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Kazzaz YM, Maghrabi F, Alkhathaami RA, Alghannam RF, Alonazi NM, Alrubaiaan AA, Alkadeeb NA, Antar M, Babakr R. Paediatric organ donation following neurological determinants of death in intensive care units in Saudi Arabia: a retrospective cross-sectional study. BMJ Open 2023; 13:e072073. [PMID: 37586859 PMCID: PMC10432649 DOI: 10.1136/bmjopen-2023-072073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 08/03/2023] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVES The aim of this retrospective cross-sectional study was to assess the performance of paediatric organ donation in intensive care units following neurological determinants of death in Saudi Arabia. DESIGN Retrospective cross-sectional study. SETTING Paediatric intensive care units at three tertiary centres over 5 years. PARTICIPANTS 423 paediatric deaths (<14 years) from January 2017 to December 2021. PRIMARY OUTCOME Patients were identified as either possible, potential, eligible, approached, consented or actual donors based on organ donation definitions from the WHO, Transplantation Society and UK potential donor audit. SECONDARY OUTCOME Secondary outcome was causative mechanisms of brain injury in possible donors. Demographics of the study cohort (age, sex, hospital length of stay (LOS), paediatric intensive care unit LOS, pre-existing comorbidities, admission type and diagnosis category) were compared between possible and non-possible donors. Demographics were also compared between patients who underwent neurological determination of death and patients who did not. RESULTS Among the 423 paediatric deaths, 125 (29.6%) were identified as possible donors by neurological criteria (devastating brain insult with likelihood of brain death, Glasgow Coma Score of 3 and ≥2 absent brainstem reflexes). Of them, 41 (32.8%) patients were identified as potential donors (neurological determination of death examinations initiated by the treating team), while only two became actual donors. The eligible death conversion rate was 6.9%. The reporting rate to organ procurement organisation was 70.7% with a consent rate of 8.3%. The most common causes of brain insult causing death were cardiac arrest (44 of 125 patients, 35.2%), followed by traumatic brain injury and drowning (31 of 125 patients, 24.8%), and intracranial bleeding (13 of 125 patients, 11.4%). CONCLUSION Major contributors to low actual donation rate were consent, donor identification and donor referral.
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Affiliation(s)
- Yasser Mohammed Kazzaz
- Department of Pediatrics, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Fidaa Maghrabi
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Raghad Ali Alkhathaami
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Rahaf Fahad Alghannam
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nora Mohammad Alonazi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Nayla Anwar Alkadeeb
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohannad Antar
- Department of Pediatrics, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Razan Babakr
- Department of Pediatrics, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
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Should We Be Utilizing More Liver Grafts From Pediatric Donation After Circulatory Death Donors? A National Analysis of the SRTR from 2002 to 2017. Transplantation 2021; 105:1998-2006. [PMID: 32947583 DOI: 10.1097/tp.0000000000003458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Rates of withdrawal of life-sustaining treatment are higher among critically ill pediatric patients compared to adults. Therefore, livers from pediatric donation after circulatory death (pDCD) could improve graft organ shortage and waiting time for listed patients. As knowledge on the utilization of pDCD is limited, this study used US national registry data (2002-2017) to estimate the prognostic impact of pDCD in both adult and pediatric liver transplant (LT). METHODS In adult LT, the short-term (1-year) and long-term (overall) graft survival (GS) between pDCD and adult donation after circulatory death (aDCD) grafts was compared. In pediatric LT, the short- and long-term prognostic outcomes of pDCD were compared with other type of grafts (brain dead, split, and living donor). RESULTS Of 80 843 LTs in the study, 8967 (11.1%) were from pediatric donors. Among these, only 443 were pDCD, which were utilized mainly in adult recipients (91.9%). In adult recipients, short- and long-term GS did not differ significantly between pDCD and aDCD grafts (hazard ratio = 0.82 in short term and 0.73 in long term, both P > 0.05, respectively). Even "very young" (≤12 y) pDCD grafts had similar GS to aDCD grafts, although the rate of graft loss from vascular complications was higher in the former (14.0% versus 3.6%, P < 0.01). In pediatric recipients, pDCD grafts showed similar GS with other graft types whereas waiting time for DCD livers was significantly shorter (36.5 d versus 53.0 d, P < 0.01). CONCLUSIONS Given the comparable survival seen to aDCDs, this data show that there is still much scope to improve the utilization of pDCD liver grafts.
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Ghavam A, Thompson NE, Lee J. Comparison of pediatric brain-dead donors to donation after circulatory death donors in the United States. Pediatr Transplant 2021; 25:e13926. [PMID: 33326666 DOI: 10.1111/petr.13926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/13/2020] [Accepted: 11/03/2020] [Indexed: 11/30/2022]
Abstract
In pediatrics, an increasing need for transplantable organs exists. This study aimed to describe the epidemiology of pediatric deceased donors in the United States. This retrospective observational study utilized data from the Organ Procurement and Transplantation Network (OPTN) from 2000 to 2015. Patients were stratified based on method of organ donation. Demographic variables and mechanism of death were then compared. A total of 14,481 deceased pediatric organ donors, donation after brain death (DBD) and donation after circulatory death (DCD), were included in the study, of which 8% were DCD donors. A significant difference (p<0.001) existed between the two donor groups with respect to ethnicity and mechanism of death. The annual trend of DCD and DBD donors showed an inverse relationship. During the 15-year study period the number of DBD donors decreased from 985 to 785 per year while DCD donors increased from 15 to 146 per year. As well, overall organs transplanted per year decreased from 3,475 to 3,117 over the 15-year study period. Significant differences exist between pediatric DBD donors and DCD donors, specifically with respect to ethnicity and mechanism of death. The number of pediatric DBD donors is decreasing while the number of pediatric DCD is slowly rising, making it increasingly important to be able to characterize these donors to better identify eligible DCD donors to optimize organ utilization.
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Affiliation(s)
- Ahmeneh Ghavam
- Division of Critical Medicine, Department of Pediatrics, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - Nathan E Thompson
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - Jane Lee
- Division of Special Needs, Department of Pediatrics, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
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Aghion A, Hussey-Gardner B, Davis NL, Falck AJ. Patient and provider factors impacting referral for neonatal organ donation. Pediatr Transplant 2020; 24:e13744. [PMID: 32478967 DOI: 10.1111/petr.13744] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/28/2020] [Accepted: 03/05/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND As determination of brain death is infrequent in neonates, the AAP endorses donation after circulatory determination of death as an acceptable alternative. Despite this recommendation, neonatal organ donation is infrequent. Timely referral to OPOs is a vital first step in the organ donation process. The aim of this study was to identify patient and provider factors impacting timely referral for neonatal organ donation. METHODS Medical records were reviewed for deaths occurring in a Level IV NICU from 2007 to 2017. Clinical and demographic factors, provider type, timing of OPO referral (before or after death), and outcome were assessed. Bivariate and multivariable logistic regression models were utilized to identify predictors of OPO referral characteristics. RESULTS Between 2007 and 2017, 329 deaths occurred in the NICU or delivery room. Of the 265 infants meeting inclusion criteria, 96% had late referrals (after death) and were declined for organ donation. Frequency of timely referrals (before death) improved when OPO contact was by an attending neonatologist, when withdrawal of life support was planned, and with increasing birthweight, gestational age, and PMA. Factors associated with decreased OPO referral included male sex, lower weight at death, earlier PMA, and deaths occurring while receiving maximal intensive care support. No organs or tissues were donated. CONCLUSIONS This study is the first to report NICU referral patterns for organ donation. We found that timely provider referral of neonates to the OPO was rare. Exploration of provider knowledge will guide future educational interventions aimed to improve the referral process.
