Brain Stem Dead Donors Research Articles

A clinically relevant sheep model of orthotopic heart transplantation 24\xa0h after donor brainstem death

BackgroundHeart transplantation (HTx) from brainstem dead (BSD) donors is the gold-standard therapy for severe/end-stage cardiac disease, but is limited by a global donor heart shortage. Consequently, innovative solutions to increase donor heart availability and utilisation are rapidly expanding. Clinically relevant preclinical models are essential for evaluating interventions for human translation, yet few exist that accurately mimic all key HTx components, incorporating injuries beginning in the donor, through to the recipient. To enable future assessment of novel perfusion technologies in our research program, we thus aimed to develop a clinically relevant sheep model of HTx following 24 h of donor BSD.MethodsBSD donors (vs. sham neurological injury, 4/group) were hemodynamically supported and monitored for 24 h, followed by heart preservation with cold static storage. Bicaval orthotopic HTx was performed in matched recipients, who were weaned from cardiopulmonary bypass (CPB), and monitored for 6 h. Donor and recipient blood were assayed for inflammatory and cardiac injury markers, and cardiac function was assessed using echocardiography. Repeated measurements between the two different groups during the study observation period were assessed by mixed ANOVA for repeated measures.ResultsBrainstem death caused an immediate catecholaminergic hemodynamic response (mean arterial pressure, p = 0.09), systemic inflammation (IL-6 - p = 0.025, IL-8 - p = 0.002) and cardiac injury (cardiac troponin I, p = 0.048), requiring vasopressor support (vasopressor dependency index, VDI, p = 0.023), with normalisation of biomarkers and physiology over 24 h. All hearts were weaned from CPB and monitored for 6 h post-HTx, except one (sham) recipient that died 2 h post-HTx. Hemodynamic (VDI - p = 0.592, heart rate - p = 0.747) and metabolic (blood lactate, p = 0.546) parameters post-HTx were comparable between groups, despite the observed physiological perturbations that occurred during donor BSD. All p values denote interaction among groups and time in the ANOVA for repeated measures.ConclusionsWe have successfully developed an ovine HTx model following 24 h of donor BSD. After 6 h of critical care management post-HTx, there were no differences between groups, despite evident hemodynamic perturbations, systemic inflammation, and cardiac injury observed during donor BSD. This preclinical model provides a platform for critical assessment of injury development pre- and post-HTx, and novel therapeutic evaluation.

Management of the brain stem dead organ donor

Management of the brain stem dead organ donor

Use of Coping Mechanisms in Organ Donation and Transplantation with Distinctive Orientation to Brain Stem Death

This paper talks about psychodynamic theory of psychology wherein individuals adopt various defense mechanisms in order to cope with unpleasant thoughts, emotions or behaviors while dealing with multifaceted processes of organ donation and transplantation. Organ donation from brain stem dead donors and transplantation involves certain psychological defense mechanisms like sublimation, introjections, projection, intellectualization, and denial that are explained through a few case studies of organ donor families, non-donor families, recipients of organs, families of recipients, organ transplant coordinators and doctors. The author discusses how individuals behave in different ways in order to deal with the unpleasant thoughts, emotions or behaviors that are intertwined with intricate debates, dilemmas and convolutions of organ donation and transplantation especially from brain stem dead donors. The organs donated by brain stem dead donors are used for transplantation into people struggling for life with end stage organ failures. The paper represents the narratives of individuals through diagrams that explain the nature of defense mechanisms adopted by people and professionals in organ donation and transplantation. Through these case studies the author wants the authorities to focus on issues that could resolve some problems that are encountered in day to day activities by professionals especially organ transplant coordinators in India. There are a number of areas wherein government needs to put efforts like making easy permissions from police, preventing double permission from police as is required in Medico Legal Cases if the accident has happened in one place and the organ retrieval at the other. There is a dire need to start extensive awareness programmes in all related ministries. The government needs to be sensitive to the plight of poor people who wait for long hours to get back the body once they decide to donate organs in Govt. hospitals. They deserve some care in government hospitals during waiting period. Some budgetary provisions needs to be made for the same. One of the very important things is to introduce a topic on defense mechanisms in organ transplant coordinators course to make them understand the coping mechanisms better. Such efforts will help them in understanding each other better and help them to become effective team members.

