Organ donation in adults: a critical care perspective

Abstract

Purpose

The shortage of organs for transplantation is an important medical and societal problem because transplantation is often the best therapeutic option for end-stage organ failure.

Methods

We review the potential deceased organ donation pathways in adult ICU practice, i.e. donation after brain death (DBD) and controlled donation after circulatory death (cDCD), which follows the planned withdrawal of life-sustaining treatments (WLST) and subsequent confirmation of death using cardiorespiratory criteria.

Results

Strategies in the ICU to increase the number of organs available for transplantation are discussed. These include timely identification of the potential organ donor, optimization of the brain-dead donor by aggressive management of the physiological consequence of brain death, implementation of cDCD protocols, and the potential for ex vivo perfusion techniques.

Conclusions

Organ donation should be offered as a routine component of the end-of-life care plan of every patient dying in the ICU where appropriate, and intensivists are the key professional in this process.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2

References

  1. 1.

    Lesieur O, Leloup M, Gonzalez F, Mamzer M-F (2014) Eligibility for organ donation following end-of-life decisions: a study performed in 43 French intensive care units. Intensive Care Med. doi:10.1007/s00134-014-3409-2

    Article  PubMed  Google Scholar 

  2. 2.

    Frontera JA, Curtis JR, Nelson JE et al (2015) Integrating palliative care into the care of neurocritically ill patients. Crit Care Med. doi:10.1097/CCM.0000000000001131

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Domínguez-Gil B, Murphy P, Procaccio F (2015) Ten changes that could improve organ donation in the intensive care unit. Intensive Care Med. doi:10.1007/s00134-015-3833-y

    Article  PubMed  Google Scholar 

  4. 4.

    Da Silva IRF, Frontera JA (2015) Worldwide barriers to organ donation. JAMA Neurol 72:112–118. doi:10.1001/jamaneurol.2014.3083

    Article  PubMed  Google Scholar 

  5. 5.

    Wahlster S, Wijdicks EFM, Patel PV et al (2015) Brain death declaration: practices and perceptions worldwide. Neurology 84:1870–1879. doi:10.1212/WNL.0000000000001540

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Wijdicks EFM, Varelas PN, Gronseth GS et al (2010) Evidence-based guideline update: determining brain death in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 74:1911–1918. doi:10.1212/WNL.0b013e3181e242a8

    Article  PubMed  Google Scholar 

  7. 7.

    Wijdicks EFM (2002) Brain death worldwide: accepted fact but no global consensus in diagnostic criteria. Neurology 58:20–25

    Article  PubMed  Google Scholar 

  8. 8.

    Citerio G, Crippa IA, Bronco A et al (2014) Variability in brain death determination in Europe: looking for a solution. Neurocrit Care 21:376–382. doi:10.1007/s12028-014-9983-x

    Article  PubMed  Google Scholar 

  9. 9.

    Greer DM, Varelas PN, Haque S, Wijdicks EFM (2008) Variability of brain death determination guidelines in leading US neurologic institutions. Neurology 70:284–289. doi:10.1212/01.wnl.0000296278.59487.c2

    Article  PubMed  Google Scholar 

  10. 10.

    Shappell CN, Frank JI, Husari K et al (2013) Practice variability in brain death determination: a call to action. Neurology 81:2009–2014. doi:10.1212/01.wnl.0000436938.70528.4a

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Powner DJ, Hernandez M, Rives TE (2004) Variability among hospital policies for determining brain death in adults. Crit Care Med 32:1284–1288

    Article  PubMed  Google Scholar 

  12. 12.

    Hornby K, Shemie SD, Teitelbaum J, Doig C (2006) Variability in hospital-based brain death guidelines in Canada. Can J Anaesth 53:613–619. doi:10.1007/BF03021854

    Article  PubMed  Google Scholar 

  13. 13.

    Citerio G, Murphy PG (2015) Brain death: the European perspective. Semin Neurol 35:139–144. doi:10.1055/s-0035-1547533

    Article  PubMed  Google Scholar 

  14. 14.

