FROM ANNALS OF SURGERY
Despite the increase in donation of organs for transplant after circulatory death, many of these donations fail, according to a new study.
Dr. Joseph Scalea of the division of transplantation at the University of Wisconsin in Madison and his colleagues sought to explicate the process resulting in unsuccessful donation after circulatory death (DCD) and to explore the factors contributing to time to death in donors with successful organ donation. They conducted a retrospective study of data obtained from all organ donors at a single transplant center during January 2011-September 2014 (Ann Surg. 2015 Jul 15. doi: 10.1097/SLA.0000000000001298 ). A total of 506 organ donation procedures were studied, 169 of which were DCD. Time of death and outcomes data was obtained in 99.4% of the cases
The reasons for DCD failure appear to be rooted in the timing of support removal and the progression to death of these potential organ donors. A study of transplantation in the United Kingdom has shown that organs are less likely to be viable for transplantation if the donor does not progress to death within the first hour of withdrawal of support ( Curr Opin Organ Transplant. 2013;18:133-9 ).
“People need to be aware that when folks have agreed to donate organs of a loved one and it is going to be a [circulatory death donation], that there is roughly a one in three chance, at least, that organ donation won’t come to fruition,” Dr. Jeffrey D. Punch , a transplant specialist at the University of Michigan in Ann Arbor, said in an interview.
Protocols vary by organization, but DCD typically involves the surgical team withdrawing life support in the absence of the organ recovery team. If circulatory death occurs within the time determined by the protocol, the organs are recovered for transplantation. Studies have indicated since the general acceptance of DCD since the 1990s, these donations account for as much as a 30% increase in donation rates in the United States and abroad ( Am J Transplant. 2006 Feb;6(2):281-91 ; N Engl J Med. 2007;357:209-13 ).
The University of Wisconsin’s DCD protocol involved waiting up to 30 minutes after withdrawal of support (WOS) to recover pancreas and liver and up to 2 hours to recover kidneys.
During the study period, 33.4% (n = 169/506) of the organ donations were DCD. At least one organ was successfully donated in 72.8% of cases (n = 123), whereas in 27.2% (n = 46), the patient did not progress to death in the protocol time frame to be considered for donation. Head trauma (21.9%), cerebrovascular accident (23.7%), and anoxia (47.3%) were the most common diagnosis leading to DCD; however, success of DCD donation was not associated with the diagnosis. But if withdrawal of support was initiated in the OR, successful donation was more likely (P = .006).
“Those patients who underwent WOS in the ICU successfully donated organs less frequently. This difference is hard to interpret, as there may be different techniques of withdrawal in the ICU, or a selection bias (i.e., deemed less likely to die quickly) with which patients are considered for an ICU withdrawal,” the researchers wrote.
Dr. Punch, the Jeremiah and Claire Turcotte Professor of Surgery at the University of Michigan added, “It certainly makes more sense for withdrawal of support to happen in the operating room. It is more effective and they are more likely to be able to donate organs.”
The mean time from WOS to death was 28 minutes and 35 seconds for successful donations and 33 hours, 37 minutes, and 15 seconds for unsuccessful donations. In patients that successfully donated, 90.2% died less than an hour after WOS.
The investigators point out, “the ability to donate organs from a family member or loved one is often the only positive memory of an otherwise devastating experience. Unfortunately, not all donors successfully donate after attempted DCD.”
The authors reported no conflicts of interests.