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VOLUME 26 , ISSUE 4 ( April, 2022 ) > List of Articles

POSITION PAPER

Organ Donation after Circulatory Determination of Death in India: A Joint Position Paper

Avnish K Seth, Ravi Mohanka, Sumana Navin, Alla GK Gokhale, Ashish Sharma, Anil Kumar, Bala Ramachandran, KR Balakrishnan, Darius Mirza, Dhvani Mehta, Kapil G Zirpe, Kumud Dhital, Manisha Sahay, Srinagesh Simha, Radha Sundaram, Rahul Pandit, Raj K Mani, Roop Gursahani, Subash Gupta, Vivek B Kute, Sunil Shroff

Keywords : Circulatory death, Donation, Organ donation

Citation Information : Seth AK, Mohanka R, Navin S, Gokhale AG, Sharma A, Kumar A, Ramachandran B, Balakrishnan K, Mirza D, Mehta D, Zirpe KG, Dhital K, Sahay M, Simha S, Sundaram R, Pandit R, Mani RK, Gursahani R, Gupta S, Kute VB, Shroff S. Organ Donation after Circulatory Determination of Death in India: A Joint Position Paper. Indian J Crit Care Med 2022; 26 (4):423-440.

DOI: 10.5005/jp-journals-10071-24198

License: CC BY-NC 4.0

Published Online: 13-05-2022

Copyright Statement:  Copyright © 2022; The Author(s).


Abstract

Organ donation following circulatory determination of death (DCDD) has contributed significantly to the donor pool in several countries. In India, majority of deceased donations happen following brain death (BD). While existing legislation allows for DCDD, there have been only few reports of kidney transplantation following DCDD from India. This document, prepared by a multidisciplinary group of experts, reviews international best practices in DCDD and outlines the path for DCDD in India. Ethical, medical, legal, economic, procedural, and logistic challenges unique to India have been addressed. The practice of withdrawal of life-sustaining treatment (WLST) in India, laid down by the Supreme Court of India, is time-consuming, possible only in patients in a permanent vegetative state, and too cumbersome for day-to-day practice. In patients where continued medical care is futile, the procedure for WLST is described. In controlled DCDD (category-III), decision for WLST is independent of and delinked from the subsequent possibility of organ donation. Families that are inclined toward organ donation are explained the procedure including the timing and location of WLST, consent for antemortem measures, no-touch period, and the possibility of stand-down and return to the intensive care unit (ICU) without donation. In donation following neurologic determination of death (DNDD), if cardiac arrest occurs during the process of BD declaration, the protocol for DCDD category-IV has been described in detail. In DCDD category-V, organ donation may be possible following unsuccessful cardiopulmonary resuscitation of cardiac arrest in the ICU. An outline of organ-specific requisites for kidney, liver, heart, and lung transplantation following DCDD and techniques, such as normothermic regional perfusion (nRP) and ex vivo machine perfusion, has been provided. The outcomes of transplantation following DCDD are comparable to those following DBDD or living donor transplantation. Documents and checklists necessary for successful execution of DCDD in India are described.


