Successful segmental auxiliary liver transplantation from a non-heart-beating donor: implications for split-liver transplantation

BACKGROUND: Liver transplantation (LT) using grafts from non-heart-beating donors (NHBDs) has been shown to be a successful practice. Recently reported primary nonfunction rates are similar to those of LT using grafts from brain-dead donors. METHOD: We report the use of an NHBD liver, which was cut into a right-lobe graft and implanted as an auxiliary partial orthotopic liver transplant for acute liver failure in a 11-year-old child. The warm ischemia time was 21 minutes, and the cold ischemia was 8 hours. RESULTS: Initial graft function was excellent, and the child is well, with normal liver function 2 months posttransplant. CONCLUSION: Reduction and splitting of livers from NHBDs for transplantation is a realistic option, provided there is careful selection of the graft.     

Long-term results for liver transplantation from non-heart-beating donors maintained with chest and abdominal compression-decompression

INTRODUCTION: The aim of this study was to evaluate long-term results after liver transplantation from non-heart-beating donors (NHBD) using the method of chest and abdominal compression-decompression to maintain donors. METHODS: From December 1995 to November 2004, 10 NHBD were identified and maintained by means of the method of chest and abdominal compression-decompression until family and judicial permission were granted. Nine donors were Maastricht type II and one was type IV. RESULTS: The mean age of donors was 40.5 years and the mean time under cardiopulmonary resuscitation (CPR) was 80 minutes. Orthotopic liver transplantation (OLT) was performed using these 10 liver grafts after a mean cold ischemia time of 561.5 minutes. All patients developed good posttransplant function, except for one patient who presented with primary nonfunction corrected with retransplantation. This complication was directly related to a long CPR time (P < .01). After a mean follow-up of 57 months, only one patient died from a hepatitis C virus (HCV) recurrence. The rest of the patients have maintained good graft function over time. CONCLUSIONS: NHBD maintained with the method of chest and abdominal compression-decompression are a valid choice to increase the donor pool. Liver transplantation using these grafts has proven good long-term results, comparable to their heart-beating counterparts.     

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.     

大鼠心脏停搏供体肝移植的实验研究

目的 探讨大鼠原位肝移植过程中,供肝可能耐受心脏停搏热缺血损伤的时间极限,方法 雄性SD大鼠,以供肝获取前供体大鼠经历心脏停搏时间0、15、30、45、60min分为5组（HB组、N-15组、N-30组、N-45组和N-60组）,而后行大鼠原位肝移植,比较各组的术后肝功能、肝脏病理和存活率。结果 HB、N-15、N-30、N-45和N-60的大鼠肝移植术后1周存活率分别为：100%（8/8）、75%（6/8）、62.5%(5/8)、25%（2/8）和0%（0/8）。其中HB、N-15、N-30组和N-45组的大鼠肝移植最长存活时间超过30d。结论 大鼠供肝对于热缺血损伤的时间应越短越好,但耐受30min心脏停搏热缺血损伤时,仍可使1周存活率达62.5%,极限时间为45min。     

Segmental Liver Transplantation from Non-Heart Beating Donors—An Early Experience with Implications for the Future

We report our experience of pediatric liver transplantation with partial grafts from non-heart beating donors (NHBD). Controlled donors less than 40 years of age with a warm ischemia time (WI) of less than 30 min were considered for pediatric recipients. Death was declared 5 min after asystole. A super-rapid recovery technique with aortic and portal perfusion was utilized. Mean donor age was 29 years and WI 14.6 min (range 11–18). Seven children, mean age 4.9 years (0.7–11), median weight 20 kg (8.4–53) received NHBD segmental liver grafts. Diagnoses included seronegative hepatitis, neonatal sclerosing cholangitis, familial intrahepatic cholestasis, hepatoblastoma, primary hyperoxaluria and factor VII deficiency (n = 2).The grafts included four reduced and one split left lateral segments, one left lobe and one right auxiliary graft. Mean cold ischemia was 7.3 h (6.2–8.8). Complications included one pleural effusion and one biliary collection drained percutaneously. At 20 months (10–36) follow-up all children are alive and well with functioning grafts.
Donation after cardiac death is a significant source of liver grafts for adults and children with careful donor selection and short cold ischemic times.     

