Donation After Cardiac Death Donors Research Articles

Outcomes of Kidney Transplants from Donation after Cardiac Death Donors Aged 70 Years or Older

Introduction: The ongoing expansion of the donation after cardiac death (DCD) donor pool raises questions as to the suitability of using kidneys from very old donors. Double kidney transplantation (DKT) may enable utilisation of a proportion of these kidneys that would otherwise have been discarded. Here we report a single-centre experience of DCD kidney transplants from donors aged 70 years and older, comparing outcomes of single kidney transplants (SKT) and DKT. Methods: Outcomes were assessed for SKT and DKT from DCD donors aged 70 years old between 1 January 2009 and 31 August 2011, with follow-up ceasing on 31 December 2011. The decision to implant a double or single kidney was based on donor and recipient characteristics, macroscopic appearance, and pre-implantation histological score (Remuzzi G et al, NEJM 2006). Estimated GFR (eGFR, mL/min/1.73 m2) was calculated using the 4-variable MDRD equation; delayed graft function (DGF) was defined as the need for dialysis within a week post-transplantation. Continuous variables were described using median (range). Results: Forty-three kidneys were implanted (27 SKT and 8 DKT), with a median follow-up of 13 months. Donor ages were similar in both groups (SKT 73 (70-78) years vs DKT 74.5 (70-79) years; p=0.20). Although median donor terminal creatinine was lower in the SKT group, it did not reach significance (66 (41-88) μmol/L vs 81 (40-235) μmol/L; p=0.07); likewise, there was no difference in donor terminal eGFR (SKT 90 (62-111) mL/min/1.73m2 vs DKT 74 (25-143) mL/min/1.73m2; p=0.25). As expected, kidneys subsequently used as DKT had significantly higher pre-implantation biopsy scores (DKT 5 (3-6) vs SKT 3 (2-6); p< 0.01). Recipients were generally elderly, but median ages were similar between the two groups (SKT 65 (48-75) years vs DKT 64 (57-70) years; p=0.37), as were the cold ischaemic times (SKT 13h18m (9h59m-20h57m) vs DKT 15h40m (11h45m-23h45m); p=0.14). DGF was more frequent in the SKT GROUP, however this did not reach significance (66% (n = 18) for SKT vs 37.5% (n = 3) for DKT, p = 0.15). Graft function (eGFR) was better in recipients of DKT, though this did not reach significance at either one month (SKT 36.7 (19.3-63) mL/min/1.73m2 vs DKT 43.3 (26.5-67.7) mL/min/1.73m2; p=0.46) or 6 months (SKT 34.5 (26.8-58.9) vs DKT 50.8 (28.3-72.7); p=0.26). There were 2 primary non functions and 3 deaths in the SKT group (heart failure, sepsis, invasive aspergillosis), but none of either in the DKT group. Actuarial one-year graft and patient survivals were 92.6% and 88.6% SKT vs 100% and 100% DKT (p=0.44, p=0.37, respectively). Discussion: These early results demonstrate that the DCD donor pool can be expanded through careful selection of donors and recipients. Recipients of DKT from elderly DCD donors had similar outcomes to those receiving SKT, implying that our selection algorithms are adequate. Utilisation of organs from this source is an acceptable strategy to reduce the growing number of older patients waiting for renal transplantation.

Prophylactic Surfactant Inhalation Attenuates Warm Ischemic Injury in Rat Lungs from Donation after Cardiac Death Donors

