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Abstract Aims The use of extended criteria donors is a routine practice that sometimes involves extracorporeal membrane oxygenation (ECMO) in donations after cardiac death or brain death. Methods We performed a retrospective study in a single center from January 2006 to December 2019. The study included 90 deceased donor liver transplants. The patients were divided into three groups: the donation after brain death (DBD) group (n = 58, 64.4%), the DBD with ECMO group (n = 11, 12.2%) and the donation after cardiac death (DCD) with ECMO group (n = 21, 23.3%). Results There were no significant differences between the DBD with ECMO group and the DBD group. When comparing the DCD with ECMO group and the DBD group, there were statistically significant differences for total warm ischemia time (p

With persistent breakthrough and maturity of surgical procedures and postoperative immunosuppressive therapy, the survival rate of liver transplant recipients and grafts has been significantly increased. The shortage of donor liver has become the main obstacle for clinical development of liver transplantation. How to expand the source of donor liver has become an urgent issue. Groundbreaking progresses have been made in the use of common marginal donor livers in clinical liver transplantation, such as elderly donor liver, steatosis donor liver, viral hepatitis donor liver and liver from donation after cardiac death. Nevertheless, multiple restrictions still exist regarding the use of marginal donor liver. Consequently, the definition of marginal donor liver and research progress in the application of common marginal donor livers were reviewed, and the opportunities and challenges of mariginal donoor liver were illustrated, aiming to provide reference for expanding the donor pool for clinical liver transplantation and bringing benefits to more patients with end-stage liver disease. [ABSTRACT FROM AUTHOR]

Donation after death is the most important ethical principle to carry out organ donation after citizens’ death. The newly-revised Regulations on Human Organ Donation and Transplantation does not define death, and avoids the key question of “whether to recognize brain death”. Certain legal risks or damages to the rights and interests of donors may exist in organ donation. Death is an inevitable part of human life. It is necessary to establish specific criteria, which is also the only approach, to define death in any era. Death criteria are established based on the view of death, and restricted by the development level of productive forces and other social factors. The determination of death criteria hugely varies between China and the West. To standardize organ donation and transplantation and promote high-quality development of organ donation, medical staff must adhere to the principle of pure motivation, take informed consents as the premise, respect the donors' and their close relatives' rights to choose their own death criteria, strictly follow the death judgment procedures and operating norms, and ensure the scientificity, accuracy and fairness of death determination. [ABSTRACT FROM AUTHOR]

Introduction and Objectives: Due to organ shortages, liver transplantation (LT) using donation-after-circulatory-death (DCD) grafts has become more common. There is limited and conflicting evidence on LT outcomes using DCD grafts compared to those using donation-after-brain death (DBD) grafts for patients with hepatocellular carcinoma (HCC). We aimed to summarize the current evidence on the outcomes of DCD-LT and DBD-LT in patients with HCC. Materials and Methods: Online databases were searched for studies comparing DCD-LT and DBD-LT outcomes in patients with HCC and a meta-analysis was conducted using fixed- or random-effects models. Results: Five studies involving 487 (33.4%) HCC DCD-LT patients and 973 (66.6%) DBD-LT patients were included. The meta-analysis showed comparable 1-year [relative risk (RR)=0.99, 95%CI:0.95 to 1.03, p=0.53] and 3-year [RR=0.99, 95%CI:0.89 to 1.09, p=0.79] recurrence-free survival. The corresponding 1-year [RR=0.98, 95%CI:0.93 to 1.03, p=0.35] and 3-year [RR=0.94, 95%CI:0.87 to 1.01, p=0.08] patient survival and 1-year [RR=0.91, 95%CI:0.71 to 1.16, p=0.43] and 3-year [RR=0.92, 95%CI:0.67 to 1.26, p=0.59] graft survival were also comparable. There were no significant differences between the two cohorts regarding the tumor characteristics, donor/recipient risk factors and the incidence of post-operative complications, including acute rejection, primary non-function, biliary complications and retransplantation. Conclusions: Based on the current evidence, it has been found that comparable outcomes can be achieved in HCC patients using DCD-LT compared to DBD-LT, particularly when employing good quality graft, strict donor and recipient selection, and effective surgical management. The decision to utilize DCD-LT for HCC patients should be personalized, taking into consideration the risk of post-LT HCC recurrence. [ABSTRACT FROM AUTHOR]

Objectives: Regarding the relationship between donor kidney quality and renal graft function after deceased kidney transplantation (KTx) following donation after cardiac death (DCD), the evaluation timing varies depending on the study. Evaluation of histology and changes in long‐term renal graft function is limited. Methods: A retrospective single‐center study included 71 recipients who underwent 0‐hour biopsy for KTx from DCD. The recipients were divided into two groups to evaluate factors related to renal graft function (study1). The two groups were categorized as stable graft function and poor graft function with the change of estimated glomerular filtration rate (eGFR) after KTx. The recipients were then divided into four groups to assess whether the factors identified in study1 were related to the change in long‐term renal graft function (study2). They were categorized as follows: Improved, Stable, Deteriorated, and Primary non‐function with the change of eGFR after KTx. Results: In study1, donor age ≥ 50 years (29.5% vs. 65.2%; p = 0.09), banff arteriolar hyalinosis (ah) score (0.66 ± 0.78 vs. 1.2 ± 1.0; p = 0.018), and presence of glomerulosclerosis (43.2% vs. 76.2%; p = 0.017) were significant risk factors for poor long‐term graft function. When the recipients were divided into four groups, the severity of ah correlated well with changes in long‐term renal function. Conclusions: We can predict the shift in long‐term renal graft function after KTx from DCD according to the severity of ah by 0‐hour biopsy. [ABSTRACT FROM AUTHOR]

Introduction: Thoracoabdominal normothermic regional perfusion (TA‐NRP) following cardiac death is an emerging multivisceral organ procurement technique. Recent national studies on outcomes of presumptive TA‐NRP‐procured organs are limited by potential misclassification since TA‐NRP is not differentiated from donation after cardiac death (DCD) in registry data. Methods: We studied 22 donors whose designees consented to TA‐NRP and organ procurement performed at our institution between January 20, 2020 and July 3, 2022. We identified these donors in SRTR to describe organ utilization and recipient outcomes and compared them to recipients of traditional DCD (tDCD) and donation after brain death (DBD) organs during the same timeframe. Results: All 22 donors progressed to cardiac arrest and underwent TA‐NRP followed by heart, lung, kidney, and/or liver procurement. Median donor age was 41 years, 55% had anoxic brain injury, 45% were hypertensive, 0% were diabetic, and median kidney donor profile index was 40%. TA‐NRP utilization was high across all organ types (88%–100%), with a higher percentage of kidneys procured via TA‐NRP compared to tDCD (88% vs. 72%, p =.02). Recipient and graft survival ranged from 89% to 100% and were comparable to tDCD and DBD recipients (p ≥.2). Delayed graft function was lower for kidneys procured from TA‐NRP compared to tDCD donors (27% vs. 44%, p =.045). Conclusion: Procurement from TA‐NRP donors yielded high organ utilization, with outcomes comparable to tDCD and DBD recipients across organ types. Further large‐scale study of TA‐NRP donors, facilitated by its capture in the national registry, will be critical to fully understand its impact as an organ procurement technique. [ABSTRACT FROM AUTHOR]

