of an ex-vivo donor heart perfusion device can have drastic consequences on graft function. We describe a case of aortic rupture occurring during ex-vivo transport for donation after cardiac death (DCD) heart transplantation. <h3>Methods</h3> Cardiac procurement in a DCD donor was performed in the standard fashion. Upon connection to the Transmedics Organ Care System, bleeding was noted to be originating from the posterior aortic wall, likely secondary to injury caused by the cardioplegia needle, inserted into the flaccid aorta of relatively small diameter. The site was successfully repaired and transport begun. The aorta was noted to be fragile during repair. Organ function parameters remained in the acceptable ranges throughout the transfer. <h3>Results</h3> As the transport vehicle approached the recipient center, an abrupt movement of the vehicle over a speed hump was followed by sudden drop in the perfusion pressure of the donor heart. Catastrophic bleeding was noted from a defect in the ascending aorta. Bleeding was controlled with digital pressure resulting in return of satisfactory perfusion pressures. The donor heart had minimal perfusion pressure for a total of five minutes. The donor heart was transported on the OCS emergently to the operating room where cardioplegia was delivered and the organ topically cooled. A defect adjacent to the original repair site was noted (image). As this was 2cm above the sinotubular junction, this area was trimmed and the heart was implanted in the standard fashion. Subsequent graft function was good, and the recipient was separated from cardiopulmonary bypass with routine levels of support. The recipient made an uneventful post-operative recovery. <h3>Conclusion</h3> This case illustrates an injury to the posterior wall of the aorta with subsequent major bleeding occurring during ex-vivo transport. Procurement teams should be familiar with the process of emergent conversion to conventional cold static preservation during organ transport.

Nonanastomotic Biliary Strictures After Liver Transplantation.

Biliary strictures constitute a major source of morbidity and mortality following liver transplantation (LT). However, studies on the impact of nonanastomotic biliary strictures (NABS) on grafts after LT are limited. 649 patients who underwent LT between January 2013 and June 2017 at our center were retrospectively analyzed and 2.6% (n = 17) of the recipients developed NABS following LT. There were no differences between recipients with and without NABS in indication of LT, graft ischemia time, and type of biliary anastomosis. The incidence of post-LT hepatic artery thrombosis (HAT) (odds ratio [OR]: 15.75, P < .001) and the use of livers from donation after cardiac death (DCD) donors (OR: 8.292, P = .004) were identified as independent significant predictors of NABS by multivariate analysis. Graft survival in those with NABS was significantly worse than in patients without NABS (1-, 3-, and 5-years survival: 64.7%, 57.5%, 0%, vs. 89.8%, 84.0%, 76.4%, P < .001). In conclusion, while the incidence of NABS in our study was relatively low compared to previous reports, NABS was still found to be associated with poor graft survival. Special attention should be paid to NABS occurrence in grafts that develop HAT as well as those from DCD donors.

Simultaneous liver-kidney transplantation from donation after cardiac death donors: an updated perspective.

Outcomes of both donation after cardiac death (DCD) liver and kidney transplants are improving. Experience in simultaneous liver-kidney transplant (SLK) using DCD donors, however, remains limited. In an updated cohort (2010-2018), outcomes of 30 DCD SLK and 131 donation after brain death (DBD) SLK from Mayo Clinic Arizona and Mayo Clinic Minnesota were reviewed. The Model for End-Stage Liver Disease score was lower in the DCD SLK group (23 vs 29, P=.01). Kidney delayed graft function (DGF) rates were similar between the 2 groups (P=.11), although the duration of DGF was longer for DCD SLK recipients (20 vs 4days, P=.01). Liver allograft (93.3% vs 93.1%, P=.29), kidney allograft (93.3% vs 93.1%, P=.91), and patient (96.7% vs 95.4%, P=.70) 1-year survival rates were similar. At 1 year, there were no differences in the estimated glomerular filtration rate (57.7±18.2 vs 56.3±17.7, P=.75) or progression of fibrosis (ci) on protocol kidney biopsy (P=.67). A higher incidence of biliary complications was observed in the DCD SLK group, with ischemic cholangiopathy being the most common (10.0% vs 0.0%, P=.03). The majority of biliary complications resolved with endoscopic management. With appropriate selection, DCD SLK recipients can have results equivalent to those of DBD SLK recipients.

Liver transplantation using grafts from donors after circulatory death - the first Czech Republic experience.

