WS05 – It’s not only extended donor criteria, it’s extending the donor pool
)Considering the characteristics of the donor, including age, previous diseases and Cardiovascular Risk factors (CRF), the Ideal deceased donor refers to a Donor after Brain Death (DBD) less than 40 years of age who died of cranial trauma and without CRF. A lack of ideal donors means that transplant teams are now grafting organs that would previously have been considered unacceptable.
The Standard and the Expanded Criteria donor are, in contrast, relative concepts that may evolve with time. A standard organ connotes an organ of average quality relative to the spectrum currently utilized for transplantation; while an expanded graft connotes an organ of lower than average quality, coming from a donor with characteristics known to be associated with suboptimal transplant outcomes. Expanded-criteria donors (ECDs) originally refer to kidneys from donors older than 60y or patients older than 60 with a significant medical history who have two of the following three features: (cerebrovascular accident as the cause of death, pre-existing hypertension, or terminal serum creatinine greater than 1.5 mg/dl.). The coincidence of multiple risk factors like older donors (>60 years old), obesity with steatosis, CRF and severe atherosclerosis, further exacerbates the extent of Ischemia–Reperfusion injury (IRI) in the graft, especially in some organs with extreme sensitivity to ischemia and reduces the chances of a successful outcome.
It’s not only the need, due to permanent misbalance between demand and supply, to accept ECD as an ordinary graft, we have to move one step further and explore new options to increase this supply. That means balancing the acceptable limit when assessing the risk of transmission of infectious disease or for cancer. It’s is risky and controversial, to go more in depth evaluating and assessing patients with past -history of cancer (defining types including not only solid tumour even haematological, time free of illnesses …) or patients with past or actual HVC and HVB (efficient treatment exist) or HIV (we face at this moment for the first patients with no response to specific treatment) as possible donors.
Maybe we need a different term for this kind of donors and recipients: Extended Criteria Donors. They fall into 2 categories of risk regarding the outcome: (1) graft dysfunction and (2) cancer and infectious disease transmission.
Because we have been involved in a COVID-19 pandemic, it’s mandatory to learn how to manage this new situation in the field of donor assessment and define clear rules regarding recovered patients or sicker ones. It’s important in this specific subject work in different sides regarding paediatric and adult population due to the different effect of the disease in each group of age. The attitude regarding donation and transplant programs and the guidelines have been completely different.
There is another area where we can improve the quality and even the number of graft, which means the efficiency of the donation retrieval. Managing appropriately in the ICU the possible and the potential donor we can improve the “quality “of organs before the retrieval.
Regarding BDD, and taking into account that the donation process has different starting points, regarding different models around Europe, and we are thinking here about ICOD practices that means admission of patients in the ICU with the solely objective to became a donor. Due to this broad spectrum of practices, implementing a common and pre-emptive management of possible and potential donors based on targeted objectives (haemodynamic, respiratory…) looking for the normality during all the process before and after brain death determination led to preventing and avoiding the IRI.
Regarding cDCD (controlled Donation after Circulatory Death) process using the available techniques to optimize the assessment of the organs or even to improve them in the theatre before retrieval.
The other side of the coin is the recipient. We need to define a specific allocation model, to tailor the best match between this grafts and recipients, taking into account direct effect on important clinical outcome: acute rejection, delayed graft function, and patient and allograft survival or some penalties due to recipient characteristics associated with no survival benefit following a non-standard –criteria donor transplantation, specific combination of donor and recipient factors that are likely to yield detrimental results.
Main objective: Rethink the attitude towards the donor procurement and assessment: Change the “just in case not” by “just in case I’ll try”
- Up-dating in infectious and cancer disease medical absolute and relatives contraindication for organ assessment
- Learn how to use tools for evaluating the risk during the assessment
- Up-dating in donor recipient matching
- Organ donor management: basic targets to increase efficiency
Target group: Trainees, students, researchers, clinicians and other health care professionals working in the field of solid organ transplantation worldwide
Leaders: Giuseppe Feltrin and Nuria Masnou
Group members: Željka Gavranović, (Croatia), Paolo Grossi (Italy), Aurora Navarro (Spain) and Peter Veitch (UK)
Forum moderator: Omar Taco
TLJ 2.0 PREPARATORY WEBINAR SERIES: WS05 ICOD – Focus on ICOD: bringing donation at the centre of end of life (18:00-19:00, 19 October, 2020)