Donation After Cardiac Death Recipients Research Articles

What's in a name? Higher risks with donation after cardiac death than public health service increased risk livers

Background: Public health service increased risk donor(IRD) and donation after cardiac death (DCD) livers are utilized to address the organ shortage in liver transplantation, particularly during the opioid epidemic. “Increased risk donor” terminology implies greater risk than DCD by its name, but without direct risk comparison.Objective: The aim of this study was to examine the risks of accepting IRD livers compared to DCD livers during the opioid epidemic.Methods: Retrospective, single center study of 92 recipients of IRD donors and 21 DCD donors(22% and 5% of adult transplants) between 1/2013-5/2017. Median post transplant follow-up was 2.6 years. The primary outcome was the composite of post-transplant risks likely to be greatest in IRD donor and DCD livers, namely, donor viral transmission (HBV, HCV, HIV) and ischemic cholangiopathy. Secondary outcomes were patient and graft survival, biopsy-proven rejection, CMV and EBV viremia. Categorical variables were analyzed using chi square and continuous variables Kruskal-Wallis techniques. Propensity score matched sensitivity analysis was conducted using logistic regression. Cox proportional hazard regression models were used for survival analyses.Results: Ischemic cholangiopathy and graft failure leading to retransplantation occurred in 40% and 14% of DCD recipients but did not occur among IRD recipients(p<0.0001). There were no occurrences of HBV, HCV, HIV transmission. Survival was similar between DCD and IRD groups(90% vs 84% respectively, p=0.23).Conclusion Despite its name, increased risk donors are less risky than DCD livers given lower rates of ischemic cholangiopathy and retransplantation, supporting the recent decision to rename this group of donors to encourage utilization.

411.6: Inferior Long-term Outcomes of Simultaneous Liver-Kidney Transplantation Using Donation After Cardiac Deaths Donors in the United Network for Organ Sharing Database

Background: Outcomes of simultaneous liver-kidney transplantation (SLKT) in donation after cardiac death (DCD) have improved over the years, but data are limited. Aim of this study was to assess the long-term outcomes of SLKT from DCD organs and then compare them to donation after brain death (DBD) organs. Methods: We analyzed data from the United Network for Organ Sharing (UNOS) from 2002 to 2021. Adult SLKT were included, other multi-organ and re-transplants were excluded from the analysis. Propensity score matching was performed to assess the outcomes between two groups. P<0.05 was considered as significant. Results: In the United States, 8733 SLKT were performed during the study period (499 SLKT from DCD and 8234 from DBD). Recipients of DCD organs, when compared to recipients of DBD organs, were older (median age 59 vs 58 years, P=0.005), had lower prevalence of dialysis (62 vs 68%, P=0.003), lower Model for End-Stage Liver Disease (MELD) score (24 vs 29, P<0.001) and longer wait-time (89 vs 68 days, P=0.009). Donors of DCD organs were younger (median age 33 vs 35 years, P<0.001), had shorter cold ischemia time in liver (5.8 vs 6.0 hours, P<0.001) and in kidney (9.5 vs 10.5 hours, P<0.001), and had similar kidney donor profile index (31 vs 30 %, P=0.18) compared to DBD donor. The most common primary diagnosis for both recipient groups was alcohol-related liver disease, while non-alcoholic steatohepatitis was more common in DCD group (28 vs 21%). Long-term outcomes including five-year overall survival and liver graft survivals were inferior in DCD recipients (71.4 vs 74.8%, P=0.11; 74.0 vs 67.1%, P=0.0011). After propensity score matching, five-year overall survival and liver graft survivals were inferior (71.4 vs 76.4%, P=0.031; 67.1 vs 76.0%, P<0.001). Multivariable cox-regression analysis in the matched-cohort showed that DCD was an independent risk factor of mortality (hazard ratio {HR}- 1.33; 95% Confidence interval{CI}, 1.04-1.68; P=0.021) and liver graft failure (HR- 1.54; 95% CI, 1.24-1.92; P<0.001). For kidney allograft outcomes in matched-cohort, delayed graft function was higher in DCD (36 vs 20%, P<0.001) and five-year kidney graft outcome was inferior in DCD (67.3 vs 74.7%, P=0.0034). The most common listed causes of five-year mortality were infection (21.4%) and multi-organ failure (20.8%) and there were no differences between two groups. Other factors associated with mortality were recipient older age (HR 1.03; 95%CI 1.02-1.04, P<0.001), male recipient (HR 1.32; 95%CI 1.06-1.64, P=0.014), and donor older age (HR 1.01; 95%CI 1.00-1.02, P=0.024). Conclusion: Recipients of SLKT from DCD donors had inferior long-term post-transplant outcomes with decrease in overall survival and allograft survival. Careful identification of risk factors associated with worse outcomes is required to improve utilization of DCD donors for SLKT.

