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Organ transplantation has become victim of a growing disparity between organ supply and waitlist demand. Donation after cardiac death (DCD) represents an attractive option to mitigate long organ transplant waiting lists. Endorsement of DCD by the Institute of Medicine followed by timely federal mandates issued by the Department of Health and Human Services and the Health Resources and Services Administration have bolstered the number of DCD transplants. Consequently, DCD has risen more than 10-fold over the past decade currently comprising >10% of all deceased donors (1). In contrast, donation after brain death (DBD) has reached a plateau and more recently has declined since 2006 (1). A decline in DBD as an unintended consequence of augmenting DCD has been identified in the Netherlands and is a source of ongoing concern in the United States, but the cause remains elusive.

In this issue of the American Journal of Transplantation, Saidi et al. (2) retrospectively analyzed trends in deceased organ donation at Massachusetts General Hospital. The authors provide novel insights into the complex interrelationship between DCD and DBD. They observed a substantial increase in DCD from 14.8% to 60% of annual donors from 1998 to 2008. Given that the overall donation rate remained stable, the progressive shift from DBD to DCD may reflect that DCD donors resulted from donors that would otherwise have progressed to brain death. Interestingly, greater utilization of neurological and neurosurgical interventions coincided with the rise in DCD. The observed growth in DCD donors might be the consequence of a more aggressive strategy in the management of acute brain injury being employed across the nation. Nonetheless, DBD was not exclusive of this approach as 38.1% and 25.7% of DBD donors underwent neurological and neurosurgical interventions, respectively. Indeed, rostro-caudal herniation is not the only pathophysiological pathway to brain death.

While this is an important study on DCD trends, it has some important limitations. First, the authors do not examine neurologic parameters including absent brain stem reflexes (i.e. corneal reflex, pupillary response, withdrawal response to pain and motor response), which are both factors in the determination of brain death and can also predict progression to death and/or poor neurologic outcome (3). This is an important omission because these data could provide predictive criteria for progression to brain death. Therefore, without these data, it may be difficult to precisely determine the proportion of patients who would have progressed to brain death and thus shifted DBD to DCD.

Second, the authors suggest that waiting for progression to brain death can strain already scarce critical care resources. However, the costs associated with these resources must be tempered against the increased costs related to organ-specific acquisition as a result of both unsuccessful procurements in donors that fail to progress to cardiac death and discarded organs due to poor quality. Moreover, costs incurred in the management of DCD-related recipient complications, which are relatively common, should not be underestimated (4). Also, since length of stay is a major determinant of cost, there seems to be no cost savings related to predonation hospitalization as the authors report that the time from either admission or referral to organ recovery was similar between DCD and DBD. However, it must also be noted that prolongation of the donation process to facilitate neurologic progression may not be possible and might occur to the detriment of the donor family. Indeed, further examination of family, clinician and Organ Procurement Organization personnel attitudes towards donation, be it donation after cardiac or brain death, might also yield important insights.

Third, this report represents the experience of a single center. While there are clear merits to institutional data, namely granularity, it may be difficult to generalize these to other centers. Also, trends in donation typically exhibit wide variation at the regional and donor service area (DSA) levels (1). Given that >50% of DSAs experienced contemporaneous DCD gains and DBD losses, granular data from these and other areas should be studied to establish whether the authors’ findings are generalizable.

Despite expansion of the organ pool with widespread acceptance of DCD protocols, DCD yields fewer organs recovered and transplanted per donor compared with DBD (1). Moreover, DCD grafts suffer from inferior outcomes compared with DBD organs (1). DCD liver transplantation is marred by higher rates of graft failure, re-transplantation and biliary complications including ischemic cholangiopathy (5). DCD kidneys, despite preserved patient and graft survival, are more commonly affected by delayed graft function and primary nonfunction (1). DCD pancreas and lung outcomes are satisfactory, but may reflect only a limited national experience (1). Given the recent growth in marginal organs (including DCD) coupled with a decline in DBD donors, every precaution must be taken to safeguard the donor pool and prevent decay of organ quality in favor of quantity.

References

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  2. References
  • 1
    2009 Annual Report of the U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1999–2008. Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation 2007.
  • 2
    Saidi RF, Bradley J, Greer D et al. Changing patterns of organ donation at a single center; are potential brain dead donors being lost to donation after cardiac death? Am J Transplant 2010; 10: 25362540.
  • 3
    Booth CM, Boone RH, Tomlinson G, Detsky AS. Is this patient dead, vegetative, or severely neurologically impaired? Assessing outcome for comatose survivors of cardiac arrest. JAMA 2004; 291: 870879.
  • 4
    Jay CL, Lyuksemburg V, Kang R et al. The increased costs of donation after cardiac death liver transplantation: Caveat emptor. Ann Surg 2010; 251: 743748.
  • 5
    Jay CL, Lyuksemburg V, Ladner DP et al. Ischemic cholangiopathy after donation after cardiac death liver transplantation: A meta-analysis. Ann Surg 2010. In press.