Extended Criteria for Organ Acceptance Following Paediatric Donation after Circulatory Death (DCD): An Underdeveloped Potential

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Introduction: There are more patients waiting for organ transplantation than there are available donor organs. In 2008, the UK commissioned an Organ Donation Taskforce to identify obstacles to successful organ transplantation [1]. National initiatives implement the recommendations: the consideration of organ donation is to become standard within end-of-life care. The diagnosis of brain stem death in paediatrics is unusual. In hospital, children may die following controlled withdrawal of life sustaining support. Organ retrieval in paediatrics is more reliant upon donation after circulatory death (DCD). The paediatric DCD program is innovative[2]; the ethical justification of change in clinical practice to accommodate the intended benefit of organ optimisation is controversial and the desired clinical parameters are not clearly defined. Clinical experience and expertise is limited. We report our first and the UK's youngest and smallest DCD that successfully progressed to transplantation. History: Our patient was a 7month 7kg infant with hypoplastic left heart syndrome (HLHS) - complex cyanotic congenital heart disease (CyCHD) where the systemic and pulmonary circulations are in parallel and result in an inherently unstable hypoxic systemic blood flow. The infant died 55 days after her 4th admission to PICU following a series of complex palliative cardiac interventions (Glenn operation and cardiac catheterisations). Our patient was dependent upon continuous inotropic support (milrinone and adrenaline), almost exclusively ventilated and had saturations 65-75%. There was clinical suspicion of chronic global ischaemia (difference in arterio-venous saturation 40-45%). The infant had been considered a candidate for heart transplantation. During end-of-life discussions, the parent's were keen to explore organ donation. The liver was declined by all UK transplanting centres due to function or size. A European centre provisionally accepted, pending direct visualisation. Only one UK centre expressed an interest in the kidneys in view of the generalised lack of experience of implanting paediatric DCD kidneys. Results: The patient became asystolic within 23 minutes of withdrawal of support. Cold aortic perfusion commenced 12 minutes thereafter. The liver was considered unfavourable. The kidneys were transplanted en-bloc into a haemodialysis dependent adult.Table: [Recipient Renal Function]Conclusion: Our case illustrates that successful transplantation following paediatric DCD is possible, despite the ‘unfavourable’ donor haemodynamic profile and the real-ime pragmatic unease imposed by the novel clinical practice changes. Transplanted infant kidneys, previously exposed to chronic marginal hypoxia and ischaemia, have the potential to normalise an adult's biochemistry. Paediatric specific threshold clinical parameters considered acceptable to explore organ transplantation have not been qualified. This allows variation in practice and bias towards excessive restriction jeopardizing the fate of potentially transplantable organs. Adult parameters cannot be applied to the child, especially if the deceased child suffered from cyanotic CHD. Clarification is needed to standardize practice and prevent the emergence of unsubstantiated obstacles. Acknowledgement: The authors acknowledge the exceptional courage and generosity of the donor family involved.