Arginine vasopressin significantly increases the rate of successful organ procurement in potential donors

Better liver transplant outcomes by donor interventions?

PURPOSE OF REVIEW

Donor risk factors and events surrounding donation impact the quantity and quality of grafts generated to meet liver transplant waitlist demands. Donor interventions represent an opportunity to mitigate injury and risk factors within donors themselves. The purpose of this review is to describe issues to address among donation after brain death, donation after circulatory determination of death, and living donors directly, for the sake of optimizing relevant outcomes among donors and recipients.

RECENT FINDINGS

Studies on donor management practices and high-level evidence supporting specific interventions are scarce. Nonetheless, for donation after brain death (DBD), critical care principles are employed to correct cardiocirculatory compromise, impaired tissue oxygenation and perfusion, and neurohormonal deficits. As well, certain treatments as well as marginally prolonging duration of brain death among otherwise stable donors may help improve posttransplant outcomes. In donation after circulatory determination of death (DCD), interventions are performed to limit warm ischemia and reverse its adverse effects. Finally, dietary and exercise programs have improved donation outcomes for both standard as well as overweight living donor (LD) candidates, while minimally invasive surgical techniques may offer improved outcomes among LD themselves.

SUMMARY

Donor interventions represent means to improve liver transplant yield and outcomes of liver donors and grafts.

Management of potential cardiac donors

Heart transplantation (HTx) outcomes have improved with careful donor selection and management; nonetheless, donor shortages remain a major challenge. Optimizing donor management is crucial for improving donor utility rates and post-HTx outcomes. Brain death leads to various pathophysiological changes that can affect multiple organs, including the heart. Understanding these alterations and corresponding management strategies is key to optimizing the donor organ condition. This review assesses several aspects of these pathophysiological changes, including hemodynamic and endocrinological considerations, and emphasizes special consideration for potential cardiac donors, including serial echocardiographic evaluations for reversible cardiac dysfunction and coronary assessments for donors with risk factors.

Patient management for thoracic organ donor candidates: the lung transplantation team's view

Despite the increasing demand for lung transplants, donor lungs remain in short supply. Although organ donations have been steadily increasing in Korea, with the utilization rate for donor lungs increasing to 40% in recent years, many potential donor organs remain unused. To match the increasing number of patients on the lung transplant waitlist, it is essential to increase the donor procurement rate through optimal management. Improvements in donor lung management programs can lead to expansion of the donor pool and optimal posttransplant outcomes. This review focuses on basic protocols for the optimal management of donor lungs and summarizes coronavirus disease 2019-related considerations for donor lung evaluation.

Anesthetic Considerations of Organ Procurement After Brain and Cardiac Death: A Narrative Review

Organ donation procedures have become more frequent in the US as the need for transplants is increasing. Defining the anesthesiologist's role in organ donations after brain and cardiac death is important, as is understanding its ethics and practical physiologic and perioperative implications. Despite this, there are few papers specifically addressing the anesthetic management of organ donors. This review summarizes the preoperative, intraoperative, and postmortem considerations for the anesthesiologist involved in organ donation after either brain or cardiac death. A search of the published literature was performed using PubMed, Excerpta Medica dataBASE (EMBASE), and Google Scholar in March of 2022 for articles addressing anesthetic considerations of organ procurement surgeries after brain and cardiac death. This review demonstrates that anesthesiologists play a significant role in the organ procurement process. Their role in the perioperative management of the donor may affect the outcomes of organ transplantation. The gap between the number of organs harvested and the number of patients awaiting organ transplantation remains high despite continued efforts to increase the number of available organs. Perioperative management of organ donors aims at counteracting the associated unique physiologic derangements and targets optimization of oxygenation of the organs intended for procurement. Optimizing care after death can help ensure the viability of organs and the best outcomes for recipients. As organ donation after cardiac death (DCD) becomes more frequent in the US, anesthesiologists should be aware of the DCD classifications of donors and emerging novel perfusion techniques.

Vasopressin Use in the Support of Organ Donors: Physiological Rationale and Review of the Literature

The objective of this review was to depict the physiological and clinical rationale for the use of vasopressin in hemodynamic support of organ donors. After summarizing the physiological, pharmacological concepts and preclinical findings, regarding vasopressin's pathophysiological impacts, we will present the available clinical data.

DATA SOURCES

Detailed search strategies in PubMed, OVID Medline, and EMBASE were undertaken using Medical Subject Headings and Key Words.

STUDY SELECTION

Physiological articles regarding brain death, and preclinical animal and human studies about the use of vasopressin or analogs, as an intervention in organ support for donation, were considered.

DATA EXTRACTION

Two authors independently screened titles, abstracts, and full text of articles to determine eligibility. Data encompassing models, population, methodology, outcomes, and relevant concepts were extracted.

DATA SYNTHESIS

Following brain death, profound reduction in sympathetic outflow is associated with reduced cardiac output, vascular tone, and hemodynamic instability in donors. In addition to reducing catecholamine needs and reversing diabetes insipidus, vasopressin has been shown to limit pulmonary injury and decrease systemic inflammatory response in animals. Several observational studies show the benefit of vasopressin on hemodynamic parameters and catecholamine sparing in donors. Small trials suggest that vasopressin increase organ procurement and have some survival benefit for recipients. However, the risk of bias is overall concerning, and therefore the quality of the evidence is deemed low.

CONCLUSIONS

Despite potential impact on graft outcome and a protective effect through catecholamine support sparing, the benefit of vasopressin use in organ donors is based on low evidence. Well-designed observational and randomized controlled trials are warranted.

