Non-heart-beating Donors Group Research Articles

The Effects of Using Pancreases Obtained from Brain-Dead Donors for Clinical Islet Transplantation in Japan.

Background: The pool of brain-dead donors (BDDs) was increased with the revision to the relevant law in 2010, and islet transplantation from BDDs was started in 2013. The present study assessed the influence of using pancreases from BDDs on islet transplantation in Japan. Methods: The donor information registered with the secretariat of islet transplants from 2012 was reviewed, and the results of 86 clinical islet isolations performed in Japan between 2003 and 2018 with non-heart-beating donors (NHBDs) (n = 71) and BDDs (n = 15) were investigated. Results: The number of cases for which donor information was registered with the secretariat of islet transplants increased to 1.84 cases/month from 2013 to 2018 in comparison to 1.44/month in 2012, when only NHBDs were used. The median pancreatic islet yield was 275,550 IEQ (Islet equivalents) in the NHBD group but 362,700 in the BDD group, which amounted to a statistically significant difference (p = 0.02). As a result, 38/71 cases (53.5%) were achieved successful islet isolation (>5000 IEQ per recipient weight (kg)) was achieved in 38/71 cases (53.5%) in the NHBD group, and 12/15 cases (80.0%) in the BDD group; thus, the rate of successful islet transplantation was higher in the BDD group. Conclusion: The use of pancreases from BDDs has increased the overall number of cases for which donor information is registered with the secretariat of islet transplants and has improved the performance of islet isolation, thereby increasing the probability of successfully achieving islet transplantation.

Non-Heart Beating Donor Kidney Transplantation Is not Associated with An Increased Risk of Post-Transplant Infection

Objectives: The use of kidneys from non-heart beating donors (NHBD) has increased notably over the last years. The impact of such strategy on the risk of post-transplant infection remains unclear. Methods: We performed a prospective cohort study including 225 patients (143 males; mean age: 54.4 ± 14.1 years) who underwent kidney transplant (KT) at our institution from November 2008 to August 2010. We compared the incidence and clinical and microbiological characteristics of post-transplant infection between recipients of brain-dead donor (BDD) and NHBD grafts (154 and 71 patients, respectively). NHBD belonged mostly to categories I and II of the Maastricht classification (uncontrolled donnors). All patients in the NHBD group received induction therapy with antithymocyte globulin (ATG) and antiviral prophylaxis (mainly valganciclovir) during the first 3 months. Multivariate adjusted odds ratios (ORs) for infection were calculated using those covariates found to be significant at P < 0.10 by univariate analysis. Results: As compared to patients in the BDD group, those in the NHBD group were younger (P < 0.001), had fewer years on pre-transplant dialysis (P = 0.004), shorter cold-ischemia times (P < 0.001), and higher number of HLA mismatches (P = 0.052). Delayed graft function (requirement for dialysis within the first week after transplantation) was more frequent in the NHBD group (84.5% vs. 52.6%; P < 0.001), as well as donor/recipient cytomegalovirus (CMV) mismatch (12.7% vs. 5,8%; P = 0.079). Incidence rates of overall infection in the NHBD and BDD groups were 1.94 and 3.25 episodes per 1,000 transplant-days, respectively (P < 0.0001). Incidence rate of early infection (during the first month) was also lower in the NHBD group than in the BDD group (8.4 vs. 14.12 episodes per 1,000 transplant-days, respectively; P = 0.006). Patients in the NHBD group exhibited lower cumulative incidences of bacterial infection (P = 0.044), acute graft pyelonephritis (P = 0.081), CMV infection (P = 0.016), and non-CMV viral infection (P = 0.028). We found no differences in the incidence of other types of infection. On the regression model, and after adjusting for age, induction therapy, and cold-ischemia time, among other variables, the receipt of a NHBD graft did not remain as an independent risk factor for post-transplant infection (OR 0.63; 95% CI 0.35-1.15; P = 0.191). Conclusion: In our experience, and despite the higher occurrence of delayed graft function and CMV mismatch and the universal use of ATG induction, KT from uncontrolled NHBD does not entail an increased risk of post-transplant infection.

