The deceased donor score system in kidney transplants from deceased donors after cardiac death

A clinical score to identify kidneys from donors after cardiac death (DCD) with a high risk of dysfunction following transplantation could be a useful tool to guide the introduction of new algorithms for the preservation of these organs and improve their outcome after transplantation. We investigated whether the deceased donor score (DDS) system could identify DCD kidneys with higher risk of early post‐transplant dysfunction. The DDS was validated in a cohort of 168 kidney transplants from donors after brain death (DBD) and then applied to a cohort of 56 kidney transplants from DCD. In the DBD cohort, the DDS grade predicted the incidence of delayed graft function (DGF) and levels of serum creatinine at 3 and 12 months post‐transplant. Similarly, in the DCD cohort, the DDS grade correlated with DGF and also predicted the levels of serum creatinine at 3 and 12 months. Interestingly, the DDS identified a subgroup of marginal DCD kidneys in which minimization of cold ischemia time produced better early clinical outcome. These results highlight the impact of early interventions on clinical outcome of marginal DCD kidneys and open the possibility of using the DDS to identify those kidneys that may benefit most from therapeutic interventions before transplantation.     

Use of living donor liver transplantation varies with the availability of deceased donor liver transplantation

The demographics of patients in the United States who undergo living donor liver transplantation (LDLT) versus patients who undergo deceased donor liver transplantation (DDLT) are interesting with respect to the demographics of the donor service areas (DSAs). We examined adult recipients of primary, non-status 1 liver-only transplants from 2003 to 2009. The likelihood of undergoing LDLT was compared to the likelihood of undergoing DDLT by multivariate logistic regression. We examined the adjusted odds ratio (OR) for undergoing LDLT versus DDLT for patients with the same diagnosis and blood type after we stratified the DSAs into quintiles by the median match Model for End-Stage Liver Disease (MELD) scores. LDLT was performed for 1497 of 32,927 liver transplants (4.5%). LDLT decreased in frequency by approximately 30% from 2003 to 2009. In comparison with DDLT recipients, LDLT recipients were younger and had higher albumin levels, lower body mass indices, and lower match MELD scores. Females had increased odds of LDLT in comparison with males (OR = 1.74, P < 0.001). Patients with MELD exception scores were less likely to undergo LDLT (OR = 0.22, P < 0.001). Patients with cholestatic liver disease (adjusted OR = 2.04, P < 0.001) or malignant neoplasms other than hepatocellular carcinoma (adjusted OR = 3.33, P < 0.001) were more likely than patients with hepatitis C virus to undergo LDLT. Other characteristics associated with decreased odds of LDLT were black race (adjusted OR = 0.41, P < 0.001) and government insurance (adjusted OR = 0.51, P < 0.001). LDLT was more frequent in DSAs with high median MELD scores; the adjusted OR for LDLT was 38 for the DSAs in the highest quintile (P < 0.001). In conclusion, there are significant differences associated with race, insurance, sex, MELD exceptions, and DSA MELD scores between patients who undergo LDLT and patients who undergo DDLT. These differences can be hypothesized to be driven in part by the relative availability of LDLT versus DDLT at both the patient level and the DSA level.     

Donation after cardiac death: the University of Wisconsin experience with liver transplantation

OBJECTIVE: To determine whether the outcomes of liver transplantation (LTx) from donation after cardiac death (DCD) donors are equivalent to those from donation after brain death (DBD) donors. SUMMARY BACKGROUND DATA: Because of the significant donor organ shortage, more transplant centers are using livers recovered from DCD donors. However, long-term, single-center outcomes of liver transplantation from DCD donors are limited. METHODS: From January 1, 1993, to July 31, 2002, 553 liver transplants were performed from DBD donors and 36 were performed from DCD donors. Differences in event rates between the groups were compared with Kaplan-Meier estimates and the log-rank test. Differences in proportion and differences of means between the groups were compared with Fisher exact test and the Wilcoxon rank sum test, respectively. RESULTS: Mean warm ischemic time at recovery in the DCD group was 17.8 +/- 10.6 minutes. The overall rate of biliary strictures was greater in the DCD group at 1 year (33% versus 10%) and 3 years (37% versus 12%; P = 0.0001). The incidence of hepatic artery thrombosis, portal vein stenosis/thrombosis, ischemic-type biliary stricture (ITBS), and primary nonfunction were similar between groups. However, the incidence of both hepatic artery stenosis (16.6% versus 5.4%; P = 0.001) and hepatic abscess and biloma formation (16.7% versus 8.3%; P = 0.04) were greater in the DCD group. Trends toward worse patient and graft survival and increased incidence of ITBS were seen in DCD donors greater than 40 years compared with DCD donors less than 40 years. Overall patient survival at 1 year (DCD, 80%; versus DBD, 91%) and 3 years (DCD, 68%; versus DBD, 84%) was significantly less in the DCD group (P = 0.002). Similarly, graft survival at 1 year (DCD, 67%; versus DBD, 86%) and 3 years (DCD, 56%; versus DBD, 80%) were significantly less in the DCD group (P = 0.0001). CONCLUSIONS: Despite similar rates of primary nonfunction, LTx after controlled DCD resulted in worse patient and graft survival compared with LTx after DBD and increased incidence of biliary complications and hepatic artery stenosis. However, overall results of LTx after controlled DCD are encouraging; and with careful donor and recipient selection, LTx after DCD may successfully increase the donor liver pool.     

