ORGAN AND TISSUE TRANSPLANTATION · 2016-03-12 · Organ and tissue donation and transplantation...
Transcript of ORGAN AND TISSUE TRANSPLANTATION · 2016-03-12 · Organ and tissue donation and transplantation...
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ORGAN AND TISSUE
DONATION AND RECOVERY
DANA BARTLETT, RN, BSN, MSN, MA
Dana Bartlett is a professional nurse and author. His clinical experience includes 16
years of ICU and ER experience and over 20 years of as a poison control center
information specialist. Dana has published numerous CE and journal articles, written
NCLEX material, written textbook chapters, and done editing and reviewing for
publishers such as Elsevire, Lippincott, and Thieme. He has written widely on the
subject of toxicology and was recently named a contributing editor, toxicology
section, for Critical Care Nurse journal. He is currently employed at the Connecticut
Poison Control Center and is actively involved in lecturing and mentoring nurses,
emergency medical residents and pharmacy students.
ABSTRACT
Organ transplantation rates have increased in the past several decades
and yet nursing education with respect to the process of organ
donation and post transplant care has been inconsistent. Certain state
jurisdictions, such as New Jersey, are now requiring nurses to receive
continuing education on organ donation and transplantation to renew
their license to practice. The goal of mandatory education is to
increase nursing knowledge and participation in organ donation and
transplantation programs, and to advance the role of nurses in this
continuously growing area of health care.
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Continuing Nursing Education Course Planners
William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,
Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner
Policy Statement
This activity has been planned and implemented in accordance with
the policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's
Commission on Accreditation for registered nurses. It is the policy of
NurseCe4Less.com to ensure objectivity, transparency, and best
practice in clinical education for all continuing nursing education (CNE)
activities.
Continuing Education Credit Designation
This educational activity is credited for 1 hour. Nurses may only claim
credit commensurate with the credit awarded for completion of this
course activity.
Statement of Learning Need
Recent studies have shown that nurses' attitudes and advocacy to
discuss transplantation among colleagues and with others increased
following the appropriate education and practice support. Additionally,
when encouraged to participate in organ donation and transplantation
education, nurses demonstrated increased confidence in working with
transplant patients and in addressing the need to educate their
communities about organ donation, encouraging others to get involved
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in local organ donation and transplantation programs.
Course Purpose
This course will provide basic learning for nurses in the coordination of
organ donation and transplantation; and, to increase nursing advocacy
to increase the rates of organ donation in their local areas.
Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses
and Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Dana Bartlett, RN, BSN, MSN, MA, William S. Cook, PhD,
Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all
have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
Reviewed by Susan DePasquale, MSN, FPMHNP-BC
Release Date: 1/1/2016 Termination Date: 12/10/2016
Please take time to complete a self-assessment of knowledge,
on page 4, sample questions before reading the article.
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Opportunity to complete a self-assessment of knowledge
learned will be provided at the end of the course. 1. True or false: Registering as an organ donor or reviewing
information about organ donation is mandatory for obtaining a driver’s
license in NJ.
a. True
b. False
2. Most organ donations are from:
a. Living donors
b. Autolgous donors
c. Deceased donors
d. Xenogenic donors
3. Common complications associated with organ transplantation
include:
a. Transfusion reaction
b. Hyper-metabolic state
c. Diabetes insipidus
d. Infection
4. Someone who is specifically allowed to discuss organ donation is a
a. Registered nurse
b. Designated requestor
c. Transplant coordinator
d. UNOS representative
5. CBIGs are intended, in part, to:
a. Keep the donor patient comfortable until organs can be obtained
b. Be diagnostic criteria for brain death
c. Help medical staff determine when to remove life support
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d. Ensure that potential donor organs are well perfused and viable
Introduction
Organ and tissue donation and transplantation are life saving and life
altering therapies. From 1988 to August 2013 over 580,000 people in
the United States have received organ transplants, and the number of
donors has been slowly but steadily increasing. Tissue transplantation
is also quite common: approximately 750,000 are performed in the
United States every year. The increasing incidence of both donations
and transplants makes it imperative that nurses understand the
processes of how organs and tissues are obtained.
