Published online October 1, 2007
PEDIATRICS Vol. 120 No. 4 October 2007, pp. e960-e966 (doi:10.1542/peds.2006-3550)
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ARTICLE

Trends in Pediatric Organ Donation After Cardiac Death

Robert Mazor, MD and Harris P. Baden, MD

Division of Critical Care Medicine, Children's Hospital and Regional Medical Center, Seattle, Washington


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVE. Organ donation after cardiac death is viewed as one way of partially closing the current gap between organ supply and demand. There are no published guidelines for organ donation after cardiac death specific to the pediatric population. The objective of this study was to examine the cumulative pediatric donation-after-cardiac-death experience to set the context for the development and sharing of best-practice guidelines.

PATIENTS AND METHODS. This was a retrospective, descriptive study that used data from the Organ Procurement and Transplantation Network/United Network for Organ Sharing database from 1993 to 2005. Organ data from all donors after cardiac death who were <18 years of age were analyzed. The list of donor medical centers was then cross-referenced with the member list from the National Association of Children's Hospitals and Related Institutions.

RESULTS. There were 683 organs from donation-after-cardiac-death donors <18 years of age. Of those, <5% were used for pediatric recipients. In comparison, ~20% of non–donation-after-cardiac-death organs from pediatric donors were used for pediatric recipients. The vast majority of donation-after-cardiac-death organs donated were kidneys and livers. More than 50% of medical centers that had a pediatric organ-donation-after-cardiac-death donor had just 1. The medical center with the largest pediatric organ-donation-after-cardiac-death donation experience had 14 donors. Forty-three percent of medical centers that had ≥1 pediatric donation-after-cardiac-death donor were members of the National Association of Children's Hospitals and Related Institutions. Fifty-six percent of all of the pediatric donation-after-cardiac-death organs were donated from the National Association of Children's Hospitals and Related Institution member centers.

CONCLUSIONS. Data regarding the use of pediatric donation-after-cardiac-death organs for pediatric recipients remain sparse. Few medical centers have had enough donation-after-cardiac-death donor experience to report a tried-and-true approach. We advocate for comprehensive collection and reporting of outcome data for all-aged recipients of pediatric donation-after-cardiac-death organs to help facilitate the generation of evidence-based best-practice guidelines for pediatric donation after cardiac death.

Key Words: end of life • transplant

Abbreviations: DCD—donation after cardiac death • UNOS—United Network for Organ Sharing • OPTN—Organ Procurement and Transplantation Network • NACHRI—National Association of Children's Hospital and Related Institutions

Currently, >90000 Americans await solid organ transplantation,1 many of whom will die before a suitable organ can be procured. As the science and techniques of solid organ transplantation have flourished, overcoming the imbalance between organ need and availability remains a significant challenge. The pediatric age group represents an important subset of patients that offers some unique challenges. This is reflected in a high waiting-list mortality rate for most organ types and is most evident in the youngest subset of pediatric patients.2

Organs for transplantation can come from either living or deceased donors. Deceased donors are subclassified according to the means by which death is determined. Customarily, deceased donors are heart-beating donors who are brain dead, but otherwise have adequate end-organ function. Alternatively, organ donation can occur from nonheart-beating donors, referred to as donation after cardiac death (DCD). DCD donors do not meet brain death criteria, but because of irreversible neurologic injury or terminal illness, the decision has been made to withdraw medical support. Discussions about organ donation occur only after this decision is made. Organ allocation occurs per the standard practice of the United Network for Organ Sharing (UNOS). Medical support is withdrawn per the usual local practice. Organ procurement proceeds if the patient expires within a prescribed time period (typically 1 hour). DCD is advocated as a way to expand the donor pool beyond the limitations of the traditional brain-dead donor group.3–7

In 1997, and again in 2000, the Institute of Medicine published consensus reports with recommendations for DCD organ donation practice.8 As of January 1, 2007, the Joint Commission on Accreditation of Healthcare Organizations has implemented a new mandate that hospitals develop and maintain a DCD protocol.9 The board of directors of the Organ Procurement and Transplantation Network (OPTN)/UNOS is currently considering a similar resolution.10 In addition, the US Department of Health and Human Services and the OPTN/UNOS Board of Directors have set forth specific goals for increasing DCD donation by 2013.11 Although pediatric-specific DCD organ donation goals are not delineated, an increase in pediatric DCD donation seems implicit in the overall strategy. One might logically expect that an increase in the rate of pediatric DCD organ donation will correspond with an increase in organ availability and transplantation for the pediatric age group.5,12 To date, however, there are no published reports demonstrating an increase in pediatric solid organ transplantation despite an annual increase in the number of pediatric DCD donors.