Aims: The use of extended criteria donors is a routine practice that sometimes involves extracorporeal membrane oxygenation (ECMO) in donations after cardiac death or brain death. Methods: We performed a retrospective study in a single center from January 2006 to December 2019. The study included 90 deceased donor liver transplants. The patients were divided into three groups: the donation after brain death (DBD) group (n = 58, 64.4%), the DBD with ECMO group (n = 11, 12.2%) and the donation after cardiac death (DCD) with ECMO group (n = 21, 23.3%). Results: There were no significant differences between the DBD with ECMO group and the DBD group. When comparing the DCD with ECMO group and the DBD group, there were statistically significant differences for total warm ischemia time (p < 0.001), total cold ischemia time (p = 0.023), and split liver transplantation (p < 0.001), and there was significantly poor recovery in regard to total bilirubin level (p = 0.027) for the DCD with ECMO group by repeated measures ANOVA. The 5‐year survival rates of the DBD, DBD with ECMO, and DCD with ECMO groups were 78.1%, 90.9%, and 75.6%, respectively. The survival rate was not significantly different when comparing the DBD group to either the DBD with ECMO group (p = 0.435) or the DCD with ECMO group (p = 0.310). Conclusions: Using ECMO in donations after cardiac death or brain death is a good technology, and it contributed to 35.6% of the liver graft pool. The findings of this study suggest that using ECMO in donations after cardiac death or brain death is a good technology and increase the pool of organs. Using ECMO of technology is convenient, but the material cost of machine perfusion is too expensive, especially in small organ donation centers. [ABSTRACT FROM AUTHOR]

Donation after cardiac death (DCD) is a growing source of organs for transplantation. DCD can be challenging to understand due to variations in practice. DCD also holds great potential for ethical compromise making it uncomfortable for many practitioners. This article traces the origin of DCD from the beginnings of organ transplant and lays out the general pattern of the process before touching on advances to this rapidly changing field. [ABSTRACT FROM AUTHOR]

Introduction and Objectives: Due to organ shortages, liver transplantation (LT) using donation-after-circulatory-death (DCD) grafts has become more common. There is limited and conflicting evidence on LT outcomes using DCD grafts compared to those using donation-after-brain death (DBD) grafts for patients with hepatocellular carcinoma (HCC). We aimed to summarize the current evidence on the outcomes of DCD-LT and DBD-LT in patients with HCC. Materials and Methods: Online databases were searched for studies comparing DCD-LT and DBD-LT outcomes in patients with HCC and a meta-analysis was conducted using fixed- or random-effects models. Results: Five studies involving 487 (33.4%) HCC DCD-LT patients and 973 (66.6%) DBD-LT patients were included. The meta-analysis showed comparable 1-year [relative risk (RR)=0.99, 95%CI:0.95 to 1.03, p=0.53] and 3-year [RR=0.99, 95%CI:0.89 to 1.09, p=0.79] recurrence-free survival. The corresponding 1-year [RR=0.98, 95%CI:0.93 to 1.03, p=0.35] and 3-year [RR=0.94, 95%CI:0.87 to 1.01, p=0.08] patient survival and 1-year [RR=0.91, 95%CI:0.71 to 1.16, p=0.43] and 3-year [RR=0.92, 95%CI:0.67 to 1.26, p=0.59] graft survival were also comparable. There were no significant differences between the two cohorts regarding the tumor characteristics, donor/recipient risk factors and the incidence of post-operative complications, including acute rejection, primary non-function, biliary complications and retransplantation. Conclusions: Based on the current evidence, it has been found that comparable outcomes can be achieved in HCC patients using DCD-LT compared to DBD-LT, particularly when employing good quality graft, strict donor and recipient selection, and effective surgical management. The decision to utilize DCD-LT for HCC patients should be personalized, taking into consideration the risk of post-LT HCC recurrence. (PROSPERO ID: CRD42023445812).

Donation after cardiac death (DCD) donor lungs have been shown to express less proinflammatory genes than donation after brain death (DBD) lungs, likely due to the absence of brain-death related inflammatory physiology. However, it is unclear whether this difference is clinically significant following reperfusion. To avoid confounding by the recipient immune system and activation state, we utilized ex vivo lung perfusion (EVLP) as a reperfusion-like event and examined the effect of EVLP on the transcriptome of DCD (n = 39) and DBD (n = 49) lungs. To validate our RNA results, banked EVLP perfusates from a separate cohort of DCD (n = 24) and DBD (n = 24) cases were assayed for IL-6, IL-8, IL-10, IL-1β, soluble TNFα receptor-1 (sTNFR1), and soluble triggering receptor expressed on myeloid cells-1 (sTREM1) protein levels at 15 minutes intervals for 3 hours. While DCD lungs demonstrated lower levels of proinflammatory transcripts and perfusate cytokine protein levels than DBD lungs prior to EVLP, after EVLP, there were no significant gene expression differences or cytokine protein levels between groups. Therefore, while DCD and DBD lungs differ by the amounts of proinflammatory cytokines following procurement, the propagation of inflammation becomes limited during EVLP, and DBD and DCD lungs reach a similar plateau of transcript expression, including proinflammatory cytokines at the end of perfusion. EVLP may therefore play a preconditioning role by dampening the proinflammatory state prior to transplant reperfusion.

Background and aims: Comparison of donation after brain death (DBD) and donation after cardiac death (DCD) lung tissue before transplantation have demonstrated activation of pro‐inflammatory cytokine pathway in DBD donors. The molecular and immunological properties of circulating exosomes from DBD and DCD donors were not previously described. Methods: : We collected plasma from 18 deceased donors (12 DBD and six DCD). Cytokines were analyzed by 30‐Plex luminex Panels. Exosomes were analyzed for liver self‐antigen (SAg), Transcription Factors and HLA class II (HLA‐DR/DQ) using western blot. C57BL/6 animals were immunized with isolated exosomes to determine strength and magnitude of immune responses. Interferon (IFN)‐γ and tumor necrosis factor‐α producing cells were quantified by ELISPOT, specific antibodies to HLA class II antigens were measured by ELISA Results: We demonstrate increased plasma levels of IFNγ, EGF, EOTAXIN, IP‐10, MCP‐1, RANTES, MIP‐β, VEGF, and interleukins – 6/8 in DBD plasma versus DCD. MiRNA isolated from exosome of DBD donors demonstrated significant increase in miR‐421, which has been reported to correlate with higher level of Interleukin‐6. Higher levels of liver SAg Collagen III (p =.008), pro‐inflammatory transcription factors (NF‐κB, p <.05; HIF1α, p =.021), CIITA (p =.011), and HLA class II (HLA‐DR, p =.0003 and HLA‐DQ, p =.013) were detected in exosomes from DBD versus DCD plasma. The circulating exosomes isolated from DBD donors were immunogenic in mice and led to the development of Abs to HLA‐DR/DQ. Conclusions: This study provides potential new mechanisms by which DBD organs release exosomes that can activate immune pathways leading to cytokine release and allo‐immune response. [ABSTRACT FROM AUTHOR]

