Normothermic extracorporeal membrane oxygenation support: Improving the function of intestinal grafts obtained from cardiac death donors.

Extracorporeal membrane oxygenation (ECMO) could ameliorate the energy status and viability of bowel grafts from cardiac death donors. However, the function of these grafts after transplantation is not clear. The purpose of the study was to evaluate the early function of intestinal grafts after transplantation from expected cardiac death donors supported with normothermic extracorporeal support using a porcine allogeneic orthotopic segmental small bowel transplantation model. Eighteen domestic crossbred donor pigs were assigned to living donation (LD), donation after cardiac death (DCD), and ECMO groups. In the LD group, small bowels were harvested and preserved immediately in cold storage. In the other two groups, the donor pigs received conventional rapid recovery treatment or 1-hour normothermic extracorporeal support after 10-minutes expected cardiac arrest. Subsequently, the small bowels were removed and preserved in cold storage. After 5-6 hours of preservation, small bowel grafts were transplanted into the recipient pigs that underwent enterectomy. The pathology and electron microscopy results, cell apoptosis rate, tight junction protein expression level in the intestinal mucosa, and plasma endotoxin level were evaluated after transplantation. All grafts functioned on the basis of the maltose absorption test results at day 7 after transplantation. There were no significant differences in the morphological changes in the intestinal mucosa among the three groups at day 7 after transplantation. The cell apoptosis rate and plasma endotoxin level in the ECMO group did not differ significantly than those in the LD group, but were evidently lower than those in the DCD group (P < .001). The intestinal absorptive function improved significantly in the ECMO group in contrast with that in the DCD group (P < .001). Short-term ECMO intervention can alleviate ischemia-reperfusion injuries in intestinal grafts and improve intestinal absorptive function in the early stage after transplantation. Reducing caspase-3 protein expression and cell apoptosis in the intestinal mucosa may be one of the protective mechanisms of ECMO intervention.

Acute kidney injury in donors of donation after brain plus cardiac death does not affect recipients' short-term prognosis in transplantation / 中华肾脏病杂志

Objective To investigate the clinical efficacy of renal transplantation from donors of donation after brain and cardiac death(DBCD) complicated with acute kidney injury (AKI),and summarize the clinical experience of evaluation and application.Methods The clinical data of the 45 DBCD donors and 80 recipients in the First People's Hospital of Foshan from September 2011 to September 2015 were retrospectively analyzed.DBCD donors were classified into the AKI group (n=26) and non-AKI group (n=19) according to the serum creatinine level and urine output when the donors were admitted to the intensive care unit (ICU) in this hospital.A total of 80 recipients were divided into the AKI group (n=46) and non-AKI group (n=34) correspondingly.The condition of the donors before organ procurement between the two groups was compared,and the incidence of various complications,the 1 years survival rates of recipients and graft after renal transplantation were compared between the two groups.Results Among 45 donors,26 cases(57.8％) suffered from AKI.The serum creatinine of donors was significantly higher in the AKI group than that in the non-AKI group (P ＜ 0.01).The incidence of delayed graft function (DGF) in AKI group and non-AKI group was 21.7％ and 8.8％ respectively (P ＞ 0.05).After 1 years,the serum creatinine of the recipients in AKI group was significantly higher than that in non-AKI group [(134.9±63.4) μmol/L vs (106.6±28.2) μmol/L,P＜ 0.05],but the survival rates of recipients and grafts did no differ between the two groups (both P ＞ 0.05).Conclusions The donors combined with AKI do nothave a worse effect on the incidence of DGF,the 1-year survival rates of recipients and grafts after transplantation.So,the donors with AKI for transplantation can widen the origin of kidney grafts.

Clinical analysis on 48 cases of kidney transplantation from brain and cardiac death donors / 中华肾脏病杂志

Objective To observe the short?term clinical outcomes of kidney transplantation from brain and cardiac death donors (DBCD) and assess its feasibility to expand organ donor pool. Methods A retrospective analysis was performed on 48 cases of kidney transplantation from DBCD. The transplant recipients had finished 12?month follow?up in the First People's Hospital of Foshan from September 2011 to February 2015, with their renal function, rejection reaction and complications at 1 week, 1 month, 3 months, 6 months and 12 months after renal transplantation being collected. Survival rates of transplant recipients and transplant kidneys, incidence of delayed graft function (DGF) and its influence for recipients and graft survival were analyzed by statistics. Results In the 48 cases, the survival rates of recipients at 1, 3, 6 and 12 months after transplantation were 100.0%, 100.0%, 97.9%, 95.8%, and the survival rates of transplanted kidneys were 95.8%, 95.8%, 93.8%, 91.7%, respectively. DGF occurred in 8 of 48 (17.0%), but the occurrence of DGF did not adversely influence patient's survival (P=0.524) or graft survival (P=0.362). Conclusions The short?term clinical outcomes of kidney transplantation from DBCD are ideal. As the legislation of donation after brain death (DBD) has not been ratified in China, the kidney transplantation from DBCD could be an important way to solve the shortage of organs, and increase the number of kidneys available for transplantation.

