Functional Warm Ischemia Time Research Articles

Thoracoabdominal Normothermic Regional Perfusion Using Mobile Closed Extracorporeal Circuit in Circulatory Death Determination Heart Donors.

Thoracoabdominal normothermic regional perfusion (TA-NRP) is increasingly implemented in donation after circulatory determination of death (DCD). Thoracoabdominal normothermic regional perfusion allows thoracic and abdominal organs to be perfused with warm, oxygenated blood after declaration of death, interrupting ischemia. Evidence is accumulating supporting the use of TA-NRP to improve the outcome of grafts from DCD donors. Thoracoabdominal normothermic regional perfusion may restore and maintain a near-physiological environment during procurement. Moreover, during TA-NRP it is feasible to evaluate the heart in situ. Thoracoabdominal normothermic regional perfusion could be performed through different cannulation techniques, central or peripheral, and, with different extracorporeal circuits. The use of conventional cardiopulmonary bypass and extracorporeal life support (ECLS) devices equipped with open circuits has been described. We report the use of a fully mobile, closed ECLS circuit to implement TA-NRP. The procedure was successfully performed in a peripheral center without a cardiac surgery program through a percutaneous cannulation approach. This strategy resulted in combined heart, liver, and kidney recovery despite a significantly prolonged functional warm ischemia time. The feasibility of TA-NRP using modified but still closed fully mobile ECLS circuits could furtherly support the expansion of DCD programs, increasing the availability of heart for transplantation, and the quality of the grafts, improving recipients' outcome.

Experiencia en DAC cardiaca en la Comunidad Valenciana: programa de extracción cardiaca extrahospitalaria

IntroductionIn Spain, since 2020, hearts obtained from donation after circulatory determination of death (DCD) have been used for heart transplants. We show our experience from the beginning of the heart DCDs program. An out-of-hospital cardiac extraction protocol has been implemented within the Valencian Community. Materials and methodFrom November 2022 to April 2024, 21 cardiac assessments have been performed in the context of DCD.Donor inclusion criteria: donor <55years old; family donation consent; functional warm ischemia time <30min.Donor exclusion criteria, additional to those of a cardiac donation: adrenaline infusion; dobutamine infusion; norepinephrine infusion >0,3μg/kg/min.This is a retrospective descriptive study. ResultsOf the 21 possible donors, 19 were valid hearts, 2 of them were for a hospital outside the community. The mean age of the donors was 40.4years, most of them men. In total, 17 patients were transplanted in our hospital. The mean cardiac ischemia time was 136.41min. Primary graft failure was described in 8 patients. ConclusionsThe cardiopulmonary bypass allowed continuous monitoring of aerobic and anaerobic metabolism, correct emptying of the cardiac chambers and the administration of cardioplegia with pressure, temperature and flow control.Our experience highlights the possibilities of success with hearts obtained from a DCD, representing an increase in the number of donors and a decrease in the waiting time for the transplant.

Impact of Warm Ischemia Time on Donation After Circulatory Death Kidney Transplant Outcomes.

Efforts to address the shortage of donor organs include increasing the use of renal allografts from donors after circulatory death (DCD). While warm ischemia time (WIT) is thought to be an important factor in DCD kidney evaluation, few studies have compared the relationship between WIT and DCD kidney outcomes, and WIT acceptance practices remain variable. We conducted a single-center retrospective review of all adult patients who underwent deceased donor kidney transplantation from 2000 to 2021. We evaluated the impact of varied functional warm ischemia time (fWIT) in controlled DCD donors by comparing donor and recipient characteristics and posttransplant outcomes between high fWIT (>60min), low fWIT (≤60min), and kidneys transplanted from donors after brain death (DBD). Two thousand eight hundred eleven patients were identified, 638 received low fWIT DCD, 93 received high fWIT DCD, and 2080 received DBD kidneys. There was no significant difference in 5-year graft survival between the DCD low fWIT, high fWIT, and DBD groups, with 84%, 83%, and 83% of grafts functioning, respectively. Five-year patient survival was 91% in the low fWIT group, 92% in the high fWIT group, and 90% in the DBD group. An increase in kidney donor risk index (KDRI) (HR 3.37, 95% CI=2.1-5.7) and high CIT compared to low CIT (HR 2.12, 95% CI=1.4-3.1) have higher hazard ratios for 1-year graft failure. Increased acceptance of kidneys from selected DCD donors with prolonged fWIT may present an opportunity to increase kidney utilization while preserving outcomes. Our group specifically prioritizes the use of kidneys from younger donors, with lower KDPI, and without acute kidney injury, or risk factors for underlying chronic kidney disease.

