Kidney donation after circulatory death (DCD): state of the art

Normothermic machine perfusion (NMP) is a technique that utilizes extracorporeal membrane oxygenation to recondition and repair kidneys at near body temperature prior to transplantation. The application of this new technology has been fueled by a significant increase in the use of the kidneys that were donated after cardiac death, which are more susceptible to ischemic injury. Preliminary results indicate that NMP itself may be able to repair marginal organs prior to transplantation. In addition, NMP serves as a platform for delivery of therapeutics. The isolated setting of NMP obviates problems of targeting a particular therapy to an intended organ and has the potential to reduce the harmful effects of systemic drug delivery. There are a number of emerging therapies that have shown promise in this platform. Nutrients, therapeutic gases, mesenchymal stromal cells, gene therapies, and nanoparticles, a newly explored modality, have been successfully delivered during NMP. These technologies may be effective at blocking multiple mechanisms of ischemia‐ reperfusion injury (IRI) and improving renal transplant outcomes. This review addresses the mechanisms of renal IRI, examines the potential for NMP as a platform for pretransplant allograft modulation, and discusses the introduction of various therapies in this setting.

Section: State Of Renal Transplantationmentioning

confidence: 99%

The future of marginal kidney repair in the context of normothermic machine perfusion

DiRito

Hosgood

Tietjen

et al. 2018

“…cDCDD protocols using the rapid recovery technique and in situ cold perfusion Many cDCDD centers use the rapid recovery technique (RRT) (4,(13)(14)(15) instead of ECMO. W-LST usually occurs in the OR, but it may occur in the ICU.…”

Section: Consentmentioning

confidence: 99%

“…In kidney transplantation with DCDD, studies have shown that long-term outcomes of patient survival, graft survival and graft function are similar to those in DBDD (4,14), with higher rates of delayed graft function (DGF) (4,14). Livers transplanted with cDCDD compared with DBDD have lower patient and graft survival rates (13,14) and higher rates of biliary complications (14), early allograft dysfunction (13) and retransplantation for ischemic cholangiopathy (14).…”

Section: Does the Use Of Ecmo In Cdcdd Programsmentioning

confidence: 99%

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

Ave¹,

Shaw

Bernat

2016

The use of donor extracorporeal membrane oxygenation (ECMO) to improve graft outcomes by some controlled donation after circulatory determination of death (cDCDD) programs raises ethical issues. We reviewed cDCDD protocols using ECMO and the relevant ethics literature to analyze these issues. It is not obvious that ECMO in cDCDD improves graft outcomes. In our opinion, ECMO implemented before death can interfere with end-of-life care and damage bodily integrity. By restoring systemic circulation, ECMO risks invalidating the preceding declaration of death if brain and cardiac perfusion is not adequately excluded because of malfunction or misplacement of the supradiaphragmatic aortic occlusion balloon. The use of ECMO is not compatible with the acronym DCDD because circulation is restored after the determination of death. Because of these deficiencies, we concluded that other techniques are preferable, such as rapid recovery or in situ cold infusion. If ECMO is performed, it requires a specific informed consent and transparency.Abbreviations: cDCDD, controlled donation after circulatory determination of death; DBDD, donation after brain determination of death; DBTL, doubleballoon triple-lumen; DCDD, donation after circulatory determination of death; DDR, dead donor rule;

“…In addition to the above, the victims of ligature asphyxiation may also develop pulmonary edema and multiorgan failure secondary to global tissue hypoxia 7. While hypoxic tissue injury following ligature asphyxiation is a concern in DBD donors, it may have an even greater impact on organs from DCD donors where the organs are also subjected to a second period of warm ischemic injury between cardiac arrest and cold perfusion of the organs 8. However, many potential donors who die following ligature asphyxiation are relatively young and previously healthy, and therefore might be a source of good quality kidneys that can be used safely for transplantation 3…”

Section: Introductionmentioning

confidence: 99%

Transplantation of kidneys from DCD and DBD donors who died after ligature asphyxiation: The UK experience

Trotter

Jochmans

Hulme

et al. 2018

There is uncertainty about whether hypoxic injury accompanying donor death from ligature asphyxiation influences renal transplant outcomes, particularly for recipients of kidneys donated after circulatory death (DCD). The UK Registry analysis was undertaken to determine transplant outcomes in recipients of kidneys from donors who died following ligature asphyxiation. From 2003 to 2016, 2.7% (n = 521) of potential organ donors died following ligature asphyxiation (mostly suicide by hanging). Of these, 409 (78.5%) donated kidneys for transplantation (46.9% donation after brain death [DBD] and 53.1% DCD donors) resulting in 650 kidney transplants. Compared to other deceased donors, those dying from ligature asphyxiation were younger, more often male, and had less hypertension. Unadjusted patient and graft survival were superior for recipients of both DBD and DCD kidneys from donors dying after ligature asphyxiation, although after adjustment for donor/recipient variables, transplant outcomes were similar. A case–control matched analysis confirmed transplant outcomes for those who received kidneys from donors dying after ligature asphyxiation were similar to controls. Although caution is required in interpreting these findings because of potential selection bias, kidneys from donors dying of ligature asphyxiation suffer an additional warm ischemic insult that does not apparently adversely influence transplant outcomes, even for kidneys from DCD donors.