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  1. Global Observatory on Organ Donation and Transplantation. Available from: http://www.transplant-observatory.org [Accessed May 11, 2021].
  2. National Organ and Tissue Organization (NOTTO). Available from: https://www.notto.gov.in/organreport.htm [Accessed May 11, 2021].
  3. Wijdicks EF. Neurology of brain death. In: Brain death. 3rd ed. New York: Oxford University Press; 2017. p. 25.
  4. Terminology in Institute of Medicine. Organ donation: opportunities for action. Washington, DC: The National Academies Press; 2006. p. 31. DOI: 10.17226/11643.
  5. WHO task force on donation and transplantation of human organs and tissues. Available from: https://www.who.int/transplantation/donation/taskforce-transplantation/en/ [Accessed May 11, 2021].
  6. WHO guiding principles on human cell, tissue and organ transplantation. Available from: https://www.who.int/transplantation/Guiding_PrinciplesTransplantation_WHA63.22en.pdf?ua=1. [Accessed March 2021].
  7. The Transplantation of Human Organs Act (THOA). 1994. Available from: https://main.mohfw.gov.in/sites/default/files/Act%201994.pdf [Accessed May 11, 2021].
  8. Harvey D, Butler J, Groves J, Manara A, Menon DK, Thomas E, et al. Management of perceived devastating brain injury after hospital admission–a consensus statement from stakeholder professional organisations. Br J Anaesth 2018;120(1):138–145. DOI: 10.1016/j.bja.2017.10.002.
  9. Seth AK, Nambiar P, Joshi A, Ramprasad R, Choubey R, Puri P, et al. First prospective study on brain stem death and attitude towards organ donation in India. Liver Transpl 2009;15(11):1443–1447. DOI: 10.1002/lt.21912.
  10. Aboubakr M, Alameda G. Brain death criteria. 2020. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021. PMID: 31424728.
  11. Kootstra G, Daemen JH, Oomen AP. Categories of non-heart-beating donors. Transplant Proc 1995;27(5):2893–2894. PMID: 7482956.
  12. Sánchez-Fructuoso AI, Prats D, Torrente J, Pérez-Contín MJ, Fernández C, Alvarez J, et al. Renal transplantation from non-heart beating donors: a promising alternative to enlarge the donor pool. J Am Soc Nephrol 2000;11(2):350–358. DOI: 10.1681/ASN.V112350.
  13. Harrison JH, Merrill JP, Murray JE. Renal homotransplantation in identical twins. Surg Forum 1956;6:432–436. PMID: 13391513.
  14. Starzl TE, Groth CG, Brettschneider L, Penn I, Fulginiti VA, Moon JB, et al. Orthotopic homotransplantation of the human liver. Ann Surg 1968;168(3):392–415. DOI: 10.1097/00000658-196809000-00009.
  15. Hardy JD, Webb WR, Dalton ML Jr, Walker GR Jr. Lung homotransplantation in man. Journal of the American Medical Association 1963;186:1065–1074. DOI: 10.1001/jama.1963.63710120001010.
  16. Barnard CN. The operation. A human cardiac transplant: an interim report of a successful operation performed at Groote Schuur Hospital, Cape Town. S Afr Med J 1967;41(48):1271–1274. PMID: 4170370.
  17. White SL, Hirth R, Mahíllo B, Domínguez-Gil B, Delmonico FL, Luc Noel L, et al. The global diffusion of organ transplantation: trends, drivers and policy implications. Bull World Health Organ 2014;92(11):826–835. DOI: 10.2471/BLT.14.137653.
  18. Parente A, Osei-Bordom DC, Ronca V, Perera MTPR, Mirza D. Organ restoration with normothermic machine perfusion and immune reaction. Front Immunol 2020;11:565616. DOI: 10.3389/fimmu.2020.565616.
  19. Lomero M, Gardiner D, Coll E, Haase-Kromwijk B, Procaccio F, Immer F, et al.; European Committee on Organ Transplantation of the Council of Europe (CD-P-TO). Donation after circulatory death today: an updated overview of the European landscape. Transpl Int 2020;33(1):76–88. DOI: 10.1111/tri.13506.
  20. Wind J, Faut M, van Smaalen TC, van Heurn EL. Variability in protocols on donation after circulatory death in Europe. Crit Care 2013;17(5):R217. DOI: 10.1186/cc13034.
  21. Australian Government Organ and Tissue Authority. National protocol for donation after cardiac death. 2010. Available from: https://donatelife.gov.au/sites/default/files/DCD%20protocol%20020311-0e4e2c3d-2ef5-4dff-b7ef-af63d0bf6a8a-1.PDF [Accessed May 13, 2021].
  22. Huang J, Wang H, Fan ST, Zhao B, Zhang Z, Hao L, et al. The national program for deceased organ donation in China. Transplantation 2013;96(1):5–9. DOI: 10.1097/TP.0b013e3182985491.
