Organ donation update

David Crosbie
Why talk about it?
Death is devastating.
But you can save someone’s life
 Transplant list

• ~ 100 people die per year waiting for a

donor
• Much more likely to need an organ
yourself than ever become a donor
ICU starts the conversation…
 Definition of Death
There are 2 ways death is legally certified (Human
Tissue Act Victoria 1982)

1) “Irreversible cessation of circulation of blood in the

body of the person” (circulatory death - common)
OR
2) “Irreversible cessation of all function of the brain of
the person” (brain death – much less common)

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 Donate Life Network
• Australian Organ & Tissue Donation and
Transplantation Authority established 2009
• Branches in each state & territory
• Significant Commonwealth funding
• Aims to lift donation rates, educate
hospital staff and public
• www.donatelife.gov.au
 Two pathways of donation
Donation after Brain Death (DBD)
– Majority Aust (72% 2015)
• ANZICS Statement on Death and Organ Donation1
Donation after Circulatory Death (DCD)
– 28% Aust 2015
• National Protocol for Donation after Cardiac Death2
• ANZICS Statement on Death and Organ Donation

1. Australian and New Zealand Intensive Care Society, Edition 3.2,

2013.
2. National Health and Medical Research Council/Organ and Tissue
Authority, 2010.
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 Pathways to Multi-Organ Donation
Donation after Brain Donation after Circulatory
Death (DBD) Death (DCD)
1. Irreversible cardio respiratory or
1. Catastrophic neurologic injury neurological illness/injury
2. Decision to withdraw therapy
2. Death certified
3. End of life discussion
3. End of life discussion
4. Donation Discussion
4. Donation discussion
5. Family Consent
5. Family Consent
6. Medical assessment
6. Medical assessment
7. Tissue Typing & serology
7. Tissue Typing & serology 8. Organ & tissue offer & allocation
8. Organ & tissue offer & allocation 9. Withdrawal of cardiorespiratory support
9. Retrieval surgery 10. Death certified
11. Retrieval surgery

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Pathways to organ and tissue donation

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 Death
• Everyday part of ICU
• Biological/cultural/spiritual interpretations
• 19th century Harvey
– Cessation of heart & circulation
• 1950s
– Artificial ventilation severely brain injured
could be “kept alive”
Brain Death

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 Brain death
• Wertheimer 1959
• Coma, areflexia, apnoea
• Defined criteria for abandoning intensive
therapies
• 1977 Australia recommended statutory
definition of death be introduced
Process of Brain Death
As this cycle
continues,
cerebral
blood flow
declines to a
point at which
it ceases
altogether
and whole
brain death
occurs

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 Causes of Brain Death
• Spontaneous Intracranial haemorrhage
– subarachnoid or intracerebral haemorrhage
• Cerebral Oedema
– meningitis, acute hyperthermia/hypothermia
• Trauma
– motor vehicle accidents, gun shot wounds, falls
• Hypoxic injuries
– cardiac arrest, drowning, hanging, asthma
• Tumours
– primary brain stem tumour, astrocytomas

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 Brain death
• Victoria 2 doctors 5 years
post MBBS
– Irreversible pathology
– Unresponsive coma
– Absent brainstem reflexes
– Absent respiratory centre
function
• If unable to determine
clinically
– absent intracranial blood
flow determined with
imaging
There has been no documented case of a
person who fulfills the preconditions and
criteria for brain death ever subsequently
developing any return of brain function.
 Death and organ donation
• Donation occurs within a legal context
– ie after death has been declared
• Dying is a process, not an event
• Certification when an irrevocable point in
the process has been reached
Donation after circulatory
death
Donation after Circulatory Death
• Original pathway of organ donation
• Superseded by brain death donation
• Australia since mid 2000s DCD rates
steadily increasing
• Issues
– Complexity
– Logistical/ethical/legal considerations
– Prediction of time of death
Donation after Circulatory
Death (DCD)
1. Irreversible cardio respiratory or
neurological illness/injury
2. Decision to withdraw therapy
3. End of life discussion
4. Donation Discussion
5. Family Consent
6. Medical assessment
7. Tissue Typing & serology
8. Organ & tissue offer & allocation
9. Withdrawal of cardiorespiratory support
10. Death certified
11. Retrieval surgery
 DCD pre-requisites
• Family acceptance of prognosis
• Family consent
– Antemortem interventions permitted
• Maastricht category 3 or 4 expected circulatory death
• Death likely to occur within a time frame to permit
donation
– 30 min liver & pancreas
– 60 minutes kidneys
– 90 minutes lungs
 Maastricht categories
Cat 1: Dead on arrival – unknown warm ischaemic time

