Controlled DCD
Organ donation which follows circulatory arrest. This may be in the context of withdrawal or non-escalation of cardio-respiratory treatments that are no longer in a
patient’s best interests or occurring in a patient already certified dead by brain stem criteria.
· Maastricht Category 3: Awaiting cardiac arrest
· Maastricht Category 4: Cardiac arrest in a brain stem dead donor
Uncontrolled DCD
Organ donation from a patient who has suffered an unexpected death that has been
confirmed on cardio-respiratory grounds.
· Maastricht Category 1: Dead on arrival
· Maastricht Category 2: Unsuccessful resuscitation
· Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient
Categorisation of DCD Donors
· Deceased circulatory death donors should be categorised according to the Maastricht classification to aid research, communication, and audit.
· The functional (or true) warm ischaemic period starts when the systolic blood pressure has a sustained (i.e., at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion.
· Although donor low oxygen saturation (<70%) is a concern and may well be a measure of inadequate organ perfusion and poor outcome, prospective evidence is awaited. The current recommendation is that oxygen saturation below 70% is not used as an indicator of poor outcome or as a reason for non-usage, but that retrieval teams should keep a record of when oxygen saturation falls below 70% in order to allow correlation with graft outcome. (C1)
Diagnosis of Death
· Death is irreversible and should be regarded as a state in which a patient has permanently lost the capacity for consciousness and brain stem function.
· Where cardio-respiratory criteria apply, death can be confirmed following five minutes of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation.
· Where possible, circulatory arrest should be identified by the absence of pulsatile flow on a correctly functioning arterial line or using echocardiography if the expertise is available; or failing that by continuous ECG monitoring.
· DCD organ retrieval protocols should recognise the potential risks around post-mortem interventions that might restore cerebral perfusion. (B1)
· The criteria for the diagnosis of death following loss of circulatory function should not be influenced by the possibility of subsequent organ retrieval. (A1)
Law, Ethics and Donor Consent
· All healthcare professionals should be aware of the complex ethical issues that are associated with donation after circulatory death (DCD) and the transplantation of donated organs. Such professionals should be familiar with the terminology used to describe and discuss the ethics of DCD transplantation.
· Good ethical practice is integral to efforts to facilitate donation and achieve transplantation in the context of DCD. This includes decisions about allocation and consent in relation to both the organ donor and recipient. (B1)
· DCD in the United Kingdom is underpinned by definitions of death that are accepted by society. The principles of donor dignity and non-maleficence must not be compromised in efforts to facilitate donation and transplantation from DCD donors.
· Ethical principles integral to the UK controlled DCD programme must extend to any future uncontrolled DCD programme.
· The BTS Ethics committee is available for guidance and information to support practice in this complex field. (Not graded)
· The UK Donation Ethics Committee is also available to offer guidance and information in this area. (Not graded)
Informing the Recipient
· Providing information, both orally and in writing, for the potential transplant recipient is a requirement for consent and is the responsibility of the multi-disciplinary transplant team. This must be updated and reviewed annually, and the outcome of discussions clearly documented in the patient’s medical record.
· Information should be tailored to the requirements of the potential recipient, recognising that not all patients wish to receive detailed information. However, this must not preclude engagement with the transplant process. (B1)
· The risk-benefit analysis presented to the potential transplant recipient must explain the relative risk for that recipient of remaining on the transplant waiting list compared to that of receiving a DCD organ.
Organ Retrieval
· Treatment withdrawal should ideally be planned for a time when the donor HLA type and virology are known, and the liver and pancreas recipients are in the recipient hospitals.
· Treatment withdrawal in the operating department is associated with shorter warm ischaemic times (asystole periods) than withdrawal on a remote intensive care unit or ward.
· The retrieval team need to be satisfied about the donor details (blood group, past medical history, illness leading to death) before treatment is withdrawn.
· Retrieval teams should be scrubbed in the operating theatre at the point of treatment withdrawal.
· Maastricht 4 donors, where death has been established previously by brain stem criteria, may be given heparin before treatment withdrawal. Death does not need to be reaffirmed once circulatory arrest has occurred.
· The specialist nurse should keep a record at regular intervals of the donor’s haemodynamic parameters following treatment withdrawal.
· Death may be confirmed 5 minutes after complete circulatory arrest. There is no need for a further stand off period following this.
· For controlled donors, retrieval starts by gaining access to a large artery and vein, typically, the right common iliac artery or aorta, and the IVC in the abdomen or right atrium in the chest.
· 20000 units heparin should be added to the first bag of ice-cold preservation solution to be perfused through the aorta.
· A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen activator may be added to the first bag of preservation solution.
· The kidneys may be removed either individually or en bloc.
· The pancreas may be removed either en bloc with the liver or following removal of the liver.
· Cannulae for preservation fluid should never be placed in the SMV or IMV when the pancreas is being retrieved.
· The liver should be recovered using a rapid technique which minimises liver congestion.
· Dual perfusion of both artery and portal vein is essential for recovery of DCD livers for transplantation.
Viability Testing
· Viability testing has a different emphasis depending on the organ being tested.Kidneys from young, controlled DCD donors who have died rapidly after withdrawal of support, undergone rapid laparotomy, aortic cannulation, perfusion and venous exsanguination will be expected to work promptly if cold ischaemia is minimised and the kidneys appear well perfused on retrieval. This is deemed to be sufficient viability testing in this case. The role of machine perfusion to ‘improve’ the kidney is controversial.
· For uncontrolled DCD or when perfusion of the kidneys on retrieval is poor, using parameters such as high resistance during machine perfusion or high enzyme levels within the perfusate may indicate increased cellular damage and an increased risk of primary non function but this is not universally accepted
· Viability testing for the liver and pancreas has not been fully established.
· Testing the graft function of warm perfused organs prior to transplantation is considered the ‘gold’ standard. However, warm perfusion of such organs is difficult to perform and usually impractical.
· Warm viability testing of donor lungs using ex-vivo lung perfusion is the exception. The test is performed by ventilating the lungs and perfusing them with Steen solution with or without added red blood cells. The ability of the ventilated lung to oxygenate the perfusate is assessed together with lung compliance, airway resistance and tidal volume via the ventilator.
Immunosuppression
· No definitive data suggest significant benefit from any particular immunosuppressive regimen in the context of DCD organs.
· Following DCD kidney transplantation, there is increased risk of delayed graft function due to DCD injury. Induction therapy with mono- or polyclonal antibodies may be used to reduce the risk of clinically unrecognised acute rejection prior torecovery from DCD injury.
· Induction therapy is often combined with delayed introduction or reduced intensity of
calcineurin inhibition to limit the incidence and duration of delayed graft function.
· Following liver transplantation, consider renal sparing regimens with delayed CNI introduction. Induction and T cell depletion may also be considered, but risk and benefit must be balanced with choice of regimen.
· Following heart and lung transplantation, there is no evidence to use a different regimen from that used in DBD transplantation.
Kidney
· Individuals with advanced or end-stage chronic kidney disease, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donors.
· The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability.
· Units undertaking cold machine perfusion of DCD kidney transplants prior to implantation should collaborate to standardise the prospective collection of data to enable aggregated analyses of outcomes.
· None of the dynamic characteristics of machine perfusion, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems – alone or in combination – have sufficient predictive value to mandate organ discard.
· Such assessment may, however, help determine when kidneys should be considered for dual transplantation.
· Long term outcomes of DCD recipients are like those of DBD recipients and the allocation system for DCD and DBD organs should be similar. Nevertheless, it is recognised that DCD kidneys appear to be more susceptible to cold ischaemia, and the proposed national allocation scheme should take this into account.
· The incidence of delayed graft function is increased in DCD recipients, and this should be discussed with the patient prior to transplantation.
· Antibody induction therapy should be considered as part of the initial immunosuppressive regimen for recipients of DCD kidneys.
· Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants.
· Graft outcome is more closely related to whether a transplant is ECD or SCD than whether the mode of donation is DCD or DBD.
· Prospective data are required to determine whether the impact of extended criteria donation (ECD) is different in DCD and DBD donors and whether different thresholds for organ use may be required.
·
Mohammed Sobair
2 years ago
Categorization of DCD Donors:
Controlled DCD:
Organ donation, which follows circulatory arrest.
· Maastricht Category 3: Awaiting cardiac arrest.
· Maastricht Category 4: Cardiac arrest in a brain stem dead donor. Uncontrolled DCD:
Organ donation from a patient who has suffered an unexpected death.
Maastricht Category 1: Dead on arrival
· Maastricht Category 2: Unsuccessful resuscitation
· Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient. Good ethical practice:
Consent in relation to both the organ donor and recipient.
Maintain donor dignity and non-maleficence. Organ Retrieval: To shorten ischemia time, retrieve done when:
Donor HLA type and virology are known, and the liver and pancreas recipients are in the recipient in the hospital.
The donor details (blood group, past medical history, illness leading to death) before treatment is withdrawn.
Retrieval teams should be scrubbed in the operating theatre.
Maastricht 4 donors, where death has been established previously by brain stem criteria, may be given heparin before treatment withdrawal. Death does not need to be reaffirmed once circulatory arrest has occurred. · The specialist nurse should keep a record at regular intervals of the donor’s hemodynamic parameters following treatment withdrawal. · Death may be confirmed 5 minutes after complete circulatory arrest.
· For controlled donors, retrieval starts by gaining access to a large artery and vein, typically the right common iliac artery or aorta, and the IVC in the abdomen or right atrium in the chest.
· 20000 units heparin should be added to the first bag of ice-cold preservation solution to be perfused through the aorta. (Not graded) · A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen activator may be added to the first bag of preservation solution. (B3) · The kidneys may be removed either individually or en bloc. Viability Testing:
Uncontrolled DCD or when perfusion of the kidneys on retrieval is poor, using parameters such as high resistance during machine perfusion or high enzyme levels within the perfuse may indicate Immunosuppression:
Induction therapy with mono- or polyclonal antibodies may be used to reduce the risk of clinically unrecognized acute rejection prior to recovery from DCD injury.
Induction therapy is often combined with delayed introduction or reduced intensity of Calcineurin inhibition to limit the incidence and duration of delayed graft function. Kidney:
· Individuals with advanced or end-stage chronic kidney disease, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donor.
Graft outcome is more closely related to whether a transplant is ECD or SCD than whether the mode of donation is DCD or DBD.
use of donors with functional warm ischemic time >2 hr. or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability.
· Units undertaking cold machine perfusion of DCD kidney transplants prior to implantation should collaborate to standardize the prospective collection of data to enable aggregated analyses of outcomes.
· None of the dynamic characteristics of machine perfusion, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems – alone or in combination – has sufficient predictive value to mandate organ discard.
· Such assessment may, however, help determine when kidneys should be considered for dual transplantation.
· Long-term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. Nevertheless, it is recognized that DCD kidneys appear to be more susceptible to cold ischemia, and the proposed national allocation scheme should take this into account.
· The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation.
· Antibody induction therapy should be considered as part of the initial immunosuppressive regimen for recipients of DCD kidneys.
· Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants. · Graft outcome is more closely related to whether a transplant is ECD.
Comments:
This guideline show road map to DCD and all facilities should be arranged before retrieving of organs. Ischemia time should be shorten.
Hamdy Hegazy
2 years ago
Please provide a summary of these guidelines
Types of Deceased donors: After brain death and after cardiac death Donors after Brain Death: manifested with coma, unresponsiveness, absent brain stem reflexes, absent corneal reflex, absent pupillary reflex, absent pharyngeal and laryngeal reflexes and apnea. It can be confirmed with neuroradiological tests, and EEG. Donors after Cardiac Death: They require cardiovascular care which include fluids, vasopressors, oxygenation, control DI with desmopressin, vasopressin, blood sugar control, thermal control and corticosteroids to reduce the systemic inflammatory response. Ethical principles and transplantation: Criteria of death (Brain and cardiac) should be explained to donors’ families and next of kin. The recipient should be counselled by the transplant team and understand criteria for extended criteria donation and possibility of dual kidney transplantation. Exclusion criteria of donation like cortical necrosis. Long ischemia time above 2 hours reduces the organ survival. How to keep donor’s organs viable till organ retrieval and transplantation happens. How to prepare the recipient and to manage the peri-operative period. Plans for induction and maintenance immunosuppression.
Wael Jebur
2 years ago
The guideline is addressing variable issues linked to organs donation after circulatory death DCD. This field was undermined by donation after brain death DBD, when criteria to define brain death was concluded afterwards. However, in an endeavor to circumvent the shortfall of donated organs, DCD was reconsidered strongly and categorized stringently to facilitate controlled donation.
Maastricht classification elucidate two types of DCD, controlled and uncontrolled.
Controlled DCD:
This is considered when patient declared dead after cardiac in the setting of withdrawal or non-escalation of cardiorespiratory support as its in best benefit of the patient. This scenario tagged as Category 3.
The second type of controlled DCD is cardiac arrest in brain stem dead patient. category 4.
Uncontrolled DCD: donation from a patient who suffered non-expected death
Category 1: dead on arrival
Category 2: failed resuscitation
category 5: unexpected cardiac arrest in critically ill patient.
Functional (true) warm ischemia time reflect a duration started by sustained drop of systolic blood pressure (more than 2 minutes) below 50 mm hg and extend until cold in situ perfusion.
Oxygen saturation below 70% is debatably linked to adverse allograft outcome.
Death is confirmed after 5 minutes of cardiorespiratory arrest. Confirmation of cardiac death by absent of pulsation in central blood line, Echo cardiography or continuous ECG monitoring.
Organ retrieval:
Has to be planned when donor HLA and virology status is known. Liver and pancreas recipients have to be in hospital.
technical details are elaboratively explained by the guideline, including assessment of viability.
Machine perfusion of cold perfusate can help assessing perfusion of organs. Increased resistance and high concentration of enzymes in perfusate are consistant with increasing cellular damage and primary non-function.
Amit Sharma
2 years ago
1. Please provide a summary of these guidelines.
The guidelines deal with organ donation after circulatory death (DCD). They define the warm ischemia time and categorize the DCD donors.
DCD donors are categorized in 5 Maastricht categories. Controlled DCD includes category 3 (awaiting cardiac arrest) and 4 (cardiac arrest in a brainstem donor). Uncontrolled DCD includes category 1 (dead on arrival), 2 (unsuccessful resuscitation), and 5 (unexpected cardiac arrest in a critically ill patient).
The warm ischemia time starts when the systolic blood pressure (SBP) reduces to <50 mmHg for >2 minutes and continues till the onset of cold in situ perfusion.
Diagnosis of death is established by 5 minutes of continuous cardiorespiratory arrest (by ECG, ECHO or absence of pulsatile flow on arterial line).
The ethical considerations and law related to donor consent has been known to the healthcare professionals and should be adhered to.
The recipient should be informed verbally and in written about the donor status while taking consent for transplant.
The process of organ retrieval involves treatment withdrawal (preferred after HLA and virology reports, in the operating department) and organ retrieval during which the hemodynamic parameters are continuously recorded.
With respect to kidney, the recommendations include using induction therapy and delaying or reducing CNI dose to decrease risk of DGF.
The potential donor should not have advanced or end stage kidney disease, or cortical necrosis on kidney biopsy. Donors with warm ischemia time >2 hours or absent BP for >30 minutes (>20 minutes is the time limit according to registry data) should be used only in experimental protocols. Kidney biopsy scoring system, perfusion pressure dynamic characteristics and perfusate effluent biochemical analysis (intracellular enzyme levels) can help in making a decision regarding dual transplant. There is no clear evidence to use machine perfusion in DCD kidney transplantation.
Although DCD kidneys are more susceptible to cold ischemia and have increased incidence of DGF and primary non function, their long-term outcomes for standard criteria donors (SCD) are similar to donation after brain death (DBD) kidneys. The graft outcomes depend on quality of donor, whether the donor is SCD or extended criteria donor (ECD) rather than mode of donation, being DBD or DCD. Cold ischemia time >12 hours and increased age of donor and recipient have worse outcomes.
CARLOS TADEU LEONIDIO
2 years ago
1 – INTRODUTION
Initially, all organs for transplantation were donated after circulatory death (DCD), but they were quickly replaced by organs donated after brain death (DBD), which had a major impact on the number of donations. However, after a few years, the average time on the waiting list rose again and so the use of DCD organs was again evaluated.
In order to optimize the use of DCD, it is necessary to establish common practices and accepted protocols that allow the safe sharing of DCD, as improved immunosuppression, improved organ recovery and implantation, and enhanced peri- and post-operative care mean that the outcomes from DCD organs compare favorably with those from DBD organs. For this purpose, guidelines have been created and revised.
2 – METHODOLOGY
The first guidelines helped to establish the main points of donation and transplantation after circulatory death, but with the growth in the number of donations and the need to explore the use of DCD organs in other areas (besides the kidney) it was decided to review the first protocol. A systematic review of the relevant literature and synthesis of the available evidence was undertaken by selected clinical experts. This was followed by peer group appraisal and expert review. Draft proposals were amended by an editorial committee and appropriate levels of evidence were added to the recommendations at an Editors and Authors’ meeting held in London in July 2011. Wider discussion with the transplant community was undertaken through ‘face to face’ consultation at a BTS consensus meeting in York in October 2011. This was attended by transplant surgeons and physicians, intensivists, Clinical Leads in Organ Donation (CL-ODs), Specialist Nurses in Organ Donation (SN-ODs), and representatives of NHS Blood and Transplant (NHSBT). The draft of the document was placed on the BTS website in March 2013 for a period of open consultation, to which patient and transplant groups were actively encouraged to contribute. The final document was posted in July 2013.
3 – DEFINITIONS
Controlled DCD
Organ donation which follows circulatory arrest. This may be in the context of withdrawal or non-escalation of cardio-respiratory treatments that are considered to be no longer in a patient’s best interests, or occurring in a patient already certified dead by brain stem criteria.
– Maastricht Category 3: Awaiting cardiac arrest
– Maastricht Category 4: Cardiac arrest in a brain stem dead donor
Uncontrolled DCD
Organ donation from a patient who has suffered an unexpected death that has been confirmed on cardio-respiratory grounds.
– Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient
4 – DIAGNOSIS OF DEATH
Death can be diagnosed When:
– Asystole has occurred, and
– Brain function has been lost, and
– The possibility of spontaneous return of cardiac function has passed;
– There will be no subsequent intervention that restores cerebral perfusion whilst the brain remains responsive to such restoration.
E é definido por critérios clínicos.
5 – LAW, ETHICS AND DONOR CONSENT
All healthcare professionals should be aware of the complex ethical issues that
are associated with donation after circulatory death (DCD), pois as decisions about allocation and consent in relation to both the organ donor and recipient and the principles of donor dignity and non-malfeasance must not be compromised in efforts
6 – IMUNOSSUPRESSION
– There is no evidence of a choice of immunosuppressants that is better for DCD organ recipients;
– DCD kidney transplatation has increased risk of delayed graft function due to DCD injury. Induction therapy with mono- or polyclonal antibodies may be used to reduce the risk of clinically unrecognised acute rejection prior to recovery from DCD injury and calcineurin inhibition to limit the incidence and duration of delayed graft function.
7 – KIDNEY
– Long term outcomes of DCD recipients are similar to those of DBD recipientes and the allocation system for DCD and DBD organs should be similar. Nevertheless, it is recognised that DCD kidneys appear to be more susceptible to cold ischaemia, and the proposed national allocation scheme should take this into account.
– The incidence of delayed graft function is increased in DCD recipientes.
– Graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD.
– Prospective data are required to determine whether the impact of expanded criteria donation (ECD) is different in DCD and DBD donors and whether different thresholds for organ use may be required.
rindhabibgmail-com
2 years ago
The guidelines discuss in detail about the DCD, thoroughly describe the categorization of DCD donors, by Maastricht category 1 to V, laws, ethics and consent, risk of infection, risk stratification after confirmation for cold and warm ischemia time, probability of graft failure
organ retrieval criteria, allograft viability test, peri and post transplantation immunosuppression regime for kidney, liver, pancreas, its islets, lungs and heart.
Abdul Rahim Khan
2 years ago
These guidelines are depicting the pathway for cadaveric kidney transplant and outline a platform to organise the transplant post DCD.
This is by adopting Maastricht classification.
DCD is divided into five subclasses.
This also includes controlled death of two subtypes:
Type 111
Cardiac arrest following withdrawl of life sustaining treatments but not considered to be brain dead
Type 4
Awaitingg cardiac arrest who is alrady brain stem dead
DCD also includes patients who had cardiac arrest in different settings
Category 1
Patient reached dead with cardiac arrest outside hospital. For donation cardiac arrest has to be witnessed and CPR would have been continued till reaching hospital.
Category 2
Declared dead in ER after failed resuscitation
Category V
Death in critically ill which was not expected.
Hussam Juda
2 years ago
Categorisation of Deceased circulatory death (DCD) Donors
· DCD donors should be categorised according the Maastricht classification to aid research, communication and audit. (A1)
· The functional (or true) warm ischaemic period starts when the systolic blood pressure is <50 mmHg for at least 2 minutes) fall below and extends up to the onset of cold in situ perfusion. (B1)
· SaO2 < 70% is not used as an indicator of poor outcome, but a record of SaO2 < 70%, should be saved
Controlled DCD: Organ donation which follows circulatory arrest. This includes:
· Maastricht Category 3: Awaiting cardiac arrest
· Maastricht Category 4: Cardiac arrest in a brain stem dead donor
Uncontrolled DCD:Organ donation from a patient who has suffered an unexpected death that has been confirmed on cardio-respiratory grounds. Includes:
· Maastricht Category 1: Dead on arrival
· Maastricht Category 2: Unsuccessful resuscitation
· Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient
Diagnosis of Death
· Death is a permanent loss of capacity for consciousness and brain stem function. (A1)
· Where cardio-respiratory criteria apply, death can be confirmed following five minutes of continuous cardio-respiratory arrest
· Confirm circulatory arrest with arterial line, or by echocardiography; or failing that by continuous ECG monitoring. (B1)
· DCD organ retrieval protocols should recognise the potential risks around post mortem interventions that might restore cerebral perfusion. (B1)
· The possibility of organ donation should not affect the criteria for the diagnosis of death
Law, Ethics and Donor Consent
· All healthcare professionals should be familiar with the terminology used to describe and discuss the ethics of DCD transplantation. (B1)
· Good ethical practice is essential to facilitate donation and achieve transplantation in the context of DCD. This includes decisions about allocation and consent in relation to both the organ donor and recipient. (B1)
· DCD in the United Kingdom is supported by definitions of death that are accepted by society. The principles of donor dignity and non-maleficence must not be compromised in efforts to facilitate donation and transplantation from DCD donors. (B1)
· Ethical principles integral to the UK controlled DCD programme must extend to any future uncontrolled DCD programme. (B1)
· The BTS Ethics committee is available for guidance and information to support practice in this complex field. (Not graded)
· The UK Donation Ethics Committee is also available to offer guidance and information in this area. (Not graded) Informing the Recipient
· Providing information, both orally and in writing, for the potential transplant recipient is a requirement for consent and is the responsibility of the multi-disciplinary transplant team. (B1)
· Information should be fitted the requirements of the potential recipient, but not all patients interested with detailed information.
· The recipient should be informed about the relative risk for that recipient of remaining on the transplant waiting list compared to that of receiving a DCD organ.
Organ Retrieval
· Treatment withdrawal should ideally be planned for a time when the donor HLA type and virology are known, and the liver and pancreas recipients are in the recipient hospitals. (C1)
· Treatment withdrawal in the operating department is associated with shorter warm ischaemic times (asystolic periods) than withdrawal on a remote intensive care unit or ward. (C1)
· The retrieval team need to be satisfied about the donor details (blood group, past medical history, illness leading to death) before treatment is withdrawn. (A1)
· Retrieval teams should be scrubbed in the operating theatre at the point of treatment withdrawal. (B1)
· Maastricht 4 donors, where death has been established previously by brain stem criteria, may be given heparin before treatment withdrawal. Death does not need to be reaffirmed once circulatory arrest has occurred. (A1)
· The specialist nurse should keep a record at regular intervals of the donor’s haemodynamic parameters following treatment withdrawal. (C1)
· Death may be confirmed 5 minutes after complete circulatory arrest. There is no need for a further stand off period following this. (A1)
· For controlled donors, retrieval starts by gaining access to a large artery and vein, typically the right common iliac artery or aorta, and the IVC in the abdomen or right atrium in the chest. (Not graded)
· 20000 units heparin should be added to the first bag of ice-cold preservation solution to be perfused through the aorta. (Not graded)
· A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen activator may be added to the first bag of preservation solution. (B3)
· The kidneys may be removed either individually or en bloc. (Not graded)
Viability Testing
· Kidneys from young controlled DCD donors who have died rapidly after withdrawal of support, undergone rapid laparotomy, aortic cannulation, perfusion and venous exsanguination will be expected to work promptly if cold ischaemia is minimised and the kidneys appear well perfused on retrieval.
· For uncontrolled DCD or when perfusion of the kidneys on retrieval is poor, using parameters such as high resistance during machine perfusion or high enzyme levels within the perfusate may indicate increased cellular damage and an increased risk of primary non function but this is not universally accepted (C1)
· Testing the graft function of warm perfused organs prior to transplantation is considered the ‘gold’ standard, but it is impractical. (C2) Immunosuppression
· No definitive data suggest significant benefit from any particular immunosuppressive regimen in the context of DCD organs. (C1)
· Following DCD kidney transplantation, there is increased risk of delayed graft function due to DCD injury. Induction therapy with mono- or polyclonal antibodies may be used to reduce the risk of clinically unrecognised acute rejection prior to recovery from DCD injury. (B1)
· Induction therapy is often combined with delayed introduction or reduced intensity of calcineurin inhibition to limit the incidence and duration of delayed graft function. (C2)
· Following liver transplantation, consider renal sparing regimens with delayed CNI introduction. Induction and T cell depletion may also be considered, but risk and benefit must be balanced with choice of regimen. (C2)
Kidney
· Individuals with advanced or ESKD, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donors. (B1)
· The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability. (B2)
· Units undertaking cold machine perfusion of DCD kidney transplants prior to implantation should collaborate to standardise the prospective collection of data to enable aggregated analyses of outcomes. (A2)
· None of the dynamic characteristics of machine perfusion, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems, have sufficient predictive value to mandate organ discard. (A2)
· Such assessment may, however, help determine when kidneys should be considered for dual transplantation. (B2)
· Long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. However, DCD kidneys more prone to cold ischaemia. (B2)
· The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation. (A1)
· Antibody induction therapy should be considered as part of the initial immunosuppressive regimen for recipients of DCD kidneys. (B1)
· Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants. (A1)
· Graft outcome is more closely related to whether a transplant is ECD or SCD than whether the mode of donation is DCD or DBD. (B2)
· Prospective data are required to determine whether the impact of extended criteria donation (ECD) is different in DCD and DBD donors and whether different thresholds for organ use may be required. (A1)
Abhijit Patil
2 years ago
Classification of DCD
Controlled DCD
Maastricht Category 3: Awaiting cardiac arrest
· Maastricht Category 4: Cardiac arrest in a brain stem dead donor
Uncontrolled DCD
· Maastricht Category 1: Dead on arrival
· Maastricht Category 2: Unsuccessful resuscitation
· Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient
Summary of guidelines:
The functional (or true) warm ischaemic period starts when the systolic blood pressure has a sustained (i.e., at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion.
Oxygen saturation below 70% should not be used as an indicator of poor outcome or as a reason for non-usage (but a record of the same should be maintained)
Where cardio-respiratory criteria apply, death can be confirmed following five minutes of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation.
Circulatory arrest –
absence of pulsatile flow on a correctly functioning arterial line
use of echocardiography
continuous ECG monitoring.
The risk-benefit analysis presented to the potential transplant recipient must explain the relative risk for that recipient of remaining on the transplant waiting list compared to that of receiving a DCD organ
The retrieval team should know all the donor details (blood group, past medical history, illness leading to death) before treatment is withdrawn
Treatment withdrawal in the operating department is associated with shorter warm ischaemic times (asystolic periods)
For controlled donors, retrieval starts by gaining access to a large artery and vein, typically the right common iliac artery or aorta, and the IVC in the abdomen or right atrium in the chest.
20 000 units heparin should be added to the first bag of ice-cold preservation solution to be perfused through the aorta.
No significant change in immunosuppressive regimen for DCD organs.
Increased risk of delayed graft function due to DCD injury is present so, induction therapy with mono- or polyclonal antibodies may be used to reduce the risk of clinically unrecognised acute rejection prior to recovery from DCD injury.
Calcineurin induction therapy should be delayed to limit the incidence and duration of delayed graft function
Individuals with advanced or end-stage chronic kidney disease, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donors.
The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be considered experimental.
None of the dynamic characteristics of machine perfusion, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems – alone or in combination – have sufficient predictive value to mandate organ discard.
Long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar.
But, it should be taken into account that DCD kidneys are more susceptible to cold ischemia.
Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants.
Graft outcome is more closely related to whether a transplant is ECD or SCD than whether the mode of donation is DCD or DBD.
Last edited 2 years ago by Abhijit Patil
Huda Al-Taee
2 years ago
Categorisation of DCD Donors:
Deceased circulatory death donors should be categorised according to the Maastricht classification to aid research, communication and audit.
The functional warm ischaemic period starts when the systolic blood pressure has a sustained fall below 50 mmHg and extends up to the onset of cold in situ perfusion.
The current recommendation is that oxygen saturation below 70% is not used as an indicator of poor outcome or as a reason for non-usage, but that retrieval teams should keep a record of when oxygen saturation falls below 70% in order to allow correlation with graft outcome.
Diagnosis of Death:
Death is irreversible and should be regarded as a state in which a patient has permanently lost the capacity for consciousness and brain stem function.
death can be confirmed following five minutes of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation.
circulatory arrest should be identified by the absence of pulsatile flow on a correctly functioning arterial line, or by the use of echocardiography if the expertise is available, or by failing by continuous ECG monitoring.
DCD organ retrieval protocols should recognise the potential risks around post-mortem interventions that might restore cerebral perfusion.
The criteria for the diagnosis of death following the loss of circulatory function should not be influenced by the possibility of subsequent organ retrieval.
Law, Ethics and Donor Consent:
All healthcare professionals should be aware of the complex ethical issues that are associated with donation after circulatory death and the transplantation of donated organs.
Good ethical practice is integral to efforts to facilitate donation and achieve transplantation in the context of DCD.
DCD in the United Kingdom is underpinned by definitions of death that are accepted by society. The principles of donor dignity and non-maleficence must not be compromised in efforts to facilitate donation and transplantation from DCD donors.
Ethical principles integral to the UK-controlled DCD programme must extend to any future uncontrolled DCD programme.
The BTS Ethics committee is available for guidance and information to support practice in this complex field.
The UK Donation Ethics Committee is also available to offer guidance and information in this area.
Informing the Recipient:
Providing information for the potential transplant recipient is a requirement for consent and is the responsibility of the multi-disciplinary transplant team.
Information should be tailored to the requirements of the potential recipient.
The risk-benefit analysis presented to the potential transplant recipient must explain the relative risk for that recipient of remaining on the transplant waiting list compared to that of receiving a DCD organ.
Organ Retrieval:
Treatment withdrawal should ideally be planned for a time when the donor HLA type and virology are known.
Treatment withdrawal in the operating department is associated with shorter warm ischaemic times than withdrawal on a remote intensive care unit or ward.
The retrieval team need to be satisfied with the donor details (blood group, past medical history, illness leading to death) before treatment is withdrawn.
Retrieval teams should be scrubbed in the operating theatre at the point of treatment withdrawal.
Maastricht 4 donors, may be given heparin before treatment withdrawal. Death does not need to be reaffirmed once a circulatory arrest has occurred.
The specialist nurse should keep a record at regular intervals of the donor’s haemodynamic parameters following treatment withdrawal.
Death may be confirmed 5 minutes after complete circulatory arrest. There is no need for a further standoff period following this.
For controlled donors, retrieval starts by gaining access to a large artery and vein, typically the right common iliac artery or aorta, and the IVC in the abdomen or right atrium in the chest.
20000 units of heparin should be added to the first bag of ice-cold preservation solution to be perfused through the aorta.
A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen activator may be added to the first bag of preservation solution.
The kidneys may be removed either individually or en bloc.
The pancreas may be removed either en bloc with the liver, or following removal of the liver.
Cannulae for preservation fluid should never be placed in the SMV or IMV when the pancreas is being retrieved.
The liver should be recovered using a rapid technique which minimises liver congestion.
Dual perfusion of both artery and portal vein is essential for the recovery of DCD livers for transplantation.
Viability Testing:
Viability testing has a different emphasis depending on the organ being tested.
For uncontrolled DCD or when perfusion of the kidneys on retrieval is poor, using parameters such as high resistance during machine perfusion or high enzyme levels within the perfusate may indicate increased cellular damage and an increased risk of primary non-function but this is not universally accepted.
Viability testing for the liver and pancreas has not been fully established.
Testing the graft function of warm perfused organs prior to transplantation is considered the ‘gold’ standard.
Warm viability testing of the donor’s lungs using ex-vivo lung perfusion is the exception. The test is performed by ventilating the lungs and perfusing them with Steen solution with or without added red blood cells. The ability of the ventilated lung to oxygenate the perfusate is assessed together with lung compliance, airway resistance and tidal volume via the ventilator.
Immunosuppression:
No definitive data suggest significant benefit from any particular immunosuppressive regimen in the context of DCD organs.
Following DCD kidney transplantation, there is an increased risk of delayed graft function due to DCD injury. Induction therapy with mono- or polyclonal antibodies may be used to reduce the risk of clinically unrecognised acute rejection prior to recovery from DCD injury.
Induction therapy is often combined with a delayed introduction or reduced intensity of calcineurin inhibition to limit the incidence and duration of delayed graft function.
Following liver transplantation, consider renal-sparing regimens with delayed CNI introduction. Induction and T cell depletion may also be considered, but risk and benefit must be balanced with the choice of regimen.
Following heart and lung transplantation, there is no evidence to use a different regimen from that used in DBD transplantation.
Kidney:
Individuals with advanced or end-stage chronic kidney disease, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donors.
The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to protocols which attempt to resuscitate organ viability.
Units undertaking cold machine perfusion of DCD kidney transplants prior to implantation should collaborate to standardise the prospective collection of data to enable aggregated analyses of outcomes.
None of the dynamic characteristics of machine perfusion, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems – alone or in combination – have sufficient predictive value to mandate organ discard.
Such assessment may, however, help determine when kidneys should be considered for dual transplantation.
Long-term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. Nevertheless, it is recognised that DCD kidneys appear to be more susceptible to cold ischaemia, and the proposed national allocation scheme should take this into account.
The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation.
Antibody induction therapy should be considered as part of the initial immunosuppressive regimen for recipients of DCD kidneys.
Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants.
Graft outcome is more closely related to whether a transplant is ECD or SCD than whether the mode of donation is DCD or DBD.
Prospective data are required to determine whether the impact of extended criteria donation is different in DCD and DBD donors and whether different thresholds for organ use may be required.
Liver:
Livers transplanted from Maastricht 3 DCD donors are a useful resource and should be used where deemed safe.
Short and medium-term outcome appear inferior to livers from DBD donors, with more PNF and ischaemic cholangiopathy and a higher rate of re-transplantation.
DCD and DBD subjects transplanted with MELD >30 or on organ-perfusion support have similar graft survival. However, there is no survival benefit when DCD livers are transplanted in patients with MELD ≤30 or in those not receiving organ-perfusion support.
The incidence of biliary stricture is significantly lower when a low-viscosity solution is used to cold flush the aorta.
DCD liver use should be matched with the need of the recipients on the waiting list, with allocation to those who will have the greatest transplant benefit.
The outcome of DCD liver transplantation is improved with short CIT, which is best kept to under 8hrs.
A favourable outcome can be expected if an ‘ideal’ DCD liver is transplanted. An ‘ideal’ DCD liver donor is <50 years old, has a functional WIT time <20 min, a shorter CIT <10 hr, and <10% steatosis.
Using more restrictive DCD Donor criteria including BMI <29 kg/m2 and a functional WIT <20 min (SAP <50 mmHg), equivalent 1 and 3-year patient and graft survival rates can be achieved for both DCD and DBD liver transplants.
Long FWIT is associated with an increased risk of ischaemic cholangiopathy.
Potential recipients of DCD liver grafts should be informed of the potential risk and be offered the choice to refuse such organs prior to transplant listing.
DCD grafts are best avoided in recipients of re-transplantation.
DCD liver grafts should be ideally used in younger recipients with age <60 years.
Factors predictive of graft failure are age ≥55 years, male sex, African–American race, HCV positivity, metabolic liver disorder, transplant MELD ≥ 35, hospitalisation at transplant, and the need for life support at transplant. Recipient predictors of mortality are age ≥55 years, hospitalisation at transplant, and re-transplantation.
A national audit should be performed to identify factors for non-utilisation of extended criteria donors to establish the incidence of cholangiopathy under ideal circumstances, identify more suitable risk factors, identify further subgroups of DCDs that could potentially be utilised, allow for medical interventions to be evaluated, and provide qualitative data regarding centre-specific performance.
Pancreas:
Although DCD organs can be used for isolated pancreas transplants in pancreas transplant alone, pancreas after kidney or simultaneous pancreas-kidney transplants, available evidence and current practice are increasingly in favour of SPK recipients.
Pancreas transplants from DCD donors are at increased risk of reperfusion pancreatitis and thrombosis and this may be exacerbated by prolonged cold ischaemia time and higher donor BMI. Ideal donors should be <60 years old and have BMI <30 kg/m2.
The pancreas team should stand down after a functional warm ischaemia time (systolic BP <50 mmHg and/or oxygen saturation of 70%) of 60 minutes.
A primary focus of any DCD pancreas transplant should be to achieve the shortest possible cold ischaemic time.
There is little evidence regarding recipient risk factors but it is logical to assume that higher recipient BMI, age, cardiovascular morbidity, and technical surgical factors may contribute to poorer outcomes.
Reported outcomes for DCD donor pancreas transplantation are broadly similar to those of DBD donors, although considerably greater donor selection is likely to have taken place.
Graft loss from thrombosis is twice as common in DCD as in DBD pancreas transplants.
Selected transplant centres will have built up a volume of expertise with DCD extended criteria pancreas grafts and these guidelines should not restrict the innovative but safe practice of pancreas transplantation.
Pancreatic islets:
Selection criteria for recipients of islets from DCD donors should be the same as for DBD donors.
Organs from DCD donors for islet isolation and transplantation should be allocated through the National Pancreas Allocation Scheme.
The long-term outcome of islet transplantation from DCD donors has been satisfactory in the UK but the cohort is small. Further audit and research is required.
Satisfactory functional islet preparations can be routinely obtained from DCD donors.
Lung:
The donor selection criteria for lung DCD should be the same as for DBD.
All patients on the lung transplant waiting list have the potential to receive DCD lungs.
DCD lungs should not be regarded as extended or marginal. Transplant outcome and quality is at least similar to DBD organs.
Perform antegrade and retrograde flush perfusion at the time of lung retrieval.
Pre-transplant ex vivo lung perfusion (EVLP) is advised in case of uncertain graft performance to safely extend donor and procedural criteria (long warm ischaemia, bad flush, clots).
Acceptance criteria on EVLP may include measures of pulmonary compliance, vascular resistance, and gas exchange.
Heart:
In the UK, heart transplantation from DCD donors is currently NOT standard of care. Because of a number of ethical issues, the use of DCD hearts is not currently recommended.
Huda Mazloum
2 years ago
In DCD :
● It is better to avoid in recipients of re-transplantation
● DCD liver grafts should be used in younger recipients with age <60 years.
● Factors predictive of graft failure are:
* age ≥55 years
* male sex
* African–American race
* HCV positivity
* metabolic liver disorder
* transplant MELD ≥ 35
* hospitalisation at transplant
* need for life support at transplant.
● Recipient predictors of mortality are
* age ≥55 years
* hospitalisation at transplant
* re-transplantation.
● Use of DCD hearts is not currently recommended.
● Warm ischaemic period starts when the SBP has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion.
● Agonal period: the time from treatment withdrawal to circulatory arrest.
● primary warm ischaemic time: the time from circulatory arrest to the perfusion of the organs with cold preservation solution in situ.
● functional (or true) warm ischaemic period: starts when the systolic blood pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in sit perfusion.
● Three concepts must be considered in the process of deceased (DBD or DCD) donor organ allocation
▪︎Equity: all those listed for a transplant have equal opportunity to receive an organ
▪︎Efficiency: ensures minimal waste of organs
▪︎Utility: distribution of organs maximises benefit to recipients, “the greatest good for the most people”
● Avoid transplanting lower risk recipients with DCD organs or those from any other higher risk donor
● good organs were not ‘wasted’ on higher risk recipients.
● Providing information, both orally and in writing, for the potential transplant recipient is a requirement for consent and is the responsibility of the multidisciplinary transplant team. This must be updated and reviewed annually
● The risk benefit analysis must explain the relative risk for that recipient of remaining on the transplant waiting list compared to that of receiving a DCD organ.
● donor blood and immunology laboratory and a pre-emptive cross match
● it is desirable that the lung, liver and pancreas recipients are all in the recipient hospital when treatment withdrawal
● Uncontrolled DCD follows an unexpected cardiac arrest in which a decision is made that continued resuscitation measures will not succeed in saving the patient’s life.
● To minimise warm ischaemic injury treatment withdrawal is best done in the operating theatre
● Three contingencies need to be considered:
1. A clinician who is not amember of trasplant team must be available throughout the period of withdrawal to enable prompt confirmation of death when it occurs.
2. The next of kin must be given the opportunity to be present before and during treatment withdrawal and until death is confirmed.
3. If the potential donor remains alive beyond the period of time that the retrieval
surgeons deem appropriate (a minimum of 3 hours), it is not suitable to keep him/her
in the operating department.
Since death is inevitable, the patient must be transferred to the most appropriate alternative accommodation,
● The retrieval team/s are responsible for reviewing the potential donor’s hospital/medical notes
● Mode of withdrawal of life sustaining treatment
** confirmation irreversible brain injury
** fulfilled a diagnosis of brain stem death.
** declaration of futility with a written
** opinion from the neurologist or neurosurgeon
** withdraw life-sustaining by supervising clinician includes ventilatory support and inotrope infusions and (ECMO) support.
** Get consent/authorisation by the patient in life, or by the next of kin at this time
● If the donor is Maastricht type 4 and death has previously been certified by brain stem criteria, the donor can be heparinised with 20 000 units heparin immediately before treatment withdrawal. This is not permitted for type 1, 2 or 3 DCD donors.
● Once circulatory arrest occurs, five minutes must elapse without any evidence of resumption of circulation before death may be verified
● The most important consideration during the withdrawal phase is the perfusion of the organs;
● a prolonged withdrawal phase is unlikely to be harmful as long as the blood pressure is maintained and urine output continues.
● Assessment the FWIT
** A different Bp threshold which vary with age and baseline BP blood pressure
** The oxygen saturation
● Individuals with advanced or end-stage chronic kidney disease, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donors
● The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability
● Units undertaking cold machine perfusion of DCD kidney transplants prior to implantation should collaborate to standardise the prospective collection of data to enable aggregated analyses of outcomes.
● None of perfusion pressure dynamic characteristics, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems – alone or in combination – have sufficient predictive value to mandate organ discard.
● Such assessment may, however, help determine when kidneys should be considered for dual transplantation.
● Long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar.Nevertheless, it is recognised that DCD kidneys appear to be more susceptible to cold ischaemia, and the proposed national allocation scheme should take this into account.
● The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation.
● Antibody induction therapy should be used as part of the initial immunosuppressive regimen for recipients of DCD kidneys.
● Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants
● Graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD.
Absolute contraindications
invasive or haematological malignancy
untreated systemic infection
prion disease
HIV disease
End-stage kidney disease (CKD stage 5, eGFR <15 ml/min)
CKD stage 4 (eGFR 15-30 ml/min)
Acute cortical necrosis on pre-implantation kidney biopsy
● Acute kidney injury, even that requiring dialysis for the donor during the current hospital admission, is not an absolute contraindication to kidney donation. However, it is likely to increase the risk of DGF or primary non function (PNF) to a greater degree than that associated with DBD donation.
● Relative contraindications
donor age
cold ischaemic time
hypertension and cardiovascular disease ● biopsy may identify kidneys with substantial arterial disease or glomerulosclerosis that are to be discarded
● good outcomes have been described using DBD kidneys with moderate disease when used as dual transplants into a single recipient
● acute renal impairment or haemodynamic instability during a prolonged period do not influence DCD kidney graft outcomes
● Warm ischaemic time Given the clear association between WIT and poor outcome, both in terms of PNF and subsequent graft failure
● prolonged warm ischaemia is a contraindication to kidney donation.
● Maximum time of FWIT is 2 hours but 30 minutes appears to be an absolute
Upper limit time for donation
● Early function is dependent upon
* underlying health of the donor
* ischaemic time
* any damage sustained during the
* process of the death and organ retrieval.
● Newcastle criteria for viability testing in DCD kidney transplantation
Flow on machine perfusion (Perfusion Flow Index) >0.4 ml/min/mmHg/100g of tissue
Intracellular enzymes (GST) (ALT, FABP, Redox iron can also be used)
GST: <100 iu/100g of kidney/litre perfusate in standard organ recovery cassette
● High GST, low donor GFR, elderly donor, diabetes, prolonged cold ischaemia Consider dual renal transplant
● viability assessment is not so critical for kidneys from 3 group of DCD
● There are currently no histological markers that predict PNF as a result of excess warm ischaemia or irreversible ischaemia-reperfusion.
● recipients of DCD kidneys have similar outcomes to recipients of DBD kidneys
● Factors influence outcomes are :
* increasing donor and recipient age
* cold ischaemic time of >12 hours are associated with worse outcome
● DGF is increased in DCD recipients, ranging from 41-51% compared with 24% in DBD recipients
● it is important to avoid exposing young patients to sensitisation from a poorly matched, poor quality organ which may fail within a short period of time.
