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Warming to Non‐heart‐beating Donors?

D. Shoskes

Published 2001 in American Journal of Transplantation

ABSTRACT

Acute organ injury in the brain death, preservation, and implantation process is increasingly recognized as a mechanism of injury that has detrimental short- and long-term consequences in transplantation (1). A mainstay of organ preservation to prevent ischemia is cooling of the organ to between 1 and 4 aeC. Cooling slows adenosine triphosphate (ATP)-consuming metabolic processes and is typically well tolerated, for up to 48 h in kidney. The heart, on the other hand, tolerates cold ischemia poorly, with preservation times of 6 h or less. However, direct cytotoxic effects of cooling have long been appreciated, but are accepted as ‘collateral damage’ because of the other beneficial effects (2). Under conventional conditions, warm ischemia, whether prior to organ retrieval or during the transplant anastomosis, produces greater ischemic damage than a comparable duration of cold ischemia. Whatever the source of ischemia, much of the damage is believed to occur during reperfusion, with the production of free oxygen radicals leading to cell membrane destruction through lipid peroxidation. Transplantation from non-heart-beating donors is complicated by inevitable warm ischemia. This has resulted in very high rates of delayed graft function and higher rates of primary nonfunction, especially if uncontrolled non-heart-beating (NHB) donors are used. (‘Uncontrolled’ means the NHB donor is identified when already dead, as opposed to a ‘controlled’ donor whose heart is still beating when the organ retrieval team is present.) Nevertheless, this high rate of delayed graft function has not translated into poor long-term graft survival, especially if acute rejection is avoided (3). Cold machine perfusion has helped to reduce delayed graft function and improve graft survival in non-heart-beating kidneys. This may be due to reduced ischemic damage and/or the ability to discard suboptimal kidneys based on machine perfusion parameters (4).

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