Non-Heart Beating Donor Kidney Transplantation Is not Associated with An Increased Risk of Post-Transplant Infection

Objectives: The use of kidneys from non-heart beating donors (NHBD) has increased notably over the last years. The impact of such strategy on the risk of post-transplant infection remains unclear. Methods: We performed a prospective cohort study including 225 patients (143 males; mean age: 54.4 ± 14.1 years) who underwent kidney transplant (KT) at our institution from November 2008 to August 2010. We compared the incidence and clinical and microbiological characteristics of post-transplant infection between recipients of brain-dead donor (BDD) and NHBD grafts (154 and 71 patients, respectively). NHBD belonged mostly to categories I and II of the Maastricht classification (uncontrolled donnors). All patients in the NHBD group received induction therapy with antithymocyte globulin (ATG) and antiviral prophylaxis (mainly valganciclovir) during the first 3 months. Multivariate adjusted odds ratios (ORs) for infection were calculated using those covariates found to be significant at P < 0.10 by univariate analysis. Results: As compared to patients in the BDD group, those in the NHBD group were younger (P < 0.001), had fewer years on pre-transplant dialysis (P = 0.004), shorter cold-ischemia times (P < 0.001), and higher number of HLA mismatches (P = 0.052). Delayed graft function (requirement for dialysis within the first week after transplantation) was more frequent in the NHBD group (84.5% vs. 52.6%; P < 0.001), as well as donor/recipient cytomegalovirus (CMV) mismatch (12.7% vs. 5,8%; P = 0.079). Incidence rates of overall infection in the NHBD and BDD groups were 1.94 and 3.25 episodes per 1,000 transplant-days, respectively (P < 0.0001). Incidence rate of early infection (during the first month) was also lower in the NHBD group than in the BDD group (8.4 vs. 14.12 episodes per 1,000 transplant-days, respectively; P = 0.006). Patients in the NHBD group exhibited lower cumulative incidences of bacterial infection (P = 0.044), acute graft pyelonephritis (P = 0.081), CMV infection (P = 0.016), and non-CMV viral infection (P = 0.028). We found no differences in the incidence of other types of infection. On the regression model, and after adjusting for age, induction therapy, and cold-ischemia time, among other variables, the receipt of a NHBD graft did not remain as an independent risk factor for post-transplant infection (OR 0.63; 95% CI 0.35-1.15; P = 0.191). Conclusion: In our experience, and despite the higher occurrence of delayed graft function and CMV mismatch and the universal use of ATG induction, KT from uncontrolled NHBD does not entail an increased risk of post-transplant infection.

Case-matched comparison of long-term results of non-heart beating and heart-beating donor renal transplants

Function and survival of non-heart-beating donor (NHBD) renal transplants have been shown to be comparable to those from heart-beating donors (HBDs) up to 10 years after transplantation. However, there are few data on outcome after 10 years, particularly from uncontrolled NHBD donors. All NHBD renal transplants (predominantly uncontrolled) performed between April 1992 and January 2002 were retrospectively matched with HBD renal transplants performed over the same period. Some 112 NHBD renal transplants were compared with 164 HBD renal transplants. Delayed graft function was significantly higher in the NHBD group (83.9 versus 22.0 per cent respectively; P < 0.001). Primary non-function rates were similar (5.4 versus 1.8 per cent respectively; P = 0.164). Overall serum creatinine was significantly higher in NHBDs (P < 0.001). Median graft and patient survival was 126 months for NHBD and 159 months for HBD kidneys. Death-censored graft survival at 1, 5, 10 and 15 years was respectively 91.8, 77.5, 61.0 and 44.2 per cent for NHBD, and 91.1, 86.3, 71.7 and 58.5 per cent for HBD kidneys (P = 0.108). Despite increased delayed graft function rates and serum creatinine levels, the long-term survival of NHBD renal transplants was similar to those from HBDs. However, there was a trend to poorer function and survival from 10 years after transplant.