Donor heart selection: Evidence-based guidelines for providers

The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review.

Hemodynamic Effects of High-dose Levothyroxine and Methylprednisolone in Brain-dead Potential Organ Donors

BACKGROUND

Hormonal replacement therapy is administered to many brain-dead organ donors to improve hemodynamic stability. Previous clinical studies present conflicting results with several randomized studies reporting no benefit.

METHODS

Consecutive adult donors (N = 199) were randomized to receive high-dose levothyroxine, high-dose methylprednisolone, both (Combo), or no hormonal therapy (Control). Vasopressor requirements using the vasoactive-inotropic score (VIS) were assessed at baseline, 4 h, and at procurement. Crossover to the Combo group was sufficient to require separate intention-to-treat and per-protocol analyses.

RESULTS

In the intention-to-treat analysis, the mean (±SD) reduction in VIS from baseline to procurement was 1.6 ± 2.6, 14.9 ± 2.6, 10.9 ± 2.6, and 7.1 ± 2.6 for the levothyroxine, methylprednisolone, Combo, and Control groups, respectively. While controlling for the baseline score, the reduction in VIS was significantly greater in the methylprednisolone and Combo groups and significantly less in the levothyroxine group compared with controls. Results were similar in the per-protocol analysis.

CONCLUSION

High-dose methylprednisolone alone or in combination with levothyroxine allowed for significant reduction in vasopressor support in organ donors. Levothyroxine alone offered no advantage in reducing vasopressor support. Organ yield, transplantation rates, and recipient outcomes were not adversely affected.

Proposal and validation of a liver graft discard score for liver transplantation from deceased donors: a multicenter Italian study

Several studies have explored the risk of graft dysfunction after liver transplantation (LT) in recent years. Conversely, risk factors for graft discard before or at procurement have poorly been investigated. The study aimed at identifying a score to predict the risk of liver-related graft discard before transplantation. Secondary aims were to test the score for prediction of biopsy-related negative features and post-LT early graft loss. A total of 4207 donors evaluated during the period January 2004–Decemeber 2018 were retrospectively analyzed. The group was split into a training set (n = 3,156; 75.0%) and a validation set (n = 1,051; 25.0%). The Donor Rejected Organ Pre-transplantation (DROP) Score was proposed: − 2.68 + (2.14 if Regional Share) + (0.03*age) + (0.04*weight)-(0.03*height) + (0.29 if diabetes) + (1.65 if anti-HCV-positive) + (0.27 if HBV core) − (0.69 if hypotension) + (0.09*creatinine) + (0.38*log10AST) + (0.34*log10ALT) + (0.06*total bilirubin). At validation, the DROP Score showed the best AUCs for the prediction of liver-related graft discard (0.82; p < 0.001) and macrovesicular steatosis ≥ 30% (0.71; p < 0.001). Patients exceeding the DROP 90th centile had the worse post-LT results (3-month graft loss: 82.8%; log-rank P = 0.024).The DROP score represents a valuable tool to predict the risk of liver function-related graft discard, steatosis, and early post-LT graft survival rates. Studies focused on the validation of this score in other geographical settings are required.

Endocrine Management and Hormone Replacement Therapy in Cardiac Donor Management: A Retrospective Observational Study

BACKGROUND

Pituitary dysfunction after brainstem death can cause various hormone deficiencies in potential heart donors. The aim of this study was to evaluate the relationship between hormone replacement therapy (HRT; including antidiuretic hormone analog, thyroid hormone, and methylprednisolone) in heart donors and the recipients' outcomes after heart transplantation (HTx).

METHODS

We retrospectively analyzed HTxs performed between January 2012 and October 2018. Donor and recipient characteristics were retrieved with a focus on endocrine parameters and HRT. The primary outcome was primary graft dysfunction (PGD). Secondary outcomes were the 30-day and 2-year mortality of the recipients. Univariate and multivariate Cox regression analyses were applied.

RESULTS

The study included 297 HTxs. PGD occurred in 56 recipients (18.9%). In the multivariable Cox analysis, methylprednisolone and thyroxine treatment in donors were associated with a lower odds for PGD (odds ratio [OR], 0.43; 95% CI, 0.19-1.01; P = .052; and OR,: 0.34; 95% CI, 0.15-0.76; P = .009, respectively). In multivariate analysis, thyroxine treatment in donors was associated with a lower odds of PGD (OR, 0.38; 95% CI, 0.17-0.86; P = .020). Donor thyroxine supplementation also had a beneficial effect on recipients' 2-year survival (OR, 0.53; 95% CI, 0.29-0.96; P = .036).

CONCLUSIONS

Combined thyroxine and methylprednisolone treatment could be a protective factor against PGD. Thyroxine administration was associated with better 2-year survival in recipients.

[Perioperative management of the brain-dead organ donor : Anesthesia between ethics and evidence]

Hintergrund

Die Anzahl postmortal gespendeter Organe ist in Deutschland weit geringer als der Bedarf. Dies unterstreicht die Wichtigkeit einer optimalen Versorgung während des gesamten Prozesses der Organspende.

Fragestellung

Es existieren internationale Leitlinien und nationale Empfehlungen zu intensivmedizinischen organprotektiven Maßnahmen beim Organspender. Für das anästhesiologische Management fehlen evidenzbasierte Empfehlungen. Ziel dieser Übersichtsarbeit ist es, anhand der vorhandenen Evidenz die pathophysiologischen Veränderungen des irreversiblen Hirnfunktionsausfalls zu rekapitulieren und sich kritisch mit den empfohlenen Behandlungsstrategien und therapeutischen Zielgrößen auseinanderzusetzen. Auch auf ethische Aspekte der Betreuung des postmortalen Organspenders wird eingegangen.