Heart Transplant Outcomes with Donation After Cardiac Death: UNOS Registry Analysis

<h3>Purpose</h3> Limitations in organ donation have led to approaches to expand the existing donor pool. Donation after cardiac death (DCD) has continued to increase after efforts led by the United Kingdom and Australia. We sought to describe the United States experience. <h3>Methods</h3> 5153 heart transplant (HT) recipients were identified in the UNOS Registry between 1/2019 and 6/2021, of which 229 were DCD recipients. HT recipients were grouped by DCD status or donation after brain death (DBD). Comparisons between groups were assessed using standard statistical methods, survival analysis was censored at 12-months via the Kaplan-Meier method. Multivariate Cox proportional hazard regression analysis (adjusted for age, sex, diabetes, race, ischemic time, dialysis, life support, waiting time & HLA mismatch) were performed. <h3>Results</h3> Recipients of DCD donors were of lower UNOS status (p<0.001), increased VAD use (p=0.01), and less dialysis (p=0.011). Additionally, DCD donor recipients had longer wait times (46.0 vs 30.0d, p=0.007), longer ischemic times (p<0.001) but younger donors (29.8 vs 23.4y, p<0.001). There was no difference in 1-month or 1-year survival by donor type (p=0.720). Unadjusted analysis demonstrated HR 0.91 (0.52-1.57) and following adjustment HR 0.88 (0.48-1.61). <h3>Conclusion</h3> Short-term survival of DCD donors is similar to DBD donors in this UNOS Registry analysis. DCD donor use has potential to expand the donor pool. Further study is warranted to assess longer term outcomes as well as best strategies for donation.

Liver allograft findings of donation after cardiac death versus brain death in recipients with hepatitis C related cirrhosis: a matched histologic comparison

As the demand for organ transplantation increases, utilization of liver allografts of donation after cardiac death (DCD) is becoming increasingly necessary. Althoughthe clinical outcomes of DCD allografts have been well described, the histologic features are not well characterized. Liver biopsies (n=131) from age-matched DCD (n=60) and donation after brain death (DBD; n=71) recipients with hepatitis C virus were compared. Histologic features were studied in a blinded fashion, subgrouped into time 0, 0-6 months, and >6 months. In time 0 biopsies, more DCD cases had zone 3 (43.8 vs 29%) and bridging necrosis (19 vs 0%), albeit not statistically significant. At 0-6 months, more DCD cases had portal edema (p=0.01). Pericholangitis (30.4% vs 18.8%) and acute cholestasis (21.7% vs 12.5%) were more common in DCD, but not statistically significant. At >6 months, pericholangitis (19% vs 4.5%) persisted in DCD, although not statistically significant. Overall, both groups had similar bile duct injury, portal inflammation, and fibrosis. Postoperative biliary complications were more common in DCD (19% vs 0%). Three-year and 10-year graft survival and patient outcomes were similar in both cohorts. Biliary alterations were more prevalent in the 0-6 month time period DCD biopsies, reflecting increased vulnerability of this group to biliary complications in the early post-orthotopic liver transplant (OLT) period. This finding may suggest poor graft perfusion despite comparable cold ischemia times. However, these features improved and DCD recipients have similar graft and overall survival compared to DBD recipients, indicating that carefully selected DCD liver allografts are a viable option for transplantation.

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.

