1. DECEASED KIDNEY
DONORS
Dr. Gurpremjit Singh
Senior Resident,
Dept. of Urology, AIIMS Rishikesh
URO-NEPHRO MEET
Moderator – Dr Vikas Kumar Panwar
Assistant Professor
Dept. of Urology, AIIMS Rishikesh
3. “An organ wasted is a life lost”
• More than 2 lakh Indians require
organ transplants annually
• Less than 10% are able to get timely
help
• At least 10 patients die every day
while on waiting list for organs
Union Health Ministry (Nov 2018)
4. 7500 kidney transplants as against
1,50,000 required (1)
1500 livers transplanted leaving
some 20,000 in waiting (2)
1.Current trends in kidney transplantation in India. Indian J Urol IJU J Urol Soc India.
2016;32(3):173–4, 2. NOTTO website
5. Indian Scenario
• Incidence of ESRD in India 151-232/ million year
• 150,000 patients need kidney transplant each year
• 7500 transplants each year
• 95% living
– 60-70% related
– 30-40% unrelated
• 5% cadaver donors
Vivekanand Jha. Current status of end-stage renal disease care in India and Pakistan. Kidney International Supplements 2013; 3(2):
6. Deceased donor
• Constitutes less than 5% of all kidney transplants in India
• Only 35 out of 200 approved renal transplant centers perform
DDRT regularly
• Tamil Nadu has donation rate of is 2.1/million vs national rate of only 0.08/million
• Around 14.4% of donors and 28.9% of recipients are females
N Gopalakrishnan, Ind journal of nephrology 2017
8. World statistics
• 60% of organ donors are deceased
• > 80 % are deceased by neurologic criteria - donation after neurologic
determination of death [DNDD]
• Remaining are deceased by circulatory death - donation after circulatory
determination of death [DCDD]
9. THE TRANSPLANTATION OF
HUMAN ORGANS ACT, 1994
also called as Transplantation of
Human Organs and Tissue Act
(THOTA)
10. Transplantation of Human Organs Act
1994
▪ Legalized the concept of brain death
thereby facilitating organ procurement
from heart beating, brain dead donors
▪ Aimed at stopping commercial dealing
of organs, especially kidneys
▪ Defined donor types – live/related,
live/unrelated and cadaver
11. Definitions according to the act
• “Brain-stem death” means the stage at which all functions of the brain-
stem have permanently and irreversibly ceased
• “Deceased person” means a person in whom permanent disappearance
of all evidence of life occurs
• Natural cardiac death- only a few organs/tissues can be donated (like
cornea, bone, skin and blood vessels)
• Brain stem death, almost 37 different organs and tissues can be
donated including vital organs such as kidneys, heart, liver and lungs
12. Procedure
• Ways to donate organs
➢ Pledge for organ donation when person is alive
➢ By consent of family after death
➢ Filling up the donor form in presence of two witnesses, one of
whom shall be a close relative
➢ After receiving the donor form, ORBO/other organization
provides the donor with an organ donor card
13. ➢ If a person expires without registration, family can donate organs
➢ Panel of 4 doctors need to declare brain death twice in span of 6 hrs, 2 of which
should be appointed by govt.
➢ Once written consent from family, organs are harvested within few hours
➢ The body is returned with dignity and without any deformation.
17. CRITERIA FOR BRAIN DEATH
• All appropriate diagnostic and therapeutic procedures have been performed and the patients
condition is irreversible
• Criteria (to be present for 30 minutes at least 6 hours after the onset of coma and apnea)
1. Coma
2. Apnea (no spontaneous respirations)
3. Absent cephalic reflexes (pupillary, corneal, oculovestibular,
oculocephalic)
4. Absent brain stem reflexes (cough, pharyngeal, and swallowing)
• Confirmatory test:
Absence of cerebral blood flow by radionuclide brain scan/ doppler
20. • Three major findings that need to be identified and
documented to confirm brain death:
➢ Coma or unresponsiveness
➢ Absence of brainstem reflexes
➢ Apnea
21. Coma or unresponsiveness
• No motor response or eye movement to noxious stimuli, typically described as nail
bed pressure or supraorbital pressure.
• This can be the most difficult part of the examination as a wide range of
spontaneous and reflex movements have been described
• These include isolated jerks of the upper extremities, cremasteric, abdominal
muscle reflexes and respiratory-like movements
• More extreme reflexes have elicited more fanciful descriptions, including the
“Lazarus sign,” where a combination of shoulder, neck, and extremity movements
makes patients appear to rise from the bed
22. Absence of brainstem reflexes
A. Pupillary reflex (cranial nerve (CN) II and III)
B. Ocular movement (CN III, VI, and VIII)
– Oculocephalic reflex otherwise known as the “doll’s eye” sign
– Vestibulo-ocular reflex. Also known as the “caloric reflex test
C. Facial sensation and facial motor response (CN V and VII)
• Absence of a corneal reflex
• Absence of a jaw reflex
D. Pharyngeal and tracheal reflexes (CN IX and X)
23. Apnea
• The absence of a drive to breathe is the final test in the clinical evaluation of brain
death.
