While the number of organ donations after circulatory death (DCD) continues to grow in the United States and worldwide, it is yet to be accepted universally as a viable option to serve patients on the waiting list. Donation after circulatory death was the topic of the 7th Innovations in Transplant Summit, hosted April 22 and 23 by Baylor University Medical Center (Baylor Dallas), part of Baylor Scott & White Health.
Baylor Dallas and Baylor Scott & White All Saints Medical Center – Fort Worth have increased the use of DCD organs for transplantation and do more than other transplant centers in the area, expanding the organ pool for patients on the waiting list. The summit was convened to identify and share best practices on all aspects of organ donation after circulatory death, including logistics, outcomes, innovations and ethical challenges.
“We believe DCD organs are the number-one underutilized source of organs for patients in need of transplant,” says Giuliano Testa, MD, MBA, FACS, chairman of Baylor Scott & WhiteAnnette C. and Harold C. Simmons Transplant Institute and chief of abdominal transplant. “We have been paving the way for DCD utilization throughout the transplant community in Texas and beyond. We hope the conversations held among the experts at this conference will gradually convince our colleagues to expand DCD donation.”
Despite the hesitancy of some in the transplant community, there are now several centers in the United States that will accept hearts and lungs from DCD donors. Normothermic regional perfusion, which utilizes extracorporeal membrane oxygenation (ECMO) technology, allows for in situ perfusion of the heart and other organs. Other centers use external machine perfusion after rapid recovery of the heart.
“At Baylor Dallas, we have a multidisciplinary team that includes thoracic surgeons, abdominal surgeons, ICU and OR staff, as well as the ECMO team,” saysDr. Testa. “This awesome team allows us to utilize normothermic regional perfusion for any potential DCD donor at our facility. Some may be full donors, i.e., heart, lung, liver and kidney, while others may be abdominal-only donors.”
Kidney and liver transplants from DCD donors do have challenges. With kidneys, there is an increased rate of delayed graft function. Some patients will need dialysis after transplant for a period of time before the kidney starts to function. For livers, the main issue is a higher rate of bile duct complications, specifically ischemic cholangiopathy. A subset of patients who develop this complication will require retransplant.
Another challenge is the higher costs of performing DCD transplant. Many times, surgeons will go out to retrieve an organ, but the patient does not die in a time frame that is acceptable to use the organ for transplant. According to Dr. Testa, only 30 percent of potential DCD donors progress to death in the acceptable time period for liver recovery, which is 30 minutes. More are able to donate kidneys, which have a 90-minute window.
Discussions at the conference also involved the ethical considerations of DCD donation. “At the foundation of DCD donation is how we pronounce death and how we understand death in these patients, which is different from a donor with brain death,” Dr. Testa says. “While these are an enormous source of organs that are completely under-utilized today, we want to make sure we truly do the right thing in the pronouncement of death.”
A paper covering the issues discussed during the two-day conference will be published in Transplantation at a later date.
