Influence of donor capnometry on renal graft evolution in uncontrolled donation after circulatory death.

AIM: To analyse the association between donor capnometry data and the short-term evolution of kidney grafts in cases of uncontrolled donation after circulatory death (uDCD). METHOD: We used an ambispective observational study design, conducted in the Community of Madrid between January and December 2019, inclusive. Patients who suffered out-of-hospital cardiac arrest (CA) with no response to advanced cardiopulmonary resuscitation (CPR) were selected as potential donors. Donor capnometry levels were measured at the start, midpoint and transfer to hospital then compared with indicators of renal graft evolution. RESULTS: The initial selection included 34 possible donors, of which 12 (35.2%) were viable donors from whom 22 (32.3%) kidneys were recovered. There was a correlation between the highest capnometry values and less need for post-transplant dialysis (≥24 mmHg, p < 0.017), fewer dialysis sessions and fewer days to recover correct renal function (Rho -0.47, p < 0.044). There was a significant inverse correlation between the capnometry values at transfer and 1-month post-transplant creatinine levels (Rho -0.62, p < 0.033). There were no significant differences between the capnometry values at transfer and primary nonfunction (PNF) or warm ischaemia time. One-year patient survival was 100% for patient receiving organ donation, while graft survival was 95%. CONCLUSIONS: Capnometry levels at transfer are a useful predictor of the short-term function and viability of kidney transplants from uncontrolled donations after circulatory death.

Impact of different COVID-19 waves on kidney replacement therapy epidemiology and mortality: REMER 2020.

BACKGROUND: Kidney replacement therapy (KRT) confers the highest risk of death from coronavirus disease 2019 (COVID-19). However, most data refer to the early pandemic waves. Whole-year analysis compared with prior secular trends are scarce. METHODS: We present the 2020 REMER Madrid KRT registry, corresponding to the Spanish Region hardest hit by COVID-19. RESULTS: In 2020, KRT incidence decreased 12% versus 2019, while KRT prevalence decreased by 1.75% for the first time since records began and the number of kidney transplants (KTs) decreased by 16%. Mortality on KRT was 10.2% (34% higher than the mean for 2008-2019). The 2019-2020 increase in mortality was larger for KTs (+68%) than for haemodialysis (+24%) or peritoneal dialysis (+38%). The most common cause of death was infection [n = 419 (48% of deaths)], followed by cardiovascular [n = 200 (23%)]. Deaths from infection increased by 167% year over year and accounted for 95% of excess deaths in 2020 over 2019. COVID-19 was the most common cause of death (68% of infection deaths, 33% of total deaths). The bulk of COVID-19 deaths [209/285 (73%)] occurred during the first COVID-19 wave, which roughly accounted for the increased mortality in 2020. Being a KT recipient was an independent risk factor for COVID-19 death. CONCLUSIONS: COVID-19 negatively impacted the incidence and prevalence of KRT, but the increase in KRT deaths was localized to the first wave of the pandemic. The increased annual mortality argues against COVID-19 accelerating the death of patients with short life expectancy and the temporal pattern of COVID-19 mortality suggests that appropriate healthcare may improve outcomes.

Family Refusal to Consent Donation: Retrospective Quantitative Analysis of Its Increasing Tendency and the Associated Factors Over the Last Decade at a Spanish Hospital.

BACKGROUND: Organ and tissue recovery remains limited by several factors. This study retrospectively analyzes the factors associated with family refusal to consent to donation at a high-donor-volume Spanish hospital. METHODS: Data regarding the annual number of potential donors and family refusal rates at hospital and regional levels were retrieved from 2008 to 2017. Descriptive, bivariate, and multivariate analyses were performed to detect those factors independently associated with family refusal. Results were cross-validated using the data from years 2018 and 2019 as the validation group. To explore potential inter-relations between factors a Multiple Correspondence Analysis was performed. RESULTS: A total of 601 family interviews for petition of consent were conducted between 2008 and 2017, 531 (88.4%) resulted in acceptance and 70 (11.6%) resulted in refusal of the donation. Lesser experience of the interviewers (odds ratio [OR], 2.980; P = .001), donation after brain death (OR, 2.485; P = .013), number of interviews conducted per family (OR, 1.892; P < .001), age of the main decision maker (OR, 1.025; P = .045), and high or middle attributed cultural levels (OR, 0.142; P < .001 and OR, 0.199; P < .001 respectively) were observed to be independently associated with the family final decision. The logistic regression model displayed good predictive power for both derivation and validation cohorts, with an overall predictive accuracy of 80.9% (95% confidence interval, 0.747-0.870; P < .001) and 74.4% (95% confidence interval, 0.635-0.854; P = .001), respectively. CONCLUSIONS: Transplant coordination team members having a thorough knowledge of the family decision mechanisms may be a key factor in donation process optimization.

Transplantation of a heart donated after circulatory death via thoraco-abdominal normothermic regional perfusion and results from the first Spanish case.

