Multiple Organ Retrieval Research Articles

Multiple organ retrieval in a brain dead left ventricular assist device donor.

Left ventricular assist device (LVAD) support in donors may contribute in preserving proper haemodynamics and systemic perfusion during organ retrieval thus decreasing the risk of multiple organ injury. This is an option to expand the current organ supply. We report on intra-abdominal organs procurement strategy in a selected LVAD recipient who suffered a fatal cerebrovascular accident at the time of COVID-19 pandemic outbreak. The liver and kidneys grafts have been successfully transplanted.

High-dose ulinastatin to prevent late-onset acute renal failure after orthotopic liver transplantation

Purpose To compare the efficacy and safety of two distinct doses of ulinastatin on late-onset acute renal failure (LARF) following orthotopic liver transplantation (OLT). Methods The high-risk recipients that underwent OLT were divided into two groups according to ulinastatin dose: low-dose (LD) ulinastatin group, 0.8 million U/d; high-dose (HD) ulinastatin group, 1.6 million U/d. The primary outcome was the incidence of LARF, which was defined the newly onset acute kidney injury (AKI) stage III (KDIGO, 2012) within 7–28 post-transplant days. The second outcomes were early multiple organ retrieval assessments, length of hospital stay and safety events. Results A total of 174 recipients were included (LD ulinastatin group, n = 55; HD ulinastatin group, n = 119). There was no significant difference in the incidence of LARF between LD (8/55, 14.50%) and HD (9/119, 7.56%) ulinastatin groups (HD vs. LD, HR, 0.49; 95%CI, 0.17–1.37; p = .1295). Multivariate Cox proportion risk regression model revealed HD ulinastatin (HR, 0.57; 95%CI, 0.38–0.98; p = .0464) was an independent protective factor for LARF. Early lactate level, oxygenation, AKI stage, graft function, and sequential organ failure assessment [SOFA] score were significantly improved in HD ulinastatin group versus LD ulinastatin group. No significant adverse events were observed in either group. Conclusions Higher dose of ulinastatin (1.6 million U/d) might be preferable to prevent LARF after OLT, and it may contribute to the enhancement of early multiple organ recovery and thus attenuate the incidence of LARF.

Obstacles of Non–heart-beating Donor Kidney Transplantation in Japan to Date and Future Perspectives

In Japan, multiple organ retrieval from brain-dead heart-beating donors has been gradually increasing since the law was adopted in 1997 and amended in 2009. However, almost more than 90% of total deceased donor kidney transplantation (DDKT) in Japan are still obtained from non–heart-beating donors (NHBD). The majority of NHBD are Maastricht categories IV and III. In category IV, we usually place a double balloon arterial and a venous drainage catheter via the femoral vessels after the diagnosis of clinical brain death and acquisition of informed consent from the family. After controlled cardiac arrest, the double balloons are inflated and in situ cold perfusion started as soon as possible to minimize warm ischemic time (WIT), seeking to achieve a zero to within a few minutes WIT in most cases. In category III, it is impossible to place the device prior to cardiac arrest. In these cases, after declaration of cardiac death, cardiopulmonary compression is accompanied by systemic heparinization, immediate laparotomy, and insertion of a cold perfusion catheter at the aortic and caval bifurcations to minimize WIT. NHBD kidney retrieval is critical; extirpation must be performed as rapidly as possible. The results of NHBD kidney transplantation in Japan are excellent, according to the advancement and utilization of in situ cannulation, organ perfusion, and sophisticated retrieval techniques. The patient and graft survival rates of DDKT at 1, 3, and 5 years in most recent 2001 to 2007 era were 95.4%, 92.2%, 89.1% (n = 945) and 89.2%, 83.7%, 77.8% (n = 919), respectively.

Fresh-stored osteochondral allografts for the treatment of femoral head defects: surgical technique and preliminary results