In this article we present data on the pediatric DCD donor experience in the United States, with particular attention paid to the possible direct impact on pediatric solid organ transplantation. In addition, we present center-specific pediatric DCD donation data. Because of the potential for a conflict of interest, many of the individuals charged with the development of institutional DCD organ donation policy have no specific affiliation with organ transplantation. As such, they approach this complicated process from a relatively naive position. The purpose of this report is to provide important historical perspective for medical centers as they implement DCD protocols. It also sets the context for the development and sharing of evidence-based best practices.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
This review was given exempt status by our institutional review board. DCD data for donors <18 years of age for the time period 1993–2005 were obtained from the publicly available database of the OPTN via the OPTN/UNOS Web site, www.OPTN.org. Additional data were compiled from reports published on the Scientific Registry of Transplant Recipients Web site, www.ustransplant.org. Data regarding the donor medical center was cross-referenced with the member list of the National Association of Children's Hospital and Related Institutions (NACHRI).


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Distribution of Pediatric DCD Organs
Figure 1 illustrates an increasing trend in annual pediatric DCD organ donations over the past 5 years. In total, <5% of pediatric DCD organs transplanted during the time period studied were used for pediatric recipients. As seen in Fig 2, there was significant variability in the annual rate of use of pediatric DCD organs for pediatric recipients. In each of the past 5 years, <7% of all DCD organs from pediatric donors were transplanted into pediatric recipients. In comparison, the relative use of pediatric non-DCD organs for pediatric recipients continued to increase on an annual basis and was 25% in 2005.


Figure 1
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  		FIGURE 1 Annual values for DCD organ donation and transplantation. The dashed line indicates the DCD donor <18 years old; numbers in parentheses, the number of DCD organs from donors of all ages for a respective year; solid line, DCD donor and recipient <18 years old.

 

Figure 2
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  		FIGURE 2 Annual percentage of organs donated from patients <18 years old that were received by patients <18 years old. The dashed line indicates non-DCD organs; solid line, DCD organs.

 
Distribution of Pediatric DCD Organs According to Organ Type
Figure 3 demonstrates the cumulative experience of pediatric DCD organ donation broken down by organ type from 1993 to 2005. Figure 4 illustrates the collective distribution of pediatric DCD organ transplantation for organs from donors <18 years old broken down by organ type. The vast majority of organs transplanted were kidneys and livers.


Figure 3
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  		FIGURE 3 Cumulative pediatric DCD donor experience according to organ type: 1993–2005.

 

Figure 4
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  		FIGURE 4 Cumulative pediatric DCD recipient experience according to organ type: 1993–2005.

 
Pediatric DCD Donor Medical Center Data
Figure 5 illustrates the cumulative experience of medical centers that had ≥1 pediatric DCD organ donor during the study period. More than 50% of medical centers that had a pediatric DCD donor had just 1. The medical center with the largest cumulative experience had 14 donors. No other center had >9 donors. The 4 medical centers with the largest cumulative DCD donor experience represented 16% of the total donor experience.


Figure 5
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  		FIGURE 5 Center-specific cumulative pediatric DCD donor experience according to NACHRI membership. The cross-hatched bar indicates NACHRI institutions; solid bar, non-NACHRI institutions.

