Liver Transplantation in a Patient With Acute-on-Chronic Liver Failure Due to Traditional Chinese Medicine Intoxication Using Donation After Circulatory Death From a Renal Transplant Recipient: A Case Report.

Acute-on-chronic liver failure (ACLF) is a clinical manifestation of acute liver failure and decompensation on the basis of chronic liver disease. To date, hepatitis B virus-related ACLF is still the main cause of liver failure in China. Liver transplantation is currently the most likely treatment option to cure ACLF, but the shortage of donor livers is a barrier to its widespread use. The shortage of organs has led to increased use of expanded-criteria donors (ECDs), that is, donation after cardiac death (DCD) and its variant donation after brain and cardiac death (DBCD-China, DCBD-Switzerland). Here we report a case of liver transplantation, whose recipient was diagnosed with ACLF as a result of use of traditional Chinese medicine while the donor liver was retrieved from a renal transplant patient 4 years after transplantation. This transplant was carried out in accordance with the Helsinki Congress and the Declaration of Istanbul.

Equity-Efficiency Trade-offs Associated With Alternative Approaches to Deceased Donor Kidney Allocation: A Patient-level Simulation.

BACKGROUND: The number of patients waiting to receive a kidney transplant outstrips the supply of donor organs. We sought to quantify trade-offs associated with different approaches to deceased donor kidney allocation in terms of quality-adjusted life years (QALYs), costs, and access to transplantation. METHODS: An individual patient simulation model was developed to compare 5 different approaches to kidney allocation, including the 2006 UK National Kidney Allocation Scheme (NKAS) and a QALY maximization approach designed to maximize health gains from a limited supply of donor organs. We used various sources of patient-level data to develop multivariable regression models to predict survival, health state utilities, and costs. We simulated the allocation of kidneys from 2200 deceased donors to a waiting list of 5500 patients and produced estimates of total lifetime costs and QALYs for each allocation scheme. RESULTS: Among patients who received a transplant, the QALY maximization approach generated 48 045 QALYs and cost £681 million, while the 2006 NKAS generated 44 040 QALYs and cost £625 million. When also taking into consideration outcomes for patients who were not prioritized to receive a transplant, the 2006 NKAS produced higher total QALYs and costs and an incremental cost-effectiveness ratio of £110 741/QALY compared with the QALY maximization approach. CONCLUSIONS: Compared with the 2006 NKAS, a QALY maximization approach makes more efficient use of deceased donor kidneys but reduces access to transplantation for older patients and results in greater inequity in the distribution of health gains between patients who receive a transplant and patients who remain on the waiting list.

Population-Based Analysis and Projections of Liver Supply Under Redistricting.

BACKGROUND: To reduce the geographic heterogeneity in liver transplant allocation, the United Network of Organ Sharing has proposed redistricting, which is impacted by both donor supply and liver transplantation demand. We aimed to determine the impact of demographic changes on the redistricting proposal and characterize causes behind geographic heterogeneity in donor supply. METHODS: We analyzed adult donors from 2002 to 2014 from the United Network of Organ Sharing database and calculated regional liver donation and utilization stratified by age, race, and body mass index. We used US population data to make regional projections of available donors from 2016 to 2025, incorporating the proposed 8-region redistricting plan. We used donors/100 000 population age 18 to 84 years (D/100K) as a measure of equity. We calculated a coefficient of variation (standard deviation/mean) for each regional model. We performed an exploratory analysis where we used national rates of donation, utilization and both for each regional model. RESULTS: The overall projected D/100K will decrease from 2.53 to 2.49 from 2016 to 2025. The coefficient of variation in 2016 is expected to be 20.3% in the 11-region model and 13.2% in the 8-region model. We found that standardizing regional donation and utilization rates would reduce geographic heterogeneity to 4.9% in the 8-region model and 4.6% in the 11-region model. CONCLUSIONS: The 8-region allocation model will reduce geographic variation in donor supply to a significant extent; however, we project that geographic disparity will marginally increase over time. Though challenging, interventions to better standardize donation and utilization rates would be impactful in reducing geographic heterogeneity in organ supply.

