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Editorials and Perspectives: Overview

Review of Randomized Clinical Trials of Donor Management and Organ Preservation in Deceased Donors: Opportunities and Issues

Dikdan, George S.; Mora-Esteves, Cesar; Koneru, Baburao1

Author Information
doi: 10.1097/TP.0b013e3182547537
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Abstract

With the perennially increasing gap between those who need transplantation and the number of available deceased donor organs, increasing the number and quality of organs transplanted per donor is very important. Randomized controlled trials (RCTs) would provide the best evidence to improve donor management and organ preservation practices that are needed to increase deceased donor organ yield. In this backdrop, we believe an overview of RCT of donor management and organ preservation in deceased donors would increase the awareness of the need for additional studies, serve as a quick reference source, promote further discussion, and help identify areas of opportunity for future studies.

LITERATURE SEARCH

MEDLINE, Cochrane Library (Cochrane Central Registry of Controlled Trials), Google Docs, ClinicalTrials.gov, and BioMed Central databases were searched using the following principal keywords: brain-dead donors, cardiac death, clinical trials, cold storage, DCD, deceased organ donors, donation after cardiac death, hypothermic perfusion, immunosuppression, machine perfusion, neurological death donors, non–heart beating donors, organ donors, organ preservation fluids, organ preservation solutions, prospective randomized trials, preconditioning, pulsatile, randomized trials, steroid, transplant, and transplantation. Additional keywords including individual vasopressors and specific steroids were combined with the principal keywords to refine the searches. Search limits were English-language only, all fields or title plus abstract, or title plus abstract plus keywords and encompassed all years covered by each database. Studies in live donors and combined donor and recipient treatment were excluded. Reports from the searches were combined with those obtained from the references of the collected reports. A total of 87 RCTs were obtained and grouped into Donor Management (Table 1), Preservation Fluids (Table 2), and Machine Perfusion (Table 3). In addition, a search of ClinicalTrials.gov and controlled-trials.com databases performed last January 15, 2012, revealed 16 registrations for new RCT.

TABLE 1
TABLE 1:
Prospective randomized trials of management with hormonal therapy, fluid resuscitation, immunosuppressants, and preconditioning in donors after brain death
TABLE 2
TABLE 2:
Prospective randomized studies of preservation fluids in deceased donor organs
TABLE 3
TABLE 3:
Prospective randomized trials of pulsatile perfusion (PP) compared with cold storage (CS) of kidneys recovered from donors after brain death (DBD) and donors after cardiac death (DCD)

DONOR MANAGEMENT

The broad goals of management of donors after brain death (DBD) include 1) maintenance of optimal circulatory and metabolic state, 2) evaluation and improvement or maintenance of organ function, 3) maximization of organs recovered and transplanted, and 4) improvement of graft quality. The evidence is conflicting regarding whether brain death results in significant changes in circulating levels of endogenous hormones and, more importantly, whether such changes contribute to the donor’s circulatory instability (1–6). Despite this, studies in brain-dead experimental animals in which hormonal (vasopressin, cortisol, triiodothyronine [T3], and insulin) administration improved metabolic and cardiovascular indices strongly suggested that hormonal therapy of DBD might be beneficial (4, 7–9).

Vasopressin

Initially, concerns existed that vasopressin, while increasing blood pressure, would decrease cardiac output and visceral blood flow and increase posttransplant acute tubular necrosis (ATN) of the kidneys (10–12). Two small RCTs showed that vasopressin was superior either to saline only or to epinephrine in maintaining blood pressure and cardiac output and in decreasing plasma osmolality and ionotrope use, in one study for more than a week after brain death (13, 14). Guesde et al. (10), in a larger RCT, tested the use of desmopressin, an analog of vasopressin, which has relatively more antidiuretic than vasopressor effects. Desmopressin decreased donor urine output without any adverse effects on the early and late posttransplant graft outcomes. The preceding studies and data from the Scientific Registry of Transplant Recipients (SRTR), which showed that use of vasopressin as part of hormonal therapy increased the number of organs recovered, have made the use of arginine vasopressin routine in management of DBD (15).