Background: To deal with the shortage of donor organs in lung transplantation, donation after cardiac death (DCD) has been introduced worldwide as one of the potential strategies to increase the donor pool. Considering ischemia-reperfusion injury in solid organ transplantation from DCD donors, it is very important to alleviate graft injury during warm ischemia. It was reported that surfactant function deteriorated with increasing warm ischemic time, resulting in graft injury. Therefore, we investigated the effect of surfactant inhalation against warm ischemic injury in rat lungs from DCD donors. In this experiment, only ventilation was initiated after warm ischemia, therefore, warm ischemic injury was assessed from the view of hypoxia-reoxygenation injury. Methods/Materials: Male Lewis rats were used. One hundred and ten minutes after cardiac arrest induced by ventricular fibrillation, the lungs were initiated to ventilate and flushed by Low Potassium Dextran solution. Thereafter, heart and lung block was isolated, and ex vivo lung ventilation (EVLV) was conducted. Rats were randomly allocated to 2 groups, the CTRL and SURF groups (n = 5 each). In the SURF group, surfactant was inhaled for 3 min, while nothing was inhaled in the CTRL group. Just after this inhalation period (total warm ischemic time: 135 min), dynamic compliance and airway resistance were evaluated on time throughout 60 min of ventilation. After 60 min of EVLV, lung tissue levels of ATP, ADP, and AMP were measured by high-performance liquid chromatography: messenger RNA (mRNA) expression of NO synthase (neuronal, inducible, endothelial), caspase-3, Bax, and Bcl-2 were measured by real-time RT-PCR: Hematoxylin-Eosin (H-E) staining, immunohistochemical staining for 8-hydroxy-2′-deoxyguanosine (8-OHdG), and in situ apoptosis detection (TUNEL assay) were examined. Results: During 60 min of ventilation, surfactant inhalation significantly increased dynamic compliance (p < 0.01), and decreased airway resistance (p < 0.001). Surfactant inhalation effectively increased lung tissue levels of ATP (p < 0.05). After 60 min of ventilation, mRNA levels of NO synthase (neuronal, inducible, endothelial) and caspase-3 were significantly lower, and mRNA levels of Bcl-2 were significantly higher in the SURF group than those in the CTRL group. In the histologic examination with H-E staining, both the CTRL and SURF groups showed no differences with relatively normal structure. However, in 8-OHdG stain and in TUNEL assay, there were fewer positive cells in the SURF group than those in the CTRL group. Conclusion: We confirmed that surfactant inhalation in the last phase of warm ischemia mitigated warm ischemic injury in an isolated rat lung ventilation model. Reduction of oxidative stress and inhibition of apoptosis might contribute to the protection of the warm ischemic lungs in our study.

Kidney Transplantation from Donation after Cardiac Death in China - A Clinical Analysis of 94 Cases

Objective: To report clinical outcome of kidney transplantation (KTx) from donation after cardiac death (DCD) in China, and to investigate the feasibility of DCD utilization to expand organ donor pool in China. Patients and methods: Night-four DCD KTx were performed from February 2007 to March 2012 in two organ transplant centers in south of China. DCD donors were supported with or without extracorporeal membrane oxygenation (ECMO) to minimize ischemic injury. The clinical data of KTx recipients were retrospectively analyzed. There were 71 male and 23 female recipients with a mean age of 44 ± 11.3 years. All donor organs were evaluated before engraft. Results: The mean follow-up was 23.4 months, with a range from 53 days to 55.5 months. Delayed graft function (DGF) occurred in 27.7% (26/94) recipients, which recovered within 3 months after KTx, except two grafts were removed due to acute graft rupture and aneurysm, as well as one patient died of ruptured aneurysm two months after KTx. Six incidents of biopsy proved acute rejection (AR) were observed in five recipients (6.4%), five of which were reversed by pulse therapy and the other one resulted in dialysis. All patients survived through the follow-up except two who died of ruptured aneurysm or fulminant hepatitis-induced liver failure. The 1-year and 2-year graft survival rate were 96.8% and 94.7% respectively. Conclusion: Although kidney transplantation from DCD donors developed higher DGF with longer duration of graft recovery, favorable short-term clinical outcome was achieved in terms of graft survival rate and function. Donation after cardiac death could be feasibly utilized to expand organ donor pool in China.

Does Increasing Donation after Cardiac Death Reduce the Brain Dead Donor Pool in Australia?

Introduction: Donation after cardiac death (DCD) provides an alternative pathway for potential donors when donation after brain death (DBD) is not possible. However, DCD may result in lost brain dead donors if withdrawal of life sustaining treatment (WLST) occurs without allowing adequate time for progression to brain death. We hypothesised that increasing DCD donor numbers in Australia has reduced the potential DBD pool by not allowing progression to brain death prior to WLST. Methods: We performed a retrospective analysis of Australian organ donors (actual and intended) registered on the Australian and New Zealand Organ Donor (ANZOD) registry from 2001-2011. Non brain injured DCD patients were excluded. Time from initiation of ventilation was used to compare time to brain death determination in DBD (n=2218) with time to WLST in DCD (n=311). Analysis was with Mann Whitney U and Kruskal-Wallis tests for continuous data and Fisher's Exact test for categorical data. Results: The period of ventilation prior to WLST in DCD, 3.8 days [IQR 2.1-6.3], exceeded the period prior to brain death determination in DBD, 1.3 days [IQR 1.0-2.4] (p< 0.0001). The period of ventilation prior to brain death determination in DBD was unchanged from 2001-2011 (p=0.83). The period of ventilation in DCD significantly (p < 0.05) exceeded DBD in all Australian jurisdictions, for all causes of death and over time.Figure: [Graph 1.]Conclusion: The longer ventilation period in DCD, and the consistent time to brain death determination in DBD, suggests adequate time allowance for progression to brain death before WLST. Therefore, increasing DCD donor numbers does not appear to reduce the brain dead donor pool in Australia.

