There are several steps on the path from potential donor to actual donor. These steps have been defined as: identification and detection of all potential donors; brain death determination; approaching potential donor families for consent; and donor medical management (1). Taking these different steps into account, transplant coordinators involved in the whole process have designed strategies to maximize donation rates, with impressive results (2). Unfortunately, these steps and the correct methods for implementing them are not widely practiced. As a result, cadaveric organ donation remains inadequate despite a large potential organ donor population.
Donor management has been considered the most neglected area of transplant medicine (3,4). In their article (5), Rosendale et al. state the consequences of inadequate cardiopulmonary support when the pathophysiological changes associated with brain death occur. Failure to provide adequate physiological support to potential donors accounts for at least 25% of lost donor organs (6). Hypotension can occur in most potential brain dead donors (over 80%), and a high rate (25%) of cardiac arrest requiring cardiopulmonary resuscitation has been described (7). This instability results in the loss of organ donors and the impairment of organ viability, leading to a lack of potential suitable organs for transplantation.
A number of papers dealing with this issue have already been published (8), and actuation rules and algorithms have been proposed (9). The adoption of an aggressive protocol for donor management, including both intensive monitoring and therapy, has allowed the donor retrieval rate to increase by approximately 30% (4). Comprehensive hemodynamic monitoring is essential in performing an objective assessment of organ function and to achieve optimum management (4).
Several relevant aspects are discussed in the study by Rosendale. It has been demonstrated that brain death is often accompanied by significant reductions in serum free thyroxine, cortisol, arginine vasopressin and insulin (4). However, sufficient hormone levels can be preserved in many donors for extended periods (10), suggesting some residual function and perfusion of the hypothalamic–pituitary axis. The role that endocrine abnormalities play in the status of donors may vary among donors, depending on the clinical scenario. Consequently, the efficacy of hormone replacement may also be expected to vary (11). The ‘Papworth Hospital hormone package’ (12) has confirmed marked improvements in cardiac function, and similar good results have been shown by other authors (13,14). However, opposite findings have also been reported (15,16). In the hemodynamically unstable donor, or in the organ donor requiring prolonged support prior to organ retrieval, this treatment may be worth considering (16). However, the cornerstone of proper donor management is adequate fluid management. In some cases it is possible to keep the donor stable using this alone (17). Nevertheless, catecholamines are often used (18) and, in some cases, careful drug treatment guided by pulmonary catheter is recommended.
The main issue is not the use or not of hormone therapy, nor of any special kind of monitoring, such as a pulmonary catheter, but increased attention to the need for improved and accurate care of potential donors, once brain death has been diagnosed. It has already been established that close attention to this issue and, even more, professionalization of this role, improve the organ donation rate and organ viability. Involving a medical transplant coordinator directly in donor management has been shown to improve results, with both reduced donor losses and improved organ retrieval rates (19). Wheeldon et al. suggested that the inclusion of a trained doctor (a cardiac-trained anesthetist) in the donor team was a crucial change in their practice (4).
The main achievement of the study presented by Rosendale has been the extensive use of an established protocol in a wide spectrum of hospitals. Algorithms and protocols have previously demonstrated their usefulness. This has also been shown in other fields: for example, the cardiopulmonary resuscitation algorithm (20) or the algorithm designed for the management of the difficult airway in anesthesia (21). In the transplant setting, the use of a ‘rapid brain death determination protocol’ led to an increase in donation rates, reducing the medical failure rate and increasing the ratio of organs per eligible donor (22).
This is even more important in small hospitals, not familiar with donor management, where the application of this protocol will lead not only to better management of donors, but also to improvement in one of the main steps of the organ procurement process: donor identification (23).
The application of this protocol, not just to a pilot center but to a wide range of hospitals, including centers with different structures and capacities and with professionals with different skills, suggests the potential for the universal application of this protocol.