● Recipient informed consent
● Kidneys retrieved from DCD donors at increased risk of both PNF and DGF.
● So strategies to reduce DGF include the use of induction therapies and the avoidance or delay in introduction of calcineurin inhibitors (CNIs).
● Use and choice of induction therapy
** low immunological risk use IL-2 receptor monoclonal antibody blockade
** high-risk recipients, such as the recipients of DCD use thymoglobulin, or Alemtuzumab
Hussein Bagha baghahussein@yahoo.com
2 years ago
The guidelines discuss donation after circulatory death
It includes the ethical principles and diagnosis of death and the retrieval methods for each organ. It also talks about getting informed consent both verbal and in writing from the recipient
Terminologies Used: Time periods
– Withdrawal period (also called agonal period): the time from treatment withdrawal to circulatory arrest.
– Primary warm ischemia time (asystolic or acirculatory warm period): the time from circulatory arrest to the perfusion of organs with cold preservation solution in situ.
– The functional warm ischemic period: it starts with the SBP falls to less than 50mmHg for at least 2 minutes and extends to the onset of cold in situ perfusion. Diagnosis of death
Death has clinical, legal and societal elements. It is defined as a state in which a patient has permanently lost the capacity for consciousness and brain stem function.
When cardiorespiratory criteria apply, death can be confirmedfollowing 5 minutes of continuous cardiorespiratory arrest provided there is no subsequent restoration of artificial cerebral circulation. The criteria for the diagnosis of death following loss of circulatory function should not be influenced by the possibility of subsequent organ retrieval.
Where possible, circulatory arrest should be identified by the absence of pulsatile flow on a correctly functioning arterial line, or by the use of echocardiography, if available.
Death is, in essence, a neurological event and occurs when there is permanent loss of:
– The capacity for consciousness
– All brain stem function.
The criteria used to diagnose death should be functional rather than anatomical, i.e. not referred to as cardiac death or brain death but based upon the loss of vital organ function.
Neurological and circulatory function are inextricably linked. Death equals to the loss of capacity for consciousness and all brain stem function, most commonly occurs following the loss of circulatory function from which a person should not or cannot be resuscitated.
The exact definition of death has given rise to a significant ethical debate. The key ethical principle is that donation should proceed only after death has been established and no prospect of spontaneous auto-resuscitation exists.
The decision to cease attempts at life preserving treatments should be taken in a manner independent of donation/transplantation considerations and be based purely on the concept of functionality with respect to prolongation of life. Law, ethics and donor consent
The principles of donor dignity and non-maleficence must not be compromised in order to facilitate donation and transplantation.
All health care providers should be aware of the complex ethical issues that are associated with donation after circulatory death (DCD) and transplantation of donated organs.
The key ethical principles underpinning the clinical practice in relation to both donors and recepients in the complex context of DCD and transplantation include:
– Altruism
– Autonomy
– Dignity
– Non-maleficence
– Fertility
– Equity Informing the recipient
The recipient should be provided information both orally and in writing, and it is the responsibility of the multidisciplinary transplant team.
This information should be tailored to the requirements of the potential recipient.
The potential recipient must be informed about the benefits and risks of receiving the DCD organ, risk of remaining on the transplant list versus receiving the DCD organ. Organ retrieval
Treatment withdrawal should ideally be planned for a time when the donor HLA type and virology are known and the liver and pancreas recipient are in the recipient hospitals. Treatment withdrawal in the operating department is associated with shorter warm ischemic times rather than withdrawal on a remote ICU.
The retrieval team need to be satisfied about donor details before treatment is withdrawn.
The specialist nurse should keep a record at regular intervals of the potential donor’s hemodynamic parameters following treatment withdrawal.
Death may be confirmed 5 minutes after complete circulatory arrest.
For controlled donors, retrieval starts by gaining access to a large artery and vein, typically the right common iliac artery or aorta, and the IVC or right atrium.
20,000 units of heparin should be added to the first two bags of ice cold preservation solution to be perfused through the aorta. The kidneys may be removed individually or en bloc.
The pancreas may be removed either en bloc with the liver or following removal of the liver.
The liver should be removed using a rapid technique whichminimizes liver congestion.
Dual perfusion of hepatic artery and portal vein is essential for the recovery of DCD livers for transplantation.
Individuals with advanced or ESKD, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donors.
The use of donors with functional warm ischemic time more than 20 hours or absent blood pressure for 30 minutes should be restricted to experimental protocols, which attempt to resuscitate organ viability.
None of the perfusion pressure dynamic characteristics, perfusate effluent biochemical characteristics or kidney transplant biopsy scoring systems have sufficient predictive value to mandate organ discard.
The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the recipient prior to transplantation. Long term outcomes od DCD recipients are similar to those of DBD recipients. Antibody induction therapy should be used as a part of the initial ISS regimen for recipients of DCD kidneys.
AKI, even that requiring dialysis for the donor during the current hospital admission, is not an absolute contraindication to kidney donation.
No definitive date currently suggest any advantage for specific preservation solutions in the context of DCD kidney transplantation. Liver
Livers transplanted for Maastricht 3 DCD donors are a useful resource. Short and medium term outcomes appear inferior to livers from DBD donors with more PNF (primary non-function) and ischemic cholangiopathy and a higher rate of re-transplantation DCD and DBD recipients transplanted with a MELD > 30 or on organ-perfusion support have similar graft survival.
The incidence of biliary strictures is significantly lower when a low viscosity solution is used to cold flush the aorta. An ‘ideal’ DCD liver donor is:
– <50 years old
– Has a function WIT <20 minutes
– A shorter CIT, <10 hours
– <10% steatosis
Long FWIT is associated with an increased risk of ischemic cholangiopathy.
Absolute contraindications include:
– End-stage liver disease
– Acute liver failure
– Moderate to severe steatosis (>30%)
– Acute liver injury that is not improving.
Reem Younis
2 years ago
Please provide a summary of these guidelines
.-Organ donation following circulatory death is classified as either ‘controlled’ or ‘uncontrolled’.
– The withdrawal period (sometimes called the agonal period): the time from
treatment withdrawal to circulatory arrest.
-The asystolic or acirculatory warm period (also known as the primary warm
ischaemic time): the time from circulatory arrest to the perfusion of the organs with cold preservation solution in situ.
– The functional (or true) warm ischaemic period: starts when the systolic blood
pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion. DIAGNOSIS OF DEATH
Statements of Recommendation
-Death is irreversible and should be regarded as a state in which a patient has
permanently lost the capacity for consciousness and brain stem function. (A1)
– Where cardio-respiratory criteria apply, death can be confirmed following five
minutes of continuous cardio-respiratory arrest providing there is no
subsequent restoration of artificial cerebral circulation. (B1)
-Where possible, circulatory arrest should be identified by the absence of
pulsatile flow on a correctly functioning arterial line, or by the use of
echocardiography if the expertise is available; or failing that by continuous
ECG monitoring. (B1)
-DCD organ retrieval protocols should recognise the potential risks around post
mortem interventions that might restore cerebral perfusion. (B1)
-The criteria for the diagnosis of death following loss of circulatory function
should not be influenced by the possibility of subsequent organ retrieval. (A1)
LAW, ETHICS AND DONOR CONSENT
-All healthcare professionals should be aware of the complex ethical issues that
are associated with donation after circulatory death (DCD) and transplantation
of donated organs. Such professionals should be familiar with the terminology
used to describe and discuss the ethics of DCD transplantation. (B1)
– Good ethical practice is integral to efforts to facilitate donation and achieve
transplantation in the context of DCD. This includes decisions about allocation
and consent in relation to both the organ donor and recipient. (B1)
-DCD in the United Kingdom is underpinned by definitions of death that are
accepted by society. The principles of donor dignity and non-malfeasance
must not be compromised in efforts to facilitate donation and transplantation
from DCD donors. (B1)
-Ethical principles integral to the UK controlled DCD programme must extend to
any future uncontrolled DCD programme. (B1)
– The BTS Ethics committee is available for guidance and information to support
practice in this complex field. (Not graded)
– The UK Donation Ethics Committee is also available for guidance and
information. (Not graded) Dignity: complex to define, but in this context reflecting the unique and precious status of the human being and the ethical requirement to treat it respectfully without inflicting harm in both life and death. Non-malificence: the ethical principle that healthcare professionals should not cause harm or distress to their patients. ORGAN RETRIEVAL
-Treatment withdrawal should ideally be planned for a time when the donor HLA
type and virology are known and the liver and pancreas recipients are in the
recipient hospitals. (C1)
-Treatment withdrawal in the operating department is associated with shorter
asystolic periods (warm ischaemic times) than withdrawal on a remote
intensive care unit or ward. (C1)
– The retrieval team need to be satisfied about the donor details (blood group,
past medical history, illness leading to death) before treatment is withdrawn.
(A1)
– Retrieval teams should be scrubbed in the operating theatre at the point of
treatment withdrawal. (B1)
– Maastricht 4 donors, where death has been established previously by brain
stem criteria, may be given heparin before treatment withdrawal. Death does
not need to be reaffirmed once circulatory arrest has occurred. (A1)
-The specialist nurse should keep a record at regular intervals of the donor’s
haemodynamic parameters following treatment withdrawal. (C1)
– Death may be confirmed five minutes after complete circulatory arrest. There is
no need for a further stand off period following this. (A1)
– For controlled donors, retrieval starts by gaining access to a large artery and
vein, typically the right common iliac artery or aorta, and the IVC in the
abdomen or right atrium in the chest. (Not graded)
-20 000 units heparin should be added to the first two bags of ice-cold
preservation solution to be perfused through the aorta. (Not graded)
– A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen
activator may be added to the first bag of preservation solution. (B3)
– The kidneys may be removed either individually or en bloc. (Not graded)
-The pancreas may be removed either en bloc with the liver, or following
removal of liver (Not graded) ORGAN SPECIFIC DISCUSSION KIDNEY
– Individuals with advanced or end-stage chronic kidney disease, or with cortical
necrosis demonstrable on biopsy should not be considered as potential kidney
donors. (B1)
– The use of donors with functional warm ischaemic time >2 hr or absent blood
pressure for 30 minutes should be restricted to (currently experimental)
protocols which attempt to resuscitate organ viability. (B2)
– Units undertaking cold machine perfusion of DCD kidney transplants prior to
implantation should collaborate to standardise the prospective collection of
data to enable aggregated analyses of outcomes. (A2)
– None of perfusion pressure dynamic characteristics, perfusate effluent
biochemical analysis, or kidney transplant biopsy scoring systems – alone or in
combination – have sufficient predictive value to mandate organ discard. (A2)
-Such assessment may, however, help determine when kidneys should be
considered for dual transplantation. (B2)
– Long term outcomes of DCD recipients are similar to those of DBD recipients
and the allocation system for DCD and DBD organs should be similar.
Nevertheless, it is recognised that DCD kidneys appear to be more susceptible
to cold ischaemia, and the proposed national allocation scheme should take
this into account. (B2)
-The incidence of delayed graft function is increased in DCD recipients and this
should be discussed with the patient prior to transplantation. (A1)
-Antibody induction therapy should be used as part of the initial
immunosuppressive regimen for recipients of DCD kidneys. (B1)
– Long-term outcomes for standard criteria donors are equivalent for DCD and
DBD kidney.
Huda Saadeddin
2 years ago
Thank you I learn more rather.than summarize
The Need for Guidelines
Transplantation offers patients with end-stage organ failure a cost-effective treatment that improves quality of life and increases life expectancy.
Prior to the introduction of guidance defining the concept of brain death in the 1970s, all organs for transplantation were donated after circulatory death (DCD).
Following the introduction of brain stem death testing, the majority of organs for transplantation were donated after brain death (DBD) or, increasingly, from living donors. However, in the UK, demand for organ transplantation has continued to rise. By 2012, the mean waiting time for deceased donor kidney transplantation had risen to over three years, while demand for other organs far outstripped the available supply with the consequence that many patients died while awaiting an organ transplant
DCD donation results in fewer donated organs per donor than DBD donation (2.6 organs compared to 4).
DCD donors are able to donate kidney, liver, pancreas, lung, and multiple tissues, and research in the UK is exploring the options for cardiac DCD following the successful development of such programmes in the USA (3).
Improved immunosuppression, improved organ recovery and implantation, and enhanced peri- and post-operative care mean that the outcomes from DCD organs compare favourably with those from DBD organs.
Controlled DCD
Organ donation which follows circulatory arrest. This may be in the context of withdrawal or non-escalation of cardio-respiratory treatments that are considered to be no longer in a patient’s best interests, or occurring in a patient already certified dead by brain stem criteria.
Maastricht Category 3: Awaiting cardiac arrest
Maastricht Category 4: Cardiac arrest in a brain stem dead donor
Uncontrolled DCD
Organ donation from a patient who has suffered an unexpected death that has been confirmed on cardio-respiratory grounds.
Maastricht Category 1: Dead on arrival
Maastricht Category 2: Unsuccessful resuscitation
Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient
Categorisation of DCD Donors
Deceased circulatory death donors should be categorised according the Maastricht classification to aid research, communication and audit.
The functional (or true) warm ischaemic period starts when the systolic blood pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion.
Although donor low oxygen saturation (<70%) is a concern and may well be a measure of inadequate organ perfusion and poor outcome, prospective evidence is awaited. The current recommendation is that oxygen saturation below 70% is not used as an indicator of poor outcome or as a reason for non usage, but that retrieval teams should keep a record of when oxygen saturation falls below 70% in order to allow correlation with graft outcome.
Diagnosis of Death
Death is irreversible and should be regarded as a state in which a patient has permanently lost the capacity for consciousness and brain stem function.
Where cardio-respiratory criteria apply, death can be confirmed following five minutes of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation.
Where possible, circulatory arrest should be identified by the absence of pulsatile flow on a correctly functioning arterial line, or by the use of echocardiography if the expertise is available; or failing that by continuous ECG monitoring.
DCD organ retrieval protocols should recognise the potential risks around post mortem interventions that might restore cerebral perfusion.
The criteria for the diagnosis of death following loss of circulatory function should not be influenced by the possibility of subsequent organ retrieval.
Organ Retrieval
Treatment withdrawal should ideally be planned for a time when the donor HLA type and virology are known, and the liver and pancreas recipients are in the recipient hospitals.
Treatment withdrawal in the operating department is associated with shorter warm ischaemic times (asystolic periods) than withdrawal on a remote intensive care unit or ward.
The retrieval team need to be satisfied about the donor details (blood group, past medical history, illness leading to death) before treatment is withdrawn.
Retrieval teams should be scrubbed in the operating theatre at the point of treatment withdrawal.
Maastricht 4 donors, where death has been established previously by brain stem criteria, may be given heparin before treatment withdrawal. Death does not need to be reaffirmed once circulatory arrest has occurred.
Kidney
Individuals with advanced or end-stage chronic kidney disease, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donors.
The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability.
Units undertaking cold machine perfusion of DCD kidney transplants prior to implantation should collaborate to standardise the prospective collection of data to enable aggregated analyses of outcomes.
None of the dynamic characteristics of machine perfusion, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems – alone or in combination – have sufficient predictive value to mandate organ discard.
Such assessment may, however, help determine when kidneys should be considered for dual transplantation.
Long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. Nevertheless, it is recognised that DCD kidneys appear to be more susceptible to cold ischaemia, and the proposed national allocation scheme should take this into account.
The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation.
Antibody induction therapy should be considered as part of the initial immunosuppressive regimen for recipients of DCD kidneys.
Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants.
Graft outcome is more closely related to whether a transplant is ECD or SCD than whether the mode of donation is DCD or DBD.
Prospective data are required to determine whether the impact of extended criteria donation (ECD) is different in DCD and DBD donors and whether different thresholds for organ use may be required.
abosaeed mohamed
2 years ago
– CATEGORISATION OF DCD DONORS & DEFINITION OF WARM ISCHAEMIC TIME
>>according the Maastricht classification 1-Maastricht Category 1: Death occurring outside of hospital
Death is confirmed outside a hospital environment. For these individuals to be potential
donors, the moment of sudden death needs to have been witnessed, the time that it
occurred documented, and ‘resuscitation’ continued after death. 2-Maastricht Category 2: Unsuccessful resuscitation
CPR is started outside of hospital following collapse. Death is confirmed on admission to
hospital.
Both Category 1 and 2 donors are also referred to as ‘Uncontrolled’ DCD donors and
usually present to the emergency department. 3-Maastricht Category 3: Awaiting cardiac arrest
Death is inevitable but brain stem death criteria are not fulfilled. These patients are cared for
in many areas within hospitals, but are most commonly identified in neurosurgical and
general intensive care units, coronary care units, emergency departments and medical
wards. 4-Maastricht Category 4: Cardiac arrest in a brain stem dead individual
Death has been diagnosed by brain stem criteria following which the patient suffers a
cardiac arrest. This may be whilst awaiting the donor team or as an intentional arrangement,
depending upon the wishes of the next of kin.
Categories 3 and 4 are also referred to as ‘Controlled’ DCD donors. 5-Maastricht Category 5: Unexpected cardiac arrest in a hospitalised patient
Category 5 is an ‘uncontrolled’ donor in a hospitalised patient so the warm ischaemic time
(WIT) between cardiac arrest and organ perfusion is likely to be longer than categories 3 or
4 but shorter than categories 1 or 2.
– The functional (or true) warm ischaemic period starts when the systolic blood
pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and
extends up to the onset of cold in situ perfusion. (B1)
– Although donor low oxygen saturation (<70%) is a concern and may well be a
measure of inadequate organ perfusion and poor outcome, prospective
evidence is awaited. The current recommendation is that oxygen saturation
below 70% is not used as an indicator of poor outcome or as a reason for non
usage, but that retrieval teams should keep a record of when oxygen saturation
falls below 70% in order to allow correlation with graft outcome.
– The withdrawal period (sometimes called the agonal period): the time from
treatment withdrawal to circulatory arrest.
– The asystolic or acirculatory warm period (also known as the primary warm ischaemic time): the time from circulatory arrest to the perfusion of the organs with
cold preservation solution in situ.
– The functional (or true) warm ischaemic period: starts when the systolic blood
pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up
to the onset of cold in situ perfusion.
– DIAGNOSIS OF DEATH
– Death is irreversible and should be regarded as a state in which a patient has
permanently lost the capacity for consciousness and brain stem function. (A1)
– Where cardio-respiratory criteria apply, death can be confirmed following five
minutes of continuous cardio-respiratory arrest providing there is no
subsequent restoration of artificial cerebral circulation. (B1)
– Where possible, circulatory arrest should be identified by the absence of
pulsatile flow on a correctly functioning arterial line, or by the use of
echocardiography if the expertise is available; or failing that by continuous
ECG monitoring. (B1)
– DCD organ retrieval protocols should recognise the potential risks around post
mortem interventions that might restore cerebral perfusion. (B1)
– The criteria for the diagnosis of death following loss of circulatory function
should not be influenced by the possibility of subsequent organ retrieval. (A1)
– the potential recipient must be explained regarding the risk ob being on waiting list compared to outcome of deceased kidney transplantation .
– Organ retrieval in OR with the team should know the donor details before treatment, Death may be confirmed five minutes after complete circulatory arrest. There is no need for a further stand off period following this. A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen activator may be added to the first bag of preservation solution.
– Regarding the KIDNEY
– Individuals with advanced or end-stage chronic kidney disease, or with cortical
necrosis demonstrable on biopsy should not be considered as potential kidney
donors. (B1)
– The use of donors with functional warm ischaemic time >2 hr or absent blood
pressure for 30 minutes should be restricted to (currently experimental)
protocols which attempt to resuscitate organ viability. (B2)
– Units undertaking cold machine perfusion of DCD kidney transplants prior to
implantation should collaborate to standardise the prospective collection of
data to enable aggregated analyses of outcomes. (A2)
– None of perfusion pressure dynamic characteristics, perfusate effluent
biochemical analysis, or kidney transplant biopsy scoring systems – alone or in
combination – have sufficient predictive value to mandate organ discard. (A2)
– Such assessment may, however, help determine when kidneys should be
considered for dual transplantation. (B2)
– Long term outcomes of DCD recipients are similar to those of DBD recipients
and the allocation system for DCD and DBD organs should be similar.
Nevertheless, it is recognised that DCD kidneys appear to be more susceptible
to cold ischaemia, and the proposed national allocation scheme should take
this into account. (B2)
– The incidence of delayed graft function is increased in DCD recipients and this
should be discussed with the patient prior to transplantation. (A1)
– Antibody induction therapy should be used as part of the initial
immunosuppressive regimen for recipients of DCD kidneys. (B1)
– Long-term outcomes for standard criteria donors are equivalent for DCD and
DBD kidney transplants. (A1)
– Graft outcome is more closely related to whether a transplant is ECD vs SCD
than whether the mode of retrieval is DCD vs DBD. (B2)
– Prospective data are required to determine whether the impact of expanded
criteria donation (ECD) is different in DCD and DBD donors and whether
different thresholds for organ use may be required. (A1)
Marius Badal
2 years ago
Summary:
This article was about Transplantation from deceased donors after circulatory death that was coordinated by the British Transplantation Society. It started with an introduction that explain how the guidelines were developed and the steps taken to ensure nothing was overlooked. Once that was done a guideline was formulated on transplantation from deceased donors after circulatory death in July 2013.
The different categories that summarize:
This article was about Transplantation from deceased donors after circulatory death that was coordinated by the British Transplantation Society. It started with an introduction that explain how the guidelines were developed and the steps taken to ensure nothing was overlooked. Once that was done a guideline was formulated on transplantation from deceased donors after circulatory death in July 2013.
The different categories that were included were:
1) Categorization of DCD donors and diagnosis of death. This was a category that was based on the Maastricht classification. It is based on the warm ischaemic time from a period of SBP of less than 50 mmHg and when the perfusion starts. Oxygen must not be less than 70%. It further went on to define death which is a nonreversible loss of consciousness and no brain stem function. Once there are proper monitoring organs can be harvested based on protocol.
The Maastricht categories are:
a) Category 1: deals with death on arrival
b) Category 2: is unsuccessful resuscitation
c) Category 3: is to wait on cardiac arrest
d) Category 4: cardiac arrest in a brain stem dead donor
e) Category 5: unexpected cardiac arrest in a critically ill patient.
2) The ethic, consent, and organ retrieval must be followed based on the guideline. The BTS ethic board is present to ensure that the guidelines are followed and there is proper guidance.
3) Once that has been attained, the recipient must be informed. Proper documentation must be documented. All the risks and complications must be explained to the recipient and no information should be withheld.
4) Now as the information is obtained based on the donor like the HLA etc. the different groups of recipients must be notified, with limited time and the operating room must be available to avoid prolonged warm ischaemic time. In the case of the kidneys, it must be removed either in a bloc or an individual.
5) Once the organ has been harvested, its viability must be tested. It is recommended that the graft function perfused of warm perfused organs before transplantation. It is the gold standard to ensure organ function. Other tests can be used based on organ harvesting.
6) Medications must be initiated once the graft has been transplanted due to the fact that the majority of graft function delays. Different groups of medications can be used like monotherapy or polyclonal antibodies. An example of a medication that can be used calcineurin inhibitors.
7) As it regards the kidneys, cortical necrosis is a contraindication and other parameters are used to see the viability or acceptance of the kidney. For example, a kidney biopsy can be done to give information about the kidney status, and based on the scoring system it can be used or rejected.
8) With the liver, it Is found that the shorter the CIT the outcome is better, and with an age less than 50 years.
9) There are certain factors that can give information about the possible factors that can influence graft failure:
a) Male patient
b) Age older than 55
c) Race African American
d) If there is any infection of Hep C
e) If there is a metabolic disorder
f) Number of hospitalization
g) If there is a need for life support
10) When it comes to the pancreas, the warm ischemic time should be less than 60 minutes. If the time is prolonged there is a high chance of developing thrombosis, and possible pancreatitis. It must be noted that the higher BMI the poorer the outcome. The graft failure most of the time is due to thrombosis.
11) As it relates to the lungs, the donor criteria for the lung on DCD is the same as DBD. One has to perform perfusion at the same time as lung retrieval.
12) heart transplantation from DCD donors is not standard care in the UK.as included were:
Hadeel Badawi
2 years ago
CATEGORISATION OF DCD DONORS
Deceased circulatory death donors should be categorized according to the Maastricht classification. Maastricht Category 1: Dead on arrival Maastricht Category 2: Unsuccessful resuscitation Maastricht Category 3: Awaiting cardiac arrest Maastricht Category 4: Cardiac arrest in a brain stem dead donor Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient.
The functional (or true) warm ischemic period starts when the SBP has a sustained ( at least 2 min) fall below 50 mmHg and extends up to the onset of cold in situ perfusion.
SPO2 below 70% is not used as an indicator of poor outcome or as a reason for non-usage, but retrieval teams should keep a record of when oxygen saturation falls below 70% to allow correlation with graft outcome.
Diagnosis of Death Death is irreversible and should be regarded as a state in which a patient has permanently lost the capacity for consciousness and brain stem function.
Death can be confirmed after 5 min of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation.
The criteria for the diagnosis of death should not be influenced by the possibility of subsequent organ retrieval.
Law, Ethics and Donor Consent
All healthcare professionals should be familiar with the terminology used to describe and discuss the ethics of DCD transplantation.
All principles of ethics and donor dignity must not be compromised in efforts to facilitate donation and Tx from DCD donors.
The BTS UK Donation ethics committee is available for guidance and information to support practice.
Organ Retrieval
Treatment withdrawal is ideally to be planned when the donor HLA type and virology are known, and the liver and pancreas recipients are in the recipient hospitals.
Retrieval is ideally done in the OR to decrease WIT.
For uncontrolled DCD or when perfusion of the kidneys on retrieval is poor, an increased risk of primary non-function, but this is not universally accepted.
Testing the graft function of warm perfused organs prior to transplantation is considered the ‘gold’ standard. However, it is difficult to perform and usually impractical, with lung being an exception.
Immunosuppression
There is increased risk of DGF due to DCD injury; therefore, induction therapy is used to reduce the risk of AR, and is often combined with delayed introduction or reduced intensity of CNI.
In liver transplantation, consider renal-sparing regimens with delayed CNI introduction.
In heart and lung transplantation, there is no evidence to use a different regimen from that used in DBD
Kidney Absolute contraindications; End-stage kidney disease CKD 4-5, Acute cortical necrosis on pre-implantation biopsy
The use of donors with WIT >2 hr or absent BP for 30 minutes should be restricted to protocols which attempt to resuscitate organ viability.
Units undertaking cold machine perfusion of DCD KTx prior to implantation should standardize the collection of data.
Using the dynamic characteristics of machine perfusion alone or in combination does not have sufficient predictive value to mandate organ discard; however, helps determine DKT
The recipient should be aware of the increased chance of DGF
The long-term outcomes of DCD recipients are similar to those of DBD recipients. However, it is more susceptible to cold ischemia, and the allocation system for should be similar.
Antibody induction therapy should be considered as the initial IS regimen for recipients of DCD kidneys.
Graft outcome is more closely related to whether a transplant is ECD or SCD than whether the donation mode is DCD or DBD.
Liver
Livers Tx from Maastricht 3 DCD donors should be used where deemed safe.
The short and medium-term outcome appears inferior to livers from DBD donors, with more PNF and ischemic cholangiopathy and a higher rate of re-transplantation.
DCD and DBD with MELD >30 or on organ-perfusion support have similar graft survival, no survival benefit when MELD ≤30 or in those not receiving organ-perfusion support.
Biliary stricture is significantly lower when a low-viscosity solution is used.
The outcome of DCD liver Tx is improved with short CIT, when kept to < 8hrs.
Ideal’ DCD liver is transplanted has a favourable outcome, meaning; the donor is <50 years old, has a functional WIT time <20 min, a shorter CIT <10 hr, and <10% steatosis.
Restrictive DCD Donor criteria; BMI <29 kg/m2 and a functional WIT <20 min (SAP <50 mmHg), equivalent 1 and 3-year patient and graft survival rates for both DCD and DBD liver transplants.
Long FWIT is associated with an increased risk of ischemic cholangiopathy
Potential recipients should be informed of the risk and be offered the choice to refuse.
DCD liver grafts should be ideally used in younger recipients with age <60 years to be avoided in re-transplantation.
Predictive of graft failure are age ≥55 years, male sex, AA race, HCV positivity, metabolic liver disorder, transplant MELD ≥ 35, hospitalization at transplant, and the need for life support at transplant.
Recipient predictors of mortality are age ≥55 years, hospitalization at transplant, and re-transplantation.
Pancreas
DCD organs can be used for isolated pancreas transplants, pancreas after kidney or simultaneous pancreas-kidney (SPK)
Lung
The donor criteria for lung Tx are the same for DCD and DBD.
DCD lungs should not be regarded as extended or marginal. Transplant outcome and quality are at least similar to DBD organs.
Perform flush perfusion at the time of lung retrieval.
Pre-transplant ex vivo lung perfusion (EVLP) is advised in case of uncertain graft performance to safely extend donor and procedural criteria (long warm ischemia, bad flush, clots).
Acceptance criteria on EVLP may include measures of pulmonary compliance, vascular resistance, and gas exchange.
Heart
In the UK, heart Tx from DCD donors is NOT standard of care, for ethical issues.
Individuals with advanced or end-stage chronic kidney disease, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donors.
The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability.
Units undertaking cold machine perfusion of DCD kidney transplants prior to implantation should collaborate to standardise the prospective collection of data to enable aggregated analyses of outcomes.
Long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. Nevertheless, it is recognised that DCD kidneys appear to be more susceptible to cold ischaemia, and the proposed national allocation scheme should take this into account.
The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation.
Antibody induction therapy should be used as part of the initial immunosuppressive regimen for recipients of DCD kidneys.
Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants.
Graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD.
Dear Dr Tuffayel, That is a good summary. Please type headings and sub-headings in bold or underline. That will make it easier to read.
Isaac Abiola
2 years ago
SUMMARY
Introduction
It is an established fact that transplantation does not only prolong time but also better quality of life for those with end stage organ failure. Previously, most of the organs are retrieved from donor with DCD and the ever-increasing demands for various organ has made the gap between demand and supply to be very wide, hence the introduction of DBD to enable more organs available for transplantation. The essence of guidelines is to provide a uniform criterial for diagnosis of most the dead before proceeding to organ retrieval.
Categorization of DCD Donors
This is largely classified into controlled DCD which involves withdrawal of service in ICU or emergency or uncontrolled which is a potential donor suffered a cardiac arrest and was already dead-on arrival at the hospital or unable to be resuscitated.
The following classification is recommended
Maastricht Category 1- Death occurring outside the hospital
Maastricht Category 2- Unsuccessful resuscitation
Maastricht Category 3- Awaiting Cardiac arrest
Maastricht Category 4- Cardiac arrest in brain stem dead individuals
Categories 1 and 2 are also called uncontrolled DCD, while categories 3 and 4 are called controlled DCD
Diagnosis of Dead
Death has clinical, legal and societal element in it and it is a biological event that the diagnosis should be seen as such.
Criterial for diagnosis of death
Asystole has occurred, and
Brian function has been lost, and
The possibility of spontaneous return of cardiac function has passed, providing that,
There will be no subsequent intervention that restores cerebral function while the brain remains responsive to such intervention
Law, Ethics, and Donor Consent
The ethical issues that must be well considered before harvesting organs are; altruism, autonomy, dignity, non-Maleficent, futility, and equity.
Consent/Authorization of organ donation
This is legally defined by Human Tissue Act 2004 in England, Wales, Northern Ireland with that of organ authorized by Human Tissue Act Scotland Act 2006.
The donor is expected to give consent or if unavailable the next of kin can be allowed to give permission for organ retrieval
Informing the Recipients
oral and written information must be giving to the recipient, and this be updated annually
they are entitled to know as much as they want to know about the process
the MDT are responsible to dissemination of all the necessary information
relative risk of accepting a particular organ and that of remaining on the waiting list must be well explained to the recipients
Organ Specific Discussion
Kidney
Kidney transplantation either by DCD or DBD is almost the same except for release of more physiological inflammatory stress and prolong warm ischemic time in those from DBD. Of not are the absolute contraindications to use of kidney from DCD like eGFR <15mil/min, CKD stage 4, and acute cortical necrosis on pr-implantation kidney biopsy
Warm Ischemic time
current opinion suggests SBP <50mmHg as critical time
NHSBT recommends 2 hours
if there is no blood pressure, 30 minutes is the upper limit of acceptance for WIT
Factors that influence outcome of recipients
increasing donor and recipient age
cold ischemic time >12 hours
Above two are associated with worse outcome, however, the use of induction therapy and the type (e,g CNI, IL-2 antagonist, monoclonal antibody) has helped to reduce the incidence of DGF or PNF
DCD donors categorization and warm ischemia
-DCD categorization have to be done according to Maastricht classification.
-Maastricht classification;
Maastricht 1: death on arrival
Maastricht 2:failed resuscitation
Maastricht 3: cardiac arrest is awaited
Maastricht 4:cardiac arrest in brain stem death
Maastricht 5: surprising cardiac arrest in critically ill case.
-3,4 are considered controlled DCD while 1,2,5 are uncontrolled.
-O2 saturation below 70 % does not indicate poor outcome but need to be monitored.
– The withdrawal period refers to the time from withdrawal of treatment to circulatory arrest.
-The asystolic period is the time from circulatory arrest till the cold preservation solution is given.
– The functional warm ischaemic period: starts is when the systolic blood pressure is persistently below 50 mmHg and extends till the onset of cold in situ perfusion. Death diagnosis
-Death indicates irreversible loss of consciousness and brain stem function ,it is confirmed after 5 minutes from persistent cardiorespiratory arrest without returning artificially cerebral circulation.
-Circulatory arrest can be detected by absence of pulsatile flow in an arterial line, or by echo or through ECG monitoring,
-Organ donation protocols must consider the possible risks regarding post mortem intervention that can regain cerebral circulation.
-Death diagnosis must not be affected by the possible organ donation.
– Death definition used in UK is theirreversible loss of the capacity for consciousness combined with irreversible loss of the capacity to breathe’.
-Healthcare professionals must be oriented to the complex ethical issues related to donation after circulatory arrest because good ethical practice is necessary to preserve the donor’s dignity and right of non malfeasance.
– the UK ethical principles of the controlled DCD programme need to be applied for future uncontrolled DCD programmes.
-Altruism indicates the donor’s own will voluntarily to donate his organs after death without any return.
-Autonomy means the donor’s right to decide for the fate of their organs after death.
– The UK Donation Ethics Committee (UKDEC) gives the right to all patients who need end of life care ,without having a medical contra-indication, to decide to donate, regardless of the environment .
-An authorised consent need to be obtained from the donor including all the details as which organ to donate , tissue and blood samples that will be taken , virology testing ,the willing to involve the organs in research if not fit for donation, and there discarding afterwards.
-To preserve donor’s dignity and non malfeasance the least invasive morally acceptable procedures can be done to preserve the organ for donation.
-There is a dilemma regarding the supportive therapy as ventilation given to facilitate the donor’s autonomous desire for donation and preserving the quality of the donated organ from one side and providing a dignified non torturing death for the donor from the other side in controlled DCD.
-Uncontrolled DCD occurring more rapid than DBD and controlled DCD, has some other ethical issues.
– Early approach to the bereaved is necessary to have a balance between autonomy and altruism.
-pre consent preservation measures can be started as in situ organ perfusion via a femoral catheter for uncontrolled DCD cases.
-Ethical concerns occur when preservative measures are done to restore cerebral circulation in a case of uncertain death criteria .
– Organ allocation schemes depend on complex algorithms that take into account numerous clinical and patient factors as predicted outcome, waiting times effects and shortage of available organs for transplantation, as it is considered non ethical to provide DCD organs to high risk cases only due to it’s poor quality and their less favourable expected outcome .
-The risk benefit details need to be explained to the recipient on different occasions confirming his will to receive an organ from a DCD and to sign the consent voluntarily.
– Su et al developed the UNOS/CHOICE system for allocation of higher risk organs, so that the recipient can understand and choose the range of kidneys that would be acceptable to
them for transplantation but it would be a complex procedure.
-MDT is responsible for providing all the required details both oral and written in a consent for the potential recipient which must be annually updated.
-The risk benefit analysis must be explained to the recipient concerning receiving an organ from DCS versus staying on the waiting list.
– Once the donor HLA type and virology are done and the liver and pancreas recipients are in the recipient hospitals, treatment withdrawal can be planned .
-Treatment withdrawal is ideally associated with shorter warm ischemia time.
-The donor data must be sufficient for the retrieval team before withdrawing the treatment.
-Heparin can be given before treatment withdrawal for Maastricht 4 donors.
-After stooping the treatment the assigned nurse need to record regularly the donor’s vitals.
– 5 minutes after circulatory arrest ,death can be confirmed without any need for a stand off period .
-for controlled donors retrieval is carried out through having an access to common iliac artery ,aorta and IVC in the abdomen and never to be placed in the SMV,IMV when pancreas is to be retrieved.
-Through the aorta 20000units of heparin are added to 2 bags of cold ice preservative solutions as well as a fibrinolytic agent can be added to the first bag.
-Kidneys can be taken on it’s own or en bloc, for the pancreas, it can be removed en bloc with the liver or after liver removal.
-Perfusing both hepatic artery and portal vien is mandatory for recovery of DCD livers .
– The type of preservative solution can affect the risk of delayed graft dysfunction and the overall outcome. Organ specific discussion Kidneys
-Candidates with advanced or ESRD or cortical necrosis cannot be considered for donation.
– Protocols to resuscitate organ viability will be needed for organs with functional warm ischaemic time >2 hr .
– Standardisation of the prospective collection of data for units doing cold machine perfusion of DCD kidney transplants to facilitate evaluation of the outcomes.
-There are no sufficient tests to define the predictive values in order to discard an organ.
– Kidneys suitable for dual transplantation need to be detected.
-DCD and DBD recipients have the same long term outcomes but DCD is more susceptible to cold ischaemia.
-DCD recipients are more liable to DGF ,and the recipient must be oriented about that
– For recipients of DCD kidneys ,initial immunosuppressive protocol include antibody induction therapy.
-ECD or SCD affects the graft prognosis more than DCD or DBD.
-More data is needed to determine if ECD is different in DCD and DBD.
– Combining donor hypertension and creatinine with histological scoring provide a suitable predictive value.
-The older the candidates are and the longer the cold ischemia time> 12h the worse the prognosis will be. Liver
– Livers retrieved from Maastricht 3 DCD donors can be used when suitable
-Livers donated from DBD have less favourable short and medium outcomes.
– DCD and DBD cases transplanted with MELD >30 have same graft survival.
– Cold flushing the aorta with low viscosity solution decreases the incidence of biliary stricture.
-DCD liver should be donated to recipients whom will benefit the most.
-CIT < 8h improves the prognosis of DCD liver transplant
– An ‘ideal’ DCD liver donor refers to a donor <50 years old, has a functional WIT time <20 min, a shorter CIT <10 hr, and <10% steatosis.
-The same 1 and 3 years graft survival for DCD and DBD can be reached with applying restrictive criteria.
– Ischaemic cholangiopathy risk is high with long FWIT.
-Retransplant candidates better not to use DCD grafts, that is better used for recipients< 60 y.
– Age ≥55 years, male sex, African–
American race, HCV positivity, metabolic liver disorder, transplant MELD ≥ 35 are factors suggestive of graft failure.
– Age ≥55 years, hospitalisation at transplant, and re-transplantation are mortality predictors.
-A national audit is needed to define the factors for either utilisation or discarding of a graft. Pancreas
-Current practice recommends the use of simultaneous pancreas and kidney transplantation
-prolonged cold ischemia time ,high BMI and possibly donor’s age are superadded risk factors to pancreas transplants from DCD donors that lead to reperfusion pancreatitis and thrombosis.
-FWIT of 60 minutes is not suitable for pancreatic transplantation.
-Minimal cold ischemia time need to be reached for DCD pancreas transplants.
– Outcomes of DCD and DBD pancreatic transplants are broadly similar.
– Thrombosis leading to graft loss is twice more common with DCD pancreatic transplants compared to DBD, therefore recipients with thromboembolic history better to avoid DCD pancreatic transplant. Pancreatic islets
-The criteria for choosing recipients for DBD and DCS pancreatic islets transplantation is the same.
– Further studies are needed to access the long term outcome of islet transplantation from DCD donors meanwhile the results from small cohort studies are acceptable.
– DCD donors can provide satisfactory functional islet preparations. Lung
– Criteria for selection of DCD and DBD are the same for lung transplantation as in both transplant quality and outcome is nearly the same so DCD lung is not counted as extended or marginal.
– Antegrade and retrograde flush perfusion is done at the time of lung retrieval.
– For uncertain graft performance pre-transplant ex vivo lung perfusion (EVLP) is recommended.
– Pulmonary compliance, vascular resistance, and gas exchange are the acceptance criteria on EVLP. Heart
-Guidelines are not updated because in UK heart transplantation from DCD donors is not a standard of care due to ethical issues. Pediatric DCD transplantation
DCD pediatric donation can be considered for cases facing end of life illnesses which can increase the pool of available organs for children.
Kidney and liver grafts from paediatric DCD donors are as good as organs donate from SCD donors regarding the graft function and recipient survival rates .
That is the same for the heart and lung transplantation.
It is a great challenge to try to put in a few words such a complex protocol as a deceased donor, but I will emphasize some key points:
1. Concept of death
1.1 – Brain death
The classic concept of brain death is the cessation of functions such as coma, unresponsiveness (absence of central brain reflexes), and apnea. Increased intracranial pressure can trigger reflexes in the spinal cord.
To rule out brain death, there must be a central reflex (pupillary, corneal, facial, oculocephalic, oculovestibular, pharyngeal, and laryngeal). Neuroradiological tests (USG Doppler, magnetic resonance angiography, technetium scintigraphy, angiography), electroencephalographic (EEG), hypothermia, sedatives, narcotics, hydro electrolytic and acid-base disturbances.
Because it is an extremely multicultural country, with several religions, and great spirituality, the concept of death by brain outcome can be confusing, applying the need for cardiac arrest to officially define death for family members.
In the case of the potentially irreversible cardiac donor, we have the Maastricht categories, where brain death has not yet occurred but there is severe damage (Maastricht 3).
1.2 – Cardiac Death
Cardiovascular care of the potential donor fluid therapy, and vasopressor drugs (dopamine is preferred) to achieve adequate blood pressure values. On the other hand, the pulmonary condition seeks adequate oxygenation rates, avoiding excess fluid therapy, so some centers use pulmonary catheters for adequate control of fluids, pressure, and volume of oxygen to be made available. Endocrine metabolic care such as diabetes insipidus (desmopressin), vasopressin, glycemic control, and thermal control decrease ischemia and ensure the quality of the organ potentially to be donated. Corticosteroids to decrease the systemic inflammatory response are also discussed in this article.
Maintain a temperature above 35 degrees Celsius, crystalloids with Ringer’s Lactate to prevent hyperchlorhydremia, blood replacement when hemoglobin is less than 10, dopamine for inotropic control, protective ventilation, and hormone replacement to increase the quality of the organ to be donated despite brain death or imminent cardiac arrest. Situations such as infections and active malignant neoplasms are still an exclusion factor.
2. Ethics
The donor’s family must be informed about the criteria for death (brain or cardiac), understand the irreversibility of the condition, and authorize or not the organ transplant.
The recipient must be accompanied by a multidisciplinary team and understand previous care regarding diet, glycemic control, body mass index, need for immunosuppressants, risks involved in the organ to be offered, position in the transplant queue and so many care related to transition.
Understand the criteria for extended donation and the possibility of double kidney transplantation to improve functionality. Older donors or those previously with underlying diseases are defining additional care after transplantation.
3. Kidney transplantation
Findings that compromise the structure of the organ (cortical necrosis, for example) exclude the possibility of proceeding with the transplant. Long ischemia times (in the case of the kidney over two hours) also compromise the organ’s viability. Understand the cardiovascular, pulmonary, metabolic, and endocrinological processes and control to keep the organ viable in the potential donor, in addition to preparing the recipient with perioperative care. Reinforce the recipient’s care regarding immunosuppression induction and maintenance treatments, as well as postoperative needs and expected goals for the first days after transplantation.