 
Of the institutions that had ≥1 pediatric DCD organ donation, 43% (52 of 122) are members of the NACHRI. Fifty-six percent of all pediatric DCD organs donated came from NACHRI member centers.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Solid organ transplantation is a burgeoning field in modern medicine that offers a viable option for restoring and maintaining health and is by and large accepted on a societal level. Unfortunately, the number of patients in need of an organ outstrips the existing supply, compelling an expansion of the available donor pool. DCD is an option and is gaining acceptance and momentum, with some groups having reported a rise in pediatric DCD organ donation.5,12 However, to our knowledge, no report has evaluated either the direct or indirect effect that increased pediatric DCD organ donation has had on organ availability for candidates <18 years of age. In this article, we present data on pediatric DCD procurement and use in the United States, and thereby give some perspective on the direct impact that pediatric DCD organ donation has had on organ availability for this patient population.

Subjectively, there seems to be a common misperception among the general pediatric community that organs procured from pediatric donors are transplanted into pediatric recipients. In fact, our data are consistent with others’ in showing that adult patients receive the majority of donated pediatric organs.5 Considering current organ allocation policy, this is not surprising. Historically, the most commonly used organs from DCD donors are kidneys. In the current kidney allocation scheme, pediatric patients receive significant priority for organs from deceased donors <35 years of age. This, combined with the prevalence of living related organ donation, and the noncritical status of most renal transplant candidates, allow pediatric transplant centers to generally avoid the use of kidneys from extended criteria donors while awaiting more suitable organs. Although pediatric DCD donation may not directly benefit pediatric transplant candidates, an increase in the availability of organs benefits the entire candidate pool regardless of the age of the recipient and is, therefore, justifiable on societal and practical levels. Although this type of age-independent allocation of organs may be acceptable, this common misconception illustrates the lack of familiarity that represents the starting point for many individuals and institutions charged with instituting pediatric DCD policies and programs.

The Institute of Medicine, the American Medical Association, the Society of Critical Care Medicine, and other prominent medical societies and national forums have examined DCD, and many have published consensus statements.8,13–16 Although many of these DCD workgroups have included pediatric subspecialist representation as part of their faculty, the consensus summaries are nearly devoid of pediatric-specific discussion. As such, as pediatric centers begin policy development, they typically look to peer institutions for best practices. The data presented here suggest that few pediatric centers have significant enough donor experience to report a tried and true approach.

We elected to define a pediatric center by membership in the NACHRI. NACHRI membership indicates an institutional commitment to providing excellent pediatric specialized health care and the ability to deal with unique end-of-life issues. Although this definition may be somewhat imprecise, the list of NACHRI members includes the majority of nationally recognized pediatric institutions.17 Interestingly, nearly half of the pediatric DCD organs donated during the study period came from donors in non-NACHRI institutions, likely using adult protocols. In a recent Institute of Medicine report,18 the Committee on Palliative and End of Life Care for Children and Their Families suggests that the psychosocial and spiritual aspects of end-of-life care for children are distinct from those of adults. Similarly, Truog et al19 warn against the practice of extrapolating adult end-of-life experiences to pediatric patients because "children's relationships with family members, and their developmental, psychological, and spiritual needs, are different from adults... ." Aside from psychosocial issues, there are important age-dependant biological differences that may necessitate differentiation between pediatric and adult protocols. For example, considering natural changes that occur during the aging process, it is reasonable to surmise that pediatric organs might be less vulnerable to the effects of ischemia,20 perhaps allowing for an extended waiting period after withdrawal of support. Given this, the ongoing intensive push for increased DCD organ donation must be paralleled by an equivalent push for the systematic, comprehensive collection and reporting of DCD transplantation outcome data of all-aged recipients of pediatric DCD organs. In the field of pediatric transplantation, where the number of such transplants is likely to be low, these data will come in the form of multicentered initiatives driven by several organ-specific collaborative groups and registries that exist in the pediatric transplant community.

The practical aspects of developing and implementing a DCD protocol are significant.21 Institutional policies and clinical practice must be sensitive to the appearance of conflict of interest. Separating discussions related to withdrawal of support and organ donation in these scenarios is imperative. End-of-life discussions among family members, medical providers, and, less commonly, the patient himself/herself should occur per usual practice. Only once the determination to withdraw support has been made should the topic of organ donation be broached.

