Normothermic Regional Perfusion in Controlled Donation After Circulatory Death Liver Transplantation: A Systematic Review and Meta-Analysis.

Liver grafts from controlled donation after circulatory death (cDCD) donors have lower utilization rates due to inferior graft and patient survival rates, largely attributable to the increased incidence of ischemic cholangiopathy, when compared with grafts from brain dead donors (DBD). Normothermic regional perfusion (NRP) may improve the quality of cDCD livers to allow for expansion of the donor pool, helping to alleviate the shortage of transplantable grafts. A systematic review and metanalysis was conducted comparing NRP cDCD livers with both non-NRP cDCD livers and DBD livers. In comparison to non-NRP cDCD outcomes, NRP cDCD grafts had lower rates of ischemic cholangiopathy [RR = 0.23, 95% CI (0.11, 0.49), p = 0.0002], primary non-function [RR = 0.51, 95% CI (0.27, 0.97), p = 0.04], and recipient death [HR = 0.5, 95% CI (0.36, 0.69), p < 0.0001]. There was no difference in outcomes between NRP cDCD donation compared to DBD liver donation. In conclusion, NRP improved the quality of cDCD livers compared to their non-NRP counterparts. NRP cDCD livers had similar outcomes to DBD grafts. This provides further evidence supporting the continued use of NRP in cDCD liver transplantation and offers weight to proposals for its more widespread adoption.

Japanese Perception of Brain Death and Implications for New Medical Technologies: Quantitative and Qualitative Social Media Analysis.

BACKGROUND: Brain death has been used to decide whether to keep sustained care and treatment. It can facilitate tissue, organ, and body donation for several purposes, such as transplantation and medical education and research. In Japan, brain death has strict diagnostic criteria and family consent is crucial, but it has been a challenging concept for the public since its introduction, including knowledge and communication issues. OBJECTIVE: We analyzed data across YouTube and Twitter in Japan to uncover actors and assess the quality of brain death communication, providing recommendations to communicate new medical technologies. METHODS: Using the keyword "" (brain death), we collected recent data from YouTube and Twitter, classifying the data into 5 dimensions: time, individuality (type of users), place, activity, and relations (hyperlinks). We employed a scale to evaluate brain death information quality. We divided YouTube videos into 3 groups and assessed their differences through statistical analysis. We also provided a text-based analysis of brain death-related narratives. RESULTS: Most videos (20/61, 33%) were uploaded in 2019, while 10,892 tweets peaked between July 3 and 9, 2023, and June 12 and 18, 2023. Videos about brain death were mostly uploaded by citizens (18/61, 27%), followed by media (13/61, 20%) and unknown actors (10/61, 15%). On the other hand, most identified users in a random sample of 100 tweets were citizens (73/100, 73%), and the top 10 retweeted and liked tweets were also mostly authored by citizens (75/100, 75%). No specific information on location was uncovered. Information videos contained guides for accreditation of the National Nursing Exam and religious points of view, while misinformation videos mostly contained promotions by spirituality actors and webtoon artists. Some tweets involved heart transplantation and patient narratives. Most hyperlinks pointed to YouTube and Twitter. CONCLUSIONS: Brain death has become a common topic in everyday life, with some actors disseminating high-quality information, others disseminating no medical information, and others disseminating misinformation. Recommendations include partnering with interested actors, discussing medical information in detail, and teaching people to recognize pseudoscience.

Comparison of Kidney Graft Function and Survival in an Emulated Trial With Living Donors and Brain-Dead Donors.

Living donation (LD) transplantation is the preferred treatment for kidney failure as compared to donation after brain death (DBD), but age may play a role. We compared the 1-year estimated glomerular filtration rate (eGFR) after kidney transplantation for recipients of LD and DBD stratified by recipient and donor age between 2015 and 2018 in a matched cohort. The strength of the association between donation type and 1-year eGFR differed by recipient age (P interaction < 0.0001). For LD recipients aged 40-54 years versus same-aged DBD recipients, the adjusted odds ratio (aOR) for eGFR ≥60 mL/min/1.73 m2 was 1.48 (95% CI: 1.16-1.90). For DBD recipients aged ≥ 60 years, the aOR was 0.18 (95% CI: 0.12-0.29) versus DBD recipients aged 40-54 years but was 0.91 (95% CI: 0.67-1.24) versus LD recipients aged ≥60 years. In the matched cohort, 4-year graft and patient survival differed by donor age and type. As compared with DBD grafts, LD grafts increased the proportion of recipients with 1-year eGFR ≥60 mL/min/1.73 m2. Recipients aged ≥60 years benefited most from LD transplantation, even if the donor was aged ≥60 years. For younger recipients, large age differences between donor and recipient could also be addressed with a paired exchange program.

