Donation After Circulatory Death

Abstract

Organ donation after circulatory death (DCD) has been endorsed by the World Health Organization and is practiced worldwide. This overview examines current DCD practices, identifies problems and challenges, and suggests clinical strategies for possible improvement. Although there is uniform agreement on DCD donor candidacy (ventilator-dependent individuals with nonrecoverable or irreversible neurologic injury not meeting brain death criteria), there are variations in all aspects of DCD practice. Utilization of DCD organs is limited by hypoxia, hypotension, reduced--then absent--organ perfusion, and ischemia/reperfusion syndrome. Nevertheless, DCD kidneys exhibit comparable function and survival to donors with brain death kidneys, although they have higher rates of primary graft nonfunction, delayed graft function, discard, and retrieval associated injury. Concern over ischemic organ injury underscores the reluctance to recover extrarenal DCD organs since lack of medical therapy to support inadequate allograft function limits their acceptability. Nevertheless, limited results with DCD pancreas, liver, and lung allografts (but not heart) are now approaching that of donors with brain death organs. Pretransplant machine perfusion of DCD kidneys (vs. static storage) may reduce delayed graft function but has no effect on long-term organ function and survival. Normothermic regional perfusion used during DCD abdominal organ retrieval may reduce ischemic organ injury and increase the number of usable organs, although critical confirmative studies have yet to be done. Minor increases in usable DCD kidneys could accrue from increased use of pediatric DCD kidneys and from selective use of DCD/ECD kidneys, whereas a modest increase could result through utilization of donors declared dead beyond 1 hr from withdrawal of life support therapy. A significant increase in transplantable kidneys could be achieved by extension of the concept of living kidney donation in relation to imminent death of potential DCD donors. Progress in research to identify, prevent, and repair DCD-associated organ retrieval injury should improve utilization of DCD organs. Recent results using ex situ pretransplant organ perfusion of DCD organs has been encouraging in this regard.

A molecular signature for delayed graft function

“…This suggests that donor characteristics are important for DGF occurrence and may be linked to organismal/organ stress levels in relation to the type of organ donation (Bon et al, 2012; Morrissey & Monaco, 2014). Ultimately, allograft quality will be related to organ resilience to stress, and this by itself provides an opportunity for the development of new therapeutic interventions aimed at exploiting this phenomenon.…”

“…The extent to which donor and recipient‐related characteristics influence the magnitude of IRI and/or DGF occurrence, beyond accepted clinical risk factors for DGF, remains to be proven (Menke et al, 2014; Mundt et al, 2015; Schroppel & Legendre, 2014), particularly in the context of allograft repair, or regeneration pathways, activated in response to IRI. Increased demand for organ donation, coupled with increasing chronological age and associated comorbidities in the donor population, has necessitated the use of organs that have been previously deemed as marginal for clinical use (Morrissey & Monaco, 2014; Nagaraja et al, 2015). …”

Comparison of Aerobic Preservation by Venous Systemic Oxygen Persufflation or Oxygenated Machine Perfusion of Warm-Ischemia-Damaged Porcine Kidneys

“…Nowadays, machine perfusion preservation (MP) is considered an established clinical procedure for kidney preservation and is associated with a reduced risk of delayed graft function compared to CS [5]. However, MP has failed to provide benefits regarding long-term graft survival; therefore, its efficacy in preserving DCD organs is still under debate [6,7]. …”

Successful Transplantation of Lungs From an Uncontrolled Donor After Circulatory Death Preserved In Situ by Alveolar Recruitment Maneuvers and Assessed by Ex Vivo Lung Perfusion

“…As a measure to increase the number of organs available for transplantation, many countries worldwide have adopted organ procurement from donors after circulatory death 1, 2, 3. The majority of organs so far have been procured from controlled donors, according to the Maastricht definition 4, 5, mainly in Belgium, The Netherlands, the United Kingdom, Australia, and the United States.…”