BRAIN DEATH AND DECEASED DONOR KIDNEY TRANSPLANTATION

Dr. Joel Arudchelvam Consultant Vascular and Transplant Surgeon

Teaching Hospital Anuradhapura

Chronic kidney disease

Renal Replacement Therapy Dialysis Renal transplantation

Live Donor Deceased Donor

SURVIVAL AND MODES OF RRT

Charlotte Medin et al. Nephrol. Dial. Transplant. 2000;15:701-704

Chronic kidney disease

Renal Replacement Therapy Dialysis Renal transplantation

Live Donor - 94% 5Yrs Deceased Donor - 76% 5yrs

Need for deceased donors

Why Number of patients awaiting transplants Number with potential live donors

Complications for live donors

Deceased donors

Types Donation after brain death - DBD Donation after cardiac death - DCD

The basic principles for excellent cadaveric organ retrieval

Identification of potential donors Early confirmation of the brain death consent Prompt notification of the retrieval team Careful and intensive management of the donor Rapid retrieval of the organs

Uniform Determination of Death Act

Who is a deceased donor: An individual is considered dead if:

1.irreversible cessation of circulatory and respiratory function or

2.irreversible cessation of all functions of the entire brain, including the brain stem.

JAMA Nov 13, 1981 – Vol 246, No. 19

Uniform Determination of Death Act

Who is a deceased donor: An individual is considered dead if:

1.irreversible cessation of circulatory and respiratory function or

2.irreversible cessation of all functions of the entire brain, including the brain stem.

JAMA Nov 13, 1981 – Vol 246, No. 19

Etiology of Brain Death

Severe head trauma Cerebrovascular injury Prolonged cardiac resuscitation or asphyxia Tumors brain surgery

Brain Death

Determination of Brain Death

The Neurologic Examination

ComaNo evidence of responsiveness.

No motor response to noxious stimuli

The Neurologic Examination (cont.) Absence of Brainstem Reflexes

No pupillary reflex Absent corneal reflex. Absent - gag oculocephalic testing (doll’s eyes test) Oculovestibular testing – ice water

irrigation of each ear canal

The Apnea Test

Brain death declaration

****Detailed documentation

Kidney donor criteria

Age less than 65 years S Creatinine normal No chronic kidney disease Serological test

Hep B,C, HIV No sepsis malignancy

The basic principles for excellent cadaveric organ retrieval

Identification of potential donors Early confirmation of the brain death consent Prompt notification of the retrieval team Careful and intensive management of the donor Rapid retrieval of the organs

For successful deceased donor organ transplant program

Members Anaesthetist Coordinators Tissue cross match facilities Retrieval team Transplant team Theatre/ ward/dialysis unit/ ICU staff Etc.

The basic principles for excellent cadaveric organ retrieval

Identification of potential donors Early confirmation of the brain death consent Prompt notification of the retrieval team Careful and intensive management of the donor Rapid retrieval of the organs

CHANGES FOLLOWING BRAIN DEATH

Effective Donor/ organ Management

Stabilize the donor Manage the donor – To optimize the function and

viability of all transplantable organs. Preserve organ

“

Donor management guidelines

Cardiac Respiratory Renal Endocrine General care

Potential brain dead donor management

Organ retrieval (A) Sternotomy and midline laparotomy with or without bilateral extension. (B) Exposure of the thoracoabdominal organs

Exposure of aorta and cold perfusion

Cellular changes during ischaemia

Principles of organ preservation

Hypothermia Prevention of oedema Prevention of acidosis Neutralise the formation of reactive O2 species

Principles of organ preservation

Hypothermia Metablism at 4 C – 10% Ideal temperature - 4 C

Prevention of oedema Prevention of acidosis Neutralise the formation of reactive O2 species

BASIC COMPONENTS OF PRESERVATION SOLUTIONS

Prevention of oedema Impermeants – saccharides e.g – Mannitol Anions – citrate, gluconate, lactobionate Colloids – dextran,polyethylene glycol

Prevention of acidosis Buffers – phosphate and histidine

Neutralise the formation of reactive O2 species Antioxidants – glutathione, tryptophan, allopurinol

Preservation solutions Euro-Collins - EC University of Wisconsin - UW Histidine-tryptophan-ketoglutarate - HTK Celsior

Preservation solutions Euro-Collins - EC University of Wisconsin - UWHistidine-tryptophan-ketoglutarate - HTK Celsior

Comparison of select preservation solutions

Euro-Collins University of Wisconsin

Histidine-tryptophan-ketoglutarate

Celsior

Impermeant

Glucose Lactobionate

Mannitol

Lactobionate

Mannitol Raffinose Mannitol

Hydroxyethyl starch

BufferPhosphate

Phosphate Histidine HistidineBicarbonate

Antioxidant Mannitol

Allopurinol Tryptophan Glutathione

glutathione Mannitol Mannitol

Histidine Histidine

All units expressed in mmol/L.

Comparison of select preservation solutions

Euro-Collins University of Wisconsin

Histidine-tryptophan-ketoglutarate

Celsior

Impermeant

Glucose Lactobionate

Mannitol

Lactobionate

Mannitol Raffinose Mannitol

Hydroxyethyl starch

BufferPhosphate

Phosphate Histidine HistidineBicarbonate

Antioxidant Mannitol

Allopurinol Tryptophan Glutathione

glutathione Mannitol Mannitol

Histidine Histidine

All units expressed in mmol/L.

In situ hypothermic perfusion and packing of abdominal cavity with ice

• Lower aorta mobilised

• Heparin 300 IU/Kg

• Aorta cannulated

• Suprarenal aorta clamped

• Perfused with Cold preservation

solution

Kidney removal

Back bench dissection

Make sure all areas are perfused well

Back table perfusion

Organ packaging and transport

Transplantation

Future recommendations National protocol development Maintenance of common list for recepient Establishment of donor coordination programme –

countrywide Education on recognition of potential donor, donor management,

consent Education of public

Establish clear legal pathways Train more personnel - ? Surgeons (8 vs 4) Transplantation and post op facilities Operating theatres and ICU facilities Follow up plans

Thank You