Donation After Cardiac Death Group Research Articles

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

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

Outcomes of Liver Transplantation Using Machine Perfusion in Donation after Cardiac Death vs Brain Death in the US.

Liver transplant (LT) outcomes using machine perfusion (MP) in donation after brain death (DBD) is promising, but the LT outcomes of MP in donation after cardiac death (DCD) is limited in the US. The aim of this study was to compare LT outcomes of MP between DCD and DBD. We analyzed data from the United Network for Organ Sharing between 2016 and 2021 among adult LT recipients. Propensity score matching was performed to assess the outcomes between DCD and DBD. A total of 380 LTs (295 from DBD and 85 from DCD) were performed using MP. When compared with DBD, DCD group had older median recipient age (61 vs 58 years, p = 0.03), higher prevalence of diabetes (41% vs 28%, p = 0.02), lower model for end-stage liver disease score (17 vs 22, p < 0.01), longer wait time (276 vs 143 days, p < 0.01) and younger median donor age (40 vs 51 years, p < 0.01). The most common primary diagnosis was alcohol-related liver disease, and hepatocellular carcinoma was more common in the DCD group (22% vs 13%). On survival analysis, 1-year overall/graft survivals (DCD 95.4% vs DBD 92.1%, p = 0.54; DCD 91.7% vs DBD 89.8%, p = 0.86) were the same. After propensity score matching, overall/graft survivals were the same. In Cox regression analysis, DCD was not an independent risk factor of mortality (hazard ratio 0.80; 95% CI 0.25 to 2.52; p = 0.70) and graft failure (hazard ratio 0.58; 95% CI 0.17 to 1.97; p = 0.38). In transplant recipients who underwent LT using MP, posttransplant outcomes of overall and graft survival were similar among DCD and DBD cohorts.

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.

Impact of Point-of-Care Assays for Hemostasis Monitoring According to Type of Donor in a Cohort of Liver Transplant Recipients

• Donation after circulatory death liver transplant offers excellent outcomes. • Perioperative hemostasis monitoring protocols with a viscoelastic point-of-care testing assay reduce blood loss and transfusion volume. • Use of machine perfusion is likely to further expand donation after circulatory death liver transplant. The aim is to compare 2 groups of liver transplant recipients, according to type of donor, within the framework of a hemostasis monitoring program using a point-of-care testing assay in terms of reduction in transfusion of blood products. This retrospective analytical observational study included 527 liver transplant recipients from 2014 to 2021. Of these, 460 were recipients of livers from donation after brain death (DBD) and 67 were orthotopic liver transplant recipients with donation after cardiac death (DCD). Statistical analysis of differences between the 2 groups included a series of intraoperative variables of blood product consumption: erythrocyte concentrate (red blood cells), fresh frozen plasma, platelets, and fibrinogen concentrates guided by algorithm with a viscoelastic technique using the ClotPro analyzer. The transfusion management was decided according to pre-established guidelines and cutoff values. The mean follow-up period was 40.3 months. Transfused red blood cells and fibrinogen units were significantly higher in the DBD group. The percentage of retransplant was significantly higher in the DCD group, and vascular complications were significantly more frequent in the DCD group ( P < .05). Cox univariate analysis showed that the DCD group had a risk ratio of death significantly higher than 1. Intraoperative monitoring of hemostasis with a point-of-care testing assay reduced blood product requirements. Type of donor had prognostic utility in our cohort. We hypothesize that other variables such as extraction technique, methods used to preserve the allograft, and later complications have a significantly greater impact than perioperative hemostasis management on retransplant rates and death.

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.

Optimal Conditions for Oxygenated Subnormothermic Machine Perfusion for Liver Grafts Using a Novel Perfusion Device