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Grafts from donors after cardiac death (DCD) have greatly contributed to expanding the donor organ pool. This study aimed to determine the benefits of subnormothermic extracorporeal membrane oxygenation (ECMO) and hypothermic machine perfusion (HMP) in a porcine model of DCD liver. Female domestic crossbred Large Yorkshire and Landrace pigs weighing approximately 20 kg were used. The abdominal aorta and inferior vena cava were cannulated and connected to an ECMO circuit for in situ perfusion of the abdominal organs at 22 °C for 60 min, 45 min after cardiac death. The pigs were divided into the cold storage (CS) group (n = 3), where liver grafts were preserved at 4 °C, and the HMP group (n = 3), where liver grafts were preserved by HMP at 8–10 °C. After 4 h of preservation, liver function was evaluated using an isolated liver reperfusion model for 2 h. Although the difference was insignificant, the liver effluent enzyme levels in the HMP group were lower than those in the CS group. Furthermore, morphological findings showed fewer injured hepatocytes in the HMP group than in the CS group. The combined use of in situ subnormothermic ECMO and HMP was beneficial for the functional improvement of DCD liver grafts. [ABSTRACT FROM AUTHOR]

This article spotlights the research highlights of this year that specifically pertain to the specialty of anesthesia for heart transplantation. This includes the research on recent developments in the selection and optimization of donors and recipients, including the use of donation after cardiorespiratory death and extended criteria donors, the use of mechanical circulatory support and nonmechanical circulatory support as bridges to transplantation, the effect of COVID-19 on heart transplantation candidates and recipients, and new advances in the perioperative management of these patients, including the use of echocardiography and postoperative outcomes, focusing on renal and cerebral outcomes. [ABSTRACT FROM AUTHOR]

Objective To explore the protective effects of dexmedetomidine (DEX) and xenon (Xe) modified university of Wisconsin solution (UW solution) in a pig model of lung donation after cardiac death (DCD). Methods Four healthy male mini-musk pigs aged 4-6 months, weighing 13-17 kg, were subjected to cardiac arrest by cis-atracurium infusion and cessation of oxygen supply. After 1 h of warm ischemia (WI), the lungs were harvested and cut into thin slices. Some of the slices served as WI group, while the other slices were preserved in N2/DEX/Xe added 4 types of UW solutions at 4 ℃ for 24 h of cold ischemia (CI). These slices were divided into WI+CI+N2 group, WI+CI+DEX group, WI+CI +DEX +30% Xe group, and WI+CI+DEX+50% Xe group. The above 5 group of tissue slices were stained with HE for pathological score. Apoptosis of pulmonary cells were detected by TUNEL. Western blotting was used to detect the expression of cleaved Caspase-3 and glutathione peroxidase 4 (GPX4). The expression of GPX4 and high mobility group protein 1 (HMGB1) were assessed by immunohistochemical staining. Results Compared with the WI group, the histology of other groups showed no significant damage to alveolar structures. Pulmonary edema and inflammatory cell infiltration were not obvious. The injury score of lung had no significant change in lung tissues of all groups (P>0.05). Compared with the WI group, the number of TUNEL-positive cells and the protein level of cleaved Caspase-3 were increased in the WI+CI+N2 group (P < 0.05). However, the protein level of GPX4 had no significant change in lung tissues of all groups. Compared with the WI group, the protein level of HMGB1 was elevated in the WI+CI+N2 group (P < 0.05). Compared with the WI+CI+N2 group, the number of TUNEL-positive cells was significantly reduced in the WI+CI+DEX group, WI+CI+DEX+30%Xe group and WI+CI+DEX+50%Xe group (P < 0.001, P < 0.05, P < 0.05, respectively). The protein level of HMGB1 was significantly reduced in the WI+CI+DEX+30%Xe group (P < 0.01). Conclusion The UW solution added with DEX alone or in combination with Xe can provide better cell protection on swine DCD lung through inhibiting cell apoptosis, down-regulating expression and restraining cytoplasmic translocation of HMGB1.

Objective To construct a marginal donor model of porcine donation after cardiac death (DCD), and evaluate the pathological alteration of DCD donor kidneys. Methods Seven male mini pigs (4~6 months old, 13~17 kg) were divided into standard donor control group (C group, n=3) and DCD group (n=4). After intramuscular injection with phenobarbital sodium, their auricular vein channels were established, then propofol and sufentanil were injected to enhance the anesthetic induction while blood pressure, electrocardiogram and oxygen saturation (SaO2) were monitored at the same time. Group C received mechanical ventilation after endotracheal intubation, and maintained anesthesia with propofol, remifentanil and cisatracurium, and the kidneys were harvested under laparotomy. In the DCD group, 300 IU/kg heparin was injected intravenously for anticoagulation, followed by single bolus venous injection with 600 mg propofol and 10 mg cisatricurium to induce cardiac and respiratory arrest, and finally, the kidneys were harvested in 30 min after cardiac arrest. The kidneys in both groups were cut into small tissues, which were further fixed with 4% paraformaldehyde, embedded in paraffin wax and stained with HE for the pathological assessment and tissue damage scores under a optical microscope. Results The mean time for SaO2 to decline to 80% was 3.25±1.89 min and the mean time for cardiac arrest was 7.75±3.10 min in the 4 pigs of DCD group after injection with overdose of anesthetics. Compared with the C group, the renal tubular injury score of DCD marginal donor kidney after suffering from warm ischemia for 30 min, was higher (P < 0.05), and the mean score of glomerular injury was increased through no statistical difference. Conclusion Intravenous injection of excessive propofol and cisatracurium can effectively establish a porcine DCD marginal donor model.

Background and aims: Warm ischaemic injury (WII) stems from incorrect energy metabolism and is the main cause of graft dysfunction. Mitochondria, as the centre of cellularmetabolic activities, may be the key in identifying accurate indicators for evaluating the quality of grafts. Our research focuses on the screening, clinical application, andmechanism of the optimal WIImitochondrion biomarker. Approach and results: Using a 100% hepatic warm ischaemia mouse model, without reperfusion, transmission electron microscopy demonstrated evident morphological changes of hepatic mitochondria at 15 min of ischaemia. However, all 13 mtmRNAs could not display continuously upregulated consistency at 0-15-30-60 min during WII. High-throughput analysis of miRNA expression in both purified mitochondria and liver tissues suggested miR-23b-5p was a potential mitochondrial microRNA (mitomiR) biomarker with high sensitivity and 0-15-30-60 min change consistency. Fluorescence in-situ hybridization and reverse transcription quantitative polymerase chain reaction (RT-qPCR) further confirmed the results. Through overexpression and inhibition, the functionality of this mitomiR during WII was identified as a protective regulator in vitro and then verified in Dicer1fl/flAlbCre mice by downregulation of other miRNAs and supplementation of mature mitomiR-23b-5p. Dual-luciferase reporter assay and the Seahorse XF analyzer determined that mitomiR-23b-5p reduced mitochondrial respiratory function by silencing mt-RNR2 (16S). Clinically, mitomiR-23b-5p was positively correlated with serum alanine aminotransferase levels 3 days after the operation (P=0.032), and the C-statistic for 90-day graft survival rate was 0.698. Conclusions: MitomiR-23b-5p plays a protective regulatory role and implements a special mitochondrial regulation mechanism not yet reported in WII. These clinical results further support the experimental result that the expression of MitomiR-23b-5p is closely related to the prognosis of clinical liver transplantation patients. This is a promising new biomarker for WII evaluation of donor livers. [ABSTRACT FROM AUTHOR]

