Medical Management of Brain-Dead Organ Donors

Management of Potential Organ Donor: Indian Society of Critical Care Medicine-Position Statement

This position statement is documented based on the input from all contributing coauthors from the Indian Society of Critical Care Medicine (ISCCM), following a comprehensive literature review and summary of current scientific evidence. Its objective is to provide the standard perspective for the management of potential organ/tissue donors after brain death (BD) in adults only, regardless of the availability of technology. This document should only be used for guidance only and is not a substitute for proper clinical decision making in particular circumstances of any case. Endorsement by the ISCCM does not imply that the statements given in the document are applicable in all or in a particular case; however, they may provide guidance for the users thus facilitating maximum organ availability from brain-dead patients. Thus, the care of potential brain-dead organ donors is "caring for multiple recipients."

How to cite this article

Zirpe K, Pandit R, Gurav S, Mani RK, Prabhakar H, Clerk A, et al. Management of Potential Organ Donor: Indian Society of Critical Care Medicine-Position Statement. Indian J Crit Care Med 2024;28(S2):S249-278.

Does the use of double hormone replacement therapy for trauma patient organ donors improve organ recovery for transplant

BACKGROUND

With an ongoing demand for transplantable organs, optimization of donor management protocols, specifically in trauma populations, is important for obtaining a high yield of viable organs per patient. Endocrine management of brain-dead potential organ donors (BPODs) is controversial, leading to heterogeneous clinical management approaches. Previous studies have shown that when levothyroxine was combined with other treatments, including steroids, vasopressin, and insulin, BPODs had better organ recovery and survival outcomes were increased for transplant recipients.

AIM

To determine if levothyroxine use in combination with steroids in BPODs increased the number of organs donated in trauma patients.

METHODS

A retrospective review of adult BPODs from a single level 1 trauma center over ten years was performed. Exclusion criteria included patients who were not solid organ donors, patients who were not declared brain dead (donation after circulatory death), and patients who did not receive steroids in their hospital course. Levothyroxine and steroid administration, the number of organs donated, the types of organs donated, and demographic information were recorded. Univariate analyses were performed with P < 0.05 considered to be statistically significant.

RESULTS

A total of 88 patients met inclusion criteria, 69 (78%) of whom received levothyroxine and steroids (ST/LT group) vs 19 (22%) receiving steroids without levothyroxine (ST group). No differences were observed between the groups for gender, race, pertinent injury factors, age, or other hormone therapies used (P > 0.05). In the ST/LT group, 68.1% (n = 47) donated a high yield (3-5) of organ types per donor compared to 42.1% (n = 8) in the ST group (P = 0.038). There was no difference in the total number of organ types donated between the groups (P = 0.068).

CONCLUSION

This study suggests that combining levothyroxine and steroid administration increases high-yield organ donation per donor in BPODs in the trauma patient population. Limitations to this study include the retrospective design and the relatively small number of organ donors who met inclusion criteria. This study is unique in that it mitigates steroid administration as a confounding variable and focuses specifically on the adjunctive use of levothyroxine.

Turning Loss Into Legacy: Opportunities for Tissue and Eye Donation in Community Hospice/Palliative Care

Organ, tissue, and eye donations provide opportunities to leave a legacy by saving and/or enhancing the quality of life of others. There has been little published related to tissue or eye donation in hospice/palliative care and few initiatives to facilitate donation among hospice patients/families. Donation myths, gaps in knowledge, and, most significantly, lack of donation referral processes result in missed opportunities for patient/families to consider donation. One donor has the potential to impact 75 lives or more through tissue donation and 2 lives through eye donation. Hospice/palliative care providers can play key roles related to education, advocacy, and collaboration. The support of hospice/palliative care organizations and the local Organ Procurement Organization/Tissue and Eye Recovery Agency are essential for facilitating donation opportunities. This article summarizes current literature, examines legislation and regulations related to donation, presents a case that illustrates an opportunity for hospice community based donation, and shares practices that support donation in hospice/palliative care organizations together with the local Organ Procurement Organization/Tissue and Eye Recovery Agency. This article will hopefully provide the impetus for further study and the development of practices to optimize donation in hospice/palliative care, thus providing more patients and families the opportunity to turn loss into legacy.

Tele-ICU enabled management of an organ donor in an under-resourced setting

A man in his 30s was involved in a road traffic crash in a small town in India, not equipped to deal with cases of brainstem death. He was declared brain-dead after a few hours. The patient's information was forwarded to organ specialists across the country, with the goal of preserving the patient's organs for donation via a tele-ICU model. The team comprising bedside doctors and remote intensivists communicating via an indigenously developed tele-ICU platform managed the patient for 24 hours, following treatment protocols and providing critical care to ensure that the patient's vital organs were optimally perfused. The following morning, specialist teams from a nearby city arrived at the local hospital to retrieve the patient's organs. This fast-tracked organ retrieval and transplant process were made possible through advances in technology and the involvement of specialists from other parts of the country through this tele-ICU model.