Linkages of Organ/Tissue Donation and Transplantation with “Maslow’s Hierarchy of Needs”- Indian Stories

This paper draws a parallel of Maslow hierarchy of needs with organ donation and transplantation and illustrates how these needs i.e., physiological, security, love and belongingness, self-esteem and self-actualization are inter-dependent, interlinked and entrenched in both living as well as deceased organ donation and transplantation. The paper illustrates the nuances of inter-linkages of need satisfaction of people and professionals in organ donation and transplantation. With some case studies, it draws attention to the plight of impoverished people and insecure women who are exploited or intimidated into donating organs for meeting their physiological and security needs in class stratified and gender insensitive social milieu respectively. It however, reveres the acts of donation of organs by relatives of deceased donors who allow donation of organs from Brain Stem Dead donors in India and illustrates how security needs of these families are met through the most powerful and altruistic act of organ donation that gives life to a number of people fighting end stage organ failures. The paper traces new expectations of love and belongingness in the form of organ donation and discusses role reversal of females even on Rakshabandan, a Hindu festival that celebrates love and affection between a sister and a brother. The sisters risk their lives and gift their organs to give a fresh lease of life to their brothers. Drawing attention to the forth level of needs, the paper discusses the plight of some vulnerable people who end up donating organs for gratification of their self-esteem needs in contrast to transplantation community who seek gratification of the same need through transplantation and influencing law making process in context of both living and deceased donation. It admires the gratification of self-actualization needs of a number of people who pledge to donate tissues, organs as well as the bodies after death/Brain Stem Death. India being a progressive country in organ donation and transplantation, this paper reveals how some professionals having satisfied all other basic needs, spend their own money and work tirelessly for pushing ahead the National Organ and Tissue Transplant Organization (NOTTO) under the aegis of National Organ Transplant Programme(NOTP ) in the country.

Resuscitation of Marginal Hearts Using Ex Vivo Perfusion.

Introduction: Increasing the usage of hearts from marginal donors and from donors after circulatory death (DCD) has the potential to expand the donor pool. Such hearts may be resuscitated when subjected to ex vivo perfusion. In addition, this may provide an opportunity for viability testing prior to transplant. We describe a novel ex vivo perfusion system designed to reanimate porcine DCD hearts. The same system was subsequently tested using a human heart from a marginal brainstem-dead donor. Method: In the first phase of the study 23 porcine hearts were procured following circulatory death. All hearts were subjected to a period of primary warm ischemia followed by 120 minutes of hypothermic preservation. The period of hypothermic preservation was initially static cold storage (SCS); then oxygenated machine perfusion and finally a combination of static cold storage and oxygen persufflation via the coronary sinus. Ex vivo perfusion of the hearts was performed with a normothermic, oxygenated blood-based solution in our Langendorff system. In the second phase of the study the same system was used to perfuse a human heart from a marginal brainstem-dead donor. This donor had not met criteria for consideration of heart donation. Results: 15 of the 23 (65.2%) DCD porcine hearts reanimated following reperfusion on the ex vivo system. Reanimation was achieved with 63.6% (7/11) in the SCS group; 33.3% (2/6) in the machine perfusion group and 100% (6/6) in the persufflation group. The human heart was placed in the system after a cold ischemic period of 7 hours 4 minutes and perfused with a mid-thermic temperature solution for a further 2 hours 40 minutes to allow for correction of hyperkalemia before warming. The heart started to work after a further hour and then maintained until the experiment was terminated after a further two hours. Conclusion: The ex vivo perfusion system described can potentially resuscitate marginal hearts including those from DCD. The system devised in this study could also be used as a platform to functionally assess marginal human hearts. This mode of viability testing would be an essential step to determine suitability for transplant.

