Deceased Donor Management and Evaluation

Phase 3 (donor evaluation) and Phase 4 (ICU donor management) are pivotal in the deceased donation pathway, directly impacting how many and how well organs can be transplanted. Recent years have seen significant progress: standardized donor management protocols, better understanding of pathophysiology after brain death, and technological innovations all contribute to improved outcomes. By thoroughly evaluating each organ with modern diagnostics and diligently optimizing the donor’s physiology (in both adult and pediatric donors), critical care and OPO teams can increase the availability of viable organs while upholding the highest ethical standards. The continuous evolution of practice – guided by emerging evidence, such as consensus guidelines and research on novel biomarkers or perfusion techniques – holds promise for further expanding the donor pool. Ultimately, phase 3 and 4 efforts translate the donor’s gift into the best possible chance of successful transplantation for recipients, embodying a bridge from tragedy to life-saving therapy. Each donor managed with excellence is a testament to medical collaboration and human solidarity, ensuring that no viable organ is lost for want of optimal care.

This podcast presents an original article detailing a phase 1-2 clinical study called VX-880-101 FORWARD, which investigates zimislecel as an allogeneic stem cell-derived islet-cell therapy for type 1 diabetes. The research aimed to assess the safety and efficacy of this new treatment, particularly its ability to restore physiologic islet function and potentially lead to insulin independence. The methods section outlines the study design, participant eligibility, and dosage regimens for zimislecel, administered via a single portal vein infusion, along with immunosuppressive therapy.

Results from 14 participants demonstrate engraftment and islet function, with most participants showing freedom from severe hypoglycemic events, improved glycemic control, and insulin independence at 12 months, despite some adverse events like neutropenia and two deaths attributed to unrelated or immunosuppression-related causes. The conclusions support further investigation into zimislecel's potential to provide a more effective and less burdensome treatment option for type 1 diabetes.

Liver transplantation demands meticulous intraoperative management tailored to each surgical phase. By anticipating the typical hemodynamic changes in the pre-anhepatic, anhepatic, and neohepatic phases, the anesthesia and surgical teams at high-volume centers can proactively mitigate risks. In the pre-anhepatic phase, controlling bleeding (often by keeping CVP low and employing rapid transfusion protocols) and maintaining perfusion is paramount. In the anhepatic phase, preserving hemodynamic stability during IVC clamping (using piggyback techniques or veno-venous bypass if needed) and managing rising acidosis/coagulopathy keep the patient primed for graft reperfusion. The neohepatic phase requires vigilance and aggressive intervention during reperfusion, treating post-reperfusion syndrome with prompt vasopressor, inotrope, and electrolyte therapy, and correcting coagulopathy with targeted blood products guided by TEG/ROTEM. Throughout all phases, advanced monitoring provides the foundation for decision-making: TEE offers real-time cardiac evaluation that is now standard in many centers, PAC use is reserved for selected cases (e.g. severe pulmonary hypertension), and continuous arterial pressure and CVP trends help integrate the overall picture. Equally important is the availability of massive transfusion support and drugs (vasopressors, calcium, antifibrinolytics) to address the rapid fluctuations in volume and vascular tone. High-volume transplant centers tend to have refined protocols – for example, predefined transfusion triggers, checklists for reperfusion, and experienced staff who recognize complications early. This level of preparedness and expertise has been associated with improved patient outcomes and graft survival. In conclusion, successful liver transplant anesthesia relies on phase-specific management of hemodynamics and coagulopathy, rigorous monitoring, and the ability to respond immediately to complications like high CVP bleeding, massive hemorrhage, reperfusion syndrome, air embolism, and arrhythmias. With these strategies, even the most challenging intraoperative issues can be navigated to ensure the best possible outcome for the recipient and their new liver graft.

Immunosuppression minimization and withdrawal in liver transplantation is an area where clinical practice and cutting-edge research intersect. The driving rationale is clear – mitigating the long-term deleterious effects of chronic immunosuppressive therapy – but the execution requires navigating complex immunological and ethical terrain. Over the past two decades, we have learned that operational tolerance, once deemed a rare curiosity, is attainable in a meaningful subset of liver recipients, particularly under ideal circumstances. Pioneering trials in both adults and children have mapped out the possibilities and pitfalls: some patients can indeed thrive off medication, whereas others cannot. This heterogeneity has propelled the search for biomarkers and tolerance-inducing strategies, aiming to shift withdrawal from a trial-and-error gamble to a guided, evidence-based endeavor. The liver’s unique immunology offers a fertile ground for such innovations, as exemplified by emerging gene-expression tests and cell therapy approaches (e.g. infusion of regulatory immune cells to foster tolerance).

