A. De Roover

Organ Procurement After Euthanasia: Belgian Experience

Euthanasia was legalized in Belgium in 2002 for adults under strict conditions. The patient must be in a medically futile condition and of constant and unbearable physical or mental suffering that cannot be alleviated, resulting from a serious and incurable disorder caused by illness or accident. Between 2005 and 2007, 4 patients (3 in Antwerp and 1 in Liège) expressed their will for organ donation after their request for euthanasia was granted. Patients were aged 43 to 50 years and had a debilitating neurologic disease, either after severe cerebrovascular accident or primary progressive multiple sclerosis. Ethical boards requested complete written scenario with informed consent of donor and relatives, clear separation between euthanasia and organ procurement procedure, and all procedures to be performed by senior staff members and nursing staff on a voluntary basis. The euthanasia procedure was performed by three independent physicians in the operating room. After clinical diagnosis of cardiac death, organ procurement was performed by femoral vessel cannulation or quick laparotomy. In 2 patients, the liver, both kidneys, and pancreatic islets (one case) were procured and transplanted; in the other 2 patients, there was additional lung procurement and transplantation. Transplant centers were informed of the nature of the case and the elements of organ procurement. There was primary function of all organs. The involved physicians and transplant teams had the well-discussed opinion that this strong request for organ donation after euthanasia could not be waived. A clear separation between the euthanasia request, the euthanasia procedure, and the organ procurement procedure is necessary.

Results of Kidney Transplantation From Donors After Cardiac Death

Confronting the organ donor shortage, many transplant centers around the world increasingly use donors after cardiac death (DCD). Over the past 20 years, follow-up studies in kidney recipients comparing DCD and donors after brain death (DBD) have shown comparable long-term graft function and survival. As a consequence, DCD programs should be continued and expanded, for these donors constitute a potential solution to the imbalance between the numbers of end-stage kidney disease patients on waiting lists versus available kidney grafts. DCD kidneys do not necessarily signify suboptimal grafts; they may merit to be allocated the same as DBD grafts.

Categories of Donation After Cardiocirculatory Death

The interest in donation after cardiocirculatory death (DCD) was renewed in the early 1990s, as a means to partially overcome the shortage of donations after brain death. In some European countries and in the United States, DCD has become an increasingly frequent procedure over the last decade. To improve the results of DCD transplantation, it is important to compare practices, experiences, and results of various teams involved in this field. It is therefore crucial to accurately define the different types of DCD. However, in the literature, various DCD terminologies and classifications have been used, rendering it difficult to compare reported experiences. The authors have presented herein an overview of the various DCD descriptions in the literature, and have proposed an adapted DCD classification to better define the DCD processes, seeking to provide a better tool to compare the results of published reports and to improve current practices. This modified classification may be modified in the future according to ongoing experiences in this field.

Liver transplant donation after cardiac death : experience at the University of Liège

OBJECTIVE Donation after cardiac death (DCD) has been proposed to overcome in part the organ donor shortage. In liver transplantation, the additional warm ischemia time associated with DCD procurement may promote higher rates of primary nonfunction and ischemic biliary lesions. We reviewed the results of liver transplantation from DCD. PATIENTS AND METHODS From 2003 to 2007, we consecutively performed 13 controlled DCD liver transplantations. The medical records of all donors and recipients were retrospectively reviewed, evaluating in particular the outcome and occurrence of biliary complications. Mean follow-up was 25 months. RESULTS Mean donor age was 51 years, and mean intensive care unit stay was 5.4 days. Mean time between ventilation arrest and cardiac arrest was 9.3 minutes. Mean time between cardiac arrest and arterial flushing was 7.7 minutes. No-touch period was 2 to 5 minutes. Mean graft cold ischemia time was 295 minutes, and mean suture warm ischemia time was 38 minutes. Postoperatively, there was no primary nonfunction. Mean peak transaminase level was 2546 UI/mL. Patient and graft survival was 100% at 1 year. Two of 13 patients (15%) developed main bile duct stenosis and underwent endoscopic management of the graft. No patient developed symptomatic intrahepatic bile duct strictures or needed a second transplantation. CONCLUSIONS Our experience confirms that controlled DCD donors may be a valuable source of transplantable liver grafts in cases of short warm ischemia at procurement and minimal cold ischemia time.

Delayed graft function does not harm the future of donation-after-cardiac death in kidney transplantation.

