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Solid organ transplantation is the standard of care for patients with end-stage organ disease. The field of transplantation is exceedingly complex and requires multidisciplinary collaboration to navigate the intricacies of patient selection, perioperative care, and operative technique. Relevant aspects include careful evaluation of patients prior to transplantation, determining the potential benefits of the procedure, and assessing any inherent risks. Prolonged waiting times due to discrepancies between organ supply and demand mandate careful consideration of all available organs; novel preservation methods may allow for the use of previously unavailable or marginal organs. High morbidity and mortality rates for patients awaiting transplantation are currently one of the most challenging areas in the field of transplantation. This chapter will focus on these topics as they relate to liver, kidney, and pancreas transplantation.
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ORGAN DONORS AND SELECTION CRITERIA
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In 2021, more than 41,000 solid organ transplantations were performed in the United States, which included almost 35,000 transplants from deceased donation: almost 25,000 kidney, more than 9000 liver, and almost 1000 pancreas transplants (either as simultaneous kidney/pancreas or isolated pancreas transplants) (Organ Procurement and Transplantation Network [OPTN] data, accessed November 14, 2022; https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/). Nevertheless, the demand for organs exceeds the available supply by far, and there are currently more than 100,000 individuals awaiting transplantation. The number of wait-listed patients has doubled over the last two decades, and more than 6000 patients die each year while awaiting transplantation.
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Deceased Donor Transplantation
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The overwhelming majority of abdominal transplants are from deceased donors (DDs), a practice that has allowed solid organ transplantation to become an established therapy for end-stage organ failure. Within this category, 80%-90% of DD transplants are from patients with brain death (BD), defined by cessation of brain stem reflexes, and the remainder are from patients after declaration of death by circulatory criteria (donation after cardiac death [DCD]); rates for DCD have increased during the last decade. Circulatory death ultimately leads to prolonged warm ischemia times as compared to BD donors, an inevitability that must be considered during perioperative planning and when analyzing outcomes. Specific time intervals between discontinuation of life support and cardiac arrest have therefore been proposed to prevent detrimental consequences to organ quality. For kidney transplant recipients from DCD donors, there is a higher rate of delayed graft function, but rates of patient and graft survival are comparable and without a risk of increased complications. However, among liver transplants, DCD donors have a fivefold higher potential for nonanastomotic biliary stricture, either due to the ischemic insult itself or impaired biliary epithelial regeneration, in addition to higher rates of graft loss and overall mortality. While specific criteria such as donor age, time from extubation to circulatory arrest, and hemodynamics impact outcomes, DCD organs have allowed for an increase in the availability of transplants with outcomes mostly comparable to those of BD donor organs. Given the risks associated with ...