Management of potential cardiac donors

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

Dialyzing a Brain-Dead Individual for Organ Procurement

Many patients are unable to receive organ transplantation as there is an expanding gap between the number of patients waiting for an organ and the number who receive it. Organ procurement from the brain-dead can address this expanding gap, especially because one brain-dead patient can potentially donate multiple organs to several recipients. Here, we describe a rare case of a previously healthy 26-year-old male who was declared brain dead after a motor vehicle accident but underwent hemodialysis to treat his acute kidney injury and hyperkalemia before successfully donating his heart and left kidney.

Facilitators and barriers in the donor family interview process from the perspective of hospital staff: a cross-sectional study

Background

Obtaining consent from potential donor families is a challenging step in the donation process and is influenced by various factors.

Methods

In this cross-sectional study, we utilized a questionnaire containing 14 questions about facilitators and barriers in the family interview process. The questionnaire was distributed in March 2023 to intensive care unit (ICU) nurses who had experience with donor family interviews. We collected the opinions of these respondents on hospital performance and drew comparisons between the studied hospitals.

Results

A total of 60 participating ICU nurses provided mean scores for hospital performance in family interviews of 2.60±0.84 for type I hospitals (those providing neurosurgery and trauma care) and 2.035±0.890 for type II hospitals (those without neurosurgery and trauma services; P=0.04). The mean scores for public and private hospitals were 1.86±0.86 and 2.59±0.85, respectively (P=0.008). Based on the findings, the most important facilitators were the availability of organ donation staff and access to a professional team for family discussions. Conversely, poor physician communication skills and limited communication capabilities among medical staff were identified as significant barriers. Implementation of a professional team for family interviews was found to be more critical for type II hospitals. Poor physician communication skills were a significant concern in public hospitals, while families' lack of awareness of patient prognosis emerged as a key barrier in private hospitals.

Conclusions

This study highlights numerous facilitators and barriers that vary across hospitals. Addressing these issues individually and developing tailored plans to enhance hospital performance in interviewing donor families is essential.

Identification of patients at high risk for brain death using an automated digital screening tool: a prospective diagnostic accuracy study

BACKGROUND

An automated digital screening tool (DETECT) has been developed to aid in the early identification of patients who are at risk of developing brain death during critical care.

METHODS

This prospective diagnostic accuracy study included consecutive patients ≥ 18 years admitted to neurocritical care for primary or secondary acute brain injury. The DETECT screening tool searched routinely monitored patient data in the electronic medical records every 12 h for a combination of coma and absence of bilateral pupillary light reflexes. In parallel, daily neurological assessment was performed by expert neurointensivists in all patients blinded to the index test results. The primary target condition was the eventual diagnosis of brain death. Estimates of diagnostic accuracy along with their 95%-confidence intervals were calculated to assess the screening performance of DETECT.

RESULTS

During the 12-month study period, 414 patients underwent neurological assessment, with 8 (1.9%) confirmed cases of brain death. DETECT identified 54 positive patients and sent 281 notifications including 227 repeat notifications. The screening tool had a sensitivity of 100% (95% CI 63.1-100%) in identifying patients who eventually developed brain death, with no false negatives. The mean time from notification to confirmed diagnosis of brain death was 3.6 ± 3.2 days. Specificity was 88.7% (95% CI 85.2-91.6%), with 46 false positives. The overall accuracy of DETECT for confirmed brain death was 88.9% (95% CI 85.5-91.8%).

CONCLUSIONS

Our findings suggest that an automated digital screening tool that utilizes routinely monitored clinical data may aid in the early identification of patients at risk of developing brain death.

Suspected Malignant Hyperthermia in a Brain-Dead Donor During Anesthesia for Organ Procurement Surgery: A Case Report

We report an unusual case of highly suspected malignant hyperthermia after inducing anesthesia in a brain-dead 18-year-old male patient undergoing organ procurement surgery. The patient was administered desflurane (3 vol%) and rocuronium bromide (50 mg) to induce and maintain general anesthesia. He experienced hypercapnia and tachycardia within 5 minutes of anesthesia induction; however, his body temperature rapidly rose only after 15 minutes. The volatile anesthetic was discontinued, and dantrolene was administered at a low dose (1 mg/kg) to avert possible hepatotoxic effects on the donor liver. Fortunately, the clinical course of the brain-dead donor until the organs were harvested and the liver transplantation outcome of the recipient was favorable. A comprehensive understanding of the pathophysiology of brain death, organ transplantation, and malignant hyperthermia is essential to respond promptly and appropriately. Based on our experience, low-dose dantrolene may be clinically used in brain-dead donors while accounting for its potential hepatotoxic effects.