Normothermic regional perfusion in controlled DCD liver procurement: Outcomes of the Swedish national implementation protocol.

Liver transplantation (LTX) using donors after controlled circulatory death (cDCD) is associated with poorer graft survival and increased incidence of nonanastomotic biliary strictures (NASs) compared to livers procured from brain-dead donors (DBD). The use of normothermic regional perfusion (NRP) during cDCD procurement may improve posttransplant outcomes and reduce the incidence of NAS. In Sweden, cDCD LTX was introduced through a national pilot protocol with mandatory NRP. This study aims to evaluate the outcome of cDCD LTX during the pilot period. Donor and recipient data were collected on all cDCD liver transplants during the pilot period between January 2020 to December 2022. Outcome on NAS, patient and graft survival, early allograft dysfunction, acute kidney injury, and comprehensive complication index was compared to a matched cohort of 28 patients transplanted with a DBD liver between 2018 and 2022. Eighteen patients were transplanted with a liver from a cDCD donor after using NRP. The mean functional warm ischemia time was 29 ± 6 minutes. The mean lactate reduction during NRP was 8.7 ± 2.4mmol/L, and the end NRP perfusate alanine aminotransferase was 1.4 ± 1µkat/L. When comparing recipients of cDCD liver transplant to DBD, no significant differences were observed in the incidence of NAS, patient and graft survival, comprehensive complication index, early allograft dysfunction, or acute kidney injury. Study protocol magnetic resonance cholangiopancreatography in cDCD patients showed no signs of subclinical biliary strictures. Evaluation of the Swedish national pilot of cDCD LTX with mandatory NRP shows comparable outcomes to a matched DBD cohort with 94.4% 1-year patient and graft survival and no incidence of NAS within the first year.

Risk Factors for Adverse Outcomes in Kidney Transplants From Donors After Circulatory Death With Normothermic Regional Perfusion: A Systematic Analysis.

This study examined 1071 adult primary kidney transplants from the French-controlled donation after the circulatory determination of death (cDCD) program, which uses normothermic regional perfusion (NRP), and involves short cold ischemia times (CIT) and constrained asystole times differing by donor age. Logistic regression identified risk factors for primary nonfunction (PNF), delayed graft function (DGF), and graft failure. Risk factors for PNF included donor hypertension, admission for ischemic vascular stroke, and HLA DR mismatches. Risk factors for DGF included functional warm ischemia time >40 min, dialysis >2 y, recipient body mass index of 30 kg/m2 or higher, recipient diabetes, and CIT >10 h. Risk factors for 1-y graft failure included donor hypertension, donor lung recovery, ostial calcification, recipient cardiovascular comorbidities, and HLA DR mismatches. A high donor estimated glomerular filtration rate protected against DGF and graft failure at 1-y. After adjustment restricted to recipient and graft factors and donor age, the risks of PNF, DGF, and graft failure increased with donor age up to 65 y and then remained stable. The study suggests that cDCD kidney transplants are highly successful, but also that its outcomes are influenced by lung recovery, poor HLA DR matching, and warm ischemia times differing with donor age. Our study identified several risk factors for kidney transplantation failure after cDCD with systematic use of NRP and some of them seem as modifiable variables associated with cDCD transplant outcome.

