Effects of Share 35 Policy on Liver Transplantation Outcomes for Patients With Nonalcoholic Steatohepatitis.

BACKGROUND: To examine the temporal variation and outcomes of liver transplantation between pre- and post-Share 35 eras for patients with nonalcoholic steatohepatitis. METHODS: A retrospective analysis was performed among 4380 patients with end-stage liver disease from the United Network for Organ Sharing database from 2009 to 2017 due to primary diagnosis of nonalcoholic steatohepatitis or cryptogenic cirrhosis with body mass index greater than 30. Cox regressions were used to model the effect of Share 35 policy on patient and graft survival comparing the first 3 years of Share 35 policy to an equivalent time period before. RESULTS: The number of nonalcoholic steatohepatitis-related transplants increased from 232 (14.1%) in 2009 to 266 (20.5%) in 2017. In post-Share 35 era, average waitlist time and cold ischemic time decreased, while Model for End-Stage Liver Disease (MELD) scores increased with higher proportion of recipients having MELD ≥35. No significant difference in average length of hospitalization or survival was found after Share 35. CONCLUSIONS: The Share 35 policy benefits patients with nonalcoholic steatohepatitis from reduced liver transplantation waiting time. It is also associated with comparable outcomes in 2 eras without increasing cold ischemic time or posttransplant length of hospitalization.

Robot-assisted Kidney Transplantation with Regional Hypothermia Using Grafts with Multiple Vessels After Extracorporeal Vascular Reconstruction: Results from the European Association of Urology Robotic Urology Section Working Group.

BACKGROUND: Kidney transplantation using grafts with multiple vessels (GMVs) is technically demanding and may be associated with increased risk of complications or suboptimal graft function. To date, no studies have reported on robot-assisted kidney transplantation (RAKT) using GMVs. OBJECTIVE: To report our experience with RAKT using GMVs from living donors, focusing on technical feasibility and early postoperative outcomes. DESIGN, SETTING, AND PARTICIPANTS: We reviewed the multi-institutional, prospectively collected European Association of Urology (EAU) Robotic Urology Section (ERUS)-RAKT database to select consecutive patients undergoing RAKT from living donors using GMVs between July 2015 and January 2018. Patients undergoing RAKT using grafts with single vessels (GSVs) served as controls. In case of GMVs, ex vivo vascular reconstruction techniques were performed during bench surgery according to the case-specific anatomy. INTERVENTION: RAKT with regional hypothermia. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Intraoperative outcomes and early (30 d) postoperative complications and functional results were the main study endpoints. Multivariable logistic regression analysis evaluated potential predictors of suboptimal renal function at 1 mo. RESULTS AND LIMITATIONS: Overall, 148 RAKTs were performed during the study period. Of these, 21/148 (14.2%) used GMVs; in all cases, single arterial and venous anastomoses could be performed after vascular reconstruction. Median anastomoses and rewarming times did not differ significantly between the GMV and GSV groups. Total and cold ischemia times were significantly higher in the GMV cohort (112 vs 88min, p=0.004 and 50 vs 34min, p=0.003, respectively). Overall complication rate and early functional outcomes were similar among the two groups. No major intra- or postoperative complications were recorded in the GMV cohort. At multivariable analysis, use of GMVs was not significantly associated with suboptimal renal function at 1 mo. Small sample size and short follow-up represent the main study limitations. CONCLUSIONS: RAKT using GMVs from living donors is technically feasible and achieved favorable perioperative and short-term functional outcomes. Larger studies with longer follow-up are needed to confirm our findings. PATIENT SUMMARY: In this study, we evaluated for the first time in literature the results of RAKT from living donors using kidneys with multiple arteries and veins. We found that, in experienced centers, RAKT using kidneys with multiple vessels is feasible and achieves optimal results in terms of postoperative kidney function with a low number of postoperative complications.

The effect of the Statewide Sharing variance on geographic disparity in kidney transplantation in the United States.

