Multiorgan Harvesting Research Articles

En bloc Kidney Transplant – A Surgical Illustration and Clinical Experience from a Tertiary Care Hospital in South India

There is a global shortage of transplantable organs, especially in a resource-limited country like India. Deceased pediatric donors provide an excellent opportunity to expand the donor pool. Herein, we report a rare case of multi-organ harvesting from a 3-year-old brain-dead donor, where both the kidneys were transplanted en bloc to an adult male recipient and the liver to a 4-year-old male child. This case report provides the surgical steps and our experience.

Surgical aspects of multi-organ harvesting for transplantation

The aim of multi-organ harvesting is to remove and condition organs so that they can be transplanted. It is an extremely well codified surgical procedure, performed in a precise order. It is unique in that it involves different teams, each with its own specialization.

The changing landscape in nephrology education in India.

Digital tools have revolutionized education in nephrology in India. All forms of in-person learning are moving online. Social media have taken over the world, with clinicians learning and promoting multidirectional education methods. E-learning is better equipped to keep up with the rapid pace of new knowledge generation and dissemination. The use of digital multimedia tools to enhance rapid learning is backed by science, viz., dual-coding theory. Digital tools such as Twitter, blogs, podcasts, YouTube, and Nephrology Simulator (NephSIM) have had an impact in facilitating nephrology education among medical professionals and the general public. Digital tools, such as NephMadness, have resulted in the gamification of nephrology learning. Social media usage by the nephrology community in India is growing at a rapid pace. Everyday Cases in Nephrology (#ECNeph), a monthly Twitter-based discussion focused on academically challenging clinical cases, has its origins in India. The Women in Nephrology, India (WIN-India) initiative is very active in facilitating digital education in India and has, in a short space of time, created phenomenal momentum. Furthermore, non-governmental organizations in India, such as the Kidney Warriors Foundation and the Multi Organ Harvesting Aid Network (MOHAN) Foundation, have successfully tapped into social media to educate and aid kidney disease patients. All technologies come with some drawbacks. Despite their acceptance and validation, digital tools have their own pitfalls. These relate to (1) accessibility and connectivity, (2) accuracy of the scientific information, (3) social media noise, and (4) patient privacy. All pitfalls of digital education can be addressed by avoiding excessive social media overload and adopting an appropriate peer-review process. It is advisable to seek written consent from patients whenever patient data are posted online, to avoid privacy issues.

Heart transplantation in India-looking back as we celebrate 25years of the transplant law.

India's heart transplantation programme is the number one programme in South Asia with an average hearttransplantation rate of 0.2 per million population (pmp) versus the global average of 1.06pmp (2016-2018). The deceased donation rate was 0.67pmp in India in 2018. The law which made it possible has completed 25years. In the first 5years, after the law was passed, less than 50 hearts had been transplanted. The foundation for the deceased donation programme was laid through the creation of an 'Organ Sharing Network' in the year 2000 by Multi Organ Harvesting Aid Network (MOHAN) Foundation, a non-governmental organisation in Chennai. The role of the Health Department of Tamil Nadu in streamlining the deceased donation process in 2008-2009 changed the course of the programme. The heart transplantation programme evolved due to a handful of committed hospitals from the private sector. The challenge was in the identification and certification of brain death, and this continues to be the main reason for the low donation rate. The referral government hospitals, which usually receive traumatic head injuries that result in brain death, seldom possess the infrastructure or financial autonomy to start a transplant programme. Hence, expensive transplants like heart and liver have catered to the needs of the economically affordable class mostly. To improve the donation rate will require innovative thinking by taking steps such as strengthening the national programme and creating cross-subsidy formulas in organ sharing so that the less affordable too have access to such surgeries. To showcase the success of the programme, it is also imperative to start a heart transplant outcome registry to study the short- and long-term outcomes.

