Transplantation Reports最新文献

The disproportion between the number of patients on the kidney transplant waiting list and the actual donors pool represents a primary issue for the international Transplant community. The development of donation after circulatory death (DCD) programs has been associated with a remarkable increase in organs procurement and transplants activities across the globe. However, effective DCD donation and transplantation require the resolution of several legal, ethical, deontological, logistical, and technical issues. In Italy, the major obstacle to this very specific type of dation was represented by the 20-minute no-touch period for the declaration of death by cardio-circulatory criteria established by the Italian legislation. Following the encouraging results obtained with the use of in situ Normothermic Regional Perfusion in the setting of a single-center exploratory trial performed between 2008 and 2013 (Alba project), the Comitato Nazionale per la Bioetica and the Centro Nazionale Trapianti eventually managed to start a national-scale controlled and uncontrolled DCD program. We herein describe the Italian DCD KT program with a special focus on the most crucial and peculiar aspects of the national organ donation and allocation process.

Background

Lung transplantation (LT) demand outpaces supply. Consequently, extended criteria for donor selection are used, resulting in LT from donors with a history of substance use (SU). The aim of this study is to assess the association between donor SU and short-term LT outcomes.

Methods

We obtained recipient and donor data for LTs performed between January 2014 to January 2019 from electronic health records and the United Network for Organ Sharing (UNOS) database. We defined SU as cigarette/e-cigarette smoking, illicit SU (cannabis, cocaine, opioids, amphetamines), or heavy alcohol use (2+ alcoholic drinks per day). Our primary outcome was late high-grade primary graft dysfunction (PGD), which we defined as grade 2-3 PGD between 48-72 hours post-LT. Secondary outcomes included mechanical ventilation (MV) hours, intensive care unit (ICU) length of stay (LOS), hospital LOS, number of bronchoscopies, cumulative acute rejection (CAR) score in the first year after LT, and overall survival (OS).

Results

A total of 352 LTs were included in this study. On multivariable regression, we found that any donor cigarette smoking was associated with increased odds of late high grade PGD (p=0.021), while any donor cannabis use was associated with reduced odds of late high grade PGD (p=0.002). There was no association between any donor SU and secondary outcomes.

Conclusions

Donor cigarette use was associated with higher risk for PGD. Our findings may suggest a history of donor cannabis use and other illicit SU are not associated with PGD or worse OS.

In Japan, since the revision of the Organ Transplant Law in July 2010, donation after brain death (DBD) has increased, while donation after cardiac death (DCD), which has been mainly used by kidney transplantation, has decreased. The number of DCD donors decreased from 98 in 2009 to 28 in 2019. There is no clear reason for the decrease in DCD donors. Furthermore, since 2020, there has been a marked decrease in DCD due to the influence of the COVID-19 pandemic. On the other hand, the outcomes after kidney transplantation from DCD donors are improving year by year. The outcomes of kidney transplantation from DCD donors in Japan are comparable to those of kidney transplantation from DBD donors in Western countries. In order to further improve transplantation outcomes from DCD donors, the clinical introduction of continuous machine perfusion preservation technology, for the purpose of reducing ischemic reperfusion injury, is expected in Japan.

Kidney transplantation is the best treatment available for patients with end-stage renal disease. There are three categories of donors: living donors (LD), brain death (DBD) or cardiac death (DCD) kidney donors. In this review we analyze the current scenario of DCD renal transplantation in Europe and in Italy. In Italy DCD donation has not yet been significantly developed because of the obstacle of the 20 min no touch period after cardiac arrest, before cannulating and perfusing organs to be recovered. This procedure is requested by current Italian law and is not going to be changed in the near future.

We analyze problems rising from this law and suggest possible solutions.

Transplantation remains the optimum treatment for many patients. The availability of donor organs has failed to keep pace with demand, resulting in an ever-increasing waiting list of potential recipients. Using organs from donation after circulatory death (DCD) donors is one of the strategies available to increases the number of donor organs. On one hand in many countries DCD donation has gained popularity and the outcomes are comparable to organ transplantations following brain death donation, but on the other hand still a lot of problems exist for both controlled and uncontrolled DCD regarding ethical and legal issues of DCD program in several regions. There are guidelines though available for the whole process of DCD donation and transplantation from national transplant societies and anaesthesiology societies.

