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Normothermic regional perfusion (NRP) allows the in situ perfusion of organs with oxygenated blood in donation after the circulatory determination of death (DCDD). We aimed at evaluating the impact of NRP on the short-term outcomes of kidney transplants in controlled DCDD (cDCDD). This is a multicenter, nationwide, retrospective study comparing cDCDD kidneys obtained with NRP versus the standard rapid recovery (RR) technique. During 2012-2018, 2302 cDCDD adult kidney transplants were performed in Spain using NRP (n = 865) or RR (n = 1437). The study groups differed in donor and recipient age, warm, and cold ischemic time and use of ex situ machine perfusion. Transplants in the NRP group were more frequently performed in high-volume centers (≥90 transplants/year). Through matching by propensity score, two cohorts with a total of 770 patients were obtained. After the matching, no statistically significant differences were observed between the groups in terms of primary nonfunction (p = .261) and mortality at 1 year (p =  .111). However, the RR of kidneys was associated with a significantly increased odds of delayed graft function (OR 1.97 [95% CI 1.43-2.72]; p < .001) and 1-year graft loss (OR 1.77 [95% CI 1.01-3.17]; p = .034). In conclusion, compared with RR, NRP appears to improve the short-term outcomes of cDCDD kidney transplants., (© 2021 The American Society of Transplantation and the American Society of Transplant Surgeons.)

A 'Critical pathway for deceased tissue donation' was developed by the European Committee on Organ Transplantation of the Council of Europe (CD-P-TO) with the aim of providing a common systematic approach to the deceased tissue donation process. Definitions of tissue donors according to the donation stage have been developed so that they can be adapted to different local scenarios. This critical pathway can be used retrospectively to evaluate the potential of tissue donation, assess performance in the tissue donation process and identify areas for improvement. It sets the basis to build indicators to compare organizations, regions and countries. The critical pathway can also be used prospectively to promote good practices in tissue donation programmes aimed at covering the tissue transplantation needs of patients., (© 2021 The Authors. Transplant International published by John Wiley & Sons Ltd on behalf of Steunstichting ESOT.)

Impact of training on end-of-life care (EOLC) and the deceased donation process in critical care physicians' perceptions and attitudes was analysed. A survey on attitudes and perceptions of deceased donation as part of the EOLC process was delivered to 535 physicians working in critical care before and after completion of a online training programme (2015-17). After training, more participants agreed that nursing staff should be involved in the end-of-life decision process (P < 0.001) and that relatives should not be responsible for medical decisions (P < 0.001). Postcourse, more participants considered 'withdrawal/withholding' as similar actions (P < 0.001); deemed appropriate the use of pre-emptive sedation in all patients undergoing life support treatment adequacy (LSTA; P < 0.001); and were favourable to approaching family about donation upon LSTA agreement, as well as admitting them in the intensive care unit (P < 0.001) to allow the possibility of donation. Education increased the number of participants prone to initiate measures to preserve the organs for donation before the declaration of death in patients undergoing LSTA (P < 0.001). Training increased number of positive terms selected by participants to describe donation after brain and circulatory death. Training programmes may be useful to improve physicians' perception and attitude about including donation as part of the patient's EOLC., (© 2020 Steunstichting ESOT. Published by John Wiley & Sons Ltd.)

