Management of Normothermic Regional Perfusion Performance in Uncontrolled Versus Controlled Donation After Circulatory Death: A Multi-Center Investigation

Abstract

Introduction: Controlled (c-) and uncontrolled (u-) DCDs are two entirely different types of donors, mainly because the duration of ischemic and reperfusion injury differs between them. We hypothesized that normothermic regional perfusion (NRP) management and performance (as indicated by the dynamic changes in blood flow and lactate) might be different in uDCDs and in cDCDs. Methods: We assessed 99 DCD donors that were consecutively evaluated by the Tuscany Regional Transplant Center from 2020 to 2024 (multi-center investigation), focusing on the comparison between NRP performance and management in uDCDs (n = 44) vs. cDCDs (n = 45). Results: NRP duration was significantly higher in uDCDs compared to cDCDs (p = 0.001). During NRP, we observed no changes in lactate values in uDCDs and cDCDs, a significant increase in transaminases, and a progressive reduction in NRP blood flow rates despite the administration of more fluids. Throughout the entire NRP duration, pH values were significantly lower and glucose levels were higher in uDCDs compared to cDCDs, even though a higher dosage of bicarbonate and insulin units were administered in uDCDs. Conclusions: In our series, we documented that NRP performance and management differed in uDCDs compared to cDCDs. This phenomenon may be mainly related to the different duration of the ischemic injury between these two types of donors. During NRP, uncontrolled DCDs showed a more severe metabolic derangement, which was only partially reversable by a more aggressive treatment (higher fluid volumes, insulin and bicarbonate dosages). Our results strongly suggest that there is likely space for optimization of NRP management in DCDs. Further research should address this issue, considering the disparity between the supply of organs and increasing transplantation needs.