Objective To evaluate the application value of perioperative interventional strategy guided by enhanced recovery after surgery (ERAS) in elderly recipients undergoing liver transplantation. Methods Clinical data of 405 liver transplant recipients were retrospectively analyzed. According to age, all recipients were divided into the elderly (≥60 years, n=122) and non-elderly groups (<60 years, n=283). All patients received perioperative interventions under the guidance of ERAS. Intraoperative and postoperative indexes, incidence of postoperative complications and discharge were analyzed between two groups. Results There were no significant differences in the duration of anesthesia, operation time, anhepatic phase, hemorrhage volume, blood transfusion volume, lactic acid level before abdominal closure, ventilatorassisted time, the length of intensive care unit (ICU) stay, Caprini score, CHIPPS score, time of gastric tube, urinary tube and drainage tube removal, time to first drinking, time to first physical activity and time to first flatus between two groups (all P>0.05). In the elderly group, the time to first feeding was later than that in the non-elderly group (P<0.05). There were no significant differences in the incidence of fever, ascites, pulmonary infection, delayed gastric emptying, hemorrhage and inactive venous thrombosis between two groups (all P>0.05). No significant differences were observed in the levels of aspartate aminotransferase, total bilirubin, direct bilirubin, serum creatinine before discharge and total length of hospital stay between two groups (all P>0.05). The alanine aminotransferase level in elderly recipients was lower than that in nonelderly counterparts, and the difference was statistically significant (P<0.05). No unplanned reoperation was performed within postoperative 30 d in two groups. There was no significant difference in the re-hospitalization rate within 30 d after discharge (P>0.05). Conclusions ERAS-guided interventional strategy contributes to perioperative recovery of elderly recipients undergoing liver transplantation, and yields equivalent postoperative recovery between elderly and non-elderly recipients. Objective To evaluate the application value of perioperative interventional strategy guided by enhanced recovery after surgery (ERAS) in elderly recipients undergoing liver transplantation. Methods Clinical data of 405 liver transplant recipients were retrospectively analyzed. According to age, all recipients were divided into the elderly (≥60 years, n=122) and non-elderly groups (<60 years, n=283). All patients received perioperative interventions under the guidance of ERAS. Intraoperative and postoperative indexes, incidence of postoperative complications and discharge were analyzed between two groups. Results There were no significant differences in the duration of anesthesia, operation time, anhepatic phase, hemorrhage volume, blood transfusion volume, lactic acid level before abdominal closure, ventilatorassisted time, the length of intensive care unit (ICU) stay, Caprini score, CHIPPS score, time of gastric tube, urinary tube and drainage tube removal, time to first drinking, time to first physical activity and time to first flatus between two groups (all P>0.05). In the elderly group, the time to first feeding was later than that in the non-elderly group (P<0.05). There were no significant differences in the incidence of fever, ascites, pulmonary infection, delayed gastric emptying, hemorrhage and inactive venous thrombosis between two groups (all P>0.05). No significant differences were observed in the levels of aspartate aminotransferase, total bilirubin, direct bilirubin, serum creatinine before discharge and total length of hospital stay between two groups (all P>0.05). The alanine aminotransferase level in elderly recipients was lower than that in nonelderly counterparts, and the difference was statistically significant (P<0.05). No unplanned reoperation was performed within postoperative 30 d in two groups. There was no significant difference in the re-hospitalization rate within 30 d after discharge (P>0.05). Conclusions ERAS-guided interventional strategy contributes to perioperative recovery of elderly recipients undergoing liver transplantation, and yields equivalent postoperative recovery between elderly and non-elderly recipients. [ABSTRACT FROM AUTHOR]

BackgroundBK virus infection after kidney transplantation can negatively impact the prognosis of patients. However, current risk factor analyses primarily focus on BK virus nephropathy, while BK viruria and BK viruria progressing to BK viremia receive less attention. This study aims to analyze the risk factors associated with BK viruria and BK viruria progressing to BK viremia in recipients of donation after cardiac death (DCD), with the goal of facilitating early intervention.MethodsDonor characteristics and clinical data of recipients before and after transplantation were evaluated, and logistic univariate and multivariate analyses were performed to determine the risk factors associated with BK viruria and the progression of BK viruria to BK viremia. Additionally, machine learning techniques were employed to identify the top five features associated with BK viruria evolving into BK viremia.ResultsDuring a median follow-up time of 1,072 days (range 739–1,418), 69 transplant recipients (15.6% incidence rate) developed BK viruria after transplantation, with 49.3% of cases occurring within 6 months post-transplantation. Moreover, 19 patients progressed to BK viremia. Donor age [OR: 1.022 (1.000, 1.045), p = 0.047] and donor procalcitonin (PCT) levels [0.5–10 ng/ml; OR: 0.482 (0.280, 0.828), p = 0.008] were identified as independent risk factors for BK viruria. High BK viruria [OR: 11.641 (1.745, 77.678), p = 0.011], recipient age [OR: 1.106 (1.017, 1.202), p = 0.018], and immunoinduction regimen [ATG; OR: 0.063 (0.006, 0.683), p = 0.023] were independent risk factors for BK viruria progressing to BK viremia. Machine learning analysis confirmed the importance of high BK viruria, recipient age, and immunoinduction regimen (ATG) in predicting the progression of BK viruria to BK viremia.ConclusionThe development and progression of BK virus in DCD kidney transplant recipients is influenced by multiple factors. Early intervention and treatment could potentially extend the lifespan of the transplanted organ.

Background: Modern advancements have made organ transplantation an increasingly viable option for patients with organ failure. The resulting increases in patients awaiting transplant has resulted in significant morbidity and mortality due to increasing waiting time for transplant. The use of Donation after Circulatory Determination of Death (DCD) organ donors has been the most successful avenue to address the increased need for organ allografts. This review provides a brief history of DCD organ donation in the United States as represented by the experience of the Houston-based LifeGift Organ Procurement Organization (OPO). Methods: Organ donation data from the Scientific Registry of Transplant Recipients (SRTR) and OPO specific data to include all available DCD donors for LifeGift were obtained for analysis. Trends in DCD donation were analyzed in the context of United Network for Organ Sharing policy. Results: By the end of 2021 20% of organs donated in the United States were from DCD donors, in a steadily increasing trend since the mid-1990′s. Metrics utilized by UNOS to monitor organ donation rates and OPO performance do not clearly capture potential DCD donors. Individual OPOs have varying success in utilization of DCD donors, with OPOs like LifeGift focusing on increased DCD utilization. Conclusion: DCD utilization remains the most successful avenue for increasing the deceased donor organ pool in the United States. Increased utilization of DCD organs by transplant centers and focused efforts by OPOs to promote DCD donation can improve the organ shortage nationally. Improved clarity in UNOS metrics can further facilitate OPO performance evaluation and promote further DCD donation in the United States.