Early Outcome After Lung Transplantation From Non–Heart-Beating Donors is Comparable to Heart-Beating Donors

The use of non-heart-beating donors (NHBD) to overcome organ shortage is moving into the clinic. In 2007, 5 of 51 lung transplantations (LTx) in our center were performed with lungs from controlled NHBD. Our aim was to describe these 5 NHBD LTx recipients and compare early outcome (<or= 6 months) with a cohort of 10 heart-beating donor (HBD) LTx recipients matched for age, gender, underlying disease, and time of surgery. Clinical outcomes were assessed, including ischemic times, gas exchange, primary graft dysfunction, time to extubation, time of discharge from intensive care unit/hospital, and pulmonary function. Airway and systematic inflammation were evaluated by bronchoalveolar lavage, total and differential cell counts, and plasma C-reactive protein levels, respectively. Early outcome in the NHBD group was comparable to the HBD group at the clinical and inflammatory level. The NHBD group showed a trend for earlier extubation (p = 0.054), greater increase in forced expiratory volume in 1 second (p = 0.054), and a significantly lower number of infections (p = 0.01). The NHBD group also had lower numbers of total cells (p = 0.04) and macrophages (p = 0.03) in bronchoalveolar lavage on day 21. Outcome after LTx in NHBD recipients is not inferior to HBD recipients during the first 6 months. Late results and effect on chronic rejection should be further awaited. Controlled NHBD may offer a valid source of lungs to overcome organ shortage in LTx.

Experimental Small Bowel Transplantation From Non–Heart-Beating Donors: A Large-Animal Study

Introduction The shortage of organs in the last 20 years is stimulating the development of new strategies to expand the pool of donors. The harvesting of a graft from non–heart-beating donors (NHBDs) has been successfully proposed for kidney and liver transplantation. To our knowledge, no studies are available for small bowel transplantation using NHBDs. In an experimental setting of small bowel transplantation, we studied the feasibility of using intestinal grafts retrieved from NHBDs. Materials and Methods Twenty five Large White piglets underwent total orthotopic small bowel transplantation and were randomly divided as follow: NHBD group ( n = 15) received grafts from NHBDs; heart-beating donor (HBD) group ( n = 10) received grafts from HBDs. The NHBD pigs were sacrificed inducing the cardiac arrest by a lethal potassium injection. After 20 minutes (no touch period = warm ischemia), they underwent cardiac massage, laparotomy, and aorta cannulation for flushing and cooling the abdominal organs. In HBDs, the cardiac arrest was induced at the time of organ cold perfusion. In both groups, immunosuppression was based on tacrolimus oral monotherapy. The animals were observed for 30 days. The graft absorptive function was studied at day 30 using the D-xylose absorption test. Histological investigation included HE (Hematoxilin and Eosin) microscopical analysis and immunohistological staining. Results Animals in the NHBD group died due to infection ( n = 3), acute cellular rejection ( n = 2), technical complications ( n = 2), and intestinal failure ( n = 8). In the HBD group, all animals but two were alive at the end of the study. The D-xylose absorption was significantly lower among the NHBD compared with the HBD group ( P < .05). Conclusions This study confirmed that intestinal mucosa is sensitive to ischemic injury. When the intestinal graft is harvested from NHBDs, the infectious-related mortality was higher and the absorptive function lower. Histological examination confirmed a higher grade of ischemic injury in the NHBD grafts that correlated with the clinical data. Therefore, this experimental study suggested that non–heart-beating donation may not be indicated for small bowel transplantation.

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 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.