These guidelines (Transplantation from deceased donors after circulatory death) are of the BTS (July 2013)
Organs can be utilized are kidney, liver, pancreas, pancreatic islets, lung, and heart
Before definition of brain death in the 1970, all organs were donated after DCD
DCD appeared again due to shortage of organ transplant to expand the donor pool
Grading of Recommendations is similar to that adopted by KDIGO guidelins
Maastricht classification of DCD
Category 1: Dead on arrival
Category 2: Unsuccessful resuscitation
Category 3: Awaiting cardiac arrest
Category 4: Cardiac arrest in a brain stem dead donor
Category 5: Unexpected cardiac arrest in a critically ill patient
Category 3 and 4 are controlled DCD. Category 1, 2 and 5 are uncontrolled DCD
Categorisation of DCD Donors
DCD should be categorized according the Maastricht classification. (A1)
The functional (or true) warm ischaemic period starts when the systolic blood pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extend up to the onset of cold perfusion. (B1)
Low oxygen saturation (<70%)may be ameasure of inadequate organ perfusion and poor outcome, butthe current recommendation is not used as an indicator of poor outcome or as a reason for non usage. (C1)
Diagnosis of Death
Death is irreversible permanent lost of the capacity for consciousness and brain stem function. (A1)
Death can be confirmed after five minutes of arrest (no restoration of artificial cerebral circulation). (B1)
Circulatory arrest is identified by the absence of pulsatile flow on a correctly functioning arterial line, or by EEG. (B1)
Informing the recipient
Providing information, both orally and in writing, for the potential transplant recipient is a requirement for consent and is the responsibility of the multi- disciplinary transplant team is responsible for the recipient consent (benefit/risk). This must be updated and reviewed annually. (B1)
Organ Retrieval
Plan of treatment withdrawal after the donor HLA type and virology are known. (C1)
The retrieval team should know donor details before treatment withdrawal. (A1)
At the point of treatment withdrawal, retrieval teams should be in the operating theatre. (B1)
Give heparin for Maastricht 4 donors before treatment withdrawal. (A1)
After treatment withdrawal, hemodynamic parameters should be followed with a specialist nurse. (C1)
Heparin (20 000 units) should be added to the first bag of ice-cold preservation solution to be perfused through the aorta. (Not graded)
A fibrinolytic( streptokinase or rTPA) may be added to the first bag of preservation solution. (B3)
The kidneys may be removed either individually or en bloc. (Not graded)
Viability Testing Kidneys appear well perfused on retrievalin controlled DCD, provided that other risks are minimal. (C2)
The role of machine perfusion to ‘improve’ the kidney is controversial. (C2)
During machine perfusion, high resistance or high enzyme levels within the perfusatemay be an indicator of cellular damage and primary non function (uncontrolled DCD). (C1)
Testing the graft function of warm perfused organs prior to transplantation is considered the ‘gold’ standard. (C2)
Immunosuppression
No data suggest benefit of any immunosuppressive in DCD organs. (C1)
As there is increased risk of DGF in DCD, induction therapy with mono- or polyclonal antibodies may be used to reduce the risk of acute rejection. (B1)
Induction therapy is often combined with delayed introduction or reduced intensity of CNI. (C2)
Kidney
Advanced or ESRD, or cortical necrosis on biopsy is an absolute contraindication of donation. (B1)
Functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to protocols which attempt to resuscitate organ viability. (B2)
Units using machine perfusion should collaborate to standardise the prospective collection of data to enable aggregated analyses of outcomes. (A2)
No organ discards because of machine perfusion, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems (but for DKT) (A2)
Long term outcomes of DCD recipients are DBD recipients, although DCD kidneys appear to be more susceptible to cold ischaemia. (B2)
DGF is increased in DCD recipients and this should be discussed with the patient prior to transplantation. (A1)
Antibody induction therapy should be considered as part of the initial immunosuppressive regimen for recipients of DCD kidneys. (B1)
Long-term outcomes for SCD are equivalent for DCD and DBD. (A1)
Graft outcome is more closely related to whether a transplant is ECD or SCD than whether the mode of donation is DCD or DBD. (B2)
Time Periods
1. The withdrawal period (agonal period): the time from treatment withdrawal to circulatory arrest
2. The asystolic or acirculatory warm period (primary warm ischaemic time): the time from circulatory arrest to the perfusion of the organs with cold preservation solution in situ
3. The functional (or true) warm ischaemic period: starts when the systolic blood pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion
PAEDIATRIC DCD TRANSPLANTATION
Families of children are more willing to agree to donation than families of adult patients Should be considered for any child
Renal and liver grafts from paediatric DCD donors have graft function and recipient survival rates comparable with organs recovered from SCD donors
The British Transplantation Society had published the guidelines of transplantation from deceased donors after circulatory death in July 2013.it involved the following domains: Categorisation of Deceased circulatory death (DCD) Donors and Diagnosis of Death:
This should be based on the Maastricht classification. The warm ischaemia period is the period between sustained SBP of below 50 mmHg and the onset of perfusion. The retrieval teams should keep a record of oxygen saturation when it drops below 70% .Death is defined as irreversible permanent loss of consciousness and brain stem function. It is confirmed after 5 minutes of continuous cardio-respiratory arrest. These need not be affected by the possibility of organ retrieval. If resources are available, use monitoring devices such as arterial line, echocardiography or ECG. The retrieval protocols should. Ethics, Consent and Organ Retrieval
All the ethical subjects and terminology related to the DCD donation need to be familiar to all healthcare professionals (allocation decision , consents, donor dignity and non-maleficence). The BTS Ethics committee and UK Donation Ethics Committee provide sources of information to practitioners. The consents to the recipient need to be both verbal and written and these should be annually updated and documented.
The planning for treatment withdrawal should be:
1- when the donor HLA type and virology are known
2- the liver and pancreas recipients are in the recipient hospitals to reduce warm ischaemia period
Before treatment withdrawal:
the following donor information need to be satisfactory: blood group, past medical history, illness leading to death and Maastricht 4 donors may be given heparin
At the time of treatment withdrawal:
1- The Retrieval teams should be scrubbed in the operating theatre
2- The specialist nurse should keep a record at regular intervals of the donor’s haemodynamic parameters following treatment withdrawal. Death may be confirmed 5 minutes after complete circulatory arrest.
Procedure of retrieval:
For controlled donors, the access can be a large artery and vein (right common iliac artery or aorta, and the IVC or right atrium in the chest, avoid SMV or IMV when the pancreas is being retrieved). Perfuse aorta by 20 000 units heparin in the first bag of ice-cold preservation solution and a fibrinolytic agent may be added too. Removal of organs can be individually or en bloc. The retrieval of the liver should be rapid with dual perfusion of both artery and portal vein. Viability testing depends on the organ retrieved and is used when there is delay in circulatory arrest.
3-Immunosuppression
As these organs are at high risk of delayed graft function , induction therapy with mono- or polyclonal antibodies may be used combined with delayed introduction or reduced intensity of calcineurin inhibition to limit the incidence and duration of delayed graft function particularly with liver transplantation. Kidney:
Avoid kidney donors with
1- advanced or end-stage chronic kidney disease
2- cortical necrosis demonstrable on biopsy should
3- Warm ischaemic time >2 hours or absent blood pressure for 30 minutes should be restricted to protocols which attempt to resuscitate organ viability. (these can be used in centers using viability protocols or dual organs but need to be standardized to compare between different centers)
The long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. The DCD kidneys are noticed to be more susceptible to cold ischaemia and DGF and hence, antibody induction therapy should be part of the initial immunosuppressive regimen Liver:
Livers from DBD donors have more PNF and ischaemic cholangiopathy and a higher rate of re-transplantation. DCD and DBD subjects transplanted with MELD >30 or on organ-perfusion support have similar graft survival. However, there is no survival benefit when DCD livers are transplanted in patients with MELD ≤30 or in those not receiving organ perfusion supports. The outcome will improve with the use of low viscosity solution to cold flush the aorta, short CIT (under 8hrs),‘ideal’ DCD liver ( donor age <50 years old, has a functional WIT time <20 min, a shorter CIT <10 hr, and <10% steatosis), BMI <29 kg/m2 and a functional WIT <20 min (SAP <50 mmHg)
DCD grafts are best avoided in recipients of re-transplantation and should be ideally used in younger recipients with age <60 years. Factors predictive of graft failure are: age ≥55 years, male sex, African–American race, HCV positivity, metabolic liver disorder, transplant MELD ≥ 35, hospitalisation at transplant, and the need for life support at transplant. Recipient predictors of mortality are age ≥55 years, hospitalization at transplant, and re-transplantation. Pancreas:
Outcomes for DCD donor pancreas transplantation are similar to those of DBD donors’ .DCD organs can be used for isolated pancreas transplants or SPK recipients but they are associated with increased risk of reperfusion pancreatitis and thrombosis. Better outcome are associated with donors age <60 years old, have BMI <30 kg/m2, warm ischaemia time of 60 minutes and shortest possible cold ischaemic time. . A DCD organ should not be transplanted into a recipient with a history of thrombo-embolic disease unless this is monitored and treated.
Pancreatic islets:
Selection criteria for recipients of islets from DCD donors should be the same as for DBD donors. Lung :
The donor selection criteria for lung DCD should be the same as for DBD as transplant outcome and quality are similar. Perform antegrade and retrograde flush perfusion at the time of lung retrieval and pre-transplant ex vivo lung perfusion (EVLP) is advised in case of uncertain graft performance. Heart:
In the UK, heart transplantation from DCD donors is currently NOT standard of care.
Dear Dr Hassan, That is a good summary. Please type headings and sub-headings in bold or underline. That will make it easier to read.
Mohamed Saad
2 years ago
Transplantation from deceased donors after circulatory death British Transplantation Society Guidelines 2013. Categorization of DCD Donors.
Maastricht Category 1: Dead on arrival.
Maastricht Category 2: Unsuccessful resuscitation.
Maastricht Category 3: Awaiting cardiac arrest.
Maastricht Category 4: Cardiac arrest in a brain stem dead donor.
Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient.
Definition of warm ischaemic period starts when the systolic blood pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion and oxygen saturation below 70% is not used as an indicator of poor outcome. Diagnosis of Death.
Irreversible loss of consciousness and brain stem function and circulatory arrest identified by the absence of pulsatile flow on a correctly functioning arterial line or Echocardiography. Law, Ethics and Donor Consent.
Decisions about allocation and consent in relation to both the organ donor and recipient should be cleared for healthcare professionals to facilitate transplantation process.
BTS Ethics committee is available for guidance and information to support practice in this complex field. Informing the Recipient.
Orally and writing information should be provided by healthcare worker to the recipient, consent should be updated and reviewed annually and the outcome of discussions clearly documented in the patients records and this is by multi-disciplinary transplant team.
Benefits versus risks should be explained for the recipients as risk of remaining on the transplant waiting list compared to that of receiving a DCD organ. Organ Retrieval.
when the donor HLA type and virology are known, and the liver and pancreas recipients are in the recipient hospitals, planning for treatment withdrawal should be started and try to keep it in operating room to decrease warm ischemia.
Blood group, past medical history, illness leading to death should be known and satisfied from retrieval team before treatment is withdrawn.
Following treatment withdrawal, hemodynamic parameters should be regularly recorded and retrieval starts by gaining access to a large artery and vein, typically the right common iliac artery or aorta, and the IVC in the abdomen or right atrium in the chest and 20000 units heparin added to first bag of ice-cold preservation solution.
The kidneys may be removed either individually or en bloc, liver should be recovered using a rapid technique and dual perfusion of both artery and portal vein is essential for recovery of DCD livers. Viability Testing.
Many factors to test kidney viability as donation from young controlled DCD, rapid laparotomy, aortic cannulation, perfusion and venous exsanguination all these short the cold ischemia.
Testing the graft function of warm perfused organs prior to transplantation is considered the ‘gold’ standard.
Ventilating the lungs and perfusing them with Steen solution with or without added red blood cells and lung compliance, airway resistance and tidal volume via the ventilator all consider viability test of the lung. Immunosuppression.
The main idea that using induction therapy is often combined with delayed introduction or reduced intensity of calcineurin inhibition to limit the incidence and duration of delayed graft function in kidney donation but in heart and lung transplantation, there is no evidence to use a different regimen from that used in DBD transplantation. Kidney.
Advanced or end-stage chronic kidney disease, or with cortical necrosis is absolute contraindications for donation.
None of the dynamic characteristics of machine perfusion, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems – alone or in combination – have sufficient predictive value to mandate organ discard but may be useful to use dual transplantation.
DCD is more liable to cold ischemia rather than DBD but same long term recipient outcomes.
Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants.
Induction therapy is often combined with delayed introduction or reduced intensity of calcineurin inhibition to limit the incidence and duration of delayed graft function. Liver.
Short and medium term outcome appears inferior to livers from DBD donors, no survival benefit when DCD livers are 18 transplanted in patients with MELD ≤30.
The outcome of DCD liver transplantation is improved with short CIT and an ideal’ DCD liver donor is less than 50 years old, WIT<20 mints, a shorter CIT<10 hours and <10% steatosis.
Long FWIT is associated with an increased risk of ischaemic cholangiopathy.
DCD liver grafts should be ideally used in younger recipients with age, but should be avoided for recipients of re-transplantation. Factors predictive of graft failure such as:
Age ≥55 years, male sex, African–American race, HCV positivity, metabolic liver disorder, transplant MELD ≥ 35, hospitalization at transplant, and the need for life support at transplant.
Recipient predictors of mortality are age ≥55 years, hospitalization at transplant, and re-transplantation. Pancreas.
The pancreas team should stand down after a functional warm ischemia time of 60 mints.
Prolonged cold ischemia & higher donor BMI can lead to reperfusion pancreatitis and thrombosis.
Higher recipient BMI, age, cardiovascular morbidity, and technical surgical factors may contribute to poorer outcome.
Outcomes for DCD donor pancreas transplantation is similar to DBD.
Graft loss from thrombosis is twice as common in DCD as DBD pancreas transplants, so better to avoid donation to recipient with a history of thrombo-embolic disease. Lung.
The donor selection criteria for lung DCD should be the same as for DBD and similar quality to DBD organs.
To perform antegrade and retrograde flush perfusion at the time of lung retrieval. Heart:
The use of DCD hearts is not currently recommended in UK.
Category 1: Dead on arrival.
Category 2: Unsuccessful resuscitation.
Category 3: Awaiting cardiac arrest.
Category 4: Cardiac arrest in a brain stem dead donor.
Category 5: Unexpected cardiac arrest in a critically ill patient.
Diagnosis of Death
– Death is irreversible and permanent loss of consciousness and brain stem function.
– Death can be diagnosed when:
Asystole has occurred, and Brain function has been lost, and The possibility of spontaneous return of cardiac function has passed, and there will be no subsequent intervention that restores cerebral perfusion
Renal transplant :
– For uncontrolled DCD or when perfusion of the kidneys on retrieval is poor, using parameters such as high resistance during machine perfusion or high enzyme levels within the perfusate may indicate increased cellular damage and an increased risk of primary non function.
-Testing the graft function of warm perfused organs prior to transplantation is
considered the ‘gold’ standard. However, warm perfusion of such organs is difficult to
perform and usually impractical
-The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability.
-· Long term outcomes of DCD recipients are similar to those of DBD recipients and the
allocation system for DCD and DBD organs should be similar.
-· The incidence of delayed graft function is increased in DCD recipients and this
should be discussed with the patient prior to transplantation.
-· Long-term outcomes for standard criteria donors are equivalent for DCD and DBD
kidney transplants.
-· Graft outcome is more closely related to whether a transplant is ECD or SCD than
whether the mode of donation is DCD or DBD.
Immunosuppression
– No definitive data suggest significant benefit from any particular immunosuppressive
regimen in the context of DCD organs.
– Following DCD kidney transplantation, there is increased risk of delayed graft
function due to DCD injury. Induction therapy with mono- or polyclonal antibodies
may be used to reduce the risk of clinically unrecognised acute rejection prior to
recovery from DCD injury Choice of CNI
The majority of the recipients of DCD kidneys reported in the literature have received
Ciclosporin. There are few data comparing the use of Ciclosporin and Tacrolimus in this
context
absolute contraindications to the use of organs for DCD kidney transplantation are:
· End-stage kidney disease (CKD stage 5, eGFR <15 ml/min)
· CKD stage 4 (eGFR 15-30 ml/min)
· Acute cortical necrosis on pre-implantation kidney biopsy Relative contraindications
donor age and cold ischaemic time. Additional factors such as donor hypertension and cardiovascular
disease
For older DCD donors (>60 years), particularly those with hypertension and/or
cardiovascular death, pre-implantation biopsy may identify kidneys with substantial arterial
disease or glomerulosclerosis that are likely to have poor long term outcome
Preservation solutions
No definitive data currently suggest any advantage for specific preservation solutions in the
context of DCD kidney transplantation
Peds DCD transplant :
-Renal and liver grafts from paediatric DCD donors have graft function and transplant
recipient survival rates comparable with organs recovered from SCD donors (3). A recent
review of the limited UK data on DCD donors in paediatric renal transplantation has
suggested that better outcomes are obtained from younger donors (up to 40 years of age)
and shorter functional warm ischaemia times (up to 60 minutes)
-Families of children are more willing to agree to donation than families of adult patients
-Parents and guardians want to be asked about organ donation, including DCD, and parents make no distinction between cardiac and neurologic death
1.Please provide a summary of these guidelines Summary of recommendations A. General: DCD donors categorization
DCD donors categorized based on Maastricht classification.(A1)
WIT starts with SBP drop < 50 mmHg to onset of cold in situ perfusion. (B1)
SaO2<70% is not indicator of poor outcome or a reason for non usage, but correlate with the outcome. (C1) Diagnosis of Death
Irreversible permanent loss of consciousness & brain stem function. (A1)
Death confirmed 5 min post cardio-respiratory arrest if no restoration of artificial cerebral circulation. (B1)
Circulatory arrest: no pulsatile flow on arterial line, or by echo; otherwise by continuous ECG monitoring. (B1)
Retrieval protocols should consider potential risks of post mortem interventions that might restore cerebral perfusion. (B1)
Diagnostic criteria of death after loss of circulatory function should not be affected by the possibility of subsequent organ retrieval. (A1) Law, Ethics & Donor Consent
Staff should be aware of the related ethics. They should be familiar with the terms used to describe & discuss these ethics. (B1)
Good ethics integrate efforts to facilitate & allow transplant in DCD. (B1)
In the UK, DCD is affected by social definitions of death. Non-maleficence not to be affected to facilitate donation & transplant. (B1)
BTS Ethics committee & UK Donation Ethics Committee are ready for guidance & information to support practice. (Not graded) Informing the Recipient
Recipient should receive informed consent by transplant MDT & updated & reviewed annually & documented in the record. (B1)
Tailor information to the requirements of the potential recipient. (B1)
The risk for remaining on the waiting list versus receiving a DCD organ must be discussed. (B1) Organ Retrieval
Treatment withdrawal planned for a time when the donor HLA & virology are known, & the liver & pancreas recipients are in the recipient hospitals. (C1)
Treatment withdrawal in the operating hospital is associated with shorter WIT than withdrawal on a remote ICU or ward. (C1)
Before treatment withdrawal, retrieval team must satisfy about donor details (ABO group,etc). (A1)
Retrieval teams scrubbed in OR at withdrawal time. (B1)
Maastricht 4 donors may be given heparin before treatment withdrawal. No need to reaffirm death once circulatory arrest has occurred. (A1)
Death confirmed 5 min after circulatory arrest. (A1)
Controlled donors: start retrieval by access to Rt CIA or aorta, & IVC abdomen or Rt atrium in chest. (Not graded)
Heparin added to 1stbag of ice-cold solution for perfusion through the aorta. (Not graded)
Streptokinase/rTPA added to 1stbag of solution. (B3)
Kidneys removed individually or en bloc. (Not graded)
Pancreas removed en bloc with liver, or after liver. (Not graded)
Pancreas retrieval: SMV or IMV not to be cannulated for preservation fluid. (B1)
A rapid technique liver retrieval. (Not graded)
Dual perfusion (artery & portal vein) for retrieval of livers. (C1) Viability Testing
Depends on the organ being tested.
Kidneys rapidly retrieved from young controlled DCD donors expected to work promptly if CIT is minimized & organs well perfused on retrieval. Machine perfusion is controversial. (C2)
Uncontrolled DCD or when perfusion of kidneys is poor, machine perfusion parameters may be used. (C1)
For liver & pancreas, viability testing not well established. (Not graded)
The ‘gold’ standard is testing graft function of warm perfused organs before transplant. However, warm perfusion is impractical & difficult. (C2)
The exception is donor lungs where viability testing of ex-vivo lung is done by ventilating the lungs & perfusing with Steen solution. (B1) Immunosuppression
No definitive benefit from any particular IS regimen in DCD organs. (C1)
In DCD kidney transplants, there is increased risk of DGF due to DCD injury. Induction may reduce risk of unrecognized AR prior to recovery from DCD injury. (B1)
Induction is combined with delayed start or reduced CNI to limit DGF incidence & duration. (C2)
In liver TX, consider renal sparing regimens with delayed CNI start. Induction & T cell depletion may also be used, but risk/benefit must be balanced with choice of regimen. (C2)
Heart & lung TX: no evidence to use a regimen different from that used in DBD TX. (C1) =============================================== B. Kidney
Advanced or ESRD, or cortical necrosis on biopsy should not be accepted as donors. (B1)
Use of donors with functional WIT>2 hr or absent BP for 30 min are restricted to protocols that attempt to resuscitate organ viability. (B2)
Units using cold machine perfusion of DCD KTX before implantation should standardize collection of data to enable outcomes analyses. (A2)
No characteristic of dynamics of machine perfusion, perfusate effluent analysis, or biopsy scoring systems (alone or in combination) can predict value to mandate organ discard. (A2)
However, it help decide when dual kidneys TX is needed. (B2)
Long term outcomes & allocation system of DCD are similar to DBD. But, DCD kidneys more susceptible to cold ischaemia. (B2)
DGF incidence increased in DCD recipients; should discuss with patient before TX. (A1)
Antibody induction considered as part of initial IS for recipients of DCD kidneys. (B1)
Long-term outcomes for SCD are equivalent for DCD & DBD KTX. (A1)
Graft outcome more dependent on whether a TX is ECD or SCD than whether donation is DCD or DBD. (B2)
Prospective data needed to know whether impact of ECD is different in DCD & DBD donors. (A1) =============================================== C.Liver
Livers TX from Maastricht 3 DCD donors are useful resource & should be used if deemed safe. (B1)
Outcome appears inferior to livers from DBD donors; more PNF & ischaemic cholangiopathy & higher rate of re-TX. (B1)
DCD & DBD TX with MELD >30 or on organ-perfusion support have similar graft survival. However, no survival benefit when DCD livers are
TX with MELD ≤30 or in those not receiving perfusion support. (B2)
Biliary stricture is lower when a low viscosity solution used to cold flush aorta. (C2)
DCD liver use should be matched & allocated to those who will have greatest transplant benefit. (B2)
Outcome of DCD liver TX improved with short CIT(<8 hrs). (B1)
A better if an ‘ideal’ DCD liver is TX. ‘ideal’ DCD liver donor is <50 yrs old, a WIT <20 min, CIT <10 hr, & <10% steatosis. (B1)
More restrictive DCD Donor criteria: BMI <29 &
WIT <20 min , equivalent 1 & 3-year patient & graft survival rates can be achieved for both DCD & DBD liver TX. (B1)
Long FWIT increased risk of ischaemic cholangio-pathy
Recipients of DCD liver grafts should be informed of the risk & offered choice to refuse such organs prior to TX listing. (C2)
DCD grafts best avoided in recipients of re-TX. (B1)
DCD liver grafts should ideally used in younger recipients (<60 yrs).(B1)
Factors predicting graft failure: age ≥55 yrs, male sex, African–American, HCV +ve, metabolic liver disorder, TX MELD ≥ 35, hospitalization at TX, & need for life support at TX. Recipient predictors of
Mortality: age ≥55 yrs, hospitalization at TX, & re-TX. (B1) =============================================== D.Pancreas
Although DCD organs can be used for isolated pancreas TX in pancreas TX alone, PAK or SPK TX, evidence & current practice are in favour of SPK recipients. (C2)
Pancreas TX from DCD donors are at increased risk of reperfusion pancreatitis & thrombosis; this may be aggravated by long CIT & higher donor BMI. Donor may be a further risk factor. Ideal donors: <60 yrs & BMI <30. (C2)
Pancreas team should stand down after a functional WIT (SBP <50 mmHg &/or SaO2 70%) of 60 min. (C2)
A primary focus of any DCD pancreas TX should be to achieve the shortest possible CIT. (B2)
Higher recipient BMI, age, CV morbidity, & technical surgical factors may contribute to poorer outcome. (C2)
Outcomes for DCD donor pancreas TX are broadly similar to those of DBD donors. (C2)
Graft loss from thrombosis is twice as common in DCD as DBD pancreas TX. A DCD should not be TX into a recipient with a H/O thrombo-embolic disease unless monitored & treated. (C2)
Some TX centers have good expertise with DCD EC pancreas grafts & these guidelines should not restrict innovative but safe practice of pancreas TX. (Not graded) =============================================== E.Pancreatic islets
Selection criteria for recipients is same as for DBD donors. (B2)
Organs from DCD donors for islet isolation & TX allocated through the National Pancreas Allocation Scheme. (B2)
Long term outcome of islet TX from DCD donors has been satisfactory in the UK but the cohort is small. Further audit & research is needed. (C2)
Satisfactory functional islet preparations can be routinely obtained from DCD donors. (C2) =============================================== F.Lung
Donor selection criteria same as for DBD. (B2)
All patients on lung TX waiting list have potential to receive DCD lungs. (C1)
DCD lungs not regarded as extended or marginal. TX outcome & quality is at least similar to DBD organs. (B1)
Do antegrade & retrograde flush perfusion at time of lung retrieval. (B2)
Pre-TX ex vivo lung perfusion (EVLP) is advised if uncertainty of graft performance to safely extend donor & procedural criteria (long WIT, bad flush, clots). (B1)
Acceptance criteria on EVLP: measures of pulmonary compliance, vascular resistance, & gas exchange. (C2) =============================================== G.Heart
In the UK, heart TX from DCD donors is currently NOT standard of care.
For ethical issues, the use of DCD hearts is not currently recommended. (Not graded)
Transplantation from deceased donors after circulatory death (BTS Guidelines-2013 Summary of the Guidelines
Definitions a) Controlled DCD
Organ donation after circulatory arrest, in the context of withdrawal or non-escalation of cardio-respiratory treatments that are considered to be no longer in a patient’s best interests, or occurring in a patient already certified dead by brain stem criteria.
· Maastricht Category 3: Awaiting cardiac arrest.
· Maastricht Category 4: Cardiac arrest in a brain stem dead donor.
b) Uncontrolled DCD
Organ donation from a patient who has suffered an unexpected death that has been confirmed on cardio-respiratory grounds.
· Maastricht Category 1: Dead on arrival.
· Maastricht Category 2: Unsuccessful resuscitation.
· Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient. Diagnosis of Death
a) Death is irreversible and permanent loss of consciousness and brain stem function. (A1)
b) Where cardio-respiratory criteria apply, death can be confirmed following five minutes of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation. (B1)
c) Circulatory arrest should be identified by the absence of pulsatile Flow(assessment of a functioning arterial line, use of echocardiography or by continuous ECG monitoring. (B1)
d) Death may be confirmed 5 minutes after complete circulatory arrest. There is no need for a further stand off period following this.
e) Death can be diagnosed when:
· Asystole has occurred, and
· Brain function has been lost, and
· The possibility of spontaneous return of cardiac function has passed, providing that
· There will be no subsequent intervention that restores cerebral perfusion whilst the brain remains responsive to such restoration.
f) Viability Testing:
· In controlled DCD donors when cold ischaemia is minimised and the kidneys appear well perfused on retrieval.
· For uncontrolled DCD or when perfusion of the kidneys on retrieval is poor, using parameters such as high resistance during machine perfusion or high enzyme levels within the perfusate may indicate increased cellular damage and an increased risk of primary non function.
· The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability. Categorization of DCD donors and warm ischemia time
· Deceased circulatory death donors should be categorised according the Maastricht classification.
· The functional (or true) warm ischaemic period starts when the systolic blood pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion. (B1)
· Donor low oxygen saturation (<70%) is a concern and may well be a measure of inadequate organ perfusion and poor outcome, prospective evidence is awaited. Nomenclature of Time Periods
· The withdrawal period (sometimes called the agonal period): the time from treatment withdrawal to circulatory arrest.
· The asystolic or acirculatory warm period (also known as the primary warm ischaemic time): the time from circulatory arrest to the perfusion of the organs with cold preservation solution in situ.
· The functional (or true) warm ischaemic period: starts when the systolic blood pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion.
Kidney; Specific Recommendation regarding deceased donation
· Individuals with advanced or end-stage chronic kidney disease, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donors. (B1)
· The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability. (B2)
· Units undertaking cold machine perfusion of DCD kidney transplants prior to implantation should collaborate to standardise the prospective collection of data to enable aggregated analyses of outcomes. (A2)
· None of perfusion pressure dynamic characteristics, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems – alone or in combination – have sufficient predictive value to mandate organ discard. (A2)
· Such assessment may, however, help determine when kidneys should be considered for dual transplantation. (B2)
· Long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. Nevertheless, it is recognised that DCD kidneys appear to be more susceptible to cold ischaemia, and the proposed national allocation scheme should take this into account. (B2)
· The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation. (A1)
· Antibody induction therapy should be used as part of the initial immunosuppressive regimen for recipients of DCD kidneys. (B1)
· Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants. (A1)
· Graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD. (B2)
· Prospective data are required to determine whether the impact of expanded criteria donation (ECD) is different in DCD and DBD donors and whether different thresholds for organ use may be required. (A1) Organ Quality Assessment
Donated organ after deceased donation may show one of the followings after transplantation:
a) May work immediately.
b) May recover after a period of impaired or absent function.
c) May never function at all.
Early function is dependent upon:
a) The underlying health of the donor.
b) The ischaemic time.
c) Any damage sustained during the process of the death and organ retrieval.
Because of the availability of dialysis to support initial graft dysfunction, the emphasis in kidney transplantation must be on minimising, and as far as possible eradicating, primary non function (PNF). Parameters for increased risk of PNF:
a) Poor perfusion on retrieval.
b) Low flow rates on machine perfusion.
c) High enzyme levels within the perfusate.
d) Composite scores combining donor hypertension and creatinine with histological scoring provide the best predictive value. Well validated scoring systems based on the ‘Pirani’, Banff, and CADI (chronic allograft damage index) scores show better predictive value for poor graft function at 1 year than clinical scoring systems alone.
Outcome of kidney transplantation afterdeceased donation:
1. It is difficult to summarise the outcome after DCD kidney transplantation as many reports are from single centres, and the donor source in these is variable.
a) In certain countries (e.g. Spain and France), DCD transplantation only occurs from uncontrolled donors.
b) Specific centres in Spain and France utilise extra-corporeal membrane oxygenation, whilst others in France use a cold storage approach.
c) In some countries (e.g. Japan), brain death is recognised but donors are managed as Maastricht 4 and cardiac death is awaited without withdrawal of treatment, so the donors become partly uncontrolled.
d) Until recently in the UK, a significant proportion of DCD was uncontrolled, but this practice is now rare.
e) The Dutch experience is also principally in controlled donors.
2. The overall graft outcome after transplantation is primarily determined by the quality of the donor rather than the mode of donation. Thus, graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD.
3. The most recent evidence suggests that ECD DCD donor kidneys are no more likely to fail early than ECD DBD donor kidneys.
4. DCD kidneys are more prone to the detrimental effects of cold ischaemia than DBD kidneys, as confirmed by a recent UK cohort study.
5. GFR is initially poorer because of the high incidence of DGF in DCD, but is equivalent after 3 months. At 3 years post- transplantation, the median GFR following DCD is 45 ml/min/1.73m2 and following DBD is 46 ml/min/1.73m2.
All health professional should be know well the ethical issue of transplantation of DCD & be familial with terminology used to discuss these ethics.
Both BTS Ethics committee & UK donation ethics committee offer the guidance & information of transplantation in UK.
Donor dignity should not be compromised by increase DCD donors pool.
Verbal & written consent should be offered to the by recipient by multidisciplinary transplant team with explanation of risk of transplantation & being on waiting list.
Organ retrieval:
Treatment withdrawal better to be done in operation department when the donor HLA type & viral screen available to reduce WIT.
Before treatment withdrawal the retrieval team need to know donor information e.g. blood group, past medical history & disease causing the death.
Category 4 Dcd need heparin before treatment withdrawal.
Regular donor hemodynamic parameters chart needed after treatment withdrawal, & for controlled DCD retrieval start by get a large vascular access with 20000 u of heparin added to first ice-cold preservation solution.
Kidney removed individually or as en block & liver also removed alone or as en block with liver.
Viability test:
For controlled DCD kidney donor rapid laparotomy & aortic cannulation & perfusion will facilitate the graft to work promptly, but uncontrolled DCD donor or poorly perfumed organ on retrieval can show high resistant during machine perfusion which indicate increase risk of primary non functioning graft.
Viability test for liver & pancreas not been fully established.
Testing of warm perfused organ before transplantation is difficult & usually impractical except for warm viability of donor lung.
Immunosuppression:
Induction therapy use may reduce subclinical AR prior recovery from DCD & delay CNI introduction can reduce incidence & duration of DGF.
Kidneys:
Patients with CKD & cortical necrosis( diagnosed by renal biopsy) should be declined.
DCD donor with WIT >2hr & absent blood pressure >30 min should be restricted for protocols that attempt to resuscitate organ viability..
Non of dynamic characteristics of machine perfusion, perfusate effluent, biochemical analysis or kidney transplant biopsy score system alone or in combination can predict organ unsuitability, but it may help in choosing dual kidney transplant.
Long term outcome of DCD is comparable to DBD , but incidence of DGF is higher in DCD transplant.
Liver:
Category 3 Maastricht DCD is useful source of liver transplant.
Short & medium term outcome is inferior in DBD donors.
DCD &DBD transplantation with MELD score>30 or organ perfusion support have similar graft survival.
The best CIT is <8hr, & ideal DCD liver donor criteria are: age<50yr, functional WIT <20min, or short CIT<10hr, & <10% steatosis.
1 & 3year survival can be equal in DCD & DBD liver transplantation if BMI<30, & functional WIT<20min( prolonged WIT can increase the risk of ischemic cholangiopathy)..
Factors increase risk of graft failure include age>55yr, male, AA, HCV+ve, metabolic liver disease, transplant MELD score>35, hospitalization at transplant & need for life support at transplant.
The factors that can predict mortality are age>55yr, hospitalization at transplant & re-transplant..
Pancreas:
DCD can be offered as isolated pancreatic transplant, pancreas transplant after kidney transplant or SPT ( favorable transplant).
Factors associated with poor outcome include: increase BMI(>30), age>60yr, & prolonged ischemic time( lead to increase risk of thrombosis & perfusion pancreatitis).
Dear Dr Ban, That is a very good summary. There is nothing unethical about using heart of DCD donors if the outcomes are acceptable.
KAMAL ELGORASHI
2 years ago
Summary of the Guidelines:
Categorization of DCD donors and definition of warm ischemic time: Maastricht classification, is the way of categorizing DCD donors. Warm ischemic period is the time between systolic BP fall below 50 mmHg at least 2 min, and the onset of cold in situ perfusion. Oxygen saturation below 70% is not an indicator of poor outcome.
Maastricht category:
Category one: Death occur outside hospital.
Category 2: unsuccessful resuscitation.
Category 3: awaiting cardiac arrest.
Category 4: cardiac arrest in a brain stem dead individual
Category 5: Unexpected cardiac arrest in a hospitalized patient.
2.Death defined as state in which a patient has permanently lost the capacity for consciousness and brain stem function. Death confirm after 5 minute of continuous cardiorespiratory arrest, providing there is no subsequent restoration of artificial cerebral circulation. Circulatory arrest identified by absence of pulsation, use of echocardiography, or by ECG monitoring. Criteria of diagnosing death should not be influenced by possibility of subsequent organ retrieval.
3.law, ethics, and donor consent; All health professionals should be aware of the complex ethical issues that are associated with DCD. Good ethical practice is to facilitate donation, allocation , and consent to both donor and recipient. DCD in UK is based on definition of death, donor dignity, and non-malfeasance must not be compromised in order to facilitate donation. BTS ethics committee is available for guidance and support practice.
4.Multidisiplinary team for transplantations should provide written information and update regarding records annually. The recipient should be aware about risk Benefit of transplantation and the risk of being on dialysis.
5.Organ retrieval; Treatment withdrawal should be planed when the HLA type and virology are ready and liver , pancreas recipient were in recipient hospital. and should be the operating hospital, with all detailed donor information is available to retrieval team. heparin treatment should be provided for category 4 donors. confirming death after 5 min following complete circulatory arrest. For controlled donor retrieval team should found access to the large arteries and veins. 20 000 iu should be added to the 2 bags of ice-cold solution to be perfused through the aorta. Streptokinase may be added to the 1st bag. Kidney may be removed individually or en bloc. pancreas may be removed in bloc or with the liver or following removal of the liver. Cannula for presrvation should not be placed in SMV or IMV when the pancreas is being retrieved. liver should recovered using a rapid technique which minimizes liver congestion. Dual perfusion of hepatic artery and portal vein is essential for recovery of DCD livers for transplantation.
6.Removal of kidneys: exclude donors from donation with ESKD or donor with cortical necrosis, Restricted use of donors with functional warm ischemic time >2hr or absent blood pressure for 30 min. Assessment should be done to evaluate need for dual transplantation. Long term outcome is equal between DCD and DBD donors Increased incidence of DGF in donors with DCD and this should be discussed with the recipient Recipient with DCD donor should receive induction therapy prior to transplantation. Equall long term outcomefor SDC for DCD and DBD kidney transplant. Graft outcome is mostly related to whether a transplant is ECD or SCD, than whether retrieval is DCD or DBD.
7.Liver; Maastricht 3 DCD donors are useful resource for liver transplant. Liver transplant from DBD donors is inferior and associated with higher rate of re transplantation. Similar graft survival with meld > 30 between DCD and DBD donors. Low viscosity solution should be used to cold flush to aorta to lower the incidence rate of biliary stricture. DCD liver should be matched with recipient in waiting list and according to allocation. DCD outcome in liver transplantation is improved with short CIT, which best kept to under 8 hours. Factors of favorable outcome include; ideal DCD liver, donor < 50 years, WIT time <20 min, shorter CIT <10 hrs, and stenosis <10%. DCD graft are best be avoided in recipient of re-transplant. DCD liver graft should be used in younger recipient < 60 years.
8.Pancreas; can be used as isolated transplant, but current practice are in favour also be transplant with kidney. Pancreas Tx from DCD donor associated with reperfusion pancreatitis, and thrombosis. Most focus of pancreas transplant from DCD donor on minimal cold ischemic time. Poorer outcome for recipient associated with higher recipient BMI, age, CVD, and technical factor. Graft loss from thrombosis is 2;1 between DCD and DBD respectively.
9.Lung: DCD and DBD donor lung transplant are similar outcome. Antegrade and retrograde flush perfusion at time of lung retrieval. Acceptance criteria on EVLP include measures of pulmonary compliance , vascular resistance and gas exchange.
9.Heart; DCD heart transplantation is not standard of care. challenges and ethical issues , so not currently recommended.
Dear Dr Kamal,
That is a good summary. Please type headings and sub-headings in bold or underline. That will make it easier to read.
Mahmoud Wadi
2 years ago
-Please provide a summary of these guidelines
————————————————————–
Deceased circulatory death donors should be categorized according the Maastricht classification .
Warm ischemic period starts when the systolic blood pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion.
Planned withdrawal of life-sustaining critical care treatments. Invasive arterial pressure monitoring, pulse oximetry and continuous surface ECG monitoring likely.
If oxygen saturation below 70% is not used as an indicator of poor outcome.
Maastricht Category 1: Death occurring outside of hospital.
Both Category 1 and 2 donors are also referred to as ‘Uncontrolled’ DCD donors and usually present to the emergency department.
Maastricht Category 3: Awaiting cardiac arrest
Maastricht Category 4: Cardiac arrest in a brain stem dead individual.
Categories 3 and 4 are also referred to as ‘Controlled’ DCD donors.
Maastricht Category 5: Unexpected cardiac arrest in a hospitalised patient
Category 5 is an ‘uncontrolled’ donor in a hospitalised patient so the warm ischaemic time (WIT) between cardiac arrest and organ perfusion is likely to be longer than categories 3 or 4 but shorter than categories 1 or 2.
The withdrawal period (agonal period): the time from treatment withdrawal to circulatory arrest.
The a systolic or a circulatory warm period (primary warm ischemic time): the time from circulatory arrest to the perfusion of the organs with cold preservation solution in situ.
The functional (or true) warm ischemic period: starts when the systolic blood
pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion.
————————————————————————————————————————————————————————————————————————————–
Diagnosis of death
Death is irreversible and should be regarded as a state in which a patient has permanently lost the capacity for consciousness and brain stem function. –
Death can be confirmed following five minutes of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation.
Circulatory arrest should be identified by the absence of pulsatile flow on a correctly functioning arterial line, or by the use of echocardiography if the expertise is available; or failing that by continuous ECG monitoring.
DCD organ retrieval protocols should recognise the potential risks around post mortem interventions that might restore cerebral perfusion.
The criteria for the diagnosis of death following loss of circulatory function should not be influenced by the possibility of subsequent organ retrieval.
DCD is associated with complex ethical issues and we should be familiar with the terminology used and discuss the ethics of DCDTX Good ethical practice is important to enhance organ donation, and allocation including consent from both donor and recipient.
The Ethics Committee is a BTS sub-committee of multidisciplinary healthcare professional practicing in transplantation and its related fields.
————————————————————————————————————————————————————————————————————————————– Organ Retrieval
The retrieval team needs to be satisfied with the donor details (blood group, past medical history, illness leading to death) before treatment is withdrawn.
Treatment withdrawal should ideally be planned for a time when the donor HLA type and virology are known and the liver and pancreas recipients are in the recipient hospitals. (C1)
Treatment withdrawal in the operating department is associated with shorter asystolic periods (warm ischaemic times) than withdrawal on a remoteintensive care unit or ward. (C1)
The retrieval team need to be satisfied about the donor details (blood group, past medical history, illness leading to death) before treatment is withdrawn.(A1)
Retrieval teams should be scrubbed in the operating theatre at the point of treatment withdrawal. (B1)
Maastricht 4 donors, where death has been established previously by brain stem criteria, may be given heparin before treatment withdrawal.
Death does not need to be reaffirmed once circulatory arrest has occurred. (A1)
The specialist nurse should keep a record at regular intervals of the donor’s hemodynamic parameters following treatment withdrawal. (C1)
Death may be confirmed five minutes after complete circulatory arrest.
There is no need for a further stand off period following this. (A1)
For controlled donors, retrieval starts by gaining access to a large artery and vein, typically the right common iliac artery or aorta, and the IVC in the abdomen or right atrium in the chest. (Not graded)
Should be added 20 000 units heparin to the first two bags of ice-cold preservation solution to be perfused through the aorta. (Not graded)
A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen activator may be added to the first bag of preservation solution. (B3)
The kidneys may be removed either individually or en bloc. (Not graded)
The pancreas may be removed either en bloc with the liver, or following removal of the liver. (Not graded)
Cannula for preservation fluid should never be placed in the SMV or IMV when the pancreas is being retrieved. (B1)
The liver should be recovered using a rapid technique which minimizes liver congestion. (Not Graded)
Dual perfusion of hepatic artery and portal vein is essential for recovery of DCD livers for transplantation. (C2
The recipient should take full information about the risk and benefits analysis according to their medical condition before proceeding to the transplantation and getting consent is the duty of the MDT transplant team.
Individuals with advanced or ESKD or with cortical necrosis demonstrable on biopsy should not be considered as potential kidneY donors. (B1)
The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability. (B2)
Units undertaking cold machine perfusion of DCD kidney transplants prior to implantation should collaborate to standardise the prospective collection of data to enable aggregated analyses of outcomes. (A2)
None of perfusion pressure dynamic characteristics, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems – alone or in combination – have sufficient predictive value to mandate organ discard. (A2)
Such assessment may, however, help determine when kidneys should be considered for dual transplantation. (B2)
Long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar.
DCD kidneys appear to be more susceptible to cold ischaemia, and the proposed national allocation scheme should take this into account. (B2)
The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation. (A1)
Antibody induction therapy should be used as part of the initial immunosuppressive regimen for recipients of DCD kidneys. (B1)
Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants. (A1)
Graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD. (B2)
Prospective data are required to determine whether the impact of expanded criteria donation (ECD) is different in DCD and DBD donors and whether different thresholds for organ use may be required.
The guideline is outlining the pathway for performing a cadaveric kidney transplantation, by advocating a comprehensive platform to streamline the process of transplantation from donors post circulatory death DCD .
Via adopting the Maastricht classification of circulatory death, DCD is categorized into 5 subtypes including controlled death of 2 subtypes:
Maastricht category 3: awaiting for cardiac arrest in a patient who is withdrawn from cardio-respiratory support .
Maastricht category 4: awaiting cardiac arrest in a patient who is already declred brain stem dead.
On the other hand uncontrolled DCD includes those patients who sustained cardiac arrest in different setting outside the hospital
Maastricht category 1: When the patient had cardiac arrest outside the hospital and reach dead to ED.in order to be potential donor, cardiac arrest has to be witnessed and CPR was continued until reaching the hospital.
Maastricht category 2:the patient failed resuscitation and declared dead in ED.
Maastricht category 5:unexpected cardiac arrest in critically ill patients.
Cardiac death is defined as persistant asystole after 5 minutes of failed cardiopulmonary resuscitation. It has to be confirmed by echocardiography or continuous ECG monitoring.
Important notes to be highlighted as it was advocated by this guideline:
Warm Ischemia time: defined by the occurance of systolic blood pressure of 50 for at least 2 minutes until the the start of Cold Ischemia time by intravascular Infusion of cold Infusate.
Its recommended that warm Ischemia time is not exceeding 2 hours, or asystole duration of 30 minutes.
DCD is not varied from DBD regarding the kidney transplant outcome. What is impactful is the ECD vs SCD.
There are 5 types of DCD divided in two major categories:
Controlled DCD :
Maastricht Category 3: Awaiting cardiac arrest.
Maastricht Category 4: Cardiac arrest in a brain stem dead donor.
Uncontroled DCD :
Maastricht Category 1: Dead on arrival.
Maastricht Category 2: Unsuccessful resuscitation.
Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient
CATEGORISATION OF DCD DONORS & DEFINITION OF WARM ISCHAEMIC TIME:
Deceased circulatory death donors should be categorised according the Maastricht classification to aid research, communication and audit. (B1)
The functional (or true) warm ischaemic period starts when the systolic blood pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion. (B1.
Although donor low oxygen saturation (<70% is of concern and may indicate organ hypo perfusion, and poor outcomes) The current recommendation is that oxygen saturation below 70% is not used as an indicator of poor outcome or as a reason for non usage, but that retrieval teams should keep a record of when oxygen saturation falls below 70% in order to allow correlation with graft outcome.
