Nurses’ Recognition in Nursing for Patients and Families about Organ Donation after Brain Death, Care for Family Members and Supports for Nurses

Background: Globally, there a problem of disequilibrium between donation and organ transplantation, this equilibrium is remarkable in Japan. Especially there are few donations from brain death, and researches from the view point of nurses in clinical situation were needed. Purpose: The purpose of this study was to clarify the recognition of nurses in organ transplantation nursing, required care for families of patients, and required support for nurses to promote quality of nurses in organ donation. Methods: We conducted this research within 2 months in 2019 in Western Japan. A researcher conducted a semi-qualitative interview for nurses in organ transplantation nursing about their recognition of nursing, required care for family members, and required support for nurses once. Results: Nurses recognized that some family members who knew patients’ thoughts made decision easily and some who didn’t know had difficulties. Many nurses felt insufficiency for family cares and some confronted ethical problems. Though some nurses felt conflict about their own thoughts or religion, they took care of patients or family members with responsibility. As for care for families, nurses thought practice of care considering families’ feeling, support of decision making, and care for family to live positively after transplantation as required care. About support for nurses, nurses required education of transplantation, increase of staff members, chance to share dilemma, and mental care. Discussion: Nurses recognized the importance of decision making, and felt an insufficiency for family care or dilemmas. To propose high quality of nursing and organ donation or transplantation, education about transplantation including family care, management about resolution of dilemma or mental health may be required.

Successful Abdominal Organ Donation after Brain Death in a Patient with a Biventricular Assist Device: Extending Extended Criteria

Few studies address the potential for donation after brain death (DBD) in the limited population of patients with ongoing mechanical circulatory support (MCS). A case study was conducted reviewing available records of both donor and recipient, and available literature. The donor was a young female with an acute myocardial infarction precipitating emergent off-pump 2-vessel bypass graft complicated by profound cardiogenic shock refractory to inotropes and intra-aortic balloon pump. A heparin drip was started following percutaneous placement of a left ventricular-assist device (TandemHeart?) which improved her hemodynamics to stabilize for transfer. She ultimately required surgical placement of biventricular assist device (CentraMag?) to normalize hemodynamics. Two days post-operatively, she developed a cerebellar hemorrhage and was declared brain dead. Pre-donation blood chemistry showed adequate end-organ function. Both kidneys were placed locally. The liver was rejected for two regional status 1 patients and by all other local centers. We accepted the liver for a patient with polycystic liver disease with a MELD exception score of 20. The recipient is now 4 years post-transplant with excellent graft function. Extending donor criteria to include MCS patients can result in successful transplantation and should be considered in selected circumstances once satisfactory donor end-organ function is established.

Pathological Characteristics of Liver Allografts from Donation after Brain Death Followed by Cardiac Death in Pigs

Donation after brain death followed by circulatory death （DBCD） is a unique practice in China. The aim of this study was to define the pathologic characteristics of DBCD liver allografts in a porcine model. Fifteen male pigs （25-30 kg） were allocated randomly into donation after brain death （DBD）, donation after circulatory death （DCD） and DBCD groups. Brain death was induced by aug- menting intracranial pressure. Circulatory death was induced by withdrawal of life support in DBCD group and by venous injection of 40 mL 10% potassium chloride in DCD group. The donor livers were perfused in situ and kept in cold storage for 4 h. Liver tissue and common bile duct samples were col- lected for hematoxylin and eosin staining, TUNEL testing and electron microscopic examination. Spot necrosis was found in hepatic parenchyma of DBD and DBCD groups, while a large area of necrosis was shown in DCD group. The apoptosis rate of hepatocytes in DBD [（0.56±0.30）%] and DBCD [（0.50 ±0.11）%] groups was much lower than that in DCD group [（3.78±0.33）%] （P〈0.05）. And there was no significant difference between DBD group and DBCD group （P〉0.05））. The structures of bile duct were intact in both DBD and DBCD groups, while the biliary epithelium was totally damaged in DCD group. Under electron microscope, the DBD hepatocytes were characterized by intact cell membrane, well-organized endoplasmic reticulum, mild mitochondria edema and abundant glycogens. Broken cell membrane, mild inflammatory cell infiltration and sinusoidal epithelium edema, as well as reduced glycogen volume, were found in the DBCD hepatocytes. The DCD hepatocytes had more profound cell organelle injury and much less glycogen storage. In conclusion, the preservation injury of DBCD liver allografts is much less severe than that of un-controlled DCD, but more severe than that of DBD liver allografts under electron microscope, which might reflect post-transplant liver function to some extent.

