Work

The real number of organs from uncontrolled donation after circulatory determination of death donors

Year: 2020

Type: letter

Abstract: To the Editor: We write about Boyarsky et al’s estimate of uncontrolled Donation after Circulatory determination of Death donors (uDCDs)1Boyarsky BJ Jackson KR Kernodle AB et al.Estimating the potential pool of uncontrolled DCD donors in the United States.Am J Transplant. 2020; 20: 2842-2846Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar using data from the 2013 to 2016 Nationwide Emergency Department Sample (NEDS). They identified 9828 Emergency Department (ED)-based refractory cardiac arrests potentially eligible for uDCD; 91% had traumatic deaths. This estimate is <50% of 22 000 predicted by the National Academies of Medicine (NAM) 15 years ago.2Organ Donation: Opportunities for Action. National Academy of Sciences, Washington, DC2006Google Scholar Unfortunately, their methods challenge their findings. Estimating potential uDCDs is complex. It requires application of eligibility considerations: pre-hospital data (e.g., cardiac arrest time, witnessed arrest, time from collapse to resuscitation or normothermic regional perfusion initiation) excluded from NEDS. The NAM report provided conservative estimates using data from the PHASE study.3Lombardi G Gallagher J Gennis P. Outcome of out-of-hospital cardiac arrest in New York City. The Pre-Hospital Arrest Survival Evaluation (PHASE) Study.JAMA. 1994; 271: 678-683Crossref PubMed Scopus (426) Google Scholar After excluding traumatic injuries, NAM projections were over double those reported by Boyarsky, which were overly selective. For example, excluding “poisonings” likely reduced numbers, despite evidence provided by the authors that some acute opiate overdoses are ideal candidates. Furthermore, estimating the true potential from uDCDs requires focusing on dense urban areas where higher volumes of eligible donors present, rather than including EDs with limited patients and resources. Most importantly, where does death occur? The authors repeatedly state their estimates were “conservative.” We believe they are inaccurate. The most glaring consideration was neglecting patients who die unexpectedly outside or inside hospitals. Most people die suddenly, outside of hospital. It is difficult to determine the actual number. The American Heart Association estimates there are 350 000 out-of-hospital adult cardiac arrest victims annually; half were treated by Emergency Medical Services (EMS) personnel, because their arrest was witnessed or was judged recent.4Virani SS Alonso A Benjamin EJ et al.Heart disease and stroke statistics-2020 update: a report from the American Heart Association.Circulation. 2020; 141: e139-e596Crossref PubMed Scopus (4099) Google Scholar The median age was 60. Hospital survival is 10%. So there may be as many as 100 000 EMS-treated out-of-hospital cardiac arrest victims under age 65 annually. There are over 200 000 in-hospital cardiac arrests annually with 152 000 fatalities. Even if median age is higher, with more comorbidities, these could provide a substantial number of uDCDs. This is where the uDCDs are. Although the processes to acquire these donors are daunting, the critical need for recipients mandates a more adequate assessment of organ donor numbers. In our small but real experience with lung recovery from uDCDs, trauma victims routinely had injured lungs, or had lost sufficient blood that donor serologies were not reliable.5Egan T Blackwell J Birchard K et al.Assessment of lungs for transplant recovered from uncontrolled donation after circulatory determination of death donors.Ann Am Thorac Soc. 2017; 14: S251Crossref PubMed Scopus (14) Google Scholar To enable organ survival from uDCDs would require maintaining circulation and transport to a hospital where organs could be recovered. In Spain this is routine practice, but is controversial in the United States. Dr. Bernat believes that maintaining circulation after death is illegal.6Bernat JL Bleck TP Blosser SA et al.Circulatory death determination in uncontrolled organ donors: a panel viewpoint.Ann Emerg Med. 2014; 63: 384-390Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar We disagree; in particular, for individuals who choose, while alive, to donate their organs. In the United States over 60% of Americans are registered to become organ donors. This consent has the legal weight of an advanced directive, and cannot be overruled by next-of-kin. There is an ethical argument to honor their wishes. Recovering organs from all uDCDs and evaluating suitability for transplant by ex-vivo perfusion could alleviate the shortage of lungs, livers, and kidneys, providing thousands more organs than the 15-year-old NAM estimate.2Organ Donation: Opportunities for Action. National Academy of Sciences, Washington, DC2006Google Scholar Dr. Egan was supported by the UNC Lung Transplant Research Fund with generous contributions from James Ferguson and his family and John Doherty. Dr. Wall and Dr. Goldfrank were supported by Health Resources and Services Administration (HRSA) grant R38OT08761. UNC Lung Transplant Research Fund; Health Resources and Services Administration (HRSA), Grant/Award Number: R38OT08761

Source: American Journal of Transplantation

DOI: 10.1111/ajt.16443

Authors: Thomas M. Egan, Stephen Wall, Lewis Goldfrank, John J. Requard III

Institutions: University of North Carolina at Chapel Hill, New York University

Language: English

Topic: Organ Donation and Transplantation

Subfield: Public Health, Environmental and Occupational Health

Field: Medicine

Domain: Health Sciences

SDG: Good health and well-being

Open Access status: hybrid

Estimated APC paid: $4,300