Assessment of liver function during extracorporeal membrane oxygenation in the non-heart beating donor swine

INTRODUCTION: Although the use of non-heart beating donors (NHBD) could bridge the widening gap between organ demand and supply, its application to liver transplantation is limited due to warm ischemia (WI), biliary tree injury, and inadequate organ assessment. Warm blood reperfusion using extracorporeal membrane oxygenation (ECMO) can be a suitable option to reduce WI in organs from NHBD, allowing one to determine hepatic flow characteristics and bile production and facilitating assessment of organ viability. METHODS: This work evaluates the use of warm blood veno-arterial ECMO reperfusion in NHBD swine. Systemic and hepatic hemodynamics, bile, urine, and mixed venous blood were measured. After baseline data collection, 10 kU heparin was given intravenously followed by 1 g KCl to elicit cardiac arrest (CA). ECMO was started after 30 or 60 minutes of CA and kept running for 120 minutes. RESULTS: One-way repeated measures analysis of variance (ANOVA) with Tukey test analysis was used within a group. Two-way ANOVA was used between groups. ECMO can restore venous SO2 and pH in both groups; the values were close to baseline in the 30-minute CA group. Also, in this group, bile production was > 65% from baseline early during reperfusion and its value was lower in the longer CA group < 55% (P < .001). Aspartate aminotransferase (AST) was doubled at the end of ECMO support in the 60-minute CA group (P < .05). CONCLUSION: In this preheparinized NHBD swine model, ECMO support restores liver perfusion, oxygenation, and bile production after 60 minutes of CA. Quantification and analysis of bile production could be a determinant of liver function during ECMO resuscitation, and it may be a predictor of graft viability before transplantation.     

经升主动脉灌注的无心跳供体大鼠原位肝移植模型的建立

目的 探讨建立一个能灌注更彻底、更易操作、热缺血时间容易控制的原位肝移植动物模型。方法 在Kamada两袖套法的基础上进行改良，供体经升主动脉进行冷灌注，肝上下腔静脉用缝合法吻合，门静脉和肝下下腔静脉用袖套法吻合，胆总管采用胆管内支架端端吻合的方法。建立无心跳供体的大鼠原位肝移植模型。结果 40例移植后1d大鼠存活率为95．0％(38／40)，1周存活率为85．5％(35／40)。结论 经升主动脉灌注的供肝灌注更彻底、均匀，更易操作，热缺血时间控制更精准，行肝移植后1周存活率较文献报道高。     

Liver transplantation using non-heart-beating donors: Belgian experience

Mortality on liver transplantation (OLT) waiting lists has increased dramatically. Until recently, non-heart-beating donors (NHBD) were not considered suitable for OLT, because of a higher risk of primary graft nonfunction (PNF) and biliary strictures. However, recent experimental/clinical evidence has indicated that NHBD-OLT is feasible when the period of warm ischemia is short. PURPOSE: To characterize the results of NHBD-OLT in Belgium, a survey was sent to all Belgian OLT centers. RESULTS: Between January 2003 and November 2005, 16 livers originating from NHBD were procured and transplanted. The mean donor age was 48.8 years, including 9 males and 7 females with mean time of stop-therapy to cardiac arrest being 18 minutes and from cardiac arrest to liver cold perfusion, 10.5 minutes. Mean recipient age was 52.2 years including 12 males and 4 females. Mean cold ischemia time was 7 hours 15 minutes. No PNF requiring re-OLT was observed. Mean post-OLT peak transaminase was 2209 IU/L, which was higher among imported versus locally procured grafts. Biliary complications occurred in 6 patients requiring re-OLT (n = 2), endoscopic treatment (n = 2), surgical treatment (n = 1), or left untreated (n = 1). These tended to be more frequent after prolonged warm ischemia. Graft and patient survivals were 62.5% and 81.3%, respectively, with a follow-up of 3 to 36 months. CONCLUSION: This survey showed acceptable graft/patient survivals after NHBD-LT. The NHBD-liver grafts suffered a high rate of ischemic injury and biliary complications and therefore should be used carefully, namely with no additional donor risk factors, lower risk recipients, and short cold/warm ischemia.     

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.     

