324 Review article
Organ donation after circulatory death: an update Murray J. Blackstocka and David C. Rayb There is an ongoing shortfall of organs for donation in the UK and worldwide. Strategies including donation after circulatory death (DCD), living donation and better identification of potential donors are attempting to increase the number of donors and donated organs. The number of DCD donors in the UK increased by 808% from 37 to 336 between 2001 and 2010 and this is continuing to increase. The most common organs donated from DCD donors are the kidneys, but there is increasing experience of liver, lung and pancreas transplantation. The process of DCD varies between different countries and institutions. The outcome of DCD transplantation has been largely encouraging, particularly for kidneys. The increase in DCD has led to an appraisal of issues that may arise during the donation process; these include the Lazarus phenomenon, the
dead donor rule, perimortem interventions, public opinion and conflict of interest for clinicians. European Journal of c 2014 Wolters Kluwer Emergency Medicine 21:324–329 Health | Lippincott Williams & Wilkins.
Introduction
and improved outcomes with DBD organ transplantation led to a reduction in DCD [2]. Subsequently, however, the number of DBD donors has decreased with improved road safety and critical care [3,4]. The concurrent increase in the organ transplant waiting list means there is a shortfall in organs. Several strategies, including DCD, living donation and better identification of potential donors, have attempted to increase the number of donated organs [4]. During the 1990s, DCD was reintroduced in the USA and UK, becoming a re-established method of organ donation [2,3,5].
Donation after circulatory death (DCD) is an important method of organ donation as the number of brain-dead donors (DBD) is insufficient to meet the increasing transplant waiting list [1]. The number of DCD organ donors continues to increase in the UK and worldwide. Historically, DCD donors have come from critical care units, but more recently, donors have been identified in emergency departments and in prehospital care. We review the history and current status of DCD, criteria for and outcomes and obstacles in DCD, and discuss the need for collaboration between prehospital care, emergency medicine and critical care.
Materials and methods We performed a literature search of MEDLINE, EMBASE, CINAHL and Cochrane Library databases using the search terms ‘donation after cardiac death’, ‘donation after circulatory death’ and ‘heart beating organ donation’, excluding non-English language articles and nonhuman studies. We hand searched the reference lists of articles and performed an internet search for relevant national organ donation websites. We identified articles that we considered most relevant for inclusion in this narrative update and reviewed these. Origins of donation after circulatory death
Before the 1970s, DCD was the established method of organ donation [2]. The first organ transplant (a living donor renal transplant) took place in 1954. In 1962, the same surgeon performed a cadaveric renal transplant. Subsequently, transplantation of the liver, lungs, pancreas and heart occurred, with variable results. The establishment of brain stem death testing, immunosuppression c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 0969-9546
European Journal of Emergency Medicine 2014, 21:324–329 Keywords: cardiac, death, organ donation, sudden, transplantation a Department of Anaesthesia, Critical Care and Pain Medicine, Western General Hospital and bDepartment of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary, Edinburgh, Scotland
Correspondence to Murray J. Blackstock, MBCHB, FRCA, MRCS, FFICM, Department of Anaesthesia, Critical Care and Pain Medicine, Western General Hospital, Edinburgh EH42XU, Scotland Tel: + 44 0131 537 1666; e-mail: [email protected] Received 21 March 2013 Accepted 14 August 2013
Methods of donation after circulatory death
DCD donors are classified by the modified Maastricht classification (Table 1). Categories 3 and 4 are considered controlled and categories 1, 2 and 5 as uncontrolled [6,7]. Although DCD donors are found in many settings, most experience is with category 3 donors in critical care and emergency departments [5,8]. In Spain and France, category 1 and 2 donation may occur from patients having out-of-hospital cardiac arrest [9–11]. Absolute contraindications to DCD are shown in Table 2. Donors are classed as optimal or standard criteria donors and suboptimal or expanded criteria donors. Optimal kidney donors are below 50 years old, with no history of hypertension or cerebrovascular accident, creatinine less than 133 mmol/l and warm ischaemic time less than 1 h; expanded criteria donors are either more than 60 years old or more than 50 years old with two of hypertension, cerebrovascular accident causing death or creatinine more than 132 mmol/l [12]. Referral can be made to the local transplant co-ordinator after the separate decisions to withdraw life-sustaining DOI: 10.1097/MEJ.0000000000000082
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Organ donation after circulatory death Blackstock and Ray 325
Category Category Category Category Category
I II III IV V
Dead on arrival Unsuccessful resuscitation Anticipated cardiac arrest Cardiac arrest in a brain-stem dead donor Unexpected cardiac arrest in an intensive care patient
Reproduced with permission from [6].
