Deceased organ donation

Waqas Ali

Objectives

• To have a basic idea of solid organ transplantation

• To know about Organ sources and donor types• To know about brain death concept and

controversies

Solid organ transplantation• Definition: – Autograft: The transfer of a tissue or organ from one part

of the body to another within the same person – Allograft:The transfer of a tissue or organ from one

individual to another individual.

Commonly transplanted organs• Cornea• Kidneys• Skin• Bone marrow• Heart and heart valves• Intestine• Bone• Lung• Liver• Pancreas

Principles of transplantation

• Transplant immunologyThe immune system recognizes graft from someone else as foreign and triggers response via immune cells or substances they produce - cytokines and antibodies

• Responses are via; recognition, amplification and memory

05/02/2023 bbinyunus2002@gmail.com 6

KeyStimulatesGives rise to

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MemoryHelper T cells

Antigen-presenting cell

Helper T cell

Engulfed by

Antigen (1st exposure)

+

+

+

+ +

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Defend against extracellular pathogens/Transplant rejection

MemoryB cells

Antigen (2nd exposure)Plasma cells

B cell

Secretedantibodies

Humoral (antibody-mediated) immune response

Organ rejections• Rejection of transplanted organs is a bigger challenge than the technical

expertise required to perform the surgery. It results mainly from HLA and ABO incompatibility

• Hyperacute: with in seconds to minutes• Acute: In first six months• Chronic: After 6 months• Rejection is controlled by immunosuppression given as

– Induction– Maintainance– Rescue agents

Organ Donors

Living-Relative-Stranger

Cadaver

• Types of Living Donor Transplants– Kidney (entire organ)– Liver (segment)– Lung (lobe)– Intestine (portion)– Pancreas (portion)

• After brain death (heart beating donor)• Kidney• Heart• Liver • Lungs• Pancreas• Intestine• Heart valves• Connective tissue

• Cadaver (non heart beating donor)– After natural death

• Cornea• Bone• Skin • Blood vessels

Living vs decease transplant

• Improved graft survival• Less recipient morbidity• Early function and

easier to manage • Avoidance long waiting

time for transplant• Less aggressive

immunosuppressive regimen

• Relatively inferior graft survivals

• More immunogenic• Surgery of recipient is

unscheduled• More likely to need

future retransplant• Waiting time is more

Contra-indications for living donor

– Mental disease– Diseased organ– Morbidity and mortality risk– ABO incompatibility – Cross matching incompatibility– Transmissible disease

Councelling

• May involve professional counselors/ psychotherapist

• Aimed at preventing / minimizing possible complication

• Need for adherence to post-op maintenance medications

• Regular follow-up with thorough evaluation• Life style modification; smoking, alcohol,

sedentary life style, junks, excessive salt ingestion.

Informed consent

• Living Donor– Education– Willingly not for any financial reason or under

duress – Most undergo extensive screening – medical

psychological– Involve family – Surgery and anesthetic complications

Informed consent

• Decease donor– Some factors influencing refusal to consent by

relatives;• non-acceptance of brain death. • Superstitions relating to being reborn with a missing organ • A delay in funeral • Lack of consensus within family members • Fear of social criticism • Dissatisfaction with the hospital staff • Religious believes

Organ procurement

After removal, the organ is flushed with chilled organ preservation solution e.g University of Wisconsin(UW)

Packaging

Non heart beating kidney donation

Ischemia duration

Warm ischemic time ; time an organ remains at body temperature between which the blood supply is cut off before cold perfusion. (within 30min)Cold ischemic time ; the time between the chilling of the organ, after blood supply has been cut off and the time it is warmed by reconnection

Maximum and optimal cold storage times (approximate)• Organ Optimal (hours ) Safe maximum(hours) • Kidney < 24 48• Liver < 12 24• Pancreas < 10 24• Small intestine < 4 8• Heart < 3 6• Lung < 3 8

Assuming zero warm ischemic time and organs obtained from a non-marginal

Brain death

• When brain injury is refractory to aggressive management and is considered nonsurvivable, with loss of consciousness and brain stem reflexes, a brain death protocol may be initiated to determine death according to neurological criteria

Brain death implications

• Heart-beating, brain-dead donors provide the majority of organs for transplant.1

• Extended times between terminal brain stem herniation, declaration of brain death, and organ recovery risk loss of organs because of refractory cardiopulmonary instability