The purpose of this study was to present the preliminary clinical and radiographic outcomes of the treatment of femoral head osteochondral defects in eight consecutive symptomatic patients with fresh-stored osteochondral allografts via a trochanteric osteotomy. This study included all consecutive patients treated in our department between 2008 and 2010 for worsening pain and mechanical symptoms of femoral head osteochondral defects. Each patient had preoperative routine hip radiographs and a preoperative magnetic resonance imaging study that determined and recorded the defect size and femoral head diameters. Allograft donors were identified through the Multiple Organ Retrieval and Exchange program (Ontario, Canada). The osteochondral defects were secondary to osteochondritis dissecans in four patients, avascular necrosis in three and femoral head fracture without dislocation in one. The patients' average age at surgery was 23.7 (range 17-42), and the average follow-up was 41 months (range 24-54). Follow-up included clinical and radiographic examinations at standard intervals. The average Harris hip scores improved from 57.7 (range 50-65) points preoperatively to 83.9 (range 72-94) points at latest follow-up. Five patients had good-to-excellent clinical outcomes, and one had a fair outcome. One patient was converted to a total hip arthroplasty due to progression of arthritis. Another patient's graft subsided and he underwent a successful repeat transplantation. An additional patient required the removal of the screws transfixing her trochanter due to persistent irritation. These findings indicate that fresh-stored osteochondral allograft transplantation using a trochanteric slide and surgical dislocation is a viable treatment option for femoral head defects in young patients.

Split Technique in Horseshoe Kidney Transplantation

Background/Aims: Nowadays, owing to a greater number of patients waiting for a kidney donation and to a shortage of organs donated, more suitable organ acceptance criteria have been formulated. Horseshoe kidney transplantations have become feasible giving good allograft outcomes. The aim of this paper is to illustrate the split technique in horseshoe kidney transplantation and to report long-term results. Methods: During the period from February 2004 to February 2005, two horseshoe kidneys were harvested from multiple organ retrieval. The surgical features and outcomes of these 2 cases are described separately. Mean follow-up time was 12.3 months. Conclusions: Organs that were previously said to be marginal are being used more regularly and the more suitable selection does not exclude elderly donors with or without underlying diseases. Horseshoe kidney transplantation requires greater skills and experience of the surgeons compared to conventional kidney transplantation. This kind of renal abnormality has to be considered a feasible option for transplantation. Good long-term results are reported.

The development and evaluation of a fuzzy logic expert system for renal transplantation assignment: Is this a useful tool?

Allocating donor kidneys to patients is a complex, multicriteria decision-making problem which involves not only medical, but also ethical and political issues. In this paper, a fuzzy logic expert system approach was proposed as an innovative way to deal with the vagueness and complexity faced by medical doctors in kidney allocation decision making. A pilot fuzzy logic expert system for kidney allocation was developed and evaluated in comparison with two existing allocation algorithms: a priority sorting system used by multiple organ retrieval and exchange (MORE) in Canada and a point scoring systems used by united network for organ sharing (UNOS) in US. Our simulated experiment based on real data indicated that the fuzzy logic system can represent the expert's thinking well in handling complex tradeoffs, and overall, the fuzzy logic derived recommendations were more acceptable to the expert than those from the MORE and UNOS algorithms.

An internet-based fuzzy logic expert system for organ transplantation assignment

Organ transplantation is lifesaving. However, the demand for organs far exceeds supply. Due to the resource scarcity (i.e. organs), the special medical requirements for organ transplanting and the urgency in getting the organ to the recipient, it is critical to use information technology to coordinate the organ procurement and transplanting process and to allocate donated organs to recipients quickly, fairly and effectively. In this paper we analyse how information technology can be used to improve organ transplantation services and propose the use of an internet-based fuzzy logic expert system to assist physicians in solving the multi-criteria kidney allocation problem. A pilot fuzzy logic expert system for kidney allocation was developed and evaluated in comparison with two existing allocation algorithms a priority sorting system used by the Multiple Organ Retrieval and Exchange (MORE) program in Ontario, Canada and a point scoring systems used by the United Network for Organ Sharing (UNOS) in the USA. Our simulated experiment based on real patient data confirms that the fuzzy logic system can represent the expert's thinking in a satisfactory manner in handling complex trade-offs and overall, the fuzzy logic derived recommendations were more acceptable to the expert than those from the MORE and UNOS algorithms.

Patch and Flap Techniques to Repair Right Renal Vein Defects Caused by Cadaver Liver Retrieval for Transplantation

We describe 2 techniques that allow right renal vein extension and prevent renal vein stenosis if the cephalic portion of the renal vein has been amputated when the liver is separated from the kidneys during multiple organ retrieval. These techniques were successfully used in 8 cadaver kidney transplant recipients.

Development of a central matching system for the allocation of cadaveric kidneys: a simulation of clinical effectiveness versus equity.