Fibrinolytic Treatment Improves the Quality of Lungs Retrieved From Non-Heart-Beating Donors

The use of non-heart-beating donors (NHBDs) is an alternative strategy to increase the limited number of donors. The ex vivo evaluation has been proposed to assess the function of the lungs from NHBDs as an interim evaluation of the graft before transplantation. We evaluated the effect of a fibrinolytic agent, urokinase, in a pig ex vivo evaluation model. Domestic pigs (30-38 kg) were divided in 3 groups of 5 pigs each. In the Control Heart-Beating Donor (HBD) Group, the lungs were flushed, explanted, and stored in cold solution (4 degrees C) of low potassium dextran for 4 hours. The pigs in the other 2 study groups were non-heart-beating donors (NHBD), and their lungs were topically cooled for 1 hour in the closed chest after 3 hours of warm ischemia. Urokinase (100,000 IU) was added into the perfusate during reperfusion 1n 1 of the NHBD groups (NHBD-UROK). Hemodynamic and aerodynamic parameters were measured. The wet-to-dry weight ratio was calculated. There was a significant difference between NHBD-UROK and NHBD Groups in pulmonary vascular resistance (22.5 +/- 3.06 vs 39.02 +/- 6.6 Wood Units, p = 0.032), partial pressure of arterial oxygen/fraction of inspired oxygen (250.8 +/- 23.3 vs 148.9 +/- 14.6 mm Hg, p = 0.032), oxygenation index (6.9 +/- 0.7 vs 15.9 +/- 3.2, p = 0.016), and wet-to-dry weight ratio (5.99 +/- 0.2 vs 7.74 +/- 0.3, p = 0.016). Pulmonary vascular resistance did not differ between the HBD and NHBD-UROK Groups but was significantly higher in the NHBD Group than in the HBD Group (p = 0.032). Adding urokinase into the perfusate during ex vivo evaluation resulted in improved graft function by reducing pulmonary vascular resistance and increasing oxygenation after 3 hours of warm ischemia. This ex vivo evaluation model is feasible and may be used to recondition grafts from NHBDs.

Sequential Quadruple Immunosuppression Including Sirolimus in Extended Criteria and Nonheartbeating Donor Kidney Transplantation

The aim was to evaluate feasibility and safety of calcineurin inhibitor-free immunosuppression in high-risk donor kidney transplantation with sequential sirolimus introduction. Kidney transplant patients (n=76) with a donor aged >60 years, donor with acute renal failure, or a nonheartbeating donor were included. Immunosuppression consisted of antithymocyte globulin or basiliximab, mycophenolate mofetil, prednisone, and sequential introduction of sirolimus. One-year patient survival was 96.2% and 95.8%; graft survival was 94.2% and 91.7%; acute rejection rates were 21.2% and 12.4%; delayed graft function was 21.2% and 66.7%; and creatinine clearance was 58+/-20 mL/min and 56+/-21 mL/min for the brain-dead donor group and the nonheartbeating donor group, respectively. Most adverse events were infections, but also three lymphoceles, three urinary fistulas, three wound seromas. Sequential sirolimus introduction in high-risk donor kidney transplantation was found to lead to good patient and graft survival and incidence of acute rejection and delayed graft function.

The Effect of Perfusion Prior to Cold Preservation and Addition of Biliverdin on the Liver Graft from Non-Heart-Beating Donors

Aim Our aim was to improve the energy status and viability of a liver graft from a non-heart-beating donor (NHBD), we investigated the effects of perfusion prior to cold preservation and the addition of an antioxidant, biliverdin. Methods Rats were divided into five groups: group 1: without 30 minutes warm ischemia (WI) and cold preservation (control group); group 2 without WI and with 6 hours of cold preservation in UW solution (HBD group); group 3 with WI and cold preservation (NHBD group); group 4 with 30 minutes perfusion prior to cold preservation (PRE group); and group 5 with addition of biliverdin to precold preservation perfusion (BV group). Oxygenated Klebs-Henseleit solution was used as the perfusate prior to and after preservation. Portal flow and bile production during reperfusion, energy charge (EC), ATP level, GOT, and TNF-α were measured as well as a histological evaluation. Results Portal flow of the PRE and BV groups during 1 hour of reperfusion was higher than of that the NHBD group. Bile production of the PRE group was also higher than that of the NHBD group, but bile production in the BV group was comparable to the NHBD group. EC of the PRE group was higher than that of the NHBD group prior to and after reperfusion. The EC and ATP levels of the BV group after reperfusion were higher than those of the NHBD and PRE groups. The GOT and TNF-α were reduced in the BV group. Conclusions Precold preservation perfusion improves the viability of grafts from NHBDs. Furthermore, biliverdin exerted an additive effect to ameliorate energy status.