Methode

Diese Übersichtsarbeit basiert auf einer selektiven Literaturrecherche in PubMed (Suchwörter: „brain dead donor“, „organ procurement“, „organ protective therapy“, „donor preconditioning“, „perioperative donor management“, „ethical considerations of brain dead donor“). Internationale Leitlinien und nationale Empfehlungen wurden besonders berücksichtigt.

Ergebnisse

Insgesamt ist die Evidenz für optimale intensivmedizinische und perioperative organprotektive Maßnahmen beim postmortalen Organspender sehr gering. Nationale und internationale Empfehlungen zu Zielwerten und medikamentösen Behandlungsstrategien unterscheiden sich teilweise erheblich: kontrollierte randomisierte Studien fehlen. Der Stellenwert einer Narkose zur Explantation bleibt sowohl unter pathophysiologischen Gesichtspunkten als auch aus ethischer Sicht ungeklärt.

Schlussfolgerungen

Die Kenntnisse über die pathophysiologischen Prozesse im Rahmen des irreversiblen Hirnfunktionsausfalls und die organprotektiven Maßnahmen sind ebenso Grundvoraussetzung wie die ethische Auseinandersetzung mit dem Thema postmortale Organspende. Nur dann kann das Behandlungsteam in dieser herausfordernden Situation sowohl dem Organempfänger als auch dem Organspender und seinen Angehörigen gerecht werden.

Hemodynamic management in brain dead donors

Donor management is the key in the complex donation process, since up to 20% of organs of brain death donors (DBD) are lost due to hemodynamic instability. This challenge is made more difficult due to the lack of strong recommendations on therapies for hemodynamic management in DBDs and more importantly to the epidemiologic changes in these donors who are becoming older and with more comorbidities (marginal donors). In the present manuscript we aimed at summarizing the available evidence on therapeutic strategies for hemodynamic management (focusing on vasoactive drugs) and monitoring (therapeutic goals). Evidence on management in elderly DBDs is also summarized. Donor management continues critical care but with different and specific therapeutic goals since the number of donor goals met is related to the number of organs retrieved and transplanted. Careful monitoring of selected parameters (possibly including serial echocardiography) is the clinical tool able to guarantee the achievement and maintaining of therapeutic goals. Despide worldwide differences, norepinephrine is the vasoactive of choice in most countries but, whenever higher doses (> 0.2 mcg/kg/min) are needed, a second vasoactive drug (vasopressin) is advisable. Hormonal therapy (desmopressin, corticosteroid and thyroid hormone) are suggested in all DBDs independently of hemodynamic instability. In the single patient, therapeutic regimen (imprimis vasoactive drugs) should be chosen also according to the potential organs retrievable (i.e. heart vs liver and kidneys).

Strategies for hemodynamic maintenance of potential brain-dead donor: integrative review

OBJECTIVE

To learn about the scientific production on strategies adopted for hemodynamic maintenance of brain-dead patients.

METHODS

Integrative review with articles published between 2007 and 2019, in Scientific Electronic Library Online (SciELO), Latin American and Caribbean Health Sciences Literature (LILACS), PubMed® and ScienceDirect. The descriptors " Hemodinâmica AND Morte Encefálica " and "Hemodynamics AND Brain Death" were used. Exclusion criteria were non-human research and gray literature.

RESULTS

A total of 21 articles were listed. As strategies, the use of drugs - noradrenaline (n=8), vasopressin (n=7), dobutamine (n=6), hydrocortisone (n=4) and methylprednisolone (n=4); invasive (n=10) and noninvasive (n=13) cardiac monitoring; control of ventilatory parameters (n=12); and correction of fluid and electrolyte disturbances (n=17) were highlighted.

CONCLUSION

The main strategies found in this integrative review were regulation of blood pressure and temperature, use of catecholamines and corticosteroids, in addition to the need for an early diagnosis of brain death. However, the lack of clearer protocols on the subject is notorious, making management with the potential donor difficult.

Brazilian guidelines for the management of brain-dead potential organ donors. The task force of the AMIB, ABTO, BRICNet, and the General Coordination of the National Transplant System

OBJECTIVE

To contribute to updating the recommendations for brain-dead potential organ donor management.

METHOD

A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, joined a task force formed by the General Coordination Office of the National Transplant System/Brazilian Ministry of Health (CGSNT-MS), the Brazilian Association of Intensive Care Medicine (AMIB), the Brazilian Association of Organ Transplantation (ABTO), and the Brazilian Research in Intensive Care Network (BRICNet). The questions were developed within the scope of the 2011 Brazilian Guidelines for Management of Adult Potential Multiple-Organ Deceased Donors. The topics were divided into mechanical ventilation, hemodynamic support, endocrine-metabolic management, infection, body temperature, blood transfusion, and use of checklists. The outcomes considered for decision-making were cardiac arrest, number of organs recovered or transplanted per donor, and graft function/survival. Rapid systematic reviews were conducted, and the quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Two expert panels were held in November 2016 and February 2017 to classify the recommendations. A systematic review update was performed in June 2020, and the recommendations were reviewed through a Delphi process with the panelists between June and July 2020.