The aim of this paper was to review the DCD activity and the possibilities to improve the number of organ transplantation in the Asian region based on literature search.

A novel donation concept, namely organ donation after brain death followed by circulatory death (DBCD) has been initiated in many Asian countries to help increase the available organs for transplantation since around 2011. The reason why there are so many DBCD donors is because brain death law has not been approved on a national level in most of the Asian countries, and culturally many relatives of deceased donors can only accept donor death when heart beating is irreversibly arrested.

Based on this review there is a need to implement DCD transplant programs and to establish reliable protocols for this type of donation across all the Asian countries to increase the number of transplantations.

Introduction

Donation after cardiac death (DCD) has been leading the way to help bridge the growing gap between availability of donors and recipients on waitlist. With advances in technology and our understanding of DCD donation the safety profile is growing. It is becoming an increasing viable option even in marginal settings.

Discussion

The ethos surroundings DCD is still a matter of contention but there is support and collaboration from larger societies and establishments with development of standardizing protocols. Preparation is key. Experience of the procurement and transplanting surgeons are pivotal. There are multiple moving parts and for the success of a DCD program, dedication is needed from the donor hospitals, organ procurement organizations and the transplant centers. Previous practices based on anecdotal experiences are now either supported by or refuted by increasing evidence and data, based on the development of consensus-based guidelines with the end goal of having uniform outcomes. Normothermic regional and machine perfusion have expanded options in the DCD world, challenging the limits and expanding our paradigm. Recognition of the weaknesses and organ specific complications allow the clinician to make choices for optimal outcomes. These advancements have allowed outcomes to be optimized.

Conclusions

Expanding the organ donor pool is one solution to increase the availability of organs for transplantation. Increasing the attention to and the use of DCD organs combined with machine and normothermic perfusion is a future strategy to obtain ongoing clinical success in organ transplantation and lower the waiting list mortality.

Tissue and organ transplantation is the best treatment option for end-stage organ failure. However, organ shortage still remains to be the greatest challenge facing the field of organ transplantation. Millions of people die and are buried with healthy organs, which could save the lives of many patients who continue to wait on transplant lists. Countries must aim to work towards a system of matching organs as much as possible with the deceased donation to meet the growing demand for organs. This action will not only result in the reduction of organ trafficking activities but shall also make an enormous difference to those patients awaiting transplants where living organ donors are not an option.

Donation after circulator death (DCD) has gained much attention over the last decade as one of the accepted practices in order to expand the donor pool. DCD donation takes place after declaration of death using cardio-respiratory criteria in contrast to donation after brain death (DBD) where neurological criteria are used. Although DCD remains a focus of interest and contributes to donor numbers in many countries, it also poses many challenges medically, ethically and legally. Unfortunately, controlled DCD is not really in practice in Turkey and the Middle East.

Therefore, the purpose of this review is to provide an overview of current status of DCD in Turkey and the Middle East and to identify associated concerns medically and ethically.

Diabetes mellitus is a major cause of morbidity and mortality worldwide. Pancreas transplantation has evolved into a viable treatment option in this patient population. While the majority of procedures are performed as either simultaneous pancreas-kidney (SPK) or pancreas after kidney (PAK), the resulting glycemic control leads to a significant delay in the progression of cardiovascular disease. At present, there is a critical organ shortage. Donation after circulatory death (DCD) may be a strategy to increase the pancreas donor pool. Herein, we examine the clinical parameters that impact organ selection and review the current experience with pancreas transplantation in the setting of DCD donation.

Livers procured from donors after circulatory death (DCD) have increasingly been used for liver transplantation (LT) to address the organ crisis. While DCD LT increases patient access to life-saving treatment, this practice creates risks for recipients, including primary allograft non-function, early allograft dysfunction, and ischemic cholangiopathy. These complications are due to the unique ischemia and reperfusion injury related to different phases of organ procurement and preservation in DCD. Therefore, substantial research efforts and innovations on DCD LT have primarily aimed at reducing these complications. One such advance is the utilization of ex vivo machine perfusion of the donor liver in DCD LT. This review focused on the data from clinical trials and studies in human DCD LT.