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Affiliation(s)
- Abigail Aghion
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brenda Hussey-Gardner
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Natalie L Davis
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Alison J Falck
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
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Niederberger P, Farine E, Raillard M, Dornbierer M, Freed DH, Large SR, Chew HC, MacDonald PS, Messer SJ, White CW, Carrel TP, Tevaearai Stahel HT, Longnus SL. Heart Transplantation With Donation After Circulatory Death. Circ Heart Fail 2020; 12:e005517. [PMID: 30998395 DOI: 10.1161/circheartfailure.118.005517] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Heart transplantation remains the preferred option for improving quality of life and survival for patients suffering from end-stage heart failure. Unfortunately, insufficient supply of cardiac grafts has become an obstacle. Increasing organ availability with donation after circulatory death (DCD) may be a promising option to overcome the organ shortage. Unlike conventional donation after brain death, DCD organs undergo a period of warm, global ischemia between circulatory arrest and graft procurement, which raises concerns for graft quality. Nonetheless, the potential of DCD heart transplantation is being reconsidered, after reports of more than 70 cases in Australia and the United Kingdom over the past 3 years. Ensuring optimal patient outcomes and generalized adoption of DCD in heart transplantation, however, requires further development of clinical protocols, which in turn require a better understanding of cardiac ischemia-reperfusion injury and the various possibilities to limit its adverse effects. Thus, we aim to provide an overview of the knowledge obtained with preclinical studies in animal models of DCD heart transplantation, to facilitate and promote the most effective and efficient advancement in preclinical research. A literature search of the PubMed database was performed to identify all relevant preclinical studies in DCD heart transplantation. Specific aspects relevant for DCD heart transplantation were analyzed, including animal models, graft procurement and storage conditions, cardioprotective approaches, and graft evaluation strategies. Several potential therapeutic strategies for optimizing graft quality are identified, and recommendations for further preclinical research are provided.
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Affiliation(s)
- Petra Niederberger
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Emilie Farine
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Mathieu Raillard
- Experimental Surgery Unit (ESI), Experimental Surgery Unit, Department for BioMedical Research and Vetsuisse Faculty, Department of Clinical Veterinary Medicine, Institute of Anaesthesiology and Pain Therapy, University of Bern, Switzerland (M.R.)
| | - Monika Dornbierer
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Darren H Freed
- Cardiac Surgery, University of Alberta, Edmonton, Canada (D.H.F., C.W.W.)
| | - Stephen R Large
- Department of Transplantation, Royal Papworth Hospital, Papworth Everard, Cambridge, United Kingdom (S.R.L., S.J.M.)
| | - Hong C Chew
- St Vincent's Hospital, University of New South Wales, Victor Chang Cardiac Research Institute, Sydney, Australia (H.C.C., P.S.M.)
| | - Peter S MacDonald
- St Vincent's Hospital, University of New South Wales, Victor Chang Cardiac Research Institute, Sydney, Australia (H.C.C., P.S.M.)
| | - Simon J Messer
- Department of Transplantation, Royal Papworth Hospital, Papworth Everard, Cambridge, United Kingdom (S.R.L., S.J.M.)
| | | | - Thierry P Carrel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Hendrik T Tevaearai Stahel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Sarah L Longnus
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
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Beaupré RA, Morgan JA. Donation After Cardiac Death: A Necessary Expansion for Heart Transplantation. Semin Thorac Cardiovasc Surg 2019; 31:721-725. [DOI: 10.1053/j.semtcvs.2019.05.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 05/13/2019] [Indexed: 12/11/2022]
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Vose LA, Nelson RM. Ethical Issues Surrounding Limitation and Withdrawal of Support in the Pediatric Intensive Care Unit. J Intensive Care Med 2016. [DOI: 10.1177/088506669901400502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Nandi D, Miyamoto SD, Pietra BA, Shaddy RE, Rossano JW. Donation after circulatory death in pediatric patients: Current utilization in the United States. J Heart Lung Transplant 2016; 35:1131-2. [PMID: 27363738 DOI: 10.1016/j.healun.2016.05.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 05/27/2016] [Indexed: 11/30/2022] Open
Affiliation(s)
- Deipanjan Nandi
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shelley D Miyamoto
- Department of Pediatrics, Division of Cardiology, University of Colorado School of Medicine, Children's Hospital Colorado Heart Institute, Aurora, Colorado, USA
| | - Biagio A Pietra
- Congenital Heart Center, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Robert E Shaddy
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joseph W Rossano
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Abstract
OBJECTIVE Although pediatric donation after circulatory determination of death is increasing in frequency, there are no national or international donation after circulatory determination of death guidelines specific to pediatrics. This scoping review was performed to map the pediatric donation after circulatory determination of death literature, identify pediatric donation after circulatory determination of death knowledge gaps, and inform the development of national or regional pediatric donation after circulatory determination of death guidelines. DATA SOURCES Terms related to pediatric donation after circulatory determination of death were searched in Embase and MEDLINE, as well as the non-MEDLINE sources in PubMed from 1980 to May 2014. STUDY SELECTION Seven thousand five hundred ninety-seven references were discovered and 85 retained for analysis. All references addressing pediatric donation after circulatory determination of death were considered. Exclusion criteria were articles that did not address pediatric patients, animal or laboratory studies, surgical techniques, and local pediatric donation after circulatory determination of death protocols. Narrative reviews and opinion articles were the most frequently discovered reference (25/85) and the few discovered studies were observational or qualitative and almost exclusively retrospective. DATA EXTRACTION Retained references were divided into themes and analyzed using qualitative methodology. DATA SYNTHESIS The main discovered themes were 1) studies estimating the number of potential pediatric donation after circulatory determination of death donors and their impact on donation; 2) ethical issues in pediatric donation after circulatory determination of death; 3) physiology of the dying process after withdrawal of life-sustaining therapy; 4) cardiac pediatric donation after circulatory determination of death; and 5) neonatal pediatric donation after circulatory determination of death. Donor estimates suggest that pediatric donation after circulatory determination of death will remain an event less common than brain death, albeit with the potential to substantially expand the existing organ donation pool. Limited data suggest outcomes comparable with organs donated after neurologic determination of death. Although there is continued debate around ethical aspects of pediatric donation after circulatory determination of death, all pediatric donation after circulatory determination of death publications from professional societies contend that pediatric donation after circulatory determination of death can be practiced ethically. CONCLUSIONS This review provides a comprehensive overview of the published literature related to pediatric donation after circulatory determination of death. In addition to informing the development of pediatric-specific guidelines, this review serves to highlight several important knowledge gaps in this topic.
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Abstract
OBJECTIVES To estimate the organ donation potential of patients dying at a children's hospital. DESIGN Retrospective cohort study. SETTING A free-standing, 271-bed, tertiary Children's Hospital with a pediatric trauma center. PATIENTS Patients dying in any ICU during 2011-2012. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 224 deaths, 23 (10%) met neurologic criteria for death: 18 donated organs (conversion rate 78%), 47 (19%) died without prior limitation of life-sustaining therapies, and the remaining 69% had withdrawal of life-sustaining therapies. Among those dying after withdrawal of life-sustaining therapies (n = 154), the organ procurement organization was not notified prior to death in 24%, and older patients were more likely to be referred compared to those less than 1 year old. Infection, cancer, and organ dysfunction were the most frequent conditions that disqualified dying patients from suitability for donation. Just over half of children more than 1 year old were suitable for donation after withdrawal of life-sustaining therapies compared to a fifth of infants (19%). Of 45 suitable for donation, 37 (82%) died within 1 hour. None of 7 infants younger than 1 month old died within 20 minutes, compared with 46% of infants between 1 month and 1 year (n = 6) and 72% of older children. Thirty-three families (73%) did not permit donation after circulatory criteria for death whereas 12 (27%) gave permission for donation, and all 12 were actual donors (conversion rate 12/37 [32%]). CONCLUSIONS The number of pediatric potential candidates for donation after circulatory determination of death was significantly larger than potential candidates for donation after neurologic determination of death at our hospital, but the actual donation rate was significantly lower. Increasing acceptance of donation after circulatory determination of death could increase organ donation. Among all children having withdrawal of life-sustaining therapies, donation after circulatory determination of death potential is less for infants.