Variable Benefits of Antibody Induction by Kidney Allograft Type

BackgroundKidneys from acute renal failure (ARF), expanded criteria donors (ECD), and donation after cardiac death (DCD) donors are often discarded due to concerns for delayed graft function (DGF) and graft failure. Induction immunosuppression may be used to minimize these risks, but practices vary widely. Furthermore, little is known regarding national outcomes of transplant recipients receiving induction immunosuppression for receipt of high-risk kidneys. Materials and methodsUsing a center-level retrospective study, deceased donor transplants (115,485) from the Scientific Registry of Transplant Recipients from January 2003 to June 2016 were evaluated. Patients who received induction immunosuppression, including lymphocyte immune globulin, muromonab CD-3, IL-1 receptor antagonist, anti-thymocyte globulin, daclizumab, basiliximab, alemtuzumab, and rituximab, were included. Associations of center-level induction use with acute rejection in the first post-transplant year, graft failure, and patient mortality were evaluated using multivariable Cox and logistic regression. ResultsAmong all kidneys, increasing percentage of center-level induction was associated with lower risk of graft failure, acute rejection, and patient mortality. In recipients of ARF kidneys, the beneficial association of induction on graft failure and acute rejection was greater than in those that received non-ARF kidneys. Marginally greater benefit of induction was seen for acute rejection in ECD compared to standard criteria donor (SCD) recipients and for graft failure in DCD compared to donors after brain death (DBD). No benefit of induction was detected for patient and graft survival in ECD recipients, acute rejection in DCD recipients, and patient survival in DGF recipients. No difference in the benefit of induction was detected in any other comparisons. ConclusionsWhile seemingly beneficial for recipients of all kidneys, induction has more robust associations with lower graft failure and acute rejection probability for recipients of ARF kidneys. Given the lack of observed benefit for ECD recipients, induction policies should be carefully considered in these patients.

Hepatic artery stenosis after liver transplant: Donation after cardiac death donor vs donation after brain death donor grafts.

Hepatic artery stenosis (HAS) after liver transplant (LT) is a source of significant morbidity. Some reports have suggested higher arterial complications in patients who receive donation after cardiac death (DCD) livers. A total of 2860 consecutive LT were reviewed from a prospectively collected database. All angiograms performed in LT recipients were reviewed and primary patency rates determined by need for further intervention or graft loss due to HAT. Hepatic artery stenosis was seen in 4.6% of DCD and donation after brain death (DBD) recipients. Recipient male gender, age at transplant, complex donor hepatic artery anatomy, and prolonged operative time were all associated with HAS, but not DCD status. While HAS in recipients of DCD grafts required more stents (1.7% vs 0.6%, P=0.04) and had worse primary patency rates (logrank, P=0.02), outcomes as defined by HAT, patient and graft survival were not significantly different between the recipients of DCD or DBD grafts. We observed no significant difference in the incidence of hepatic artery complications, patient survival, or graft survival in recipients of DCD or DBD grafts. However, HAS in DCD recipients had worse primary patency and a higher need for stent placement.

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

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

Outcomes of Liver Transplantation Using Organ Donation After Brain Death (DBD) versus Organ Donation After Cardiac Death (DCD): A Single Center Experience

