Past, present, and future of donation after circulatory death in Italy

Abstract

Different strategies have been advocated to overcome the shortage of organs for transplantation. In addition to accepting extended criteria organs from donation after brain death (DBD) and promoting living donation, donation after circulatory death (DCD) is an option worth considering. This is confirmed by the policy of some European countries, such as the United Kingdom, where, in 2018, DCD reached a peak of 40% of all deceased donation [1, 2]. In Italy, the declaration of death based on circulatory criteria requires a no-touch period of at least 20 min, much longer compared to the 5 min accepted in other countries. Concerns about warm ischemia arising from this legal constraint have long discouraged the development of a DCD transplant program in Italy. A handful of DCD kidneys were recovered with the superrapid technique and transplanted, but this practice was soon abandoned after the enactment of brain death legislation. Nevertheless, in 2007, a pilot project on kidney transplants from uncontrolled DCD donors was initiated in Pavia using normothermic regional perfusion (NRP) between death declaration and organ recovery [3]. In 2014, Valenza et al. started a protocol to procure lungs from uncontrolled DCD that included donor maintenance on mechanical ventilation only and subsequent evaluation of the recovered lungs with ex vivo perfusion. Over 10 cases, only one underwent the full process and was transplanted, showing good graft function after a six-month follow-up [4]. One year later, the team of Niguarda Hospital performed the first successful DCD liver transplant in Italy from a donor maintained on NRP [5]. The same group implemented the initial protocol with the use of hypothermic oxygenated machine perfusion (HOPE) after NRP [6, 7]. Novel protocols including normothermic machine perfusion or the combined recovery of thoracic and abdominal organs during NRP are currently under development in Italy. Abdominal NRP relies on an extracorporeal circuit made up of a centrifugal pump and a membrane oxygenator. The donor’s femoral vessels are cannulated, and a Fogarty balloon is inflated in the supraceliac aorta to exclude the chest and avoid reperfusion of the brain. In Italy, percutaneous insertion of introducer sheaths is allowed pre-mortem to facilitate vessel cannulation, which is performed after death has been declared. In this way, NRP acts as a perfusion bridge between cardiac arrest and organ recovery, allowing the repletion of cellular energy stores after warm ischemia and an initial assessment of liver function [8, 9]. Moreover, different types of organ machine perfusion (MP), ranging from hypothermia to normothermia, have been recently introduced in clinical practice. The combined use of in situ and ex situ perfusion offers potential advantages of particular importance for DCD transplantation: organ reconditioning, viability testing and improved preservation times which favour transplant logistics [10]. The feasibility of DCD liver transplantation despite a no-touch period of 20 min has drawn renewed interest in the DCD practice in Italy. But was DCD just a one-day wonder or does it have a future in this country? To answer the question, two elements must be considered: the outcomes of transplants from DCD and the current trend in * Riccardo De Carlis [email protected]