Potential approaches to improve the outcomes of donation after cardiac death liver grafts

There is a growing discrepancy between the supply and demand of livers for transplantation resulting in high mortality rates on the waiting list. One of the options to decrease the mortality on the waiting list is to optimize organs with inferior quality that otherwise would be discarded. Livers from donation after cardiac death(DCD) donors are frequently discarded because they are exposed to additional warm ischemia time, and this might lead to primary-non-function, delayed graft function, or severe biliary complications. In order to maximize the usage of DCD livers several new preservation approaches have been proposed. Here, we will review 3 innovative organ preservation methods:(1) different ex vivo perfusion techniques;(2) persufflation with oxygen; and(3) addition of thrombolytic therapy. Improvement of the quality of DCD liver grafts could increase the pool of liver graft's for transplantation, improve the outcomes, and decrease the mortality on the waiting list.

Critical care specialists,the missing link in organ procurement for transplantation

The procurement process for organ donation begins with the identification of potential organ donors in emergency or critical care units(CCU),followed by their clinical evaluation,diagnostic procedures,and therapeutic interventions,mostly conducted in CCUs.It concludes with the request for organ donation and,if accepted,the retrieval of organs.Despite most interventions occurring in detection units,there has been a neglect of the strategic role played by critical care specialists(CCS)in managing and caring for brain-dead or near-brain-death patients.Questions arise:Are they willing to undertake this responsibility?Do they fully comprehend the nature of organ procurement?Are they aware of the specific interventions required to maintain possible organ donors in optimal physiological condition?Our objective is to examine the role of CCS in organ procurement and propose ways to enhance it,ultimately aiming to increase and enhance organ donation rates.

Does the use of double hormone replacement therapy for trauma patient organ donors improve organ recovery for transplant

BACKGROUND With an ongoing demand for transplantable organs,optimization of donor management protocols,specifically in trauma populations,is important for obta-ining a high yield of viable organs per patient.Endocrine management of brain-dead potential organ donors(BPODs)is controversial,leading to heterogeneous clinical management approaches.Previous studies have shown that when levo-thyroxine was combined with other treatments,including steroids,vasopressin,and insulin,BPODs had better organ recovery and survival outcomes were increased for transplant recipients.AIM To determine if levothyroxine use in combination with steroids in BPODs increased the number of organs donated in trauma patients.METHODS A retrospective review of adult BPODs from a single level 1 trauma center over ten years was performed.Exclusion criteria included patients who were not solid organ donors,patients who were not declared brain dead(donation after circulatory death),and patients who did not receive steroids in their hospital course.Levothyroxine and steroid administration,the number of organs donated,the types of organs donated,and demographic information were recorded.Univariate analyses were performed with P<0.05 considered to be statistically significant.RESULTS A total of 88 patients met inclusion criteria,69(78%)of whom received levothyroxine and steroids(ST/LT group)vs 19(22%)receiving steroids without levothyroxine(ST group).No differences were observed between the groups for gender,race,pertinent injury factors,age,or other hormone therapies used(P>0.05).In the ST/LT group,68.1%(n=47)donated a high yield(3-5)of organ types per donor compared to 42.1%(n=8)in the ST group(P=0.038).There was no difference in the total number of organ types donated between the groups(P=0.068).CONCLUSION This study suggests that combining levothyroxine and steroid administration increases high-yield organ donation per donor in BPODs in the trauma patient population.Limitations to this study include the retrospective design and the relatively small number of organ donors who met inclusion criteria.This study is unique in that it mitigates steroid administration as a confounding variable and focuses specifically on the adjunctive use of levothyroxine.