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

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

A Conceptual Framework for Evaluating National Organ Donation and Transplantation Programs

Conceptual frameworks are valuable resources that can be used to guide the planning, evaluation, and development of healthcare services. However, there are currently no comprehensive frameworks focused on organ donation and transplantation that identify the critical factors underlying a successful national program. To address this knowledge gap, we developed a conceptual framework that takes into account all major domains of influence, including political and societal aspects as well as clinical implementation. The framework was initially constructed based on a targeted review of the relevant medical literature. Feedback provided by a panel of international experts was incorporated into the framework via an iterative process. The final framework features 16 essential domains that are critical for initiating and maintaining a successful program and improving the health of patients with organ failure. Of particular note, these domains are subject to three overarching health system principles: responsiveness, efficiency, and equity. This framework represents a first attempt to develop a whole-system view of the various factors that contribute to the success of a national program. These findings provide a useful tool that can be adapted to any jurisdiction and used to plan, evaluate, and improve organ donation and transplantation programs.

Donor Pericardial Interleukin and Apolipoprotein Levels May Predict the Outcome after Human Orthotopic Heart Transplantation

The proinflammatory cascade that is activated at the time of brain death plays a crucial role in organ procurement. Our aim of this study was to explore the relationship between the clinical outcome of orthotopic heart transplantation, as well as cytokine and apolipoprotein profiles of the pericardial fluid obtained at donation. Interleukin, adipokine and lipoprotein levels in the pericardial fluid, as well as clinical data of twenty donors after brain death, were investigated. Outcome variables included primary graft dysfunction, the need for posttransplantation mechanical cardiac support and International Society for Heart and Lung Transplantation grade ≥ 2R rejection. Hormone management and donor risk scores were also investigated. Lower levels of IL-6 were observed in primary graft dysfunction (median: 36.72 [IQR: 19.47–62.90] versus 183.67 [41.21–452.56]; p = 0.029) and in the need for mechanical cardiac support (44.12 [20.12–85.70] versus 247.13 [38.51–510.38]; p = 0.043). Rejection was associated with lower ApoAII (p = 0.021), ApoB100 (p = 0.032) and ApoM levels (p = 0.025). Lower adipsin levels were detected in those patients receiving desmopressin (p = 0.037); moreover, lower leptin levels were found in those patients receiving glucocorticoid therapy (p = 0.045), and higher T3 levels were found in those patients treated with L-thyroxine (p = 0.047) compared to those patients not receiving these hormone replacement therapies. IL-5 levels were significantly associated with UNOS-D score (p = 0.004), Heart Donor Score (HDS) and Adapted HDS (p < 0.001). The monitoring of immunological and metabolic changes in donors after brain death may help in the prediction of potential complications after heart transplantation, thus potentially optimizing donor heart allocation.

Induced Coma, Death, and Organ Transplantation: A Physiologic, Genetic, and Theological Perspective

In the clinic, the death certificate is issued if brain electrical activity is no longer detectable. However, recent research has shown that in model organisms and humans, gene activity continues for at least 96 h postmortem. The discovery that many genes are still working up to 48 h after death questions our definition of death and has implications for organ transplants and forensics. If genes can be active up to 48 h after death, is the person technically still alive at that point? We discovered a very interesting parallel between genes that were upregulated in the brain after death and genes upregulated in the brains that were subjected to medically-induced coma, including transcripts involved in neurotransmission, proteasomal degradation, apoptosis, inflammation, and most interestingly, cancer. Since these genes are involved in cellular proliferation, their activation after death could represent the cellular reaction to escape mortality and raises the question of organ viability and genetics used for transplantation after death. One factor limiting the organ availability for transplantation is religious belief. However, more recently, organ donation for the benefit of humans in need has been seen as “posthumous giving of organs and tissues can be a manifestation of love spreading also to the other side of death”.

The Clinical Outcomes of Marginal Donor Hearts: A Single Center Experience

BACKGROUND AND OBJECTIVES

Although the shortage of donor is a common problem worldwide, a significant portion of unutilized hearts are classified as marginal donor (MD) hearts. However, research on the correlation between the MD and the prognosis of heart transplantation (HTx) is lacking. This study was conducted to investigate the clinical impact of MD in HTx.

