Management and Evaluation Prior to Transplantation of Deceased Donor

Jong Hwan Jung; Sung Kwang Park; Sik Lee

doi:10.4285/jkstn.2014.28.2.51

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Jung, Park, and Lee: Management and Evaluation Prior to Transplantation of Deceased Donor

Review Article

J Korean Soc Transplant 2014;28(2):51-58.

Published online: 10 June 2014

DOI: https://doi.org/10.4285/jkstn.2014.28.2.51

Management and Evaluation Prior to Transplantation of Deceased Donor

Jong Hwan Jung, M.D., Sung Kwang Park, M.D., Sik Lee, M.D.

Department of Internal Medicine, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, Korea

책임저자：이 식, 전북 전주시 덕진구 건지로 20전북대학교 의학전문대학원 내과학교실 신장내과, 561-712 Tel: 063-250-2151, Fax: 063-254-1609 E-mail: kidney@jbnu.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The number of people awaiting organ transplantation continues to exceed the number of organs available for transplantation, especially at a time when kidney transplantation is recognized as the best treatment option for end stage renal disease. There may be many reasons for this disparity of organ supply and demand, including the lack of consent, absence of an experienced coordinator team to help in closing the widening gap between organ supply and demand, and an unstandardized critical care management of potential organ donors. According to the report of the Korean Organ Transplant Registry in March 2014, due to a serious organ shortage in Korea, kidneys of deceased donors with low initial estimated glomerular filtration rate of ＜45 mL/min/1.73 m² (21.2%) and expanded criteria donors (18.3%) are frequently used, and the number of wife donors and ABO-incompatible transplants for blood type O recipients is increasing. Because the number of donor organs compared with the demand is very restricted, proper management of deceased donors in the intensive care unit has been recognized as a critical determinant for a successful transplantation. Therefore, for successful transplantation of harvested organs, many medical doctors who play an integral role in the transplantation process should understand the pathophysiology of brain death-related systemic changes and well-designed management guidelines should be used prior to transplantation of deceased donors. This article reports on brain death-related systemic changes and proper management for preservation of function of donor organs.

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Keywords: Organ transplantation, Organ preservation

References

1). Korean Network for Organ Sharing (KONOS). The second quarter 2013 transplant statistis [Internet]. Seoul: KONOS;2013. [cited 2013 Nov 20]. Available from:. http://konos.go.kr.

2). Ahn C, Koo TY, Jeong JC, Kim M, Yang J, Lee J, et al. Initial report of the Korean Organ Transplant Registry: the first report of national kidney transplantation data. Transplant Proc. 2014; 46:425–30.

3). A definition of irreversible coma. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. JAMA. 1968; 205:337–40.

4). Practice parameters for determining brain death in adults (summary statement). The Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 1995; 45:1012–4.

5). Johnson LS, Subramanian RM. Brain death and cardiac death: donor criteria and care of deceased donor. Morris PJ, Knechtle SJ, editors. ed,. Kidney transplantation: principles and practice. 7th ed.Edinburgh: Saunders, Elsevier;2014. p. 91–104.

6). Kim JG, Yang CW. Management of deceased donor. J Neurocrit Care. 2012; 5:40–3.

7). DuBose J, Salim A. Aggressive organ donor management protocol. J Intensive Care Med. 2008; 23:367–75.

8). Kim SJ. Organ donor management. J Korean Med Assoc. 2006. 49. ;502–6.

9). Gottmann U, Brinkkoetter PT, Bechtler M, Hoeger S, Karle C, Schaub M, et al. Effect of pre-treatment with catecholamines on cold preservation and ischemia/re-perfusion-injury in rats. Kidney Int. 2006; 70:321–8.

10). Rosendale JD, Kauffman HM, McBride MA, Chabalewski FL, Zaroff JG, Garrity ER, et al. Hormonal resuscitation yields more transplanted hearts, with improved early function. Transplantation. 2003; 75:1336–41.

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Fig. 1.

General approach to the diagnosis of brain death.

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Fig. 2.

The pathophysiological changes according to parts which are injuried in brain.

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Fig. 3.

Protocol for aggressive donor management. Abbreviations: ICU, intensive care unit; MAP, mean arterial pressure; SIADH, syndrome of inappropriate secretion of antidiuretic hormone.

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Table 1.