Memorandum of Understanding between NHSBT, UK and Multi Organ Harvesting Aid Network Foundation, Chennai, India

Memorandum of Understanding between NHSBT, UK and Multi Organ Harvesting Aid Network Foundation, Chennai, India

Retro-peritoneal cooling for kidney preservation from multi-organ cadaver donors

BackgroundMinimizing ischemia is paramount in the procurement of kidneys for transplantation. A fast cooling and expeditious removal is ideal to minimize damage from warm ischemia, however, since the removal of kidneys is delayed in cadaver donation until all other organs are harvested, the risk of kidney damage increases due to contact with the warmer soft body tissues. Surgical techniques that expedite organ retrieval were developed to avoid organ damage. MethodsWe test a modification of Thomas Starzl's improved technique for multi-organ harvesting by interposing an ice bag between the posterior aspect of the kidney and the psoas muscle in a randomized trial with 21 multi-organ cadaver donors. ResultsThe modified technique decreases the extraction temperature of the kidneys significantly in comparison with the controls, p < .001. ConclusionsThis simple technique improves the preservation of kidneys from cadaver donors, and can potentially have more impact on multi-organ donation after cardiac death.

Road map to organ donation in Tamil Nadu: an excellent model for India.

Road map to organ donation in Tamil Nadu: an excellent model for India.

Intrapancreatic Common Hepatic Artery Arising From the Superior Mesenteric Artery, a Challenging Anatomic Variation in a Multiorgan Harvesting

IntroductionUnderstanding abdominal vascular anatomy is crucial for multiorgan recovery. In this case report, we have described a common hepatic artery that arises from the superior mesenteric artery but follows an intrapancreatic course. MethodsThe donor was ideal for multiorgan recovery and the recipient was a 29-year-old woman awaiting a second transplant owing to primary nonfunction of her first engrafted organ. The indication for transplantation was secondary biliary cirrhosis. A type I diabetic recipient on dialysis therapy was awaiting the kidney and pancreas. ResultsThe urgent condition of our liver recipient combined with the anatomical finding prioritized liver procurement, therefore the pancreas was discarded. ConclusionsThe recognition of all anatomic variations will allow us to improve the use of the scarce resource of deceased donor organs.

2C1-4 脳死ドナー多臓器摘出手術の教育アニメーション制作

2C1-4 脳死ドナー多臓器摘出手術の教育アニメーション制作

Cryopreserved Semilunar Heart Valve Allografts: Leaflet Surface Damage in Scanning Electron Microscopy

Allograft heart valves (AHV), biological valves of human origin, offer potential advantages over conventional xenografts in terms of superior hemodynamics and, perhaps, better durability. The most important factors for long-term AHV clinical performance are the processing and cryopreservation methods. The aim of this study was to evaluate the impact of current processing protocol on valve tissue morphology, mainly to address the effect of successive processing steps on the leaflet surface structure. For the detection of fine changes in endothelial covering and underlying layers, our own modification of the scanning electron microscopy (SEM) technique was utilized. The study was based on an investigation of 20 AHV (40 specimens). Fourteen valves came from heart-beating donors (multiorgan harvesting) when the heart could not be transplanted for any reason (donor criteria, availability of recipient and/or logistics). Six were obtained at the time of routine postmortems--non heart-beating donors (NHBD). All specimens were initially fixed in Baker's solution. Tissue samples were dissected, dried with hexamethyldisilazane (HMDS), gold-coated, studied and photographed by SEM (Tesla BS 301). In order to define the integrity of the endothelium, subendothelial layers and the quality of the surface under SEM, a special six-level score system was introduced: 1-intact endothelium, 2-confluent endothelium with structural inhomogeneity, 3-disruption of intercellular contacts, 4-separation of endothelial cells, 5-complete loss of endothelium, 6-damage of subendothelial layers). AHV samples were divided into 4 groups for comparison. One aortic AHV "fresh" control sample obtained from a heart-beating donor was evaluated without any processing and was compared with (i) tissue from AHV obtained from NHBD with warm ischemia of 12 and 48 hours, (ii) samples stored at +4 degrees C in saline for 24 h, (iii) antibiotic-treated tissue for 24 h at 37 degrees C and finally with (iv) cryopreserved valves stored in liquid nitrogen (-196 degrees C) for 6-38 months. Our alternative for drying samples by the HMDS method proved to be suitable for thin membranes of human semilunar valves. We were able to detect early changes in the endothelium after harvesting and denudation of the endothelial covering during preservation with and without freezing. The surface of the AHV samples revealed the typical features and score system determined endothelial cell damage. Control "fresh" sample: score 2, (i) NHBD samples with warm ischemia of 12 h: score 3-4, with warm ischemia of 48 h: score 4-5, (ii) samples stored at +4 degrees C in saline for 48 h: score 5-6, (iii) antibiotic-treated tissue for 24 h at 37 degrees C: score 5, (iv) cryopreserved valves stored in liquid nitrogen for 6-38 months: score 5-6. SEM (using HMDS drying) together with other methods may be helpful for the morphological control of processing, cryopreservation and liquid nitrogen storage of AHV. Severe AHV leaflet endothelial destruction was proven on AHV grafts. These changes arose already in the initial steps of tissue processing, just after the donor heart harvesting and then at the time of antibiotic valve graft treatment. These results are considered as the starting point for the development of a better preservation protocol.

