Management of the potential deceased donor
- Ron Shapiro, MD
Ron Shapiro, MD
- Professor of Surgery
- Surgical Director, Kidney/Pancreas Transplant Program
- Mount Sinai Hospital - Recanati Miller Transplantation Institute
- Michael A DeVita, MD
Michael A DeVita, MD
- Director of Critical Care Medicine
- Harlem Hospital Center
- Section Editors
- Scott Manaker, MD, PhD
Scott Manaker, MD, PhD
- Section Editor — Critical Care
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Daniel C Brennan, MD, FACP
Daniel C Brennan, MD, FACP
- Editor-in-Chief — Nephrology
- Section Editor — Renal Transplantation
- Professor of Medicine
- Washington University School of Medicine
Over 50 percent of kidneys and most of the extrarenal solid organs that are transplanted are recovered from deceased donors. Most deceased-donor organs are recovered from donors who meet criteria for brain death and have ongoing cardiac function. Brain death is irreversible, and the ability to recover transplantable organs exists only because the technology of the intensive care unit (ICU) can maintain physiologic homeostasis, including circulation and respiration. Without this support, "brain death" occurs almost simultaneously with "cardiac death." (See "Diagnosis of brain death".)
The issues involved in the pre-recovery medical management of the deceased donor will be discussed here. Issues related to the determination of brain death and the selection and preservation of donated organs are presented separately. (See "Lung transplantation: Donor lung preservation" and "Liver transplantation: Donor selection".)
The recovery of viable organs for transplantation is dependent upon appropriate medical management both before and after death is determined, regardless of whether brain criteria or cardiac criteria for death are utilized. Even with intensive care support, the brain-dead donor can be challenging to manage because the pathophysiologic changes induced by brain death upset homeostasis. The medical team managing the potential donor must anticipate and prevent (preferably) or detect and treat abnormalities that can cause circulatory collapse or permanent damage to otherwise transplantable organs.
Clinicians who care for critically ill or injured patients in the emergency department, intensive care unit (ICU), or operating room must be able to recognize potential organ donors and be aware of the criteria for brain death and organ donation [1,2]. In the United States, the Centers for Medicare and Medicaid Services require that the option of organ donation be discussed only by individuals with specialized training in this area [1,3]. Most authors agree that requests by the organ procurement coordinator along with the treating physician represent the most effective approach to organ donation. In addition, efficient coordination among these physicians, organ procurement organizations, and transplant centers to promote the best physiologic donor management is required to maximize the number of viable organs available for transplantation [4,5]. This is particularly important in specialized, high-volume trauma centers .
In the United States, the system of deceased-donor organ donation is based upon "explicit consent," in which the individual is assumed to not be a donor unless the individual indicates their wish of becoming an organ donor upon their death. The decision to donate must be registered by the individual or is expressed by family members at the time of death. By comparison, there is a system of "presumed consent" in many other nations, in which the individual who is against donating an organ must either register their desire or express this desire to a family member. If this has not occurred, it is assumed that the person is an organ donor. Deceased-donor kidney transplantation rates are higher in nations with "presumed consent" compared with those with an "explicit consent" system . However, living-donor kidney transplantation rates are lower in nations with presumed consent. The underlying reasons for this difference are unclear.
- Williams MA, Lipsett PA, Rushton CH, et al. The physician's role in discussing organ donation with families. Crit Care Med 2003; 31:1568.
- Karcioğlu O, Ayrik C, Erbil B. The brain-dead patient or a flower in the vase? The emergency department approach to the preservation of the organ donor. Eur J Emerg Med 2003; 10:52.
- Guadagnoli E, Christiansen CL, Beasley CL. Potential organ-donor supply and efficiency of organ procurement organizations. Health Care Financ Rev 2003; 24:101.
- Döşemeci L, Yilmaz M, Cengiz M, et al. Brain death and donor management in the intensive care unit: experiences over the last 3 years. Transplant Proc 2004; 36:20.
- Powner DJ, Darby JM, Kellum JA. Proposed treatment guidelines for donor care. Prog Transplant 2004; 14:16.
- Shafer TJ, Davis KD, Holtzman SM, et al. Location of in-house organ procurement organization staff in level I trauma centers increases conversion of potential donors to actual donors. Transplantation 2003; 75:1330.
- Horvat LD, Cuerden MS, Kim SJ, et al. Informing the debate: rates of kidney transplantation in nations with presumed consent. Ann Intern Med 2010; 153:641.
- Wood KE, Becker BN, McCartney JG, et al. Care of the potential organ donor. N Engl J Med 2004; 351:2730.
- Watts RP, Thom O, Fraser JF. Inflammatory signalling associated with brain dead organ donation: from brain injury to brain stem death and posttransplant ischaemia reperfusion injury. J Transplant 2013; 2013:521369.
- Boyd GL, Phillips MG, Henry ML. Cadaver Donor Management. In: UNOS, Organ Procurement, Preservation and Distribution in Transplantation, 2nd ed., Phillips MG (Ed), Richmond, VA 1996.
