Transcript Estimated Supply of Organ Donors After Circulatory Determination of

Donation After Cardiac Death
2016 Transplant Workshop: Trending
Issues in Transplantation
Nora Colman
Oct 22, 2016
Organ Donation
https://youtu.be/3ONunH_ql5M
• Published on Feb 1, 2016
• A mom in Arizona donated her son's organs after he died in
2013. Recently, she met with the family of one of the lives he
saved.
Outline
• Organ donation statistics
• Pediatric considerations
• Organ allocation
• History of determining death
• Death criteria
• Brain Death
• Cardiac Death
• Organ donation after cardiac death
• Certification of death
• DCD candidates
• Organ procurement and transplant
• Ethical considerations and barriers
• DCD at CHOA
Statistics
at a
Glance
www.UNOS.org
Statistics at a Glance
www.UNOS.org
Organ
wait list
www.UNOS.org
Pediatric Organ Transplant
• In 2011, 2000 pediatric patients were awaiting a solid organ
transplant
• Children from birth to 17 years old account for 2-3% of the
national waiting list
• More than 70% of children are waiting for a liver or kidney
• Small bowel is the organ with the greatest increase in need
Organ Donation
• Advances in surgical techniques, perioperative management,
and immunosuppression contribute to an ever-widening gap
between the number of children eligible for transplantation
and the number of organs available
• In the past 15 years, about 4000 children have died without
receiving a transplant
Organ Wait List
Yoo P, Olthoff K, Abt P. (2011) Donation after cardiac death in pediatric organ donation Curr op organ trans 16(5):483-8
History of Organ Donation
• In 1951 Dr. David Hume performed the first donation after
circulatory determination of death kidney transplant in Boston
• In 1968 Harvard Medical School proposed a brain based
definition of death
• The uniform anatomical gift act of 1968 and the Uniform
determination of death act of 1980 further cemented the
standards by which death was established
• By the 1990’s organ transplantation was recognized as an
effective therapy for end stage organ failure.
• In 1992 Physicians at the University of Pittsburgh released a
protocol outlining the first formal policy on organ donation
after elective withdrawal of life sustaining measures
History of Organ Donation
• In 1997, the Institute of Medicine determined that DCD was
safe, ethically acceptable, and a medically useful method to
increase the supply of available organs for transplant
• In 1998, hospitals participating in Medicare and Medicaid
programs were required to refer potential organ donors to
their local OPO (organ procurement organization)
History of Organ Donation
• The Children’s Health Act was passed in October of 2000
• Called on the OPTN to develop specific criteria, policies, and
procedures to address the unique needs of children and adults
• By 2007, the Joint Commission mandated that all hospitals
develop and maintain a DCD protocol
• All families of potential organ donors be made aware of their
option to donate
• Legislation also requires all hospitals to have trained
designated requestors available to discuss organ donation
with families of potential donors
Infrastructure
• Organ Procurement and Transplantation Network
• Nation’s organ procurement, donation, and transplantation
system
• The United Network of Organ Sharing (UNOS)
• Nonprofit organization that operates under OTN under a contract
from the federal government
Infrastructure
• American Academy of Pediatrics supports the role of OPOs by
recommending that:
• All potential donor families be approached in a systematic
method
• That individuals trained in the psychological, social, and
medical aspects of organ donation
• The team must separate the death notification from the organ
donation consent process
Death Criteria
• Death is legally established by one of two sets of criteria
• Brain Death
• Cessation of whole brain function
• Cardiac Death
• Cessation of cardiopulmonary function
Brain Death Criteria
• Irreversible loss of all functions of the entire brain, including
brain stem
• Donors are on ventilators but their heart continues to function
Brain
Death
Criteria
Nakagawa TA, Ashwal S, Mathur M et al.