Reduced Liver Apoptosis After Venous Systemic Oxygen Persufflation in Non-Heart-Beating Donors

Graft injury caused by warm ischemia in livers from non-heart-beating donors (NHBDs) strongly affects posttransplantation outcome and is associated with liver apoptosis, which is mediated by death receptors, such as Fas, a surface receptor of the tumor necrosis factor (TNF)-α family. The aim of this study was to test the ability of venous systemic oxygen persufflation (VSOP) to reduce apoptotic changes and Fas activation in the liver after warm ischemic insult in vivo. Livers of male Wistar rats were harvested 30 min after cardiac arrest from non-heart-beating donors (NHBD) with (NHBD + O2) or without (NHBD) application of gaseous oxygen during the cold storage period via the suprahepatic caval vein. After 24 h of storage in University of Wisconsin solution at 4°C, viability of the livers was assessed upon isolated reperfusion in vitro. Conventional signs of tissue damage like enzyme release and bile production showed a significantly elevated nonspecific cell injury in the NHBD group. TUNEL staining revealed increased DNA fragmentation of sinusoidal endothelial cells in the NHBD group and more apoptotic hepatocytes than in the control group. All these alterations could be almost abrogated by the use of VSOP in the NHBD + O2 group. The immunohistochemical staining of Fas antigen expression showed a significantly elevated Fas receptor expression in the NHBD and NHBD + O2 groups, in accord with an eightfold increase of Fas receptor mRNA detected by real-time reverse-transcription polymerase chain reaction (RT-PCR). These results demonstrate that the postischemic apoptotic rate of sinusoidal endothelial cells in NHBD livers can be reduced by the use of VSOP. A significant improvement in liver integrity and viability was obtained with this technique, without influencing the expression of Fas expression.

Expanding the donor pool: use of renal transplants from non‐heart‐beating donors supported with extracorporeal membrane oxygenation

In response to organ shortage, we used the renal grafts from non-heart-beating donors (NHBDs). Extracorporeal membrane oxygenation (ECMO) was used to maintain NHBDs before organ procurement. We compared the results of renal transplantation from different donors, including heart-beating donors (HBDs), living-related donors (LDs), and NHBDs supported with ECMO. From February 1998 to June 2003, we recruited 219 patients receiving renal transplantation at National Taiwan University Hospital. Among them, 31 received kidneys from NHBDs supported with ECMO, 120 from HBDs, and 68 from LDs. Multiple organ transplant recipients were not included in this study. We compared the graft survival, serum creatinine levels, and estimated glomerular filtration rates of the three groups. The rate of delayed graft function was higher in NHBD recipients (41.9%) than in HBD recipients (27.0%) and LD recipients (10.9%) (p = 0.003). In the NHBD group, the recipients of grafts with delayed function had significantly longer ECMO runs (63.1 +/- 3.0 min) than those without delayed function (53.7 +/- 2.5 min) (p = 0.024). Estimated glomerular filtration rate (p = 0.472) and mean serum creatinine level (p = 0.286) were not significantly different between the three groups using a longitudinal approach. The 5-yr graft survival rates for NHBD (88.4%, 95% CI: 0.680-0.962), HBD (83.2%, 95% CI: 0.728-0.899), and LD transplant recipients (89.3%, 95% CI: 0.619-0.974) were not significantly different (p = 0.239). The 5-yr patient survival rates for NHBD, HBD, and LD transplant recipients were 100, 93.0 (95% CI: 0.859-0.966) and 100% respectively. The long-term allograft survival and function of kidneys from NHBDs supported by ECMO, HBD, and LD did not differ significantly. Long ECMO running time tended to delay graft function.