Pharmacokinetic analysis of tacrolimus in infants subject to living related liver transplantation and cardiac death liver transplantation / 中华器官移植杂志

Objective To analyze and compare the dosage,blood concentration and metabolic characteristics of Tacrolimus (Tac) for pediatric patients who underwent living related liver transplantation (LRLT) or donation after cardiac death liver transplantation (DDLT).Methods The clinical data of 75 liver transplantation pediatric patients from October 2012 to August 2015 were retrospectively analyzed.According to the different source of donors,the recipients were divided into two groups:LRLT group (40 cases) and DDLT group (35 cases).Results (1) Under the condition of same initial Tac dosage,the Tac dosage in LRLT group was less than in DDLT group during the first 28 days post-transplantation (P＞ 0.05).However,the Tac dosage in DDLT group was significantly higher than in LRLT group on the second and third months after sugery (P =0.000).(2) Correlation analysis revealed that graft-recipient body weight ratio (GRWR) was correlated with Tac dosage (mg·kg-1 ·d-1) on the 14th day postoperative (LRLT group:r=0.579,P＜0.05;DDLT group:r =0.583,P＜0.05) and Tac concentration/dosage ratio (LRLT group:r =-0.607,P＜0.05;DDLT group:r=-0.680,P＜0.05).Conclusion Tac has a satisfactory anti-rejection effect on liver transplantation pediatric patients while the metabolism varied with each individual.There is a positive correlation between the early Tac dosage and the GRWR in both groups.It is necessary to set individualized Tac administration regimen according to the metabolic characteristics and GRWR.

Donation after cardiac death liver transplantation is associated with increased risk of end-stage renal disease.

Limited organ supply has led to greater use of liver allografts with higher donor risk indices (DRI) and/or donated after cardiac death (DCD). DCD status is associated with acute kidney injury after liver transplantation; however, less is known about the association between donor quality and end-stage renal disease (ESRD). Using SRTR data, we assembled a cohort of liver transplant recipients from 2/2002 to 12/2010. We fit multivariable Cox regression models for ESRD. Model 1 included total DRI; model 2 included components of DRI, including DCD, as separate variables. Forty thousand four hundred and sixty-three liver transplant recipients were included. Median DRI was 1.40 (IQR 1.14, 1.72); 1822 (5%) received DCD livers. During median follow-up of 3.93 years, ESRD occurred in 2008 (5%) and death in 11 075 (27%) subjects. There was a stepwise increase in ESRD risk with higher DRI (DRI ≥1.14 and <1.40: HR 1.17, P = 0.06; DRI ≥1.40 and <1.72: HR 1.29, P = 0.003; DRI ≥1.72: HR 1.39, P < 0.001, compared with DRI <1.14). Adjusting for DRI components separately, DCD status was most strongly associated with ESRD (HR 1.40, P = 0.008). Higher DRI is associated with ESRD after liver transplantation, driven in part by DCD status. Donor quality is an important predictor of long-term renal outcomes in liver transplant recipients.

Should we reconsider lung transplantation through uncontrolled donation after circulatory death?

Lung transplantation through controlled donation after circulatory death (cDCD) has slowly gained universal acceptance with reports of equivalent outcomes to those through donation after brain death. In contrast, uncontrolled DCD (uDCD) lung use is controversial and requires ethical, legal and medical complexities to be addressed in a limited time. Consequently, uDCD lung use has not previously been reported in the United States. Despite these potential barriers, we present a case of a patient with multiple gunshot wounds to the head and the body who was unsuccessfully resuscitated and ultimately became an uDCD donor. A cytomegalovirus positive recipient who had previously consented for CDC high-risk, DCD and participation in the NOVEL trial was transplanted from this uDCD donor, following 3 h of ex vivo lung perfusion. The postoperative course was uneventful, and the recipient was discharged home on day 9. While this case represents a "best-case scenario," it illustrates a method for potential expansion of the lung allograft pool through uDCD after unsuccessful resuscitation in hospitalized patients.

The effect of CYP 3A5 genotypic analysis of donor from cardiac death donation on the individualized administration of Tacrolimus / 中华器官移植杂志

Objective To investigate the effect of the genotypic analysis of donor from cardiac death donation on the initial dose of Tac for liver transplant recipients and provide individualized administration for the early use of Tac in liver transplantation patients.Method Thirty recipients with a different genotype of CYP3A5 from cardiac death donors were collected from March 2010 to February 2013.The matched recipients were randomly divided into experiment group and control group.There was an adjustment of initial doses of Tac according to the donors' different CYP3A5 genotypes in experiment group but not in control group.Result In experiment and control groups,the average Tac blood concentrations at the 7th day after operation were (7.47 ± 1.83) and (8.68 ± 5.14) ng/mL,and the percent of recipeints reaching the optimal Tac concentrations was 72.2％ and 38.9％,respectively (P＜0.05).In experiment and control groups,22.2％ and 55.6％ recipients needed adjustments of Tac concentrations respectively (P＜0.05).Conclusion Individualized adjustment of Tac initial doses of recipients according to cardiac death donors' different CYP3A5 genotypes was benefit for reaching optimal concentrations as soon as possible and could decrease the rate of rejection,and reduce the side effects of Tac.