The use of pre‐procurement normothermic regional perfusion (NRP) allowed us to implement controlled DCD liver transplantation with results comparable to brain death donors, but the use of uncontrolled DCD is declining due to logistic challenges and the high incidence of post‐transplant complications. In Italy, the mandatory stand‐off period of 20 min for DCD donors has driven the combined use of NRP and ex‐situ machine perfusion with the intent to counterbalance the negative impact of prolonged warm ischemia. Organ viability during NRP is based on duration of warm ischemia, regional perfusion flow, lactate, transaminases values and histology, and those used in Italy are the widest worldwide. However, this evaluation can be difficult, especially when the acute damage is particularly severe. The use of ex‐situ NRP could provide a safe organ evaluation. In the period from 06/2020 to 06/2022, all DCD grafts exceeding NRP viability criteria at a single center were eventually evaluated using ex‐situ normothermic machine perfusion. Machine perfusion viability criteria were based on lactate clearance, irrespectively to bile production, unless 1‐h transaminases perfusate level were not exceeding 5000 IU/L. Three cases of uncontrolled DCD grafts in excess of NRP viability criteria underwent ex‐situ graft evaluation. Two matched ex‐situ normothermic machine perfusion viability criteria and were successfully transplanted. Both recipients are doing well after 26 and 5 months after surgery with no signs of ischemic cholangiopathy. This experience suggests that the sequential use of NRP and normothermic machine perfusion may further expand the boundaries of organ viability in uncontrolled DCD liver transplantation. [ABSTRACT FROM AUTHOR]

The number of children being listed for transplant continues to be greater than the number of available organs. In fact, over the past decade, rates of liver and kidney transplants in pediatric transplantation are essentially unchanged (Am J Transplant. 2020;20:193 and Am J Transplant. 2020;20:20). The use of DCD donors offers a potential solution to organ scarcity; however, the use of DCD organs in pediatric transplantation remains a rare event. Pediatric transplants done using carefully chosen DCD donor organs have shown to have outcomes similar to those seen with the use of donation after brain death (DBD) donors. Herein, we review the literature to examine the utilization of DCD livers and kidneys, outcomes of these allografts, and assess if DCD organs are a viable method to increase organ availability in pediatric transplantation. [ABSTRACT FROM AUTHOR]

In the US, only 23% of lungs offered for transplantation are transplanted. Ex vivo lung perfusion (EVLP) allows for evaluation of additional donor lungs; its adoption has been limited by resources and expertise. Dedicated facilities with a centralized lung evaluation system (CLES) could expand access to EVLP. In this unblinded, nonrandomized, traditional feasibility study, 7 US transplant centers referred lungs declined for standard transplantation to a dedicated EVLP facility, which utilized a CLES. EVLP was remotely monitored by the transplant teams. CLES lungs were matched with contemporaneous conventional static cold-preserved controls at each center. A total of 115 recipients were enrolled, and 66 received allografts from 63 donors after EVLP at the dedicated CLES facility. Forty-nine contemporaneous patients served as controls. Primary graft dysfunction grade 3 at 72 hours (PGD3-72 hours) was higher in the CLES group with 16 (24%) vs 2 (4%) in the control (common RD 95% CI, 0.07-0.32; p = 0.0009). All recipients survived to 30 days and 1-year survival was similar for both groups (92% controls vs 89% CLES; common RD 95% CI, -0.14-0.08; p = 0.58). Total preservation time, hospital and ICU lengths of stay, and time to first extubation were longer in the CLES group. Remote ex vivo perfusion of lung allografts declined for conventional transplantation at a dedicated CLES facility is feasible and resulted in additional transplants. Recipients of allografts assessed with a CLES had a higher rate of PGD3-72 hours, but similar 30-day and 1-year outcomes compared to conventional lung recipients. (NCT02234128) [ABSTRACT FROM AUTHOR]

Background: The shortage of donors' livers for pediatric recipients inspired the search for alternatives including donation after cardiac death (DCD). Methods: Retrospective review of pediatric liver transplant (PLT) using DCD grafts. Patients were divided into either FLG or RLG recipients. Pre‐transplant recipient parameters, donor parameters, operative parameters, post‐transplant recipient parameters, and outcomes were compared. Results: Overall, 14 PLTs from DCD donors between 2005 and 2018 were identified; 9 FLG and 5 RLG. All donors were Maastricht category III. Cold ischemia time was significantly longer in RLG (8.2 h vs. 6.2 h; p =.038). Recipients of FLG were significantly older (180 months vs. 7 months; p =.012) and waited significantly longer (168 days vs. 22 days; p =.012). Recipients of RLG tended to be sicker in the immediate pre‐transplant period and this was reflected by the need for respiratory or renal support. There was no significant difference between groups regarding long‐term complications. Three patients in each group survived more than 5 year post‐transplant. One child was re‐transplanted in the RLG due to portal vein thrombosis but failed to survive after re‐transplant. One child from FLG also died from a non‐graft‐related cause. Conclusions: Selected DCD grafts are an untapped source to widen the donor pool, especially for sick recipients. In absence of agreed criteria, graft and recipient selection for DCD grafts should be undertaken with caution. [ABSTRACT FROM AUTHOR]

Waiting list mortality together, with limited availability of organs, are one of the major challenges in liver transplantation (LT). Especially in the paediatric population, another limiting factor is the scarcity of transplantable liver grafts due to additional concerns regarding graft size matching. In adults, donation after circulatory death (DCD) liver grafts have been used to expand the donor pool with satisfactory results. Although several studies suggest that DCD livers could also be used in paediatric recipients with good outcomes, their utilisation in children is still limited to a small number of reports. Novel organ perfusion strategies could be used to improve organ quality and help to increase the number of DCD grafts utilised for children. With the current manuscript, we present the available literature of LT using DCD grafts in paediatric recipients, discussing current challenges with the use of these livers in children and how machine perfusion technologies could be of impact in the future.

Resumen: El incremento en el número de pacientes en lista de espera de trasplante renal ha llevado a intentar aumentar el número de posibles donantes incorporando candidatos que anteriormente no se habrían considerado óptimos, incluyendo entre estos a los donantes de pacientes de asistolia (DA) y aquellos con criterios «expandidos» (DCE). Los receptores de injertos de DA controlada (DAc) sufren más función retrasada del injerto, pero presentan una evolución a largo plazo equiparable a los de donantes de muerte encefálica, lo que ha permitido un aumento en el número de trasplantes de DAc en distintos países en los últimos años. De forma paralela, el uso de DAc con criterios expandidos (DAc/DCE) se ha incrementado en los últimos años en diferentes países, permitiendo acortar la lista de espera del trasplante renal. El uso de estos injertos, aunque se relaciona con una mayor frecuencia de función retrasada del injerto, ofrece supervivencias del injerto a largo plazo similares o solo ligeramente inferiores a las de los donantes de muerte encefálica con criterios expandidos. Distintos estudios han observado que los receptores de injertos DAc/DCE tienen peor función renal que los DAc/estándar y que los donantes de muerte encefálica/DCE. La mortalidad asociada al trasplante de injertos de DAc/DCE se relaciona principalmente con la elevada edad del receptor. Los pacientes que reciben un trasplante renal de DAc/≥ 60 años presentan mejor supervivencia que los que continúan en la lista de espera, aunque este hecho no se ha demostrado en los receptores de DAc/> 65 años. La utilización de este tipo de órganos debe llevar pareja la optimización de los tiempos quirúrgicos y el menor tiempo de isquemia fría posible. Abstract: The increase in the number of patients on the kidney transplant waiting list has led to an attempt to increase the number of potential donors by incorporating candidates that previously would not have been considered optimal, including donors after cardiac death (DCD) and those with “expanded” criteria (ECD). Recipients of controlled DCD (cDCD) grafts suffer more delayed graft function (DGF), but have a long-term evolution comparable to those of brain-dead donors, which has allowed an increase in the number of cDCD transplants in different countries in recent years. In parallel, the use of cDCD with expanded criteria (cDCD/ECD) has increased in recent years in different countries, allowing the waiting list for kidney transplantation to be shortened. The use of these grafts, although associated with a higher frequency of DGF, offers similar or only slightly lower long-term graft survival than those of brain death donors with expanded criteria. Different studies have observed that cDCD/ECD graft recipients have worse kidney function than cDCD/standard and brain death/ECD. Mortality associated with cDCD/ECD graft transplantation mostly relates to the recipient age. Patients who receive a cDCD/≥60 graft have better survival than those who continue on the waiting list, although this fact has not been demonstrated in recipients of cDCD/>65 years. The use of this type of organ should be accompanied by the optimization of surgical times and the shortest possible cold ischemia.

