Uncontrolled Donation After Circulatory Death: A Unique Opportunity

Abstract

Uncontrolled donation after circulatory death (uDCD) refers to donation from persons who die following an unexpected and unsuccessfully resuscitated cardiac arrest. Despite the large potential for uDCD, programs of this kind only exist in a reduced number of countries with a limited activity. Barriers to uDCD are of a logistical and ethical-legal nature, as well as arising from the lack of confidence in the results of transplants from uDCD donors. The procedure needs to be designed to reduce and limit the impact of the prolonged warm ischemia inherent to the uDCD process, and to deal with the ethical issues that this practice poses: termination of advanced cardiopulmonary resuscitation, extension of advanced cardiopulmonary resuscitation beyond futility for organ preservation, moment to approach families to discuss donation opportunities, criteria for the determination of death, or the use of normothermic regional perfusion for the in situ preservation of organs. Although the incidence of primary nonfunction and delayed graft function is higher with organs obtained from uDCD donors, overall patient and graft survival is acceptable in kidney, liver, and lung transplantation, with a proper selection and management of both donors and recipients. Normothermic regional perfusion has shown to be critical to achieve optimal outcomes in uDCD kidney and liver transplantation. However, the role of ex situ preservation with machine perfusion is still to be elucidated. uDCD is a unique opportunity to improve patient access to transplantation therapies and to offer more patients the chance to donate organs after death, if this is consistent with their wishes and values.

Recomendaciones de «hacer» y «no hacer» en el tratamiento de los pacientes críticos ante la pandemia por coronavirus causante de COVID-19 de los Grupos de Trabajo de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC)

“…Han de considerarse tanto potenciales donantes en muerte encefálica, como en asistolia controlada. En este escenario epidemiológico, los centros podrían considerar suspender temporalmente procesos de mayor complejidad logística y menor probabilidad de utilización de órganos, como son los cuidados intensivos orientados a la donación (38), la donación en asistolia no controlada (39), en la que se añade la imposibilidad de realizar en tiempo el cribado del donante para SARS-CoV-2 y la donación con donante vivo considerada una cirugía programada y no urgente en la mayoría de las ocasiones. En los hospitales que se encuentren en áreas más afectadas, puede ser necesario reducir la actividad trasplantadora por la saturación de los servicios hospitalarios y de las UCI y en aras de garantizar la seguridad de los pacientes en el periodo postrasplante con respecto a la infección nosocomial y comunitaria por COVID-19 (40).…”

COVID-19 in Spain: Transplantation in the midst of the pandemic

“…Centers in less affected areas should try to develop donation and transplantation as close to usual as possible. Centers in the most affected areas may decide to pursue donation only from ideal donors (both donation after brain death and controlled donation after circulatory death), temporarily suspending more complex donation procedures as those represented by intensive care to facilitate organ donation 19 and uncontrolled donation after circulatory death 20 . Similarly, these centers may limit their activity to providing transplantation to critically ill patients and to those with particular difficulties to access transplantation based on their immunological and/or anthropometrical characteristics (eg, pediatric patients), deferring less urgent procedures, particularly kidney and pancreas transplantation.…”

Strict selection criteria in uncontrolled donation after circulatory death provide excellent long‐term kidney graft survival

“…[10][11][12][13][14]16,24 All of our kidneys had been preserved with NRP, which has already been associated with lower rates of PNF as compared to the use of continuous cold flush via an intra-abdominal double-balloon catheter. 9,13,16 Although our median uDCD donor age was similar to that of most published series, no donor over 60 years was included, which is known to be a risk factor for the PNF 13,15 In our study, recipients transplanted from uDCD donors tripled the probability of developing DGF in the multivariate analysis.…”

“…The role of pulsatile machine perfusion has not been clarified, which has been effective in reducing the incidence of DGF, both in DBD and in DCD, but has not been associated with a decreased risk of PNF. 13,15,27 However, it seems to be helpful to evaluate the potential viability of a kidney graft in uDCD, 10 being a common practice nowadays to discard those kidneys with RI >0.30 mmHg/mg/ min. In our study, although a renal resistance threshold had been predefined of 0.3 not a single kidney was discarded due to a high RI.…”

“…High kidney discard rates also remain a challenge that lower the conversion rates of potential into utilized donors. 14,15 Several factors such as donor age, the duration of the no-flow period, prolonged warm ischemic time (WIT), and the type of preservation have been linked to higher rates of PNF and graft loss. 13,15,16 Hence, a very restrictive protocol and strict adherence to national guidelines seems to be the best option to achieve an excellent longterm graft survival in order to fully exploit the potential contribution of uDCD to donation and transplantation activities.…”