Andreas H Kramer1,2, Kerry Holliday3, Sean Keenan4,5, George Isac4,5, Demetrios J Kutsogiannis6,7, Norman M Kneteman8,9, Adrian Robertson10,11, Peter Nickerson11,12, Lee Anne Tibbles13,14. 1. Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W, Calgary, AB, T2N 5A1, Canada. Andreas.Kramer@AlbertaHealthServices.ca. 2. Southern Alberta Organ and Tissue Donation Program, Alberta Health Services, Calgary, AB, Canada. Andreas.Kramer@AlbertaHealthServices.ca. 3. Southern Alberta Organ and Tissue Donation Program, Alberta Health Services, Calgary, AB, Canada. 4. Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada. 5. BC Transplant, Vancouver, BC, Canada. 6. Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada. 7. Human Organ, Procurement, and Exchange (HOPE) Program, University of Alberta, Edmonton, AB, Canada. 8. Department of Surgery, University of Alberta, Edmonton, AB, Canada. 9. Alberta Transplant Institute, Edmonton, AB, Canada. 10. Division of Critical Care Medicine, University of Manitoba, Winnipeg, MB, Canada. 11. Transplant Manitoba, Winnipeg, MB, Canada. 12. Department of Medicine, University of Manitoba, Winnipeg, MB, Canada. 13. Southern Alberta Transplant Program, Calgary, AB, Canada. 14. Department of Medicine, University of Calgary, Calgary, AB, Canada.
Abstract
PURPOSE: Donation after circulatory determination of death (DCD) has been performed in Canada since 2006. Numerous aspects of donor management remain controversial. METHODS: We performed a multicentre cohort study involving potential DCD donors in western Canada (2008-2017), as well as recipients of their organs, to describe donor characteristics and critical care practices, and their relation to one-year recipient and graft survival. RESULTS: There were 257 patients in four provinces that underwent withdrawal of life-sustaining therapies (WLST) in anticipation of possible DCD. The proportion of patients that died within two hours of WLST ranged from 67% to 88% across provinces (P = 0.06), and was predicted by deeper coma (P = 0.01), loss of pupillary light or corneal reflexes (P = 0.02), and vasopressor use (P = 0.01). There were significant differences between provinces in time intervals from onset of hypotension to death (9-11 min; P = 0.02) and death to vascular cannulation (7-10 min; P < 0.001). There was inconsistency in pre-mortem heparin administration (82-96%; P = 0.03), including timing (before vs after WLST; P < 0.001) and dose (≥ 300 vs < 300 units·kg-1; P < 0.001). Donation after circulatory death provided organs for 321 kidney, 81 liver, and 50 lung transplants. One-year recipient and graft survival did not differ among provinces (range 85-90%, P = 0.45). Predictors of death or graft failure included older recipient age (odds ratio [OR] per year, 1.04; 95% confidence interval [CI],1.01 to 1.07) and male donor sex (OR, 3.35; 95% CI, 1.39 to 8.09), but not time intervals between WLST and cannulation or practices related to heparin use. CONCLUSION: There is significant variability in critical care DCD practices in western Canada, but this has not resulted in significant differences in recipient or graft survival. Further research is required to guide optimal management of potential DCD donors.
PURPOSE: Donation after circulatory determination of death (DCD) has been performed in Canada since 2006. Numerous aspects of donor management remain controversial. METHODS: We performed a multicentre cohort study involving potential DCD donors in western Canada (2008-2017), as well as recipients of their organs, to describe donor characteristics and critical care practices, and their relation to one-year recipient and graft survival. RESULTS: There were 257 patients in four provinces that underwent withdrawal of life-sustaining therapies (WLST) in anticipation of possible DCD. The proportion of patients that died within two hours of WLST ranged from 67% to 88% across provinces (P = 0.06), and was predicted by deeper coma (P = 0.01), loss of pupillary light or corneal reflexes (P = 0.02), and vasopressor use (P = 0.01). There were significant differences between provinces in time intervals from onset of hypotension to death (9-11 min; P = 0.02) and death to vascular cannulation (7-10 min; P < 0.001). There was inconsistency in pre-mortem heparin administration (82-96%; P = 0.03), including timing (before vs after WLST; P < 0.001) and dose (≥ 300 vs < 300 units·kg-1; P < 0.001). Donation after circulatory death provided organs for 321 kidney, 81 liver, and 50 lung transplants. One-year recipient and graft survival did not differ among provinces (range 85-90%, P = 0.45). Predictors of death or graft failure included older recipient age (odds ratio [OR] per year, 1.04; 95% confidence interval [CI],1.01 to 1.07) and male donor sex (OR, 3.35; 95% CI, 1.39 to 8.09), but not time intervals between WLST and cannulation or practices related to heparin use. CONCLUSION: There is significant variability in critical care DCD practices in western Canada, but this has not resulted in significant differences in recipient or graft survival. Further research is required to guide optimal management of potential DCD donors.
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