BACKGROUND: Controlled donation after circulatory death (cDCD) has emerged as one of the main strategies for increasing the organ donor pool. Because of the ischemic injury that follows the withdrawal of life-sustaining therapies, hearts from cDCD donors have not been considered for transplantation until recently. The ex-situ perfusion of hearts directly procured from cDCD donors has been used to allow the continuous perfusion of the organ and the assessment of myocardial viability prior to transplantation. Based on our experience with abdominal normothermic regional perfusion in cDCD, we designed a protocol to recover and validate hearts from cDCD donors using thoraco-abdominal normothermic regional perfusion without the utilization of an ex-situ device. CASE PRESENTATION: We describe the first case of a cDCD heart transplant performed with this approach in Spain. The donor was a 43-year-old asthmatic female diagnosed with severe hypoxic encephalopathy. She was considered a potential cDCD donor and a suitable candidate for multiorgan procurement including the heart via thoraco-abdominal normothermic regional perfusion. The heart recipient was a 60-year-old male diagnosed with amyloid cardiomyopathy. Cold ischemia time was 55 min. The surgery was uneventful. CONCLUSIONS: This case report, the first of its kind in Spain, supports the feasibility of evaluating and successfully transplanting cDCD hearts without the need for ex-situ perfusion based on the use of thoraco-abdominal normothermic regional perfusion opening the way for multiorgan donation in cDCD.

Implementation of a mobile team to provide normothermic regional perfusion in controlled donation after circulatory death: Pilot study and first results.

Normothermic regional perfusion (NRP) in controlled donation after circulatory death is becoming a popular method due to the favorable results of the grafts procured under this technique. This procedure requires experience, and, sometimes, the availability of extracorporeal membrane oxygenation (ECMO) machines to implement NRP is limited to tertiary hospitals. In order to provide support with NRP in controlled donation after circulatory death across the different hospitals of the Autonomous Community of Madrid, a mobile NRP team was created. In the first 18 months since its creation, the mobile NRP team participated in 33 procurements across nine different hospitals, representing 72% of all controlled donations after circulatory death in the Autonomous Community of Madrid. NRP was successfully performed in 29 (88%) cases, with a mean duration of 69 ± 27 minutes. A total of 39 kidneys, 12 livers, and 5 bilateral lungs were recovered and transplanted. None of the livers were discarded due to an elevation in transaminases during NRP. A mobile NRP team is a feasible option and, in our series, aided in the optimization and recovery of organs from donors after controlled circulatory death in centers where ECMO technology was not available.

[Factors affecting the survival of transplants from donors after prehospital cardiac death]. / Factores que influyen en la evolución de los injertos de donantes tras muerte cardiaca extrahospitalaria.

OBJECTIVES: To evaluate factors that influence the survival of transplanted organs from donors after prehospital cardiac death. MATERIAL AND METHODS: Retrospective observational study of data collected from hospital emergency service records. Information included prehospital cardiac deaths evaluated as donors as well as patients who received transplants. RESULTS: Two hundred cases from 2008 through 2011 were studied. Sixty-nine potential donors (34.5%) were rejected. Three hundred organs were extracted from the remaining 131 donor cases, to yield a mean (SD) of 2.32 (0.83) transplanted organs/donor or 1.52 (1.29) organs/potential donor. One hundred fifty-two potential donors (76%) were treated with mechanical cardiopumps during transport. We detected no significant differences between cases transported with manual chest compressions and cases treated with cardiopumps regarding age (40.1 vs 43.5 years, P=.06), responder arrival times (13 min 54 s vs 12 min 54 s, P=.45), or transport times (1 h 27 min vs 1 h 32 min). However, case transported with manual chest compressions yielded significantly more kidneys (mean, 1.96/potential donor) than those transported with cardiopump compressions (mean, 1.38/potential donor) (P=.008). Eleven of the 229 kidneys harvested (4%) were not transplanted. The median (interquartile range) serum creatinine concentrations after kidney transplants at 6 and 12 months, respectively, were 1.37 (1.10-1.58) mg/dL and 1.43 (1.11-1.80) mg/dL. CONCLUSION: Our findings suggest that the use of a cardiopump reduces donor recruitment. Long-term creatinine levels are similar after transplantation of kidneys from donors transported with a cardiopump or with manual compressions.

