Non-heart-beating Donors Research Articles

Carbon Monoxide Protects Against Ischemia-Reperfusion Injury in an Experimental Model of Controlled Nonheartbeating Donor Kidney

CO-releasing molecule-3 (CORM-3) is a transitional metal carbonyl that liberates carbon monoxide under appropriate conditions. Carbon monoxide exerts effects on intracellular apoptotic and inflammatory pathways, which suggest a role in reducing the effects of renal ischemia/reperfusion (I/R) injury. This study investigated the effects of CORM-3 administered at the time of reperfusion in a model of controlled nonheartbeating donor kidneys. Porcine kidneys (n=4) were subjected to 10 min warm ischemia and 18 hr cold storage (CS) and then treated as follows: CORM-3 (50, 100, 200, and 400 microM doses), iCORM-3 (inactive carbon monoxide-releasing molecule, 50 microM), and control (no further intervention). Renal hemodynamics and function were then measured during 3-hr reperfusion with autologous blood using an isolated organ-perfusion system. CORM-3 at a concentration of 50 microM improved renal blood flow (RBF) compared with the iCORM and control groups (area under the curve 774+/-19 vs. 448+/-88 vs. 325+/-70, respectively, P=0.002). CO-releasing molecule-3 at a concentration of 50 microM also improved renal function during reperfusion with a greater area under the curve for creatinine clearance (CORM-3: 14+/-6 vs. iCORM: 3.3+/-0.1 vs. control: 2.2+/-2 mL/min, P=0.006) and higher urine output (CORM-3: 793+/-212 vs. iCORM: 368+/-72 vs. control: 302+/-211 mL, P=0.01). CO-releasing molecule-3 at a concentration of 100 microM exerted similar effects. Treatment with CORM-3 at higher doses (200 and 400 microM) led to poor renal hemodynamics and function after reperfusion. Low-dose CORM-3 significantly ameliorates the effects of ischemia/reperfusion in a porcine model of controlled nonheartbeating donor kidney transplantation.

Liver Transplantation for Hepatocellular Carcinoma: Impact of the MELD Allocation System and Predictors of Survival

Since February 27, 2002, patients with early-stage hepatocellular carcinoma (HCC) have received priority for liver transplantation in the United States under the Model for End-Stage Liver Disease (MELD) allocation system. We aimed to determine the impact of this system on liver transplantation for HCC. Data were provided by the United Network for Organ Sharing on 19,404 first-time, cadaveric, adult liver transplantations performed in the United States between 2002 and 2007 and 15,906 performed between 1997 and 2002, an equal-duration period immediately preceding the MELD allocation system. In 1997-2002, 4.6% of liver transplant recipients had HCC compared with 26% in 2002-2007, the majority of whom received "HCC-MELD-exceptions" allowing expedited transplantation. Posttransplantation survival of patients with HCC without an "HCC-MELD-exception" was significantly worse than the survival of patients without HCC. In 2002-2007, patients with an "HCC-MELD-exception" had similar survival to patients without HCC. However, for the subgroup of patients with tumors 3-5 cm in size had significantly worse survival. When compared with patients with similar MELD scores, patients in the "HCC-MELD-exception" group had worse posttransplantation survival than patients without HCC. The most important predictors of poor posttransplantation survival were MELD score >/=20 (hazard ratio, 1.61; 95% CI: 1.3-2.1) and serum alpha-fetoprotein level >/=455 ng/mL (hazard ratio, 2.15; 95% CI: 1.5-2.0). The adoption of the MELD allocation system has led to a 6-fold increase in the proportion of transplantation patients with HCC. Patients with larger (3-5 cm) tumors, serum alpha-fetoprotein level >/=455 ng/mL, or a MELD score >/=20 have poor posttransplantation survival.

143: The Non-Heart Beating Donor for Heart Transplantation: A New and Evolving Source of Organs

The non-heart beating donor (NHBD) is an increasing source of organs for transplantation. Cardiac donation from NHBD has been considered unsuitable due to concerns over irreversible myocardial damage resulting from warm ischemia. We describe successful cardiac resuscitation in a NHBD with extracorporeal perfusion. Furthermore, we review this donor source to estimate what proportion would be suitable for cardiac donation.