Detection of spontaneous breathing during an apnea test in a patient with suspected brain death using electrical impedance tomography: a case report.

INTRODUCTION: The apnea test (AT) is a crucial procedure in determining brain death (BD), with detection of spontaneous breathing efforts serving as a key criterion. Numerous national statutes mandate complete disconnection of the patient from the ventilator during the procedure to open the airway directly to the atmosphere. These regulations mandate visual observation as an exclusive option for detecting breathing efforts. However, reliance on visual observation alone can pose challenges in identifying subtle respiratory movements. CASE PRESENTATION: This case report presents a 55-year-old morbidly obese male patient with suspected BD due to cerebral hemorrhage undergoing an AT. The AT was performed with continuous electrical impedance tomography (EIT) monitoring. Upon detection of spontaneous breathing movements by both visual observation and EIT, the AT was aborted, and the patient was reconnected to the ventilator. EIT indicated a shift in ventilation distribution from the ventral to the dorsal regions, indicating the presence of spontaneous breathing efforts. EIT results also suggested the patient experienced a slow but transient initial recovery phase, likely due to atelectasis induced by morbid obesity, before returning to a steady state of ventilatory support. CONCLUSION: The findings suggest EIT could enhance the sensitivity and accuracy of detecting spontaneous breathing efforts, providing additional insights into the respiratory status of patients during the AT.

Increasing Multiorgan Heart Transplantations From Donation After Circulatory Death Donors in the United States.

INTRODUCTION: Donation after circulatory death (DCD) donors are becoming an important source of organs for heart-transplantation (HT), but there are limited data regarding their use in multiorgan-HT. METHODS: Between January 2020 and June 2023, we identified 87 adult multiorgan-HTs performed using DCD-donors [77 heart-kidney, 6 heart-lung, 4 heart-liver] and 1494 multiorgan-HTs using donation after brain death (DBD) donors (1141 heart-kidney, 165 heart-lung, 188 heart-liver) in UNOS. For heart-kidney transplantations (the most common multiorgan-HT combination from DCD-donors), we also compared donor/recipient characteristics, and early outcomes, including 6-month mortality using Kaplan-Meier (KM) and Cox hazards-ratio (Cox-HR). RESULTS: Use of DCD-donors for multiorgan-HTs in the United States increased from 1% in January to June 2020 to 12% in January-June 2023 (p < 0.001); but there was a wide variation across UNOS regions and center volumes. Compared to recipients of DBD heart-kidney transplantations, recipients of DCD heart-kidney transplantations were less likely to be of UNOS Status 1/2 at transplant (35.06% vs. 69.59%) and had lower inotrope use (22.08% vs. 43.30%), lower IABP use (2.60% vs. 26.29%), but higher durable CF-LVAD use (19.48% vs. 12.97%), all p < 0.01. Compared to DBD-donors, DCD-donors used for heart-kidney transplantations were younger [28(22-34) vs. 32(25-39) years, p = 0.004]. Recipients of heart-kidney transplantations from DCD-donors and DBD-donors had similar 6-month survival using both KM analysis, and unadjusted and adjusted Cox-HR models, including in propensity matched cohorts. Rates of PGF and in-hospital outcomes were also similar. CONCLUSIONS: Use of DCD-donors for multiorgan-HTs has increased rapidly in the United States and early outcomes of DCD heart-kidney transplantations are promising.

End-of-life practices in Hong Kong intensive care units: results from the Ethicus-2 study.

