Corticosteroids in the management of brain-dead potential organ donors: a systematic review

Abstract

Summary Current guidelines recommend the administration of hormonal combination therapy including immunosuppressive doses of corticosteroids to donors with low left ventricular ejection fractions and to consider hormonal therapy administration to all donors. However, these recommendations are largely based on observational data. The aim of this systematic review (SR) was to assess the clinical efficacy and safety of corticosteroids in brain-dead potential organ donors. MEDLINE and EMBASE were searched from the earliest accessible date up to March 2013 with a qualified librarian. Studies comparing the effects of any corticosteroid with those of placebo, standard treatment, or another active comparator were sought. Two independent reviewers evaluated each citation retrieved and selected studies independently and in duplicate. A third independent reviewer resolved any disagreement. Outcomes included donor haemodynamics and oxygenation, organ procurement, recipient survival, and graft survival. This review included 11 randomized controlled trials (RCTs) and 14 observational studies. The majority used methylprednisolone and often combined it with other hormonal therapies. Ten out of the 11 RCTs yielded neutral results. However, in observational studies, use of corticosteroids generally resulted in improved donor haemodynamics and oxygenation status, increased organ procurement, and improved recipient and graft survival. Overall quality of included studies was poor, as most of them presented high risks of confounding. This SR highlights the low quality and conflicting evidence supporting the routine use of corticosteroids in the management of organ donors. A large trial evaluating the effect of corticosteroids on outcomes such as organ recovery and graft survival is warranted.

Steroids can reduce warm ischemic reperfusion injury in a porcine donation after circulatory death model withex vivolung perfusion evaluation

“…The rationale to add steroids in the donor is to block the upregulation of several pro‐inflammatory cytokines during the onset of brain death and improvement of hemodynamic instability following adrenal insufficiency . The evidence, however, is not robust based on a recent meta‐analysis . In addition, besides these potential benefits in DBD donors, their role in warm ischemic injury and DCD donation has never been investigated.…”

Anesthetic considerations in organ procurement surgery: a narrative review

“…The observational studies generally show improved donor hemodynamics, oxygenation, organ procurement rates, graft survival, and recipient survival. 52 Brain-dead donor Table 2 Recommended combined hormone therapy for organ donors with an ejection fraction \ 40% or hemodynamic instability and consideration in all donors 37 Hormone Dose Anesthesia for organ donation surgery 533 treatment is typically cortisol (3-5 mgÁkg -1 qd) vs methylprednisolone (15-60 mgÁkg -1 or 3-5 g once or qd). 37,52 A retrospective review of brain-dead donor highdose (15 mgÁkg -1 methylprednisolone) vs low-dose (300 mg hydrocortisone) corticosteroid treatment found that low-dose treatment led to no difference in donor pulmonary or cardiac function, a similar organ transplantation rate, a decreased insulin requirement, and improved glycemic control.…”

Conséquences cardiovasculaires de la mort cérébrale et prise en charge pour prélèvement d’organe(s)

“…Brièvement, ceux-ci mettent en jeu le relargage de cytokines pro-inflammatoires, l'expression tissulaire de protéines d'adhésion favorisant une infiltration tissulaire leucocytaire et des phénomènes d'apoptose cellulaire médiés notamment par la voie des caspases [23][24][25][26][27]. Cet état inflammatoire est susceptible d'entraîner des conséquences délétè-res pour les greffons et le receveur [28,29], conduisant certains à proposer un traitement anti-inflammatoire par corticoïdes, afin d'optimiser le prélèvement des greffons potentiels et leur qualité [30,31].…”

“…Cet effet étant en dehors des objectifs de cette mise au point, nous ne détaillerons pas ici ces travaux, dont le niveau de preuve est faible et dont les résultats divergent. Cette stratégie pourrait néanmoins être intéressante pour le greffon pulmonaire [30,31]. D'un autre côté, une supplémentation en glucocorticoïdes à des doses plus faibles a été proposée afin de pallier l'insuffisance corticotrope induite par la ME, dans le but d'améliorer la défaillance hémodynamique du potentiel DDME [33,65].…”