Pediatr Transplantation 2014: 18: 549–550
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Pediatric Transplantation DOI: 10.1111/petr.12304
Letter to the Editor Extracorporeal membrane oxygenation in pediatric organ donation Organ donation and subsequent transplant rates vary significantly across continents with a universal shortage of organs remaining a major limitation for transplantation, especially in children. A recent analysis of the Organ Procurement and Transplantation Network from 2001 to 2010 found that the number of pediatric organ transplant recipients increased from 1170 to 1475, while death on the waiting list decreased from 262 to 110 (1). While this analysis found that adults received fewer pediatric allografts during this time period (1), significantly fewer cadaveric donors exist for any given child when compared to adults (2). With a limited donor organ supply, alternative methods for procuring organs should be considered. Although controversial, extracorporeal membrane oxygenation (ECMO) has been used successfully in supporting donor organ procurement (3). The restoration of circulation of the brain and heart through ECMO could potentially retroactively disaffirm previous death determination where circulatory determination is more acceptable if proper standards are followed (4). A recent small case series by Migliaccio et al. (5) demonstrated that ECMO permitted organ donation in brain-dead patients. These investigators initiated ECMO as a life-saving procedure in the early phase of hospitalization in seven patients and as a means to permit the determination of brain death in another patient (5). Of these eight patients in this cohort, two were older adolescents with both initiated on ECMO prior to brain death (5). The preservation of organs through ECMO could potentially lead to the reappearance of signs of life that in reality was not occurring. As divisive is the fact that temporary organ support by ECMO through means not expressed by consent could be viewed as a violation of respect for donor autonomy (6). Despite ethical and legal concerns in this
setting, ECMO is supported by enthusiasts, ethicists, and theologians (7). Current practices limit the use of ECMO as a method of organ preservation with some countries using this method of support more than others. In their case series, Migliaccio et al. (5) reported that they “. . .do not use ECMO as supportive therapy for organ donation but as supportive/rescue therapy in emergency clinical situations. . .” and their use of ECMO concedes “. . .organs will be available for donation is the consequence and not the goal. . .” It is our opinion that donors should be permitted the opportunity to execute their right to gift organs. Current policies should include transparency regarding the use of ECMO as a means to support donor organs, including children, and thus reduce risks associated with this practice, which would potentially enhance organ procurement. Funding No funding was required to complete this work.
Conflict of interest
The authors have no conflict of interests to report and have no relevant disclosures. Authors’ contribution Don Hayes, Jr. was involved in conception and design, and drafting of the manuscript; Sylvester M. Black was involved in conception and design, and revision of the manuscript; Bryan A. Whitson was involved in conception and design, and revision of the manuscript.
Don Hayes, Jr., MD, MS1,2,3, Sylvester M. Black, MD, PhD3,4 and Bryan A. Whitson, MD, PhD2,4 1 Department of Pediatrics, The Ohio State University, Columbus, OH, USA, 2Department of Internal Medicine, The Ohio State University, Columbus, OH, USA,
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Letter to the Editor 3
The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration Laboratory, The Ohio State University, Columbus, OH, USA, 4Department of Surgery, The Ohio State University, Columbus, OH, USA, E-mail: [email protected]
The manuscript represents original work that is not being considered or has been accepted for publication elsewhere. The work and subsequent manuscript was completed at The Ohio State University Wexner Medical Center and Nationwide Children’s Hospital, Columbus, Ohio. The development of this manuscript did not require approval by The Ohio State University Wexner Medical Center and Nationwide Children’s Hospital Institutional Review Boards.
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References 1. WORKMAN JK, MYRICK CW, MEYERS RL, BRATTON SL, NAKAGAWA TA. Pediatric organ donation and transplantation. Pediatrics 2013: 131: e1723–e1730. 2. BRIERLEY J, HASAN A. Aspects of deceased organ donation in paediatrics. Br J Anaesth 2012: 108(Suppl 1): i92–i95. 3. KO WJ, CHEN YS, TSAI PR, LEE PH. Extracorporeal membrane oxygenation support of donor abdominal organs in non-heartbeating donors. Clin Transplant 2000: 14: 152–156. 4. BERNAT JL, CAPRON AM, BLECK TP, et al. The circulatory-respiratory determination of death in organ donation. Crit Care Med 2010: 38: 963–970. 5. MIGLIACCIO ML, ZAGLI G, CIANCHI G, et al. Extracorporeal membrane oxygenation in brain-death organ and tissues donors: A single-centre experience. Br J Anaesth 2013: 111: 673–674. 6. VERHEIJDE JL, RADY MY, MCGREGOR J. Presumed consent for organ preservation in uncontrolled donation after cardiac death in the United States: A public policy with serious consequences. Philos Ethics Humanit Med 2009: 4: 15. 7. DEJOHN C, ZWISCHENBERGER JB. Ethical implications of extracorporeal interval support for organ retrieval (EISOR). ASAIO J 2006: 52: 119–122.
