The Extra Corporeal Membrane Oxygenation in the Deceased Donors After Brain Death With Severe Hemodynamic Instability Allow to Optimize the Viability of Organs Procured for Transplantation

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Abstract

Introduction

Some of the brain death donors manifest severe circulatory dysfunction that can lead to cardiac arrest and subsequently to donor lose or low quality of organs procured. Extra-corporeal membrane oxygenation (ECMO) can be applied to these donors to obtain organs with better quality with less ischemic damage.

Objective

To observe the clinical effect of the maintenance of organ function by ECMO in brain death donors with severe hemodynamic instability.

Methods

89 brain death donors maintained by ECMO were followed-up. The criteria for using ECMO to protect organ function were: A. Cardiac arrest, cardiopulmonary resuscitation history (cardiac compression > 20 min); B. Mean arterial pressure (MAP): in Adults < 60 ~ 70 mmHg; in children <50 ~ 60 mmHg; in infants < 40 ~ 50 mmHg; C. Cardiac index < 2 L/(m2 · min) (3 h); D. Large doses of vasoactive drugs: dopamine > 20 μg/(kg · min); (norepinephrine) epinephrine > 1.0 μg/(kg • min) (3 h); E. Oliguria: <0.5 mL/(kg · h); F. Blood biochemical indexes: Moderate, severe impairment on acute hepatic and renal function; G. Others: ST-T significantly changes in electrocardiogram; difficulty to correct the metabolic acidosis (3h). The organs were evaluated during their retrieval. Their evolution after transplantation was also evaluated.

Results

A total of 89 cases with ECMO maintenance were collected. 178 kidneys, 89 livers were procured from these donors; meanwhile 13 kidneys and 38 livers were discarded. Out of the discarded organs, 8 and 25, kidneys and livers respectively, were discarded due to ischemic damage as it was shown in a macroscopic evaluation. 165 of the procured kidneys were transplanted. Delayed Graft Function (DGF) of kidney transplantation was observed in 18.8 % of the cases. Acute rejection incidence was 12.1%. Kidney survival rate was: 99.3% in one year, 97.8% in three-year, and 97.8% in five year.

Conclusions

ECMO for brain-dead donors with severe circulatory dysfunction allows to avoid organ donors lose and obtain good quality kidneys and livers; meaning low rates of primary dysfunction, DGF and acute rejection with excellent graft survival after transplantation. Our experience indicates that ECMO allows the maintenance of abdominal organ tissue perfusion without warm ischemia before organ procurement, providing sufficient time for safe organ donation procedures and reducing the risk of unpredictable cardiac arrest that could lead to donor death and graft loss.

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