Marie-France Hans

What is the potential increase in the heart graft pool by cardiac donation after circulatory death

Heart transplantation remains the only definite treatment option for end‐stage heart diseases. The use of hearts procured after donation after circulatory death (DCD) could help decrease the heart graft shortage. The aim of this study was to evaluate the potential increase in heart graft pool by developing DCD heart transplantation. We retrospectively reviewed our local donor database from 2006 to 2011, and screened the complete controlled DCD donor population for potential heart donors, using the same criteria as for donation after brain death (DBD) heart transplantation. Acceptable donation warm ischemic time (DWIT) was limited to 30 min. During this period 177 DBD and 70 DCD were performed. From the 177 DBD, a total of 70 (39.5%) hearts were procured and transplanted. Of the 70 DCD, eight (11%) donors fulfilled the criteria for heart procurement with a DWIT of under 30 min. Within the same period, 82 patients were newly listed for heart transplantation, of which 53 were transplanted, 20 died or were unlisted, and 9 were waiting. It could be estimated that 11% of the DCD might be heart donors, representing a 15% increase in heart transplant activity, as well as potential reduction in the deaths on the waiting list by 40%.

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.

End of life care in the operating room for non-heart-beating donors: organization at the University Hospital of Liège.

Non-heart-beating (NHB) organ donation has become an alternative source to increase organ supply for transplantation. A NHB donation program was implemented in our institution in 2002. As in many institutions the end of life care of the NHB donor (NHBD) is terminated in the operating room (OR) to reduce warm ischemia time. Herein we have described the organization of end of life care for these patients in our institution, including the problems addressed, the solution proposed, and the remaining issues. Emphasis is given to our protocol elaborated with the different contributors of the chain of the NHB donation program. This protocol specifies the information mandatory in the medical records, the end of life care procedure, the determination of death, and the issue of organ preservation measures before NHBD death. The persisting malaise associated with NHB donation reported by OR nurses is finally documented using an anonymous questionnaire.

Contribution of Donors After Cardiac Death to the Deceased Donor Pool: 2002 to 2009 University of Liege Experience

OBJECTIVE In this study, we have evaluated the organ procurement and transplantation activity from donors after cardiac death (DCD) at our institution over an 8-year period. Our aim was to determine whether this program influenced transplantation programs, or donation after brain death (DBD) activity. METHODS We prospectively collected our procurement and transplantation statistics in a database for retrospective review. RESULTS We observed an increasing trend in potential and actual DCD number. The mean conversion rate turning potential into effective donors was 58.1%. DCD accounted for 16.6% of the deceased donor (DD) pool over 8 years. The mean age for effective DCD donors was 53.9 years (range, 3-79). Among the effective donors, 63.3% (n = 31) came from the transplant center and 36.7% (n = 18) were referred from collaborative hospitals. All donors were Maastricht III category. The number of kidney and liver transplants using DCD sources tended to increase. DCD kidney transplants represented 10.8% of the DD kidney pool and DCD liver transplants made up 13.9% of the DD liver pool over 8 years. The DBD program activity increased in the same time period. In 2009, 17 DCD and 33 DBD procurements were performed in a region with a little >1 million inhabitants. CONCLUSION The establishment of a DCD program in our institution enlarged the donor pool and did not compromise the development of the DBD program. In our experience, DCD are a valuable source for abdominal organ transplantation.

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.

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.

60 h of anhepatic state without neurologic deficit

Two-stage liver transplantation (LT), i.e. emergent total hepatectomy with prolonged anhepatic state and subsequent LT, has been described as a means to stabilize patients with fulminant hepatic failure (FHF), primary nonfunction after LT, or massive hepatic trauma [1]. After total hepatectomy, patient survival only depends on the future availability of a liver graft. The pathophysiological consequences of prolonged anhepatic state are not fully known, as it is not known how long a patient may be anhepatic before it is too late for hope of survival. As FHF may lead to brain oedema, the cerebral outcome of patients submitted prolonged anhepatic state seems particularly critical. A 34-year-old woman was suffering from end-stage liver cirrhosis with refractory ascites and portal hypertension from unknown origin. She underwent living-related LT with a left liver graft (segments II–IV). On postoperative day 1, INR rose from 1.7 to 5.3, and there was no arterial or portal flow within the graft at Doppler ultrasonography. At reintervention the graft was tense and ischemic, and both hepatic artery and portal vein were occluded. The necrotic graft was removed and the patient was registered for urgent cadaveric reLT. During the anhepatic state body temperature was maintained between 34 C and 37 C with warming blanket. Blood glucose level was controlled by intravenous glucose 20% infusion. The patient became anuric within 24 h and was supported with continuous veno-venous hemofiltration. Pulmonary and cardiac functions remained stable. Anaesthesia was maintained by continuous infusion of propofol and remifentanyl. The patient finally received a cadaveric liver that was reperfused 60 h after the first graft removal. The patient slowly woke up after anaesthesia interruption. She was extubated 7 days after reLT without neurologic sequel. She was fully conscious and had no motor deficits. However, she developed Aspergillus fumigatus infection and finally died from sepsis and progressive multiorgan failure. The full awakening of this patient after 60 h of anhepatic state, and other cases published in the literature [1–3, demonstrate that survival without neurological sequel is possible after >2 days of anhepatic state. The reason for the absence of neurological complications in these anhepatic patients is unclear. It may be possible that anhepatic patients do not develop life-threatening neurologic complications, or might be at least less prone to develop brain oedema than patients suffering from hyperacute FHF who may develop brain oedema within 24 h. It was demonstrated that LT anhepatic phase is linked to lowering of intracranial pressure in FHF patients (4). In an animal model, the anhepatic pigs did not develop cranial hypertension, at the contrary of the ischemic FHF group (5). These observations may be interpreted as an argument in favour of the ‘toxic liver hypothesis’ that suggests that the presence of the diseased liver may be important to the genesis of brain oedema and elevation of intracranial pressure during FHF. The possibility and the reasons of absence of brain oedema in prolonged anhepatic state largely deserve further human observations and animal experiments.

[150] CADAVERIC WHOLE LIVER TRANSPLANTATION FOR NON-ACETAMINOPHEN FULMINANT HEPATIC FAILURE: A 20-YEAR EXPERIENCE

AIM: To investigate the long-term results of liver transplantation (LT) for non-acetaminophen fulminant hepatic failure (FHF). METHODS: Over a 20-year period, 29 FHF patients underwent cadaveric whole LT. Most frequent causes of FHF were hepatitis B virus and drug-related (not acetaminophen) liver failure. All surviving patients were regularly controlled at the out-patient clinic and none was lost to follow-up. Mean follow-up was 101 mo. RESULTS: One month, one-, fi ve- and ten-year patient survival was 79%, 72%, 68% and 68%, respectively. One month, one-, fi ve- and ten-year graft survival was 69%, 65%, 51% and 38%, respectively. Six patients needed early (< 2 mo) retransplantation, four for primary non-function, one for early acute refractory rejection because of ABO blood group incompatibility, and one for a malignant tumor found in the donor. Two patients with hepatitis B FHF developed cerebral lesions peri-transplantion: one developed irreversible and extensive brain damage leading to death, and one suffered from deep defi cits leading to continuous medical care in a specialized institution.