Introduction: Donation after cardiac death (DCD) liver allografts have been associated with primary nonfunction, ischemic cholangiopathy, hepatic artery stenosis and a higher re-transplantation rate when compared with donation after brain death (DBD) allografts. The number of liver transplantation (LT) with DCD allografts has increased in the recent years. We present our experience with using this extended criteria donor grafts. Primary objective: To compare patient and graft survival between DBD and DCD allografts. Secondary objective: To compare biliary and vascular rates of LT complications between both groups. Methods: We retrospectively reviewed all LTs performed at a major transplant center from January 2012 to April 2017. We included patients who received a combined liver and kidney transplant (n = 29), and excluded patients who received a split LT (n =4). DCD and DBD allografts were compared using Chisquare, Fischer exact test, log-rank tests and Kaplan-Meier plot analysis. Results: A total of 409 patients were analyzed, 100 patients received DCD grafts, and 309 patients received DBD grafts. There was no significant difference in the recipient age, gender, BMI or donor age, gender and BMI of both groups. The DBD recipients had a higher biological (p = 0.001) and match MELD scores, (p = 0.005) while the DCD donors had a higher donor risk index (p < 0.0001). Cholangiopathy in the DCD group was 12.2% and 3.6% in the DBD group, p = 0.001. Although, the rate of non-anastomotic biliary strictures, however, was significantly different between both groups (Table 1), cholangiopathy did not appear to be significant in predicting patient or graft survival in a sub-group analysis. Patient survival in DCD recipients was 92.7% at 1 year, and 80.3% at 4 years versus 96% at 1 year and 88.5% at 4 years in DBD recipients, p = 0.27. Graft survival in DCD recipients was 88% at 1 year, and 76.3% at 4 years versus 94.1% at 1 year and 78.8% at 4 years in DBD recipients, p = 0.34 (Figure 1).Figure: Patient and graft survival Kaplan-Meier curves.Conclusion: With careful selection, LT outcomes of DCD organs are comparable to DBD organs.Figure: Demographics and outcomes by donor relationship.

MP30-14 SURVIVAL OUTCOMES FROM DCD RENAL TRANSPLANT ARE COMPARABLE TO DBD TRANSPLANTS FROM KIDNEYS PROCURED FROM DONORS OVER 50 YEARS OF AGE: UNOS/OPTN ANALYSIS

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery II1 Apr 2017MP30-14 SURVIVAL OUTCOMES FROM DCD RENAL TRANSPLANT ARE COMPARABLE TO DBD TRANSPLANTS FROM KIDNEYS PROCURED FROM DONORS OVER 50 YEARS OF AGE: UNOS/OPTN ANALYSIS Patrick Luke, Hemant Sharma, Jingwen Chen, and Alp Sener Patrick LukePatrick Luke More articles by this author , Hemant SharmaHemant Sharma More articles by this author , Jingwen ChenJingwen Chen More articles by this author , and Alp SenerAlp Sener More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.947AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There is hesitancy when utilizing DCD grafts of older age. We assess the long-term graft/ patient survival outcomes in donation after cardiac death ( DCD) and donation after brain death (DBD) transplants from kidneys procured from donors > 50 years of age. METHODS Utilizing the UNOS/OPTN database, we analyzed 14288 deceased donor kidney transplants (1833 DCD and 13533 DBD) from donors > 50 years between 2005-2013. Analysis of graft and patient survival was with multivariate regression analysis and Cox models with single imputation by dummy variable method to manage missing data. RESULTS Donor and recipient demographics between DCD and DBD recipients were similar including donor age, BMI, history of diabetes, and smoking. However, KDRI Rao was 1.5 (1.06-3.31) in DCD and 1.6 in DBD (1.6 (0.96-4.1), which was significant (p<0.001). Death censored graft survival in patients receiving grafts from donors >50 years at 1 and 5 years was 90 and 76% in DCD group vs 92% and 77% in DBD (p = NS). Furthermore, patient survival was 90 and 70% in DCD vs. 91 and 72% in DBD ( p = NS). When analyzing patients receiving grafts >60 years of age, graft survival was similar between DCD and DBD groups, but patient survival was inferior in the DCD group (p<0.05). CONCLUSIONS Results of renal transplantation with grafts >50 years are similar between DCD and DBD recipients, but caution should be taken when utilizing grafts >60 years. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e394-e395 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Patrick Luke More articles by this author Hemant Sharma More articles by this author Jingwen Chen More articles by this author Alp Sener More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Basiliximab induction in kidney transplantation with donation after cardiac death donors.