METHODS

Consecutive 73 HTxs during 2014 and 2021 in a tertiary hospital were analyzed. MD was defined as follows; a donor age >55 years, left ventricular ejection fraction <50%, cold ischemic time >240 minutes, or significant cardiac structural problems. Preoperative characteristics and postoperative hemodynamic data, primary graft dysfunction (PGD), and the survival rate were analyzed. Risk stratification by Index for Mortality Prediction after Cardiac Transplantation (IMPACT) score was performed to examine the outcomes according to the recipient state. Each group was sub-divided into 2 risk groups according to the IMPACT score (low <10 vs. high ≥10).

RESULTS

A total of 32 (43.8%) patients received an organ from MDs. Extracorporeal membrane oxygenation was more frequent in the non-MD group (34.4% vs. 70.7, p=0.007) There was no significant difference in PGD, 30-day mortality and long-term survival between groups. In the subgroup analysis, early outcomes did not differ between low- and high-risk groups. However, the long-term survival was better in the low-risk group (p=0.01).

CONCLUSIONS

The outcomes of MD group were not significantly different from non-MD group. Particularly, in low-risk recipient, the MD group showed excellent early and long-term outcomes. These results suggest the usability of selected MD hearts without increasing adverse events.

Costs related to obtaining organs for transplantation: A systematic review

INTRODUCTION

The number of transplants in the world is growing, although there is a demand that exceeds supply. It is worth mentioning that the costs for obtaining organs are considered high. However, few studies have been developed on analyzing the costs of obtaining organs and tissues for transplants in order to support the decision-making of managers and health professionals.

OBJECTIVE

To summarize the studies related to the cost of obtaining organs for transplants from a deceased donor.

METHOD

A systematic literature review was conducted in the following databases: PubMed, Cochrane Library CINAHAL, Virtual Health Library (BVS), SCOPUS, Web of Science and EMBASE, using the following descriptors: Costs and cost analysis; Donor Selection; Tissue and Organ Procurement; Tissue and Organ Harvesting; and Tissue Donors, in studies published until April 2021. The risk of bias assessment was performed using the Joanna Briggs Institute's Checklist for Economic Assessments. It was not possible to perform a meta-analysis due to the heterogeneity of the studies.

RESULTS

A total of 1731 studies were identified, of which 11 were analyzed. The cost of kidneys in US dollars (USD) ranged between USD $1672 and USD $25,058. Obtaining a liver ranged from USD $586 to USD $44,478. Heart procurement ranged from USD $633 to USD $24,264. The combined heart-lung transplant ranged from USD $860 to USD $23,203. Obtaining the pancreas ranged from USD $413 to USD $29,708.

CONCLUSIONS

Cost of obtaining organs for transplants from a deceased donor is substantial and varies widely across different studies. The overall cost of failures to obtain organs is currently unknown. Understanding organ procurement expenses can help clarify areas in which organ and tissue procurement can improve in cost and efficiency.

Specialized Donor Care Facility Model and Advances in Management of Thoracic Organ Donors

BACKGROUND

Donor hearts and lungs are more susceptible to the inflammatory physiologic changes that occur after brain death. Prior investigations have shown that protocolized management of potential organ donors can rehabilitate donor organs that are initially deemed unacceptable. In this review we discuss advances in donor management models with particular attention to the specialized donor care facility model. In addition we review specific strategies to optimize donor thoracic organs and improve organ yield in thoracic transplantation.

METHODS

We performed a literature review by searching the PubMed database for medical subject heading terms associated with organ donor management models. We also communicated with our local organ procurement organization to gather published and unpublished information first-hand.

RESULTS

The specialized donor care facility model has been shown to improve the efficiency of organ donor management and procurement while reducing costs and minimizing travel and its associated risks. Lung protective ventilation, recruitment of atelectatic lung, and hormone therapy (eg, glucocorticoids and triiodothyronine/thyroxine) are associated with improved lung utilization rates. Stroke volume-based resuscitation is associated with improved heart utilization rates, whereas studies evaluating hormone therapy (eg, glucocorticoids and triiodothyronine/thyroxine) have shown variable results.

CONCLUSIONS

Lack of high-quality prospective evidence results in conflicting practices across organ procurement organizations, and best practices remain controversial. Future studies should focus on prospective, randomized investigations to evaluate donor management strategies. The specialized donor care facility model fosters a collaborative environment that encourages academic inquiry and is an ideal setting for these investigations.