As of 2014, the New Jersey Board of Nursing requires every
professional registered nurse to complete a one-hour course that
covers organ and tissue donation and recovery. As organ donation and
transplantation is more complex than tissue donation and
transplantation (and in many ways the two procedures are carried out
in the same way) this module will primarily focus on organ donation
and transplantation.
Epidemiology And Statistics
The first successful organ transplant was performed in 1954. Since
that time, organ and tissue donation and transplantation have become
accepted treatments for a wide variety of diseases and medical
conditions. The three most commonly donated and transplanted
organs in descending order are kidneys, liver, and heart. The organs
that can and are transplanted also include intestines, lungs, and
pancreas and multiple transplants can be done, as well. Tissue
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transplantation can be done with amnion, bone, bone marrow,
connective tissue, cord blood, corneas, heart valves, ovarian tissue,
pancreatic islet cells, skin, and veins. Most donated organs are from
the deceased.
Although the number of organ and tissue donations and
transplantations is increasing every year, the demand far exceeds the
supply. There are almost 120,000 people on the transplant waiting list
and each day 18 people die that a transplant could have saved. In New
Jersey in 2012, 551 transplants were performed. However, more than
5000 people are on the waiting list, and waiting for an organ is a long
process. In the United States the median waiting time for a kidney is
1219 days, for a liver 361 days, and for pancreas 260 days.
Transplants and donations are well established in New Jersey, but
there is a critical lack of registered donors. New Jersey ranks number
44 out of the 50 states in the percentage of registered organ and
tissue donors, and only one-third of New Jersey drivers are registered
as organ donors. Efforts have been made to increase the number of
donors. New Jersey drivers must register through Donate Life NJ
(http://donatelifenj.org/) as someone that is an organ donor or review
information about organ donation when applying for, or renewing a
driver’s license; however, the need for organ donation is still not being
met.
As tissue donation can affect the lives of 50 - 75 people and one organ
donor can save the lives of eight people, the need to increase
participation is painfully clear.
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Basics Of Organ And Tissue Donation And Transplantation
Organ Donation and Transplantation
Organ donation and transplantation can be divided into many different
categories.
Donation from deceased donors:
This is the most common type of organ donation. To date in
2013, there have been 5502 deceased donors and 3944 living
donors.
Donation from living donors:
A donation from a living donor offers several advantages. This
approach increases the possible pool of donors. It allows for a
thorough evaluation of the donor and the recipient and
planning/organization of the surgery. A living donor also
provides an organ that is, usually, well perfused.
Allogenic donation:
An allogenic donation is the donation of an organ from another
person.
Isogenic donation:
The organ is donated from an identical twin.
Autologous donation:
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Tissue is transplanted from one site in the body to another.
Autologous blood donations are relatively common.
Xenogenic donation:
The organ or tissue has been harvested from another species,
i.e., heart valves from pigs.
Donation after brain death:
Donation after brain death is performed with an organ from
someone who meets the criteria for brain death. These
donations, usually, offer an organ that is well perfused. Also,
these donors can donate multiple organs, such as, heart, both
lungs, both kidneys, liver, pancreas, and the small intestine.
Donation after cardiac death:
Donation after cardiac death increases the pool of possible
donors: a 2012 Canadian study noted that the number of
kidney transplants in some transplant programs increased by
40% when this approach was used. Typically only kidneys and
the liver are transplanted from patients that have suffered
cardiac death, but lung transplantation using this method is
also possible.
Donation of organs after cardiac death is usually considered to
be less desirable and less successful than donation after brain
death, as this method of donation and transplantation has an
inherent risk of increasing ischemia to the donated organ.
