June 6, 2008

Protocol enhances transplant options

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Beau Kelly, M.D.

Protocol enhances transplant options

Vanderbilt Medical Center recently performed its third organ transplant in which the organs were harvested from donors who were pronounced dead by cardiac death.

The new organ procurement protocol differs from the longstanding practice of using an organ donor whose heart is still beating until the time the organs are harvested.

This new procedure — called Donation After Cardiac Death (DCD) — for organ recovery and transplantation offers promising options for families wanting to donate a loved one’s organs, as well as increases the availability of donor organs desperately needed for transplantation.

Vanderbilt's three DCD donors have helped eight recipients receive a total of six kidney and two liver transplants.

With a growing number of patients on organ transplant waiting lists — estimates are nearly 100,000 in the U.S. — the United Network for Organ Sharing (UNOS) recently implemented DCD as another donation opportunity for families.

Prior to 1982, DCD was the primary source of organ donations. In the majority of those cases, a person's heart stopped beating causing the body to shut down, which meant many of the organs were not viable for transplant. Under those circumstances, the kidneys were the only organ allowed for recovery for transplantation.

When donation after brain death was introduced by UNOS, the number of organs that could be donated increased and brain death became the primary protocol utilized by procurement agencies for organ recovery.

“Eighty-five percent of organ donation, as the general public knows it right now is presently in the form of organs being donated by people after they have suffered a brain death,” said Beau Kelly, M.D., surgical director for the pediatric liver transplant program.

“In the absence of an organ donation, the heart would eventually stop beating. The heartbeat is a reflex,” he explained.

“But now, donation after cardiac death is being offered as an option for families interested in organ donation. With donation after cardiac death, these people are not brain dead; rather they have suffered an anoxic brain injury and are in a debilitated state … with no chance of recovery.”

Examples of such scenarios include drowning that did not result in death, heart attacks with low blood flow to the brain and high spinal cord injuries from motor vehicle accidents.

“In a donation after cardiac death, you are recovering those organs after the heart has stopped and there is no blood circulation. The need for recovery is more urgent, the recovery must happen much faster.”

In both donation scenarios the families must initiate the request or process — either the patient has documented wishes or the family has decided to withdraw all care and support, Kelly explained.

“The message I want to express is this — families withdraw care and support from loved ones every day across the country,” said Kelly. “Unfortunately, people will leave the hospital with a memory of the person they knew. But organ donation after withdrawal of care, hopefully gives life to another person. Hopefully, the recipient family will leave the hospital with more than just a memory.”

With the emotions that surround withdrawal of care, it is important that people understand the protocol Vanderbilt has initiated, Kelly said. Withdrawal of care and organ recovery are two separate processes.

The Vanderbilt transplant team is not involved in the potential donor patient's care. The team is only notified after a patient's family has made the decision to donate organs and the patient has met the criteria for being a donor.

“Moving forward with this type of option is a testament to the hospital's vision,” Kelly said.

“We established a protocol that not only addresses all the ethical concerns, but also provides the most optimum outcome for transplant.

“There are two goals that must be met with this procedure — first is being respectful in the withdrawal of care process, allowing the family to be present and then educating them in their decision to donate their loved one’s organs. It was imperative that we established protocols that met both of these objectives.”

Kelly, assistant professor of surgery, came to Vanderbilt in 2005 from UCLA, where he was clinical instructor in the Division of Liver and Pancreas Transplantation.

He received his medical degree in 1995 from Howard University and his bachelor's degree from Michigan in 1989.