Extended criteria brain-dead organ donors:Prevalence and impact on the utilisation of livers for transplantation in Brazil

BACKGROUND Despite its association with higher postoperative morbidity and mortality,the use of extended criteria donor(ECD)livers for transplantation has increased globally due to the high demand for the procedure.AIM To investigate the prevalence of ECD in donation after brain death(DBD)and its impact on organ acceptance for transplantation.METHODS Retrospective analysis of DBD organ offers for liver transplantation between 2017 and 2020 in a high-volume transplant centre.The incidence of the Eurotransplant risk factors to define an ECD(ET-ECD)among DBD donors and the likelihood of organ acceptance over the years were analysed.The relationship between organ refusal for transplantation,the occurrence,and the number of ET-ECD was assessed by simple and multiple logistic regression adjustment.RESULTS A total of 1619 organ donors were evaluated.Of these,78.31%(n=1268)had at least one ET-ECD criterion.There was an increase in the acceptance of ECD DBD organs for transplantation(1 criterion:from 23.40%to 31.60%;2 criteria:from 13.10%to 27.70%;3 criteria:From 6.30%to 13.60%).For each addition of one ETECD variable,the estimated chance of organ refusal was 64.4%higher(OR 1.644,95%CI 1.469-1.839,P<0.001).Except for the donor serum sodium>165 mmol/L(P=0.310),all ET-ECD criteria increased the estimated chance of organ refusal for transplantation.CONCLUSION A high prevalence of ECD DBD was observed.Despite the increase in their utilisation,the presence and the number of extended donor criteria were associated with an increased likelihood of their refusal for transplantation.

Validation of a pediatric bedside tool to predict time to death after withdrawal of life support

AIM: To evaluate the accuracy of a tool developed to predict timing of death following withdrawal of life support in children. METHODS: Pertinent variables for all pediatric deaths(age ≤ 21 years) from 1/2009 to 6/2014 in our pediatric intensive care unit(PICU) were extracted through a detailed review of the medical records. As originally described, a recently developed tool that predicts timing of death in children following withdrawal of life support(dallas predictor tool [DPT]) was used to calculate individual scores for each patient. Individual scores were calculated for prediction of death within 30 min(DPT30) and within 60 min(DPT60). For various resulting DPT30 and DPT60 scores, sensitivity, specificity and area under the receiver operating characteristic curve were calculated.RESULTS: There were 8829 PICU admissions resulting in 132(1.5%) deaths. Death followed withdrawal of life support in 70 patients(53%). After excluding subjects with insufficient data to calculate DPT scores, 62 subjects were analyzed. Average age of patients was 5.3 years(SD: 6.9), median time to death after withdrawal oflife support was 25 min(range; 7 min to 16 h 54 min). Respiratory failure, shock and sepsis were the most common diagnoses. Thirty-seven patients(59.6%) died within 30 min of withdrawal of life support and 52(83.8%) died within 60 min. DPT30 scores ranged from-17 to 16. A DPT30 score ≥-3 was most predictive of death within that time period, with sensitivity = 0.76, specificity = 0.52, AUC = 0.69 and an overall classification accuracy = 66.1%. DPT60 scores ranged from-21 to 28. A DPT60 score ≥-9 was most predictive of death within that time period, with sensitivity = 0.75, specificity = 0.80, AUC = 0.85 and an overall classification accuracy = 75.8%.CONCLUSION: In this external cohort, the DPT is clinically relevant in predicting time from withdrawal of life support to death. In our patients, the DPT is more useful in predicting death within 60 min of withdrawal of life support than within 30 min. Furthermore, our analysis suggests optimal cut-off scores. Additional calibration and modifications of this important tool could help guide the intensive care team and families considering DCD.