Liver transplantation is established as alifesaving procedure for patients with acute and chronic liver failure, as well as certain selected malignancies. Due to acontinuing organ shortage and ever-growing patient waiting lists, donation after cardiac death (DCD) is becoming more frequently utilized in order to close the gap between &#8220;supply and demand&#8221;. Aretrospective analysis of DCD and subsequent liver transplantations was performed. From May 2016 to September 2019, atotal of 9 DCD liver transplantations were performed in our institution. All cases except one were primary liver transplantations. The recipients comprised 5 (56%) males and 4 (44%) females. The mean DCD donor age was 41±12 (22-57) years, with ventilation duration of 7±1 days and warm ischemia time 19±3 minutes. The average recipient age was 51±22 (4-73) years, with an average cold ischemia 3h:59m±27m and manipulation time of 23±5 minutes. Periprocedural mortality was 1 (11%). Hepatitis C recurrence was documented in 1 (11%) patient. The mean follow-up time was 19±13 (7-37) months. Until now, we have not observed any signs of ischemic cholangiopathy. DCD liver transplantation allows us to enlarge the pool of potential liver grafts, thus decreasing the time spent on the liver recipient waiting list. This paper documents the first series of DCD liver transplantations in the Czech Republic.

Effects of Short-Term Normothermic and Subnormothermic Perfusion After Cold Preservation on Liver Transplantation From Donors After Cardiac Death

BackgroundLiver transplantation from donors after cardiac death (DCD) could increase the pool of organs. We previously reported that oxygenated subnormothermic (20°C-25°C) ex vivo liver perfusion (SELP) improved the graft viability in rats. This study aimed to compare the effectiveness of SELP and normothermic (37°C) ex vivo liver perfusion (NELP) after cold storage (CS) in DCD liver grafts. MethodsMale Wistar rats were used, and grafts were retrieved 30 minutes after cardiac arrest. We performed oxygenated NELP and SELP with a Krebs-Henseleit buffer for different time points and durations: Group 0, donation performed from heart-beating donors (control); Group 1 (DCD group), donation performed from DCD donors with no treatments; Group 2, NELP performed before CS (30 minutes); Group 3, NELP performed after CS (30 minutes); Group 4, SELP performed after CS (30 minutes); Group 5, SELP performed after CS (60 minutes); and Group 6, SELP performed after CS (90 minutes). After 15 minutes of incubation at room temperature, the grafts were reperfused under normothermic conditions for 60 minutes as a model of liver transplantation. ResultsNo significant differences in body and liver weight were observed between all groups. In the SELP after CS groups, even 30 minutes of perfusion improved bile production, tumor necrosis factor-α, and interleukin-1β significantly compared with the DCD group (P < .05), comparable with NELP groups. ConclusionSELP rescued DCD livers from ischemia-reperfusion injury the same as the normothermic perfusion before or after CS groups. SELP after CS is more convenient than normothermic perfusion; hence, this technique may increase the organ pool.

Eight Years of Extracorporeal Membrane Oxygenation in Liver Transplantation: Our Experience

Liver grafts from donors after cardiac death (DCD) involve a risk of failure owing to warm ischemia, among other factors. To minimize this important issue, new systems like normothermic regional perfusion have arisen. We report an observational and unicentric study focused on the results of liver transplantation after DCD, performing normothermic regional perfusion using extracorporeal membrane oxygenation. In the period between 2011 and 2018, 33 recipients underwent the procedure, 9 from Maastricht II DCD donor liver transplantation (LT) and 24 from Maastricht III DCD donors. The median recipient survival rose to 67 ± 9 months and 41 ± 7 months, respectively. Only 1 patient suffered from ischemic cholangiopathy needing retransplantation. Therefore, according to our experience, liver grafts from DCD using extracorporeal membrane oxygenation are suitable for LT.

Impact of the use of vasoactive drugs in cardiac death donors on the early postoperative renal function and related complications in renal transplant recipients.

