Donation after circulatory death

Dr R R Guru, MBBS,MD.
Hospital Administration
PGIMER, Chandigarh , India
 Overview

 Global Statistics

 Feasibility in Indian context

 Future of DCD Practices

Waiting list
Waiting list for organs
 Organ sources
1. Living donors
 Genetically related
 Emotionally related
 Unrelated
2. Deceased (cadaver) donors
 Heart beating with brain stem death / DBD
 Non heart beating / Donation after cardiac
death/ Donation after circulatory arrest /
DCD
 DCD
• What then is DCD?
A procedure whereby organs are surgically recovered following
pronouncement of death based on “irreversible cessation of circulatory
and respiratory functions.”

• Uncontrolled
Cardiac arrest is unplanned. Timing of other aspects of organ recovery
are not controlled.

• Controlled
Death & organ recovery can be predictably controlled following the
withdrawal of life support.
 DBD DCD

• Lost all brain function • Primary event is cardiac

arrest
• Blood is still circulating to
• Heart is no longer
organs other than the
pumping blood to the
brain
organs

• Plenty of time to • Have to start the

organize organ donation operation as soon as
possible after death has
been determined –
ischemia time is critical
https://optn.transplant.hrsa.gov
Increase in DCD donors across the world - Reasons
• Improved neurocritical care
– Prevents brain death in devastating brain injuries

• Wider acceptance of futility of continuing care in these situations

– Families and physicians don’t want to wait for brain death to
develop
– Expense associated with critical care of terminally ill patient

• Advanced directives of end of life care

DCD well-accepted across the world

Ever increasing waiting list of patients

 Brain dead donors – Plateau/ Decline

 Increasing interest organs from DCD

donors
Modified Maastricht classification of donation after
circulatory death
 Uncontrolled DCD Controlled DCD
Rush and retrieve Comparatively relaxed
 DCD INDIAN SCENARIO
 Not attempted so far in a systematic manner

 Lack of clarity in the Transplantation of Human Organs Act (THOA)

1994

 No guidelines for withdrawal of life support

 OUR DCD EXPERIENCE AT PGIMER CHANDIGARH

Donor Cause of Death

Donor Cause of Death
• 38 Kidneys were retrieved from 19 DCD 16

donors over span of 11 years. 14

15

• 15 donors had severe head injury. 12

10
• One patient had stroke.
8
• One patient had terminal Lung disease 6

• 2 patients were neonates. 4

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 OUR DCD EXPERIENCE AT PGIMER CHANDIGARH

• Total 19 Donors
DCD Scenario
• 7 underwent DCD after brain death 7.5

certification. 6.5

• 7 Underwent DCD after first committee 5.5

for brain death certification. 4.5

3.5
• 4 donors were refused brain death
2.5
certification due to confounding factors.
1.5

• One consented patient suffering from 0.5 7 7 4 1

end stage lung disease was arrested in After Brain After first Refused Brain Arrest In ICU
death declara- committee Death certifica-
tion tion due to
ICU. Confounding
Factors

DCD 7 7 4 1
Scenario
 Challenges for India – DCD
• Awareness and willingness of team

• Transplant team

 No dedicated teams

• Immunologists

• Adminstrative support

 Permission of Police

 Consent from family

 Challenges Uncontrolled DCD
• Infrastructure and manpower
o Availability of operation theatre at a short notice
o Local X match/tissue typing/Pathology lab
o Facility to store samples of patients for x match
o Auto-CPR machines
o Double balloon
o Perfusion systems
o Retrieval teams on prolonged stand by
• In-hospital donor
 Challenges controlled DCD
• Most common form of DCD donation worldwide
• No end of life care narrative
 LAMA is widely practised
• Willingness
o Government
o Recipient
o Donors and Families
o Physicians (Intensivists/Neurophysicians)

o End of life should be primarily an ICU problem

o SOP’s for end of life
o Separate area in hospitals for withdrawal of care
 Future of DCD

 Increasing worldwide

 Limited ICU care

 Increasing and accurate recognition of end of life situations

 Ever increasing demand

 Commercial solutions

 Warm perfusion

 ECMO for resuscitation

 Conclusions

 Kidney transplantation from DCD donors yields good results

 DCD grafts may be a good option to cope with increasing organ shortages in

order to expand the donor pool.

 Withdrawal of care guidelines for terminally ill patients is desperately

required

 For both promoting DCD donations and to provide a dignity

of death in an end of life situation.

THANK YOU