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Pediatric Transplantation DOI: 10.1111/petr.12304
Letter to the Editor Extracorporeal membrane oxygenation in pediatric organ donation Organ donation and subsequent transplant rates vary significantly across continents with a universal shortage of organs remaining a major limitation for transplantation, especially in children. A recent analysis of the Organ Procurement and Transplantation Network from 2001 to 2010 found that the number of pediatric organ transplant recipients increased from 1170 to 1475, while death on the waiting list decreased from 262 to 110 (1). While this analysis found that adults received fewer pediatric allografts during this time period (1), significantly fewer cadaveric donors exist for any given child when compared to adults (2). With a limited donor organ supply, alternative methods for procuring organs should be considered. Although controversial, extracorporeal membrane oxygenation (ECMO) has been used successfully in supporting donor organ procurement (3). The restoration of circulation of the brain and heart through ECMO could potentially retroactively disaffirm previous death determination where circulatory determination is more acceptable if proper standards are followed (4). A recent small case series by Migliaccio et al. (5) demonstrated that ECMO permitted organ donation in brain-dead patients. These investigators initiated ECMO as a life-saving procedure in the early phase of hospitalization in seven patients and as a means to permit the determination of brain death in another patient (5). Of these eight patients in this cohort, two were older adolescents with both initiated on ECMO prior to brain death (5). The preservation of organs through ECMO could potentially lead to the reappearance of signs of life that in reality was not occurring. As divisive is the fact that temporary organ support by ECMO through means not expressed by consent could be viewed as a violation of respect for donor autonomy (6). Despite ethical and legal concerns in this
setting, ECMO is supported by enthusiasts, ethicists, and theologians (7). Current practices limit the use of ECMO as a method of organ preservation with some countries using this method of support more than others. In their case series, Migliaccio et al. (5) reported that they “. . .do not use ECMO as supportive therapy for organ donation but as supportive/rescue therapy in emergency clinical situations. . .” and their use of ECMO concedes “. . .organs will be available for donation is the consequence and not the goal. . .” It is our opinion that donors should be permitted the opportunity to execute their right to gift organs. Current policies should include transparency regarding the use of ECMO as a means to support donor organs, including children, and thus reduce risks associated with this practice, which would potentially enhance organ procurement. Funding No funding was required to complete this work.
Conflict of interest
The authors have no conflict of interests to report and have no relevant disclosures. Authors’ contribution Don Hayes, Jr. was involved in conception and design, and drafting of the manuscript; Sylvester M. Black was involved in conception and design, and revision of the manuscript; Bryan A. Whitson was involved in conception and design, and revision of the manuscript.
Don Hayes, Jr., MD, MS1,2,3, Sylvester M. Black, MD, PhD3,4 and Bryan A. Whitson, MD, PhD2,4 1 Department of Pediatrics, The Ohio State University, Columbus, OH, USA, 2Department of Internal Medicine, The Ohio State University, Columbus, OH, USA,
549
Letter to the Editor 3
The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration Laboratory, The Ohio State University, Columbus, OH, USA, 4Department of Surgery, The Ohio State University, Columbus, OH, USA, E-mail: [email protected]
The manuscript represents original work that is not being considered or has been accepted for publication elsewhere. The work and subsequent manuscript was completed at The Ohio State University Wexner Medical Center and Nationwide Children’s Hospital, Columbus, Ohio. The development of this manuscript did not require approval by The Ohio State University Wexner Medical Center and Nationwide Children’s Hospital Institutional Review Boards.
550
References 1. WORKMAN JK, MYRICK CW, MEYERS RL, BRATTON SL, NAKAGAWA TA. Pediatric organ donation and transplantation. Pediatrics 2013: 131: e1723–e1730. 2. BRIERLEY J, HASAN A. Aspects of deceased organ donation in paediatrics. Br J Anaesth 2012: 108(Suppl 1): i92–i95. 3. KO WJ, CHEN YS, TSAI PR, LEE PH. Extracorporeal membrane oxygenation support of donor abdominal organs in non-heartbeating donors. Clin Transplant 2000: 14: 152–156. 4. BERNAT JL, CAPRON AM, BLECK TP, et al. The circulatory-respiratory determination of death in organ donation. Crit Care Med 2010: 38: 963–970. 5. MIGLIACCIO ML, ZAGLI G, CIANCHI G, et al. Extracorporeal membrane oxygenation in brain-death organ and tissues donors: A single-centre experience. Br J Anaesth 2013: 111: 673–674. 6. VERHEIJDE JL, RADY MY, MCGREGOR J. Presumed consent for organ preservation in uncontrolled donation after cardiac death in the United States: A public policy with serious consequences. Philos Ethics Humanit Med 2009: 4: 15. 7. DEJOHN C, ZWISCHENBERGER JB. Ethical implications of extracorporeal interval support for organ retrieval (EISOR). ASAIO J 2006: 52: 119–122.
