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
- Medical Director and Co-Director of the Comprehensive Transplant Center, Department of Internal Medicine, Division of Nephrology
- Johns Hopkins Medical School
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.
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