Impact of a Full-Time Donor Management Protocol on Donors' Liver Biopsy Findings: Progress to Date.

OBJECTIVES: This study investigated a fixed coordinator-directed donor management strategy's impact on donated liver quality, as determined by definitive biopsy results. MATERIALS AND METHODS: We collected donated liver biopsy results from donations both before and after implementing a fixed coordinator-directed donor management strategy. This strategy involved full-time attendance by a donor coordinator and continued resuscitation of brain-dead donors. All donations took place in a single organ procurement unit. We also followed up results of biopsies from the Liver Transplantation Center database of Namazi Hospital in Shiraz, Iran. RESULTS: We compared biopsy findings of 192 livers donated from 2012 to 2013 (group A) with 276 livers donated from 2015 until August 2016 (group B). Data analysis showed that 67 livers (34.9%) in group A were rejected for transplant owing to severe steatosis in 17 (8.9%), moderate/severe fibrosis in 9 (4.7%), moderate/severe necrosis in 28 (14.6%), and 13 (6.8%) rejected for other pathologies. Among group B livers, 59 (21.4%) were not deemed suitable for transplant owing to severe steatosis in 37 (13.5%), moderate/severe fibrosis in 6 (2.1%), and moderate/ severe necrosis in 16 (5.7%). Overall, steatosis was found in 94 livers (49.2%) in group A versus 175 livers (63.3%) in group B (P = .007). Donor age in group A averaged 36.5 years versus 47.9 years in group B (P = .02). Necrosis was found in 33 livers (17.2%) in group A and 22 livers (7.9%) in group B (P = .008). One-month survival rates were 95.3% and 96.3% for groups A and B (P = .08). CONCLUSIONS: Donated liver disqualification before transplant noticeably decreased despite the shift in demographic patterns from 2012 to 2016. In group A, brain-dead liver donors were younger and more often died from trauma, whereas group B donors had more cerebrovascular accident-induced deaths. This achievement took place alongside increased rates of steatosis and decreased rates of necrosis.

Renal xenotransplantation: experimental progress and clinical prospects.

There are >100,000 patients waiting for kidney transplants in the United States and a vast need worldwide. Xenotransplantation, in the form of the transplantation of kidneys from genetically engineered pigs, offers the possibility of overcoming the chronic shortage of deceased and living human donors. These genetic manipulations can take the form of (i) knockout of pig genes that are responsible for the expression of antigens against which the primate (human or nonhuman primate) has natural "preformed" antibodies that bind and initiate complement-mediated destruction or (ii) the insertion of human transgenes that provide protection against the human complement, coagulation, or inflammatory responses. Between 1989 and 2015, pig kidney graft survival in nonhuman primates increased from 23 days to almost 10 months. There appear to be no clinically significant physiological incompatibilities in renal function between pigs and primates. The organ-source pigs will be housed in a biosecure environment, and thus the risk of transferring an exogenous potentially pathogenic microorganism will be less than that after allotransplantation. Although the risk associated with porcine endogenous retroviruses is considered small, techniques are now available whereby they could potentially be excluded from the pig. The US Food and Drug Administration suggests that xenotransplantation should be restricted to "patients with serious or life-threatening diseases for whom adequately safe and effective alternative therapies are not available." These might include those with (i) a high degree of allosensitization to human leukocyte antigens or (ii) rapid recurrence of primary disease in previous allografts. The potential psychosocial, regulatory, and legal aspects of clinical xenotransplantation are briefly discussed.

Lessons Learned From Review of a Single Center Experience With 500 Consecutive Liver Transplants in a Region With Insufficient Deceased-Donor Support.

