Machine perfusion following static cold storage preservation in kidney transplantation: donor-matched pair analysis of the prognostic impact of longer pump time.

The impact of machine perfusion (MP) time on kidney transplant outcome is mixed in previous studies using multivariable analyses. In an analysis of 66 pairs of donor-matched adult, first transplant recipients (N = 132) with identical donor characteristics except for pump time, tests of association of shorter versus longer pump time (first versus second kidney removed) by delayed graft function(DGF), slow graft function(SGF), and biopsy proven acute rejection(BPAR) were performed using McNemar's test. Freedom-from-BPAR, graft and patient survival, and renal function were also compared. Mean ± SD pump times for paired recipients with first and second kidneys were 22.7 ± 7.3 h and 31.2 ± 7.9 h, respectively (mean difference: 8.5 ± 4.5 h, P < .000001). There was no significant impact of pump time on DGF or SGF, with discordant pairs favoring less SGF with longer pump time (N.S.). The incidence of BPAR during the first 12 months post-transplant yielded a borderline difference favoring longer pump time (P = .09), and freedom-from-BPAR during the first 12 months was significantly more favorable for longer pump times (95% vs. 84%, P = 0.04). No differences were observed in graft and patient survival, and renal function. While offering significantly favorable protection from BPAR, this analysis of donor-matched recipient pairs corroborates longer MP (pump) times having no unfavorable effect on other clinical outcomes.

Liver transplantation using elderly donors: a risk factor analysis.

Survival after liver transplantation is negatively impacted by use of elderly deceased donors, but excluding them would increase waiting times and waiting list mortality. We reviewed our experience with liver transplantation (LT) utilizing livers from deceased donors 65 yr of age and older to identify those factors that impact graft survival. All adult patients (≥ 18 yr old) who underwent primary LT using deceased donor livers from donors aged ≥ 65 yr between February 1995 and November 2003 were included. With multivariate analysis we found four unfavorable characteristics significantly associated with higher post-transplant graft failure rate. These characteristics are hepatitis C as an etiology of liver disease, Model for End-Stage Liver Disease score >20, serum glucose level of donor > 200 mg/dL at the time of liver recovery, and skin incision to aortic cross-clamp time > 40 minutes in the donor surgery. The five-yr estimated graft survival rates having 0, 1, 2, 3, and 4 unfavorable characteristics were 100%, 82.0%, 81.7%, 39.3%, and 25.0%, respectively (p < 0.05). Our data demonstrated good graft survival can be achieved in LT using elderly donor liver allografts with appropriate patient selection, donor blood glucose management and efficient liver recovery with minimal manipulation of the liver during donor surgery.

Favorable outcomes with machine perfusion and longer pump times in kidney transplantation: a single-center, observational study.

BACKGROUND: Hypothermic machine perfusion (MP) preservation is used for all deceased donor kidney transplants at our center. Kidneys are placed in cold storage at retrieval, then transferred to MP on arrival. Because a lack of consensus regarding optimal use of MP still exists, we evaluated the overall impact of using MP at our center and the prognostic value of MP (Pump) time. METHODS: We retrospectively analyzed 339 adult, primary deceased donor kidney transplant recipients who were pooled across three prospective, randomized immunosuppression trials (since 2000) at our center. In addition to providing overall results for delayed graft function (DGF) (requirement for dialysis in the first week), slow graft function (SGF), first biopsy-proven acute rejection (BPAR), and graft failure, stepwise logistic and Cox regression analyses were used to determine the prognostic value of pump time, particularly after controlling for other significant prognosticators. RESULTS: Mean cold storage and pump times were 6.6 and 26.7 hr, consistent across immunosuppression protocols. Overall DGF and SGF rates were 4.4% (15/339) and 12.1% (41/339). DGF was equally low for pump time less than 24 vs. more than or equal to 24 hr, 5.2% (6/116) vs. 4.0% (9/223) (P=0.63), with similar results after adjusting for known DGF predictors. A significantly lower first BPAR rate was observed for longer pump time (as a continuous variable) among more immunologically active recipients (those having more risk factors: DGF, age <50 yr, and non-white) (univariable P=0.005; multivariable P=0.009), with an estimated hazard ratio of 0.43 (P=0.006) favoring pump time more than or equal to 24 hr among those with more than or equal to two risk factors. CONCLUSIONS.: In this single-center, observational study, MP with prolonged pump times was associated with low DGF/SGF and first BPAR rates, supporting continued use of MP.

A cause-specific hazard rate analysis of prognostic factors among 877 adults who received primary orthotopic liver transplantation.

BACKGROUND: In orthotopic liver transplantation (OLT) distinct causes of graft failure (GF) and death with a functioning graft (DFG) exist. Prognostic factors for one failure type may be distinctly different from those predictive of other types, and an accurate portrayal of these relationships may more clearly explain each factor's importance. METHODS: A multivariable cause-specific hazard (CSH) rate analysis using Cox stepwise regression was performed among 877 adults who received primary OLT during 1996-2004 with tacrolimus+steroids as immunosuppression. RESULTS: Older donor age (P=0.004) implied greater primary dysfunction GF, while primary sclerosing cholangitis (PSC; P=0.0002) implied greater vascular thrombosis GF. Recurrent nonmalignant liver disease GF was higher among hepatitis C virus patients (P<0.00001), and younger recipient age (P=0.005) implied greater death from recurrent (metastatic) hepatocellular carcinoma. African-American race (P<0.00001), PSC (P=0.003), and younger recipient age (P=0.005) were independently associated with greater GF due to chronic rejection. Older donor age (P=0.003) implied greater infection DFG, while older recipient age (P=0.003) and pretransplant diabetes (P=0.03) were independently associated with greater cardiovascular/cerebrovascular DFG. Finally, most of these cause-specific predictors were not significant in an overall Cox model for graft survival. CONCLUSIONS: The CSH approach should be more widely used in investigations of prognostic factors. The result of older donor age implying greater primary dysfunction GF and infection DFG but having no association with other failure types demonstrates that its impact is specific to the graft's early posttransplant functional status. In addition, while recipient age was an important prognosticator, its direction of association reverses depending upon the outcome being analyzed.