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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. Crit Care Med 2015; 43:1291-325. [PMID: 25978154 DOI: 10.1097/ccm.0000000000000958] [Citation(s) in RCA: 200] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Longnus SL, Mathys V, Dornbierer M, Dick F, Carrel TP, Tevaearai HT. Heart transplantation with donation after circulatory determination of death. Nat Rev Cardiol 2014; 11:354-63. [DOI: 10.1038/nrcardio.2014.45] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Hanley H, Kim S, Willey E, Castleberry D, Mathur M. Identifying potential kidney donors among newborns undergoing circulatory determination of death. Pediatrics 2014; 133:e82-7. [PMID: 24298008 DOI: 10.1542/peds.2013-2002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Over 96,000 patients await kidney transplantation in the United States, and 35,000 more are wait-listed annually. The demand for donor kidneys far outweighs supply, resulting in significant waiting list morbidity and mortality. We sought to identify potential kidney donors among newborns because en bloc kidney transplantation donation after circulatory determination of death (DCDD) may broaden the donor pool. METHODS We reviewed discharges from our 84-bed NICU between November 2002 and October 2012 and identified all deaths. The mode of death among potential organ donors (weight ≥ 1.8 kg) was recorded. Patients undergoing withdrawal of life support were further evaluated for DCDD potential. After excluding patients with medical contraindications, those with warm ischemic time (WIT) less than 120 minutes were characterized as potential kidney donors. RESULTS There were 11,201 discharges. Of 609 deaths, 359 patients weighed ≥ 1.8 kg and 159 died after planned withdrawal of life support. The exact time of withdrawal could not be determined for 2 patients, and 100 had at least 1 exclusion criterion. Of the remaining patients, 42 to 57 infants were potential en bloc kidney donors depending on acceptance threshold for WIT. Applying a 40% to 70% consent rate range would yield 1.7 to 4 newborn DCDD donors per year. CONCLUSIONS A neonatal DCDD kidney program at our institution could provide 2 to 4 paired kidneys for en bloc transplantation each year. Implementing a DCDD kidney donation program in NICUs could add a new source of donors and increase the number of kidneys available for transplantation.
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Affiliation(s)
- Heather Hanley
- Division of Pediatric Critical Care, 11175 Campus St, CP A1117, Loma Linda, CA 92354.
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Incidence and distribution of transplantable organs from donors after circulatory determination of death in U.S. intensive care units. Ann Am Thorac Soc 2013; 10:73-80. [PMID: 23607834 DOI: 10.1513/annalsats.201211-109oc] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE All U.S. acute care hospitals must maintain protocols for recovering organs from donors after circulatory determination of death (DCDD), but the numbers, types, and whereabouts of available organs are unknown. OBJECTIVES To assess the maximal potential supply and distribution of DCDD organs in U.S. intensive care units. METHODS We conducted a population-based cohort study among a randomly selected sample of 50 acute care hospitals in the highest-volume donor service area in the United States. We identified all potentially eligible donors dying within 90 minutes of the withdrawal of life-sustaining therapy from July 1, 2008 to June 30, 2009. MEASUREMENTS AND MAIN RESULTS Using prespecified criteria, potential donors were categorized as optimal, suboptimal, or ineligible to donate their lungs, kidneys, pancreas, or liver. If only optimal DCDD organs were used, the deceased donor supplies of these organs could increase by up to 22.7, 8.9, 7.4, and 3.3%, respectively. If optimal and suboptimal DCDD organs were used, the corresponding supply increases could be up to 50.0, 19.7, 18.5, and 10.9%. Three-quarters of DCDD organs could be recovered from the 17.2% of hospitals with the highest annual donor volumes-typically those with trauma centers and more than 20 intensive care unit beds. CONCLUSIONS Universal identification and referral of DCDD could increase the supply of transplantable lungs by up to one-half, and would not increase any other organ supply by more than one-fifth. The marked clustering of DCDD among a small number of identifiable hospitals could guide targeted interventions to improve DCDD identification, referral, and management.
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Workman JK, Myrick CW, Meyers RL, Bratton SL, Nakagawa TA. Pediatric organ donation and transplantation. Pediatrics 2013; 131:e1723-30. [PMID: 23690525 DOI: 10.1542/peds.2012-3992] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There is increasing unmet need for solid organ donation. Alternative donor sources, such as donation after circulatory determination of death (DCDD), are needed. The objective of this study was to examine the impact of DCDD on trends in pediatric organ donation and transplantation. METHODS Data were obtained from the Organ Procurement and Transplantation Network for US organ recipients and donors from 2001 to 2010 stratified according to age, organ, and deceased donor type (DCDD or donation after neurologic determination of death). Additional data included transplant wait-list removals due to death. RESULTS From 2001 to 2010, pediatric organ transplant recipients increased from 1170 to 1475. Organs from DCDD donors were transplanted into children infrequently but increased from 1 to 31. Pediatric donation after neurologic determination of death decreased by 13% whereas DCDD increased by 174% (50 to 137). Recipients of pediatric grafts decreased from 3042 to 2751. Adults receiving grafts from pediatric donors decreased from 2243 to 1780; children receiving pediatric grafts increased from 799 to 971. Transplant recipients receiving pediatric DCDD grafts were few but increased annually from 50 to 128 adults and 0 to 9 children. Pediatric candidates dying waiting for an organ decreased from 262 to 110. CONCLUSIONS From 2001 to 2010, children received more solid organ transplants and fewer children died waiting. Organ recovery from pediatric and adult DCDD donors increased. The number of pediatric recipients of DCDD grafts remains small. Adults primarily receive the direct benefit from pediatric DCDD but other changes in organ allocation have directly benefited children.
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Stadelmann M, Dornbierer M, Clément D, Gahl B, Dick F, Carrel TP, Tevaearai HT, Longnus S. Mild hypothermia during global cardiac ischemia opens a window of opportunity to develop heart donation after cardiac death. Transpl Int 2012. [DOI: 10.1111/tri.12022] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - Monika Dornbierer
- Department of Cardiovascular Surgery; Inselspital; Berne University Hospital and University of Berne; Switzerland
| | | | - Brigitta Gahl
- Department of Cardiovascular Surgery; Inselspital; Berne University Hospital and University of Berne; Switzerland
| | - Florian Dick
- Department of Cardiovascular Surgery; Inselspital; Berne University Hospital and University of Berne; Switzerland
| | - Thierry P. Carrel
- Department of Cardiovascular Surgery; Inselspital; Berne University Hospital and University of Berne; Switzerland
| | - Hendrik T. Tevaearai
- Department of Cardiovascular Surgery; Inselspital; Berne University Hospital and University of Berne; Switzerland
| | - Sarah Longnus
- Department of Cardiovascular Surgery; Inselspital; Berne University Hospital and University of Berne; Switzerland
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de Vries EE, Hoogland PE, Wind J, Snoeijs MG, van Heurn EL. Transplantation of kidneys from paediatric DCD donors: a comparison with DBD donors. Nephrol Dial Transplant 2012. [DOI: 10.1093/ndt/gfs464] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Cowl AS, Cummings BM, Yager PH, Miller B, Noviski N. Organ donation after cardiac death in children: acceptance of a protocol by multidisciplinary staff. Am J Crit Care 2012; 21:322-7. [PMID: 22941705 DOI: 10.4037/ajcc2012479] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Organ donation after cardiac death is increasingly implemented, with outcomes similar to those of organ donation after brain death. Many hospitals hesitate to implement a protocol for donation after cardiac death because of the potential negative reactions among health care providers. OBJECTIVES To determine the acceptance of a protocol for donation after cardiac death among multidisciplinary staff in a pediatric intensive care unit. METHODS An anonymous, 15-question, Likert-scale questionnaire (scores 1-5) was used to determine the opinions of staff about donation after brain death and after cardiac death in a pediatric intensive care unit of a tertiary-care university hospital. RESULTS Survey response rate was 67% (n = 60). All physicians, 89% of nurses, and 82% of the remaining staff members stated that they understood the difference between donation after brain death and donation after cardiac death; staff supported both types of donation, at rates of 90% and 85%, respectively. Staff perception was the same for each type of donation (ρ = 0.82; r = 0.92; P < .001). The 20 staff members who provided care directly to patients who were donors after cardiac death considered such donation worthwhile. However, 60% of those providers offered suggestions to improve the established protocol for donation. CONCLUSIONS The multidisciplinary staff has accepted organ donation after cardiac death and has fully integrated this kind of donation without reported differences from their acceptance of donation after brain death.