Basiliximab is a monoclonal antibody that binds to the α-chain of the interleukin (IL)-2 receptor. It is used as induction therapy in kidney transplantation. The objective of the present study was to evaluate induction therapy with single-dose basiliximab (Simulect®) in kidney transplantation with donation after cardiac death (DCD) donors. A total of 33 DCD kidney transplants were performed between December 2010 and July 2013 in patients who received single-dose basiliximab (20 mg) as induction therapy. The maintenance immunosuppression included calcineurin inhibitor (cyclosporine A or tacrolimus), mycophenolate mofetil and corticosteroids. The follow-up time was 1 year. The mean ages of the DCD donors and recipients were 29.3 and 41.1 years, respectively. Within the 1-year follow-up, the overall incidence of acute rejection was 9.1%. There were 10 cases of delayed graft function among the recipients. Mean serum creatinine values at 1 week and at 1, 3, 6, 9 and 12 months post-transplantation were 257.6, 238.2, 194.5, 159.3, 137.9 and 110.8 µmol/l, respectively, with a favorable trend to allograft function recovery over time. The 1-year patient and graft survival rates were 96.9 and 90.9%, respectively, with an infection rate of 24.2%. Increased alanine aminotransferase/aspartate transaminase levels in only 2 patients were considered to be associated with basiliximab. This experience with single-dose basiliximab for induction therapy in DCD kidney transplantation showed that favorable clinical outcomes were achieved in terms of graft survival and function within 1 year.

Outcomes of standard dose EC-MPS with low exposure to CsA in DCD renal transplantation recipients with DGF.

The lower limit of exposure to cyclosporine A (CsA) has not yet been established in donation after cardiac death (DCD) renal transplantation recipients with delayed graft function (DGF) receiving enteric-coated mycophenolate sodium (EC-MPS) therapy. Stable and adequate mycophenolic acid (MPA) dosing may facilitate lower CsA exposure after DCD renal transplantation in recipients with DGF without compromising safety. A 12-month, single-centre open-label prospective trial was performed in our centre. According to their DGF risk index using the previous DGF prediction models, we divided up the patients on oral CsA into either a DGF group (n = 26) and no DGF group (n = 48). All of the patients initially received the standard EC-MPS dosing (1440 mg/day). The initial dose of CsA in the low risk of DGF group was 4.5 mg/kg/day and in the high risk of DGF group was 2.5 mg/kg/day. Efficacy parameters, safety and tolerability were assessed over a 12-month study period. The incidence of DGF was 18.5% in the 162 DCD recipients. Between the DGF group and the no DGF group, the 1-year patient survival and graft survival were not significantly different. The incidence of BPAR was higher in the DGF group (26.9% vs. 8.3%, p = 0.032). Most patients in the DGF group had recovery of renal function after 1 month. The adverse events between the two groups were not significantly different. The daily EC-MPS doses of the DGF group were significantly higher than the no DGF group before the 6-month follow-up period. There were no significant differences between the two groups regarding the mean AUC levels during the follow-up period. These results show that low expose CsA with standard dosing of EC-MPS and thymoglobulin was efficacious, safe and well-tolerated in DCD renal transplant recipients with DGF in China. Furthermore, stable and adequate MPA exposure helped to reduce the dose of and exposure to CsA. Thus, this may lead to less-induced nephrotoxicity and better renal function recovery.

Outcomes Using Grafts from Donors after Cardiac Death

Previous reports suggest that donation after cardiac death (DCD) liver grafts have increased primary nonfunction (PNF) and cholangiopathy thought to be due to the graft warm ischemia before cold flushing. In this single-center, retrospective study, 866 adult liver transplantations were performed at our institution from January 2005 to August 2014. Forty-nine (5.7%) patients received DCD donor grafts. The 49 DCD graft recipients were compared with all recipients of donation after brain death donor (DBD) grafts and to a donor and recipient age- and size-matched cohort. The DCD donors were younger (age 28, range 8 to 60 years) than non-DCD (age 44.3, range 9 to 80 years) (p < 0.0001), with similar recipient age. The mean laboratory Model for End-Stage Liver Disease (MELD) was lower in DCD recipients (18.7 vs 22.2, p = 0.03). Mean cold and warm ischemia times were similar. Median ICU and hospital stay were 2 days and 7.5 days in both groups (p = 0.37). Median follow-ups were 4.0 and 3.4 years, respectively. Long-term outcomes were similar between groups, with similar 1-, 3- and 5-year patient and graft survivals (p = 0.59). Four (8.5%) recipients developed ischemic cholangiopathy (IC) at 2, 3, 6, and 8 months. Primary nonfunction and hepatic artery thrombosis did not occur in any patient in the DCD group. Acute kidney injury was more common with DCD grafts (16.3% of DCD recipients required dialysis vs 4.1% of DBD recipients, p = 0.01). An increased donor age (>40 years) was shown to increase the risk of IC (p = 0.006). Careful selection of DCD donors can provide suitable donors, with results of liver transplantation comparable to those with standard brain dead donors.