• Cost of intensive care

1. United Network of Organ Sharing. 2012 data: spring regional meetings.

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Pathophysiology of Brain Injury• Terminal brain stem herniation is often the final stage in

refractory brain injury caused by trauma, ischemia or infarction, hemorrhage, intracranial tumors, and infectious processes such as encephalitis and meningitis

• Progression of injury follows a rostral to caudal path

Brain edema + Inc ICP

Compressed cortex

Compromised blood flow

Pathological posturing/ seizures

Transtentorial herniation

Brainstem displacement

Cushing response; HTN, brady, wide

pulse pressure

Sympathetic outflow; HTN,

tachy, Vasoconstriction

Catecholamine depletion

Clinical brain stem assessment

Confounding factors in brain death

• spinal cord injury, • movements in brain death (complex spinal

reflexes, muscle fasciculations, ventilator autotriggering),

• therapeutic hypothermia• transient brain stem depression after

cardiopulmonary arrest

Ethical concerns • The World Health Organization argues that

transplantations promote health, but the notion of “transplantation tourism” has the potential to violate human rights or exploit the poor

• There is also a powerful opposing view, that trade in organs, if properly and effectively regulated to ensure that the seller is fully informed of all the consequences of donation, is a mutually beneficial transaction between two consenting adults, and that prohibiting it would itself be a violation of Articles 3 and 29 of the Universal Declaration of Human Rights.

History of Organ transplant

The Chinese physician Pien Chi'ao reportedly exchanged hearts between a man of strong spirit but weak will with one of a man of weak spirit but strong will in an attempt to achieve balance in each man.

• Roman Catholic accounts report the third-century saints Damian and Cosmas as replacing the gangrenous leg of the Roman deacon Justinian with the leg of a recently deceased Ethiopian.

• The first reasonable account is of the Indian surgeon Sushruta in the second century BC, who used autografted skin transplantation in nose reconstruction rhinoplasty.

• Centuries later, the Italian surgeon performed successful skin autografts; he also failed consistently with allografts

• the first successful human corneal transplant, a keratoplastic operation, was performed by Eduard Zirm in Austria in 1905.

• Their skillful anastomosis operations, the new suturing techniques, laid the groundwork for later transplant surgery and won Carrel the 1912 Nobel Prize for Medicine or Physiology

• Archibald McIndoe carried on the work into World War II as reconstructive surgery

• The first attempted human deceased-donor transplant was performed by the Ukrainian surgeon in the 1930s

Yu Yu Voronoy

• the late 1940s Peter Medawar, working for the National Institute for Medica Research, improved the understanding of rejection.

• On March 9th 1981 t the first successful heart-lung transplant took place at Stanford University Hospital. The head surgeon, Bruce Reitz, credited the patient's recovery to cyclosporine-A.

Timeline of successful transpants • 1905: First successful cornea transplant by Eduard Zirm • 1954: First successful kidney transplant by Joseph Murray (Boston, U.S.A.) • 1966: First successful pancreas transplant by Richard Lillehei and William Kelly (Minnesota,

U.S.A.) • 1967: First successful liver transplant by Thomas Starzl (Denver, U.S.A.) • 1967: First successful heart transplant by Christiaan Barnard (Cape Town, South Africa) • 1970: First successful monkey head transplant by Robert White (Cleveland, U.S.A.) • 1981: First successful heart/lung transplant by Bruce Reitz (Stanford, U.S.A.) • 1983: First successful lung lobe transplant by Joel Cooper (Toronto, Canada) • 1986: First successful double-lung transplant (Ann Harrison) by Joel Cooper (Toronto,

Canada) • 1987: First successful whole lung transplant by Joel Cooper (St. Louis, U.S.A.) • 1995: First successful laparoscopic live-donor nephrectomy by Lloyd Ratner and Louis

Kavoussi (Baltimore, U.S.A.) • 1998: First successful live-donor partial pancreas transplant by David Sutherland (Minnesota,

U.S.A.) • 1998: First successful hand transplant (France) • 2005: First successful partial face transplant (France) • 2006: First successful penis transplant (China)

Thank you

• References• Brain Death: Assessment, Controversy, and Confounding Factors RICHARD B. ARBOUR, RN, MSN, CCRN, CNRN, CCNS• LIVING DONOR KIDNEY TRANSPLANT Kelli Willard West, MSSW, APSW Living Donation Outreach Educator• PRINCIPLES INVOLVED IN ORGAN TRANSPLANT DR BASHIR YUNUS SURGERY DEPT. AKTH 19/1/15 Wikipedia and google