382: Initial Experience with Lung Transplantation from Non-Heart-Beating Donors

Lung transplantation (LTx) is limited by the number of suitable brain-dead donors. Non-heart-beating donors (NHBD) have been proposed as an alternative source for organs. We reviewed our initial experience with LTx from NHBD.

296: Non Heart Beating Lung Donation: How Big Is the Pool?

ungs from non– heart-beating (NHB) donors are seldom used in The Netherlands despite the good quality of hese organs. Based on a retrospective analysis of 162 NHB donor procedures we found that only 5% of the ungs were actually utilized, but that 30% of the lungs were suitable for transplantation. Not recognizing the uitability of NHB lungs is likely the main reason for their non-availability. J Heart Lung Transplant 2008;27: 040 –2. Copyright © 2008 by the International Society for Heart and Lung Transplantation.

Effects of erythropoietin on ischaemia/reperfusion injury in a controlled nonheart beating donor kidney model

Erythropoietin (EPO) has been shown to have an anti-apoptotic action and has the potential to protect against ischaemia/reperfusion injury. This study investigated the effect of high dose EPO (5000 U), administered as a bolus at the onset of reperfusion and at the onset of cold storage in a model of controlled nonheart beating donors kidneys. Porcine kidneys(n = 6) were subjected to 10min warm ischaemia and preserved as follows: Group 1:16 h Cold storage +2 h Normothermic perfusion (16 h CS + 2 h NP) Group 2:16 h CS + 2 h NP + EPO given at the onset of reperfusion Group 3:18 h CS (static hypothermic storage) Group 4:18 h CS + EPO given at the onset of cold storage Haemodynamic and functional parameters were assessed during 3-h reperfusion using autologous blood. Renal blood flow improved in Groups 1 and 2 vs. Groups 3 and 4 though no difference was noted between Groups 3 and 4 (563 +/- 119 vs. 491 +/- 95 vs. 325 +/- 70 vs. 418 +/- 112, respectively; P = 0.012). Total urine output showed no difference between Groups (271 +/- 172 vs. 359 +/- 184 vs. 302 +/- 21 vs. 421 +/- 88; P = 0.576). Percentage serum creatinine fall at 3 h was significantly better in Groups 1 and 2 vs. Group 3 (64 +/- 17 vs. 60 +/- 11 vs. 44 +/- 13 vs. 52 +/- 8; P = 0.04). Fractional-excretion of sodium was significantly lower for Groups 1 and 2 vs. Group 3 and 4 (17 +/- 14 vs. 18 +/- 9 vs. 49 +/- 21 vs. 45 +/- 16 respectively; P = 0.002). There was significant improvement in oxygen consumption in Groups 2 vs. Groups 3 and 4 (P = 0.037) (39 +/- 10 vs. 46 +/- 10 vs. 24 +/- 12 vs. 24 +/- 7 respectively). EPO added at the time of reperfusion improved oxygen consumption when added to NP in comparison to static hypothermic storage but did not exert any other major benefits.

Biliary Complications After Liver Transplantation From Maastricht Category-2 Non-Heart-Beating Donors

There are unresolved issues regarding the security of liver transplantation with non-heart-beating donors (NHBDs). Recently, an increased incidence of biliary complications, mainly intrahepatic ischemic-type biliary strictures, has been described after controlled NHBDs. We studied the incidence and risk factors for biliary complications among uncontrolled NHBDs recipients compared with a large population of HBD recipients. Overall, 16.8% of patients in the HBD group and 41.7% of patients in the NHBD group suffered any type of biliary complication (P=0.66). However, the incidence of nonanastomotic biliary strictures was significantly greater in the NHBD group (P<0.001). Multivariate analysis showed that independent risk factors for nonanastomotic strictures were hepatic artery thrombosis (relative risk; 98.7) and receiving a liver from a NHBD (relative risk; 47.1). If this type of donors is accepted as a source of liver organs, the high incidence of biliary complications should be considered and efforts should be made to decrease ischemic injury.