RESULTS

A total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong (lung-protective ventilation strategy, vasopressors and combining arginine vasopressin to control blood pressure, antidiuretic hormones to control polyuria, serum potassium and magnesium control, and antibiotic use), 11 as weak (alveolar recruitment maneuvers, low-dose dopamine, low-dose corticosteroids, thyroid hormones, glycemic and serum sodium control, nutritional support, body temperature control or hypothermia, red blood cell transfusion, and goal-directed protocols), and 1 was considered a good clinical practice (volemic expansion).

CONCLUSION

Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak. The observed lack of robust evidence on the topic highlights the importance of the present guideline to improve the management of brain-dead potential organ donors.

Vasopressor selection during critical care management of brain dead organ donors and the effects on kidney graft function

BACKGROUND

Delayed graft function (DGF), the need for dialysis in the first week following kidney transplant, affects approximately one quarter of deceased-donor kidney transplant recipients. Donor demographics, donor serum creatinine, and graft cold ischemia time are associated with DGF. However, there is no consensus on the optimal management of hemodynamic instability in organ donors after brain death (DBDs). Our objective was to determine the relationship between vasopressor selection during donor management and the development of DGF.

METHODS

Prospective observational data, including demographic and critical care parameters, were collected for all DBDs managed by 17 organ procurement organizations from nine Organ Procurement and Transplantation Network Regions between 2012 and 2018. Recipient outcome data were linked with donor data through donor identification numbers. Donor critical care parameters, including type of vasopressor and doses, were recorded at three standardized time points during donor management. The analysis included only donors who received at least one vasopressor at all three time points. Vasopressor doses were converted to norepinephrine equivalent doses and analyzed as continuous variables. Univariate analyses were conducted to determine the association between donor variables and DGF. Results were adjusted for known predictors of DGF using binary logistic regression.

RESULTS

Complete data were available for 5,554 kidney transplant recipients and 2,985 DBDs. On univariate analysis, donor serum creatinine, donor age, donor subtype, kidney donor profile index, graft cold ischemia time, phenylephrine dose, and dopamine dose were associated with DGF. After multivariable analysis, increased donor serum creatinine, donor age, kidney donor profile index, graft cold ischemia time, and phenylephrine dose remained independent predictors of DGF.

CONCLUSION

Higher doses of phenylephrine were an independent predictor of DGF. With the exception of phenylephrine, the selection and dose of vasopressor during donor management did not predict the development of DGF.

LEVEL OF EVIDENCE

Prognostic study, Level III.

Optimisation of the organ donor and effects on transplanted organs: a narrative review on current practice and future directions

Mortality remains high for patients on the waiting list for organ transplantation. A marked imbalance between the number of available organs and recipients that need to be transplanted persists. Organs from deceased donors are often declined due to perceived and actual suboptimal quality. Adequate donor management offers an opportunity to reduce organ injury and maximise the number of organs than can be offered in order to respect the donor's altruistic gift. The cornerstones of management include: correction of hypovolaemia; maintenance of organ perfusion; prompt treatment of diabetes insipidus; corticosteroid therapy; and lung protective ventilation. The interventions used to deliver these goals are largely based on pathophysiological rationale or extrapolations from general critical care patients. There is currently insufficient high-quality evidence that has assessed whether any interventions in the donor after brain death may actually improve immediate post-transplant function and long-term graft survival or recipient survival after transplantation. Improvements in our understanding of the underlying mechanisms following brain death, in particular the role of immunological and metabolic changes in donors, offer promising future therapeutic opportunities to increase organ utilisation. Establishing a UK donor management research programme involves consideration of ethical, logistical and legal issues that will benefit transplanted patients while respecting the wishes of donors and their families.

Pediatric donor management to optimize donor heart utilization

Optimal management of pediatric cardiac donors is essential in order to maximize donor heart utilization and minimize the rate of discarded organs. This review was performed after a systematic literature review and gives a detailed overview on current practices and guidelines. The review focuses on optimal monitoring of pediatric donors, donor workup, hormonal replacement, and obliterating the adverse effects of brain death. The current evidence on catecholamine support and thyroid hormone replacement is also discussed. Recognizing and addressing this shall help in a standardized approach toward donor management and optimal utilization of pediatric heart donors organs.

Donor Heart Utilization in Korea

Background and Objectives

Donor heart utilization patterns in Korea are not well known. We aimed to analyze the current utilization rate of donor heart and to evaluate the reason for non-utilization in Korea.

Methods

Brain death donors were identified from the Korean Network for Organ Sharing registry from November 2009 to December 2019. Baseline characteristics and heart transplant related parameters were compared between transplanted and discarded donor hearts.

Results

Among 4,401 donors, 1,383 (31.4%) hearts were utilized. Hearts from younger, male donors without history of hypertension or diabetes mellitus were utilized more frequently. The most common blood type in the transplanted group was O, while blood type A was the most common blood type in the discarded group. The ejection fraction in the discarded group were significantly lower (57.0 ± 13.5% vs. 61.7 ± 7.0%, p<0.001). Reasons for non-utilization were as follows: medical condition (34.4%), old age (31.8%), refused by all candidates (22.5%), refused to donate (11.0%), and others (0.2%). The most common cause of brain death was cerebrovascular disease in both the transplanted and discarded groups, but the incidence was significantly higher in the discarded group (46.8% vs. 37.5%, p<0.001). In multivariate analysis, old age, small body surface area, rapid heart rate, blood type other than O, abnormal echocardiography findings were independent predictors for non-utilization.

