A meta‐analysis and meta‐regression of outcomes including biliary complications in donation after cardiac death liver transplantation

Donation after cardiac death (DCD) liver transplantation is increasingly common but concerns exist over the development of biliary complications and ischemic cholangiopathy (IC). This study aimed to compare outcomes between DCD and donation after brain death (DBD) liver grafts. Studies reporting on post‐transplantation outcomes after Maastricht category III DCD liver transplantation were screened for inclusion. Odds ratios (OR) with 95% confidence intervals were produced using random‐effects models for the incidence of biliary complications, IC, graft and recipient survival. Meta‐regression was undertaken to identify between‐study predictors of effect size for biliary complications and IC. PROSPERO Record: CRD42012002113. Twenty‐five studies with 62 184 liver transplant recipients (DCD = 2478 and DBD = 59 706) were included. In comparison with DBD, there was a significant increase in biliary complications [OR = 2.4 (1.9, 3.1); P < 0.00001] and IC [OR = 10.5 (5.7, 19.5); P < 0.00001] following DCD liver transplantation. In comparison with DBD, at 1 year [OR = 0.7 (0.5, 0.8); P = 0.0002] and 3 years [OR = 0.6 (0.5, 0.8); P = 0.001], there was a significant decrease in graft survival following DCD liver transplantation. At 1 year, there was also a nonsignificant decrease [OR = 0.8 (0.6, 1.0); P = 0.08] and by 3 years a significant decrease [OR = 0.7 (0.5, 1.0); P = 0.04] found in recipient survival following DCD liver transplantation. Eleven factors were entered into meta‐regression models, but none explained the variability in effect size between studies. DCD liver transplantation is associated with an increase in biliary complications, IC, graft loss and mortality. Significant unexplained differences in effect size exist between centers.     

Kidney transplantation from donation after cardiac death donors: lack of impact of delayed graft function on post‐transplant outcomes

Singh RP, Farney AC, Rogers J, Zuckerman J, Reeves‐Daniel A, Hartmann E, Iskandar S, Adams P, Stratta RJ. Kidney transplantation from donation after cardiac death donors: lack of impact of delayed graft function on post‐transplant outcomes.
Clin Transplant 2011: 25: 255–264. © 2010 John Wiley & Sons A/S. Abstract: Introduction: Delayed graft function (DGF) is more common in recipients of kidney transplants from donation after cardiac death (DCD) donors compared to donation after brain death (DBD) donors. Methods: Single‐center retrospective study to evaluate the impact of DGF on controlled (Maastricht category III) DCD donor kidney transplant outcomes. Results: From 10/01 to 6/08, 578 adult deceased donor kidney transplants were performed including 70 (12%) from DCD and 508 (88%) from DBD donors. Mean follow‐up was 36 months. DCD donor kidney transplants had significantly greater rates of DGF (57% DCD vs. 21% DBD, p < 0.0001)) and acute rejection (29% DCD vs. 16% DBD, p = 0.018) compared to DBD donor kidney transplants, but patient and graft survival rates were similar. DBD donor kidney transplants with DGF (n = 109) had significantly greater rates of death‐censored graft loss (12.5% DCD vs. 31% DBD), primary non‐function (0 DCD vs. 10% DBD) and higher 2 year mean serum creatinine levels (1.4 DCD vs. 2.7 mg/dL DBD) compared to DCD donor kidney transplants with DGF (n = 40, all p < 0.04). On univariate analysis, the presence of acute rejection and older donor age were the only significant risk factors for death‐censored graft loss in DCD donor kidney transplants, whereas DGF was not a risk factor. Conclusion: Despite higher rates of DGF and acute rejection in DCD donor kidney transplants, subsequent outcomes in DCD donor kidney transplants with DGF are better than in DBD donor kidney transplants experiencing DGF, and similar to outcomes in DCD donor kidney transplants without DGF.     