Liver transplantation with grafts obtained after cardiac death-current advances in mastering the challenge

The scarcity of donor livers has increased the interest in donation after cardiac death(DCD) as an additional pool to expand the availability of organs. However, the initial results of liver transplantation with DCD grafts have been suboptimal due to an increased rate of complications, as well as decreased graft survival. These challenges have led to many developments in DCD donation outcome, as well as basic and translational research. In this article we review the unique characteristics of DCD donors, nuances of DCD organ procurement, the effect of prolonged warm and cold ischemia times, and discuss major studies that compared DCD to donation after brain death liver transplantation, in terms of outcomes and complications. We also review the different methods of donor treatment that has been applied to ameliorate DCD organ outcome, and we discuss the role of machine perfusion techniques in organ reconditioning. We discuss the two major perfusionmodels, namely, hypothermic machine perfusion and normothermic machine perfusion; we compare both methods, and delineate their major differences.

病原体宏基因检测在器官捐献患者中的应用

目的探讨病原体宏基因组二代测序(metagenomic next-generation sequencing,mNGS)应用于器官捐献者病原微生物的检测,为器官移植后的抗感染药物靶向治疗提供依据。方法回顾性分析了武汉大学中南医院于2021年8月至2023年6月142例器官捐献者的临床病例,收集捐献者的血液样本的mNGS检测和病原微生物培养检测结果,对其进行分析比较。结果142例捐献者中98例在mNGS中检测到病原微生物,阳性检出率为69.01%。其中,59例(60.20%)为单纯病毒感染,12例(12.24%)为单纯细菌感染,4例(4.08%)为单纯真菌感染,混合感染23例(23.47%)。共检测出病原微生物173株。其中,病毒125株(72.25%),细菌40株(23.12%),真菌8株(4.62%)。对捐献者血液样本送检mNGS同时送检微生物培养检测,142例捐献者中20例(14.08%)血培养检测到病原微生物,共检测出21株病原微生物,其中20例(95.24%)为细菌,1例(4.76%)为真菌。器官保存液中培养出病原微生物2例(1.40%)。结论mNGS对病原微生物的检出率高于微生物血培养检测。mNGS检测和血培养病原微生物检测在细菌的诊断上差异不明显,而在检测真菌及病毒阳性时有统计学意义,且mNGS检测比血培养病原微生物检测能大幅度缩短检验时长。

中国遗体器官捐献供肾体外低温机械灌注保存指南

为促进遗体器官捐献供肾体外低温机械灌注保存技术的规范应用,中华医学会器官移植学分会组织制定了《中国遗体器官捐献供肾体外低温机械灌注保存指南》。该指南整合了肾脏移植学和遗体器官捐献学领域的专家共识,依据现有的临床指南、系统评价、病例研究、专家共识等资料,并结合近年国内外遗体器官捐献供肾体外低温机械灌注保存技术的临床问题。在多次专家研讨和达成一致意见后,完成了该指南的撰写。该指南共包含11个临床问题,14条推荐意见,并按照2009版牛津大学循证医学中心的证据分级与推荐强度标准,对每个临床问题的推荐意见强度与证据级别进行了分级。该指南旨在为临床实践提供指导,提高我国遗体器官捐献供肾保存水平,减少器官弃用率,缓解器官短缺问题。

中国儿童遗体器官捐献肾脏的功能维护、评估和应用指南

儿童遗体器官捐献是遗体器官捐献中重要的组成部分,其与成人器官捐献存在较大差异。为规范我国儿童遗体器官捐献肾脏的功能维护、评估和应用,中华医学会器官移植学分会发起制订《中国儿童遗体器官捐献肾脏的功能维护、评估和应用指南》,指南采用2009版牛津大学循证医学中心的证据分级与推荐强度标准制订,针对儿童遗体器官捐献肾脏有关的功能维护、评估及应用方面的29个临床问题,给出了33条推荐意见,旨在规范操作流程,为临床工作提供指引,全面提升我国器官捐献与移植质量。