Comparison of renal allograft fibrosis after transplantation from heart-beating and non-heart-beating donors

Renal transplants from non-heart-beating donors (NHBDs) yield acceptable function and allograft survival rates in the medium term. However, the long-term results are less certain and there is a paucity of information relating to the development of chronic allograft nephropathy. The aim of this study was to compare allograft fibrosis in kidneys transplanted from NHBDs and conventional heart-beating donors (HBDs). A series of 37 NHBD and 75 HBD renal transplants were studied. Protocol renal transplant biopsies were performed at 6 and 12 months after transplantation. Biopsy sections were stained with Sirius red to demonstrate interstitial extracellular matrix. Renal allograft fibrosis was quantified using a computerized image analysis system. The mean first warm ischaemia time for kidneys from NHBDs was 24 min. A significant delay in graft function occurred in eight of 75 recipients in the HBD group and 31 of 37 in the NHBD group (P < 0.001). There were no significant differences in the level of allograft fibrosis between the two groups at any time point. Despite high rates of delayed graft function secondary to a prolonged warm ischaemia time, NHBD kidneys do not appear to be more susceptible to the development of renal allograft fibrosis. This study supports the growing body of evidence that kidneys from NHBDs are an acceptable alternative to those from HBDs.

A comparison of bile composition from heart-beating and non–heart-beating rabbit organ donors during normothermic extracorporeal liver perfusion: Experimental evaluation using proton magentic resonance spectroscopy

Background Organs retrieved from marginal and non–heart-beating donors (NHBDs) have sustained variable degrees of preretrieval damage that result in an increased incidence of complications. Normothermic extracorporeal liver perfusion (NELP) provides an opportunity to evaluate and resuscitate such organs. The aim of this study was to identify markers of ischemic injury in bile during perfusion of livers from heart-beating donors (HBDs) and NHBDs. Methods Livers were retrieved from New Zealand white rabbits. The HBD group ( n = 4) had no in situ warm ischemia before retrieval and the NHBD group ( n = 4), 45 minutes of in situ warm ischemia before liver retrieval. After 40 minutes of postretrieval cold ischemia, all livers were dual vessel reperfused, normothermically with oxygenated buffer solution supplemented with rabbit red blood cells, for 6 hours. Bile was collected and examined with 1HMRS. Results Perfusion bile from HBD group showed an increased concentration of bile acids, lactate, glucose, and phosphatidylcholine, but a decreased concentration of acetate as compared to retrieval bile. This trend was further enhanced in NHBD group. The mean ± SD (in μmol/L) were bile acids (10.48 ± 2.8 vs 26.05 ± 12.1 vs 44.5 ± 44.5), lactate (10.66 ± 4.5 vs 14.66 ± 5.2 vs 13.22 ± 1.8), glucose (5.37 ± 2 vs 21.2 ± 5.0 vs 29.09 ± 15.3), phosphatidylcholine (0.21 ± 0.02 vs 5.57 ± 1.7 vs 6.42 ± 0.3), and acetate (1.8 ± 0.5 vs 0.39 ± 0.1 vs 0.38 ± 0.09) for retrieval bile, HBD perfusion bile, and NHBD perfusion bile, respectively. One animal from each group did not produce any bile during perfusion. Conclusions 1HMRS of biliary constituents revealed differences with the type of ischemia. These indices may be potential markers of the extent of warm ischemic injury and the functional activity of an extracorporeally perfused liver.

Continuous infusion of nitroglycerin improves pulmonary graft function of non-heart-beating donor lungs.