INTRODUCTION Delayed graft function (DGF) occurs more frequently in kidney transplants from donation after cardiac death (DCD) than from donation after brain death (DBD). We investigated the effect of DGF on posttransplantation outcomes among grafts from controlled DCD kidneys. PATIENTS AND METHODS This single-center retrospective study recruited 80 controlled DCD kidneys transplanted from January 2005 to December 2011. Mean patient follow-up was 28.5 months. RESULTS There were no primary nonfunction grafts; the DGF rate was 35.5%. Overall graft survival rates between groups with versus without DGF were 92.4% and 95.2% at 1 year, 92.4% and 87.1% at 3 years, and 84.7% and 87.1% at 5 years, respectively (P = not significant (NS)). Patients with versus without DGF showed the same survival rates at the corresponding time 92.4% vs 97.2%, 92.4% vs 93.9%, and 84.7% vs 93.9% (P = NS). Estimated glomerular filtration rate was significantly lower in the DGF compared with the non-DGF group at hospital discharge (29 vs 42 mL/min; P = .00) and at 6 months posttransplantation (46 vs 52 mL/min; P = .04), but the difference disappeared thereafter: 47 vs 52 mL/min at 1 year, 50 vs 48 mL/min at 3 years, and 54 vs 53 mL/min at 5 years (P = NS). DGF did not increase the risk of an acute rejection episode (29.6% vs 30.6%; P = NS) or rate of surgical complications (33.3% vs 26.5%; P = NS). However, DGF prolonged significantly the length of hospitalization in the DGF versus the non- DGF group (18.9 vs 13 days; P = .00). Donor body mass index (BMI) ≥ 30 kg/m(2), recipient BMI ≥30 kg/m(2), and pretransplantation dialysis duration increased the risk of DGF upon multivariate logistic regression analysis. CONCLUSIONS Apart from the longer hospital stay, DGF had no deleterious impact on the future of kidney allografts from controlled DCD, which showed comparable graft and patient survivals, renal function, rejection rates, and surgical complications as a group without DGF. Therefore, DGF should no longer be considered to be a medical barrier to the use of kidney grafts from controlled DCD.

Fulminant Hepatic Failure Induced by Venlafaxine and Trazodone Therapy: A Case Report

Although acute hepatitis may be a side effect of many medications, most cases are reversible after treatment interruption, and fulminant hepatic failure (FHF) is rare. Venlafaxine and trazodone are 2 popular antidepressant agents. Alteration of liver enzyme levels has been reported as a side effect of these drugs at normal doses. Herein we have reported the case of a 48-year-old woman without any previous history of liver disease, who developed fulminant liver failure after 4 months of venlafaxine and trazodone therapy. She required liver transplantation, a procedure that was successful with full patient recovery. The first 5 years of follow-up were uneventful. This case documented that venlafaxine and trazodone at normal doses can produce severe liver toxicity. Liver tests should be monitored regularly in patients who receive this therapy.

Budd-Chiari Syndrome Complicating Hepatic Sarcoidosis: Definitive Treatment by Liver Transplantation: A Case Report

Sarcoidotic involvement of the liver is frequent, albeit uncommonly symptomatic. Severe complications are rare, but may seldom require liver transplantation. Budd-Chiari syndrome has been described in a few patients with hepatic sarcoidosis. Herein we have reported the case of a young woman suffering from hepatic sarcoidosis who developed severe cholestasis and chronic Budd-Chiari syndrome. She successfully underwent orthotopic liver transplantation (OLT) and is asymptomatic with normal liver function at 3 years follow-up. Histopathological assessment of the liver explant demonstrated a florid granulomatous process, with involvement of the large intrahepatic veins, providing an anatomical basis for the vascular flow disturbances. This case adds further evidence that liver transplantation may be the curative treatment for complicated sarcoidotic liver disease.

A More Than 20% Increase in Deceased-Donor Organ Procurement and Transplantation Activity After the Use of Donation After Circulatory Death