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Affiliation(s)
- Allison S. Cowl
- Allison S. Cowl is a pediatric intensivist at Connecticut Children’s Medical Center in Hartford. Brian M. Cummings, Phoebe H. Yager, and Natan Noviski are pediatric intensivists and Brenda Miller is a nurse manager in the Division of Pediatric Critical Care Medicine, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Brian M. Cummings
- Allison S. Cowl is a pediatric intensivist at Connecticut Children’s Medical Center in Hartford. Brian M. Cummings, Phoebe H. Yager, and Natan Noviski are pediatric intensivists and Brenda Miller is a nurse manager in the Division of Pediatric Critical Care Medicine, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Phoebe H. Yager
- Allison S. Cowl is a pediatric intensivist at Connecticut Children’s Medical Center in Hartford. Brian M. Cummings, Phoebe H. Yager, and Natan Noviski are pediatric intensivists and Brenda Miller is a nurse manager in the Division of Pediatric Critical Care Medicine, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Brenda Miller
- Allison S. Cowl is a pediatric intensivist at Connecticut Children’s Medical Center in Hartford. Brian M. Cummings, Phoebe H. Yager, and Natan Noviski are pediatric intensivists and Brenda Miller is a nurse manager in the Division of Pediatric Critical Care Medicine, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Natan Noviski
- Allison S. Cowl is a pediatric intensivist at Connecticut Children’s Medical Center in Hartford. Brian M. Cummings, Phoebe H. Yager, and Natan Noviski are pediatric intensivists and Brenda Miller is a nurse manager in the Division of Pediatric Critical Care Medicine, Massachusetts General Hospital for Children, Boston, Massachusetts
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Dornbierer M, Stadelmann M, Sourdon J, Gahl B, Cook S, Carrel TP, Tevaearai HT, Longnus SL. Early reperfusion hemodynamics predict recovery in rat hearts: a potential approach towards evaluating cardiac grafts from non-heart-beating donors. PLoS One 2012; 7:e43642. [PMID: 22928009 PMCID: PMC3424125 DOI: 10.1371/journal.pone.0043642] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 07/24/2012] [Indexed: 11/19/2022] Open
Abstract
Aims Cardiac grafts from non-heartbeating donors (NHBDs) could significantly increase organ availability and reduce waiting-list mortality. Reluctance to exploit hearts from NHBDs arises from obligatory delays in procurement leading to periods of warm ischemia and possible subsequent contractile dysfunction. Means for early prediction of graft suitability prior to transplantation are thus required for development of heart transplantation programs with NHBDs. Methods and Results Hearts (n = 31) isolated from male Wistar rats were perfused with modified Krebs-Henseleit buffer aerobically for 20 min, followed by global, no-flow ischemia (32°C) for 30, 50, 55 or 60 min. Reperfusion was unloaded for 20 min, and then loaded, in working-mode, for 40 min. Left ventricular (LV) pressure was monitored using a micro-tip pressure catheter introduced via the mitral valve. Several hemodynamic parameters measured during early, unloaded reperfusion correlated significantly with LV work after 60 min reperfusion (p<0.001). Coronary flow and the production of lactate and lactate dehydrogenase (LDH) also correlated significantly with outcomes after 60 min reperfusion (p<0.05). Based on early reperfusion hemodynamic measures, a composite, weighted predictive parameter, incorporating heart rate (HR), developed pressure (DP) and end-diastolic pressure, was generated and evaluated against the HR-DP product after 60 min of reperfusion. Effective discriminating ability for this novel parameter was observed for four HR*DP cut-off values, particularly for ≥20 *103 mmHg*beats*min−1 (p<0.01). Conclusion Upon reperfusion of a NHBD heart, early evaluation, at the time of organ procurement, of cardiac hemodynamic parameters, as well as easily accessible markers of metabolism and necrosis seem to accurately predict subsequent contractile recovery and could thus potentially be of use in guiding the decision of accepting the ischemic heart for transplantation.
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Affiliation(s)
- Monika Dornbierer
- Department of Cardiovascular Surgery, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland
| | - Mathieu Stadelmann
- Department of Cardiovascular Surgery, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland
- Cardiology, University & Hospital, Fribourg, Switzerland
| | - Joevin Sourdon
- Department of Cardiovascular Surgery, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland
- University of Auvergne, Institute of Technology, Clermont-Ferrand, France
| | - Brigitta Gahl
- Department of Cardiovascular Surgery, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland
| | - Stéphane Cook
- Cardiology, University & Hospital, Fribourg, Switzerland
| | - Thierry P. Carrel
- Department of Cardiovascular Surgery, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland
| | - Hendrik T. Tevaearai
- Department of Cardiovascular Surgery, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland
- * E-mail:
| | - Sarah L. Longnus
- Department of Cardiovascular Surgery, Inselspital, Berne University Hospital and University of Berne, Berne, Switzerland
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Development of a bedside tool to predict time to death after withdrawal of life-sustaining therapies in infants and children. Pediatr Crit Care Med 2012; 13:415-22. [PMID: 22067986 DOI: 10.1097/pcc.0b013e318238b830] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To generate a preliminary bedside predictor of rapid time-to-death after withdrawal of support in children to help identify potential candidates for organ donation after circulatory death. DESIGN Retrospective chart review. SETTING Pediatric intensive care unit of an academic children's hospital. PATIENTS All deaths in the pediatric intensive care unit from May 1996 to April 2007. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 1389 deaths, 634 patients underwent withdrawal of support and 518 with complete data regarding demographics, life-supportive therapies, and end-of-life circumstances were analyzed. Three hundred seventy-three (72%) patients died within 30 mins of withdrawal and 452 (87%) died within 60 mins. Using multiple logistic regression, significant predictors of death within 30 or 60 mins (typical cut-off times for organ donation) were identified and a predictor score was generated. Significant predictors included: age 1 month or younger; norepinephrine, epinephrine, or phenylephrine >0.2 µg/kg/min; extracorporeal membrane oxygenation; and positive end-expiratory pressure >10 cmH2O; and spontaneous ventilation. Possible scores for the 30-min predictor ranged from -17 to 67; a score ≤-9 predicted a 37% probability of death ≤ 30 mins, whereas a score ≥ 38 predicted an 85% probability of death within 30 mins. For the 60-min predictor, scores ranged from -21 to 38; score ≤-10 predicted a 59% probability of death within 60 mins and a score ≥ 16 predicted a 98% probability of death within 60 mins. CONCLUSIONS This tool is a reasonable preliminary predictor for death within 30 or 60 mins after withdrawal of support in terminally ill or injured children and might assist in identifying potential pediatric candidates for donation after circulatory death, although prospective validation is required.
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Joffe AR, Carcillo J, Anton N, deCaen A, Han YY, Bell MJ, Maffei FA, Sullivan J, Thomas J, Garcia-Guerra G. Donation after cardiocirculatory death: a call for a moratorium pending full public disclosure and fully informed consent. Philos Ethics Humanit Med 2011; 6:17. [PMID: 22206616 PMCID: PMC3313846 DOI: 10.1186/1747-5341-6-17] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Accepted: 12/29/2011] [Indexed: 05/20/2023] Open
Abstract
Many believe that the ethical problems of donation after cardiocirculatory death (DCD) have been "worked out" and that it is unclear why DCD should be resisted. In this paper we will argue that DCD donors may not yet be dead, and therefore that organ donation during DCD may violate the dead donor rule. We first present a description of the process of DCD and the standard ethical rationale for the practice. We then present our concerns with DCD, including the following: irreversibility of absent circulation has not occurred and the many attempts to claim it has have all failed; conflicts of interest at all steps in the DCD process, including the decision to withdraw life support before DCD, are simply unavoidable; potentially harmful premortem interventions to preserve organ utility are not justifiable, even with the help of the principle of double effect; claims that DCD conforms with the intent of the law and current accepted medical standards are misleading and inaccurate; and consensus statements by respected medical groups do not change these arguments due to their low quality including being plagued by conflict of interest. Moreover, some arguments in favor of DCD, while likely true, are "straw-man arguments," such as the great benefit of organ donation. The truth is that honesty and trustworthiness require that we face these problems instead of avoiding them. We believe that DCD is not ethically allowable because it abandons the dead donor rule, has unavoidable conflicts of interests, and implements premortem interventions which can hasten death. These important points have not been, but need to be fully disclosed to the public and incorporated into fully informed consent. These are tall orders, and require open public debate. Until this debate occurs, we call for a moratorium on the practice of DCD.