1) To develop a computer-based simulation to prospectively study the impacts of explicitly incorporating different equity criteria into the process of allocating kidneys to recipients, given the scarcity of this resource. 2) To assess the tradeoffs between systems that allocate kidneys based only on medical criteria, systems that allocate kidneys based only on equity criteria, and systems that consider both medical and equity criteria. A computer-based simulation was developed that describes the flows of patients and kidneys. This model provides information at various time points about the number of patients in the system who are awaiting transplants, the number of kidneys available for transplantation, the number of transplantations performed for each matching algorithm, and the number of kidneys discarded (when applicable), as well as the means and standard deviations of the HLA-match scores, number of days from registration to transplantation, and number of days (from registration) of those who are still waiting for transplants. Five different matching algorithms were compared, ranging from determination of the allocation by a single medical criterion (i.e, HLA match) to determination by a single equity criterion (i.e., relative position in the waiting queue). The remaining algorithms represent different strategies of weighting these two considerations. Estimates regarding the main parameters of the model were derived utilizing data collected through the Multiple Organ Retrieval and Exchange Programme of Ontario, Canada. The simulation was set to run for a period of ten years. A tradeoff between graft survival (or improved HLA matching) and equal treatment of patients regardless of their likelihood to benefit was found. It is clear that an algorithm that allocates kidneys based only on temporal location of patient on the waiting list is likely to be unacceptable because of the very poor average HLA-match scores that it yields. Pool size was found to be a major determinant in the attainment of optimal matching from a medical perspective. 1) The final choice about any allocation algorithm to be used requires that a value judgment be made, i.e., how great a reduction in HLA-match score should be traded in order to improve equity score (or vice versa). 2) A computer-based simulation model is a feasible way to prospectively test the impact of any given allocation algorithm on any given system.

Analyzing the number of "rejection episodes" in renal transplant studies.

Transplantation has become the treatment of choice for many chronic and debilitating diseases. Generally, the primary endpoints in evaluating therapy are graft and patient survival time. However, an important secondary outcome is the number of "rejection episodes" experienced by study patients. This response has a distinctive statistical character. That is, it is a categorical variable since it assumes only a small number of integer values, but it is measured on a ratio-level scale since the ratio of any two values is scientifically meaningful. Historical methods for analyzing this endpoint, for example, t tests, logistic regression and Kaplan-Meier analysis, have failed to take these characteristics into account. In this study, we investigated statistical procedures for analyzing the number of rejection episodes arising during the first three months posttransplant. Data compiled by the Multiple Organ Retrieval and Exchange (MORE) of the Province of Ontario were used for this purpose. It was found that assumptions underlying normal distributional techniques were not satisfied by these data. An alternative model based on Poisson regression models was considered and was shown to provide an adequate fit.

Small intestinal transplantation in nonhuman primates

Small intestinal transplantation represents a potentially therapeutic procedure for individuals with short gut syndrome. The purpose of this study was to develop a model for small intestinal transplantation in primates that is: technically feasible without microsurgery; consistent in the prevention of allograft rejection; functional in terms of nutrient absorption; and compatible with harvest for multiple organ procurement. First, autotransplantations on four rhesus monkeys were performed in order to study a variety of harvesting techniques and vascular anastomoses. Then, a study was performed with 14 heterotopic allotransplants in 4 baboons and 10 rhesus primates. The successful donor model consisted of division of the pancreas, harvesting the small bowel with a superior mesenteric artery and portal vein pedicle. The allograft vascular pedicle was anastomosed to the recipient's common iliac vessels in end-to-side fashion. The graft was transplanted as an out-of-continuity loop, both ends being exteriorized as stomas providing access for absorption studies and biopsy. Three immunosuppressive regimens were tested: (1) cyclosporine A (CyA) 20 mg/kg/d, solumedrol (SML) 2 mg/kg/d, and graft irradiation (150 rad) (n = 4); (2) CyA 20 mg/kg/d and SML 2 mg/kg/d (n = 3); and (3) CyA 40 mg/kg/d, SML 2 mg/kg/d, and azathioprine 5 mg/kg/d (n = 3). There were 4 deaths due to technical error in the first 24 hours. Weekly graft biopsy, serum CyA levels, complete blood count, and automated 24-channel serum analysis were performed. Grafts surviving greater than 14 days underwent absorption study via luminal perfusion with sucrose, maltose, dextrose, Pregestimil, xylose, and cyclosporine. Average graft survival was 7.5 (range, 6 to 9), 26.3 (range, 15 to 41), and 75.3 (range, 68 to 84) days, respectively, for the three immunosuppressive regiments. Absorption of carbohydrate was documented by serial measurement of serum glucose in fasted primates after infusion of maltose, dextrose, sucrose, and Pregestimil via the allograft. Absorption of xylose was similarly documented. Absorption of CyA was documented by serial serum CyA levels after luminal infusion of 40 mg/kg. A clinically applicable model for small intestinal harvest was developed that is consistent with multiple organ retrieval. A reliable allotransplantation technique and immunosuppressive regimen was developed resulting in long-term graft survival and functional absorption of carbohydrates and CyA.