The Relative Effects of Warm and Cold Ischemic Injury in an Experimental Model of Nonheartbeating Donor Kidneys

Ischemia reperfusion injury (I/R) leads to delayed graft function and remains an important problem in renal transplantation. The aim of this experimental study was to assess the effects of warm (WI) and cold ischemia (CI) in models of heartbeating (HBD) and controlled/uncontrolled nonheartbeating donor (NHBD) kidneys. A reperfusion model utilizing cardiopulmonary bypass technology was used to perfuse isolated porcine kidneys with autologous blood after the following conditions: 0 min WI+2 h cold storage (CS); 0 min WI+18 h CS; 10 min WI+2 h CS; 10 min WI+18 h CS; 25 min WI+2 h CS; 25 min WI+18 h CS. Renal function was measured over a period of 3 hr. Renal functional parameters were not significantly different between 0, 10, 25 WI with 2 h CS [AUC creatinine (Cr) decrease of 1057+/-177, 1102+/-260, and 1245+/-143 micromol/L h, P=0.338; AUC creatinine clearance (CrCl) of 37.7+/-15.8, 36.2+/-21.7, 19.8+/-9.1 ml/min/100 g h, P=0.099]. After 18 h CS, renal function was severely impaired in the 10 and 25 WI groups compared to 0 min WI [AUC Cr of 2156+/-401, 2287+/-148, 1563+/-395 micromol/L h, P=0.037; AUC CrCl of 2.2+/-1.7, 1.5+/-1.5, 21.7+/-13.4 ml/min/100 g h, P=0.007). Warm ischemia of up to 25 min was only detrimental to renal function when kidneys were subsequently preserved in cold storage for 18 hr. This data suggests that limiting the cold storage period is of paramount importance when transplanting kidneys subjected from nonheartbeating donors.

The Significance of Preserving the Energy Status and Microcirculation in Liver Grafts from Non-Heart-Beating Donor

To complete a successful liver transplantation (LTx) from non-heart-beating donors (NHBD), it is necessary to both improve the energy status in liver grafts and to reduce the exposure to free radicals. This study investigated the effects of short perfusion with oxygenated buffer on the grafts prior to cold preservation. In addition, the effects of the antioxidant, biliverdin, for reduction of free radicals was investigated. Male Wistar rats were used. Livers were retrieved, preserved in UW solution, and perfused for 60 min with oxygenated Krebs-Henseleit solution. Rats were allocated to six groups as follows (n=5): (i) control group-no warm ischemia (WI) and cold preservation, (ii) HBD group--no WI with cold preservation for 6 h; (iii) NHBD group--with 30 min of WI and cold preservation, (iv) NM group--with WI including nafamostat mesilate infusion before cardiac arrest and cold preservation; (v) PRE group--with WI, 30-min pre-cold preservation perfusion with oxygenated buffer after cardiac arrest, and cold preservation, (vi) BV group-with the same treatment as the PRE group plus the addition of biliverdin to the pre-cold preservation perfusion. The portal flow volume, bile production, AST, and TNF-alpha in perfusate, energy charge (EC), and ATP level in the tissue, and histological findings were investigated. The portal flow volume in the NM, PRE, and BV groups were higher than in the NHBD group. The bile production in the PRE and BV groups were also higher than in the NHBD group. The EC and ATP level of the BV group after reperfusion were higher than those of the NHBD group. Pre-cold preservation perfusion and addition of biliverdin to perfusate improved viability of grafts from NHBD. The results indicate that the preservation of the energy status and microcirculation of the graft is important for successful LTx from NHBD.

Preservation of non-heart-beating donor livers in extracorporeal liver perfusion and histidine-trytophan-ketoglutarate solution

To compare the preservation of non-heart-beating donor (NHBD) livers in cold histidine-trytophan-ketoglutarate (HTK) solution and extracorporeal liver perfusion (ECLP). Livers harvested from healthy pigs were stored for 10 h in cold HTK solution (group A, n = 4) or perfused with oxygenated autologous blood at body temperature (group B, n = 4). Both groups were then tested on the circuit for 4 h. Bile production, hemodynamic parameters, hepatocyte markers and reperfusion injury of extracorporeal livers were tested in each group. Liver tissues from each group were examined at the end of reperfusion. At 1, 2, 3 and 4 h after reperfusion, bile production, hemodynamic parameters, hepatocyte markers and reperfusion injury of livers in group A were statistically different from those in group B (P < 0.05 or P < 0.01). ECLP is better than HTK solution to preserve NHBD livers. ECLP can assess the graft viability before liver transplantation.

