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

Paul Morrissey, MDDepartment of SurgeryRhode Island HospitalBrown Medical School

Brown Ethics Forum Transplantation

• State of Organ Transplantation

• Need for organs

• Brain death• Cardiac death (DCD)

– Results– Issues

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

ESRD Modalities

0

50

100

150

200

1988 89 90 91 92 93 94 95 96 97

Count (1000s)

HD

Transplant

PD

Transplant Wait List – RIH 2003

• ABO N PRA>10 TU

– A 30 18 14– B 20 11 3– O 53 18 6– AB 2 2 0

– Total 105 49 23

0102030405060708090

1997 1998 1999 2000 2001 2002 Proj

TotalLive donor

Renal Transplants – RIH

Renal Transplants vs. Wait List

3521

0

10000

20000

30000

40000

50000

1988 1992 1994 1996 1998 2000 2002

Live donorCadaver

Waiting list

Renal Tx vs. Wait List

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

Time on dialysis: strongest modifiable risk factor for renal tx outcomes

Mortality on Dialysis

• 23 % per year• 5 year survival

– ESRD - 30 %– ESRD + DM- 20

%– ESRD + Age >

65 - 15 %.

Kidney donors - USA

0

2000

4000

6000

1988 1992 1994 1996 1998 2000 2001 2002

Live donor Cadaver

Cadaver Donors – Percent by Age

0

5

10

15

20

25

30

35

40

90 91 92 93 94 95 96 97 98 99 0 1 2

18-34Over 50

Over 65

Organ Donor NumbersGrowth: 136 % Spain, 33 % USA

Deceased Donors by Age

Terasaki et al. Clin Transplant 1997; 11: 366.

Kidney allograft survival by donor age

0

10

20

30

40

50

60

70

80

90

20-9 30-9 40-9 50-9 60+

One yearFive year

0 1 2 3 4 5 6 7 8 9 10

Id Sib1-haplo SibUnrelatedCadaver

1009080706050403020100

Perc

ent

Su

rviv

al

Years Post transplant

2,1293,1402,071

34,572

39.216.116.710.2

n T1/2Relationship

82

64

47

Cecka, M.UNOS

1994-1999

Graft Survival Rates for LRD and LURD grafts

Kidneys for Transplantation:Where 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

Head trauma: Epidural hematoma

• Severe brain injury• Irreversible brain

injury

• Persistent vegetative state

• Brain dead– Cortical brain– Brain stem

Brain Death Concept (1968)

– Defined as:•Irreversible loss of brain function•Including brain stem (respiration)

– Brain death = death•Medically•Legally•Ethically

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

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

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.

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

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?

Kidney Graft-Survival RatesCho, Terasaki, Cecka, Gjertson. NEJM 338: 221, 1998.

Graft-Survival by Cause of Death

DCD: Long-term outcomes

A. Censored for death with function.

B. Uncensored data – graft survival.

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

DCD Experience - RIH

• 14 potential donors evaluated• 6 families refused consent• 4 failed to progress to asystole in < 1

hour– BP and O2 sat. declined– Donation aborted

• 4 became donors– 8 kidneys transplanted

DCD kidneys procured at RIH

Pt. Cr LOS Follow-up/complicationsA 1.7 5 A&W 38 monthsB 1.4 23 Delayed function, died.C 0.9 6 A&W 36 monthsD 1.2 13 A&W 36 monthsE 1.5 5 A&W 9 monthsF 1.4 7 A&W 9 monthsG HD 7 Graft thrombosisH 1.0 6 A&W 2 months

DCD in NEOB

• 1999 4 cases• Effort to increase NHBD

– Reinvigorate one program– Develop 6 other programs

• 2003 19 cases

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 %)

Who is the NEOB?

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

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)

Cadaver Donors – RIH1998-2002 – 125 potential donors

75

39

11

DonorNo consentConsent - not suitable

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

Organ Donation - Best practice

66%

17%

17%

ConsentStrongly opposePotential

Organ Donors - NEOB

0

50

100

150

200

250

94 95 96 97 98 99 2000 2001 2002

CVA

TraumaAll

Organ Donation - room for growth?

• DCD– Emergency room

• 2-for-1– Discard rate is 30%

• Live donors– Family interventions– Unrelated donors including “altruistic”

Categories of DCD

Description LocationDOA EDUnsuccessful CPR ED, ICU, WardWithdraw support ICU or OR

Cardiac arrest ICU, OR while brain dead

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

Live donor renal transplantation Black Market

Thank you