OBJECTIVES: We present here the outcomes of our first 500 liver transplants and discuss the lessons learned during this time. MATERIALS AND METHODS: We retrospectively analyzed the first 500 consecutive transplants within the listing criteria of the United Network for Organ Sharing, with recipients and donors with minimum 1-year follow-up. Patient survival and donor complications were analyzed for 31 liver transplant recipients with hepatocellular carcinoma beyond the Milan criteria who had transplant performed during the same time. RESULTS: Between August 2006 and March 2013, there were 519 liver transplants performed in 500 patients (365 adult, 135 pediatric). There were 394 living-donor and 125 deceased-donor liver transplants. In addition, 31 adult liver transplants were performed in patients with hepatocellular carcinoma beyond Milan criteria (22 living-donor and 9 deceased-donor transplants). The main cause of chronic liver failure was biliary atresia in pediatric patients (30.4%) and chronic hepatitis B infection in adults (35.6%). The complication rate for primary nonfunction was 3.8%, overall biliary complications 24.0% (significantly higher after adult living-donor liver transplant, 30.3%), hepatic artery thrombosis 1.6%, portal vein thrombosis 3.0%, retransplant 3.8%, acute cellular rejection 29.6%, and bacterial infection 39.4%. Overall 1-, 3-, and 5-year patient survival rates in the first 500 consecutive transplants performed on recipients within United Network for Organ Sharing listing criteria were 87.8%, 85.0%, and 78.6%; for hepatocellular carcinoma patients beyond the Milan criteria, survival rates were 71.9%, 52.5%, and 38.2%. CONCLUSIONS: In regions without a sufficient number of deceased donors, living-donor liver transplant, with its associated problems, is the only alternative to deceased-donor liver transplant. Liver transplant requires teamwork, with all players working well together for a successful outcome. The important keys to success in liver transplant include decision-making, timing, surgical skills, experience, and close follow-up.

Organ Donation From Deceased Donors: A Proactive Detection Program in Saudi Arabia.

Several challenging obstacles remain to increasing the number of organ donations from deceased patients in a hospital setting. These include medical, administrative, and ethical issues. Possible medical obstacles include the failure of early recognition of possible donors and inadequate care of potential and actual donors. To maximize the use of donated organs, proper care of the donors and expedited donor consent cannot be overemphasized. The care rendered to patients should ensure appropriate perfusion and nutrition of the organs, with meticulous follow-up until organ recovery. For example, patients involved in accidents are presumed to be healthy, but many have no available medical history on file. At the time of organ recovery, unexpected infections or malignancies can be minimized by raising the index of suspicion of the presence of serious conditions in donors, especially in donors with unknown medical history. A careful physical examination and an appropriate and aggressive laboratory investigation may disclose the cause of suspected clinical conditions in these potential donors. Individuals who work in intensive care units are the main group of health care providers directly involved in the process of organ donation. Appointing a donor coordinator in each intensive care unit could improve all aspects of organ donation. Such coordination could harmonize efforts toward the goals mentioned above and surmount the obstacles encountered during deceased-donor organ donation. Here, we describe the preliminary results of the Proactive Detection Program, a collaboration between the Saudi Center for Organ Transplantation (the national organ donation and transplant supervising center) and intensive care units of donating hospitals. With its success in Saudi Arabia, it is hoped that it will be widely adopted in other regions.

Organ Transplants in Kazakhstan.

The Republic of Kazakhstan is one of the fastest developing countries in the world and has a health care system that is unique in Central Asia. Its organ transplant services are also developing rapidly. We aimed to analyze and briefly report on the current status of organ transplant in the Republic of Kazakhstan. We analyzed organ transplant activities in that country for the period 2012 to 2014. All data were collected from the official database of the National Transplant Coordinating Center of the Republic of Kazakhstan. At the end of 2014, the number of transplant centers had increased to 10, three of which could perform multiorgan transplants; during the same period, the number of deceased-donor organ-donating hospitals increased up to 37. By 2013, the transplant activity rate for all centers had reached 9.22 per million population. During the previous 3 years (2012-2014), there was a 3-fold increase in the number of living donors and an 18-fold increase in the number of kidney transplants. Between 2012 and 2014, the number of living-donor liver transplants increased from 17 to 25, and the number of deceased-donor transplants increased from 3 to 7. During the last 3 years (2012-2014), the number of heart transplants increased to 7 cases. During the last 3 years (2012-2014), Kazakhstan achieved a significant improvement in the organization of its transplant services, and a noticeable upward trend in the system continues.