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Affiliation(s)
- Ari R Joffe
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital; Edmonton Clinic Health Academy 11405-87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
- John Dossetor Health Ethics Center, University of Alberta, Edmonton, Alberta, Canada
| | - Joe Carcillo
- Department of Pediatrics and Critical Care Medicine, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh, 400 45th Street, Pittsburgh, PA, 15201, USA
| | - Natalie Anton
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital; Edmonton Clinic Health Academy 11405-87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
| | - Allan deCaen
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital; Edmonton Clinic Health Academy 11405-87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
| | - Yong Y Han
- Department of Pediatrics & Communicable Diseases, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Michael J Bell
- Department of Pediatrics and Critical Care Medicine, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh, 400 45th Street, Pittsburgh, PA, 15201, USA
| | - Frank A Maffei
- Department of Pediatrics, Pediatric Critical Care Medicine, Janet Weis Children's Hospital, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA, 17822, USA
| | - John Sullivan
- Department of Pediatrics, Pediatric Critical Care Medicine, Janet Weis Children's Hospital, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA, 17822, USA
- Golisano Children's Hospital at Strong, University of Rochester School of Medicine, 601 Elmwood Avenue, Rochester, NY 15642, USA
| | - James Thomas
- Department of Pediatrics, University of Texas, Southwestern Medical Center; 5323 Harry Hines Blvd, Dallas, Texas, 75390-9063, USA
| | - Gonzalo Garcia-Guerra
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital; Edmonton Clinic Health Academy 11405-87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
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Shore PM, Huang R, Roy L, Darnell C, Grein H, Robertson T, Thompson L. Potential for liver and kidney donation after circulatory death in infants and children. Pediatrics 2011; 128:e631-8. [PMID: 21859917 DOI: 10.1542/peds.2010-3319] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To determine the potential effect of organ donation after circulatory death (DCD) on the number of kidney and liver donors in a PICU. PATIENTS AND METHODS All deaths in the PICU of an academic, tertiary care children's hospital from May 1996 to April 2007 were retrospectively reviewed. Patient demographics, premortem physiology, and end-of-life circumstances were recorded and compared with basic criteria for potential organ donation. A sensitivity analysis was performed to examine the effect of more strict physiologic and time criteria as well as 3 different rates of consent for donation. RESULTS There were 1389 deaths during 11 years; 634 children (46%) underwent withdrawal of life support, of whom 518 had complete data and were analyzed. There were 131 children (25% of those withdrawn, 9% of all deaths) who met basic physiologic and time criteria for organ donation (80 kidney; 107 liver). Consideration of consent rates in sensitivity analysis resulted in an estimated 24 to 85 organ donors, an increase of 28% to 99% over the 86 actual brain-dead donors during the same time period. Assuming historical rates of organ recovery, these DCD donors might have produced 30 to 88 additional kidneys and 8 to 56 additional livers, an increase of 21% to 60% in kidney donation and 13% to 80% in livers above the number of organs recovered from brain-dead donors. CONCLUSIONS Although relatively few children may have been eligible for DCD, they might have increased the number of organ donors from our institution, depending greatly on consent rates. DCD merits additional discussion and exploration.
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Affiliation(s)
- Paul M Shore
- Department of Pediatrics, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.
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Mathur M, Castleberry D, Job L. Identifying potential heart donors among newborns undergoing circulatory determination of death. J Heart Lung Transplant 2011; 30:389-94. [DOI: 10.1016/j.healun.2010.09.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Revised: 08/21/2010] [Accepted: 09/21/2010] [Indexed: 10/18/2022] Open
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Labrecque M, Parad R, Gupta M, Hansen A. Donation after cardiac death: the potential contribution of an infant organ donor population. J Pediatr 2011; 158:31-6. [PMID: 20732689 DOI: 10.1016/j.jpeds.2010.06.055] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Revised: 05/07/2010] [Accepted: 06/29/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine the percentage of deaths in level III neonatal intensive care unit (NICU) settings that theoretically would have been eligible for donation after cardiac death (DCD), as well as the percentage of these who would have been potential DCD candidates based on warm ischemic time. STUDY DESIGN We conducted a retrospective study of all deaths in 3 Harvard Program in Neonatology NICUs between 2005 and 2007. Eligible donors were identified based on criteria developed with our transplantation surgeons and our local organ procurement organization. Potential candidates for DCD were then identified based on an acceptable warm ischemic time. RESULTS Of the 192 deaths that occurred during the study period, 161 were excluded, leaving 31 theoretically eligible donors. Of these, 16 patients had a warm ischemic time of <1 hour and were potential candidates for DCD of 14 livers and 18 kidneys, and 14 patients had a warm ischemic time of <30 minutes and were potential candidates for DCD of 10 hearts. CONCLUSIONS Eight percent of NICU mortalities were potential candidates for DCD. Based on the size of the potential donor pool, establishing an infant DCD protocol for level III NICUs should be considered.
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Affiliation(s)
- Michelle Labrecque
- Division of Newborn Medicine, Children's Hospital Boston, Boston, MA, USA
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Abstract
Pediatric organ donation and organ transplantation can have a significant life-extending benefit to the young recipients of these organs and a high emotional impact on donor and recipient families. Pediatricians, pediatric medical specialists, and pediatric transplant surgeons need to be better acquainted with evolving national strategies that involve organ procurement and organ transplantation to help acquaint families with the benefits and risks of organ donation and transplantation. Efforts of pediatric professionals are needed to shape public policies to provide a system in which procurement, distribution, and cost are fair and equitable to children and adults. Major issues of concern are availability of and access to donor organs; oversight and control of the process; pediatric medical and surgical consultation and continued care throughout the organ-donation and transplantation process; ethical, social, financial, and follow-up issues; insurance-coverage issues; and public awareness of the need for organ donors of all ages.
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Fondevila C, García-Valdecasas J. Liver transplantation from donors after cardiac death. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/s1594-5804(09)60031-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Mah D, Singh TP, Thiagarajan RR, Gauvreau K, Piercey GE, Blume ED, Fynn-Thompson F, Almond CSD. Incidence and risk factors for mortality in infants awaiting heart transplantation in the USA. J Heart Lung Transplant 2009; 28:1292-8. [PMID: 19782580 DOI: 10.1016/j.healun.2009.06.013] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 06/08/2009] [Accepted: 06/10/2009] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Infants awaiting heart transplantation (HT) face the highest wait-list mortality among all children and adults listed for HT in the USA. We sought to determine the risk of death for infants <12 months old while awaiting HT in the current era, and to identify the principle risk factors associated with wait-list mortality. METHODS We analyzed outcomes for all infants listed for HT in the USA from January 1999 to July 2006, using data reported to the U.S. Scientific Registry of Transplant Recipients. RESULTS Of the 1,133 listed infants, 61% were <3 months of age, 80% were listed as Status 1A, 64% had a congenital heart disease (CHD) and 31% had cardiomyopathy. Of 724 infants with CHD, 25% were on prostaglandin (PG) and 27% had a history of prior surgery. By 6 months after listing, 23% died on the wait-list and 54% were transplanted. Multivariate factors associated with wait-list mortality were weight <3 kg (hazard ratio [HR] 1.4, 95% confidence interval [CI] 1.0 to 1.9), extracorporeal membrane oxygenation (ECMO) support (HR 5.6, CI 4.0 to 7.9), ventilator support (HR 2.1, 95% CI 1.6 to 2.8), CHD with PG support (HR 2.8, 95% CI 1.8 to 4.3), CHD without prior surgery (HR 2.8, 95% CI 1.9 to 3.9) and non-white race/ethnicity (HR 1.8, 95% CI 1.4 to 2.3). CONCLUSIONS One in four infants listed for HT in the USA die before a donor heart can be identified. Wait-list mortality is associated with weight <3 kg, level of invasive support and CHD, but not listing status, which captures medical urgency poorly. Measures to expand infant organ donation, especially among neonates, are urgently needed.
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Affiliation(s)
- Douglas Mah
- Department of Cardiology, Children's Hospital, Boston, Massachusetts 02115, USA
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Fondevila C, Jiménez-Galanes S, García-Valdecasas JC. [How can the number of liver transplantations be increased?]. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 32:519-30. [PMID: 19608299 DOI: 10.1016/j.gastrohep.2009.01.184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2007] [Accepted: 01/28/2009] [Indexed: 12/30/2022]
Abstract
The number of patients suitable for liver transplantation is progressively increasing due to the excellent results achieved with this procedure, giving rise to a growing imbalance in the number of candidates on the waiting list and the number of donors. This situation has prompted transplant teams to search for alternatives to increase the number of liver grafts. On the one hand, the criteria for donation have been broadened to include donors with advanced age, liver steatosis, hepatitis B and C viruses, neoplasms, and benign underlying diseases. On the other hand, new transplant techniques have been used with grafts from split livers, living donors, sequential or domino transplants and non-heart-beating donors. Other options such as xenotransplantation and hepatocyte transplants currently lack clinical applicability.
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Affiliation(s)
- Constantino Fondevila
- Unidad de Cirugía Hepática y Trasplante, Hospital Clínic i Provincial, IMDM, CIBEREHD, Universidad de Barcelona, Barcelona, España.