Synergistic effects of prolonged warm ischemia and donor age on the immune response following donation after cardiac death kidney transplantation

Organs from DCD (donation after cardiac death) donors are increasingly used for transplantation. The impact of advanced donor age and warm ischemia on the immune response of the recipient has not been studied. We developed a novel and clinically relevant model of DCD kidney transplantation and investigated the effects of donor age and prolonged warm ischemia on the recipient immune response after following DCD kidney transplantation. DCD grafts from young and old F-344 donor rats were engrafted into LEW recipients who were nephrectomized bilaterally after a short (20 minutes) or prolonged (45 minutes) warm ischemia time. Analysis of the recipient's immune response early after transplantation showed an enhanced innate and adaptive immune response when old DCD kidneys were engrafted. Next, we studied DCD recipients with a supportive, contralateral native kidney in place, which allowed the recovery of the transplanted DCD kidney. Old DCD kidneys, demonstrated an impaired renal function associated with pronounced histomorphologic graft deterioration and an enhanced immune response by day 100 after transplantation. Interestingly, young DCD kidneys with a long warm ischemic time recovered from acute tubular necrosis and did not stimulate the long-term immune response. Our observations emphasize that prolonged warm ischemic time and advanced donor age augment the immune response after transplantation of DCD grafts. These results provide an experimental model and a mechanistic framework of clinically relevant aspects in DCD donation.

Delayed graft function after DCD kidney transplantation: risk factors for and impact on transplantation

To evaluate the risk factors of delayed graft function (DGF) and its impact on renal transplantation from donation after cardiac death (DCD). We conducted a retrospective study consisting of 48 subjects who underwent a DCD kidney transplantation from February 2010 to March 2012. We classified the recipients into two groups: an IGF (immediate graft function) group (n=30) and a DGF group (n=18), and analyzed the risk factors of DGF and its impact on transplantation. DGF occurred in 18 of the 48 (37.5%) kidneys from DCD donors, and the occurrence of DGF did not adversely influence the survival of patients (P=0.098) and graft (P=0.447). In the univariate analysis, the preoperative dialysis time of recipients (P<0.001), HLA mismatch site (P<0.001), the cause of brain death (P=0.011), BMI (P<0.001), preoperative serum creatinine of donors (P=0.0001), norepinephrine used in donors (P<0.001), warm ischema time (WIT) (P<0.001), cold ischema time (CIT) (P<0.001) showed significant differences. In the multivariate analysis, cerebral hemorrhage as the cause of brain death (P=0.022, OR=39.652), preoperative serum creatinine of donors≥177 μmol/L (P=0.008, OR=57.148) and the preoperative dialysis time of recipients≥12 months (P=0.060, OR=15.060) were independent risk factors for DGF development. The independent risk factors for DGF are the cause of brain death, the terminal creatinine level, and the preoperative dialysis time.

Liver transplantation in the critically ill: donation after cardiac death compared to donation after brain death grafts

Patients with end stage liver disease may become critically ill prior to LT requiring admission to the intensive care unit (ICU). The high acuity patients may be thought too ill to transplant; however, often LT is the only therapeutic option. Choosing the correct liver allograft for these patients is often difficult and it is imperative that the allograft work immediately. Donation after cardiac death (DCD) donors provide an important source of livers, however, DCD graft allocation remains a controversial topic, in critically ill patients. Between January 2003-December 2008, 1215 LTs were performed: 85 patients at the time of LT were in the ICU. Twelve patients received DCD grafts and 73 received donation after brain dead (DBD) grafts. After retransplant cases and multiorgan transplants were excluded, 8 recipients of DCD grafts and 42 recipients of DBD grafts were included in this study. Post-transplant outcomes of DCD and DBD liver grafts were compared. While there were differences in graft and survival between DCD and DBD groups at 4 month and 1 year time points, the differences did not reach statistical significance. The graft and patient survival rates were similar among the groups at 3-year time point. There is need for other large liver transplant programs to report their outcomes using liver grafts from DCD and DBD donors. We believe that the experience of the surgical, medical and critical care team is important for successfully using DCD grafts for critically ill patients.