The criteria in determining of brain death in Korea

다음의 선행조건 및 판정기준에 모두 적합하여야 한다.
1. 선행조건
(1) 원인질환이 확실하고 치료될 가능성이 없는 기질적 뇌병변이 있다.
(2) 깊은 혼수상태로서 자발호흡이 없고 인공호흡기로 호흡이 유지된다.
(3) 치료 가능한 약물중독(마취제, 수면제, 진정제, 근육이완제 또는 독극물 등에 의한 중독)이나 대사성 또는 내분비성 장애(간성혼수, 요독성 혼수 또는 저혈당성 뇌증)의 가능성이 없어야 할 것
(4) 저체온상태(직장온도가 섭씨 32 ^o C 이하)가 아니어야 할 것
(5) 쇼크상태가 아니어야 할 것
2. 판정기준
(1) 외부자극에 전혀 반응이 없는 깊은 혼수 상태
(2) 자발호흡이 되살아 날 수 없는 상태로의 소실
(3) 두 눈의 동공이 확대 고정되어 있을 것
(4) 뇌간반사가 완전히 소실되어 있을 것
다음에 해당하는 반사가 모두 소실된 것을 말한다.
A. 광반사(light reflex)
B. 각막반사(corneal reflex)
C. 안구두부반사(oculo-cephalic reflex)
D. 전정안구반사(vestibulo-ocular reflex)
E. 모양체척수반사(cilio-spinal reflex)
F. 구역반사(gag reflex)
G. 기침반사(cough reflex)
(5) 자발운동, 제뇌강직, 제피질강직, 및 경련 등이 나타나지 아니할 것
(6) 무호흡 검사 결과 자발호흡이 유발되지 아니하여 자발호흡이 되살아날 수 없다고 판정될 것. 무호흡 검사가 불충분하거나중단된 경우에는 뇌혈류검사로 추가 확인하여야 한다.
(7) 다음의 구분에 따른 방법에 따라 (1)부터 (6)까지의 규정에 따른 판정 결과를 재확인하였을 때에도 그 결과가 같을 것
A. 뇌사판정대상자가 6세 이상인 경우: 1차 판정부터 6시간이 지난 후에 실시
B. 뇌사판정대상자가 1세 이상, 6세 미만인 경우: 1차 판정부터 24시간이 지난 후에 실시
C. 뇌사판정대상자가 생후 2개월 이상, 1세 미만인 경우: 1차 판정부터 48시간이 지난 후에 실시
(8) 다음의 구분에 따른 방법에 따라 뇌파검사를 하였을 때에 평탄뇌파가 30분 이상 지속될 것
A. 뇌사판정대상자가 1세 이상인 경우: (7)에 따른 재확인 이후에 실시
B. 뇌사판정대상자가 생후 2개월 이상, 1세 미만인 경우: (7)에 따른 재확인 이전과 이후에 실시

Table 2.

The guidelines of proper management of deceased donor

Cardiovascular management
Mean arterial pressure 70∼90 mmHg
Short-acting beta-blocker with esmolol in hypertension
Vasodilator with nitroprusside in hypertension
Fluide replacement followed by vasoactive agents in hypotension
Heart rate 60∼120 beats per minutes
Central venous pressure 4∼12 mmHg
Central venous oxygen saturation (ScvO²) ≥70%
Respiratory management
Mechanical ventilation
Fraction of inspired oxygen 0.40
Tidal volume 8∼10 mL/kg
Plateau pressure ＜35 cmH² O
Peak end expiratory pressure (PEEP) 5∼10 cmH² O
Arterial blood gas analysis
Ph 7.35∼7.45
PaCO² 30∼45 mmHg
PaO² ≥80 mmHg,
O² saturation ≥95%
Fluid management
Avoid excess fluid replacement to avoid pulmonary edema
Renal management
Urine output 0.5∼3 mL/kg/hr
Early recognition and correction of diabetes insipidus (urine output ＞4 mL/kg/hr)
If urine output is over 4 mL/kg/hr, use synthetic analogue of arginine vasopressin 8 ng/kg IV loading dose followed by 4 ng/kg/h IV to urine output ＜3 mL/kg/hr
Plasma sodium 140∼155 mEq/L
Normal concentration of plasma potassium, calcium, magnesium, phosphorous
Endocrine management
Euglycemia: plasma glucose 90∼180 mg/dL
Hormonal resuscitation
Methylprednisolone 15 mg/kg bolus
Triiodothyronine (T3) 4μ g/hr bolus followed by 3μ g/hr infusion
Arginine vasopressin 1 U bolus followed by 0.5∼4 U/hr
Miscellaneous
Normothermia (core temperature should be maintained above 34 ^o C)
Do initial baseline blood culture and repeat after 24 hours for infectious management
Pay attention to several clinical markers, including the skin examination, sputum characteristics, chest X-ray findings, and urinalysis results for infectious management
It is important to tailor broad empiric therapy as soon as culture results are available
Target hemoglobin level ＞8 g/dL

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