Use of model for end-stage liver disease exceptions for donation after cardiac death graft recipients relisted for liver transplantation.

Donation after cardiac death (DCD) liver transplantation is associated with increased biliary complications and graft failure. Yet for unclear reasons, DCD recipients relisted for transplantation have lower wait-list mortality than other retransplant candidates. We used Organ Procurement and Transplantation Network and United Network for Organ Sharing data from 2002 to 2011 to evaluate all DCD recipients relisted for transplantation to evaluate the impact of the utilization of Model for End-Stage Liver Disease (MELD) exception points on wait-list outcomes. Of 262 DCD recipients relisted for liver transplantation >2 weeks after initial transplantation, 82 (31.3%) applied for a nonstandardized MELD exception, and 68 (82.9%) had ≥1 exception approved. Of the relisted DCD recipients, 187 (71.4%) underwent retransplantation; among those with an approved MELD exception, 85.2% underwent retransplantation versus 57.1% of those with an exception denied and 69.4% of those not applying for an exception (P=0.02). In contrast, those receiving MELD exception points were significantly less likely to be removed from the wait list for death or clinical deterioration in comparison with those not applying for an exception (7.1% versus 19.4%, P=0.02). In multivariate models, patients with an approved exception were 3.3 times more likely to undergo retransplantation than those not applying for an exception. Standardized criteria for exception points among DCD recipients should be established to ensure uniform access to retransplantation.

Clinical outcomes and quality of life in recipients of livers donated after cardiac death.

Donation after cardiac death (DCD) has expanded in the last decade in the US; however, DCD liver utilization has flattened in recent years due to poor outcomes. We examined clinical and quality of life (QOL) outcomes of DCD recipients by conducting a retrospective and cross-sectional review of patients from 2003 to 2010. We compared clinical outcomes of DCD recipients (n = 60) to those of donation after brain death (DBD) liver recipients (n = 669) during the same time period. DCD recipients had significantly lower rates of 5-year graft survival (P < 0.001) and a trend toward lower rates of 5-year patient survival (P = 0.064) when compared to the DBD cohort. In order to examine QOL outcomes in our cohorts, we administered the Short Form Liver Disease Quality of Life questionnaire to 30 DCD and 60 DBD recipients. The DCD recipients reported lower generic and liver-specific QOL. We further stratified the DCD cohort by the presence of ischemic cholangiopathy (IC). Patients with IC reported lower QOL when compared to DBD recipients and those DCD recipients without IC (P < 0.05). While the results are consistent with clinical experience, this is the first report of QOL in DCD recipients using standardized measures. These data can be used to guide future comparative effectiveness studies.

Polyclonal Versus Monoclonal Induction Therapy in a Calcineurin Inhibitor–Free Immunosuppressive Therapy in Renal Transplantation: A Comparison of Efficacy and Costs

BackgroundInduction therapy in renal transplantation reduces the incidence of acute rejection (AR) in expanded criteria donation (ECD) and donation after cardiac death (DCD). We compared the efficacy of Thymoglobulin (Sanofi-Aventis, Spain), ATG Fresenius (ATG-Fresenius, Spain), and Simulect (Novartis Farm, Spain) in a calcineurin-free protocol in ECD and DCD renal transplantation by evaluating patient survival, graft survival, and AR at 1 year and overall costs. MethodsAn observational retrospective study was performed using our database of 289 consecutive cadaveric ECD renal transplant recipients (n = 178) and DCD recipients (n = 111) from April 1999 to December 2011. Induction therapy consisted of Simulect, Thymoglobulin, and ATG Fresenius. Calcineurin-inhibitor (CNI)–free maintenance therapy consisted of mycophenolate mofetil or sodium and steroids. ResultsThere were no differences in the patients' demographic characteristics or patient and graft survival. One-year AR rates were equivalent (ECD: 10%, 19.1%, 17.7% versus DCD: 14.3%, 7.1%, 16.7%). Leukopenia and thrombopenia were significantly more frequent in the ECD group treated with polyclonal induction. The average total cost of transplantation was higher in the ECD group but there were no significant differences in the average total cost between ECD and DCD: 39,970.31 ± 7,732€ versus 35,058.34 ± 6,801€ (P = NS). ConclusionOur study shows the same efficacy with polyclonal and monoclonal antibody induction and a CNI-free treatment regimen in ECD and DCD renal transplantation with no differences in overall costs at 1 year after transplantation.