Donation after cardiac death liver transplantation: Lose a bit on each one and make it up in volume

See Article on Page 771 DBD, donation after brain death; DCD, donation after cardiac death. Liver transplant surgeons are engaged in a race to reduce waiting-list death rates, and this increasingly is requiring the expanded use of organs with a higher risk of graft failure. Declining rates of young brain-dead donors have resulted in national and international efforts to increase the donor pool, often at the expense of posttransplant outcomes. Nowhere is this more true than donation after cardiac death (DCD) liver transplantation. In multiple single-center and registry analyses, DCD liver transplantation has been demonstrated to increase the risk of graft loss from ischemic biliary injury, and retransplantation is often required.1 The impact of DCD allografts on overall patient survival remains controversial, with some centers reporting equivalent patient survival after transplantation but many demonstrating increased rates of death and retransplantation.2, 3 Although the clinical impact of DCD liver transplantation continues to be debated, it is now well established that DCD transplantation is associated with dramatically greater costs during the posttransplant period in comparison with donation after brain death (DBD) transplantation.4, 5 In this issue of Liver Transplantation, Broomhead et al.6 report a matched case series analysis comparing early posttransplant events in recipients of organs from DBD and DCD donors. They demonstrate a higher risk of perioperative events, more postoperative complications, and increases in resource utilization (including longer intensive care unit stays) among recipients of DCD organs. Among their important observations is the impact of DCD transplantation on intraoperative coagulopathy and hemodynamic instability. Compared with the DBD recipients, the DCD recipients had prolonged heparin effects (which led to increased transfusion requirements and thus increased use of expensive blood products, even though this was not a statistically significant finding), extended periods of vasopressor support, and greater evidence of allograft injury (manifested by higher serum transaminase levels). Postoperatively, the DCD patients also needed prolonged mechanical ventilator support and renal replacement therapy. Finally, the rate of graft survival at 1 year was markedly lower in the DCD liver group (75% versus 100%, P = 0.03). Despite the dire need to increase the number of organs available for transplantation, the use of DCD liver transplantation in the United States appears to have leveled off.7 Currently, 6% of liver transplants nationally use DCD organs, and this rate appears to have been unchanged for the past 4 years. There is marked regional variation in the utilization of these organs, which is driven by ongoing disparities in access to deceased donor organs. Highly competitive in access regions 1, 5, 9 continue to use the majority of the DCD organs nationally. Despite a leveling-off of the demand for DCD livers, the proportion of DCD donors in the overall donor pool increased from 2% in 2000 to 11.5% in 2009. Whether this reflects economic incentives at donor hospitals to shorten the intensive care unit length of stay and limit the opportunity for patients to progress to brain death, changes in neurosurgical or critical care treatment plans, or educational efforts and donor management by the organ procurement organizations is unclear. What is certain is that the number of donors who have progressed to brain death is diminishing. As aptly demonstrated by Broomhead et al.,6 the outcomes of DCD liver transplantation are inferior to the outcomes of DBD liver transplantation. In comparison with DBD liver transplantation, patients may survive end-stage organ failure only to have a more difficult intraoperative course and a recovery characterized by repeated intrahepatic abscesses, early graft loss, and higher utilization of costly resources. Each DCD transplant represents an unpredictable risk of long-term morbidity that might have been avoided had the donor progressed to brain death. As a result, a growing tension exists between the well-intentioned efforts of the organ donation and transplantation collaborative of the Health Resources and Services Administration to expand access to transplantation through the goal of “every organ, every time” and the day-to-day realities facing transplant centers. Unfortunately, our current reimbursement and public reporting mechanisms may be inadequate to mitigate the economic and outcome risks that DCD organs pose to transplant centers. While we are waiting for improved methods to protect organs from the deleterious impact of warm ischemic injury during the agonal period, we would be well advised to focus our attention on strategies promoting donor support to brain death if possible. Unlike business, if you lose a bit of benefit from each transplant, you cannot make it up in increased volume.

