Donation After Circulatory Death

Background

  • Donation After Circulatory Death (DCD) Has Been Reintroduced Due to the Shorten of Organs for Transplant
    • DCD was Historically the First Method of Organ Procurement that was Used: DCD was used to harvest the first heart used for transplant
    • DCD Contrasts with Organ Procurement by Standard Means (Namely, Donation After Brain Death (see Brain Death, [[Brain Death]])
    • DCD May Be Used for Procurement of Kidneys, as Well as Organs with a Lower Tolerance for Warm Ischemia (Such as the Liver, Pancreas, and Lungs)
  • Common Diagnoses of Patients Undergoing DCD
    • Intracranial/Intracerebral Hemorrhage (see Intracerebral Hemorrhage, [[Intracerebral Hemorrhage]]): 45% of cases
    • Hypoxic-Ischemic Brain Injury (see Hypoxic-Ischemic Brain Injury, [[Hypoxic-Ischemic Brain Injury]]): 25% of cases
    • Traumatic Brain Injury (TBI) (see Traumatic Brain Injury, [[Traumatic Brain Injury]]): 11.3% of cases
    • Respiratory Disease: 5% of cases
    • Cardiac Arrest (see Cardiac Arrest, [[Cardiac Arrest]]): 1.5% of cases
    • Other: 4.9% of cases

Technique

Definitions

  • Organ Harvest After Death is Confirmed by Circulatory Criteria

Modified Maastricht Classification of Donation After Circulatory Death (Transplant Proc, 1995) [MEDLINE]

  • Type I
    • Description: Dead on Arrival
    • Type of DCD: Uncontrolled DCD
    • Location: ED in a Transplant Center
  • Type II
    • Description: Unsuccessful Resuscitation
    • Type of DCD: Uncontrolled DCD
    • Location: ED in a Transplant Center
  • Type III
    • Description: Anticipated Cardiac Arrest
    • Type of DCD: Controlled DCD
    • Location: ICU and ED
  • Type IV
    • Description: Cardiac Arrest in a Brain Dead Donor
    • Type of DCD: Controlled DCD
    • Location: ICU and ED
  • Type V
    • Description: Unexpected Arrest in ICU Patient
    • Type of DCD: Uncontrolled DCD
    • Location: ICU in a Transplant Center

Warm Ischemic Injury in Controlled DCD

  • Organs from DCD Donors are Exposed to a Longer Duration of Warm Ischemia than Organs from Donation After Brain Death Donors
    • Warm Ischemia Occurs to Some Extent During Preceding Phase of Cardiovascular Collapse: which precedes asystole
    • Warm Ischemia Occurs to the Greatest Degree Between the Onset of Asystole and the Establishment of Cold Organ Perfusion
  • “Functional Warm Ischemia Time”: begins when the systolic blood pressure falls below 50 mm Hg and/or the SaO2 falls below 70% and ends with cold perfusion
    • There is a Defined Interval Between Withdrawal of Care (Most Commonly Reduction/Withdrawal of Ventilation or Extubation) and the Onset of Asystole
    • While Not Universally Agreed Upon, Many Criteria Specify that Death Can Be Confirmed After 5 min of Continuous Cardiopulmonary Arrest (Including Asystole)
  • Ischemic Injury
    • Increases the Risk of Primary Graft Failure
    • Increases Other Complications: such as biliary stricture, etc
  • Interventions Which Might Prevent/Reverse Ischemic Injury
    • Ante-Mortem Interventions
      • Corticosteroids
      • Heparin
      • Vasodilators
    • Consistent Application of Published Schedules for the Prompt Identification of Death
    • Decrease in Time Interval Between Diagnosis of Death and Organ Retrieval: therefore, withdrawal of treatment in the operating room is commonly practiced
    • Post-Mortem Reperfusion of Particularly Vulnerable Organs (Liver, etc)
    • Early Tissue Typing to Allow Prompt Identification and Mobilization of Suitable Recipients

Clinical Outcomes

  • Kidneys Harvested by DCD Have the Same Outcome than Those Harvested by Donation After Brain Death

References

  • Categories of non-heart beating organ donors. Transplant Proc 1995; 27: 2893–4 [MEDLINE]
  • Donation after circulatory death. Br J Anaesth. 2012 Jan;108 Suppl 1:i108-21. doi: 10.1093/bja/aer357 [MEDLINE]