CHAPTER 33: Donation after Cardiac Death (DCD)

INTRODUCTION

• Interest in Donation after Cardiac Death (DCD) was renewed in the early 1990s, as a means to partially overcome the shortage of Donation after Brain Death (DBD)

• DCD donors have a significant contribution to the potential donor pool¹

• In Middle Eastern countries and in Asia, DCD has become an increasingly frequent procedure²

• In 1995, the first consensus was published in Maastricht classifying DCD into four categories (Table 33-1)^3–5

• Uncontrolled DCD: Organs procured after an unexpected cardiopulmonary arrest.

  • Variable period of ischemic damage due to cardiac standstill followed by cardiac resuscitation

• Controlled DCD: Cardiocirculatory arrest is a consequence of a planned and timed withdrawal of ventilator and organ-perfusion support (minimal warm ischemia)

ORGAN PROCUREMENT IN DCD

• DCD organs suffer from a period of hypotension and hypoxia before the cardiac arrest

• Outcomes have been shown to be similar when compared to donation after brain death (DBD)⁶

• Length of warm ischemic time correlates with organ post-implantation function and recovery

• Failure of DCD donors to progress to circulatory arrest within a specified time frame (usually 1 hour) precludes procurement. In these instances the donor is returned to the ICU or transferred to palliative care

Definition of Cardiac Death

“Irreversible cessation of circulatory and respiratory functions”⁷

• Diagnosed by the cessation of heartbeat and/or blood circulation

• Assessed by electrocardiography, monitoring of arterial pulses, and/or invasive arterial pressure readings

POTENTIAL DCD CANDIDATES SELECTION⁷

• Medically appropriate for donation

• Brain death criteria not met. Potential donors are still alive, and procurement should not take place until death has been pronounced. Some donors may progress to brain death prior to procurement

• No expectation of meaningful survival, as determined by the patient’s treating physician

  • Withdrawal of ventilator and organ perfusion support approved by the patient’s legal decision maker(s)

• Informed consent obtained from the patient’s legal decision maker(s)

  • Requested prior to becoming a potential DCD donor

• Risk Factors associated with DCD^2,9–12

  • Donor true warm ischemia time >20-30 min

    • Time from mean arterial pressure <60 mm Hg to perfusion)

  • Donor total warm ischemia time > 30-45 minutes

    • Time from withdrawal of ventilation to perfusion)

  • Cold ischemia time > 12h

  • Donor age > 60 years

  • Terminal serum creatinine level of >1.5 mg/dl

  • Cerebrovascular accident as the cause of death

  • History of hypertension in the donor

  • Increased HLA-mismatch grade

DCD versus ...