  23. Sprung CL, Ricou B, Hartog CS, Maia P, Mentzelopoulos SD, Weiss M, et al. Changes in end-of-life practices in European Intensive Care Units from 1999 to 2016. Journal of the American Medical Association 2019;322(17):1–12.
  24. https://bts.org.uk/wp-content/uploads/2016/09/15_BTS_Donors_DCD-1.pdf.
  25. Smith M, Dominguez-Gil B, Greer DM, Manara AR, Souter MJ. Organ donation after circulatory death: current status and future potential. Intensive Care Med 2019;45(3):310–321. DOI: 10.1007/s00134-019-05533-0.
  26. Ortega-Deballon I, Hornby L, Shemie SD. Protocols for uncontrolled donation after circulatory death: a systematic review of international guidelines, practices and transplant outcomes. Crit Care 2015;19:268. DOI: 10.1186/s13054-015-0985-7.
  27. Morrissey PE, Monaco AP. Donation after circulatory death: current practices, ongoing challenges, and potential improvements. Transplantation 2014;97(3):258–264. DOI: 10.1097/01.TP.00004 37178.48174.db.
  28. Domínguez-Gil B, Haase-Kromwijk B, Van Leiden H, Neuberger J, Coene L, Morel P, et al.; European Committee (Partial Agreement) on Organ Transplantation. Council of Europe (CD-P-TO). Current situation of donation after circulatory death in European countries. Transpl Int 2011;24(7):676–686. DOI: 10.1111/j.1432-2277.2011.01257.x.
  29. Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, et al. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med 2008;36(3):953–963. DOI: 10.1097/CCM.0B013E3181659096.
  30. Domínguez-Gil B, Ascher N, Capron AM, Gardiner D, Manara AR, Bernat JL, et al. Expanding controlled donation after the circulatory determination of death: statement from an international collaborative. Intensive Care Med 2021;47(3):265–281. DOI: 10.1007/s00134-020-06341-7.
  31. Shemie SD, Baker AJ, Knoll G, Wall W, Rocker G, Howes D, et al. National recommendations for donation after cardiocirculatory death in Canada: donation after cardiocirculatory death in Canada. Canadian Medical Association Journal 2006;175(8):S1. DOI: 10.1503/cmaj.060895.
  32. Weiss MJ, Hornby L, Witteman W, Shemie SD. Pediatric donation after circulatory determination of death: a scoping review. Pediatr Crit Care Med 2016;17(3):e87–e108. DOI: 10.1097/PCC.0000000000000602.
  33. Weiss MJ, Hornby L, Rochwerg B, van Manen M, Dhanani S, Sivarajan VB, et al. Canadian guidelines for controlled pediatric donation after circulatory determination of death-summary report [published correction appears in Pediatr Crit Care Med 2018;19(2):178]. Pediatr Crit Care Med 2017;18(11):1035–1046. DOI: 10.1097/PCC.0000000000001320.
  34. Gries CJ, White DB, Truog RD, Dubois J, Cosio CC, Dhanani S, et al.; American Thoracic Society Health Policy Committee. An official American Thoracic Society/International Society for Heart and Lung Transplantation/Society of Critical Care Medicine/Association of Organ and Procurement Organizations/United Network of Organ Sharing Statement: ethical and policy considerations in organ donation after circulatory determination of death. Am J Respir Crit Care Med 2013;188(1):103–109. DOI: 10.1164/rccm.201304-0714ST.
  35. Kute VB, Vanikar AV, Shah PR, Gumber MR, Patel HV, Modi PR, et al. Outcome of renal transplantation from deceased donors after cardiac death: a single-center experience from a developing country. Transplant Proc 2013;45(6):2147–2151. DOI: 10.1016/j.transproceed.2013.02.128.
  36. Singh S, Kumar S, Dasgupta S, Kenwar DB, Rathi M, Sharma A, et al. A single-center experience of kidney transplantation from donation after circulatory death: challenges and scope in India. Indian J Nephrol 2017;27(3):205–209. DOI: 10.4103/0971-4065.202843.
  37. Shroff S, Navin S. “Brain death” and “circulatory death”: Need for a uniform definition of death in India. Indian J Med Ethics 2018; 3(4)NS:321–323. DOI: 10.20529/IJME.2018.070.
  38. Transplantation of human organs rules. 1995. Available from: https://main.mohfw.gov.in/sites/default/files/Rules%201995.pdf [Accessed May 11, 2021].
  39. THOA amendment. 2011. Available from: https://main.mohfw.gov.in/sites/default/files/THOA-amendment-2011%20%281%29.pdf [Accessed May 11, 2021].
  40. Transplantation of human organs and tissues rules. 2014. Available from: https://main.mohfw.gov.in/sites/default/files/THOA-Rules-2014%20%281%29.pdf [Accessed May 11, 2021].