INTRODUCTION: The need for end-of-life care is common in intensive care units (ICUs). Although guidelines exist, little is known about actual end-of-life care practices in Hong Kong ICUs. The study aim was to provide a detailed description of these practices. METHODS: This prospective, multicentre observational sub-analysis of the Ethicus-2 study explored end-of-life practices in eight participating Hong Kong ICUs. Consecutive adult ICU patients admitted during a 6-month period with life-sustaining treatment (LST) limitation or death were included. Follow-up continued until death or 2 months from the initial decision to limit LST. RESULTS: Of 4922 screened patients, 548 (11.1%) had LST limitation (withholding or withdrawal) or died (failed cardiopulmonary resuscitation/brain death). Life-sustaining treatment limitation occurred in 455 (83.0%) patients: 353 (77.6%) had decisions to withhold LST and 102 (22.4%) had decisions to withdraw LST. Of those who died without LST limitation, 80 (86.0%) had failed cardiopulmonary resuscitation and 13 (14.0%) were declared brain dead. Discussions of LST limitation were initiated by ICU physicians in most (86.2%) cases. Shared decision-making between ICU physicians and families was the predominant model; only 6.0% of patients retained decision-making capacity. Primary medical reasons for LST limitation were unresponsiveness to maximal therapy (49.2%) and multiorgan failure (17.1%). The most important consideration for decision-making was the patient's best interest (81.5%). CONCLUSION: Life-sustaining treatment limitations are common in Hong Kong ICUs; shared decision-making between physicians and families in the patient's best interest is the predominant model. Loss of decision-making capacity is common at the end of life. Patients should be encouraged to communicate end-of-life treatment preferences to family members/surrogates, or through advance directives.

The Impact of Early Brain-Dead Donor Detection in the Emergency Department on the Organ Donation Process in Iran.

We aimed to assess the impact of hospital characteristics on the outcomes of detected possible brain-dead donors, in our organ procurement network in Iran. Data was collected through twice-daily calls with 57 hospitals' intensive care units and emergency departments over 1 year. The donation team got involved when there was suspicion of brain death before the hospital officially declared it. The data was categorized by hospital size, presence of neurosurgery/trauma departments, ownership, and referral site. Out of 813 possible donors, 315 were declared brain dead, and 203 were eligible for donation. After conducting family interviews (consent rate: 62.2%), 102 eligible donors became actual donors (conversion rate: 50.2%). While hospital ownership and the presence of trauma/neurosurgery care did not affect donation, early referral from the emergency department had a positive effect. Therefore, we strongly recommend prioritizing possible donor identification in emergency rooms and involving the organ donation team as early as possible. The use of twice-daily calls for donor identification likely contributed to the consistency in donation rates across hospitals, as this approach involves the donation team earlier and mitigates the impact of hospital characteristics. Early detection of possible donors from the emergency department is crucial in improving donation rates.

Brain Death Scintigraphy: Do Not Blow the Flow.

Brain death denotes the loss of function in both the cerebrum and the brain stem, leading to coma, absence of spontaneous respiration in the setting of adequate stimulus, and the cessation of all brain stem reflexes. Although spinal reflexes such as deep tendon, plantar flexion, and withdrawal reflexes may persist, recovery is not possible. The cessation of brain function qualifies as death because of its central role in coordinating vital bodily functions. Although brain death is largely determined by a clinical and neurologic examination, confounding variables may necessitate ancillary testing such as cerebral brain perfusion imaging.

Extended Criteria Donor Use in Lung Transplants From Donation After Controlled Circulatory Death.

BACKGROUND: Most institutions apply the criteria for controlled donation after cardiac death (cDCD) lung retrieval identical to the criteria for donation after brain death (DBD). The availability of extended criteria donor (ECD) in lung transplants from cDCD remains unclear. METHODS: The United Network for Organ Sharing (UNOS) database was queried for adult lung transplants from cDCD, from May 03, 2005, to March 15, 2022. ECDs were defined by one or more items at variance from standard criteria: age 55 years or more, PaO2:FiO2 300 or less, smoking 20 pack-years or more, diabetes, or purulent secretions upon bronchoscopy. Recipients were divided into the standard criteria donor (SCD) group and the ECD group, and assessed for short- and long-term survival and postoperative events. RESULTS: Among 827 records, the SCD and ECD group showed no differences in 5-year (P = .56) survival. No significant differences were found in 30-day, 90-day, 1-year mortality and postoperative outcomes before discharge, whether in length of hospital stay, rate of ventilator support for >48 hours or reintubation, incidence of grade 3 PGD 72 hours posttransplant, acute rejection, or dialysis. None of the 5 donor factors used as criteria for lung retrieval was independently associated with cDCD recipient survival. CONCLUSIONS: Using donor lungs that extend the DBD criteria may be a safe strategy in cDCD lung transplantation. However, the current criteria may not be a perfect fit for cDCD lung retrieval. The specific DCD criteria for standard lung retrieval need to be determined.

Single-centre real-life observational study on mortality and outcomes: decompressive craniectomy and brain death in traumatic brain injury, haemorrhage, and other cerebral diseases.

