Uncontrolled Donors with Controlled Reperfusion after Sixty Minutes of Asystole: A Novel Reliable Resource for Kidney Transplantation

Abstract

BackgroundOrgan shortage leads to usage of kidneys from donors after sudden cardiac death, or uncontrolled donors (UDCD). Ischemic injury due to cessation of circulation remains a crucial problem that limits adoption of UDCD. Our clinical investigation was to determine the applicability of kidneys obtained from UDCD and resuscitated by extracorporeal perfusion in situ after 60 minutes of asystole.MethodsIn 2009–2011, organ procurement service of St. Petersburg, obtained kidneys from 22 UDCD with critically expanded warm ischemic time (WIT). No patients were considered as potential organ donors initially. All donors died after sudden irreversible cardiac arrest. Mean WIT was 61.4±4.5 minutes. For kidney resuscitation, the subnormothermic extracorporeal abdominal perfusion with thrombolytics and leukocyte depletion was employed. Grafts were transplanted into 44 recipients. The outcomes of transplantation of resuscitated kidneys were compared to outcomes of 87 KTx from 74 brain death donors (BDDs).ResultsImmediate functioning of kidney grafts was observed in 21 of the 44 recipients, with no cases of primary non function. By the end of the first post-transplant year there was an acute rejection rate of 9.1% (4 episodes of rejection) in the UDCD group versus 14.2% (13 episodes of rejection) in the BDD group. The actual 1-year graft survival rate was 95.5% (n = 42) in UDCD group, and 94.6% (n = 87) in BDD group. Creatinine levels at the end of the first year were 0.116±0.008 and 0.115±0.004 mmol/l in UDCD and BDD groups, respectively.ConclusionsUDCD kidneys with critically expanded WIT could be succefully used for transplantation if in situ organ “resuscitation” perfusion is included into procurement protocol. The results of 1-year follow-up meet the generally accepted criteria for graft survival and function. In situ reperfusion may exert a therapeutic effect on grafts before procurement. This approach could substantially expand the organ donors' pool.

Thrombolytic-Enhanced Extracorporeal Cardiopulmonary Resuscitation After Prolonged Cardiac Arrest

“…With ECPR return of circulation is achieved after periods of CA long enough to allow for intravascular coagulation causing the no-reflow phenomenon, and thus the potential for improving reperfusion could be maximized with thrombolytic agents. Streptokinase pre-flush during ex situ and in situ perfusion of kidneys from donors after cardiac death (DCD) has been shown to improve function of transplanted organs after up to 60 minutes of asystole [26, 27]. Organs transplanted after in situ perfusion during DCD procurement undergo the same pathophysiological events of ischemia-reperfusion as organs resuscitated after prolonged CA including the possible occurrence of no-reflow phenomenon.…”

“…Fischer et al demonstrated that intravenous thrombolytic therapy given during CPR reduces the brain no-reflow phenomenon in animals after prolonged cardiac arrest [25]. Recent studies of organ in vivo perfusion for donation after cardiac death (DCD) have demonstrated that addition of thrombolytic agents to the initial perfusate enhances the function of transplanted organs [26, 27]. Since in vivo perfusion for DCD is typically performed after prolonged durations of untreated CA, we hypothesized that a similar strategy would be effective in ECPR.…”

Normothermic Extracorporeal Perfusion in Situ in Deceased Organ Donors With Irreversible Cardiac Arrest and One Hour of Asystole. 5-Year Outcomes of Kidney Transplantation

“…Сегодня их называ-ют органами, полученными от доноров с расширен-ными критериями (ДРК) [17,18]. К ним относятся доноры со смертью мозга старшей возрастной груп-пы, с сопутствующими заболеваниями, в том числе с артериальной гипертензией и сахарным диабетом, а также погибшие в результате внезапной необра-тимой остановки кровообращения, или асистоли-ческие доноры (АСД) [19][20][21][22]. Внезапно умершие пациенты представляются перспективным ресур-сом трансплантации.…”

Perfusion device for liver preservation ex vivo before transplantation: first experimental study

“…Поскольку пере садка печени является «хирургией одного шанса», то повышаются требования к методам верификации качества трансплантата перед операцией. Мини мизация нежелательных изменений в донорском органе могла бы быть достигнута за счет создания перфузионных устройств, с помощью которых воз можно проведение искусственного кровообраще ния для селекции, «лечения» и поддержания жиз неспособности in situ и ex vivo [4,6,7,10,12,13].…”