Extracorporeal Support for Emergent (Uncontrolled) Donation Following Cardiac Death Introduction: The limited availability of donor organs for transplantation has led to an increased interest in the use of donation following cardiac death (DCD) donors. However, uncontrolled or emergent DCD (eDCD) use has been limited by logistical difficulties and, with rare exception, has not been utilized. eDCD involves procuring organs from a patient who dies following unsuccessful resuscitative efforts. In many situations, patients have suffered either fatal traumatic injury or unexpected cardiac arrest. Resuscitation is attempted until it is deemed futile in reestablishing circulation, a determination that is made by physicians within an emergency department or intensive care unit. In order to limit warm ischemic damage to transplantable organs, it is necessary to provide immediate in situ preservation of abdominal organs soon after death has been declared. Since October 2000, the University of Michigan has utilized normothermic extracorporeal support (ECS) after death has been declared for controlled DCD donors. The donor abdominal organs are restored to normal function and maintained until they are procured in a semi-elective fashion, similar to donation following brain death (DBD). We have used ECS-DCD for 36 controlled DCD donors, resulting in 67 kidneys, 19 livers, and 6 pancreata taken for transplantation. Compared to rapid recovery DCD without the use of ECS, ECS-DCD resulted in a greater number of organs transplanted per donor (OTPD), decreased kidney DGF rates (8%) and liver recipient and graft survival rates similar to DBD donors. We recently conducted a nationally representative survey of 1,049 subjects and asked their preference for organ donation given scenarios describing brain death, controlled donation following cardiac death, and emergent donation following cardiac death. To our surprise, subjects were much more willing to donate in the setting of both controlled and emergent cardiac death rather than brain death. These results suggest that the general public is actually more supportive of DCD, including emergent, than DBD. Over the past year, the University of Michigan has developed protocols for the use of ECS-assisted emergent (uncontrolled) DCD donation. This protocol has been developed in conjunction with the Transplant Center and the Emergency Department and has been reviewed and approved by Gift of Life Michigan, the University of Michigan Adult Ethics Committee, and the Gift of Life Michigan Donor Family Counsel. Consenting potential donors (either from donor registry or family) who fail resuscitative efforts in the University of Michigan Emergency Department will undergo cannulation of the femoral artery and vein after pronouncement of death. Extracorporeal support will be initiated to restore perfusion to abdominal organs. An aortic occlusion balloon will be placed in a supraceliac position to prevent reperfusion of the coronary or cerebral vasculature. Abdominal organs will then be procured in the operating room and allocated in a standard fashion. During an 18 month period, 45 patients received CPR/ACLS in the Emergency Department at the University of Michigan. Of these, 84% died in the ED and may have been potential emergent DCD donors. After excluding ineligible potential donors (age >60 years, malignancy, multisystem organ failure, and HIV infection), approximately 17 patients were identified as likely emergent DCD donors, increasing the donor pool at the University of Michigan by 52%. Over the next 2 years, the following specific aims are expected to be achieved: 1. To determine the number of donors and OTPD for emergent DCD when compared to controlled DCD and DBD. 2. To compare the outcomes of kidneys (year 1) and livers and kidneys (year 2) transplanted from emergent DCD donors when compared to controlled DCD and DBD donors. 3. To compare perceptions and attitudes of potential donor families to emergent DCD, controlled DCD, and DBD. Conclusions: Based on preliminary observations, we expect to find that eDCD results in a) a significant increase in the number of organ donors, b) similar rates of kidney graft survival compared to DBD and controlled DCD, and c) similar or greater acceptance of eDCD when compared to DBD by donor families. If ECS-eDCD is well accepted by donor families and results in acceptable posttransplant outcomes, we would then expand its use throughout the Gift of Life Michigan donor service area to study a large enough population to support developing a national program.
The limited availability of donor organs for transplantation has led to an increased interest in the use of donation following cardiac death (DCD) donors, or donation after the heart has stopped compared to death defined as lack of blood flow to the brain (donation following brain death). Because of logistic difficulties, obtaining organs for transplant from people who die after cardiac arrest in an emergency room is rarely performed. This project proposes to study a new method of perfusing organs using a technique similar to heart-lung bypass after a consenting donor is declared dead to preserve abdominal organs for transplant and allow procuring them to occur in an easier fashion.