  41. Myatra SN, Salins N, Iyer S, Macaden SC, Divatia JV, Muckaden M, et al. End-of-life care policy: an integrated care plan for the dying: a joint position statement of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Association of Palliative Care (IAPC). Indian J Crit Care Med 2014;18(9):615–635. DOI: 10.4103/0972-5229.140155.
  42. The Mathura Declaration–a call to action to promote palliative and end of life care in India. Available from: https://ehospice.com/india_posts/the-mathura-declaration-a-call-to-action-to-promote-palliative-end-of-life-care-in-india [Accessed April 25, 2021].
  43. Macaden SC, Salins N, Muckaden M, Kulkarni P, Joad A, Nirabhawane V, et al. End of life care policy for the dying: consensus position statement of Indian association of palliative care. Indian J Palliat Care 2014;20(3):171–181. DOI: 10.4103/0973-1075.138384.
  44. Mishra S, Mukhopadhyay K, Tiwari S, Bangal R, Yadav BS, Sachdeva A, et al. End-of-life care: consensus statement by Indian Academy of Pediatrics. Indian Pediatr 2017;54(10):851–859. DOI: 10.1007/s13312-017-1149-4.
  45. Mathur R. ICMR consensus guidelines on ‘Do Not Attempt Resuscitation’. Indian J Med Res 2020;151(4):303–310. DOI: 10.4103/ijmr.IJMR_395_20.
  46. Aruna Ramachandra Shanbaug vs. Union of India. 2011. 4 SCC 454.
  47. Justice K.S. Puttaswamy (Retd.) &, Anr. vs. Union of India case & Ors. Writ Petition (Civil) No 494 of 2012; (2017) 10 SCC 1; AIR 2017 SC 4161.
  48. Common Cause vs. Union of India. Supreme Court of India, Civil Original Jurisdiction; Writ Petition (Civil) No 215 of 2005.
  49. http://ficci.in/spdocument/23114/FICCI-ELICIT-Guide-for-Doctors-and-Administrators.pdf [Accessed May 13, 2021].
  50. AIIMS EOLC document on withholding life sustaining treatment. Available from: https://www.aiims.edu/en/notices/notices.html?id=11428 [Assessed May 11, 2021].
  51. End of Life Care in India. A model legal framework 2.0. Available from: https://vidhilegalpolicy.in/wp-content/uploads/2021/02/Model-End-of-Life-Care-Bill_Version-2.0.pdf [Accessed May 11, 2021].
  52. Potter JE, Herkes RG, Perry L, Elliott RM, Aneman A, Brieva JL, et al. COMmunication with Families regarding ORgan and Tissue donation after death in intensive care (COMFORT): protocol for an intervention study. BMC Health Serv Res 2017;17:42. DOI: 10.1186/s12913-016- 1964-7.
  53. Rudich SM, Kaplan B, Magee JC, Arenas JD, Punch JD, Kayler LK, et al. Renal transplantations performed using non-heart-beating organ donors: going back to the future? Transplantation 2002;74(12): 1715–1720. DOI: 10.1097/00007890-200212270-00013.
  54. Mathur AK, Heimbach J, Steffick DE, Sonnenday CJ, Goodrich NP, Merion RM. Donation after cardiac death liver transplantation: predictors of outcome. Am J Transplant 2010;10(11):2512–2519. DOI: 10.1111/j.1600-6143.2010.03293.x.
  55. Shapey IM, Muiesan P. Regional perfusion by extracorporeal membrane oxygenation of abdominal organs from donors after circulatory death: a systematic review. Liver Transpl 2013;19(12): 1292–1303. DOI: 10.1002/lt.23771.
  56. Haque O, Yuan Q, Uygun K, Markmann JF. Evolving utilization of donation after circulatory death livers in liver transplantation: the day of DCD has come. Clin Transplant 2021;35(3):e14211. DOI: 10.1111/ctr.14211.
  57. Dhital KK, Iyer A, Connellan M, Chew HC, Gao L, Hicks M, et al. Adult heart transplantation with distant procurement and ex-vivo preservation of donor heart after circulatory death: a case series. Lancet 2015;9987:2585–2591. DOI: 10.1016/S0140-6736(15)60038-1.
  58. Messer SJ, Axell RG, Colah S, White PA, Ryan M, Page AA, et al. Functional assessment and transplantation of the donor heart after circulatory death. J Heart Lung Transplant 2016;35(12): 1443–1452.
  59. Anguela-Calvet L, Moreno-Gonzalez G, Sbraga F, Gonzalez-Costello J, Tsui S, Oliver-Juan E. Heart donation from donors after controlled circulatory death. Transplantation 2020. DOI: 10.1097/TP.0000000000003545.
  60. Dhital K, Ludhani P, Scheuer S, Connellan M, Macdonald P. DCD donations and outcomes of heart transplantation: the Australian experience. Indian J Thorac Cardiovasc Surg 2020;36(Suppl. 2): 224–232. DOI: 10.1007/s12055-020-00998-x.
