Copyright restrictions may apply JAMA Pediatrics Journal Club Slides: Neonatal Organ Tissue Donation After Circulatory Determination of Death Stiers J, Aguayo C, Siatta A, Presson AP, Perez R, DiGeronimo R. Potential and actual neonatal organ and tissue donation after circulatory determination of death. JAMA Pediatr. Published online May 11, doi: /jamapediatrics

Copyright restrictions may apply Background –Historically, neonates have not been eligible for organ donation owing to the technical difficulties and the high risk for graft complications. –Ongoing organ shortages coupled with improved technology and surgical techniques have led to a renewed interest in neonates as potential candidates for organ donation after circulatory determination of death (DCDD). –Despite DCDD potential, the percentage of neonates who actually donate organs at the time of death is unknown. Study Objective –To describe the percentage of neonates potentially eligible for DCDD, including those who underwent successful donation, and reasons for ineligibility in those who did not. Introduction

Copyright restrictions may apply Study Design –Data were obtained from the Children’s Hospital Neonatal Database and Intermountain Donor Services (IDS) organ procurement records and reviewed retrospectively. Setting –Neonatal intensive care unit (NICU) at Primary Children’s Hospital, Salt Lake City, Utah. Participants –The 136 deaths that occurred from January 1, 2010, through May 7, 2013, were reviewed to determine potential eligibility for DCDD as determined by IDS criteria: requirement of life-sustaining interventions at the time of organ procurement organization (OPO) referral and weight >2 kg. Methods

Copyright restrictions may apply Methods Outcomes –Potential eligibility for DCDD and timeliness of OPO referral among neonates who died. –For patients who did not undergo DCDD, we reviewed records to determine the reasons for ineligibility. Limitations –The study involved a single, level IV referral NICU with a high rate of medical complexity that may limit translation of findings to other centers. –OPO referral and medical records were the only measures to assess consideration of organ donation for any given patient. –The study sample size is small and may not identify clinically important differences between those referred to the OPO in a timely manner and those referred late.

Copyright restrictions may apply Results Flowchart for Determining Potential Organ Donation Among Neonates

Copyright restrictions may apply 76 neonates (55.9%) weighed >2 kg at the time of death. 65 neonates (47.8%) had elective withdrawal of life-sustaining interventions; 5 (3.7%) of these neonates did not require mechanical ventilation for life support. Of the 60 neonates eligible for DCDD, 45 (33.1%) died within 90 minutes of withdrawal of life-sustaining interventions, meeting warm ischemic time (WIT) criteria for en bloc kidney and hepatocyte donation. 8 neonates (5.9%) had a WIT of minutes, making them eligible for hepatocyte donation; 7 neonates (5.1%) exceeded the WIT, precluding organ donation. 57 neonates (41.9%) exceeded 2.74 kg, making them eligible for heart valve donation regardless of WIT. Results

Copyright restrictions may apply The timing of OPO referral was evaluated for all patients meeting minimum eligibility criteria for DCDD. Only 11 neonates (8.1%) had timely OPO referral (prior to withdrawal of life-sustaining interventions). –Medical records indicated the family inquired about and actively pursued organ donation in all 11 cases. –Of the 11 neonates referred, 4 were found to be ineligible on further review, 4 families declined participation, and 3 donated en bloc kidneys. The remaining 49 neonates (36.0%) were referred to the OPO after withdrawal of life-sustaining interventions or were not referred at all. –One neonate donated heart valves at the time of autopsy despite late referral. Results

Copyright restrictions may apply Results OPO Referral in Patients Weighing >2 kg

Copyright restrictions may apply Comment Adults receiving en bloc kidney transplants from neonatal donors (as small as 1.9 kg, shown below) have excellent results, and experience with these challenging cases is increasing. In our study, we found more than one-third of all NICU deaths met the minimum criteria for DCDD. Of these, only a small percentage were identified and referred to the OPO early enough to undergo evaluation for DCDD. Intraoperative picture of en bloc kidneys from a 1.9-kg donor, successfully transplanted into an adult recipient (courtesy of IDS). Our study supports recent estimations 1,2 that universal adoption of DCDD programs in US NICUs could provide kidney donations annually. 1 Hanley H, Kim S, Willey E, Castleberry D, Mathur M. Identifying potential kidney donors among newborns undergoing circulatory determination of death. Pediatrics. 2014;133(1):e82-e87. 2 Labrecque M, Parad R, Gupta M, Hansen A. Donation after cardiac death: the potential contribution of an infant organ donor population. J Pediatr. 2011;158(1):31-36.

Copyright restrictions may apply Comment Successful DCDD relies on early identification of eligible patients and OPO referral prior to withdrawal of life-sustaining interventions. In addition to minimum eligibility requirements (weight and WIT) for DCDD, the number of potential candidates who actually become donors also depends on end-organ function, coexisting conditions, family wishes, and surgeon availability. A significant disconnect exists between donor potential and the identification and timely OPO referral that ultimately leads to successful transplants. Improved education of NICU practitioners and staff regarding the process of OPO referral will likely improve the potential opportunities for families to participate in organ donation.

Copyright restrictions may apply If you have questions, please contact the corresponding author: –Justin Stiers, MD, Division of Neonatology, Department of Pediatrics, University of Utah, 295 Chipeta Way, Williams Building, Salt Lake City, UT Conflict of Interest Disclosures None reported. Contact Information