The jury is out on the utilization of donors after cardiac death for simultaneous liver and kidney transplantation.

The organ shortage continues to worsen, and so it is up to the transplant community to investigate all avenues of increasing the supply of transplantable organs. One such potential supply of transplantable organs comes from donation after cardiac death (DCD) (1). The DCD organs have been successfully used in kidney-alone transplantation with the known risk of higher rates of delayed graft function but similar rates of graft and patient survivals when compared to deceased brain dead (DBD) donors (2, 3). For liver transplantation, the outcomes have been questioned. Most publications show worse outcomes with DCD donors when compared to DBD donors (4–6). Particular concerns involve the development, morbidity and cost of the ischemic cholangiopathy (7, 8). Still, not all recipients have the same needs or life expectancy, and so if the risks and benefits are properly considered and explained, DCD liver-alone transplantation still represents an option for selected patients with end-stage liver disease. In the MELD era, we have seen an increase in the number of simultaneous liver and kidney transplantation (SLK) driven, at least in part, by the importance of renal dysfunction in the calculation of the MELD score. However, the use of DCD donors in SLK transplantation has been poorly investigated, with only a single small report previously published (9). Other studies of SLK are inherently limited because they use as a comparison a nonrandomized cohort of liver transplant-alone patients. In this issue of Transplantation, Alhamad et al. (10) ask important questions regarding the outcomes of organs from DCD donors in the setting of SLK. Importantly, this study decreases previous biases by shifting the control group to a nonrandom zedcohort of DBD SLK recipients. The authors analyzed the United Network Organ Sharing database comparing outcomes of DCD SLK (n=98) versus DBD SLK recipients (n=3,026), transplanted between 2002 and 2011. Based on the demographics, we find that DCD SLK is a rare event comprising 3% of the SLK analyzed in this study. The DCD SLKs were more likely to be imported as a regional or national offer, indicating urgency. That said, the authors looked at several available data points that suggest the recipients of DCD SLK were of similar illness, including being in the hospital, on dialysis and on a ventilator. This is a critical point because outcomes are inexorably linked pretransplant health, and if one group is “sicker” then we might expect and even accept inferior outcomes for this group. In fact, recipients of DBD SLK have a higher “liver component” of their MELD score suggesting that the DCD recipients were sicker overall and perhaps more likely to have multi-system organ failure. Differently from the previous report on outcomes of DCD for five SLKs, the authors found that kidney, liver, and patient survival from DCD donors were inferior to DBD donors at 1, 3, and 5 years (9). Moreover, DCD use was a significant risk factor for kidney and liver allograft failure and also for patient mortality. As transplant centers continue to be heavily scrutinized based on their outcomes, studies such as these are important to help frame the conversation around what are the “expected” outcomes with a given donor and recipient combination. Although risk adjustment for these outcomes, based solely on registry analysis, will always have shortcomings, the data from this study can have an important effect on transplant center’s willingness to take an acceptable risk and allow access to transplant for some ill patients under extreme circumstances. The jury, therefore, is out for professionals involved with difficult decisions regarding the use of DCD organs for ill recipients who are in urgent need of an SLK transplantation.

