Organ Retrieval Research Articles

Zonal organ allocation system and its impact on long-term outcomes after lung transplantation: a propensity score matched analysis†.

Zonal organ allocation system comprises organ procurement by teams within a specific geographical area of each retrieval team. Therefore, in a substantial number of cases organs are retrieved by 'foreign' teams and are sent for transplantation to the implanting centre. The aim of this study was to assess the impact of zonal organ allocation system on early- and long-term outcomes after lung transplantation (LTx). Included were 331 consecutive patients who underwent LTx performed at Harefield Hospital between January 2007 and January 2015. Recipients were divided into two groups depending on the organ retrieval team: 204 (61.6%) patients were transplanted using lungs procured by our institutional team (institutional group), whereas 127 (38.4%) organs were retrieved by other teams (external group) from experienced transplant centres in the UK. To exclude selection bias and other confounders, a 1:1 propensity score-based matching procedure was performed resulting in a total number of 238 donors and recipients who were well matched for baseline characteristics. The primary end-points were overall survival after LTx and freedom from bronchiolitis obliterans syndrome (BOS). Secondary end-points were perioperative clinical characteristics as well as adverse events that occurred over the follow-up. After propensity score matching all donor characteristics and all baseline recipient characteristics were statistically similar between the two groups. In terms of early postoperative results, both groups were statistically comparable. However, there was a trend towards higher incidence of primary graft dysfunction in the external group (P = 0.054). Regarding long-term results with up to 7 years of follow-up, the overall survival also appeared to be poorer in the external group; however, this difference did not reach statistical significance. The freedom from BOS over the long-term follow was significantly poorer in the external group (P = 0.040). Despite excellent early outcomes the zonal allocation system might be associated with significantly poorer long-term outcomes in terms of freedom from BOS after bilateral LTx. Further research is needed to find the underlying factors leading to these results.

Use of Coping Mechanisms in Organ Donation and Transplantation with Distinctive Orientation to Brain Stem Death

This paper talks about psychodynamic theory of psychology wherein individuals adopt various defense mechanisms in order to cope with unpleasant thoughts, emotions or behaviors while dealing with multifaceted processes of organ donation and transplantation. Organ donation from brain stem dead donors and transplantation involves certain psychological defense mechanisms like sublimation, introjections, projection, intellectualization, and denial that are explained through a few case studies of organ donor families, non-donor families, recipients of organs, families of recipients, organ transplant coordinators and doctors. The author discusses how individuals behave in different ways in order to deal with the unpleasant thoughts, emotions or behaviors that are intertwined with intricate debates, dilemmas and convolutions of organ donation and transplantation especially from brain stem dead donors. The organs donated by brain stem dead donors are used for transplantation into people struggling for life with end stage organ failures. The paper represents the narratives of individuals through diagrams that explain the nature of defense mechanisms adopted by people and professionals in organ donation and transplantation. Through these case studies the author wants the authorities to focus on issues that could resolve some problems that are encountered in day to day activities by professionals especially organ transplant coordinators in India. There are a number of areas wherein government needs to put efforts like making easy permissions from police, preventing double permission from police as is required in Medico Legal Cases if the accident has happened in one place and the organ retrieval at the other. There is a dire need to start extensive awareness programmes in all related ministries. The government needs to be sensitive to the plight of poor people who wait for long hours to get back the body once they decide to donate organs in Govt. hospitals. They deserve some care in government hospitals during waiting period. Some budgetary provisions needs to be made for the same. One of the very important things is to introduce a topic on defense mechanisms in organ transplant coordinators course to make them understand the coping mechanisms better. Such efforts will help them in understanding each other better and help them to become effective team members.

Risk‐based decision making and ethical considerations in donor compensation for plasma‐derived medicinal products

Risk‐based decision making and ethical considerations in donor compensation for plasma‐derived medicinal products

Organ Donation and Transplantation From Donors With Systemic Infection: A Single-Center Experience.