Conclusions

Average donor heart utilization rate was 31.4% and it improved to 42.9% in 2019. However, substantial numbers of donor hearts are still discarded. A strategic approach to improve donor heart utilization is necessary.

Management of the Pediatric Organ Donor

Management of the pediatric organ donor necessitates understanding the physiologic changes that occur preceding and after death determination. Recognizing these changes allows application of the therapeutic strategies designed to optimize hemodynamics and metabolic state to allow for preservation of end-organ function for maximal organ recovery and minimal damage to the donor grafts. The pediatric pharmacist serves as the medication expert and may collaborate with the organ procurement organizations for provision of pharmacologic hemodynamic support, hormone replacement therapy, antimicrobials, and nutrition for the pediatric organ donor.

Medical Management of Brain-Dead Organ Donors

With improving healthcare services, the demand for organ transplants has been increasing daily worldwide. Deceased organ donors serve as a good alternative option to meet this demand. The first step in this process is identifying potential organ donors. Specifically, brain-dead patients require aggressive and intensive care from the declaration of brain death until organ retrieval. Currently, there are no specific protocols in place for this, and there are notable variations in the management strategies implemented across different transplant centers. Some transplant centers follow their own treatment protocols, whereas other countries, such as Bangladesh, do not have any protocols for potential organ donor care. In this review, we discuss how to identify brain-dead donors and describe the physiological changes that occur following brain death. We then summarize the management of brain-dead organ donors and, on the basis of a review of the literature, we propose recommendations for a treatment protocol to be developed in the future.

Management of the brain-dead donor in the ICU: general and specific therapy to improve transplantable organ quality

PURPOSE

To provide a practical overview of the management of the potential organ donor in the intensive care unit.

METHODS

Seven areas of donor management were considered for this review: hemodynamic management; fluids and electrolytes; respiratory management; endocrine management; temperature management; anaemia and coagulation; infection management. For each subchapter, a narrative review was conducted.

RESULTS AND CONCLUSIONS

Most elements in the current recommendations and guidelines are based on pathophysiological reasoning, epidemiological observations, or extrapolations from general ICU management strategies, and not on evidence from randomized controlled trials. The cardiorespiratory management of brain-dead donors is very similar to the management of critically ill patients, and the same applies to the management of anaemia and coagulation. Central diabetes insipidus is of particular concern, and should be diagnosed based on clinical criteria. Depending on the degree of vasopressor dependency, it can be treated with intermittent desmopressin or continuous vasopressin, intravenously. Temperature management of the donor is an area of uncertainty, but it appears reasonable to strive for a core temperature of > 35 °C. The indications and controversies regarding endocrine therapies, in particular thyroid hormone replacement therapy, and corticosteroid therapy, are discussed. The potential donor should be assessed clinically for infections, and screening tests for specific infections are an essential part of donor management. Although the rate of infection transmission from donor to receptor is low, certain infections are still a formal contraindication to organ donation. However, new antiviral drugs and strategies now allow organ donation from certain infected donors to be done safely.

Hormone replacement therapy in brain-dead organ donors: a comprehensive review with an emphasis on traumatic brain injury

BACKGROUND

Organ shortage is an ongoing problem in the United States. Most donor organs are procured following brain death and a significant portion of brain-dead donors result from devastating brain injury. Without a standard practice for hormone replacement therapy (HRT) in the setting of brain death, a comprehensive review of the literature was deemed necessary.

METHODS

A search of published literature was conducted with terms "TBI" or "brain injury" or "head injury" AND "hormone" or "management" AND "organ" AND "donor" or "donation." Abstracts and full texts were screened for relevance and inclusion of information on HRT. Additional studies were selected from references cited within these. Excluded studies were non-English, nonhuman based, or had small sample size, (i.e., case reports or series with fewer than five subjects).

RESULTS

Fifteen studies were selected for inclusion and contained Level III or Level IV evidence. Combinations of thyroid hormone, insulin, and corticosteroids were the most commonly cited HRT. Ninety-three percent of studies found a significant increase in organ procurement rate among donors who received HRT. Hormone replacement therapy was administered after brain death declaration in eight studies. Only two studies specifically explored the effects of starting HRT earlier and identified even greater procurement rates. Four studies were specific to traumatic brain injury (TBI); the remaining 11 studies involved TBI in 22% to 89% of the sample.

CONCLUSION

Organ shortage remains a growing problem in the United States. Donor management including HRT has been proposed to combat the endocrine derangement associated with brain death and, in particular, TBI. While the existing literature reported compelling outcomes using HRT, there remains a need for further Level I and Level II evidence studies to define optimal practice.

LEVEL OF EVIDENCE

Review article, level IV.

[Critical care management of the potential organ donor : Current recommendation for adults]

The shortage of donor organs has not improved in recent years. To increase the number and success of transplantation it is crucial to optimize the processes of early identification of potential organ donors and structured critical care management. The therapy starts long before brain death is diagnosed. Structured in-house organ donor management protocols ensure a highly qualified critical care that has a direct impact on the transplantation outcome. The therapy is based on the established standards. The main focus is on differentiated catecholamine and volume therapy. Vasopressin, in combination with norepinephrine, is effective for both treating vasoplegia and electrolyte disturbances. Despite poor evidence, steroids are useful for stabilizing hemodynamics and treating the consequences of neuroendocrine dysfunction. Overall, prospective studies are required to give general recommendations for critical care.