Does Time to Asystole in Donors After Circulatory Death Impact Recipient Outcome in Liver Transplantation?

The agonal phase can vary following treatment withdrawal in donor after circulatory death (DCD). There is little evidence to support when procurement teams should stand down in relation to donor time to death (TTD). We assessed what impact TTD had on outcomes following DCD liver transplantation. Data were extracted from the UK Transplant Registry on DCD liver transplant recipients from 2006 to 2021. TTD was the time from withdrawal of life-sustaining treatment to asystole, and functional warm ischemia time was the time from donor systolic blood pressure and/or oxygen saturation falling below 50 mm Hg and 70%, respectively, to aortic perfusion. The primary endpoint was 1-y graft survival. Potential predictors were fitted into Cox proportional hazards models. Adjusted restricted cubic spline models were generated to further delineate the relationship between TTD and outcome. One thousand five hundred fifty-eight recipients of a DCD liver graft were included. Median TTD in the entire cohort was 13 min (interquartile range, 9-17 min). Restricted cubic splines revealed that the risk of graft loss was significantly greater when TTD ≤14 min. After 14 min, there was no impact on graft loss. Prolonged hepatectomy time was significantly associated with graft loss (hazard ratio, 1.87; 95% confidence interval, 1.23-2.83; P = 0.003); however, functional warm ischemia time had no impact (hazard ratio, 1.00; 95% confidence interval, 0.44-2.27; P > 0.9). A very short TTD was associated with increased risk of graft loss, possibly because of such donors being more unstable and/or experiencing brain stem death as well as circulatory death. Expanding the stand down times may increase the utilization of donor livers without significantly impairing graft outcome.

The Potential for Heart Donation After Death Determination by Circulatory Criteria in the Province of Québec

BackgroundHeart donation (HD) by those with death determination by circulatory criteria (DDCC) has been proposed as a method to increase the heart donor pool in response to the growing need for heart transplantation (HT). However, the potential level of HD after DDCC in the province of Québec has not yet been reported. This study aims to assess the suitability for HD among donors with DDCC, and to estimate its impact on HT activity. MethodsDonation records by those with DDCC in the province of Québec, from January 2016 to December 2020, were retrospectively reviewed for donor and predonation characteristics. Predetermined exclusion criteria were used to evaluate eligibility for HD. ResultsOf the 122 patients with DDCC who were included, 42 (34%) were identified as potentially-eligible heart donors. The median age of potentially-eligible donors was 52 years; 60% were female; and the most prevalent causes leading to organ donation in this group were medical aid in dying (26%), traumatic brain injury (26%), and anoxia (24%). A 19% increase (42 of 225) in potential HT activity was estimated using strict criteria. In only one case did functional warm ischemia time exceed the 30-minute limit. ConclusionsUsing those with DDCC as a new source of heart donors can significantly increase the volume of heart donation in the province of Québec. Implementing an HD program for those with DDCC in Québec may reduce waiting time and increase the number of heart recipients.

Outcomes of liver transplantation with thoracoabdominal normothermic regional perfusion: a matched-controlled initial experience in Spain.

Thoracoabdominal (TA) normothermic regional perfusion (NRP) should allow the safe recovery of heart and liver grafts simultaneously in the context of controlled donation after circulatory death (cDCD). We present the initial results of cDCD liver transplantation with simultaneous liver and heart procurement in Spain until October 2021. Outcomes were compared with a matched cohort of cDCD with abdominal NRP (A-NRP) from participating institutions. Primary endpoints comprised early allograft dysfunction (EAD) or primary non-function (PNF), and the development of ischemic-type biliary lesions (ITBL). Six transplants were performed using cDCD with TA-NRP during the study period. Donors were significantly younger in the TA-NRP group than in the A-NRP group (median 45.6 years and 62.9 years respectively, p = 0.011), with a median functional warm ischemia time of 12.5 min in the study group and 13 min in the control group. Patient characteristics, procurement times, and surgical baseline characteristics did not differ significantly between groups. No patient in the study group developed EAD or PNF, and over a median follow-up of 9.8 months, none developed ITBL or graft loss. Extending A-NRP to TA-NRP for cardiac procurement may be technically challenging, but it is both feasible and safe, showing comparable postoperative outcomes to A-NRP.