Donors with bacteremia and sepsis are often considered to be controversial for organ retrieval due to potential transmission of an infectious agent to the recipient. Herein we report our initial experience of organ donation and transplantation results from donors with systemic infection. From January 2013 to December 2014, 125 cases of donation were completed in our organ procurement organization including 90 cases of donation after brain death (DBD) and 35 cases of donation after circulatory death (DCD). The results of bacterial culture of the donor's peripheral venous blood (PVB), blood from central venous catheter (BCVC), urine, bronchial aspiration, and tip of central venous catheter (TCVC; Maki's semiquantitative culture) were retrospectively reviewed. All liver transplant recipients received specific antibiotics according the susceptibility profiles of the PVB cultures, and all kidney transplant recipients received specific antibiotics according the susceptibility profiles of the PVB and urine cultures. Bacterial infection diseases transmission from donors of the liver and kidney transplant recipients were also retrospectively reviewed. The positive rates of the bacterial culture of the donor's bronchial aspiration, PVB, BCVC, TCVC, and urine were 46.4% (39/84), 20.2% (24/119), 15.8% (12/76), 11.1% (3/27), and 7.0% (8/115), respectively. Only 28.1% (9/32) of donors with positive cultures of PVB or urine received specific antimicrobial therapy before harvesting. Twenty-two livers and 46 kidneys from donors with systemic infection (positive PVB culture) were transplanted, and no case of bacterial infection diseases transmission occurred in the recipients. In the circumstance of donor systemic infection with positive bacterial culture of PVB, the liver and kidney can be transplanted safely with prophylactic antibiotics. Donors with systemic infection are not a contraindication for organ donation.

Factors Associated With Delayed Graft Function and Their Influence on Outcomes of Kidney Transplantation.

One of the main postoperative complications of kidney transplant is delayed graft function (DGF), which means absence of graft function after transplant or the need for dialysis during the first week post procedure. The occurrence of DGF currently in our hospital is high and has been attributed to a combination of many factors. The aim of this study was to evaluate the factors associated to DGF and their influence in the outcome of kidney transplants. Historical cohort of 150 patients transplanted with live or deceased donor kidneys from 2011 to2013. DGF was associated to time in dialysis and the number of recipient pre-transplant transfusions, donors age, serum creatinine level, use of vasoactive drugs in the donor, distance from place of organ retrieval and transplant center, and duration of cold ischemia time. DGF influenced post-transplantation outcome in regard to length of stay in intensive care, length of hospital stay, acute rejection episodes, and higher creatinine levels at discharge. Patients and graft survival were shorter in the DGF group. There are multiple factors related to DGF, the most important being those related to donors, and organ storage. The most important factor related to the recipient was the dialysis vintage. We did not find a correlation between DGF and HLA-compatibility. DGF consequences are important, including worse graft function and survival, as well as impact in recipient morbidity and mortality.

Liver transplantation in the United Kingdom.

Liver transplantation (LT) services in the United Kingdom are provided by 7 designated transplant centers for a population of approximately 64 million. The number of deceased organ donors has grown, and in 2014-2015 it was 1282 (570 donation after circulatory death and 772 donation after brain death). Donor risk is increasing. In 2014-2015, there were 829 LTs from deceased and 38 from living donors. The common causes for transplantation are liver cell cancer, viral hepatitis, and alcohol-related liver disease. Livers are allocated first nationally to super-urgent listed patients and then on a zonal basis. The United Kingdom will be moving toward a national allocation scheme. The median interval between listing and transplantation is 152 days for adults awaiting their first elective transplant. Of the adults listed for the first elective transplant, 68% underwent transplantation at < 1 year; 17% are waiting; and 4% and 11% were removed or died, respectively. The 1- and 5-year adult patient survival rate from listing is 81% and 68%, respectively, and from transplantation is 92% and 80%, respectively. The transplant program is funded through general taxation and is free at the point of care to those who are eligible for National Health Service (NHS) treatment; some have to pay for medication (up to a maximum payment of US $151/year). The competent authority is the Human Tissue Authority which licenses donor characterization, retrieval, and implantation; transplant units are commissioned by NHS England and NHS Scotland. National Health Service Blood and Transplant (NHSBT) promotes organ donation, maintains the organ donor register, obtains consent, and undertakes donor characterization and offering. NHSBT also maintains the national waiting list, develops and applies selection and allocation policies, monitors outcomes, and maintains the UK National Transplant Registry and commissions a national organ retrieval service. Liver Transplantation 22 1129-1135 2016 AASLD.

