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Editorials and Perspectives: Editors' Forum

Donors after Cardiac Death: Opportunity Missed

Johnson, Scott R.

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doi: 10.1097/01.tp.0000168574.81450.1c
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Howard et al. reviewed the UNOS database of all organs recovered from deceased donors from 1994-2003. The objective of the article was to review trends in donation after cardiac death utilization in the U.S. In a review of greater than 55,000 donors during 1994-2003, a number of interesting findings were noted. First, only 1,177 of 55,206 or 2.1% of all donors are donors after cardiac death (DCD). Despite a steady rise in utilization of DCD donors during the period of review, a surprisingly small fraction of the organs recovered and utilized were extrarenal organs. In fact, during the 10-year period of study, only 395 livers and 54 pancreata were procured and transplanted. The most striking finding of the report is the simple fact that 19 of 59 organ procurement organizations (OPOs) had not recovered a DCD donor, and in an additional 24 OPOs, DCD donor procurement accounted for less than 1% of the total number of donors procured. Thus 43 of 59 (72.8%) OPOs recover less than 1% of their donors from those after cardiac death. In an era where much effort is expended by the transplant community highlighting the shortage of donor organs available, how is it that we fail to optimize utilization DCD donors?

A number of authors have postulated the impact of DCD donors on the number of transplanted organs. Terasaki et al. speculated that full utilization of DCD kidneys could dramatically increase the number of renal transplants performed and also stated that DCD donors could potentially eliminate the waitlist entirely, if all organs were transplanted (1). Others have described single center experience of DCD organ use and their impact on transplant volume. Daemen and others have reported that recovered kidneys comprised up to 40% of transplanted organs in these centers (2,3). Although other reports have not confirmed this level of DCD organ activity, many centers report renal transplants from DCD donors comprising 10-25% transplants performed (4,5). The implication from these reports is clear: more can be done, yet utilization of DCD donors remains lackluster. A number of reasons have been cited for poor utilization of these organs.

Lack of acceptance by the medical community has been described as hindering DCD recovery. This criticism has come from shifting roles in end of life care and confusion that it generates as well as concerns about premortem procedures such as femoral canulation and intravenous heparinization. In most instances, potential DCD donors are approached for consent in the ICU where end-of-life care is commonly delivered. When consent is obtained, donors are transported to the operating room for extubation. Perioperative staff may have little training in end-of-life care and their involuntary role in the dying process may give rise to conflict regarding the implementation of DCD procurement. A number of DCD donors do not progress to asystole and must be transferred from the operating room to another site to complete the dying process. This lack of continuity of care is likely a significant source of confusion for family and medical staff (6,7). In the process of implementing a DCD program at our institution, this became a significant impediment to its success. Ultimately, we feel we have been able to solve the issue by performing virtually all DCD donor extubations in the ICU and using the 5-minute period of asystole for transport to the operating room without adversely affecting organ function.

Another cited reason for failure of DCD procurement is lack of manpower and added expense. The procurement of DCD donors, once consent is obtained, is not a certainty as are brain-dead (BD) donors and surgeons may be reluctant to spend significant time waiting for a procurement that may not occur. The lack of conversion comes primarily from failure of the donor to progress to cardiac arrest within an acceptable time frame after extubation and a higher organ discard rate as noted in the Howard study. Added expense is incurred by having a fully staffed and supplied operating room ready for recovery if the donor progresses to asystole and death. Although these concerns are real, they should not defray the transplant community from pursuing DCD donors with the same vigor that BD donors are pursued.

The most common reason cited for poor DCD organ utilization is poor organ function. Ample data exists documenting excellent long-term function of renal transplants from DCD donors. These reports include large single center and national database reviews (5,8–10). In these manuscripts, despite a higher incidence of delayed graft function in the DCD organs, long-term graft survival was not different than organs procured form BD donors. Although most of us are confident of renal allograft function from DCD donors, the graft function of extrarenal organs procured from DCD donors is less well documented in the literature. In fact, most reports to date are single-center, retrospective reviews, the largest of which reports the results of 19 DCD livers; others report smaller volumes (11–13). Although the authors report patient and graft survival comparable to BD organs, a higher incidence of primary nonfunction and biliary complications have been noted. Despite this, they conclude that DCD donor livers can safely expand the donor pool. Pancreata, heart, and lung recovery and transplantation have been reported but the numbers remain small; although results reported to date are encouraging, additional outcome data are necessary (14,15).

Outcome data on renal transplants from DCD donors are clear that utilization of these organs do not lead to inferior outcomes. The results of studies published to date on extrarenal DCD organ transplantation suggest acceptable patient and allograft survival but additional data is necessary to confirm acceptable long-term outcomes. Several questions inherent in DCD donors that impact on organ function need further study. What are acceptable times from extubation to cardiac arrest? What is the impact of hemodynamic instability and or hypoxia during this period? What are the effects of other factors such as donor age, degree of hepatic steatosis, time from declaration of death to aortic perfusion, cold and warm ischemia times, severity of recipient disease (MELD score) on DCD organ function? Because we have increasingly, and rightly so, turned to data to guide both utilization and allocation of donor organs, it is time the transplant community makes a concerted effort to obtain the necessary data to demonstrate the noninferiority of DCD extrarenal organs. Only then will demand for these organs drive OPOs to aggressively pursue DCD recovery.

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Keywords:

Donor after cardiac death; Organ donation; Organ procurement organization

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