Organ Donation and Transplantation—The Chennai Experience in India

Tamil Nadu has been at the forefront of medical care in the country. It was the first state in the country that started a living kidney transplant program. It is also the first state to successfully start the cadaver programme after the passing of the “Transplantation of Human Organ Act” of 1994 and in the last 5 years has formed a network between hospitals for organ sharing. From the year 2000 to 2006 an organ sharing network was started in Tamil Nadu and the facilitator of this programme has been a non-government organization called MOHAN (acronym for Multi Organ Harvesting Aid Network) Foundation. The organs shared during the period number over 460 organs in two regions (both Tamil Nadu and Hyderabad). In Tamil Nadu the shared organs have included 166 Kidneys, 24 livers, 6 hearts, and 180 eyes. In 2003 sharing network was initiated by MOHAN in Hyderabad and to some extent the Tamil Nadu model was duplicated. with some success and 96 cadaver organs have been transplanted in the last 3 years. There are many advantages of organ sharing including the cost economics. At present there is a large pool of brain dead patients who could become potential organ donors in the major cities in India. Their organs are not being utilized for various support logistics. A multi-pronged strategy is required for the long term success of this program. These years in Tamil Nadu have been the years of learning, un-learning and relearning and the program today has matured slowly into what can perhaps be evolved as an Indian model. In all these years there have been various difficulties in its implementation and some of the key elements for the success of the program is the need to educate our own medical fraternity and seek their cooperation. The program requires trained counselors to be able to work in the intensive cares. The government’s support is pivotal if this program to provide benefit to the common man. MOHAN Foundation has accumulated considerable experience to be able to evolve a model to take this program to the national level and more so as it recently has been granted 100% tax exemption on all donations to form a countrywide network for organ sharing.

A Solution to Organ Shortage: Vascular Reconstructions for Pancreas Transplantation

Multiorgan harvesting (MOH) accounts for approximately 40% of all organ procurements in Poland. Simultaneous procurement of the pancreas and liver necessitates division of the vessels supplying both organs. Therefore, reconstruction of the pancreas vasculature is mandatory for proper function of the transplanted organ. The aim of this study was to present various methods of vascular reconstruction to prepare the pancreas for transplantation. Between January 1999 and April 2005, among 42 whole pancreas transplantations, 35 came from MOH necessitating arterial reconstruction. In 32 cases, the splenic artery (SA) and superior mesenteric artery (SMA) were sewn into a single trunk using the common iliac arterial bifurcation. Occasionally, the iliac Y-graft was unsuitable for vascular reconstruction due to atherosclerosis or iatrogenic injury. Therefore, the SA was anastomosed to the side of the SMA in two cases. In one case we utilized the brachiocephalic trunk bifurcation. Portal vein elongation employed an external iliac vein procured from the donor in all 35 cases. Good perfusion was achieved in all transplanted pancreata. During the early follow-up period, two venous and one arterial thromboses were noted. No negative effects of pancreatic vessel reconstruction were observed in postoperative graft function. Reconstruction of the pancreas vasculature did not affect the long-term function of the allograft while significantly increasing the available donor organ pool.