People’s Perspectives: Insights into Organ Donation from Brain Stem Dead Donors

This article gives us insights into the grey areas and conflicts surrounding organ donation from brain stem dead donors from the perspective of people in India. Brain stem death is a new definition of death which is not commonly understood. This article questions the recipient centric organ donation law given to understand the anti-therapeutic effect of apnea test on the donor, a prerequisite for diagnosing brain stem death. The articlealso voices concern overthe partial instructions given to donors or donor families, mistrusted medical fraternity, unregulated market of organ donation and altruism not percolating in the system. It also deals with factors like Lazarus sign and body movements of the brain stem dead; non-acceptance of conditionaldonation and undisclosed identities of recipients post donation acting as dissuading factors in popularizing organ donation. Thearticle makes a strong case for developing common man’s faith in the medial system and professionals and prevention of doctors from succumbing to the pressures to diagnose patients as brainstem dead. This article suggests making family consent for apnea test mandatory; giving the family an option to be present during the test and giving them the choice to say no to postmortem. The paper also suggests creating awareness on the new definition of death, the Law of organ donation and transplantation, disseminating comprehensive information, regularizing market, providing health related incentives to donor families, conducting research on people’s perspective and allowing conditional donation of at least one organ. Key Words; Brain Stem Death, People’s perspective,THOA 1994, Organ

Use of donor bladder tissues for in vitro research

To evaluate deceased non-heart beating (DNHB) donors and deceased heart beating (DHB) brain-stem dead donors, as sources of viable urological tissue for use in biomedical research. To identify sources of viable human bladder tissue as an essential resource for cell biological research aimed at understanding human diseases of the bladder and for developing new tissue engineering and regenerative medicine strategies for bladder reconstruction. Typically, normal human urinary tract tissue is obtained from adult or paediatric surgical patients with benign urological conditions, but few surgical procedures yield useful quantities of healthy bladder tissue for research. Research ethics committee approval was obtained for collection of donor bladder tissue. Consent for DHB donors was undertaken by the Donor Transplant Coordinators. Tissue Donor Coordinators were responsible for consent for DNHB donors and the retrieval of bladders was coordinated through the National Blood Service Tissue Banking Service. All retrievals were performed by practicing urologists and care was taken to maintain sterility and to minimise bacterial contamination. Two bladders were retrieved from DNHB donors and four were retrieved from DHB donors. By histology, DNHB donor bladder tissue exhibited marked urothelial tissue damage and necrosis, with major loss or absence of urothelium. No cell cultures could be established from these specimens, as the urothelial cells were not viable in primary culture. Bladder urothelium from DHB donors was intact, but showed some damage, including loss of superficial cells and variable separation from the basement membrane. All four DHB bladder specimens yielded viable urothelial cells that attached in primary culture, but cell growth was slow to establish and cultures showed a limited capacity to form a functional barrier epithelium and a propensity to senesce early. We have shown that normal human bladder urothelial cell cultures can be established and serially propagated from DHB donor bladders. However, our study suggests that rapid post-mortem changes to the bladder affect the quality and viability of the urothelium, rendering tissue from DNHB donors an inadequate source for urothelial cell culture. Our experience is that whereas patients are willing to donate surgical tissue for research, there is a barrier to obtaining consent from next of kin for retrieved tissues to be used for research purposes.

Ex vivo perfusion of the swine heart as a method for pre-transplant assessment

We describe a cost-effective, reproducible circuit in a porcine, ex vivo, continuous warm-blood, bi-ventricular, working heart model that has future possibilities for pre-transplant assessment of marginal hearts donated from brain stem dead donors and hearts donated after circulatory determination of death (DCDD). In five consecutive experiments over five days, pressure volume loops were performed. During working mode, the left ventricular end systolic pressure volume relationship (LV ESPVR) was 23.1±11.1 mmHg/ml and the LV preload recruitable stroke work (PRSW) was 67.8±7.2. (Standard PVAN analysis software) (Millar Instruments, Houston, TX, USA) All five hearts were perfused for 219±64 minutes and regained normal cardiac function on the perfusion system.They displayed a significant upward and leftward shift of the end systolic pressure volume relationship, a significant increase in preload recruitable stroke work and minimal stiffness. These hearts could potentially be considered for transplantation. The circuit was effective during reperfusion and working modes whilst proving to be successful in maintaining cardiac function in excess of four hours. Using an autologous prime of approximately 20% haematocrit (Hct), electrolytes and blood gases were easy to control within this period using standard perfusion techniques.