Centralized Organ Recovery and Reconditioning Centers

An increased focus on improving efficiency and decreasing costs has resulted in alternative models of donor management and organ recovery. The specialized donor care facility model provides highly efficient and cost-effective donor care at a free-standing facility, resulting in improved organ yield, shorter ischemic times, decreased travel, and fewer nighttime operations. Ex vivo lung perfusion (EVLP) improves utilization of extended criteria donor lungs, and centralized EVLP facilities have the potential to increase transplant volumes for smaller transplant programs in specified geographic regions. These alternative models are increasingly being used in the United States to improve waitlist mortality and combat the ongoing donor organ shortage.

Evaluation of donor heart for transplantation

Cardiac transplantation is considered the gold-standard treatment option for patients suffering from end-stage heart failure refractory to maximum medical therapy. A major determinant of graft function and recipient survival is a comprehensive evaluation of the donor allograft. Challenges arise when designing and implementing an evidence-based donor evaluation protocol due to the number of influential donor-specific characteristics and the complex interactions that occur between them. Here, we present our systematic approach to donor evaluation by examining the impact that relevant donor variables have on graft function and recipient outcomes.

A translational rat model for ex vivo lung perfusion of pre-injured lungs after brain death

The process of brain death (BD) detrimentally affects donor lung quality. Ex vivo lung perfusion (EVLP) is a technique originally designed to evaluate marginal donor lungs. Nowadays, its potential as a treatment platform to repair damaged donor lungs is increasingly studied in experimental models. Rat models for EVLP have been described in literature before, yet the pathophysiology of BD was not included in these protocols and prolonged perfusion over 3 hours without anti-inflammatory additives was not achieved. We aimed to establish a model for prolonged EVLP of rat lungs from brain-dead donors, to provide a reliable platform for future experimental studies. Rat lungs were randomly assigned to one of four experimental groups (n = 7/group): 1) healthy, directly procured lungs, 2) lungs procured from rats subjected to 3 hours of BD and 1 hour cold storage (CS), 3) healthy, directly procured lungs subjected to 6 hours EVLP and 4), lungs procured from rats subjected to 3 hours of BD, 1 hour CS and 6 hours EVLP. Lungs from brain-dead rats showed deteriorated ventilation parameters and augmented lung damage when compared to healthy controls, in accordance with the pathophysiology of BD. Subsequent ex vivo perfusion for 6 hours was achieved, both for lungs of healthy donor rats as for pre-injured donor lungs from brain-dead rats. The worsened quality of lungs from brain-dead donors was evident during EVLP as well, as corroborated by deteriorated ventilation performance, increased lactate production and augmented inflammatory status during EVLP. In conclusion, we established a stable model for prolonged EVLP of pre-injured lungs from brain-dead donor rats. In this report we describe tips and pitfalls in the establishment of the rat EVLP model, to enhance reproducibility by other researchers.

Nursing Diagnosis for Potential Organ Donors: Accuracy Study

The objective was to analyze the diagnostic accuracy of Impaired physiological balance syndrome in potential brain-dead organ donors. It is a study of diagnostic accuracy. Data was retrospectively collected from 145 medical records through the filling out of an instrument containing 25 indicators of the nursing diagnosis (ND). Descriptive and inferential statistics were used. The prevalence of the ND was 77 (53.1%). The indicator with the best measures of accuracy was altered heart rate. Therefore, it has the best predictive capacity for determining the ND. It was identified that the absence of the indicators altered heart rate, hyperglycemia, and altered blood pressure is associated with the absence of the ND, while the presence of the indicators hyperthermia, hypothermia, and altered heart rhythm is associated with the presence of the ND. Accurate indicators will assist in diagnostic inference and the interventions and results will have greater chances of targeting and effectiveness.

Inflammatory responses in lungs from donation after brain death: Mechanisms and potential therapeutic targets

The vast majority of lungs used in clinical transplantation are donated after brain death (DBD). The utilization of DBD lungs is low due to brain death-induced lung injury. Moreover, inflammatory responses in DBD lungs used for transplantation contribute to ischemia-reperfusion injury and primary graft dysfunction. Work from human observational studies has demonstrated overexpression of cytokines, activation of endothelial cells, and cell death in DBD lungs, are associated with the activation of signaling pathways. Animal models have characterized the pulmonary injury induced by brain death and identified potential strategies to improve donor management. Interestingly, transcriptomic studies comparing DBD and donated after circulatory death (DCD) lungs have found that inflammatory responses are elevated in DBD lungs, while cell death pathways are elevated in DCD lungs. Development of the ex vivo lung perfusion technique, has made it possible to assess donor lungs using inflammation and cell death biomarkers. In the future, identification of potential therapeutic targets and development of novel treatments strategies may allow for lung repair during EVLP prior to transplantation.