BACKGROUND AND OBJECTIVES: The Statewide Sharing variance to the national kidney allocation policy allocates kidneys not used within the procuring donor service area (DSA), first within the state, before the kidneys are offered regionally and nationally. Tennessee and Florida implemented this variance. Known geographic differences exist between the 58 DSAs, in direct violation of the Final Rule stipulated by the US Department of Health and Human Services. This study examined the effect of Statewide Sharing on geographic allocation disparity over time between DSAs within Tennessee and Florida and compared them with geographic disparity between the DSAs within a state for all states with more than one DSA (California, New York, North Carolina, Ohio, Pennsylvania, Texas, and Wisconsin). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A retrospective analysis from 1987 to 2009 was conducted using Organ Procurement and Transplant Network data. Five previously used indicators for geographic allocation disparity were applied: deceased-donor kidney transplant rates, waiting time to transplantation, cumulative dialysis time at transplantation, 5-year graft survival, and cold ischemic time. RESULTS: Transplant rates, waiting time, dialysis time, and graft survival varied greatly between deceased-donor kidney recipients in DSAs in all states in 1987. After implementation of Statewide Sharing in 1992, disparity indicators decreased by 41%, 36%, 31%, and 9%, respectively, in Tennessee and by 28%, 62%, 34%, and 19%, respectively in Florida, such that the geographic allocation disparity in Tennessee and Florida almost completely disappeared. Statewide kidney allocations incurred 7.5 and 5 fewer hours of cold ischemic time in Tennessee and Florida, respectively. Geographic disparity between DSAs in all the other states worsened or improved to a lesser degree. CONCLUSIONS: As sweeping changes to the kidney allocation system are being discussed to alleviate geographic disparity--changes that are untested run the risk of unintended consequences--more limited changes, such as Statewide Sharing, should be further studied and considered.

Independent organ donor facilities: The future of organ donation?

Since 2001 independent Organ Donor Facilities(OFOs) have been proposed within Organ Procurement Organizations (OPOs) with the aim of reducing organ procurement costs 1, cold ischemia time of donor organs and the flight-related risk 2 for donor surgeons, perfusionists and coordinators. An independent OFO has been established in 2001 in St. Louis 3, half away between the 2 Transplant Centers (TCs) (Washington University School of Medicine and St. Louis University) and now includes a two-bed intensive care facility, a complete laboratory, a cardiac catheterization facility, a Computed Tomography (CT) scanner and an operating room. All brain-dead (BD) patients within OPO (Mid-America Transplant Services), after family's informed consent, are transferred, if necessary by an OPO owned and operated airplane, to this facility, where undergo multiorgan harvesting. By doing so the organ acquisition charges (OACs) apparently decreased, as well as delay in recovery, which can affect organ viability and move families to withdraw consent; also risks and tiring of transplant surgeons were reduced. This independent OFO successfully procured in 2001 not only livers, but also pancreas, kidneys, hearts and lungs 4-6. Cold ischemia time was reduced and there was no Primary Non Function (PNF) of harvested organs, but only kidney delayed graft function (DGF). In the past, heart donors were moved to the recipient's hospital. With the development of multiorgan harvesting, usually donor surgeons are sent by the TCs in order to evaluate liver, pancreas, heart and lungs, while the only local surgeons is the "nephrectomist", that in local hospital is not a transplant surgeon. To move a donor, although hemodinamically stable, is always a risk. Finally, the decrease of OAC must balance the extra expenses to create and operate independent OFOs. In all the papers published by the members of this OFO, the control group of the retrospective analysis consisted of less selected BD donors, requiring more vasosuppressor support, which can be a study bias. It has been proposed that OPOs should organize "recovery teams" for multiple TCs but most transplant surgeons, in case of marginal donors, would like to inspect the organ prior to starting recipient surgery or would send their own team to harvest organs. According to literature, there are no other independent OFOs in US, probably because there is no need for them, and increasing their numbers would not increase organ donation rate. Considering Europe, we do not have information about the existence of independent OFOs: this may be a consequence of logistical organization and minor distances, as well as the higher concentration of TCs. However, the acceptance of such a procedure from donors' families may be less enthusiastic in Europe than in USA, particularly from minorities. In Italy would not be acceptable that the maintenance of BD donors and more generally the operation of independent OFO would rely on non-physicians, to save costs. Finally it is not clear from the reviewed papers who pay for transportation of the donor's body from the independent OFO back to home, but donor's family should not be charged for these expenses. At least 5 donors were lost during transportation, confirming that moving of BD donors remains a risky procedure. The potential economical and organizative benefits of independent OFOs could be counterweighted by the perceived (by relatives and public opinion) commodification/ reification of BD patients. Anyway, the authors of these papers should be congratulated for their innovative proposal. However, a prospective randomized trial would be needed to draw more definitive conclusions on the real benefits of independent OFOs.

Thoracic organs: current preservation technology and future prospects; part 1: lung.