Definition –terms: The withdrawal period (agonal period): the time from treatment withdrawal to circulatory arrest. The asystolic or acirculatory warm period (primary warm ischaemic time): the time from circulatory arrest to the perfusion of the organs with cold preservation solution in situ. The functional warm ischaemic period: starts when the systolic blood pressure falls below 50 mmHg for 2 minutes or more and extends up to the onset of cold in situ perfusion.
DIAGNOSIS OF DEATH
Death is irreversible and should be regarded as a state in which a patient has permanently lost the capacity for consciousness and brain stem function. (A1)
Cardio-respiratory criteria death can be confirmed following five minutes of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation. (B1).
Circulatory arrest should be identified by the absence of pulsatile flow on a correctly functioning arterial line, or by the use of echocardiography if the expertise is available; or failing that by continuous ECG monitoring. (B1).
DCD organ retrieval protocols should recognise the potential risks around post mortem interventions that might restore cerebral perfusion. (B1).
The criteria for the diagnosis of death following loss of circulatory function should not be influenced by the possibility of subsequent organ retrieval. (A1).
LAW, ETHICS AND DONOR CONSENT
Healthcare professionals should be familiar with the terminology used to describe and discuss the ethics of DCD transplantation. (B1). Altruism, Autonomy, Dignity, do no harm, Futility, and Equity.
Good ethical practice is integral to efforts to facilitate donation and achieve transplantation in the context of DCD. This includes decisions about allocation and consent in relation to both the organ donor and recipient. (B1).
DCD in the United Kingdom is underpinned by definitions of death that are accepted by society. The principles of donor dignity and non-malfeasance must not be compromised in efforts to facilitate donation and transplantation from DCD donors. (B1).
Ethical principles integral to the UK controlled DCD programme must extend to any future uncontrolled DCD programme. (B1).
INFORMING THE RECIPIENT
Providing oral and in writing information, for the potential transplant recipient is a requirement for consent and is the responsibility of the transplant team. This must be updated and reviewed annually and the outcome of discussions clearly documented in the patient’s medical record. (B1).
Information should be tailored to the requirements of the potential recipient, some patients wish to receive detailed information, this must not preclude engagement with the transplant process. (B1).
The risk benefit analysis presented to the potential transplant recipient must explain the relative risk for that recipient of remaining on the transplant waiting list compared to that of receiving a DCD organ. (B1).
ORGAN RETRIEVAL
Treatment withdrawal should ideally be planned for a time when the donor HLA type and virology are known and the liver and pancreas recipients are in the recipient hospitals. (C1).
Treatment withdrawal in the operating department is associated with shorter warm ischemia time than withdrawal on a remote intensive care unit or ward. (C1).
The retrieval team need to be satisfied about the donor details (blood group, past medical history, illness leading to death) before treatment is withdrawn. (A1).
Retrieval teams should be scrubbed in the operating theatre at the point of treatment withdrawal. (B1).
Maastricht 4 donors, where death has been established previously by brain stem criteria, may be given heparin before treatment withdrawal. Death does not need to be reaffirmed once circulatory arrest has occurred. (A1).
The specialist nurse should keep a record at regular intervals of the donor’s haemodynamic parameters following treatment withdrawal. (C1).
Death may be confirmed five minutes after complete circulatory arrest. There is no need for a further stand off period following this. (A1).
For controlled donors, retrieval starts by gaining access to a large artery and vein, typically the right common iliac artery or aorta, and the IVC in the abdomen or right atrium in the chest. (Not graded).
20,000 units heparin should be added to the first two bags of ice-cold preservation solution to be perfused through the aorta. (Not graded).
A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen activator may be added to the first bag of preservation solution. (B3).
The kidneys may be removed either individually or en bloc. (Not graded).
Abdominal Organs: Specific Procedures
The article summaries the surgical procedure to remove each organ.
ORGAN SPECIFIC DISCUSSION The kidney:
Individuals with end-stage chronic kidney disease, or with cortical necrosis demonstrated by biopsy should not be considered as a kidney donors. (B1).
The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to protocols which attempt to resuscitate organ viability. (B2).
Units undertaking cold machine perfusion of DCD kidney transplants prior to implantation should collaborate to standardise the prospective collection of data to enable aggregated analyses of outcomes. (A2)
None of perfusion pressure dynamic characteristics, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems, have sufficient predictive value to mandate organ discard. (A2).
This help determine when kidneys should be considered for dual transplantation. (B2).
Long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. but DCD kidneys appear to be more susceptible to cold ischemia, and the proposed national allocation scheme should take this into account. (B2).
The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation. (A1).
Antibody induction therapy should be used as part of the initial immunosuppressive regimen for recipients of DCD kidneys. (B1).
Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants. (A1).
Graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD. (B2).
Prospective data are required to determine whether the impact of expanded criteria donation (ECD) is different in DCD and DBD donors and whether different thresholds for organ use may be required. (A1).
BTS guide line of DBD AND DCD;
first will speak about the categorization from 1to 5 :
Category 1: patient died outside the hospital, witnessed, time of collapse is known and resuscitation done.
Category 2: patient collapsed and CPR started outside the hospital, and death occur inside the hospital (Unsuccessful resuscitation)
Category 3: Cardiac arrest is inevitable in a patient without brain stem death (awaiting cardiac arrest)
Category 4: Cardiac arrest after brain stem death
Category 5: Unexpected cardiac arrest in a hospitalised patient
usually category 1,2,3 are uncontrolled DCD with poor kidney while controlled DCD is better regarding kidney viability .
warm ischemia time started once the systolic bp drop to below 50for 2 mint till the the start of cold perfusion .and it is usually longer in Category 1 and 2 .
before starting organ retrieval ,all the donor family and the recipient should be aware of all the proceeduer and written consent should be taken .
Donor HLA and virology screening should be known before treatment withdrawal ,after the family agreed with donation the the patient will be taken to the operating room for extubation and will hold the type of medications and continue with iv heparin infusion to prevent organ thrombosis.
the specialize nurse will closely observe the patient as once all medications stopped the team will wait 5 mint after that will start the cold preservative infusion through cannulation for the right common iliac artery and IVC and the surgical team will start removing all organs .
If patient after 2hour not arrested ,then will be taken to ICU .
Hi Dr Rihab,
I did not understand when you typed, and I quote, “patient after 2hour not arrested ,then will be taken to ICU.”
I would clarify over here that withdrawal of treatment of such prospective DCD donors is done wherever they are located usually in ICU or in HDU. Then why to take to ICU is donor did not reach fruition.
Last edited 2 years ago by Ajay Kumar Sharma
Sherif Yusuf
2 years ago
Categories of DCD Donors (Maastricht classification)
Category 1: patient died outside the hospital, witnessed, time of collapse is known and resuscitation done.
Category 2: patient collapsed and CPR started outside the hospital, and death occur inside the hospital (Unsuccessful resuscitation)
Category 3: Cardiac arrest is inevitable in a patient without brain stem death (awaiting cardiac arrest)
Category 4: Cardiac arrest after brain stem death
Category 5: Unexpected cardiac arrest in a hospitalised patient
Category 1, 2 and 5 are considered uncontrolled DCD donors and usually are found in ER department, while category 3 and 4 are referred to as controlled DCD donors and are usually found in the ICU, CCU
Warm ischemia time
Warm ischemia time starts when SBP is persistently < 50 mm Hg for at least 2 min and ends at the start of cold solution perfusion
It is longer in category 1 and 2, followed by 5 and is shorter in category 3 and 4 DCD donors
Diagnosis of death and circulatory arrest
Death is defined by permanent loss of consciousness associated with absences of brain stem function
Circulatory arrest is diagnosed by either the absence of pulsatile flow in a well-functioning arterial line, ECG or ECHO
Organ Retrieval
Before treatment withdrawal the donor HLA and virology should be known and the recipient should be in the hospital in case of liver or pancrease transplantation
A written consent and an oral explanation of the procedure including the risk and benefit should be done for both deceased donor family and the recipient
After decision of withdrawal of life support by the family and after taking consent for organ donation, the patient is transferred to the operating room (to decrease warm ischemia time) for withdrawal of life support (medications, IV fluids and ventillatory support), at that time systemic heparin is usually administered to prevent organ thrombosis. Surgical team should be present before extubation, then lastly extubation should be done at the operating theater
The specialist nurse should keep a vital signs record of the donor after withdrawal of life supports, If cardiorespiratory arrest occurs (absence of respiration, systole, and irresponsiveness) within 2 hours of withdrawal ventilatory support, the team will wait for 5 min in order to confirm cardiac death then canulation of the right common iliac artery or aorta and IVC is done with infusion of cold preservative and the surgical team will work to remove organs
Hypoxia with O2 saturation of < 70 % is not considered by these guidelines as an indicator for poor graft outcome but if happen it should be recorded for further studies
20000 units of heparin (sometimes streptokinase or TPA ) should be added to the first bag of cold perfusing solution
If cardiac arrest did not occur within 2 hours the patient should return to the ICU and should not be considered as a potential donor
The kidney either is removed alone or en bloc
Viability testing
In case of controlled DCD donors, viability of the kidney can be determined by inspection and expectation of being well perfused while in uncontrolled DCD the poor quality kidney can be known form resistance during perfusion and elevation of enzymes in the solution (not universally accepted)
No viability testing is done for the liver or the pancerase
Immunosuppression
No clear benefit of immunosuppressive over the other in case of DCD organs transplantation but because of the higher risk of DGF it is better to give induction therapy using mono- or polyclonal antibodies, and delay CNI to decrease both the probability and duration of DGF and this issue should be discussed with the recipient
Graft outcome
DCD transplantation has reasonable long term graft outcome comparable to DBD transplantation, but it is more susceptible to cold ischemia time and this should be put in consideration while allocating the organs, and the main determinant of graft outcome is the criteria (ECD or SCD) not the mode of the donor kidney (DCD or DBD)
Donation of organs from dead donors following circulatory death
BTS guidelines
PART 1: GENERAL PRINCIPLES
3 CATEGORISATION OF DCD DONORS & DEFINITION OF WARM ISCHAEMIC TIME
Donors who have died of circulatory death should be classified according to the Maastricht categorization in order to facilitate study, communication, and auditing. (B1). The functional (or genuine) warm ischemia phase begins when the systolic blood pressure falls below 50 mmHg and ends when cold in situ perfusion begins. Retrieval teams should record when oxygen saturation falls below 70% to allow linkage with graft outcome.
Maastricht Categorical 1: Deaths outside of the hospital
The death has been confirmed outside of a medical setting. For these people to be considered acceptable organ donors, the moment of sudden death must have been observed, the time of death must be recorded, and’resuscitation’ must have continued after death.
Maastricht Category 2: Unsuccessful resuscitation
Following the collapse, CPR was begun outside of the hospital. Death is verified upon hospital arrival.
Both Category 1 and Category 2 donors are referred to as “uncontrolled” DCD donors and typically appear in the emergency department.
Death is inevitable (terminal condition), but the requirements for brain stem death are not met. These patients are often recognized in neurosurgery and general critical care units, coronary care units, emergency departments, and medical wards, but are treated in a variety of hospital departments.
Maastricht Category 4: Cardiac arrest in a patient with brain stem death
The patient has a cardiac arrest following a diagnosis of death based on brain stem criteria.
Donors in categories 3 and 4 of DCD are also known as “controlled” donors.
unanticipated cardiac arrest in a hospitalized patient: uncontrolled donor in a hospitalized patient.
These categories primarily address the warm ischemic time (WIT) differential between cardiac arrest and organ perfusion. Category 5 tends to be longer than Categories 3 and 4, but shorter than Categories 1 and 2.
DIAGNOSIS OF DEATH
Expressions of Recommendation
Death results in the irreversible loss of consciousness and brain stem function. (A1) After five minutes of sustained cardiorespiratory arrest, death can be proven if there is no subsequent restoration of artificial cerebral circulation. (B1) circulatory arrest must be diagnosed by the lack of pulsatile flow on a properly functioning arterial line, by the use of echocardiography if the requisite knowledge is available, or by the failure to detect circulatory arrest with continuous ECG monitoring. (B1)
ALL HEALTHCARE PROFESSIONALS MUST BE AWARE OF THE COMPLEX ETHICAL ISSUES ASSOCIATED WITH DONOR CONSENT AND DONATION AFTER CARDIOVASCULAR DEATH (DCD) AND ORGAN TRANSPLANTATION
Socially accepted criteria of death are the foundation of a successful cadaveric program, and donor dignity and non-malfeasance must not be compromised in attempts to promote donation and transplantation from DCD donors. (B1). The BTS Ethics committee is ready to provide guidance and assistance for practice in this complicated subject. (Not graded)
NOTIFYING THE RECIPIENT OF:
The multidisciplinary transplant team is responsible for providing information (the risk-benefit analysis) orally and in writing with informed consent. This must be reviewed and updated on a yearly basis, and the outcome of these conversations must be properly noted in the patient’s medical record. (B1)
ORGAN RETRIEVAL Treatment withdrawal should preferably be scheduled at a time when the donor’s HLA type and viral load are known and the liver and pancreas recipients are at the recipient hospitals. (C1)
Treatment withdrawal in the operation room is related to a shorter A systolic period (warm ischemic periods) compared to withdrawal in a distant critical care unit or ward. Before treatment is stopped, the retrieval team must be satisfied with the donor’s data (blood type, medical history, and cause of death). (A1)
Maastricht 4 donors, for whom brain stem criteria have already confirmed death, may be administered heparin prior to treatment cessation. Once circulatory arrest has occurred, there is no need to reconfirm death. Following treatment withdrawal, the expert nurse should document the donor’s hemodynamic parameters at regular intervals. (C1)
Death can be verified five minutes after circulatory arrest is complete. There is no additional need for a standoff period after this. (A1)
For controlled donors, retrieval begins by getting access to a big artery and vein, often the right common iliac artery or aorta, as well as the IVC in the belly or the right atrium in the chest. 20,000 units of heparin must be added to the first two bags of ice-cold preservation solution before they are perfused into the aorta. A fibrinolytic agent, such as streptokinase or recombinant tissue plasminogen activator, may be added to the first bag of preservation solution. (B3)
The kidneys may be extracted separately or collectively. The pancreas may be removed either simultaneously with the liver or after the liver has been removed. (Not graded)
Never insert a cannula for preservation fluid into the SMV or IMV when retrieving the pancreas. (B1)
The liver should be recovered rapidly using a method that minimizes congestion. (Not Weighted)
Dual perfusion of the hepatic artery and portal vein is needed for the transplantation of DCD livers. (C2)
PART 2: ORGAN-SPECIFIC DISCUSSION
(Kidney-liver-pancreas-lung-heart)
1-KIDNEY
When should kidneys be discarded? The use of donors with functional warm ischemia duration of >2 hours or absent blood pressure for 30 minutes should be limited to experimental techniques that aim to restore organ viability. (B2) Individually or in combination, none of the perfusion pressure dynamic features, perfusate effluent biochemical analyses, or kidney transplant biopsy grading methods had significant prognostic value for force organ disposal. However, this evaluation may assist in determining when kidneys may be considered for dual transplantation. (B2).
Is there a distinction between DCD and DBD in terms of the kidneys?
The long-term results for DCD and DBD patients are comparable, and the allocation systems for DCD and DBD organs should be similar. However, it is acknowledged that DCD kidneys tend to be more sensitive to cold ischemia, and the suggested national allocation mechanism should account for this. (B2): The incidence of delayed graft function is higher in DCD recipients; this should be communicated with the patient before transplantation. (A1) Long-term results for donors meeting standard criteria are equal for DCD and DBD transplants. (A1) -ECD versus SCD transplantation had a stronger correlation with graft outcome than DCD versus DBD retrieval. (B2) o Prospective data are required to establish if the impact of extended criteria donation (ECD) differs between DCD and DBD donors and if alternative organ usage thresholds may be necessary. Does DCD necessitate any special immunosuppressive regimen modifications?
Antibody induction therapy should be incorporated into the first immunosuppressive regimen for DCD kidney transplant patients. (B1)
Hi Dr Habli,
When you mention ‘functional warm ischemia’ do you mean ‘agonal phase’?
saja Mohammed
2 years ago
Summary
The concept of brain death was defined in the 1970s in order to bridge the gap between the supply and the need for organs in order to reduce waiting time and since that time the DD has evolved over time from DCD, brain stem death (DBD), and controlled vs uncontrolled DCD, in the UK most DD programs include controlled DCD ‘controlled’ Maastricht category 3. Efforts to expand donations are
likely to lead to increased ‘uncontrolled’ DCD activity (Maastricht category 2 or even 1). This guideline discusses in 3 parts Part 1
includes general principles about the definition of DD including the differentiation between DBD, DCD, uncontrolled vs-controlled DCD the definition of worm ischemia time
Frameworks for the diagnosis and confirmation of death
Ethics and law of donation, donor uncontrolled DCD donation, donor distress and rights after death, quality of organ and recipient risk organ preservation solution and organ recovery, staffing for retrieval procedures, specific procedures related to the abdomen and thorax Part 2.
organ-specific discussion including kidney heart, lung, liver, and pancreas and discusses the donor selection, organ preservation, quality of organ assessment, recipients’ selection, immunotherapy, and outcome Part 3
Pediatric DCD transplantation
Classification of DCD is important for the logistics of organ retrievals and functional assessment of the organ and its effect on transplant outcome Controlled DCD refers to organ donation after circulatory death without activating the CPR or in a patient already certified dead by brain stem criteria.in ICU or ER setting
Maastricht Category 3: Awaiting cardiac arrest
Maastricht Category 4: Cardiac arrest in a brain stem dead donor
Uncontrolled DCD refers to organ donations from patients with the unexpected death that had been confirmed by cardiorespiratory ground
Maastricht Category 1: Dead on arrival or death witness outside the hospital and resuscitation should be continued and time should be counted
Maastricht Category 2: Unsuccessful resuscitation in a hospital setting
Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient with long warm ischemia time (WIT)than categories 3 or 4 but less than categories1 or 2 Categorization of DCD Donors 1. Sustained systolic BP < the 50smmgh for two minutesand extends up to the onset of cold in situ perfusion is the functional or true time for warm ischemia. While primary warm ischemia is the systolic or circulatory warm period. true warm ischemia is important in assessing organ damage, not the asystole period.
2. Oxygen saturation below 70% is no longer used as an indicator of poor outcome or as a reason for non-usage
3. at the warm ischemia time the cells shift from aerobic to anaerobic metabolism due to the depletion of ATP which is essential for membranes ion exchange activity and lead to cellular dysfunction and cell death however in cold ischemia the metabolism will be slowed down so cells and organs can survive for longer time Diagnosis of Death
Refers to the state of irreversible and permanent unconsciousness with loss of brain stem functions
cardio-respiratory criteria apply, death can be confirmed following five minutes
of continuous cardio-respiratory arrest providing, there is no subsequent restoration of artificial cerebral circulation
circulatory death can be recognized by absent arterial pulsation through functional arterial line or failing by ECG monitoring, or by echo
the criteria for the diagnosis of death following circulatory arrest should not be motivated by possible organ retrieval (A1).
DCD is associated with complex ethical issues and we should be familiar with the terminology used and discuss the ethics of DCDTX
Good ethical practice is important to enhance organ donation, and allocation including consent from both donor and recipient, the BTS ethics committee is available and can provide all the information needed to this extent. Organ Retrieval 1. The retrieval team needs to be satisfied with the donor details (blood group, past medical history, illness leading to death) before treatment is withdrawn. (A1)
2. Treatment withdrawal should be planned at the time of Donor HLA-typing and virology is known for liver and pancreas recipients should be hospitalized.
3. retrieval teams should be scrubbed in the operating room at the point of treatment withdrawal this will shorten the ischemia times. and maastricht4 donors should be given heparin before treatment withdrawal and the nurses should keep interval vitals parameters following treatment removal
Confirmation of death after 5 minutes from complete circulatory arrest(A1).
controlled donors, retrieval starts by gaining access to a large artery and vein, the right common iliac artery or aorta, and the IVC in the abdomen or right atrium in the chest.
Additional anticoagulation like heparin 20000 iu should be added to the ice-cold preservation solution and to be transfused to the aorta
Fibrinolytic agents like streptokinase or Plasminogen activator may also be added to the preservation solution
The kidney can be removed alone or en bloc, pancreas either en bloc with the liver or after the removal of the liver. Dual perfusion of both artery and portal vein is essential for the recovery of DCD livers for transplantation. (C1)
Three concepts are important to balance the donor and recipient risk in the case of DCD, DBD donor allocation
1. equity
2. productivity ensures minimal waste of organs
3. effectiveness, delivery of organs, and making the best use of benefits to recipients. avoid transplanting low-risk recipients with DCD organs or from higher-risk donors and the more clinical justification would be allocation of DCD to higher-risk recipients and good organs were not wasted and this should go through very complex organ allocation algorithms.
The recipient should take full information about the risk and benefits analysis according to their medical condition before proceeding to the transplantation and getting consent is the duty of the MDT transplant team.
Donors with advanced or ESKD or cortical necrosis (biopsy proven) should be declined, and the use of donors with FWIT> 2 hr or no BP for > 30 minutes should be limited to protocols with resuscitating organ viability., cold machine perfusion of DCD kidney transplants should standardize the probable gathering of information and help in the examination for organ outcomes.
None of the perfusion pressure dynamic, perfusate effluent biochemical analysis, or kidney biopsy scoring alone or in combination have adequate analytical value to dictate organ discard but can help regulate when should consider for dual transplantation
Long-term outcomes For SCD are similar for DCD and DBD kidney transplants (A1). however, transplant outcome is more linked to a transplant is ECD vs SCD rather than the mode of retrieval ( DCD vs DBD).
Absolute contraindications to using organs for DCD kidney transplants
In addition to the general known contraindication including active infection, active invasive or hematological malignancy, HIV
1. Advanced CKD stage 4.5
2.Acute cortical necrosis (pre-implantation biopsy proven), but ATN including the transient need for dialysis is a relative contraindication and associated with a higher risk of DGF or primary nonfunctioning graft
3. Additional relative CI includes donor age> 60 yr, cold ischemia time, donor comorbid (hypertension, CVD) preimplant biopsy with confirmed arterial disease, and or glomerulosclerosis which can affect the long-term graft outcome
Immunosuppression in the DD setting
Includes induction, mono or polyclonal agents with delayed introduction of CNI due to increased risk and frequency PNF graft or more DGF, especially with DCD, many cohort studies encourage the use of 1L2 inhibitors basiliximab or daclizumab For low or standard immunological risk and polyclonal ATG or monoclonal alemtuzumab preferred for high immunological risk with preferred delayed the introduction of CNI, especially in DCD with prolonged ischemia time and risk of subclinical rejection can be masked in the presence of DGF
-The Maastricht classification should be used to classify circulatory death donors who have died. This will help with research, communication, and auditing.
-The functional (or true) warm ischaemic period begins when the systolic blood pressure stays below 50 mmHg for at least two minutes and ends when cold in situ perfusion starts.
– Donor low oxygen saturation (70%) is a concern and may be a sign of poor organ perfusion and a bad outcome, but evidence from the future is still needed. The current recommendation is that an oxygen saturation of less than 70% shouldn’t be taken as a sign of a bad outcome or a reason not to use the graft. Instead, retrieval teams should keep track of when the oxygen saturation drops below 70% so that they can compare it to the graft’s outcome.
– Whenever possible, the circulatory arrest should be spotted by the lack of pulsating blood flow through an arterial line that is working properly, by using echocardiography if the right skills are available, or by keeping an eye on the ECG.
-Protocols for organ retrieval after DCD should take into account the possible risks of post-mortem interventions that could restore blood flow to the brain.
-The fact that organs might be taken out later shouldn’t change how you decide if someone is dead after their circulation stops working.
-All people who work in health care should know about the complicated ethical issues that come with organ donation after circulatory death (DCD) and organ transplantation. These professionals should know the terms used to talk about and explain the ethics of DCD transplantation.
– This includes making decisions about allocation and consent for both the organ donor and the person who will receive the organ.
– In order to make a donation and transplantation from DCD donors easier, the dignity of the donor and the idea that no wrongdoing should be done must not be compromised.
-Any future uncontrolled DCD program must follow the same ethical rules as the UK’s controlled DCD program.
-The BTS Ethics committee can help with advice and information about how to work in this complicated field. (Not graded)
-You can also get advice and information from the UK Donation Ethics Committee. (Not graded).
The multidisciplinary transplant team is in charge of giving the potential transplant recipient information both verbally and in writing. This is a requirement for consent and is part of their job. This must be updated and looked over once a year, and the results of any talks must be written down in the patient’s medical record.
Information should be tailored to the needs of the person who might get it since not all patients want to know a lot of details. But this shouldn’t stop people from taking part in the transplant process.
The risk-benefit analysis given to the person who might get a transplant must explain how much more dangerous it is for that person to stay on the transplant waiting list than to get a DCD organ.
People with advanced or end-stage chronic kidney disease or cortical necrosis that can be seen on a biopsy shouldn’t be thought of as possible kidney donors.
Donors with a functional warm ischaemic time of more than 2 hours or no blood pressure for more than 30 minutes should only be used in experimental protocols that try to bring back organ viability.
Units that do cold machine perfusion of DCD kidney transplants before putting them in should work together to standardize the prospective collection of data so that results can be looked at as a whole.
Neither perfusion pressure dynamic characteristics, perfusate effluent biochemical analysis, nor kidney transplant biopsy scoring systems, alone or together, have enough predictive value to force organ discard.
However, this kind of evaluation could help figure out when two kidneys should be considered for transplantation.
The long-term results for people who get organs through DCD are the same as those for people who get organs through DBD, so the system for giving out organs through DCD and DBD should be the same.
Still, DCD kidneys seem more likely to be damaged by cold ischaemia, and the proposed national allocation scheme should take this into account.
DCD recipients are more likely to have delayed graft function, which should be talked about with the patient before the transplant.
Antibody induction therapy should be part of the first immunosuppressive plan for people who get kidneys from DCD.
The long-term results for donors who meet standard criteria are the same for both DCD and DBD transplants.
-Livers transplanted from Maastricht 3 DCD donors are a useful resource and should be used where deemed safe.
-Even though DCD organs can be used for isolated pancreas transplants (pancreas transplant alone or pancreas after kidney), evidence and current practice are increasingly in favour of using them for simultaneous pancreas and kidney transplantation (SPK).
-Selection criteria for recipients of islets from DCD donors should be the same as for DBD donors.
– The donor selection criteria for lung DCD should be the same as for DBD.
Summary of recommendation
The functional(or true)warm ischemia period starts when the systolic blood pressure has a sustained(i.e.at least 2 minutes)fall below50mmhg and extend up to the onset of cold in situ perfusion(B1).
Good ethical practise is to efforts to facilitate donation and achieve transplantation in the context of DCD .this include decision about allocation and consent in relation to both the organ donor and recipient(B1).
The criteria for the diagnosis of death following loss of circulatory function should not be influenced by the possibility of subsequent organ retrieval.(A1).i
The retrieval team need to be satisfied about the donor details(blood group ,past medical history ,illness leading to death)before treatment is withdrawn.(A1).
Injury Following DCD kidney transplantation, there is increased risk of delayed graft function due to DCD injury. Induction therapy with mono- or polyclonal antibodies may be used to reduce the risk of clinically unrecognized acute rejection prior to recovery from DCD injury.(B1).
The incidence of delay graft function is increased in CDC recipient and this should be discussed with the patient prior to transplantation.(A1).
None of perfusion pressure dynamic characteristic, perfusate effluent biochemical analysis ,or kidney transplant biopsy system alone or in combination have sufficient predictive value to mandate organ discard.(A2).
Maastricht 4 donors ,where death has been established previously by brain stem criteria, may be given heparin before treatment withdrawal(A1).
Antibody induction therapy should be used as part of the initial immunosuppressive regimen for recipient of DCD kidneys.(B1).
Graft outcome related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD(B2).
· Categorization of DCD donors & definition of warm ischemic time:
o categorised according the Maastricht classification into 5 categories.
o Categories 1, 2 and 5 are called (non-controlled) and (3, 4 are called controlled).
o Controlled means that the treatment is withdrawn on an intensive care unit (ICU) or emergency department (ED) and death follows. Uncontrolled donation means that the potential donors who suffer an unexpected cardiac arrest and are either brought into hospital dead or when death is declared in hospital following unsuccessful attempts at cardiopulmonary resuscitation (CPR).
o Donation after Circulatory (previously called cardiac) Death (DCD) was previously known as Non Heart Beating Donation (NHBD).
· Important definitions:
o The withdrawal period(agonal period): the time from treatment withdrawal to circulatory arrest.
o Warm ischemia time (asystolic/acircualtory warm period) is defined as time between the circulatory arrest (fall of systolic blood pressure below 50 mmHg and sustained (for at least 2 minutes)) up to the onset of cold in situ perfusion.
· Diagnosis of death:
o Death is an irreversible state, in which a patient has permanently lost consciousness and brain stem function.
o Death can be confirmed following five minutes of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation.
o Circulatory arrest can be identified by the absence of pulsatile flow on a correctly functioning arterial line, or by the use of echocardiography or by continuous ECG monitoring.
o DCD organ retrieval protocols should recognize the potential risks around post mortem interventions that might restore cerebral perfusion.
o The criteria for the diagnosis of death following loss of circulatory function should not be influenced by the possibility of subsequent organ retrieval.
o Death is confirmed after 5 min from circulatory arrest.
· Ethical issues: all the team should be aware of them and consent must be taken from the donor relatives and the recipient as well.
· Organ retrieval:
o Best outcome when treatment withdrawal occurs in the operating room
o treatment withdrawal from deceased donor only done when donor HLA , ABO blood group, virology status and cause of death are known, and the recipient is ready to shorten warm ischemia time.
o Access or cannulation of aorta and IVC should be established.
o Heparin and fibrinolytic agents are added to the first infused cold ice preservation saline.
§ Donor selection:
o Kidney with ESKD or cortical necrosis should be declined.
o The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability.
o DBD has similar graft outcome to DCD in spite of prolonged cold ischemia time in DCD with higher risk of DGF.
o The graft outcome is more related to either it is strict or extended criteria donor rather than it is related to DCD or DBD.
· Immunosuppressive therapy:
o Better to use induction therapy to prevent subclinical unrecognized acute rejection and to delay start of nephrotoxic CNI (to limit and avoid DGF, occurring with cadaveric donor)
· Systemic heparin is used if there is no immediate graft function
· Prophylactic antibiotic cover including anaerobic prophylaxis may be needed for high risk recipients before the transplantation for three days
Summary of BTS Transplantation guidelines for deceased donors after circulatory death :
Deceased circulatory death donors are categorized based on Maastricht classification.
If oxygen saturation goes below 70%, then it has to be recorded so that later it can be considered with respect to graft outcome.
Circulatory arrest should be identified by absence of pulsatilla flow on arterial line, or by echocardiography.The last option would be continuous ECH monitoring.
Risks of postmortem intervention should be considered because of restoration of cerebral perfusion.
Consent from relations/guardian of organ donor and recipient is paramount.
Death does not need to be reaffirmed once circulatory arrest has occurred.
Kidneys can be removed individually or en bloc.
Individuals with ESKD or cortical necrosis on biopsy cannot be taken for donation.
Restricted use of donors with more than 2 hours of functional warm ischaemic time or absent BP for 30 minutes
Antibody induction therapy should be started as part of initial immunosuppressive regimen
20,000 units heparin should be added to the first two bags of ice cold preservation solution to be perfumed through the aorta.
Cyclosporine is used in these recipients as CNI therapy. Some cases use tacrolimus.
Induction therapy would be Basiliximab for low risk recipients and Alemtuzumab or ATG for highly sensitized or high risk recipients.
Systemic heparinisation is used if there is no immediate graft function
Peophylactic antibiotic cover including anaerobic prophylaxis may be needed for high risk recipients before the transplantation for three days.
Graft outcome depends on whether the kidney is ECD vs SCD or whether mode of retrieval is DCD vs DBD. DCD kidneys are more significantly impacted by cold ischaemia than DBD kidneys. CIT is to be minimized as far as possible.
I appreciate your short write-up, dear Dr Nandita Sugumar
Dr Ps Vali
2 years ago
I will summarize the guidelines relavant to my practise as a Transplant Nephrologist:
There are five categories of Donation after cardiac death – Maastricht classification.
The purpose of this classification is to facilitate logistics, research and auditing of the outcomes
The five categories include:
Category 1: Death was decleared outside a hospital environment
Category 2: CPR was initiated outside the hospital but death was declared upon arrival to the hospital
Category 3: Death is inevitable in a hospitalized individual but Brain death criteria are not met
Category 4: A brain dead individual sustaining a cardiac arrest
Category 5: Cardiac arrest in a hospitalized patient
Uncontrolled DCD donor: category 1,2 and 5
Controlled DCD donor: Category 3 & 5
What is functional (True) warm ischemia time: Time period after sustained hypotension amounting to SBP < 50 (atleast for 2 minutes) and perfusion of cold perfusate
SpO2 < 70 = Not indicative of poor outcome but need to be documented
Definition of Death = Permanent loss of consciousness & Brain stem functions
Definition of Death when cardio respiratory criteria apply: 5 minutes of continuous CPR + Non restoration of artificial cerebral perfusion
Confirmation of circulatory failure: Absence of pulsatile flow in arterial canula / 2d Echocardiography / continuous ECG
No compromise of donor dignity and non-maleficence
Organ retrieval:
Best outcome = Treatment withdrawl in the operating room
Maastricht 4 donors, where death has been established previously by brain stem criteria, may be given heparin before treatment withdrawl
Access of a major vessel – Rt common ileac artery / Aorta + IVC / Rt atrium
First bag of cold perfusate = Add 20,000 IU of Heparin & Fibrinolytic agent
pancreas retrieval = No Cannulae placement in the SMV or IMV
people with kidney disease should not be considered as potential kidney donors.(B1)
Units performing cold machine perfusion of DCD before implantation must work together to standardize data collection and analyze the outcomes.(A2)
Organ discard should not depend on ; dynamic characteristics of machine perfusion, perfusate effluent biochemical analysis or kidney transplant biopsy scoring system- alone or in combination .(A2). However, these assessments may help to decide when kidneys should be considered for dual transplantation.(B2)
Both DCD and DBD recipients have similar long-term outcome and the allocation system for both should be the same although DCD kidneys are more susceptible to cold ischemia. (B2)
DCD recipients are at high risk of DGF and the patient must be carefully counsel for that before transplantation. (A1)
DCD recipients should received anti-body induction therapy as pat of their initial immunosuppression.(B1)
Long-term outcomes for standard criteria donor (SCD) are equivalent for DCD and DBD kidney transplants. (A1)
ECD or SCD are more important than the donation mode of DCD or DBD in terms of graft survival. (B2)
Further research is needed to determine whether the impact of extended criteria donation(ECD) is different in DCD and DBD donors and whether different thresholds for for organ use may be required. (A1)
Liver;
Liver transplanted from DCD category 3 should be used as long as it is safe. (B1)
Liver from DBD donors are associated with poor outcomes including primary non function, ischemic cholangiopathy , higher rate of re-transplantation. (B1)
Both DCD and DBD donors transplanted with MELD > 30 or on organ-perfusion support have similar graft survival.Nevertheless, there is no survival advantage when DCD livers are transplanted in patients with MELD =< or in those not receiving organ perfusion support. (B2)
DCD liver use should be matched with the need of the recipients with allocation to those who will have the greatest advantage.(B2)
Outcomes of DCD with CIT < 8 h is improved in liver transplantation. (B1)
An ideal DCD is associated with better outcomes in liver transplantation. An ideal DCD criteria are ; Age < 50 years, functional WIT time < 20 min, CIT < 10 h and < 10% steatosis. (B1)
The use of more restrictive DCD donors (BMI < 29, FWIT < 20 min, SAP < 50 mmHg) ,equivalent 1 and 3 years patient and graft survival rate can be achieved for both DCD and DBD Transplants. (B1)
The longer the FWIT, the higher the risk of ischemic cholangiopathy
Avoid DCD grafts in re-transplantation. (B1)
Use DCD graft in young recipients < 60 years.(B1)
Risk factors for graft failure are ; age > 55, male, African American, HCV, MELD >35, metabolic liver disease, hospitalization, and the use of live support during transplantation .(B1)
Pancreas ;
Evidence is favoring the use of DCD for simultaneous pancreas kidney(SPK) recipient. (C2)
DCD donors may be associated with higher risk of re-perfusion pancreatitis and thrombosis. Donor age may be another risk factor( ideal donor should be < 60 with BMI < 30 kg/m2). (C2)
The shortest CIT must be the primray goal of any DCD pancreas transplant (B2)
Poor graft outcomes are associated with ; Higher BMI, age, cardiovascular morbidity, and surgical. (C2)
Both DCD and BCD have similar outcomes with proper donor selection.(C2)
DCD is associated with two fold risk of graft thrombosis and is contraindicated in patients with history of thrombo-embolism unless the patient is well treated. (C2)
Pancreatic ilets;
The same criteria should be used to select DCD and DBD donors. (B2)
DCD organs should be allocated through the National Pancreas Allocation Scheme. (B2)
Graft outcomes from DCD donor are acceptable in UK but the number are small and further research is needed. (C2)
Lung;
The same criteria should be used to select DCD and DBD donors. (B2)
Graft outcomes of DCD lungs are similar to DBD lungs. (B1)
Pre-transplant ex vivo lung perfusion is suggested in situations of uncertain graft performance to safely extend donor and procedural criteria. (B1)
Antegrade and retrograde flush perfusion are required during organ retrieval. (B2)
Criteria for ex vivo lung perfusion are measurement of the pulmonary compliance, vascular resistance, and gas exchange
Heart;
At the moment DCD donors are not utilized in UK heart transplantation program due some ethical consideration.( Not graded)
Transplantation from deceased donors after circulatory death
British transplantation society July 2013
PART 1: GENERAL PRINCIPLES
3 CATEGORISATION OF DCD DONORS & DEFINITION OF WARM ISCHAEMIC TIME · Deceased circulatory death donors should be categorized according to the Maastricht classification to aid research, communication, and audit. (B1) · The functional (or true) warm ischemic period starts from the dropping of systolic blood pressure below 50 mmHg till the onset of cold in situ perfusion. (B1) · regarding donor’s oxygen saturation: The current recommendation is that oxygen saturation below 70% is not used as an indicator of poor outcome or as a reason for non-usage, but that retrieval teams should keep a record of when oxygen saturation falls below 70% in order to allow correlation with graft outcome. Maastricht Category 1: Death occurring outside of the hospital Death is confirmed outside a hospital environment. For these individuals to be potential donors, the moment of sudden death needs to have been witnessed, the time that it occurred documented, and ‘resuscitation’ continued after death. Maastricht Category 2: Unsuccessful resuscitation CPR is started outside of the hospital following the collapse. Death is confirmed on admission to the hospital. Both Category 1 and 2 donors are also referred to as ‘Uncontrolled’ DCD donors and usually present to the emergency department. Maastricht Category 3: Awaiting cardiac arrest Death is inevitable (terminal case) but brain stem death criteria are not fulfilled. These patients are cared for in many areas within hospitals but are most commonly identified in neurosurgical and general intensive care units, coronary care units, emergency departments, and medical wards. Maastricht Category 4: Cardiac arrest in a brain stem dead individualDeath has been diagnosed by brain stem criteria following which the patient suffers a cardiac arrest. Categories 3 and 4 are also referred to as ‘Controlled’ DCD donors. Maastricht Category 5: Unexpected cardiac arrest in a hospitalized patient: uncontrolled donor in a hospitalized patient. These categories consider mainly the difference in the warm ischemic time (WIT) between cardiac arrest and organ perfusion. Category 5 is more likely to be longer than Category 3 or 4 but shorter than Category 1 or 2. DIAGNOSIS OF DEATH Statements of Recommendation · Death is permanently lost of the capacity for consciousness and brain stem function. (A1) · death can be confirmed following five minutesof continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation. (B1) · circulatory arrest should be identified by the absence of pulsatile flow on a correctly functioning arterial line, by the use of echocardiography if the expertise is available, or by failing by continuous ECG monitoring. (B1) LAW, ETHICS, AND DONOR CONSENT · All healthcare professionals should be aware of the complex ethical issues that are associated with donation after circulatory death (DCD) and transplantation of donated organs. · definitions of death that are accepted by society are the cornerstone for the successful cadaveric program with the preservation of donor dignity and non-malfeasance must not be compromised in efforts to facilitate donation and transplantation from DCD donors. (B1) · The BTS Ethics committee is available for guidance and information to support practice in this complex field. (Not graded) INFORMING THE RECIPIENT: Providing information (The risk-benefit analysis), both orally and in writing consent and is the responsibility of the multidisciplinary transplant team. This must be updated and reviewed annually and the outcome of discussions clearly documented in the patient’s medical record. (B1) ORGAN RETRIEVAL · Treatment withdrawal should ideally be planned for a time when the donor HLA type and virology are known and the liver and pancreasrecipientsare in the recipient hospitals. (C1) · Treatment withdrawal in the operating department is associated with shorter A systolic period (warm ischemic times) then withdrawal to a remote intensive care unit or ward. (C1) · The retrieval team needs to be satisfied with the donor details (blood group, past medical history, illness leading to death) before treatment is withdrawn (A1) · Maastricht 4 donors, where death has been established previously by brain stem criteria, may be given heparin before treatment withdrawal. Death does not need to be reaffirmed once a circulatory arrest has occurred. (A1) · The specialist nurse should keep a record at regular intervals of the donor’s hemodynamic parameters following treatment withdrawal. (C1) · Death may be confirmed five minutes after complete circulatory arrest. There is no need for a further stand-off period following this. (A1) · For controlled donors, retrieval starts by gaining access to a large artery and vein, typically the right common iliac artery or aorta, and the IVC in the abdomen or right atrium in the chest. (Not graded) · 20 000 units of heparin should be added to the first two bags of ice-cold preservation solution to be perfused through the aorta. (Not graded) · A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen activator may be added to the first bag of preservation solution. (B3) · The kidneys may be removed either individually or en a bloc. (Not graded) · The pancreas may be removed either en-bloc with the liver, or following removal of the liver. (Not graded) · Cannula for preservation fluid should never be placed in the SMV or IMV when the pancreas is being retrieved. (B1) · The liver should be recovered using a rapid technique that minimizes liver congestion. (Not Graded) · Dual perfusion of the hepatic artery and portal vein is essential for the recovery of DCD livers for transplantation. (C2)
PART 2: ORGAN-SPECIFIC DISCUSSION
(Kidney-liver-pancreas-lung-heart)
1-KIDNEY
When to discard kidneys?? · The use of donors with functional warm ischemic time >2 hr. or absent blood pressure for 30 minutes should be restricted to currently experimentalprotocols which attempt to resuscitate organ viability. (B2) · None of the perfusion pressure dynamic characteristics, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems – alone or in combination – have sufficient predictive value to mandate organ discard. (A2) Such assessment may, however, help determine when kidneys should be considered for dual transplantation. (B2). is there a difference between DCD and DBD regarding kidneys??? o Long-term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. Nevertheless, it is recognized that DCD kidneys appear to be more susceptibleto cold ischemia, and the proposed national allocation scheme should take this into account. (B2) o The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation. (A1) o Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants. (A1) o Graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD. (B2) o Prospective data are required to determine whether the impact of expanded criteria donation (ECD) is different in DCD and DBD donors and whether different thresholds for organ use may be required. (A1) Any specific modification for an immunosuppressive protocol in DCD??? Antibody induction therapy should be used as part of the initial immunosuppressive regimen for recipients of DCD kidneys. (B1)
2-LIVER
long ischemia time associated with ischemic cholangiopathy and biliary stricture so, the organ is better to be discarded: o Livers transplanted from Maastricht 3DCD donors are a useful resource and should be used where deemed safe BUT still inferior to livers from DBD donors with more PNF and ischemic cholangiopathy, and a higher rate of re-transplantation. (B1) o The incidence of biliary stricture is significantly lower when a low-viscosity solution is used to cold flush the aorta. (C2) o The outcome of DCD liver transplantation is improved with short CIT (cold ischemia time), which is best kept to under 8hrs. (B1) o A favorable outcome can be expected if an ‘ideal’ DCD liver is transplanted.An ‘ideal’ DCD liver donor is <50 years old, has a functional WIT time <20 min,a shorter CIT <10 hr, BMI <29 kg/m2and <10% steatosis. (B1) difference between DCD and DBD?? o DCD and DBD subjects transplanted with MELD >30or on organ-perfusion support have similar graft survival. However, there is no survival benefit when DCD livers are transplanted in patients with MELD ≤30or in those not receiving organ-perfusion support(B2). o DCD grafts are best avoided in recipients of re-transplantation (B1) o DCD liver grafts should be ideally used in younger recipients with ages <60years. (B1) Factors predictive of graft failure are age ≥55 years, male sex, African– American race, HCV positivity, metabolic liver disorder, transplant MELD ≥ 35, hospitalization at transplant, and the need for life support at transplant. Recipient predictors of mortality are age ≥55 years, hospitalization at transplant, and re-transplantation. (B1)
3-PANCREAS
Long ischemia time in pancreas transplantation is associated with reperfusion pancreatitis and thrombosis and the organ maybe needs to be discarded. · risk of reperfusion pancreatitis and thrombosis and this may be exacerbated by prolonged coldischemia time and higher donor body mass index. The contribution of donorage to the incidence of reperfusion pancreatitis/thrombosis in DCD organs ispoorly studied but may constitute a further risk factor. Ideal donors should be <60 years old and have BMI <30 kg/m2. (C2) · The pancreas team should stand down after a functional warm ischemia time of 60 minutes (pancreas will be discarded) (C2) · There is little evidence regarding recipient risk factors but it is logical to assume that higher recipient BMI, age, cardiovascular morbidity, and technical surgical factors may contribute to poorer outcomes. is there any difference between DCD and DBD regarding the pancreas · Reported outcomes for DCD donor pancreas transplantation are broadlysimilar to those from DBD donors, although considerably greater donor selection is likely to have taken place. (C2) · Graft loss from thrombosis is twice as common in DCD as in DBD pancreastransplants. Particular attention should be paid to measures to preventthrombosis in recipients of DCD organs. A DCD organ should not betransplanted into a recipient with a history of thrombo-embolic disease unlessthis is monitored and treated. (C2) available evidence and current practice are increasingly in favor of their use for simultaneous pancreas and kidney (SPK) transplantation from DCD donors. (C2)
4-LUNG
When to discard DCD lung?? · Lung quality evaluated by what is called (Pre-transplant ex-vivo lung perfusion (EVLP) is advised in case of uncertain graft performance to safely extend donor and procedural criteria (long warm ischemia, bad flush, clots). (B1) · Perform antegrade and retrograde flush perfusion at the time of lung retrieval. (B2) Acceptance criteria on EVLP may include measures of pulmonary compliance, vascular resistance, and gas exchange is are any difference between DCD and DBD The donor selection criteria for lung DCD should be the same as for DBD. (B2) DCD lungs should not be regarded as extended or marginal. Transplant quality and outcome is at least similar to DBD organs. (B1)
5-HEART
In the UK, heart transplantation from DCD donors is currently NOT standard of care. Because of a number of ethical issues, the use of DCD hearts is not currently recommended. Once these are resolved this guideline will be updated. (Not graded)
Summary:
Organ transplantation is the ultimate treatment options of end stage organ dysfunction. Diseased donor organ transplantation increase the donor pool and may save more life along with live organ donation.
