PEDIATRICS Vol. 119 No. 1 January 2007, pp. e219-e224 (doi:10.1542/peds.2006-0375)
ARTICLE |
Potential for Donation After Cardiac Death in a Children's Hospital
a Division of Critical Care, Department of Anesthesia, Perioperative and Pain Medicine
c Department of Cardiology, Children's Hospital Boston, Boston, Massachusetts
b Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVES. A task force was convened to decide whether a donation after cardiac death policy should be implemented at Children's Hospital Boston. As part of this process, we sought to determine the number of potential kidney donation after cardiac death donors in our PICUs.
METHODS. We examined all 254 deaths in the Medical/Surgical ICU and the Cardiac ICU from 2002 to 2004 and identified potential donation after cardiac death donors. Inclusion criteria were age 
3 months, mechanical ventilation, and creatinine 
1.5 mg/dL. Exclusion criteria were HIV infection, malignancy other than primary brain tumor or nonmelanoma skin cancer, evidence of ongoing infection, death despite resuscitation attempts, and brain death.
RESULTS. Twenty-one of the 254 deaths met criteria for brain death, and 233 patients did not. Of the 116 patients >3 months of age for whom life support was withdrawn, 92 were not suitable for kidney donation after cardiac death. Of the 24 children identified as potentially eligible for donation after cardiac death, 14 died within 1 hour of withdrawal of support and could have proceeded with donation after cardiac death. In the other 10 children, donation would have been aborted because of prolonged time to death.
CONCLUSIONS. Of all patients who died in our ICUs, 5.5% would have been potential candidates for donation after cardiac death. Assuming the rates of parental consent are similar to that of our heart-beating organ donors (47%), a donation after cardiac death protocol could have potentially yielded 7 additional organ donors and 14 additional kidneys over this 3-year period.
Key Words: donation after cardiac death • pediatric
Abbreviations: DCD—donation after cardiac death • CICU—cardiac ICU • OPO—organ procurement organization • CHOP—Children's Hospital of Philadelphia • MAP—mean arterial pressure • ARDS—acute respiratory distress syndrome • BMT—bone marrow transplant • CNS—central nervous system • HIE—hypoxic ischemic encephalopathy
Organ transplantation is a potentially life-saving treatment option for those with end-stage organ failure. When organ transplantation began in the 1950s, kidneys were procured from either living related donors or from those patients who suffered cardiopulmonary arrest after illness or injury. After the establishment of brain death criteria in 1968,1 organ donors consisted primarily of brain-dead patients rather than those in which death occurred by cardiopulmonary arrest. Because of advances in surgical techniques and immunosuppression therapy, the number of organ transplantations has grown and both early and late outcomes have improved.2 As of May 2006, there were >91000 people awaiting transplantation of 1 organ, with >66000 listed for a kidney transplant.3 Currently, the waiting list for organ recipients continues to increase, whereas the number of organ donors meeting brain death criteria remains relatively stable, thereby prolonging the waiting time for a transplant.2 As an example, the median wait time for a renal transplant increased from 
750 days in 1994 to 1200 days in 2001.2 Although the gap widens between the number of organ donors and recipients, 17 people die each day waiting for an organ transplant.3 As one method to increase the number of potential organ donors, the transplantation of select organs from nonheart beating donors, known as donation after cardiac death (DCD) has been supported by organ procurement organizations, the Institute of Medicine4 and the Department of Health and Human Services.4,5 The Institute of Medicine concluded that DCD is an ethically acceptable and medically useful method to increase the available supply of organs for transplantation.4 According to data from Scientific Registry of Transplant Recipients, there has been a significant increase in the number of organs transplanted from nonbeating heart donors over recent years, with the number more than doubling since 20002 (Fig 1). For example, Reiner et al6 reported an increase in their DCD rate from 2% to 5% per year to >10% after significant effort to increase the number of nonheart-beating organ donors. In addition, they found that 74% of kidneys and 90% of livers that were procured from DCD donors were transplanted. Furthermore, Tanaka et al7 determined that 48% of their potential DCD donors were able to be kidney donors. The majority of nonheart-beating organ donations have come from adult institutions, and the total reported experience of DCD from freestanding children's hospitals has been small.3
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Because of the complexity of issues surrounding DCD, a multidisciplinary task force at Children's Hospital Boston, was formed to decide whether a DCD policy should be developed. The first actions of the task force were to determine whether a DCD protocol was consistent with the mission of Children's Hospital Boston and to determine whether the number of donors would justify the effort needed to create, implement, and maintain a DCD protocol. Therefore, we sought to determine the number of potential kidney donors that would be eligible for controlled DCD in our hospital.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Deaths were identified prospectively and maintained in a separate database in each ICU used for tracking morbidity and mortality. We retrospectively examined the charts of all 254 of the deaths in the medical/surgical or cardiac ICUs (CICUs) from 2002 to 2004. The institutional review board waived the need for informed consent for this study. We first identified those patients who fulfilled criteria for brain death. The patients who did not qualify as brain dead were then stratified based on age. Those patients <3 months of age were excluded because of size limitations of the vessels for kidney transplantation. The mode of death for those patients who were