Kidney Transplantation From Cardiac Death Donors With Terminal Acute Renal Failure

ObjectivesKidney transplantation from donation after cardiac death (DCD) donors with terminal acute renal failure (ARF) is not widely accepted due to concern about the organ quality. Here we report our initial clinical outcomes of kidney transplantation from DCD donors with ARF. Materials and MethodsThe results of 29 kidney transplants from ARF DCD donors were compared with those of 60 kidney transplants from non-ARF DCD donors performed at our center from August 2011 to March 2013. ResultsThere was no difference in the incidence of delayed graft function and acute rejection between ARF and non-ARF kidneys (27.6% vs 16.7%, 10.3% vs 8.3%, respectively). Estimated glomerular filtration rate at 12 months was similar between ARF and non-ARF kidneys. With a mean follow-up of 18 months (range 7 to 26 months), actual patient and graft survival rates for ARF DCD recipients were 100% and 96.6%, respectively, which were similar to those of the control group of kidney transplants from non-ARF kidneys (98.3% and 95.0%). ConclusionsKidneys from DCD donors with terminal ARF have excellent short-term outcomes and may represent another potential method to safely expand the donor pool.

Inferior survival in liver transplant recipients with hepatocellular carcinoma receiving donation after cardiac death liver allografts

The impact of ischemia/reperfusion injury in the setting of transplantation for hepatocellular carcinoma (HCC) has not been thoroughly investigated. The present study examined data from the Scientific Registry of Transplant Recipients for all recipients of deceased donor liver transplants performed between January 1, 1995 and October 31, 2011. In a multivariate Cox analysis, significant predictors of patient survival included the following: HCC diagnosis (P < 0.01), donation after cardiac death (DCD) allograft (P < 0.001), hepatitis C virus-positive status (P < 0.01), recipient age (P < 0.01), donor age (P < 0.001), Model for End-Stage Liver Disease score (P < 0.001), recipient race, and an alpha-fetoprotein level > 400 ng/mL at the time of transplantation. In order to test whether the decreased survival seen for HCC recipients of DCD grafts was more than would be expected because of the inferior nature of DCD grafts and the diagnosis of HCC, a DCD allograft/HCC diagnosis interaction term was created to look for potentiation of effect. In a multivariate analysis adjusted for all other covariates, this interaction term was statistically significant (P = 0.049) and confirmed that there was potentiation of inferior survival with the use of DCD allografts in recipients with HCC. In conclusion, patient survival and graft survival were inferior for HCC recipients of DCD allografts versus recipients of donation after brain death allografts. This potentiation of effect of inferior survival remained even after adjustments for the inherent inferiority observed in DCD allografts as well as other known risk factors. It is hypothesized that this difference could reflect an increased rate of recurrence of HCC.

Comparison of Kidney Function Between Donation After Cardiac Death and Donation After Brain Death Kidney Transplantation

Kidney graft survival is comparable between donation after cardiac death (DCD) and donation after brain death (DBD) kidney transplantation. However, data concerning kidney function after DCD kidney transplantation are lacking. We retrospectively compared kidney function between 64 DCD and 248 DBD kidney transplant recipients. Graft function was assessed using iothalamate glomerular filtration rate at 1, 4, and 12 months, then annually. The primary endpoint was the composite of death-censored graft loss or two consecutive iothalamate glomerular filtration rates less than 50 mL/min/1.73 m² occurring within 5 years from transplantation. Secondary endpoints included death and graft loss or death. Of the 312 patients, 102 (33%) experienced the primary endpoint, 78 (25%) experienced graft loss or death, and 44 (14%) died. In multivariable Cox regression analysis, there was no difference between DCD and DBD recipients regarding the primary endpoint (relative risk [RR], 1.16; P=0.59), death (RR, 0.97; P=0.94), or graft loss or death (RR, 1.09; P=0.79). In the subgroup of 64 DCD recipients, each 10-year increase in donor age was associated with increased risk of the primary endpoint (RR, 1.51; P=0.027) with the highest risk observed for donors older than 45 years (RR, 4.81; P=0.001). Delayed graft function affected 45% of the DCD recipients but had no impact on kidney function, graft survival, or patient survival. Posttransplantation kidney function is comparable between DCD and DBD kidney transplantations. In the subgroup of DCD recipients, kidneys from donors older than 45 years may be associated with a higher risk of poor kidney function; however, this finding requires validation in a larger patient group.