The price of donation after cardiac death in liver transplantation: a prospective cost‐effectiveness study

This study aims to perform a detailed prospective observational multicenter cost‐effectiveness study by comparing liver transplantations with Donation after Brain Death (DBD) and Donation after Cardiac Death (DCD) grafts. All liver transplantations in the three Dutch liver transplant centers between 2004 and 2009 were included with 1‐year follow‐up. Primary outcome parameter was cost per life year after transplantation. Secondary outcome parameters were 1‐year patient and graft survival, complications, and patient‐level costs. From 382 recipients that underwent 423 liver transplantations, 293 were primarily transplanted with DBD and 89 with DCD organs. Baseline characteristics were not different between both groups. The Donor Risk Index was significantly different as were cold and warm ischemic time. Ward stay was significantly longer in DCD transplantations. Patient and graft survival were not significantly different. Patients receiving DCD organs had more and more severe complications. The cost per life year for DBD was € 88 913 compared to € 112 376 for DCD. This difference was statistically significant. DCD livers have more and more severe complications, more reinterventions and consequently higher costs than DBD livers. However, patient and graft survival was not different in this study. Reimbursement should be differentiated to better accommodate DCD transplantations.     

Liver transplantation from donation after cardiac death donors: initial Belgian experience 2003–2007

The Belgian experience with donation after cardiac death (DCD) liver transplantation (LT) was retrospectively reviewed, particularly evaluating patient and graft survivals, and biliary complications. From 2003 to 2007, 58 DCD‐LT were performed in Belgium. Mean procurement total warm ischemia time was 25 ± 2 min (mean ± SEM). Mean cold ischemia time was 451 ± 18 min. Mean follow‐up was 23 ± 2.2 months. Post‐transplant peak aspartate aminotransminases was 2241 ± 338 UI/l. Patient survivals at 1 month, 1 and 3 years, were 91.3%, 83.3% and 66.9% respectively. Graft survivals at 1 month, 1 and 3 years, were 84.4%, 72.4% and 48.8% respectively. Two patients (3.4%) developed primary nonfunction. Regarding the biliary complications, seven grafts (12%) were lost because of intrahepatic cholangiopathy, and 12 other patients (20.6%) developed bile duct stenoses requiring endoscopic and/or surgical management. The rate of symptomatic ischemic biliary lesions for grafts surviving more than 3 months was 38% (19/50). Although DCD organ donors may be a source of viable liver grafts, results were inferior to those obtained with donation after brain death LT in this series. Prognostic criteria have to be developed to improve results of DCD‐LT.     

Long‐term outcome of pediatric renal transplantation: a single center experience

Abe T, Ichimaru N, Kakuta Y, Okumi M, Imamura R, Isaka Y, Takahara S, Kokado Y, Okuyama A. Long‐term outcome of pediatric renal transplantation: a single center experience.
Clin Transplant 2011: 25: 388–394. © 2010 John Wiley & Sons A/S. Abstract: Renal transplantation is the optimal treatment for pediatric end‐stage renal disease. We examined 51 children <20 yr old who underwent a total of 52 living‐donor renal transplantations at Osaka University Hospital between 1972 and 2004. The mean age at transplantation was 13.7 (3–19 yr). The mean duration of follow‐up was 16.5 yr. The five‐, 10‐, and 20‐yr patient survival rates following renal transplantation were 94%, 90%, and 87%, respectively. The five‐, 10‐, and 20‐yr graft survival rates were 76%, 65%, and 48%, respectively. A double‐drug regimen was used before 1987; this was replaced by a triple‐drug regimen including a calcineurin inhibitor in 1988. The five‐, 10‐, and 20‐yr graft survival rates after 1988 (89%, 80%, and 60%, respectively) were higher than those before 1987. Growth was examined among patients <15 yr old at the time of surgery, and height standard deviation (SD) scores (Z‐scores) were analyzed in 14 patients who displayed favorable renal function after transplantation. At the time of transplantation, mean SD score (SDS) was ?2.39, and mean final adult SDS was ?1.79. Rates of patient and graft survival after renal transplantation were mostly favorable. Future goals must include overcoming chronic rejection and establishing a steroid discontinuation protocol to improve growth.     

Lung transplantation from donation after cardiac death (non-heart-beating) donors

Although lung transplantation is a well-accepted treatment for advanced lung diseases, donor shortage remains a significant limiting factor resulting in an increasing number of deaths of people on waiting lists. Recently, some transplant centers have begun to use lungs retrieved from donors after circulatory arrest. This review outlines the relevant published experimental data and clinical experiences with lung transplantation from donation after cardiac-death donors (DCDs) or non-heart-beating donors (NHBDs). Techniques for lung preservation and ex vivo lung assessment of DCD (NHBD) lungs are reviewed, and aspects of primary graft dysfunction after DCD (NHBD) lung transplantation are discussed. This review was submitted at the invitation of the editorial committee.     

