Title: Dead or Dead-Enough? DCD and Organ Donation in 2003
1Dead or Dead-Enough?DCD and Organ Donation in
2003
- Paul Morrissey, MD
- Department of Surgery
- Rhode Island Hospital
- Brown Medical School
2Brown Ethics Forum Transplantation
- State of Organ Transplantation
- Need for organs
- Brain death
- Cardiac death (DCD)
- Results
- Issues
3ESRD 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
4ESRD Modalities
5Transplant 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
6Renal Transplants RIH
7Renal Transplants vs. Wait List
8Renal Tx vs. Wait List
- 1993-1996
- 16 annual growth of wait list
- 1.6 annual increase in CRT donors
9Time on dialysis strongest modifiable risk
factor for renal tx outcomes
10Mortality on Dialysis
- 23 per year
- 5 year survival
- ESRD - 30
- ESRD DM- 20
- ESRD Age gt 65 - 15 .
11Kidney donors - USA
12Cadaver Donors Percent by Age
13Organ Donor NumbersGrowth 136 Spain, 33 USA
14Deceased Donors by Age
15Kidney allograft survival by donor age
16Graft Survival Rates for LRD and LURD grafts
100 90 80 70 60 50 40 30 20 10 0
82
64
n
T1/2
Relationship
47
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
17Kidneys 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
18Head trauma Epidural hematoma
- Severe brain injury
- Irreversible brain injury
- Persistent vegetative state
- Brain dead
- Cortical brain
- Brain stem
19Brain Death Concept (1968)
- Defined as
- Irreversible loss of brain function
- Including brain stem (respiration)
- Brain death death
- Medically
- Legally
- Ethically
20DCD 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
21DCD (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
22DCD - 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.
23Time 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
24DCD 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?
25Kidney Graft-Survival RatesCho, Terasaki, Cecka,
Gjertson. NEJM 338 221, 1998.
26Graft-Survival by Cause of Death
27DCD Long-term outcomes
- Censored for death with function.
- Uncensored data graft survival.
28Donors 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
29DCD 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
30DCD 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
31DCD in NEOB
- 1999 4 cases
- Effort to increase NHBD
- Reinvigorate one program
- Develop 6 other programs
- 2003 19 cases
32DCD 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 )
33Who is the NEOB?
- Donor coordinator
- Social Workers
- Family Support Team
- Community Educator
- Medical Director
- Administrators
34Brain 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)
35Cadaver Donors RIH1998-2002 125 potential
donors
36Organ 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
37Organ Donation - Best practice
38Organ Donors - NEOB
39Organ Donation - room for growth?
- DCD
- Emergency room
- 2-for-1
- Discard rate is 30
- Live donors
- Family interventions
- Unrelated donors including altruistic
40Categories of DCD
- Description Location
- DOA ED
- Unsuccessful CPR ED, ICU, Ward
- Withdraw support ICU or OR
- Cardiac arrest ICU, OR
- while brain dead
41DCD - 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
42Live donor renal transplantation Black Market
43Thank you