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The Alliance

Spotlight Series

The Alliance Spotlight Series is a recurring one-page publication for front-line healthcare professionals, offering quick-takes on critical topics affecting the field of organ donation and transplantation. We encourage you to download these issues and share them with your front-line colleagues and partners.

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The Alliance Spotlight Series
Volume IX ,
Issue 2
Close Up Of Gloved Hands Passing The Surgical Scissors, Operatin
As with many new approaches or procedures in medicine, NRP comes with legal and ethical considerations, clinical considerations, as well as operational considerations. This issue will focus on the clinical aspects of NRP.

Clinical Considerations of Normothermic Regional Perfusion (NRP)

Normothermic regional perfusion (NRP) is an in-situ perfusion of a portion of the donor’s body with the aid of mechanical organ support. This practice is utilized in a growing number of donation after circulatory determination of death (DCD) cases.

The overall advantage of NRP is that organs previously not utilized can now be utilized for transplantation, allowing for improved stewardship of the gift from the donor and their family and providing hope for those in need of a life-saving transplant.

As with many new approaches or procedures in medicine, NRP comes with legal and ethical considerations, clinical considerations, as well as operational considerations. This issue will focus on the clinical aspects of NRP.

There are two approaches to NRP:

  1. Thoracic-abdominal (TA)-NRP – in which the thoracic and abdominal organs are perfused. This approach is utilized for DCD heart recovery.
  2. Abdominal (A)-NRP – in which only the abdominal organs are perfused.

How does the use of NRP change the current DCD process?

Following the required “hands-off” period of 2-5 minutes after the patient has been declared dead according to circulatory and respiratory criteria, a full upper and lower midline incision is made. The next step is to re-establish perfusion within a specific region of the body, i.e., thoracic and abdominal or just the abdominal area. To isolate the perfusion to the thoracic and abdominal area, the arch vessels are clamped (including the cerebral arteries) and vented to prevent brain perfusion, and the aorta and right atrium are cannulated. Oxygenated blood flow is then reinitiated to the designated regional area with the aid of mechanical organ support.

Screenshot 2023 04 24 151857

Risks & Benefits of NRP

With every clinical procedure, risks and benefits must be weighed.

Overall, the Risks of NRP are:

  • Risk of primary graft dysfunction (PGD): This risk is no different than in a brain dead donor.
  • Ethical concerns: This will be further discussed in a separate Spotlight publication.
  • Technically challenging: It takes practice.
  • DCD protocols vary between hospitals and OPOs: Standardization is currently being addressed.

TA-NRP Risks & Benefits:

2

**It is worth noting that even if the above complications occur, the abdominal organs are still being perfused and can be recovered for transplant.

A-NRP Risks & Benefits:

1

Conclusion:

  • NRP mitigates the detrimental impact of warm ischemic time (WIT).
  • NRP can improve graft and patient outcomes in multiple organs.
  • NRP can increase the number of potential organs for transplant.
  • NRP has significant cost savings in comparison to ex-vivo perfusion machines.

Moving forward, ongoing monitoring of outcome data is needed, the impact of NRP on lung donors should be explored, and the ability of NRP to increase utilization of organs from Extended Criteria Donors should be evaluated.

Helpful Resources

Learning Pathway – 2023 National Critical Issues Forum: Normothermic Regional Perfusion (NRP)

References:

Brubaker AL, Urey MA, Taj R, et al. Heart-liver-kidney transplantation for AL amyloidosis using normothermic recovery and storage from a donor following circulatory death: Short-term outcome in a first-in-world experience. American Journal of Transplantation. 2023;23(2):291-293. doi: https://doi.org/10.1016/j.ajt.2022.11.003

Hessheimer AJ, Coll E, Torres F, et al. Normothermic regional perfusion vs. super-rapid recovery in controlled donation after circulatory death liver transplantation. Journal of Hepatology. 2019;70(4):658-665. doi: https://doi.org/10.1016/j.jhep.2018.12.013

Hoffman JRH, McMaster WG, Rali AS, et al. Early US experience with cardiac donation after circulatory death (DCD) using normothermic regional perfusion. The Journal of Heart and Lung Transplantation: The Official Publication of the International Society for Heart Transplantation. 2021;40(11):1408-1418. doi: https://doi.org/10.1016/j.healun.2021.06.022

James L, LaSala VR, Hill F, et al. Donation after circulatory death heart transplantation using normothermic regional perfusion:The NYU Protocol. JTCVS techniques. 2023;17:111-120. doi: https://doi.org/10.1016/j.xjtc.2022.11.014

Sellers MT, Nassar A, Musab Alebrahim, et al. Early United States experience with liver donation after circulatory determination of death using thoraco‐abdominal normothermic regional perfusion: A multi‐institutional observational study. Clinical transplantation. 2022;36(6). doi: https://doi.org/10.1111/ctr.14659

Shah AS. Normothermic regional perfusion in donor heart recovery: Establishing a new normal. The Journal of Thoracic and Cardiovascular Surgery. 2022;164(1):142-146. doi: https://doi.org/10.1016/j.jtcvs.2021.11.084

Questions & Comments

Please send all questions and/or feedback to [email protected].

A special thanks to Dr. Marty Sellers, Dr. Aleah Brubaker, and Dr. John Trahanas for their contributions to this Spotlight. This Spotlight is based on two presentations from the NRP National Critical Issues Forum held in March 2023: “Clinical Consideration of Abdominal Normothermic Regional Perfusion” and “Clinical Considerations in Thoracic Normothermic Regional Perfusion”.

Sign-up for the Learning Pathway to gain access to a recording of the conference: https://www.organdonationalliance.org/courses/2023-national-critical-issues-forum-normothermic-regional-perfusion-nrp/

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Volume IX, Issue 2 V3
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A Special Thanks to This Series’ Contributors

Hedi Aguiar
Speaker
Hedi Aguiar
RN, MSN
Program Consultant
Organ Donation and Transplantation Alliance
Deanna Fenton
About the Editor |
Deanna Fenton

Deanna is a knowledgeable and versatile professional with diverse experiences in healthcare, client relations, marketing, project management and demonstrated skills in leadership and advocacy. Prior to joining The Alliance, she worked in Hospital Development at her local OPO in the state of New Jersey where she served as the clinical liaison to a number of Level 1 Trauma & Neuroscience centers as well as community hospitals. Her personal connection as a donor family and friend fuels her passion to support her colleagues across the donation-transplantation continuum through the development of valuable educational resources that ultimately boost performance and improve outcome measures. Deanna holds a Bachelor of Arts in Psychology and a minor degree in Public Health from Montclair State University. In her spare time, Deanna enjoys visiting vineyards, spending time with her family, and traveling in hopes of visiting all seven wonders of the world.

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