脑-心双死亡供肝与尸体供肝移植安全性比较

目的 探讨脑-心双死亡（donation after brain plus cardiac death,DBCD）供肝肝移植手术安全性及近期疗效。方法 收集本科肝移植相关资料：供肝热缺血时间（warm ischemic time,WIT）、冷缺血时间（cold ischemic time,CIT）、手术时间、受体无肝期时间,术后第1、3、7天肝功能变化（ALT、TBIL）,及术后早期各种并发症发生率等。按供肝来源不同分为DBCD组（观察组）与尸体供肝组（对照组）,比较两组相关资料的差异及与术后肝功能和并发症的关系。冷/热缺血时间和早期肝功能受损程度相关性分析采用Pearson检验。结果 与对照组相比,DBCD组热缺血时间较长[（9.5±2.2）min vs （4.9±1.5）min,t =10.719,P ＜0.001],冷缺血时间较短[（4.7±0.9）h vs （7.2±2.2）h,t =8.008,P ＜0.001]。术后第1、3天肝功能ALT和TBIL,DBCD组较对照组增高明显[（1 294.3±181.7）IU/L vs （641.3±41.0）IU/L,P =0.001;（497.4±56.4）IU/L vs （308.6±15.9）IU/L,P =0.003]。术后第7 天两组肝功能变化差异不大（P ＞0.05）。两组术后早期并发症率和手术死亡率比较无统计学意义差异（P＞0.05）。DBCD组数据显示热缺血时间长短与移植术后1周内ALT峰值呈正相关（r 2=0.826,P ＜0.001）。结论 DBCD组冷缺血时间较尸体供肝组缩短,但热缺血时间较尸体供肝组延长,总体在安全范围内且可控性良好,因此DBCD肝移植是安全的。     

供体红细胞输血在DCD肝移植中应用的技术改进和效果

目的探讨公民逝世后捐献(DCD)供体血液采集的改进方法和效果。方法回顾性收集2020年5月至2021年1月期间四川大学华西医院移植团队对供体血液采集及处理方法改进前即Ⅰ期临床试验以及2021年9月至2021年11月期间血液采集及处理方法改进后的供体的临床病理资料。结果与Ⅰ期临床试验数据比较,改进技术之后,血液采集量和经过自体回收机过滤、离心、洗涤之后获得浓缩红细胞悬液量以及获得红细胞悬液量/kg体质量更多(P<0.05)。此外,与库存红细胞悬液的成分比较,经过改进技术后获得的红细胞悬液的p H值、钠离子和氯离子浓度均更高(P<0.05)且钾离子浓度均<1 mmol/L,无一例乳酸浓度>15 mmol/L。结论经过改进技术后能增加供体红细胞血液的采集量,其生化、电解质等指标较库存血更加符合生理要求。     

Safe use of segmental liver grafts from donors after cardiac death (DCD) in children with acute liver failure

Emergency liver transplantation is a life-saving procedure in selected subset of children with acute liver failure (ALF), when most recipients receive a segmental graft from a living or heart-beating deceased donor. The increased use of full-liver grafts from donors after cardiac death (DCD) has had a beneficial impact on elective liver transplantation in adults. These grafts however are more susceptible to poor initial function, and most centres are reluctant to consider their use as segmental grafts, let alone in the situation of ALF where good initial function is imperative. In this short article, we describe the use and successful outcome in two children aged 6 weeks and 6 years with acute liver failure who received reduced-size DCD liver grafts.     

Current situation of donation after circulatory death in European countries

The aim of the present study was to describe the current situation of donation after circulatory death (DCD) in the Council of Europe, through a dedicated survey. Of 27 participating countries, only 10 confirmed any DCD activity, the highest one being described in Belgium, the Netherlands and the United Kingdom (mainly controlled) and France and Spain (mainly uncontrolled). During 2000–2009, as DCD increased, donation after brain death (DBD) decreased about 20% in the three countries with a predominant controlled DCD activity, while DBD had increased in the majority of European countries. The number of organs recovered and transplanted per DCD increased along time, although it remained substantially lower compared with DBD. During 2000–2008, 5004 organs were transplanted from DCD (4261 kidneys, 505 livers, 157 lungs and 81 pancreas). Short‐term outcomes of 2343 kidney recipients from controlled versus 649 from uncontrolled DCD were analyzed: primary non function occurred in 5% vs. 6.4% (P = NS) and delayed graft function in 50.2% vs. 75.7% (P < 0.001). In spite of this, 1 year graft survival was 85.9% vs. 88.9% (P = 0.04), respectively. DCD is increasingly accepted in Europe but still limited to a few countries. Controlled DCD might negatively impact DBD activity. The degree of utilization of DCD is lower compared with DBD. Short‐term results of DCD are promising with differences between kidney recipients transplanted from controlled versus uncontrolled DCD, an observation to be further analyzed.     

