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Dead or Dead-Enough? DCD and Organ Donation in 2003 Paul Morrissey, MD Department of Surgery Rhode Island Hospital Brown Medical School.

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Presentation on theme: "Dead or Dead-Enough? DCD and Organ Donation in 2003 Paul Morrissey, MD Department of Surgery Rhode Island Hospital Brown Medical School."— Presentation transcript:

1 Dead or Dead-Enough? DCD and Organ Donation in 2003 Paul Morrissey, MD Department of Surgery Rhode Island Hospital Brown Medical School

2 Brown Ethics Forum Transplantation State of Organ Transplantation Need for organs Brain death Cardiac death (DCD) –Results –Issues

3 ESRD in R.I 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

4 ESRD Modalities

5 Transplant Wait List – RIH 2003 ABON PRA>10TU –A –B20113 –O53186 –AB220 –Total

6 Renal Transplants – RIH

7 Renal Transplants vs. Wait List

8 Renal Tx vs. Wait List –16% annual growth of wait list –1.6 % annual increase in CRT donors

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

10 Mortality on Dialysis 23 % per year 5 year survival –ESRD - 30 % –ESRD + DM- 20 % –ESRD + Age > %.

11 Kidney donors - USA

12 Cadaver Donors – Percent by Age

13 Organ Donor Numbers Growth: 136 % Spain, 33 % USA

14 Deceased Donors by Age

15 Terasaki et al. Clin Transplant 1997; 11: 366. Kidney allograft survival by donor age

16 Id Sib 1-haplo Sib Unrelated Cadaver Percent Survival Years Post transplant 2,129 3,140 2,071 34, nT1/2 Relationship Cecka, M. UNOS Graft Survival Rates for LRD and LURD grafts

17 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

18 Head trauma: Epidural hematoma Severe brain injury Irreversible brain injury Persistent vegetative state Brain dead –Cortical brain –Brain stem

19 Brain Death Concept (1968) –Defined as: Irreversible loss of brain function Including brain stem (respiration) –Brain death = death Medically Legally Ethically

20 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

21 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

22 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.

23 Time sequence for DCD Asystole5 minutes Cannulate, cold perfuse5 minutes Transport to OR5 minutes Laparotomy, clamp aorta5 minutes Procure kidneys30 minutes 2 kidneys for transplantPriceless

24 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?

25 Kidney Graft-Survival Rates Cho, Terasaki, Cecka, Gjertson. NEJM 338: 221, 1998.

26 Graft-Survival by Cause of Death

27 DCD: Long-term outcomes A.Censored for death with function. B.Uncensored data – graft survival.

28 Donors at RIH Overall –240 transplants –196 living Altruistic9 Exchange3 Unrelated Related CRT –0-mm12 –DCD23 –Region 1 plan140 Over 5026 Over 6013 –2-for-17

29 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

30 DCD kidneys procured at RIH Pt. CrLOSFollow-up/complications A1.75A&W 38 months B1.423Delayed function, died. C0.96A&W 36 months D1.213A&W 36 months E1.55A&W 9 months F1.47A&W 9 months GHD7Graft thrombosis H1.06A&W 2 months

31 DCD in NEOB cases Effort to increase NHBD –Reinvigorate one program –Develop 6 other programs cases

32 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 %)

33 Who is the NEOB? Donor coordinator Social Workers Family Support Team Community Educator Medical Director Administrators

34 Brain dead Organ Donation Could 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)

35 Cadaver Donors – RIH – 125 potential donors

36 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 % of brain dead donors

37 Organ Donation - Best practice

38 Organ Donors - NEOB

39 Organ Donation - room for growth? DCD –Emergency room 2-for-1 –Discard rate is 30% Live donors –Family interventions –Unrelated donors including altruistic

40 Categories of DCD DescriptionLocation DOAED Unsuccessful CPRED, ICU, Ward Withdraw supportICU or OR Cardiac arrestICU, OR while brain dead

41 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

42 Live donor renal transplantation Black Market

43 Thank you

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