Liver transplantation from donors after cardiac death (DCD) resolves donor shortages. We investigated the optimal time for subnormothermic oxygenated perfusion in DCD liver transplantation. Ten F1 pigs (body weight: 27-32 kg) were allocated to 2 groups: the heart beating group (n=6), from which livers were retrieved while the heart was beating, and the donation after cardiac death (DCD) group (n=4), in which liver retrieval was performed on pigs under apnea-induced cardiac arrest for 20 minutes. In both groups, the livers were kept in cold storage for 2 hours after retrieval and perfused with a subnormothermic oxygenated Krebs-Henseleit buffer for 120 minutes. We used a novel perfusion device, which can set maximum perfusion pressures of arteries and portal vein, developed by Asahikawa Medical University and Chuo Seiko Co. Bile production, liver enzymes, and inflammatory cytokines were measured and the sinusoidal space, using tissue specimens taken from liver grafts, was measured at 30, 60, 90, and 120 minutes after the start of perfusion. Bile production peaked at 90 minutes. Significantly higher levels of liver enzymes and inflammatory cytokines were found in the DCD group (P < .05). The release of liver enzymes peaked at 60 minutes and that of inflammatory cytokines peaked at 90 minutes. The hepatic sinusoidal space was wide at 90 minutes and narrowed after 120 minutes. The results suggest that subnormothermic oxygenation perfusion may maintain optimal graft condition until around 90 minutes and perfusion for more than 120 minutes may be counterproductive.

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.

Cytoprotective Effects of Mesenchymal Stem Cells During Liver Transplantation From Donors After Cardiac Death in Swine

BackgroundLiver transplantation from donors after cardiac death (DCDs) can increase the pool of available organs. Recently, mesenchymal stem cells (MSCs) have been used to treat various diseases. Some studies have reported that MSCs improve the outcome of liver transplantation from DCDs in mice. The aim of this study was to evaluate the cytoprotective effects and safety of MSC transplantation on liver grafts from DCDs in swine. MethodsFor the MSCs, we used swine adipose-derived stem cells (ADSCs). Landrace swine were divided into 3 groups (n = 5) as follows: 1. the heart-beating (HB) group, from which liver grafts were retrieved and transplanted; 2. the DCD group, from which liver grafts were retrieved 10 minutes after apnea-induced cardiac arrest and transplanted; and 3. the ADSC group, from which liver grafts were retrieved as with the DCD group, transplanted, and then infused with 1.0 × 107 ADSCs 2 hours after reperfusion. ResultsIn the HB group, all 5 recipients survived for >7 days, whereas all 5 recipients in the DCD group died within 24 hours after transplantation. In the ADSC group, 3 recipients survived for >7 days, whereas 2 recipients died within 4 days after transplantation. The survival rate was significantly higher in the ADSC group than in the DCD group. ConclusionsMSCs could protect the function of liver grafts from warm ischemia-reperfusion injury and improve the viability of DCD liver grafts.

Normothermic extracorporeal membrane oxygenation support: Improving the function of intestinal grafts obtained from cardiac death donors.

Extracorporeal membrane oxygenation (ECMO) could ameliorate the energy status and viability of bowel grafts from cardiac death donors. However, the function of these grafts after transplantation is not clear. The purpose of the study was to evaluate the early function of intestinal grafts after transplantation from expected cardiac death donors supported with normothermic extracorporeal support using a porcine allogeneic orthotopic segmental small bowel transplantation model. Eighteen domestic crossbred donor pigs were assigned to living donation (LD), donation after cardiac death (DCD), and ECMO groups. In the LD group, small bowels were harvested and preserved immediately in cold storage. In the other two groups, the donor pigs received conventional rapid recovery treatment or 1-hour normothermic extracorporeal support after 10-minutes expected cardiac arrest. Subsequently, the small bowels were removed and preserved in cold storage. After 5-6hours of preservation, small bowel grafts were transplanted into the recipient pigs that underwent enterectomy. The pathology and electron microscopy results, cell apoptosis rate, tight junction protein expression level in the intestinal mucosa, and plasma endotoxin level were evaluated after transplantation. All grafts functioned on the basis of the maltose absorption test results at day 7 after transplantation. There were no significant differences in the morphological changes in the intestinal mucosa among the three groups at day 7 after transplantation. The cell apoptosis rate and plasma endotoxin level in the ECMO group did not differ significantly than those in the LD group, but were evidently lower than those in the DCD group (P<.001). The intestinal absorptive function improved significantly in the ECMO group in contrast with that in the DCD group (P<.001). Short-term ECMO intervention can alleviate ischemia-reperfusion injuries in intestinal grafts and improve intestinal absorptive function in the early stage after transplantation. Reducing caspase-3 protein expression and cell apoptosis in the intestinal mucosa may be one of the protective mechanisms of ECMO intervention.

Outcomes in kidney transplantation with mycophenolate mofetil-based maintenance immunosuppression in China: a large-sample retrospective analysis of a national database.