CATEGORISATION OF DCD DONORS & DEFINITION OF WARM ISCHAEMICTIME · Deceased circulatory death donors should be categorized according the Maastricht classification to aid research, communication and audit. · The functional (or true) warm ischemic period starts when the systolic bloodpressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg andextends up to the onset of cold in situ perfusion. · Although donor low oxygen saturation (<70%) is a concern and may well be ameasure of inadequate organ perfusion and poor outcome, prospectiveevidence is awaited. DIAGNOSIS OF DEATH · Death is irreversible and should be regarded as a state in which a patient haspermanently lost the capacity for consciousness and brain stem function. · Where cardio-respiratory criteria apply, death can be confirmed following fiveminutes of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation. · Where possible, circulatory arrest should be identified by the absence of pulsatile flow on a correctly functioning arterial line, or by the use of echocardiography if the expertise is available; or failing that by continuous ECG monitoring. · DCD organ retrieval protocols should recognise the potential risks around postmortem interventions that might restore cerebral perfusion.
LAW, ETHICS AND DONOR CONSENT · Healthcare professionals should be aware of the complex ethical issues thatare associated with donation after circulatory death (DCD) and transplantationof donated organs. Such professionals should be familiar with the terminologyused to describe and discuss the ethics of DCD transplantation. · Good ethical practice is integral to efforts to facilitate donation and achievetransplantation in the context of DCD. This includes decisions about allocationand consent in relation to both the organ donor and recipient.
INFORMING THE RECIPIENT
· To povide information, both orally and in writing, for the potential transplant recipient is a requirement for consent and is the responsibility of the multidisciplinary transplant team.
ORGAN RETRIEVAL
· Treatment withdrawal should ideally be planned for a time when the donor HLA type and virology are known and the liver and pancreas recipients are in the recipient hospitals.
· Treatment withdrawal in the operating department is associated with shorter asystolic periods (warm ischaemic times) than withdrawal on a remote intensive care unit or ward.
· The retrieval team need to be satisfied about the donor details (blood group, past medical history, illness leading to death) before treatment is withdrawn.
· Maastricht 4 donors, where death has been established previously by brain stem criteria, may be given heparin before treatment withdrawal. Death does not need to be reaffirmed once circulatory arrest has occurred.
· The specialist nurse should keep a record at regular intervals of the donor’s haemodynamic parameters following treatment withdrawal.
· Death may be confirmed five minutes after complete circulatory arrest. There is no need for a further stand off period following this.
· For controlled donors, retrieval starts by gaining access to a large artery and vein, typically the right common iliac artery or aorta, and the IVC in the
abdomen or right atrium in the chest.
· 20 000 units heparin should be added to the first two bags of ice-cold
preservation solution to be perfused through the aorta.
· A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen activator may be added to the first bag of preservation solution.
· The kidneys may be removed either individually or en bloc.
ORGAN SPECIFIC DISCUSSION
KIDNEY
· Individuals with advanced or end-stage chronic kidney disease, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donors.
· The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability.
Transplantation offers patients with end-stage organ failure a cost-effective treatment that improves quality of life and increases life expectancy. Prior to the introduction of guidance defining the concept of brain death in the 1970s, all organs for transplantation were donated after circulatory death (DCD). Following the introduction of brain stem death testing, the majority of organs for transplantation were donated after brain death (DBD) or, increasingly, from living donors DCD provides a valuable source of organs for transplantation and helps to address the shortfall between supply and demand. It also offers an additional donation choice for families of critically ill patients who are suffering from severe injury or illness that is incompatible with life but have not deteriorated to brain death.
PART 1: GENERAL PRINCIPLES
3 CATEGORISATION OF DCD DONORS & DEFINITION OF WARM ISCHAEMIC
TIME
Statements of Recommendation
Deceased circulatory death donors should be catego rised according the
Maastricht classification to aid research, communication and audit. (B1)
The functional (or true) warm ischaemic period starts when the systolic blood
pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and
extends up to the onset of cold in situ perfusion. (B1)
Although donor low oxygen saturation (<70%) is a concern and may well be a
measure of inadequate organ perfusion and poor outcome, prospective evidence is awaited. The current recommendation is that oxygen saturation below 70% is not used as an indicator of poor outcome or as a reason for non usage, but that retrieval teams should keep a record of when oxygen saturation falls below 70% in order to allow correlation with graft outcome.
Maastricht Category 1: Death occurring outside of hospital
Death is confirmed outside a hospital environment. For these individuals to be potential
donors, the moment of sudden death needs to have been witnessed, the time that it
occurred documented, and ‘resuscitation’ continued after death.
Maastricht Category 2: Unsuccessful resuscitation
CPR is started outside of hospital following collapse. Death is confirmed on admission to hospital.
Both Category 1 and 2 donors are also referred to as ‘Uncontrolled’ DCD donors and usually present to the emergency department.
Maastricht Category 3: Awaiting cardiac arrest
Death is inevitable but brain stem death criteria are not fulfilled. These patients are cared for in many areas within hospitals, but are most commonly identified in neurosurgical and general intensive care units, coronary care units, emergency departments and medical wards.
Maastricht Category 4: Cardiac arrest in a brain stem dead individual
Death has been diagnosed by brain stem criteria following which the patient suffers a
cardiac arrest. This may be whilst awaiting the donor team or as an intentional arrangement, depending upon the wishes of the next of kin.
Categories 3 and 4 are also referred to as ‘Controlled’ DCD donors.
Maastricht Category 5: Unexpected cardiac arrest in a hospitalised patient
Category 5 is an ‘uncontrolled’ donor in a hospitalised patient so the warm ischaemic time (WIT) between cardiac arrest and organ perfusion is likely to be longer than categories 3 or 4 but shorter than categories 1 or 2.
DIAGNOSIS OF DEATH
Statements of Recommendation
Death is irreversible and should be regarded as a state in which a patient has
permanently lost the capacity for consciousness and brain stem function. (A1)
Where cardio-respiratory criteria apply, death can be confirmed following five
minutes of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation. (B1)
Where possible, circulatory arrest should be identified by the absence of
pulsatile flow on a correctly functioning arterial line, or by the use of echocardiography if the expertise is available; or failing that by continuous ECG monitoring. (B1)
DCD organ retrieval protocols should recognise the potential risks around post
mortem interventions that might restore cerebral perfusion. (B1)
The criteria for the diagnosis of death following loss of circulatory function
should not be influenced by the possibility of subsequent organ retrieval. (A1)
LAW, ETHICS AND DONOR CONSENT
Statements of Recommendation
All healthcare professionals should be aware of the complex ethical issues that
are associated with donation after circulatory death (DCD) and transplantation
of donated organs. Such professionals should be familiar with the terminology
used to describe and discuss the ethics of DCD transplantation. (B1)
Good ethical practice is integral to efforts to facilitate donation and achieve
transplantation in the context of DCD. This includes decisions about allocation
and consent in relation to both the organ donor and recipient. (B1)
DCD in the United Kingdom is underpinned by definitions of death that are
accepted by society. The principles of donor dignity and non-malfeasance
must not be compromised in efforts to facilitate donation and transplantation
from DCD donors. (B1)
Ethical principles integral to the UK controlled DCD programme must extend to
any future uncontrolled DCD programme. (B1)
The BTS Ethics committee is available for guidance and information to support practice in this complex field. (Not graded)
The UK Donation Ethics Committee is also available for guidance and
information. (Not graded
INFORMING THE RECIPIENT
Statements of Recommendation
Providing information, both orally and in writing, for the potential transplant
recipient is a requirement for consent and is the responsibility of the multidisciplinary
transplant team. This must be updated and reviewed annually and the outcome of discussions clearly documented in the patient’s medical record. (B1)
Information should be tailored to the requirements of the potential recipient,
recognising that not all patients wish to receive detailed information. However,
this must not preclude engagement with the transplant process. (B1)
The risk benefit analysis presented to the potential transplant recipient must
explain the relative risk for that recipient of remaining on the transplant waiting
list compared to that of receiving a DCD organ. (B1)
ORGAN RETRIEVAL
Statements of Recommendation
Treatment withdrawal should ideally be planned for a time when the donor HLA
type and virology are known and the liver and pancreas recipients are in the recipient hospitals. (C1)
Treatment withdrawal in the operating department is associated with shorter
asystolic periods (warm ischaemic times) than withdrawal on a remote intensive care unit or ward. (C1)
The retrieval team need to be satisfied about the donor details (blood group,
past medical history, illness leading to death) before treatment is withdrawn.
(A1) Retrieval teams should be scrubbed in the operating theatre at the point oftreatment withdrawal. (B1)
Maastricht 4 donors, where death has been established previously by brain
stem criteria, may be given heparin before treatment withdrawal. Death does
not need to be reaffirmed once circulatory arrest has occurred. (A1)
The specialist nurse should keep a record at regular intervals of the donor’s
haemodynamic parameters following treatment withdrawal. (C1)
Death may be confirmed five minutes after complete circulatory arrest. There is
no need for a further stand off period following this. (A1)
For controlled donors, retrieval starts by gaining access to a large artery and
vein, typically the right common iliac artery or aorta, and the IVC in the abdomen or right atrium in the chest. (Not graded)
20 000 units heparin should be added to the first two bags of ice-cold
preservation solution to be perfused through the aorta. (Not graded)
A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen
activator may be added to the first bag of preservation solution. (B3)
The kidneys may be removed either individually or en bloc. (Not graded) The pancreas may be removed either en bloc with the liver, or following removal of the liver. (Not graded)
Cannulae for preservation fluid should never be placed in the SMV or IMV when
the pancreas is being retrieved. (B1)
The liver should be recovered using a rapid technique which minimises liver
congestion. (Not Graded)
Dual perfusion of hepatic artery and portal vein is essential for recovery of
DCD livers for transplantation. (C2)
PART 2: ORGAN SPECIFIC DISCUSSION
KIDNEY
Statements of Recommendation
Individuals with advanced or end-stage chronic kidney disease, or with cortical
necrosis demonstrable on biopsy should not be considered as potential kidney
donors. (B1)
The use of donors with functional warm ischaemic time >2 hr or absent blood
pressure for 30 minutes should be restricted to (currently experimental)
protocols which attempt to resuscitate organ viability. (B2)
Units undertaking cold machine perfusion of DCD kidney transplants prior to
implantation should collaborate to standardise the prospective collection of
data to enable aggregated analyses of outcomes. (A2)
None of perfusion pressure dynamic characteristics, perfusate effluent
biochemical analysis, or kidney transplant biopsy scoring systems – alone or in
combination – have sufficient predictive value to mandate organ discard. (A2)
Such assessment may, however, help determine when kidneys should be
considered for dual transplantation. (B2)
Long term outcomes of DCD recipients are similar to those of DBD recipients
and the allocation system for DCD and DBD organs should be similar.
Nevertheless, it is recognised that DCD kidneys appear to be more susceptible
to cold ischaemia, and the proposed national allocation scheme should take
this into account. (B2)
The incidence of delayed graft function is increased in DCD recipients and this
should be discussed with the patient prior to transplantation. (A1)
Antibody induction therapy should be used as part of the initial immunosuppressive regimen for recipients of DCD kidneys. (B1)
Long-term outcomes for standard criteria donors are equivalent for DCD and
DBD kidney transplants. (A1
Graft outcome is more closely related to whether a transplant is ECD vs SCDthan whether the mode of retrieval is DCD vs DBD. (B2)
Prospective data are required to determine whether the impact of expanded
criteria donation (ECD) is different in DCD and DBD donors and whether
different thresholds for organ use may be required. (A1)
LIVER
Statements of Recommendation
Livers transplanted from Maastricht 3 DCD donors are a useful resource and
should be used where deemed safe. (B1)
Short and medium term outcome appears inferior to livers from DBD donors
with more PNF and ischaemic cholangiopathy, and a higher rate of retransplantation.
(B1)
DCD and DBD subjects transplanted with MELD >30 or on organ-perfusion
support have similar graft survival. However, there is no survival benefit when
DCD livers are transplanted in patients with MELD ≤30 or in those not receiving
organ-perfusion support. (B2)
The incidence of biliary stricture is significantly lower when a low viscosity
solution is used to cold flush the aorta. (C2)
DCD liver use should be matched with the need of the recipients on the waiting
list, with allocation to those who will have the greatest transplant benefit. (B2)
The outcome of DCD liver transplantation is improved with short CIT, which isbest kept to under 8hrs. (B1)
A favourable outcome can be expected if an ‘ideal’ DCD liver is transplanted.
An ‘ideal’ DCD liver donor is <50 years old, has a functional WIT time <20 min,
a shorter CIT <10 hr, and <10% steatosis. (B1)
Using more restrictive DCD Donor criteria including BMI <29 kg/m2 and a
functional WIT <20 min (SAP <50 mmHg), equivalent 1 and 3-year patient and
graft survival rates can be achieved for both DCD and DBD liver transplants.
(B1)
Long FWIT is associated with an increased risk of ischaemic cholangiopathy
Potential recipients of DCD liver grafts should be informed of the potential risk
and be offered the choice to refuse such organs prior to transplant listing. (C2)
DCD grafts are best avoided in recipients of re-transplantation (B1)
DCD liver grafts should be ideally used in younger recipients with age <60
years. (B1)
Factors predictive of graft failure are: age ≥55 years, male sex, African–
hospitalisation at transplant, and the need for life support at transplant.
Recipient predictors of mortality are age ≥55 years, hospitalisation at
transplant, and re-transplantation. (B1)
A national audit should be performed to identify factors for non-utilisation of
extended criteria donors to establish the incidence of cholangiopathy under
ideal circumstances, identify more suitable risk factors, identify further
subgroups of DCDs that could potentially be utilised, allow for medical
interventions to be evaluated, and provide qualitative data regarding centrespecific
performance. (C1)
PANCREAS
Statements of Recommendation
Although DCD organs can be used for isolated pancreas transplants in
pancreas transplant alone or pancreas after kidney, available evidence and
current practice are increasingly in favour of their use for simultaneous
pancreas and kidney (SPK) transplantation. (C2)
Pancreas transplants from DCD donors are at increased risk of reperfusion
pancreatitis and thrombosis and this may be exacerbated by prolonged cold
ischaemia time and higher donor body mass index. The contribution of donor
age to the incidence of reperfusion pancreatitis/thrombosis in DCD organs is
poorly studied but may constitute a further risk factor. Ideal donors should be
<60 years old and have BMI <30 kg/m2. (C2)
The pancreas team should stand down after a functional warm ischaemia time
(systolic BP <50 mmHg and oxygen saturation of 70%) of 60 minutes. (C2)
A primary focus of any DCD pancreas transplant should be to achieve the
minimum cold ischaemic time. (B2)
There is little evidence regarding recipient risk factors but it is logical to
assume that higher recipient BMI, age, cardiovascular morbidity, and technical
surgical factors may contribute to poorer outcome. (C2)
Reported outcomes for DCD donor pancreas transplantation are broadly
similar to those from DBD donors, although considerably greater donor selection is likely to have taken place. (C2)
Graft loss from thrombosis is twice as common in DCD as DBD pancreas
transplants. Particular attention should be paid to measures to prevent
thrombosis in recipients of DCD organs. A DCD organ should not be
transplanted into a recipient with a history of thrombo-embolic disease unless
this is monitored and treated. (C2
Selected transplant centres will have built up a volume of expertise with DCD
extended criteria and these guidelines should not restrict innovative but safe
practice of pancreas transplantation. (Not graded)
PANCREATIC ISLETS
Statements of Recommendation
Selection criteria for recipients of islets from DCD donors should be the same
as for DBD donors. (B2)
Organs from DCD donors for islet isolation and transplantation should be
allocated through the National Pancreas Allocation Scheme. (B2)
The long term outcome of islet transplantation from DCD donors has been
satisfactory in the UK but the cohort is small. Further audit and research are
required. (C2)
Satisfactory functional islet preparations can be routinely obtained from DCD
donors. (C2)
LUNG
Statements of Recommendation
The donor selection criteria for lung DCD should be the same as for DBD. (B2)
All patients on the lung transplant waiting list have the potential to receive DCD
lungs. (C1)
DCD lungs should not be regarded as extended or marginal. Transplant quality and
outcome is at least similar to DBD organs. (B1)
Perform ante grade and retrograde flush perfusion at the time of lung retrieval. (B2)
Pre-transplant ex vivo lung perfusion (EVLP) is advised in case of uncertain graft
performance to safely extend donor and procedural criteria (long warm ischaemia,
bad flush, clots). (B1)
Acceptance criteria on EVLP may include measures of pulmonary compliance,
vascular resistance, and gas exchange. (C2)
HEART
Statement of Recommendation
In the UK, heart transplantation from DCD donors is currently NOT standard of
care. Because of a number of ethical issues, the use of DCD hearts is not
currently recommended. Once these are resolved this guideline will be updated. (Not graded)
In our country no deceased donor, we have no expreince Lesson from this gudlines :
established deceased donorprogram in our country according to this guidlines
I appreciate your short write-up, dear Dr Nahla Alam. This is bigger than a summary, however.
Ajay Kumar Sharma
Admin
2 years ago
Please write your comments in light of your own experience with DCD.
What lessons do you learn from these guidelines, even though we all know that it is level 5 evidence?
Controlled DCD
Organ donation which follows circulatory arrest. This may be in the context of withdrawal or non-escalation of cardio-respiratory treatments that are no longer in a
patient’s best interests or occurring in a patient already certified dead by brain stem criteria.
· Maastricht Category 3: Awaiting cardiac arrest
· Maastricht Category 4: Cardiac arrest in a brain stem dead donor
Uncontrolled DCD
Organ donation from a patient who has suffered an unexpected death that has been
confirmed on cardio-respiratory grounds.
· Maastricht Category 1: Dead on arrival
· Maastricht Category 2: Unsuccessful resuscitation
· Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient
Categorisation of DCD Donors
· Deceased circulatory death donors should be categorised according to the Maastricht classification to aid research, communication, and audit.
· The functional (or true) warm ischaemic period starts when the systolic blood pressure has a sustained (i.e., at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion.
· Although donor low oxygen saturation (<70%) is a concern and may well be a measure of inadequate organ perfusion and poor outcome, prospective evidence is awaited. The current recommendation is that oxygen saturation below 70% is not used as an indicator of poor outcome or as a reason for non-usage, but that retrieval teams should keep a record of when oxygen saturation falls below 70% in order to allow correlation with graft outcome. (C1)
Diagnosis of Death
· Death is irreversible and should be regarded as a state in which a patient has permanently lost the capacity for consciousness and brain stem function.
· Where cardio-respiratory criteria apply, death can be confirmed following five minutes of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation.
· Where possible, circulatory arrest should be identified by the absence of pulsatile flow on a correctly functioning arterial line or using echocardiography if the expertise is available; or failing that by continuous ECG monitoring.
· DCD organ retrieval protocols should recognise the potential risks around post-mortem interventions that might restore cerebral perfusion. (B1)
· The criteria for the diagnosis of death following loss of circulatory function should not be influenced by the possibility of subsequent organ retrieval. (A1)
Law, Ethics and Donor Consent
· All healthcare professionals should be aware of the complex ethical issues that are associated with donation after circulatory death (DCD) and the transplantation of donated organs. Such professionals should be familiar with the terminology used to describe and discuss the ethics of DCD transplantation.
· Good ethical practice is integral to efforts to facilitate donation and achieve transplantation in the context of DCD. This includes decisions about allocation and consent in relation to both the organ donor and recipient. (B1)
· DCD in the United Kingdom is underpinned by definitions of death that are accepted by society. The principles of donor dignity and non-maleficence must not be compromised in efforts to facilitate donation and transplantation from DCD donors.
· Ethical principles integral to the UK controlled DCD programme must extend to any future uncontrolled DCD programme.
· The BTS Ethics committee is available for guidance and information to support practice in this complex field. (Not graded)
· The UK Donation Ethics Committee is also available to offer guidance and information in this area. (Not graded)
Informing the Recipient
· Providing information, both orally and in writing, for the potential transplant recipient is a requirement for consent and is the responsibility of the multi-disciplinary transplant team. This must be updated and reviewed annually, and the outcome of discussions clearly documented in the patient’s medical record.
· Information should be tailored to the requirements of the potential recipient, recognising that not all patients wish to receive detailed information. However, this must not preclude engagement with the transplant process. (B1)
· The risk-benefit analysis presented to the potential transplant recipient must explain the relative risk for that recipient of remaining on the transplant waiting list compared to that of receiving a DCD organ.
Organ Retrieval
· Treatment withdrawal should ideally be planned for a time when the donor HLA type and virology are known, and the liver and pancreas recipients are in the recipient hospitals.
· Treatment withdrawal in the operating department is associated with shorter warm ischaemic times (asystole periods) than withdrawal on a remote intensive care unit or ward.
· The retrieval team need to be satisfied about the donor details (blood group, past medical history, illness leading to death) before treatment is withdrawn.
· Retrieval teams should be scrubbed in the operating theatre at the point of treatment withdrawal.
· Maastricht 4 donors, where death has been established previously by brain stem criteria, may be given heparin before treatment withdrawal. Death does not need to be reaffirmed once circulatory arrest has occurred.
· The specialist nurse should keep a record at regular intervals of the donor’s haemodynamic parameters following treatment withdrawal.
· Death may be confirmed 5 minutes after complete circulatory arrest. There is no need for a further stand off period following this.
· For controlled donors, retrieval starts by gaining access to a large artery and vein, typically, the right common iliac artery or aorta, and the IVC in the abdomen or right atrium in the chest.
· 20000 units heparin should be added to the first bag of ice-cold preservation solution to be perfused through the aorta.
· A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen activator may be added to the first bag of preservation solution.
· The kidneys may be removed either individually or en bloc.
· The pancreas may be removed either en bloc with the liver or following removal of the liver.
· Cannulae for preservation fluid should never be placed in the SMV or IMV when the pancreas is being retrieved.
· The liver should be recovered using a rapid technique which minimises liver congestion.
· Dual perfusion of both artery and portal vein is essential for recovery of DCD livers for transplantation.
Viability Testing
· Viability testing has a different emphasis depending on the organ being tested.Kidneys from young, controlled DCD donors who have died rapidly after withdrawal of support, undergone rapid laparotomy, aortic cannulation, perfusion and venous exsanguination will be expected to work promptly if cold ischaemia is minimised and the kidneys appear well perfused on retrieval. This is deemed to be sufficient viability testing in this case. The role of machine perfusion to ‘improve’ the kidney is controversial.
· For uncontrolled DCD or when perfusion of the kidneys on retrieval is poor, using parameters such as high resistance during machine perfusion or high enzyme levels within the perfusate may indicate increased cellular damage and an increased risk of primary non function but this is not universally accepted
· Viability testing for the liver and pancreas has not been fully established.
· Testing the graft function of warm perfused organs prior to transplantation is considered the ‘gold’ standard. However, warm perfusion of such organs is difficult to perform and usually impractical.
· Warm viability testing of donor lungs using ex-vivo lung perfusion is the exception. The test is performed by ventilating the lungs and perfusing them with Steen solution with or without added red blood cells. The ability of the ventilated lung to oxygenate the perfusate is assessed together with lung compliance, airway resistance and tidal volume via the ventilator.
Immunosuppression
· No definitive data suggest significant benefit from any particular immunosuppressive regimen in the context of DCD organs.
· Following DCD kidney transplantation, there is increased risk of delayed graft function due to DCD injury. Induction therapy with mono- or polyclonal antibodies may be used to reduce the risk of clinically unrecognised acute rejection prior torecovery from DCD injury.
· Induction therapy is often combined with delayed introduction or reduced intensity of
calcineurin inhibition to limit the incidence and duration of delayed graft function.
· Following liver transplantation, consider renal sparing regimens with delayed CNI introduction. Induction and T cell depletion may also be considered, but risk and benefit must be balanced with choice of regimen.
· Following heart and lung transplantation, there is no evidence to use a different regimen from that used in DBD transplantation.
Kidney
· Individuals with advanced or end-stage chronic kidney disease, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donors.
· The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability.
· Units undertaking cold machine perfusion of DCD kidney transplants prior to implantation should collaborate to standardise the prospective collection of data to enable aggregated analyses of outcomes.
· None of the dynamic characteristics of machine perfusion, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems – alone or in combination – have sufficient predictive value to mandate organ discard.
· Such assessment may, however, help determine when kidneys should be considered for dual transplantation.
· Long term outcomes of DCD recipients are like those of DBD recipients and the allocation system for DCD and DBD organs should be similar. Nevertheless, it is recognised that DCD kidneys appear to be more susceptible to cold ischaemia, and the proposed national allocation scheme should take this into account.
· The incidence of delayed graft function is increased in DCD recipients, and this should be discussed with the patient prior to transplantation.
· Antibody induction therapy should be considered as part of the initial immunosuppressive regimen for recipients of DCD kidneys.
· Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants.
· Graft outcome is more closely related to whether a transplant is ECD or SCD than whether the mode of donation is DCD or DBD.
· Prospective data are required to determine whether the impact of extended criteria donation (ECD) is different in DCD and DBD donors and whether different thresholds for organ use may be required.
·
Categorization of DCD Donors:
Controlled DCD:
Organ donation, which follows circulatory arrest.
· Maastricht Category 3: Awaiting cardiac arrest.
· Maastricht Category 4: Cardiac arrest in a brain stem dead donor.
Uncontrolled DCD:
Organ donation from a patient who has suffered an unexpected death.
Maastricht Category 1: Dead on arrival
· Maastricht Category 2: Unsuccessful resuscitation
· Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient.
Good ethical practice:
Consent in relation to both the organ donor and recipient.
Maintain donor dignity and non-maleficence.
Organ Retrieval:
To shorten ischemia time, retrieve done when:
Donor HLA type and virology are known, and the liver and pancreas recipients are in the recipient in the hospital.
The donor details (blood group, past medical history, illness leading to death) before treatment is withdrawn.
Retrieval teams should be scrubbed in the operating theatre.
Maastricht 4 donors, where death has been established previously by brain stem criteria, may be given heparin before treatment withdrawal. Death does not need to be reaffirmed once circulatory arrest has occurred. · The specialist nurse should keep a record at regular intervals of the donor’s hemodynamic parameters following treatment withdrawal. · Death may be confirmed 5 minutes after complete circulatory arrest.
· For controlled donors, retrieval starts by gaining access to a large artery and vein, typically the right common iliac artery or aorta, and the IVC in the abdomen or right atrium in the chest.
· 20000 units heparin should be added to the first bag of ice-cold preservation solution to be perfused through the aorta. (Not graded) · A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen activator may be added to the first bag of preservation solution. (B3) · The kidneys may be removed either individually or en bloc.
Viability Testing:
Uncontrolled DCD or when perfusion of the kidneys on retrieval is poor, using parameters such as high resistance during machine perfusion or high enzyme levels within the perfuse may indicate
Immunosuppression:
Induction therapy with mono- or polyclonal antibodies may be used to reduce the risk of clinically unrecognized acute rejection prior to recovery from DCD injury.
Induction therapy is often combined with delayed introduction or reduced intensity of Calcineurin inhibition to limit the incidence and duration of delayed graft function.
Kidney:
· Individuals with advanced or end-stage chronic kidney disease, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donor.
Graft outcome is more closely related to whether a transplant is ECD or SCD than whether the mode of donation is DCD or DBD.
use of donors with functional warm ischemic time >2 hr. or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability.
· Units undertaking cold machine perfusion of DCD kidney transplants prior to implantation should collaborate to standardize the prospective collection of data to enable aggregated analyses of outcomes.
· None of the dynamic characteristics of machine perfusion, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems – alone or in combination – has sufficient predictive value to mandate organ discard.
· Such assessment may, however, help determine when kidneys should be considered for dual transplantation.
· Long-term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. Nevertheless, it is recognized that DCD kidneys appear to be more susceptible to cold ischemia, and the proposed national allocation scheme should take this into account.
· The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation.
· Antibody induction therapy should be considered as part of the initial immunosuppressive regimen for recipients of DCD kidneys.
· Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants. · Graft outcome is more closely related to whether a transplant is ECD.
Comments:
This guideline show road map to DCD and all facilities should be arranged before retrieving of organs. Ischemia time should be shorten.
Please provide a summary of these guidelines
Types of Deceased donors:
After brain death and after cardiac death
Donors after Brain Death: manifested with coma, unresponsiveness, absent brain stem reflexes, absent corneal reflex, absent pupillary reflex, absent pharyngeal and laryngeal reflexes and apnea. It can be confirmed with neuroradiological tests, and EEG.
Donors after Cardiac Death: They require cardiovascular care which include fluids, vasopressors, oxygenation, control DI with desmopressin, vasopressin, blood sugar control, thermal control and corticosteroids to reduce the systemic inflammatory response.
Ethical principles and transplantation:
Criteria of death (Brain and cardiac) should be explained to donors’ families and next of kin.
The recipient should be counselled by the transplant team and understand criteria for extended criteria donation and possibility of dual kidney transplantation.
Exclusion criteria of donation like cortical necrosis.
Long ischemia time above 2 hours reduces the organ survival.
How to keep donor’s organs viable till organ retrieval and transplantation happens.
How to prepare the recipient and to manage the peri-operative period.
Plans for induction and maintenance immunosuppression.
The guideline is addressing variable issues linked to organs donation after circulatory death DCD. This field was undermined by donation after brain death DBD, when criteria to define brain death was concluded afterwards. However, in an endeavor to circumvent the shortfall of donated organs, DCD was reconsidered strongly and categorized stringently to facilitate controlled donation.
Maastricht classification elucidate two types of DCD, controlled and uncontrolled.
Controlled DCD:
This is considered when patient declared dead after cardiac in the setting of withdrawal or non-escalation of cardiorespiratory support as its in best benefit of the patient. This scenario tagged as Category 3.
The second type of controlled DCD is cardiac arrest in brain stem dead patient. category 4.
Uncontrolled DCD: donation from a patient who suffered non-expected death
Category 1: dead on arrival
Category 2: failed resuscitation
category 5: unexpected cardiac arrest in critically ill patient.
Functional (true) warm ischemia time reflect a duration started by sustained drop of systolic blood pressure (more than 2 minutes) below 50 mm hg and extend until cold in situ perfusion.
Oxygen saturation below 70% is debatably linked to adverse allograft outcome.
Death is confirmed after 5 minutes of cardiorespiratory arrest. Confirmation of cardiac death by absent of pulsation in central blood line, Echo cardiography or continuous ECG monitoring.
Organ retrieval:
Has to be planned when donor HLA and virology status is known. Liver and pancreas recipients have to be in hospital.
technical details are elaboratively explained by the guideline, including assessment of viability.
Machine perfusion of cold perfusate can help assessing perfusion of organs. Increased resistance and high concentration of enzymes in perfusate are consistant with increasing cellular damage and primary non-function.
1. Please provide a summary of these guidelines.
The guidelines deal with organ donation after circulatory death (DCD). They define the warm ischemia time and categorize the DCD donors.
DCD donors are categorized in 5 Maastricht categories. Controlled DCD includes category 3 (awaiting cardiac arrest) and 4 (cardiac arrest in a brainstem donor). Uncontrolled DCD includes category 1 (dead on arrival), 2 (unsuccessful resuscitation), and 5 (unexpected cardiac arrest in a critically ill patient).
The warm ischemia time starts when the systolic blood pressure (SBP) reduces to <50 mmHg for >2 minutes and continues till the onset of cold in situ perfusion.
Diagnosis of death is established by 5 minutes of continuous cardiorespiratory arrest (by ECG, ECHO or absence of pulsatile flow on arterial line).
The ethical considerations and law related to donor consent has been known to the healthcare professionals and should be adhered to.
The recipient should be informed verbally and in written about the donor status while taking consent for transplant.
The process of organ retrieval involves treatment withdrawal (preferred after HLA and virology reports, in the operating department) and organ retrieval during which the hemodynamic parameters are continuously recorded.
With respect to kidney, the recommendations include using induction therapy and delaying or reducing CNI dose to decrease risk of DGF.
The potential donor should not have advanced or end stage kidney disease, or cortical necrosis on kidney biopsy. Donors with warm ischemia time >2 hours or absent BP for >30 minutes (>20 minutes is the time limit according to registry data) should be used only in experimental protocols. Kidney biopsy scoring system, perfusion pressure dynamic characteristics and perfusate effluent biochemical analysis (intracellular enzyme levels) can help in making a decision regarding dual transplant. There is no clear evidence to use machine perfusion in DCD kidney transplantation.
Although DCD kidneys are more susceptible to cold ischemia and have increased incidence of DGF and primary non function, their long-term outcomes for standard criteria donors (SCD) are similar to donation after brain death (DBD) kidneys. The graft outcomes depend on quality of donor, whether the donor is SCD or extended criteria donor (ECD) rather than mode of donation, being DBD or DCD. Cold ischemia time >12 hours and increased age of donor and recipient have worse outcomes.
1 – INTRODUTION
Initially, all organs for transplantation were donated after circulatory death (DCD), but they were quickly replaced by organs donated after brain death (DBD), which had a major impact on the number of donations. However, after a few years, the average time on the waiting list rose again and so the use of DCD organs was again evaluated.
In order to optimize the use of DCD, it is necessary to establish common practices and accepted protocols that allow the safe sharing of DCD, as improved immunosuppression, improved organ recovery and implantation, and enhanced peri- and post-operative care mean that the outcomes from DCD organs compare favorably with those from DBD organs. For this purpose, guidelines have been created and revised.
2 – METHODOLOGY
The first guidelines helped to establish the main points of donation and transplantation after circulatory death, but with the growth in the number of donations and the need to explore the use of DCD organs in other areas (besides the kidney) it was decided to review the first protocol. A systematic review of the relevant literature and synthesis of the available evidence was undertaken by selected clinical experts. This was followed by peer group appraisal and expert review. Draft proposals were amended by an editorial committee and appropriate levels of evidence were added to the recommendations at an Editors and Authors’ meeting held in London in July 2011. Wider discussion with the transplant community was undertaken through ‘face to face’ consultation at a BTS consensus meeting in York in October 2011. This was attended by transplant surgeons and physicians, intensivists, Clinical Leads in Organ Donation (CL-ODs), Specialist Nurses in Organ Donation (SN-ODs), and representatives of NHS Blood and Transplant (NHSBT). The draft of the document was placed on the BTS website in March 2013 for a period of open consultation, to which patient and transplant groups were actively encouraged to contribute. The final document was posted in July 2013.
3 – DEFINITIONS
Controlled DCD
Organ donation which follows circulatory arrest. This may be in the context of withdrawal or non-escalation of cardio-respiratory treatments that are considered to be no longer in a patient’s best interests, or occurring in a patient already certified dead by brain stem criteria.
– Maastricht Category 3: Awaiting cardiac arrest
– Maastricht Category 4: Cardiac arrest in a brain stem dead donor
Uncontrolled DCD
Organ donation from a patient who has suffered an unexpected death that has been confirmed on cardio-respiratory grounds.
– Maastricht Category 1: Dead on arrival
– Maastricht Category 2: Unsuccessful resuscitation
– Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient
4 – DIAGNOSIS OF DEATH
Death can be diagnosed When:
– Asystole has occurred, and
– Brain function has been lost, and
– The possibility of spontaneous return of cardiac function has passed;
– There will be no subsequent intervention that restores cerebral perfusion whilst the brain remains responsive to such restoration.
E é definido por critérios clínicos.
5 – LAW, ETHICS AND DONOR CONSENT
All healthcare professionals should be aware of the complex ethical issues that
are associated with donation after circulatory death (DCD), pois as decisions about allocation and consent in relation to both the organ donor and recipient and the principles of donor dignity and non-malfeasance must not be compromised in efforts
6 – IMUNOSSUPRESSION
– There is no evidence of a choice of immunosuppressants that is better for DCD organ recipients;
– DCD kidney transplatation has increased risk of delayed graft function due to DCD injury. Induction therapy with mono- or polyclonal antibodies may be used to reduce the risk of clinically unrecognised acute rejection prior to recovery from DCD injury and calcineurin inhibition to limit the incidence and duration of delayed graft function.
7 – KIDNEY
– Long term outcomes of DCD recipients are similar to those of DBD recipientes and the allocation system for DCD and DBD organs should be similar. Nevertheless, it is recognised that DCD kidneys appear to be more susceptible to cold ischaemia, and the proposed national allocation scheme should take this into account.
– The incidence of delayed graft function is increased in DCD recipientes.
– Graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD.
– Prospective data are required to determine whether the impact of expanded criteria donation (ECD) is different in DCD and DBD donors and whether different thresholds for organ use may be required.
The guidelines discuss in detail about the DCD, thoroughly describe the categorization of DCD donors, by Maastricht category 1 to V, laws, ethics and consent, risk of infection, risk stratification after confirmation for cold and warm ischemia time, probability of graft failure
organ retrieval criteria, allograft viability test, peri and post transplantation immunosuppression regime for kidney, liver, pancreas, its islets, lungs and heart.
These guidelines are depicting the pathway for cadaveric kidney transplant and outline a platform to organise the transplant post DCD.
This is by adopting Maastricht classification.
DCD is divided into five subclasses.
This also includes controlled death of two subtypes:
Type 111
Cardiac arrest following withdrawl of life sustaining treatments but not considered to be brain dead
Type 4
Awaitingg cardiac arrest who is alrady brain stem dead
DCD also includes patients who had cardiac arrest in different settings
Category 1
Patient reached dead with cardiac arrest outside hospital. For donation cardiac arrest has to be witnessed and CPR would have been continued till reaching hospital.
Category 2
Declared dead in ER after failed resuscitation
Category V
Death in critically ill which was not expected.
Categorisation of Deceased circulatory death (DCD) Donors
· DCD donors should be categorised according the Maastricht classification to aid research, communication and audit. (A1)
· The functional (or true) warm ischaemic period starts when the systolic blood pressure is <50 mmHg for at least 2 minutes) fall below and extends up to the onset of cold in situ perfusion. (B1)
· SaO2 < 70% is not used as an indicator of poor outcome, but a record of SaO2 < 70%, should be saved
Controlled DCD: Organ donation which follows circulatory arrest. This includes:
· Maastricht Category 3: Awaiting cardiac arrest
· Maastricht Category 4: Cardiac arrest in a brain stem dead donor
Uncontrolled DCD: Organ donation from a patient who has suffered an unexpected death that has been confirmed on cardio-respiratory grounds. Includes:
· Maastricht Category 1: Dead on arrival
· Maastricht Category 2: Unsuccessful resuscitation
· Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient
Diagnosis of Death
· Death is a permanent loss of capacity for consciousness and brain stem function. (A1)
· Where cardio-respiratory criteria apply, death can be confirmed following five minutes of continuous cardio-respiratory arrest
· Confirm circulatory arrest with arterial line, or by echocardiography; or failing that by continuous ECG monitoring. (B1)
· DCD organ retrieval protocols should recognise the potential risks around post mortem interventions that might restore cerebral perfusion. (B1)
· The possibility of organ donation should not affect the criteria for the diagnosis of death
Law, Ethics and Donor Consent
· All healthcare professionals should be familiar with the terminology used to describe and discuss the ethics of DCD transplantation. (B1)
· Good ethical practice is essential to facilitate donation and achieve transplantation in the context of DCD. This includes decisions about allocation and consent in relation to both the organ donor and recipient. (B1)
· DCD in the United Kingdom is supported by definitions of death that are accepted by society. The principles of donor dignity and non-maleficence must not be compromised in efforts to facilitate donation and transplantation from DCD donors. (B1)
· Ethical principles integral to the UK controlled DCD programme must extend to any future uncontrolled DCD programme. (B1)
· The BTS Ethics committee is available for guidance and information to support practice in this complex field. (Not graded)
· The UK Donation Ethics Committee is also available to offer guidance and information in this area. (Not graded)
Informing the Recipient
· Providing information, both orally and in writing, for the potential transplant recipient is a requirement for consent and is the responsibility of the multi-disciplinary transplant team. (B1)
· Information should be fitted the requirements of the potential recipient, but not all patients interested with detailed information.
· The recipient should be informed about the relative risk for that recipient of remaining on the transplant waiting list compared to that of receiving a DCD organ.
Organ Retrieval
· Treatment withdrawal should ideally be planned for a time when the donor HLA type and virology are known, and the liver and pancreas recipients are in the recipient hospitals. (C1)
· Treatment withdrawal in the operating department is associated with shorter warm ischaemic times (asystolic periods) than withdrawal on a remote intensive care unit or ward. (C1)
· The retrieval team need to be satisfied about the donor details (blood group, past medical history, illness leading to death) before treatment is withdrawn. (A1)
· Retrieval teams should be scrubbed in the operating theatre at the point of treatment withdrawal. (B1)
· Maastricht 4 donors, where death has been established previously by brain stem criteria, may be given heparin before treatment withdrawal. Death does not need to be reaffirmed once circulatory arrest has occurred. (A1)
· The specialist nurse should keep a record at regular intervals of the donor’s haemodynamic parameters following treatment withdrawal. (C1)
· Death may be confirmed 5 minutes after complete circulatory arrest. There is no need for a further stand off period following this. (A1)
· For controlled donors, retrieval starts by gaining access to a large artery and vein, typically the right common iliac artery or aorta, and the IVC in the abdomen or right atrium in the chest. (Not graded)
· 20000 units heparin should be added to the first bag of ice-cold preservation solution to be perfused through the aorta. (Not graded)
· A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen activator may be added to the first bag of preservation solution. (B3)
· The kidneys may be removed either individually or en bloc. (Not graded)
Viability Testing
· Kidneys from young controlled DCD donors who have died rapidly after withdrawal of support, undergone rapid laparotomy, aortic cannulation, perfusion and venous exsanguination will be expected to work promptly if cold ischaemia is minimised and the kidneys appear well perfused on retrieval.
· For uncontrolled DCD or when perfusion of the kidneys on retrieval is poor, using parameters such as high resistance during machine perfusion or high enzyme levels within the perfusate may indicate increased cellular damage and an increased risk of primary non function but this is not universally accepted (C1)
· Testing the graft function of warm perfused organs prior to transplantation is considered the ‘gold’ standard, but it is impractical. (C2)
Immunosuppression
· No definitive data suggest significant benefit from any particular immunosuppressive regimen in the context of DCD organs. (C1)
· Following DCD kidney transplantation, there is increased risk of delayed graft function due to DCD injury. Induction therapy with mono- or polyclonal antibodies may be used to reduce the risk of clinically unrecognised acute rejection prior to recovery from DCD injury. (B1)
· Induction therapy is often combined with delayed introduction or reduced intensity of calcineurin inhibition to limit the incidence and duration of delayed graft function. (C2)
· Following liver transplantation, consider renal sparing regimens with delayed CNI introduction. Induction and T cell depletion may also be considered, but risk and benefit must be balanced with choice of regimen. (C2)
Kidney
· Individuals with advanced or ESKD, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donors. (B1)
· The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability. (B2)
· Units undertaking cold machine perfusion of DCD kidney transplants prior to implantation should collaborate to standardise the prospective collection of data to enable aggregated analyses of outcomes. (A2)
· None of the dynamic characteristics of machine perfusion, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems, have sufficient predictive value to mandate organ discard. (A2)
· Such assessment may, however, help determine when kidneys should be considered for dual transplantation. (B2)
· Long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. However, DCD kidneys more prone to cold ischaemia. (B2)
· The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation. (A1)
· Antibody induction therapy should be considered as part of the initial immunosuppressive regimen for recipients of DCD kidneys. (B1)
· Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants. (A1)
· Graft outcome is more closely related to whether a transplant is ECD or SCD than whether the mode of donation is DCD or DBD. (B2)
· Prospective data are required to determine whether the impact of extended criteria donation (ECD) is different in DCD and DBD donors and whether different thresholds for organ use may be required. (A1)
Classification of DCD
Controlled DCD
Maastricht Category 3: Awaiting cardiac arrest
· Maastricht Category 4: Cardiac arrest in a brain stem dead donor
Uncontrolled DCD
· Maastricht Category 1: Dead on arrival
· Maastricht Category 2: Unsuccessful resuscitation
· Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient
Summary of guidelines:
Categorisation of DCD Donors:
Diagnosis of Death:
Law, Ethics and Donor Consent:
Informing the Recipient:
Organ Retrieval:
Viability Testing:
Immunosuppression:
Kidney:
Liver:
Pancreas:
Pancreatic islets:
Lung:
Heart:
In DCD :
● It is better to avoid in recipients of re-transplantation
● DCD liver grafts should be used in younger recipients with age <60 years.
