Victor John Emmanuel Borlaza, MD, FPCEM
DECEASED DONOR
DETECTION
“TO THE WORLD YOU MAY
BE ONE PERSON. BUT TO
ONE PERSON, YOU MAY BE
THE WORLD.”
- DR. SEUSS
Presentation title 2
Objectives
2023 Donor Statistics and the PCGH
Experience
Types of Organ Donor;
Organ Donation Nomenclature
Deceased Donor Detection
Donor Evaluation
Presentation title 3
Data from the National Kidney and Transplant Institute (NKTI) reveals
that approximately one Filipino develops chronic renal failure every
hour, translating to roughly 120 Filipinos per million population
annually1.
The number of dialysis patients in the country rose by 42%—from 25,125
in 2022 to 35,714 in 20232.
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Why should we be concerned about
the need for organ donation?
6 million DIABETICS
12 million HYPERTENSIVES
40,000 Filipinos on dialysis
73% of them have DM or HTN
8th leading cause of death –
kidney disease
RISING INCIDENCE OF ESRD TREATED WITH
DIALYSIS: 2005 - 2016
25000
WIDENING GAP between hemodialysis
prevalence and Kidney Transplants
20000
Rising incidence of ESRD treated with dialysis:
2005-2016
NUMBER OF PATIENTS
15000
10000
5000
0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
INCIDENCE 5997 6249 7109 7589 8707 9716 10491 12340 14395 15983 17741 21207
KT 629 690 1046 679 511 399 389 342 363 401 475 480
2022 PCGH Experience
• Thirty patients were identified as possible donors in
Pasig City General Hospital and subsequently
referred to Pasig City General Hospital Human
Organ Preservation Effort (PCGH – HOPE).
• ALL THESE POSSIBLE DONORS WERE
IDENTIFIED EXCLUSIVELY FROM THE
EMERGENCY DEPARTMENT
• No possible donors were identified from the
specialty ward areas including in the Intensive Care
Unit.
• Out of these referrals 6 turned out to be actual
donors
Presentation title 8
TYPES OF DONORS
Living donors: A living human being from whom cells, tissues or organs are
removed for the purpose of transplantation.
Deceased donors: A human being declared, by established medical criteria,
to be dead and from whom cells, tissues or organs are recovered for the
purpose of transplantation
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DECEASED DONORS
"Deceased donor" will be used to refer to any donor that has been
DECLARED DEAD by established medical criteria BEFORE donation.
"Deceased" needs to be correctly translated into other languages to avoid
any confusion.
It is no longer recommended using words such as “Cadaveric donors”.
Presentation title 13
DECEASED DONORS
• Deceased donors can be divided into two
different categories depending on the
cause of death as following:
• Donor after Brain Death (DBD): is a donor
who was declared dead and diagnosed
by means of neurological criteria.
• Donor after Cardiac (Circulatory) Death
(DCD): is a donor who was declared dead
and diagnosed by means of cardio-
pulmonary criteria.
Presentation title 14
DONOR AFTER BRAIN DEATH (DBD)
• Brain death is defined as the
irreversible cessation of
hemispheric and brainstem
neurological functions.
• The most frequent causes of brain
death are
• Haemorrhagic (a) or
ischemic (b) cerebrovascular disease/
stroke
• Brain trauma (c)
• Anoxic encephalopathy
• Primary brain tumour (d)
Presentation title 15
DONOR AFTER CIRCULATORY
DEATH (DCD)
• Donors after cardiac death
(DCD) have been initially
classified according to the
Maastricht criteria established
in 1995.
• the classifications of more
practical nature categorize
DCD in "uncontrolled" or
"controlled" depending on
whether the circulatory arrest
occurs spontaneously or after
medical therapy limitation.