There is no large data analysis reporting the outcome of Chinese kidney transplant patients using mycophenolate mofetil (MMF). This study analyzed 6719 patients from the Chinese Scientific Registry of Kidney Transplantation using MMF, which included 1153 from donation after cardiac death (DCD), 1271 from donation after brain and cardiac death (DBCD), and 4295 from living donor (LD). Compared with the transplants from deceased donor (DD), better outcomes including 3-year graft survival probabilities (LD=95.8% vs. DD=91.3%), incidence of delayed graft function (DGF, LD=2.4% vs. DD=17.7%), infection (LD=10.7% vs. DD=20.7%), graft loss (LD=2.3% vs. DD=6.3), and death (LD=1.3% vs. DD=3.2%) were shown in the LD group, with similar incidences of acute rejection (AR, LD=3.7% vs. DD=4.7%), hyperuricemia (LD=21.7% vs. DD=22.2%) within postoperative 1year, and serum creatinine (Scr) >133μmol/l at 1year (LD=18.8% vs. DD=18.6%). Nonsignificant differences were found between the DCD and DBCD group. The 5-year survival of patient and graft in the LD group were 97.5% and 93.0%. Adjusted Cox model for graft loss showed significant associations with DGF [hazard ratio 3.7 (95% CI: 2.4, 5.8)], AR [2.8 (1.7, 4.6)], Scr >133μmol/l at 1year [2.6 (1.5, 4.2)], hyperuricemia [2.3 (1.6, 3.3)], and DD [1.6 (1.1, 2.4)].

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.

The Effects of Short-Term Subnormothermic Perfusion after Cold Preservation on Liver Grafts from Donors after Cardiac Death

Background We previously reported that short oxygenated warm perfusion before cold storage (CS) had improved the graft viability of rat livers from donors after cardiac death (DCD). In this study, we investigated the effectiveness of short-term oxygenated subnormothermic perfusion for different durations after CS in a rat DCD model, and investigated the effects of 30-min subnormothermic perfusion for DCD livers in pigs. Methods In Study 1: We used an isolated rat liver perfusion system. The grafts were retrieved from Wistar rats 30min after cardiac arrest (thoracotomy), preserved in CS for 6h, and perfused with oxygenated subnormothermic (23-26°C) Krebs-Henseleit buffer for different durations (0, 30, 60, and 90min). After that, 15min incubation at 23-26°C, the grafts were reperfused under normothermic condition for 60min as a model of liver transplantation (0, 30, 60, and 90min groups; n=5 in each). In Study 2, landrace pigs (25-30kg) were randomly allocated into three types of groups (n = 5 per group): heart-beating (HB) graft, transplanted after a 4-h period of cold storage (CS); DCD graft, retrieved 20min after apnea induced cardiac arrest (respiratory withdrawal) and transplanted after a 4-h period of CS; and subnormothermic ex vivo liver perfusion (SELP) graft, retrieved in the same manner as the DCD graft but perfused with a subnormothermic oxygenated Krebs-Henseleit buffer (21-25°C, 10-15cmH2O) for 30min in the simplified dripping manner, without a machine perfusion system, after the 4-h period of CS, and subsequently transplanted. Results In Study 1, performing SELP groups significantly improved portal flow volume (P <0.05), and bile production (P <0.05), decreased liver enzymes (P <0.05), and increased tissue ATP (P <0.01) compared to DCD group. In the histological examinations, additional SELP ameliorated tissue deterioration, preserved the parenchymal structure, and decreased apoptosis compared to DCD group (P <0.01). In Study 2, the survival rate in the SELP group was significantly better than that in the DCD group (P = 0.0016). In the histological examination, preserved structure of the parenchyma was observed in the SELP group, and SELP significantly decreased apoptosis compared to DCD group (P <0.0001). Conclusion Even 30min of subnormothermic perfusion after CS recovered DCD livers from ischemia-reperfusion injury and might improve the viability of the grafts. Although 30min SELP was not sufficient to improve the survival rate as a level of HB group and to prevent primary graft non-function completely, this simple technique has the potential to expand the donor liver pool.

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.

