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The satisfactory early function of transplanted organs depends in part upon procurement techniques that minimize the ischemic injury to those organs. The amount of ischemia, warm or cold, that an organ can tolerate and still provide life-sustaining function following transplantation is different for each organ system. The combination of procurement techniques for hearts or livers with those for kidneys has been described elsewhere.1,2 These reports concentrated on demonstrating satisfactory early function of the renal allografts obtained with these techniques. More recently, we have outlined the principles of combination procurement procedures for all three organ systems.3 The present communication is a report of our experience using the procurement techniques described for obtaining organs from all three systems from single donors.
From March 28, 1981, until August 7, 1982, surgical teams from the University of Pittsburgh transplant team participated in the combined procurement of hearts, livers, and kidneys from 11 individual donors. A total of 44 organs, (11 hearts, 11 livers, and 22 kidneys) were thus made available for transplantation. Tables 1, ,2,2, and and33 outline the origin and distribution of these organs. Eleven hearts, 9 livers, and 21 kidneys were transplanted. Two livers were not used because of problems with recipients. One kidney was discarded because of a surgical injury by the nephrectomy team.
As seen in Table 4, 12 of the 21 kidneys transplanted were preserved by pump perfusion; the other 9 were stored in ice. Preservation times ranged from 7 to 40 hr (mean 22.6 ± 13.2) for the perfused group and from 8 to 37 hr (mean 20.9 ± 9.1) in the ice-stored group.
The 9 hearts transplanted at the University of Pittsburgh were core-cooled in the donor by infusing a cold (4°C) cardioplegic solution containing potassium (20 meq/liter) via a catheter in the ascending aorta.24 The two hearts procured and used by another transplant center were surface cooled by immersion of the beating heart in an ice bath without the use of cardioplegic solution. All hearts were stored and transported in ice and transplanted within a mean time of 121.4 ± 48.1 min (range, 45 min to 3 hr).
All transplanted livers were preserved in ice storage with preservation times varying from 45 min to 9 hr (mean 219.4 ± 143 min).
Table 5 summarizes the immediate functional results following transplantation of all 41 organs.
One of 21 recipients of kidneys required dialysis during the first week following renal transplantation. That patient’s graft had been stored in ice for 28 hr before transplantation. The contralateral mate to this graft was the 1 kidney that was discarded because of a surgical injury.
All 11 transplanted hearts provided satisfactory early function, as defined by successful removal of the recipients from all extracorporeal circulatory support. Although 1 recipient at another center died within 24 hr of transplantation, the cause was reported to be hyperacute rejection.
None of the liver recipients experienced difficulties with early graft dysfunction. One liver recipient transplanted outside of Pittsburgh reportedly had good liver function immediately postoperatively and survived for over 2 weeks with normal liver function. Two of the recipients in Pittsburgh experienced severe acute rejection and required retransplantation after 11 and 12 days of satisfactory liver function. One of these (OT 244) also received his second liver from a combination heart, liver, and kidney donor. The serum transaminase levels and bilirubins on the first, third, and fifth postoperative days are shown in Table 6 and summarized in Table 7.
Two patients in this group eventually required hepatic retransplantation. In both instances a period of satisfactory graft function was followed by an episode of rapid deterioration consistent with severe acute rejection. Five of the 6 patients (one patient received two livers) transplanted in Pittsburgh and 1 of 2 patients transplanted elsewhere eventually were discharged from the hospital. This includes 1 of the 2 patients requiring retransplantation.
The function of an organ immediately following its transplantation is largely dependent upon the efficacy of the procurement technique in preventing warm ischemia. When compared with livers and hearts, kidneys are relatively more tolerant of both warm and cold ischemia and thus allow for considerable latitude in the efficiency of procurement procedures. Nevertheless, the incidence of dialysis during the first week following transplantation is quite variable in the literature, ranging from 17% to 54% when kidneys alone are harvested.5–10 Although many factors other than the procurement procedure will influence the number of kidney recipients who require dialysis in the first week following transplantation, the additional task of obtaining the heart and liver from the same donor must not exaggerate that number. We have previously shown that combined procurement of hearts and kidneys2 or livers and kidneys1 does not adversely influence this first-week dialysis incidence. In fact, in 56 transplanted kidneys obtained in combination with livers and in 36 obtained with hearts, the incidence of first-week dialysis was 18% and 12%, respectively.1,2 The incidence in these 11 cases of procurement of all three organ systems is <5%.
To what degree donor selection played a role in providing for a low incidence of first-week dialysis among these kidney recipients is not easily determined. However, donors who suffer from prolonged periods of cardiovascular instability or multiple cardiac arrests are seldom acceptable as either liver or heart donors. The relative intolerance of the extrarenal organs to ischemia demands careful attention to donor maintenance during the actual donor operation. Finally, the high level of professional input normally attendant during the procurement of multiple organs normally assures the quality of all grafts obtained.
All livers in this report experienced only minor ischemic injuries as evidenced by rises in transaminases that decreased rapidly following transplantation. Both of the patients who eventually required hepatic retransplantation obtained at least 12 days of adequate function from their first liver before an episode of acute deterioration signaled acute graft failure. The clinical impression that the cause of these two failures was immunologically mediated was confirmed by histologic examination of the organs removed at the time of retransplantation. One of these 2 patients died from a variety of complications, including sepsis. The other retransplanted patient and all of the other patients transplanted at Pittsburgh have survived for at least 9 months.
The precooling step described elsewhere1 and known to be a critical step in eliminating hepatic warm ischemia also has the added advantage of reducing donor core temperature to 28–30°C and thus provides added protection to both the heart and kidneys. As long as donor acid-base status, electrolytes, cardiac-filling volume, and blood oxygen content are well maintained, the hypothermia induced by the portal precooling step does not predispose to premature development of cardiac arrhythmias.
Supported by grant nos. AM-30183 and AM-2996I from the Veterans Administration and the National Institutes of Health, Bethesda, MD.