By Todd Neale, Staff Writer, MedPage Today
Published: January 06, 2011
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner
Organs from infants who die of cardiac reasons in the neonatal intensive care unit may represent a new donor source for patients awaiting transplantation, a retrospective study showed.
Of 192 infants who died over a three-year period in one of three Boston NICUs, 16 (8%) were deemed candidates for organ donation after cardiac death, according to Anne Hansen, MD, MPH, of Children's Hospital Boston, and colleagues.
Based on warm ischemic time -- the interval between the withdrawal of life support and death -- and other factors, the candidate donors had the potential to provide 18 kidneys, 14 livers, and 10 hearts, the researchers reported in the January issue of the Journal of Pediatrics.
"The need to increase the pool of organ donors is clear," they wrote, noting that through the end of October 2009, there were 441 infants added to the waiting list for organs, compared with just 109 donors.
"The discrepancy between the number of possible recipients and donors underscores the importance of understanding the potential role of an infant donation-after-cardiac-death program in maximizing the donor pool for this population," Hansen and her colleagues wrote.
Historically limited to brain-dead patients, organ donation after cardiac death has gained more attention in recent years as a way to expand the donor pool. In 1997, the Institute of Medicine approved the practice as ethically acceptable and medically useful. In 2007, the Joint Commission required all of its accredited hospitals to develop a donation-after-cardiac-death policy.
To see how many deaths in a level III NICU would be theoretically eligible for donation after cardiac death, the researchers performed a retrospective study of all deaths in three Harvard Program in Neonatology NICUs -- at Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, and Children's Hospital Boston -- between 2005 and 2007.
Over the study period, there were 192 deaths in infants who had reached at least 23 weeks of gestation.
Eligibility criteria for donation after cardiac death were developed by transplant surgeons in collaboration with the New England Organ Bank. Exclusion criteria were as follows:
• Postmenstrual age at death of less than 37 weeks
• Weight at death of less than 3 kilograms
• Active infection
• Known HIV-positive status
• Active malignancy, excluding a primary brain tumor
• Encephalopathy of unknown etiology
• Brain death
• No requirement for mechanical ventilation when life support is withdrawn
After those exclusions, 31 infants who died during the study were considered eligible for organ donation. Only 16, however, had a warm ischemic time of less than one hour and were classified as potential donor candidates for kidney and liver transplantation. Of those, 14 had an interval of less than 30 minutes, and also qualified as donors for heart transplantation.
In an accompanying editorial, Lainie Friedman Ross, MD, PhD, of the University of Chicago, and Joel Frader, MD, of Northwestern University in Chicago, wrote that the study raises important clinical controversies, including whether organs can be collected in infants as small as those deemed eligible by the study authors.
Ethical controversies around procuring organs from infants who die of cardiac causes remain as well, they said.
Many pediatricians are not confident that infants who are candidates for organ donation after cardiac death are really dead, "a problem not helped by the variability in practices on how long one waits to certify death after circulatory arrest or subsequently how long surgeons must wait to ensure lack of 'auto-resuscitation' after the pronouncement of death," they wrote.
Also, the editorialists wrote, tension exists between the delivery of optimal end-of-life care and the preparations necessary for efficiently procuring organs.
"Donation after cardiac death almost always challenges standard, even when unproven, end-of-life practices that allow families to have substantial time alone with the patient immediately after death."
Two issues must be addressed before implementing newborn donation-after-cardiac-death programs, Ross and Frader argued.
"First, we need to ensure that donation-after-cardiac-death protocols conform to quality end-of-life care for all concerned: patients, parents, and healthcare professionals," they wrote.
"Second, allocation policies should be designed to promote broader geographic sharing of infant organs so these small-size organs are distributed to children who might otherwise die on the deceased donor wait list."
The study authors reported that they had no conflicts of interest.
Editorialist Ross was funded in part by a grant from the National Library of Medicine on Ethical and Policy Issues in Living Donor Transplantation. Editorialist Frader reported that he had no conflicts of interest.
Primary source: Journal of Pediatrics
Source reference:
Labrecque M, et al "Donation after cardiac death: The potential contribution of an infant organ donor population" J Pediatr 2011; 158: 87-92.
Additional source: Journal of Pediatrics
Source reference:
Ross L, Frader J "Are we ready to expand donation after cardiac death to the newborn population?" J Pediatr 2011; 158: 6-8.
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