The discrepancy between the number of patients awaiting liver transplantation and the number of available donors has become a key issue in the transplant setting. There is a limited access to liver transplantation, as a result, it is increasingly dependent on the use of extended criteria donors (ECD) to increase the organ donor pool and address rising demand. However, there are still many unknown risks associated with the use of ECD, among which preservation before liver transplantation is important in determining whether patients would experience complications survive after liver transplantation. In contrast to traditional static cold preservation of donor livers, normothermic machine perfusion (NMP) may reduce preservation injury, improve graft viability, and potentially ex vivo assessment of graft viability before transplantation. Data seem to suggest that NMP can enhance the preservation of liver transplantation to some extent and improve the early outcome after transplantation. In this review, we provided an overview of NMP and its application in ex vivo liver preservation and pre-transplantation, and we summarized the data from current clinical trials of normothermic liver perfusion.

Introduction: Donation after cardiac death (DCD) has been leading the way to help bridge the growing gap between availability of donors and recipients on waitlist. With advances in technology and our understanding of DCD donation the safety profile is growing. It is becoming an increasing viable option even in marginal settings. Discussion: The ethos surroundings DCD is still a matter of contention but there is support and collaboration from larger societies and establishments with development of standardizing protocols. Preparation is key. Experience of the procurement and transplanting surgeons are pivotal. There are multiple moving parts and for the success of a DCD program, dedication is needed from the donor hospitals, organ procurement organizations and the transplant centers. Previous practices based on anecdotal experiences are now either supported by or refuted by increasing evidence and data, based on the development of consensus-based guidelines with the end goal of having uniform outcomes. Normothermic regional and machine perfusion have expanded options in the DCD world, challenging the limits and expanding our paradigm. Recognition of the weaknesses and organ specific complications allow the clinician to make choices for optimal outcomes. These advancements have allowed outcomes to be optimized. Conclusions: Expanding the organ donor pool is one solution to increase the availability of organs for transplantation. Increasing the attention to and the use of DCD organs combined with machine and normothermic perfusion is a future strategy to obtain ongoing clinical success in organ transplantation and lower the waiting list mortality.

In Japan, since the revision of the Organ Transplant Law in July 2010, donation after brain death (DBD) has increased, while donation after cardiac death (DCD), which has been mainly used by kidney transplantation, has decreased. The number of DCD donors decreased from 98 in 2009 to 28 in 2019. There is no clear reason for the decrease in DCD donors. Furthermore, since 2020, there has been a marked decrease in DCD due to the influence of the COVID-19 pandemic. On the other hand, the outcomes after kidney transplantation from DCD donors are improving year by year. The outcomes of kidney transplantation from DCD donors in Japan are comparable to those of kidney transplantation from DBD donors in Western countries. In order to further improve transplantation outcomes from DCD donors, the clinical introduction of continuous machine perfusion preservation technology, for the purpose of reducing ischemic reperfusion injury, is expected in Japan.

With the continued deficit of available organs for transplantation, optimal care of the brain-dead and cardiac death donor is essential to optimize quality and quantity of precious organs. Anesthesiologists are a critical part of the perioperative surgical retrieval process, although individually, may rarely care for a donor. Prospective data to inform specific clinical practices is sparse although educational resources exist to guide anesthesiologists with ethical or clinical questions and protocols from intensive care units and organ procurement organizations serve as useful templates for maintenance of organ function. Pre-surgical resuscitation, optimization and homeostatic strategies should be continued into the operating room. Cautious titration of low dose anesthetic and analgesic agents may be required to blunt sympathetic and spinal reflexes but should not aggravate hypotension and muscle relaxation is recommended to facilitate surgical exposure. Anesthesiologists should be aware of procedural and pharmaceutical aspects of the donation process, including re-intubation of a deceased donor after death is confirmed when lung retrieval is planned.

Shortage of healthy donors' organs has appeared as one of the main challenges for organ transplantation. This study focuses on the novel endovascular device development to increase the number of available organs from cardiac death donors. The primary objective of this study is the design validation of a newly developed stent graft for the abdominal organ perfusion with cardiac blood flow isolation. In this paper, the effectiveness of the device design has been validated via the assessment of the device performance both in vitro and in vivo. The radial force of stent structure was first numerically analyzed using finite element method, then was quantified experimentally. The blood perfusion parameters were investigated to demonstrate their effect on the blood delivered to the abdominal organs, maintaining the organs healthy for donation. In vitro flow leakage was measured using a 3-D printing-based silicone aortic model to evaluate the isolation between cardiac flow and perfusion flow with minimum values. Following the design validation process, a functional prototype stent graft has been successfully fabricated using optimized laser welding conditions and subsequent joining processes. In vivo porcine study results have demonstrated smooth delivery and successful placement of the device showing complete cardiac flow separation isolating abdominal regions only with the oxygenated blood flow. [ABSTRACT FROM AUTHOR]

Introduction: Machine perfusion of heart for donation after circulatory death (DCD) is being increasingly utilized. Current protocols for utilizing heart DCD's machine perfusion might prolong donor warm ischemic time for nonheart organs. The aim of this study was to analyze the effects of utilizing heart machine perfusion on liver and kidney transplants from the same donor. Methods: We analyzed data of DCD donors from the United Network for Organ Sharing (UNOS) from January‐2020 to September‐2021 among two groups: donors with heart machine perfusion (HM) and without heart machine perfusion (NHM). Propensity score (PS) matching was performed to compare the short‐term outcomes of liver and kidney transplants between two groups. Results: Total of 102 liver and 319 kidney transplants were performed using organs from donors with HM. After PS matching, no statistically significant difference was seen in 1‐year graft survival (GS) for both liver and kidney transplants between two groups (liver HM 90.6% vs. NHM 90.2%, p =.47; kidney HM 95.2% vs. NHM 92.9%, p =.40). There was no difference in the delayed graft function (DGF) rates in kidney transplantation (KT) (HM 42% vs. NHM 35%, p =.062). Conclusion: Utilization of heart machine perfusion in DCD donors had no significant impact on 1‐year outcomes of liver and kidney transplantation. [ABSTRACT FROM AUTHOR]