Absolute contraindications to donation after circulatory death donors organ donation
Table 2
Absolute contraindications to DCD organ donation Age >80 years Active invasive cancer in the last 3 years excluding nonmelanoma skin cancer, localized prostate cancer, thyroid cancer, in-situ cervical cancer Haematological malignancy (myeloma, lymphoma, leukaemia) Choriocarcinoma Variant Creutzfeldt–Jakob disease (vCJD) HIV disease (but not HIV infection) TB – active and untreated or within 6 months of the start of treatment Malaria Meningoencephalitis (for which no infection has been identified) NHBTS (May 2012, personal communication). DCD, donation after circulatory death donors. Reproduced with permission from [8].
measures and considering the potential for DCD. The process of treatment withdrawal varies internationally and between hospitals in the same country. Treatment withdrawal may occur in the emergency department, critical care unit or operating theatre depending on where the patient is identified, local logistics and protocols. The patient may be moved to a different location to allow treatment withdrawal; this requires close collaboration between the emergency department and critical care unit, necessitating the development of agreed pathways for DCD donation [8]. Warm ischaemic time [the period from onset of hypotension (systolic blood pressure
Organ donation after circulatory death: an update Murray J. Blackstocka and David C. Rayb There is an ongoing shortfall of organs for donation in the UK and worldwide. Strategies including donation after circulatory death (DCD), living donation and better identification of potential donors are attempting to increase the number of donors and donated organs. The number of DCD donors in the UK increased by 808% from 37 to 336 between 2001 and 2010 and this is continuing to increase. The most common organs donated from DCD donors are the kidneys, but there is increasing experience of liver, lung and pancreas transplantation. The process of DCD varies between different countries and institutions. The outcome of DCD transplantation has been largely encouraging, particularly for kidneys. The increase in DCD has led to an appraisal of issues that may arise during the donation process; these include the Lazarus phenomenon, the
dead donor rule, perimortem interventions, public opinion and conflict of interest for clinicians. European Journal of c 2014 Wolters Kluwer Emergency Medicine 21:324–329 Health | Lippincott Williams & Wilkins.
Introduction
and improved outcomes with DBD organ transplantation led to a reduction in DCD [2]. Subsequently, however, the number of DBD donors has decreased with improved road safety and critical care [3,4]. The concurrent increase in the organ transplant waiting list means there is a shortfall in organs. Several strategies, including DCD, living donation and better identification of potential donors, have attempted to increase the number of donated organs [4]. During the 1990s, DCD was reintroduced in the USA and UK, becoming a re-established method of organ donation [2,3,5].
Donation after circulatory death (DCD) is an important method of organ donation as the number of brain-dead donors (DBD) is insufficient to meet the increasing transplant waiting list [1]. The number of DCD organ donors continues to increase in the UK and worldwide. Historically, DCD donors have come from critical care units, but more recently, donors have been identified in emergency departments and in prehospital care. We review the history and current status of DCD, criteria for and outcomes and obstacles in DCD, and discuss the need for collaboration between prehospital care, emergency medicine and critical care.
