Purpose of the review

To summarize the international experience with heart-liver (joint) donation after circulatory death (DCD) procurements and to explore the technical challenges in joint abdominal and thoracic DCD procurement.

Recent findings

Following completion of the Donors After Circulatory Death Heart Trial in the US, combined thoracic and abdominal DCD is poised to become the standard of care, expanding access to life-saving heart and lung allografts. DCD heart procurement relies on collection of donor blood for priming of the normothermic perfusion pump, which delays cooling of abdominal organs and increases risk of ischemic injury. We review the effect of donor ischemia time on abdominal organs, with several proposed technical solutions to optimize transplant outcomes for all organs.

Summary

The strategies reviewed in this manuscript may inform clinical decision-making, preoperative coordination between thoracic and abdominal procurement teams, and surgical technique for joint DCD procurements. Several approaches to organ procurement organization (OPO) and national policy, as well as future areas of focus for research are proposed.

Racial/ethnic minorities experience higher rates of wait-list mortality and longer waiting times on the liver transplant wait list. We hypothesized that racial/ethnic minorities may encounter greater logistical barriers to maintaining "readiness" on the wait list, as reflected in offer nonacceptance. We identified all candidates who received an organ offer between 2009 and 2018 and investigated candidates who did not accept an organ offer using a free-text refusal reason associated with refusal code 801. We isolated patients who did not accept an organ offer due to "candidate-related logistical reasons" and evaluated their characteristics. We isolated 94,006 "no 801" patients and 677 "with 801 logistical" patients. Common reasons for offer decline among the 677 were 60% "unable to travel/distance," 22% "cannot be contacted," 13% "not ready/unspecified," and 5% "financial/insurance." Compared to "no 801," "with 801 logistical" patients were more likely to be Hispanic (19% vs. 15%, P < 0.01). Multivariate logistic modeling showed Hispanic (odds ratio [OR] 1.44, 95% confidence interval [CI] 1.17-1.76, P < 0.01) and multiracial/other ethnicity (OR 1.82, 95% CI 1.08-3.05, P = 0.02) were associated with "with 801 logistical" status. The "with 801 logistical" patients were listed with higher allocation (inclusive of exception points) Model for End-Stage Liver Disease scores (16 vs. 15, P < 0.01) and remained longer on the wait list (median 428 days vs. 187 days, P < 0.01). Conclusion: In this analysis of wait-list candidates, we isolated 677 patients who declined an organ offer with a free-text reason consistent with a "candidate-related logistical reason." Compared with non-Hispanic Whites, Hispanics were at 1.44 odds of not accepting organ offers due to logistical reasons. These limited findings motivate further research into interventions that would improve candidates' "readiness" to accept organ offers and may benefit racial/ethnic minorities on the liver-transplantation wait list.

Bariatric surgery has been shown to be safe in the dialysis population. Whether bariatric surgery before kidney transplantation influences posttransplant outcomes has not been examined nationally. We included severely obese (BMI >35) dialysis patients between 18 and 70 years who received a kidney transplant according to the US Renal Data System. We determined the association between history of bariatric surgery and risk of 30-day readmission, graft failure, or death after transplantation using multivariable logistic, Fine-Gray, and Cox models. We included 12 573 patients, of whom 503 (4%) received bariatric surgery before transplantation. Median age at transplant was 53 years; 42% were women. Overall, history of bariatric surgery was not statistically significantly associated with graft failure (HR 1.02; 95% CI 0.77-1.35) or death (HR 1.10; 95% CI 0.84-1.45). However, sleeve gastrectomy (vs. no bariatric surgery) was associated with lower risk of graft failure (HR 0.39; 95% CI 0.16-0.95). In conclusion, history of bariatric surgery prior to kidney transplantation was not associated with allograft or patient survival, but findings varied by surgery type. Sleeve gastrectomy was associated with better graft survival and should be considered in severely obese transplant candidates receiving dialysis.

Background

While there exist case reports of anaphylaxis occurring during renal transplant surgery, descriptions of continuing transplant surgery post-anaphylaxis have been scarce. Anaphylactic reactions that present solely with hypotension without pulmonary or mucocutaneous signs have yet to be described during renal transplant surgery.