Impact of Ischemia and Preservation Times on Survival in Transplant Recipients From After Circulatory Death Donors

The limitation of ischemia times, which damages the organs and impacts transplant outcomes, is a drawback of controlled donation after circulatory death. The aim of the study was to analyze the influence of preservation and ischemia times on overall survival and both censured graft survival and overall graft survival. This was an observational and retrospective study of patients undergoing liver transplantation with grafts from controlled donation after circulatory death between November 2013 and November 2022. Sixty-five patients were included in the study. Twenty percent (12 patients) developed early graft dysfunction according to Olthoff's classification, and 7 patients (11.6%) scored ≥7 points according to the Model for Early Allograft Function Scoring scale. Five patients (7.6%) met the criteria for primary graft failure. The retransplantation rate was 9.2% (6 cases). Fifty patients (76.9%) remained alive, and 15 patients (23.1%) died. When analyzing overall survival based on the main preservation and ischemia times, we observed that the best results occurred in the group with a functional warm ischemia time <12 minutes, with a survival rate at 1, 3, and 5 years of 95.8%, 87.1%, and 87.1%, respectively (P=.043). Regarding the analysis of censured graft survival based on the main preservation and ischemia times, we found that the worst results occurred in the group with a cold ischemia time ≥6 hours, with a survival rate of around 48% at 3 and 5 years (P=.047). High-risk patients have lower overall and graft survival in the short and long term in grafts from controlled donation after circulatory death.

213.6: Expanding the boundaries of functional warm ischemia time (fWIT): successful kidney transplantation using normothermic machine perfusion (nmp) of a discarded kidney from uncontrolled circulatory determination of death donor.

213.6: Expanding the boundaries of functional warm ischemia time (fWIT): successful kidney transplantation using normothermic machine perfusion (nmp) of a discarded kidney from uncontrolled circulatory determination of death donor.

Evaluation of Functional Warm Ischemia Time during Controlled Donation after Circulatory Determination of Death using Normothermic Regional Perfusion (ECMO-TT): a prospective multicenter cohort study.

Controlled donation after circulatory determination of death (cDCD) seems an effective way to mitigate the critical shortage of available organs for transplant worldwide. As a recently developed procedure for organ retrieval, some questions remain unsolved such as the uncertainty regarding the effect of functional warm ischemia time (FWIT) on organs´ viability. We developed a multicenter prospective cohort study collecting all data from evaluated organs during cDCD from 2017 to 2020. All the procedures related to cDCD were performed with normothermic regional perfusion. The analysis included organ retrieval as endpoint and FWIT as exposure of interest. The effect of FWIT on the likelihood for organ retrieval was evaluated with Relative distribution analysis. A total amount of 507 organs´ related information was analyzed from 95 organ donors. Median donor age was 62 years, and 63% of donors were male. Stroke was the most common diagnosis before withdrawal life sustaining therapy (61 %), followed by anoxic encephalopathy (21 %). This analysis showed that length of FWIT was inversely associated with organ retrieval rates for liver, kidneys, and pancreas. No statistically significant association was found for lungs. Results showed an inverse association between functional warm ischemia time (FWIT) and retrieval rate. We also have postulated optimal FWIT's thresholds for organ retrieval. FWIT for liver retrieval remained between 6 and less than 11 min and in case of kidneys and pancreas, the optimal FWIT for retrieval was 6 to 12 min. These results could be valuable to improve organ utilization and for future analysis.

In situ normothermic regional perfusion versus ex situ normothermic machine perfusion in liver transplantation from donation after circulatory death.