Ten Years of Training Community Urologists and General Surgeons to Do Cadaver Kidney Retrievals

We trained 82 community hospital cadaver kidney retrieval teams during a 10-year period ending June 30, 1987. During the last 5 years of that period the concept of multiple organ retrieval was introduced into the training sessions and 429 cadaver kidney grafts were retrieved. Of those kidneys 292 were transplanted at our hospital, and the function of 220 cadaver kidney grafts retrieved by the community hospital teams was compared to that of 72 retrieved by the transplant center retrieval team. Of the cadaver kidney transplants 114 were from multiple organ donors. There was no significant difference in 1-month serum creatinine nadir of surviving grafts (2.1 ± 1.8 versus 1.9 ± 1.7mg. per dl.), β-month serum creatinine level (1.7 ± 0.8 versus 1.6 ± 0.6mg. per dl.), 12-month serum creatinine level (1.8 ± 0.9 versus 1.6 ± 0.6mg. per dl.) and 5-year actuarial graft survival (44.8 ± 4.1 versus 52.4 ± 7.5%), with the community hospital data presented first. The delayed graft function rate was significantly higher in the recipients of cadaver kidney grafts retrieved by community hospital teams (54 versus 35%), which was reduced by the in situ flush technique. There was no significant difference in delayed graft function rate (48 versus 40%) for the 114 cadaver kidney transplants retrieved from multiple organ donors by either community hospital or transplant center teams.With continuing education and quality control, community hospital retrieval teams can provide kidneys satisfactory for transplantation, even when working with multiple organ retrieval teams. (J. Urol, 143: 897–899, 1990)

Influence of cadaveric organ source on delayed renal allograft function.

From 1984 to 1987, 110 locally retrieved cadaveric kidneys were transplanted into 108 local recipients, including 50 kidneys from multiple-organ retrieval (MOR) procedures and 60 from kidney-only (KO) donors. Conventional multiple organ retrieval technique, iced Euro-Collins storage, and cyclosporine-prednisone immunosuppression were employed. Delayed graft function (DGF), defined as dialysis dependence after transplantation, was twice as high in the MOR allografts as in the KO allografts, 46% vs. 22%, P less than 0.01. DGF was associated with longer hospitalization postoperatively and reduced eventual allograft function. The greater concordance of DGF in allograft pairs from the MOR group (25% vs. 7% in the KO group) and the increased incidence of DGF when more complex forms of MOR were used (40% with liver or heart retrieval, 55% with liver and heart retrieval) suggested that retrieval-related factors influenced allograft function. DGF in the MOR allografts was unrelated to other differences in donor, preservation, or recipient characteristics in the comparative groups. Unrecognized warm ischemia during conventional MOR is a plausible cause of DGF in kidneys from multiple-organ donors.

Les prélèvements multiples d'organes en vue de transplantation

In the last few years, the tremendous growth of clinical transplantations has greatly increased the need for grafts. Combined heart, liver and kidney harvesting in a same donor could provide an answer. The results are presented of multiple organ retrieval (MOR) carried out in an University hospital located in an area with 1,350,000 inhabitants. In addition to the usual problems of donor maintenance and legal aspects, it was necessary to carry out a specific work-up for each organ to be harvested. The job of the local coordinator was extremely important in the search for potential recipients and the organization of the procedure (time-table, air transport) in order to give optimal conditions. The priority given to retrieving the heart and in situ cooling of the liver and kidneys guaranteed the good quality of the harvested organs. Over a period of three years, 28 MOR have been carried out. Of the 94 organs harvested, 88 were transplanted in France or another European country (49 kidneys, 23 hearts, 16 livers); 75 are still functioning (47 kidneys, 19 hearts, 9 livers). As a result of this experience, and taking into account the need for organs, all brain dead patients should be considered as potential multiple organ donors, and not just as kidney donors. The intervention of several teams, often quite distant from the site of retrieval, requires careful planning. The surgical procedure, even when performed by a trained team, is often complex, perfect synchronization of the surgical steps of the operation being the most important point. However, the centre where MOR is to be carried out must have adequate laboratory back-up, technical, medical and paramedical personnel and facilities. Co-operation from the hospital administration is also essential. Special financial facilities must be planned by the Ministry of Health, so that those centres involved in MOR may support the costs of such an activity (33,650 FF per MOR). This last problem should not hinder MOR, as its need is obvious if organ transplantation is to progress.