公民逝世后器官捐献供肝移植62例临床分析

目的分析公民逝世后器官捐献供肝移植的流程方法及疗效,为公民逝世后器官捐献供肝移植提供一定借鉴。 方法回顾性分析中山大学附属中山医院2008年10月至2015年12月完成62例公民逝世后器官捐献肝移植病例的临床资料。 结果62例均符合《中国心脏死亡器官捐献工作指南》三类捐献标准（脑-心双死亡标准器官捐献,DBCD）。所有病例按标准成功完成了肝脏捐献及获取流程,其中15例使用体外膜肺氧合技术（ECMO）维持至器官获取。供肝热缺血时间0~30（16.2±6.5）min,冷缺血时间190~680（347±39）min。62例受体均顺利植入供肝,未出现原发性移植肝无功能、排斥反应。1例围手术期死于多发动脉血栓形成,1例发生胆漏经引流后自愈,2例发生胆道狭窄并发症,经胆道支架置入后缓解;肿瘤复发转移死亡3例。 结论通过合理流程充分利用ECMO,加强获取器官管理,缩短热冷缺血时间,公民逝世后器官捐献供肝移植可以获得较满意的临床效果。     

Single-center experience with liver transplantation from controlled non-heartbeating donors: a viable source of grafts

BACKGROUND: To increase the number of livers available for transplantation a non-heartbeating donor (NHBD) liver transplant program was started after obtaining hospital ethical committee approval. METHODS: Controlled donors with a warm ischemia of <30 minutes were considered. A 5-minute stand-off period was observed from asystole to skin incision. A super-rapid technique was used for the retrieval. Methods used to assess the suitability for transplantation included liver function tests, morphologic and histologic assessment, and hepatocyte viability testing. RESULTS: Sixty livers were retrieved from NHBDs. Of these, 33 were judged suitable for transplantation. Of these one was exported and transplanted, and one could not be matched to a suitable recipient. A further 27 were not used because of liver appearance in 21, prolonged hypoxia and hypotension in 4, poor perfusion in 1, and donor malignancy in 1. Mean donor age was 39.4 years (range, 0.75-67 years). Causes of death were head trauma in 10 donors, intracranial bleed in 24, and anoxic/ischemic brain injury in 26. Mean warm ischemia time was 14.7 minutes (range, 7-40 minutes). Thirty-two patients were transplanted (one split liver), and the mean age of the recipients was 38.4 years (range, 0.7-72 years). All grafts had good early function except one right lobe split. There were 4 deaths resulting from ischemic brain injury, chronic rejection, biliary sepsis, and multiorgan failure following retransplantation for primary nonfunction. Overall patient and graft survival is 87% and 84%, respectively, at a median follow-up of 15 months. CONCLUSIONS: Early results suggest that controlled NHBDs are a significant new source of grafts, but careful donor selection and short cold ischemia are mandatory.     

Kidney transplantation from non-heart-beating donors: analysis of organ procurement and outcome

INTRODUCTION: Most donors in Japan have been non-heart-beating donors (NHBD), so-called "marginal donors." In Western countries kidney transplants from NHBD have also been increasing. We analyzed 120 kidneys harvested from NHBD with regard to organ procurement, renal function, graft survival, and the donor factors that affected graft survival. METHODS: Donors were moved into the operating room after cardiac arrest. A double-balloon catheter was inserted into the abdominal aorta via laparotomy. In situ cooling by Euro-Collins solution was started at 500 mL/min. We did not performed cannulation into the femoral artery or vein prior to cardiac arrest. RESULTS: Warm ischemia time (WIT) was 18.6 minutes. Among 108 kidneys (90%) used for transplantation, 102 kidneys functioned. There were no cases of bilateral nonfunctioning kidneys. The delayed graft function (DGF) rate was 86%; however, the death-censored graft survival was 80.0% at 5 years and 62.9% at 10 years. Kidneys implanted after more than 24 hours of total ischemia time required a significantly longer period of hemodialysis. Donor risk factors that affected graft survival included WIT >/= 20 minutes, donor age >/= 50 years, and serum creatinine level at admission > 1.0 mg/dL. CONCLUSIONS: Organ procurement without cannulation prior to cardiac arrest entailed a long WIT and a high DGF rate. However, the graft survival was good. It has been necessary to use grafts from NHBD despite the inherent risk factors. It is important to reduce kidney damage both at the organ procurement and during the posttransplant management.     

Isolation of hepatocytes from livers from non-heart-beating donors for cell transplantation.