Case presentation

Here we report a case of a 33-year-old female with end-stage renal disease who underwent cadaveric renal transplant. She developed anaphylaxis following the administration of cefazolin. Despite this reaction, the surgery was ultimately completed after patient stabilization, and the patient had excellent graft function postoperatively. The patient had an elevated tryptase at the time of the reaction and postoperative allergy testing revealed a positive intradermal test to cefazolin. Written informed consent was obtained from the patient for all procedures, studies, and publication of this case report.

Conclusions

This is the first case of a successful zero-mismatch cadaveric renal transplant following an anaphylactic reaction to cefazolin. Although anaphylaxis during transplant surgery typically warrants cancellation due to the hemodynamic effects that may lead to graft dysfunction, here we describe a case where surgery was continued following patient stabilization. The decision to proceed with surgery despite an intraoperative emergency along with the management and workup of intraoperative anaphylaxis are described, which can be beneficial for others who are presented with similar scenarios in the future.

Liver transplantation (LT) recipients with hepatocellular carcinoma (HCC) receive a higher proportion of livers from donation after circulatory death (DCD) donors compared with non-HCC etiologies. Nevertheless, data on outcomes in patients with HCC receiving DCD grafts are limited. We evaluated the influence of DCD livers on post-LT outcome among HCC patients. We identified 7563 patients in the United Network for Organ Sharing (UNOS) database who underwent LT with Model for End-Stage Liver Disease score exceptions from 2012 to 2016, including 567 (7.5%) who received a DCD donor organ and 6996 (92.5%) who received a donation after brain death (DBD) donor organ. Kaplan-Meier probabilities of post-LT HCC recurrence at 3 years were 7.6% for DCD and 6.4% for DBD recipients (P = 0.67) and post-LT survival at 3 years was 81.1% versus 85.5%, respectively (P = 0.008). On multivariate analysis, DCD donor (hazard ratio, 1.38; P = 0.005) was an independent predictor of post-LT mortality. However, a survival difference after LT was only observed in subgroups at higher risk for HCC recurrence including Risk Estimation of Tumor Recurrence After Transplant (RETREAT) score ≥4 (DCD 57.0% versus DBD 72.6%; P = 0.02), alpha-fetoprotein (AFP) ≥100 (60.1% versus 76.9%; P = 0.049), and multiple viable tumors on last imaging before LT (69.9% versus 83.1%; P = 0.002). In this analysis of HCC patients receiving DCD versus DBD livers in the UNOS database, we found that patients with a low-to-moderate risk of HCC recurrence (80%-90% of the DCD cohort) had equivalent survival regardless of donor type. It appears that DCD donation can best be used to increase the donor pool for HCC patients with decompensated cirrhosis or partial response/stable disease after locoregional therapy with AFP at LT <100 ng/mL.

Recipient diabetes accounts for ~34% of end-stage renal disease in patients awaiting renal transplantation and has been linked to poor graft function. We conducted a single-center, open-label, randomized controlled trial to determine whether moderately intense glucose control during allograft reperfusion would reduce the incidence of poor graft function. Adult diabetics undergoing deceased donor renal transplant were randomized to moderately intense glucose control (n=30) or standard control (n=30). The primary outcome was poor graft function (dialysis within seven days of transplant or failure of serum creatinine to fall by 10% for three consecutive days). Recipients with moderately intense glucose control had less poor graft function in the intention-to-treat (43.3% vs 73.3%, P=.02) and per-protocol analysis (43.2% vs 81%, P<.01). Recipients with moderately intense control also had higher glomerular filtration rate (GFR) at 30 days after transplant in the per-protocol and intention-to-treat analyses. There were no episodes of severe hypoglycemia in either group and no differences in mortality, seizures, stroke, graft loss, or biopsy-proven rejection. Moderately intense glucose control at the time of allograft reperfusion reduces the incidence of poor graft function in diabetic renal transplant recipients and improves glomerular filtration rate at 30 days.