    Haupt WF, Rudolf J (1999) European brain death codes: a comparison of national guidelines. J Neurol 246:432–437

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    Scott JB, Gentile MA, Bennett SN et al (2013) Apnea testing during brain death assessment: a review of clinical practice and published literature. Respir Care 58:532–538. doi:10.4187/respcare.01962

    Article  PubMed  Google Scholar 

  16. 16.

    Shemie SD, Hornby L, Baker A et al (2014) International guideline development for the determination of death. Intensive Care Med 40:788–797. doi:10.1007/s00134-014-3242-7

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Shemie S, Baker A (2015) Uniformity in brain death criteria. Semin Neurol 35:162–168. doi:10.1055/s-0035-1547538

    Article  PubMed  Google Scholar 

  18. 18.

    Shemie SD, Baker A (2014) Where have we been? Where are we going? Initiatives to improve uniformity of policies, integrity of practice, and improve understanding of brain death within the global medical community and lay public. J Crit Care 29:1114–1116. doi:10.1016/j.jcrc.2014.08.007

    Article  PubMed  Google Scholar 

  19. 19.

    Gries CJ, White DB, Truog RD et al (2013) An Official American Thoracic Society/International Society for Heart and Lung Transplantation/Society of Critical Care Medicine/Association of Organ and Procurement Organizations/United Network of Organ Sharing Statement: ethical and policy considerations in organ donation after circulatory determination of death. Am J Respir Crit Care Med 188:103–109. doi:10.1164/rccm.201304-0714ST

    Article  PubMed  Google Scholar 

  20. 20.

    Dalal AR (2015) Philosophy of organ donation: review of ethical facets. World J Transpl 5:44–51. doi:10.5500/wjt.v5.i2.44

    Article  Google Scholar 

  21. 21.

    Shaw D (2015) Organ donation is the right decision: a delicate truth. Intensive Care Med. doi:10.1007/s00134-015-3891-1

    Article  PubMed  Google Scholar 

  22. 22.

    Shemie SD (2007) Clarifying the paradigm for the ethics of donation and transplantation: was “dead” really so clear before organ donation? Philos Ethics Humanit Med 2:18. doi:10.1186/1747-5341-2-18

    Article  PubMed  PubMed Central  Google Scholar 

  23. 23.

    Sixty-Third World Health Assembly World Health Organization (2010) WHO guiding principles on human cell, tissue and organ transplantation. Cell Tissue Bank 11:413–419

    Article  Google Scholar 

  24. 24.

    Steinbrook R (2007) Organ donation after cardiac death. N Engl J Med 357:209–213. doi:10.1056/NEJMp078066

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Bernat JL (2008) The boundaries of organ donation after circulatory death. N Engl J Med 359:669–671. doi:10.1056/NEJMp0804161

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    Morrissey PE, Monaco AP (2014) Donation after circulatory death: current practices, ongoing challenges, and potential improvements. Transplantation 97:258–264. doi:10.1097/01.TP.0000437178.48174.db

    Article  PubMed  Google Scholar 

  27. 27.

    Domínguez-Gil B, Haase-Kromwijk B, Van Leiden H et al (2011) Current situation of donation after circulatory death in European countries. Transpl Int 24:676–686. doi:10.1111/j.1432-2277.2011.01257.x

    Article  PubMed  Google Scholar 

  28. 28.

    Borry P, Van Reusel W, Roels L, Schotsmans P (2008) Donation after uncontrolled cardiac death (uDCD): a review of the debate from a European perspective. J Law Med Ethics 36:752–759. doi:10.1111/j.1748-720X.2008.00334.x

    Article  PubMed  Google Scholar 

  29. 29.

    Bernat JL, Bleck TP, Blosser SA et al (2014) Circulatory death determination in uncontrolled organ donors: a panel viewpoint. Ann Emerg Med 63:384–390. doi:10.1016/j.annemergmed.2013.05.018

    Article  PubMed  Google Scholar 

  30. 30.

