Upload
nataly-speakman
View
217
Download
0
Tags:
Embed Size (px)
Citation preview
Dead or Dead-Enough?DCD and Organ Donation in 2003
Paul Morrissey, MDDepartment of SurgeryRhode Island HospitalBrown Medical School
Brown Ethics Forum Transplantation
• State of Organ Transplantation
• Need for organs
• Brain death• Cardiac death (DCD)
– Results– Issues
ESRD in R.I. 2002
• Patients– 812 on HD– 34 on CAPD/CCPD– 400 with functioning renal transplant
• 2002– New cases ESRD – 310– Dialysis deaths – 248– Renal transplants – 85 – Wait List Total - 128
ESRD Modalities
0
50
100
150
200
1988 89 90 91 92 93 94 95 96 97
Count (1000s)
HD
Transplant
PD
Transplant Wait List – RIH 2003
• ABO N PRA>10 TU
– A 30 18 14– B 20 11 3– O 53 18 6– AB 2 2 0
– Total 105 49 23
0102030405060708090
1997 1998 1999 2000 2001 2002 Proj
TotalLive donor
Renal Transplants – RIH
Renal Transplants vs. Wait List
3521
0
10000
20000
30000
40000
50000
1988 1992 1994 1996 1998 2000 2002
Live donorCadaver
Waiting list
Renal Tx vs. Wait List
• 1993-1996– 16% annual growth of wait list– 1.6 % annual increase in CRT donors
Time on dialysis: strongest modifiable risk factor for renal tx outcomes
Mortality on Dialysis
• 23 % per year• 5 year survival
– ESRD - 30 %– ESRD + DM- 20
%– ESRD + Age >
65 - 15 %.
Kidney donors - USA
0
2000
4000
6000
1988 1992 1994 1996 1998 2000 2001 2002
Live donor Cadaver
Cadaver Donors – Percent by Age
0
5
10
15
20
25
30
35
40
90 91 92 93 94 95 96 97 98 99 0 1 2
18-34Over 50
Over 65
Organ Donor NumbersGrowth: 136 % Spain, 33 % USA
Deceased Donors by Age
Terasaki et al. Clin Transplant 1997; 11: 366.
Kidney allograft survival by donor age
0
10
20
30
40
50
60
70
80
90
20-9 30-9 40-9 50-9 60+
One yearFive year
0 1 2 3 4 5 6 7 8 9 10
Id Sib1-haplo SibUnrelatedCadaver
1009080706050403020100
Perc
ent
Su
rviv
al
Years Post transplant
2,1293,1402,071
34,572
39.216.116.710.2
n T1/2Relationship
82
64
47
Cecka, M.UNOS
1994-1999
Graft Survival Rates for LRD and LURD grafts
Kidneys for Transplantation:Where do we get them?
• Live donors– Related– Unrelated– Stranger – altruistic (9 at RIH)
• Deceased, brain-dead donors (cadaver donors)– Local– Regional– National – zero-mismatch (“perfect match”)
• DCD (NHBD)– Asystolic (5 minutes) donors
Head trauma: Epidural hematoma
• Severe brain injury• Irreversible brain
injury
• Persistent vegetative state
• Brain dead– Cortical brain– Brain stem
Brain Death Concept (1968)
– Defined as:•Irreversible loss of brain function•Including brain stem (respiration)
– Brain death = death•Medically•Legally•Ethically
DCD: how it works!
• Recognize potential donor– Ventilator dependent– Irreversible brain injury
• Does not meet criteria for brain death• Family and MD have opted to remove
life support, DNR order in chart• Suitable renal function• Consent for DCD
DCD (continued):
• Medical examiner approval• Standard donor evaluation• Assemble team from NEOB• Prepare right groin for cannulation• Extubate the donor, D/c pressors and
IVF• Morphine drip per institutional protocol• Observe for 5 minute period of asystole
DCD - surgical procedure:
• Potential donor– Prolonged cardiac function – no donation– Rapid progression to asystole
• Declaration of death• Organ donation
• Cannulate femoral vessels– Artery – 18 Fr. Chest tube– Vein – Foley bag
• Cold perfuse and transport to O.R.