Prospective audit to evaluate the potential of the coronial system to increase solid organ donation

ObjectivesAnecdotal evidence suggests that organ donation from deceased donors referred to the Coroner/Procurator Fiscal (PF) could be increased if all followed best practice. The aim of this prospective audit was...

Effective Application of a Quality System in the Donation Process at Hospital Level

This article describes the application of a quality system at the hospital level at the Multidisciplinary Hospital in Warsaw–Międzylesie in Poland. A quality system of hospital procedures (in accordance with the ISO system 9001:2008) regarding the donation process, from the identification of a possible donor to the retrieval of organs, was applied there in 2014.Seven independent documents about hospital procedures, were designed to cover the entire process of donation. The number of donors identified increased after the application of the quality system. The reason for this increase is, above all, the cooperation of the well-trained team of specialists who have been engaged in the process of donation for many years, but formal procedures certainly organize the process and make it easier.

MP80-06 INTRAOPERATIVE BIMANUAL EXAMINATION AND FROZEN-SECTION ANALYSIS DURING ROBOT-ASSISTED RADICAL PROSTATECTOMY: A NOVEL TECHNIQUE FOR REDUCING POSITIVE SURGICAL MARGINS

INTRODUCTION AND OBJECTIVES: To describe the feasibility and early outcomes of a Modification to robot-assisted radical prostatectomy (RARP) that allows for mitigation of the lack of tactile feedback during RARP by allowing immediate Organ Retrieval for Examination and targeted frozen-section biopsies (MORE technique). METHODS: MORE consists of a GelPOINT device inserted periumbilically. Prostate is excised and retrieved through the GelPOINT without undocking the robot, and examined bimanually on-table by the surgeon. Lesions suspicious for positive surgical margin (PSM) are sent for frozen section analysis (Figure). Biopsies positive/suspicious for cancer resulted in more tissue excision from the corresponding pelvic bed site. 352 patients with a probability of extracapsular extension (EPE) >25% (Partin table) were selected to undergo MORE RARP. MORE RARP patients with pT3a at final pathology (n1⁄4103) were compared to a control group of 74 consecutive patients with pT3a after conventional RARP. RESULTS: Except a greater proportion of clinically palpable disease in the MORE RARP vs. control group (43.7 vs. 17.6%; p1⁄40.005), the two groups had comparable rates of nodal dissection, nerve sparing, pathological stage, grade and nodal status. The PSM rate in the MORE group was 17.5% (18/103) compared to 36.5% (27/74) in the control group (p1⁄40.004); the odds ratio was 0.37 (CI: 0.18-0.74; p1⁄40.005). 8 patients in each group had biochemical recurrence; short follow-up (median 16.6 and 15.4 months respectively) precluded detection of any significant difference. Frozen section biopsy site matched the EPE site at final pathology in 59/79 (73.4%) cases selected for frozen section analyses. CONCLUSIONS: Adoption of the MORE technique led to a significant reduction in the PSM rate following RARP in patients harboring locally advanced disease without increasing operative time. Its easy reproducibility may also allow potential utility in other robotassisted urologic oncologic procedures. Source of Funding: none

Contrast-Based Real-Time Assessment of Microcirculatory Changes in a Fatty Liver After Ischemia Reperfusion Injury.

A fatty liver is known to have impairment of microcirculation, which is worsened after ischemia reperfusion injury (IRI). This makes most fatty grafts unsuitable for transplantation, and in the absence of real time assessment of microcirculation this selection has been at best, random. The aim of this study was to demonstrate the utility of a contrast enhanced ultrasound model in quantitative assessment of the microcirculation of a fatty liver. We subjected fatty mice to IRI, and blood flow dynamics were assessed before and after the injury. There was a significant increase in the resistive and pulsatility index of the extrahepatic artery and a significant decrease in velocity of the portal vein. There was also a quantifiable decrease in the intrahepatic blood volume, blood flow, time to peak flow, and perfusion index of mice with fatty liver, suggesting that a fatty liver develops hemodynamic abnormalities after IRI, leading to increased hepatocellular injury. Hemodynamic abnormalities in liver can be reliably quantified using a contrast, enhanced Doppler ultrasound, which is an inexpensive technique with multiple clinical applications. It can be used to assess the quality of the fatty liver donor graft before organ retrieval; for determining live donor candidacy, for making post-IRI recovery prognosis, and for assessing the effectiveness of therapeutic interventions.