(2011)Guidelines for the Determination of
Brain Death in Infants and Children: An
Update of the 1987 Task Force
Recommendations Pediatrics 128(3):e720740
Cardiac Death Criteria
• When death is declared on the basis of
cardiopulmonary criteria
• Diagnosis of Death requires
• Cessation of Functions
• Irreversibility
Potential DCD patients
• DCD occurs in a patient with a catastrophic brain injury who
has not deteriorated to brain death
• devastating irreversible brain injuries caused by trauma or
intracranial bleeding,
• high spinal cord injuries
• end stage musculoskeletal disease
Donation after Cardiac Death
• Evidence based clinical judgment should be used to assess
whether cardiac death will occur within 1 hour after
withdrawal of life support
• DCD discussions can only occur after the family and medical
team have made the decision to withdraw support and
terminate care
Dead Donor Rule
• Affirms that it is unethical to procure organs before death
• Occurs when a family has come to terms with the
consequences of the injury and has elected to withdraw
support
• Consent can only be given after the decision to withdraw
support has been made
DCD Organs
• Initial studies suggested that implementation of widespread
DCD could increase the number of organ donors by 20-25%
• One pediatric center reported a 58% increase in organ donors
when DCD was used
UNOS Criteria for identifying
potential DCD patients
Estimated Supply of Organ Donors After Circulatory Determination of Death: A Population-Based Cohort Study
JAMA. 2010;304(23):2592-2594. doi:10.1001/jama.2010.1824
Criteria for Defining Potential
DCDD
Estimated Supply of Organ Donors After Circulatory Determination of Death: A Population-Based Cohort
Study
JAMA. 2010;304(23):2592-2594. doi:10.1001/jama.2010.1824
Donation after Cardiac Death
• Location of withdrawal of support varies and is driven by the
practical need to rapidly recover organs once death occurs
• Support may be withdrawn in the operating suite, recovery
room, or ICU provided that the patient can be moved and
prepared for organ recovery within 5-10 minutes of cardiac
death
• If the child does not succumb to cardiac death within the
allotted time, he or she cannot be a solid organ donor,
although tissue donation may remain an option
Certification of Death
• After extubation, the physician monitors the patient for
absence of pulse pressure , absence of heart tones, apnea,
and unresponsiveness
• The IOM recommends 5 minutes of observation to minimize
the risk of autoresuscitation
• Society of Critical Care Medicine recommends >2 minutes of
observation with >5 minutes not recommended
DCD Organ Procurement
• Administration of pharmacologic agents
• Minimize ischemic and reperfusion injury
• Improve organ function after DCD
Organ Procurement
• Warm Ischemic Time
• In DCD there is a time between the cessation of mechanical
ventilation and the initial of cold perfusion
• During this time organs experience metabolic and inflammatory
derangements which leads to the potential functioning
differences between DCD and DBD organs
Ischemic Time
Pediatric Organ Scarcity
Yoo P, Olthoff K, Abt P. (2011) Donation after cardiac death in pediatric organ donation Curr op organ trans 16(5):483-8
Distribution of Pediatric DCD
Organs
Mazor R, Baden H. (2007) Trends in pediatric organ donation after cardiac death Pediatrics 120 (4): e960-6
Distribution of Pediatric DCD
Organs
Mazor R, Baden H. (2007) Trends in pediatric organ donation after cardiac death Pediatrics 120 (4): e960-6
Distribution of Pediatric DCD
Organs
Mazor R, Baden H. (2007) Trends in pediatric organ donation after cardiac death Pediatrics 120 (4): e960-6
Heart
•
•
•
•
Denver Children’s Hospital recovered 3 hearts after DCD
Mean donor age was 3.7 years
Mean time to death was 18.3 minutes
6 month survival was 100% compared to 84% among controls
that underwent donation after transplantation with DBD
organs
• No difference in rejection or ventricular function at 6 months
• This protocol remains to be replicated at other centers
Lung
• Only case reports detailing lung transplants from DCD donors
• Lung may be especially suited to DCD recovery due to its low
metabolic rate when compared to other transplantable organs
Liver
• Abt et al recorded US experience of liver transplants in
children from 1995-2005
• 4991 liver transplants were performed in children
