New England Organ Bank

Brief normothermic machine perfusion is increasingly used to assess and recondition grafts before transplant. During normothermic machine perfusion, metabolic activity is typically maintained using red blood cell (RBC)-based solutions. However, the utilization of RBCs creates important logistical constraints. This study explored the feasibility of human kidney normothermic perfusion using William's E-based perfusate with no additional oxygen carrier. Sixteen human kidneys declined for transplant were perfused with a perfusion solution containing packed RBCs or William's E medium only for 6 h using a pressure-controlled system. The temperature was set at 37 °C. Renal artery resistance, oxygen extraction, metabolic activity, energy metabolism, and histological features were evaluated. Baseline donor demographics were similar in both groups. Throughout perfusion, kidneys perfused with William's E exhibited improved renal flow (P = 0.041) but similar arterial resistance. Lactic acid levels remained higher in kidneys perfused with RBCs during the first 3 h of perfusion but were similar thereafter (P = 0.95 at 6 h). Throughout perfusion, kidneys from both groups exhibited comparable behavior regarding oxygen consumption (P = 0.41) and reconstitution of ATP tissue concentration (P = 0.55). Similarly, nicotinamide adenine dinucleotide levels were preserved during perfusion. There was no evidence of histological damage caused by either perfusate. In human kidneys, William's E medium provides a logistically convenient, off-the-shelf alternative to packed RBCs for up to 6 h of normothermic machine perfusion.

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We appreciate the commending remarks by Weiss and Chaudhary on the algorithm showing the process of donation following the determination of death by neurological and circulatory criteria via clinical conditions of a pathway of end-of-life care: the transition from death to organ recovery and transplantation. The clinical conditions detailed in the algorithm did not include voluntary euthanasia as a pathway to organ donation. Although Weiss and Chaudhary noted that this approach has been undertaken in Quebec, Canada, the Netherlands, and Belgium, the legal permissibility, ethical acceptance, and international experience of voluntary euthanasia followed by organ recovery has not reached a sufficient threshold to become a standard practice—and thus, not included in the algorithm. THE LEGAL BARRIERS THAT PRECLUDE INTERNATIONAL STANDARDIZATION Voluntary euthanasia including euthanasia followed by organ donation remains illegal in the majority of European countries and in the United States (where some states do permit medically assisted suicide). In contrast, withdrawal of life-sustaining treatment under the circumstances of controlled donation after circulatory death is legally permissible and widely accepted internationally. This distinction regarding legal permissibility is the primary reason for omission of voluntary euthanasia and organ recovery into the algorithm. THE LACK OF INTERNATIONAL EXPERIENCE TO STANDARDIZE A SUCCESSFUL PRACTICE OF ORGAN TRANSPLANTATION AFTER EUTHANASIA There is insufficient data and experience to recognize a standard protocol for euthanasia followed by organ donation. The 2019 reference cited by Weiss and Chaudhary identifies the issue of insufficient data to develop further standardization in practice: “…although some authors have suggested that organ donation after medical assistance in dying might have a substantial impact on organ availability, the practice of organ donation after medical assistance in dying in Canada is still rare. More data about this practice must be collected to determine whether this guidance document is helpful or needs to be updated.”1 Without a recognized standard protocol with understood outcomes, the pathway of organ donation following euthanasia is not sufficiently developed to include into the algorithm. THE ETHICAL CONTROVERSY REGARDING EUTHANASIA COULD UNDERMINE PUBLIC TRUST IN THE SYSTEM OF DONATION Significant controversy remains regarding the ethical propriety of sanctioning voluntary euthanasia as a standardized practice. Until such ethical concerns regarding euthanasia are adequately addressed, introduction of a pathway to organ recovery following euthanasia may serve to amplify these ethical issues and erode the public trust in donation. Specifically, the public trust that the donation of organs remains independent of a decision to facilitate ending a patient’s life. Introducing these concepts together in the midst of unresolved significant ethical controversy over euthanasia might undermine public trust in donation. Given these legal, ethical, and experiential limitations, we conclude that the threshold for considering voluntary euthanasia to organ recovery as an international standard has not been sufficiently achieved and therefore it is appropriately excluded in an algorithm designed to derive consensus regarding recognized standard donation practices.

To compare the progression-free survival of dogs with high-grade T-cell lymphoma treated with either a cyclophosphamide, doxorubicin, vincristine and prednisone-based or a modified mechlorethamine, vincristine, prednisone and procarbazine chemotherapy protocol. In this retrospective study, cases were selected based on histologic or cytologic diagnosis of lymphoma, T-cell phenotype, hypercalcaemia, or both, and no previous chemotherapy for lymphoma. Treatment was not randomly allocated. Seventy-three dogs were included in this study: 50 in the cyclophosphamide, doxorubicin, vincristine and prednisone group and 23 in the mechlorethamine, vincristine, prednisone and procarbazine group. The median progression-free survival was 133 days for dogs in the cyclophosphamide, doxorubicin, vincristine and prednisone group and 97 days for dogs in the mechlorethamine, vincristine, prednisone and procarbazine group. When golden retrievers (n = 16) were evaluated -separately, progression-free survival was longer in the cyclophosphamide, doxorubicin, vincristine and prednisone versus mechlorethamine, vincristine, prednisone and procarbazine treatment group (medianPFS 154 days versus 70.5days, respectively). The progression-free survival time for dogs with multi-centric T-cell lymphoma treated with a modified mechlorethamine, vincristine, prednisone and procarbazine protocol was similar to that of dogs treated with cyclophosphamide, doxorubicin, vincristine and prednisone. Further studies, including those evaluating golden retrievers separately, are needed to confirm these findings.

IntroductionSince 2004, an international training institute has educated more than 8,000 organ and tissue donation professionals in traditional classroom settings. In 2014, institute launched a Virtual Classroom Training (VCT) initiative using combination of eLearning modules, instructor-led webinar

The clinical characteristics of all New England Organ Bank (NEOB) donors after circulatory death (DCD) donors were analyzed between July 1, 2009, and June 30, 2014. During that 5-year period, there were 494 authorized medically suitable potential DCDs that the NEOB evaluated, constituting more than 30% of deceased donors coordinated annually by the NEOB. From the cohort of 494 authorized potential DCDs, 331 (67%) became actual DCD, 82 (17%) were attempted as a DCD but did not progress to donation, and 81 (16%) transitioned to an actual donor after brain death (DBD). Two hundred seventy-six organs were transplanted from the 81 donors that transitioned from DCD to actual DBD, including 24 heart, 70 liver, 12 single and 14 bilateral lung, and 12 pancreas transplants. When patients with devastating brain injury admitted to the intensive care units are registered donors, the Organ Procurement Organization staff should share the patient's donation decision with the health care team and the patient's family, as early as possible after the comfort measures only discussion has been initiated. The experience of the NEOB becomes an important reference of the successful implementation of DCD that enables an expansion of deceased donation (inclusive of DBD).

Vascularized composite allograft (VCA) transplantation is a medically acceptable treatment for the reconstruction of major tissue loss. The advent of VCA transplantation has spurred regulatory and policy development in the United States to address the multiple clinical, ethical and legal issues that must be considered for the practice of VCA donation and transplantation to develop within the existing framework of public trust and transparency vital to the success of donation and transplantation.