Organ-Protective Intensive Care in Organ Donors

BACKGROUND

The ascertainment of brain death (the irreversible, total loss of brain function) gives the physician the opportunity to limit or stop further treatment. Alternatively, if the brain-dead individual is an organ donor, the mode of treatment can be changed from patient-centered to donationcentered. Consensus-derived recommendations for the organ-protective treatment of brain-dead organ donors are not yet available in Germany.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed, and on the authors' clinical experience.

RESULTS

Brain death causes major pathophysiological changes, including an increase in catecholamine levels and a sudden drop in the concentration of multiple hormones, among them antidiuretic hormone, cortisol, insulin, and triand tetraiodothyronine. These changes affect the function of all organ systems, as well as the hemodynamic state and the regulation of body temperature. The use of standardized donor management protocols might well increase the rate of transplanted organs per donor and improve the quality of the transplanted organs. In addition, the administration of methylprednisolone, desmopressin, and vasopressin could be a useful supplement to treatment in some cases. Randomized controlled trials have not yet demonstrated either improved organ function or prolonged survival of the transplant recipients.

CONCLUSION

The evidence base for organ-protective intensive care is weak; most of the available evidence is on the level of expert opinion. There is good reason to believe, however, that the continuation of intensive care, in the sense of early donor management, can make organ transplantation more successful both by increasing the number of transplantable organs and by improving organ quality.

Guidelines for the management of a brain death donor in the rhesus macaque: A translational transplant model

Introduction

The development of a translatable brain death animal model has significant potential to advance not only transplant research, but also the understanding of the pathophysiologic changes that occur in brain death and severe traumatic brain injury. The aim of this paper is to describe a rhesus macaque model of brain death designed to simulate the average time and medical management described in the human literature.

Methods

Following approval by the Institutional Animal Care and Use Committee, a brain death model was developed. Non-human primates were monitored and maintained for 20 hours after brain death induction. Vasoactive agents and fluid boluses were administered to maintain hemodynamic stability. Endocrine derangements, particularly diabetes insipidus, were aggressively managed.

Results

A total of 9 rhesus macaque animals were included in the study. The expected hemodynamic instability of brain death in a rostral to caudal fashion was documented in terms of blood pressure and heart rate changes. During the maintenance phase of brain death, the animal’s temperature and hemodynamics were maintained with goals of mean arterial pressure greater than 60mmHg and heart rate within 20 beats per minute of baseline. Resuscitation protocols are described so that future investigators may reproduce this model.

Conclusion

We have developed a reproducible large animal primate model of brain death which simulates clinical scenarios and treatment. Our model offers the opportunity for researchers to have translational model to test the efficacy of therapeutic strategies prior to human clinical trials.

Anesthesia Management of Organ Donors

The shortage of suitable organs is the biggest obstacle for transplants. At present, most organs for transplant in the United States are from donation after neurologic determination of death (brain death). Potential organs for transplant need to maintain their viability during a series of insults, including the original disease, physiologic derangements during the dying process, ischemia, and reperfusion. Proper donor management before, during, and after procurement has potential to increase the number and quality of organs from donors. Anesthesiologists need to understand the physiologic derangements associated with brain death and the updated donor management during the periprocurement period.

Evaluation and Management of the Potential Lung Donor

The expansion of the donor lung pool has involved an evidence-driven redefinition of acceptable donors. Proceeding with transplantation with an acceptable rather than ideal donor depends on specific patient-related and organ-related risk factors as well as the severity of recipient illness. Although the physiologic optimization of brain-dead donors has not changed significantly in recent years, the use of donor management protocols has improved procurement rates. Ex vivo lung perfusion is an increasingly viable strategy to recondition lungs that would otherwise fall below the acceptable threshold for transplant. Ex vivo perfusion trials for preservation of standard donor lungs are ongoing.

Organ donor management: Eight common recommendations and actions that deserve reflection

Despite major advances in our understanding of the physiopathology of brain death (BD), there are important controversies as to which protocol is the most appropriate for organ donor management. Many recent reviews on this subject offer recommendations that are sometimes contradictory and in some cases are not applied to other critically ill patients. This article offers a review of the publications (many of them recent) with an impact upon these controversial measures and which can help to confirm, refute or open new areas of research into the most appropriate measures for the management of organ donors in BD, and which should contribute to discard certain established recommendations based on preconceived ideas, that lead to actions lacking a physiopathological basis. Aspects such as catecholamine storm management, use of vasoactive drugs, hemodynamic objectives and monitoring, assessment of the heart for donation, and general care of the donor in BD are reviewed.

Positive impact of a clinical goal-directed protocol on reducing cardiac arrests during potential brain-dead donor maintenance

Background

The disproportion between the large organ demand and the low number of transplantations performed represents a serious public health problem worldwide. Reducing the loss of transplantable organs from deceased potential donors as a function of cardiac arrest (CA) may contribute to an increase in organ donations. Our purpose was to test the hypothesis that a goal-directed protocol to guide the management of deceased donors may reduce the losses of potential brain-dead donors (PBDDs) due to CA.

Methods

The quality improvement project included 27 hospitals that reported deceased donors prospectively to the Transplant Center of the State of Santa Catarina, Brazil. All deceased donors reported prospectively between May 2012 and April 2014 were analyzed. Hospitals were encouraged to use the VIP approach checklist during the management of PBDDs. The checklist was composed of the following goals: protocol duration 12–24 hours, temperature > 35 °C, mean arterial pressure ≥ 65 mmHg, diuresis 1–4 ml/kg/h, corticosteroids, vasopressin, tidal volume 6–8 ml/kg, positive end-expiratory pressure 8–10 cmH₂O, sodium < 150 mEq/L, and glycemia < 180 mg/dl. A logistic regression model was used to identify predictors of CA.