Single-center study on transplantation of livers donated after cardiac death: A report of 6 cases.

Effective use of all available donated organs is critical, in order to meet the increasing demand for transplants. The present study explored liver transplantation with livers that were donated following cardiac death (DCD). According to the guidelines established by The Red Cross Society of China, 42 DCD organs were procured. Selected donors were treated with extracorporeal membrane oxygenation (ECMO) prior to the organ retrieval. The present single-center study included 6 liver transplantations of DCD organs (5 liver transplants and 1 liver-kidney combined transplant). All 6 recipients had a successful recovery without significant complications. The serum alanine transaminase, total bilirubin and international normalized ratio returned to the normal levels within a short period of time following transplantation, and the liver function remained normal during the follow-up period, which lasted up to 24 months. The present report demonstrated the feasibility of orthotopic liver transplantation using DCD livers. The pre-conditioning DCD donors and optimization of the recipient's condition using ECMO, played a crucial role in ensuring the success of transplantation.

Ethical, legal, and societal issues and recommendations for controlled and uncontrolled DCD.

This report deals with organ retrieval procedures in both controlled and uncontrolled DCD, looking at the ethical, legal, and psychosocial aspects during the different phases of the process. A recently published report by the UK Donation Ethics Committee (UKDEC) has served as an important reference document to outline the steps in the controlled DCD patient-donor pathway (Academy of Medical Royal Colleges. UK Donation Ethics Committee. An ethical framework for controlled donation after circulatory death. December 2011). For uncontrolled DCD, the UKDEC pathway description was adapted. At the 6th International Conference in Organ Donation held in Paris in 2013, an established expert European Working Group reviewed the UKDEC reports, which were then considered along with the available published literature. Along this pathway, the crucial ethical, legal, and psychosocial aspects have been flagged, and relevant recommendations have been formulated based on a consensus of the working group.

Kidney transplantation in India: Challenges and future recommendation

Successful kidney transplantation offers the best possible quality of life for patients with end stage renal disease (ESRD). Despite this, renal transplantation rates in the developing world are considerably lower than in the developed world. Identified reasons for this include lack of awareness, low education levels, lack of a clear national policy, absence of functional dialysis and transplant units with adequately trained staff, and absence of an organized system of organ retrieval from deceased donors and lack of opportunities to fund long-term immunosuppression. Measures to improve the quality of care should center on improvement of the socioeconomic status of the country. Key action points include the implementation of: (1) Chronic kidney disease (CKD) screening and prevention programs; (2) ESRD and transplantation registries; (3) transplantation legislation, covering both living and deceased organ donation; (4) international and regional collaborations for transfer of knowledge and technology. The government should make transplantation more affordable by strengthening the public sector hospitals and by making the transplant medication more affordable. With the National Organ Transplant Programme (NOTP) in the process of being established in India, the transplant community should strive to increase the organ donation awareness, improve the infrastructure for organ retrieval, storage and allocation in an equitable way.

Deceased Organ Donation.

SRTR uses data collected by OPTN to calculate metrics such as donation/conversion rate, organ yield, and rate of organs recovered for transplant but not transplanted. In 2014, 9252 eligible deaths were reported by organ procurement organizations, a slight increase from 8944 in 2012, and the donation/conversation rate was 73.4 eligible donors per 100 eligible deaths, a slight increase from 71.3 in 2013. Some metrics show variation across organ procurement organizations, suggesting that sharing best practices could lead to gains in efficiency and organ retrieval.

A study of factors influencing decisions on organ donation among patient attendees in a Tertiary Care Hospital in North India