The warm ischemic period of lungs harvested from a non-heart-beating donor (NHBD) results in an increased ischemia-reperfusion injury after transplantation. The intravenous application of nitroglycerin (NTG), a nitric oxide (NO) donor, proved to be beneficial during reperfusion of lung grafts from heart-beating donors. The objective of the present study was to investigate the effect of nitroglycerin on ischemia-reperfusion injury after transplantation of long-term preserved NHBD-lungs. Sixteen pigs (body weight, 20-30 kg) underwent left lung transplantation. In the control group (n=5), lungs were flushed (Perfadex, 60 mL/kg) and harvested immediately after cardiac arrest. In the NHBD group (n=5) and the NHBD-NTG group (n=6), lungs were flushed 90 min (warm ischemia) after cardiac arrest. After a total ischemia time of 19 hr, lungs were reperfused and graft function was observed for 5 hr. Recipient animals in the NHBD-NTG group received 2 microg/kg/min of NTG administered intravenously during the observation period starting 5 min before reperfusion. Tissue specimens and bronchoalveolar lavage fluid (BALF) were obtained at the end of the observation period. Compared with the control group, pulmonary gas exchange was significantly impaired in the NHBD group, whereas graft function in the NHBD-NTG group did not change. Leukocyte fraction and protein concentration in the BALF and histologic alteration of the NHBD-NTG group were not different from controls. Continuous infusion of NTG in the early reperfusion period improves pulmonary graft function of NHBD lungs after long-term preservation. The administration of an NO donor during reperfusion may favor the use of NHBD lungs to alleviate the critical organ shortage in lung transplantation.

Non-Heart Beating Donor Kidneys with Delayed Graft Function Have Superior Graft Survival Compared with Conventional Heart-Beating Donor Kidneys That Develop Delayed Graft Function

Delayed graft function may have an association with reduced graft survival, and nonheart-beating donor (NHBD) kidneys have higher rates of delayed graft function (DGF) than heart-beating donor (HBD) kidneys. This study compared outcome of renal transplants from HBDs who developed DGF, with NHBDs who developed DGF. All recipients of HBD and NHBD kidneys who developed DGF were identified during a 10-year period. All patients with graft primary nonfunction were excluded from analysis. Four hundred and fifty-six functioning transplants were performed. Delayed graft function occurred in 69 (17%) HBD and 55 (93%) NHBD kidneys. The grafts developing DGF were well matched for donor and recipient age. The rate of acute rejection was similar; [n = 16/69 (23%) HBD vs. n = 13/55 (24%) NHBD]. Cold ischaemia was 21 h in the HBD group and 17 h in NHBD group (p > 0.05). Serum creatinine was similar for both groups at 1.3 and 6 years (p > 0.05 for all time points). Graft survival in the NHBD recipients with DGF was significantly better at 3 years (84%) compared with recipients of a HBD renal transplant that developed DGF (73%) (p < 0.05), and at 6 years (62% survival for HBDs and 84% survival for NHBDs). This study shows that graft survival was better for NHBD kidneys up to 6 years after transplantation.

Use of two biomarkers of renal ischemia to assess machine-perfused non-heart-beating donor kidneys.

Renal transplantation is a recognized treatment for end-stage renal failure, offering a better quality of life, independence from dialysis, better survival rates, and decreased cardiovascular complications compared with renal replacement therapy (1). Recently, continued increases in the prevalence of end-stage renal failure and the length of transplantation waiting lists have not been matched by an increased supply of donors from the traditional brainstem dead donors and living donors. Non-heart-beating donor (NHBD) kidneys are regaining importance to substantially increase the kidney donor pool, with estimates indicating a potential increase of 20–40% (2)(3). The use of NHBD kidneys is associated with the development of two adverse conditions, primary nonfunction (PNF) and delayed graft function (DGF), which are caused by the ischemic injury that occurs after cardio-respiratory arrest. Therefore, in centers with NHBD programs, it has become necessary to screen-out damaged kidneys that will never work. Machine preservation using continuous hypothermic pulsatile perfusion has been adopted in NHBD kidney screening initiatives, and perfusion characteristics (flow, pressure, resistance, temperature, weight gain) with enzyme analysis of kidney effluents are used to assess viability. Since its isolation and identification as ligandin, glutathione S -transferase (GST) has evolved as a suitable biomarker in the pretransplantation assessment of machine-perfused NHBD kidneys. Different isoforms have been identified from the distal and proximal renal tubules, and the commonest isoform, α-GST, has previously been used as a biomarker of renal ischemia as assessed by ELISA (4). However, we have previously demonstrated that a spectrophotometric assay for total GST activity (tGST) could reliably be substituted for α-GST (5). Original work by the Maastricht NHBD group has established threshold limits for tGST activity in kidney perfusates for the selection of “viable” kidneys for transplantation (6). This criterion has been introduced in Newcastle, England, where 69 NHBD renal transplants have …