Presentation title 16
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ORGAN DONOR NOMENCLATURE
POSSIBLE DONOR POTENTIAL DONOR ELIGIBLE DONOR ACTUAL DONOR UTILIZED DONOR
• a person with a • A person whose clinical • A MEDICALLY • CONSENTED ELIGIBLE • An ACTUAL DONOR
condition is suspected to SUITABLE PERSON DONOR IN WHOM FROM WHO AT LEAST
devastating brain fulfill the brain dead who has been declared AN OPERATIVE ONE ORGAN WAS
injury or lesion; or criteria dead based on INCISION WAS MADE TRANSPLANTED
a person with • a person whose neurologic criteria or with an intent of organ
Circulatory Failure circulatory and irreversible absence of recovery for
and apparently respiratory functions circulatory and transplantation or from
have ceased and respiratory functions as whom an ORGAN
medically suitable stipulated by law WAS RECOVERED for
resuscitative measures
for organ donation are not to be attempted the purpose of
or continued transplantation
• a person in whom the
cessation of circulatory
and respiratory functions
is anticipated to occur
within a time frame that
will enable organ
recovery
Presentation title 18
DECEASED DONOR DETECTION
Important Questions in the Deceased Donor Detection Process
• Who Can Become a Potential Donor
• Who Is Responsible for Donor Detection
• How Should We Proceed?
Presentation title 19
WHO CAN BECOME A DONOR
• WHEN TO START IDENTIFICATION
• should ideally occur as early as in the stage of
“possible deceased organ donor”,
• Glasgow Coma Scale is a good marker of the person’s
neurological status and may be used to predict
eventual brain death, especially when a coma score
below 5 is recorded.
Presentation title 20
WHO CAN BECOME A DONOR
• DEAD DONOR RULE
• patients may only become donors after death, and the
recovery of organs must not cause donor’s death.
• Referral only means the action of making the key TPM
or organization aware of the possibility of deceased
donation
• Referral does not include any other subsequent action.
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WHAT? Need early
identification and referral!
CLINICAL
TRIGGERS
FOR
REFERRAL
Severe brain
injury
+
GCS of < 5
Intubated
Ventilated
End of life
care
CLINICAL TRIGGERS
Ischemic Brain Intracerebral Secondary Cerebral Brain
Injury hemorrhage cerebral trauma Tumor
anoxia
Clinical Trigger NIHSS > 27 ICH > 4 or GCS < 5 GCS < 5 GCS < 5
(patient with Hunt-Hess > 4
high risk of brain
death)
Clinical trigger GCS 3 and progressive absence of at least 3 out of 6 brain stem reflexes
(patient with
very high risk of
brain death)
Presentation title 23
WHERE? PLACES WHERE THE
POSSIBLE DONORS ARE
Presentation title 24
WHO IS RESPONSIBLE FOR ORGAN
DETECTION?
In the best-case scenario, all possible donors should be
referred to a TPM /ORGAN PROCUREMENT ORGANIZATION
(OPO) (NKTI HOPE) by their physicians in charge,
irrespective to their location.
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Donor detection is a shared task of the
healthcare professionals in charge and the TCs
through a well-established and thoroughly
accepted cooperation between them and the
hospital’s management.
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HOW SHOULD WE PROCEED?
• ADMINISTRATIVE METHODS
• Review of ADMISSIONS Typically in the ICU, (ER)
• MEDICAL METHOD
• Compliments Administrative Methods Allowing TC to visit units where possible
potential donors are located
•
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HOW SHOULD WE PROCEED?
• MEDICAL METHOD
• Compliments Administrative Methods Allowing TC to visit units where possible
potential donors are located
• "active detection" when the TC takes initiative to do
daily visits to units, ICU, Neuro Ward, ER
• "passive detection" patient's physician who decides
who is the potential donor. TC waits for notification from
units and departments
Presentation title 30
ORGAN DONATION PROCESS
The Organ Procurement Process
Donor maintenance
Brain
Donor Initial Referral
Death
detection screening to OPO
Diagnosis
ORGAN DONATION PROCESS
The Organ Procurement Process
Donor management
Brain
Donor Initial Referral
Death
detection screening to OPO
Diagnosis
Review Donation Full
case with request Donor
team (Consent) Evaluation
Family approach
ORGANThe
DONATION PROCESS
Organ Procurement Process
Donor manangement
Brain
Donor Initial Referral
Death
detection screening to OPO
Diagnosis
Organ
allocation
Transp-
lantation
Review Donation Full Organ
case with request Donor
team (Consent) Evaluation retrieval
Family approach
ORGAN DONATION PROCESS
The Organ Procurement Process
Donor management
Complex, many steps,
many specialists
Brain
Donor Initial Referral
Death
detection screening to OPO
Diagnosis
Organ
allocation
Transp-
lantation
Review Donation Full Organ
case with request Donor
team (Consent) Evaluation retrieval
Family approach
ORGAN DONATION PROCESS
Family conversations
BUT THE MOST
IMPORTANT STEP IS
Brain
DONOR Initial
Death
Referral
screening to OPO
DETECTION Diagnosis
Organ
allocation
Transp-
lantation
Review Donation Full Organ
case with request Donor
team (Consent) Evaluation retrieval
Donor maintenance
WHO? ORGAN DONATION PROCESS
AND YOU, NOT THE
Family conversations TRANSPLANT SPECIALIST,
ARE THE CRUCIAL
DONOR Brain
PERSONS
Initial Referral
Death
DETECTION screening
Diagnosis
to OPO
Organ
allocation
Transp-
lantation
Review Donation Full Organ
case with request Donor
team (Consent) Evaluation retrieval
Donor maintenance
DONOR EVALUATION
• The objective of donor evaluation is:
• To avoid the transmission of infectious diseases and
cancer
• To ensure that organs will function once transplanted
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DONOR EVALUATION
• CAUSE OF DEATH
• Tests such as CT are recommended to establish the
cause of death to eliminate primary or secondary
tumours of the CNS.