To explore the impact of the use of vasoactive drugs in donation after cardiac death (DCD) donors on graft function, with an attempt to guide the clinical practices of organ preservation and DCD kidney transplantation. The clinical data of 187 DCD donors and 304 recipients who were operated on in our center from February 2018 to May 2019 were retrospectively analyzed. Based on whether vasoactive drugs were used for maintaining blood pressure in DCD donors, the renal donors and recipients were divided into a high-dose group (norepinephrine ≥1.3 µg/kg/min or in combination with dopamine), a low-dose group (norepinephrine <1.3 µg/kg/min or in conjunction with dopamine), and a no-medication group (without the use of vasoactive drugs). The clinical features, post-transplant renal function, and complications were compared among these three groups. The early renal function 1 and 7 days after surgery was significantly superior in the high-dose group and no-medication group (P<0.05) but showed no significant difference between the low-dose group and the no-medication group (P>0.05). Blood urea nitrogen (BUN) on the 1st postoperative days was significantly higher in the high-dose group than in the low-dose group and the no-medication group (P<0.05). Renal function indicators, including serum creatinine (CRE), BUN, and blood uric acid (UA) on the 30th postoperative day, showed no significant difference among these three groups (P>0.05). The incidence of delayed graft function (DGF) after renal transplantation was significantly higher in the high-dose group than in the low-dose group and the no-medication group (P<0.05), whereas there was no significant difference between the groups in the incidences of graft rejection and infections (P>0.05). The use of vasoactive drugs in DCD donors can affect the early recovery of renal function in renal transplant recipients, particularly for those donors who are administered a high dose of vasoactive drugs. Therefore, donor maintenance should be performed cautiously with vasoactive drugs.

Results in liver transplantation using grafts from donors after controlled circulatory death: A single-center experience comparing donor grafts harvested after controlled circulatory death to those harvested after brain death.

In recent years, interest in donation after cardiac death (DCD) has increased. Although DCD liver transplantation (LT) has demonstrated satisfactory long-term outcomes, different studies have shown poorer patient and graft survival after DCD than after donation after brain death (DBD). This study aimed to evaluate the results of LT using controlled DCD (cDCD) donors, specifically the incidence of primary non-function and ischemic cholangiopathy (IC), and to compare these results with those of LT using DBD in the same time period. Between June 2012 and July 2018, we performed 66 transplants using cDCD and 258 with DBD grafts. The incidence of IC was similar in both groups (2% in DBD, 1.5% in DCD; P=.999). No significant differences were found for overall graft and patient survival rates between the groups at 1 and 2years post-transplantation. This study provided evidence that cDCD donors exhibit excellent graft and patient survival outcomes. When the warm ischemia time is <30minutes and cold ischemia time is <6hours, the graft and patient survival rates and the incidence of IC in DCD are similar to those in DBD, even when using donors without age restrictions.

Transplanting kidneys from donation after cardiac death donors with acute kidney injury.

Donation after cardiac death (DCD) and acute kidney injury (AKI) donors have historically been considered independent risk factors for delayed graft function (DGF), allograft failure, and inferior outcomes. With growing experience, updated analyses have shown good outcomes. There continues to be limited data, however, on outcomes specific to DCD donors who have AKI. Primary outcomes for this study were post-kidney transplant patient and allograft survival comparing two donor groups: DCD AKIN stage 2-3 and DBD AKIN stage 2-3. In comparing these groups, there were no short- or long-term differences in patient (hazard ratio [HR] 1.07, 95% confidence interval [CI] 0.54-1.93, P=.83) or allograft survival (HR 1.47, 95% CI 0.64-2.97, P=.32). In multivariate models, the DCD/DBD status had no significant impact on the estimated GFR (eGFR) at 1 (P=.38), 2 (P=.60), and 3 years (P=.52). DGF (57.9% vs 67.9%, P=.09), rejection (12.1% vs 13.9%, P=.12), and progression of interstitial fibrosis/tubular atrophy (IFTA) on protocol biopsy (P=.16) were similar between the two groups. With careful selection, good outcomes can be achieved utilizing severe AKI DCD kidneys. Historic concerns regarding primary nonfunction, DGF resulting in interstitial fibrosis and rejection, and inferior outcomes were not observed. Given the ongoing organ shortage, increased effort should be undertaken to further utilize these donors.