Surfactant alterations following donation after cardiac death donor lungs

The use of lungs from donation after cardiac death (DCD) donors is one of the strategies to increase the donor pool. The aim of this study was to assess the surfactant alterations in DCD donor lungs. Pigs were sacrificed and left untouched for 1 (DCD1), 2 (DCD2) and 3 (DCD3) h. Lungs were then topically cooled with saline for 1, 2 or 3 h to reach a total ischemic time of 4 h. Heart‐beating donors (HBD) served as control group. Bronchoalveolar lavage (BAL) samples were assessed for protein levels and surfactant function. Left lungs were prepared for ex‐vivo evaluation. Pulmonary vascular resistance (PVR), oxygenation, airway pressure (AWP) and wet‐to‐dry weight ratio were significantly different between HBD and DCD3 groups (P < 0.05). BAL protein levels were statistically higher in DCD3 compared with HBD group (P < 0.05). Surface tension and surface tension measured at minimal bubble diameter (adsorption) were lower in HBD compared with DCD groups (P < 0.05). Adsorption was also lower in DCD1 compared with DCD2 (P < 0.05). Adsorption and surface tension were correlated with oxygenation and AWP (P < 0.05). This study has shown that lung function deteriorates with increasing warm ischemic time intervals. BAL protein, surface tension, adsorption, peak AWP and PVR increase significantly after 2 h of warm ischemia together with a significant reduction of the ratio PaO₂/FiO₂.     

Eurotransplant donor‐risk‐index and recipient factors: influence on long‐term outcome after liver transplantation – A large single‐center experience

The organ shortage has led to increased use of marginal organs. The Eurotransplant Donor‐Risk‐Index (ET‐DRI) was established to estimate outcome after Liver Transplantation (LT). Currently, data on impact of ET‐DRI on long‐term outcome for different indications and recipient conditions are missing. Retrospective, single‐center analysis of long‐term graft survival (GS) of 1767 adult primary LTs according to indication, labMELDcategory (1: ≤18; 2: >18–25; 3: >25–35; 4: >35), and ET‐DRI. Mean ET‐DRI in our cohort was 1.63 (±0.43). One‐, 10, and 15‐yr GS was 83.5%, 63.3%, and 54.8%. Long‐term GS was significantly influenced by ET‐DRI. Accordingly, four ET‐DRI categories were defined and analyzed with respect to underlying disease. Significant impact of these categories was observed for: Alcohol, cholestatic/autoimmune diseases (CD/AIH), and HCV, but not for HCC, HBV, cryptogenic cirrhosis, and acute liver failure. labMELD categories showed no significant influence on graft, but on patient survival. Matching ET‐DRI categories with labMELD revealed significant differences in long‐term GS for labMELDcategories 1, 2, and 3, but not 4. In multivariate analysis, HCV combined with ET‐DRI > 2 and labMELDcategory 3 combined with ET‐DRI > 2 emerged as negative predictors. To achieve excellent long‐term graft survival, higher risk organs (ET‐DRI > 1.4) should be used restrictively for patients with CD/AIH or HCV. Organs with ET‐DRI > 2 should be avoided in patients with a labMELD of >25–35.     

Long‐term psychosocial outcomes after nondirected donation: A single‐center experience

Short‐term studies have demonstrated that nondirected donors (NDDs) have psychosocial outcomes that are similar to donors who donate directly, but long‐term studies have not been done. NDDs at our center were surveyed regarding motivation; support during donation; stress related to donation; regret; financial resources used for donation; preferences about communication with the recipient; and cost reimbursement. Of 100 NDDs who donated at our center in the last 20 years, 95 remain in contact with us, and 77 responded to our survey (mean ± standard deviation [SD] 6.7 ± 4 years postdonation). The most common motivation for donation was the desire to help another (99%). Many NDDs received support from family, friends, and employers. NDDs voiced stress about the possibility of recipient kidney rejection, physical consequences to themselves, and financial burden. Only one donor expressed regret. Almost half wanted some recipient information at donation; 61% preferred routine recipient status updates; 56% believed meeting the recipient should occur at any mutually agreeable time; and 55% endorsed reimbursement for expenses. Stressors for NDDs are analogous to those of directed donors; NDDs prefer having some information about the recipient and prefer to be given a choice regarding the timing for communication with the recipient. NDDs supported donation being financially neutral.     