机器人辅助肾移植术单中心初步经验

目的 探索机器人辅助肾移植(RAKT)的安全性、有效性及可行性。方法 收集行肾移植术的16例患者资料,其中8例采用RAKT(RAKT组),接受同一供者对侧肾脏的8例患者采用开放肾移植术(OKT组)。对比两组受者围手术期结果及移植肾功能恢复情况。结果 所有患者均成功完成手术,RAKT组无患者在术中转开放手术。RAKT组手术时间长于OKT组(P=0.015)。两组受者术前血清肌酐及出院时血清肌酐差异无统计学意义(均为P>0.05)。OKT组1例受者出现移植物功能延迟恢复(DGF),其余患者均未出现围手术期并发症。两组术后短期肾功能恢复差异无统计学意义(P>0.05)。结论 RAKT术后恢复与OKT相当,对于肾移植手术经验丰富的团队而言,RAKT是一种安全有效的手术方式,可以尝试开展。

脑死亡器官捐献供体评估和供心选择临床分析

目的总结73例脑死亡器官捐献供体评估和供心选择的临床经验。方法回顾73对脑死亡器官捐献心脏移植供受者临床资料,评估供体,选择供心,分析心脏移植受者生存情况和边缘供心使用情况。结果发现潜在供体,在判定脑死亡状态后,明确供体家属同意器官捐献后,评估供体,选择供心,使供受体最大限度匹配。73例心脏移植受者手术成功率为94.5%(69/73),围手术期死亡4例,术后随访1年死亡4例。边缘供心使用情况:供体年龄≥45岁17例,供受体体质量不匹配2例,供体中毒1例,供心冷缺血时间≥4 h 43例,大部分心脏移植受者予主动脉内球囊反搏和(或)体外膜肺氧合辅助,最终顺利出院。结论供受体最大限度匹配可使心脏移植患者获益最大;同时,适当放宽供心选择标准,增加供心数量,将为众多等待心脏移植患者带来希望。

基于文献计量学分析我国器官捐献和移植领域的伦理研究现状和进展

目的通过文献计量学分析我国器官捐献和移植领域伦理研究的进展和现状。方法检索中国知网期刊数据库2000年1月至2023年12月的主题文献,应用CiteSpace 6.2.6从发文量、核心作者合作网络、发文机构合作网络、关键词共现、关键词突现及关键词聚类等进行分析。结果检索共获得有效文献399篇,发文量趋势中的3次高峰受到政策时事和移植技术发展影响。2000年至2014年,发文量呈上升趋势,该阶段研究关注器官捐献和移植领域的伦理学思辨;2015年至2023年发文量呈波动趋势,该阶段关注捐献和移植工作体系和医疗实践下伦理问题,公民逝世后器官捐献、伦理审查等成为研究前沿。作者共现知识图谱反映出作者以单独节点为主,缺乏作者群之间交流,发文核心作者有25位。发文机构来源多样,包括高校医学相关院系、伦理学研究机构、医院器官移植科室、医院伦理委员会、人体器官获取组织(OPO)等,发文量最多的单位是昆明市第一人民医院。共提取252个关键词,13个突现词,突现度最强的关键词为脑死亡、器官捐献、立法、伦理审查。共生成14个关键词聚类,聚类主题包括器官移植、器官捐献、公民逝世后器官捐献、伦理道德、伦理审查、医务人员。结论器官捐献和移植伦理研究领域的作者和机构合作不足,应促进多中心研究和作者间合作。建议加强基于当前工作体系和医疗实践的伦理问题挖掘和实证研究,为器官捐献和移植事业的改革与实践提供伦理基础和辩护。