Objective: We evaluate the impact of a web-based collaborative system on the referral of possible organ donors from outside of the intensive care unit (ICU)., Study Design: Cohort prospective study., Settings: University hospital., Patients and Intervention: In 2015 a virtual collaborative system using a cross-platform instant messaging application replaced the previous 2014 protocol for the referral of patients outside of the ICU with a severe brain injury in whom all treatment options were deemed futile by the attending team to the donor coordination (DC). Once the DC evaluated the medical suitability and likelihood of progression to brain death (BD), the option of intensive care to facilitate organ donation (ICOD) was offered to the patient's relatives. This included admission to the ICU and elective non-therapeutic ventilation (ENTV), where appropriate., Results: A two-fold increase of referrals was noted in 2015 [n=46/74; (62%)] compared to 2014 [n=13/40; (32%)]; p<0.05. Patients were mostly referred from the stroke unit (58.6%) in 2015 and from the emergency department (69.2%) in 2014 (p<0.01). Twenty (2015: 42.5%) and 4 (2014: 30.7%) patients were discarded as donors mostly due to medical unsuitability. Family accepted donation in 16 (2015: 62%) and 6 (2014: 66%) cases, all admitted to the ICU and 10 (2015: 62.5%) and 3 (50%) being subject to ENTV. Ten (2015: 66.6%) and 5 (2014: 83.3%) patients progressed to BD, 60.5±20.2 and 44.4±12.2h after referral respectively. Nine (2015) and 4 (2014) of these patients became utilized donors, representing 29.0% (2015) and 13.0% (2014) of the BD donors in the hospital during the study period (p<0.05)., Conclusion: The implementation of a virtual community doubled the number of patients whose families were presented with the option of donation prior to their death., (Copyright © 2018 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.)

Background: Intensive care to facilitate organ donation (ICOD) has been defined as the initiation or continuation of intensive care measures in patients with a devastating brain injury (DBI) in whom treatment for curative purposes is deemed futile, and who are considered possible organ donors, with the aim of offering donation after brain death (DBD) inside their end-of-life care plans. We describe the effect on the donation and transplantation activity of the implementation of ICOD protocol at a university hospital., Methods: Retrospective analysis (2015-2018) of demographics and outcomes of all patients with a DBI, in whom ICOD was considered as part of their end-of-life care in Vall d'Hebron University Hospital, Barcelona., Results: Of the 983 possible donors evaluated, ICOD was considered in 206 (21%), of whom 115 (55.8%) were medically unsuitable for donation. Family consent was obtained for 69 (76%) of the remaining patients. Refusal rate was twice as high when nontherapeutic ventilation was required for organ donation (34%) vs patients previously ventilated (13.6%) (P = .02). Patients subject to ICOD died in a median of 2 days (1-3 d) and 88.4% became actual donors (39 after brain death; 22 after circulatory death). Nine (17.6%) donors were finally not utilized. ICOD contributed to 29% (ranging from 27.7% in 2015 to 31.6% in 2018) of the 208 actual donors and 26% of the 603 organs transplanted., Conclusions: ICOD is well-accepted by families and offers the donation option to an increasing number of patients at our hospital. It provides an important and sustained increment of the organ pool for transplantation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

With the aim of consolidating recommendations about the practice of initiating or continuing intensive care to facilitate organ donation (ICOD), an ad hoc working group was established, comprising 10 intensivists designated by the Spanish Society of Intensive Care and Coronary Units (SEMICYUC) and the Spanish National Transplant Organization (ONT). Consensus was reached in all recommendations through a deliberative process. After a public consultation, the final recommendations were institutionally adopted by SEMICYUC, ONT, and the Transplant Committee of the National Health-Care System. This article reports on the resulting recommendations on ICOD for patients with a devastating brain injury for whom the decision has been made not to apply any medical or surgical treatment with a curative purpose on the grounds of futility. Emphasis is made on the systematic referral of these patients to donor coordinators, the proper assessment of the likelihood of brain death and medical suitability, and on transparency in communication with the patient's family. The legal and ethical aspects of ICOD are addressed. ICOD is considered a legitimate practice that offers more patients the opportunity of donating their organs upon their death and helps to increase the availability of organs for transplantation., (© 2019 The American Society of Transplantation and the American Society of Transplant Surgeons.)