17β-Estradiol Treatment Protects Lungs Against Brain Death Effects in Female Rat Donor

BACKGROUND

Brain death (BD) affects the viability of lungs for transplantation. A correlation exists between high-lung inflammation after BD and the decrease in female sex hormones, especially estradiol. Therefore, we investigated the effects of 17β-estradiol (E2) treatment on the lungs of female brain dead rats.

METHODS

Female Wistar rats were divided into 4 groups: BD (submitted to BD for 6 h), sham (false operated), E2-T0 (treated with E2 immediately after BD; 50 μg/mL, 2 mL/h), and E2-T3 (treated with E2 after 3 h of BD; 50 μg/mL, 2 mL/h). Lung edema, hemorrhage, and leukocyte infiltration were analyzed. Adhesion molecules were evaluated, and analysis of NO synthase gene and protein expression was performed using real-time PCR and immunohistochemistry, respectively. Release of chemokines and matrix degradation in the lungs was analyzed.

RESULTS

BD increased leukocyte infiltration, as shown by intravital microscopy (P = 0.017), bronchoalveolar lavage cell count (P = 0.016), the release of inflammatory mediators (P = 0.02), and expression of adhesion molecules. BD also increased microvascular permeability and the expression and activity of matrix metalloproteinase-9 in the lungs. E2 treatment reduced leukocyte infiltration, especially in the E2-T3 group, release of inflammatory mediators, adhesion molecules, and matrix metalloproteinase activity in the lungs.

CONCLUSIONS

E2 treatment was successful in controlling the lung inflammatory response in females submitted to BD. Our results suggest that E2 directly decreases the release of chemokines, restraining cell traffic into the lungs. Thus, E2 has a therapeutic potential, and its role in improving donor lung quality should be explored further.

Peritransplant Cardiometabolic and Mitochondrial Function: The Missing Piece in Donor Heart Dysfunction and Graft Failure

Primary graft dysfunction is an important cause of morbidity and mortality after cardiac transplantation. Donor brain stem death (BSD) is a significant contributor to donor heart dysfunction and primary graft dysfunction. There remain substantial gaps in the mechanistic understanding of peritransplant cardiac dysfunction. One of these gaps is cardiac metabolism and metabolic function. The healthy heart is an "omnivore," capable of utilizing multiple sources of nutrients to fuel its enormous energetic demand. When this fails, metabolic inflexibility leads to myocardial dysfunction. Data have hinted at metabolic disturbance in the BSD donor and subsequent heart transplantation; however, there is limited evidence demonstrating specific metabolic or mitochondrial dysfunction. This review will examine the literature surrounding cardiometabolic and mitochondrial function in the BSD donor, organ preservation, and subsequent cardiac transplantation. A more comprehensive understanding of this subject may then help to identify important cardioprotective strategies to improve the number and quality of donor hearts.

A marginal liver graft with hyperbilirubinemia transplanted successfully by ischemia-free liver transplantation

The shortage of transplant organs remains a serious issue worldwide, and using liver grafts from extended criteria donors could expand the donor pool. Extended criteria donor liver allografts have a high chance of complications such as primary nonfunction, early allograft dysfunction, and ischemic-type biliary lesions. How to employ these extended criteria donors safely and effectively warrants further investigation. Herein, we report the successful use of a marginal donor liver with hyperbilirubinemia to save the life of an acute-on-chronic liver failure recipient using a new surgical technique: ischemia-free liver transplantation (IFLT). The graft was retrieved for transplantation due to the following reasons: (I) the recipient was in a life-threatening situation and no living donor donation candidate was available; (II) the graft was considered transplantable except for cholestasis; and (III) IFLT could reduce ischemia/reperfusion injury (IRI), resuscitate the allograft ex situ, and maintain organ viability before transplantation. The graft was transplanted successfully using the IFLT procedure. Although anatomic biliary stricture occurred after surgery, no IRI-related complications were found during the follow-up. The use of liver grafts from extended criteria donors is safe and effective under IFLT. Additional IFLT clinical studies need to be performed, particularly concerning donor management, graft selection, and ex situ resuscitation.