Asystole to cross-clamp period predicts development of biliary complications in liver transplantation using donation after cardiac death donors

This study sought to determine the procurement factors that lead to development of intrahepatic bile duct strictures (ITBS) and overall biliary complications in recipients of donation after cardiac death (DCD) liver grafts. Detailed information for different time points during procurement (withdrawal of support; SBP < 50 mmHg; oxygen saturation <30%; mandatory wait period; asystole; incision; aortic cross clamp) and their association with the development of ITBS and overall biliary complications were examined using logistic regression. Two hundred and fifteen liver transplants using DCD donors were performed between 1998 and 2010 at Mayo Clinic Florida. Of all the time periods during procurement, only asystole-cross clamp period was significantly different between patients with ITBS versus no ITBS (P = 0.048) and between the patients who had overall biliary complications versus no biliary complications (P = 0.047). On multivariate analysis, only asystole-cross clamp period was significant predictor for development of ITBS (P = 0.015) and development of overall biliary complications (P = 0.029). Hemodynamic changes in the agonal period did not emerge as risk factors. The results of the study raise the possibility of utilizing asystole-cross-clamp period in place of or in conjunction with donor warm ischemia time in determining viability or quality of liver grafts.

The Case for Kidney Donation Before End-of-Life Care

Donation after cardiac death (DCD) is associated with many problems, including ischemic injury, high rates of delayed allograft function, and frequent organ discard. Furthermore, many potential DCD donors fail to progress to asystole in a manner that would enable safe organ transplantation and no organs are recovered. DCD protocols are based upon the principle that the donor must be declared dead prior to organ recovery. A new protocol is proposed whereby after a donor family agrees to withdrawal of life-sustaining treatments, premortem nephrectomy is performed in advance of end-of-life management. Since nephrectomy should not cause the donor's death, this approach satisfies the dead donor rule. The donor family's wishes are best met by organ donation, successful outcomes for the recipients, and a dignified death for the deceased. This proposal improves the likelihood of achieving these objectives.

Liver transplantation with donation after cardiac death donors: A comprehensive update

BackgroundUse of donation after cardiac death (DCD) donors has been proposed as an effective way to expand the availability of hepatic allografts used in orthotopic liver transplantation (OLT); yet, there remains no consensus in the medical literature as to how to choose optimal recipients and donors based on available information. MethodsWe queried the United Network of Organ Sharing/Organ Procurement and Transplantation Network database for hepatic DCD allografts used in OLT. As of March 31, 2011, 85,148 patients received hepatic allografts from donation-after-brain-death (DBD) donors, and 2351 patients received hepatic allografts from DCD donors. We performed survival analysis using log-rank and Kaplan-Meier tests. We performed univariate and multivariate analyses using the Cox proportional hazards model. All statistics were performed with SPSS 15.0. ResultsPatients receiving hepatic DCD allografts had significantly worse survival compared with patients receiving hepatic DBD allografts. Pediatric patients who received a hepatic DCD allograft had similar survival to those who received a hepatic DBD allograft. The optimal recipient-related characteristics were age <50 y, International Normalized Ratio <2.0, albumin >3.5 gm/dL, and cold ischemia time <8 h; optimal donor-related characteristics included age <50 y and donor warm ischemia time <20 min. ConclusionsBy identifying certain characteristics, the transplant clinician’s decision-making process can be assisted so that similar survival outcomes after OLT can be achieved with the use of hepatic DCD allografts.

Donation after Cardiac Death in Queensland: Review of the Pilot Project

Organ transplantation is a viable therapeutic option for patients with endstage organ failure when other therapies have been exhausted. Donation after cardiac death (DCD) is re-emerging as a potential option to expand the donor pool to meet an increasing demand for organ transplantation. In this review, we evaluate the evolution of the Queensland DCD pilot project since its inception in August 2008. A retrospective analysis of registry data from Australia and New Zealand Organ Donation (ANZOD) and DonateLife Queensland was performed to collect information relating to donor characteristics, DCD process and outcomes. Data was compared with the ANZOD registry annual reports from 2008 to 2010. Twenty-three (82%) out of 28 potential DCD organ donors were successful in donating their organs. The median time from presentation to reaching consensus to withdraw cardiorespiratory support was four days (interquartile range three to eight days). The median time from withdrawal to death was 20 minutes (interquartile range 18 to 25 minutes), and the median warm ischaemia time was 17 minutes (interquartile range 14 to 19 minutes). DCD donors represented 16% (23) of the 144 deceased donors over the study period and provided approximately 10% (48) of the 505 deceased organs in Queensland. The DCD pilot project resulted in an increase in solid organ transplantation in Queensland. It allowed the development of policies to facilitate DCD, in accordance with state's legislation and DonateLife practices. If implemented state-wide, the program has the potential to be an effective way to improve organ donation rates in Queensland.