Time sequence for DCD
• Asystole 5 minutes• Cannulate, cold perfuse 5 minutes• Transport to OR 5 minutes• Laparotomy, clamp aorta 5 minutes• Procure kidneys 30 minutes• 2 kidneys for transplant Priceless
DCD – Are there issues?
• Why not brain death?• Will the donor progress to asystole?
– Within one hour time limit?– Ever?
• Does DCD hasten patient death?• Is 5 minutes of asystole sufficient?• Will the kidneys function suitably?
Kidney Graft-Survival RatesCho, Terasaki, Cecka, Gjertson. NEJM 338: 221, 1998.
Graft-Survival by Cause of Death
DCD: Long-term outcomes
A. Censored for death with function.
B. Uncensored data – graft survival.
Donors at RIH
• Overall– 240 transplants– 196 living
• Altruistic 9• Exchange 3• Unrelated• Related
• CRT– 0-mm 12– DCD 23– Region 1 plan 140
• Over 50 26• Over 60 13
– 2-for-1 7
DCD Experience - RIH
• 14 potential donors evaluated• 6 families refused consent• 4 failed to progress to asystole in < 1
hour– BP and O2 sat. declined– Donation aborted
• 4 became donors– 8 kidneys transplanted
DCD kidneys procured at RIH
Pt. Cr LOS Follow-up/complicationsA 1.7 5 A&W 38 monthsB 1.4 23 Delayed function, died.C 0.9 6 A&W 36 monthsD 1.2 13 A&W 36 monthsE 1.5 5 A&W 9 monthsF 1.4 7 A&W 9 monthsG HD 7 Graft thrombosisH 1.0 6 A&W 2 months
DCD in NEOB
• 1999 4 cases• Effort to increase NHBD
– Reinvigorate one program– Develop 6 other programs
• 2003 19 cases
DCD in NEOB cont.
• DCD donors – 49– Extubation: 9 in OR, 40 in ICU
• Mean age – 36 +/- 14• Progress to asystole 1* – 50 %• Time to asystole – 25 +/- 45 minutes• Transplants:
– 85 kidneys (90 % success)– 4 liver transplants (100 %)
Who is the NEOB?
• Donor coordinator• Social Workers• Family Support Team• Community Educator• Medical Director• Administrators
Brain dead Organ DonationCould we do better at RIH?
• 1200 deaths annually at RIH– 35-40 meet criteria for organ
donation• Brain death• No active cancer or infection
– Few excluded for organ unsuitability– 50-65% consent rate– 12-16 kidney donors per year
• (24-32 CRT, 1/4 exported)
Cadaver Donors – RIH1998-2002 – 125 potential donors
75
39
11
DonorNo consentConsent - not suitable
Organ Donation - Best practice
• We currently recognize greater than 95% of brain dead organ donors
• Consent rates at best centers approach 65-80%
• 15-30% of people are strongly opposed to organ donation
• Best practice - 80-85% of brain dead donors
Organ Donation - Best practice
66%
17%
17%
ConsentStrongly opposePotential
Organ Donors - NEOB
0
50
100
150
200
250
94 95 96 97 98 99 2000 2001 2002
CVA
TraumaAll
Organ Donation - room for growth?
• DCD– Emergency room
• 2-for-1– Discard rate is 30%
• Live donors– Family interventions– Unrelated donors including “altruistic”
Categories of DCD
Description LocationDOA EDUnsuccessful CPR ED, ICU, WardWithdraw support ICU or OR
Cardiac arrest ICU, OR while brain dead
DCD - Controversies
• DNR / CMO• Asystole• Heparin• Morphine• Premortem
cannulation• Location
• Transplant team• 2, 5, 10 minutes• Hasten death• Double effect• Intervention for
recipient• ICU, ED, Ward
Live donor renal transplantation Black Market
Thank you