PURPOSE OF REVIEW: The critical organ shortage has forced lung transplant teams to extend their donor criteria, thereby compromising a good early outcome in the recipient. Better preservation solutions for longer storage are welcomed to further reduce incidence of primary graft dysfunction. New ex-vivo techniques to assess and to condition lungs prior to transplantation are hoped to increase the number of available pulmonary grafts. RECENT FINDINGS: Although no prospective clinical trial has been carried out so far, clinical and experimental evidence suggest that an extracellular solution is currently the preservation fluid of choice for lung transplantation. The combination of an antegrade and retrograde pulmonary flush and technique to control reperfusion and ventilation are becoming common practice, although the evidence to support this method is low. Ex-vivo lung perfusion to assess and to recondition lungs has been demonstrated to be well tolerated and effective in small clinical series. SUMMARY: New extracellular preservation solutions have contributed in decreasing the incidence of primary graft dysfunction over the last decade leaving more room to extend the donor criteria and ischemic time. Ex-vivo lung perfusion is now on the horizon as a potential method to prolong the preservation time and to resuscitate lungs of inferior quality.

Current preservation technology and future prospects of thoracic organs. Part 2: heart.

PURPOSE OF REVIEW: The problem of organ shortage continuously emphasizes the importance of proper donor management and selection, organ preservation and recipient selection and treatment. This review summarizes state of the art of cardiac allograft preservation with special regard to recent clinical and experimental findings. RECENT FINDINGS: Over the past years no major strategy changes have found their way to the clinical setting of cardiac allograft preservation. Static, antegrade, cold, crystalloid flush perfusion is still the commonly used technique to preserve the heart. The importance of electrolyte composition, substrates and ischemia/reperfusion injury inhibiting additives are discussed with special attention to recent findings. Machine perfusion during preservation has regained attention over recent years and has led to the first clinical safety and feasibility trials in Europe and the USA. SUMMARY: No major changes were introduced in the technique of heart preservation over the past years. Many new ideas based upon experimental data were postulated but still have to find their way to the clinical setting.There is a renewed interest in mechanical perfusion. Everyone is curiously awaiting the first clinical reports.

Machine perfusion of the liver: past, present and future.

PURPOSE OF REVIEW: This review considers the potential of machine perfusion to preserve livers for clinical transplantation, including steatotic or ischaemically damaged grafts and aims to go over the most significant achievements in liver machine perfusion over the last year. To reach acceptance in liver preservation, machine perfusion will need to improve outcomes compared with simple cold storage (SCS), provide objective measures of graft viability, and resuscitate less-than-ideal grafts before transplantation. RECENT FINDINGS: Current machine perfusion protocols comprise both hypothermic (HMP) and normothermic (NMP) approaches. HMP increases energy stores compared to SCS, and NMP shows additional resuscitative potential. Dutkowski transplanted ischaemically damaged pig livers after HMP following SCS, which avoided graft failure observed after SCS alone. Guarrera performed 20 clinical transplants after 4-7 h HMP. Friend has performed porcine transplantations after NMP of 4-20 h and univocally demonstrated the significant resuscitative effects on ischaemically damaged grafts otherwise destined to fail. Whereas NMP promises resuscitative effects, it demands challenging, near-physiologic conditions. Subnormothermic perfusion is being tested as a promising medium in between. SUMMARY: Despite recent substantial improvements, liver preservation by machine perfusion remains limited and in contrast to the global revival of kidney machine perfusion. However, liver machine perfusion may be close to returning to clinical practice if it has not already done so. History shows that superiority alone does not guarantee immediate clinical use. Further clear-cut benefits of machine perfusion such as viability assessment will have to be accompanied by usability and human factors, and innovative and improved perfusion solutions applied in novel perfusion protocols.

Organ transplantation in Switzerland: impact of the new transplant law on cold ischaemia time and organ transports.

BACKGROUND: On 1 July 2007 a new transplant law came into force in Switzerland. The principal item of this new law is the change from centre-oriented allocation to patient-oriented national allocation of organs. The aim of the present study is to assess the impact on cold ischaemia time (CIT) and transport requirements. METHODS: From 1 July 2006 to 30 June 2008 168 brain-dead donors were registered by Swisstransplant in Switzerland. Donors have been analysed in a retrospective cohort study design. Donor characteristics, transportation requirements and CIT were assessed from the Necroreport. RESULTS: 74 donors (44%) were allocated in the period before the introduction of the new law (period A) and 94 donors (56%) after the new law. Donor characteristics were similar. In period A, 114 organs (37.9%) were allocated within the procurement centre, compared to 54 organs (15.5%) in period B. Transport time for liver and kidney was remarkably longer in period B. Overall, CITs remained largely stable except for a significant increase of nearly 115 minutes in the liver graft median CIT (p <0.01). CONCLUSIONS: The new Swiss transplant law clearly entails an increase in the frequency of organ transports. Overall CIT is not affected. However, liver transplantation is afflicted by an increase in transports and CIT. This may affect mid-term outcome and should therefore be followed closely.