3 months of age was then determined. Based on these data, the patients were further subdivided into 2 groups: those for whom life-sustaining treatment was withdrawn and those who experienced cardiopulmonary arrest. This was done to place patients into the appropriate category. There are 4 categories into which DCD donors may be placed, defined at the First International Workshop on nonheart-beating donation held in Maastricht, the Netherlands8: category 1 donors are considered "dead on arrival"; category 2 donors have sustained cardiopulmonary arrest with an unsuccessful resuscitation attempt; category 3 donors are those who are "awaiting cardiac arrest"; and category 4 donors experience "cardiac arrest while brain dead." Originally Maastricht category 3 patients were defined as having suffered irreversible brain damage but did not fulfill criteria for brain death. Currently, all patients with any kind of devastating illness or injury are included in this category. Our study involved only Maastricht category 3 donors because of the long warm ischemic times associated with categories 1, 2, and 4. Patients who were classified as category 3 donors were further evaluated by both a critical care fellow and attending. In addition, a representative from our local organ procurement organization (OPO) reviewed all of the deaths to confirm that all of the potential DCD cases met criteria for inclusion in the study. Patients were declared ineligible for DCD if they met any of the following criteria: HIV infection, malignancy other than primary brain tumor or nonmelanoma skin cancer, sepsis, bacterial colonization with virulent pathogens, viral or unidentified infections, and severe clinical instability such that cardiopulmonary arrest was imminent and the patient would likely die before completion of the donation process. In addition, those patients who were not intubated and mechanically ventilated did not qualify because of inability to maximize oxygenation and because death would likely be too long after withdrawal of support. Those remaining patients were then examined for suitability for kidney transplantation by assessing the serum creatinine level, urine output, blood pressure measurements, and oxygen saturation before withdrawal of medical treatment. Patients who had a creatinine of 1.5 mg/dL were reviewed for time of death after withdrawal of life-sustaining measures. This creatinine level was chosen because pediatric patients with a creatinine of 1.5 mg/dL with adequate urine output demonstrate sufficient renal function to consider for transplantation. One hour after withdrawal of life support was chosen as a cutoff to minimize warm ischemic time of the kidneys. |
RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Over the 3-year study period, there were 9119 admissions to the medical/surgical and CICUs. Figure 2 shows the categorizations of the 254 children (2.8%) who died during this period. Twenty-one (8.3%) of the 254 deaths met criteria for brain death, and 8 families consented to organ donation. Of the 233 children (91.7%) who did not meet brain death criteria, 116 children (49.8%) were
3 months of age and had life support was withdrawn. Ninety-two (79.3%) of these children were not suitable for kidney transplantation. The 24 remaining children (9.4% of all deaths in the medical/surgical and CICUs) were identified as potentially eligible for DCD. Fourteen (58.3%) of these children sustained cardiac arrest within 1 hour after withdrawal of support and were considered DCD candidates. Figure 3 shows the breakdown of time to cardiac arrest, and Table 1 shows the characteristics of the children who sustained cardiac arrest within an hour. After detailed review of the 14 possible candidates, 5 of these children might potentially have been excluded as DCD candidates by the organ bank evaluators based on items in the clinical history and physical examination, including persistent hypoxia, hypotension despite vasoactive support, rising creatinine with urine output dependent on diuretic therapy, and immunosuppression after stem cell transplant (for a nonmalignant condition). In addition, 7 of the 14 possible candidates weighed <15 kg making the possibility of finding an appropriate recipient less likely.
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, Pathway for identifying potential DCD candidates.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Donation of organs after cardiac death is advocated as a means to increase the total organ pool available for transplantation. Although embraced at adult transplantation centers, the experience with DCD in pediatric institutions remains quite small.3 As part of our task force evaluating whether we should consider and implement a DCD protocol at Children's Hospital Boston, our study determined that 5.5% (14 of 254) of the children who died over a 3-year period in our medical/surgical and CICUs could have been considered for organ DCD. If the rates of parental consent are similar to our rate of donation after brain death determination (47%), approaching the families of these children could have yielded 7 additional organ donors and 14 additional kidneys over the 3-year period. Although this seems low, this rate is comparable to the number organs donated from our brain dead donors.