The number of organs retrieved from donation after circulatory death (DCD) donors has continued to rise in recent years. The functional superiority of DCD organs is achieved when the lungs are perfused with cold perfusion and livers with normothermic regional perfusion (NRP). Thus, a precise surgical technique is required to combine thoracic and abdominal organ procurement. The technique used at our center consists of a rapid laparotomy and middle sternotomy, then the abdominal aorta (Ao) and abdominal inferior vena cava (VC) are cannulated and the descending thoracic Ao is cross-clamped. NRP is started at that point. As a variation of previously described techniques, the thoracic vena cava is not initially clamped in order to improve the return of blood volume to the NRP circuit. The pulmonary artery is cannulated to flush the lungs and the left atrial appendage is opened for drainage. After 120 minutes, NRP perfusion is stopped and the organs are flushed with cold preservation solution. In 2016, 3 livers and 6 lungs were harvested at our center using the technique described. After a minimum follow-up of 1 year, no evidence of biliary complications was observed. The combined procurement of lungs after room temperature perfusion and liver after NRP without initial clamping of the thoracic VC is feasible, with excellent function post-transplantation., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The increasing gap between availability of solid organs for transplantation and the demand has led to the inclusion of donor organs that, according to current guidelines, may be discarded, some of them because of the possibility for transmission of infection to the recipients. We present the first report, to the best of our knowledge, of a case of a brain-dead donor with a localized and treated Actinomyces israelii central nervous system infection who, after a thorough evaluation, provided organs for successful transplant procedures in four recipients. There was no evidence of transmission of infection within a 6-month follow-up. Relative contraindications must be individualized in order to expand the number of real organ donors, emphasizing caution in rare causes for brain death in which patients should be thoroughly evaluated for possible donation., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Intensive Care to facilitate Organ Donation (ICOD) may help to increase the donor pool. We describe the Spanish experience with ICOD., Methods: Achieving Comprehensive Coordination in Organ Donation (ACCORD)-Spain consisted of an audit of the donation pathway from patients who died as a result of a devastating brain injury (possible donors) in 68 hospitals during November 1, 2014, to April 30, 2015. We focused on possible donors whose families were interviewed to discuss organ donation once intensive care with a therapeutic purpose was deemed futile and brain death (BD) was a likely outcome., Results: Of the 1970 possible donors in ACCORD-Spain, in 257, the family was interviewed once the decision had been made not to intubate/ventilate (n = 105), with the patient under intubation/ventilation outside of the intensive care unit (n = 59), or with the patient intubated/ventilated within the intensive care unit (n = 93).Consent to ICOD was obtained in 174 cases. Consent was higher when the donor coordinator participated in the interview (odds ratio, 2.32; 95% confidence interval, 1.33-4.11; P = 0.003). One hundred thirty-one patients developed BD, of whom 117 transitioned to actual donation after BD. Of the 35 patients who did not develop BD, 2 transitioned to actual donation after circulatory death. Sixteen patients subject to ICOD were finally medically unsuitable organ donors.ICOD contributed to 24% of the 491 actual donors registered in ACCORD-Spain., Conclusions: Despite the complexity of the interview, the majority of families consented to ICOD. Estimating the probability of BD and assessing medical suitability are additional challenges of the practice. ICOD represents a clear opportunity to increase the donor pool and ensures organ donation is posed at every end-of-life care pathway.

Objective: To describe end-of-life care practices relevant to organ donation in patients with devastating brain injury in Spain., Design: A multicenter prospective study of a retrospective cohort., Period: 1 November 2014 to 30 April 2015., Setting: Sixty-eight hospitals authorized for organ procurement., Patients: Patients dying from devastating brain injury (possible donors). Age: 1 month-85 years., Primary Endpoints: Type of care, donation after brain death, donation after circulatory death, intubation/ventilation, referral to the donor coordinator., Results: A total of 1,970 possible donors were identified, of which half received active treatment in an Intensive Care Unit (ICU) until brain death (27%), cardiac arrest (5%) or the withdrawal of life-sustaining therapy (19%). Of the rest, 10% were admitted to the ICU to facilitate organ donation, while 39% were not admitted to the ICU. Of those patients who evolved to a brain death condition (n=695), most transitioned to actual donation (n=446; 64%). Of those who died following the withdrawal of life-sustaining therapy (n=537), 45 (8%) were converted into actual donation after circulatory death donors. The lack of a dedicated donation after circulatory death program was the main reason for non-donation. Thirty-seven percent of the possible donors were not intubated/ventilated at death, mainly because the professional in charge did not consider donation alter discarding therapeutic intubation. Thirty-six percent of the possible donors were never referred to the donor coordinator., Conclusions: Although deceased donation is optimized in Spain, there are still opportunities for improvement in the identification of possible donors outside the ICU and in the consideration of donation after circulatory death in patients who die following the withdrawal of life-sustaining therapy., (Copyright © 2016 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.)

