Organ Donation in DCD: 10 Year Experience at the University of

Michigan

A Rojas-Pena, MD; L Sall, BS; K. Koch, BS; E Cooley, RN; M Gravel, RN; R Bartlett, MD; J Punch, MD; S Pelletier, MD

University of Michigan Health SystemDepartment of Surgery, Section of Transplantation and the

Extracorporeal Life Support Program

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DCD History at UM

Large transplant program + large extracorporeal life support (ECS) program

• 2000, both programs were combined Extracorporeal support (ECS) resuscitate and recover abdominal organs in controlled DCD (Maastricht category III) when the family requests organ donation

• Successful recovery / transplantation of kidneys, liver and pancreas

• Initial experience reported in 2005 with 20 ECS-DCD

Magliocca, et al. The Journal of trauma 2005;58(6):1095-101; discussion 1101-2.

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Objectives

• Retrospective review of DCD program:– 10-year experience – cases between October 2000 to August 2010

• Update UM first series study on ECS assisted donation in controlled DCD

ECS-cDCD

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Methods

• Potential cDCD abdominal organs OK for procurement after dead

• Recipient outcome data of:– Kidneys and livers procured and

transplanted at UM only

• RR technique (RR-DCD group)

vs• ECS technique (ECS-DCD group)

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DCD selection

• <65yo/ Maastricht type III– Severe irreversible brain injury NO BD criteria

• Intensive Care Unit (ICU) on MV and/or life support

• Cardio-circulatory arrest after planned withdrawal of life support

• Family for donation

– Consent for cannulation

• No contraindications to transplant grafts

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UM – ECS circuit

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Final DCD at UM

Donor Type

Potential (n)

Excluded (n)

Reason for Exclusion

ECS 50 13Prolonged CA = 11

Sx complication = 1 Positive Serology = 1

RR 29 4 Prolonged CA = 4

37 ECS-DCD & 25 RR-DCD

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ORPD & OTPD Rates

 

Organs Recovered (n)

Organs Transplanted (n)

DCD type K L P ORPD K L P OTPD

ECS-DCD 37 73 21 2 2.59 48 13 1 1.68

RR-DCD 25 44 17 0 2.44 25 8 0 1.32

Total at UM 62 117 38 2 2.53 73 21 1 1.53

ORPD: Organs Recovered per Donor / OTPD: Organs Transplanted per Donor / K:Kidney; L: Liver; P: Pancreas

January-June 2011 DCD: 2.45 ORPD & 2.0 OTPD / Discard rate: 18%

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Summary of the ECS run

VariableInitiation of

ECSTermination of

ECS

pH 7.099±0.024 7.288±0.027SVO2

(%) 45.5±3.6 67.0±3.2PaCO2

(mmHg) 55.5±8.4 34.5±2.4

SaO2 (%) 84.4±3.5 90.4±3.4K+

(mmol/L) 6.1±0.8 4.9±0.5SVO2: mixed venous oxygen saturation; PaCO2: Partial pressure of

Carbon Dioxide; SaO2: Arterial Blood Saturation

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ECS-DCD Complications

Complication (n) % Management & Outcome

ECS flow (<45mL/kg/min)

4 10.8 Converted to RR = 3 DCDECS continued = 1 DCD

Cannulation(No vascular access)

2 5.4 Converted to RR = 1DCDNo Recovery = 1 DCD

Bleeding 1 2.7 No Recovery

Aortic Balloon 1 2.7 No Recovery

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UM Outcomes Renal Grafts

• 37 patients (5 yr follow up)

DGF: Need of HD within the first week post-transplantation

- 50% due to hyperkalemia

DCD Type

Renal Tx (n) DGF PGNF

ECS 29 31% 3.5%

RR 8 64% 3.5%

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Graft Survival Rates

89% 77% 66%US graft survival rate:

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Outcomes Livers

• 20 DCD liver recipients • Full records / HIPPA (3 year follow up)

• Recipient MELD score = 15-17

Donor Type

Liver DCD (n)

1 year survival

3 year survival

ECS 7 86% 69%

RR 13 71% 62%National

(Cadaveric) -- 82% 72%

Ischemic cholangiopathy: 15% (both groups)

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Take Home MessageDCD Organ Recovery - Technique Comparison

Issues RR- DCD ECS-DCD

Organs Donated Kidneys / Selective livers

All, except heart 30%

Goal Deep cooling / metabolism

Restores circulation and 02 / normal Metabolism

Time to Organ Procurement

Urgent Elective

Cold Storage Routine / Pump Perfusion

??

Organ Assessment

Pump perfusion / Transplant

Recovery ./ pump perfusion / Transplant

Limitations Rapid cooling / WI / OR logistics

Cannulation and ECS management

Post Tx Function 40-60% DGF 8-30% DGF

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Acknowledgments

ECLS Program Staff• Pula Baldridge, RN

– Manager

• Sheri Bignall

Faculty• Jonathan Haft

– ECLS Director

• Gail Annich– ECLS co-Director

• George Mychaliska• Robert Bartlett

ECLS Lab• Lauren Sall• Kelly Koch

Transplant Team• Jeff Punch

– Director Transplant Program

• Swan Pelletier• Larry Slate II

– Chief Transplant perfusionist