Deceased Donor Transplantation

8/3/2019 Deceased Donor Transplantation

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DECEASEDDONOR

TRANSPLANTATIO

N

SANJEEV V NAIR


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TERMINOLOGY &DEFINITIONS

In order to be dead enough to bury butalive enough to be a donor, you must beirreversibly brain dead. If its reversible,

youre no longer dead; youre a patient-

David Crippen MD

Living donors: Related Unrelated-

Deceased donors: Brain dead Donor after cardiac

Explicit vs Implicit consent


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Facts and Figures

1962: Drs Murray &Hume; Boston

1967: KEM, MumbaiTHOAct 19941995: 1st successful

multi-organ Tx,Apollo Chennai

Amendment toTHOA passed in Aug2011

~1000 deceased

donor renaltrans lants in India


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What are we doing wrong?

Liver Transpl 15:1443-1447,2009.

Brain death donationassent rate: 19%


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1959 Mollaret & Goulon: le come depasseEducating caregivers about potential donorsWho?

-Pts with irremediable brain injury-Pts with apnea requiring ventilation Accepted fact but variabilities in diagnosis Brainstem death vs Brain death

Diagnosing Brainstemdeath


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Exclusion of confounding conditions: Hypothermia


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Absent brainstem reflexes: Pupillary reflex Dolls eye reflex

Corneal reflex Gag reflex Cough reflex Cold caloric test

Criteria for diagnosis


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Apnea test: Baseline ABG Pre-requisites: Core temp >35oC SBP > 90mmHg

Euvolemia

pCO2 > 40mmHg

pO2 > 200mmHg

Disconnect ventilator: O2 from trachealcannula placed at carina 10L/m

Criteria for Diagnosis


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Apnea test: Observe for resp movts ABG after 8-10mins and reconnect vent

Abort test if SBP15mmHg from

baseline

Test may be indeterminate or negative



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The above tests have to be repeated 2times 6 hours apart.

Indian law does not mandate confirmatorytests to diagnose brainstem death.



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Panel of 4 Doctors: THOA 1994Doctor in charge of hospitalTreating physician

Neurologist/Neurosurgeon*Independent specialist of unspecified

specialty

THOA Amendment*

v Time of death

Who can Certify?


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Non heart beating organ donor:Death determined by demonstrating irreversiblecessation of cardiopulmonary function

The three required elements of the criteria

are simultaneous and irreversible unresponsiveness apnea

absent circulation Observe for >2mins but


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When to start care? Ideally before brain death occurs

Atleast before withdrawal of life support Shift of focus

Why?

Brainstem damage has adverse effects on function ofother organs

Care of potential donor


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Exclusion criteria: Overwhelming sepsis with MODS

Active malignancy HIV, HTLV, Systemic viral infections

Prion disease

Herpetic meningoencephalitis

A localized infection should not preclude organdonation.



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Cardiovascular effects:Progressive rostral to caudal ischemia deactivation ofSNS, s.catecholamines, loss of cardiac stimulation cardiac dysfunction and vasodilation ischemiareperfusion injury inflammatory response

Goal:

Achieve euvolemia, maintain BP, optimize CO with theleast amount of vasoactive drug support.


Thresholds of cardiovascular stability:MAP >60mmHg

Vasoactive Dx: 10 g/kg/min (DA/DOB)UOP >1.0ML/KG/HR

LVEF 45%NEJM 2004;351:2730-9


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Pulmonary artery catheterization

Vasoactive drugs @ lowest doses to achievetargets


Targets:PCW Pressure: 8-

12mmHgCVP: 6-8mmHgCardiac index:2.4l/minUOP: 1.0ml/kg/hrMAP: 60 mmHg

NEJM 2004;351:2730-9


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Hypotension:80% initially, ~ 20%

persist

Multifactorial



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Hydration: Crystalloids vs Colloids

Avoid HES Warm to 37oC

Cautions: Unregulated NS use esp in unrecognised DI

Overzealous rehydration

Correction of hyperNa with 5D



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Diabetes insipidus: 2o to pituitary destruction

Hypovolemia, hyperosmolarity, electrolyteabnormalities

If UOP 250ml/hr: Vasopressin or Desmopressin

Strict monitoring of labs

Care of the potential donor


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Hormone therapy:Direct injury to HPA, effect of cytokines and

catecholamines



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NEJM 2004;351:2730-9


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Hypothermia Target temp >35oC

Hyperglycemia: Target 80-150mg/dl

Coagulation abnormalities: Target Hct >30%

INR: 80000/cm3



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Evaluation of potentialdonor

General screening:CBP,RFT,SE,RBS,ABG, CUEABO & HLA typingPan c/sHIV, HTLV, CMV, EBV, Hep B& CVDRL/RPR

Heart donor:ECG2DECHCK, TropTCardiac cath

Lungdonor:SerialABGsCXRBronchosc

opy

Liverdonor:LFTLiver BxPT/APTT

Pancreas

donor:Serial bloodglucoseS. Amylase &Lipase


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Request for EYES FIRST - SEE HOW FAMILYREACTS

Family Willing Family Reluctant

Ask For Solid Organs AbandonEfforts

(Heart, Liver, Kidneys ..)

Inform Transplant Co-coordinator

The RamachandraProtocol

Courtesy Dr Sunil Shroff


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Multiple organ recovery

Multidisciplinaryapproach

Incision, explorationand inspection

Mobilization ofindividual organs

In situ perfusion

Removal of organs Closure of incision &handing over ofbody


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2 phases of damage: warm & cold ischemicphases

Mechanisms of injury: Altered integrity of cell membr

Ionic composition of the cell

ATP generation Reperfusion injury

Techniques: Hypothermic preservation: 2 methods Cryopreservation

Vitrification

Organ Presevation


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Preservation solutions

UW solutionOsmolality :320 mmol/kgpH 7.4

Potassium 135 mmol/L

Sodium 35 mmol/LMagnesium 5 mmol/L

Lactobionate 100 mmol/L

Phosphate 25 mmol/L

Sulphate 5 mmol/LRaffinose 30 mmol/L

Adenosine 5 mmol/L

Allopurinol 1 mmol/L

Glutathione 3 mmol/LInsulin 100 U L

Euro-Collinssolution:

potassium 110 mMhos hate 60 mM

Andhra Pradesh Govt


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Andhra Pradesh GovtOrder:

11/11/2009CadaverTransplantationAdvisoryCommittee (CTAC):

1.The PrincipalSecretary, HM&FWDepartment

2. The Director of

Medical Education

3. TheSuperintendent,Osmania MedicalCollege


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Deceased donor transplantation is best wayto address organ shortage

Intensive awareness programmes need ofthe hour

The care of the potential donor issimultaneous care of multiple recipients

Best results with an Organ sharing model likeFORTE, ZTCC, AORTA OR MOHAN

Conclusion


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Thank

you

Deceased Donor Transplantation

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