The number of potential DCD donors from our institution (5.5%) is comparable to the study by Lacroix et al,9 who evaluated the potential for DCD in their institution's adult population. In contrast, our potential DCD rate is lower than the 9.7% estimate reported by Koogler and Costarino10 in 1998 from the Children's Hospital of Philadelphia (CHOP), the only other published study we found in the literature that describes the potential for DCD in a pediatric population. Both institutions had PICUs similar in size and a similar number of patients that were withdrawn from life support. There are several differences, however, between the 2 studies. The CHOP study included infants as potential donors, whereas we excluded infants <3 months of age because of size limitations of renal transplantation. The potential DCD candidates' cause of death in the CHOP study was primarily because of neurologic dysfunction, whereas many of our patients suffered a primary respiratory insult. The DCD criteria were not clearly defined in the CHOP study, and no creatinine cutoff was specified for kidney donation. Furthermore, inclusion criteria at CHOP allowed death to occur within 2 hours of withdrawal of life support, whereas our institution included only those who died within 1 hour, the currently accepted limit recommended by the United Network for Organ Sharing to limit warm ischemic time.
The 1-hour limit on time to death currently recommended by United Network for Organ Sharing can be problematic. It can be difficult to predict which patients will die within this hour, and one must consider the emotional impact that it would have on the family to undergo a failed attempt at DCD. Our review of the literature demonstrated that the time to death after withdrawal of life-sustaining treatment was <1 hour in the majority of the cases.10–16 In contrast, we found that 40% of eligible children did not die within 1 hour. It is imperative to discuss with the family the possibility that the patient may be taken to the operating room, have support withdrawn, and then need to come back to the ICU unable to donate because of prolonged time to death.
It is important to note that, currently, children are unlikely to be the recipients of DCD kidneys. Children are given higher priority for receiving organs. Of children aged 1 to 17 years listed for kidney transplantation from 2001 to 2002, 74% had received a transplant within 2 years compared with 25% of adults.3 Children generally are not good candidates for extended criteria donor kidneys because of the risk of reduced long-term graft survival associated with these organs and possibilities for sensitization after transplant.2 Because DCD kidneys are considered extended criteria donor kidneys, those donated from children are usually transplanted into adults.2 Thus, pediatric DCD may not benefit children specifically but would contribute to the overall number of organ donors.
Although we estimated that 5.5% of deaths in our ICUs would be DCD candidates, this number may be <3% if organs from very young children are not considered for technical reasons. Although kidneys from DCD donors have a higher incidence of delayed graft function, long-term graft survival is similar to that of kidneys from heart beating donors. Renal transplantation using infant donors, however, is associated with increased morbidity compared with older donors.17–21 This is an important issue, because 52% of the patients whose families we would have approached for donation weighed <15 kg. Therefore, it is possible that kidneys from these young children may not have been transplanted successfully and may have been rejected at the donation stage.
All of the deaths in our ICUs over the 3-year study period were reviewed, assuring that all of the eligible cases were identified, and 2 intensive care physicians and a transplant coordinator from our local OPO reviewed all of the charts to verify potential organ donors. Although the study was retrospective, the data needed to determine suitability for DCD were present in the chart. However, many factors are taken into account when considering the suitability of patients for organ donation, such as mode of injury, risk for infection, other end-organ injury, and potential recipient characteristics, including organ size in relation to recipient size. Therefore, it is likely that we may have overestimated the number of potential donors.
Another limitation of our study is the difficulty in predicting parental consent rates for DCD. We based our conclusions on the consent rates for our heart-beating donations during the same time period. Although the national experience with pediatric DCD is limited, in most cases the parents or families have instigated the request for organ donation. As such, these families are motivated to complete donation and accept the limitation imposed by a DCD protocol. The process of DCD and the importance of limiting the warm ischemic time for the transplanted organs mean that the majority of the withdrawals of life support occur in the operating room. Concerns for sterility and having the patient prepared for organ donation on the operating table may limit access for parents and families to hold their child at the time of withdrawal. Furthermore, surgery for the procurement of donor organs occurs as soon as possible after death has been declared, which means that parents and families are unable to spend time after death with their child. When confronted with the necessary logistics of the DCD process, the number of parents prepared to consent to donation may be lower than our current consent rate for brain-dead patients.
An analysis of the types of cases and number of potential DCD donors within a pediatric institution, such as presented in this study, may be helpful for developing and implementing a DCD protocol for children in collaboration between hospital staff and the OPOs. It might be helpful for institutions deciding on whether or how to implement a DCD protocol if they assessed their own DCD potential over a specified period of time. An addition benefit may come from prospective data collected and reported by those institutions that are currently performing DCD in children.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Although our study demonstrated a relatively small number of DCD candidates, DCD could improve our overall donor rate. DCD potential will vary by hospital based on the institution's patient case mix. Implementation of DCD and maintenance of a high quality process requires significant effort. It is important for hospitals to ensure that they have an accurate estimate of their potential for DCD before conducting the significant work required to execute and maintain an ethical and humane DCD protocol.
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ACKNOWLEDGMENTS |
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We thank our colleagues at the New England Organ Bank for providing supplemental data and their assistance in reviewing patient charts.
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FOOTNOTES |
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Accepted Jul 19, 2006.
Address correspondence to Amy L. Durall, MD, Children's Hospital Boston, 300 Longwood Ave, Farley 517, Boston, MA 02115. E-mail: amy.durall{at}childrens.harvard.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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