We conducted a multicentre study of 1844 patients from 42 Spanish intensive care units, and analysed the clinical characteristics of brain death, the use of ancillary testing, and the clinical decisions taken after the diagnosis of brain death. The main cause of brain death was intracerebral haemorrhage (769/1844, 42%), followed by traumatic brain injury (343/1844, 19%) and subarachnoid haemorrhage (257/1844, 14%). The diagnosis of brain death was made rapidly (50% in the first 24 h). Of those patients who went on to die, the Glasgow Coma Scale on admission was ≤ 8/15 in 1146/1261 (91%) of patients with intracerebral haemorrhage, traumatic brain injury or anoxic encephalopathy; the Hunt and Hess Scale was 4-5 in 207/251 (83%) of patients following subarachnoid haemorrhage; and the National Institutes of Health Stroke Scale was ≥ 15 in 114/129 (89%) of patients with strokes. Brain death was diagnosed exclusively by clinical examination in 92/1844 (5%) of cases. Electroencephalography was the most frequently used ancillary test (1303/1752, 70.7%), followed by transcranial Doppler (652/1752, 37%). Organ donation took place in 70% of patients (1291/1844), with medical unsuitability (267/553, 48%) and family refusal (244/553, 13%) the main reasons for loss of potential donors. All life-sustaining measures were withdrawn in 413/553 of non-donors (75%)., (© 2015 The Association of Anaesthetists of Great Britain and Ireland.)

Objective: The objective of this study was to describe tissue procurement activity performed during 10 years (2004-2014) by trained medical students in a large university hospital., Methods: In this study, third to sixth year medical students were trained as in-hospital Tissue Coordinators (Tc) to perform tissue procurement activity on a 24/7 schedule supervised by an on-call senior Transplant Coordinator (sTC) in a large university hospital. Tc duty consisted of detection, initial evaluation of all hospital deaths, donor's family approach for tissue donation, and retrieval logistics organization, including corneal tissue retrieval after training and certification. They also assist sTC in organ procurement activity., Results: A total of 18,931 deaths were prospectively evaluated, 79% of whom (n = 14,879) presented medical contraindications for tissue donation. Of the remaining 4052 (21%) potential tissue donors (PTD), 2522 (62%) were not converted into real donors, mostly due to family refusal (66%; n = 1650) followed by detection system failure and other logistical issues (34%; n = 872). A total of 2814 corneal units, 225 skin donations, 327 muscleskeletal tissue donations, 91 blood vessels donations, and 177 heart valve donations were obtained from the remaining 1530 (38%) real donors. Tissue potentiality increased from 19% to 43% throughout the study period as a consequence of the fluctuating acceptance criteria used by tissue banks depending on tissue demand., Conclusions: The tissue donation program performed by trained students was successful in achieving a high and sustainable tissue donation rate in a large university hospital., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To analyze the profile, incidence of life support therapy limitation (LSTL) and donation potential in neurocritical patients., Study Design: A multicenter prospective study was carried out., Setting: Nine hospitals authorized for organ harvesting for transplantation., Patients: All patients consecutively admitted to the hospital with GCS < 8 during a 6-month period were followed-up until discharge or day 30 of hospital stay., Study Variables: Demographic data, cause of coma, clinical status upon admission and outcome were analyzed. LSTL, brain death (BD) and organ donation incidence were recorded., Results: A total of 549 patients were included, with a mean age of 59.0 ± 14.5 years. The cause of coma was cerebral hemorrhage in 27.0% of the cases.LSTL was applied in 176 patients (32.1%). In 78 cases LSTL consisted of avoiding ICU admission. Age, the presence of contraindications, and specific causes of coma were associated to LSTL. A total of 58.1% of the patients died (n=319). One-hundred and thirty-three developed BD (24.2%), and 56.4% of these became organ donors (n=75). The presence of edema and mid-line shift on the CT scan, and transplant coordinator evaluation were associated to BD. LSTL was associated to a no-BD outcome. Early LSTL (first 4 days) was applied in 9 patients under 80 years of age, with no medical contraindications for donation and a GCS ≤ 4 who finally died in asystole., Conclusions: LSTL is a frequent practice in neurocritical patients. In almost one-half of the cases, LSTL consisted of avoiding admission to the ICU, and on several occasions the donation potential was not evaluated by the transplant coordinator., (Copyright © 2014 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.)