BACKGROUND Organ procurement and transplant activity from controlled donation after circulatory death (DCD) was evaluated over an 11-year period to determine whether this program influenced the transplant and donation after brain death (DBD) activities. MATERIAL AND METHODS Deceased donor (DD) procurement and transplant data were prospectively collected in a local database for retrospective review. RESULTS There was an increasing trend in the potential and actual DCD numbers over time. DCD accounted for 21.9% of the DD pool over 11 years, representing 23.7% and 24.2% of the DD kidney and liver pool, respectively. The DBD retrieval and transplant activity increased during the same time period. Mean conversion rate turning potential into effective DCD donors was 47.3%. Mean DCD donor age was 54.6 years (range, 3-83). Donors ≥60 years old made up 44.1% of the DCD pool. Among referred donors, reasons for nondonation were medical contraindications (33.7%) and family refusals (19%). Mean organ yield per DCD donor was 2.3 organs. Mean total procurement warm ischemia time was 19.5 minutes (range, 6-39). In 2012, 17 DCD and 37 DBD procurements were performed in the Liege region, which has slightly >1 million inhabitants. CONCLUSIONS This DCD program implementation enlarged the DD pool and did not compromise the development of DBD programs. The potential DCD pool might be underused and seems to be a valuable organ donor source.

Adjuvant hyperthermic intraperitoneal peroperative chemotherapy (HIPEC) associated with curative surgery for locally advanced gastric carcinoma. An initial experience.

Abstract Aim of the study : After macroscopic radical (R0) surgery for advanced gastric carcinoma, 40 to 50% of the tumors recur in the abdomen as locoregional or peritoneal disease. We initiated a protocol in which patients with suspicion of macroscopic serosal, lymphatic or peritoneal invasion, treated with R0 resection, underwent adjuvant HIPEC. Methods : Between June 1998 and January 2003, 16 patients with locally advanced adenocarcinoma of the stomach were included in the study. Surgery consisted of a total gastrectomy with a D2 lymphadenectomy. Splenectomy (n = 1), splenopancreatectomy (n = 4), transverse colectomy (n = 3), left hepatectomy (n = 1), localized peritonectomy (n = 3) were associated to obtain a R0 resection. HIPEC protocol consisted of heated (42.5°C) intraperitoneal mitomycin C (15 mg/m2) for a planned duration of 90 minutes. Results : HIPEC median duration was limited to 73(20–90) min because of central hyperthermia recognition in half of the cases. One patient died in the postoperative period of sepsis secondary to a duodenal fistula. Postoperative morbidity included pancreatic fistula (n = 2), pulmonary oedema (n = 1), pulmonary embolus (n = 1) and transient renal failure (n = 1). UICC staging was IB (n = 2), II (n = 2), IIIA (n = 5), IIIB (n = 1), IV (n = 6). Nine of the 16 patients are alive without recurrence with a median follow-up of 52 months. Four patients developed a recurrence, intraperitoneal (n = 2), systemic (n = 1), or combined (n = 1). Two patients were lost to follow-up. Conclusions : Aggressive surgical therapy and HIPEC might represent the standard of care in a selected population with locoregional disease and for whom a r0 resection can be achieved. This protocol was associated in this study with a 75% 5-year survival with a low peritoneal recurrence rate and an acceptable morbidity.

A Retrospective Monocenter Review of Simultaneous Pancreas-Kidney Transplantation.

OBJECTIVE Herein we have reviewed a consecutive series of simultaneous pancreas-kidney (SPK) transplantations performed at our institution over a 6-year period. PATIENTS AND METHODS The study population included 22 patients (15 males and 7 females) who underwent SPK transplantation between 2001 and 2007. The mean recipient age was 47 years (range, 26-63 years). Eighteen patients suffered type 1 and 4 type 2 diabetes mellitus. The mean donor age was 33 years (range, 14-56 years). The mean HLA match was 2.1 (range, 1-5). Immunosuppressive treatment consisted of basiliximab induction followed by tacrolimus, mycophenolate mofetil, and prednisone. RESULTS The mean hospital stay was 20 days (range, 11-52 days). After a mean follow-up of 44 months (range, 17-88 months), patient, kidney, and pancreas graft survivals were 86%, 82%, and 73%, respectively. Two patients died in the immediate postoperative period due to, respectively, disseminated intravascular coagulation and pulmonary embolism. A kidney graft was lost due to early hyperacute rejection. Other early complications associated with the pancreas graft included 2 cases of immediate reperfusion defects that led to early vascular thrombosis in 1 patient and a duodenal graft fistula in the other patient; a third patient developed type 2 diabetes mellitus. Beyond the postoperative period, graft loss was limited to 1 case of noncompliance to the immunosuppressive medications and 1 death secondary to pulmonary infection with a functional allograft after 4 years. CONCLUSIONS SPK transplantation is a valid therapeutic option for patients with insulin-dependent diabetes mellitus and renal failure due to diabetic nephropathy. The main complications of SPK transplantation occur in the immediate postoperative period consequent to vascular or rejection processes.