● Factors predictive of graft failure are:
* age ≥55 years
* male sex
* African–American race
* HCV positivity
* metabolic liver disorder
* transplant MELD ≥ 35
* hospitalisation at transplant
* need for life support at transplant.
● Recipient predictors of mortality are
* age ≥55 years
* hospitalisation at transplant
* re-transplantation.
● Use of DCD hearts is not currently recommended.
● Warm ischaemic period starts when the SBP has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion.
● Agonal period: the time from treatment withdrawal to circulatory arrest.
● primary warm ischaemic time: the time from circulatory arrest to the perfusion of the organs with cold preservation solution in situ.
● functional (or true) warm ischaemic period: starts when the systolic blood pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in sit perfusion.
● Three concepts must be considered in the process of deceased (DBD or DCD) donor organ allocation
▪︎Equity: all those listed for a transplant have equal opportunity to receive an organ
▪︎Efficiency: ensures minimal waste of organs
▪︎Utility: distribution of organs maximises benefit to recipients, “the greatest good for the most people”
● Avoid transplanting lower risk recipients with DCD organs or those from any other higher risk donor
● good organs were not ‘wasted’ on higher risk recipients.
● Providing information, both orally and in writing, for the potential transplant recipient is a requirement for consent and is the responsibility of the multidisciplinary transplant team. This must be updated and reviewed annually
● The risk benefit analysis must explain the relative risk for that recipient of remaining on the transplant waiting list compared to that of receiving a DCD organ.
● donor blood and immunology laboratory and a pre-emptive cross match
● it is desirable that the lung, liver and pancreas recipients are all in the recipient hospital when treatment withdrawal
● Uncontrolled DCD follows an unexpected cardiac arrest in which a decision is made that continued resuscitation measures will not succeed in saving the patient’s life.
● To minimise warm ischaemic injury treatment withdrawal is best done in the operating theatre
● Three contingencies need to be considered:
1. A clinician who is not amember of trasplant team must be available throughout the period of withdrawal to enable prompt confirmation of death when it occurs.
2. The next of kin must be given the opportunity to be present before and during treatment withdrawal and until death is confirmed.
3. If the potential donor remains alive beyond the period of time that the retrieval
surgeons deem appropriate (a minimum of 3 hours), it is not suitable to keep him/her
in the operating department.
Since death is inevitable, the patient must be transferred to the most appropriate alternative accommodation,
● The retrieval team/s are responsible for reviewing the potential donor’s hospital/medical notes
● Mode of withdrawal of life sustaining treatment
** confirmation irreversible brain injury
** fulfilled a diagnosis of brain stem death.
** declaration of futility with a written
** opinion from the neurologist or neurosurgeon
** withdraw life-sustaining by supervising clinician includes ventilatory support and inotrope infusions and (ECMO) support.
** Get consent/authorisation by the patient in life, or by the next of kin at this time
● If the donor is Maastricht type 4 and death has previously been certified by brain stem criteria, the donor can be heparinised with 20 000 units heparin immediately before treatment withdrawal. This is not permitted for type 1, 2 or 3 DCD donors.
● Once circulatory arrest occurs, five minutes must elapse without any evidence of resumption of circulation before death may be verified
● The most important consideration during the withdrawal phase is the perfusion of the organs;
● a prolonged withdrawal phase is unlikely to be harmful as long as the blood pressure is maintained and urine output continues.
● Assessment the FWIT
** A different Bp threshold which vary with age and baseline BP blood pressure
** The oxygen saturation
● Individuals with advanced or end-stage chronic kidney disease, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donors
● The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability
● Units undertaking cold machine perfusion of DCD kidney transplants prior to implantation should collaborate to standardise the prospective collection of data to enable aggregated analyses of outcomes.
● None of perfusion pressure dynamic characteristics, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems – alone or in combination – have sufficient predictive value to mandate organ discard.
● Such assessment may, however, help determine when kidneys should be considered for dual transplantation.
● Long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar.Nevertheless, it is recognised that DCD kidneys appear to be more susceptible to cold ischaemia, and the proposed national allocation scheme should take this into account.
● The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation.
● Antibody induction therapy should be used as part of the initial immunosuppressive regimen for recipients of DCD kidneys.
● Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants
● Graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD.
Absolute contraindications
invasive or haematological malignancy
untreated systemic infection
prion disease
HIV disease
End-stage kidney disease (CKD stage 5, eGFR <15 ml/min)
CKD stage 4 (eGFR 15-30 ml/min)
Acute cortical necrosis on pre-implantation kidney biopsy
● Acute kidney injury, even that requiring dialysis for the donor during the current hospital admission, is not an absolute contraindication to kidney donation. However, it is likely to increase the risk of DGF or primary non function (PNF) to a greater degree than that associated with DBD donation.
● Relative contraindications
donor age
cold ischaemic time
hypertension and cardiovascular disease ● biopsy may identify kidneys with substantial arterial disease or glomerulosclerosis that are to be discarded
● good outcomes have been described using DBD kidneys with moderate disease when used as dual transplants into a single recipient
● acute renal impairment or haemodynamic instability during a prolonged period do not influence DCD kidney graft outcomes
● Warm ischaemic time Given the clear association between WIT and poor outcome, both in terms of PNF and subsequent graft failure
● prolonged warm ischaemia is a contraindication to kidney donation.
● Maximum time of FWIT is 2 hours but 30 minutes appears to be an absolute
Upper limit time for donation
● Early function is dependent upon
* underlying health of the donor
* ischaemic time
* any damage sustained during the
* process of the death and organ retrieval.
● Newcastle criteria for viability testing in DCD kidney transplantation
Flow on machine perfusion (Perfusion Flow Index) >0.4 ml/min/mmHg/100g of tissue
Intracellular enzymes (GST) (ALT, FABP, Redox iron can also be used)
GST: <100 iu/100g of kidney/litre perfusate in standard organ recovery cassette
● High GST, low donor GFR, elderly donor, diabetes, prolonged cold ischaemia Consider dual renal transplant
● viability assessment is not so critical for kidneys from 3 group of DCD
● There are currently no histological markers that predict PNF as a result of excess warm ischaemia or irreversible ischaemia-reperfusion.
● recipients of DCD kidneys have similar outcomes to recipients of DBD kidneys
● Factors influence outcomes are :
* increasing donor and recipient age
* cold ischaemic time of >12 hours are associated with worse outcome
● DGF is increased in DCD recipients, ranging from 41-51% compared with 24% in DBD recipients
● it is important to avoid exposing young patients to sensitisation from a poorly matched, poor quality organ which may fail within a short period of time.
● Recipient informed consent
● Kidneys retrieved from DCD donors at increased risk of both PNF and DGF.
● So strategies to reduce DGF include the use of induction therapies and the avoidance or delay in introduction of calcineurin inhibitors (CNIs).
● Use and choice of induction therapy
** low immunological risk use IL-2 receptor monoclonal antibody blockade
** high-risk recipients, such as the recipients of DCD use thymoglobulin, or Alemtuzumab
The guidelines discuss donation after circulatory death
It includes the ethical principles and diagnosis of death and the retrieval methods for each organ. It also talks about getting informed consent both verbal and in writing from the recipient
Terminologies Used:
Time periods
– Withdrawal period (also called agonal period): the time from treatment withdrawal to circulatory arrest.
– Primary warm ischemia time (asystolic or acirculatory warm period): the time from circulatory arrest to the perfusion of organs with cold preservation solution in situ.
– The functional warm ischemic period: it starts with the SBP falls to less than 50mmHg for at least 2 minutes and extends to the onset of cold in situ perfusion.
Diagnosis of death
Death has clinical, legal and societal elements. It is defined as a state in which a patient has permanently lost the capacity for consciousness and brain stem function.
When cardiorespiratory criteria apply, death can be confirmedfollowing 5 minutes of continuous cardiorespiratory arrest provided there is no subsequent restoration of artificial cerebral circulation. The criteria for the diagnosis of death following loss of circulatory function should not be influenced by the possibility of subsequent organ retrieval.
Where possible, circulatory arrest should be identified by the absence of pulsatile flow on a correctly functioning arterial line, or by the use of echocardiography, if available.
Death is, in essence, a neurological event and occurs when there is permanent loss of:
– The capacity for consciousness
– All brain stem function.
The criteria used to diagnose death should be functional rather than anatomical, i.e. not referred to as cardiac death or brain death but based upon the loss of vital organ function.
Neurological and circulatory function are inextricably linked. Death equals to the loss of capacity for consciousness and all brain stem function, most commonly occurs following the loss of circulatory function from which a person should not or cannot be resuscitated.
The exact definition of death has given rise to a significant ethical debate. The key ethical principle is that donation should proceed only after death has been established and no prospect of spontaneous auto-resuscitation exists.
The decision to cease attempts at life preserving treatments should be taken in a manner independent of donation/transplantation considerations and be based purely on the concept of functionality with respect to prolongation of life.
Law, ethics and donor consent
The principles of donor dignity and non-maleficence must not be compromised in order to facilitate donation and transplantation.
All health care providers should be aware of the complex ethical issues that are associated with donation after circulatory death (DCD) and transplantation of donated organs.
The key ethical principles underpinning the clinical practice in relation to both donors and recepients in the complex context of DCD and transplantation include:
– Altruism
– Autonomy
– Dignity
– Non-maleficence
– Fertility
– Equity
Informing the recipient
The recipient should be provided information both orally and in writing, and it is the responsibility of the multidisciplinary transplant team.
This information should be tailored to the requirements of the potential recipient.
The potential recipient must be informed about the benefits and risks of receiving the DCD organ, risk of remaining on the transplant list versus receiving the DCD organ.
Organ retrieval
Treatment withdrawal should ideally be planned for a time when the donor HLA type and virology are known and the liver and pancreas recipient are in the recipient hospitals. Treatment withdrawal in the operating department is associated with shorter warm ischemic times rather than withdrawal on a remote ICU.
The retrieval team need to be satisfied about donor details before treatment is withdrawn.
The specialist nurse should keep a record at regular intervals of the potential donor’s hemodynamic parameters following treatment withdrawal.
Death may be confirmed 5 minutes after complete circulatory arrest.
For controlled donors, retrieval starts by gaining access to a large artery and vein, typically the right common iliac artery or aorta, and the IVC or right atrium.
20,000 units of heparin should be added to the first two bags of ice cold preservation solution to be perfused through the aorta. The kidneys may be removed individually or en bloc.
The pancreas may be removed either en bloc with the liver or following removal of the liver.
The liver should be removed using a rapid technique whichminimizes liver congestion.
Dual perfusion of hepatic artery and portal vein is essential for the recovery of DCD livers for transplantation.
Individuals with advanced or ESKD, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donors.
The use of donors with functional warm ischemic time more than 20 hours or absent blood pressure for 30 minutes should be restricted to experimental protocols, which attempt to resuscitate organ viability.
None of the perfusion pressure dynamic characteristics, perfusate effluent biochemical characteristics or kidney transplant biopsy scoring systems have sufficient predictive value to mandate organ discard.
The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the recipient prior to transplantation. Long term outcomes od DCD recipients are similar to those of DBD recipients. Antibody induction therapy should be used as a part of the initial ISS regimen for recipients of DCD kidneys.
AKI, even that requiring dialysis for the donor during the current hospital admission, is not an absolute contraindication to kidney donation.
No definitive date currently suggest any advantage for specific preservation solutions in the context of DCD kidney transplantation.
Liver
Livers transplanted for Maastricht 3 DCD donors are a useful resource. Short and medium term outcomes appear inferior to livers from DBD donors with more PNF (primary non-function) and ischemic cholangiopathy and a higher rate of re-transplantation DCD and DBD recipients transplanted with a MELD > 30 or on organ-perfusion support have similar graft survival.
The incidence of biliary strictures is significantly lower when a low viscosity solution is used to cold flush the aorta. An ‘ideal’ DCD liver donor is:
– <50 years old
– Has a function WIT <20 minutes
– A shorter CIT, <10 hours
– <10% steatosis
Long FWIT is associated with an increased risk of ischemic cholangiopathy.
Absolute contraindications include:
– End-stage liver disease
– Acute liver failure
– Moderate to severe steatosis (>30%)
– Acute liver injury that is not improving.
Please provide a summary of these guidelines
.-Organ donation following circulatory death is classified as either ‘controlled’ or ‘uncontrolled’.
– The withdrawal period (sometimes called the agonal period): the time from
treatment withdrawal to circulatory arrest.
-The asystolic or acirculatory warm period (also known as the primary warm
ischaemic time): the time from circulatory arrest to the perfusion of the organs with cold preservation solution in situ.
– The functional (or true) warm ischaemic period: starts when the systolic blood
pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion.
DIAGNOSIS OF DEATH
Statements of Recommendation
-Death is irreversible and should be regarded as a state in which a patient has
permanently lost the capacity for consciousness and brain stem function. (A1)
– Where cardio-respiratory criteria apply, death can be confirmed following five
minutes of continuous cardio-respiratory arrest providing there is no
subsequent restoration of artificial cerebral circulation. (B1)
-Where possible, circulatory arrest should be identified by the absence of
pulsatile flow on a correctly functioning arterial line, or by the use of
echocardiography if the expertise is available; or failing that by continuous
ECG monitoring. (B1)
-DCD organ retrieval protocols should recognise the potential risks around post
mortem interventions that might restore cerebral perfusion. (B1)
-The criteria for the diagnosis of death following loss of circulatory function
should not be influenced by the possibility of subsequent organ retrieval. (A1)
LAW, ETHICS AND DONOR CONSENT
-All healthcare professionals should be aware of the complex ethical issues that
are associated with donation after circulatory death (DCD) and transplantation
of donated organs. Such professionals should be familiar with the terminology
used to describe and discuss the ethics of DCD transplantation. (B1)
– Good ethical practice is integral to efforts to facilitate donation and achieve
transplantation in the context of DCD. This includes decisions about allocation
and consent in relation to both the organ donor and recipient. (B1)
-DCD in the United Kingdom is underpinned by definitions of death that are
accepted by society. The principles of donor dignity and non-malfeasance
must not be compromised in efforts to facilitate donation and transplantation
from DCD donors. (B1)
-Ethical principles integral to the UK controlled DCD programme must extend to
any future uncontrolled DCD programme. (B1)
– The BTS Ethics committee is available for guidance and information to support
practice in this complex field. (Not graded)
– The UK Donation Ethics Committee is also available for guidance and
information. (Not graded)
Dignity: complex to define, but in this context reflecting the unique and precious status of the human being and the ethical requirement to treat it respectfully without inflicting harm in both life and death.
Non-malificence: the ethical principle that healthcare professionals should not cause harm or distress to their patients.
ORGAN RETRIEVAL
-Treatment withdrawal should ideally be planned for a time when the donor HLA
type and virology are known and the liver and pancreas recipients are in the
recipient hospitals. (C1)
-Treatment withdrawal in the operating department is associated with shorter
asystolic periods (warm ischaemic times) than withdrawal on a remote
intensive care unit or ward. (C1)
– The retrieval team need to be satisfied about the donor details (blood group,
past medical history, illness leading to death) before treatment is withdrawn.
(A1)
– Retrieval teams should be scrubbed in the operating theatre at the point of
treatment withdrawal. (B1)
– Maastricht 4 donors, where death has been established previously by brain
stem criteria, may be given heparin before treatment withdrawal. Death does
not need to be reaffirmed once circulatory arrest has occurred. (A1)
-The specialist nurse should keep a record at regular intervals of the donor’s
haemodynamic parameters following treatment withdrawal. (C1)
– Death may be confirmed five minutes after complete circulatory arrest. There is
no need for a further stand off period following this. (A1)
– For controlled donors, retrieval starts by gaining access to a large artery and
vein, typically the right common iliac artery or aorta, and the IVC in the
abdomen or right atrium in the chest. (Not graded)
-20 000 units heparin should be added to the first two bags of ice-cold
preservation solution to be perfused through the aorta. (Not graded)
– A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen
activator may be added to the first bag of preservation solution. (B3)
– The kidneys may be removed either individually or en bloc. (Not graded)
-The pancreas may be removed either en bloc with the liver, or following
removal of liver (Not graded)
ORGAN SPECIFIC DISCUSSION
KIDNEY
– Individuals with advanced or end-stage chronic kidney disease, or with cortical
necrosis demonstrable on biopsy should not be considered as potential kidney
donors. (B1)
– The use of donors with functional warm ischaemic time >2 hr or absent blood
pressure for 30 minutes should be restricted to (currently experimental)
protocols which attempt to resuscitate organ viability. (B2)
– Units undertaking cold machine perfusion of DCD kidney transplants prior to
implantation should collaborate to standardise the prospective collection of
data to enable aggregated analyses of outcomes. (A2)
– None of perfusion pressure dynamic characteristics, perfusate effluent
biochemical analysis, or kidney transplant biopsy scoring systems – alone or in
combination – have sufficient predictive value to mandate organ discard. (A2)
-Such assessment may, however, help determine when kidneys should be
considered for dual transplantation. (B2)
– Long term outcomes of DCD recipients are similar to those of DBD recipients
and the allocation system for DCD and DBD organs should be similar.
Nevertheless, it is recognised that DCD kidneys appear to be more susceptible
to cold ischaemia, and the proposed national allocation scheme should take
this into account. (B2)
-The incidence of delayed graft function is increased in DCD recipients and this
should be discussed with the patient prior to transplantation. (A1)
-Antibody induction therapy should be used as part of the initial
immunosuppressive regimen for recipients of DCD kidneys. (B1)
– Long-term outcomes for standard criteria donors are equivalent for DCD and
DBD kidney.
Thank you I learn more rather.than summarize
The Need for Guidelines
Transplantation offers patients with end-stage organ failure a cost-effective treatment that improves quality of life and increases life expectancy.
Prior to the introduction of guidance defining the concept of brain death in the 1970s, all organs for transplantation were donated after circulatory death (DCD).
Following the introduction of brain stem death testing, the majority of organs for transplantation were donated after brain death (DBD) or, increasingly, from living donors. However, in the UK, demand for organ transplantation has continued to rise. By 2012, the mean waiting time for deceased donor kidney transplantation had risen to over three years, while demand for other organs far outstripped the available supply with the consequence that many patients died while awaiting an organ transplant
DCD donation results in fewer donated organs per donor than DBD donation (2.6 organs compared to 4).
DCD donors are able to donate kidney, liver, pancreas, lung, and multiple tissues, and research in the UK is exploring the options for cardiac DCD following the successful development of such programmes in the USA (3).
Improved immunosuppression, improved organ recovery and implantation, and enhanced peri- and post-operative care mean that the outcomes from DCD organs compare favourably with those from DBD organs.
Controlled DCD
Organ donation which follows circulatory arrest. This may be in the context of withdrawal or non-escalation of cardio-respiratory treatments that are considered to be no longer in a patient’s best interests, or occurring in a patient already certified dead by brain stem criteria.
Uncontrolled DCD
Organ donation from a patient who has suffered an unexpected death that has been confirmed on cardio-respiratory grounds.
Categorisation of DCD Donors
Diagnosis of Death
Organ Retrieval
Kidney
– CATEGORISATION OF DCD DONORS & DEFINITION OF WARM ISCHAEMIC TIME
>>according the Maastricht classification
1-Maastricht Category 1: Death occurring outside of hospital
Death is confirmed outside a hospital environment. For these individuals to be potential
donors, the moment of sudden death needs to have been witnessed, the time that it
occurred documented, and ‘resuscitation’ continued after death.
2-Maastricht Category 2: Unsuccessful resuscitation
CPR is started outside of hospital following collapse. Death is confirmed on admission to
hospital.
Both Category 1 and 2 donors are also referred to as ‘Uncontrolled’ DCD donors and
usually present to the emergency department.
3-Maastricht Category 3: Awaiting cardiac arrest
Death is inevitable but brain stem death criteria are not fulfilled. These patients are cared for
in many areas within hospitals, but are most commonly identified in neurosurgical and
general intensive care units, coronary care units, emergency departments and medical
wards.
4-Maastricht Category 4: Cardiac arrest in a brain stem dead individual
Death has been diagnosed by brain stem criteria following which the patient suffers a
cardiac arrest. This may be whilst awaiting the donor team or as an intentional arrangement,
depending upon the wishes of the next of kin.
Categories 3 and 4 are also referred to as ‘Controlled’ DCD donors.
5-Maastricht Category 5: Unexpected cardiac arrest in a hospitalised patient
Category 5 is an ‘uncontrolled’ donor in a hospitalised patient so the warm ischaemic time
(WIT) between cardiac arrest and organ perfusion is likely to be longer than categories 3 or
4 but shorter than categories 1 or 2.
– The functional (or true) warm ischaemic period starts when the systolic blood
pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and
extends up to the onset of cold in situ perfusion. (B1)
– Although donor low oxygen saturation (<70%) is a concern and may well be a
measure of inadequate organ perfusion and poor outcome, prospective
evidence is awaited. The current recommendation is that oxygen saturation
below 70% is not used as an indicator of poor outcome or as a reason for non
usage, but that retrieval teams should keep a record of when oxygen saturation
falls below 70% in order to allow correlation with graft outcome.
– The withdrawal period (sometimes called the agonal period): the time from
treatment withdrawal to circulatory arrest.
– The asystolic or acirculatory warm period (also known as the primary warm
ischaemic time): the time from circulatory arrest to the perfusion of the organs with
cold preservation solution in situ.
– The functional (or true) warm ischaemic period: starts when the systolic blood
pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up
to the onset of cold in situ perfusion.
– DIAGNOSIS OF DEATH
– Death is irreversible and should be regarded as a state in which a patient has
permanently lost the capacity for consciousness and brain stem function. (A1)
– Where cardio-respiratory criteria apply, death can be confirmed following five
minutes of continuous cardio-respiratory arrest providing there is no
subsequent restoration of artificial cerebral circulation. (B1)
– Where possible, circulatory arrest should be identified by the absence of
pulsatile flow on a correctly functioning arterial line, or by the use of
echocardiography if the expertise is available; or failing that by continuous
ECG monitoring. (B1)
– DCD organ retrieval protocols should recognise the potential risks around post
mortem interventions that might restore cerebral perfusion. (B1)
– The criteria for the diagnosis of death following loss of circulatory function
should not be influenced by the possibility of subsequent organ retrieval. (A1)
– the potential recipient must be explained regarding the risk ob being on waiting list compared to outcome of deceased kidney transplantation .
– Organ retrieval in OR with the team should know the donor details before treatment, Death may be confirmed five minutes after complete circulatory arrest. There is no need for a further stand off period following this. A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen activator may be added to the first bag of preservation solution.
– Regarding the KIDNEY
– Individuals with advanced or end-stage chronic kidney disease, or with cortical
necrosis demonstrable on biopsy should not be considered as potential kidney
donors. (B1)
– The use of donors with functional warm ischaemic time >2 hr or absent blood
pressure for 30 minutes should be restricted to (currently experimental)
protocols which attempt to resuscitate organ viability. (B2)
– Units undertaking cold machine perfusion of DCD kidney transplants prior to
implantation should collaborate to standardise the prospective collection of
data to enable aggregated analyses of outcomes. (A2)
– None of perfusion pressure dynamic characteristics, perfusate effluent
biochemical analysis, or kidney transplant biopsy scoring systems – alone or in
combination – have sufficient predictive value to mandate organ discard. (A2)
– Such assessment may, however, help determine when kidneys should be
considered for dual transplantation. (B2)
– Long term outcomes of DCD recipients are similar to those of DBD recipients
and the allocation system for DCD and DBD organs should be similar.
Nevertheless, it is recognised that DCD kidneys appear to be more susceptible
to cold ischaemia, and the proposed national allocation scheme should take
this into account. (B2)
– The incidence of delayed graft function is increased in DCD recipients and this
should be discussed with the patient prior to transplantation. (A1)
– Antibody induction therapy should be used as part of the initial
immunosuppressive regimen for recipients of DCD kidneys. (B1)
– Long-term outcomes for standard criteria donors are equivalent for DCD and
DBD kidney transplants. (A1)
– Graft outcome is more closely related to whether a transplant is ECD vs SCD
than whether the mode of retrieval is DCD vs DBD. (B2)
– Prospective data are required to determine whether the impact of expanded
criteria donation (ECD) is different in DCD and DBD donors and whether
different thresholds for organ use may be required. (A1)
Summary:
This article was about Transplantation from deceased donors after circulatory death that was coordinated by the British Transplantation Society. It started with an introduction that explain how the guidelines were developed and the steps taken to ensure nothing was overlooked. Once that was done a guideline was formulated on transplantation from deceased donors after circulatory death in July 2013.
The different categories that summarize:
This article was about Transplantation from deceased donors after circulatory death that was coordinated by the British Transplantation Society. It started with an introduction that explain how the guidelines were developed and the steps taken to ensure nothing was overlooked. Once that was done a guideline was formulated on transplantation from deceased donors after circulatory death in July 2013.
The different categories that were included were:
1) Categorization of DCD donors and diagnosis of death. This was a category that was based on the Maastricht classification. It is based on the warm ischaemic time from a period of SBP of less than 50 mmHg and when the perfusion starts. Oxygen must not be less than 70%. It further went on to define death which is a nonreversible loss of consciousness and no brain stem function. Once there are proper monitoring organs can be harvested based on protocol.
The Maastricht categories are:
a) Category 1: deals with death on arrival
b) Category 2: is unsuccessful resuscitation
c) Category 3: is to wait on cardiac arrest
d) Category 4: cardiac arrest in a brain stem dead donor
e) Category 5: unexpected cardiac arrest in a critically ill patient.
2) The ethic, consent, and organ retrieval must be followed based on the guideline. The BTS ethic board is present to ensure that the guidelines are followed and there is proper guidance.
3) Once that has been attained, the recipient must be informed. Proper documentation must be documented. All the risks and complications must be explained to the recipient and no information should be withheld.
4) Now as the information is obtained based on the donor like the HLA etc. the different groups of recipients must be notified, with limited time and the operating room must be available to avoid prolonged warm ischaemic time. In the case of the kidneys, it must be removed either in a bloc or an individual.
5) Once the organ has been harvested, its viability must be tested. It is recommended that the graft function perfused of warm perfused organs before transplantation. It is the gold standard to ensure organ function. Other tests can be used based on organ harvesting.
6) Medications must be initiated once the graft has been transplanted due to the fact that the majority of graft function delays. Different groups of medications can be used like monotherapy or polyclonal antibodies. An example of a medication that can be used calcineurin inhibitors.
7) As it regards the kidneys, cortical necrosis is a contraindication and other parameters are used to see the viability or acceptance of the kidney. For example, a kidney biopsy can be done to give information about the kidney status, and based on the scoring system it can be used or rejected.
8) With the liver, it Is found that the shorter the CIT the outcome is better, and with an age less than 50 years.
9) There are certain factors that can give information about the possible factors that can influence graft failure:
a) Male patient
b) Age older than 55
c) Race African American
d) If there is any infection of Hep C
e) If there is a metabolic disorder
f) Number of hospitalization
g) If there is a need for life support
10) When it comes to the pancreas, the warm ischemic time should be less than 60 minutes. If the time is prolonged there is a high chance of developing thrombosis, and possible pancreatitis. It must be noted that the higher BMI the poorer the outcome. The graft failure most of the time is due to thrombosis.
11) As it relates to the lungs, the donor criteria for the lung on DCD is the same as DBD. One has to perform perfusion at the same time as lung retrieval.
12) heart transplantation from DCD donors is not standard care in the UK.as included were:
CATEGORISATION OF DCD DONORS
Deceased circulatory death donors should be categorized according to the Maastricht classification.
Maastricht Category 1: Dead on arrival
Maastricht Category 2: Unsuccessful resuscitation
Maastricht Category 3: Awaiting cardiac arrest
Maastricht Category 4: Cardiac arrest in a brain stem dead donor
Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient.
The functional (or true) warm ischemic period starts when the SBP has a sustained ( at least 2 min) fall below 50 mmHg and extends up to the onset of cold in situ perfusion.
SPO2 below 70% is not used as an indicator of poor outcome or as a reason for non-usage, but retrieval teams should keep a record of when oxygen saturation falls below 70% to allow correlation with graft outcome.
Diagnosis of Death
Death is irreversible and should be regarded as a state in which a patient has permanently lost the capacity for consciousness and brain stem function.
Death can be confirmed after 5 min of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation.
The criteria for the diagnosis of death should not be influenced by the possibility of subsequent organ retrieval.
Law, Ethics and Donor Consent
All healthcare professionals should be familiar with the terminology used to describe and discuss the ethics of DCD transplantation.
All principles of ethics and donor dignity must not be compromised in efforts to facilitate donation and Tx from DCD donors.
The BTS UK Donation ethics committee is available for guidance and information to support practice.
Organ Retrieval
Treatment withdrawal is ideally to be planned when the donor HLA type and virology are known, and the liver and pancreas recipients are in the recipient hospitals.
Retrieval is ideally done in the OR to decrease WIT.
For uncontrolled DCD or when perfusion of the kidneys on retrieval is poor, an increased risk of primary non-function, but this is not universally accepted.
Testing the graft function of warm perfused organs prior to transplantation is considered the ‘gold’ standard. However, it is difficult to perform and usually impractical, with lung being an exception.
Immunosuppression
There is increased risk of DGF due to DCD injury; therefore, induction therapy is used to reduce the risk of AR, and is often combined with delayed introduction or reduced intensity of CNI.
In liver transplantation, consider renal-sparing regimens with delayed CNI introduction.
In heart and lung transplantation, there is no evidence to use a different regimen from that used in DBD
Kidney
Absolute contraindications; End-stage kidney disease CKD 4-5, Acute cortical necrosis on pre-implantation biopsy
The use of donors with WIT >2 hr or absent BP for 30 minutes should be restricted to protocols which attempt to resuscitate organ viability.
Units undertaking cold machine perfusion of DCD KTx prior to implantation should standardize the collection of data.
Using the dynamic characteristics of machine perfusion alone or in combination does not have sufficient predictive value to mandate organ discard; however, helps determine DKT
The recipient should be aware of the increased chance of DGF
The long-term outcomes of DCD recipients are similar to those of DBD recipients. However, it is more susceptible to cold ischemia, and the allocation system for should be similar.
Antibody induction therapy should be considered as the initial IS regimen for recipients of DCD kidneys.
Graft outcome is more closely related to whether a transplant is ECD or SCD than whether the donation mode is DCD or DBD.
Liver
Livers Tx from Maastricht 3 DCD donors should be used where deemed safe.
The short and medium-term outcome appears inferior to livers from DBD donors, with more PNF and ischemic cholangiopathy and a higher rate of re-transplantation.
DCD and DBD with MELD >30 or on organ-perfusion support have similar graft survival, no survival benefit when MELD ≤30 or in those not receiving organ-perfusion support.
Biliary stricture is significantly lower when a low-viscosity solution is used.
The outcome of DCD liver Tx is improved with short CIT, when kept to < 8hrs.
Ideal’ DCD liver is transplanted has a favourable outcome, meaning; the donor is <50 years old, has a functional WIT time <20 min, a shorter CIT <10 hr, and <10% steatosis.
Restrictive DCD Donor criteria; BMI <29 kg/m2 and a functional WIT <20 min (SAP <50 mmHg), equivalent 1 and 3-year patient and graft survival rates for both DCD and DBD liver transplants.
Long FWIT is associated with an increased risk of ischemic cholangiopathy
Potential recipients should be informed of the risk and be offered the choice to refuse.
DCD liver grafts should be ideally used in younger recipients with age <60 years to be avoided in re-transplantation.
Predictive of graft failure are age ≥55 years, male sex, AA race, HCV positivity, metabolic liver disorder, transplant MELD ≥ 35, hospitalization at transplant, and the need for life support at transplant.
Recipient predictors of mortality are age ≥55 years, hospitalization at transplant, and re-transplantation.
Pancreas
DCD organs can be used for isolated pancreas transplants, pancreas after kidney or simultaneous pancreas-kidney (SPK)
Lung
The donor criteria for lung Tx are the same for DCD and DBD.
DCD lungs should not be regarded as extended or marginal. Transplant outcome and quality are at least similar to DBD organs.
Perform flush perfusion at the time of lung retrieval.
Pre-transplant ex vivo lung perfusion (EVLP) is advised in case of uncertain graft performance to safely extend donor and procedural criteria (long warm ischemia, bad flush, clots).
Acceptance criteria on EVLP may include measures of pulmonary compliance, vascular resistance, and gas exchange.
Heart
In the UK, heart Tx from DCD donors is NOT standard of care, for ethical issues.
Dear Dr Hadeel,
That is a good summary.
Individuals with advanced or end-stage chronic kidney disease, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donors.
The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability.
Units undertaking cold machine perfusion of DCD kidney transplants prior to implantation should collaborate to standardise the prospective collection of data to enable aggregated analyses of outcomes.
Long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. Nevertheless, it is recognised that DCD kidneys appear to be more susceptible to cold ischaemia, and the proposed national allocation scheme should take this into account.
The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation.
Antibody induction therapy should be used as part of the initial immunosuppressive regimen for recipients of DCD kidneys.
Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants.
Graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD.
Dear Dr Tuffayel,
That is a good summary. Please type headings and sub-headings in bold or underline. That will make it easier to read.
SUMMARY
Introduction
It is an established fact that transplantation does not only prolong time but also better quality of life for those with end stage organ failure. Previously, most of the organs are retrieved from donor with DCD and the ever-increasing demands for various organ has made the gap between demand and supply to be very wide, hence the introduction of DBD to enable more organs available for transplantation. The essence of guidelines is to provide a uniform criterial for diagnosis of most the dead before proceeding to organ retrieval.
Categorization of DCD Donors
This is largely classified into controlled DCD which involves withdrawal of service in ICU or emergency or uncontrolled which is a potential donor suffered a cardiac arrest and was already dead-on arrival at the hospital or unable to be resuscitated.
The following classification is recommended
Categories 1 and 2 are also called uncontrolled DCD, while categories 3 and 4 are called controlled DCD
Diagnosis of Dead
Death has clinical, legal and societal element in it and it is a biological event that the diagnosis should be seen as such.
Criterial for diagnosis of death
Law, Ethics, and Donor Consent
The ethical issues that must be well considered before harvesting organs are; altruism, autonomy, dignity, non-Maleficent, futility, and equity.
Consent/Authorization of organ donation
This is legally defined by Human Tissue Act 2004 in England, Wales, Northern Ireland with that of organ authorized by Human Tissue Act Scotland Act 2006.
The donor is expected to give consent or if unavailable the next of kin can be allowed to give permission for organ retrieval
Informing the Recipients
Organ Specific Discussion
Kidney
Kidney transplantation either by DCD or DBD is almost the same except for release of more physiological inflammatory stress and prolong warm ischemic time in those from DBD. Of not are the absolute contraindications to use of kidney from DCD like eGFR <15mil/min, CKD stage 4, and acute cortical necrosis on pr-implantation kidney biopsy
Warm Ischemic time
Factors that influence outcome of recipients
Above two are associated with worse outcome, however, the use of induction therapy and the type (e,g CNI, IL-2 antagonist, monoclonal antibody) has helped to reduce the incidence of DGF or PNF
Dear Dr Issac
That is a good summary.
DCD donors categorization and warm ischemia
-DCD categorization have to be done according to Maastricht classification.
-Maastricht classification;
Maastricht 1: death on arrival
Maastricht 2:failed resuscitation
Maastricht 3: cardiac arrest is awaited
Maastricht 4:cardiac arrest in brain stem death
Maastricht 5: surprising cardiac arrest in critically ill case.
-3,4 are considered controlled DCD while 1,2,5 are uncontrolled.
-O2 saturation below 70 % does not indicate poor outcome but need to be monitored.
– The withdrawal period refers to the time from withdrawal of treatment to circulatory arrest.
-The asystolic period is the time from circulatory arrest till the cold preservation solution is given.
– The functional warm ischaemic period: starts is when the systolic blood pressure is persistently below 50 mmHg and extends till the onset of cold in situ perfusion.
Death diagnosis
-Death indicates irreversible loss of consciousness and brain stem function ,it is confirmed after 5 minutes from persistent cardiorespiratory arrest without returning artificially cerebral circulation.
-Circulatory arrest can be detected by absence of pulsatile flow in an arterial line, or by echo or through ECG monitoring,
-Organ donation protocols must consider the possible risks regarding post mortem intervention that can regain cerebral circulation.
-Death diagnosis must not be affected by the possible organ donation.
– Death definition used in UK is theirreversible loss of the capacity for consciousness combined with irreversible loss of the capacity to breathe’.
-Healthcare professionals must be oriented to the complex ethical issues related to donation after circulatory arrest because good ethical practice is necessary to preserve the donor’s dignity and right of non malfeasance.
– the UK ethical principles of the controlled DCD programme need to be applied for future uncontrolled DCD programmes.
-Altruism indicates the donor’s own will voluntarily to donate his organs after death without any return.
-Autonomy means the donor’s right to decide for the fate of their organs after death.
– The UK Donation Ethics Committee (UKDEC) gives the right to all patients who need end of life care ,without having a medical contra-indication, to decide to donate, regardless of the environment .
-An authorised consent need to be obtained from the donor including all the details as which organ to donate , tissue and blood samples that will be taken , virology testing ,the willing to involve the organs in research if not fit for donation, and there discarding afterwards.
-To preserve donor’s dignity and non malfeasance the least invasive morally acceptable procedures can be done to preserve the organ for donation.
-There is a dilemma regarding the supportive therapy as ventilation given to facilitate the donor’s autonomous desire for donation and preserving the quality of the donated organ from one side and providing a dignified non torturing death for the donor from the other side in controlled DCD.
-Uncontrolled DCD occurring more rapid than DBD and controlled DCD, has some other ethical issues.
– Early approach to the bereaved is necessary to have a balance between autonomy and altruism.
-pre consent preservation measures can be started as in situ organ perfusion via a femoral catheter for uncontrolled DCD cases.
-Ethical concerns occur when preservative measures are done to restore cerebral circulation in a case of uncertain death criteria .
– Organ allocation schemes depend on complex algorithms that take into account numerous clinical and patient factors as predicted outcome, waiting times effects and shortage of available organs for transplantation, as it is considered non ethical to provide DCD organs to high risk cases only due to it’s poor quality and their less favourable expected outcome .
-The risk benefit details need to be explained to the recipient on different occasions confirming his will to receive an organ from a DCD and to sign the consent voluntarily.
– Su et al developed the UNOS/CHOICE system for allocation of higher risk organs, so that the recipient can understand and choose the range of kidneys that would be acceptable to
them for transplantation but it would be a complex procedure.
-MDT is responsible for providing all the required details both oral and written in a consent for the potential recipient which must be annually updated.
-The risk benefit analysis must be explained to the recipient concerning receiving an organ from DCS versus staying on the waiting list.
– Once the donor HLA type and virology are done and the liver and pancreas recipients are in the recipient hospitals, treatment withdrawal can be planned .
-Treatment withdrawal is ideally associated with shorter warm ischemia time.
-The donor data must be sufficient for the retrieval team before withdrawing the treatment.
-Heparin can be given before treatment withdrawal for Maastricht 4 donors.
-After stooping the treatment the assigned nurse need to record regularly the donor’s vitals.
– 5 minutes after circulatory arrest ,death can be confirmed without any need for a stand off period .
-for controlled donors retrieval is carried out through having an access to common iliac artery ,aorta and IVC in the abdomen and never to be placed in the SMV,IMV when pancreas is to be retrieved.
-Through the aorta 20000units of heparin are added to 2 bags of cold ice preservative solutions as well as a fibrinolytic agent can be added to the first bag.
-Kidneys can be taken on it’s own or en bloc, for the pancreas, it can be removed en bloc with the liver or after liver removal.
-Perfusing both hepatic artery and portal vien is mandatory for recovery of DCD livers .
– The type of preservative solution can affect the risk of delayed graft dysfunction and the overall outcome.
Organ specific discussion
Kidneys
-Candidates with advanced or ESRD or cortical necrosis cannot be considered for donation.
– Protocols to resuscitate organ viability will be needed for organs with functional warm ischaemic time >2 hr .
– Standardisation of the prospective collection of data for units doing cold machine perfusion of DCD kidney transplants to facilitate evaluation of the outcomes.
-There are no sufficient tests to define the predictive values in order to discard an organ.
– Kidneys suitable for dual transplantation need to be detected.
-DCD and DBD recipients have the same long term outcomes but DCD is more susceptible to cold ischaemia.
-DCD recipients are more liable to DGF ,and the recipient must be oriented about that
– For recipients of DCD kidneys ,initial immunosuppressive protocol include antibody induction therapy.
-ECD or SCD affects the graft prognosis more than DCD or DBD.
-More data is needed to determine if ECD is different in DCD and DBD.
– Combining donor hypertension and creatinine with histological scoring provide a suitable predictive value.
-The older the candidates are and the longer the cold ischemia time> 12h the worse the prognosis will be.
Liver
– Livers retrieved from Maastricht 3 DCD donors can be used when suitable
-Livers donated from DBD have less favourable short and medium outcomes.
– DCD and DBD cases transplanted with MELD >30 have same graft survival.
– Cold flushing the aorta with low viscosity solution decreases the incidence of biliary stricture.
-DCD liver should be donated to recipients whom will benefit the most.
-CIT < 8h improves the prognosis of DCD liver transplant
– An ‘ideal’ DCD liver donor refers to a donor <50 years old, has a functional WIT time <20 min, a shorter CIT <10 hr, and <10% steatosis.
-The same 1 and 3 years graft survival for DCD and DBD can be reached with applying restrictive criteria.
– Ischaemic cholangiopathy risk is high with long FWIT.
-Retransplant candidates better not to use DCD grafts, that is better used for recipients< 60 y.
– Age ≥55 years, male sex, African–
American race, HCV positivity, metabolic liver disorder, transplant MELD ≥ 35 are factors suggestive of graft failure.
– Age ≥55 years, hospitalisation at transplant, and re-transplantation are mortality predictors.
-A national audit is needed to define the factors for either utilisation or discarding of a graft.
Pancreas
-Current practice recommends the use of simultaneous pancreas and kidney transplantation
-prolonged cold ischemia time ,high BMI and possibly donor’s age are superadded risk factors to pancreas transplants from DCD donors that lead to reperfusion pancreatitis and thrombosis.
-FWIT of 60 minutes is not suitable for pancreatic transplantation.
-Minimal cold ischemia time need to be reached for DCD pancreas transplants.
– Outcomes of DCD and DBD pancreatic transplants are broadly similar.
– Thrombosis leading to graft loss is twice more common with DCD pancreatic transplants compared to DBD, therefore recipients with thromboembolic history better to avoid DCD pancreatic transplant.
Pancreatic islets
-The criteria for choosing recipients for DBD and DCS pancreatic islets transplantation is the same.
– Further studies are needed to access the long term outcome of islet transplantation from DCD donors meanwhile the results from small cohort studies are acceptable.
– DCD donors can provide satisfactory functional islet preparations.
Lung
– Criteria for selection of DCD and DBD are the same for lung transplantation as in both transplant quality and outcome is nearly the same so DCD lung is not counted as extended or marginal.
– Antegrade and retrograde flush perfusion is done at the time of lung retrieval.
– For uncertain graft performance pre-transplant ex vivo lung perfusion (EVLP) is recommended.
– Pulmonary compliance, vascular resistance, and gas exchange are the acceptance criteria on EVLP.
Heart
-Guidelines are not updated because in UK heart transplantation from DCD donors is not a standard of care due to ethical issues.
Pediatric DCD transplantation
DCD pediatric donation can be considered for cases facing end of life illnesses which can increase the pool of available organs for children.
Kidney and liver grafts from paediatric DCD donors are as good as organs donate from SCD donors regarding the graft function and recipient survival rates .
That is the same for the heart and lung transplantation.
Dear Dr Doaa,
That is a good summary.
It is a great challenge to try to put in a few words such a complex protocol as a deceased donor, but I will emphasize some key points:
1. Concept of death
1.1 – Brain death
The classic concept of brain death is the cessation of functions such as coma, unresponsiveness (absence of central brain reflexes), and apnea. Increased intracranial pressure can trigger reflexes in the spinal cord.
To rule out brain death, there must be a central reflex (pupillary, corneal, facial, oculocephalic, oculovestibular, pharyngeal, and laryngeal). Neuroradiological tests (USG Doppler, magnetic resonance angiography, technetium scintigraphy, angiography), electroencephalographic (EEG), hypothermia, sedatives, narcotics, hydro electrolytic and acid-base disturbances.
Because it is an extremely multicultural country, with several religions, and great spirituality, the concept of death by brain outcome can be confusing, applying the need for cardiac arrest to officially define death for family members.
In the case of the potentially irreversible cardiac donor, we have the Maastricht categories, where brain death has not yet occurred but there is severe damage (Maastricht 3).
1.2 – Cardiac Death
Cardiovascular care of the potential donor fluid therapy, and vasopressor drugs (dopamine is preferred) to achieve adequate blood pressure values. On the other hand, the pulmonary condition seeks adequate oxygenation rates, avoiding excess fluid therapy, so some centers use pulmonary catheters for adequate control of fluids, pressure, and volume of oxygen to be made available. Endocrine metabolic care such as diabetes insipidus (desmopressin), vasopressin, glycemic control, and thermal control decrease ischemia and ensure the quality of the organ potentially to be donated. Corticosteroids to decrease the systemic inflammatory response are also discussed in this article.
Maintain a temperature above 35 degrees Celsius, crystalloids with Ringer’s Lactate to prevent hyperchlorhydremia, blood replacement when hemoglobin is less than 10, dopamine for inotropic control, protective ventilation, and hormone replacement to increase the quality of the organ to be donated despite brain death or imminent cardiac arrest. Situations such as infections and active malignant neoplasms are still an exclusion factor.
2. Ethics
The donor’s family must be informed about the criteria for death (brain or cardiac), understand the irreversibility of the condition, and authorize or not the organ transplant.
The recipient must be accompanied by a multidisciplinary team and understand previous care regarding diet, glycemic control, body mass index, need for immunosuppressants, risks involved in the organ to be offered, position in the transplant queue and so many care related to transition.
