Using IV-Tubing "Bridge" from Splenic Artery to Superior Mesentery Artery to Create a Single Arterial Cannulation for Normothermic Machine Perfusion When Donor Liver Has Replaced Right Hepatic Artery.

BACKGROUND The presence of anatomical variations of the hepatic artery poses a challenge for normothermic machine perfusion (NMP). Here, we describe our experience of creating a single arterial cannulation for NMP in 3 donor livers with replaced right hepatic artery. CASE REPORT Three donor livers with replaced right hepatic artery were perfused using NMP (OrganOx® metra®) for liver transplantation. To maintain hepatic artery integrity and establish an intact arterial vascular inflow for NMP, a single vasculature was created to allow single arterial cannulation for NMP. A piece of intravenous-line tubing was used as a bridge from the splenic artery to the superior mesenteric artery during the back-table preparation. After 1 h of NMP, the lactate of 2 livers decreased from >10.0 to about 1.0 mmol/L, and the lactate of 1 liver decreased from >4.0 to <0.4 mmol/L. Three livers made >100 mL of bile after 4 h of NMP and were successfully implanted after >10 h of NMP. The recipients spent 2, 3, and 4 days in the Intensive Care Unit and were discharged home at 6, 7, and 9 days, respectively. None of the patients experienced early allograft dysfunction or any early technical complication or non-anastomotic biliary stricture. CONCLUSIONS Creating an intravenous-line tubing bridge from the splenic artery to the superior mesenteric artery prior to NMP of liver grafts associated with replaced right hepatic artery could reduce the cold ischemia time associated with vessel reconstruction and reduce bleeding risk during NMP. This is feasible, safe, and effective.

Neonatal Organ and Tissue Donation for Research: Options Following Death by Natural Causes.

The donation of organs and tissues from neonates (birth to 28 days) for transplantation has been a relatively infrequent occurrence. Less common has been the use of neonatal organs and tissues for research. Specific ethical and legal questions beg for rational and transparent guidelines with which to evaluate referrals of potential donors. Donation of organs and tissues from a neonate can play a key role in the care and support provided to families by health care professionals around the time of a neonate's death. We report on the recovery of neonatal organs and tissues for research. A working group made up of bioethicists, neonatologists, lawyers, obstetric practioners as well as organ procurement and tissue banking professionals evaluated legal, ethical and medical issues. Neonatal donor family members were also consulted. Our primary goals were (a) to ensure that referrals were made in compliance with all applicable federal and state laws, regulations and institutional protocols, and (b) to follow acceptable ethical standards. Algorithms and policies designed to assist in the evaluation of potential neonatal donors were developed. Neonatal donation is proving increasingly valuable for research into areas including diabetes, pulmonary, gastrointestinal, genitourinary and neurological development, rheumatoid arthritis, autism, childhood psychiatric and neurologic disorders, treatment of MRSA infection and pediatric emergency resuscitation. The development of policies and procedures will assist medical professionals who wish to offer the option of donation to family members anticipating the death of a neonate.

Envisioning and Leading Organizational Transformation: One Organ Procurement Organization's Journey.

BACKGROUND:  In 2012, one organ procurement organization (OPO) welcomed a new President and Chief Executive Officer (CEO). This OPO, LifeShare Transplant Donor Services of Oklahoma (LifeShare), had just celebrated its 25th anniversary in 2011. While LifeShare was well-established chronologically, growth in organ donors and organs transplanted from these donors had occurred at a much slower rate during the collaborative era and afterward (2003-2011) than the donor/transplant growth the United States (US), as a whole, had experienced. While this performance had been stable, it was in the lower quartile of US OPOs on a per capita basis (organs transplanted per donor), and conversion rates were unremarkable. It was the sense of the OPO and donation service area (DSA) constituents that there was an opportunity for growth. It was under this premise that the new CEO was recruited in late 2011 and assumed leadership in February 2012. METHOD:  It important to note that the new CEO (the author) found LifeShare possessed numerous significant assets upon which to build. These included a strong core of committed and dedicated staff, a supportive Board, supportive transplant centers, and a strong state donor registry. Therefore, it was apparent that, while achieving the DSA's potential would require a transformation of the organization, the transformation did not necessarily require replacing core staff, often a common step undertaken by new chief executives. Beginning in 2012, the CEO sought to transform both the culture and the operation of the organization by focusing on a short list of key strategies. Culturally, three primary initiatives were undertaken: leadership development, staff development, and establishing "organizational clarity". Operationally, the primary focus was identifying organ donor potential and then, based upon the opportunities for improvement, focusing on operational policies and practices. As LifeShare's team began to identify pockets of unrealized potential donors, recognized best practices were deployed to areas of opportunity, including responding to all vented referrals, implementation of dedicated family requestors, broadening of already-existing in-house coordinator programs, and aggressive expansion of the donors after cardiac death (DCD) program. RESULTS: From 2008 through 2011, the four years prior to the organization beginning its change journey, LifeShare recovered 344 organ donors from which 1,007 organs were transplanted in 48 months. During the first 48 months of the change journey (2012 through 2015), 498 organ donors (+44.8%) provided 1,536 organs transplanted (+52.5%). DCD donors increased from 22 to 91 (+413.4%) and brain death (BD) donors from 322 to 407 (+26.4%). While the rate of growth is slowing somewhat, the first eight months of 2016 continue to show a percentage growth over 2015 in double digits for both organ donors and organs transplanted. DISCUSSION: Clearly, our results have been transformed and continue to be transformed. A cultural foundation for both leadership and staff, combined with a single-minded focus on maximizing recovery of potential organ donors and maximizing transplantation of every potential organ, has allowed us to achieve exceptional growth rates on a scale that has resulted in more than 500 additional organs transplanted and lives saved over the last four years when compared to pre-change results.