Hepatopulmonary syndrome after living donor liver transplantation and deceased donor liver transplantation: a single-center experience.

Hepatopulmonary syndrome (HPS) is a progressive, debilitating complication of end-stage liver disease. In contrast to the well-established reversal of HPS after deceased donor liver transplantation (DDLT), little has been written about the natural course of HPS after the newer procedure of living donor liver transplantation (LDLT). We describe HPS in a small series of 4 liver transplant recipients (2 DDLT; 2 LDLT) at a single center. Before transplantation, these 4 patients had a mean shunt fraction of 23.6 +/- 14.3% and a mean PaO2 of 58.5 +/- 11.3 mm Hg. All 4 patients used supplemental oxygen before transplantation. Sixteen weeks after transplantation, all 4 patients had normalized or improved shunt fraction and PaO2. These patients regained normal pulmonary function within a few months, despite the period of hepatic regeneration after LDLT. In conclusion, both DDLT and LDLT are associated with rapid and dramatic reversal of HPS.     

Donation after cardiac death: two case studies

Few transplant centers consider using lungs from cardiac death donors because of warm ischemic damage. In certain scenarios, the recovery and transplantation of lungs from cardiac death donors are appropriate. A young person with a severe neurologic and spinal cord injury, who is not brain dead and who is otherwise healthy, should be considered as a cardiac death donor. A protocol should be established with local lung transplant surgeons to facilitate the successful procurement of lungs from cardiac death donors. In addition, when patients present to hospital emergency rooms with nonsurvivable injuries either in cardiac arrest or with extremely labile vital signs, uncontrolled donation after cardiac death can be considered. It is important to obtain informed consent from the family and to suspend any previous do-not-resuscitate orders before initiating resuscitative efforts. If an organ procurement coordinator and team are within close proximity to the hospital, consideration should be given to uncontrolled donation after cardiac death.     

HBsAg(+) donor as a kidney transplantation deceased donor

Background

The organ shortage and high prevalence of hepatitis B (HB) infection in the general population are important issues in Taiwan. It is difficult for us to abandon HBsAg(+) donors. Hereby we present our experience transplanting kidneys from deceased donors with HB virus infection.

Methods

From November 1977 to March 2007, 21 patients with end-stage renal disease received kidney grafts from 12 HBsAg(+) deceased donors (3.92% of 306 donors). One of the 12 donors was hepatitis Be antigen (HBeAg) (+), and 5 displayed antibody to hepatitis core antigen (anti-HBc) (+). Four of the 21 recipients were HBsAg(+) before transplantation.

Results

Four HBsAg(+) recipients remained surface antigen positive after transplantation. One of them died of an intracranial hemorrhage. Two (11.76%) of the other 17 HBsAg(−) recipients became HBsAg(+), 1 of whom died of hepatic failure and the other of sepsis. The other 15 HBsAg(−) recipients (88.23%) remained HBsAg(−) after transplantation. They displayed normal serum levels of aspartate aminotransferase/alanine aminotransferase during the follow-up period. The 5-year patient and graft survivals were 85.15% and 61.14%, respectively.

Conclusion

Although the number of patients is relatively small, it does suggest that a kidney allograft from an HBsAg(+) deceased donor transplanted to an HBsAg(+) or (−) recipient is safe. This strategy shortens the waiting time. Additional prophylactic HB immunoglobulin and antiviral medications are also suggested. Frequent surveillance after transplantation is essential.     

