Objectives: Efficient intensive care donor management can help alleviate the shortage of organs for trans­plant. The aim of this study was to investigate the efficiency of management of donors after brain death from our neurointensive care unit.

Materials and Methods: We conducted a prospective observational 5-year follow-up on 29 transplanted organs from 14 brain-dead donors after acute stroke (7 subarachnoid and 4 intracerebral hemorrhages, 3 ischemic strokes). Mean age of donors was 56.2 ± 8.70 years, and mean number of days of artificial ventila­tion was 5.0 ± 3.84. We transplanted 27 kidneys and 2 livers to 29 patients with mean age of 55.3 ± 9.76 years. No hearts or lungs were transplanted from these donors.

Results: Of the 27 patients who underwent kidney transplant, 21 patients (78%) lived 5 years; of those, 17 patients (63%) had functional grafts. One patient (4%) had a primary afunctional graft, and 3 patients (11%) had graft rejection (at 3, 15, and 41 mo). Six patients (22%) died after kidney transplant, with 1 patient in this group having a functional graft, 1 patient having a primary afunctional graft, and 4 patients (15%) having graft rejection (at 1, 12, 44, and 56 mo). The 2 patients with liver transplants lived 5 years with functional grafts.

Conclusions: The 5-year follow-up showed that organs from 14 brain-dead donors improved and saved 19 lives, with 17 patients receiving kidney transplants and 2 patients receiving liver transplants. Another 7 patients had only partially improved quality of life.

Key words : Neurointensive care, Potential organ donors, Transplantation

Introduction

Transplant programs have significant roles in health care. They can improve quality of life and even save lives. Therefore, intensive care units that admit po­tential organ donors should support this program.^1,2 This is a challenge for neurointensivists who care for patients with acute neurologic diseases and disorders needing treatment by neurosurgeons. Some of these patients have extensive and irreversible brain damage and cannot be saved. When clinical brain death occurs, these patients could become potential organ donors.^3-5

There is a worldwide shortage of donors, including in our country; therefore, every potential donor in the neurointensive care unit is important and should be offered to the transplant center that manages further procedures. Preparing organs for retrieval is an important part of transplant management in the intensive care unit.⁶ This is a difficult task for the whole team, but transplant management can save or improve the lives of others. We conducted this prospective study to determine the efficiency of our management of donors after brain death from our neurocritical care unit.

Materials and Methods

We performed a 5-year prospective observational cohort follow-up study of 14 donors after brain death from the adult eight-bed neurointensive care unit (NICU) of our regional hospital. This study was approved by the hospital’s ethics committee.

Characteristics of donors after brain death
All patients were admitted acutely with stroke to our NICU. Seven patients had subarachnoid hemorrhage, 4 patients had intracerebral hemorrhage, and 3 patients had ischemic stroke. Five patients were admitted primarily to the NICU, 6 patients within 24 hours, and 3 patients after 24 hours. The mean age was 56.2 ± 8.70 years, and the mean number of days of artificial ventilation was 5.0 ± 3.84. Patient history included hypertension (5 patients), diabetes mellitus (2 patients), coronary artery disease (2 patients), atrial fibrillation (1 patient), pulmonary embolism (1 patient), gastric ulcer (2 patients), thyroid disease (2 patients), lupus anticoagulant (donor 12 in Table 1), interstitial nephritis (donor 9 in Table 1), and colon cancer (donor 14 in Table 1). Eleven patients underwent surgery (mean duration of 132 ± 81.01 min), which included craniotomy (5 patients), craniectomy (2 patients), trepanation (3 patients), and carotid endarterectomy (1 patient). During their stay in the NICU, 11 patients received antibiotic prophylaxis, with 10 patients receiving antibiotics in association with an operation. The other patient received antibiotic therapy for a nosocomial urinary tract infection. No patients had extended-spectrum beta-lactamase bacteria or methicillin-resistant Staphylococcus aureus. Further characteristics of the donors are presented in Table 1.

The diagnosis of brain death was made according to Transplant Law. These patients were identified as donors by the National Transplant Center. Two brain dead donors were identified as marginal due to interstitial nephritis (donor 9) and cancer of the colon (donor 14).

Overall, 27 kidneys and 2 livers were retrieved from 14 brain dead donors and transplanted to 29 patients who had a mean age of 55.3 ± 9.76 years (Table 2). A follow-up was conducted 5 years after transplant.