BACKGROUND: Decompressive hemicraniectomy (DHC) is used after severe brain damages with elevated, refractory intracranial pressure (ICP). In a non age-restricted population, mortality rates and long-term outcomes following DHC are still unclear. This study's objectives were to examine both, as well as to identify predictors of unfavourable outcomes. METHODS: We undertook a retrospective observational analysis of patients aged 18 years and older who underwent DHC at the University Hospital of Bonn between 2018 and 2020, due to traumatic brain injury (TBI), haemorrhage, tumours or infections. Patient outcomes were assessed by conducting telephone interviews, utilising questionnaires for modified Rankin Scale (mRS) and extended Glasgow Outcome scale (GOSE). We evaluated the health-related quality of life using the EuroQol (EQ-5D-5L) scale. RESULTS: A total of 144 patients with a median age of 58.5 years (range: 18 to 85 years) were evaluated. The mortality rate was 67%, with patients passing away at a median of 6.0 days (IQR [1.9-37.6]) after DHC. Favourable outcomes, as assessed by the mRS and GOSE were observed in 10.4% and 6.3% of patients, respectively. Cox regression analysis revealed a 2.0% increase in the mortality risk for every year of age (HR = 1.017; 95% CI [1.01-1.03]; p = 0.004). Uni- and bilateral fixed pupils were associated with a 1.72 (95% CI [1.03-2.87]; p = 0.037) and 3.97 (95% CI [2.44-6.46]; p < 0.001) times higher mortality risk, respectively. ROC-analysis demonstrated that age and pupillary reactivity predicted 6-month mortality with an AUC of 0.77 (95% CI [0.69-0.84]). The only parameter significantly associated with a better quality of life was younger age. CONCLUSIONS: Following DHC, mortality remains substantial, and favourable outcomes occur rarely. Particularly in elderly patients and in the presence of clinical signs of herniation, mortality rates are notably elevated. Hence, the indication for DHC should be set critically.

Improvement of a Model of Brain Death for Transplant-Associated Studies in Rats.

BACKGROUND: The most common method of inducing brain death in rats is inflating an intracranially placed balloon of a Fogarty catheter inserted through a burr hole. However, because of the poor controllability of balloon position, the standardization and stability of the model are compromised. This study examined an improved technique in which the balloon is placed and fixed through double holes. METHODS: Forty adult male Sprague-Dawley (SD) rats were randomly and equally assigned into the single-hole (SH) group and the double-hole (DH) group. In each rat in the DH group, 2 holes were made, at the left frontal bone and parietal bone. A Fogarty catheter was inserted outside of the dura mater through the frontal hole, and its tip was guided out through the parietal hole using an arc-shaped needle. The SH group served as a control. In both groups, normal saline was injected into the balloon at 40 µL/minute until breathing stopped. Mechanical ventilation was instituted immediately and provided for another 6 hours after the determination of brain death. RESULTS: Typical blood pressure patterns were observed in both groups during the brain death induction period, whereas the fluctuation seemed relatively mild in the DH group. Stable brain death with normotension for 6 hours was induced successfully in 18 rats (90%) in the DH group and in 9 rats (45%) in the SH group (P = .002). The mean arterial pressure at 3 hours and thereafter was significantly higher in the DH group compared to the SH group (P < .05). CONCLUSIONS: Our results demonstrate that the DH method is a simple and effective technique to make the brain death model more stable and standardized, possibly due to precise control of the direction of the cannulation and the position of the balloon.

Donation After Circulatory Death Heart Transplantation: A Narrative Review.

Heart transplantation is the definitive treatment for refractory, end-stage heart failure. The number of patients awaiting transplantation far exceeds available organs. In an effort to expand the donor pool, donation after circulatory death (DCD) heart transplantation has garnered renewed interest. Unlike donation after brain death, DCD donors do not meet the criteria for brain death and are dependent on life-sustaining therapies. Procurement can include a direct strategy or a normothermic regional perfusion, whereby there is restoration of perfusion to the organ before explantation. There are new developments in cold storage and ex vivo perfusion strategies. Since its inception, there has been a steady improvement in post-transplant outcomes, largely attributed to advancements in operative and procurement strategies. In this narrative review, the authors address the unique considerations of DCD heart transplantation, including withdrawal of care, the logistics of procuring and resuscitating organs, outcomes compared with standard donation after brain death, and ethical considerations.