Cat 2: Unsuccessful resuscitation – known warm ischaemic time

Cat 3: Waiting cardiac death after planned withdrawal of cardio-

respiratory support – known and limited warm ischaemic time

Cat 4: Cardiac arrest after confirmation brain death but prior to

organ retrieval. Warm ischaemic time known and potentially
limited

Cat 5: Unexpected cardiac arrest in a critically ill patient – warm

ischaemic time known and potentially limited
Protocol
- NH protocol developed 2010
- based on national protocol from
Donate Life
- Designated Officer
- Coronial notification
- WCRS & declaration of death in
ICU
- family at bedside
- coordination with theatre team
- communication essential
 DCD at Northern
• Protocol as above
• 2011 – 1 intended
• 2012 – 2 intended
• 2013 – 1 intended
• 2014 - 4 successful cases, 1 intended
– All OHCA with HIE
• Kidneys, liver (research), whole eyes
• Kidney only x 2
• Kidneys, tissue, heart valves

• 2015 – 2 intended
• 2016 – 3 successful cases, 4 intended
– All OHCA with HIE
•
lungs
• kidneys & eyes
• kidneys, eyes, skin & bone tissue
 Prognostic factors in DCD
• Donor age
• Ischaemic times
• Warm ischaemia: once SBP < 50
• Perfusion techniques
• Antemortem interventions
 DCD outcomes
• Lung outcomes may be superior
• Kidney similar
• Liver generally not as good
– Prolonged ischaemia
– Bile duct injury
– Prefer donors < 40, death < 30 minutes
How do I identify a potential
donor?
 GIVE trigger
• Formally introduced in 2009
• ED, theatre, ICU
• Aims to identify every potential donor
• Call Intensivist!
 Deceased donors 2016
• 503 deceased donors, 104% increase on
2009 (establishment of Donate Life)
Deceased donors by jurisdiction
Deceased donors (pmp) by jurisdiction
Organs transplanted 2016
International comparison
Potential for
improvement
- Auditing identified 1 177 potential
donors
- 1.5 % of all hospital deaths
- Request rate 91.2%% ie 1 074
- Consent rate % ie 60.1%
- national goal is to aim for 75%
consent rate
 Donation at Northern Health
• David Crosbie, MDS,Monica Dowling NDS
• Recent activities
– Community education
• Donate Life Week
• Meetings with community groups
– Hospital education
• DCD simulation
 Northern Health statistics
• 2016
– 1 BD, 3 DCD donors
• 2 BD NMS, 4 DCD NMS
• 2 planned DCD 2015
– NMS
• 1 BD, 4 DCD donors 2014
– 1 planned DCD but NMS
• 2 brain death donations 2012, 2013
• 2 planned DCD 2012,2013
• 100% request rate 2012, 2013
– 100% for BD 2014, 67% for DCD
– but only 20% consent rate 2012, 33% 2013
– 2014 83%
• 15 eye/corneal donors 2012, 14 2013, 7 2014
 Collaborative Requesting
• NH first Vic hospital to participate in pilot
program
• Formal structured trial of using
“Designated Requestor”
• Specialist nurse or medical consultant
• Improve our consent rates
• Assess utility of 2 person requesting in
rigorous manner
 Eye & Tissue donation
Eye and tissue donation for transplantation
refers to donation of:
• Eyes – corneas and sclera
• Heart tissue – valves and pericardium
• Musculoskeletal tissue – bone, fascia,
tendons / ligaments and meniscus
• Skin
 Eye & tissue donation
• Most frequently performed transplant
surgeries
 Who can donate?
• Any person who has died may be able to donate eyes
and tissues
• Hospital deaths
– Circulatory death in hospital wards (the majority for eyes)
– Brain dead organ donors
– Donation after cardiac death organ donors
• Community deaths
– Coronial Centre or under coronial jurisdiction
– (the majority of tissue donors in this donor pool) in some
jurisdictions
– Hospice, Nursing Homes, Funeral Directors
– (in-practice eyes only) in some jurisdictions
 Eye donation
Inclusions Exclusions
• Anyone < 80 yo • Uncontrolled sepsis
• Coronial cases • Neurodegenerative
• Malignancy disease
• Treated bacteraemia • Haem malignancy
• HIV/HBV/HCV risk factors
Indications for Corneal Transplant
KERATOCONUS – ‘coning’ of the cornea
• progressive, presents in early teens & 20s