Deceased Organ Transplantation in Bangladesh: The Dynamics of Bioethics, Religion and Culture

Organ transplantation from living related donors in Bangladesh first began in October 1982, and became commonplace in 1988. Cornea transplantation from posthumous donors began in 1984 and living related liver and bone marrow donor transplantation began in 2010 and 2014 respectively. The Human Organ Transplantation Act officially came into effect in Bangladesh on 13th April 1999, allowing organ donation from both brain-dead and related living donors for transplantation. Before the legislation, religious leaders issued fatwa, or religious rulings, in favor of organ transplantation. The Act was amended by the Parliament on 8th January, 2018 with the changes coming into effect shortly afterwards on 28th January. However, aside from a few posthumous corneal donations, transplantation of vital organs, such as the kidney, liver, heart, pancreas, and other body parts or organs from deceased donors, has remained absent in Bangladesh. The major question addressed in this article is why the transplantation of vital organs from deceased donors is absent in Bangladesh. In addition to the collection of secondary documents, interviews were conducted with senior transplant physicians, patients and their relatives, and the public, to learn about posthumous organ donation for transplantation. Interviews were also conducted with a medical student and two grief counselors to understand the process of counseling the families and obtaining consent to obtain posthumous cornea donations from brain-dead patients. An interview was conducted with a professional anatomist to understand the processes behind body donation for the purposes of medical study and research. Their narrative reveals that transplant physicians may be reticent to declare brain death as the stipulations of the 1999 act were unclear and vague. This study finds that Bangladeshis have strong family ties and experience anxiety around permitting separating body parts of dead relatives for organ donation for transplantation, or donating the dead body for medical study and research purposes. Posthumous organ donation for transplantation is commonly viewed as a wrong deed from a religious point of view. Religious scholars who have been consulted by the government have approved posthumous organ donation for transplantation on the grounds of necessity to save lives even though violating the human body is generally forbidden in Islam. An assessment of the dynamics of biomedicine, religion and culture leads to the conclusion that barriers to posthumous organ donation for transplantation that are perceived to be religious may actually stem from cultural attitudes. The interplay of faith, belief, religion, social norms, rituals and wider cultural attitudes with biomedicine and posthumous organ donation and transplantation is very complex. Although overcoming the barriers to organ donation for transplantation is challenging, initiation of transplantation of vital organs from deceased donors is necessary within Bangladesh. This will ensure improved healthcare outcomes, prevent poor people from being coerced into selling their organs to rich recipients, and protect the solidarity and progeny of Bangladeshi families.

Effects of Gut Metabolites and Microbiota in Healthy and Marginal Livers Submitted to Surgery

Microbiota is defined as the collection of microorganisms within the gastrointestinal ecosystem. These microbes are strongly implicated in the stimulation of immune responses. An unbalanced microbiota, termed dysbiosis, is related to the development of several liver diseases. The bidirectional relationship between the gut, its microbiota and the liver is referred to as the gut-liver axis. The translocation of bacterial products from the intestine to the liver induces inflammation in different cell types such as Kupffer cells, and a fibrotic response in hepatic stellate cells, resulting in deleterious effects on hepatocytes. Moreover, ischemia-reperfusion injury, a consequence of liver surgery, alters the microbiota profile, affecting inflammation, the immune response and even liver regeneration. Microbiota also seems to play an important role in post-operative outcomes (i.e., liver transplantation or liver resection). Nonetheless, studies to determine changes in the gut microbial populations produced during and after surgery, and affecting liver function and regeneration are scarce. In the present review we analyze and discuss the preclinical and clinical studies reported in the literature focused on the evaluation of alterations in microbiota and its products as well as their effects on post-operative outcomes in hepatic surgery.

Donor Heart Utilization in Korea

Background and Objectives

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

Methods

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

Results

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

Conclusions

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

Public opinion and legislations related to brain death, circulatory death and organ donation

BACKGROUND

It is poorly understood how public perception of the difference between brain death and circulatory death may influence attitudes towards organ donation. We investigated the public opinion on brain death versus circulatory death and documented inconsistencies in the legislations of countries with different cultural and socioeconomic backgrounds.

METHODS

Using a crowdsourcing approach, we randomized 1072 participants from 30 countries to a case report of organ donation after brain death or to one following circulatory death. Further, we sampled guidelines from 24 countries and 5 continents.

RESULTS

Of all participants, 73% stated they would be willing to donate all organs, while 16% would want to donate some of their organs. To increase the rate of donations, 47% would agree with organ donation without family consent as the default. Exposure to "brain death" was not associated with a lesser likelihood of participants agreeing with organ donation (82.1%) compared to "circulatory death" (81.9%; relative risk 1.02, 95% CI 0.99 to 1.03; p = .11). However, participants exposed to "circulatory death" were more certain that the patient was truly dead (87.9% ± 19.7%) than participants exposed to "brain death" (84.1% ± 22.7%; Cohen's d 0.18; p = 0:004). Sampling of guidelines revealed large differences between countries regarding procedures required to confirm brain death and circulatory death, respectively.