Understand the criteria for extended donation and the possibility of double kidney transplantation to improve functionality. Older donors or those previously with underlying diseases are defining additional care after transplantation.
3. Kidney transplantation
Findings that compromise the structure of the organ (cortical necrosis, for example) exclude the possibility of proceeding with the transplant. Long ischemia times (in the case of the kidney over two hours) also compromise the organ’s viability. Understand the cardiovascular, pulmonary, metabolic, and endocrinological processes and control to keep the organ viable in the potential donor, in addition to preparing the recipient with perioperative care. Reinforce the recipient’s care regarding immunosuppression induction and maintenance treatments, as well as postoperative needs and expected goals for the first days after transplantation.
Dear Dr Filipe
That is a good summary.
Please provide a summary of these guidelines
INTRODUCTION
These guidelines (Transplantation from deceased donors after circulatory death) are of the BTS (July 2013)
Organs can be utilized are kidney, liver, pancreas, pancreatic islets, lung, and heart
Before definition of brain death in the 1970, all organs were donated after DCD
DCD appeared again due to shortage of organ transplant to expand the donor pool
Grading of Recommendations is similar to that adopted by KDIGO guidelins
Maastricht classification of DCD
Category 1: Dead on arrival
Category 2: Unsuccessful resuscitation
Category 3: Awaiting cardiac arrest
Category 4: Cardiac arrest in a brain stem dead donor
Category 5: Unexpected cardiac arrest in a critically ill patient
Category 3 and 4 are controlled DCD. Category 1, 2 and 5 are uncontrolled DCD
Categorisation of DCD Donors
DCD should be categorized according the Maastricht classification. (A1)
The functional (or true) warm ischaemic period starts when the systolic blood pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extend up to the onset of cold perfusion. (B1)
Low oxygen saturation (<70%) may be a measure of inadequate organ perfusion and poor outcome, but the current recommendation is not used as an indicator of poor outcome or as a reason for non usage. (C1)
Diagnosis of Death
Death is irreversible permanent lost of the capacity for consciousness and brain stem function. (A1)
Death can be confirmed after five minutes of arrest (no restoration of artificial cerebral circulation). (B1)
Circulatory arrest is identified by the absence of pulsatile flow on a correctly functioning arterial line, or by EEG. (B1)
Informing the recipient
Providing information, both orally and in writing, for the potential transplant recipient is a requirement for consent and is the responsibility of the multi- disciplinary transplant team is responsible for the recipient consent (benefit/risk). This must be updated and reviewed annually. (B1)
Organ Retrieval
Plan of treatment withdrawal after the donor HLA type and virology are known. (C1)
The retrieval team should know donor details before treatment withdrawal. (A1)
At the point of treatment withdrawal, retrieval teams should be in the operating theatre. (B1)
Give heparin for Maastricht 4 donors before treatment withdrawal. (A1)
After treatment withdrawal, hemodynamic parameters should be followed with a specialist nurse. (C1)
Heparin (20 000 units) should be added to the first bag of ice-cold preservation solution to be perfused through the aorta. (Not graded)
A fibrinolytic( streptokinase or rTPA) may be added to the first bag of preservation solution. (B3)
The kidneys may be removed either individually or en bloc. (Not graded)
Viability Testing
Kidneys appear well perfused on retrievalin controlled DCD, provided that other risks are minimal. (C2)
The role of machine perfusion to ‘improve’ the kidney is controversial. (C2)
During machine perfusion, high resistance or high enzyme levels within the perfusatemay be an indicator of cellular damage and primary non function (uncontrolled DCD). (C1)
Testing the graft function of warm perfused organs prior to transplantation is considered the ‘gold’ standard. (C2)
Immunosuppression
No data suggest benefit of any immunosuppressive in DCD organs. (C1)
As there is increased risk of DGF in DCD, induction therapy with mono- or polyclonal antibodies may be used to reduce the risk of acute rejection. (B1)
Induction therapy is often combined with delayed introduction or reduced intensity of CNI. (C2)
Kidney
Advanced or ESRD, or cortical necrosis on biopsy is an absolute contraindication of donation. (B1)
Functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to protocols which attempt to resuscitate organ viability. (B2)
Units using machine perfusion should collaborate to standardise the prospective collection of data to enable aggregated analyses of outcomes. (A2)
No organ discards because of machine perfusion, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems (but for DKT) (A2)
Long term outcomes of DCD recipients are DBD recipients, although DCD kidneys appear to be more susceptible to cold ischaemia. (B2)
DGF is increased in DCD recipients and this should be discussed with the patient prior to transplantation. (A1)
Antibody induction therapy should be considered as part of the initial immunosuppressive regimen for recipients of DCD kidneys. (B1)
Long-term outcomes for SCD are equivalent for DCD and DBD. (A1)
Graft outcome is more closely related to whether a transplant is ECD or SCD than whether the mode of donation is DCD or DBD. (B2)
Time Periods
1. The withdrawal period (agonal period): the time from treatment withdrawal to circulatory arrest
2. The asystolic or acirculatory warm period (primary warm ischaemic time): the time from circulatory arrest to the perfusion of the organs with cold preservation solution in situ
3. The functional (or true) warm ischaemic period: starts when the systolic blood pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion
PAEDIATRIC DCD TRANSPLANTATION
Families of children are more willing to agree to donation than families of adult patients
Should be considered for any child
Renal and liver grafts from paediatric DCD donors have graft function and recipient survival rates comparable with organs recovered from SCD donors
Dear Dr Abdallah,
That is a good summary.
The British Transplantation Society had published the guidelines of transplantation from deceased donors after circulatory death in July 2013.it involved the following domains:
Categorisation of Deceased circulatory death (DCD) Donors and Diagnosis of Death:
This should be based on the Maastricht classification. The warm ischaemia period is the period between sustained SBP of below 50 mmHg and the onset of perfusion. The retrieval teams should keep a record of oxygen saturation when it drops below 70% .Death is defined as irreversible permanent loss of consciousness and brain stem function. It is confirmed after 5 minutes of continuous cardio-respiratory arrest. These need not be affected by the possibility of organ retrieval. If resources are available, use monitoring devices such as arterial line, echocardiography or ECG. The retrieval protocols should.
Ethics, Consent and Organ Retrieval
All the ethical subjects and terminology related to the DCD donation need to be familiar to all healthcare professionals (allocation decision , consents, donor dignity and non-maleficence). The BTS Ethics committee and UK Donation Ethics Committee provide sources of information to practitioners. The consents to the recipient need to be both verbal and written and these should be annually updated and documented.
The planning for treatment withdrawal should be:
1- when the donor HLA type and virology are known
2- the liver and pancreas recipients are in the recipient hospitals to reduce warm ischaemia period
Before treatment withdrawal:
the following donor information need to be satisfactory: blood group, past medical history, illness leading to death and Maastricht 4 donors may be given heparin
At the time of treatment withdrawal:
1- The Retrieval teams should be scrubbed in the operating theatre
2- The specialist nurse should keep a record at regular intervals of the donor’s haemodynamic parameters following treatment withdrawal. Death may be confirmed 5 minutes after complete circulatory arrest.
Procedure of retrieval:
For controlled donors, the access can be a large artery and vein (right common iliac artery or aorta, and the IVC or right atrium in the chest, avoid SMV or IMV when the pancreas is being retrieved). Perfuse aorta by 20 000 units heparin in the first bag of ice-cold preservation solution and a fibrinolytic agent may be added too. Removal of organs can be individually or en bloc. The retrieval of the liver should be rapid with dual perfusion of both artery and portal vein. Viability testing depends on the organ retrieved and is used when there is delay in circulatory arrest.
3-Immunosuppression
As these organs are at high risk of delayed graft function , induction therapy with mono- or polyclonal antibodies may be used combined with delayed introduction or reduced intensity of calcineurin inhibition to limit the incidence and duration of delayed graft function particularly with liver transplantation.
Kidney:
Avoid kidney donors with
1- advanced or end-stage chronic kidney disease
2- cortical necrosis demonstrable on biopsy should
3- Warm ischaemic time >2 hours or absent blood pressure for 30 minutes should be restricted to protocols which attempt to resuscitate organ viability. (these can be used in centers using viability protocols or dual organs but need to be standardized to compare between different centers)
The long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. The DCD kidneys are noticed to be more susceptible to cold ischaemia and DGF and hence, antibody induction therapy should be part of the initial immunosuppressive regimen
Liver:
Livers from DBD donors have more PNF and ischaemic cholangiopathy and a higher rate of re-transplantation. DCD and DBD subjects transplanted with MELD >30 or on organ-perfusion support have similar graft survival. However, there is no survival benefit when DCD livers are transplanted in patients with MELD ≤30 or in those not receiving organ perfusion supports. The outcome will improve with the use of low viscosity solution to cold flush the aorta, short CIT (under 8hrs),‘ideal’ DCD liver ( donor age <50 years old, has a functional WIT time <20 min, a shorter CIT <10 hr, and <10% steatosis), BMI <29 kg/m2 and a functional WIT <20 min (SAP <50 mmHg)
DCD grafts are best avoided in recipients of re-transplantation and should be ideally used in younger recipients with age <60 years. Factors predictive of graft failure are: age ≥55 years, male sex, African–American race, HCV positivity, metabolic liver disorder, transplant MELD ≥ 35, hospitalisation at transplant, and the need for life support at transplant. Recipient predictors of mortality are age ≥55 years, hospitalization at transplant, and re-transplantation.
Pancreas:
Outcomes for DCD donor pancreas transplantation are similar to those of DBD donors’ .DCD organs can be used for isolated pancreas transplants or SPK recipients but they are associated with increased risk of reperfusion pancreatitis and thrombosis. Better outcome are associated with donors age <60 years old, have BMI <30 kg/m2, warm ischaemia time of 60 minutes and shortest possible cold ischaemic time. . A DCD organ should not be transplanted into a recipient with a history of thrombo-embolic disease unless this is monitored and treated.
Pancreatic islets:
Selection criteria for recipients of islets from DCD donors should be the same as for DBD donors.
Lung :
The donor selection criteria for lung DCD should be the same as for DBD as transplant outcome and quality are similar. Perform antegrade and retrograde flush perfusion at the time of lung retrieval and pre-transplant ex vivo lung perfusion (EVLP) is advised in case of uncertain graft performance.
Heart:
In the UK, heart transplantation from DCD donors is currently NOT standard of care.
Dear Dr Hassan,
That is a good summary. Please type headings and sub-headings in bold or underline. That will make it easier to read.
Transplantation from deceased donors after circulatory death British Transplantation Society Guidelines 2013.
Categorization of DCD Donors.
Maastricht Category 1: Dead on arrival.
Maastricht Category 2: Unsuccessful resuscitation.
Maastricht Category 3: Awaiting cardiac arrest.
Maastricht Category 4: Cardiac arrest in a brain stem dead donor.
Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient.
Definition of warm ischaemic period starts when the systolic blood pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion and oxygen saturation below 70% is not used as an indicator of poor outcome.
Diagnosis of Death.
Irreversible loss of consciousness and brain stem function and circulatory arrest identified by the absence of pulsatile flow on a correctly functioning arterial line or Echocardiography.
Law, Ethics and Donor Consent.
Decisions about allocation and consent in relation to both the organ donor and recipient should be cleared for healthcare professionals to facilitate transplantation process.
BTS Ethics committee is available for guidance and information to support practice in this complex field.
Informing the Recipient.
Orally and writing information should be provided by healthcare worker to the recipient, consent should be updated and reviewed annually and the outcome of discussions clearly documented in the patients records and this is by multi-disciplinary transplant team.
Benefits versus risks should be explained for the recipients as risk of remaining on the transplant waiting list compared to that of receiving a DCD organ.
Organ Retrieval.
when the donor HLA type and virology are known, and the liver and pancreas recipients are in the recipient hospitals, planning for treatment withdrawal should be started and try to keep it in operating room to decrease warm ischemia.
Blood group, past medical history, illness leading to death should be known and satisfied from retrieval team before treatment is withdrawn.
Following treatment withdrawal, hemodynamic parameters should be regularly recorded and retrieval starts by gaining access to a large artery and vein, typically the right common iliac artery or aorta, and the IVC in the abdomen or right atrium in the chest and 20000 units heparin added to first bag of ice-cold preservation solution.
The kidneys may be removed either individually or en bloc, liver should be recovered using a rapid technique and dual perfusion of both artery and portal vein is essential for recovery of DCD livers.
Viability Testing.
Many factors to test kidney viability as donation from young controlled DCD, rapid laparotomy, aortic cannulation, perfusion and venous exsanguination all these short the cold ischemia.
Testing the graft function of warm perfused organs prior to transplantation is considered the ‘gold’ standard.
Ventilating the lungs and perfusing them with Steen solution with or without added red blood cells and lung compliance, airway resistance and tidal volume via the ventilator all consider viability test of the lung.
Immunosuppression.
The main idea that using induction therapy is often combined with delayed introduction or reduced intensity of calcineurin inhibition to limit the incidence and duration of delayed graft function in kidney donation but in heart and lung transplantation, there is no evidence to use a different regimen from that used in DBD transplantation.
Kidney.
Advanced or end-stage chronic kidney disease, or with cortical necrosis is absolute contraindications for donation.
None of the dynamic characteristics of machine perfusion, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems – alone or in combination – have sufficient predictive value to mandate organ discard but may be useful to use dual transplantation.
DCD is more liable to cold ischemia rather than DBD but same long term recipient outcomes.
Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants.
Induction therapy is often combined with delayed introduction or reduced intensity of calcineurin inhibition to limit the incidence and duration of delayed graft function.
Liver.
Short and medium term outcome appears inferior to livers from DBD donors, no survival benefit when DCD livers are 18 transplanted in patients with MELD ≤30.
The outcome of DCD liver transplantation is improved with short CIT and an ideal’ DCD liver donor is less than 50 years old, WIT<20 mints, a shorter CIT<10 hours and <10% steatosis.
Long FWIT is associated with an increased risk of ischaemic cholangiopathy.
DCD liver grafts should be ideally used in younger recipients with age, but should be avoided for recipients of re-transplantation.
Factors predictive of graft failure such as:
Age ≥55 years, male sex, African–American race, HCV positivity, metabolic liver disorder, transplant MELD ≥ 35, hospitalization at transplant, and the need for life support at transplant.
Recipient predictors of mortality are age ≥55 years, hospitalization at transplant, and re-transplantation.
Pancreas.
The pancreas team should stand down after a functional warm ischemia time of 60 mints.
Prolonged cold ischemia & higher donor BMI can lead to reperfusion pancreatitis and thrombosis.
Higher recipient BMI, age, cardiovascular morbidity, and technical surgical factors may contribute to poorer outcome.
Outcomes for DCD donor pancreas transplantation is similar to DBD.
Graft loss from thrombosis is twice as common in DCD as DBD pancreas transplants, so better to avoid donation to recipient with a history of thrombo-embolic disease.
Lung.
The donor selection criteria for lung DCD should be the same as for DBD and similar quality to DBD organs.
To perform antegrade and retrograde flush perfusion at the time of lung retrieval.
Heart:
The use of DCD hearts is not currently recommended in UK.
Dear Dr Saad,
That is a good summary.
Maastricht Categories :
Category 1: Dead on arrival.
Category 2: Unsuccessful resuscitation.
Category 3: Awaiting cardiac arrest.
Category 4: Cardiac arrest in a brain stem dead donor.
Category 5: Unexpected cardiac arrest in a critically ill patient.
Diagnosis of Death
– Death is irreversible and permanent loss of consciousness and brain stem function.
– Death can be diagnosed when:
Asystole has occurred, and Brain function has been lost, and The possibility of spontaneous return of cardiac function has passed, and there will be no subsequent intervention that restores cerebral perfusion
Renal transplant :
– For uncontrolled DCD or when perfusion of the kidneys on retrieval is poor, using parameters such as high resistance during machine perfusion or high enzyme levels within the perfusate may indicate increased cellular damage and an increased risk of primary non function.
-Testing the graft function of warm perfused organs prior to transplantation is
considered the ‘gold’ standard. However, warm perfusion of such organs is difficult to
perform and usually impractical
-The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability.
-· Long term outcomes of DCD recipients are similar to those of DBD recipients and the
allocation system for DCD and DBD organs should be similar.
-· The incidence of delayed graft function is increased in DCD recipients and this
should be discussed with the patient prior to transplantation.
-· Long-term outcomes for standard criteria donors are equivalent for DCD and DBD
kidney transplants.
-· Graft outcome is more closely related to whether a transplant is ECD or SCD than
whether the mode of donation is DCD or DBD.
Immunosuppression
– No definitive data suggest significant benefit from any particular immunosuppressive
regimen in the context of DCD organs.
– Following DCD kidney transplantation, there is increased risk of delayed graft
function due to DCD injury. Induction therapy with mono- or polyclonal antibodies
may be used to reduce the risk of clinically unrecognised acute rejection prior to
recovery from DCD injury
Choice of CNI
The majority of the recipients of DCD kidneys reported in the literature have received
Ciclosporin. There are few data comparing the use of Ciclosporin and Tacrolimus in this
context
absolute contraindications to the use of organs for DCD kidney transplantation are:
· End-stage kidney disease (CKD stage 5, eGFR <15 ml/min)
· CKD stage 4 (eGFR 15-30 ml/min)
· Acute cortical necrosis on pre-implantation kidney biopsy
Relative contraindications
donor age and cold ischaemic time. Additional factors such as donor hypertension and cardiovascular
disease
For older DCD donors (>60 years), particularly those with hypertension and/or
cardiovascular death, pre-implantation biopsy may identify kidneys with substantial arterial
disease or glomerulosclerosis that are likely to have poor long term outcome
Preservation solutions
No definitive data currently suggest any advantage for specific preservation solutions in the
context of DCD kidney transplantation
Peds DCD transplant :
-Renal and liver grafts from paediatric DCD donors have graft function and transplant
recipient survival rates comparable with organs recovered from SCD donors (3). A recent
review of the limited UK data on DCD donors in paediatric renal transplantation has
suggested that better outcomes are obtained from younger donors (up to 40 years of age)
and shorter functional warm ischaemia times (up to 60 minutes)
-Families of children are more willing to agree to donation than families of adult patients
-Parents and guardians want to be asked about organ donation, including DCD, and parents make no distinction between cardiac and neurologic death
Dear Dr Farah,
That is a good summary.
1.Please provide a summary of these guidelines
Summary of recommendations
A. General:
DCD donors categorization
DCD donors categorized based on Maastricht classification. (A1)
WIT starts with SBP drop < 50 mmHg to onset of cold in situ perfusion. (B1)
SaO2<70% is not indicator of poor outcome or a reason for non usage, but correlate with the outcome. (C1)
Diagnosis of Death
Irreversible permanent loss of consciousness & brain stem function. (A1)
Death confirmed 5 min post cardio-respiratory arrest if no restoration of artificial cerebral circulation. (B1)
Circulatory arrest: no pulsatile flow on arterial line, or by echo; otherwise by continuous ECG monitoring. (B1)
Retrieval protocols should consider potential risks of post mortem interventions that might restore cerebral perfusion. (B1)
Diagnostic criteria of death after loss of circulatory function should not be affected by the possibility of subsequent organ retrieval. (A1)
Law, Ethics & Donor Consent
Staff should be aware of the related ethics. They should be familiar with the terms used to describe & discuss these ethics. (B1)
Good ethics integrate efforts to facilitate & allow transplant in DCD. (B1)
In the UK, DCD is affected by social definitions of death. Non-maleficence not to be affected to facilitate donation & transplant. (B1)
BTS Ethics committee & UK Donation Ethics Committee are ready for guidance & information to support practice. (Not graded)
Informing the Recipient
Recipient should receive informed consent by transplant MDT & updated & reviewed annually & documented in the record. (B1)
Tailor information to the requirements of the potential recipient. (B1)
The risk for remaining on the waiting list versus receiving a DCD organ must be discussed. (B1)
Organ Retrieval
Treatment withdrawal planned for a time when the donor HLA & virology are known, & the liver & pancreas recipients are in the recipient hospitals. (C1)
Treatment withdrawal in the operating hospital is associated with shorter WIT than withdrawal on a remote ICU or ward. (C1)
Before treatment withdrawal, retrieval team must satisfy about donor details (ABO group,etc). (A1)
Retrieval teams scrubbed in OR at withdrawal time. (B1)
Maastricht 4 donors may be given heparin before treatment withdrawal. No need to reaffirm death once circulatory arrest has occurred. (A1)
Death confirmed 5 min after circulatory arrest. (A1)
Controlled donors: start retrieval by access to Rt CIA or aorta, & IVC abdomen or Rt atrium in chest. (Not graded)
Heparin added to 1stbag of ice-cold solution for perfusion through the aorta. (Not graded)
Streptokinase/rTPA added to 1stbag of solution. (B3)
Kidneys removed individually or en bloc. (Not graded)
Pancreas removed en bloc with liver, or after liver. (Not graded)
Pancreas retrieval: SMV or IMV not to be cannulated for preservation fluid. (B1)
A rapid technique liver retrieval. (Not graded)
Dual perfusion (artery & portal vein) for retrieval of livers. (C1)
Viability Testing
Depends on the organ being tested.
Kidneys rapidly retrieved from young controlled DCD donors expected to work promptly if CIT is minimized & organs well perfused on retrieval. Machine perfusion is controversial. (C2)
Uncontrolled DCD or when perfusion of kidneys is poor, machine perfusion parameters may be used. (C1)
For liver & pancreas, viability testing not well established. (Not graded)
The ‘gold’ standard is testing graft function of warm perfused organs before transplant. However, warm perfusion is impractical & difficult. (C2)
The exception is donor lungs where viability testing of ex-vivo lung is done by ventilating the lungs & perfusing with Steen solution. (B1)
Immunosuppression
No definitive benefit from any particular IS regimen in DCD organs. (C1)
In DCD kidney transplants, there is increased risk of DGF due to DCD injury. Induction may reduce risk of unrecognized AR prior to recovery from DCD injury. (B1)
Induction is combined with delayed start or reduced CNI to limit DGF incidence & duration. (C2)
In liver TX, consider renal sparing regimens with delayed CNI start. Induction & T cell depletion may also be used, but risk/benefit must be balanced with choice of regimen. (C2)
Heart & lung TX: no evidence to use a regimen different from that used in DBD TX. (C1)
===============================================
B. Kidney
Advanced or ESRD, or cortical necrosis on biopsy should not be accepted as donors. (B1)
Use of donors with functional WIT>2 hr or absent BP for 30 min are restricted to protocols that attempt to resuscitate organ viability. (B2)
Units using cold machine perfusion of DCD KTX before implantation should standardize collection of data to enable outcomes analyses. (A2)
No characteristic of dynamics of machine perfusion, perfusate effluent analysis, or biopsy scoring systems (alone or in combination) can predict value to mandate organ discard. (A2)
However, it help decide when dual kidneys TX is needed. (B2)
Long term outcomes & allocation system of DCD are similar to DBD. But, DCD kidneys more susceptible to cold ischaemia. (B2)
DGF incidence increased in DCD recipients; should discuss with patient before TX. (A1)
Antibody induction considered as part of initial IS for recipients of DCD kidneys. (B1)
Long-term outcomes for SCD are equivalent for DCD & DBD KTX. (A1)
Graft outcome more dependent on whether a TX is ECD or SCD than whether donation is DCD or DBD. (B2)
Prospective data needed to know whether impact of ECD is different in DCD & DBD donors. (A1)
===============================================
C.Liver
Livers TX from Maastricht 3 DCD donors are useful resource & should be used if deemed safe. (B1)
Outcome appears inferior to livers from DBD donors; more PNF & ischaemic cholangiopathy & higher rate of re-TX. (B1)
DCD & DBD TX with MELD >30 or on organ-perfusion support have similar graft survival. However, no survival benefit when DCD livers are
TX with MELD ≤30 or in those not receiving perfusion support. (B2)
Biliary stricture is lower when a low viscosity solution used to cold flush aorta. (C2)
DCD liver use should be matched & allocated to those who will have greatest transplant benefit. (B2)
Outcome of DCD liver TX improved with short CIT(<8 hrs). (B1)
A better if an ‘ideal’ DCD liver is TX. ‘ideal’ DCD liver donor is <50 yrs old, a WIT <20 min, CIT <10 hr, & <10% steatosis. (B1)
More restrictive DCD Donor criteria: BMI <29 &
WIT <20 min , equivalent 1 & 3-year patient & graft survival rates can be achieved for both DCD & DBD liver TX. (B1)
Long FWIT increased risk of ischaemic cholangio-pathy
Recipients of DCD liver grafts should be informed of the risk & offered choice to refuse such organs prior to TX listing. (C2)
DCD grafts best avoided in recipients of re-TX. (B1)
DCD liver grafts should ideally used in younger recipients (<60 yrs).(B1)
Factors predicting graft failure: age ≥55 yrs, male sex, African–American, HCV +ve, metabolic liver disorder, TX MELD ≥ 35, hospitalization at TX, & need for life support at TX. Recipient predictors of
Mortality: age ≥55 yrs, hospitalization at TX, & re-TX. (B1)
===============================================
D.Pancreas
Although DCD organs can be used for isolated pancreas TX in pancreas TX alone, PAK or SPK TX, evidence & current practice are in favour of SPK recipients. (C2)
Pancreas TX from DCD donors are at increased risk of reperfusion pancreatitis & thrombosis; this may be aggravated by long CIT & higher donor BMI. Donor may be a further risk factor. Ideal donors: <60 yrs & BMI <30. (C2)
Pancreas team should stand down after a functional WIT (SBP <50 mmHg &/or SaO2 70%) of 60 min. (C2)
A primary focus of any DCD pancreas TX should be to achieve the shortest possible CIT. (B2)
Higher recipient BMI, age, CV morbidity, & technical surgical factors may contribute to poorer outcome. (C2)
Outcomes for DCD donor pancreas TX are broadly similar to those of DBD donors. (C2)
Graft loss from thrombosis is twice as common in DCD as DBD pancreas TX. A DCD should not be TX into a recipient with a H/O thrombo-embolic disease unless monitored & treated. (C2)
Some TX centers have good expertise with DCD EC pancreas grafts & these guidelines should not restrict innovative but safe practice of pancreas TX. (Not graded)
===============================================
E.Pancreatic islets
Selection criteria for recipients is same as for DBD donors. (B2)
Organs from DCD donors for islet isolation & TX allocated through the National Pancreas Allocation Scheme. (B2)
Long term outcome of islet TX from DCD donors has been satisfactory in the UK but the cohort is small. Further audit & research is needed. (C2)
Satisfactory functional islet preparations can be routinely obtained from DCD donors. (C2)
===============================================
F.Lung
Donor selection criteria same as for DBD. (B2)
All patients on lung TX waiting list have potential to receive DCD lungs. (C1)
DCD lungs not regarded as extended or marginal. TX outcome & quality is at least similar to DBD organs. (B1)
Do antegrade & retrograde flush perfusion at time of lung retrieval. (B2)
Pre-TX ex vivo lung perfusion (EVLP) is advised if uncertainty of graft performance to safely extend donor & procedural criteria (long WIT, bad flush, clots). (B1)
Acceptance criteria on EVLP: measures of pulmonary compliance, vascular resistance, & gas exchange. (C2)
===============================================
G.Heart
In the UK, heart TX from DCD donors is currently NOT standard of care.
For ethical issues, the use of DCD hearts is not currently recommended. (Not graded)
Dear Dr Mohamed,
That is a good detailed summary.
Transplantation from deceased donors after circulatory death
(BTS Guidelines-2013
Summary of the Guidelines
Definitions
a) Controlled DCD
Organ donation after circulatory arrest, in the context of withdrawal or non-escalation of cardio-respiratory treatments that are considered to be no longer in a patient’s best interests, or occurring in a patient already certified dead by brain stem criteria.
· Maastricht Category 3: Awaiting cardiac arrest.
· Maastricht Category 4: Cardiac arrest in a brain stem dead donor.
b) Uncontrolled DCD
Organ donation from a patient who has suffered an unexpected death that has been confirmed on cardio-respiratory grounds.
· Maastricht Category 1: Dead on arrival.
· Maastricht Category 2: Unsuccessful resuscitation.
· Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient.
Diagnosis of Death
a) Death is irreversible and permanent loss of consciousness and brain stem function. (A1)
b) Where cardio-respiratory criteria apply, death can be confirmed following five minutes of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation. (B1)
c) Circulatory arrest should be identified by the absence of pulsatile Flow(assessment of a functioning arterial line, use of echocardiography or by continuous ECG monitoring. (B1)
d) Death may be confirmed 5 minutes after complete circulatory arrest. There is no need for a further stand off period following this.
e) Death can be diagnosed when:
· Asystole has occurred, and
· Brain function has been lost, and
· The possibility of spontaneous return of cardiac function has passed, providing that
· There will be no subsequent intervention that restores cerebral perfusion whilst the brain remains responsive to such restoration.
f) Viability Testing:
· In controlled DCD donors when cold ischaemia is minimised and the kidneys appear well perfused on retrieval.
· For uncontrolled DCD or when perfusion of the kidneys on retrieval is poor, using parameters such as high resistance during machine perfusion or high enzyme levels within the perfusate may indicate increased cellular damage and an increased risk of primary non function.
· The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability.
Categorization of DCD donors and warm ischemia time
· Deceased circulatory death donors should be categorised according the Maastricht classification.
· The functional (or true) warm ischaemic period starts when the systolic blood pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion. (B1)
· Donor low oxygen saturation (<70%) is a concern and may well be a measure of inadequate organ perfusion and poor outcome, prospective evidence is awaited.
Nomenclature of Time Periods
· The withdrawal period (sometimes called the agonal period): the time from treatment withdrawal to circulatory arrest.
· The asystolic or acirculatory warm period (also known as the primary warm ischaemic time): the time from circulatory arrest to the perfusion of the organs with cold preservation solution in situ.
· The functional (or true) warm ischaemic period: starts when the systolic blood pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion.
Kidney; Specific Recommendation regarding deceased donation
· Individuals with advanced or end-stage chronic kidney disease, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donors. (B1)
· The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability. (B2)
· Units undertaking cold machine perfusion of DCD kidney transplants prior to implantation should collaborate to standardise the prospective collection of data to enable aggregated analyses of outcomes. (A2)
· None of perfusion pressure dynamic characteristics, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems – alone or in combination – have sufficient predictive value to mandate organ discard. (A2)
· Such assessment may, however, help determine when kidneys should be considered for dual transplantation. (B2)
· Long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. Nevertheless, it is recognised that DCD kidneys appear to be more susceptible to cold ischaemia, and the proposed national allocation scheme should take this into account. (B2)
· The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation. (A1)
· Antibody induction therapy should be used as part of the initial immunosuppressive regimen for recipients of DCD kidneys. (B1)
· Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants. (A1)
· Graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD. (B2)
· Prospective data are required to determine whether the impact of expanded criteria donation (ECD) is different in DCD and DBD donors and whether different thresholds for organ use may be required. (A1)
Organ Quality Assessment
Donated organ after deceased donation may show one of the followings after transplantation:
a) May work immediately.
b) May recover after a period of impaired or absent function.
c) May never function at all.
Early function is dependent upon:
a) The underlying health of the donor.
b) The ischaemic time.
c) Any damage sustained during the process of the death and organ retrieval.
Because of the availability of dialysis to support initial graft dysfunction, the emphasis in kidney transplantation must be on minimising, and as far as possible eradicating, primary non function (PNF).
Parameters for increased risk of PNF:
a) Poor perfusion on retrieval.
b) Low flow rates on machine perfusion.
c) High enzyme levels within the perfusate.
d) Composite scores combining donor hypertension and creatinine with histological scoring provide the best predictive value. Well validated scoring systems based on the ‘Pirani’, Banff, and CADI (chronic allograft damage index) scores show better predictive value for poor graft function at 1 year than clinical scoring systems alone.
Outcome of kidney transplantation after deceased donation:
1. It is difficult to summarise the outcome after DCD kidney transplantation as many reports are from single centres, and the donor source in these is variable.
a) In certain countries (e.g. Spain and France), DCD transplantation only occurs from uncontrolled donors.
b) Specific centres in Spain and France utilise extra-corporeal membrane oxygenation, whilst others in France use a cold storage approach.
c) In some countries (e.g. Japan), brain death is recognised but donors are managed as Maastricht 4 and cardiac death is awaited without withdrawal of treatment, so the donors become partly uncontrolled.
d) Until recently in the UK, a significant proportion of DCD was uncontrolled, but this practice is now rare.
e) The Dutch experience is also principally in controlled donors.
2. The overall graft outcome after transplantation is primarily determined by the quality of the donor rather than the mode of donation. Thus, graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD.
3. The most recent evidence suggests that ECD DCD donor kidneys are no more likely to fail early than ECD DBD donor kidneys.
4. DCD kidneys are more prone to the detrimental effects of cold ischaemia than DBD kidneys, as confirmed by a recent UK cohort study.
5. GFR is initially poorer because of the high incidence of DGF in DCD, but is equivalent after 3 months. At 3 years post- transplantation, the median GFR following DCD is 45 ml/min/1.73m2 and following DBD is 46 ml/min/1.73m2.
Dear Dr Assafi,
That is a good summary.
DCD category according Maastricht :
Functional WIT start when SBP sustained <50mmHg (for at least 2min) to the onset of cold in situ perfusion.
Diagnosis of death;
All health professional should be know well the ethical issue of transplantation of DCD & be familial with terminology used to discuss these ethics.
Both BTS Ethics committee & UK donation ethics committee offer the guidance & information of transplantation in UK.
Donor dignity should not be compromised by increase DCD donors pool.
Verbal & written consent should be offered to the by recipient by multidisciplinary transplant team with explanation of risk of transplantation & being on waiting list.
Organ retrieval:
Viability test:
Immunosuppression:
Kidneys:
Liver:
Pancreas:
Lung:
Heart:
In UK due to ethical issues DCD heart is not recommended.
Dear Dr Ban,
That is a very good summary. There is nothing unethical about using heart of DCD donors if the outcomes are acceptable.
Summary of the Guidelines:
Maastricht category:
Category one: Death occur outside hospital.
Category 2: unsuccessful resuscitation.
Category 3: awaiting cardiac arrest.
Category 4: cardiac arrest in a brain stem dead individual
Category 5: Unexpected cardiac arrest in a hospitalized patient.
2.Death defined as state in which a patient has permanently lost the capacity for consciousness and brain stem function. Death confirm after 5 minute of continuous cardiorespiratory arrest, providing there is no subsequent restoration of artificial cerebral circulation. Circulatory arrest identified by absence of pulsation, use of echocardiography, or by ECG monitoring. Criteria of diagnosing death should not be influenced by possibility of subsequent organ retrieval.
3.law, ethics, and donor consent; All health professionals should be aware of the complex ethical issues that are associated with DCD. Good ethical practice is to facilitate donation, allocation , and consent to both donor and recipient. DCD in UK is based on definition of death, donor dignity, and non-malfeasance must not be compromised in order to facilitate donation. BTS ethics committee is available for guidance and support practice.
4.Multidisiplinary team for transplantations should provide written information and update regarding records annually. The recipient should be aware about risk Benefit of transplantation and the risk of being on dialysis.
5.Organ retrieval; Treatment withdrawal should be planed when the HLA type and virology are ready and liver , pancreas recipient were in recipient hospital. and should be the operating hospital, with all detailed donor information is available to retrieval team. heparin treatment should be provided for category 4 donors. confirming death after 5 min following complete circulatory arrest. For controlled donor retrieval team should found access to the large arteries and veins. 20 000 iu should be added to the 2 bags of ice-cold solution to be perfused through the aorta. Streptokinase may be added to the 1st bag. Kidney may be removed individually or en bloc. pancreas may be removed in bloc or with the liver or following removal of the liver. Cannula for presrvation should not be placed in SMV or IMV when the pancreas is being retrieved. liver should recovered using a rapid technique which minimizes liver congestion. Dual perfusion of hepatic artery and portal vein is essential for recovery of DCD livers for transplantation.
6.Removal of kidneys: exclude donors from donation with ESKD or donor with cortical necrosis, Restricted use of donors with functional warm ischemic time >2hr or absent blood pressure for 30 min. Assessment should be done to evaluate need for dual transplantation. Long term outcome is equal between DCD and DBD donors Increased incidence of DGF in donors with DCD and this should be discussed with the recipient Recipient with DCD donor should receive induction therapy prior to transplantation. Equall long term outcomefor SDC for DCD and DBD kidney transplant. Graft outcome is mostly related to whether a transplant is ECD or SCD, than whether retrieval is DCD or DBD.
7.Liver; Maastricht 3 DCD donors are useful resource for liver transplant. Liver transplant from DBD donors is inferior and associated with higher rate of re transplantation. Similar graft survival with meld > 30 between DCD and DBD donors. Low viscosity solution should be used to cold flush to aorta to lower the incidence rate of biliary stricture. DCD liver should be matched with recipient in waiting list and according to allocation. DCD outcome in liver transplantation is improved with short CIT, which best kept to under 8 hours. Factors of favorable outcome include; ideal DCD liver, donor < 50 years, WIT time <20 min, shorter CIT <10 hrs, and stenosis <10%. DCD graft are best be avoided in recipient of re-transplant. DCD liver graft should be used in younger recipient < 60 years.
8.Pancreas; can be used as isolated transplant, but current practice are in favour also be transplant with kidney. Pancreas Tx from DCD donor associated with reperfusion pancreatitis, and thrombosis. Most focus of pancreas transplant from DCD donor on minimal cold ischemic time. Poorer outcome for recipient associated with higher recipient BMI, age, CVD, and technical factor. Graft loss from thrombosis is 2;1 between DCD and DBD respectively.
9.Lung: DCD and DBD donor lung transplant are similar outcome. Antegrade and retrograde flush perfusion at time of lung retrieval. Acceptance criteria on EVLP include measures of pulmonary compliance , vascular resistance and gas exchange.
9.Heart; DCD heart transplantation is not standard of care. challenges and ethical issues , so not currently recommended.
Dear Dr Kamal,
That is a good summary. Please type headings and sub-headings in bold or underline. That will make it easier to read.
-Please provide a summary of these guidelines
————————————————————–
pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion.
————————————————————————————————————————————————————————————————————————————–
Diagnosis of death
————————————————————————————————————————————————————————————————————————————–
Organ Retrieval
ORGAN SPECIFIC DISCUSSION
Statements of Recommendation
Dear Dr Wadi
That is a very good summary, as usual for you.
Thanks very much for you Prof.Sharma
The guideline is outlining the pathway for performing a cadaveric kidney transplantation, by advocating a comprehensive platform to streamline the process of transplantation from donors post circulatory death DCD .
Via adopting the Maastricht classification of circulatory death, DCD is categorized into 5 subtypes including controlled death of 2 subtypes:
Maastricht category 3: awaiting for cardiac arrest in a patient who is withdrawn from cardio-respiratory support .
Maastricht category 4: awaiting cardiac arrest in a patient who is already declred brain stem dead.
On the other hand uncontrolled DCD includes those patients who sustained cardiac arrest in different setting outside the hospital
Maastricht category 1: When the patient had cardiac arrest outside the hospital and reach dead to ED.in order to be potential donor, cardiac arrest has to be witnessed and CPR was continued until reaching the hospital.
Maastricht category 2:the patient failed resuscitation and declared dead in ED.
Maastricht category 5:unexpected cardiac arrest in critically ill patients.
Cardiac death is defined as persistant asystole after 5 minutes of failed cardiopulmonary resuscitation. It has to be confirmed by echocardiography or continuous ECG monitoring.
Important notes to be highlighted as it was advocated by this guideline:
Warm Ischemia time: defined by the occurance of systolic blood pressure of 50 for at least 2 minutes until the the start of Cold Ischemia time by intravascular Infusion of cold Infusate.
Its recommended that warm Ischemia time is not exceeding 2 hours, or asystole duration of 30 minutes.
DCD is not varied from DBD regarding the kidney transplant outcome. What is impactful is the ECD vs SCD.
Dear Dr Jebur,
That is a good summary.
Please provide a summary of these guidelines
There are 5 types of DCD divided in two major categories:
Maastricht Category 3: Awaiting cardiac arrest.
Maastricht Category 4: Cardiac arrest in a brain stem dead donor.
Maastricht Category 1: Dead on arrival.
Maastricht Category 2: Unsuccessful resuscitation.
Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient
CATEGORISATION OF DCD DONORS & DEFINITION OF WARM ISCHAEMIC TIME:
Definition –terms:
The withdrawal period (agonal period): the time from treatment withdrawal to circulatory arrest.
The asystolic or acirculatory warm period (primary warm ischaemic time): the time from circulatory arrest to the perfusion of the organs with cold preservation solution in situ.
The functional warm ischaemic period: starts when the systolic blood pressure falls below 50 mmHg for 2 minutes or more and extends up to the onset of cold in situ perfusion.
DIAGNOSIS OF DEATH
LAW, ETHICS AND DONOR CONSENT
INFORMING THE RECIPIENT
ORGAN RETRIEVAL
Abdominal Organs: Specific Procedures
The article summaries the surgical procedure to remove each organ.
ORGAN SPECIFIC DISCUSSION
The kidney:
.
Dear Dr Alshaikh,
That is a very good summary, as usual for you.
Thank you Prof. Ajay
BTS guide line of DBD AND DCD;
first will speak about the categorization from 1to 5 :
usually category 1,2,3 are uncontrolled DCD with poor kidney while controlled DCD is better regarding kidney viability .
warm ischemia time started once the systolic bp drop to below 50for 2 mint till the the start of cold perfusion .and it is usually longer in Category 1 and 2 .
before starting organ retrieval ,all the donor family and the recipient should be aware of all the proceeduer and written consent should be taken .
Donor HLA and virology screening should be known before treatment withdrawal ,after the family agreed with donation the the patient will be taken to the operating room for extubation and will hold the type of medications and continue with iv heparin infusion to prevent organ thrombosis.
the specialize nurse will closely observe the patient as once all medications stopped the team will wait 5 mint after that will start the cold preservative infusion through cannulation for the right common iliac artery and IVC and the surgical team will start removing all organs .
If patient after 2hour not arrested ,then will be taken to ICU .
Hi Dr Rihab,
I did not understand when you typed, and I quote, “patient after 2hour not arrested ,then will be taken to ICU.”
I would clarify over here that withdrawal of treatment of such prospective DCD donors is done wherever they are located usually in ICU or in HDU.
Then why to take to ICU is donor did not reach fruition.
Categories of DCD Donors (Maastricht classification)
Category 1, 2 and 5 are considered uncontrolled DCD donors and usually are found in ER department, while category 3 and 4 are referred to as controlled DCD donors and are usually found in the ICU, CCU
Warm ischemia time
Diagnosis of death and circulatory arrest
Organ Retrieval
Viability testing
Immunosuppression
Graft outcome
I appreciate your summary, dear Dr Yusuf.
Donation of organs from dead donors following circulatory death
BTS guidelines
PART 1: GENERAL PRINCIPLES
3 CATEGORISATION OF DCD DONORS & DEFINITION OF WARM ISCHAEMIC TIME
Donors who have died of circulatory death should be classified according to the Maastricht categorization in order to facilitate study, communication, and auditing. (B1). The functional (or genuine) warm ischemia phase begins when the systolic blood pressure falls below 50 mmHg and ends when cold in situ perfusion begins. Retrieval teams should record when oxygen saturation falls below 70% to allow linkage with graft outcome.
Maastricht Categorical 1: Deaths outside of the hospital
The death has been confirmed outside of a medical setting. For these people to be considered acceptable organ donors, the moment of sudden death must have been observed, the time of death must be recorded, and’resuscitation’ must have continued after death.
Maastricht Category 2: Unsuccessful resuscitation
Following the collapse, CPR was begun outside of the hospital. Death is verified upon hospital arrival.
Both Category 1 and Category 2 donors are referred to as “uncontrolled” DCD donors and typically appear in the emergency department.
Maastricht Category 3: Patients anticipating cardiac arrest
Death is inevitable (terminal condition), but the requirements for brain stem death are not met. These patients are often recognized in neurosurgery and general critical care units, coronary care units, emergency departments, and medical wards, but are treated in a variety of hospital departments.
Maastricht Category 4: Cardiac arrest in a patient with brain stem death
The patient has a cardiac arrest following a diagnosis of death based on brain stem criteria.
Donors in categories 3 and 4 of DCD are also known as “controlled” donors.
unanticipated cardiac arrest in a hospitalized patient: uncontrolled donor in a hospitalized patient.
These categories primarily address the warm ischemic time (WIT) differential between cardiac arrest and organ perfusion. Category 5 tends to be longer than Categories 3 and 4, but shorter than Categories 1 and 2.