Effects of bone marrow mesenchymal stem cells combined with normothermic mechanical perfusion on biliary epithelial cells donated after cardiac death in rats

To investigate the protective effect of bone marrow mesenchymal stem cells (BMMSC) combined with normothermic mechanical perfusion (NMP) on biliary epithelial cells (BEC) in rats receiving donation after cardiac death (DCD) donor liver transplantation. The BMMSC were isolated from male Sprague-Dawley (SD) rats aged 2-3 weeks and weighing 40-60 g, and then cultured, identified and expanded to the third generation in vitro. Male SD rats aged 6-8 weeks and weighing 200-220 g were divided into sham-operated group (Sham group), static cold storage (SCS group), simple NMP group (NMP group) and BMMSC combined with NMP group (BMMSC+NMP group) by random number table method with 44 rats in each group. The DCD donor liver transplantation models in rats were reproduced with 30-minute warm ischemic time. While the rats in Sham group merely received perihepatic ligaments-separation, which did not affect their liver blood supply, and then their incisions were sutured after 30 minutes. The DCD donor grafts in SCS group were preserved in the University of Wisconsin (UW) cold storage solution for 4 hours. While the DCD donor grafts in the NMP group and the BMMSC+NMP group were perfused with the DMEM/F12-based culture solution or combined with BMMSC for 4 hours through the established ex vivo NMP system. The orthotopic liver transplantation model was reproduced, and the survival rate of the recipients was observed at 0, 1, 7 and 14 days after liver transplantation. The biochemical liver function of rats in different groups was determined at each time point after operation. The morphological changes in bile ducts of liver grafts were observed by hematoxylin-eosin (HE) staining, and the expression of cytokeratin 19 (CK19) was determined qualitatively by immunohistochemistry and quantitatively by Western Blot after protein extraction from BEC in liver samples. The morphology, differentiation function and phenotypic identification of BMMSC confirmed that the stem cells used in this experiment were standard BMMSC. The survival rates of rats in the NMP group and the BMMSC+NMP group were significantly higher than that in the SCS group at 0, 1, 7 and 14 days after operation. The increase was more significant in the BMMSC+NMP group, with 100% on postoperative day (POD) 0, and the 14-day survival rate was still significantly higher than that in the SCS group and the NMP group [80.0% (16/20) vs. 20.0% (4/20), 70.0% (14/20), both P < 0.05]. As the time after liver transplantation prolonged, the liver function parameters of rats in the SCS group were deteriorated gradually, which reached the peak at 1-7 days after operation. The damage of biliary tissue increased gradually under the microscope, and the injury was most serious on POD 7 in the SCS group, showing a lot of balloon-like changes in hepatocytes, with obvious bile duct dilatation accompanied by large area inflammatory cell infiltration. Immunohistochemistry and Western Blot showed that the expression of CK19 in BEC cytoplasm was decreased gradually in the SCS group, reached the lowest on POD 7, and then gradually increased. The BMMSC+NMP group and the NMP group were significantly better than the SCS group in terms of liver function, pathological injury of biliary tract and CK19 expression in BEC, and the improvement was more significant in the BMMSC+NMP group. These results suggested that the protective effects of BMMSC combined with NMP on BEC was significantly better than that of the SCS and NMP. Preservation of rat DCD donor liver by BMMSC combined with NMP can reduce the BEC injury after liver transplantation significantly, thus improving both the prognosis and the survival rate after transplantation.

Impact of Donor Hepatectomy Time During Organ Procurement in Donation After Circulatory Death Liver Transplantation: The United Kingdom Experience

No data exist to evaluate how hepatectomy time (HT), in the context of donation after cardiac death (DCD) procurement, impacts short- and long-term outcomes after liver transplantation (LT). In this study, we analyze the impact of the time from aortic perfusion to end of hepatectomy on outcomes after DCD LT in the United Kingdom. An analysis of 1112 DCD donor LT across all UK transplant centers between 2001 and 2015 was performed, using data from the UK Transplant Registry. Donors were all Maastricht Category III. Graft survival after transplantation was estimated using Kaplan-Meier method and logistic regression to identify risk factors for primary nonfunction (PNF) and short- and long-term graft survivals after LT. Incidence of PNF was 4% (40) and in multivariate analysis only cold ischemia time (CIT) longer than 8 hours (hazard ratio [HR], 2.186; 95% confidence interval [CI], 1.113-4.294; P = 0.023) and HT > 60 minutes (HR, 3.669; 95% CI, 1.363-9.873; P = 0.01) were correlated with PNF. Overall 90-day, 1-, 3-, and 5-year graft survivals in DCD LT were 91.2%, 86.5%, 80.9%, and 77.7% (compared with a donation after brain death cohort in the same period [n = 7221] 94%, 91%, 86.6%, and 82.6%, respectively [P < 0.001]). In multivariate analysis, the factors associated with graft survival were HT longer than 60 minutes, donor older than 45 years, CIT longer than 8 hours, and recipient previous abdominal surgery. There is a negative impact of prolonged HT on outcomes on DCD LT and although HT is 60 minutes or longer is not a contraindication for utilization, it should be part of a multifactorial assessment with established prognostic donor factors, such as age (>45 y) and CIT (>8 h) for an appropriately selected recipient.