  61. Messer S, Cernic S, Page A, Berman M, Kaul P, Colah S, et al. A 5-year single-center early experience of heart transplantation from donation after circulatory-determined death donors. J Heart Lung Transplant 2020;39(12):1463–1475. DOI: 10.1016/j.healun.2020.10.001.
  62. Villavicencio MA, Axtell AL, Spencer PJ, Heng EE, Kilmrx S, Dalpozzal N, et al. Lung transplantation from donation after circulatory death: United States and single-center experience. Ann Thorac Surg 2018;106(6):1619–1627. DOI: 10.1016/j.athoracsur.2018.07.024.
  63. Saxena P, Zimmet AD, Snell G, Levvey B, Marasco SF, McGiffin DC. Procurement of lungs for transplantation following donation after circulatory death: the Alfred technique. J Surg Res 2014;192(2): 642–646. DOI: 10.1016/j.jss.2014.07.063.
  64. Van Raemdonck D, Keshavjee S, Levvey B, Cherikh WS, Snell G, Erasmus M, et al.; International Society for Heart and Lung Transplantation. Donation after circulatory death in lung transplantation-five-year follow-up from ISHLT Registry. J Heart Lung Transplant 2019;38(12):1235–1245. DOI: 10.1016/j.healun.2019.09.007.
  65. Schlegel A, Muller X, Kalisvaart M, Muellhaupt B, Perera MTPR, Isaac JR, et al. Outcomes of DCD liver transplantation using organs treated by hypothermic oxygenated perfusion before implantation. J Hepatol 2019;70(1):50–57. DOI: 10.1016/j.jhep.2018.10.005.
  66. Giorgakis E, Khorsandi SE, Mathur AK, Burdine L, Jassem W, Heaton N. Comparable graft survival is achievable with the usage of donation after circulatory death liver grafts from donors at or above 70 years of age: a long-term UK national analysis. Am J Transplant 2020. DOI: 10.1111/ajt.16409.
  67. Duan X, Yan L, Shen Y, Zhang M, Bai X, Liang T. Outcomes of liver transplantation using moderately steatotic liver from donation after cardiac death (DCD). Ann Transl Med 2020;8(18):1188. DOI: 10.21037/atm-20-5888.
  68. Laing RW, Scalera I, Isaac J, Mergental H, Mirza DF, Hodson J, et al. Liver transplantation using grafts from donors after circulatory death: a propensity score-matched study from a single center. Am J Transplant 2016;16(6):1795–1804. DOI: 10.1111/ajt.13699.
  69. Schlegel A, Kalisvaart M, Scalera I, Laing RW, Mergental H, Mirza DF, et al. The UK DCD Risk Score: a new proposal to define futility in donation-after-circulatory-death liver transplantation. J Hepatol 2018;68(3):456–464. DOI: 10.1016/j.jhep.2017.10.034.
  70. Nasralla D, Coussios CC, Mergental H, Akhtar MZ, Butler AJ, Ceresa CDL, et al.; Consortium for Organ Preservation in Europe. A randomized trial of normothermic preservation in liver transplantation. Nature 2018;557(7703):50–56. DOI: 10.1038/s41586-018-0047-9.
  71. van Rijn R, Schurink IJ, de Vries Y, van den Berg AP, Cortes Cerisuelo M, Darwish Murad S, et al.; DHOPE-DCD Trial Investigators. Hypothermic machine perfusion in liver transplantation–a randomized trial. N Engl J Med 2021;384(15):1391–1401. DOI: 10.1056/NEJMoa2031532.
  72. Hosgood SA, Bagul A, Nicholson ML. Minimising cold ischaemic injury in an experimental model of kidney transplantation. Eur J Clin Invest 2011;41(3):233–240. DOI: 10.1111/j.1365-2362.2010.02396.x.
  73. Gavriilidis P, Inston NG. Recipient and allograft survival following donation after circulatory death versus donation after brain death for renal transplantation: a systematic review and meta-analysis. Transplant Rev (Orlando) 2020;34(4):100563. DOI: 10.1016/j.trre.2020.100563.
  74. Molina M, Guerrero-Ramos F, Fernández-Ruiz M, González E, Cabrera J, Morales E, et al. Kidney transplant from uncontrolled donation after circulatory death donors maintained by nECMO has long-term outcomes comparable to standard criteria donation after brain death. Am J Transplant 2019;19(2):434–447. DOI: 10.1111/ajt.14991.
  75. Schaapherder A, Wijermars LGM, de Vries DK, de Vries APJ, Bemelman FJ, van de Wetering J, et al. Equivalent long-term transplantation outcomes for kidneys donated after brain death and cardiac death: conclusions from a nationwide evaluation. EClinicalMedicine 2018;4–5:25–31. DOI: 10.1016/j.eclinm.2018.09.007.
  76. Bellini MI, Charalampidis S, Herbert PE, Bonatsos V, Crane J, Muthusamy A, et al. Cold pulsatile machine perfusion versus static cold storage in kidney transplantation: a single centre experience. Biomed Res Int 2019;2019:7435248. DOI: 10.1155/2019/7435248.
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