Organ Donation

Published on 10/03/2015 by admin

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Last modified 10/03/2015

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Chapter 86 Organ Donation

Benjamin T. Suratt, MD , Kapil Patel, MD

1 Who governs the rules and regulations for organ donation?

The Organ Procurement and Transplantation Network (OPTN) is a system for operating and monitoring the unbiased allocation, through established medical criteria, of organs donated for transplantation and maintaining a recipients’ waiting list (including the listing and delisting of recipients).

The United Network for Organ Sharing (UNOS) is a nonprofit organization awarded the contract by the Department of Health and Human Services in 1986 to implement the OPTN.

Organ Procurement Organizations (OPO) serve specific regions in the country for clinical services including working with hospital staff to maintain donor-organ function, working with UNOS to match donor organs with recipients, coordinating organ recovery surgery, and giving compassionate and professional support to donors’ families.

2 Who can be a potential organ donor?

Potential for organ or tissue donation has few absolute contraindications: human immunodeficiency virus infection, active hepatitis B virus infection, active visceral or hematologic neoplasm, or active bacterial infection, with no age limitation. Appropriateness for donation is assessed when the occasion arises. The majority of cases that are considered for organ donation occur within the intensive care unit (ICU). Despite severe organ shortage, no set universal protocol exists for organ donation. It is at the discretion of the intensivist to consider cases for organ donation. If a case is considered, then the next step is to notify the local OPO, which will then gather data and discuss the critical care management with the regional organ donation specialist, usually an intensivist.

The general rule for the possibility for organ donation is that there should be no evidence of end-organ damage (e.g., acute tubular necrosis, myocardial depression, or pneumonia), with the final decision per the accepting transplant center.

3 Which organs can be donated?

Organs: kidney, heart, lung, liver, pancreas, and the intestines. Of note, combined organ transplantations (kidney-pancreas, heart-lung, other transplant) can be performed.

Tissue: corneas, the middle ear, skin, heart valves, bones, veins, cartilage, tendons and ligaments.

4 What is the current standard for organ donation?

Organ donation is possible in patients who are declared brain dead. New brain death guidelines have been published (see Box 86-1). Despite efforts to promote organ donation, an enormous shortage of available organs for transplant continues to exist. As a result, efforts have been undertaken to expand the settings in which organs may become available (i.e., donation after cardiac death (DCD); see later). See Boxes 86-2, 86-3, and 86-4 and Tables 86-1 and 86-2.

Box 86-1 Brain death criteria

Unresponsiveness or coma

Core body temperature (≥ 32° C)

Absence of cerebral motor responses to pain in all extremities

Absence of brainstem reflexes, that is, pupillary, oculocephalic (doll’s eyes), vestibuloocular (cold calorics), corneal, gag, and cough reflexes

Apnea test (see Boxes 86–2, 86–3, and 86–4)

Exclusion of conditions that may confound clinical assessment of brain death, that is, metabolic or endocrine abnormality or drug intoxication

^{Table 86-1} Confirmatory brain death testing

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Electroencephalography	No electrical activity for a period of 30 minutes
Cerebral angiography	No intracerebral filling at the level of the carotid bifurcation or circle of Willis Patent external carotid circulation
Transcranial Doppler sonography	No diastolic or reverberating flow Systolic-only or retrograde diastolic flow Small systolic peaks in early systole
Somatosensory evoked potential	Bilateral absence of response to medial nerve stimulation
Cerebral scintigraphy (technetium Tc 99m brain scan)	No uptake of radionuclide in brain parenchyma (hollow skull phenomenon)

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