Improving the Outcomes of Organs Obtained From Controlled Donation After Circulatory Death Donors Using Abdominal Normothermic Regional Perfusion

Abstract

The use of donation after circulatory death (DCD) has increased significantly during the past decade. However, warm ischemia results in a greater risk for transplantation. Indeed, controlled DCD (cDCD) was associated with inferior outcomes compared with donation after brain death. The use of abdominal normothermic regional perfusion (nRP) to restore blood flow before organ recovery in cDCD has been proposed as better than rapid recovery to reverse the effect of ischemia and improve recipients' outcome. Here, the first Spanish series using abdominal nRP as an in situ conditioning method is reported. A specific methodology to avoid restoring circulation to the brain after death determination is described. Twenty-seven cDCD donors underwent abdominal nRP during at least 60 min. Thirty-seven kidneys, 11 livers, six bilateral lungs, and one pancreas were transplanted. The 1-year death-censored kidney survival was 91%, and delayed graft function rate was 27%. The 1-year liver survival rate was 90.1% with no cases of ischemic cholangiopathy. Transplanted lungs and pancreas exhibited primary function. The use of nRP may represent an advance to increase the number and quality of grafts in cDCD. Poor results in cDCD livers could be reversed with nRP. Concerns about restoring brain circulation after death are easily solved.

Heparin but not tissue plasminogen activator improves outcomes in donation after circulatory death liver transplantation in a porcine model

“…Mounting clinical evidence suggests that NRP has a significant positive impact on biliary preservation in the setting of DCD liver transplantation because it limits the length of warm ischemia, restores cellular energy stores, and reconditions the graft prior to cold perfusion and storage . There are now several single‐center series that describe excellent posttransplantation survival rates and virtually no ITBL using DCD livers recovered with postmortem NRP . At our own center, postmortem NRP has been used to recover livers from cDCD donors .…”

Machine perfusion for liver transplantation in the era of marginal organs—New kids on the block

“…This should result in less time‐pressure on the retrieval team, easier in situ evaluation of graft quality and expansion of the donor pool with overall improved graft quality . While NRP is a technically feasible approach, it has raised numerous ethical and logistical questions concerning premortem interventions such as administration of heparin, cannulation and including the possibility of resuscitating the donor following declaration of death . These concerns have been partially eliminated by technical innovations (heparin‐coated circuits, initial bypassing the oxygenator to prevent clotting; aortic occlusion balloon to exclude the brain from the perfusion); however, several issues, which have been summarized elsewhere, remain to be elucidated …”

Mobile ECMO team for controlled donation after circulatory death

“…[2][3][4] A pitfall of this method is its complexity and the unavailability of this resource in some hospitals, especially in regional hospitals, where potential DCD donors may exist. Also, nRP facilitates graft quality assessment prior to validation, prevents surgical injury in super-rapid extractions, and reduces the duration of cold ischemia as it facilitates coordination between the extraction and the implantation team.…”