The impact of donor cocaine use on the outcome of adult liver transplantation.

BACKGROUND: To investigate the feasibility of adult liver transplantation from donors with cocaine use. METHODS: Of 807 adult liver transplantations performed between 1994 and 2000, 72 donors (8.9%) were current cocaine users. Donor characteristics and post-transplantation outcomes were retrospectively compared between the 72 cocaine and 126 control group selected from the remaining 735 donors, matched for age and having no history of drug use. RESULTS: Marijuana, opiates and amphetamines were drugs of abuse often present with cocaine. Except for a high incidence of acute alcohol use in the cocaine donors, donor characteristics were comparable. The cocaine group had a significantly higher graft loss within three months of transplant (18.1% vs. 7.9%, p < 0.05), and had a trend toward lower graft survival (76% vs. 86% at one yr). CONCLUSIONS: Potential adverse effect of cocaine and substances concurrently involved on donor liver was suggested. To clarify the distinct acceptance criteria of cocaine users for liver donation, prospective study is warranted.

The impact of donor chemical overdose on the outcome of liver transplantation.

BACKGROUND: To overcome the critical shortage of liver grafts, many centers have been widening the acceptance criteria for liver donation. Use of liver grafts from victims who have suffered chemical overdose (COD) may be one option that could help to expand the donor pool. However, this practice has been poorly documented. METHODS: Of 1,195 orthotopic liver transplantations performed at our institution between June 1994 and March 2001, 22 involved livers (1.8%) were retrieved from COD donors. Donor and recipient characteristics and posttransplantation outcomes were analyzed retrospectively. RESULTS: The main chemicals causing brain death of the donor were carbon monoxide (n=4), cocaine (n=4), tricyclic antidepressants (n=3), 3,4-methylenedioxy- methamphetamine (n=2), opiates (n=2), aspirin (n=1), gamma hydroxybutyrate (n=1), heroin (n=1), insulin (n=1), verapamil (n=1), barbiturate (n=1), and brompheniramine/phenylpropanolamine (n=1). Primary nonfunction developed in one patient who had received a liver from an 3,4-methylenedioxymethamphetamine-intoxicated donor. Another patient died of fungal meningitis 10 days after transplantation with a functioning graft. The remaining 20 patients experienced acceptable early graft function, as demonstrated by initial mean peak values of bilirubin (4.8 mg/dL), aspartate aminotransferase (624 U/L), and alanine aminotransferase (730 U/L). One-year graft survival rate estimated by the Kaplan-Meier method was 86%. CONCLUSIONS: Satisfactory outcomes of graft function were achieved in orthotopic liver transplantations from COD donors. The cautious use of liver grafts from selected COD donors may be a worthwhile method of increasing the availability of scarce donor organs.

Use of older controlled non-heart-beating donors for liver transplantation.

BACKGROUND: Use of liver grafts from non-heart-beating donors (NHBDs) warrants consideration so to expand the donor pool. Because the results of controlled NHBDs (CNHBDs) were acceptable, we have recently tried to expand the criteria to older CNHBDs. Here, we report our experience using liver grafts from older CNHBDs. METHODS: We retrospectively studied our donor records from June 1994 through December 2001. CNHBDs were divided into two groups by age: older donors (O) were more than or equal to 55 years old, and younger donors (Y) were less than 55 years old. We compared donor and recipient demographics and peak laboratory values during the first postoperative week. RESULTS: Twenty-five grafts from CNHBDs were transplanted in our center. Five livers were harvested from O (63+/-6 years) and 20 were from Y (32+/-15 years). No differences other than age in donor characteristics were noted between O and Y. Mean age of recipients was 50 years in both groups. Mean cold ischemic time (CIT) was 5.4 hours in O and 7.3 hours in Y (P<.05). Peak glutamic oxaloacetic transaminase (U/L), glutamic pyruvic transaminase (U/L), bilirubin (mg/dL), and prothrombin time (sec) during the first postoperative week were 611, 500, 3.9, and 16 in O and 846, 593, 5.9, and 17 in Y. There were no significant differences between the two groups. The graft survival at 1 year was 80% in O and 70% in Y. CONCLUSIONS: In our preliminary experience, recipients of liver grafts from older CNHBDs had an outcome equivalent to that of younger CNHBDs. With the strict evaluation of the donors and brief CIT, liver grafts from older CNHBDs may be used to expand the donor pool.

A simple technique for aortic cannulation in organ donors with advanced aortic disease.

Cannulation of the abdominal aorta in organ donors with advanced arteriosclerotic disease or extensive trauma may be problematic owing to difficulty in securing a watertight tie around the diseased aorta, the danger of creating a false passageway in the aorta, and the risk of breaking off plaque particles that can advance into the arteries of donated organs. Cannulation problems can be avoided in these challenging donors by using a simplified technique for cannulation of the thoracic aorta in which a Foley catheter is passed down around the aortic arch, the balloon is inflated, and cool flushing is initiated.