Presentation on theme: "Expanding the Donor Pool: ECD and DCD Practice Carl-Ludwig Fischer-Fröhlich, Stuttgart, Germany."— Presentation transcript:
Expanding the Donor Pool: ECD and DCD Practice Carl-Ludwig Fischer-Fröhlich, Stuttgart, Germany
frequent co-morbidities in donors donor derived diseases transmission Mortality / Morbiditiy pitfalls infection malignancy gene defect poisoning acute – chronic – latent – cured – recurrence free ? global or local problem ? treatment in the recipient possible ? benefit for the individual recipient ? Expanded criteria donors (ECD)
Example: 52 yrs, SAH (admitted 10 h after event) Infection parameters: = become unreliable - brain injury - brainstem coning - overlay of infection ?? Leuco. 251718 G/l CRP 2986181223mg/l Platelets 267271211 G/l Fibrinogen 2,63,84,97,4mg/l NA135 149146mmol/l Brain death and Inflammation:
Infections (1) Previous mental or neurological changes (skin / fever / diarrhea / pain / body examination): poisoning? malignancy? exotic virus – fungus – bacteria – parasite - zoonosis? Living conditions / social situation / „antecedents“: chance for collecting infectious pathogens traveling, working, living, pets, animals, sanitary condition, CDC-risk Diagnostic tests may fail ! serology, cultures, PCR etc.: specific / sensitive? false pos./neg. ? Minimum screening (serology +/-PCR if indicated in high risk population): HIV, Hepatitis B & C, CMV, EBV, Toxoplasmosis Further pathogens according to regional prevalence (WMV, Dengue, Malaria…) Critical Symptoms Council of Europe: Guide to the safety and quality of organs in transplantation of organs (5 th ed., 2013)
Infections (2) systematic spread / blood = transmission latent / locally restricted = different patterns of transmission (e.g. CMV) properly treated infection= no exclusion (e.g. 48h antibiotics in bacteria) communicate all in coming results / data to recipient centers reassess with recipient CMV-, PCP-, antibiotic-prophylaxis et al. Absolute Contraindication: Encephalitis or Meningitis of unknown origin Un-treated true Sepsis or tuberculosis Bacteria, Virus, Fungus, Parasites et al.: Council of Europe: Guide to the safety and quality of organs in transplantation of organs (5 th ed., 2013)
Malignancy staging TNM – histology – therapy – recurrence free – kind of follow up brain tumor vs. other solid tumors vs. haematopoetic disorders tumor markers: not reliable transmission risk assessment: Final decision depends on recipient’s needs Transplant Registries (e.g. UNOS / IPTTR), case reports: low rate of transmission if donor was properly screened lethal adverse events if overseen in donor current practice: ~ non cerebral: some T1N0M0, if recurrence free survival > * years ~ cerebral: WHO Grade + duration + therapy Council of Europe: Guide to the safety and quality of organs in transplantation of organs (5 th ed., 2013) …but never forget to screen for malignancy in a potential donor
Gene Defect or rare diseases Donor 73 yr., cerebral stroke -> bleeding Glycogenosis Type 5 (Mc Ardle): - gene 11q13 defect for muscle-myophosphorylase - isoenzyme for liver and brain coded by other gene - risk for rhabdomyolysis after severe exercise www.orphanet.net Glycogenosis Council of Europe: Guide to the safety and quality of organs in transplantation of organs (5 th ed., 2013)
Poisoning CO and / or Cyanide (smoke) Council of Europe: Guide to the safety and quality of organs in transplantation of organs (5 th ed., 2013) Check for detoxication and recovery from poisoning
- 100 kg, 170cm, ICB, untreated hypertension, smoker, alcohol, - ICU-Nurse: “Hi, needs volume and MAP >75 for diuresis, Crea. normal” prevention of acute kidney injury (with assumed chronic damage) liver-fibrosis, 3 vessel-CAD, arteriosclerosis both kidneys had primary function Preservation of organ function before recovery… Donor maintenance improves marginal organs !
…pitfalls at recovery Final check in thorax and abdomen !
