Transcript Slide 1

JAMA Pediatrics Journal Club Slides:
Neonatal Organ Tissue Donation After
Circulatory Determination of Death
Stiers J, Aguayo C, Siatta A, Presson AP, Perez R, DiGeronimo R.
Potential and actual neonatal organ and tissue donation after
circulatory determination of death. JAMA Pediatr. Published online
May 11, 2015. doi:10.1001/jamapediatrics.2015.0317.
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Introduction
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Background
– Historically, neonates have not been eligible for organ donation owing
to the technical difficulties and the high risk for graft complications.
– Ongoing organ shortages coupled with improved technology and
surgical techniques have led to a renewed interest in neonates as
potential candidates for organ donation after circulatory determination
of death (DCDD).
– Despite DCDD potential, the percentage of neonates who actually
donate organs at the time of death is unknown.
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Study Objective
– To describe the percentage of neonates potentially eligible for DCDD,
including those who underwent successful donation, and reasons for
ineligibility in those who did not.
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Methods
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Study Design
– Data were obtained from the Children’s Hospital Neonatal Database
and Intermountain Donor Services (IDS) organ procurement records
and reviewed retrospectively.
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Setting
– Neonatal intensive care unit (NICU) at Primary Children’s Hospital, Salt
Lake City, Utah.
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Participants
– The 136 deaths that occurred from January 1, 2010, through May 7,
2013, were reviewed to determine potential eligibility for DCDD as
determined by IDS criteria: requirement of life-sustaining interventions
at the time of organ procurement organization (OPO) referral and
weight >2 kg.
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Methods
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Outcomes
– Potential eligibility for DCDD and timeliness of OPO referral among
neonates who died.
– For patients who did not undergo DCDD, we reviewed records to
determine the reasons for ineligibility.
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Limitations
– The study involved a single, level IV referral NICU with a high rate of
medical complexity that may limit translation of findings to other centers.
– OPO referral and medical records were the only measures to assess
consideration of organ donation for any given patient.
– The study sample size is small and may not identify clinically important
differences between those referred to the OPO in a timely manner and
those referred late.
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Results
Flowchart for Determining Potential Organ Donation Among Neonates
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Results
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76 neonates (55.9%) weighed >2 kg at the time of death.
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65 neonates (47.8%) had elective withdrawal of life-sustaining
interventions; 5 (3.7%) of these neonates did not require mechanical
ventilation for life support.
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Of the 60 neonates eligible for DCDD, 45 (33.1%) died within 90 minutes
of withdrawal of life-sustaining interventions, meeting warm ischemic time
(WIT) criteria for en bloc kidney and hepatocyte donation.
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8 neonates (5.9%) had a WIT of 90-180 minutes, making them eligible for
hepatocyte donation; 7 neonates (5.1%) exceeded the WIT, precluding
organ donation.
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57 neonates (41.9%) exceeded 2.74 kg, making them eligible for heart
valve donation regardless of WIT.
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Results
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The timing of OPO referral was evaluated for all patients meeting
minimum eligibility criteria for DCDD.
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Only 11 neonates (8.1%) had timely OPO referral (prior to withdrawal of
life-sustaining interventions).
– Medical records indicated the family inquired about and actively
pursued organ donation in all 11 cases.
– Of the 11 neonates referred, 4 were found to be ineligible on further
review, 4 families declined participation, and 3 donated en bloc
kidneys.
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The remaining 49 neonates (36.0%) were referred to the OPO after
withdrawal of life-sustaining interventions or were not referred at all.
– One neonate donated heart valves at the time of autopsy despite late
referral.
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Results
OPO Referral in Patients Weighing >2 kg
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Comment
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Adults receiving en bloc kidney transplants from neonatal donors (as small
as 1.9 kg, shown below) have excellent results, and experience with these
challenging cases is increasing.
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In our study, we found more than one-third of all NICU deaths met the
minimum criteria for DCDD. Of these, only a small percentage were
identified and referred to the OPO early enough to undergo evaluation for
DCDD.
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Our study supports recent estimations1,2 that
universal adoption of DCDD programs in US
NICUs could provide 400-1100 kidney
donations annually.
1Hanley
H, Kim S, Willey E, Castleberry D, Mathur M. Identifying potential kidney donors
among newborns undergoing circulatory determination of death. Pediatrics.
2014;133(1):e82-e87.
2Labrecque M, Parad R, Gupta M, Hansen A. Donation after cardiac death: the potential
contribution of an infant organ donor population. J Pediatr. 2011;158(1):31-36.
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Intraoperative picture of en bloc
kidneys from a 1.9-kg donor,
successfully transplanted into an
adult recipient (courtesy of IDS).
Comment
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Successful DCDD relies on early identification of eligible patients and OPO
referral prior to withdrawal of life-sustaining interventions.
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In addition to minimum eligibility requirements (weight and WIT) for DCDD,
the number of potential candidates who actually become donors also
depends on end-organ function, coexisting conditions, family wishes, and
surgeon availability.
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A significant disconnect exists between donor potential and the identification
and timely OPO referral that ultimately leads to successful transplants.
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Improved education of NICU practitioners and staff regarding the process of
OPO referral will likely improve the potential opportunities for families to
participate in organ donation.
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Contact Information
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If you have questions, please contact the corresponding author:
– Justin Stiers, MD, Division of Neonatology, Department of
Pediatrics, University of Utah, 295 Chipeta Way, Williams
Building, Salt Lake City, UT 84108 ([email protected])
Conflict of Interest Disclosures
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None reported.
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