Thyroid Hormones

Several retrospective studies in DBD showed that thyroid hormone treatment improves donor hemodynamics, heart and lung utilization, and posttransplant cardiac allograft function (16–19). Interestingly, however, RCTs did not substantiate this. The number of donors per study varied from 23 to 80 (1, 5, 17, 20–24). Only one study evaluated posttransplant cardiac, renal, and hepatic graft outcomes (17). Doses of T3 varied from 2 to 4 µg every 30 or 60 min to a bolus combined with continuous infusion. In three studies, T3 was combined with steroids (5, 20, 24). Importantly, thyroid hormone treatment demonstrated no effect on donor hemodynamics, organ recovery, and/or function. In one study, thyroid hormone therapy paradoxically increased acidosis during surgery (22).

Colloids

Management of DBD often requires large volumes of crystalloids to combat hypotension, with consequent tissue edema. Thus, use of colloids in donor resuscitation is logical and it was tested in two RCTs. In one study, DBDs were randomized to receive either hydroxyethylstarch or crystalloids (25). While the hydroxyethylstarch group required significantly less fluids, no information on tissue edema, number of organs recovered, and organ function was provided. In another study, Cittanova et al. (26) compared hydroxyethylstarch plus gelatin with gelatin only and examined outcomes in kidney recipients. Hydroxyethylstarch increased serum creatinine and the need for dialysis.

Immunosuppressants

Steroids have been used in management of DBD in two eras with different rationale. Initially, methylprednisolone (MP) and cyclophosphamide (CP) were used with the notion that depletion of passenger leukocytes would improve kidney graft survival, which was supported by animal and retrospective clinical studies (27–30). Dienst (31) conducted a sequential study in which increasing doses of either MP or CP or both were used. Although combined use of 3 g of each improved 6-month kidney graft survival in a nonrandomized segment of their study, this was not substantiated in the randomized and blinded segments of the study. Chatterjee et al. (32, 33) investigated the effects of MP or CP given alone in two RCTs. Neither study reported improved kidney survival nor did a Swiss study in which both agents were used together (34).

Impetus for new RCTs of steroids came from experimental animal studies showing that steroids attenuate brain death-induced inflammation and improve organ function before and after transplantation and decrease rejection (35). Also, retrospective clinical studies showed that steroid use increases lung recovery (36) and improves posttransplant cardiac allograft function (37). In the largest RCT of steroid use, MP failed to decrease delayed graft function (DGF) despite down-regulation of expression of inflammatory and immune response genes in the kidneys (38). In contrast, in another recent RCT, MP, at a higher dose and over a longer duration than in the above mentioned kidney study, improved outcomes in liver transplantation (39). Methylprednisolone significantly decreased several proinflammatory cytokines in the donor serum, recipient serum aminotransferases, total bilirubin, and biopsy-confirmed acute rejection (AR). As in the kidney study, steroids favorably altered the expression of genes in the liver. Using a factorial design, two RCTs tested the effects of MP, T3, both, or placebo in thoracic organ donors. In lung donors, none of the active interventions improved the primary endpoint of donor partial pressure of arterial oxygen-to-fraction inspired oxygen (P:F) ratio, but the enrollment fell short of the targeted 96 donors (24). Despite this and based on finding a decreased accumulation of extravascular lung water index, the authors recommended the use of steroids in lung donors as an adjunct to active donor management. In heart donors, where enrollment target was reached, none of the interventions resulted in any improvement (5).

Thus, RCT of steroids in DBD showed no beneficial effects either in the donor or in recipients except in liver donors. Potential reasons for relative lack of efficacy could be the small size of the studies (5, 24) and/or suboptimal dosing and timing of steroid administration (5, 24, 38). Presently, a hormonal “cocktail” consisting of steroids, thyroid hormones, vasopressin, and insulin is widely used in management of DBD in the United States. Such a wide use is mainly based on SRTR data, which showed that use of hormonal protocol not only increased the number of organs recovered and transplanted but also improved posttransplant function of heart allografts and survival of kidney allografts (15, 37, 40). In a more recent report of SRTR data, 76% of DBD received steroids, 47% received thyroxine, and 22% received desmopressin (41). However, in this more recent data set, whereas steroid, diuretic, and desmopressin use is associated with increased organ yield, thyroxine use is not.