Reply to the Editor

Reply to the Editor

Molecular changes occurring with aneurysm formation: Possible impact of sampling error

Molecular changes occurring with aneurysm formation: Possible impact of sampling error

P-glycoprotein expression influences the result of 99mTc-MIBI scintigraphy in tertiary hyperparathyroidism

Precise localization of parathyroid glands using 99mTc-labeled hexakis-2-methoxyisobutylisonitrile (99mTc-MIBI) scintigraphy could be affected by various biological factors. There is increasing evidence that radiotracer retention could be controlled by members of multidrug resistance (MDR) system, especially P-glycoprotein (P-gp). Since the role of P-gp in tertiary hyperparathyroidism (T-HPTH) scintigraphic studies is poorly recognized, the aim of the study was to compare the correlation between parathyroid P-gp expression and results of their scintigraphy in T-HPTH versus primary hyperparathyroidism (P-HPTH). P-HPTH (n = 19) and T-HPTH (n = 18) patients were subjected to 99mTc-MIBI scintigraphy followed by surgical treatment. The parathyroid glands were assessed in routine hematoxylin-eosin staining and P-gp expression was analyzed using immunohistochemistry. Parathyroids collected during cadaver donor multi-organ harvesting were used as a control. It has been found that P-HPTH-derived parathyroid glands with predominating adenoma morphology expressed less P-gp, as compared to P-gp-rich T-HPTH glands, mainly displaying nodular or diffused hyperplasia phenotype. This finding reversely correlated with results of 99mTc-MIBI scintigraphy. However, we did not observe any difference in P-gp expression nor scintigraphy result between nodular or diffused hyperplasia. Altogether, these data suggest that P-gp overexpression in T-HPTH could be responsible for decreased sensitivity of 99mTc-MIBI scintigraphy in those patients. Therefore, the recently proposed reduced neck exploration or limited parathyroid resection on the basis of scintigraphy could create the risk of persisted/recurrent hyperparathyroidism. However, this problem requires further study.

Persisted/recurrent hyperparathyroidism associated with development of multi-drug resistance phenotype and proliferation of parathyroid transplants.

The surgical treatment of secondary hyperparathyroidism (HPTH) requires sub-total excision of parathyroid glands or total excision with their autotransplantation. Although this approach has been considered as a safe method of treatment, in this report we describe persisted/recurrent HPTH after parathyroid transplantation. Due to parathormone (PTH) hypersecretion and uncontrolled proliferation, the parathyroid grafts were removed and used for generation of cell cultures, which further have been subjected to in vitro studies. As a control we used parathyroid tissue, obtained during multiorgan harvesting. We found increased proliferation and up-regulated PTH production by the graft-derived, but not control in vitro cultured cells. Moreover, due to decrease of in vivo radiotracer uptake by parathyroid grafts, the expression of multi-drug resistance-involved factors, including P-glycoprotein (P-gp/mdr1), multi-drug resistance-associated protein (mrp) and bcl-2 have been investigated using RT-PCR. The analysis revealed increased expression of both, mdr1 and mrp in graft-derived cells, in contrast to control cells, which did not express P-gp/mdr1 or mrp. However, we did not observe any difference in expression of bcl-2 between analyzed cells. The up-regulated expression of P-gp/mdr1 on graft-derived cells was further confirmed by immunofluorescence studies. The described case indicates potential risk associated with transplantation of parathyroid tissue. Our results confirm a role of MDR phenomenon in occurrence of false negative results in parathyroid tissue scintigraphy studies. Moreover, they indicate that standard histological examination of transplanted material could not be sensitive enough to exclude any potential danger of abnormal graft progression. Thus, they could support the concept to use encapsulated parathyroid transplants.

A multicenter pilot prospective study comparing Celsior and University of Wisconsin preserving solutions for use in liver transplantation