Death, organ transplantation and medical practice

A series of papers in Philosophy, Ethics and Humanities in Medicine (PEHM) have recently disputed whether non-heart beating organ donors are alive and whether non-heart beating organ donation (NHBD) contravenes the dead donor rule. Several authors who argue that NHBD involves harvesting organs from live patients appeal to "strong irreversibility" (death beyond the reach of resuscitative efforts to restore life) as a necessary criterion that patients must meet before physicians can declare them to be dead. Sam Shemie, who defends our current practice of NHBD, holds that in fact physicians consider patients to be dead or not according to physician intention to resuscitate or not.We suggest that criteria for a concept are not necessarily truth conditions for assertions involving the concept. Hence, non-heart beating donors may be declared dead without meeting the criterion of strong irreversibility even though strong irreversibility is implied by the concept of death. Our perception that a concept applies in a given case is determined not by the concept itself but by our necessary skill and judgment when using it. In the case of deciding that a patient is dead, such judgment is learned by physicians as they learn the practice of medicine and may vary according to circumstances. Current practice of NHBD can therefore be defended without abandoning death as an empirical concept, as Shemie appears to do. We conclude that the dead donor rule continues to be viable and ought to be retained so as to guarantee what the public most cares about as regards organ donation: that physicians can be trusted to make determinations of eligibility for organ donation in the interests of patients and not for other purposes such as increasing the availability of organs.

Experimental renal preservation by normothermic resuscitation perfusion with autologous blood

Normothermic perfusion (NP) has the potential to improve metabolic support and maintain the viability of ischaemically damaged organs. This study investigated the effects of NP compared with current methods of organ preservation in a model of controlled non-heart-beating donor (NHBD) kidneys. Porcine kidneys (n = 6 in each group) were subjected to 10 min warm ischaemia and then preserved as follows: 2 h cold storage (CS) in ice (CS2 group), 18 h CS (CS18 group), 18 h cold machine perfusion (CP group) or 16 h CS + 2 h NP (NP group). Renal haemodynamics and function were measured during 3 h reperfusion with autologous blood using an isolated organ perfusion system. Increasing CS from 2 to 18 h reduced renal blood flow (mean(s.d.) area under the curve (AUC) 444(57) versus 325(70) ml per 100 g; P = 0.004), but this was restored by NP (563(119) ml per 100 g; P = 0.035 versus CS18). Renal function was also better in CS2, CP and NP groups than in the CS18 group (mean(s.d.) serum creatinine fall 92(6), 79(9) and 64(17) versus 44(13) per cent respectively; P = 0.001). The AUC for serum creatinine was significantly lower with CS for 2 h than for 18 h (mean(s.d.) 1102(2600) versus 2156(401) micromol/l.h; P = 0.001), although values in CP and NP groups were not significantly different from those in the CS2 group (1354(300) and 1756(280) micromol/l.h respectively). Two hours of NP increased the adenosine 3'-triphosphate : adenosine 3'-diphosphate ratio to a significantly higher level than the preperfusion values in all other groups (P = 0.046). NP with oxygenated blood was able to restore depleted ATP levels and reverse some of the deleterious effects of CS.

Dual Transplantation of Marginal Kidneys From Nonheart Beating Donors Selected Using Machine Perfusion Viability Criteria

Dual Transplantation of Marginal Kidneys From Nonheart Beating Donors Selected Using Machine Perfusion Viability Criteria

Improved Kidney Graft Function After Preservation Using a Novel Hypothermic Machine Perfusion Device

To study graft function and ischemia/reperfusion injury of porcine kidneys after preservation with the new Groningen Machine Perfusion (GMP) system versus static cold storage (CS). The increasing proportion of marginal and nonheart beating donors necessitates better preservation methods to maintain adequate graft viability. Hypothermic machine preservation (HMP) is a promising alternative to static CS. We have therefore developed and tested an HMP device, which is portable and actively oxygenates the perfusate via an oxygenator. The aim of the present study was to examine the efficacy of the GMP system in a transplantation experiment. In a porcine autotransplantation model, kidneys were retrieved and either cold stored in University of Wisconsin CS for 20 hours at 4 degrees C or subjected to HMP using University of Wisconsin machine perfusion at 4 degrees C with 2 different pressure settings: 30/20 mm Hg or 60/40 mm Hg. HMP at 30/20 mm Hg was found to better preserve the viability of kidneys reflected by improved cortical microcirculation, less damage to the proximal tubule, less damage mediated by reactive oxygen species, less proinflammatory cytokine expression, and better functional recovery after transplantation. However, high perfusion pressures (60/40 mm Hg) resulted in higher expression of von Willebrand factor and monocyte chemotactic peptide-1 in postpreservation biopsies and subsequent graft thrombosis in 2 kidneys. It is concluded that the GMP system improves kidney graft viability and perfusion pressures are critically important for outcome.