The journey toward minimization must always be patient-centric. It is as much about improving quality of life (less medication burden, fewer side effects) as it is about improving quantity of life (reducing drug-related mortality). Any approach to immunosuppression withdrawal demands rigorous monitoring, prompt intervention at signs of rejection, and a commitment that patient safety remains paramount. As of 2025, routine weaning is not standard care, but it is a realistic goal in select cases and is actively being incorporated into clinical trials and protocols. The coming years will likely see a refinement of criteria – aided by genomics and immunology – to more accurately identify those liver transplant recipients who can safely enjoy a drug-free life. Achieving the “holy grail” of transplantation, immune tolerance, will require this blend of scientific precision and ethical stewardship. Each success moves us closer to a future where long-term transplant survivors are liberated from lifelong immunosuppression, living healthier and fuller lives with their grafts.

Ex vivo machine perfusion has ushered in a new era where a liver graft’s viability can be tested before the irreversible step of transplantation. Both normothermic and hypothermic perfusion techniques play roles in modern liver preservation, with NMP in particular enabling real-time functional evaluation. Key viability markers – lactate clearance, perfusate pH, glucose consumption, transaminase release, perfusion flow dynamics, bile production, and bile composition – have been identified through extensive research and are now applied in clinical decision-making. These markers, especially when considered together, correlate with whether a liver will function or fail after transplant. Clinical trials over the last decade demonstrate that viability testing can dramatically improve outcomes: many marginal livers have been successfully transplanted with excellent survival, and patients are spared the danger of graft primary non-function by avoiding transplantation of nonviable organs. At the same time, we have learned that viability criteria must continue evolving – for example, to better predict biliary complications in DCD livers.

The most recent advancements point to a future of even more sophisticated viability assessments, incorporating molecular diagnostics, advanced imaging, and perhaps automated perfusion analytics. As more centers adopt machine perfusion and share data, consensus guidelines will likely solidify around optimal viability criteria. In sum, viability testing in liver machine perfusion is already a transformative tool in transplantation, and ongoing innovations will further refine our ability to gauge organ quality, expand the donor pool safely, and improve transplant success rates for patients in need.

Transplant tourism sits at the troubling intersection of medical need and global inequality. On one hand, it underscores the desperation of patients willing to do anything for a life-saving organ; on the other, it exposes the plight of the poor who are driven (or coerced) to literally sell parts of their bodies. The ethical global practice of transplantation demands that life be preserved without sacrificing human rights or dignity. The international community – through the WHO, the Declaration of Istanbul, the UN, and various national initiatives – has recognized transplant tourism and organ trafficking as urgent issues and has taken steps to combat them.

The ultimate solutions lie in increasing legitimate organ donation worldwide (so patients no longer feel the need to go to black markets) and in enforcing justice so that those who would profit from human organs are stopped. Transplant medicine has achieved miraculous life-saving feats; ensuring those miracles are accomplished ethically and equitably is a responsibility that extends across borders. Only by addressing the root causes (organ scarcity and global inequities) and strengthening oversight can we hope to relegate transplant tourism to history and uphold the principle that the gift of life should not come at the cost of exploiting the world’s most vulnerable.

A-NRP utilizes extracorporeal membrane oxygenation (ECMO) technology, including a pump, oxygenator, and heater, to maintain normothermic (37°C) blood flow to abdominal organs in situ. This process reverses warm ischemic damage, improving organ quality for transplantation. However, simultaneous procurement of thoracic organs, such as lungs, can lead to significant blood loss in the chest, compromising circulatory support for abdominal organs. Blood conservation techniques are thus essential to ensure adequate perfusion and maintain organ function.

This podcast discusses about both cannulation techniques TA-NTP and A-NRP

• ​ Elevated liver enzymes after a liver transplant can stem from various causes, including surgical complications, infections, or rejection, with no single definitive source.
• ​ Workup involves blood tests, imaging like ultrasounds, and sometimes biopsies to identify the cause, though outcomes can vary.
• ​ The evidence leans toward treatments being tailored to the specific cause, such as medications for infections or procedures for blockages, but effectiveness depends on timely diagnosis.

• Research suggests AI and deep learning are enhancing liver transplant outcomes.

• It seems likely that donor-recipient matching and post-transplant predictions are improving.

• The evidence leans toward AI helping with organ allocation and surgical innovations.

• Challenges include data quality and validation, with ongoing efforts to address them.

• ​ Research suggests EBV is a significant risk post-transplant, with PTLD incidence at 4-22% in children and 1-2% in adults, higher in EBV-negative recipients.
• ​ It seems likely that CMV remains the most common viral infection, with varying incidence based on donor/recipient status.
• ​ The evidence leans toward BK virus being a major concern for kidney transplants, with no effective prophylaxis.
• ​ HHV8 is linked to Kaposi’s sarcoma, with higher incidence in endemic areas (3-5%).
• ​ Diagnosis typically involves PCR and clinical symptoms, with treatment often including reducing immunosuppression and antivirals like ganciclovir.
• ​ Recent 2025 updates highlight a 22% PTLD risk in EBV-negative kidney recipients from EBV-positive donors, emphasizing monitoring needs.