Introduction: Organ transplantation is the most preferred treatment modality for end-stage organ disease and organ failures as it improves the quality of life. Patients deemed fit for transplantation by the transplant team often wait expectantly for a donor organ. Each year thousands of individuals wait for organs to be donated for transplantation. There remains, therefore, a great need for increasing organ donation and harnessing of donor organs. Aims and Objectives: To determine knowledge, attitude, and practices of the general population for organ donation. To determine the factors which facilitate or inhibit general population from organ donation. Methodology: A cross-sectional survey was conducted among a total of 120 patient attendants attending outpatient department in the age group of 18–65 years at Sir Ganga Ram Hospital, New Delhi. Results: One hundred and twenty participants were enrolled in the study, but only 119 participated. The mean age of males was 37.7 ± 14.7 years while that of females was 32.7 ± 11.5. Maximum awareness was found to be for kidney donation, least awareness for ear drums, and intestine donation. About 49.1% males and 51.6% females were aware of the legislation related to organ transplantation. The majority of female respondents (73.3%) showed their willingness to donate their organs in contrast to males only 16.7% were ready to donate in any situation. Females (60.7%) outnumbered males (45.8%) in their readiness to sign an organ donor card. About 73.3% females and 64.4% males were ready to participate in any promotion campaign related to organ donation. Conclusion: The magnitude of organ retrieval for the execution of a successful donor program is heavily dependent upon the level of knowledge and attitudes of the general public, so the need of hour is to increase the awareness among masses.

The WHO Shorter MDR-TB Regimen: Who Will Benefit With It?

Lung transplantation is a surgical option to replace a diseased lung with a healthy lung from a donor. This surgical process causes stop of blood flow from the point of organ retrieval or procurement followed by cold and warm storage phase (ischemia), followed by the re-instatement of blood flow with implantation (reperfusion) that occurs upon transplant. The injury incurred during ischemia (retrieval and storage) together with the injury from reperfusion (I/R injury) is considered as the main driver of onset of primary graft dysfunction (PGD). PGD is a multifactorial injury that is characterized by cellular infiltrates and severe oxidative damage; it occurs within 24 h post-transplant and is a critical factor in determining transplant outcome. PGD occurs in large part due to inflammation post-transplant when polymorphonuclear neutrophils (PMN) are recruited to and adhere to the endothelium of the lung, transmigrate and release reactive oxygen species (ROS). Recognizing the role of PMN in poor transplant outcome, the clinical strategy at present is to block PMN activation by a non-specific immunosuppression regimen administered to the transplant recipient.As immunosuppression therapy has severe side effects, alternate means of blocking and inhibiting inflammation in the lung are being considered. The binding of PMN to the endothelium is a prerequisite of inflammation; thus our research is focused on the endothelium of the donor lung so as to block endothelial signals that facilitate its bindingto PMN. Such a strategy of inhibiting the moieties on the vascular wall so that as prevent donor lung endothelial interaction with the recipient’s PMN is an early intervention and has the potential to prevent injury completely. In contrast, immunosuppression involves minimizing influx and recruitment of PMN and immune cells after the initial adherence and binding that would take place immediately upon transplant. Our extensive work on lung storage or ischemia shows that the pulmonary endothelium responds to stop of blood flow by a signaling cascade that involves K ATP channel closure, PI3Kinase activation and assembly of the enzyme NADPH oxidase 2 (NOX2) leading to the generation of ROS. We found that the ROS thus produced triggers the onset of an inflammation cascade during the storage period itself, ahead of the transplant event. Onset of inflammation causes damage to the donor lung during storage thus affecting donor lung availability; additionally it can potentially drive immune cell recruitment via inflamed lung vessel wall. Thus optimal storage conditions such as keeping the lung (organ) perfused or inhibiting ischemia induced signaling by blocking K ATP closure, PI3K activation or NOX2 assembly may potentially preserve lung viability and minimize inflammation and injury post-transplant.

Translational Research in Pediatrics IV: Solid Tissue Collection and Processing.

Solid tissues are critical for child-health research. Specimens are commonly obtained at the time of biopsy/surgery or postmortem. Research tissues can also be obtained at the time of organ retrieval for donation or from tissue that would otherwise have been discarded. Navigating the ethics of solid tissue collection from children is challenging, and optimal handling practices are imperative to maximize tissue quality. Fresh biopsy/surgical specimens can be affected by a variety of factors, including age, gender, BMI, relative humidity, freeze/thaw steps, and tissue fixation solutions. Postmortem tissues are also vulnerable to agonal factors, body storage temperature, and postmortem intervals. Nonoptimal tissue handling practices result in nucleotide degradation, decreased protein stability, artificial posttranslational protein modifications, and altered lipid concentrations. Tissue pH and tryptophan levels are 2 methods to judge the quality of solid tissue collected for research purposes; however, the RNA integrity number, together with analyses of housekeeping genes, is the new standard. A comprehensive clinical data set accompanying all tissue samples is imperative. In this review, we examined: the ethical standards relating to solid tissue procurement from children; potential sources of solid tissues; optimal practices for solid tissue processing, handling, and storage; and reliable markers of solid tissue quality.