Expected number of deaths in the liver transplantation waiting list in the state of São Paulo, Brazil

São Paulo is the pioneer Brazilian state in transplantation surgery. The biggest challenge facing the field of transplantation is the critical shortage of donor organs, which has led to a dramatic increase in the number of patients on the waiting-list as well as in their waiting time for transplantation. In a previous work [1], we projected the size of the waiting-list of Sao Paulo State in comparison with the number of transplantations carried out in the same period. We demonstrated [1] that the list size grows at a rate much higher than the number of transplantations actually performed. We wish to report the expected number of deaths in the waiting-list of liver transplantation in the State of São Paulo for a projected period of 10 years starting from the year 2005. We collected official data from State Center of Transplantation – State Secretariat of São Paulo about our liver transplantation program for the period between July 1997 and October 2004. Only cadaver liver transplantation was recorded. Living-related liver transplantation was excluded. The data related to the actual number of liver transplantation, Tr, and the incidence of new patients in the list, I, in the State of São Paulo since 1997 can be seen in Table 1. We took the data of Tr and that of I from Table 1 and fitted a continuous curve by the method of maximum likelihood [2] to project the number of transplantations, Tr, and the incidence of new patients in the list, I, in future. Next, we calculated the number of deaths in the list assuming an average survival time in the list of 18 months and assuming also that death is the inexorable fate of these patients. Taking the difference between the incidence of new cases and the incidence of transplantations allowed the calculation of the number of deaths in the waiting list. The results, projected for 10 years from 2005 can be visualized in Fig. 1. Projected number of deaths in the liver transplantation waiting-list in the State of Sao Paulo, Brazil. Liver transplantation was first performed at University of Sao Paulo School of Medicine in 1968 [3]. Since then, the patient waiting-list for liver transplantation has increased by approximately 150 new cases per month, all being referred to a single list at the central organ procurement organization. The gap between the number of available organs from deceased donors and the number of patients in the waiting-list continues to widen each year. Liver transplantation has increased, approximately, 1.84-fold (from 160 to 295) from 1988 to 2004. In contrast, the number of patients in the liver waiting-list has jumped by 2.71 fold (from 553 to 1500). As a result of this, the number of deaths on the liver waiting-list has moved to a higher level from 321 to 671 increasing 2.09 fold. The present study found that 4.7 liver transplantations were performed per million inhabitants in 2003 when we should have performed at least 33 transplantations per million inhabitants [4]. As the liver is a limited national resource, our proposals are: (i) to improve organ donation campaign as we have not yet reached the full capacity of donation (currently 7.09 per million inhabitants) [4]. (ii) To concentrate on funding resources to public university hospitals to improve the liver transplantation performance. (iii) To change the law to start using nonheart-beating donors (NHBD). Nonheart-beating donors programs remain unpopular despite the potential to increase the donor pool by up to 30% [5]. A number of legal, ethical and logistic reasons as well as medical concerns are responsible for this and have even compromised existing NHBD programs [6]. In conclusion, provided the conditions of the present study remain unchanged, the number of deaths in the liver transplantation waiting-list will grow in an exponential way in the years to come. Therefore, there is an urgent need both for increasing the number of liver transplantation in the State of São Paulo and for changing the law introducing nonheart-beating donors to avoid the overwhelming number of deaths in the liver transplantation waiting-list.

Ischemic Cholangiopathy After Liver Transplantation From Controlled Non–Heart-Beating Donors–A Single-Center Experience

