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Organ Donation in DCD: 10 Year Experience at the University o f Michigan. A Rojas-Pena, MD; L Sall, BS; K. Koch, BS; E Cooley, RN; M Gravel, RN; R Bartlett, MD ; J Punch, MD; S Pelletier, MD University of Michigan Health System Department of Surgery, Section of Transplantation and the - PowerPoint PPT Presentation
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Organ Donation in DCD: 10 Year Experience at the University of
Michigan
A Rojas-Pena, MD; L Sall, BS; K. Koch, BS; E Cooley, RN; M Gravel, RN; R Bartlett, MD; J Punch, MD; S Pelletier, MD
University of Michigan Health SystemDepartment of Surgery, Section of Transplantation and the
Extracorporeal Life Support Program
2
DCD History at UM
Large transplant program + large extracorporeal life support (ECS) program
• 2000, both programs were combined Extracorporeal support (ECS) resuscitate and recover abdominal organs in controlled DCD (Maastricht category III) when the family requests organ donation
• Successful recovery / transplantation of kidneys, liver and pancreas
• Initial experience reported in 2005 with 20 ECS-DCD
Magliocca, et al. The Journal of trauma 2005;58(6):1095-101; discussion 1101-2.
3
Objectives
• Retrospective review of DCD program:– 10-year experience – cases between October 2000 to August 2010
• Update UM first series study on ECS assisted donation in controlled DCD
ECS-cDCD
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Methods
• Potential cDCD abdominal organs OK for procurement after dead
• Recipient outcome data of:– Kidneys and livers procured and
transplanted at UM only
• RR technique (RR-DCD group)
vs• ECS technique (ECS-DCD group)
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DCD selection
• <65yo/ Maastricht type III– Severe irreversible brain injury NO BD criteria
• Intensive Care Unit (ICU) on MV and/or life support
• Cardio-circulatory arrest after planned withdrawal of life support
• Family for donation
– Consent for cannulation
• No contraindications to transplant grafts
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UM – ECS circuit
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Final DCD at UM
Donor Type
Potential (n)
Excluded (n)
Reason for Exclusion
ECS 50 13Prolonged CA = 11
Sx complication = 1 Positive Serology = 1
RR 29 4 Prolonged CA = 4
37 ECS-DCD & 25 RR-DCD
8
ORPD & OTPD Rates
Organs Recovered (n)
Organs Transplanted (n)
DCD type K L P ORPD K L P OTPD
ECS-DCD 37 73 21 2 2.59 48 13 1 1.68
RR-DCD 25 44 17 0 2.44 25 8 0 1.32
Total at UM 62 117 38 2 2.53 73 21 1 1.53
ORPD: Organs Recovered per Donor / OTPD: Organs Transplanted per Donor / K:Kidney; L: Liver; P: Pancreas
January-June 2011 DCD: 2.45 ORPD & 2.0 OTPD / Discard rate: 18%
9
Summary of the ECS run
VariableInitiation of
ECSTermination of
ECS
pH 7.099±0.024 7.288±0.027SVO2
(%) 45.5±3.6 67.0±3.2PaCO2
(mmHg) 55.5±8.4 34.5±2.4
SaO2 (%) 84.4±3.5 90.4±3.4K+
(mmol/L) 6.1±0.8 4.9±0.5SVO2: mixed venous oxygen saturation; PaCO2: Partial pressure of
Carbon Dioxide; SaO2: Arterial Blood Saturation
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ECS-DCD Complications
Complication (n) % Management & Outcome
ECS flow (<45mL/kg/min)
4 10.8 Converted to RR = 3 DCDECS continued = 1 DCD
Cannulation(No vascular access)
2 5.4 Converted to RR = 1DCDNo Recovery = 1 DCD
Bleeding 1 2.7 No Recovery
Aortic Balloon 1 2.7 No Recovery
11
UM Outcomes Renal Grafts
• 37 patients (5 yr follow up)
DGF: Need of HD within the first week post-transplantation
- 50% due to hyperkalemia
DCD Type
Renal Tx (n) DGF PGNF
ECS 29 31% 3.5%
RR 8 64% 3.5%
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Graft Survival Rates
89% 77% 66%US graft survival rate:
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Outcomes Livers
• 20 DCD liver recipients • Full records / HIPPA (3 year follow up)
• Recipient MELD score = 15-17
Donor Type
Liver DCD (n)
1 year survival
3 year survival
ECS 7 86% 69%
RR 13 71% 62%National
(Cadaveric) -- 82% 72%
Ischemic cholangiopathy: 15% (both groups)
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Take Home MessageDCD Organ Recovery - Technique Comparison
Issues RR- DCD ECS-DCD
Organs Donated Kidneys / Selective livers
All, except heart 30%
Goal Deep cooling / metabolism
Restores circulation and 02 / normal Metabolism
Time to Organ Procurement
Urgent Elective
Cold Storage Routine / Pump Perfusion
??
Organ Assessment
Pump perfusion / Transplant
Recovery ./ pump perfusion / Transplant
Limitations Rapid cooling / WI / OR logistics
Cannulation and ECS management
Post Tx Function 40-60% DGF 8-30% DGF
15
Acknowledgments
ECLS Program Staff• Pula Baldridge, RN
– Manager
• Sheri Bignall
Faculty• Jonathan Haft
– ECLS Director
• Gail Annich– ECLS co-Director
• George Mychaliska• Robert Bartlett
ECLS Lab• Lauren Sall• Kelly Koch
Transplant Team• Jeff Punch
– Director Transplant Program
• Swan Pelletier• Larry Slate II
– Chief Transplant perfusionist
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