公民逝世后器官捐献激励政策的伦理研究

近年来,随着公民逝世后器官捐献与移植事业的快速发展,国家及地方相继出台了激励政策。为保障公民逝世后器官捐献者及其家属的合法权益,本文从伦理学视角对公民逝世后器官捐献激励政策现状进行梳理与分析,结合公正、尊重自主、不伤害、有利原则,梳理我国当前在实践公民逝世后器官捐献激励政策中存在的问题,如精神激励缺乏延续性心理干预、人道救助在实践中被曲解及间接经济激励对个人捐献自主性的影响等,并从政府、社会和个人三个层面提出相关对策与建议,以期为完善我国公民逝世后器官捐献激励政策提供参考,促进我国器官捐献事业的发展。

伴急性肾损伤的DBD供肾肾移植的临床结局

目的探讨伴急性肾损伤(AKI)的脑死亡器官捐献(DBD)供者供肾肾移植的临床结局。方法回顾性分析216例DBD供者的资料,按照改善全球肾脏病预后组织(KDIGO)标准将分为AKI组(69例)与正常组(147例),AKI组进一步分为KDIGO 1期和2~3期两组,AKI组受者135例,正常组受者288例。总结受者术后肾功能恢复情况及临床结局。分析移植物功能延迟恢复(DGF)发生的危险因素。结果AKI组供者血清肌酐(Scr)最高值、获取前Scr值、血钠最高值、获取前血钠值均高于正常组,升压药物应用时间长于正常组,48 h内液体复苏用量高于正常组,入院HCO3−值低于正常组,尿崩症、低血压发生率高于对照组;KDIGO 2~3期供者Scr最高值、获取前Scr值较KDIGO 1期供者高(均为P<0.05)。与正常组比较,AKI组受者DGF、急性排斥反应发生率较高,行连续性肾脏替代治疗的比例较高,术后90 d内Scr水平较高,术后3 d尿量较少;与KDIGO 1期受者比较,KDIGO 2~3期受者术后3、4、5、15 d Scr水平较高,术后2 d尿量较少(均为P<0.05)。单因素分析结果显示供者年龄、Scr最高值、血钠最高值、48 h内液体复苏用量是肾移植术后受者发生DGF的危险因素,多因素分析结果显示,供者年龄是肾移植术后受者发生DGF的独立危险因素(均为P<0.05)。结论伴AKI的DBD供者供肾用于肾移植,经过积极的器官维护可纠正AKI,对术后6个月移植物功能和存活率没有影响,可达到与非AKI供肾同样的效果,可作为扩大供肾来源。

人体器官捐献中的死亡标准问题

死亡后捐献是开展公民逝世后器官捐献工作最重要的伦理原则。新修订的《人体器官捐献和移植条例》未定义死亡,且回避了“是否承认脑死亡”这一关键性问题,器官捐献工作中可能存在一定的法律风险或损害捐献者权益的情况。死亡是人类生命过程最终无法避免的事实,任何时代都需要而且只能通过一些具体的标准来判定死亡。死亡标准的建立基础是人们所持有的死亡观,并受到生产力发展水平和其他社会因素制约。中西方死亡判定标准的认定上存在明显差异。为了规范器官捐献和移植工作,推进器官捐献高质量发展,必须坚持动机纯正原则,以知情同意为前提,尊重捐献者及其近亲属的死亡标准自主选择权,严格遵循死亡判定程序和操作规范,确保死亡认定的科学性、准确性和公正性。

Cold ischemia time in liver transplantation:An overview

The standard approach to organ preservation in liver transplantation is by static cold storage and the time between the cross-clamping of a graft in a donor and its reperfusion in the recipient is defined as cold ischemia time(CIT).This simple definition reveals a multifactorial time frame that depends on donor hepatectomy time,transit time,and recipient surgery time,and is one of the most important donor-related risk factors which may influence the graft and recipient’s survival.Recently,the growing demand for the use of marginal liver grafts has prompted scientific exploration to analyze ischemia time factors and develop different organ preservation strategies.This review details the CIT definition and analyzes its different factors.It also explores the most recent strategies developed to implement each timestamp of CIT and to protect the graft from ischemic injury.