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, and 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.
ORGAN DONORS AND SELECTION CRITERIA
In 2017 alone, 34,770 solid organ transplantations were performed in the United States, which included more than 28,000 transplants from deceased donation: almost 20,000 kidney, more than 8000 liver, and just over 1000 pancreas transplants (either as simultaneous kidney/pancreas, pancreas after kidney, or isolated pancreas transplants; Organ Procurement and Transplantation Network [OPTN] data from https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/). The demand for organs exceeds the available supply by far, and there are currently more than 125,000 patients awaiting transplantation. Moreover, the number of waitlisted patients has doubled over the past two decades, and more than 6000 patients die each year while awaiting transplantation. Among abdominal organs transplanted, there has been a decline in patients listed for pancreas and liver transplants; in contrast, patients listed for renal transplants have steadily increased by approximately 3% per year.
Deceased Donor Transplantation
The overwhelming majority of abdominal transplants are from deceased donors, a practice that has allowed solid organ transplantation to become an established therapy for end-stage organ failure. Within this category, 80%-90% of deceased donor transplants are from patients with brain death (BD), defined as cessation of brainstem reflexes, and the remainder are from patients after a declaration of death has been made by circulatory criteria (so-called donor after cardiac death [DCD]). Rates for donation after cardiac death have increased over the past decade. Circulatory death ultimately leads to prolonged warm ischemia times as compared to BD, 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 DCDs, 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, DCDs have a fivefold higher potential for nonanastomotic biliary stricture, either due to the ischemic insult itself or due to impaired biliary epithelial regeneration, in addition to higher rates of graft loss and overall mortality. Although specific criteria such as donor age, ...