Primary dysfunction (PDF) still occurs after orthotopic liver transplantation (OLT). Celsior solution (CS) might offer some advantages over the conventional University of Wisconsin (UW) solution for organ preservation, but to date, this has not been prospectively evaluated in the context of OLT. In this prospective, randomized, multicenter, pilot study, 215 potential liver donors were enrolled and randomized. In 42 cases, the livers were unsuitable for transplantation; therefore, 173 randomized livers ultimately were implanted after perfusion and cold preservation with CS (n = 83) or UW solution (n = 90). In accord with the indications of the CS manufacturing company, total CS infusion volume was 90 mL/kg, greater than that of UW solution (60 mL/kg). The main aim of the study is to compare the prevalence of PDF between the two groups. Donor and recipient variables were similar in the two groups. Episodes of PDF were numerically lower in the CS (2.4%) than UW group (7.8%), but the difference was not statistically significant. There was a trend toward a lesser need for early re-OLT (<30 days) in the CS group (P = .0507), but again, no statistically significant difference emerged. Overall and time-differentiated postoperative deaths also were similar. One-year actuarial patient (UW, 89% v CS, 87%) and graft (UW, 83% v CS, 85%) survival rates were similar. In conclusion, CS was similar to UW solution as a preservation solution in the clinical setting of OLT at the infusion volumes described, although some theoretical advantages of CS composition suggest that CS might prove a valid alternative to UW preservation solution in multiorgan harvesting, including the liver. A study on a larger patient basis is needed. (Liver Transpl 2003;9:814-821.)

Human Pancreas Preservation Prior to Islet Isolation

Islet transplantation has become a feasible treatment option for patients with type 1 diabetes mellitus after improvements regarding less diabetogenic immunosuppression and preparation of sufficient quantities of highly viable islets for transplantation. While the current techniques of multiorgan harvesting and transportation of organs to distant hospitals often result in 12 h or more of cold storage time before transplantation, University of Wisconsin (UW) solution has proven to be effective in pancreas preservation, leading to successful clinical whole pancreas transplantation, and human pancreatic grafts can be preserved by UW solution for periods exceeding 24 h. In the case of clinical islet transplantation, however, prolonged cold ischemia in UW solution before islet isolation significantly reduced recovery of viable islets, and it is still difficult to recover sufficient numbers of islets from a single cadaveric donor pancreas to achieve insulin independence after transplantation. Therefore, preservation of the pancreas has been an important factor in the subsequent success of clinical islet transplantation. We review pancreas preservation prior to islet isolation and discuss a two-layer (UW solution/perfluorochemical) cold storage method of the human pancreas as a potential method for pancreas rescue.

Multiorgan harvesting as a source of corneal grafts: single center experience

Multiorgan harvesting as a source of corneal grafts: single center experience

How local transplant coordinators might increase the number of potential donors: our experience in lower silesia

RENAL transplantation is the treatment of choice for end-stage diseases of the kidney, but it is limited by a shortage of organ donors. In the early 1990s, organ donations were in a state of crisis, and not only in Poland. National organ-sharing organizations and health services try to resolve this problem in various ways. Fortunately, some organizations, such as the Spanish one, have found a proper solution by developing a system of local transplant coordinators. Now we can speak of the “Spanish model” as one that is worth imitating. The first cadaveric renal transplantation in Poland occurred in 1965 in Wroclaw, the capital of Lower Silesia, and a regular kidney transplant program was begun in Wroclaw in 1983. It was limited by a small number of potential organ donors (PODs) reported to our Transplant Center (TC). Therefore, from 1983 to 1992 only 197 potential organ donors (mean 19.7/year) were reported to our TC from the Lower Silesia region, and only 87 harvesting procedures (mean 8.7/year) were performed during that time. A dramatic decrease in organ retrievals occurred between 1993 and 1996 (in 1993, 31 PODs were reported and 11 were harvested; in 1994, 24 PODs were reported and 5 were harvested; in 1995, 22 PODs were reported and 10 were retrieved; and in 1996, 23 were reported and 6 were retrieved), resulting in a small number of transplanted kidneys and therefore in a growing waiting list. Thus, in such situations we have tried to apply a modified “Spanish model” of organ donation in our region. Since the end of 1996, transplant coordinators have been situated in 31 local hospitals. Twice a year they have a special training session with psychologists in management of donors’ families. This has resulted in an increase of reported PODs in 1997 and 1998. In 1997, 40 PODs were reported to our TC from Lower Silesia and 28 organ retrievals were done. By the end of 1998, 43 PODs were reported to our TC and 28 harvesting procedures were performed (Fig 1). The multiorgan harvesting rate was 67.8% in 1997 and 57.1% in 1998. During that period we sent six livers to Germany and two livers to Austria. To increase the number of detected PODs, we developed a Donor Action program in two local hospitals in 1999.