Effects of Subnormothermic Perfusion Before Transplantation for Liver Grafts from Donation After Cardiac Death: A Simplified Dripping Perfusion Method in Pigs

BackgroundLiver transplantation from donors after cardiac death (DCD) provides a solution to the donor shortage. However, DCD liver grafts are associated with a high incidence of primary graft nonfunction. We investigated the effectiveness of subnormothermic porcine liver perfusion, before transplantation from DCD, on graft viability. MethodsLandrace pigs (25–30 kg) were randomly allocated to 3 groups (5 per group): heart-beating (HB) graft, transplanted after a 4-hour period of cold storage (CS); DCD graft, retrieved 20 minutes after apnea-induced cardiac arrest (respiratory withdrawal) and transplanted after a 4-hour period of CS; and subnormothermic ex vivo liver perfusion (SELP) graft, retrieved in the same manner as the DCD graft but perfused with a subnormothermic oxygenated Krebs-Henseleit buffer (21–25°C, 10–15 cm H2O) for 30 minutes in a simplified dripping manner, without a machine perfusion system, after the 4-hour period of CS, and subsequently transplanted. ResultsAlthough all animals in the HB group survived for >7 days, all animals in the DCD group died within 12 hours after transplantation. In the SELP group, 2 recipients survived for >7 days and another 2 recipients were killed on day 5. The survival rate was significantly better for SELP than for DCD grafts (P = .0016). The values of tumor necrosis factor α were not significantly different between the SELP and HB groups. Preserved structure of the parenchyma was observed in the SELP group on histologic examination. ConclusionsA simplified subnormothermic perfusion before liver transplantation is expected to improve graft viability and survival.

Cytoprotective Effects of Mesenchymal Stem Cells During Liver Transplantation from Donors After Cardiac Death in Rats

BackgroundLiver transplantation from donors after cardiac death (DCD) might increase the pool of available organs. Recently, some investigators reported the potential use of mesenchymal stem cells (MSCs) to improve the outcome of liver transplantation from DCD. The aim of this study was to evaluate the cytoprotective effects and safety of MSC transplantation on liver grafts from DCD. MethodsRats were divided into 4 groups (n = 5) as follows: 1. the heart-beating group, in which liver grafts were retrieved from heart-beating donors; 2. the DCD group, in which liver grafts were retrieved from DCD that had experienced apnea-induced agonal conditions; 3. the MSC-1 group, and 4. the MSC-2 group, in which liver grafts were retrieved as with the DCD group, but were infused MSCs (2.0 × 105 or 1.0 × 106, respectively). The retrieved livers were perfused with oxygenated Krebs-Henseleit bicarbonate buffer (37°C) through the portal vein for 2 hours after 6 hours of cold preservation. Perfusate, bile, and liver tissues were then investigated. ResultsBile production in the MSC-2 group was significantly improved compared with that in the DCD group. Based on histologic findings, narrowing of the sinusoidal space in the both MSC groups was improved compared with that in the DCD group. ConclusionsMSCs could protect the function of liver grafts from warm ischemia-reperfusion injury and improve the viability of DCD liver grafts. In addition, we found that the infusion of 1.0 × 106 MSCs does not obstruct the hepatic sinusoids of grafts from DCD.

First Canadian experience with donation after cardiac death simultaneous pancreas and kidney transplants.

Compared with neurologic determination of death (NDD) donor organs, donation after cardiac death (DCD) donor organs have traditionally been considered of inferior quality owing to warm ischemia experienced during procurement. We present, to our knowledge, the first analysis of simultaneous pancreas and kidney (SPK) transplants using DCD donor organs in Canada. We carried out a retrospective cohort study of SPK transplants from 13 DCD and 68 NDD donors performed between October 2008 and July 2016. In all patients immunosuppression was induced with thymoglobulin and continued with tacrolimus, mycophenolate mofetil and prednisone maintenance therapy. Donor and recipient characteristics of DCD and NDD groups were similar with respect to age, sex, body mass index, kidney and pancreas cold ischemia times, and donor terminal creatinine. Mean DCD graft warm ischemia time was 0.5 (range 0.4-0.7) hours. Median follow-up was 2.2 (range 0.1-6.7) years and 2.7 (range 0.3-6.3) years for the DCD and NDD groups, respectively. The DCD and NDD groups were similar with regards to recipient percent panel reactive antibody and presence of human leukocyte antigen antibodies. The groups also received similar total doses of thymoglobulin. In total 38% of patients in the DCD group experienced renal delayed graft function (DGF) compared with 10% in the NDD group (p = 0.027). There were 7 cases of pancreas graft thrombosis requiring relaparotomy in the NDD group compared with none in the DCD group. No patients from either group required insulin at any time after transplant. Although the estimated glomerular filtration rate (eGFR) was lower in the DCD than the NDD group on postoperative days 7 and 14 (p = 0.025), no difference was noted on day 30 or through 4 years after transplant. No differences were seen between the groups with respect to amylase, lipase, or glycosated hemoglobin (HbA1c) up to 4 years after transplant, or in kidney, pancreas, or patient survival at any time after transplant. Our results show that, apart from a higher renal DGF rate, SPK transplants with DCD donor organs have comparable outcomes to standard transplants with NDD donor organs.