Background

Living donor liver transplantation (LDLT) has become increasingly common in an effort to increase organ availability for the treatment of end-stage liver disease. Donor safety is a primary concern in LDLT. The majority of complications experienced by living donors are infectious or biliary in nature. The purpose of this paper was to review the existing literature on biliary complications in living donors.

Methods

Studies were eligible for inclusion if they were published in English between 2006-present, focused on adult-to-adult LDLT, and were available via PubMed/MEDLINE.

Results

A total of 33 studies reporting outcomes from 12,653 donors (right lobe: 8231, left lobe: 4422) were included. Of 33 studies, 12 reported outcomes from right lobe donors, 1 from left lobe donors, 14 compared left and right, and 6 focused specifically on biliary complications. A total of 830 biliary complications (6.6%) were reported, with 75 donors requiring re-operation for biliary complications and 1 donor death attributed to biliary complications.

Conclusion

Although bile leaks and strictures are still relatively common following living donor hepatectomy, the majority of complications are minor and resolve with conservative measures. Approximately 6% of living donors will experience a biliary complication and, of these 6%, approximately 9% (total of 0.6% of donors) will require operative management of the biliary complication.

Deceased donor kidney allocation was reorganized in the United States to address several problems, including the highly sensitized patients disadvantaged with large, diverse repertoires of antibodies. Here, five transplant surgeons review their center's experience with the new allocation changes: highlighting areas of accomplishment, opportunities for improvement and, in some cases, stark differences in practice. Across these five centers the highly sensitized patients (CPRA ⩾98%) range from 5.5 to 9.2% of the 12,364 candidates on their collective waitlist. All centers reported greater rates of kidney transplantations in highly sensitized patients (12.4-27%). Three of the programs (Emory, UCSF, UW) relied upon the virtual crossmatch prior to organ acceptance in a majority of cases (70-86%)-the mere presence of antibody on HLA antibody screen was sufficient to exclude the donor in most cases at Emory and UCSF. Penn and UAB relied upon the physical flow crossmatch in almost all cases prior to proceeding with transplantation. Current or historical donor-specific antibody was occasionally crossed in certain cases at UW and UAB necessitating IVIG/plasmapheresis and/or B cell depletion perioperatively. Some authors raised concerns for cost efficiency given the increased need for organ/specimen transportation, and extensive use of hospital resources and ancillary services. In general, we found that the new allocation system has successfully achieved one of its primary goals-increased kidney transplantation in the disadvantaged, highly sensitized patients; the long-term outcomes in all patients and the cost ramifications of these changes will require continued reassessment and clarification.

Background

In the United States, 1 in 10 infants and 1 in 20 older children die on the liver transplant waiting list. Increasing split liver transplantation could increase organ availability for these children, without decreasing transplants in adults.

Methods

Using United Network for Organ Sharing Standard Transplant Analysis and Research data, we identified livers transplanted 2010 to 2015 that could potentially have been used for split transplant, based on strict criteria. Livers not suitable for pediatric patients or allocated to high-risk recipients were excluded. Number and distribution of potentially "split-able" livers were compared to pediatric waitlist deaths in each region.

Results

Of 37 333 deceased donor livers transplanted, 6.3% met our strict criteria for utilization in split liver transplant. Only 3.8% of these were actually utilized for split liver transplantation. 96% were used for a single adult recipient. Of the 2253 transplanted as whole livers, 82% of their recipients were listed as willing to accept a segmental liver, and only 3% were listed as requiring a cold ischemia time less than 6 hours. Over the same 5 years, 299 children died on the waitlist. In every United Network for Organ Sharing region, there were more potentially "split-able" livers than pediatric waitlist deaths. Thirty-seven percent of pediatric waitlist deaths occurred at transplant centers that averaged 1 or less pediatric split liver transplantation annually during the study period.

Conclusions

This comparison, although not conclusive, suggests that we might be missing opportunities to reduce pediatric waitlist mortality without decreasing access for adults-using split liver transplant. Barriers are significant, but further work on strategies to increase split liver transplant is warranted.