Donation after cardiac death for lung transplant: a case study

In late 2009, Gift of Life Michigan facilitated a donation after cardiac death lung recovery resulting in the first set of donation after cardiac death lungs to be utilized by a Michigan transplant center. Although placing lungs obtained via donation after cardiac death is more difficult because of a multitude of factors, the transplant coordinators, in conjunction with the transplant center, overcame several obstacles in order to transplant the lungs with good outcomes so far. Lung donation after cardiac death is becoming a more acceptable method of decreasing the length of the transplant waiting list as more data are becoming available.     

Early postoperative deaths of recipients after deceased donor liver transplantation

Aim-Background

Liver transplant often results in haemodynamic and biochemical changes in the immediate postoperative period, often causing concern to the treating physician.

The aim

of the present study is to determine the preoperative clinical profile, along with the haematological and biochemical changes following deceased donor liver transplantation (DDLT) in the immediate 7-day postoperative period.

Method

A detailed assessment of the patients preoperative clinical diagnosis, presence of co-morbid illness and postoperative haematological, biochemical, and clinical events was made between survivors and those who died. Various parameters were compared between two groups to help us understand the variants that determined the early postoperative outcome in DDLT patients.

Results

A total of 26 patients were categorized into two groups: 18 patients were allocated to Group 1 (survivors) and 8 patients to Group 2 (mortality). There was no difference in the fluctuation of haemoglobin levels between the two groups. Early leukocytosis and persistent azotemia predicted early morbidity and mortality. A significant fall of platelet count predicted mortality. Transaminases showed a significant increase between the 2^nd and 3rd postoperative day, after which they stabilised and showed a downwards trend by the 7th to 9th postoperative day in both groups. Intraoperative events like cardiac arrhythmias, ischaemic cardiac events, pulmonary thromboembolism, hepatic artery thrombosis, sepsis and multiorgan failure rank among the causes of death.

Conclusion

Preoperative co-morbid illness, postoperative worsening azotemia, persistent leukocytosis, and sepsis and cardiac events in the immediate postoperative period are factors that appear to predict the outcome post DDLT.     

心脏死亡器官捐献供肾移植单中心60例经验总结

目的 探讨单中心DCD供肾移植的临床效果,总结DCD供肾移植的经验.方法 回顾性分析2011年12月至2013年4月间60例DCD和112例DCD供肾移植的临床资料.结果 依据《中国心脏死亡器官捐献指南》,实施DCD 60例,共捐献肾脏118个,实施肾移植112例.14例受者术后发生移植肾功能延迟恢复(DGF),发生率12.5％,其中未使用LifePort机械灌注冷保存DGF发生率23.1％ (6/26),使用LifePort移植肾DGF发生率9.3％(8/86).14例DGF受者4例切除移植肾,10例肾功能术后16～52 d恢复正常.急性排斥反应发生率6.3％(7/112),其中1例术后第12天移植肾破裂切除肾脏,其余经治疗后逆转.1例受者术后第15天因急性心肌梗死亡,1例术后第7天发生急性心功能衰竭死亡.移植肾存活的105例受者,随访1～15个月,移植肾功能正常.结论 在我国实施DCD切实可行,是符合伦理和我国国情的器官来源根本途径.DCD供肾移植临床效果良好,Lifeport具有清除肾脏残余微血栓、疏通肾脏微血管、评估肾脏功能及预防DGF的良好作用.     

Heterotopic heart transplantation--a means to increase donor availability

From November 1985 to August 1989, 105 patients underwent heart transplantation at our institution of whom 8 (7%) underwent heterotopic heart transplantation (HHTx). There were 7 males and 1 female with a mean age of 49 +/- 6 years (range, 41-58 years), 7 of whom had ischaemic cardiomyopathy and 1 had dilated cardiomyopathy. The indications for HHTx were gross donor/recipient size mismatch, unreliable donor heart, elevated pulmonary vascular resistance and the need for urgent transplantation or their combination. HHTx was performed as a left ventricular bypass in 6 patients and as biventricular bypass in 2 combined with various surgical procedures on the native heart in 5. There was one perioperative death with a mean follow-up of the survivors of 17 +/- 10 months (range, 6-30 months). Comparison of preoperative and postoperative (1 year) 2-D echocardiographic studies of the native heart showed haemodynamic stability of the latter with no substantial changes in left ventricular ejection fraction and cardiac index, while left ventricular end-diastolic volume tended to increase in 2 patients. In conclusion, preservation of the native heart allows recovery or growth of a graft considered unsuitable for orthotopic transplantation. Our experience confirms that HHTx may still be considered a valuable alternative to orthotopic transplantation in selected patients, thus expanding donor utilization.     