Despite a record setting number of heart transplants performed annually, the national donor shortage continues to plague transplant teams across the United States. Here we describe the barriers to adaptation of numerous "non-traditional" orthotopic heart transplant donor characteristics including donors with hepatitis C virus, those meeting criteria for donation after cardiac death, donors with coronavirus disease 19 infection, donors with the human immunodeficiency virus, and grafts with left ventricular systolic dysfunction. Our center's objective was to increase our transplant volume by expanding our donor pool from "traditional" donors to these "non-traditional" donors. We detail how medical advances such as certain laboratory studies, pharmacologic interventions, and organ care systems have allowed our center to expand the donor pool thereby increasing transplantation volume without adverse effects on outcomes., Competing Interests: Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Ischemia-reperfusion injury (IRI) is the pathophysiological hallmark of hepatic dysfunction after orthotopic liver transplantation (OLT). Related to IRI, early allograft dysfunction (EAD) after OLT affects short- and long-term outcome. During inflammatory states, the liver seems to be the main source of procalcitonin (PCT), which has been shown to increase independently of bacterial infection. This study investigates the association of PCT, IRI and EAD as well as the predictive value of PCT during the first postoperative week in terms of short- and long-term outcome after OLT.Methods: Patients ≥ 18 years undergoing OLT between January 2016 and April 2020 at the University Hospital of Zurich were eligible for this retrospective study. Patients with incomplete PCT data on postoperative days (POD) 1 + 2 or combined liver-kidney transplantation were excluded. The PCT course during the first postoperative week, its association with EAD, defined by the criteria of Olthoff, and IRI, defined as aminotransferase level > 2000 IU/L within 2 PODs, were analysed. Finally, 90-day as well as 12-month graft and patient survival were assessed.Results: Of 234 patients undergoing OLT, 110 patients were included. Overall, EAD and IRI patients had significantly higher median PCT values on POD 2 [31.3 (9.7-53.8) mcg/l vs. 11.1 (5.3-25.0) mcg/l; p < 0.001 and 27.7 (9.7-51.9) mcg/l vs. 11.5 (5.5-25.2) mcg/l; p < 0.001] and impaired 90-day graft survival (79.2% vs. 95.2%; p = 0.01 and 80.4% vs. 93.8%; p = 0.033). IRI patients with PCT < 15 mcg/l on POD 2 had reduced 90-day graft and patient survival (57.9% vs. 93.8%; p = 0.001 and 68.4% vs. 93.8%; p = 0.008) as well as impaired 12-month graft and patient survival (57.9% vs. 96.3%; p = 0.001 and 68.4% vs. 96.3%; p = 0.008), while the outcome of IRI patients with PCT > 15 mcg/l on POD 2 was comparable to that of patients without IRI/EAD.Conclusion: Generally, PCT is increased in the early postoperative phase after OLT. Patients with EAD and IRI have a significantly increased PCT maximum on POD 2, and impaired 90-day graft survival. PCT measurement may have potential as an additional outcome predictor in the early phase after OLT, as in our subanalysis of IRI patients, PCT values < 15 mcg/l were associated with impaired outcome. [ABSTRACT FROM AUTHOR]

Limited availability of suitable donor hearts remains a challenge to pediatric heart transplantation, contributing to waitlist mortality. Controlled donation after circulatory death (DCD) has demonstrated success in adults. Early series of pediatric DCD heart transplantation using cold storage alone reported significant early mortality. We report a collaboration between 2 centers in the United Kingdom, combining expertise in adult DCD organ retrieval and pediatric transplantation. This retrospective series comprises 6 children (4 male, all >20 kg) undergoing DCD heart transplantation at Great Ormond Street Hospital between 1 February and 30 September 2020, following retrieval with direct procurement and perfusion using portable normothermic machine perfusion by the Royal Papworth Hospital service. Baseline characteristics and 1-year follow-up were compared to 9 children who underwent donation after brain death (DBD) transplants contemporaneously. Mean DCD donor age was 24.67 years and mean DCD recipient age was 13.83 years. Mean functional warm ischemic time was 28.5 minutes and ex-situ heart perfusion time was 280 minutes. Median ICU and hospital stay were 9 and 17 days, respectively. All children survived to 1-year post-transplant. Survival and ICU and hospital stay were similar between the DCD and DBD cohorts. Performing DCD transplants resulted in a 66.7% increase in transplants for children >20 kg at GOSH during the study. This series demonstrates that DCD heart transplant can be performed safely with excellent short-term survival in children. Although the cohort is small, there was no significant difference in major outcomes compared to a DBD cohort. [ABSTRACT FROM AUTHOR]

Over the last three decades, liver transplantation (LT) in China has made breakthroughs from scratch. Now, new techniques are being continuously incorporated. However, LT in China differs from that in other countries due to cultural differences and the disease burden. The advances made in and the current issues with LT in China need to be summarized. Living donor LT (LDLT) has developed dramatically in China over the last 30 years, with the goal of increasing transplant opportunities and dealing with the shortage of donors. Western candidate selection criteria clearly are not appropriate for Chinese patients. Thus, the current authors reviewed the literature, and this review has focused on the topics of technological advancements in LDLT and Chinese candidate selection. The Milan criteria in wide use emphasize tumor morphology rather than pathology or biomarkers. a-fetoprotein (AFP) and pathology were incorporated as predictors for the first time in the Hangzhou criteria. Moreover, Xu et al. divided the Hangzhou criteria into type A (tumor size = 8 cm or tumor size > 8 cm but AFP = 100 ng/mL) and type B (tumor size > 8 cm but AFP between 100 and 400 ng/mL), with type B serving as a relative contraindication in the event of a liver donor shortage. In addition, surgeons in Chengdu and Shanghai have the ability to perform a laparoscopic hepatectomy for right and left lobe donors, respectively. China has established a complete LT system, including recipient criteria suitable for Chinese people, a fair donor allocation center, a transplant quality monitoring platform, and mature deceased donor or living donor LT techniques. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to analyze the combined effect of cold ischemia time (CIT) and donation after cardiac death (DCD, with requisite warm ischemia time, WIT) on kidney transplant (KT) outcomes. Methods: Single center retrospective review of DCD KT recipients stratified by CIT. Results: From 6/08 to 10/20, we performed 446 DCD KTs (115 CIT ≤20, 205 CIT 20–30, 88 CIT 30–40, 38 CIT ≥40 h). Mean WITs (26/25/27/23 min) and KDPI values (59%/55%/55%/59%) were similar while mean CITs (16.4/23.6/33.4/42.5 h) and pump times (10.3/13.6/16.1/20.4 h) differed across groups (P <.05). With a mean 6‐year follow‐up, patient survival (84%/84%/74%/84%) was similar. Kidney graft survival (GS) (72%/72%/56%/58%) and death censored GS (DCGS) (82%/80%/63%/67%) rates decreased whereas rates of primary nonfunction (PNF,.9%/2.4%/9.1%/7.9%) and delayed graft function (DGF) (36%/48%/50%/69%) increased with longer CIT (≥30 h, P <.05). Meaningful years free of dialysis, which we refer to as Allograft Life Years, were achieved in all cohorts (4.5/4.3/3.9/4.3 years per patient transplanted). Conclusion: DCD donor kidneys with prolonged CIT (≥30 h) are associated with increased rates of DGF and PNF, along with decreased GS and DCGS. Despite this, Allograft Life Years were gained even with longer CITs, demonstrating the utility of using these allografts. [ABSTRACT FROM AUTHOR]