OBJETIVO: Valorar los factores extrahospitalarios que pueden influir en la viabilidad de los injertos en los receptores. METODO: Estudio observacional retrospectivo que recoge datos de los registros del sistema de emergencias (pacientes con muerte cardiaca extrahospitalaria que fueron trasladados al hospital para valorar) y del hospital (pacientes trasplantados) de aquellos pacientes con muerte cardiaca extrahospitalaria que fueron trasladados al hospital para valorar. RESULTADOS: Se recogen 200 casos entre los años 2008 y 2011, de los que 69 (34,5%) no fueron donantes. De los 131 donantes utilizados se extrajeron 300 órganos [media de 2,32 (DE 0,83) órganos/donante utilizado y 1,52 (DE 1,29) órganos/donante potencial]. De los 200 pacientes, 152 fueron trasladados bajo cardiocompresión mecánica (76%). No hay diferencia significativa en edad (40,1 frente a 43,5 años, p = 0,06) y tiempo de llegada (13' 54' ' frente a 12' 54' ' , p = 0,45) y tiempo de trasferencia (1 h y 27' frente a 1 h y 32') entre el grupo de pacientes trasladados con cardiocompresión manual y con cardiocompresión mecánica, pero si en la media de órganos por donante potencial en favor de la cardiocompresión manual (1,96 frente a 1,38, p = 0,008). De los 229 riñones extraídos, no se trasplantaron 11 (4%). La mediana de la creatinina a los 6 meses de los riñones fue de 1,37 mg/dl (RIC: 1,10-1,58) y a los 12 meses de 1,43 mg/dl (RIC: 1,11-1,80), sin diferencias entre ambos grupos. CONCLUSIONES: Nuestros datos sugieren que el uso de compresores mecánicos disminuye el reclutamiento de donantes. A largo plazo la concentración de creatinina en los riñones trasplantados es similar independientemente del tipo de compresión usada durante el traslado y ninguna variable extrahospitalaria predice la evolución de los injertos.

Lung transplant of extrahospitalary donor after cardiac death.

Non-heart-beating donors (NHBDs) have to meet the predefined criteria for organ donation including death from irreversible cessation of the beating heart. The Maastricht conference defined 4 NHBD categories to differentiate their viability and ethical-legal support. In Spain, NHBDs who originate from an out-of-hospital setting correspond to type II donors. These are patients who have had a cardiac arrest outside hospital and, after failed CPR attempts, are transferred with hemodynamic support measures to the hospital for organ donation. The Hospital Clínico San Carlos also has a lung donation program in collaboration with the Hospital Puerta de Hierro in Madrid and the Hospital Marques de Valdecilla in Santander. The objective of this study is to describe the results of lung transplantation of after cardiac death program, specifically the section regarding lung extraction donation. Twenty potential lung donors were obtained during the study. Most patients were male (19 cases), with a mean age of 42 years (36.5-49.5 years). A total of 33 lungs were donated (18 right and 15 left lungs). Most extractions were multiorganic (19 cases). One liver, 19 kidneys, 2 pancreas, and 19 corneas were obtained from these donors; bone tissue was obtained from all donors. The transplantation was bipulmonary in 13 cases and unipulmonary in 7. Thirty days after transplantation, 2 recipients died, 1 died of stroke associated with bilateral pneumonia and 1 died of hypovolemic shock resulting from hemothorax. The remaining 18 patients were progressing well at 30 days. Our data suggest that lung transplantation from patients after extrahospitalary cardiac death is feasible.

Out-hospital donors after cardiac death in Madrid, Spain: a 5-year review.

OBJECTIVE: The Medical Emergencies Service of Madrid (Spain) (Servicio de Urgencias Medicas de Madrid), SUMMA112, forms part of an organ donor program involving patients who have suffered out-hospital cardiac arrest and fail to respond to advanced cardiopulmonary resuscitation maneuvers. Subjects meeting the inclusion criteria are moved to a transplant unit under sustained resuscitation maneuvering in order to harvest the organs. This paper presents compliance with the timelines of the program, the proportion of donors, the characteristics of donors and non-donors, and the number of organs obtained. MATERIAL: A retrospective descriptive study was made based on the review of case histories. The SPSS(©) version 16.0 statistical package was used for data analysis. RESULTS: A total of 214 cases were recorded, of which 84% were males. The mean age was 40 years. The mean time to arrival on scene was 13 min and 34 s. The mean time to arrival in hospital was 88 min and 10 s. A total of 522 organs and tissues were harvested (250 kidneys, 33 livers, 123 corneas, 97 bone tissues and 19 lungs), corresponding to 3.2 organs/tissues per patient on average. A total of 21.7% of the patients were not valid. There were no differences between the valid and non-valid patients in terms of age and gender. The causes of non-donation included extracorporeal circuit failure (6.3%), family refusal (15.6%), patient refusal expressed in life (4.7%), legal denial (1.6%), biological causes (51.6%), and others (20.3%). Cardiac compressors were used in 85 cases, yielding 92 kidneys, 41 corneas, 30 bone tissues, 19 livers and 9 lungs, corresponding to 2.1 organs/tissues per patient on average. CONCLUSION: This program affords a very important number of organs for transplantation. Further studies are needed to assess the efficacy of mechanical cardiac compressor use in generating more organs.

[Organ preservation]. / Preservación de órganos.

Maintaining organ viability from extraction to transplantation is crucial to ensure the function and survival of the graft. In recent years, maintaining organ viability has become more challenging because the shortage of donors has led to broader criteria for donor acceptability and consequently to organs with greater compromise. Organ damage occurs primarily as a result of ischemia-reperfusion injury, which is associated to additional damage from the preservation process. To minimize this damage, different techniques of organ preservation are used with the aim of optimizing organ function once perfusion is restored. Static cold storage is the most commonly used method of preservation because it is extremely simple, nearly universally available, and easy to transport. However, static cold storage may be unable to prevent the deterioration of the quality of organs from donors included under the broader criteria. In this article, we describe current preservation techniques; we place special emphasis on continuous machine perfusion.