Use of a Multilayered Stent for the Treatment of Hepatic Artery Pseudoaneurysm After Liver Transplantation

To the Editor: We would like to use this opportunity to share with the wider clinical community our experience in managing a hepatic artery pseudoaneurysm (HAP) of a 59-year-old man after liver transplant using a multilayered stent. HAP is a rare but well-recognised complication occurring after orthotopic liver transplantation (OLT). The reported incidence is 0.3% to 2.6% [1, 2]. The majority of cases of HAP occurring after OLT arise in the context of endovascular intervention or secondary to diathermy injury to the artery during surgery [3]. They have also been reported to complicate other hepato-pancreatico-biliary surgical procedures [4]. With time, the natural history of HAP is of enlargement and an associated risk of rupture, which can be fatal [5]. Patients most commonly present with intraperitoneal bleeding or gastrointestinal haemorrhage secondary to haemobilia; however, incidental and asymptomatic HAP may be recognised [6]. Established management options include surgical ligation and endovascular coil embolisation; however, both of these methods are associated with a significant risk of hepatic ischaemia, which often requires retransplantation [5]. Coronary artery stent-grafts have also been used to treat HAP, often after failure of coil embolisation [7]. The introduction of the Multilayer Aneurysm Repair System (MARS) stent (Cardiatis SA, Belgium) is a recent development in endovascular aneurysm repair. This is an uncovered stent comprised of three-dimensional braided tubing that decreases blood flow velocity in the aneurysmal sac whilst improving laminar blood flow in the main artery and surrounding arterial tributaries [8]. Its use for the treatment of HAP occurring after OLT has not previously been reported. Our case involves a 59 year-old man who underwent OLT for alcoholic cirrhosis in January 2011. The patient’s main indication for OLT was recurrent ascites. A transjugular intrahepatic portosystemic shunt was inserted in November 2010 before emergency surgical repair of a ruptured umbilical hernia. He was transplanted in early January 2011. He received a whole liver from a 74-year-old brainstem-dead donor who was involved in a road-traffic accident. His hepatectomy was performed whilst he was on veno-venous bypass and was uncomplicated. The implantation included a cavocavostomy, end-to-end pulmonary vein anastomosis using 5.0 Prolene (Ethicon, UK) suture material, end-to-end arterial anastomosis to the common hepatic artery using 6.0 Prolene (Ethicon, UK) suture material, and duct-to-duct biliary anastomosis using 5.0 polydioxanone (Ethicon, UK) suture material. The cold ischaemic time was 12 h and 40 min. During surgery, he received 4 U of blood, 1 pool of platelets, and 6 U of fresh frozen plasma. His postoperative recovery was complicated by mild acute cellular rejection on day 10, which required augmentation with intravenous methylprednisolone. He was discharged home on day 16. His immunosuppression medication included tacrolimus, azathioprine, and prednisolone. Because he was a cytomegalovirus mismatch, vanganciclovir was given for 100 days. At 3 months after OLT, the patient was admitted to our hospital for investigation of graft dysfunction. Liver histology showed evidence of perivenular haemorrhage and A. M. Elsharkawy (&) G. Sen M. Hudson S. Masson D. M. Manas Liver Unit, Freeman Hospital, Freeman Road, Newcastle Upon Tyne NE7 7DN, UK e-mail: ahmede@doctors.org.uk

Successful Treatment of De Novo Posttransplant Thrombotic Microangiopathy With Eculizumab