- Kainz A, Wilflingseder J, Mitterbauer C, et al. Steroid pretreatment of organ donors to prevent postischemic renal allograft failure: a randomized, controlled trial. Ann Intern Med 2010; 153:222.
- Miñambres E, Rodrigo E, Ballesteros MA, et al. Impact of restrictive fluid balance focused to increase lung procurement on renal function after kidney transplantation. Nephrol Dial Transplant 2010; 25:2352.
- Orban JC, Quintard H, Cassuto E, et al. Effect of N-acetylcysteine pretreatment of deceased organ donors on renal allograft function: a randomized controlled trial. Transplantation 2015; 99:746.
- Smith M. Physiologic changes during brain stem death--lessons for management of the organ donor. J Heart Lung Transplant 2004; 23:S217.
- Szabó G. Physiologic changes after brain death. J Heart Lung Transplant 2004; 23:S223.
- Marik PE, Monnet X, Teboul JL. Hemodynamic parameters to guide fluid therapy. Ann Intensive Care 2011; 1:1.
- Dimopoulou I, Tsagarakis S, Anthi A, et al. High prevalence of decreased cortisol reserve in brain-dead potential organ donors. Crit Care Med 2003; 31:1113.
- Salim A, Vassiliu P, Velmahos GC, et al. The role of thyroid hormone administration in potential organ donors. Arch Surg 2001; 136:1377.
- Rosendale JD, Kauffman HM, McBride MA, et al. Aggressive pharmacologic donor management results in more transplanted organs. Transplantation 2003; 75:482.
- Rosendale JD, Kauffman HM, McBride MA, et al. Hormonal resuscitation yields more transplanted hearts, with improved early function. Transplantation 2003; 75:1336.
- Lloyd-Jones H, Wheeldon DR, Smith JA, et al. An approach to the retrieval of thoracic organs for transplantation. AORN J 1996; 63:416.
- Wheeldon DR, Potter CD, Oduro A, et al. Transforming the "unacceptable" donor: outcomes from the adoption of a standardized donor management technique. J Heart Lung Transplant 1995; 14:734.
- Zawistowski CA, DeVita MA. Non-heartbeating organ donation: a review. J Intensive Care Med 2003; 18:189.
- Reich DJ, Mulligan DC, Abt PL, et al. ASTS recommended practice guidelines for controlled donation after cardiac death organ procurement and transplantation. Am J Transplant 2009; 9:2004.
- Brook NR, Waller JR, Nicholson ML. Nonheart-beating kidney donation: current practice and future developments. Kidney Int 2003; 63:1516.
- Kootstra G, Kievit J, Nederstigt A. Organ donors: heartbeating and non-heartbeating. World J Surg 2002; 26:181.
- D'alessandro AM, Hoffmann RM, Knechtle SJ, et al. Liver transplantation from controlled non-heart-beating donors. Surgery 2000; 128:579.
- Casavilla A, Ramirez C, Shapiro R, et al. Experience with liver and kidney allografts from non-heart-beating donors. Transplantation 1995; 59:197.
- Bernat JL, D'Alessandro AM, Port FK, et al. Report of a National Conference on Donation after cardiac death. Am J Transplant 2006; 6:281.
- Nicholson ML, Metcalfe MS, White SA, et al. A comparison of the results of renal transplantation from non-heart-beating, conventional cadaveric, and living donors. Kidney Int 2000; 58:2585.
- Metcalfe MS, Butterworth PC, White SA, et al. A case-control comparison of the results of renal transplantation from heart-beating and non-heart-beating donors. Transplantation 2001; 71:1556.
- Gok MA, Buckley PE, Shenton BK, et al. Long-term renal function in kidneys from non-heart-beating donors: A single-center experience. Transplantation 2002; 74:664.
- Sánchez-Fructuoso AI, Marques M, Prats D, et al. Victims of cardiac arrest occurring outside the hospital: a source of transplantable kidneys. Ann Intern Med 2006; 145:157.
- Steen S, Sjöberg T, Pierre L, et al. Transplantation of lungs from a non-heart-beating donor. Lancet 2001; 357:825.
- Bernat JL, Capron AM, Bleck TP, et al. The circulatory-respiratory determination of death in organ donation. Crit Care Med 2010; 38:963.
- Ethics Committee, American College of Critical Care Medicine, Society of Critical Care Medicine. Recommendations for nonheartbeating organ donation. A position paper by the Ethics Committee, American College of Critical Care Medicine, Society of Critical Care Medicine. Crit Care Med 2001; 29:1826.
- D'Alessandro AM, Fernandez LA, Chin LT, et al. Donation after cardiac death: the University of Wisconsin experience. Ann Transplant 2004; 9:68.
- Lewis J, Peltier J, Nelson H, et al. Development of the University of Wisconsin donation After Cardiac Death Evaluation Tool. Prog Transplant 2003; 13:265.
- DeVita MA, Brooks MM, Zawistowski C, et al. Donors after cardiac death: validation of identification criteria (DVIC) study for predictors of rapid death. Am J Transplant 2008; 8:432.