Organ Donation in DCD: 10 Year Experience at the University of Michigan A Rojas-Pena, MD; L Sall, BS; K. Koch, BS; E Cooley, RN; M Gravel, RN; R Bartlett, MD; J Punch, MD; S Pelletier, MD University of Michigan Health System Department of Surgery, Section of Transplantation and the Extracorporeal Life Support Program

2 DCD History at UM Large transplant program + large extracorporeal life support (ECS) program 2000, both programs were combined Extracorporeal support (ECS)  resuscitate and recover abdominal organs in controlled DCD (Maastricht category III) when the family requests organ donation Successful recovery / transplantation of kidneys, liver and pancreas Initial experience reported in 2005 with 20 ECS- DCD Magliocca, et al. The Journal of trauma 2005;58(6): ; discussion

3 Objectives Retrospective review of DCD program: –10-year experience –cases between October 2000 to August 2010 Update UM first series study on ECS assisted donation in controlled DCDECS-cDCD

4 Methods Potential cDCD  abdominal organs OK for procurement after dead Recipient outcome data of: –Kidneys and livers procured and transplanted at UM only RR technique (RR-DCD group) vs ECS technique (ECS-DCD group)

5 DCD selection <65yo/ Maastricht type III –Severe irreversible brain injury  NO BD criteria Intensive Care Unit (ICU) on MV and/or life support Cardio-circulatory arrest after planned withdrawal of life support Family  for donation –Consent for cannulation No contraindications to transplant grafts

6 UM – ECS circuit

7 Final DCD at UM Donor Type Potential (n) Excluded (n) Reason for Exclusion ECS5013 Prolonged CA = 11 Sx complication = 1 Positive Serology = 1 RR294 Prolonged CA = 4 37 ECS-DCD & 25 RR-DCD

8 ORPD & OTPD Rates Organs Recovered (n) Organs Transplanted (n) DCD typeKLP ORPD ORPDKLP OTPD OTPD ECS-DCD RR-DCD Total at UM ORPD: Organs Recovered per Donor / OTPD: Organs Transplanted per Donor / K:Kidney; L: Liver; P: Pancreas January-June 2011 DCD: 2.45 ORPD & 2.0 OTPD / Discard rate: 18% 2.45 ORPD & 2.0 OTPD / Discard rate: 18%

9 Summary of the ECS run Variable Initiation of ECS Termination of ECS pH7.099± ±0.027 SVO 2 (%) 45.5± ±3.2 PaCO 2 (mmHg) 55.5± ±2.4 SaO 2 (%)84.4± ±3.4 K + (mmol/L) 6.1±0.84.9±0.5 SVO 2 : mixed venous oxygen saturation; PaCO 2 : Partial pressure of Carbon Dioxide; SaO 2 : Arterial Blood Saturation

10 ECS-DCD Complications Complication(n)%Management & Outcome ECS flow (<45mL/kg/min) Converted to RR = 3 DCD ECS continued = 1 DCD Cannulation (No vascular access) 25.4 Converted to RR = 1DCD No Recovery = 1 DCD Bleeding 12.7 No Recovery Aortic Balloon 12.7 No Recovery

11 UM Outcomes Renal Grafts 37 patients (5 yr follow up) DGF: Need of HD within the first week post-transplantation - 50% due to hyperkalemia DCD Type Renal Tx (n)DGFPGNF ECS2931%3.5% RR864%3.5%

12 Graft Survival Rates 89% 77% 66% US graft survival rate:

13 Outcomes Livers 20 DCD liver recipients Full records / HIPPA (3 year follow up) Recipient MELD score = Donor Type Liver DCD (n) 1 year survival 3 year survival ECS786%69% RR1371%62% National (Cadaveric) --82%72% Ischemic cholangiopathy: 15% (both groups)

14 Take Home Message DCD Organ Recovery - Technique ComparisonIssues RR- DCD ECS-DCD Organs DonatedKidneys / Selective livers All, except heart  30% GoalDeep cooling /  metabolism Restores circulation and 0 2 / normal Metabolism Time to Organ Procurement UrgentElective Cold StorageRoutine / Pump Perfusion ?? Organ Assessment Pump perfusion / Transplant Recovery./ pump perfusion / Transplant LimitationsRapid cooling / WI / OR logistics Cannulation and ECS management Post Tx Function40-60% DGF8-30% DGF

15 Acknowledgments ECLS Program Staff Pula Baldridge, RN –Manager Sheri Bignall Faculty Jonathan Haft –ECLS Director Gail Annich –ECLS co-Director George Mychaliska Robert Bartlett ECLS Lab Lauren Sall Kelly Koch Transplant Team Jeff Punch –Director Transplant Program Swan Pelletier Larry Slate II –Chief Transplant perfusionist