In situ normothermic regional perfusion (NRP) and ex situ normothermic machine perfusion (NMP) aim to improve the outcomes of liver transplantation (LT) using controlled donation after circulatory death (cDCD). NRP and NMP have not yet been compared directly. In this international observational study, outcomes of LT performed between 2015 and 2019 for organs procured from cDCD donors subjected to NRP or NMP commenced at the donor center were compared using propensity score matching (PSM). Of the 224 cDCD donations in the NRP cohort that proceeded to asystole, 193 livers were procured, resulting in 157 transplants. In the NMP cohort, perfusion was commenced in all 40 cases and resulted in 34 transplants (use rates: 70% vs. 85% [p=0.052], respectively). After PSM, 34 NMP liver recipients were matched with 68 NRP liver recipients. The two cohorts were similar for donor functional warm ischemia time (21 min after NRP vs. 20 min after NMP; p=0.17), UK-Donation After Circulatory Death risk score (5 vs. 5 points; p=0.38), and laboratory Model for End-Stage Liver Disease scores (12 vs. 12 points; p=0.83). The incidence of nonanastomotic biliary strictures (1.5% vs. 2.9%; p > 0.99), early allograft dysfunction (20.6% vs. 8.8%; p=0.13), and 30-day graft loss (4.4% vs. 8.8%; p=0.40) were similar, although peak posttransplant aspartate aminotransferase levels were higher in the NRP cohort (872 vs. 344 IU/L; p < 0.001). NRP livers were more frequently allocated to recipients suffering from hepatocellular carcinoma (HCC; 60.3% vs. 20.6%; p < 0.001). HCC-censored 2-year graft and patient survival rates were 91.5% versus 88.2% (p=0.52) and 97.9% versus 94.1% (p=0.25) after NRP and NMP, respectively. Both perfusion techniques achieved similar outcomes and appeared to match benchmarks expected for donation after brain death livers. This study may inform the design of a definitive trial.

Heart Transplantation Utilizing Organs Following Donation After Circulatory Death (DCD)

<h3>Purpose</h3> Donation after circulatory death (DCD) is gaining momentum for heart transplantation worldwide. Central to the process is a detailed assessment of the donor heart following the circulatory arrest and unpredictable warm ischemia time. Our team used the Organ Care System as the principal means of assessment and preservation of the DCD hearts. Here we describe our single centre experience with DCD heart transplantation. <h3>Methods</h3> Between 2015 and 2021, 36 donor hearts were procured via the DCD pathway. Donor management involved the withdrawal of treatment (WoT) in the donor, stand-down time of 5 minutes following circulatory arrest (asystole), transfer of the patient to the operating theatre, collection of 1.2L donor blood from right atrium for Organ Care System (OCS) prime, delivery of cardioplegia and its procurement. The organs were assessed utilizing OCS and 25 suitable hearts that met the criteria of suitability were transplanted. <h3>Results</h3> The mean age of donors was 30.6±10.7 years (12% females) with intracranial haemorrhage and hypoxic brain damage as main causes of WoT. 52% of the donors suffered cardiac arrest before hospital admission, 25% had a history of cocaine abuse and 48% were current smokers. Mean WoT to asystole time was 11.8±4.1 min, mean WoT to cardioplegia time was 23.1±4.6 min and a mean functional warm ischemia time was 16.3±3.5 min. The mean OCS perfusion time was 245 ±81min.The mean recipient age was 42.6±13.2 years (12% females) with dilated (64%) and ischemic (24%) cardiomyopathy as an aetiology of heart failure in the majority. 6 (24%) patients had long term LVAD while 2(8%) were supported on short-term mechanical support per-operatively.9 (36%) patients required mechanical circulatory support postoperatively with ECMO and IABP and 20 (80%) required continuous renal replacement therapy. The mean ICU stay was 17.8±16.5 days and the mean hospital stay was 45±40 days. Postoperative survival at 30-days was 88%. <h3>Conclusion</h3> Donor hearts procured following donation after circulatory death were transplanted with acceptable short-term survival especially given the high proportion of preoperative mechanical circulatory support and urgency of transplantation in our cohort. ‘Direct procurement and perfusion' method of procurement in DCD offers an opportunity to assess the donor heart for the suitability of transplantation.