Background Previous reports have shown that livers from controlled non–heart-beating-donors (NHBD) are associated with higher rates of primary failure and ischemic cholangiopathy of orthotopic liver transplantation (OLT) as a complication of the prolonged warm ischemia. Methods This retrospective review of activities from 1999 to 2006 examined donor characteristics of age, liver function tests, warm ischemic time before (1WITa) and after cardiac arrest (1WITb), cold ischemic time (CIT) and transplant results. Results Eleven NHBD retrieved livers were transplanted from “ideal” donors except for one elderly donor (73 years). Of the 11 recipients, 3 developed biliary cholangiopathy (27%). There were no episodes of primary graft nonfunction, but one recipient displayed primary graft dysfunction. Two recipients died: one due to biliary complications with sepsis (long CIT >10 hours, fatty liver), and the other due to aspiration pneumonia and hypoxic brain damage with normal liver function. One recipient required retransplantation owing to ischemic cholangiopathy (1WITb 45 min) at 6 months after OLT with a good result. The other eight recipients are alive (observation period 72 to 14 months) including six with normal liver function, one with biopsy-proven biliary ischemia and one with recurrent primary sclerosing cholangitis without biliary ischemic changes on biopsy. Among 164 heart-beating donors recipients transplanted in the same period, biliary complications occurred in 27 patients (16%), of whom 12 were leaks and 15 anastomotic strictures. Conclusion NHBD were a good source for livers with reasonable early results. To avoid late complications especially ischemic cholangiopathy, caution is urged with the use of these organs as well as strict donor and ischemic time criteria.

Non‐survivors of out‐of‐hospital cardiac arrest should always be␣considered potential non‐heart‐beating organ donors

We read with great interest the recent paper by Gratrix et al. [1] in which it was concluded that only a small increase in donor organs could be potentially achieved by considering non-heart-beating (NHB) donation from patients with out-of-hospital cardiac arrest (OHCA). The aim of the study was to identify patients suitable for NHB donation – the main result being that only four of 57 (7%) OHCA patients who died after withdrawal of life support would qualify as NHB donors. Patients were excluded from the study because of age, medical history, but mainly because the length of time between stopping treatment and death exceeded 120 min. We believe that the conclusion that OHCA patients are not commonly suitable for NHB donation cannot be derived from the data as presented. Firstly, the study reports that different modes of withdrawal of treatment were used, suggesting that the stopping of treatment was often performed by successively withdrawing one form of life support, evaluating the effect, followed by withdrawing another. Although this is probably the best way to achieve good end-of-life care, it is unlikely that this is the best way to withdraw treatment in a patient eligible for NHB organ donation. In contrast, it is our practice that, once the decision has been made to withdraw life support because of futility, all life-saving support is withdrawn at once. Secondly, there is no clear definition of the point at which their patients died. For many patients who die in an ICU the process of dying is monitored and it is determined that the patient has died when the electrical activity of the heart has stopped. This is not the same as the definition of death in most NHB protocols, in which the time of death is defined as the moment of circulatory arrest. In the UK protocol to certify death in NHB donors the ‘absence of cardiac output and respiration, the lack of response to supraorbital pressure and absence of the pupillary and corneal reflexes after a minimum of five minutes after cardiorespiratory arrest’ is required [2], but the absence of electrical activity of the heart is not. In many dying patients, electrical activity of the heart is present for up to 10 min after circulatory arrest, and sometimes longer [3]. This may have reduced the number of eligible potential donors in this study. No criteria for predicting death after stopping life support were described by the authors. Both the Wisconsin [4] and unos[2] criteria have been evaluated and provide a reasonable prediction for whether a patient will be suitable for NHB organ donation. Using these or similar criteria will help to identify potential donors and thereby decrease the risk of seeking unnecessary consent from an already distressed and grieving family. We wonder how the decision was made to withdraw or withhold treatment. Although there is very good evidence that we should stop treating patients with persistent coma without pupillary reaction [6] or with absent evoked potentials [7, 8] after 72 h, it is not clear whether these criteria were used. This may have influenced the results, as the neurological condition may be relevant in relation to early death after withdrawal of life-support., Gratrix et al. report a hospital mortality of 95% in patients with OHCA. This, of course, is a selected group of OHCA patients as those in whom a spontaneous circulation did not return were not studied, nor were patients regaining consciousness. This group is not completely comparable therefore with the patients included in the hypothermia studies by Bernard et al. [9] and Holzer et al. [10]. However, the difference in outcome (almost 50% survival in both studies) is striking and brings us to the question whether treatment in these patients included therapeutic hypothermia. In addition, 9% survival was reported in OHCA patients in the Amsterdam area in 1998, including all patients who died during resuscitation (75%) or reaching hospital without spontaneous circulation. In the same study, 82 of 216 patients (38%) admitted to the ICU survived [11]. More recent data from 2005–2006 shows a survival of almost 17% of a cohort of OHCA patients [12]. How do these patients compare with those studied by Gratrix et al.? In conclusion, we consider that the potential for organ donors among non-survivors of OHCA may be greater than suggested by Gratrix et al. We propose that in all ICU patients who have their treatment withdrawn, the possibility of non-heart-beating organ donation is evaluated.