Atypical hemolytic uremic syndrome (aHUS) is a disease characterized by complement hyperactivation secondary to defects in complement genes and acquired autoantibodies against complement regulatory proteins (1). The clinical features include thrombotic microangiopathy (TMA), hemolytic anemia, thromb

MP-06.13 A Comparison of the Outcomes of Renal Transplantation from Heart-Beating Cadaveric Donors and Non-Heart-Beating Who Present Irreversible Cardiac Arrest Occurring Outside the Hospital

Non-heart-beating donors who present irreversible cardiac arrest occurring outside the hospital are a valuable source of kidneys for renal transplantation and they could help shorten the list of patients who are waiting for a kidney transplant. However, the significant degree of warm ischemic injury suffered by non-heart-beating kidneys leads to a greater incidence of primary non-function and delayed graft function than those from brainstem dead heart-beating donors. Our purpose was to compare the outcomes of kidney transplants from non-heart-beating donors (Maastricht donors type I and II) and heart-beating cadaveric donors.

2065 A COMPARISON OF THE OUTCOMES OF RENAL TRANSPLANTATION FROM HEART-BEATING CADAVERIC DONORS, AND NON-HEART-BEATING WHO PRESENT IRREVERSIBLE CARDIAC ARREST OCCURRING OUTSIDE THE HOSPITAL

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation, Vascular Surgery1 Apr 20112065 A COMPARISON OF THE OUTCOMES OF RENAL TRANSPLANTATION FROM HEART-BEATING CADAVERIC DONORS, AND NON-HEART-BEATING WHO PRESENT IRREVERSIBLE CARDIAC ARREST OCCURRING OUTSIDE THE HOSPITAL Felipe Villacampa, José Medina-Polo, Federico de la Rosa, Manuel Pamplona, Alfredo Rodríguez, Juan Passas, José Manuel Duarte, Eduardo Gutiérrez, Teresa Dipalma, and Rafael Díaz Felipe VillacampaFelipe Villacampa Madrid, Spain More articles by this author , José Medina-PoloJosé Medina-Polo Madrid, Spain More articles by this author , Federico de la RosaFederico de la Rosa Madrid, Spain More articles by this author , Manuel PamplonaManuel Pamplona Madrid, Spain More articles by this author , Alfredo RodríguezAlfredo Rodríguez Madrid, Spain More articles by this author , Juan PassasJuan Passas Madrid, Spain More articles by this author , José Manuel DuarteJosé Manuel Duarte Madrid, Spain More articles by this author , Eduardo GutiérrezEduardo Gutiérrez Madrid, Spain More articles by this author , Teresa DipalmaTeresa Dipalma Madrid, Spain More articles by this author , and Rafael DíazRafael Díaz Madrid, Spain More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.2338AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Non-heart-beating donors who present irreversible cardiac arrest occurring outside the hospital are a valuable source of kidneys for renal transplantation and they could help shorten the list of patients who are waiting for a kidney transplant. However, the significant degree of warm ischemic injury suffered by non-heart-beating kidneys leads to a greater incidence of primary non-function and delayed graft function than those from brainstem dead heart-beating donors. Our purpose was to compare the outcomes of kidney transplants from non-heart-beating donors (Maastricht donors type I and II) and heart-beating cadaveric donors. METHODS We retrospectively compared the results of kidney transplants from non-heart-beating donors performed in our institution from July 2005 to December 2009 with a control group of heart-beating cadaveric donors with similar donor and recipient age. The non-heart-beating donors were mostly of the Maastricht I category. RESULTS Results are shown in the table. Non-heart-beating donors (n = 100) Heart-beating cadaveric donors (n = 100) p value Donors age (years) 38.5±10 39.2±18 ns Recipients age (years) 46±11 45±14 ns Donor serum creatinine (mg/dl) 1.1±0.3 0.9±0.3 ns Delayed onset of Tacrolimus with Timoglobulin induction (%) 85% 8% 0.001 Primary non-function (%) 8% 4% ns Delayed graft function (%) 85% 39% 0.001 Acute rejection incidence (%) 6% 17% 0.01 Graft survival (%) 88% 90% ns Patient survival (%) 98% 98% ns Final serum creatinine (mg/dl) 1.4±0.3 1.4±0.6 ns Follow-up (months) 15±12 15±12 ns Among non-heart-beating donors, the causes of primary non-function were renal venous thrombosis (5), allograft rupture caused by acute rejection (2), and allograft rupture after a graft biopsy (1). Moreover, four more kidneys were lost despite primary graft function, one due to renal artery thrombosis, one due to hydronephrosis, and two patients died during follow-up. CONCLUSIONS Despite being associated with higher rates of primary non-function, and delayed graft function; the intermediate-term graft survival of non-heart-beating donors is very encouraging. It is our conclusion that, with an adequate infrastructure, people who die of cardiac arrest that occurs outside the hospital can be a viable source for kidney transplantation. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e826-e827 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Felipe Villacampa Madrid, Spain More articles by this author José Medina-Polo Madrid, Spain More articles by this author Federico de la Rosa Madrid, Spain More articles by this author Manuel Pamplona Madrid, Spain More articles by this author Alfredo Rodríguez Madrid, Spain More articles by this author Juan Passas Madrid, Spain More articles by this author José Manuel Duarte Madrid, Spain More articles by this author Eduardo Gutiérrez Madrid, Spain More articles by this author Teresa Dipalma Madrid, Spain More articles by this author Rafael Díaz Madrid, Spain More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Vasopressin for the treatment of catecholamine-resistant hypotension during a phaeochromocytoma resection in a 6-year-old child