One of the limitations to hepatocyte transplantation is the restricted availability of donor liver tissue. The aim of this study was to evaluate livers from non-heart-beating donors (NHBDs) as a source of hepatocytes for cell transplantation. A total of 20 livers/segments obtained from NHBD were perfused under good manufacturing practices using a standard collagenase digestion method. The donor liver median warm ischemia time was 15 minutes (range, 11-40 minutes), and cold ischemia time was 13 hours (range, 6-30 hours) prior to cell isolation. The cell viability of the hepatocytes obtained was 52% (1-81%), with a yield of 2.2 x 10(6)(0.2-29.7 x 10(6)) cells per gram of tissue. There was a significant negative correlation between hepatocyte viability and length of both warm ischemia (r = -0.544, P = 0.013) and cold ischemia (r = -0.510, P = 0.022). Preliminary experiments were performed on the viability testing of NHBD livers based on digestion of needle biopsies with collagenase and assessment of the hepatocytes produced. Two of the NHBD cell preparations, which had been cryopreserved, were used as part of a series of cell infusions for hepatocyte transplantation. A 3.5-yr-old girl with Crigler-Najjar syndrome type I received 9.7 x 10(8) NHBD hepatocytes (viability on thawing, 65%), and a 4-month-old boy with inherited clotting factor VII deficiency received 5.0 x 10(8) hepatocytes (viability, 57%). In conclusion, hepatocytes suitable for cell transplantation can be obtained from NHBD livers. Higher viability values may be obtained if both warm and cold ischemia times of donor liver can be reduced prior to processing.     

Extracorporeal membrane oxygenation support of donor abdominal organs in non-heart-beating donors

Both family consent and legal consent were required for organ/tissue donation from non-heart-beating donors (NHBD) in Taiwan. A district attorney had to come to the bedside to confirm the donor's asystole, confirm the family consent, and complete some legal documents before a legal consent was issued for organ donation. The resultant warm ischemic time would be unpredictably long and in fact precluded the organ donation from NHBD in Taiwan. We developed a method of using extracorporeal membrane oxygenation (ECMO) to maintain NHBD for a longer time and prevent warm ischemic injury of the donor abdominal organs. After ventilator disconnection in NHBD, phentolamine and heparin were injected and mannitol infusion was given. After the donor's asystole was confirmed by the electrocardiogram (EKG) strip recording, the ECMO support was set up through the right femoral veno-arterial route, an occlusion balloon catheter was inserted through the left femoral artery to occlude the thoracic aorta, and bilateral femoral arteries were ligated. Usually, the ECMO could begin within 10 min after the donor's asystole. The ECMO, combined with a cooler, provided cold oxygenated blood to the abdominal visceral organs, and prevented their warm ischemic injuries. Under the ECMO support (range: 45-70 min), eight renal grafts were procured from 4 NHBD. With the exception of the first two renal grafts with delayed function, all others had immediate function postoperatively and dialysis was no longer needed. In conclusion, by our ECMO technique, NHBD could be maintained for a longer time and the renal grafts had better immediate postoperative function than those reported by other methods.     

外源性三磷酸腺苷-氯化镁预处理对大鼠供肝热缺血损伤的保护作用

目的 观察三磷酸腺苷-氯化镁(ATP-MgCl2)预处理对无心跳大鼠供肝热缺血损伤的保护作用.方法 根据ATP-MgCl2预处理与否及供肝获取前经历的供体心脏停搏时间(即热缺血时间)30min或45min,将实验动物分为4组,即非预处理的30min(N-30min)组和45min(N-45min)组,以及ATP-MgCl2预处理的30min(tN-30min)组和45min(tN-45min)组行原位肝移植,观察存活状况,取材行光学显微镜及电子显微镜检查,移植术后1、3、7d 采集血样检测肝功能.结果 N-30min组和N-45min组的1周存活率分别为50.0%和16.7%,而tN-30min组和tN-45min组的1周存活率分别为83.3%和66.7%,预处理组移植肝脏的病理及肝功能明显好于非预处理组.结论 ATP-MgCl2预处理能够减轻供肝的热缺血损伤,改善肝功能,减轻病理损害,提高大鼠肝移植的存活率.     

Non-immunological risk factors associated with chronic allograft nephropathy following kidney transplantation

Although the precise mechanisms are unclear, not only alloantigen-dependent but also antigen-independent factors are generally thought to influence the development of chronic allograft nephropathy (CAN). Among the non-immunological determinants, there are various factors related with donor, recipient and graft procurement. As donor factors, age and cause of death were demonstrated to be significantly independent in long-term graft survival of cadaveric kidney transplantation. Grafts from aged donors and from donors with athelosclerosis showed poor prognosis on graft survival. Regarding recipient factors, cardiovascular complications, as hypertension and hyperlipidemia, were responsible for graft as well as patient survival. In addition, CMV infection and drug nephrotoxicity were also shown to affect graft survival. For procurement factors, warm ischemia was determined to possess the strongest impact on long-term graft survival in our series of kidney transplant using grafts from non-heart beating donors (NHBDs). Delayed graft function, which correlated well with length of warm ischemia, also influenced long-term graft survival. These results proved that the supply of viable donor nephrons and the physiologic demands of the recipient are important determinants of long-term graft survival. So far there seems to be neither definitive nor specific treatment for CAN. It is basically essential to avoid graft damage before transplant and keep recipients from risk factors after transplant as much as possible. To improve long-term graft survival in cadaveric kidney transplantation, recipient selection is greatly important in terms of not only immunological compatibility but also body to nephron mass imbalance and ischemic time, which might cause fatal damage to grafts before engraftment.     