Human Islets Derived From Donors After Cardiac Death Are Fully Biofunctional

Islets from brain-dead donors (BDDs) are being used in the treatment of Type 1 diabetes. However, both donor numbers and islet survival are limited. We explored the clinical potential for islets from non-heart-beating donors (NHBDs), who have lower circulating cytokines, by comparing islets from 10 NHBDs against 12 identically-isolated islets from BDDs over the same time period. The quantity and quality of islets from NHBDs was good. NHBD yielded approximately 12.6% more islets than those of BDDs (505,000 +/- 84,230 vs. 400,970 +/- 172,430 islet equivalent number [IEQ]/pancreas, p = 0.01) with comparable viability. ATP and GTP contents were lower (6.026 +/- 3.076 vs. 18.105 +/- 7.8 nM/mg protein, p = 0.01 and 1.52 +/- 0.87 vs. 3.378 +/- 0.83 nM/mg protein, p = 0.04) and correlated negatively to warm ischemia time (R(2)= 0.8022 and R(2)= 0.7996, respectively). Islets from NHBDs took longer to control hyperglycemia in diabetic mice, but were equally able to sustain euglycemia. With a warm ischemia time (WIT) of <or=25 min, islets from NHBDs are at least as competent as islets from BDDs and should be suitable for clinical use.

Kidney transplantation from non–heart-beating donors: a Spanish view

All over the world, the waiting list and waiting time for transplant will inevitably become longer as the demand for kidneys continues to exceed the supply. Although there is a need to extend the use of brain-dead donors with heartbeats, there is still room for additional sources of organs, and this has prompted the use of the non–heart-beating donor (NHBD). The viability of the kidney from the NHBD, which is invariably subjected to a period of warm ischemia, is the most crucial factor for transplant outcome. However, in our experience, by applying a strict warm ischemia protocol and carefully managing the donor, the percentage of non-functioning grafts is low. The results presented in terms of graft survival and mid-term renal function with NHBD are encouraging and comparable to those related to the use of kidneys from young heart-beating donors. Based on these data, NHBDs should not be considered suboptimal, since other marginal donors such as elderly donors, for instance, have resulted in worse outcomes. In our experience, the NHBD kidney is an extremely useful contribution to the donor pool, and its use has allowed us to increase the total number of kidney transplants performed and, as consequence, to decrease the waiting list.

The Choice of Recipient Does Not Have a Bearing on Early Outcome in Liver Transplant Patients Receiving Grafts From Non–Heart-Beating Donors: A Reappraisal?

Introduction Donation after cardiac death has reemerged as a potential way of increasing the supply of organs for transplantation. We retrospectively reviewed the outcomes of non–heart-beating donor (NHBD) liver transplantation (OLT) experience and compared with standard heart-beating donation (HBD) at a single center. Methods From October 2003 to November 2006, 13/111 liver transplantations were performed in our institution with NHBD. Living donor liver transplantation, splitting procedures, combined, and pediatric liver transplantations were excluded from this analysis. Results Donor population was similar in both groups. The median warm ischemia time was 10 minutes (range 6 to 38). The median cold ischemia times 6 hours and 16 minutes (2.4 to 6.30 hours and 9 hours and 14 minutes (2.15 to 15.35 hours) for NHBD and HBD groups, respectively ( P = .0002). In the NHBD groups, 4/13 (31%) grafts were retransplanted within 3 months, due to ischemic biliary lesions with severe cholestasis ( n = 3) or due to the occurrence of primary nonfunction ( n = 1). The retransplantation rate was significantly lower in the HBD group (11/98, 11%; P = .03). One-year patient and graft survivals were 62% and 54% versus 86% and 79%, respectively, for the NHBD and HBD groups ( P = .107 and P = .003). Conclusion Liver grafts procured from donors after cardiac death accounted for a significantly greater retransplantation rates, mainly due to nonanastomotic biliary strictures. This risk must be taken into account when transplanting such grafts. Based upon this experience, NHBD cannot rival HBD to be a comparable source of quality organs for liver transplantation.