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Protocols for uncontrolled donation after circulatory death: a systematic review of international guidelines, practices and transplant outcomes.

Ortega-Deballon I, Hornby L, Shemie SD - Crit Care (2015)

Bottom Line: The outcome studies report good results for kidney, liver, and lung transplantation with high discard rates for livers.Further standardization of protocols and outcomes is required, as is further research into the role of extracorporeal resuscitation and other novel therapies for treatment of some refractory cardiac arrest.It is essential to ensure the maintenance of trust in uDCD programs by health professionals and the public.

View Article: PubMed Central - PubMed

Affiliation: Canadian National Transplant Research Program, Montréal, Canada. iviortega@gmail.com.

ABSTRACT

Introduction: A chronic shortage of organs remains the main factor limiting organ transplantation. Many countries have explored the option of uncontrolled donation after circulatory death (uDCD) in order to expand the donor pool. Little is known regarding the variability of practices and outcomes between existing protocols. This systematic review addresses this knowledge gap informing policy makers, researchers, and clinicians for future protocol implementation.

Methods: We searched MEDLINE, EMBASE, and Google Scholar electronic databases from 2005 to March 2015 as well as the reference lists of selected studies, abstracts, unpublished reports, personal libraries, professional organization reports, and government agency statements on uDCD. We contacted leading authors and organizations to request their protocols and guidelines. Two reviewers extracted main variables. In studies reporting transplant outcomes, we added type, quantity, quality of organs procured, and complications reported. Internal validity and the quality of the studies reporting outcomes were assessed, as were the methodological rigour and transparency in which a guideline was developed. The review was included in the international prospective register of systematic reviews (Prospero, CRD42014015258).

Results: Six guidelines and 18 outcome studies were analysed. The six guidelines are based on limited evidence and major differences exist between them at each step of the uDCD process. The outcome studies report good results for kidney, liver, and lung transplantation with high discard rates for livers.

Conclusions: Despite procedural, medical, economic, legal, and ethical challenges, the uDCD strategy is a viable option for increasing the organ donation pool. Variations in practice and heterogeneity of outcomes preclude a meta-analysis and prevented the linking of outcomes to specific uDCD protocols. Further standardization of protocols and outcomes is required, as is further research into the role of extracorporeal resuscitation and other novel therapies for treatment of some refractory cardiac arrest. It is essential to ensure the maintenance of trust in uDCD programs by health professionals and the public.

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Related in: MedlinePlus

Timelines and clinical pathway in the process of uncontrolled donation after circulatory death (DCD). CPR cardiopulmonary resuscitation
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Fig2: Timelines and clinical pathway in the process of uncontrolled donation after circulatory death (DCD). CPR cardiopulmonary resuscitation

Mentions: Figure 2 is an illustrative example of the uDCD procedure timelines and clinical pathway described within the guidelines. Timelines begin with a cardiac arrest, followed by initiation of cardiopulmonary resuscitation (CPR), termination of CPR, continuation of organ-preserving interventions, diagnosis of death, and cannulation for organ preservation. As will be further described below, there are variable periods of no-flow and low-flow states that may impact on pre- and post-mortem ischemic organ injury and there is variability in the timing of, and requirement for consent for, donation or organ preservation or both.Fig. 2


Protocols for uncontrolled donation after circulatory death: a systematic review of international guidelines, practices and transplant outcomes.

Ortega-Deballon I, Hornby L, Shemie SD - Crit Care (2015)

Timelines and clinical pathway in the process of uncontrolled donation after circulatory death (DCD). CPR cardiopulmonary resuscitation
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4495857&req=5

Fig2: Timelines and clinical pathway in the process of uncontrolled donation after circulatory death (DCD). CPR cardiopulmonary resuscitation
Mentions: Figure 2 is an illustrative example of the uDCD procedure timelines and clinical pathway described within the guidelines. Timelines begin with a cardiac arrest, followed by initiation of cardiopulmonary resuscitation (CPR), termination of CPR, continuation of organ-preserving interventions, diagnosis of death, and cannulation for organ preservation. As will be further described below, there are variable periods of no-flow and low-flow states that may impact on pre- and post-mortem ischemic organ injury and there is variability in the timing of, and requirement for consent for, donation or organ preservation or both.Fig. 2

Bottom Line: The outcome studies report good results for kidney, liver, and lung transplantation with high discard rates for livers.Further standardization of protocols and outcomes is required, as is further research into the role of extracorporeal resuscitation and other novel therapies for treatment of some refractory cardiac arrest.It is essential to ensure the maintenance of trust in uDCD programs by health professionals and the public.

View Article: PubMed Central - PubMed

Affiliation: Canadian National Transplant Research Program, Montréal, Canada. iviortega@gmail.com.

ABSTRACT

Introduction: A chronic shortage of organs remains the main factor limiting organ transplantation. Many countries have explored the option of uncontrolled donation after circulatory death (uDCD) in order to expand the donor pool. Little is known regarding the variability of practices and outcomes between existing protocols. This systematic review addresses this knowledge gap informing policy makers, researchers, and clinicians for future protocol implementation.

Methods: We searched MEDLINE, EMBASE, and Google Scholar electronic databases from 2005 to March 2015 as well as the reference lists of selected studies, abstracts, unpublished reports, personal libraries, professional organization reports, and government agency statements on uDCD. We contacted leading authors and organizations to request their protocols and guidelines. Two reviewers extracted main variables. In studies reporting transplant outcomes, we added type, quantity, quality of organs procured, and complications reported. Internal validity and the quality of the studies reporting outcomes were assessed, as were the methodological rigour and transparency in which a guideline was developed. The review was included in the international prospective register of systematic reviews (Prospero, CRD42014015258).

Results: Six guidelines and 18 outcome studies were analysed. The six guidelines are based on limited evidence and major differences exist between them at each step of the uDCD process. The outcome studies report good results for kidney, liver, and lung transplantation with high discard rates for livers.

Conclusions: Despite procedural, medical, economic, legal, and ethical challenges, the uDCD strategy is a viable option for increasing the organ donation pool. Variations in practice and heterogeneity of outcomes preclude a meta-analysis and prevented the linking of outcomes to specific uDCD protocols. Further standardization of protocols and outcomes is required, as is further research into the role of extracorporeal resuscitation and other novel therapies for treatment of some refractory cardiac arrest. It is essential to ensure the maintenance of trust in uDCD programs by health professionals and the public.

Show MeSH
Related in: MedlinePlus