Terasaki et al. Clin Transplant 1997; 11: 366. Kidney allograft survival by donor age
012345678910 Id Sib 1-haplo Sib Unrelated Cadaver 100 90 80 70 60 50 40 30 20 10 0 Percent Survival Years Post transplant 2,129 3,140 2,071 34,572 39.2 16.1 16.7 10.2 nT1/2 Relationship 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 Asystole5 minutes Cannulate, cold perfuse5 minutes Transport to OR5 minutes Laparotomy, clamp aorta5 minutes Procure kidneys30 minutes 2 kidneys for transplantPriceless
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?
DCD in NEOB 19994 cases Effort to increase NHBD –Reinvigorate one program –Develop 6 other programs 200319 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 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)
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