However, this issue is being actively investigated and some
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transplant centers have reported equivalent results for kidney
and liver transplants when the two methods are compared.
Tissue Donation and Transplantation
Tissue donation and transplantation is performed in much the same
way as is solid organ donation and transplantation. However, the types
of tissues that can be used are more numerous, and composite
transplantation – transplantation of several tissue types in one
procedure - can also be performed.
Donation and Transplantation Complications and Risks
The most common complications and risks associated with donation
and transplantation are: 1) Rejection, 2) Infection, and 3) Increased
risk of disease. These are further explained as:
Rejection:
Rejection can be acute - up to three months post-transplantation
- or chronic. Immuno-suppressive drugs reduce the rate of
rejections, but acute rejection rate for kidney transplants is still
between 10-15% and between 15-25% for liver transplants.
Infection:
Infection associated with transplantation is uncommon, but
tuberculosis and other bacteria, Clostridium, HCV, Epstein-Barr
virus, rabies, group A streptococci, Candida albicans and molds,
and other microorganisms have all been transmitted during
transplant procedures. The risk of infection associated with
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transplantation is very small, probably < 1%; however,
surveillance for, and reporting of post-transplant infections is not
ideal so the actual number of infections is not known. In
addition, there are no universally agreed upon protocols for
screening of organ or tissue donors.
Donors who have infectious diseases such as hepatitis B,
hepatitis C, encephalitis, meningitis, pneumonia, tuberculosis,
and other infectious conditions can be considered as donors if
informed consent from the recipient is obtained and therapy and
follow-up are possible.
Increased risk of disease:
People who have had a transplant are at increased risk for
developing bone disease and orthopedic problems, cancer, heart
disease, and other medical problems.
The Process Of Organ And Tissue Transplantation
The process of organ donation is usefully divided into the following
steps.
1. Referral
2. Evaluation
3. Family discussion
4. Recovery and allocation
The process of organ and tissue transplantation starts with a referral.
Suitable cases are referred to the local Organ Procurement
Organization (OPO). There are two in New Jersey, which are:
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New Jersey Organ and Tissue Sharing Network:
The New Jersey Organ and Tissue Sharing Network operates in
northern and central New Jersey in Bergen, Essex, Hudson,
Hunterdon, Mercer, Middlesex, Morris, Monmouth, Ocean,
Passaic, Somerset, Sussex, Union, and Warren counties. Their
24-hour telephone number is 1-800-742-7365. Their website
address is https://www.njsharingnetwork.org/.
Gift of Life Donor Program:
The Gift of Life Donor Program operates in southern New Jersey
in Atlantic, Burlington, Camden, Cape May, Cumberland,
Gloucester and Salem counties. Their 24-hour telephone number
is 1-800-366-6771. Their website address is
http://www.donors1.org/.
Referral
The referral starts with identification of a patient’s clinical situation in
which organ donation may be likely or could be a possibility. These
situations are recognized by the presence of imminent death and
clinical triggers.
Federal regulations require that hospitals contact the local OPO about
all patients that have died or are near death - imminent death. When
the OPO has been contacted, it will start the process of evaluation and,
possibly matching of donor to recipient. It was in the federal
regulations that hospitals develop a definition of imminent death, and
this definition is usually:
1. A patient with acute, severe, brain injury who requires
mechanical ventilation
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2. A patient who is being evaluated for brain death
3. The presence of certain clinical findings
The clinical findings that are used most often are: 1) A Glasgow Coma
Scale of ≤ 5, and; 2) The absence of two or more cranial reflexes, i.e.,
caloric response, cough/gag reflex, corneal reflex, failure to respond to
pain, pupillary response to light, etc. The Glasgow Coma Scale and the
cranial reflexes are used because they have a high degree of inter-
observer reliability and they correlate well with outcome, i.e., the
lower the Glasgow Coma Scale and the fewer intact cranial reflexes the
worse the outcome is likely to be.