One-Year Outcome after Lung Transplantation from Controllo DCD with Long WIT. Initial Experience

Purpose Although the lung tolerance to prolonged ischemia is theoretically widely accepted in donation after cardiac death (DCD) setting, most of the centres have strict criteria for warm ischemia time (WIT). We present the 1-year follow up of first 3 lung transplants (LuTx) from controlled DCD donors after extended WIT. Methods We established a dedicated technical protocol, consisting of a non-rapid normothermic open-lung procurement during abdominal normothermic regional perfusion (NRP) without pleural cooling before the pneumoplegia. After treatments withdrawal, asystole onset, death is declared (20-min of flat ECG). NRP is established percutaneously with the aortic balloon, respiratory setting provided cycles of recruitment manoeuvres and protective ventilation. During the lung procurement, we performed two NRP tests in order to decide the definitive retrieval. After lung block stored on ice, chest haemostasis ensured. NRP is continued until necessary for abdominal organs. The lungs are evaluated by ex vivo lung perfusion (EVLP). Results Table 1 shows recipients characteristics, details of procurement, EVLP run, transplantation and clinical outcome. Notably, in Case 1, treatments withdrawal did not include extubation. Due to detection of thrombi during retrograde perfusion, urokinase was added to the solution in Case 1 and we proceeded to atypical resection of parenchymal infarction of right lower lobe. For sizing mismatch, right upper lobectomy was carried out in Case 2. The recipients were females, median age 42 years; 2 patients had cystic fibrosis, 1 usual interstitial pneumonia. In all cases, we performed a bilateral transplantation. All 3 patients are alive, with good respiratory function. Patient 1 experienced an episode of acute rejection 6 weeks after transplantation. Conclusion Our initial experience resulted in successful LuTx without detrimental effects on abdominal organs procurement. Promising results confirm the possibility of overcoming the obstacle of a long WIT.

Donation After Cardiac Death: A Necessary Expansion for Heart Transplantation

The gold standard and sole curative therapy for advanced stage heart failure is cardiac transplantation. As the population ages, the number of patients diagnosed with advanced heart failure and listed for transplant steadily increases annually. However, there remains a paucity of eligible donation after brain death (DBD) donor hearts which severely limits access to cardiac transplantation and leads to increasing wait-list times and avoidable patient mortalities. Though the first human heart transplant in 1967 was performed using a deceased donor heart, the advent of brain death criteria and the ability to avoid long warm ischemic times led donation after cardiac death (DCD) transplantation to fall out of favor. Due the current state of cardiac transplantation, there has been a resurgence in interest in DCD heart transplantation leading to the development of DCD heart transplantation programs in the UK and Australia after positive reports of successful DCD cardiac transplantation in the pediatric literature. These programs have demonstrated favorable post-transplantation outcomes equivalent to matched traditional DBD transplants with current techniques and strict donor criteria. This technique has been proven safe with favorable outcomes and has been demonstrated to significantly increase transplant volumes and decrease patient mortality. Given these outcomes and the high patient benefit to risk ratio, DCD donor heart transplantation is necessary to expand the donor pool and decrease patient mortality and should be developed in high volume experienced cardiac transplant centers.

Warm ischemia time and elevated serum uric acid are associated with metabolic syndrome after liver transplantation with donation after cardiac death.

AIMTo describe the prevalence of posttransplant metabolic syndrome (PTMS) after donation after cardiac death (DCD) liver transplantation (LT) and the pre- and postoperative risk factors.METHODSOne hundred and forty-seven subjects who underwent DCD LT from January 2012 to February 2016 were enrolled in this study. The demographics and the clinical characteristics of pre- and post-transplantation were collected for both recipients and donors. PTMS was defined according to the 2004 Adult Treatment Panel-III criteria. All subjects were followed monthly for the initial 6 mo after discharge, and then, every 3 mo for 2 years. The subjects were followed every 6 mo or as required after 2 years post-LT.RESULTSThe prevalence of PTMS after DCD donor orthotopic LT was 20/147 (13.6%). Recipient’s body mass index (P = 0.024), warm ischemia time (WIT) (P = 0.045), and posttransplant hyperuricemia (P = 0.001) were significantly associated with PTMS. The change in serum uric acid levels in PTMS patients was significantly higher than that in non-PTMS patients (P < 0.001). After the 1st mo, the level of serum uric acid of PTMS patients rose continually over a period, while it was unaltered in non-PTMS patients. After transplantation, the level of serum uric acid in PTMS patients was not associated with renal function.CONCLUSIONPTMS could occur at early stage after DCD LT with growing morbidity with the passage of time. WIT and post-LT hyperuricemia are associated with the prevalence of PTMS. An increased serum uric acid level is highly associated with PTMS and could act as a serum marker in this disease.