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.     

供肝短缺形势下的我国肝移植策略

近5年来我国肝移植发展非常迅速,然而,供肝短缺成为制约临床肝移植发展的瓶颈。因此,拓展供肝来源成为目前肝移植临床的重点。活体肝移植在尸体供肝受限的情况下可以很好地扩展供肝来源,且活体供肝具有活力强、冷缺血时间短等优势;劈裂式肝移植可增加15％～28％的供肝数量,有望成为解决供肝短缺的主要手术方式之一;脑死亡供者在西方国家是移植器官的主要来源,在我国亦有广大的应用前景,但脑死亡供者器官移植刚刚起步,有许多问题亟待研究;此外,边缘供肝,包括脂肪变性肝脏、HBsAg阳性肝脏、超过60岁的高龄供者捐献的肝脏、冷缺血时间超过14h的盱脏等均可用以缓解日益突出的供肝短缺矛盾。     

Pre-arrest heparinization and ventilation during warm ischemia preserves lung function in non-heart-beating donors

BACKGROUND/PURPOSE: To solve the problem of donor scarcity, many attempts have been made including improved community education, relaxed organ acceptance criteria, increased reliance on single lung transplantation, and the use of partial organ donation. Unfortunately, these efforts have produced only modest increases in lung allograft availability; therefore, the so-called non-heart-beating organ donation must be considered. The aim of this study is to assess the viability of the non-heart-beating donor (NHBD) lung transplant rat model and determine the best strategy to manage the donor before and after cardiac arrest. METHODS: Fifty-five inbred Fischer rats were used as donors and recipients in an isogenic model of left lung transplantation. The rats were divided into 6 groups (n = 5): group I, normal controls without transplant; group II, heart-beating donor controls (HBD); group III, NHBD, no heparin, no ventilation during warm ischemia; group IV, NHBD, heparin, no ventilation; group V, NHBD, no heparin, ventilation; group VI, NHBD, heparin, ventilation. All lungs were stored at 4 degrees C for 4 hours. Animals were killed 24 hours after implantation. Gas exchange, pulmonary artery pressure, compliance, chest x-ray score, and histological score were assessed. RESULTS: Heparinized and ventilated animals during warm ischemia (group VI) had similar performance than those transplanted without warm ischemia time in a scenario of heart-beating donor (group II). Groups III, IV, and V transplanted lungs showed severe damage. CONCLUSIONS: The authors conclude that the rat lung transplantation model is useful to study the phenomena that occur in a setting of transplantation using NHBD and that heparinization and ventilation before cardiac arrest is the best strategy to manage non-heart-beating donors in this model.     

Factors affecting graft survival after liver transplantation from donation after cardiac death donors

BACKGROUND: Liver transplantation from donation after cardiac death (DCD) donors is an increasingly common approach for expansion of the donor organ supply. However, transplantation with DCD livers results in inferior graft survival. In this study, we examined donor and recipient characteristics that are associated with poor allograft outcomes and present a set of criteria that permit allograft survival that is comparable to that of donation after brain death (DBD) grafts in both low- and high-risk recipients. METHODS: The United Network for Organ Sharing/Organ Procurement and Transplantation Network Liver Transplantation Registry between January 1996 and March 2006 was investigated. Adult DCD liver transplants (n = 874) were included. RESULTS: A DCD risk index was developed using the statistically significant factors from a multivariate Cox model: history of previous transplantation, life support status at transplantation, donor age, donor warm ischemia time (DWIT), and cold ischemia time (CIT). Favorable DCD donor criteria were donor age < or =45 years, DWIT < or =15 min, and CIT < or =10 hr. Four risk groups were developed based upon index scores that showed different graft survival. Graft survival of the favorable DCD group (84.9% at 1 year, 75.2% at 3 years, and 69.4% at 5 years) was comparable to that for DBD liver transplantation irrespective of recipient condition. Increasing donor age was more highly predictive of poor outcomes in DCD compared to DBD, especially in recipients in poor preoperative condition. CONCLUSIONS: DCD livers from young donors with short DWIT and CIT should be given greater consideration in order to expand the number of available donor organs.