Is donation after circulatory determination of death feasible for pediatric patients in italy?

To determine the potential effect of a donation after cardiac death active program on the number of organ donors in a Italian Pediatric Intensive Care Unit (PICU). We conducted a retrospective study of all deaths in PICU of an academic Children Hospital between 2012 and 2020, tracing the organ donation activity. Patients were categorized as brain deaths, deaths despite maximal resuscitation, and deaths after withdrawal or limitation of life support. Patient demographics, premortem physiology, end-of-life circumstances, and functional warm ischemia time were recorded. Eligible donors after cardiac death were identified by the absence of medical contraindication and functional warm ischemia time <60 minutes. Of 124 deaths that occurred during the study period, 34 met criteria for brain death, 23 were potential donors, and 13 became actual donors. Of the remaining 90 patients that met criteria for cardiac death, 66 died despite maximal resuscitation, 24 died after withdrawal or limitation of care and between them 13 were identified as theoretically eligible DCD donors. Of these, 5 patients had a functional warm ischemia time of <1 hour and were potential candidates for DCD of 10 kidneys and 2 lungs. Even if few children could have been eligible for DCD in the study period, an active program could have been able to increase the number of potential organ donors by 20% in the last eight years at our institution. DCD deserves to be explored in Italy as a new option for children.

The first donation after circulatory death following withdrawal of life-sustaining treatment in Korea

Background: We would like to report the first case of successful organ donation after withdrawal of life-sustaining treatment (WLST) in Korea. Methods: A 52-year-old male patient who had cerebral hemorrhage was the potential brain-dead donor. After passing the first brain death examination, according to the recommendation of a neurologist, electroencephalograms (EEG) were performed 5 times at intervals of 2 to 3 days and they did not show flat EEGs. Since the family members’ willingness to donate organs was very strong, they agreed to donation after circulatory death (DCD) after WLST in the operating room (OR) without them. The pa tient was transferred to the OR at 7:30 PM on July 3, 2020. Surgical drape was done for the donor. At 8:00 PM, an intensivist in charge of the patient performed extubation and stopping the vasopressors at the same time. In 1 minute, oxygen saturation (SpO2) fell below 70%, which meant functional warm ischemia time began. At 8:15 PM, asystole was confirmed, and after a 5-minute “no touch time”, declaration of circulatory death was done by the intensivist at 8:20 PM. Afterwards, all recipient surgeons who were waiting with surgical gown at the next OR moved to the donor’s OR and performed organ procurement surgery. Results: Aortic clamp and HTK fluid perfusion started at 8:22 PM, 2 minutes after the incision started. Liver was out at 8:56 PM and kidney was out at 9:11 PM. Organs quality were good and they were donated well to the recipients. Conclusions: Since this case started with donation after brain-death, it is strictly categorized as DCD IV. In DCD IV, if the life-sus taining treatment is stopped due to unsuccessful brain death determination, it becomes DCD III process. All potential recipients were already arranged through KONOS. We can actively perform DCD after WLST in Korea with the set-up of laws and systems for DCD.

Sequential Use of Normothermic Regional and Ex Situ Machine Perfusion in Donation After Circulatory Death Liver Transplant.