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.

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.

Outcome of Kidney Transplantation From Donor After Cardiac Death: Reanalysis of the US Mycophenolic Renal Transplant Registry

BackgroundKidney transplantation is limited by the shortage of donor kidneys. Donation after cardiac death (DCD) has been explored to alleviate this problem. To better understand the outcome of DCD kidney transplantation, we reanalyzed the Mycophenolic Renal Transplant (MORE) Registry. MethodsWe compared delayed graft function (DGF), biopsy-proved acute rejection (BPAR), graft loss, and patient death between DCD and donation after brain death (DBD) kidney transplantations. Recipients were further stratified into depleting and nondepleting induction groups for exploratory analysis. ResultsThere were 548 patients who received kidney transplants from deceased donor in the MORE Registry. Among them, 133 received grafts from DCD donors and 415 received from DBD donors. The incidence of DGF was 29.4% and 23.5% in the DCD group and the DBD group, respectively (P = .1812), and the incidence of BPAR at 12 months was 9.0% and 9.9% respectively (P = .7713). The 1-year graft loss rate in the DCD group was higher than that in the DBD group (7.5% vs 3.1%, P = .0283), and the 4-year graft loss rate and patient death rate were not significantly different between the 2 groups. ConclusionsThe DCD kidney transplant group had acceptable short-term outcomes and good long-term outcomes as compared with the DBD kidney transplant group.

Epidemiology of carbapenem-resistant Klebsiella pneumoniae bloodstream infections after renal transplantation from donation after cardiac death in a Chinese hospital: a case series analysis

BackgroundAlthough the high mortality rates have been extensively reported worldwide, few studies have investigated the epidemiology of CRKP-BSIs in the early stage after kidney transplantation (KTx) from donation after cardiac death (DCD). We sought to describe the epidemiological and clinical characteristics of cases of carbapenem resistant Klebsiella pneumoniae bloodstream infections (CRKP-BSIs) in kidney transplantation recipients (KTRs) from DCD in our hospital.MethodsA retrospective analysis of clinical data of CRKP-BSIs in KTRs admitted to a Chinese hospital in Beijing, China, between January 1, 2012 and December 31, 2016 was performed. The annual percentage of patients with CRKP, the annual number of total KTRs and KTRs from DCD were determined. The genetic relatedness of the strains was determined by polymerase chain reaction and pulse field gel electrophoresis (PFGE).ResultsDuring the study period, there were total 947 KTRs in our hospital, including 275 KTRs from DCD. Five incidences of CRKP-BSIs in KTRs were identified, and two of them (Case 1,3) from the same foreign hospital. The incidence of CRKP-BSIs in the early stage (within 3 months) following kidney transplantation (KTx) from DCD was about 1.1% (3/275). In Case 1–3 and 5, the rupture of renal transplant artery was presented on the 40th, 16th, 43th and 74th day after KTx, and in Case 4, the thrombus of renal transplant artery was presented on the 13th day after KTx. Three cases (Case 1,2,5) occurring pneumothorax on the 45th, 51th and 32th day after KTx. Four cases (Case 1–4) received the excision of the transplanted kidney for the treatment. Polymerase chain reaction showed the bands for case 2 were distinctive from other cases. Pulse field gel electrophoresis showed mainly three clusters of the bands for all the isolates.ConclusionsDuring the study period, we observed an increase in the occurrence of CRKP-BSIs among KTRs from DCD in our hospital. We demonstrated that rupture/thrombus of the renal transplant artery was associated with CRKP-BSI in the early stage after KTx from DCD. Albeit the low incidence of CRKP-BSI (1.1%) after KTx from DCD, the high mortality (4/5) had been observed from the prognosis of the patients. Thorough surveillance of DCD donors, early identification of CRKP-BSI, necessary preventative measurements and use of appropriate treatments should be the strategy for CRKP-BSI in the early stage after KTx from DCD.