The clinical relevance of Organ Procurement and Transplantation Network screening criteria for program performance review in the United States.

The Organ Procurement and Transplantation Network is charged with overseeing the quality of transplant programs in the United States. However, there has been controversy over whether too many programs are being identified as underperforming. It has also been suggested that dramatic improvements in outcomes throughout the United States have made the thresholds for determining which deceased donor transplant programs are underperforming no longer clinically relevant. The Scientific Registry of Transplant Recipients compared actual and expected 1-y graft survival for transplant programs identified as underperforming in the most recent cohort (transplants from July 1, 2012 to December 31, 2014). For most organs, actual 1-y graft survival was substantially lower for programs identified as underperforming than for programs identified as performing as expected. Differences were smallest for kidney programs: median 1-y graft survival 89.2% vs 95.4% in large-volume programs identified and not identified for Membership and Professional Standards Committee review, respectively. Median expected graft survival was only slightly lower (94.8% vs 95.1%, respectively), suggesting that identified and not identified programs tend to have similar risk tolerances. An excess of 143 grafts were lost from kidney programs identified as underperforming. Transplant programs identified as underperforming generally have reduced 1-y graft survival that stakeholders may consider clinically relevant.

"Every organ, every time" attitude teamed up with SoftMD results in successful lung transplant from a 72-year-old donor.

Since 1998, lung transplants have increased almost 75%, making lung transplant the fastest growing form of organ transplant in the United States. However, the supply of transplantable lungs continues to fall short of the demand. Strategies for expanding the lung donor pool by increasing the number of older donor lungs used has been effective, although these donors do not meet typical clinical selection criteria based on age. In these older donors, effective communication of in-depth donor information is necessary to place and transplant lungs successfully. The following case study illustrates how an "every organ, every time" attitude combined with a technique to communicate clinical information resulted in the successful transplant of 72-year-old donor lungs into a bilateral lung recipient. Since the case outlined in this study, the organ procurement organization has successfully recovered and transplanted an additional 2 lungs from a 74-year-old and 1 lung from a 76-year-old, 2 of the oldest lung donors in the United States. This case demonstrates that although many older donor lungs are deemed unsuitable by clinical selection criteria, an extended criteria population offers an untapped resource for donor organs.

Zero risk tolerance costs lives: loss of transplantable organs due to human immunodeficiency virus nucleic acid testing of potential donors.

Patients' deaths due to the organ donor shortage make it imperative that every suitable organ be transplanted. False-positive results of tests for infection with the human immunodeficiency virus (HIV) result in lost organs. A survey of US organ procurement organizations collected the numbers of donors and ruled-out potential donors who had a positive result on an HIV test from January 1,2006, to October 31, 2008. Sixty-two percent of US organ procurement organizations participated. Of the 12397 donor/nondonor cases, 56 (0.45%) had an initial positive result on an HIV antibody or HIV nucleic acid test, and only 8 (14.3%) of those were confirmed positive. Of the false-positive results, 50% were from HIV antibody tests and 50% were from HIV nucleic acid tests. Organs are a scarce, finite, and perishable resource. Use of HIV antibody testing has produced a remarkably safe track record of avoiding HIV transmission, with 22 years of nonoccurrence between transmissions. Because false positives occur with any test, including the HIV Ab test, adding nucleic acid testing to the standard donor testing panel doubles the number of false-positive HIV test results and thus the number of medically suitable donors lost. The required HIV antibody test is 99.99% effective in preventing transmission of the HIV virus. Adding the HIV nucleic acid test to routine organ donor screening could result in as many as 761 to 1551 unnecessary deaths of patients between HIV transmission events because medically suitable organs are wasted.