Materials and methods We performed a literature search of MEDLINE, EMBASE, CINAHL and Cochrane Library databases using the search terms ‘donation after cardiac death’, ‘donation after circulatory death’ and ‘heart beating organ donation’, excluding non-English language articles and nonhuman studies. We hand searched the reference lists of articles and performed an internet search for relevant national organ donation websites. We identified articles that we considered most relevant for inclusion in this narrative update and reviewed these. Origins of donation after circulatory death
Before the 1970s, DCD was the established method of organ donation [2]. The first organ transplant (a living donor renal transplant) took place in 1954. In 1962, the same surgeon performed a cadaveric renal transplant. Subsequently, transplantation of the liver, lungs, pancreas and heart occurred, with variable results. The establishment of brain stem death testing, immunosuppression c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 0969-9546
European Journal of Emergency Medicine 2014, 21:324–329 Keywords: cardiac, death, organ donation, sudden, transplantation a Department of Anaesthesia, Critical Care and Pain Medicine, Western General Hospital and bDepartment of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary, Edinburgh, Scotland
Correspondence to Murray J. Blackstock, MBCHB, FRCA, MRCS, FFICM, Department of Anaesthesia, Critical Care and Pain Medicine, Western General Hospital, Edinburgh EH42XU, Scotland Tel: + 44 0131 537 1666; e-mail: [email protected] Received 21 March 2013 Accepted 14 August 2013
Methods of donation after circulatory death
DCD donors are classified by the modified Maastricht classification (Table 1). Categories 3 and 4 are considered controlled and categories 1, 2 and 5 as uncontrolled [6,7]. Although DCD donors are found in many settings, most experience is with category 3 donors in critical care and emergency departments [5,8]. In Spain and France, category 1 and 2 donation may occur from patients having out-of-hospital cardiac arrest [9–11]. Absolute contraindications to DCD are shown in Table 2. Donors are classed as optimal or standard criteria donors and suboptimal or expanded criteria donors. Optimal kidney donors are below 50 years old, with no history of hypertension or cerebrovascular accident, creatinine less than 133 mmol/l and warm ischaemic time less than 1 h; expanded criteria donors are either more than 60 years old or more than 50 years old with two of hypertension, cerebrovascular accident causing death or creatinine more than 132 mmol/l [12]. Referral can be made to the local transplant co-ordinator after the separate decisions to withdraw life-sustaining DOI: 10.1097/MEJ.0000000000000082
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Organ donation after circulatory death Blackstock and Ray 325
Category Category Category Category Category
I II III IV V
Dead on arrival Unsuccessful resuscitation Anticipated cardiac arrest Cardiac arrest in a brain-stem dead donor Unexpected cardiac arrest in an intensive care patient
Reproduced with permission from [6].
Absolute contraindications to donation after circulatory death donors organ donation
Table 2
Absolute contraindications to DCD organ donation Age >80 years Active invasive cancer in the last 3 years excluding nonmelanoma skin cancer, localized prostate cancer, thyroid cancer, in-situ cervical cancer Haematological malignancy (myeloma, lymphoma, leukaemia) Choriocarcinoma Variant Creutzfeldt–Jakob disease (vCJD) HIV disease (but not HIV infection) TB – active and untreated or within 6 months of the start of treatment Malaria Meningoencephalitis (for which no infection has been identified) NHBTS (May 2012, personal communication). DCD, donation after circulatory death donors. Reproduced with permission from [8].
measures and considering the potential for DCD. The process of treatment withdrawal varies internationally and between hospitals in the same country. Treatment withdrawal may occur in the emergency department, critical care unit or operating theatre depending on where the patient is identified, local logistics and protocols. The patient may be moved to a different location to allow treatment withdrawal; this requires close collaboration between the emergency department and critical care unit, necessitating the development of agreed pathways for DCD donation [8]. Warm ischaemic time [the period from onset of hypotension (systolic blood pressure