Preconditioning in Donors After Brain Death

Pharmacological Preconditioning

Diltiazem, epoprostenol, and other vasodilators and dopamine were tested in RCT to improve outcomes of transplanted kidneys and livers (42–47). In some of the earliest studies to address pharmacological conditioning, diltiazem administered either to the donor (42, 47) or in the preservation solution (44) improved renal graft function in some studies, but this was not substantiated in other studies (43). Similarly, donor administration of epoprostenol before cross clamp improved hepatic transaminases in liver recipients but clinical outcomes did not improve (46). On the other hand, in one of the largest donor intervention studies, dopamine administered for several hours before organ recovery significantly decreased incidence and duration of DGF (45).

Ischemic and Remote Ischemic Preconditioning

Evidence in experimental animals that a brief period of ischemia to an organ provided protection against longer periods of ischemia, reinforced by RCT in patients undergoing liver resection, served as the foundation for RCT of ischemic preconditioning (IPC) in liver transplantation from DBD (48). However, outcomes have been disappointing. Ischemic preconditioning has not improved clinical outcomes even when biochemical parameters of ischemic injury improved (49–55). Additional RCT of IPC in DBD is very unlikely. Remote ischemic preconditioning (RIPC), wherein a brief period of ischemia to a tissue, such as the skeletal muscle, provides protection to distant organs, offers several advantages over IPC. Its ease of implementation by inflation and deflation of either a blood pressure cuff or a pneumatic tourniquet in either the upper or the lower limb make RIPC feasible well before organ recovery. This feature combined with its relative inexpensiveness and the potential to benefit several donor organs makes RIPC an attractive donor intervention strategy that merits clinical investigation. One RCT in deceased donors is underway (Table 4).

TABLE 4
TABLE 4:
Prospective randomized trials of donor management and organ preservation in donors after brain death (DBD) and cardiac death (DCD) listed atClinicalTrials.gov and controlled-trials.com

Future Considerations

Conduct of new RCT of steroids versus no steroids would be difficult, at least in the United States. However, whether larger doses of steroids administered immediately after brain death determination and continued until organ recovery would further improve organ yield and organ function after transplantation could be tested against current protocols. Also, whether steroid use improves short-term and long-term organ functional outcomes needs further investigation. Because thyroxine is used in nearly half of DBD at some considerable expense without any clear evidence of benefit, additional RCTs are needed. Whether intensive insulin therapy of DBD would improve donor renal function and early posttransplant function is being tested in an ongoing RCT (Table 4). Also, several opportunities exist for RCT of preconditioning with remote ischemia, volatile anesthetics (56, 57), other gases such as helium and carbon monoxide (58–60), opioids (61, 62), and others (63–65). Research in the management of DBD is hampered by issues related to informed consent, research approval and regulation, and the need for a “buy in” from multiple stakeholders arising from the complexities of organ allocation (66–68). Facilitation of evolution of uniform donor research guidelines, practices, and regulations by federal agencies such as Health Resources and Services Administration and United Network for Organ Sharing are needed. Furthermore, not only the number but also the quality of organs transplanted must become an integral part of donor management research. In addition to recipient clinical outcomes, donor blood and/or other body fluid biomarkers that are either general, such as plasma interleukin-6 (69), or organ-specific, such as urinary neutrophil gelatinase–associated lipocalin (70), and others have the potential to enhance our ability to evaluate the effects of donor interventions on organ quality. Finally, RCTs of clinical management in donors after cardiac death (DCD) are severely restricted by current laws. With the increased use of organs from such donors, multipronged efforts are required to modify the legal standards to facilitate clinical investigation.

ORGAN PRESERVATION SOLUTIONS

While the goal of a preservation solution universal to all solid organs still remains elusive, the University of Wisconsin (UW) solution is the closest to it. For the sake of clarity, we will discuss the various RCTs in an organ-specific manner.

Liver

Since the first report of use of UW solution in human liver transplantation (71), which prolonged the safe preservation time of the liver, all randomized studies but for one (72) used UW solution as the comparator, an acknowledgment of UW solution as the gold standard. Despite this, its cost, low flow rates resulting from high viscosity (relevant in DCD), and potential cardiac problems during reperfusion encourage the quest for alternatives. Overall, the outcomes in RCTs comparing UW with histidine-tryptophan-ketoglutarate (HTK), Celsior, and Institut Georges Lopez 1 solutions in liver have been similar except for two reports wherein biliary complications were more in HTK group in one study (73) and surgical complications were greater in the Celsior group in another (74).