• For meningitis or encephalitis → perform
bacteriological or virological studies.
• For poisoning determine the impact of toxicity on
organs’ function.
• Poisoning is not a formal contraindication to donation.
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DONOR EVALUATION
• MEDICAL SOCIAL HISTORY
• Age - age is not a factor for clinical contraindication.
.
Presentation title 39
DONOR EVALUATION
• MEDICAL SOCIAL HISTORY
• RISK FACTORS - behavioural habits and life-styles that
increase the likelihood of disease transmission.
• Sexual habits (homosexuality, promiscuity etc.)
• Toxic habits (alcoholism, drug abuse etc.)
• Travel history (to endemic areas of malaria, prion-
infection / Bovine Spongiform Encephalitis (BSE) etc.)
.
Presentation title 40
Presentation title
DONOR EVALUATION
• PAST MEDICAL HISTORY
• Arterial hypertension and diabetes mellitus
• per se are not absolute contraindications.
• Their evolution and their impact on specific organ functions have
to be evaluated, particularly on kidney and heart.
• In systemic diseases, damage of one or all organs must
be considered (e.g. Panarteritis Nodosa).
• Pre-existing malignant diseases will be covered in the
following pages.
• Congenital diseases are not formal contraindications,
• liver related congenital diseases can contraindicate donation.
Presentation title 42
DONOR EVALUATION
• CURRENT CLINICAL STATUS
• HEMODYNAMIC STATUS
• BP, SBP, Oliguria → ORGAN PERFUSSION
• Cardiac arrest, as well as hypotension is not an absolute
contraindication for donation
• Hemodilution -could alter the serological
determinations and may jeopardize the organ and
tissue viability
• Review of Medications - Vasopressors Antibiotics
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DONOR EVALUATION
• PHYSICAL EXAM • PHYSICAL EXAM
• TRAUMA
• TRAUMA
• SCARS IVDU
• TATTOOS
• SCARS IVDU •
•
SKIN LESSIONS
PREVIOUS SURGICAL SCARS
• TATTOOS
• SKIN LESSIONS
• PREVIOUS SURGICAL SCARS
Presentation title 44
LABORATORY AND COMPLEMENTARY TESTS
CONTRAINDICATION FOR DONATION
• Human immunodeficiency virus – HIV
• donor who is tested and found to be positive for HIV
types 1 and 2 antibodies must be rejected
• Improved antibodies tests→ diagnostic windows
periods reduced upto 14 days
• PCR test (for RNA or DNA) reduces it to 11 days
• donors with negative serological markers for HIV but
medical and social history of risk (e.g. intravenous drug
abuse during the past 12 months) should be rejected
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CONTRAINDICATION FOR DONATION
• ACUTE/ACTIVE INFECTION
• important to confirm the presence of infection (generalised
or localised) and the antibiotic treatment.
• antibiotic therapy for at least 48 hours before organ
recovery should be continued with the recipient for at least
10 more days.
• Absolute contraindications to donation: disseminated
infections, bacterial sepsis, fungemia.
• Local infection is not a contraindication to donate other
organs than the one affected
Presentation title 47
EXTENDED CRITERIA DONORS
WHY DO WE NEED ECD’s?
EXPANDED KIDNEY CRITERIA
TAKE HOME MESSAGES
Thank you