Tissue damage of non-heart-beating donor lungs after long-term preservation: evaluation of histologic alteration, bronchoalveolar lavage, and energy metabolism.

Several studies have shown that warm ischemia before short-term preservation of pulmonary grafts from non-heart-beating donors (NHBD) induced morphological changes, but still provided a good pulmonary graft function. The aim of this study was to investigate morphological and metabolic changes of NHBD lungs after long-term preservation. Left lung allotransplantation was performed on 12 native-bred pigs. In the NHBD group, lungs were subjected to 90 min of warm ischemia before harvesting, whereas lungs in the HBD group were harvested immediately after cardiac arrest. After a total ischemic period of 19 h, lungs were reperfused and pulmonary gas exchange was assessed. Bronchoalveolar lavage (BAL) and tissue specimen for wet-to-dry weight (W/D) ratio, histologic examination, and measurement of high-energy phosphates were taken 5 h after reperfusion. All parameters were compared with a sham-operated control group. Five hours after reperfusion, mean paO2 and paCO2 were 288 +/- 52 and 48 +/- 0.8 mmHg, respectively, during isolated ventilation of the pulmonary graft with 100% oxygen in the NHBD group. W/D ratio and high-energy phosphates of the pulmonary graft did not differ between our study groups. Histologic examination showed significant morphological changes in the HBD and NHBD group, but alterations were more pronounced in the NHBD group. The percentage of neutrophils, total protein content, and potassium concentration were significantly elevated in the BAL fluid of the NHBD group. Despite the observed aggravation of cellular injury after long-term preservation, NHBD lungs still performed a good pulmonary graft function.

Fas Receptor Is Upregulated in Livers from Non-Heart-Beating Donors

Cell injury in livers from non-heart-beating donors (NHBDs) is not only caused by necrosis, but it is increasingly being recognized that apoptotic transformation contributes to postischemic cell death. It remains unclear which pathways lead to apoptosis. We suggested that apoptosis in NHBD livers might be mediated by the Fas receptor. Therefore the aim of our study was the detection and quantification of the Fas receptor, Fas mRNA and apoptosis in NHBD livers. Livers of male Wistar rats were harvested either from heart-beating donors (control, n = 15) or 30 min after cardiac arrest from NHBDs (n = 15). All livers were stored in University of Wisconsin solution for 24 h at 4°C, and reperfused using a recirculating model with oxygenated Krebs-Henseleit buffer for 120 min at 37°C. Conventional signs of cell damage, such as enzyme release and bile production, showed an elevated nonspecific cell injury in NHBD livers. The immunohistochemical staining of Fas antigen expression revealed a 7% rate of Fas receptor-expressing hepatocytes in the control group, but a considerable increase up to 38% in the NHBD group. No Fas antigen expression was detected on sinusoidal endothelial cells. Real-time RT-PCR detected an approximately eightfold elevated concentration of Fas mRNA transcripts in NHBD livers. We conclude that upregulation of the Fas receptor on hepatocytes in NHBDs will prime these cells to eventually undergo apoptosis upon reperfusion in vivo. Therefore, therapeutic modulation of the Fas pathway must be considered as a new strategy in order to additionally protect NHBD livers which are otherwise prone to parenchymal apoptosis.