Vasopressin for the treatment of catecholamine-resistant hypotension during a phaeochromocytoma resection in a 6-year-old child

The Effects of Acute Triiodothyronine Therapy on Myocardial Gene Expression in Brain Stem Dead Cardiac Donors

After brain stem death (BSD), a low T(3) state is common, and T(3) supplementation has been advocated to improve heart function and yield for transplantation. The aim of the study was to assess the effects of T(3) on expression of mRNAs encoding T(3)-responsive genes in the post-BSD human heart. Within a prospective double-blind trial, potential BSD cardiac donors undergoing hemodynamic optimization were randomized to T(3) (0.8 microg . kg(-1) bolus; infusion 0.113 microg . kg(-1) . h(-1)) or placebo (5% dextrose) for up to 6 h. Left ventricular biopsies were obtained at end-assessment from 30 donors (T(3); n=16). TaqMan real-time PCR was performed to investigate mRNA expression of the voltage-gated potassium channel Kv1.5, beta-1 adrenergic receptor (ADRB1), sarcoplasmic reticulum calcium ATPase type 2a (SERCA2a), and phospholamban (PLB). Time between diagnosis of BSD and donor management was 13.2 h (range, 9.7-16.8 h). T(3) donors were managed for 7.6 (6.9-8.3) h. Median serum free T(3) (fT3) at baseline was 2.9 (2.3-3.8) pmol . liter(-1) (reference range, 3.3-7.5 pmol . liter(-1)). At baseline, 19 of 30 (56.7%) had low serum fT3, and T(3) treatment increased fT3 to supraphysiological levels (P < 0.001). Expression of mRNAs encoding Kv1.5 and SERCA2a was increased 1.99-fold and 1.51-fold (P = 0.015 and 0.043). There was no significant change in the expression of mRNAs encoding ADRB1 and PLB. Treatment with T(3) did not improve hemodynamic function compared with placebo. Acute administration of T(3) in the BSD cardiac donor reverses the low T(3) state and increases expression of the mRNAs encoding Kv1.5 and SERCA2a, but not ADRB1 or PLB and is not associated with any improvement in hemodynamic performance.