Abstract Background Adverse attitudes and insufficient knowledge about organ donation after Circulatory Determined Death (DCD) among emergency staff can have important consequences for the proper identification of potential DCD donors. This is aided by the constant application of donation after Circulatory Determined Death policies, and the relative strength of support for this type of donation. Therefore, this study was conducted to investigate the awareness and attitude of emergency personnel about organ donation after Circulatory Determined Death. Methods This descriptive study was carried out with the participation of 49 physicians and 145 nurses working in the emergency departments of educational and medical centers of Tabriz University of Medical Sciences. Nurses were selected by simple random sampling, and all physicians working in the emergency departments were included in the study. The questionnaire of Knowledge and Attitude regarding Organ Donation after Circulatory Determined Death designed by Rodrigue et al. was used. Data were analyzed using descriptive statistics and independent samples t-test, one-way ANOVA, and chi-square test. Results Most of the nurses (62.8%) and physicians (66.7%) had a high level of knowledge about organ donation after circulatory determined death. The mean attitude score was 101.84 (SD: 9.88) out of 170 for nurses and 106.53 (SD: 11.77) for physicians. Physicians who carried organ donation cards had a more positive attitude toward organ donation after circulatory determined death. Conclusion According to this study findings, knowledge and attitude of the emergency staff about organ donation was both high and positive. It is recommended to devise necessary guidelines for organ donation in Iranian emergency departments to assist in the training of colleagues in organ donation ensuring no necessary measures are missed. The results of this study would support the development of guidelines for the successful introduction of DCD in Iran.

Introduction: Since the beginning of pancreas transplantation, the rate of donation after cardiac (or circulatory) death (DCD) accounts for only 3% of all transplants in the US. This is the result of perceived higher complication rates and overall worse outcome with DCD donors. Such misconceptions and an increased demand for deceased donor (DD) organs warrant a systematic review of the use of DCD compared with donation after brain death (DBD) pancreata to objectively assess DCD outcome after pancreas transplantation in the US. Methods: All 22,160 DD pancreas transplants performed in diabetic patients between 1/1/2001 and 12/31/2020 were included in this analysis. To assess changes in outcomes, patient and graft survival was computed using the Kaplan-Meier method in 5-year intervals. Comprehensive univariate and multivariable comparisons of posttransplant complications and patient and pancreas and kidney graft survival between DCD and DBD pancreas transplants were performed to assess the donor impact. Results: In the US over the past 20 years most DCD donors were used for simultaneous pancreas and kidney (SPK) transplants and less often for solitary pancreas transplants. DCD transplants never accounted for more than 4% per year of all pancreas transplants. A comparison of the pancreas donor risk index (pDRI) between DCD and DBD pancreata showed that the only distinguishing factor was DCD donation. SPK patient, pancreas, and kidney graft survival for DCD donors did not change significantly over time. One- and 3 -year DCD patient survival reached 96% and 93%, pancreas graft survival 90% and 84%, and kidney graft survival 96% and 91%, respectively. For the last decade, no differences in patient and graft survival between DCD and DBD donors were detected (P > 0.67). The relative risk for the use of a DCD donor was not increased (P > 0.6). Influential risk factors were older donor and recipient age as well as longer preservation times. Larger transplant center accepted DCD donors more frequently and showed better outcome. While the rate of early pancreas complications was the same for DCD vs. DBD transplants, delayed kidney graft function was significantly higher in DCD kidneys secondary to more long-distance shipping across the country. The multivariable analysis showed a 4-times higher rate in delayed graft function. Longer cold preservation time and older donor age further increased the risk of graft failure. The use of machine perfusion of the kidney graft reduced the relative risk of delayed graft function by 50%. Summary: The use of DCD donor organs in pancreas transplantation is not associated with higher failure or complication rates in the US. A pancreas offer from a DCD donor should not be the sole reason to decline the organ for transplantation. Careful selection of specific donor and recipient factors, as well as advanced preservation techniques are essential for good outcome.

Abstract Background Medical assistance in dying (MAID) has been legal in Québec since December 2015 and in the rest of Canada since July 2016. Since then, more than 60 people have donated their organs after MAID. Such donations raise ethical issues about respect of patients’ autonomy, potential pressure to choose MAID, the information given to potential donors, the acceptability of directed donations in such a context and the possibility of death by donation. The objective of this study was to explore Québec professionals’ perspectives on the ethical issues related to organ donation after MAID. Methods We conducted semi-directed interviews with 21 health care professionals involved in organ donation such as intensivists and intensive care nurses, operating room nurses, organ donation nurses and coordinators. Results The participants were all favourable to organ donation after MAID in order to respect patients’ autonomy. They also favoured informing all potential donors of the possibility of donating organs. They highlighted the importance of assessing donors’ reasons for requesting MAID during the assessment. They were divided on directed donation, living donation before MAID and death by donation. Conclusion Organ donation after MAID was widely accepted among the participants, based on the principle of respect for the donor’s autonomy. The findings of this study only provide the perspectives of Québec health care professionals involved in organ donation. Future studies are needed to gather other stakeholders’ perspectives on this issue as well as patients’ and families’ experiences of organ donation after MAID.

Background: Use of lungs donated after circulatory death (DCD) has expanded, but changes in donor/recipient characteristics and comparison to brain dead donors (DBD) has not been studied. We examined the evolution of the use of DCD lungs for transplantation and compare outcomes to DBD lungs. Methods: The SRTR database was used to construct three 5-year intervals. Perioperative variables and survival were compared by era and for DCD vs. DBD. Geographic variation was estimated using recipient permanent address. Results: 728 DCD and 27,205 DBD lung transplants were identified. DCD volume increased from Era 1 (n = 73) to Era 3 (n = 528), representing 1.1% and 4.2% of lung transplants. Proportionally more DCD recipients were in ICU or on ECMO pre-transplant, and had shorter waitlist times. DCD donors were older, had lower PaO2/FiO2 ratios compared to DBD, more likely to be bilateral, had longer ischemic time, length of stay, post-op dialysis, and increased use of lung perfusion. There was no difference in overall survival. Geographically, use was heterogeneous. Conclusion: DCD utilization is low but increasing. Despite increasing ischemic time and transplantation into sicker patients, survival is similar, which supports further DCD use in lung transplantation. DCD lung transplantation presents an opportunity to continue to expand the donor pool. [ABSTRACT FROM AUTHOR]

Background: Careful graft and recipient selection have resulted in improved outcomes in liver transplantation (LT) using donation after cardiac death (DCD) organs. The UK DCD Risk Score was established as a risk stratification tool to guide selection. Methods: We evaluated the applicability of the UK DCD Risk Score in a contemporary US cohort of adult DCD LT recipients using the United Network for Organ Sharing registry (2011‐2020). Results: A total of 3,899 DCD LTs were included in our study (UK DCD Risk Score 0–5 points: 1,438 [36.9%], 6–10 points: 2,034 [52.2%]; 11–20 points: 427 [11.0%]). Compared to a score of 6–10 points, a score of 0–5 points was associated with decreased risk of graft loss (HR =.79, 95%CI:.68‐.93, p =.004), while a score of 11–20 points was associated with increased risk of graft loss (HR = 1.26, 95%CI: 1.01‐1.56, p =.04). The 5‐year graft survival for patients with risk scores of 0–5, 6–10, and 11–20 were 75.9%, 71.8%, and 66.5%, respectively. The C‐statistic for the UK DCD Risk Score in our contemporary cohort was.611. Conclusions: The UK DCD Risk Score demonstrates a more limited ability to differentiate recipient outcomes in the modern era of DCD LT in the US. Acceptable long‐term outcomes are achievable for patients stratified to the highest‐risk group. [ABSTRACT FROM AUTHOR]