BackgroundOrgan shortage leads to usage of kidneys from donors after sudden cardiac death, or uncontrolled donors (UDCD). Ischemic injury due to cessation of circulation remains a crucial problem that limits adoption of UDCD. Our clinical investigation was to determine the applicability of kidneys obtained from UDCD and resuscitated by extracorporeal perfusion in situ after 60 minutes of asystole.MethodsIn 2009–2011, organ procurement service of St. Petersburg, obtained kidneys from 22 UDCD with critically expanded warm ischemic time (WIT). No patients were considered as potential organ donors initially. All donors died after sudden irreversible cardiac arrest. Mean WIT was 61.4±4.5 minutes. For kidney resuscitation, the subnormothermic extracorporeal abdominal perfusion with thrombolytics and leukocyte depletion was employed. Grafts were transplanted into 44 recipients. The outcomes of transplantation of resuscitated kidneys were compared to outcomes of 87 KTx from 74 brain death donors (BDDs).ResultsImmediate functioning of kidney grafts was observed in 21 of the 44 recipients, with no cases of primary non function. By the end of the first post-transplant year there was an acute rejection rate of 9.1% (4 episodes of rejection) in the UDCD group versus 14.2% (13 episodes of rejection) in the BDD group. The actual 1-year graft survival rate was 95.5% (n = 42) in UDCD group, and 94.6% (n = 87) in BDD group. Creatinine levels at the end of the first year were 0.116±0.008 and 0.115±0.004 mmol/l in UDCD and BDD groups, respectively.ConclusionsUDCD kidneys with critically expanded WIT could be succefully used for transplantation if in situ organ “resuscitation” perfusion is included into procurement protocol. The results of 1-year follow-up meet the generally accepted criteria for graft survival and function. In situ reperfusion may exert a therapeutic effect on grafts before procurement. This approach could substantially expand the organ donors' pool.

The availability of brain death donors is restricted by many factors. Use of uncontrolled donors after cardiac death could be a promising perspective, but the limiting factor in uncontrolled donation after cardiac death is the warm ischemic time. The purpose of our work was to develop an in situ kidney preservation protocol with application of the extracorporal normothermic abdominal perfusion for organ resuscitation in uncontrolled donors after cardiac death. The main attention was paid to the elimination of leukocytes as the key damaging factor from modified donor oxygenated blood circulating in the device. In 2009, we had 10 uncontrolled donors with warm ischemic time from 45 to 92 min; a normothermic extracorporal perfusion device was applied, providing preservation and restoration of kidney after ischemic damage. In 6 out of 20 kidney recipients, graft function was recovered immediately. All kidney grafts are functioning, and to the end of the third month, the average creatinine was 118.5 ± 19.9 mM. Treatment of ischemically damaged kidney by normothermic extracorporal perfusion with leukocyte depletion before procurement seems to be a challenging protocol for expanding donors' pool and demands further study.

Background Venous thromboembolism (VTE) with the prevalence of pulmonary microcirculatory thrombosis is considered a common complication of novel coronavirus disease (COVID-19) that develops despite anticoagulation. Methods The clinical course of the disease and the autopsy findings of seven deceased patients with verified COVID-19 were analyzed. The chest computed tomography (CT) scan was routinely performed while CT pulmonary angiography and a duplex ultrasound scan (DUS) of the lower limbs were used in cases of suspected VTE. The VTE prophylaxis was administered to all patients with intermediate or therapeutic doses of low-molecular-weight heparin. The histological examination of the lung tissue and other organs was performed with particular attention paid to the pulmonary vasculature. Results Venous thromboembolism, including deep vein thrombosis in one patient and pulmonary artery thrombosis in two patients, was confirmed by imaging tests despite anticoagulation. Systemic thrombolysis was performed in two patients with putative and confirmed pulmonary embolism. An autopsy revealed the signs of acute respiratory distress syndrome in all seven patients. Abnormalities of lung vessels were found in all cases and were represented by dystrophy and necrosis in the endothelium and muscle fibers, and by infiltration by plasmatic cells, neutrophils, and lymphocytes. Multiple clots of variable maturity were observed. All those changes developed despite anticoagulation and were preserved after systemic thrombolysis. Conclusion Inflammatory and prothrombotic changes in the arterial wall in parallel with the lack of lung perfusion may cause diffuse arterial thrombosis in the lungs. This background may be responsible for the low response to systemic anticoagulation and thrombolysis in severe forms of COVID-19.

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Introduction. In megacities, the use of organs obtained from those who died as a result of sudden out-of-hospital cardiac arrest (OHCA) for transplantation is one of the promising ways of addressing the problem of organ donor shortage. In St. Petersburg, the model of transition from life support via extracorporeal membrane oxygenation (ECMO) of patients after OHCA to ECMO life support for organs of potential donors was tested for the first time.Materials and methods. In order to implement the program, round-the-clock ECMO and transplantation teams were organized at the inpatient emergency ward of Pavlov First St. Petersburg State Medical University. Interaction with the St. Petersburg City Emergency Station, St. Petersburg was established. The protocol of work with potential donors brought to the hospital after a sudden circulatory arrest was developed, approved by the ethics committee, and implemented in clinical practice. This was the first in Russia and in international practice. Between 2017 and 2020, 67 patients with sudden OHCA were brought to the inpatient emergency ward. In 4 (5.97%) cases, advanced cardiovascular life support was successful, and 11 (16.42%) patients became effective donors. Mortality among this group of patients without subsequent postmortem donation was 77.61% (52 patients).Results. Liver transplantation from non-heart-beating donors (NHBDs) whose blood circulation was restored by ECMO (ECMO NHBD) was performed in 5 recipients who were in severe condition against the background of liver failure. In 1 (20%) case, there was severe liver allograft dysfunction for 33 days with subsequent complete restoration of function. Kidney transplantation was performed in 22 patients. Immediate graft function occurred in 10 (45.45%), while delayed function occurred in 12 (54.55%) patients. Kidney graft survival was 86.4%, kidney graft recipient survival was 95.5%, liver graft recipient survival was 80%, and the follow-up period was 24.1 ± 7.15 months.Conclusion. The use of ECMO to save the lives of patients with sudden OHCA can be implemented in conditions of a high degree of organization and synchronization of the work of the city emergency medical station and the emergency department of a multidisciplinary hospital. If cardiopulmonary resuscitation with ECMO (ECMO CPR) fails, it is possible to launch the ECMO NHBD donor program. Long-term outcomes of liver and kidney transplantation from ECMO NHBD are consistent with those using organs from brain-dead donors. Widespread implementation of the new organ donation model will increase the availability of transplant care.