Dead or Dead-Enough? DCD and Organ Donation in 2003

1
Dead or Dead-Enough?DCD and Organ Donation in
2003

• Paul Morrissey, MD
• Department of Surgery
• Rhode Island Hospital
• Brown Medical School

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Brown Ethics Forum Transplantation

• State of Organ Transplantation
• Need for organs
• Brain death
• Cardiac death (DCD)
• Results
• Issues

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ESRD in R.I. 2002

• Patients
• 812 on HD
• 34 on CAPD/CCPD
• 400 with functioning renal transplant
• 2002
• New cases ESRD 310
• Dialysis deaths 248
• Renal transplants 85
• Wait List Total - 128

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ESRD Modalities
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Transplant Wait List RIH 2003

• ABO N PRAgt10 TU
• A 30 18 14
• B 20 11 3
• O 53 18 6
• AB 2 2 0
• Total 105 49 23

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Renal Transplants RIH
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Renal Transplants vs. Wait List
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Renal Tx vs. Wait List

• 1993-1996
• 16 annual growth of wait list
• 1.6 annual increase in CRT donors

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Time on dialysis strongest modifiable risk
factor for renal tx outcomes
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Mortality on Dialysis

• 23 per year
• 5 year survival
• ESRD - 30
• ESRD DM- 20
• ESRD Age gt 65 - 15 .

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Kidney donors - USA
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Cadaver Donors Percent by Age
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Organ Donor NumbersGrowth 136 Spain, 33 USA
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Deceased Donors by Age
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Kidney allograft survival by donor age
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Graft Survival Rates for LRD and LURD grafts
100 90 80 70 60 50 40 30 20 10 0
82
64
n
T1/2
Relationship
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Percent Survival
2,129 3,140 2,071 34,572
39.2 16.1 16.7 10.2
Id Sib 1-haplo Sib Unrelated Cadaver
0
1
2
3
4
5
6
7
8
9
10
Cecka, M. UNOS 1994-1999
Years Post transplant
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Kidneys for TransplantationWhere do we get them?

• Live donors
• Related
• Unrelated
• Stranger altruistic (9 at RIH)
• Deceased, brain-dead donors (cadaver donors)
• Local
• Regional
• National zero-mismatch (perfect match)
• DCD (NHBD)
• Asystolic (5 minutes) donors

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Head trauma Epidural hematoma

• Severe brain injury
• Irreversible brain injury
• Persistent vegetative state
• Brain dead
• Cortical brain
• Brain stem

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Brain Death Concept (1968)

• Defined as
• Irreversible loss of brain function
• Including brain stem (respiration)
• Brain death death
• Medically
• Legally
• Ethically

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DCD how it works!

• Recognize potential donor
• Ventilator dependent
• Irreversible brain injury
• Does not meet criteria for brain death
• Family and MD have opted to remove life support,
  DNR order in chart
• Suitable renal function
• Consent for DCD

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DCD (continued)

• Medical examiner approval
• Standard donor evaluation
• Assemble team from NEOB
• Prepare right groin for cannulation
• Extubate the donor, D/c pressors and IVF
• Morphine drip per institutional protocol
• Observe for 5 minute period of asystole

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DCD - surgical procedure

• Potential donor
• Prolonged cardiac function no donation
• Rapid progression to asystole
• Declaration of death
• Organ donation
• Cannulate femoral vessels
• Artery 18 Fr. Chest tube
• Vein Foley bag
• Cold perfuse and transport to O.R.

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Time sequence for DCD

• Asystole 5 minutes
• Cannulate, cold perfuse 5 minutes
• Transport to OR 5 minutes
• Laparotomy, clamp aorta 5 minutes
• Procure kidneys 30 minutes
• 2 kidneys for transplant Priceless

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DCD Are there issues?

• Why not brain death?
• Will the donor progress to asystole?
• Within one hour time limit?
• Ever?
• Does DCD hasten patient death?
• Is 5 minutes of asystole sufficient?
• Will the kidneys function suitably?

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Kidney Graft-Survival RatesCho, Terasaki, Cecka,
Gjertson. NEJM 338 221, 1998.
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Graft-Survival by Cause of Death
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DCD Long-term outcomes

• Censored for death with function.
• Uncensored data graft survival.

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Donors at RIH

• Overall
• 240 transplants
• 196 living
• Altruistic 9
• Exchange 3
• Unrelated
• Related

• CRT
• 0-mm 12
• DCD 23
• Region 1 plan 140
• Over 50 26
• Over 60 13
• 2-for-1 7

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DCD Experience - RIH

• 14 potential donors evaluated
• 6 families refused consent
• 4 failed to progress to asystole in lt 1 hour
• BP and O2 sat. declined
• Donation aborted
• 4 became donors
• 8 kidneys transplanted

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DCD kidneys procured at RIH

• Pt. Cr LOS Follow-up/complications
• A 1.7 5 AW 38 months
• B 1.4 23 Delayed function, died.
• C 0.9 6 AW 36 months
• D 1.2 13 AW 36 months
• E 1.5 5 AW 9 months
• F 1.4 7 AW 9 months
• G HD 7 Graft thrombosis
• H 1.0 6 AW 2 months

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DCD in NEOB

• 1999 4 cases
• Effort to increase NHBD
• Reinvigorate one program
• Develop 6 other programs
• 2003 19 cases

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DCD in NEOB cont.

• DCD donors 49
• Extubation 9 in OR, 40 in ICU
• Mean age 36 /- 14
• Progress to asystole 1 50
• Time to asystole 25 /- 45 minutes
• Transplants
• 85 kidneys (90 success)
• 4 liver transplants (100 )

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Who is the NEOB?

• Donor coordinator
• Social Workers
• Family Support Team
• Community Educator
• Medical Director
• Administrators

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Brain dead ? Organ DonationCould we do better at
RIH?

• 1200 deaths annually at RIH
• 35-40 meet criteria for organ donation
• Brain death
• No active cancer or infection
• Few excluded for organ unsuitability
• 50-65 consent rate
• 12-16 kidney donors per year
• (24-32 CRT, 1/4 exported)

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Cadaver Donors RIH1998-2002 125 potential
donors
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Organ Donation - Best practice

• We currently recognize greater than 95 of brain
  dead organ donors
• Consent rates at best centers approach 65-80
• 15-30 of people are strongly opposed to organ
  donation
• Best practice - 80-85 of brain dead donors

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Organ Donation - Best practice
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Organ Donors - NEOB
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Organ Donation - room for growth?

• DCD
• Emergency room
• 2-for-1
• Discard rate is 30
• Live donors
• Family interventions
• Unrelated donors including altruistic

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Categories of DCD

• Description Location
• DOA ED
• Unsuccessful CPR ED, ICU, Ward
• Withdraw support ICU or OR
• Cardiac arrest ICU, OR
• while brain dead

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DCD - Controversies

• DNR / CMO
• Asystole
• Heparin
• Morphine
• Premortem cannulation
• Location

• Transplant team
• 2, 5, 10 minutes
• Hasten death
• Double effect
• Intervention for recipient
• ICU, ED, Ward

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Live donor renal transplantation Black Market
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Thank you