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Abstract
OBJECTIVES To determine the impact of a pediatric donation after cardiac death (DCD) program on organ donation. DESIGN Retrospective case series. SETTING A free-standing children's hospital. PATIENTS All ventilated pediatric intensive care unit patients who died between September 1, 2005 and April 30, 2007. INTERVENTIONS Institution of a DCD program. MEASUREMENTS AND MAIN RESULTS Data collected included clinical features, medical eligibility and consent for organ donation, as well as outcome for donation among eligible patients. One hundred ten patients who died in the pediatric intensive care unit and were treated with mechanical ventilation immediately before death were identified. Thirty-one patients met exclusion criteria, 26 patients were not referred, and 53 patients were evaluated for potential DCD by the organ procurement agency. The majority of patients had anoxia or trauma as their primary diagnosis. Family members initiated discussions regarding donation in 17% of evaluations. Sixty-eight percent of patients were deemed medically ineligible by the organ procurement agency. Of the 17 medically eligible patients, consent for donation was given in 9 cases (53%). Of these, 7 patients (41%) successfully donated; accounting for 37% of organ donors during the study period. Two families gave consent for donation which did not occur; one child did not die within the required time period and one could not be matched with any recipients. CONCLUSIONS Although a small percentage of dying patients are eligible for and will undergo DCD, such a program can markedly increase the number of organ donors at a children's hospital.
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Boucek MM, Mashburn C, Dunn SM, Frizell R, Edwards L, Pietra B, Campbell D. Pediatric heart transplantation after declaration of cardiocirculatory death. N Engl J Med 2008; 359:709-14. [PMID: 18703473 DOI: 10.1056/nejmoa0800660] [Citation(s) in RCA: 283] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In three infants awaiting orthotopic cardiac transplantation, transplantation was successfully performed with the use of organs from donors who had died from cardiocirculatory causes. The three recipients had blood group O and were in the highest-risk waiting-list category. The mean age of donors was 3.7 days, and the mean time to death after withdrawal from life support was 18.3 minutes. The 6-month survival rate was 100% for the 3 transplant recipients and 84% for 17 control infants who received transplants procured through standard organ donation. The mean number of rejection episodes among the three infants during the first 6 months after surgery was 0.3 per patient, as compared with 0.4 per patient among the controls. Echocardiographic measures of ventricular size and function at 6 months were similar among the three infants and the controls (left ventricular shortening fraction, 43.6% and 44.9%, respectively; P=0.73). No late deaths (within 3.5 years) have occurred in the three infants, and they have had functional and immunologic outcomes similar to those of controls. Mortality while awaiting a transplant is an order of magnitude higher in infants than in adults, and donors who died from cardiocirculatory causes offer an opportunity to decrease this waiting-list mortality.
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Affiliation(s)
- Mark M Boucek
- Department of Pediatrics, Joe DiMaggio Children's Hospital, Hollywood, FL 33021, USA.
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Abstract
OBJECTIVE To describe our experience with pediatric donation after cardiac death. DESIGN Retrospective chart review of all cases of donation after cardiac death from 1995 to 2005. SETTING The Children's Hospital of Philadelphia pediatric intensive care unit. PATIENTS Twelve patients who were pediatric organ donors after cardiac death. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Charts for 12 patients were located, and donation after cardiac death was confirmed. There were two females and ten males. Patient age ranged from 1 to 17 yrs (mean 8 yrs). Four patients had severe traumatic brain injury, and eight patients had hypoxic ischemic encephalopathy. The organs procured were 24 kidneys, eight livers, four lungs, and one pancreas. The organs transplanted were 23 kidneys, four livers, and one pancreas. Ten of 12 cases of withdrawal of life-sustaining support occurred in the operating room area; the other two occurred in the holding area and the postanesthesia care unit. Children received a wide range of medications at the time of extubation. No neuromuscular blockers were used. The time of extubation to time of death ranged from 4 mins to 30 mins, with a mean of 14.5 mins. Death was declared based on cardiac asystole confirmed by auscultation and transthoracic impedance, with organ procurement initiated 5 mins later. Regarding who initiated conversation about donation after cardiac death, nine cases were family initiated, one case was physician initiated, and in two there was a collaborative approach with the physician and representative from the organ procurement organization. Of the organs transplanted, all organs other than one kidney and one split liver graft were functioning at 1 yr post-transplant. CONCLUSIONS Pediatric donation after cardiac death can be performed successfully; its impact on end-of-life care and bereavement needs further investigation.
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Nurses' attitudes toward donation after cardiac death: implications for nurses' roles and moral distress. Pediatr Crit Care Med 2008; 9:339-40. [PMID: 18446100 DOI: 10.1097/pcc.0b013e318172ea27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVE Organ donation after cardiac death is viewed as one way of partially closing the current gap between organ supply and demand. There are no published guidelines for organ donation after cardiac death specific to the pediatric population. The objective of this study was to examine the cumulative pediatric donation-after-cardiac-death experience to set the context for the development and sharing of best-practice guidelines. PATIENTS AND METHODS This was a retrospective, descriptive study that used data from the Organ Procurement and Transplantation Network/United Network for Organ Sharing database from 1993 to 2005. Organ data from all donors after cardiac death who were < 18 years of age were analyzed. The list of donor medical centers was then cross-referenced with the member list from the National Association of Children's Hospitals and Related Institutions. RESULTS There were 683 organs from donation-after-cardiac-death donors < 18 years of age. Of those, < 5% were used for pediatric recipients. In comparison, approximately 20% of non-donation-after-cardiac-death organs from pediatric donors were used for pediatric recipients. The vast majority of donation-after-cardiac-death organs donated were kidneys and livers. More than 50% of medical centers that had a pediatric organ-donation-after-cardiac-death donor had just 1. The medical center with the largest pediatric organ-donation-after-cardiac-death donation experience had 14 donors. Forty-three percent of medical centers that had > or = 1 pediatric donation-after-cardiac-death donor were members of the National Association of Children's Hospitals and Related Institutions. Fifty-six percent of all of the pediatric donation-after-cardiac-death organs were donated from the National Association of Children's Hospitals and Related Institution member centers. CONCLUSIONS Data regarding the use of pediatric donation-after-cardiac-death organs for pediatric recipients remain sparse. Few medical centers have had enough donation-after-cardiac-death donor experience to report a tried-and-true approach. We advocate for comprehensive collection and reporting of outcome data for all-aged recipients of pediatric donation-after-cardiac-death organs to help facilitate the generation of evidence-based best-practice guidelines for pediatric donation after cardiac death.
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Affiliation(s)
- Robert Mazor
- Children's Hospital and Regional Medical Center, Division of Critical Care Medicine, W-9824, 4800 Sandpoint Way NE, Seattle, WA 98105, USA.
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Curley MAQ, Harrison CH, Craig N, Lillehei CW, Micheli A, Laussen PC. Pediatric staff perspectives on organ donation after cardiac death in children. Pediatr Crit Care Med 2007; 8:212-9. [PMID: 17417125 DOI: 10.1097/01.pcc.0000262932.42091.09] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The aims of this project were to describe whether pediatric clinical staff members believe that a donation after cardiac death (DCD) program could be consistent with the mission and core values of a children's hospital and to identify what staff consider essential to the acceptability of such a program. DESIGN Qualitative study. SETTING Children's hospital. SUBJECTS Pediatric clinical staff. INTERVENTIONS Data were gathered from pediatric clinical staff during eight focus groups conducted in a children's hospital in March and April 2005. MEASUREMENTS AND MAIN RESULTS Eighty-eight staff members participated. Six major themes emerged from qualitative analysis of the data: a) identifying children who could be candidates for DCD; b) considering the best interests of the dying child; c) approaching parents about DCD; d) preparing parents for their child's DCD; e) doing DCD well; and f) maintaining program integrity. Themes were used to construct a conceptual framework describing a model pediatric DCD program. Pediatric staff voiced numerous concerns. However, they identified "making it happen for families" who voice a desire to participate in organ donation as the primary reason for program adoption. CONCLUSIONS This study provides a framework for understanding pediatric staff perspectives on DCD programs in children. Results suggest several possible elements that may be helpful in framing interdisciplinary dialogue and informing institutional practices in the design of a pediatric DCD program.
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Affiliation(s)
- Martha A Q Curley
- Critical Care and Cardiovascular Program, Children's Hospital Boston, Boston, MA, USA.