326 A Randomized Trial of Nebulized Albuterol To Enhance Resolution of Pulmonary Edema in 506 Brain Dead Organ Donors

Purpose: To review our experience after 5 years of lung transplantation (LTx) using lung donation after cardiac death (DCD). Methods and Materials: Outcomes DCD LTx were compared with contemporaneous recipients receiving lungs from brain death donors(BDD). Incidence of severe primary graft dysfunction(PGD), ICU and hospital length of stay(LOS), 30 day mortality, and overall survival were analyzed. Results: During the study period, 448 LTx were performed; 408 from BDD and 40 from DCD donors. The proportion of DCD donors among cadaveric donors and the proportion lung transplants using DCD donors are shown in Figure 1. Recipient diagnosis was similar in both groups (BDD vs. DCD): Emphysema (26% vs. 30%), pulmonary fibrosis (33% vs. 32%), cystic fibrosis (20% vs. 23%), and others (22% vs. 14%). Median donor P/F was 422 mmHg in BDD group and 360 mmHg in DCD group (p 0.004). Median recipient P/F at ICU arrival was 350 mmHg in BDD vs. 301 mmHg in DCD (p 0.06). Incidence of severe primary graft dysfunction after LTx requiring ECMO support was 2.7% in BDD and 7.5% in DCD (p 0.14). Median ICU stay was 4 days in BDD and 5 days in DCD. Median hospital LOS was 23 days in both groups (p 0.05). 30 day, 1 year and 3 year proportional survival were 95.7%, 84%, and 70% in BDD and 95%, 85%, and 64% in DCD respectively (P 0.05 for all comparisons). Within the DCD group, 18 lungs underwent ex vivo lung perfusion (EVLP). Lungs undergoing EVLP had decreased incidence of PGD 3 at 72h after LTx: 0 vs 22% (p 0.04). Conclusions: Lung transplantation using DCD donors currently accounts for 15-20% of our LTx activities. The use of controlled DCD lungs is associated with similar clinical outcomes as LTx using BDD donors. EVLP led to decreased incidence of severe PGD in the DCD population.

228 Therapeutic Effect of Surfactant Inhalation on Lungs Donated after Cardiac Death in a Canine Lung Transplantation Model

In lung transplantation, donation after cardiac death (DCD) has been introduced worldwide. To date, several programs have reported acceptable outcomes; however, the number of patients on waiting lists is indeed much more than that of the donated organs. Therefore, we considered the effective use of marginal donor grafts from uncontrolled DCD donors by investigating the effect of surfactant inhalation against pulmonary ischemia-reperfusion injury in canine lungs from DCD donors.

Kidney Transplantation from a Donor Following Cardiac Death Supported with Extracorporeal Membrane Oxygenation

To expand the donor pool, organ donation after cardiac death (DCD) has emerged. However, kidneys from DCD donors have a period of long warm ischemia between cardiac arrest and the harvesting of the organs. Recently, we used extracorporeal membrane oxygenation (ECMO) to minimize ischemic injury during 'no touch' periods in a Maastricht category II DCD donor and performed two successful kidney transplantations. The kidneys were procured from a 49-yr-old male donor. The warm ischemia time was 31 min, and the time of maintained circulation using ECMO was 7 hr 55 min. The cold ischemia time was 9 hr 15 min. The kidneys were transplanted into two recipients and functioned immediately after reperfusion. The grafts showed excellent function at one and three months post-transplantation; serum creatinine (SCr) levels were 1.0 mg/dL and 0.8 mg/dL and the estimated glomerular filtration rates (eGFR) were 63 mL/min/1.73 m2 and 78 mL/min/1.73 m2 in the first recipient, and SCr levels were 1.1 mg/dL and 1.0 mg/dL and eGFR were 56 mL/min/1.73 m2 and 64 mL/min/1.73 m2 in the second recipient. In conclusion, it is suggested that kidney transplantation from a category II DCD donor assisted by ECMO is a reasonable modality for expanding donor pool.