Although the temporal separation of these topics can be clear, the separation in one's mind may be a bit blurrier. Given the spatial and resource centralization of pediatric critical care present in most pediatric centers, the possibility that providers will simultaneously care for both a potential DCD donor and a potential recipient is distinct. According to our data, such a situation occurred only 4 times during the time period studied, with no center having such a situation occur more than once (data not shown).

Nonetheless, these scenarios are certain to occur with some frequency and necessitate a thoughtful process to minimize the potential for angst or real conflict. Furthermore, as DCD donation becomes widespread, public awareness will increase, and families are likely to bring up the topic as part of end-of-life discussions. In fact, in a recent report, parents surveyed indicated that they would want to be asked about organ donation in cases of withdrawal of support.22 At a minimum, institutions need to be prepared to address such requests or risk depriving family members seeking meaning from tragic events. Hence, the need for detailed institutional DCD organ donation policies that put in place mechanisms that minimize the personal biases of care providers. This is consistent with the Institute of Medicine recommendation that "organ procurement should be conducted only after advance thought and planning that has been reduced to a written protocol... ."8

Although patient eligibility criteria are fairly standard, the logistics of DCD donation currently vary among institutions. After the decision has been made to withdraw medical support, the medical care team and the local organ procurement organization determine the patient's potential suitability for donation. Generally, because of the importance of timing, withdrawal of medical support takes place in the operating room or in a room near the operating room. At the time of withdrawal of support, analgesia and sedative agents are administered per standard institutional end-of-life practice. Once the patient is pronounced dead and a brief period (2–5 minutes) elapses to assure irreversibility, organ procurement begins in this state of warm ischemia.

Published clinical outcomes data from adult transplant centers are encouraging, although results have not been uniformly positive, and the literature specific to pediatric DCD organ transplantation is sparse. In adults, studies involving kidney transplantation have demonstrated a relative delay in graft function for DCD grafts compared with brain-dead donor grafts, although long-term function seems to be the same.23–25 The experience with adult DCD liver transplantation has demonstrated mixed results, with some centers reporting outcomes comparable to donors who are brain dead, whereas other centers report worse graft survival and an increased incidence of biliary complications.26–30 Despite this, considering size limitations, the critical status of many infant liver candidates, and the lack of reasonable alternative supportive therapies, the ability to use livers from pediatric DCD donors may have a significant immediate impact on pediatric waiting-list mortality. Data on DCD lung transplantation are limited to small series and animal studies,31,32 whereas DCD heart transplantation remains largely experimental, making it less likely that DCD donation will have a significant effect on the pediatric waiting list for these organs in the near future. Although experience using pediatric organs for adults is accumulating, data supporting increased use of organs from DCD donors for pediatric recipients is lacking.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
These data suggest that pediatric DCD organ donation may not have a significant direct effect on pediatric solid organ waiting-list mortality in the current era. The impact of these organs on the entire candidate pool is not known. As experience accumulates, organ-specific outcome studies comparing traditional and DCD pediatric organ transplantation are required to affirm the feasibility of this mode of transplantation for pediatric patients. These data also demonstrate that there is a paucity of pediatric DCD donation experience. Extrapolating practices from adult DCD donation experience may be misguided. This compels the systematic collection and reporting of outcome data for all recipients of pediatric DCD organs. As this report demonstrates, this will require significant collaboration between adult and pediatric transplantation organizations. In addition, ongoing investigation that elucidates the psychosocial needs of donor families is necessary. As these data become available, evidence-based best-practice guidelines for pediatric organ DCD should be established to optimize recipient outcome and donor family experience.


   ACKNOWLEDGMENTS
 
This work was supported in part by Health Resources and Services Administration contract 234-2005-370011C.

We thank Katarina Anderson, Tim Baker, and Cindy Cors of the UNOS research department for help with data acquisition.


   FOOTNOTES
 
Accepted Mar 14, 2007.

Address correspondence to Robert Mazor, MD, Children's Hospital and Regional Medical Center, Division of Critical Care Medicine, W-9824, 4800 Sandpoint Way NE, Seattle, WA 98105. E-mail: robert.mazor{at}seattlechildrens.org

The authors have indicated they have no financial relationships relevant to this article to disclose.

The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government.


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 ABSTRACT
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics




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