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Abt P, Kashyap R, Orloff M, Jain A, Tsoulfas G, Bozorgzadeh A, Olthoff K. Pediatric liver and kidney transplantation with allografts from DCD donors: A review of UNOS data. Transplantation 2007; 82:1708-11. [PMID: 17198264 DOI: 10.1097/01.tp.0000254762.95625.d0] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Donation after cardiac death (DCD) is recognized as an important source of allografts to bridge the growing disequilibrium between the number of donors and recipients. Current transplant experience with DCD organs has focused on the adult recipient population, however little is known about the pediatric recipient experience. While there is increasing acceptance of these grafts in adults, transplant centers appear reluctant to use these grafts in the pediatric population. METHODS We reviewed the United Network for Organ Sharing database from 1995-2005 to determine the national experience with pediatric recipients of DCD organs. RESULTS Among 4026 renal transplants performed in children 18 years and younger, 26 (0.6%) received a renal allograft from a DCD donor. Ten (38.5%) received kidney allografts from pediatric donors (age < or = 18) and 16 (61.5%) from adult donors (age > 18 years). Graft survival at one and five years was 82.5%, 74.3% for kidneys from DCD donors compared to 89.6%, 64.8% from brain dead donors (DBD) (P = 0.7). Among 4991 liver transplants, 19 (0.4%) were from DCD donors. Sixteen patients (84.2%) received livers from pediatric donors and three (15.8%) from adult donors. Graft survival at one and five years was 89.2%, 79.3% for livers from DCD, compared to 75.6%, 65.8% for DBD (P = 0.3). CONCLUSION The use of DCD donors in the pediatric population is very limited; however graft survival is comparable to DBD grafts. Although pediatric centers may have been reluctant to utilize this donor source, this limited experience demonstrates that the select use of DCD organs can produce acceptable and durable graft survival in the pediatric population.
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Affiliation(s)
- Peter Abt
- Department of Surgery, Solid Organ Transplantation and Hepatobiliary Surgery Division, University of Rochester Medical Center, Rochester, NY 14642-8410, USA.
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Abstract
OBJECTIVES A task force was convened to decide whether a donation after cardiac death policy should be implemented at Children's Hospital Boston. As part of this process, we sought to determine the number of potential kidney donation after cardiac death donors in our PICUs. METHODS We examined all 254 deaths in the Medical/Surgical ICU and the Cardiac ICU from 2002 to 2004 and identified potential donation after cardiac death donors. Inclusion criteria were age > or = 3 months, mechanical ventilation, and creatinine < or = 1.5 mg/dL. Exclusion criteria were HIV infection, malignancy other than primary brain tumor or nonmelanoma skin cancer, evidence of ongoing infection, death despite resuscitation attempts, and brain death. RESULTS Twenty-one of the 254 deaths met criteria for brain death, and 233 patients did not. Of the 116 patients > 3 months of age for whom life support was withdrawn, 92 were not suitable for kidney donation after cardiac death. Of the 24 children identified as potentially eligible for donation after cardiac death, 14 died within 1 hour of withdrawal of support and could have proceeded with donation after cardiac death. In the other 10 children, donation would have been aborted because of prolonged time to death. CONCLUSIONS Of all patients who died in our ICUs, 5.5% would have been potential candidates for donation after cardiac death. Assuming the rates of parental consent are similar to that of our heart-beating organ donors (47%), a donation after cardiac death protocol could have potentially yielded 7 additional organ donors and 14 additional kidneys over this 3-year period.
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Affiliation(s)
- Amy L Durall
- Division of Critical Care, Department of Anesthesia, Perioperative and Pain Medicine, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115, USA.
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Rodríguez Núñez A, López-Herce Cid J, Hermana Tezanos MT, Rey Galán C. Ética y reanimación cardiopulmonar pediátrica. An Pediatr (Barc) 2007; 66:45-50. [PMID: 17402183 DOI: 10.1157/13097359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cardiopulmonary resuscitation (CPR) is a medical activity that involves major ethical issues. As in other areas of clinical ethics, CPR decisions must be based on the principles of autonomy, beneficence, nonmaleficence, and justice. The decision-making process is more difficult in emergency situations, and when the patient is a minor, the parents and the child's best interests must be taken into consideration. There are specific situations in which starting CPR is clearly indicated and others in which ceasing resuscitation maneuvers is justified. Do not attempt resuscitation orders must be respected by health staff. Other ethical issues involved in CPR include resuscitation of potential organ donors, learning CPR procedures, research in CPR, and the information given to the parents of children with cardiorespiratory arrest.
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Affiliation(s)
- A Rodríguez Núñez
- Comité de Etica Asistencial del Complejo Hospitalario Universitario de Santiago de Compostela y Servicio de Críticos y Urgencias Pediátricas, Spain
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Edwards J, Mulvania P, Robertson V, George G, Hasz R, Nathan H, D’Alessandro A. Maximizing Organ Donation Opportunities Through Donation After Cardiac Death. Crit Care Nurse 2006. [DOI: 10.4037/ccn2006.26.2.101] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- John Edwards
- John Edwards is the clinical administrator for Gift of Life Donor Program in Philadelphia, Pa, overseeing all clinical aspects of organ and tissue recovery, and a faculty member for the Gift of Life Institute, Philadelphia, providing training and mentoring for healthcare organizations nationally
| | - Patti Mulvania
- Patti Mulvania oversees the clinical education program for the Gift of Life Donor Program in Philadelphia and is a faculty member of the Gift of Life Institute, specializing in consent and clinical communication
| | - Virginia Robertson
- Virginia Robertson is the associate director of the Gift of Life Institute in Philadelphia. Formerly, she was the director of hospital services for the Gift of Life Donor Program
| | - Gweneth George
- Gweneth George is the director of hospital services for the Gift of Life Donor Program in Philadelphia. She directs a team of nearly 20 hospital development staff accountable for donation performance in 150 acute care hospitals
| | - Richard Hasz
- Richard Hasz is vice president of clinical services for the Gift of Life Donor Program in Philadelphia. He oversees the day-to-day clinical operations, including transplant coordination, hospital development, organ preservation, and tissue recovery
| | - Howard Nathan
- Howard Nathan is president and chief executive officer of the Gift of Life Donor Program in Philadelphia. The program has been involved in coordinating more than 22 000 organ transplantations and tens of thousands of tissue transplantations since 1974
| | - Anthony D’Alessandro
- Anthony D’Alessandro is a professor of surgery at the University of Wisconsin Medical School and the executive director of the University of Wisconsin Hospital and Clinics organ procurement organization, Madison, Wis. He is currently the cochair of the Organ Transplantation Breakthrough Collaborative
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Singhal AK, Abrams JD, Mohara J, Hasz RD, Nathan HM, Fisher CA, Furukawa S, Goldman BI. Potential Suitability for Transplantation of Hearts From Human Non–Heart-Beating Donors: Data Review From the Gift of Life Donor Program. J Heart Lung Transplant 2005; 24:1657-64. [PMID: 16210144 DOI: 10.1016/j.healun.2004.11.043] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2004] [Revised: 11/12/2004] [Accepted: 11/21/2004] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Organ availability limits use of heart transplantation for treatment for end-stage heart disease. Hearts are currently obtained from donors declared brain dead (heart-beating donors [HBDs]). Although use of hearts from non-heart-beating donors (NHBDs) could reduce the shortage, they are considered unusable because of possible peri-mortem ischemic injury. METHODS To project how use of NHBD hearts could increase heart donation, we retrospectively reviewed donor databases from the Gift of Life Donor Program (GLDP), our local organ procurement organization, from 2001 through 2003. We screened the NHBD population using conservative donor criteria, assuming an acceptable hypoxic/ischemic time (time from withdrawal of care to cross-clamp) of 30 minutes. RESULTS During the study period, there were 894 HBDs, 334 heart transplants and 119 NHBDs. NHBDs were similar to HBDs with respect to gender and ethnicity, but NHBDs were proportionately younger. Of 119 NHBDs, 55 did not meet the age criteria (< or =45 years) and 20 were eliminated because of incomplete data. Eighty-two NHBDs were cross-clamped within 30 minutes of care withdrawal. Twenty NHBDs met all cardiac donor criteria, and 14 of these 20 had hypoxic/ischemic times < or =30 minutes. Pro rata estimation for the 20 NHBDs with incomplete data suggested 7 potential additional donors. CONCLUSIONS Based on our assumptions, 12% to 18% of NHBDs in the study period (14 to 21 of 119 total) were potential heart donors, representing a 4% to 6% increase over of the number of heart transplants performed during the same time interval.