Results

Of the 27 patients who underwent a kidney transplant, 21 patients (78%) lived 5 years; of these, 17 patients (63%) had functional grafts. One patient (4%) had a primary afunctional graft, and 3 patients (11%) had graft rejection (at 3, 15, and 41 mo). Six patients (22%) died after kidney transplant: 1 patient with a functional graft, 1 patient with a primary afunctional graft, and 4 patients (15%) with graft rejection (at 1, 12, 44, and 56 mo). The two patients with liver transplants lived 5 years with functional grafts (Table 2).

Discussion

The efficiency of intensive care donor management can help alleviate organ shortages for transplant. The shortage of donors is well known, not just in our country but all over the world.¹ Intensive care units, particularly those that admit patients who have acute neurologic diseases and disorders needing treatment by neurosurgeons, can play an important role in transplant programs, as some of these patients with extensive irreversible brain damage cannot be saved.⁷ When clinical brain death occurs, these patients could become potential organ donors. Therefore, intensive care units that care for potential organ donors should have a well-established relation with a transplant program and establishing transplant management in the intensive care unit should be a standard procedure.^2,5 The implementation of such a program is not easy, not only for doctors, but also for nurses and other personnel working in the NICU. In our NICU, a transplant management program was started in 2001.

The first aim of transplant management in the NICU is to identify potential organ donors, and the second aim is not to waste these donors and to offer them to the transplant centers that manage further procedures and that decide which organs to procure. This decision is made according to the quality of donors, blood group, and recipients. In our cases, the transplant center did not indicate the procurement of any hearts or lungs and excluded 12 livers.

Not wasting donors is a difficult task for the whole team. We should strive to seek ways to support this important aspect, which starts in the intensive care unit. One way is to investigate what happened to the organs after recovery. Which organs were transplanted? Who did the organs help? How did the patients recover? How long did recuperation take? How long did they live? In this study, we aimed to answer these questions by analyzing patients who received organs from donors seen at our NICU. Our 5-year follow-up of these patients showed that our transplant program was able to improve quality of life. At 5 years, functional grafts were shown in 17 of the 27 patients who received kidney transplants (63%) and both liver transplant patients. Unfortunately, 1 patient died with a functional graft. For the remaining patients, a reaction occurred, although after 1 year or more in 5 patients. We only had 2 primary afunctional grafts.

For some patients, organs are vital to survival (for example, those needing heart and liver transplants). For kidney patients, the situation is different. Although they can live on dialysis, their quality of life is greatly reduced. Every day without the necessity of regular dialysis is precious. In addition, survival rates of patients after kidney transplant are significantly better than shown for patients who are on dialysis and waiting for a kidney transplant.

There is a large disproportion between those who need transplant organs and organs available according to the laws of the country, which leads to lengthy wait lists. Implementing an efficient transplant management system for patients with clinical signs of brain death in the NICU can help to reduce this disproportion and shorten the wait lists. Although the donors after brain death in our study group were relatively old, there is no upper age limit for recipients of organs. Indeed, we had a kidney transplanted into an 82-year-old recipient who, at the 5-year follow-up, was without dialysis.

Conclusions

We present the results of 14 patients with acute stroke and subsequently brain death who became donors. The 5-year follow-up showed that we improved and saved 19 lives, as 17 patients had survived after kidney transplant and 2 patients survived after liver transplant. We improved quality of life for another 7 patients but only partially.

References:

1. Nathan SD, King CS. Organ donors: making the most of what is offered. Chest. 2015;148(2):303-305.
   CrossRef - PubMed
   
2. Singbartl K, Murugan R, Kaynar AM, et al. Intensivist-led management of brain-dead donors is associated with an increase in organ recovery for transplantation. Am J Transplant. 2011;11(7):1517-1521.
   CrossRef - PubMed
   
3. Gridelli B, Remuzzi G. Strategies for making more organs available for transplantation. N Engl J Med. 2000;343(6):404-410.
   CrossRef - PubMed
   
4. Bell MD. Early identification of the potential organ donor: fundamental role of intensive care or conflict of interest? Intensive Care Med. 2010;36(9):1451-1453.
   CrossRef - PubMed
   
5. Citerio G, Cypel M, Dobb GJ, et al. Organ donation in adults: a critical care perspective. Intensive Care Med. 2016;42(3):305-315.
   CrossRef - PubMed
   
6. Salim A, Martin M, Brown C, Rhee P, Demetriades D, Belzberg H. The effect of a protocol of aggressive donor management: Implications for the national organ donor shortage. J Trauma. 2006;61(2):429-433.
   CrossRef - PubMed
   
7. Dickerson J, Valadka AB, Levert T, Davis K, Kurian M, Robertson CS. Organ donation rates in a neurosurgical intensive care unit. J Neurosurg. 2002;97(4):811-814.
   CrossRef - PubMed