Factors That Complicated the Implementation of a Program of Donation After Unexpected Circulatory Death of Lungs and Kidneys. Lessons Learned From a Regional Trial in the Netherlands.

BACKGROUND: Organ shortage remains a problem in transplantation. An expansion of the donor pool could be the introduction of unexpected donation after circulatory death (uDCD) donors. The goal of this study was to increase the number of transplantable kidneys and lungs by implementing a uDCD protocol. METHODS: A comprehensive protocol for uDCD donation was developed and implemented in the emergency departments (EDs) of 3 transplant centers. All out-of-hospital cardiac arrest (OHCA) patients were screened for uDCD donation. Inclusion criteria were declaration of death in the ED, age (<50 y for kidneys, <65 y for lungs), witnessed arrest, and basic and advanced life support started within 10 and 20 min, respectively. RESULTS: A total of 553 OHCA patients were reported during the project, of which 248 patients survived (44.8%). A total of 87 potential lung and 42 potential kidneys donors were identified. A broad spectrum of reasons resulted in termination of all uDCD procedures. Inclusion and organ-specific exclusion criteria were the most common reason for not proceeding followed by consent. None of the potential donors could be converted into an actual donor. CONCLUSION: Although uDCD potential was shown by successful recognition of potential donors in the ED, we were not able to transplant any organs during the study period. The Dutch Emergency medical service guidelines to stop futile OHCA in the prehospital setting and the strict use of inclusion and exclusion criteria like age and witnessed arrest hampered the utilization. A prehospital uDCD protocol to bring all OHCA patients who are potential uDCD candidates to an ED would be helpful in creating a successful uDCD program.

Does the meld system provide equal access to liver transplantation for patients with different ABO blood groups?

This study investigates the relationship between blood group and waiting time until transplantation or death on the waiting list. All patients listed for liver transplantation in the Netherlands between 15 December 2006 and 31 December 2012, were included. Study variables were gender, age, year of listing, diagnosis, previous transplantations, blood group, urgency, and MELD score. Using a competing risks analysis, separate cumulative incidence curves were constructed for death on the waiting list and transplantation and used to evaluate outcomes.In 517 listings, the mean death rate per 100 patient-years was 10.4. A total of 375 (72.5% of all listings) were transplanted. Of all transplantations, 352 (93.9%) were ABO-identical and 23 (6.1%) ABO-compatible. The 5-year cumulative incidence of death was 11.2% (SE 1.4%), and of transplantation 72.5% (SE 2.0%). Patient blood group had no multivariate significant impact on the hazard of dying on the waiting list nor on transplantation. Age, MELD score, and urgency status were significantly related to the death on the waiting list and transplantation. More recent listing had higher probability of being transplanted. In the MELD era, patient blood group status does not have a significant impact on liver transplant waiting list mortality nor on waiting time for transplantation.

Lung transplantation from nonheparinized category III non-heart-beating donors. A single-centre report.

BACKGROUND: Despite the increasing use of extended lung donors, the shortage of lung donors remains. Usage of non-heart-beating (NHB) lung donors contributes to fight this shortage. We describe our experience in 21 consecutive adult lung transplantations using nonheparinized category III NHB donors and standard flush preservation. METHODS: From January 2005 to December 2008, we collected donor and recipient data of all NHB category III lung transplantations performed in our center. For comparison, we also collected the data of all heart-beating (HB) lung transplantations in the same period. We focused on data describing the donor, the donor procedure, the recipient's primary graft dysfunction, survival, rejection episodes, and the lung graft function. RESULTS: Twenty-one NHB and 77 HB lung transplantations were performed. Circulation arrest occurred after 14 (4-62) min and warm ischemia time was 30 (19-44) min. Occurrence of primary graft dysfunction, acute rejection episodes, development of bronchiolitis obliterans syndrome was equal to the HB cohort as was the 2 years survival of 95% in the NHB group compared with 86% in the HB group. Lung graft function during the first 2 years tended to be better preserved in the NHB group. CONCLUSION: Category III NHB lung donation is a good alternative in addition to HB lung donation. Using nonheparinized category III NHB donors and standard ante- and retrograde, flush perfusion resulted in good lung graft function and survival. NHB donation offers a great opportunity to reduce the burden of donor lung shortage.

Non-heart-beating lung donation: how big is the pool?

Lungs from non-heart-beating (NHB) donors are seldom used in The Netherlands despite the good quality of these organs. Based on a retrospective analysis of 162 NHB donor procedures we found that only 5% of the lungs were actually utilized, but that 30% of the lungs were suitable for transplantation. Not recognizing the suitability of NHB lungs is likely the main reason for their non-availability.

Surgical injuries of postmortem donor livers: incidence and impact on outcome after adult liver transplantation.

The exact frequency and clinical consequences of surgical hepatic injuries during organ procurement are unknown. We analyzed the incidence, risk factors, and clinical outcome of surgical injuries in 241 adult liver grafts. Hepatic injuries were categorized as parenchymal, vascular, or biliary. Outcome variables were bleeding complications, hepatic artery thrombosis (HAT), and graft survival. In 82 livers (34%), 96 injuries were detected. Most injuries were minor, but clinically relevant injuries were detected in 6.6% (16/241) of the livers. Fifty (21%) liver grafts had some degree of parenchymal or capsular injury, 40 (17%) had vascular injury, and 6 (2%) had an injury to the bile duct. Procurement region was the only risk factor significantly associated with surgical injury. The rate of hepatic artery injury was significantly higher in livers with aberrant arterial anatomy. Bleeding complications were found in 18% of patients who received livers with a parenchymal or capsular injury in contrast to 9% without parenchymal injury (P = 0.065). HAT was found in 23% of the patients who received a liver with arterial injury compared to 4% without arterial injury (P = 0.001). Overall graft survival rates were not significantly different for grafts with or without anatomical injury. In conclusion, surgical injuries of donor livers are an underestimated problem in liver transplantation and can be observed in about one-third of all cases. Clinically relevant injuries are detected in 6.6% of all liver grafts. Arterial injuries are associated with an increased risk of HAT.