Taken as a whole, these conditions 1 and 2 listed above and the
clinical findings are referred to as clinical triggers. The clinical triggers
are identified in cases in which the patient is critically ill and near
death, and identify patients that may be donor candidates because
they are likely to die or progress to brain death.
These clinical triggers may vary from hospital to hospital and between
different OPOs. It is also considered necessary to contact the OPO
prior to discussing organ donation with the patient’s family. In the
case of a death and possible organ or tissue donation, the referral
must be made within an hour of the death.
Donations can be made from a patient who has been declared brain
dead or from a patient who has suffered cardiac death. If a patient has
suffered a non-survivable injury but does not meet the criteria for
brain death, the decision may be made to remove the patient from life
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support, and this would be considered donation after cardiac death. If
this happens, organ donation is a possibility.
Evaluation
A donation specialist from an OPO does the evaluation of a patient and
the clinical situation for the possibility of organ donation. Once the
OPO has been contacted about a potential donor, the evaluation
specialist will immediately go to the hospital. The evaluation specialist
will examine the patient’s medical record, tests for infectious diseases
may be ordered, and a decision will be made as to whether or not
organ donation is possible. If the patient was enrolled in the state
registry as a donor, that registration is considered to be the legal
consent for the donation. If the patient was not registered as a donor
and the patient’s driver’s license did not indicate that he/she wished to
be a donor, family or next of kin will be contacted.
Viability of organs is obviously a critical concern in the donation
process. Unfortunately, the majority of donated organs come from
people who are brain dead and these organs are less viable than
organs from living donors. In addition, many people who have suffered
brain death are physiologically and hemodynamically unstable,
decreasing the potential for maintaining organs in a condition suitable
for transplant.
In response to this issue, OPOs and hospitals have adopted the use of
catastrophic brain injury guidelines (CBIGs) in the evaluation process
of organ donation. Catastrophic brain injury guidelines (CBIGs) are
recommendations used to treat people who: 1) Have suffered a
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catastrophic brain injury; and, 2) Have been assessed by a neurologist
and a neurosurgery specialist as having a non-survivable neurological
injury or neurologic death. These guidelines are intended to ensure
hemodyanamic stability and tissue perfusion. In this way, the patient’s
clinical progress as it would naturally evolve can be observed and end
of life decisions can be made. As viability of organs is obviously a
critical issue in the donations process, these CBIGs are also used if the
patient is deemed to be a potential organ donor; and, they have been
shown to help OPOs and hospitals increase the number and quality of
donated organs.
The CBIGs listed below are from the New Jersey Organ and Tissue
Sharing Network website, clinical resources section.
1. Make sure the patient is adequately hydrated and euvolemic
2. Maintain systolic blood pressure of > 100 mm Hg/MAP > 60 mm
Hg. If needed, neosynephrine up to 2 mcg/kg/minute is the
vasopressor of choice, followed by dopamine.
3. Maintain urine output of > 0.5 ml/k/hour, < 400 mL/hour.
4. Ensure adequate oxygenation and acid-base balance: Maintain
the PO2 at > 100 mm HG, maintain pH between 7.35-7.45
5. Maintain temperature between 36-37.5°C
6. Maintain normal values for coagulation/clotting, complete blood
count, electrolytes and glucose.
The CBIGs will vary from place to place. For example, some OPOs and
hospitals will recommend that the patient be maintained on all
medications he/she was receiving prior to the application of the CBIGs
and that hemodynamic monitoring be used. Tissue matching and blood
typing are an important part of the evaluation process. Blood will be
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tested to determine ABO and Rh type, a cross-match between donor
and recipient will be performed, and human leukocyte antigen (HLA)
testing will be done, as well red blood cell antibodies
Family Discussion
The transplant coordinator or evaluation specialist will meet with the
potential donor’s family to discuss the donation procedure. If the
patient had already indicated an intention to donate by registering as a
donor then in most instances this is considered the only authorization
that is needed and this process may be relatively brief. If the patient
had not expressed a preference then certainly more time will be
needed. If the procedure is to be a living donation then obviously a
family discussion is not needed. It is a requirement that anyone who
approaches a family regarding organ donation must have special
training as a designated requestor.