CONCLUSIONS

Implementation of organ donation after circulatory death is unlikely to negatively influence the willingness to donate organs, but legislation is still brain death-based in most countries. The time seems ripe to increase the rate of circulatory death-based organ donation.

Domino heart transplant following heart-lung transplantation: a systematic review and meta-analysis

Background

The domino-donor operation occurs when a "conditioned" heart from the heart-lung transplant (HLT) recipient is transplanted into a separate heart transplant (HT) recipient. The purpose of this systematic review was to investigate the indications and outcomes associated with the domino procedure.

Methods

An electronic search was performed to identify all prospective and retrospective studies on the domino procedure in the English literature. Eight studies reported 183 HLT recipients and 263 HT recipients who were included in the final analysis.

Results

HLT indications included cystic fibrosis in 58% (95% CI: 27-84%) of recipients, primary pulmonary hypertension (PPH) in 17% (95% CI: 12-24%), bronchiectasis in 5% (95% CI: 3-10%), emphysema in 5% (95% CI: 0-45%), and Eisenmenger's syndrome in 4% (95% CI: 2-8%). HT indications included ischemic heart disease in 40% (95% CI: 33-47%), non-ischemic disease in 39% (95% CI: 25-56%), and re-transplantation in 10% (95% CI: 1-59%). The pooled mean pulmonary vascular resistance (PVR) in HT recipients was 3.05 Woods units (95% CI: 0.14-5.95). The overall mortality in the HLT group was 28% (95% CI: 18-41%) at an average follow-up of 15.68 months (95% CI: 0.82-30.54), and 35% (95% CI: 17-58%) in the HT group at an average follow-up of 37.26 months (95% CI: 6.68-67.84). Freedom from rejection in HT was 94% (95% CI: 75-99%) at 1 month, 77% (95% CI: 30-96%) at 6 months, and 41% (95% CI: 33-50%) at 1 year.

Conclusions

The domino procedure appears to be a viable option in properly selected patients that can be performed safely with acceptable outcomes.

Increase in Cadaver Organ Donation Rate at a Tertiary Care Hospital: 23 Years of Experience

Background

Transplantation of Human Organ Act was passed in India in 1994 to streamline organ donation and transplantation activities. It is time to retrospect ourselves and analyze the method to increase organ donation.

Type of study

Retrospective observational analysis.

Objectives

To evaluate the change in organ donation rate and reasons for changes in rates.

Subjects

Brainstem dead declared patients whose family consented for organ donations in the last 23 years (1997–2019) at Ruby Hall Clinic, Pune, India.

Materials and methods

Retrospectively demographic data of the brainstem dead declared donors, the primary diagnoses, comorbidities, and the complete data of their management till organ retrieval was assessed.

Results

One hundred cases in the age group 15–75 years (mean 41.6 ± 15.3 years) of brainstem death consented for organ donation were retrospectively studied. The period was divided into two groups, group I and group II included study duration from 1997 to 2013 and from 2013 to 2019 respectively. During the entire period, though the major cause of donor death remained road traffic accidents (RTA) in both the groups (84.21% till 2013 vs 48.15% after 2013), the proportion of donors declared brain dead due to RTA dipped significantly after 2013 (p = 0.004) and the non-RTA causes of brain dead contributed more than RTA causes (51.85% non-RTA vs 48.15% RTA). The major contributor among non-RTA causes was intracranial bleeds (5.26% before 2013 vs 33.33% after 2013, p = 0.014). Compared to the previous 17 years (from 1997) there were more than fourfold rise in the rate of transplantation in the last 6 years (2014–2019) at our institute. Kidneys were retrieved from 90% donors followed by cornea 84%, liver 65%, heart 22%, skin 7%, lungs 6%, and pancreas 5%.

Conclusion

We have observed that the cadaveric organ donation rate significantly improved after 2013. Reasons might be widening of the donor pool by the selection of more of non-RTA brain death donors over RTA, acceptability of elderly population donor (>60 years) by our transplant teams, early identification of potential organ donor, and better protocol-based management of the cadaver organ donor.

How to cite this article

Zirpe KG, Suryawanshi P, Gurav S, Deshmukh A, Pote P, Tungenwar A, et al. Increase in Cadaver Organ Donation Rate at a Tertiary Care Hospital: 23 Years of Experience. Indian J Crit Care Med 2020;24(9):804–808.

Brain Death and Management of Potential Organ Donor: An Indian Perspective

How to cite this article: Zirpe K, Gurav S. Brain Death and Management of Potential Organ Donor: An Indian Perspective. Indian J Crit Care Med 2019;23(Suppl 2):S151-S156.