BULLOUS KERATOPATHY – painful epithelial blisters

• sequela of eye surgery, ageing

CORNEAL DYSTROPHIES – “hazing”

• progressive, genetic (Fuchs’ dystrophy)

INFECTION – inflammation & vascularisation

TRAUMA
• ulceration, perforation
 Corneal recipient
Wayne was told that he would probably lose his eye as he had an extremely
rare infection. A fireman for 18 years, Wayne had been in many dangerous
situations but he couldn’t recall ever being scared. After that visit to the
doctor, he knew true fear.

His eye was eventually saved through intensive therapy and two corneal
transplants. “There probably isn’t a day that I don’t think about my eye, and the
two people who donated their corneas. Saying thank you is not enough for me,
nowhere near enough.”
 Tissue donation
Inclusions Exclusions
• < 70 years • Most malignancies
• Within 24h of death • Untreated sepsis
• Coronial cases • HIV etc risk factors
• Neurodegenerative
diseases
 Heart valve recipient
The birth of their fourth child should have been a joyous occasion but it quickly turned
into a nightmare for Shaun and Liv White. At only five and a half weeks old Dane
White faced the first of many challenges; surgery to transplant a new aortic heart
valve.

It was a decision to donate that saved Dane’s life. Dane is now heading
towards his fourth birthday and is currently in a time of “bliss” as his
mother calls it. It’s a time when he is growing well, putting on weight and
is not on any medication.
 Indications for heart tissue use
Human heart valves are allografts used for:

• Paediatrics (1-2% of population)

• Women of child bearing age
• Active adults or non-compliant with medications
• People living in remote areas
• No need for anti-coagulant therapy
• Durability - average 10-12yrs (up to 20yrs)
• Young recipients, valves are replaced as the
recipient grows
 Tissue recipients - tendons
The generosity of her donor and their family have
changed Morgan’s outlook on life - “I never really
thought about organ donation before… I may not
have received a heart or a lung or something that is
totally life-changing, but I have received…(a patella
tendon graft)… something that is helping me
achieve my goals”

Tina Morgan, Australian Tae kwon doe athlete, Sydney Morning Herald,
Sept 24, 2007

Winning her second Olympic gold medal Alisa Camplin

thanked the organ donor whose generosity allowed
doctors to repair her right knee so she could compete -“I
am a registered organ donor and I am the lucky recipient
of one …thank you, thank you …”

Alisa Camplin, Australian Aerial ski jumping athlete, The Age, January 27, 2004
 Skin
• Victoria had to
import skin after
Black Saturday
 Eye & tissue donation NH
• 15 eye donors 2012, 14 2013, 7 2014
– Majority ICU
• Femoral head program planned
• Planned roll out of policy for ward patients
• Death in < 80 yo?
– Ask the family
– Call Lions eye bank
• They will do the rest!
Organ donor register
 References
• Coulson TG, Pilcher DV et al
– Single centre experience of donation after cardiac
death MJA 2012 197: 166-169
• AOTA performance report 2014
• Donate Life website
• Levvey BJ, Harkess M et al
– Excellent clinical outcomes from a national donation-
after-determination-of-cardiac-death lung transplant
collaborative Am J Transplant. 2012 Sep;12(9):2406-
13.
Questions?