In February 2018, the Withdrawal of the Life-sustaining Treatment (WLST) Decision Act was legalized in Korea. Donation after circulatory death (DCD) after WLST was classified as DCD category III. We report the first case of successful organ donation after WLST in Korea. A 52-year-old male who experienced cerebral hemorrhage was a potential brain-dead donor with donation consent. During the first brain death examination, Babinski reflex was present, which disappeared two days later. Then, electroencephalography was performed five times at intervals of 2 to 3 days, according to the recommendation of a neurologist. The patient was transferred to the OR at 19:30 July 3, 2020. At 20:00, an intensive care unit specialist performed extubation and discontinued vasopressors. Oxygen saturation fell to < 70% in 1 minute, which signaled the beginning of functional warm ischemia. At 20:15, asystole was confirmed; after 5 minutes of “no-touch time,” circulatory death was declared. Organ procurement surgery was initiated, with surgeons performing the recipient surgery ready in the adjacent OR. Through the first successful DCD case, we expected that DCD will be actively implemented in Korea, saving the lives of patient waiting for transplantation and resolving the imbalance between organ receipt and donation.

The “Act on hospice and palliative care and decisions on life-sustaining treatment for patients at the end of life” was enacted in February 2018 in Korea. Therefore, we suggest a Korean guideline for organ donation after circulatory death (DCD) category III after the withdrawal of life-sustaining treatment (WLST). Implementation of WLST includes stopping ventilation, extubation, discontinuation of inotropics and vasoconstrictors, cessation of continuous renal replacement therapy, and cessation of extracorporeal membrane oxygenation. Medical staff involved in organ procurement or transplantation surgery cannot participate in the WLST process. Following cardiac arrest, 5 minutes of “no touch time” should pass, after which circulatory death can be declared. The procurement team can enter the room after the declaration of death. The final procurement decision is made after the surgeon visually checks the organ condition. DCD category III activation in Korea will help increase organ donation and reduce the demand-supply mismatch of organ transplantation.

Background: Because of the Korean Network for Organ Sharing (KONOS) guidelines, brain-dead donor transplantation (liver/kidney) from Hepatitis B or C (+) donors only can be done to the same hepatitis (+) recipients. In the US, organ transplantation from hepatitis (+) donors to (-) recipients has been implemented for more than 15 years. We need to consider the safety of transplantation from hepatitis B or C (+) donors to hepatitis (-) recipients. The aim of the study is to show the transplantation results from hepatitis B or C (+) donors to each hepatitis (-) recipient and make it as a starting point for the consideration. Methods: This is a retrospective, observational study using data from Korean Organ Transplantation Registry (KOTRY) data analysis. A total of 2,105 kidney transplantations from brain-dead donors, from January 2015 to June 2020 were included in this study. It consists of 80 HBV (+) grafts, 12 HCV (+) grafts and 2013 hepatitis (-) grafts. Results: In donor characteristics, median ages of the three groups [HBV (+), HCV (+), hepatitis (-)] were 57.4±10.1, 50.1±11.8 and 48.7±14.9, respectively (P=0.02; HCV (+)-hepatitis (-), P=0.04). Baseline serum creatinine (median, mg/dL) were 1.25±0.87, 1.45±0.46 and 1.57±1.34, respectively (P=0.02; HBV (+)-hepatitis (-), P=0.01). In recipient characteristics, male/female ratio were 60/20, 7/5 and 1228/785, respectively (P=0.04; HBV (+)-hepatitis (-), P=0.04). Wait time (median, days) were 1550.8±1145.5, 1434.3±957.2 and 2188±1207.9, respectively (P<0.001; HBV (+)-hepatitis (-), P<0.001). In posttransplant results, there were no significant differences in follow-up serum creatinine, survival, postop hospital day and complication between the three groups. From a Kaplan-Meier analysis, overall patient survival rates after KT at 5 years were 95%, 100% and 76.2%, respectively (HBV [+]-hepatitis [-], P<0.001). Overall graft survival rates after KT at 5 years were 95%, 83.3% and 84.5%, respectively (HBV [+]-hepatitis [-], P=0.02). Conclusions: There were no differences in baseline, postop and follow-up serum creatinine between the three groups. Moreover, 5-year patient and graft survival were significantly higher in HBV (+) grafts than in hepatitis (-) grafts. Do not hesitate to consider implementing brain-dead donor transplantation from hepatitis (+) donors to hepatitis (-) recipients.

Background:In Korea, due to the Korean Network for Organ Sharing (KONOS) guidelines, brain-dead donor liver/kidney transplantation from hepatitis B or C positive donors can be implemented only to identical hepatitis-positive recipients. However, in the US, it has been more than 15 years since organ transplantation from hepatitis-positive donors to negative recipients had been implemented. Korea also needs to discuss transplantation safety from hepatitis B or C positive donors to hepatitis negative recipients. But we cannot get the results due to the KONOS guidelines. Instead, we studied transplantation results from hepatitis B or C positive donors to each hepatitis negative recipient as a starting point to support expanding indication criteria. Methods: This is a retrospective, observational study using data from Korean Organ Transplantation Registry (KOTRY) data analysis. A total of 1,035 liver transplantations from brain-dead donors, from April 2014 to March 2021 were included in this study. It consists of 24 HBV (+) grafts, one HCV (+) graft and 1,010 hepatitis (-) grafts. Results:In donor characteristics, the rate of the standard donor was higher in hepatitis (-) donors than HBV (+) donors (735/274, 11/13; P<0.01). In recipient characteristics, median model for end-stage liver disease (MELD) score (baseline) of HBV (+), HCV (-), hepatitis (-) were 22.4±9.3, 16 and 33.0±15.4, respectively (HBV [+]-hepatitis [-], P<0.01). Median MELD score (KONOS final) were 27.8±7.8, 11 and 35.5±7.1, respectively (HBV [+]-hepatitis [-] and HCV [-]-hepatitis [-], P<0.01, respectively). From a Kaplan-Meier analysis, overall patient survival rate after LT at 5 years were 85.6%, N/A (2-year patient survival rate 100%) and 76.7%, respectively and showed no statistically significant differences (HBV [+]-HCV [+], P=0.695; HCV [+]-hepatitis [-], P=0.638; HBV [+]-hepatitis [-], P=0.383). Overall graft survival rates after LT at 5 years was 87.5%, N/A (2-year patient survival rate 100%) and 76.6%, respectively and showed no statistically significant differences. Conclusions: There were no significant differences in the 5-year transplantation patient/graft survival rate between HBV (+), HCV (+) and hepatitis (-) grafts. One more step, it's time to consider implementing transplantation from hepatitis (+) donors to hepatitis (-) recipients.

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