• Normally, an elevation in CO2 above a critical level (defined as >60 mmHg) will
stimulate the respiratory center in the medulla
• The apnea test is designed to provoke this response
24. Prerequisites
• Normotension (systolic blood pressure ≥90 mmHg)
• Normothermia (core temperature >36 °C)
• Euvolemia
• Eucapnia (PaCo2 35–45 mmHg)
• Absence of hypoxia
• No prior history of CO2 retention (COPD or OSA)
25. • Preparation
➢ Preoxygenate the patient with 100% O2 prior to the test, target PaO2 >200mmHg
➢ Reduce the ventilation frequency to 10–12 breaths/min to achieve eucapnia
➢ Measure arterial Po2, PCo2, and pH after these preparatory steps prior to starting
the test
• Testing
Disconnect the patient from the ventilator
Observe closely for respiratory movements (abdominal, chest, neck) that could
produce adequate tidal volumes
28. Establishing brain death
• Strict guidelines laid down by law
• Certified by team of four doctors
not connected with the transplant
team
Neurologist,
Neurosurgeon
Critical care specialist
• Tests done at least twice, 6 hours
apart
• Only in institutions with
appropriate license
29. Contraindications to Organ Donation
• Malignancy (except primary brain
tumors, low grade skin
malignancies)
• Uncontrolled Sepsis
• Active viral infections – causing
encephalitis, herpes, hepatitis and
AIDS
30. • Deceased donor score system: Six donor variables obtained at procurements
( 0-39)
– Donor age (0-25 points)
– History of hypertension (0-4 points)
– Creatinine clearance (0-4 points)
– HLA mismatch (0-3 points)
– Cause of death (0-3 points)
– Body weight (0-1)
– Greater than 20 points cumulative has poorer outcomes
Scoring System
31. DCD
• More precise term Donation after Circulatory Determination of Death (DCDD)
• Cardiac standstill or cessation of cardiac function occurred before the organs
were procured
• Modified Maastricht classification: depending on the circumstances and
manner in which cardiac standstill occurred
• Two subtypes of DCD :
– Uncontrolled DCD
– Controlled DCD
32. Uncontrolled DCD
OPTN defines uncontrolled DCD (uDCD) as :
“a candidate who expires in the emergency room or elsewhere in the hospital before
consent for organ donation is obtained and catheters are placed in the femoral vessels
and peritoneum to cool organs until consent can be obtained”
Or
“a candidate who is consented for organ donation but suffers a cardiac arrest requiring
CPR during procurement of the organs.”
Thoung et al, Transplant International 2016
33. Uncontrolled DCD
1 No flow: Kidney ≤ 30 min
2 CPR duration: ≥ 30 min
3 No-touch period: 2 min to 20 min
4 Total WIT: 90 min to 120 min
Thoung et al, Transplant International 2016
34. Controlled DCD
OPTN defines Controlled DCD (c DCD) as
“a donor whose life support will be withdrawn and whose family has given written
consent for organ donation in the controlled environment of the operating room”
Or
“In which the donor's hemodynamic stability and respiratory function were maintained
until the patient is extubated”
Thoung et al, Transplant International 2016
35. Controlled DCD
1. Functional WIT starts
when SBP is ≤50 mmHg
2 No-touch period: 2 min to
20 min
Thoung et al, Transplant International 2016
36. Thoung et al, Transplant International 2016
Modified Maastricht classification (DCD C. Paris 2013)
37. This study included
grafts donated after
brain death (DBD) (n
= 3611) and cardiac
death (n= 2711)
performed between
2000 and 2017
Netherlands
38. Extended criteria donors
a) Aged 60 or
b) Aged 50 to 59 yr and has any two of the following
➢ Cause of death is CVA
➢ History of hypertension and
➢ Terminal serum creatinine 1.5 mg/dl
39.
40. Criteria For Cadaver Donor Selection
• Irreversible brain damage
• Normal organ function appropriate for age
• No evidence of preexisting disease
• No evidence of transmissible diseases
• ABO blood group-compatible
• Negative cross-match
• Best HLA match possible
• OPTN---- Time frame tests (ABG, CXR, LFT, Urine analysis, C/S)
• Organ specific tests---- Echocardiography, Bronchoscopy
41.
42. Cadaveric Organ Retrieval
• Usually part of a multi organ retrieval
• Long midline incision
– Sternal notch to pubis
– Sternum split
• Abdomen & chest cavities visually inspected for any
contraindications to organ donation ( malignancy)
46. • After widely opening and
exploring the peritoneal cavity, the
small bowel is retracted to expose
the posterior parietal peritoneum,
which is incised
• This allows retraction of the bowel
superiorly and to the left.
47. • The duodenum and pancreas
are retracted superiorly to obtain
exposure of the proximal aorta
and vena cava
• The superior mesenteric and
celiac trunks are ligated and
divided several centimeters
above the level of the left renal
vein crossing the aorta
48. • The infrarenal aorta circumferentially dissected , prepared for insertion of an in-situ
perfusion cannula
• Umbilical tapes are placed around the aorta
• After systemic heparinization, the proximal aorta is ligated and
perfusion started through the aortic cannula
49.
50. • After ligation of the
proximal and distal aorta and
the distal vena cava, perfusion
of the kidneys is begun
through the intravenous
tubing that has been
introduced into the distal
aorta
51. . Perinephric tissues are generously divided
on both sides, and ligaments as well as
attachments of the kidneys and great
vessels posteriorly are sharply divided
directly on the spine
52. • Mobilization of the kidneys
and ureters from the
retroperitoneum is completed
58. Packing and transportation
• The graft is
- Placed in sterile plastic bags containing
preservation solution
- Strong plastic container and an additional
plastic bag
- Proper insulation, temp.
59. WHO Terminology
• Possible donor- Pt with a devastating brain injury on mechanical ventilation
• Potential donor- Pt whose clinical condition is suspected to fulfil brain death criteria
• Eligible donor- Pt with diagnosis of brain death with no known C/I to donation
• Actual donor- Pt in which an incision is made with intent of organ recovery
• Utilized donor- Donor from whom at least one organ was transplanted
60. Take home message
• Wide gap exist between Recipients and donor pool
• India has one of the least number of deceased donors and needs revolutionary
changes
• Proper donor evaluation key to graft success in these patients
All of us must sign up for organ donation