Results

There were 726 PBDD notifications, of which 324 (44.6) were actual donors, 141 (19.4 %) CAs, 226 (31.1 %) family refusals, and 35 (4.8 %) contraindications. Factors associated with CA reduction included use of the checklist (odds ratio (OR) 0.43, p < 0.001), maintenance performed inside the ICU (OR 0.49, p = 0.013), and vasopressin administration (OR 0.56, p = 0.04). More than three interventions had association with less CAs (OR 0.19, p < 0.001). After 24 months, CAs decreased from 27.3 % to 14.6 % (p = 0.002), reaching 12.1 % in the following two 4-month periods (p < 0.001). Simultaneous increases in organ recovered per donor and in actual donors were observed.

Conclusions

A quality improvement program based on education and the use of a goal checklist for the management of potential donors inside the ICU is strongly associated with a decrease in donor losses and an increase in organs recovered per donor.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1484-1) contains supplementary material, which is available to authorized users.

Pharmacists' guide to the management of organ donors after brain death

PURPOSE

This article reviews organ donor pathophysiology as it relates to medication use with the goal of maximizing the successful procurement and transplantation of donor organs.

SUMMARY

The number of patients requiring organ transplantation continues to grow, yet organ donation rates remain flat, making it critical to appropriately manage each organ donor in order to ensure viability of all transplantable organs. The care given to one organ donor is tantamount to the care of several transplant recipients. Aggressive donor management ensures that the largest number of organs can be successfully procured and improves the organs' overall quality. Hospital pharmacists are responsible for processing orders and preparing the medications outlined in donor management algorithms developed by their respective medical systems. It is important that pharmacists understand the details of the medications used in these protocols in order to critically evaluate each medication order and appropriately manage the donor. Typical medications used in organ donors after brain death include medications for blood pressure management and fluid resuscitation, medications necessary for electrolyte management, blood products, vasopressors, hormone replacement therapy, antiinfectives, anticoagulants, paralytics, and organ preservation solutions.

CONCLUSION

It is essential to provide optimal pharmacotherapy for each organ donor to ensure organ recovery and donation. Typical medications used in organ donors include agents for blood pressure management and fluid resuscitation, medications necessary for electrolyte management, blood products, vasopressors, hormone replacement therapy, antiinfectives, anticoagulants, paralytics, and organ preservation solutions.

The development and current status of Intensive Care Unit management of prospective organ donors

Introduction:

Despite continuous advances in transplant medicine, there is a persistent worldwide shortage of organs available for donation. There is a growing body of research that supports that optimal management of deceased organ donors in Intensive Care Unit can substantially increase the availability of organs for transplant and improve outcomes in transplant recipients.

Methods:

A systematic literature review was performed, comprising a comprehensive search of the PubMed database for relevant terms, as well as individual assessment of references included in large original investigations, and comprehensive society guidelines.

Results:

In addition to overall adherence to catastrophic brain injury guidelines, optimization of physiologic state in accordance with established donor management goals (DMGs), and establishment of system-wide processes for ensuring early referral to organ procurement organizations (OPOs), several specific critical care management strategies have been associated with improved rates and outcomes of renal transplantation from deceased donors. These include vasoactive medication selection, maintenance of euvolemia, avoidance of hydroxyethyl starch, glycemic control, targeted temperature management, and blood transfusions if indicated.

Conclusions:

Management of deceased organ donors should focus first on maintaining adequate perfusion to all organ systems through adherence to standard critical care guidelines, early referral to OPOs, and family support. Furthermore, several specific DMGs and strategies have been recently shown to improve both the rates and outcomes of organ transplantation.

Endocrine Considerations of the Pediatric Organ Donor

Patients determined to be neurologically deceased exhibit potentially harmful changes in various endocrine pathways due to disruptions of the body's neurohormonal control mechanisms. These deviations from endocrine homeostasis lead to hemodynamic, metabolic, and immunologic aberrations that are associated with reduced graft procurement and function for the purposes of organ donation. Existing literature has attempted to describe the pathophysiology that associates disruptions in endocrine pathways with organ dysfunction, both to increase understanding and to identify strategies to support the donor. For example, diabetes insipidus due to arginine vasopressin deficiency is commonly encountered, and should be anticipated. The significance of abnormalities in other pathways such as those involving cortisol and thyroid hormone is less established; however, there is increasing support for treating potential organ donors with combined hormonal therapies. While there are published documents aimed at guiding management of organ donors in general, many controversies exist and pediatric-specific literature is scarce. This article aims to review several of the important endocrine-specific aspects of managing the neurologically deceased organ donor, with an emphasis on pediatrics where information is available.

Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement

This document was developed through the collaborative efforts of the Society of Critical Care Medicine, the American College of Chest Physicians, and the Association of Organ Procurement Organizations. Under the auspices of these societies, a multidisciplinary, multi-institutional task force was convened, incorporating expertise in critical care medicine, organ donor management, and transplantation. Members of the task force were divided into 13 subcommittees, each focused on one of the following general or organ-specific areas: death determination using neurologic criteria, donation after circulatory death determination, authorization process, general contraindications to donation, hemodynamic management, endocrine dysfunction and hormone replacement therapy, pediatric donor management, cardiac donation, lung donation, liver donation, kidney donation, small bowel donation, and pancreas donation. Subcommittees were charged with generating a series of management-related questions related to their topic. For each question, subcommittees provided a summary of relevant literature and specific recommendations. The specific recommendations were approved by all members of the task force and then assembled into a complete document. Because the available literature was overwhelmingly comprised of observational studies and case series, representing low-quality evidence, a decision was made that the document would assume the form of a consensus statement rather than a formally graded guideline. The goal of this document is to provide critical care practitioners with essential information and practical recommendations related to management of the potential organ donor, based on the available literature and expert consensus.

