Estimating the Potential Pool of Uncontrolled DCD Donors in the United States

Brian J. Boyarsky; Kyle R. Jackson; Amber B. Kernodle; Joseph V. Sakran; Jacqueline M. Garonzik-Wang; Dorry L. Segev; Shane E. Ottmann

Disclosures

American Journal of Transplantation. 2020;20(10):2842-2846. 

In This Article

Abstract and Introduction

Abstract

Organs from uncontrolled DCD donors (uDCDs) have expanded donation in Europe since the 1980s, but are seldom used in the United States. Cited barriers include lack of knowledge about the potential donor pool, lack of robust outcomes data, lack of standard donor eligibility criteria and preservation methods, and logistical and ethical challenges. To determine whether it would be appropriate to invest in addressing these barriers and building this practice, we sought to enumerate the potential pool of uDCD donors. Using data from the Nationwide Emergency Department Sample, the largest all-payer emergency department (ED) database, between 2013 and 2016, we identified patients who had refractory cardiac arrest in the ED. We excluded patients with contraindications to both deceased donation (including infection, malignancy, cardiopulmonary disease) and uDCD (including hemorrhage, major polytrauma, burns, and poisoning). We identified 9828 (range: 9454–10 202) potential uDCDs/y; average age was 32 years, and all were free of major comorbidity. Of these, 91.1% had traumatic deaths, with major causes including nonhead blunt injuries (43.2%) and head injuries (40.1%). In the current era, uDCD donors represent a significant potential source of unused organs. Efforts to address barriers to uDCD in the United States should be encouraged.

Introduction

Despite a transplant waitlist of nearly 115 000 patients in the United States, organs from only 10 000 (range: 9079–11 871) deceased donors are recovered annually, resulting in more than 6000 waitlist deaths per year. Eighty percent of deceased donation is enabled through donation after brain death (DBD). The remainder takes place following donation after circulatory death (DCD). Typically, DCD is controlled (cDCD) and organs are recovered following an anticipated cardiac arrest after withdrawal of life-sustaining therapy. An alternative pathway, uncontrolled DCD (uDCD), enables donation from patients who have an unexpected, witnessed cardiac arrest without return of spontaneous hemodynamic activity following advanced cardiac life support (ACLS). In uDCD, organ preservation begins following declaration of death and perfusion is established either through normothermic regional perfusion, which circulates oxygenated blood to the isolated abdominal compartment through an external pump and oxygenator, or extracorporeal membrane oxygenation.[1,2]

Since the 1980s, several European countries have used uDCD donors to expand the donor pool; between 2000 and 2014, Spain used 1247 donors, France used 414 donors, and the Netherlands used 159 donors.[3–5] Compared with DBD kidney transplantation (KT), the delay between cardiac arrest and organ preservation in uDCD may increase rates of primary nonfunction (6.8%-22%), and delayed graft function (up to 73.4%).[6–9] However, among well-selected donors, long-term graft and patient survival have been demonstrated to be comparable to both cDCD donation and DBD donation in KT.[10–16]

However, uDCD has been used minimally in the United States.[17] Barriers include lack of knowledge about the potential pool of uDCD donors, lack of robust outcomes data, lack of standard donor eligibility criteria and preservation methods, and logistical and ethical dilemmas.[18,19] The first step to addressing these barriers is estimating the pool of potential uDCD donors, to see whether the potential expansion of the donor pool would merit the work and policy efforts involved. Similar paradigms of impact estimates followed by policy changes were successful in expanding kidney paired donation,[20] leading to the Norwood Act of 2007, and in allowing transplantation of organs from human immunodeficiency (HIV) + donors,[21] leading to the HIV Organ Policy Equity (HOPE) Act of 2013.

Thus, the aim of this study was to inform potential policy efforts by estimating the national pool of potential uDCD donors. To accomplish this, we used the Nationwide Emergency Department Sample (NEDS) to calculate the number of patients who have refractory cardiac arrest in the ED who might have been eligible for uDCD.

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