67 years SAH ICU = 17 days ALAT = 91 IU/l BMI = 35 kg/m² paO 2 /FIO 2 = 134 Is it safe to use this liver for transplantation? Diabetes Typ II Hypertension Tetanus as child anti-HBc +, HBsAg - Consensus: Qualified examination at recovery + biopsy + care for HBV-transmission 5% macrovesiuclar steatosis, slight choelstasis, slight cholangitis
Multiple Cox RegressionGraft failure (n=2175) DonorRisk Ratio 95%-CIp-value Age (yrs.)1.011[1.005-1.017]<0.001 Organquality (reduced)1.243[1.001-1.545]0.049 RecipientRisk Ratio 95%-CIp-value Age(yrs.)1.014[1.006-1.022]0.001 High Urgent1.809[1.398-2.342]<0.001 Creatinine (mg/dl)1.205[1.136-1.278]<0.001 Bilirubine (mg/dl)1.023[1.016-1.030]<0.001 Donor: Age Recipient:Co-Morbidity (age) + actual status (Bili, Crea, HU) EDC are not relevant after proper donor selection Frühauf NR, Fischer-Fröhlich CL, Kutschmann M, Schmidtmann I, Kirste G. Transplantation, 2011 ; 92: 1378-1384 Liver: Interaction donor & ECD & recipient
Death censored graft survival rate (p < 0,0001): Graft survival rate (p < 0,0001): Donor age n 0-17 yrs. 244 18-54 yrs. 3372 55-64 yrs. 1517 65-74 yrs. 1625 75-84 yrs. 513 ≥ 85 yrs. 38 Days after transplantation Kidney: donor age = ECD ? (Germany 2009-2012, n=7309, courtesy DSO/Aqua) Donor age n 0-17 yrs. 244 18-54 yrs. 3372 55-64 yrs. 1517 65-74 yrs. 1625 75-84 yrs. 513 ≥ 85 yrs. 38 Donor age explaining variable in all COX regressions in German population
* 3 Experiment: explosive ICP ~ irreversible myocard damage ~ contraction band necrosis Donor chatecholamine support heart transplantion * 1 - if (after SAH/ICB) primary graft failure * 2 - if (at vasoplegia) no effect on graft function * 1 Santise, Interact Cardiovasc Surg 2009, 9, 476-479 * 2 Silva, Intens Care Med, 2002, 28, Suppl. 66 * 3 Shivalkar, Circulation 1993, 87, 230-239 * 4 Bybee, Prasa, Circulation 2008, 118, 397-409 * 4 Stress related cardiomyopathy: …acute stress, severe illness or …”sudden intracranial disease” ~ explosive catecholamine release at nerve ends of myocard ~ arrythmia, akinesia, LVF … The Brain - Heart Connection: * 5 SAH cardiac failure ~ cardiac function workup * 6 avoid at brain stem coning ~ by Esmolol or Urapidil * 7 after brain stem coning ~ donor resucitation protocol (covers other pathologies) * 5 Lee Neuro Crti Care 2006,5, 243-249 * 6 Mertens, Organs Tissues Cells 2007, 10, 159-165 * 7 Zaroff, Ciruclation 2002, 106, 836-841 Poor cardiac output mitigated by inotropic support (dobutamine) after stress cardiomyopathy Peripheral vasoconstriction after brain death (norepinephrine)
FIRST INTERNATIONAL MEETING OF DCD (MAASTRICHT - criteria 1995) uncontrolled DCDMAASTRICHT I (dead on arrival) MAASTRICHT II (CPR not succeeded) controlled DCDMAASTRICHT III (waiting for cardiac arrest) MAASTRICHT IV (cardiac arrest after BD) DCD categories: Kootstra G, Daemen JH, Oomen AP. 1995. Categories of non-heart-beating donors. Transplantation Proceedings 27(5):2893–2894.
DCD: some basics How do you confirm death after the terminal cessation of heart function ? Does this DCD concept fit your legislation about brain death diagnostics ? How complies your no-touch period with the ”Donor Dead Rule“ ? Is DCD accepted within your health care system ? You must have a convinced team with all partners in the hospital integrated ! You must have an effective protocol for all steps in your hospital ! Example Germany: in every donor death & irreversible cessation of all brain functions must be confirmed before an organ can be recovered for transplantation after consent. any no-touch-period does not confirm this as safe sign of death……
Controlled DCD Severe cerebral lesion (Anoxia, ICB et al.) / No severe cerebral lesion (e.g. terminal neurodegenerative or cardio-pulmoinary disease) No brain death criteria Previous consent to withdrawl life sustaining therapy (WLST) Organ donation acceptance consent for canulation & medication pre-mortem Predictive Score of Cardiac arrest <120’ Clinical evaluaiton If all ok: apply your protocol (e.g.) prepare recovery prepare WLST Consider farewell Perform WLST In case of cardiac arrest <120’ proceed with recovery after appropriate no-touch period for assuring irreversible cardiac arrest otherwise stop procedure Keep ischemia times low Select appropriate recipients Compensate side effects of pro- longed warm ischemia by proper organ preservation Results might be equivalent to DBD when performed properly.
uncontrolled DCD Apply protocol consented with all partners in your healthcare system: CPR failed, usually otherwise healthy persons (outside/inside hospital) Rapid arrangements in your hospital (unexpected event) Death certification by team independent from recovery or transplantation Appropriate family approach (time constraints) If consent farewell & recovery (see controlled DCD) or otherwise stop Critical issue: Some maneuvers mandatory pre-consent & CPR continued until… et al.
Conclusion: Case wise decision Expanded donor criteria ~ risk for compromised grafts Restricted donor criteria ~ dead on waiting list anyway Personal alert: - “I may oversee a donor” - fit recipient to donor - update protocols (research) Thank you Expanding the donor pool: ECD and DCD practice