Anesthetic considerations in organ procurement surgery: a narrative review

PURPOSE

While a few publications specify the anesthetic implications of either brain or cardiac death, they lack detail on how to provide anesthesia during organ donation surgery. We provide a thorough description of important anesthetic considerations during organ donation surgery in patients with either brain or cardiac death.

SOURCE

A thorough literature review was undertaken to locate all relevant articles that describe systemic effects of brain and cardiac death and their anesthetic implications. We searched PubMed, Pubget, and EMBASE™ for relevant articles using the following search terms: anesthesia, management, donation cardiac death, donation brain death. In addition, we reviewed the relevant protocols at our own institution.

PRINCIPAL FINDINGS

Highly specific intraoperative management by an anesthesiologist is required during organ procurement after brain death. To manage the heart-beating brain-dead donor, the anesthesiologist must incorporate knowledge of the effects of brain death on each organ system as well as the effects of the preoperative measures that the donor required in the intensive care unit. It is also important to know which organs are going to be procured in order to establish specific goals and implement strategies (e.g., lung-protective ventilation or intraoperative glycemic control) to optimize donor outcome. During organ procurement after cardiac death, an anesthesiologist's direct involvement is particularly important for lung donors.

CONCLUSION

Anesthesiologist-guided physiological optimization of the brain-dead donor may be a factor in determining the outcome of the organ recipient. Additionally, anesthesiologists have an important role in helping to ensure that the highest quality and most appropriate care are rendered to non-heart-beating donors. This is achieved through establishing protocols in their hospitals for donation after cardiac death that maximize the number of available organs with the best chance for long-term graft viability.

Brain death increases COX-1 and COX-2 expression in the renal medulla in a pig model

BACKGROUND

Brain death is linked to a systemic inflammatory response that includes prostaglandins and cytokines among its mediators. The levels of cyclooxygenase-1 and cyclooxygenase-2 (COX-1 and COX-2) affect graft survival, but it remains unknown whether these enzymes are modified during brain death. The aims of this study were to investigate the organ expression of COX and to analyse the cytokine response in the plasma, cerebrospinal fluid (CSF), and organs in a porcine model of intracerebral haemorrhage and brain death.

METHODS

Twenty pigs were randomly assigned to either a brain death group or a control group. Brain death was induced by an intracerebral injection of blood, and the animals were observed over the next 8 h. Tissue samples were tested for COX-1, COX-2 messenger RNA (mRNA) expression (heart, lung, and kidney), haeme oxygenase-1 (HO-1) (kidney), interleukin-1β (IL-1β), IL-6, IL-8, IL-10, and tumour necrosis factor-α. These cytokines were also measured at eight time points in the plasma and CSF.

RESULTS

At the organ level, the levels of COX-1 and COX-2 mRNA expression were increased only in the renal medulla (P = 0.03 and P = 0.02, respectively). The cytokine levels in the tissue, plasma, and CSF revealed no differences between the groups. HO-1 expression decreased (P = 0.0088).

CONCLUSION

Brain death increases the expression of COX-1 and COX-2 mRNA in the renal medulla. The release of cytokines into the plasma and CSF did not vary between the groups.

Current research on organ donor management

A shortage of organs is available for transplantation, with 116,000 patients on the Organ Procurement and Transplantation Network/United Network for Organ Sharing wait list. Because the demand for organs outweighs the supply, considerable care must be taken to maximize the number of organs transplanted per donor and optimize the quality of recovered organs. Studies designed to determine optimal donor management therapies are limited, and this research has many challenges. Although evidenced-based guidelines for managing potential organ donors do not exist, research in this area is increasing. This article reviews the existing literature and highlights recent trials that can guide management.

The effect of arginine vasopressin on organ donor procurement and lung function

BACKGROUND

Hormone replacement therapy (HRT) is becoming more common when managing brain-dead donors. Arginine vasopressin (AVP) is associated with benefits but is not consistently used. We hypothesize that AVP is associated with the maintenance of lung function and successful recovery in donors and enhanced lung graft performance in recipients.

METHODS

The Organ Procurement and Transplantation Network database was used. Study donors were those treated with HRT and procured from January 1, 2009 to June 30, 2011. AVP (+) and AVP (-) donors were compared. Donor lung function, the rate of successful lung procurement, and the incidence of graft failure in recipients were studied.

RESULTS

There were 12,322 donors included, of which 7686 received AVP (62.4%). Cerebrovascular accident (4722 [38.3%]) was the most common cause of donor death. There was a significant increase in high yield (≥4 organs) (51.0% versus 39.3%, <0.001), mean number of organs (3.75 versus 3.33, <0.001), and rate of successful lung recovery (26.3% versus 20.5%, <0.001) with AVP. Lung function was preserved to a greater degree in donors receiving AVP. Adjusting the significant factors, AVP was independently associated with lung procurement (1.220 [1.114-1.336], <0.001). The incidence of early graft failure was not changed.

CONCLUSIONS

AVP with HRT is associated with the maintenance of lung function and a significant increase in successful organ recovery in donors without untoward effects in the recipient. AVP should be universally adopted as a component of HRT in the management of donors with neurologic death.