Regional perfusion by extracorporeal membrane oxygenation of abdominal organs from donors after circulatory death: A systematic review

Abstract

Organs from donors after circulatory death (DCDs) are particularly susceptible to the effects of warm ischemia injury. Regional perfusion (RP) by extracorporeal membrane oxygenation (ECMO) is increasingly being advocated as a useful remedy to the effects of ischemia/reperfusion injury, and it has been reported to enable the transplantation of organs from donors previously deemed unsuitable. The MEDLINE, Embase, and Cochrane databases were searched, and articles published between 1997 and 2013 were obtained. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two hundred ten articles were identified, and 11 were eligible for inclusion. Four hundred eighty-two kidneys and 79 livers were transplanted from regional perfusion-supported donor after circulatory death (RP-DCD) sources. One-year graft survival was lower with uncontrolled RP-DCD liver transplantation, whereas 1-year patient survival was similar. Primary nonfunction and ischemic cholangiopathy were significantly more frequent with RP-DCDs versus donors after brain death (DBDs), but there was no difference in postoperative mortality between the 2 groups. The 1-year patient and graft survival rates for RP-DCD kidney transplantation were better than the rates with standard DCDs and were comparable to, if not better than, the rates with DBDs. At experienced centers, delayed graft function (DGF) for kidney transplantation from RP-DCDs was much less frequent in comparison with all other donor types. In conclusion, RP aids the recovery of DCD organs from ischemic injury and enables transplantation with acceptable survival. RP may help to increase the donor pool, but its benefits must still be balanced with the recognition of significantly higher rates of complications in liver transplantation. In kidney transplantation, significant reductions in DGF can be obtained Abbreviations: ABI, anoxic brain injury; ALS, advanced life support; ALT, alanine aminotransferase; AST, aspartate aminotrans-

When Do DCD Donors Die?

“…In some small studies, 1 year patient and graft survivals after ECMO-RP of donor kidneys were better than DCD and were comparable with DBD organs. 3,13,14 However, with regard to liver transplantation, ECMO-RP was associated with high rates of primary nonfunction, graft failure, and post-transplantation complications. Thus, authors have suggested that RP for liver transplantation be approached with caution.…”

“…Thus, authors have suggested that RP for liver transplantation be approached with caution. 13 Additional considerations with regard to ECMO include the resource-heavy implications of using such a technology. It is unlikely that many of the smaller hospitals where organ donation often takes place have ECMO units, and the expense and expertise required in developing and providing portable ECMO units for procurements limits the excitement for this.…”

Potential approaches to improve the outcomes of donation after cardiac death liver grafts

“…Abdominal regional perfusion is being done via cannulation of femoral artery and vein using cardio pulmonary bypass machine or extracorporeal membrane oxygenation machine. For the first time regional perfusion was performed by a Spanish surgeon at 1989 [42] . The perfusion is being used in two categories after one hour of WIT [32] .…”

Review of anesthesia in liver transplantation

“…3e5 The main problem in LT is the wide disparity between supply (available donors) and demand (patients needing liver grafts). 3e5 To increase the pool of donors from the conventional beating heart, brainstem-dead donors, various effortsdsuch as using marginal donor from controlled non-heart beating donor by perfusion of cold preservation solution in the femoral artery immediately after cardiac arrest, 6 or regional extracorporeal membrane oxygenation (ECMO) perfusion of the abdominal organs after cardiac arrest, 7 or systemic ECMO support after cardiac deathdhave been performed. 8 Improvement in the surgical technique via using reduced liver graft has shortened the waiting period of pediatric recipients and eliminated death in the waiting list.…”