Presumed consent for organ donation: illusion of a choice

India has been following informed consent (opt- in) system of organ donation but soft pressures to shift to presumed consent (opt- out) system are simultaneously palpable. This paper describes presumed consent briefly and explains why the need to shift to this system is felt. The paper challenges the morality of presumed consent system and describes its use as absolutely unethical in view of socio cultural diversity, educational disparity and profound class stratification of our country. The paper throws some light on our own system which, unlike other countries, is not ready for this change. It focuses on thought-provoking issues that are deterrents to achieving increase in organ donation even if presumed consent system is adopted in India. It reflects the outcome of this coercive legal option in some countries. In some countries there was no change in organ donation rates. A few countries witnessed negative repercussions of presumed consent system. Some of these countries had no option except to revert back to opt- in system. The paper tries to give a message to the public and professionals by comparing Spain to India that has high donation rates in the world not because of presumed consent but because of other contributory factors. Spain initiated organ donation and transplant activities much ahead of India and their healthcare services are rated the best in the world. Socio-cultural, religious and political milieu unlike India is conducive to organ donation in Spain. Adequate investments in public health, adequate budget for organ donation and transplantation, excellent infrastructure, availability of public health assistance to 99% population, adequate availability of ICU beds, extending end of life care to all, positive approach to organ donation by majority of people, thorough professionalism and public trust is what makes Spain the best country in organ donation. The same is lacking in India. The paper warns us of this coercive option by drawing a parallel to the coercions that took place when India acted coercively to control population through compulsory sterilization and led to the wrath of masses in 1976. India as on date needs to focus on other issues to increase organ donation rates like development of infrastructure, developing well-functioning national, regional and state level organizations, building in trust of people, identifying potential donors, managing donors, caring for donor families, training manpower, increasing awareness on organ donation and transplantation, reimbursing fees to organ retrieval hospitals, merging efforts of various stakeholders, developing transparent and workable organ sharing policies and regular auditing of brain stem deaths.

The use of ex-vivo normothermic perfusion for the resuscitation and assessment of human kidneys discarded because of inadequate in situ perfusion.

BackgroundMany kidneys are rejected for transplantation due to inadequate in situ perfusion during organ retrieval because of the risk of additional ischaemic injury and microvasculature thrombosis. This study describes the use of ex vivo normothermic perfusion (EVNP) for the resuscitation and assessment of human kidneys that were discarded after inadequate in situ perfusion.MethodsTwenty-two human kidneys were retrieved but then deemed unsuitable for transplantation, primarily due to inadequate in situ perfusion. After a period of static cold storage, kidneys were perfused for 60 min with an oxygenated red cell based solution at 36 °C.ResultsNineteen out of 22 kidneys (86 %) were from DCD donors. During EVNP, kidneys were assessed and scored based on their macroscopic appearance, measures of renal blood flow and urine production. Kidneys were scored from 1 indicating the least injury to 5, indicating the worst. Twelve kidneys had an EVNP score of 1–2, 7 scored 3–4 and 3 kidneys scored 5. The EVNP score 5 kidneys had a low level of tubular function compared to the score 1–4 kidneys. Their perfusion parameters did not improve during EVNP and they were considered non-transplantable. There was no association between the histological evaluation and EVNP parameters.ConclusionEVNP restores function ex vivo and enables an assessment of kidneys that have been declined for transplantation due to inadequate in situ perfusion.

Diagnostic workup of brain-dead organ donors and organ retrieval

Renal transplantation is well established as the best and often the only treatment for many patients with end-stage kidney failure. Because of an increasing shortfall between the diminishing number of deceased donor organs available and the increasing waiting list of patients in need of transplantation the shortage of suitable donors remains one of the most pressing challenges. The success of organ transplantation can be attributed to many factors but ultimately depends upon retrieval and preservation techniques to maintain the quality of an organ. Although the literature on organ retrieval is extensive, the level of evidence provided is mainly low. But as techniques and treatments improve, it may be possible to use organs from donors who were previously thought to be unsuitable. This article provides the reader an overview on the topic of organ donation.