Donation after cardiac death has a minimal impact on thoracic organ recovery

BACKGROUND: Our organ procurement organization recently developed an aggressive donation after cardiac death program. Thoracic organs are rarely recovered from non-heart-beating donors. Therefore, there is concern that donation after cardiac death may affect the recovery of thoracic organs from donors not allowed to progress to brain death. OBJECTIVE: To evaluate the potential impact of donation after cardiac death on the recovery of thoracic organs. METHODS: On the assumption that prolongation of care on all cases would result in a diagnosis of brain death. By retrospective chart review, all donations after cardiac death were evaluated for thoracic organ potential using the same standards that were used to evaluate brain-dead donors. RESULTS: During the study period there were 34 of 44 (77%) non-heart-beating donors qualified to donate abdominal organs only. Ten of 44 non-heart-beating donors (24%) qualified to potentially donate thoracic organs; the families of 4 of 10 of these donors insisted on the immediate withdrawal of life support, leaving only 6 donors with thoracic organ potential. All 6 of these donors qualified as potential heart donors and 3 as potential lung donors. CONCLUSIONS: A total of 97 organs were recovered and successfully transplanted from 44 non-heart-beating donors. If all the donors who qualified to donate thoracic organs progressed to brain death and if their thoracic organs were transplantable, then 6 additional hearts and 3 pairs of lungs may have been recovered. These data demonstrate that an aggressive donation after cardiac death program contributes significantly to the organ donor pool, with a minimal impact on potential thoracic organ recovery.     

Donation after cardiac death liver transplant recipients have an increased frequency of acute kidney injury

Donation after cardiac death (DCD) liver transplantation is associated with an increased frequency of hepato-biliary complications. The implications for renal function have not been explored previously. The aims of this single-center study of 88 consecutive DCD liver transplant recipients were (1) to compare renal outcomes with propensity-risk-matched donation after brain death (DBD) patients and (2) in the DCD patients specifically to examine the risk factors for acute kidney injury (AKI; peak creatinine ≥2 times baseline) and chronic kidney disease (CKD; eGFR <60 mL/min/1.73 m(2) ). During the immediate postoperative period DCD liver transplantation was associated with an increased incidence of AKI (DCD, 53.4%; DBD 31.8%, p = 0.004). In DCD patients AKI was a risk factor for CKD (p = 0.035) and mortality (p = 0.017). The cumulative incidence of CKD by 3 years post-transplant was 53.7% and 42.1% for DCD and DBD patients, respectively (p = 0.774). Importantly, increasing peak perioperative aspartate aminotransferase, a surrogate marker of hepatic ischemia reperfusion injury, was the only consistent predictor of renal dysfunction after DCD transplantation (AKI, p < 0.001; CKD, p = 0.032). In conclusion, DCD liver transplantation is associated with an increased frequency of AKI. The findings suggest that hepatic ischemia reperfusion injury may play a critical role in the pathogenesis of post-transplant renal dysfunction.     

Graft and patient survival after adult live donor liver transplantation compared to a matched cohort who received a deceased donor transplantation.

Live donor liver transplantation (LDLT) has become increasingly common in the United States and around the world. In this study, we compared the outcome of 764 patients who received LDLT in the United States and compared the results with a matched population that received deceased donor transplantation (DDLT) using the United Network for Organ Sharing (UNOS) database. For each LDLT recipient (n = 764), two DDLT recipients (n = 1,470), matched for age, gender, race, diagnosis, and year of transplantation, were selected from the UNOS data after excluding multiple organ transplantation or retransplantation, children, and those with incomplete data. Despite our matching, recipients of LDLT had more stable liver disease, as shown by fewer patients with UNOS status 1 or 2A, in an intensive care unit, or on life support. Creatinine and cold ischemia time were also lower in the LDLT group. Primary graft nonfunction, hyperacute rejection rates, and patient survival by Kaplan-Meier analysis were similar in both groups (2-year survival was 79.0% in LDLT vs. 80.7% in case-controls; P = .5), but graft survival was significantly lower in LDLT (2-year graft survival was 64.4% vs. 73.3%; P < .001). Cox regression (after adjusting for confounding variables) analysis showed that LDLT recipients were 60% more likely to lose their graft compared to DDLT recipients (hazard ratio [HR] 1.6; confidence interval 1.1-2.5). Among hepatitis C virus (HCV) patients, LDLT recipients showed lower graft survival when compared to those who received DDLT. In conclusion, short-term patient survival in LDLT is similar to that in the DDLT group, but graft survival is significantly lower in LDLT recipients. LDLT is a reasonable option for patients who are unlikely to receive DDLT in a timely fashion.