LifePort保存心脏死亡器官捐献供肾的临床研究

目的:探讨采用LifePort保存心脏死亡器官捐献(DCD)供肾对移植肾功能恢复的影响。方法:分析解放军三〇三医院2012年8月~2013年10月期间30个DCD案例肾移植后受者的临床资料。根据同一供体两只供肾采用不同的保存方式,随机分入LifePort组(n=30)和普通冷藏组(n=30例),比较两组受者肾功能恢复延迟(DGF)、急性排斥反应(AR)等并发症的发生率及移植肾功能恢复等情况。结果:LifePort组受者的DGF发生率为20%(6/30),而普通冷藏组的DGF发生率为46.7%(14/30),差异有统计学意义(P0.05)。两组间AR发生率、围手术期移植肾存活率及受者存活率的差异无统计学意义(P0.05)。LifePort组受者术后出院时血清肌酐恢复优于普通冷藏组,且平均住院时间较短,差异有统计学意义(P0.05)。结论:LifePort能有效改善离体DCD供肾的保存质量,降低受者DGF发生率,有利于移植肾功能恢复。     

Successful outcome following transplantation of an injured liver from a nonheart beating donor

Nonheart beating donation (NHBD) of the liver is a relatively new potential source of grafts. Guidelines to indications and contraindications to donation from controlled nonheart beating donors are still being formulated. We report a successful case of transplantation of a liver from a controlled nonheart beating donor who sustained significant injuries following a road traffic accident. Emergency laparotomy with peri-hepatic packing was performed to control haemorrhage from lacerations in segments VI and VII. Forceful packing resulted in an area of focal ischaemia in segment VI. Trauma to the liver should not be considered an absolute contraindication to controlled NHBD.     

儿童心脏死亡器官捐献的现状与研究进展

心脏死亡器官捐献(DCD)已经成为增加供器官来源的重要途径之一,儿童DCD也逐渐得到重视。儿童DCD不仅可以扩大供器官来源,而且对儿童器官移植具有重要意义。本文就儿童DCD的现状和研究进展作一综述,重点介绍儿童DCD的历史、儿童DCD供器官分配、移植预后、伦理问题等,以期为我国儿童DCD工作提供参考。     

心脏死亡供体肝移植12例初步经验

目的总结心脏死亡供体（DCD）肝移植的具体流程和临床经验。方法回顾性分析2008年10月至2012年12月中山市人民医院12例DCD临床资料、供体维护、器官获取、受体围手术期及预后等。结果12例供体均为脑、心双死亡供体,按标准成功完成了肝脏捐献及获取流程。其中3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（16．5±7．0）min。12例受体均顺利植入供肝,无围手术期死亡。术后胆道并发症2例,肿瘤复发1例,死亡2例。结论DCD供体肝移植能获得较满意的效果。通过快速获取器官、合理利用ECMO,能提高器官捐献成功率、减少供肝热缺血时间及冷缺血时间。     

Kidney transplant from uncontrolled donation after circulatory death donors maintained by nECMO has long‐term outcomes comparable to standard criteria donation after brain death

Uncontrolled donation after circulatory death (uDCD) increases organ availability for kidney transplant (KT) with short‐term outcomes similar to those obtained from donation after brain death (DBD) donors. However, heterogeneous results in the long term have been reported. We compared 10‐year outcomes between 237 KT recipients from uDCD donors maintained by normothermic extracorporeal membrane oxygenation (nECMO) and 237 patients undergoing KT from standard criteria DBD donors during the same period at our institution. We further analyzed risk factors for death‐censored graft survival in the uDCD group. Delayed graft function (DGF) was more common in the uDCD group (73.4% vs 46.4%; P < .01), although glomerular filtration rates at the end of follow‐up were similar in the 2 groups. uDCD and DBD groups had similar rates for 10‐year death‐censored graft (82.1% vs 80.4%; P = .623) and recipient survival (86.2% vs 87.6%; P = .454). Donor age >50 years was associated with graft loss in the uDCD group (hazard ratio: 1.91; P = .058), whereas the occurrence of DGF showed no significant effect. uDCD KT under nECMO support resulted in similar graft function and long‐term outcomes compared with KT from standard criteria DBD donors. Increased donor age could negatively affect graft survival after uDCD donation.