    Simpkin AL, Robertson LC, Barber VS, Young JD (2009) Modifiable factors influencing relatives’ decision to offer organ donation: systematic review. BMJ 338:b991–b991. doi:10.1136/bmj.b991

    Article  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Singbartl K, Murugan R, Kaynar AM et al (2011) Intensivist-led management of brain-dead donors is associated with an increase in organ recovery for transplantation. Am J Transpl 11:1517–1521. doi:10.1111/j.1600-6143.2011.03485.x

    CAS  Article  Google Scholar 

  32. 32.

    Bastami S, Matthes O, Krones T, Biller-Andorno N (2013) Systematic review of attitudes toward donation after cardiac death among healthcare providers and the general public. Crit Care Med 41:897–905. doi:10.1097/CCM.0b013e31827585fe

    Article  PubMed  Google Scholar 

  33. 33.

    Manara AR, Murphy PG, O’Callaghan G (2011) Donation after circulatory death. Br J Anaesth 108:i108–i121. doi:10.1093/bja/aer357

    Article  Google Scholar 

  34. 34.

    Souter MJ, Blissitt PA, Blosser S et al (2015) Recommendations for the critical care management of devastating brain injury: prognostication, psychosocial, and ethical management. Neurocrit Care 23:4–13. doi:10.1007/s12028-015-0137-6

    Article  PubMed  Google Scholar 

  35. 35.

    Mark NM, Rayner SG, Lee NJ, Curtis JR (2015) Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: a systematic review. Intensive Care Med. doi:10.1007/s00134-015-3810-5

    CAS  Article  PubMed  Google Scholar 

  36. 36.

    Sprung CL, Cohen SL, Sjokvist P et al (2003) End-of-life practices in European intensive care units: the Ethicus Study. JAMA 290:790–797. doi:10.1001/jama.290.6.790

    Article  PubMed  Google Scholar 

  37. 37.

    Patel S, Martin JR, Marino PS (2014) Donation after circulatory death. Crit Care Med 42:2219–2224. doi:10.1097/CCM.0000000000000511

    Article  PubMed  Google Scholar 

  38. 38.

    Algahim MF, Love RB (2015) Donation after circulatory death. Current Opinion Organ Transpl 20:1–6. doi:10.1097/MOT.0000000000000179

    Article  Google Scholar 

  39. 39.

    McKeown DW, Bonser RS, Kellum JA (2011) Management of the heartbeating brain-dead organ donor. Br J Anaesth 108:i96–i107. doi:10.1093/bja/aer351

    Article  Google Scholar 

  40. 40.

    Youn TS, Greer DM (2014) Brain death and management of a potential organ donor in the intensive care unit. Crit Care Clin 30:813–831. doi:10.1016/j.ccc.2014.06.010

    Article  PubMed  Google Scholar 

  41. 41.

    Smith M (2004) Physiologic changes during brain stem death-lessons for management of the organ donor. J Heart Lung Transpl 23:S217–S222. doi:10.1016/j.healun.2004.06.017

    Article  Google Scholar 

  42. 42.

    Kotloff RM, Blosser S, Fulda GJ et al (2015) Management of the potential organ donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations consensus statement. Crit Care Med 43:1291–1325. doi:10.1097/CCM.0000000000000958

    Article  PubMed  Google Scholar 

  43. 43.

    Al-Khafaji A, Elder M, Lebovitz DJ et al (2015) Protocolized fluid therapy in brain-dead donors: the multicenter randomized MOnIToR trial. Intensive Care Med. doi:10.1007/s00134-014-3621-0

    Article  PubMed  PubMed Central  Google Scholar 

  44. 44.

    Greer DM, Valenza F, Citerio G (2015) Improving donor management and transplantation success: more research is needed. Intensive Care Med. doi:10.1007/s00134-015-3661-0

    Article  PubMed  Google Scholar 

  45. 45.

    Dupuis S, Amiel J-A, Desgroseilliers M et al (2014) Corticosteroids in the management of brain-dead potential organ donors: a systematic review. Br J Anaesth 113:346–359. doi:10.1093/bja/aeu154

    CAS  Article  PubMed  Google Scholar 

  46. 46.