In Italy, 20minutes of a continuous flat line on an electrocardiogram are required for declaration of death. In the setting of donation after circulatory death (DCD), prolonged warm ischemia time prompted the introduction of abdominal normothermic regional perfusion (NRP) followed by postprocurement ex situ machine perfusion (MP). This is a retrospective review of DCD liver transplantations (LTs) performed at 2 centers using sequential NRP and ex situ MP. From January 2018 to April 2019, 34 DCD donors were evaluated. Three (8.8%) were discarded before NRP, and 11 (32.4%) were discarded based on NRP parameters (n=1, 3.0%), liver macroscopic appearance at procurement and/or biopsy results (n=9, 26.5%), or severe macroangiopathy at back-table evaluation (n=1, 3.0%). A total of 20 grafts (58.8%; 11 uncontrolled DCDs, 9 controlled DCDs) were considered eligible for LT, procured and perfused ex situ (9 normothermic and 11 dual hypothermic MPs). In total, 18 (52.9%; 11 uncontrolled) livers were eventually transplanted. Median (interquartile range) no-flow time was 32.5 (30-39) minutes, whereas median functional warm ischemia time was 52.5 (47-74) minutes (controlled DCD), and median low-flow time was 112 minutes (105-129 minutes; uncontrolled DCD). There was no primary nonfunction, while postreperfusion syndrome occurred in 8 (44%) recipients. Early allograft dysfunction happened in 5 (28%) patients, while acute kidney injury occurred in 5 (28%). After a median follow-up of 15.1 (9.5-22.3) months, 1 case of ischemic-type biliary lesions and 1 patient death were reported. DCD LT is feasible even with the 20-minute no-touch rule. Strict NRP and ex situ MP selection criteria are needed to optimize postoperative results.

Kidney Transplant From Uncontrolled Donation After Circulatory Death: Contribution of Normothermic Regional Perfusion.

The French uncontrolled donors after circulatory death (DCD) protocol restricts donor age to <55 years, no-flow time to <30 minutes, and functional warm ischemia time to <150 minutes. In situ kidney perfusion can be performed at either 4°C (in situ cooling [ISC]) or 33-36°C (normothermic regional perfusion [NRP]). Hypothermic machine perfusion is systematically used. Only nonimmunized first transplant recipients were eligible. To improve the management of uncontrolled DCD, we tried to identify factors predictive of outcome. We identified all kidney transplants from uncontrolled DCD between 2007 and 2014 from the French Transplant Registry. Risk factors for primary nonfunction (PNF; n = 37) and poor renal function (estimated glomerular filtration rate < 30 mL/min or graft loss at 1 y, n = 66) were analyzed by using a multivariate logistic model. This study analyzed 499 kidney transplantations, 50% of which were performed with NRP. Mean functional warm ischemia time was 135 minutes. Mean cold ischemia time was 14 hours. The principal PNF risk factor was young donor age (odds ratio [OR] = 0.95; P = 0.002). A sensitivity analysis showed a higher risk of PNF with ISC than with NRP (OR = 4.5; P = 0.015). Risk factors for poor renal function were donor body mass index (OR = 1.2; P < 0.001) and ISC versus NRP. Univariate analysis of uncontrolled DCD-specific risk factors showed no-flow time, functional warm time, and cold ischemia time did not affect the risk of PNF or poor renal function. Uncontrolled DCD kidneys are an additional source of valuable transplants. NRP appears to decrease graft failure by restoring oxygenated blood as the first step of preconditioning.

University of Modena Experience With Liver Grafts From Donation After Circulatory Death: What Really Matters in Organ Selection?