Recovery and Allocation
The patient is maintained as per protocol until it has been decided to
obtain the organs. If life support is removed, as in donation after
cardiac death, the organs must be removed within 90 minutes of
extubation. Once the patient has expired, the organs and tissues are
recovered. The transplant coordinator will be working with the Organ
Procurement and Transplant Network (OPTN) and local transplant
surgeons to find the best match for the donation. The OPTN is
explained as follows:
“the unified transplant network established by the United States
Congress under the National Organ Transplant Act (NOTA) of
1984. The act called for the network to be operated by a private,
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non-profit organization under federal contract. The primary goals
of the OPTN are to increase the effectiveness and efficiency of
organ sharing and equity in the national system of organ
allocation, and to increase the supply of donated organs
available for transplantation. The United Network for Organ
Sharing (UNOS) . . . administers the OPTN under contract with
the Health Resources and Services Administration of the U.S.
Department of Health and Human Services.”
The OPTN, working through UNOS, collects, stores, and analyzes
information that pertains to donors and recipients: donor/recipient
matching, deceased and living donors, and potential recipients, the
patient waiting list, and other information such as name, gender, race,
age, height, weight, medical history, ABO blood group, peak and
current panel reactive antibody (PRA) levels, HLA data, and acceptable
donor characteristics. Race, gender, income, and social status are not
included in the database.
When an organ becomes available a computer program compares
information about the donor with recipient information in the database.
The transplant coordinator and the OPTN will be reviewing all of this
information about potential recipients and the donors. Their work and
the input of a histocompatability laboratory and a transplant team will
be coordinated and, hopefully, an allocation and a match will be made.
Summary
Organ and tissue donation and transplantation are life saving and life
altering therapies, and nurses have a key role in educating their
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communities about the existing health need to help save lives.
Despite the rise in need, there remains a critical lack of registered
organ donors that some states, such as New Jersey, are addressing
through mandatory education for nurses and local public programs.
The various organ donation and transplantation steps are supported
through regulatory agencies and healthcare policies, which include
centralized databases and specially trained support staff. Through local
awareness campaigns, such as Save A Life, potential donors may be
informed and take steps to begin the process of helping to save a life,
which begins with the proper referral through to the right
donor/recipient match.
Please take time to help NurseCe4Less.com course planners
evaluate the nursing knowledge needs met by completing the
self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.
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Completing the study questions is optional and is NOT a course
requirement.
1. True or false: Registering as an organ donor or reviewing
information about organ donation is mandatory for obtaining a driver’s
license in NJ.
a. True
b. False
2. Most organ donations are from:
a. Living donors
b. Autolgous donors
c. Deceased donors
d. Xenogenic donors
3. Common complications associated with organ transplantation
include:
a. Transfusion reaction
b. Hyper-metabolic state
c. Diabetes insipidus
d. Infection
4. Someone who is specifically allowed to discuss organ donation is a
a. Registered nurse
b. Designated requestor
c. Transplant coordinator
d. UNOS representative
5. CBIGs are intended, in part, to:
a. Keep the donor patient comfortable until organs can be obtained
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b. Be diagnostic criteria for brain death
c. Help medical staff determine when to remove life support
d. Ensure that potential donor organs are well perfused and viable
Correct Answers:
1. a
2. c
3. d
4. b
5. d
References Section
The reference section of in-text citations include published works
intended as helpful material for further reading. Unpublished works
and personal communications are not included in this section, although
may appear within the study text.
1. Hoy, H., Alexander, S. and Frith, K.H. (2011). Effect of transplant
education on nurses' attitudes toward organ donation and plans to
work with transplant patients. Prog Transplant. 2011 Dec; 21(4):
317-21.