Kidney donation after cardiac death

There is continuing disparity between demand for and supply of kidneys for transplantation. This review describes the current state of kidney donation after cardiac death (DCD) and provides recommendations for a way forward. The conversion rate for potential DCD donors varies from 40%-80%. Compared to controlled DCD, uncontrolled DCD is more labour intensive, has a lower conversion rate and a higher discard rate. The super-rapid laparotomy technique involving direct aortic cannulation is preferred over in situ perfusion in controlled DCD donation and is associated with lower kidney discard rates, shorter warm ischaemia times and higher graft survival rates. DCD kidneys showed a 5.73-fold increase in the incidence of delayed graft function (DGF) and a higher primary non function rate compared to donation after brain death kidneys, but the long term graft function is equivalent between the two. The cold ischaemia time is a controllable factor that significantly influences the outcome of allografts, for example, limiting it to < 12 h markedly reduces DGF. DCD kidneys from donors < 50 function like standard criteria kidneys and should be viewed as such. As the majority of DCD kidneys are from controlled donation, incorporation of uncontrolled donation will expand the donor pool. Efforts to maximise the supply of kidneys from DCD include: implementing organ recovery from emergency department setting; improving family consent rate; utilising technological developments to optimise organs either prior to recovery from donors or during storage; improving organ allocation to ensure best utility; and improving viability testing to reduce primary non function.

Events in procurement as risk factors for ischemic cholangiopathy in liver transplantation using donation after cardiac death donors

The use of donation after cardiac death (DCD) liver grafts is controversial because of the overall increased rates of graft loss and morbidity, which are mostly related to the consequences of ischemic cholangiopathy (IC). In this study, we sought to determine the factors leading to graft loss and the development of IC and to compare patient and graft survival rates for recipients of DCD liver grafts and recipients of donation after brain death (DBD) liver grafts in a large series at a single transplant center. Two hundred liver transplants with DCD donors were performed between 1998 and 2010 at Mayo Clinic Florida. Logistic regression models were used in the univariate and multivariate analyses of predictors for the development of IC. Additional analyses using Cox regression models were performed to identify predictors of graft survival and to compare outcomes for DCD and DBD graft recipients. In our series, the patient survival rates for the DCD and DBD groups at 1, 3, and 5 years was 92.6%, 85%, and 80.9% and 89.8%, 83.0%, and 76.6%, respectively (P = not significant). The graft survival rates for the DCD and DBD groups at 1, 3, and 5 years were 80.9%, 72.7%, and 68.9% and 83.3%, 75.1%, and 68.6%, respectively (P = not significant). In the DCD group, 5 patients (2.5%) had primary nonfunction, 7 patients (3.5%) had hepatic artery thrombosis, and 3 patients (1.5%) experienced hepatic necrosis. IC was diagnosed in 24 patients (12%), and 11 of these patients (5.5%) required retransplantation. In the multivariate analysis, the asystole-to-cross clamp duration [odds ratio = 1.161, 95% confidence interval (CI) = 1.021-1.321] and African American recipient race (odds ratio = 5.374, 95% CI = 1.368-21.103) were identified as significant factors for predicting the development of IC (P < 0.05). This study has established a link between the development of IC and the asystole-to-cross clamp duration. Procurement techniques that prolong the nonperfusion period increase the risk for the development of IC in DCD liver grafts.

Donation after cardiac death liver transplantation: Time for policy to catch up with practice