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.

Outcomes for primary kidney transplantation from donation after Citizens\u2019 death in China: a single center experience of 367 cases

BackgroundThe cases of donation after brain death followed by circulatory death (DBCD) and donation after cardiac death (DCD) have been increased year by year in China. Further research is needed to understand in the outcomes and risk factors of delayed graft function (DGF) in order to minimize the risk of DGF and ameliorate its potential impact on long-term outcomes. This study was to explore the differences in outcomes between DBCD and DCD transplant and the main risk factors for DGF in DBCD.MethodsRetrospective analysis of the clinical data of 367donations after citizens’ death kidney transplant procedures (donors and recipients) between July 2012 and August 2015 at our center.ResultsDuring the study period, the donation success rate was 25.3%. 164 cases of DBCD and 35 cases of DCD had been implemented and 367 kidneys were transplanted. The incidence of DGF in DBCD group were significantly lower than that of DCD group (12.0% vs. 27.0%, p = 0.002). The 1-year percent freedom from acute rejection (AR) was significantly higher in DBCD group compared with it of DCD group (94% vs. 82%, p = 0.036). Multivariate logistic regression analysis of the kidney transplants revealed that the high risk factors for DGF after renal transplantation in DBCD were history of hypertension (Odds Ratio [OR] = 5.88, 95% CI: 1.90 to 18.2, p = 0.002), low blood pressure (BP < 80 mmHg) (OR = 4.86, 95% CI: 1.58 to 14.9, p = 0.006) and serum creatinine of donor (OR = 1.09, 95% CI: 1.03 to 1.16, p = 0.003) before donation.ConclusionsThe outcomes of DBCD could be better than DCD in DGF and AR. The main risk factors for DGF in DBCD kidney transplants are donors with a history of hypertension, low blood pressure, and serum creatinine of donor before donation.

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 ...

Intestinal Conditioning After Cardiac Arrest: The Use of Normothermic Extracorporeal Membrane Oxygenation in the Non-Heart-Beating Animal Model.

The effect of normothermic extracorporeal membrane oxygenation (NECMO) on small bowel preservation in a clinically relevant large animal model of expected donation after cardiac death (eDCD) was evaluated. Thirty domestic crossbred donor pigs were divided into five groups. The first group served as the live donation (LD) group, the second group served as the donation after cardiac death (DCD) group, and the remaining were further assigned into three subgroups: E1 group (1 h NECMO support), E3 group (3 h NECMO support), and E5 group (5 h NECMO support). Pathology, electron microscopy, energy metabolism, cell apoptosis, and tight junction (TJ) protein expression level of intestinal mucosa and the level of plasma d-lactic acid were evaluated in normal, cardiac death and at the end of extracorporeal support, respectively. The mean arterial pressure and PaO2 were maintained over 60 and 267 mmHg during NECMO support, respectively. One hour of extracorporeal support could improve the energy status in intestines of the DCD group. Although the histologic damage and apoptosis of the E1 group had no significant difference with those of the LD and DCD groups (P > 0.05), the levels of intestinal mucosa TJ protein decreased (P < 0.05), and plasma d-lactic acid increased progressively (P < 0.05). With the extension of extracorporeal support, the degree of intestinal mucosa damage and intestinal permeability gradually increased, as well as the content of adenosine triphosphate in intestinal mucosa. The normothermic extracorporeal support for 1 h in DCD is beneficial for improving the energy status and viability of the bowel. However, the integrity of intestinal mucosa was destroyed gradually as extracorporeal support time went by. And the activation of intestinal epithelial apoptosis and hyperoxia might be the factors that lead to intestinal mucosa injury.