DIAGNOSIS OF DEATH
Expressions of Recommendation
Death results in the irreversible loss of consciousness and brain stem function. (A1) After five minutes of sustained cardiorespiratory arrest, death can be proven if there is no subsequent restoration of artificial cerebral circulation. (B1) circulatory arrest must be diagnosed by the lack of pulsatile flow on a properly functioning arterial line, by the use of echocardiography if the requisite knowledge is available, or by the failure to detect circulatory arrest with continuous ECG monitoring. (B1)
ALL HEALTHCARE PROFESSIONALS MUST BE AWARE OF THE COMPLEX ETHICAL ISSUES ASSOCIATED WITH DONOR CONSENT AND DONATION AFTER CARDIOVASCULAR DEATH (DCD) AND ORGAN TRANSPLANTATION
Socially accepted criteria of death are the foundation of a successful cadaveric program, and donor dignity and non-malfeasance must not be compromised in attempts to promote donation and transplantation from DCD donors. (B1). The BTS Ethics committee is ready to provide guidance and assistance for practice in this complicated subject. (Not graded)
NOTIFYING THE RECIPIENT OF:
The multidisciplinary transplant team is responsible for providing information (the risk-benefit analysis) orally and in writing with informed consent. This must be reviewed and updated on a yearly basis, and the outcome of these conversations must be properly noted in the patient’s medical record. (B1)
ORGAN RETRIEVAL Treatment withdrawal should preferably be scheduled at a time when the donor’s HLA type and viral load are known and the liver and pancreas recipients are at the recipient hospitals. (C1)
Treatment withdrawal in the operation room is related to a shorter A systolic period (warm ischemic periods) compared to withdrawal in a distant critical care unit or ward. Before treatment is stopped, the retrieval team must be satisfied with the donor’s data (blood type, medical history, and cause of death). (A1)
Maastricht 4 donors, for whom brain stem criteria have already confirmed death, may be administered heparin prior to treatment cessation. Once circulatory arrest has occurred, there is no need to reconfirm death. Following treatment withdrawal, the expert nurse should document the donor’s hemodynamic parameters at regular intervals. (C1)
Death can be verified five minutes after circulatory arrest is complete. There is no additional need for a standoff period after this. (A1)
For controlled donors, retrieval begins by getting access to a big artery and vein, often the right common iliac artery or aorta, as well as the IVC in the belly or the right atrium in the chest. 20,000 units of heparin must be added to the first two bags of ice-cold preservation solution before they are perfused into the aorta. A fibrinolytic agent, such as streptokinase or recombinant tissue plasminogen activator, may be added to the first bag of preservation solution. (B3)
The kidneys may be extracted separately or collectively. The pancreas may be removed either simultaneously with the liver or after the liver has been removed. (Not graded)
Never insert a cannula for preservation fluid into the SMV or IMV when retrieving the pancreas. (B1)
The liver should be recovered rapidly using a method that minimizes congestion. (Not Weighted)
Dual perfusion of the hepatic artery and portal vein is needed for the transplantation of DCD livers. (C2)
PART 2: ORGAN-SPECIFIC DISCUSSION
(Kidney-liver-pancreas-lung-heart)
1-KIDNEY
When should kidneys be discarded? The use of donors with functional warm ischemia duration of >2 hours or absent blood pressure for 30 minutes should be limited to experimental techniques that aim to restore organ viability. (B2) Individually or in combination, none of the perfusion pressure dynamic features, perfusate effluent biochemical analyses, or kidney transplant biopsy grading methods had significant prognostic value for force organ disposal. However, this evaluation may assist in determining when kidneys may be considered for dual transplantation. (B2).
Is there a distinction between DCD and DBD in terms of the kidneys?
The long-term results for DCD and DBD patients are comparable, and the allocation systems for DCD and DBD organs should be similar. However, it is acknowledged that DCD kidneys tend to be more sensitive to cold ischemia, and the suggested national allocation mechanism should account for this. (B2): The incidence of delayed graft function is higher in DCD recipients; this should be communicated with the patient before transplantation. (A1) Long-term results for donors meeting standard criteria are equal for DCD and DBD transplants. (A1) -ECD versus SCD transplantation had a stronger correlation with graft outcome than DCD versus DBD retrieval. (B2) o Prospective data are required to establish if the impact of extended criteria donation (ECD) differs between DCD and DBD donors and if alternative organ usage thresholds may be necessary. Does DCD necessitate any special immunosuppressive regimen modifications?
Antibody induction therapy should be incorporated into the first immunosuppressive regimen for DCD kidney transplant patients. (B1)
Hi Dr Habli,
When you mention ‘functional warm ischemia’ do you mean ‘agonal phase’?
Summary
The concept of brain death was defined in the 1970s in order to bridge the gap between the supply and the need for organs in order to reduce waiting time and since that time the DD has evolved over time from DCD, brain stem death (DBD), and controlled vs uncontrolled DCD, in the UK most DD programs include controlled DCD ‘controlled’ Maastricht category 3. Efforts to expand donations are
likely to lead to increased ‘uncontrolled’ DCD activity (Maastricht category 2 or even 1).
This guideline discusses in 3 parts
Part 1
includes general principles about the definition of DD including the differentiation between DBD, DCD, uncontrolled vs-controlled DCD the definition of worm ischemia time
Frameworks for the diagnosis and confirmation of death
Ethics and law of donation, donor uncontrolled DCD donation, donor distress and rights after death, quality of organ and recipient risk organ preservation solution and organ recovery, staffing for retrieval procedures, specific procedures related to the abdomen and thorax
Part 2.
organ-specific discussion including kidney heart, lung, liver, and pancreas and discusses the donor selection, organ preservation, quality of organ assessment, recipients’ selection, immunotherapy, and outcome
Part 3
Pediatric DCD transplantation
Classification of DCD is important for the logistics of organ retrievals and functional assessment of the organ and its effect on transplant outcome
Controlled DCD refers to organ donation after circulatory death without activating the CPR or in a patient already certified dead by brain stem criteria.in ICU or ER setting
Maastricht Category 3: Awaiting cardiac arrest
Maastricht Category 4: Cardiac arrest in a brain stem dead donor
Uncontrolled DCD refers to organ donations from patients with the unexpected death that had been confirmed by cardiorespiratory ground
Maastricht Category 1: Dead on arrival or death witness outside the hospital and resuscitation should be continued and time should be counted
Maastricht Category 2: Unsuccessful resuscitation in a hospital setting
Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient with long warm ischemia time (WIT)than categories 3 or 4 but less than categories1 or 2
Categorization of DCD Donors
1. Sustained systolic BP < the 50smmgh for two minutes and extends up to the onset of cold in situ perfusion is the functional or true time for warm ischemia. While primary warm ischemia is the systolic or circulatory warm period. true warm ischemia is important in assessing organ damage, not the asystole period.
2. Oxygen saturation below 70% is no longer used as an indicator of poor outcome or as a reason for non-usage
3. at the warm ischemia time the cells shift from aerobic to anaerobic metabolism due to the depletion of ATP which is essential for membranes ion exchange activity and lead to cellular dysfunction and cell death however in cold ischemia the metabolism will be slowed down so cells and organs can survive for longer time
Diagnosis of Death
Refers to the state of irreversible and permanent unconsciousness with loss of brain stem functions
cardio-respiratory criteria apply, death can be confirmed following five minutes
of continuous cardio-respiratory arrest providing, there is no subsequent restoration of artificial cerebral circulation
circulatory death can be recognized by absent arterial pulsation through functional arterial line or failing by ECG monitoring, or by echo
the criteria for the diagnosis of death following circulatory arrest should not be motivated by possible organ retrieval (A1).
DCD is associated with complex ethical issues and we should be familiar with the terminology used and discuss the ethics of DCDTX
Good ethical practice is important to enhance organ donation, and allocation including consent from both donor and recipient, the BTS ethics committee is available and can provide all the information needed to this extent.
Organ Retrieval
1. The retrieval team needs to be satisfied with the donor details (blood group, past medical history, illness leading to death) before treatment is withdrawn. (A1)
2. Treatment withdrawal should be planned at the time of Donor HLA-typing and virology is known for liver and pancreas recipients should be hospitalized.
3. retrieval teams should be scrubbed in the operating room at the point of treatment withdrawal this will shorten the ischemia times. and maastricht4 donors should be given heparin before treatment withdrawal and the nurses should keep interval vitals parameters following treatment removal
Confirmation of death after 5 minutes from complete circulatory arrest(A1).
controlled donors, retrieval starts by gaining access to a large artery and vein, the right common iliac artery or aorta, and the IVC in the abdomen or right atrium in the chest.
Additional anticoagulation like heparin 20000 iu should be added to the ice-cold preservation solution and to be transfused to the aorta
Fibrinolytic agents like streptokinase or Plasminogen activator may also be added to the preservation solution
The kidney can be removed alone or en bloc, pancreas either en bloc with the liver or after the removal of the liver. Dual perfusion of both artery and portal vein is essential for the recovery of DCD livers for transplantation. (C1)
Three concepts are important to balance the donor and recipient risk in the case of DCD, DBD donor allocation
1. equity
2. productivity ensures minimal waste of organs
3. effectiveness, delivery of organs, and making the best use of benefits to recipients. avoid transplanting low-risk recipients with DCD organs or from higher-risk donors and the more clinical justification would be allocation of DCD to higher-risk recipients and good organs were not wasted and this should go through very complex organ allocation algorithms.
The recipient should take full information about the risk and benefits analysis according to their medical condition before proceeding to the transplantation and getting consent is the duty of the MDT transplant team.
Donors with advanced or ESKD or cortical necrosis (biopsy proven) should be declined, and the use of donors with FWIT> 2 hr or no BP for > 30 minutes should be limited to protocols with resuscitating organ viability., cold machine perfusion of DCD kidney transplants should standardize the probable gathering of information and help in the examination for organ outcomes.
None of the perfusion pressure dynamic, perfusate effluent biochemical analysis, or kidney biopsy scoring alone or in combination have adequate analytical value to dictate organ discard but can help regulate when should consider for dual transplantation
Long-term outcomes For SCD are similar for DCD and DBD kidney transplants (A1). however, transplant outcome is more linked to a transplant is ECD vs SCD rather than the mode of retrieval ( DCD vs DBD).
Absolute contraindications to using organs for DCD kidney transplants
In addition to the general known contraindication including active infection, active invasive or hematological malignancy, HIV
1. Advanced CKD stage 4.5
2.Acute cortical necrosis (pre-implantation biopsy proven), but ATN including the transient need for dialysis is a relative contraindication and associated with a higher risk of DGF or primary nonfunctioning graft
3. Additional relative CI includes donor age> 60 yr, cold ischemia time, donor comorbid (hypertension, CVD) preimplant biopsy with confirmed arterial disease, and or glomerulosclerosis which can affect the long-term graft outcome
Immunosuppression in the DD setting
Includes induction, mono or polyclonal agents with delayed introduction of CNI due to increased risk and frequency PNF graft or more DGF, especially with DCD, many cohort studies encourage the use of 1L2 inhibitors basiliximab or daclizumab For low or standard immunological risk and polyclonal ATG or monoclonal alemtuzumab preferred for high immunological risk with preferred delayed the introduction of CNI, especially in DCD with prolonged ischemia time and risk of subclinical rejection can be masked in the presence of DGF
I appreciate your summary, dear Dr Saja.
-The Maastricht classification should be used to classify circulatory death donors who have died. This will help with research, communication, and auditing.
-The functional (or true) warm ischaemic period begins when the systolic blood pressure stays below 50 mmHg for at least two minutes and ends when cold in situ perfusion starts.
– Donor low oxygen saturation (70%) is a concern and may be a sign of poor organ perfusion and a bad outcome, but evidence from the future is still needed. The current recommendation is that an oxygen saturation of less than 70% shouldn’t be taken as a sign of a bad outcome or a reason not to use the graft. Instead, retrieval teams should keep track of when the oxygen saturation drops below 70% so that they can compare it to the graft’s outcome.
– Whenever possible, the circulatory arrest should be spotted by the lack of pulsating blood flow through an arterial line that is working properly, by using echocardiography if the right skills are available, or by keeping an eye on the ECG.
-Protocols for organ retrieval after DCD should take into account the possible risks of post-mortem interventions that could restore blood flow to the brain.
-The fact that organs might be taken out later shouldn’t change how you decide if someone is dead after their circulation stops working.
-All people who work in health care should know about the complicated ethical issues that come with organ donation after circulatory death (DCD) and organ transplantation. These professionals should know the terms used to talk about and explain the ethics of DCD transplantation.
– This includes making decisions about allocation and consent for both the organ donor and the person who will receive the organ.
– In order to make a donation and transplantation from DCD donors easier, the dignity of the donor and the idea that no wrongdoing should be done must not be compromised.
-Any future uncontrolled DCD program must follow the same ethical rules as the UK’s controlled DCD program.
-The BTS Ethics committee can help with advice and information about how to work in this complicated field. (Not graded)
-You can also get advice and information from the UK Donation Ethics Committee. (Not graded).
The multidisciplinary transplant team is in charge of giving the potential transplant recipient information both verbally and in writing. This is a requirement for consent and is part of their job. This must be updated and looked over once a year, and the results of any talks must be written down in the patient’s medical record.
Information should be tailored to the needs of the person who might get it since not all patients want to know a lot of details. But this shouldn’t stop people from taking part in the transplant process.
The risk-benefit analysis given to the person who might get a transplant must explain how much more dangerous it is for that person to stay on the transplant waiting list than to get a DCD organ.
People with advanced or end-stage chronic kidney disease or cortical necrosis that can be seen on a biopsy shouldn’t be thought of as possible kidney donors.
Donors with a functional warm ischaemic time of more than 2 hours or no blood pressure for more than 30 minutes should only be used in experimental protocols that try to bring back organ viability.
Units that do cold machine perfusion of DCD kidney transplants before putting them in should work together to standardize the prospective collection of data so that results can be looked at as a whole.
Neither perfusion pressure dynamic characteristics, perfusate effluent biochemical analysis, nor kidney transplant biopsy scoring systems, alone or together, have enough predictive value to force organ discard.
However, this kind of evaluation could help figure out when two kidneys should be considered for transplantation.
The long-term results for people who get organs through DCD are the same as those for people who get organs through DBD, so the system for giving out organs through DCD and DBD should be the same.
Still, DCD kidneys seem more likely to be damaged by cold ischaemia, and the proposed national allocation scheme should take this into account.
DCD recipients are more likely to have delayed graft function, which should be talked about with the patient before the transplant.
Antibody induction therapy should be part of the first immunosuppressive plan for people who get kidneys from DCD.
The long-term results for donors who meet standard criteria are the same for both DCD and DBD transplants.
-Livers transplanted from Maastricht 3 DCD donors are a useful resource and should be used where deemed safe.
-Even though DCD organs can be used for isolated pancreas transplants (pancreas transplant alone or pancreas after kidney), evidence and current practice are increasingly in favour of using them for simultaneous pancreas and kidney transplantation (SPK).
-Selection criteria for recipients of islets from DCD donors should be the same as for DBD donors.
– The donor selection criteria for lung DCD should be the same as for DBD.
I appreciate your summary, dear Dr Waem.
Summary of recommendation
The functional(or true)warm ischemia period starts when the systolic blood pressure has a sustained(i.e.at least 2 minutes)fall below50mmhg and extend up to the onset of cold in situ perfusion(B1).
Good ethical practise is to efforts to facilitate donation and achieve transplantation in the context of DCD .this include decision about allocation and consent in relation to both the organ donor and recipient(B1).
The criteria for the diagnosis of death following loss of circulatory function should not be influenced by the possibility of subsequent organ retrieval.(A1).i
The retrieval team need to be satisfied about the donor details(blood group ,past medical history ,illness leading to death)before treatment is withdrawn.(A1).
Injury Following DCD kidney transplantation, there is increased risk of delayed graft function due to DCD injury. Induction therapy with mono- or polyclonal antibodies may be used to reduce the risk of clinically unrecognized acute rejection prior to recovery from DCD injury.(B1).
The incidence of delay graft function is increased in CDC recipient and this should be discussed with the patient prior to transplantation.(A1).
None of perfusion pressure dynamic characteristic, perfusate effluent biochemical analysis ,or kidney transplant biopsy system alone or in combination have sufficient predictive value to mandate organ discard.(A2).
Maastricht 4 donors ,where death has been established previously by brain stem criteria, may be given heparin before treatment withdrawal(A1).
Antibody induction therapy should be used as part of the initial immunosuppressive regimen for recipient of DCD kidneys.(B1).
Graft outcome related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD(B2).
I appreciate your summary, dear Dr Manal Malik.
club 1, summary of guidelines for DDKT:
· Categorization of DCD donors & definition of warm ischemic time:
o categorised according the Maastricht classification into 5 categories.
o Categories 1, 2 and 5 are called (non-controlled) and (3, 4 are called controlled).
o Controlled means that the treatment is withdrawn on an intensive care unit (ICU) or emergency department (ED) and death follows. Uncontrolled donation means that the potential donors who suffer an unexpected cardiac arrest and are either brought into hospital dead or when death is declared in hospital following unsuccessful attempts at cardiopulmonary resuscitation (CPR).
o Donation after Circulatory (previously called cardiac) Death (DCD) was previously known as Non Heart Beating Donation (NHBD).
· Important definitions:
o The withdrawal period (agonal period): the time from treatment withdrawal to circulatory arrest.
o Warm ischemia time (asystolic/acircualtory warm period) is defined as time between the circulatory arrest (fall of systolic blood pressure below 50 mmHg and sustained (for at least 2 minutes)) up to the onset of cold in situ perfusion.
· Diagnosis of death:
o Death is an irreversible state, in which a patient has permanently lost consciousness and brain stem function.
o Death can be confirmed following five minutes of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation.
o Circulatory arrest can be identified by the absence of pulsatile flow on a correctly functioning arterial line, or by the use of echocardiography or by continuous ECG monitoring.
o DCD organ retrieval protocols should recognize the potential risks around post mortem interventions that might restore cerebral perfusion.
o The criteria for the diagnosis of death following loss of circulatory function should not be influenced by the possibility of subsequent organ retrieval.
o Death is confirmed after 5 min from circulatory arrest.
· Ethical issues: all the team should be aware of them and consent must be taken from the donor relatives and the recipient as well.
· Organ retrieval:
o Best outcome when treatment withdrawal occurs in the operating room
o treatment withdrawal from deceased donor only done when donor HLA , ABO blood group, virology status and cause of death are known, and the recipient is ready to shorten warm ischemia time.
o Access or cannulation of aorta and IVC should be established.
o Heparin and fibrinolytic agents are added to the first infused cold ice preservation saline.
§ Donor selection:
o Kidney with ESKD or cortical necrosis should be declined.
o The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability.
o DBD has similar graft outcome to DCD in spite of prolonged cold ischemia time in DCD with higher risk of DGF.
o The graft outcome is more related to either it is strict or extended criteria donor rather than it is related to DCD or DBD.
· Immunosuppressive therapy:
o Better to use induction therapy to prevent subclinical unrecognized acute rejection and to delay start of nephrotoxic CNI (to limit and avoid DGF, occurring with cadaveric donor)
· Systemic heparin is used if there is no immediate graft function
· Prophylactic antibiotic cover including anaerobic prophylaxis may be needed for high risk recipients before the transplantation for three days
I appreciate your short write-up, dear Dr Mai.
Summary of BTS Transplantation guidelines for deceased donors after circulatory death :
I appreciate your short write-up, dear Dr Nandita Sugumar
I will summarize the guidelines relavant to my practise as a Transplant Nephrologist:
I appreciate your short write-up, dear Dr Vali
I appreciate your short write-up, dear Dr Ben.
Thank you prof Ajay
Transplantation from deceased donors after circulatory death
British transplantation society July 2013
PART 1: GENERAL PRINCIPLES
3 CATEGORISATION OF DCD DONORS & DEFINITION OF WARM ISCHAEMIC
TIME
· Deceased circulatory death donors should be categorized according to the Maastricht classification to aid research, communication, and audit. (B1)
· The functional (or true) warm ischemic period starts from the dropping of systolic blood pressure below 50 mmHg till the onset of cold in situ perfusion. (B1)
· regarding donor’s oxygen saturation: The current recommendation is that oxygen saturation below 70% is not used as an indicator of poor outcome or as a reason for non-usage, but that retrieval teams should keep a record of when oxygen saturation falls below 70% in order to allow correlation with graft outcome.
Maastricht Category 1: Death occurring outside of the hospital
Death is confirmed outside a hospital environment. For these individuals to be potential donors, the moment of sudden death needs to have been witnessed, the time that it occurred documented, and ‘resuscitation’ continued after death.
Maastricht Category 2: Unsuccessful resuscitation
CPR is started outside of the hospital following the collapse. Death is confirmed on admission to the hospital.
Both Category 1 and 2 donors are also referred to as ‘Uncontrolled’ DCD donors and usually present to the emergency department.
Maastricht Category 3: Awaiting cardiac arrest
Death is inevitable (terminal case) but brain stem death criteria are not fulfilled. These patients are cared for in many areas within hospitals but are most commonly identified in neurosurgical and general intensive care units, coronary care units, emergency departments, and medical wards.
Maastricht Category 4: Cardiac arrest in a brain stem dead individual Death has been diagnosed by brain stem criteria following which the patient suffers a cardiac arrest.
Categories 3 and 4 are also referred to as ‘Controlled’ DCD donors.
Maastricht Category 5: Unexpected cardiac arrest in a hospitalized patient: uncontrolled donor in a hospitalized patient.
These categories consider mainly the difference in the warm ischemic time (WIT) between cardiac arrest and organ perfusion. Category 5 is more likely to be longer than Category 3 or 4 but shorter than Category 1 or 2.
DIAGNOSIS OF DEATH
Statements of Recommendation
· Death is permanently lost of the capacity for consciousness and brain stem function. (A1)
· death can be confirmed following five minutes of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation. (B1)
· circulatory arrest should be identified by the absence of pulsatile flow on a correctly functioning arterial line, by the use of echocardiography if the expertise is available, or by failing by continuous ECG monitoring. (B1)
LAW, ETHICS, AND DONOR CONSENT
· All healthcare professionals should be aware of the complex ethical issues that are associated with donation after circulatory death (DCD) and transplantation of donated organs.
· definitions of death that are accepted by society are the cornerstone for the successful cadaveric program with the preservation of donor dignity and non-malfeasance must not be compromised in efforts to facilitate donation and transplantation from DCD donors. (B1)
· The BTS Ethics committee is available for guidance and information to support practice in this complex field. (Not graded)
INFORMING THE RECIPIENT:
Providing information (The risk-benefit analysis), both orally and in writing consent and is the responsibility of the multidisciplinary transplant team. This must be updated and reviewed annually and the outcome of discussions clearly documented in the patient’s medical record. (B1)
ORGAN RETRIEVAL
· Treatment withdrawal should ideally be planned for a time when the donor HLA
type and virology are known and the liver and pancreas recipients are in the recipient hospitals. (C1)
· Treatment withdrawal in the operating department is associated with shorter
A systolic period (warm ischemic times) then withdrawal to a remote intensive care unit or ward. (C1)
· The retrieval team needs to be satisfied with the donor details (blood group, past medical history, illness leading to death) before treatment is withdrawn (A1)
· Maastricht 4 donors, where death has been established previously by brain stem criteria, may be given heparin before treatment withdrawal. Death does not need to be reaffirmed once a circulatory arrest has occurred. (A1)
· The specialist nurse should keep a record at regular intervals of the donor’s hemodynamic parameters following treatment withdrawal. (C1)
· Death may be confirmed five minutes after complete circulatory arrest. There is no need for a further stand-off period following this. (A1)
· For controlled donors, retrieval starts by gaining access to a large artery and vein, typically the right common iliac artery or aorta, and the IVC in the abdomen or right atrium in the chest. (Not graded)
· 20 000 units of heparin should be added to the first two bags of ice-cold preservation solution to be perfused through the aorta. (Not graded)
· A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen activator may be added to the first bag of preservation solution. (B3)
· The kidneys may be removed either individually or en a bloc. (Not graded)
· The pancreas may be removed either en-bloc with the liver, or following removal of the liver. (Not graded)
· Cannula for preservation fluid should never be placed in the SMV or IMV when the pancreas is being retrieved. (B1)
· The liver should be recovered using a rapid technique that minimizes liver congestion. (Not Graded)
· Dual perfusion of the hepatic artery and portal vein is essential for the recovery of DCD livers for transplantation. (C2)
PART 2: ORGAN-SPECIFIC DISCUSSION
(Kidney-liver-pancreas-lung-heart)
1-KIDNEY
When to discard kidneys??
· The use of donors with functional warm ischemic time >2 hr. or absent blood pressure for 30 minutes should be restricted to currently experimental protocols which attempt to resuscitate organ viability. (B2)
· None of the perfusion pressure dynamic characteristics, perfusate effluent biochemical analysis, or kidney transplant biopsy scoring systems – alone or in combination – have sufficient predictive value to mandate organ discard. (A2) Such assessment may, however, help determine when kidneys should be considered for dual transplantation. (B2).
is there a difference between DCD and DBD regarding kidneys???
o Long-term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. Nevertheless, it is recognized that DCD kidneys appear to be more susceptible to cold ischemia, and the proposed national allocation scheme should take this into account. (B2)
o The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation. (A1)
o Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants. (A1)
o Graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD. (B2)
o Prospective data are required to determine whether the impact of expanded criteria donation (ECD) is different in DCD and DBD donors and whether different thresholds for organ use may be required. (A1)
Any specific modification for an immunosuppressive protocol in DCD???
Antibody induction therapy should be used as part of the initial immunosuppressive regimen for recipients of DCD kidneys. (B1)
2-LIVER
long ischemia time associated with ischemic cholangiopathy and biliary stricture so, the organ is better to be discarded:
o Livers transplanted from Maastricht 3 DCD donors are a useful resource and should be used where deemed safe BUT still inferior to livers from DBD donors with more PNF and ischemic cholangiopathy, and a higher rate of re-transplantation. (B1)
o The incidence of biliary stricture is significantly lower when a low-viscosity solution is used to cold flush the aorta. (C2)
o The outcome of DCD liver transplantation is improved with short CIT (cold ischemia time), which is best kept to under 8hrs. (B1)
o A favorable outcome can be expected if an ‘ideal’ DCD liver is transplanted.An ‘ideal’ DCD liver donor is <50 years old, has a functional WIT time <20 min,a shorter CIT <10 hr, BMI <29 kg/m2 and <10% steatosis. (B1)
difference between DCD and DBD??
o DCD and DBD subjects transplanted with MELD >30 or on organ-perfusion support have similar graft survival. However, there is no survival benefit when DCD livers are transplanted in patients with MELD ≤30 or in those not receiving organ-perfusion support(B2).
o DCD grafts are best avoided in recipients of re-transplantation (B1)
o DCD liver grafts should be ideally used in younger recipients with ages <60years. (B1)
Factors predictive of graft failure are age ≥55 years, male sex, African–
American race, HCV positivity, metabolic liver disorder, transplant MELD ≥ 35,
hospitalization at transplant, and the need for life support at transplant.
Recipient predictors of mortality are age ≥55 years, hospitalization at
transplant, and re-transplantation. (B1)
3-PANCREAS
Long ischemia time in pancreas transplantation is associated with reperfusion pancreatitis and thrombosis and the organ maybe needs to be discarded.
· risk of reperfusion pancreatitis and thrombosis and this may be exacerbated by prolonged cold ischemia time and higher donor body mass index. The contribution of donor age to the incidence of reperfusion pancreatitis/thrombosis in DCD organs is poorly studied but may constitute a further risk factor. Ideal donors should be <60 years old and have BMI <30 kg/m2. (C2)
· The pancreas team should stand down after a functional warm ischemia time of 60 minutes (pancreas will be discarded) (C2)
· There is little evidence regarding recipient risk factors but it is logical to assume that higher recipient BMI, age, cardiovascular morbidity, and technical surgical factors may contribute to poorer outcomes.
is there any difference between DCD and DBD regarding the pancreas
· Reported outcomes for DCD donor pancreas transplantation are broadly similar to those from DBD donors, although considerably greater donor selection is likely to have taken place. (C2)
· Graft loss from thrombosis is twice as common in DCD as in DBD pancreas transplants. Particular attention should be paid to measures to prevent thrombosis in recipients of DCD organs. A DCD organ should not be transplanted into a recipient with a history of thrombo-embolic disease unless this is monitored and treated. (C2)
available evidence and current practice are increasingly in favor of their use for simultaneous pancreas and kidney (SPK) transplantation from DCD donors. (C2)
4-LUNG
When to discard DCD lung??
· Lung quality evaluated by what is called (Pre-transplant ex-vivo lung perfusion (EVLP) is advised in case of uncertain graft performance to safely extend donor and procedural criteria (long warm ischemia, bad flush, clots). (B1)
· Perform antegrade and retrograde flush perfusion at the time of lung retrieval. (B2) Acceptance criteria on EVLP may include measures of pulmonary compliance, vascular resistance, and gas exchange
is are any difference between DCD and DBD
The donor selection criteria for lung DCD should be the same as for DBD. (B2)
DCD lungs should not be regarded as extended or marginal. Transplant quality and outcome is at least similar to DBD organs. (B1)
5-HEART
In the UK, heart transplantation from DCD donors is currently NOT standard of
care. Because of a number of ethical issues, the use of DCD hearts is not
currently recommended. Once these are resolved this guideline will be updated. (Not graded)
I appreciate your short write-up, dear Dr Ramy. This is bigger than a summary, however.
Thanks professor Ajay
I will try to make it more condensed next time
Summary:
Organ transplantation is the ultimate treatment options of end stage organ dysfunction. Diseased donor organ transplantation increase the donor pool and may save more life along with live organ donation.
CATEGORISATION OF DCD DONORS & DEFINITION OF WARM ISCHAEMIC TIME
· Deceased circulatory death donors should be categorized according the
Maastricht classification to aid research, communication and audit.
· The functional (or true) warm ischemic period starts when the systolic blood pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and extends up to the onset of cold in situ perfusion.
· Although donor low oxygen saturation (<70%) is a concern and may well be a measure of inadequate organ perfusion and poor outcome, prospective evidence is awaited.
DIAGNOSIS OF DEATH
· Death is irreversible and should be regarded as a state in which a patient has permanently lost the capacity for consciousness and brain stem function.
· Where cardio-respiratory criteria apply, death can be confirmed following five minutes of continuous cardio-respiratory arrest providing there is no
subsequent restoration of artificial cerebral circulation.
· Where possible, circulatory arrest should be identified by the absence of
pulsatile flow on a correctly functioning arterial line, or by the use of
echocardiography if the expertise is available; or failing that by continuous
ECG monitoring.
· DCD organ retrieval protocols should recognise the potential risks around post mortem interventions that might restore cerebral perfusion.
LAW, ETHICS AND DONOR CONSENT
· Healthcare professionals should be aware of the complex ethical issues that are associated with donation after circulatory death (DCD) and transplantation of donated organs. Such professionals should be familiar with the terminology used to describe and discuss the ethics of DCD transplantation.
· Good ethical practice is integral to efforts to facilitate donation and achieve transplantation in the context of DCD. This includes decisions about allocation and consent in relation to both the organ donor and recipient.
INFORMING THE RECIPIENT
· To povide information, both orally and in writing, for the potential transplant recipient is a requirement for consent and is the responsibility of the multidisciplinary transplant team.
ORGAN RETRIEVAL
· Treatment withdrawal should ideally be planned for a time when the donor HLA type and virology are known and the liver and pancreas recipients are in the recipient hospitals.
· Treatment withdrawal in the operating department is associated with shorter asystolic periods (warm ischaemic times) than withdrawal on a remote intensive care unit or ward.
· The retrieval team need to be satisfied about the donor details (blood group, past medical history, illness leading to death) before treatment is withdrawn.
· Maastricht 4 donors, where death has been established previously by brain stem criteria, may be given heparin before treatment withdrawal. Death does not need to be reaffirmed once circulatory arrest has occurred.
· The specialist nurse should keep a record at regular intervals of the donor’s haemodynamic parameters following treatment withdrawal.
· Death may be confirmed five minutes after complete circulatory arrest. There is no need for a further stand off period following this.
· For controlled donors, retrieval starts by gaining access to a large artery and vein, typically the right common iliac artery or aorta, and the IVC in the
abdomen or right atrium in the chest.
· 20 000 units heparin should be added to the first two bags of ice-cold
preservation solution to be perfused through the aorta.
· A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen activator may be added to the first bag of preservation solution.
· The kidneys may be removed either individually or en bloc.
ORGAN SPECIFIC DISCUSSION
KIDNEY
· Individuals with advanced or end-stage chronic kidney disease, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donors.
· The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability.
I appreciate your short write-up, dear Dr Ansary.
Summary :
Transplantation offers patients with end-stage organ failure a cost-effective treatment that improves quality of life and increases life expectancy. Prior to the introduction of guidance defining the concept of brain death in the 1970s, all organs for transplantation were donated after circulatory death (DCD). Following the introduction of brain stem death testing, the majority of organs for transplantation were donated after brain death (DBD) or, increasingly, from living donors DCD provides a valuable source of organs for transplantation and helps to address the shortfall between supply and demand. It also offers an additional donation choice for families of critically ill patients who are suffering from severe injury or illness that is incompatible with life but have not deteriorated to brain death.
PART 1: GENERAL PRINCIPLES
3 CATEGORISATION OF DCD DONORS & DEFINITION OF WARM ISCHAEMIC
TIME
Statements of Recommendation
Deceased circulatory death donors should be catego rised according the
Maastricht classification to aid research, communication and audit. (B1)
The functional (or true) warm ischaemic period starts when the systolic blood
pressure has a sustained (i.e. at least 2 minutes) fall below 50 mmHg and
extends up to the onset of cold in situ perfusion. (B1)
Although donor low oxygen saturation (<70%) is a concern and may well be a
measure of inadequate organ perfusion and poor outcome, prospective evidence is awaited. The current recommendation is that oxygen saturation below 70% is not used as an indicator of poor outcome or as a reason for non usage, but that retrieval teams should keep a record of when oxygen saturation falls below 70% in order to allow correlation with graft outcome.
Maastricht Category 1: Death occurring outside of hospital
Death is confirmed outside a hospital environment. For these individuals to be potential
donors, the moment of sudden death needs to have been witnessed, the time that it
occurred documented, and ‘resuscitation’ continued after death.
Maastricht Category 2: Unsuccessful resuscitation
CPR is started outside of hospital following collapse. Death is confirmed on admission to hospital.
Both Category 1 and 2 donors are also referred to as ‘Uncontrolled’ DCD donors and usually present to the emergency department.
Maastricht Category 3: Awaiting cardiac arrest
Death is inevitable but brain stem death criteria are not fulfilled. These patients are cared for in many areas within hospitals, but are most commonly identified in neurosurgical and general intensive care units, coronary care units, emergency departments and medical wards.
Maastricht Category 4: Cardiac arrest in a brain stem dead individual
Death has been diagnosed by brain stem criteria following which the patient suffers a
cardiac arrest. This may be whilst awaiting the donor team or as an intentional arrangement, depending upon the wishes of the next of kin.
Categories 3 and 4 are also referred to as ‘Controlled’ DCD donors.
Maastricht Category 5: Unexpected cardiac arrest in a hospitalised patient
Category 5 is an ‘uncontrolled’ donor in a hospitalised patient so the warm ischaemic time (WIT) between cardiac arrest and organ perfusion is likely to be longer than categories 3 or 4 but shorter than categories 1 or 2.
DIAGNOSIS OF DEATH
Statements of Recommendation
Death is irreversible and should be regarded as a state in which a patient has
permanently lost the capacity for consciousness and brain stem function. (A1)
Where cardio-respiratory criteria apply, death can be confirmed following five
minutes of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation. (B1)
Where possible, circulatory arrest should be identified by the absence of
pulsatile flow on a correctly functioning arterial line, or by the use of echocardiography if the expertise is available; or failing that by continuous ECG monitoring. (B1)
DCD organ retrieval protocols should recognise the potential risks around post
mortem interventions that might restore cerebral perfusion. (B1)
The criteria for the diagnosis of death following loss of circulatory function
should not be influenced by the possibility of subsequent organ retrieval. (A1)
LAW, ETHICS AND DONOR CONSENT
Statements of Recommendation
All healthcare professionals should be aware of the complex ethical issues that
are associated with donation after circulatory death (DCD) and transplantation
of donated organs. Such professionals should be familiar with the terminology
used to describe and discuss the ethics of DCD transplantation. (B1)
Good ethical practice is integral to efforts to facilitate donation and achieve
transplantation in the context of DCD. This includes decisions about allocation
and consent in relation to both the organ donor and recipient. (B1)
DCD in the United Kingdom is underpinned by definitions of death that are
accepted by society. The principles of donor dignity and non-malfeasance
must not be compromised in efforts to facilitate donation and transplantation
from DCD donors. (B1)
Ethical principles integral to the UK controlled DCD programme must extend to
any future uncontrolled DCD programme. (B1)
The BTS Ethics committee is available for guidance and information to support practice in this complex field. (Not graded)
The UK Donation Ethics Committee is also available for guidance and
information. (Not graded
INFORMING THE RECIPIENT
Statements of Recommendation
Providing information, both orally and in writing, for the potential transplant
recipient is a requirement for consent and is the responsibility of the multidisciplinary
transplant team. This must be updated and reviewed annually and the outcome of discussions clearly documented in the patient’s medical record. (B1)
Information should be tailored to the requirements of the potential recipient,
recognising that not all patients wish to receive detailed information. However,
this must not preclude engagement with the transplant process. (B1)
The risk benefit analysis presented to the potential transplant recipient must
explain the relative risk for that recipient of remaining on the transplant waiting
list compared to that of receiving a DCD organ. (B1)
ORGAN RETRIEVAL
Statements of Recommendation
Treatment withdrawal should ideally be planned for a time when the donor HLA
type and virology are known and the liver and pancreas recipients are in the recipient hospitals. (C1)
Treatment withdrawal in the operating department is associated with shorter
asystolic periods (warm ischaemic times) than withdrawal on a remote intensive care unit or ward. (C1)
The retrieval team need to be satisfied about the donor details (blood group,
past medical history, illness leading to death) before treatment is withdrawn.
(A1) Retrieval teams should be scrubbed in the operating theatre at the point oftreatment withdrawal. (B1)
Maastricht 4 donors, where death has been established previously by brain
stem criteria, may be given heparin before treatment withdrawal. Death does
not need to be reaffirmed once circulatory arrest has occurred. (A1)
The specialist nurse should keep a record at regular intervals of the donor’s
haemodynamic parameters following treatment withdrawal. (C1)
Death may be confirmed five minutes after complete circulatory arrest. There is
no need for a further stand off period following this. (A1)
For controlled donors, retrieval starts by gaining access to a large artery and
vein, typically the right common iliac artery or aorta, and the IVC in the abdomen or right atrium in the chest. (Not graded)
20 000 units heparin should be added to the first two bags of ice-cold
preservation solution to be perfused through the aorta. (Not graded)
A fibrinolytic agent such as streptokinase or recombinant tissue plasminogen
activator may be added to the first bag of preservation solution. (B3)
The kidneys may be removed either individually or en bloc. (Not graded) The pancreas may be removed either en bloc with the liver, or following removal of the liver. (Not graded)
Cannulae for preservation fluid should never be placed in the SMV or IMV when
the pancreas is being retrieved. (B1)
The liver should be recovered using a rapid technique which minimises liver
congestion. (Not Graded)
Dual perfusion of hepatic artery and portal vein is essential for recovery of
DCD livers for transplantation. (C2)
PART 2: ORGAN SPECIFIC DISCUSSION
KIDNEY
Statements of Recommendation
Individuals with advanced or end-stage chronic kidney disease, or with cortical
necrosis demonstrable on biopsy should not be considered as potential kidney
donors. (B1)
The use of donors with functional warm ischaemic time >2 hr or absent blood
pressure for 30 minutes should be restricted to (currently experimental)
protocols which attempt to resuscitate organ viability. (B2)
Units undertaking cold machine perfusion of DCD kidney transplants prior to
implantation should collaborate to standardise the prospective collection of
data to enable aggregated analyses of outcomes. (A2)
None of perfusion pressure dynamic characteristics, perfusate effluent
biochemical analysis, or kidney transplant biopsy scoring systems – alone or in
combination – have sufficient predictive value to mandate organ discard. (A2)
Such assessment may, however, help determine when kidneys should be
considered for dual transplantation. (B2)
Long term outcomes of DCD recipients are similar to those of DBD recipients
and the allocation system for DCD and DBD organs should be similar.
Nevertheless, it is recognised that DCD kidneys appear to be more susceptible
to cold ischaemia, and the proposed national allocation scheme should take
this into account. (B2)
The incidence of delayed graft function is increased in DCD recipients and this
should be discussed with the patient prior to transplantation. (A1)
Antibody induction therapy should be used as part of the initial immunosuppressive regimen for recipients of DCD kidneys. (B1)
Long-term outcomes for standard criteria donors are equivalent for DCD and
DBD kidney transplants. (A1
Graft outcome is more closely related to whether a transplant is ECD vs SCDthan whether the mode of retrieval is DCD vs DBD. (B2)
Prospective data are required to determine whether the impact of expanded
criteria donation (ECD) is different in DCD and DBD donors and whether
different thresholds for organ use may be required. (A1)
LIVER
Statements of Recommendation
Livers transplanted from Maastricht 3 DCD donors are a useful resource and
should be used where deemed safe. (B1)
Short and medium term outcome appears inferior to livers from DBD donors
with more PNF and ischaemic cholangiopathy, and a higher rate of retransplantation.
(B1)
DCD and DBD subjects transplanted with MELD >30 or on organ-perfusion
support have similar graft survival. However, there is no survival benefit when
DCD livers are transplanted in patients with MELD ≤30 or in those not receiving
organ-perfusion support. (B2)
The incidence of biliary stricture is significantly lower when a low viscosity
solution is used to cold flush the aorta. (C2)
DCD liver use should be matched with the need of the recipients on the waiting
list, with allocation to those who will have the greatest transplant benefit. (B2)
The outcome of DCD liver transplantation is improved with short CIT, which isbest kept to under 8hrs. (B1)
A favourable outcome can be expected if an ‘ideal’ DCD liver is transplanted.
An ‘ideal’ DCD liver donor is <50 years old, has a functional WIT time <20 min,
a shorter CIT <10 hr, and <10% steatosis. (B1)
Using more restrictive DCD Donor criteria including BMI <29 kg/m2 and a
functional WIT <20 min (SAP <50 mmHg), equivalent 1 and 3-year patient and
graft survival rates can be achieved for both DCD and DBD liver transplants.
(B1)
Long FWIT is associated with an increased risk of ischaemic cholangiopathy
Potential recipients of DCD liver grafts should be informed of the potential risk
and be offered the choice to refuse such organs prior to transplant listing. (C2)
DCD grafts are best avoided in recipients of re-transplantation (B1)
DCD liver grafts should be ideally used in younger recipients with age <60
years. (B1)
Factors predictive of graft failure are: age ≥55 years, male sex, African–
American race, HCV positivity, metabolic liver disorder, transplant MELD ≥ 35,
hospitalisation at transplant, and the need for life support at transplant.
Recipient predictors of mortality are age ≥55 years, hospitalisation at
transplant, and re-transplantation. (B1)
A national audit should be performed to identify factors for non-utilisation of
extended criteria donors to establish the incidence of cholangiopathy under
ideal circumstances, identify more suitable risk factors, identify further
subgroups of DCDs that could potentially be utilised, allow for medical
interventions to be evaluated, and provide qualitative data regarding centrespecific
performance. (C1)
PANCREAS
Statements of Recommendation
Although DCD organs can be used for isolated pancreas transplants in
pancreas transplant alone or pancreas after kidney, available evidence and
current practice are increasingly in favour of their use for simultaneous
pancreas and kidney (SPK) transplantation. (C2)
Pancreas transplants from DCD donors are at increased risk of reperfusion
pancreatitis and thrombosis and this may be exacerbated by prolonged cold
ischaemia time and higher donor body mass index. The contribution of donor
age to the incidence of reperfusion pancreatitis/thrombosis in DCD organs is
poorly studied but may constitute a further risk factor. Ideal donors should be
<60 years old and have BMI <30 kg/m2. (C2)
The pancreas team should stand down after a functional warm ischaemia time
(systolic BP <50 mmHg and oxygen saturation of 70%) of 60 minutes. (C2)
A primary focus of any DCD pancreas transplant should be to achieve the
minimum cold ischaemic time. (B2)
There is little evidence regarding recipient risk factors but it is logical to
assume that higher recipient BMI, age, cardiovascular morbidity, and technical
surgical factors may contribute to poorer outcome. (C2)
Reported outcomes for DCD donor pancreas transplantation are broadly
similar to those from DBD donors, although considerably greater donor selection is likely to have taken place. (C2)
Graft loss from thrombosis is twice as common in DCD as DBD pancreas
transplants. Particular attention should be paid to measures to prevent
thrombosis in recipients of DCD organs. A DCD organ should not be
transplanted into a recipient with a history of thrombo-embolic disease unless
this is monitored and treated. (C2
Selected transplant centres will have built up a volume of expertise with DCD
extended criteria and these guidelines should not restrict innovative but safe
practice of pancreas transplantation. (Not graded)
PANCREATIC ISLETS
Statements of Recommendation
Selection criteria for recipients of islets from DCD donors should be the same
as for DBD donors. (B2)
Organs from DCD donors for islet isolation and transplantation should be
allocated through the National Pancreas Allocation Scheme. (B2)
The long term outcome of islet transplantation from DCD donors has been
satisfactory in the UK but the cohort is small. Further audit and research are
required. (C2)
Satisfactory functional islet preparations can be routinely obtained from DCD
donors. (C2)
LUNG
Statements of Recommendation
The donor selection criteria for lung DCD should be the same as for DBD. (B2)
All patients on the lung transplant waiting list have the potential to receive DCD
lungs. (C1)
DCD lungs should not be regarded as extended or marginal. Transplant quality and
outcome is at least similar to DBD organs. (B1)
Perform ante grade and retrograde flush perfusion at the time of lung retrieval. (B2)
Pre-transplant ex vivo lung perfusion (EVLP) is advised in case of uncertain graft
performance to safely extend donor and procedural criteria (long warm ischaemia,
bad flush, clots). (B1)
Acceptance criteria on EVLP may include measures of pulmonary compliance,
vascular resistance, and gas exchange. (C2)
HEART
Statement of Recommendation
In the UK, heart transplantation from DCD donors is currently NOT standard of
care. Because of a number of ethical issues, the use of DCD hearts is not
currently recommended. Once these are resolved this guideline will be updated. (Not graded)
In our country no deceased donor, we have no expreince
Lesson from this gudlines :
established deceased donorprogram in our country according to this guidlines
I appreciate your short write-up, dear Dr Nahla Alam. This is bigger than a summary, however.
Please write your comments in light of your own experience with DCD.
What lessons do you learn from these guidelines, even though we all know that it is level 5 evidence?
Dear prof;
I like your optimism and vision, dear Dr Ben
Thank you prof Ajay