The Spanish Quality Assurance Program applied to the process of donation after brain death entails an internal stage consisting of a continuous clinical chart review of deaths in critical care units (CCUs) performed by transplant coordinators and periodical external audits to selected centers. This paper describes the methodology and provides the most relevant results of this program, with information analyzed from 206,345 CCU deaths. According to the internal audit, 2.3% of hospital deaths and 12.4% of CCU deaths in Spain yield potential donors (clinical criteria consistent with brain death). Out of the potential donors, 54.6% become actual donors, 26% are lost due to medical unsuitability, 13.3% due to refusals to donation, 3.1% due to maintenance problems and 3% due to other reasons. Although the national pool of potential donors after brain death has progressively decreased from 65.2 per million population (pmp) in 2001 to 49 pmp in 2010, the number of actual donors after brain death has remained at about 30 pmp. External audits reveal that the number of actual donors could be 21.6% higher if all potential donors were identified and preventable losses avoided. We encourage other countries to develop similar comprehensive approaches to deceased donation performance., (© Copyright 2012 The American Society of Transplantation and the American Society of Transplant Surgeons.)

The shortage of organs for transplantation has prompted the investigation of extended criteria donors, such as donors with transmissible infectious diseases. Here we report our recent experience with liver transplantation using organs from donors who were serologically positive for Chagas disease. We also provide a review of the literature and emphasize donor screening and preventive measures., (Copyright © 2011 American Association for the Study of Liver Diseases.)

The initial experience in facial composite tissue allotransplantation has demonstrated that it is surgically feasible, safe, and reproducible. A robust team approach is necessary to warrant successful outcomes. We designed a specific face organ donation that limits facial donation requests followed by synchronous in situ dissection with the internal organs that has proved to be efficient and safe for face and solid organ procurement and transplantation. The first human full face transplantation in our institution was performed on March 27, 2010. The holistic team approach of donation and procurement proved to be effective and reproducible; the recipient showed excellent outcomes at 12 months., (Copyright © 2011 Elsevier Inc. All rights reserved.)

The face is the latest body structure to be added to the field of transplantation and the learning curve is ongoing. In the scenario of multiorgan recovery, the face is a nonvital 'organ' structure compared with other life-saving organs. To date, the face has been the first 'organ' to be procured in a multiorgan procurement. A technique for simultaneous recovery of the whole face, heart, lungs, liver, pancreas and kidneys is described. Thirty professionals participated in the procedure, of whom 13 were surgeons. No tracheotomy was performed. A mask of the donor's face was made from a mold impression. Duration of the procedure from skin incision to the end of surgery was 7.3 h. The face was perfused with Wisconsin solution through a cannula inserted into the aortic arch between the origin of the brachiocephalic arterial trunk and the left subclavian artery. Blood requirements consisted of 4 units of packed red blood cells. After the procedure, the mask was placed on the donor's face. All recovered grafts functioned immediately. In summary, simultaneous multiorgan procurement including the whole face is feasible, effective and saves time without jeopardizing life-saving organs and without the need for tracheotomy., (©2011 The Authors Journal compilation©2011 The American Society of Transplantation and the American Society of Transplant Surgeons.)