BackgroundDonation after circulatory death (DCD) can increase the pool of available organs for transplantation. This pilot study evaluates the implementation of a controlled DCD (cDCD) protocol using normothermic regional perfusion in Norway.MethodsPatients aged 16 to 60 years that are in coma with documented devastating brain injury in need of mechanical ventilation, who would most likely attain cardiac arrest within 60 minutes after extubation, were eligible. With the acceptance from the next of kin and their wish for organ donation, life support was withdrawn and cardiac arrest observed. After a 5-minute no-touch period, extracorporeal membrane oxygenation for post mortem regional normothermic regional perfusion was established. Cerebral and cardiac reperfusion was prevented by an aortic occlusion catheter. Measured glomerular filtration rates 1 year postengraftment were compared between cDCD grafts and age-matched grafts donated after brain death (DBD).ResultsEight cDCD were performed from 2014 to 2015. Circulation ceased median 12 (range, 6-24) minutes after withdrawal of life-sustaining treatment. Fourteen kidneys and 2 livers were retrieved and subsequently transplanted. Functional warm ischemic time was 26 (20-51) minutes. Regional perfusion was applied for 97 minutes (54-106 minutes). Measured glomerular filtration rate 1 year postengraftment was not significantly different between cDCD and donation after brain death organs, 75 (65-76) vs 60 (37-112) mL/min per 1.73 m2 (P = 0.23). No complications have been observed in the 2 cDCD livers.ConclusionA protocol for cDCD is successfully established in Norway. Excellent transplant outcomes have encouraged us to continue this work addressing the shortage of organs for transplantation.

Background: In order to meet the increasing demand for donor organs the concept of donation after circulatory death (DCD) was reintroduced in Norway. First a pilot study, followed by the use of DCD as an institutional practice. We here report the current Norwegian experience with liver transplantation following DCD. Methods: After acceptance from next of kin, life support was withdrawn and cardiac arrest observed. After a five minute "no-touch" period, extracorporeal membrane oxygenation for post mortem normothermic perfusion (NRP) by ECMO circuit was established. Data from all liver transplant recipients receiving cDCD livers in Oslo were analyzed. Results: From 2015 to 2017, 8 patients underwent liver transplantation with cDCD and NRP livergrafts in Norway. Median MELD was 26, (range 6-40). There were no cases of delayed graft function or graft loss. Seven patients have reached 1 year of follow-up, 1 patient has reached 6 months. Two patients have recurrence of primary disease (PSC and steatohepatitis). All patients had normalized liver function at last follow-up. Two patients underwent procedures for the biliary complications: One with leakage from the cystic duct which was successfully handled endoscopically by stenting. In the other patient, a suspected stricture on MRI led to an ERCP procedure which did not confirm signs of biliary stenosis. There was one instance of hepatic artery stenosis, which was managed with endovascular technique. Conclusion:

Organs available for solid organ transplantation are mainly procured from brain dead donors. The inflammation associated with brain death may reduce organ quality and increase organ immunogenicity, thus leading to inferior recipient outcome. We hypothesized that the extensive surgical procedure performed during multiorgan procurement enhances the levels of systemic inflammatory biomarkers. We measured the levels of 27 cytokines and the terminal complement complex (TCC) in plasma samples from brain dead organ donors (n = 34) drawn before and at three specific time points during procurement surgery. Baseline levels of G-CSF, interferon-γ, IL-1ra, IL-4, IL-6, IL-7, IL-8, IL-10, IP-10, MCP-1, macrophage inflammatory protein (MIP)-1β, platelet derived growth factor (PDGF), regulated upon activation T cell expressed and secreted, and tumor necrosis factor-α were significantly elevated in brain dead donors compared with normal individuals (n = 14), but they were not associated with time on ventilator or any other registered clinical variable. Notably, the secretion of G-CSF, IL1-ra, IL-6, IL-8, IL-10, IP-10, MCP-1, MIP-1β, PDGF, and TCC, the latter reflecting ongoing complement activation, increased significantly during surgery. None of the biomarker increases were correlated with operation duration. Multiorgan procurement surgery significantly adds to the inflammatory response revealed by both pro- and anti-inflammatory biomarkers associated with brain death. Future studies should determine whether this is associated with inferior recipient outcome.

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