Circuitous Path to Live Donor Liver Transplantation from the Coordinator’s Perspective

Background: The live donor liver transplantation (LDLT) process is circuitous and requires a considerable amount of coordination and matching in multiple aspects that the literature does not completely address. From the coordinators’ perspective, we systematically analyzed the time and risk factors associated with interruptions in the LDLT process. Methods: In this retrospective single center study, we reviewed the medical records of wait-listed hospitalized patients and potential live donors who arrived for evaluation. We analyzed several characteristics of transplant candidates, including landmark time points of accompanied live donation evaluation processes, time of eventual LDLT, and root causes of not implementing LDLT. Results: From January 2014 to January 2021, 417 patients (342 adults and 75 pediatric patients) were enrolled, of which 331 (79.4%) patients completed the live donor evaluation process, and 205 (49.2%) received LDLT. The median time from being wait-listed to the appearance of a potential live donor was 19.0 (interquartile range 4.0–58.0) days, and the median time from the appearance of the donor to an LDLT or a deceased donor liver transplantation was 68.0 (28.0–188.0) days. The 1-year mortality rate for patients on the waiting list was 34.3%. Presence of hepatitis B virus, encephalopathy, and hypertension as well as increased total bilirubin were risk factors associated with not implementing LDLT, and biliary atresia was a positive predictor. The primary barriers to LDLT were a patient’s critical illness, donor’s physical conditions, motivation for live donation, and stable condition while on the waiting list. Conclusions: Transplant candidates with potential live liver donors do not necessarily receive LDLT. The process requires time, and the most common reason for LDLT failure was critical diseases. Aggressive medical support and tailored management policies for these transplantable patients might help reduce their loss during the process.

Markers of the Endothelial Glycocalyx Are Improved following Kidney Transplantation

<b><i>Introduction:</i></b> The endothelial glycocalyx on the vascular luminal surface contributes to endothelial health and function. Damage to this layer is indicative of vascular injury, reflected by increased levels of its shed constituents in serum and an increase in the perfused boundary region (PBR) when measured in sublingual capillaries using the GlycoCheck™ device. We aimed to examine the longitudinal effects of kidney transplantation on the glycocalyx by measuring biochemical markers of the glycocalyx and endothelial dysfunction and the PBR. <b><i>Methods:</i></b> We recruited healthy controls and stage 5 CKD patients scheduled to undergo a kidney transplant. Investigations were performed before transplant and then 1 and 3 months after transplantation. At each point, blood was collected for hyaluronan, syndecan-1, vascular cell adhesion molecule (VCAM-1), and von Willebrand factor (vWF), and a PBR measurement was performed. <b><i>Results:</i></b> Thirty healthy controls and 17 patients undergoing a kidney transplant were recruited (9 cadaveric and 8 live donation; 12 on dialysis and 5 pre-emptive). Before transplant, transplant recipients had greater evidence of glycocalyx damage than controls. After transplant, PBR improved from median 2.22 (range 1.29–2.73) to 1.98 (1.65–2.25) µm, <i>p</i> = 0.024, and syndecan-1 levels decreased from 98 (40–529) to 36 (20–328) ng/mL, <i>p</i> &#x3c; 0.001. Similarly, VCAM-1 fell from 1,479 (751–2,428) at baseline to 823 (516–1,674) ng/mL, <i>p</i> &#x3c; 0.001, and vWF reduced from 3,114 (1,549–5,197) to 2,007 (1,503–3,542) mIU/mL, <i>p</i> = 0.002. Serum levels of hyaluronan remained unchanged. <b><i>Conclusion:</i></b> The combination of reduced PBR and syndecan-1 following transplant suggests that transplantation may improve glycocalyx stability at 3 months after transplant.

Living Organ Donation Role of Ethics for Improved Clinical Practice

Solid organ transplantation represents one of the most important achievements in history of medicine. Over the last decades, the increasing number of transplants has not been of the same extent of the number of patients in the waiting lists. Live donation has been implemented in order to reduce the gap between supply and demand. From an ethical standpoint, the donation process from a live donor seems to violate the traditional first rule of medicine—primum non nocere because inevitably exposes healthy persons to a risk in order to benefit another person. In the chapter will be presented the crucial role of ethics and specific ethical issues in the different forms of live donation, such as financial incentives for living donation, reimbursement in unrelated live donation, minor sibling-to-sibling organ donation. The ethical aspects of live donor organ transplantation are continuously evolving; in order to make this strategy more beneficial and lifesaving, everyone involved in the process should make every possible effort with in mind the best interests of the patients.

Kidney transplantation

Kidney transplantation is by far the best therapeutic option for most end-stage renal disease patients. However, there is an increased demand for donor organs worldwide, which cannot be met by the number of currently available organs. Live donation is the key to solving this problem, at least for kidneys. Besides the advantages of better patient and graft survival, short ischaemia times, and pre-emptive transplantation, live donor kidney transplantation offers many creative options to facilitate more transplants, such as paired kidney exchange programmes (or cross-over), unspecified and domino-paired donation. Due to new immunological possibilities, blood group AB0-incompatible transplantation and desensitization prior to transplantation are now a clinical reality. Over the years, the evolution of surgical techniques (from invasive towards minimally-invasive) for live donor nephrectomy has contributed tremendously to the success of the programme. This chapter gives a state-of-the-art overview of kidney donation and transplantation, with an emphasis on surgical aspects.

Beating heart organ donation

Transplantation is the optimal treatment of end-stage dysfunction of many organs and can be life-saving. Despite increases in live donation and donation after circulatory death, donation after brain death remains the most important source of donor organs, and is currently the only source of thoracic organs in most countries. Brain death is associated with profound physiological changes including cardiovascular and respiratory changes, and severe metabolic and endocrine dysfunction that can jeopardize transplantable organ function. Although adequate time must be allowed for the proper confirmation of brain death, unnecessary delays should be avoided because the incidence of systemic complications that jeopardize transplantable organ function increases progressively with time. Aggressive donor management increases the number of potential donors who actually become donors, increases the total number of organs transplanted per donor, and improves transplantation outcomes. Various donor management strategies have been described and these are reviewed in this chapter.