Prélèvements d’organes sur donneurs décédés après arrêt cardiaque

The transplant of an allograft after cardiac arrest has been allowed in France since 2005 (decree of 2 august 2005: art R.1232-4-1, 2 and 3 of the public health code). Recently, according to the international scale, 4 situations that could lead to the realization of transplantable organs after cardiac arrest were identified according to a classification called "Maastricht" which describes the potential donors. In France the donors of class III (cessation of all medical care) were excluded. Ethical questions concerning this new practice come up. Are criteria adopted to define death enough sure? What is the place of non-heart beating donor transplantation with new technical resuscitation as extracorporeal life support for prolonged cardiac arrest? How does family and medical staff live this protocol? Despite this, non heart-beating donor kidney transplants offer the opportunity to compensate for the growing discrepancy between supply and demand for donor kidneys. Results from foreign studies have shown that they have the same survival and long term function as kidneys from traditional brain-stem dead donors. This practice is defined by legislation and supervised by the "Agence de la biomédecine" which guarantees technical efficiency and respect of ethics.

347: The Effect of Tri-Iodothyronine (T3) on Thyroid Hormone Responsive Cardiac Genes in the Brain Stem Dead Cardiac Donor

347: The Effect of Tri-Iodothyronine (T3) on Thyroid Hormone Responsive Cardiac Genes in the Brain Stem Dead Cardiac Donor

20: The Resuscitated DCD Donor Heart Is Functionally Superior to the Brainstem Dead Donor Heart

20: The Resuscitated DCD Donor Heart Is Functionally Superior to the Brainstem Dead Donor Heart

Aggressive Management of Multiorgan Donor

Transplantation of vital human organs is a lifesaving therapy for patients with end-stage organ failure who are medically fit to undergo the surgical procedure. However, deceased donor management remains one of the most neglected areas in transplantation medicine. Brainstem death leads to hemodynamic, metabolic, and immune consequences. Failure to recognize them and provide adequate physiological support accounts for loss of the scarce source of valuable donor organs. Donor optimization leads to increased organ procurement and contributes to improved organ function in the recipient. This article reviews the management advances and controversies of the brainstem-dead donor in an intensive care unit.

Diabetic Donors as a Source of Non–Heart-Beating Renal Transplants

Due to the organ shortage, many renal transplantation centers attempt to increase the donor pool by using non–heart-beating donors (NHBDs). These kidneys are generally regarded as “marginal” grafts. Many centers do not consider transplantation from an NHBD with a history of diabetes as it is a more suboptimal donor. We began our NHBD program in 1998 and have performed 5 renal transplants from diabetic NHBDs. Viability testing identified kidneys suitable for single or dual transplantation. Although kidneys from brain stem dead donors with diabetes have been used successfully, our data suggested that kidneys from diabetic NHBDs can also be used although we still need long-term results.

Brainstem death and the management of the organ donor

Brainstem death results in the irreversible loss of the capacity for consciousness and spontaneous respiration. In the UK, brainstem death is equivalent to somatic death and allows for the withdrawal of futile treatments and provides the potential for heart-beating organ donation. The diagnosis is made clinically with strict pre-conditions and exclusions. Pathophysiological responses to brainstem death mean that intensive support must be given to the donor, to ensure adequate organ perfusion to prevent asystole before donation can occur. A major predictive determinant in organ transplantation is the ischaemic time from cessation of cardiac output in the host, until restoration of circulation in the recipient. In particular, the warm ischaemic time from loss of perfusion until flushing and cooling with preservative solution is crucial. With heart-beating, brainstem dead donors, this can be kept to a minimum. More recently, improved preservation techniques and better assessment of organ function have enabled transplant teams to procure kidneys, livers, lungs and pancreases from asystolic donors. These individuals have suffered a catastrophic brain insult, do not fulfil the criteria for brainstem death, but have their treatment withdrawn on the basis of futility. Kidneys taken from these controlled non-heart-beating organ donors often show delayed graft function in the recipient and can require ongoing renal replacement therapy. The results at 5 years, however, are equivalent to those kidneys taken from heart-beating donors who maintain their cardiac output until the point of donation.