Comparative Study of Acute Kidney Injury in Liver Transplantation: Donation after Circulatory Death versus Brain Death.

BACKGROUND Acute kidney injury (AKI) after orthotopic liver transplantation (OLT) contributes to morbidity and mortality. Donation after circulatory death (DCD) has been established to increase the pool of organs. While surgical complications are reported to be comparable in DCD and donation after brain death (DBD) OLT, there is a knowledge gap concerning adverse kidney events in these 2 groups. MATERIAL AND METHODS In this retrospective cohort study, 154 patients received a DBD and 68 received a DCD organ (2016-2020). The primary outcome was a major adverse kidney event within 30 days (MAKE-30). The secondary outcome was dynamics of AKI and kidney replacement therapy (KRT) during the first postoperative week and on postoperative day 30. Incidence and resolution from AKI and KRT and patient survival (PS) 30 days after OLT were compared between the DCD and DBD recipients. RESULTS MAKE-30 incidence after OLT was comparable in DCD (n=27, 40%) vs DBD (n=41, 27%) recipients (risk ratio 1.49 [95% CI 1.01, 2.21], p=0.073). AKI incidence was comparable in DCD (n=58, 94%) vs DBD (n=95, 82%) recipients (risk ratio 1.14 [95% CI: 1.03, 1.27], P=0.057). Overall, 40% (n=88) of patients required KRT, with no difference between DCD (n=27, 40%) vs DBD (n=61, 40%) recipients (risk ratio 1.00 [95% CI 0.71, 1.43], P>0.999). Resolution of AKI by day 30 was lower in DCD (n=29, 50%) than in DBD (n=66, 69%) recipients (risk ratio 0.71 [95% CI: 0.53, 0.95], P=0.032). Survival after 30 days (DCD: n=64, 94% vs DBD: n=146, 95%, risk ratio 0.99 [95% CI 0.93, 1.06], P>0.999) was also comparable. CONCLUSIONS MAKE-30, short-term renal outcome, and survival did not significantly differ between DBD and DCD-OLT. Resolution of AKI by day 30 was lower in DCD than in DBD recipients.

Evaluating the Effects of Time From Brain Death and Type of Inotrope Usage on Result of Heart Transplant: Results of 1-Year Follow-Up.

OBJECTIVES: Heart transplant is the most effective treatment in patients with advanced heart failure who are refractory to medical treatment. The brain death interval and type of inotrope We assessed the effects of these parameters on heart transplant outcomes. MATERIALS AND METHODS: In this follow-up study, we followed heart transplant recipients for 1 year to study patient survival, ejection fraction, adverse events, and organ rejection. We evaluated follow-up results on time from brainstem death test to the cross-clamp placement, as well as the type of inotrope used. RESULTS: Our study enrolled 54 heart transplant candidates. The inotrope dose was 3.66 ± 0.99 µg/kg/min, and the most used inotrope, with 28 cases (51.9%), was related to dopamine. Six cases (11.1%) of death and 1 case of infection after transplant were observed in recipients. The average ejection fraction of transplanted hearts before transplant, instantly at time of transplant, and 1 month, 6 months, and 1 year after transplant was 54.9 ± 0.68, 52.9 ± 10.4, 51.9 ± 10.7, 50.1 ± 10.9, and 46.8 ± 17, respectively; this decreasing trend over time was significant (P =.001). Furthermore, ejection fraction changes following transplant did not differ significantly in transplanted hearts regarding brain death interval and type of inotrope used. CONCLUSIONS: Our study revealed that cardiac output of a transplanted heart may decrease over time and the time elapsed from brain death, and both dopamine and norepinephrine could have negligible effects on cardiac function.

Opening a Donor Management Center.

ABSTRACT: In the United States alone, more than 100,000 people are waiting for a lifesaving organ transplant. In response to the growing need for viable organs to transplant, donor management centers have opened to provide care to brain-dead organ donors prior to the organ procurement operation. This article describes donor management center operations, details the opening of one such unit, and describes the results and lessons learned. More research is needed on the impact of nursing care on the specialized organ donor population.

Brain death: A review of the latest guidelines.

ABSTRACT: The incidence of brain death/death by neurologic criteria (BD/DNC) among all hospital deaths in the US is approximately 2.06% or 15,000-20,000 cases annually. This article reviews the latest guidelines for adult and pediatric BD/DNC. Although there have not been many changes to the guidelines over the years, BD/DNC guideline updates maintain consistency in determining BD/DNC.