Evolving utilization of donation after circulatory death livers in liver transplantation: The day of DCD has come

A bstract Organ donation following circulatory determination of death (DCDD) has contributed significantly to the donor pool in several countries. In India, majority of deceased donations happen following brain death (BD). While existing legislation allows for DCDD, there have been only few reports of kidney transplantation following DCDD from India. This document, prepared by a multidisciplinary group of experts, reviews international best practices in DCDD and outlines the path for DCDD in India. Ethical, medical, legal, economic, procedural, and logistic challenges unique to India have been addressed. The practice of withdrawal of life-sustaining treatment (WLST) in India, laid down by the Supreme Court of India, is time-consuming, possible only in patients in a permanent vegetative state, and too cumbersome for day-to-day practice. In patients where continued medical care is futile, the procedure for WLST is described. In controlled DCDD (category-III), decision for WLST is independent of and delinked from the subsequent possibility of organ donation. Families that are inclined toward organ donation are explained the procedure including the timing and location of WLST, consent for antemortem measures, no-touch period, and the possibility of stand-down and return to the intensive care unit (ICU) without donation. In donation following neurologic determination of death (DNDD), if cardiac arrest occurs during the process of BD declaration, the protocol for DCDD category-IV has been described in detail. In DCDD category-V, organ donation may be possible following unsuccessful cardiopulmonary resuscitation of cardiac arrest in the ICU. An outline of organ-specific requisites for kidney, liver, heart, and lung transplantation following DCDD and techniques, such as normothermic regional perfusion (nRP) and ex vivo machine perfusion, has been provided. The outcomes of transplantation following DCDD are comparable to those following DBDD or living donor transplantation. Documents and checklists necessary for successful execution of DCDD in India are described. How to cite this article Seth AK, Mohanka R, Navin S, Gokhale AGK, Sharma A, Kumar A, et al . Organ Donation after Circulatory Determination of Death in India: A Joint Position Paper. Indian J Crit Care Med 2022;26(4):421–438.

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“…Outcomes equivalent to DNDD transplants and consistently superior to waiting list mortality for most organs have been reported. 53 – 56 …”

Section: O Rgan -S Pecific C ...mentioning

confidence: 99%

Organ Donation after Circulatory Determination of Death in India: A Joint Position Paper

Gupta¹,

Sahay²,

Ramachandran³

et al. 2022

Indian Journal of Critical Care Medicine

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“…DCD grafts were reported as one of the strongest adverse risk factors in two well‐known liver donor risk indices from the United States (US) and Europe [4,5]. These grafts are still not well utilized compared with DBD livers, accounting for less than 10% of LT in the US [6,7]. This is primarily attributed to the inherent risks associated with these organs, especially in the early post‐transplant period [8].…”

Section: Introductionmentioning

confidence: 99%

Conditional probability of graft survival in liver transplantation using donation after circulatory death grafts – a retrospective study

et al. 2021

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Summary The use of livers from donation after circulatory death (DCD) is historically characterized by increased rates of biliary complications and inferior short‐term graft survival (GS) compared to donation after brain death (DBD) allografts. This study aimed to evaluate the dynamic prognostic impact of DCD livers to reveal whether they remain an adverse factor even after patients survive a certain period following liver transplant (LT). This study used 74 961 LT patients including 4065 DCD LT in the scientific registry of transplant recipients from 2002–2017. The actual, 1 and 3‐year conditional hazard ratio (HR) of 1‐year GS in DCD LT were calculated using a conditional version of Cox regression model. The actual 1‐, 3‐, and 5‐year GS of DCD LT recipients were 83.3%, 73.3%, and 66.3%, which were significantly worse than those of DBD (all P < 0.01). Actual, 1‐, and 3‐year conditional HR of 1‐year GS in DCD compared to DBD livers were 1.87, 1.49, and 1.39, respectively. Graft loss analyses showed that those lost to biliary related complications were significantly higher in the DCD group even 3 years after LT. National registry data demonstrate the protracted higher risks inherent to DCD liver grafts in comparison to their DBD counterparts, despite survival through the early period after LT. These findings underscore the importance of judicious DCD graft selection at individual center level to minimize the risk of long‐term biliary complications.

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“…While the total number of liver donations after brain death (DBD) and donations after circulatory death (DCD) have increased over the years, about 7.1% of DBD livers and 30% of DCD livers are discarded. As many as 58.5% of DCD discards meet the standard acceptance criteria proposed by American Society of Transplant Surgeons [ 6 ]. Many waitlisted patients die or become too sick to undergo transplantation, representing several thousand deaths a year in the US alone [ 7 , 8 ].…”

Section: Introductionmentioning

confidence: 99%

Non-invasive quantification of the mitochondrial redox state in livers during machine perfusion

et al. 2021

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Ischemia reperfusion injury (IRI) is a critical problem in liver transplantation that can lead to life-threatening complications and substantially limit the utilization of livers for transplantation. However, because there are no early diagnostics available, fulminant injury may only become evident post-transplant. Mitochondria play a central role in IRI and are an ideal diagnostic target. During ischemia, changes in the mitochondrial redox state form the first link in the chain of events that lead to IRI. In this study we used resonance Raman spectroscopy to provide a rapid, non-invasive, and label-free diagnostic for quantification of the hepatic mitochondrial redox status. We show this diagnostic can be used to significantly distinguish transplantable versus non-transplantable ischemically injured rat livers during oxygenated machine perfusion and demonstrate spatial differences in the response of mitochondrial redox to ischemia reperfusion. This novel diagnostic may be used in the future to predict the viability of human livers for transplantation and as a tool to better understand the mechanisms of hepatic IRI.

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Evolving utilization of donation after circulatory death livers in liver transplantation: The day of DCD has come

Cited by 28 publications

References 42 publications

Organ Donation after Circulatory Determination of Death in India: A Joint Position Paper

Organ Donation after Circulatory Determination of Death in India: A Joint Position Paper

Conditional probability of graft survival in liver transplantation using donation after circulatory death grafts – a retrospective study

Non-invasive quantification of the mitochondrial redox state in livers during machine perfusion

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