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Expanding the Donor Pool: ECD and DCD Practice Carl-Ludwig Fischer-Fröhlich, Stuttgart, Germany.

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Presentation on theme: "Expanding the Donor Pool: ECD and DCD Practice Carl-Ludwig Fischer-Fröhlich, Stuttgart, Germany."— Presentation transcript:

1 Expanding the Donor Pool: ECD and DCD Practice Carl-Ludwig Fischer-Fröhlich, Stuttgart, Germany

2 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)

3 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:

4 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)

5 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)

6 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

7 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)

8 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

9 - 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 !

10 …pitfalls at recovery  Final check in thorax and abdomen !

11 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

12 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

13 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

14 * 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)

15 Donors after circulatory death (DCD)

16 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.

17 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……

18 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.

19 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.

20 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


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