Kidney

The pivotal RCTs comparing UW and HTK with the erstwhile standard of Euro-Collins solution showed clear superiority of UW (75) and HTK solutions (76) in improving both immediate function and graft survival. Additional studies comparing UW with Celsior (74, 77–79) and HTK solutions (76, 80) showed them to be comparable in clinical outcomes except for one study in which surgical complications were greater in the Celsior group (74). In the very few RCTs in DCD, one study compared Euro-Collins with UW (81) and another with HTK solution (82). Although in the former, there were no overall differences, the HTK solution proved superior in both short-term and long-term outcomes. In another interesting double-blinded RCT, administration of streptokinase versus saline immediately before organ flush not only decreased mottled appearance of the kidneys but also improved pulsatile perfusate flow and perfusate biomarker levels (83).

Pancreas

There are four reports of RCTs of preservation solutions in pancreas transplantation. Two compared Celsior versus UW and showed no differences (79, 84). In another RCT, UW was compared with HTK solution with similar outcomes (85). The fourth RCT, which compared UW versus HTK solutions in kidney recipients, included nine simultaneous kidney pancreas grafts but did not report pancreas-specific outcomes (80).

Heart

Although many solutions have been used in preservation of heart for transplantation in humans, only seven RCTs reports are available. In four small RCTs, UW was superior to Celsior (86), crystalloid (87), Stanford (88), and St. Thomas solutions (89). In another RCT, blood, when compared with crystalloid cardioplegia, reduced acute right heart failure, conduction abnormalities, and creatine kinase levels (90). In another study regarding which only preliminary but no final data are available in the literature, Celsior was superior to the HTK solution (91). In the largest RCT, Celsior was compared with a variety of preservation solutions and resulted in fewer adverse cardiac-related events (92).

Lung

Euro-Collins and, subsequently, UW solutions were used routinely for lung preservation until the advent of additional preservation solutions (93). In the only RCT of preservation solutions in the lung, D’armini et al. (94) compared outcomes with Celsior versus UW solutions. Although P:F ratios were better in the UW group, long time survival was comparable. However, because of concerns that solutions with high potassium such as UW induce pulmonary vasoconstriction, an extracellular fluid mimic containing low potassium, 1% glucose, a phosphate buffer, and Dextran 40 is increasingly used for lung preservation. Although no RCTs are available, SRTR data show that this solution is superior to UW solution in improving 1-year survival of lung recipients (95).

Registry Data

Of concern is a series of reports based on SRTR data comparing UW with HTK in liver, kidney, and pancreas and UW with Celsior solutions in heart transplantation (96–99). Risk of graft loss was higher in recipients of HTK livers from DCD, in donors older than 70 years, and in donors with cold ischemia for more than 8 hr (96). Also, the risk of kidney graft loss was greater with HTK solution (97). The increased risk of pancreas graft loss with HTK applied not only to isolated but also to simultaneous kidney or pancreas transplants (98). In heart transplantation, use of UW solution was associated with improved 30-day and 1-year patient survival (99).

Future Considerations

Several additives such as M101 (100) and perfluorocarbons (101), which can carry dissolved oxygen, polyethylene glycols of varying molecular size with “immunocamouflage” properties (102), and newer preservative solutions such as Lifor (103) and phosphate-buffered sucrose (104), are being evaluated in experimental animals. Also, sodium hydrogen ion exchanger inhibitors such as cariporide and cytoprotective recombinant human neuregulin are being examined as potential additives to heart preservation solutions (105, 106). Some have the potential to reach clinical trials stage. However, postmarketing experiences with the HTK solution indicate the need for larger phase 3 trials in the future in the evaluation of preservation fluids.