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Affiliation(s)
- Arun K Singhal
- Division of Cardiac and Thoracic Surgery, Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA
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Howard RJ, Schold JD, Cornell DL. A 10-year Analysis of Organ Donation after Cardiac Death in the United States. Transplantation 2005; 80:564-8. [PMID: 16177625 DOI: 10.1097/01.tp.0000168156.79847.46] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The greatest challenge facing transplantation today is how to increase the number of organ donors. Patients with severe brain injury who are not brain-dead can donate organs after they are removed from a ventilator and allowed to die, termed donation after cardiac death (DCD). METHODS We analyzed the database of all organs recovered from deceased donors in the United States from 1994 through 2003 to determine DCD trends in the United States. The database was obtained from the United Network for Organ Sharing (UNOS). RESULTS There were 57,681 deceased donors reported from 1994 through 2003. Of these, 1,177 were donors without a heartbeat (DWHB), 55,206 were brain dead donors, and 1,298 were unspecified donors. At least one organ was transplanted from 1010 of the 1177 DWHB. Organ procurement organizations (OPOs) reported 0-212 DWHB accounting for up to 12.3 percent of deceased donors. There was a steady annual increase in the number of DWHB, but in 2003 there were still 19 of 59 OPOs that recovered no DWHB. A total of 2,231 organs were transplanted from the 1,177 DWHB donors, and another 665 organs were recovered for transplantation but not transplanted. The transplanted organs included 1,779 kidneys, 395 livers, 54 pancreata, 2 lungs, and 1 heart. Organs from DWHB can be successfully transplanted. CONCLUSIONS Wider use of DWHB has the potential to greatly increase the number of organ transplants performed each year in the United States.
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Non-heartbeating donors: special considerations for procurement and preservation in liver transplantation. Curr Opin Organ Transplant 2005. [DOI: 10.1097/01.mot.0000163044.71825.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abt PL, Desai NM, Crawford MD, Forman LM, Markmann JW, Olthoff KM, Markmann JF. Survival following liver transplantation from non-heart-beating donors. Ann Surg 2004; 239:87-92. [PMID: 14685105 PMCID: PMC1356197 DOI: 10.1097/01.sla.0000103063.82181.2c] [Citation(s) in RCA: 300] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine whether patient and graft survival following transplantation with non-heart-beating donor (NHBD) hepatic allografts is equivalent to heart-beating-donor (HBD) allografts. SUMMARY BACKGROUND DATA With the growing disparity between the number of patients awaiting liver transplantation and a limited supply of cadaveric organs, there is renewed interest in the use of hepatic allografts from NHBDs. Limited outcome data addressing this issue exist. METHODS Retrospective evaluation of graft and patient survival among adult recipients of NHBD hepatic allografts compared with recipients of HBD livers between 1993 and 2001 using the United Network of Organ Sharing database. RESULTS NHBD (N = 144) graft survival was significantly shorter than HBD grafts (N = 26856). One- and 3-year graft survival was 70.2% and 63.3% for NHBD recipients versus 80.4% and 72.1% (P = 0.003 and P = 0.012) for HBD recipients. Recipients of an NHBD graft had a greater incidence of primary nonfunction (11.8 vs. 6.4%, P = 0.008) and retransplantation (13.9% vs. 8.3%, P = 0.04) compared with HBD recipients. Prolonged cold ischemic time and recipient life support were predictors of early graft failure among recipients of NHBD livers. Although differences in patient survival following NHBD versus HBD transplant did not meet statistical significance, a strong trend was evident that likely has relevant clinical implications. CONCLUSIONS Graft and patient survival is inferior among recipients of NHBD livers. NHBD donors remain an important source of hepatic grafts; however, judicious use is warranted, including minimization of cold ischemia and use in stable recipients.
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Affiliation(s)
- Peter L Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA
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Sasaki K, Miyake H, Kinoshita T, Ikeyama S, Tashiro S. Protective effect of FK506 and Thromboxane synthase inhibitor on ischemia-reperfusion injury in non-heart-beating donor in rat orthotopic liver transplantation. THE JOURNAL OF MEDICAL INVESTIGATION 2004; 51:76-83. [PMID: 15000260 DOI: 10.2152/jmi.51.76] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The study investigated the possibility of pharmacologically modulating hepatic allograft function from non-heart-beating donors (NHBDs) using male Lewis rats. The donors were divided into 4 groups: Group 1 in which the vehicle was administered, Group 2 in which FK506 (tacrolimus; a powerful immunosuppressive agent) was administered, Group 3 in which OKY046 (a specific thromboxane synthetase inhibitor) was administered and Group 4 in which FK506 and OKY046 were administered. The recipients received orthotopic liver transplantation. The survival rates differed significantly between the recipients that had received liver transplantation from Groups 1 and 4. The serum liver enzyme and inflammatory cytokine concentrations of the recipients which had received liver transplantation from Groups 2, 3 and 4 were significantly lower than those of the recipients that had received liver transplantation from Group 1. Although there was no significant difference, all parameters were better in the recipients that had received transplantation from Group 4 than those that had received transplantation from Groups 2 and 3. The action mechanisms of FK506 and OKY046 are completely different. Therefore, concomitant use of FK506 and OKY046 might have additive effects on liver transplantation from NHBDs. In conclusion, we demonstrated that pretreatment of NHBDs using FK506 and OKY046 ameliorated graft viability.
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Affiliation(s)
- Katsuya Sasaki
- Department of Digestive Pediatric Surgery, The University of Tokushima School of Medicine, Tokushima, Japan
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Abt P, Crawford M, Desai N, Markmann J, Olthoff K, Shaked A. Liver transplantation from controlled non-heart-beating donors: an increased incidence of biliary complications. Transplantation 2003; 75:1659-63. [PMID: 12777852 DOI: 10.1097/01.tp.0000062574.18648.7c] [Citation(s) in RCA: 232] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hepatic allografts from non-heart-beating donors (NHBD) have been cited as a means to expand the supply of donor livers. Concern exists that donor warm ischemic time in addition to subsequent cold ischemia-reperfusion injury may result in damage to sensitive cell populations within the liver. Because the biliary epithelium is sensitive to ischemia-reperfusion injury, the authors surmised that an increased incidence of biliary complications might occur among recipients of an NHBD allograft. METHODS This study was a retrospective evaluation of NHBD recipients compared to a group of heart-beating donor (HBD) recipients from a single institution. RESULTS Fifteen patients received a hepatic allograft from a controlled NHBD donor. NHBD and HBD (n=221) graft survival did not differ at 1 (71.8% vs. 85.4%, P=0.23) or 3 years (71.8% vs. 73.9%, P=0.68). Patient survival at 1 (79% vs. 90.9%, P=0.16) and 3 years (79.0% vs. 77.7%, P=0.8) was also similar. Major biliary complications occurred in five (33.3%) NHBD recipients; 66.6% of the NHBD biliary complications consisted of intrahepatic strictures versus 19.2% among HBD recipients (P<0.01). Major biliary complications in the NHBD recipients resulted in multiple interventional procedures, retransplantation, and death. CONCLUSIONS Donor warm ischemic time may predispose hepatic allografts to an increased incidence of ischemic type strictures. Although graft and patient survival was similar to a cohort of HBD recipients, caution is urged with the use of these organs.
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Affiliation(s)
- Peter Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA
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Anton ME, Schatz-Salzman D. Expanding the donor pool: the elderly non-heart-beating donor. Prog Transplant 2003. [PMID: 12688645 DOI: 10.7182/prtr.13.1.n8w4x84827t6j777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The need for transplantable organs continues to far outweigh the number of organs available for transplantation through donation. To date, many avenues for expanding the donor pool have been explored, including non-heart-beating donor protocols and the expansion of acceptable criteria. This case study reviews the successful procurement of a liver and kidney from a 72-year-old non-heart-beating donor.
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Affiliation(s)
- Mary-Ellen Anton
- Life Alliance Organ Recovery Agency, University of Miami, Miami, Fla, USA
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Anton ME, Schatz-Salzman D. Expanding the Donor Pool: The Elderly Non—Heart-Beating Donor. Prog Transplant 2003; 13:24-7. [PMID: 12688645 DOI: 10.1177/152692480301300105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The need for transplantable organs continues to far outweigh the number of organs available for transplantation through donation. To date, many avenues for expanding the donor pool have been explored, including Non—Heart-beating donor protocols and the expansion of acceptable criteria. This case study reviews the successful procurement of a liver and kidney from a 72-year-old Non—Heart-beating donor.
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Affiliation(s)
- Mary-Ellen Anton
- Life Alliance Organ Recovery Agency, University of Miami, Miami, Fla, USA
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