EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Donor organ shortage is related to the organ transplant and many articles have been written on strategies to best use the deceased-donor organ pool.^1,2 With a receding number in the quality of organs, transplant surgeons are faced with the challenge of selecting the best out of marginal or high-risk donor offers. Donor malignancy and infections are key factors that have negative effect on organ donation.³ Most surgeons are likely to consider organs from these donors with caution as both of these conditions carry a risk disease transmission to organ recipients. We believe evidence in the literature (including the individual case reports, reviews, and registry data) greatly help in the decision-making process when faced with a difficult donor offer. Adhering to traditional clinical practice of decision-making based on clinical experience or confining oneself to a rigid protocol-based approach does not contribute to the progress of an organ transplant.

Regarding liver transplant, the change in quality of life and additional quality life years gained after a successful liver transplant should be weighed against the dying from advanced liver disease or hepato-cellular carcinoma; a case for considering marginal or high-risk donors.

We would like to recount briefly 2 recent clinical scenarios with difficult donor offers. On both occasions, the donor offers were either rejected by all other transplant centers or deemed high risk of transmitting infection based on laboratory findings at the time of donor offer. We referred to the literature on both occasions to ascertain the risk posed to the recipient by accepting these offers. Two recently published papers appeared on top of literature search on both occasions, which greatly helped to explain the prospective recipients the risk of accepting such grafts.

A liver graft was offered from a 44-year-old donor confirmed of brain death. The immediate medical history entailed a debulking cranial operation for a brain tumor (grade III oligodendroastrocytoma). The donor offer was refused by all transplant centers before offering to authors’ center. A literature search on this occasion returned the manuscript advising potential recipients on the use of organs from donors with primary central nervous system tumors by Warren and associates⁴; this manuscript, which systematically analyzed the risk of brain tumor transmission to the recipient supplemented with registry data from different programs in the United States, the United Kingdom, and Australia.

Having accepted the donor offer, we selected a recipient with advanced hepatocellular carcinoma, a lesion positioned close to the inferior vena cava. The recipient had previously undergone 2 cycles of transarterial chemoembolization (TACE). The most recent alpha-fetoprotein assay was over 6700, suggesting rapid tumor growth and was due for a repeat scan in 2 weeks. The patient waited 7 months on transplant wait list; meanwhile, he had been called in twice previously for transplant with DCD liver grafts, which was not materialized because of nonprogression of organ donation.

The article by Warren and associates helped the discussion with the patient before the transplant. When presented with the latest evidence, the patient was convinced that the likelihood of brain tumor transmission (6.4 at 95% confidence interval for grade 3 tumor and additional 1% for debulking operation) was actually lower, compared with his narrow window to have a lifesaving transplant or fall out of transplant wait list. In this case, the benefit of having the liver graft from the donor with brain tumor was in the favor, considering the stigma of rapidly growing lesion in the liver. The patient underwent a successful transplant with caval replacement technique, and was discharged home on the seventh postoperative day. He is now being followed-up as an outpatient.

The second donor offer came with 1 week apart from the first; a 71-old-brain dead donor was offered; however, the mandatory virology testing confirmed positive serology for HTLV-1 virus. The current National Health Service Blood and Transplant (NHSBT) in the United Kingdom recommends the use of organs from HTLV-1 positive donors with caution.⁵ Decision making is vested with clinicians accepting such offers. The literature review on this occasion returned the manuscript HTLV-1 in Solid-Organ Transplantation: Current Challenges and Future Management Strategies by Armstrong and associates,⁶ published in Transplantation as an early online, at the time of the search. The clear account on risk of more serious disease, and also the possibility of false-positive testing was immensely helpful in quantifying the risk. Moreover, the strategies for postexposure prophylaxis helped the discussion with our prospective recipient, a 62-year-old patient awaiting a re-graft for recurrent primary biliary cirrhosis. This woman was convinced, in the presence of deteriorating clinical condition with high MELD score and renal dysfunction, her chances for life were greater compared with the possible transmission of HTLV-1 disease. She was started on prophylactic treatment; however, as the authors of the above paper outlined in their manuscript, the confirmatory test for HTLV was proved negative after 72 hours. After a successful retransplant, she was discharged home on the 10th postoperative day.

In above cases, the decision-making would have been extremely difficult with the latest data and opinion published Transplantation. Patients and families were presented with the latest evidence in the literature and the management guidelines, and this boosted their confidence on our decision making. In both occasions, the recipient selection considered adding risks of disease transmission, weighed against the mortality without a transplant. In our opinion, the literature plays a major part in transplant practice. As clinicians always wanting to explore the ways to best use the marginal donor pool, we are often encountered with unusual or unconventional donor offers. It is the responsibility of transplant surgeons to report the success or failures of these donor offers, however rare they may be.

On the other hand, the journal editors dedicated to transplantation should consider these articles for publication in their journals as it may help in day-to-day decision making. Prominence to basic science articles is the undoubtedly the way forward, and the progress of transplant relies heavily on the basic science and translational research. On the other hand, we believe focus has to be equally on avenues to maximize the benefits of depleted donor organ pool currently at hand. In an era of safe medical practice, clinicians should be well informed of potential risks of donor offers (that probably comes from exper-ience).

The demand for more tests to ensure the safety of transplanted organs is mandatory. However, lack of guidelines to act upon in case of positive such tests probably accounts for significant amount of organ waste. The classic example being the positive serology for HTLV-1 screening where the con-firmatory tests may take up to 48 to 72 hours and until such time that the organs cannot await transplant. Rejecting such organs should not be the option for the surgeon who accepts these offers during socially unfriendly hours. Provisional acceptance, at least until such time the literature search or best available information is gathered by further enquiries and reference, may help increase the donor organ pool.

Finally, we commend the authors of 2 papers published in Transplantation for their contributions and the editorial team of the journal for timely publication of these that helped save to the most-deserving patients. We believe these articles and others provide significant help and confidence to transplant surgeons to take additional calculated risks, even though several written guidelines suggest a more-conservative approach.

Volume: 13 Issue: 5 October 2015

FULL TEXT