Cadaveric Renal Transplant-CPG

39. CADAVERIC TRANSPLANTATION

39.1 Selection of donors
Any comatose patients with irreversible cerebral damage who appears likely to progress to brain death prior to terminal circulatory failure should be considered as a potential donor, regardless of age. Physicians caring for the potential donors should be encouraged to make early contact with the tissue organ procurement (TOP) team or the HKL transplant coordinator for assistance in the further management of the donor and the donor family (Tel. No: 03-26942704 or 03-26942705 during office hours, or 013-3759887)

39.2 Contraindications
39.2.1 Absolute contraindication (Level B)
a. Severe untreated septicaemia or septicaemia of unknown origin
b. HIV positive serology or a history of activities with high risk for HIV infection
c. Acute hepatitis
b. History of cancer other then non invasive brain tumor, non melanotic non metastatic skin tumor.
The Council of Europe has recently published an international consensus on the prevention of neoplastic disease in transplantation and classified primary brain tumors according to acceptability for organ donation1
• Brains tumors that do not exclude the donor from organ donation are: benign meningiomas, pituitary adenomas, acoustic schwannomas, craniopharyngiomas, pilocytic astrocytomas (astrocytomas grade I), epidermoid cysts, colloid cysts of the third ventricle, choroid plexus papillomas, haemangioblastomas, ganglional cell tumors, pineocytomas, low grade oligodendrogliomas, ependymomas and well differentiated teratoma.
• Tumours where the donor can be considered for organ donation depending on characteristics: low grade astrocytoma (grade II), gliomatosis cerebri
• Tumours where the donor should not be considered for organ donation: Anaplastic astrocytoma (grade III), glioblastoma multiforme, medulloblastoma, anaplastic oligodendroglioma (Schmidt C & D), malignant ependymomas, pineoblastomas, anaplastic and malignant meningiomas, intracranial sarcomas, germ cell tumours (except well differentiated teratomas), chordamas and primary cerebral lymphomas.


39.2.2 Relative contraindication (Level C)
a. Very elderly donor (>70 years)2
b. Severe vascular disease
c. Long term insulin dependent diabetes mellitus
d. Hypertension or other condition with impaired renal function
e. Suboptimal or non acceptable renal function
It is recommended that donors should be evaluated on the basis of renal function (calculated creatinine clearance),3 age and vascular disease. Limit may be set as CrCl >60ml/min as acceptable, 50-60 ml/min as marginal and <50> 330C
c. Poisoning, sedation, and metabolic, electrolyte or acid/base disturbance are excluded

39.4.2 Clinical criteria
a. Unconscious. No reaction to speech, touch or pain
b. Spontaneous breathing absent
c. Spontaneous muscular movement in area innervated by cranial nerves absent. Spinal reflexes in trunk or extremities may be seen
d. Defensive movement of head, extremities and trunk on painful stimuli absent. Spinal reflexes may be present
e. Reactions of pupils to light absent
f. Corneal reflexes absent bilaterally
g. Doll’s eye movement absent
h. Cardiocerebral reflexes absent (eye bulb pressure)
i. Blinking reflexes on sound stimuli absent
j. Laryngeal reflexes absent
k. Apnoea test shows absence of spontaneous breathing

39.5 Support of the potential donor and optimisation of organ function
Any comatose patient with irreversible cerebral disease should be identified as a potential donor and monitored carefully awaiting determination of brain death, evaluation and consent for organ donation. The management of a potential donor should be similar to normal ICU care and simplified goal for management should be to13,14 (Level C):
39.5.1 Maintain a CVP of 10cm H2O. Blood volume can be increased with crystalloids and colloids

39.5.2 A systolic arterial pressure of 100 mmHg.15 If this cannot be reached using fluids alone, dopamine may be added as an inotropic support.

39.5.3 A urine output of 100 ml/hr. (Level C) The best treatment
of diabetes insipidus is vasopressin or one of its analogues.

39.5.4 Maintain normal values of blood gas analysis. A positive end expiratory pressure of 5cm H2O is advisable to retard the development of atelectasis.















References
1. Council of Europe International Consensus. Committee of experts on the organisational aspects of cooperation in organ transplantation. Standardisation of organ donor screening to prevent transmission of neoplastic diseases. 1997
2. Karpinski J, Lajoie G, Cattran D et al. Outcome of kidney transplantation from high risk donors is determined by both structure and function. Transplantation 1999; 67: 1162-1167
3. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976; 16: 31-41
4. Sola R, Guirado LL, Lopez Navidad et al. Renal transplantation with limited donors. To what extent should the good results obtained be attributed? Transplantation 1998; 66: 1159-1163
5. Alfred EJ, Lee CM, Scandling JD et al. When should expanded criteria donor kidneys be used for single versus dual kidney transplants? Transplantation 1997; 64: 1142-1146
6. Morales JM, Campistol JM, Castellano G et al. Transplantation of kidneys from donors with hepatitis C antibody into recipient with pre transplantation anti HCV. Kidney Int 1995; 47: 236-240
7. Periera BJ, Wright TL, Schmid CH, Levey AS. A controlled study of hepatitis C transmission by organ transplantation. Lancet 1995; 345: 484-487
8. Widell A, Mansson S, Persson NH et al. Hepatitis C superinfection in hepatits C virus infected patients transplanted with a HCV infected lidney. Transplantation 1995; 60: 642-647
9. Eastlund T. Infectious disease transmission through cell, tissue, and organ transplantation: Reducing the risk through donor selection. Cell Transpl 1995; 4: 455-477
10. Wijnen RMH, Booster MH, Kootstra G et al. Outcome of transplantation of non heart beating donors kidneys. Lancet 1995; 345: 1067-1070
11. Cho YW, Terasaki PI, Cecka JM, Gjerston DW. Transplantation of kidneys from donors whose hearts have stopped beating. N Eng J Med 1998; 338: 221-225
12. Sanchez-Fructuoso Al, Prats D, Torrente J et al. Renal transplantation from non heart beating donors: a promising alternative to enlarge the donor pool. J Am Soc Nephrol 2000; 11: 350-358
13. Soifer BE, Gleb AW. The multiple organ donor: Identification and management. Ann Int Med 1989; 110: 814-823
14. Nygaard CE, Townsend RN, Diamond DL. Organ donation management and outcome: a 6 year review from a level 1 Trauma Centre. Trauma 1990; 30: 728-732
15. Caroll RPN, Chisholm GD, Shackman R. Factors influencing early function of cadaver renal transplants. Lancet 1969; 551-552