2. Chon WJ, Brennan DC. Acute renal allograft rejection: Treatment.
UpTo Date. June 5, 2013. Retrieved 11/10/2013 from
http://www.uptodate.com/contents/acute-renal-allograft-
rejection-
treatment?detectedLanguage=en&source=search_result&search=
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kidney+transplant+rejection&selectedTitle=2%7E150&provider=n
oProvider.
3. Cotler S. Treatment of acute cellular rejection in liver
transplantation. UpToDate. August 26, 2013. Retrieved
11/10/2013 from
http://www.uptodate.com/contents/acute-renal-allograft-
rejection-
treatment?detectedLanguage=en&source=search_result&search=
kidney+transplant+rejection&selectedTitle=2%7E150&provider=n
oProvider.
4. Deng R, Gu G, Wang, D, et al. Machine perfusion versus cold
storage of kidneys derived from donation after cardiac death: A
meta-analysis. PLosS One. 2013. 8:art. no. e56368
5. Engels EA, Pfieffer RM, Fraumeni JF, et al. Spectrum of cancer risk
among US solid organ transplant recipients. Journal of the
American Medical Association. 2011. 306:1891-1901.
6. Fishman JA, Greenwald MA, Grossi PA. Transmission of infection
with human allografts: Essential considerations in donor
screening. Clinical Infectious Diseases. 2012. 55:720-727.
7. Greenwald MA, Kuehnert M.J, Fishman JA. Infectious disease
transmission during organ and tissue transplantation. Emerging
Infectious Diseases. 2012. 8:e1. doi: 10.3201/eid1808.120277.
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8. Harring TR, Nguyen NTT, Cotton RT, et al. Liver transplantation
with donation after cardiac death donors: A comprehensive
update. The Journal of Surgical Research. 2012. 178:502-511.
9. Malinoski DJ, Daly MC, Patel MS, et al. Achieving donor
management goals before deceased donor procurement is
associated with more organs transplanted per donor. Journal of
Trauma – Injury, Infection and Critical Care. 2011;71: 990-996.
10. Moser M, Sharpe M, Weernink C, et al. Five-year experience with
donation after cardiac death kidney transplantation in a Canadian
transplant program: Factors affecting outcomes. Canadian
Urological Association Journal. 2012. 6:448-452.
11. New Jersey Organ and Tissue Sharing Network. Retrieved
11/10/2013 from:
https://www.njsharingnetwork.org/
12. Organ Procurement and Transplantation Network. Retrieved
11/10/2013 from: http://optn.transplant.hrsa.gov/optn/.
13. Pruitt AA, Graus F, Rosenfeld MR. Neurological complications of
solid organ transplantation. Neurohospitalist. 2013. 3:152-166.
14. Quinn L, McTague W, Orlowski JP. Impact of catastrophic brain
injury guidelines on donor management goals at a level I trauma
center. Transplantation Proceedings. 2102. 47:2190-2192
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15. United Network for Organ Sharing. Retrieved 11/10/2013 from:
http://unos.org/.
16. US Department of Health and Human Services: Organ Donation.
Retrieved 11/10/2013 from: http://organdonor.gov/index.html.
17. Vanatta JM, Dean AG, Hathaway DK, et al. Liver transplant using
donors after cardiac death: A single-center approach providing
outcomes comparable to donation after brain death. Experimental
and Clinical Transplantation. 2013. 11:154-163.
18. Wadei HM, Heckman MG, Rawal B, et al. Comparison of kidney
function between donation after cardiac death and donation after
brain death kidney transplantation. Transplantation. 2013;96:
274-281.
19. Yazbek DC, de Carvalho AB, Barros CS, et al. Cardiovascular
disease in early kidney transplantation: comparison between
living and deceased donor recipients. Transplantation
Proceedings. 2012. 44:3001-306.
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