Functional Warm Ischemia Time Research Articles

Preliminary experience of sequential use of normothermic and hypothermic oxygenated perfusion for donation after circulatory death kidney with warm ischemia time over the conventional criteria - a retrospective and observational study.

Donation after circulatory death (DCD) is a potential source of reducing organ demand. In Italy, DCD requires a 20-min no-touch period that prolongs warm ischemia and increases delayed graft function (DGF) risk and graft loss. We report here our preliminary experience of sequential use of normothermic regional perfusion (NRP), as standard procedure, and hypothermic oxygenated perfusion (HOPE), as an experimental technique of organ preservation, in 10 kidney transplants (KT) from five DCD Maastricht III with extensive functional warm ischemia time (fWIT) up to 325 min. During NRP, renal function tests were evaluated to accept organs which were retrieved according to standard fashion with biopsy. While waiting for pathology and cross-match results, organs were preserved with HOPE through pressure- and temperature-controlled arterial pulsatile flow. All grafts with Karpinski score ≤4 were used for conventional single KT with mean cold ischemia time of 584 ± 167 min and mean fWIT of 151 ± 132 min. At the end of HOPE, lactate levels increased significantly in all cases with DGF (P = 0.0095), which were 3/10 (30%). No primary nonfunctions were recorded, and all patients had sCr < 1.5 mg/dl at 6-month post-KT. NRP and HOPE for DCD may overcome fWIT limits safely, and lactate during HOPE predicts DGF.

Liver Transplant From Controlled Cardiac Death Donors Using Normothermic Regional Perfusion: Comparison With Liver Transplants From Brain Dead Donors

BackgroundLiver transplantation from donors after either controlled or uncontrolled cardiac death (DCD) is associated with considerable rates of primary nonfunction (PNF) and ischemic cholangiopathy (IC). Normothermic regional perfusion (NRP) could significantly reduce such rates. MethodsRetrospective study to analyze short-term (mortality, PNF, vascular complications) and long-term (IC, survival) complications in 11 liver transplants from controlled DCDs using NRP with extracorporeal membrane oxygenation (ECMO) (group 1). They were compared with 51 patients transplanted with grafts from donors after brain death (DBD) (group 2). Mean recipient age, sex, and Model for End-stage Liver Disease (MELD) score were not significantly different. ResultsIn group 1, mean functional warm ischemia time was 15.8 (range, 7–40) minutes and 94.1 (range, 20–150) minutes on NRP. The ischemic damage was minimal, as shown by the slight alanine aminotransferase (ALT) and aspartate aminotransferase (AST) rises in the donor serum after 1 hour on NRP and similar rises 24 hours after transplantation in both groups. No patient had IC or acute renal failure. No significant difference was found between the groups for vascular or biliary complications. One group 1 patient had PNF (9.1%), resulting in death. Overall retransplantation and in-hospital death rates were 8.1% and 4.8%, respectively, with no significant difference between groups. Estimated mean survival was 24.6 (95% confidence interval [CI], 20.2–29.1) months in group 1 and 32.3 (95% CI, 30.4–34.2) months in group 2 (not a statistically significant difference). ConclusionIn our experience, liver transplants from controlled DCDs using NRP with ECMO is associated with a low risk of PNF and IC, with short- and long-term results comparable to those in DBD transplants.

Prediction of potential for organ donation after circulatory death in neurocritical patients

The success or failure of donation after circulatory death depends largely on the functional warm ischemia time, which is closely related to the duration between withdrawal of life-sustaining treatment and circulatory arrest. However, a reliable predictive model for the duration is absent. We aimed to compare the performance of the Chinese Donation after Circulatory Death Nomogram (C-DCD-Nomogram) and 3 other tools in a cohort of potential donors. In this prospective, multicenter, observational study, data were obtained from 219 consecutive neurocritical patients in China. The patients were followed until circulatory death after withdrawal of life-sustaining treatment. The C-DCD-Nomogram performed well in predicting patient death within 30, 60, 120 and 240 minutes after withdrawal of life-sustaining treatment with c-statistics of 0.87, 0.88, 0.86 and 0.95, respectively. The DCD-N score was a poor predictor of death within 30, 60 and 240 minutes, with c-statistics of 0.63, 0.69 and 0.59, respectively, although it was able to predict patient death within 120 minutes, with a c-statistic of 0.73. Neither the University of Wisconsin DCD evaluation tool (UWDCD) nor the United Network for Organ Sharing (UNOS) criteria was able to predict patient death within 30, 60, 120 and 240 minutes after withdrawal of life-sustaining treatment (UWDCD tool: 0.48, 0.45, 0.49 and 0.57; UNOS criteria: 0.50, 0.53, 0.51 and 0.63). The C-DCD-Nomogram is superior to the other 3 tools for predicting death within a limited duration after withdrawal of life-sustaining treatment in Chinese neurocritical patients. Thus, it appears to be a reliable tool identifying potential donors after circulatory death.

Chinese Pediatric Organ Donation With Scheduled Cardiac Arrest After Brain Death: A Novel China Classification Beyond Maastricht

ObjectiveOrgan donation with scheduled cardiac arrest after brain death (s-DBCD) is a special category in China. This study was to evaluate the procedure of pediatric s-DBCD, graft quality, and clinical outcomes of single kidney transplantation. MethodsWe retrospectively analyzed the data of 8 Chinese pediatric donors. ResultsThe death causes of the donors (age 4–12 years) were cerebral hypoxia after cardiopulmonary resuscitation (n = 1), intracranial vascular malformation (n = 1), severe traumatic brain injury (n = 3), and brain malignancy (n = 3). The functional warm ischemia time of the grafts was 18 (13–26) minutes. Sixteen kidneys were recovered using liver-kidney en bloc procurement after in situ perfusion. All kidneys had a length >7 cm and were transplanted to 3 adolescent and 13 adult recipients. Two cases of delayed graft function occurred. The patients had a median serum creatinine level of 97 (55–123) μmol/L by the last visit. The median estimated glomerular filtration rate level was 85.4 (58–136) mL/min. Five episodes of biopsy-proven acute rejection occurred in 4 patients, which were reversed by methylprednisolone pulse therapy. Renal arterial stenosis was observed in 1 patient, which was cured by interventional balloon dilatation and stent implantation. ConclusionPediatric s-DBCD is feasible with acceptable graft quality. Single kidney transplantation with pediatric graft size >7 cm has good clinical outcomes.