IntroductionThe use of grafts from donation after circulatory death (DCD) is an important additional source to implement within the donor pool. We herein report the outcomes of our early experience with DCD grafts for liver transplantation (LT). MethodsTen patients successfully underwent LT with grafts from DCD donors between August 2017 and January 2019 at the Hepato-Pancreato-Biliary Surgery and Liver Transplant Unit of University of Modena and Reggio Emilia. All donors underwent normothermic regional perfusion after death declaration and, after the procurement, all the suitable grafts underwent ex situ hypothermic perfusion prior to transplantation. ResultsMean postoperative hospital stay after transplant was 12.7 days (range, 5-26), and in 5 cases we placed a biliary drainage (Kehr tube) during surgery. Primary graft nonfunction did not occur after LT in this cohort, although, we registered one case of biliary anastomosis stricture that was managed endoscopically by endoscopic retrograde cholangiopancreatography. All patients are alive and none required retransplantation. ConclusionsIn our experience with controlled DCD donors, the demonstration of: (1) a negative trend of lactate during normothermic regional perfusion; (2) an aspartate aminotransferase and alanine aminotransferase level lower than 2000 mU/dL; and (3) less than 1 hour of functional warm ischemia time along with no signs of microscopic or macroscopic ischemia of the grafts, are related to positive outcomes in the first year after transplant. A DCD risk score based on Italian population characteristics and regulations on death observation may improve donor-recipient match and avoid futile transplants.

Expanding the Donor Pool With the Use of Extended Criteria Donation After Circulatory Death Livers.

Use of donation after circulatory death (DCD) donor livers for transplantation has remained cautious in the United States. The aim of this study was to demonstrate the expansion of a DCD liver transplantation (LT) program with the use of extended criteria donor (ECD) DCD livers. After institutional review board approval, 135 consecutive DCD LTs were retrospectively studied. ECD DCD livers were defined as those with 1 of the following factors: donor age >50 years, donor body mass index >35 kg/m2 , donor functional warm ischemia time >30 minutes, and donor liver macrosteatosis >30%. An optimization protocol was introduced in July 2011 to improve outcomes of DCD LT, which included thrombolytic donor flush and efforts to minimize ischemia times. The impact of this protocol on outcomes was evaluated in terms of graft loss, ischemic cholangiopathy (IC), and change in DCD LT volume. Of 135 consecutive DCD LTs, 62 were ECD DCDs. In total, 24 ECD DCD LTs were performed before (era 1) and 38 after the institution of optimization protocol (era 2), accounting for an increase in the use of ECD DCD livers from 39% to 52%. Overall outcomes of ECD DCD LT improved in era 2, with a significantly lower incidence of IC (5% versus 17% in era 1; P=0.03) and better 1-year graft survival (93% versus 75% in era 1; P=0.07). Survival outcomes for ECD DCD LT in era 2 were comparable to matched deceased donor LT. With the expansion of the DCD donor pool, the number of DCD LTs performed at our center gradually increased in era 2 to account for >20% of the center's LT volume. In conclusion, with the optimization of perioperative conditions, ECD DCD livers can be successfully transplanted to expand the donor pool for LT.

Can we reduce ischemic cholangiopathy rates in donation after cardiac death liver transplantation after 10 years of practice? Canadian single-centre experience

Outcomes in liver transplantation with organs obtained via donation after cardiocirculatory death (DCD) have been suboptimal compared to donation after brain death, attributed mainly to the high incidence of ischemic cholangiopathy (IC). We evaluated the effect of a 10-year learning curve on IC rates among DCD liver graft recipients at a single centre. We analyzed all DCD liver transplantation procedures from July 2006 to July 2016. Patients were grouped into early (July 2006 to June 2011) and late (July 2011 to July 2016) eras. Those with less than 6months of follow-up were excluded. Primary outcomes were IC incidence and IC-free survival rate. Among the 73DCD liver transplantation procedures performed, 70recipients fulfilled the selection criteria, 32 in the early era and 38 in the late era. Biliary complications were diagnosed in 19 recipients (27%). Ischemic cholangiopathy was observed in 8patients (25%) in the early era and 1patient (3%) in the late era (p= 0.005). The IC-free survival rate was higher in the late era than the early era (98% v. 79%, p= 0.01). The warm ischemia time (27 v. 24min, p= 0.049) and functional warm ischemia time (21 v. 17min, p= 0.002) were significantly lower in the late era than the early era. We found a significant reduction in IC rates and improvement in ICfree survival among DCD liver transplantation recipients after a learning curve period that was marked by more judicious donor selection with shorter procurement times.