Uncontrolled organ donation after circulatory death protocols in out-of-hospital cardiac arrests. A potential solution to organ shortage? Alexandre Garioud1*, Fredrik Folke1, Freddy Lippert1 1 Emergency Medical Services Copenhagen, University of Copenhagen, Denmark * Corresponding author, email: tfl459@alumni.ku.dk BACKGROUND Increasing transplantation waiting lists in countries exerting organ transplantation demonstrate that traditional donation after brain death (DBD) is failing to meet the increasing request for donations. The shortage of organs is growing with recent improvements in medical and surgical treatments for brain injuries. This has led to the pioneering of protocols for donation after circulatory death (DCD) as a possible solution. The aim of this study was to evaluate the implementation of uncontrolled donation after circulatory death (uDCD) protocols following out-of-hospital cardiac arrests (OHCA) by reviewing the procedures published to date, assessing the results and outcomes for transplanted organs, and outlining the current ethical concerns related to these practices. METHODS We performed a review based on the PRISMA guidelines [1]. We included studies on potential adult uDCD candidates and active protocols for uDCD between 2005 and 2016 – either alone or in comparison with controlled DCD or DBD - for kidney, liver or lung donation. We included systematic reviews, reviews, clinical studies and ethical articles in English and French. The exclusion criteria were: studies on DBD, controlled DCD or in-hospital cardiac arrests only, tissue donation, pediatric deaths, forensic deaths, and traumatic cardiopulmonary arrests. We performed a search based on the MEDLINE database supplemented with a GOOGLE SCHOLAR search on September 10th, 2016. Data were extracted from all included studies and classified into three main categories: Algorithms for uDCD after OHCA protocols (timeline, checkpoints, patient inclusion criteria, organ preservation techniques) Transplant outcomes (type of organ and comparison to non-uDCD donation) Ethics (arguments for or against uDCD) We performed a literary systematic review summarizing current practices and knowledge on uDCD after OHCA . We found no randomized clinical controlled studies. We aimed to summarize the ethical debate objectively. RESULTS Out of 288 screened original articles, we selected 25 articles for inclusion in our review (Figure 1). ALGORITHMS FOR uDCD IN OHCA The key points of the algorithms are summarized in Figure 2, illustrating the timeline from cardiac arrest (CA), over advanced or basic life support (ALS/BLS), termination of resuscitation (TOR), the “no-touch” period prior to the death declaration, resuming CPR, preservation techniques, to organ recovery and transplant. Techniques and target times varied considerably. TRANSPLANT OUTCOMES Kidney donation showed the best results with no significant differences in outcome compared to donation after brain death (1-year graft survival ranges from 87.4 to 100%) and a significant increase in the number of transplants (10%). Liver and lung donations did not achieve as strong outcomes (1-year liver graft survival from 50 to 80%, 1-year lung-transplanted survival from 68 to 69%) but showed promising results. ETHICAL DILEMMAS The protocols have raised concerns related to the use of preservation techniques in association with the death declaration and the moment of donation consent, as well as debates concerning the death declaration by circulatory criteria and the potential conflict of interest between uDCD and therapeutic resuscitation attempts. *Basic preservation started pre-hospital while maintaining CPR until death declaration or in-hospital after death declaration and consent. Depending on legislation Figure 2. Timelines and crucial check points in the clinical pathway of uDCD algorithms. CONCLUSION uDCD in OHCA is a complex and controversial process. The concept is yet in its developmental phase but has proven to be a feasible alternative to fight growing transplantation lists. It has presented encouraging and still improving results. However, further standardization of procedures is needed to perform a systematic analysis of uDCD outcomes. Prior to implementation of the protocols, ethical concerns such as presumed consent, death declaration by circulatory criteria, and the associated potential conflicts of interest should be clearly addressed. REFERENCES 1. Moher, D., et al., Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Bmj, 2009. 339: p. b2535. Figure 1. Flow-chart of exclusions from initial search to final study selection. From 288 potential citations to 25 selected studies.