PULSATILE PERFUSION VERSUS COLD STORAGE FOR ORGAN PRESERVATION

The first RCT in clinical kidney preservation was conducted by Sterling et al. (107). In this very small study of 10 recipients, outcomes of pulsatile perfusion (PP) were similar to those of cold storage (CS). Additional and larger RCTs comparing both modalities followed in both DBD and DCD (Table 3). The primary endpoint in most of these studies was DGF or ATN, usually defined as dialysis use during first posttransplant week. Results were mixed: some studies showed that PP improved DGF (108–111) and graft survival (109, 110), whereas in others, PP provided no benefit (112–117). This backdrop of uncertainty combined with logistical complexities and expense of PP had led to widespread adoption of CS as the preferred method of deceased donor kidney preservation. A systematic review by Wight et al. (118) in 2003 concluded that PP decreased the risk of DGF by 20% but did not improve 1-year graft survival. To prospectively test the perceived potential of the small benefit of PP in improving graft survival, the authors believed that very large studies with a long follow-up would be required.

Interest in PP resurged owing to the increased contribution of extended criteria donors and DCD to the deceased donor kidney pool. Data suggest that PP may increase utilization of extended criteria donor kidneys (119). Furthermore, in a recent, well-designed European multicenter RCT, Moers et al. (120) reported that PP, which was instituted in a well-controlled setting soon after organ recovery, not only decreased DGF and its duration but also improved 1-year graft survival of DBD kidneys. An extension of that study subsequently showed that PP decreased DGF in DCD kidneys as well (121). In contrast, another multicenter British RCT was preemptively stopped because there was no evidence that PP would decrease DGF in DCD kidneys (122). However, it is noteworthy that unlike in the study by Moers et al., PP was started several hours after organ recovery. In a recent review, Taylor and Baicu (123) discuss the many potential opportunities that machine preservation offers in addition to organ preservation such as ex vivo pharmacological treatment of the organ and evaluation of suitability for transplantation. Although efficacy of pharmacological therapy at low temperatures is not well established, two RCTs point to the potential of pharmacological treatment of organs ex vivo through additives to the perfusate (124, 125). Perfusate flow and resistance data are often taken together with the clinical information in the decision before transplantation of pumped kidneys. Retrospective studies suggest the potential utility of perfusate flow, resistance (126), glutathione-S-transferase (127), and redox active iron (128) in kidney selection. A recent RCT in which biomarker analyses were performed after transplantation showed that glutathione-S-transferase, N-acetyl-β-D-glucosaminidase, and heart-type fatty acid binding protein bore association with DGF (129). Thus, additional RCTs are needed to validate the aforementioned and other biomarkers of organ quality during PP.

Future Considerations

With the experience and knowledge gained with kidneys, PP preservation is being expanded to include liver (130, 131), heart (132), and pancreas (123). In a recent clinical feasibility study of PP of liver, Guarrera et al. (131) reported excellent outcomes. Additional studies of the liver and heart are underway (Table 4). Unlike in donor management research, there is considerable investment by industry in this area. However, as with other technical innovations, PP is costly. Hence, in the present economic constraints related to health care, rigorous proof that PP increases the number of transplanted extrarenal organs and improves their quality is needed.

CONCLUSIONS

Our review shows an encouraging increase in clinical trials in donor management and organ preservation practices (Table 4). A majority of past studies have been small with the attendant risks of inadequate power. Well-designed, large, and multicenter trials exemplified by some of those conducted with preservation fluids, steroids, and machine preservation of the kidney are needed. Short-term evaluation of organ function must include clinically important recipient outcomes such as DGF in the kidney, early allograft dysfunction of the liver, and primary graft dysfunction of the lung rather than only routine biochemical parameters. Utilization of biochemical and molecular biomarkers would further facilitate the conduct of the trials but awaits development and validation of such markers. Although long-term graft outcomes would remain the gold standard to evaluate donor organ quality, given the resources required, validation, and use of surrogate endpoints of long-term graft survival such as estimated glomerular filtration rate at one year and others would be helpful (133). Funding of donor management and related research when compared with other areas of transplantation has lagged behind. Given the inherent lack of potential for a “blockbuster” drug because of the relatively small number of deceased donors and thus the lack of interest from pharmaceutical sponsors, increased federal funding is very much needed.

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                                      Keywords:

                                      Randomized trials; Clinical trials; Deceased donors; Donor management; Pulsatile perfusion; Preservation solutions; Preconditioning

                                      © 2012 Lippincott Williams & Wilkins, Inc.