Donation after brain death (DBD) is the predominant source of organs for transplantation, even though brain death accounts for only a small percentage of all-cause mortality in the United States. In contrast, cardiovascular death is a leading cause of mortality. Therefore, donation after cardiac death (DCD) represents an attractive strategy for remedying organ shortage and improving transplant wait-list mortality. The transplantation of DCD organs has risen dramatically over the last decade in response to federal mandates issued by the Health Resources and Services Administration and the Centers for Medicare and Medicaid Services, and 10.6% of all organ transplants currently use DCD organs. The utilization of livers from DCD donors for transplantation declined by nearly 10% from 2007 to 2008, and this decline could undermine the goal set by the Organ Donation and Transplantation Collaborative: 10% of all donors from DCD sources. This downward trend in DCD liver utilization likely stems from recent reports demonstrating inferior outcomes with DCD liver transplants versus DBD liver transplants. In particular, DCD livers are marred by higher rates of graft failure, retransplantation, and patient mortality, which are due at least in part to biliary complications (primarily ischemic cholangiopathy). In this issue of Liver Transplantation, Taner et al. report graft and patient survival data for DCD liver transplants similar to DBD liver transplants at the Mayo Clinic in Jacksonville. Although the authors should be commended for achieving such favorable outcomes, other single-institution experiences have also failed to identify differences in graft and patient survival rates between DCD and DBD livers because of limited sample sizes. The study by Taner et al. was powered to resolve a 10% or greater differential in graft survival, which is admittedly greater than the differences observed between DCD and DBD livers in many studies. Consequently, although statistical significance was not achieved, there were clearly disparate trends in graft survival for DCD and DBD grafts. A peculiar feature of this study is the fact that although DCD livers yielded an inferior graft survival rate, they were associated with a superior patient survival rate in comparison with DBD livers. Because this result could have been achieved only with aggressive retransplantation, the local availability of livers for retransplantation in Jacksonville may help to explain this outcome. Therefore, it is not clear whether these results are generalizable to other localities. Despite the debate about the relative merits of census (registry) data versus sample (single-center) data, the national registry reliably captures both retransplantation and patient mortality data because of the linkage with the Social Security Death Master File. As for issues of sample size, analyses of the national registry have clearly demonstrated worse graft survival and, more recently, worse patient survival. In a complementary manner, single-institution reports provide important insights into

Outcome of Kidney Transplantation From Elderly Donors After Cardiac Death

Background The rate of renal transplantation is limited by the number of donor organs available. A valuable source of organs is currently supplied by donation after cardiac death (DCD). At the Richard Bright Renal Unit, we have expanded our criteria for DCD, increasing the upper age limit for donation from 65 to 70. Method We performed a retrospective analysis of all DCD recipients between 2003 and 2009. We compared outcomes for patients age <60 versus >60 as measured by delayed graft function and estimated glomerular filtration rate (eGFR) and incidence of graft failure. Results One hundred thirty-six DCD transplantations took place. Our early data showed excellent results for non–heart-beating donation. Over the last 7 years, the average age of DCD donors has increased from 43 in 2003 to 50 in 2009. The increase in age has been correlated with a decrease in average recipient eGFR from 59 in 2003 to 32 in 2009. Recipients of kidneys from older DCD donors (>60) have significantly lower eGFRs at 1 month and 1 year compared to kidneys from donors aged <60. The incidence of delayed graft function in recipients of kidneys from donors aged >60 was 71% compared to 40% for <60 age group. Despite this, we have not found any evidence of higher graft failure rates in the recipients of grafts from the >60 donor age group. Conclusions Expanding the age limits of our DCD donor program has led to an increased average donor age, reduced average eGFR, and increased delayed graft function. There is no evidence of reduced graft survival.

Effect of Preprocurement Ventilation on Lungs Donated After Cardiac Death in a Canine Lung Transplantation Model

One method of countering chronic lung donor shortages is the practice of donation after cardiac death (DCD). However, this technique inevitably leads to pulmonary dysfunction related to warm ischemia. One promising method of alleviating this problem is ventilation. However, it can rarely be initiated from the onset of cardiac arrest, particularly in uncontrolled DCD donors. We investigated the protective effect of the last 60 min of ventilation during a 240-min warm ischemic time. We rendered donor dogs cardiac dead and left them at room temperature. Six dogs received ventilation with 100% oxygen for 60 min starting at 180 min after cardiac arrest (ventilation group). Eight dogs received no ventilation. Lungs were harvested 240 min after cardiac arrest, then transplanted into recipient dogs. At 60 min after reperfusion, the right pulmonary artery was ligated, and the function of the left transplanted lung was evaluated. In the ventilation group, all six animals survived for 240 min after reperfusion, whereas in the nonventilation group, only four of eight survived. The ventilation group demonstrated significantly better pulmonary oxygenation, shunt fraction, and wet-to-dry weight ratio. Furthermore, the ventilation group revealed significantly higher levels of high-energy phosphates in the lung tissues, fewer apoptotic cells, lower levels of tumor necrosis factor-α and interleukin-8 messenger RNA in the lung tissues, and lower levels of interleukin-6 messenger RNA in the serum. Our results suggest that ventilation during the late phase of the preprocurement period may ameliorate ischemia-reperfusion injury in DCD donors.