The fall of a myth: the first three cases of DCD in intestinal transplantation

Introduction: The universal shortage of organs has prompted the growing use of donations after circulatory death (DCDs). Kidneys, liver, lungs, pancreas, and, more recently, the heart from DCDs have been successfully employed for transplantation in many centers worldwide. Nonetheless, the use of DCD as a source of intestinal grafts has been denied due to concerns regarding their ischemic susceptibility. This belief, in fact, has been widely accepted by the scientific community for years. Now this myth is over: we present the first three DCD cases in intestinal transplantation in the world. Methods: We reviewed the cases of intestinal transplantation after DCD performed at our center. Technical, demographic and clinical data relating both donors and recipients were collected. Recipients were also studied in detail during their clinical and histological follow-up. Results: Three DCD multivisceral transplants (MVT) were performed at our institution in June and October 2022 and January 2023. Donors (3M) had a mean age and weight of 3 months (1-6) and 5.3 kg (4-8). Their death was declared after their cardiac arrest and a 5-min “no-touch period”. Then, a rapid laparotomy was performed and a normothermic regional perfusion (NRP) was established by the cannulation of the aorta and the inferior vena cava. Mean warm-ischemia time was 25 minutes (23-29). During NRP, the grafts were prepared for procurement, when the same cannulas were used for cold perfusion with cold-preservation solution. The recipients were 3 patients (2F/1M) with short bowel syndrome (jejunal atresia and meconium cyst, Hirschsprung’s disease, multiple intestinal atresia with severe combined immunodeficiency). Their mean age and weight were 19 months (9-36) and 4.9 kg (3.88-6.8). They all received a MVT with preservation of the native spleen and a ileostomy for protection and study. Mean cold-ischemia time was 383 minutes (340-420). After MVT, biopsies showed a complete recovery of the architecture of the intestinal epithelium in all cases. After a mean follow up of 3 months (0-7), two patients have done exceptionally well with only a mild self-limited cutaneous GVHD in one case and a humoral sensitization perfectly controlled in the other. Ileostomy could be taken-down in one 8 months after MVT. The third patient is being treated for enterocolitis and has needed a proximal jejunostomy. Conclusion: The use of DCD donors in intestinal transplantation is feasible as demonstrated by our world-leading series. The ischemia-reperfusion injury in these grafts seems to be transient and reversible. Although experience is limited, their use could address the mismatch between the waiting list for intestinal transplantation and the scarcity of donors, especially in situations of need such as pediatric transplantation.