    Pinsard M, Ragot S, Mertes PM et al (2014) Interest of low-dose hydrocortisone therapy during brain-dead organ donor resuscitation: the CORTICOME study. Crit Care 18:R158. doi:10.1186/cc13997

    Article  PubMed  PubMed Central  Google Scholar 

  47. 47.

    Macdonald PS, Aneman A, Bhonagiri D et al (2012) A systematic review and meta-analysis of clinical trials of thyroid hormone administration to brain dead potential organ donors. Crit Care Med 40:1635–1644. doi:10.1097/CCM.0b013e3182416ee7

    CAS  Article  PubMed  Google Scholar 

  48. 48.

    Mascia L, Mastromauro I, Viberti S et al (2009) Management to optimize organ procurement in brain dead donors. Minerva Anestesiol 75:125–133. doi:10.2147/CLEP.S71403

    CAS  PubMed  Google Scholar 

  49. 49.

    Mascia L, Pasero D, Slutsky AS et al (2010) Effect of a lung protective strategy for organ donors on eligibility and availability of lungs for transplantation: a randomized controlled trial. JAMA 304:2620–2627. doi:10.1001/jama.2010.1796

    CAS  Article  PubMed  Google Scholar 

  50. 50.

    Niemann CU, Feiner J, Swain S et al (2015) Therapeutic hypothermia in deceased organ donors and kidney-graft function. N Engl J Med 373:405–414. doi:10.1056/NEJMoa1501969

    CAS  Article  PubMed  Google Scholar 

  51. 51.

    Dikdan GS, Mora-Esteves C, Koneru B (2012) Review of randomized clinical trials of donor management and organ preservation in deceased donors. Transplantation. doi:10.1097/TP.0b013e3182547537

    Article  Google Scholar 

  52. 52.

    Dhital KK, Iyer A, Connellan M et al (2015) Adult heart transplantation with distant procurement and ex vivo preservation of donor hearts after circulatory death: a case series. Lancet. doi:10.1016/S0140-6736(15)60038-1

    Article  Google Scholar 

  53. 53.

    Cypel M, Yeung JC, Liu M et al (2011) Normothermic ex vivo lung perfusion in clinical lung transplantation. N Engl J Med 364:1431–1440. doi:10.1056/NEJMoa1014597

    CAS  Article  PubMed  Google Scholar 

  54. 54.

    Cypel M, Yeung JC, Hirayama S et al (2008) Technique for prolonged normothermic ex vivo lung perfusion. J Heart Lung Transpl 27:1319–1325. doi:10.1016/j.healun.2008.09.003

    Article  Google Scholar 

  55. 55.

    Machuca TN, Mercier O, Collaud S et al (2015) Lung transplantation with donation after circulatory determination of death donors and the impact of ex vivo lung perfusion. Am J Transpl 15:993–1002. doi:10.1111/ajt.13124

    CAS  Article  Google Scholar 

  56. 56.

    Reeb J, Keshavjee S, Cypel M (2015) Expanding the lung donor pool: advancements and emerging pathways. Current Opinion Organ Transpl. doi:10.1097/MOT.0000000000000233

    Article  PubMed  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Giuseppe Citerio.

Ethics declarations

Conflicts of interest

The authors declare no conflict of interest for this manuscript.

Additional information

All the authors have contributed equally to this work.

Take-home message: The shortage of organs for transplantation is an important medical and societal problem. Strategies in the ICU can increase the number of organ available for transplantation. These include: 1. optimizing the management of donors after brain death (DBD). 2. Implementing controlled DCD (cDCD). 3. Introducing a pathway for patients with devastating brain Injury (DBI).

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 102 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Citerio, G., Cypel, M., Dobb, G.J. et al. Organ donation in adults: a critical care perspective. Intensive Care Med 42, 305–315 (2016). https://doi.org/10.1007/s00134-015-4191-5

Download citation

Keywords

  • Organ donation
  • Brain death
  • Donation after brain death
  • Donation after circulatory death
  • Intensive care