• 0.4% were from DCD donors
• Of these, 84% received livers from pediatric donors and 15% from
adult donors
• Graft survival at 1 and 5 years was 89.2 and 79.3% from DCD
livers compared to 75.6 and 65.8% from controls with livers
from DBD donors
• This study concluded that selective use of livers from DCD
donors can yield graft survival rates comparable to results
seen with DBD livers
Kidney
• 4026 kidney transplants were performed in children in the US
between 1995-2005
• 26% of the allografts were from DCD donors
• 10 DCD organs were retrieved from pediatric patients, and the
remained from adults
• Graft survival at 1 and 5 years was 82.5 and 74.3%
• Compared to 89.6 and 64.8% for kidneys from DBD donors
Kidney
• A Dutch group reported 88 patients who received kidney
transplants from DCD donors
• Incidence of immediate function was 49%, delayed graft
function was 44% and primary non function was 7%
• Only significant risk factor for primary non function was warm
ischemic of > 25 minutes
• Graft and patient survival and 1 and 5 years was 80 and 88%
Barriers to DCD
•
•
•
•
•
Lack of Knowledge
Concerns about dead donor rule
Potential for conflict of interest
“Making donation happen” for those who want it
Call for standardized protocols
CHOA Policy: DCD
• Policy
• The patient/family has elected to withdraw life support
independent of the discussion of organ donation
• The ME must be called for permission to proceed with donation,
prior to offering option to the family
• The organ recovery team will not be involved at any point in the
medical management of the patient
• There will be no direct interaction of the Organ Recovery Team with
the primary medical team
CHOA Policy: DCD
• Procedure
• The patient/legal guardian has made the decision to withdraw life
support. This decision is separate from any organ donation
discussion or considerations
• The End of Life Support Team will discuss the details of organ
donation and the DCD process with the family
• The location of withdrawal will be at the discretion of the ICU
family liaison, the OPO, and OR charge nurse and will be based on
family logistics and wishes
CHOA Policy: DCD
• Planning, withdrawal of care, declaration of death, and
transport to the OR
• The place of withdrawal include the ICU bed with immediate
access to the OR, or an OR anteroom
• The family will be invited and encouraged to stay with the patient
during withdrawal through death declaration, but this is not
mandated
• No organ recovery team members will be present during the
withdrawal of treatment or during the dying process
CHOA Policy: DCD
• Withdrawal of life support measures
•
•
•
•
Termination of blood pressure medications
Termination of all IV fluids
Removal of ETT
Heparin bolus as ordered by the OPO
• Following withdrawal the primary medical team will be encouraged
to maintain patient comfort measures
• The attending intensivist will monitor patient for signs of death
based on established critical care criteria
• Once confirmed the attending will declare death
• At 5 minutes following death declaration, the attending will monitor
the patient for spontaneous cardiac or respiratory function (autoresuscitation) for 20 seconds
• At that time transfer of the body will occur from the primary medical
team to the organ recovery team and OPO
CHOA Organ Donation
• 2003-2016
• 54 successful DCD statewide
• 10 DCD cases in 2015
• 298 organ donors last year
Organ Transplanted from
CHOA DCD Cases
References
• Bastami S, Matthes O, Krones T, et al. (2013) Systemic review of
attitudes toward donation after cardiac death among healthcare
providers and the general public Crit Care Med 41 (3):897-905
• Haplerm SD, Barnes B, Hasz RD, Abt PL (2010) Estimated supply of
organ donors after circulatory determination of death: a population
based cohort study JAMA 304 (23):2592-4
• Mazor R, Baden H. (2007) Trends in pediatric organ donation after
cardiac death Pediatrics 120 (4): e960-6
• Nakagawa TA, Ashwal S, Mathur M et al. (2011)Guidelines for the
Determination of Brain Death in Infants and Children: An Update of
the 1987 Task Force Recommendations Pediatrics 128(3):e720-740
• Steinbrook, R. (2007) Organ donation after cardiac death. NEJM
367:209-213
• Yoo P, Olthoff K, Abt P. (2011) Donation after cardiac death in
pediatric organ donation Curr op organ trans 16(5):483-8