Donation rates: what matters?

INTRODUCTION: The increase in the number of donors is the main objective of all transplantation organizations around the world. Further understanding of the factors involved in increasing donation rates is very important for planning future strategies to improve outcomes in each country. OBJECTIVE AND METHOD: With this purpose we analyzed the relationship between social and economic factors of the countries and organizational aspects of health systems and institutions dedicated to transplantation in relation to the number of actual donors per million population. We analyzed rates of deceased donors per million population of Latin America, North America, and Europe (20 countries) and correlated them with the human development index and its most important indicators. We also studied the correlation with spending on health and organizational aspects of the health system. RESULTS: On the one hand, we found that donation rates (DRs) per million population (pmp) were not statistically significantly correlated with the human development index (significant correlation 0.61 and 0.181). There is a correlation, albeit weak, between observed donation rates and gross domestic product (GDP) of each country (significance, 0.04; correlation, 0.46). On the other hand, there exists a strong correlation between the percentage of GDP spent on health and DRs pmp (significance, 0.01; correlation, 0.53). Those countries with an integrated national health system (P = .01) and a higher percentage of hospitals with intrahospital transplantation coordinators (P = .001) had higher DRs pmp. CONCLUSIONS: The best DRs are closely linked to organizational aspects of the donation system in particular and the health system in general. There is a weak correlation between observed DRs and socio-economic and development indicators of countries. These data should be taken into account in planning future strategies to increase DRs, health plan policies, and investments.

Body composition analysis of patients on waiting list for cadaveric renal transplantation: a comparison of hemodialysis and peritoneal dialysis patients.

BACKGROUND: Bioelectrical impedance analysis is a simple, noninvasive method of assessing body composition. Dialysis modality and selection of buffer type may have an impact on body composition. The aim of our study was to compare body compositions of patients from the waiting list for cadaveric renal transplantation according to the dialysis modality. METHODS: We examined a total of 152 (110 hemodialysis [HD] and 42 continuous ambulatory peritoneal dialysis [CAPD]) patients. Demographic data were collected from patient charts. The last 6 months routine laboratory evaluations including hemoglobin, serum creatinine, intact parathyroid hormone, albumin, C reactive protein, calcium, phosphorus were collected. Body compositions were measured using the Tanita BC-420MA Body Composition Analyzer (Tanita, Tokyo, Japan). We made a subanalysis of the CAPD group according to buffer choices as follows: lactate-buffered (n = 16) and bicarbonate/lactate-buffered (n = 26) solution users. RESULTS: The body weight (P = .022), body mass index (BMI; 25.8 ± 4.7 vs 23.4 ± 4.9 kg/m(2), P = .009), muscle mass (P = .01), fat-free mass (P = .013), and visceral fat ratio (9.5 ± 5.4 vs 7.3 ± 4.1 %, P = .022) were significantly higher in the CAPD group. Total body water of CAPD patients were also higher (P = .003), but total body water ratios of HD and CAPD groups were similar. Fat and fat-free mass ratios of patient groups were also similar. Comparing CAPD subgroups we observed that patients using bicarbonate/lactate-buffered solutions had higher body weights (P = .038), BMI (27.1 ± 5 vs 23.7 ± 3.5 kg/m(2), P = .018) values, and visceral fat ratios (8.0 ± 5.2 vs 4.6 ± 2.5 %, P = .023). These patients also tend to have higher fat mass without statistical significance (P = .074). Fat, muscle, and fat-free mass total body water ratios of peritoneal dialysis subgroups were similar. CONCLUSION: We believe that body composition analysis should be used as a complementary method for assessing nutritional status of PD and CAPD patients as body weight or BMI measurements do not reflect fat, muscle masses, and visceral fat ratios in these patients. Stable, well nourished CAPD patients should be closely observed and be encouraged to increase daily exercise and/or decrease calorie intake from other sources to decrease risks associated with abdominal obesity.

