In Situ Normothermic Regional Perfusion for Controlled Donation After Circulatory Death—The United Kingdom Experience

Abstract

Organs recovered from donors after circulatory death (DCD) suffer warm ischemia before cold storage which may prejudice graft survival and result in a greater risk of complications after transplant. A period of normothermic regional perfusion (NRP) in the donor may reverse these effects and improve organ function. Twenty-one NRP retrievals from Maastricht category III DCD donors were performed at three UK centers. NRP was established postasystole via aortic and caval cannulation and maintained for 2 h. Blood gases and biochemistry were monitored to assess organ function. Sixty-three organs were recovered. Forty-nine patients were transplanted. The median time from asystole to NRP was 16 min (range 10-23 min). Thirty-two patients received a kidney transplant. The median cold ischemia time was 12 h 30 min (range 5 h 25 min-18 h 22 min). The median creatinine at 3 and 12 months was 107 mmol/L (range 72-222) and 121 mmol/L (range 63-157), respectively. Thirteen (40%) recipients had delayed graft function and four lost the grafts. Eleven patients received a liver transplant. The first week median peak ALT was 389 IU/L (range 58-3043). One patient had primary nonfunction. Two combined pancreaskidney transplants, one islet transplant and three double lung transplants were performed with primary function. NRP in DCD donation facilitates organ recovery and may improve short-term outcomes.

Short, Cool, and Well Oxygenated – HOPE for Kidney Transplantation in a Rodent Model

“…On the basis of this, starting normothermic perfusion already in donors may lead to different results. 33,34 Furthermore, we cannot exclude that perfusion for >1 hour would have been more effective (warm and cold).…”

Advancing Transplantation

“…47 Different thermic regional perfusion techniques show promise; when studied in organs donated after circulatory death, normothermic regional perfusion, in particular, has considerable potential to restore the quality of these grafts. 43 Oniscu et al 48 also demonstrated a low occurrence of DGF (40%) when normothermic regional perfusion was used. When looking at clinical practice, we see that machine reperfusion is being used, especially in centers that have ongoing ECD programs.…”

Ethical Issues in the Use of Extracorporeal Membrane Oxygenation in Controlled Donation After Circulatory Determination of Death

“…Furthermore, cannulation was implemented postmortem, which also increased WIT. Oniscou et al reported 40% incidence of DGF in 32 renal grafts with ECMO and 12.5% incidence of PNF (12). In this U.K. protocol, cannulation was implemented postmortem after sternotomy, and thus WIT was prolonged.…”

“…Description of cDCDD protocols using ECMO and an aortic clamp In the United Kingdom, three centers (Cambridge, Birmingham, and Edinburgh) recently developed another procedure using ECMO, called normothermic regional perfusion (NRP) (12). After W-LST occurs either in the intensive care unit (ICU) or in the OR, death is determined after a notouch period of 5 min.…”

“…Only a few cDCDD centers, however, have reported the use of extracorporeal membrane oxygenation (ECMO) to improve future graft outcome, including National Taiwan University Hospital, Taiwan (9); the University of Michigan, Ann Arbor, Michigan (10); the Henry Ford Health System, Detroit, Michigan (11); Wake Forest University, WinstonSalem, North Carolina (2); and three centers (Cambridge, Birmingham, and Edinburgh) in the United Kingdom (12).…”