[Deceased donor liver transplantation]. / Lebertransplantation mit postmortalen Organen.

Deceased donor liver transplantation is nowadays a routine procedure for the treatment of terminal liver failure and often represents the only chance of a cure. Under given optimal conditions excellent long-term results can be obtained with 15-year survival rates of well above 60 %.In Germany the outcome after liver transplantation has deteriorated since the introduction of an allocation policy, which is based on the medical urgency. At present 25 % of liver graft recipients die within the first year after transplantation. In contrast 1-year survival in most other countries, e.g. in the USA or the United Kingdom is around 90 % and therefore significantly better. Reasons for the inferior results in Germany are on the one hand an increasing number of critically ill recipients and on the other hand an unfavorable situation for organ donation. In comparison with other countries the organ donation rate is low and moreover the risk profile of these donors is above average. This combination of organ shortage and organ allocation represents a big challenge for the future orientation of liver transplantation and creates the potential for conflict. These cannot be solved on a medical basis but require a social consensus.Because of the present inferior results and because of the high expenses of the present system we suggest a discussion on future allocation policies as well as on future centre structures in Germany. In addition to the medical urgency the maximum benefit should also be considered for organ allocation.

Heart transplantation and left ventricular assist device therapy: two comparable options in end-stage heart failure?

Heart transplantation is the only curative therapy for chronic heart failure, and it plays an important role in the treatment of chronic heart failure with a survival rate of approximately 50% of all patients after 10 years. This has to be kept in mind when alternative therapies enter into our daily routine in treating this patient population. However, the shortage of appropriate donor organs and the expanding pool of patients waiting for heart transplantation have led to growing interest in alternative strategies, particularly in left ventricular assist device (LVAD) therapy. With growing clinical experience and continued technical advances, continuous-flow pumps are evolving as a bridge to transplantation or as a destination therapy for advanced heart failure. Nevertheless, the importance of this new indication of chronic cardiac support compared to heart transplantation is still completely open and the object of controversial ongoing discussion. This review (1) describes the clinical use and long-term outcome of a currently available miniaturized LVAD in the context to the standard of care-heart transplantation, (2) provides an outlook of the ongoing process of further optimization of LVADs, and (3) comments on the challenges with assist devices as alternatives to transplantation with a 5-year outlook.

Institutional policy learning and public consultation: the Canadian xenotransplantation experience.

Attempts to evaluate public consultations, participatory technology assessment, and deliberative democracy have typically considered impacts on either policy or participants. The determination of impacts on policy institutions has been limited due to the challenges of tracing effects through the policy process, or penetrating bureaucratic walls. This paper presents findings from a retrospective study exploring the institutional lessons learned from a 2001 Canadian national public consultation on xenotransplantation. The consultation was conducted through an arm's-length process and involved the use of citizen juries in six regional sites. We conducted in-depth interviews of regulatory and policy actors who were engaged in early policy discussions and the consultation process. We reviewed evaluations of this process, both internal and external, which gave us richer insights into what institutional actors saw as the impacts of this consultative experience on their policy environment. Participants in our research identified a broader shift toward openness in policy culture which they linked specifically to the innovative consultation process employed for xenotransplantation. We argue that beyond input into policy decisions, a consultation may have an impact in terms of its contribution to overall shifts in institutional culture (related to institutional learning), such as an "opening" of technological decision processes to a broader range of actors, knowledge, and values.