Resuscitation 81 (2010) 904–907

Contents lists available at ScienceDirect

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

Short communication

Kidney transplant function using organs from non-heart-beating donors maintained by mechanical chest compressions
Alonso Mateos-Rodríguez a,∗ , Luis Pardillos-Ferrer a , José María Navalpotro-Pascual a , Carlos Barba-Alonso a , María Eugenia Martin-Maldonado a , Amado Andrés-Belmonte b
a b

Servicio de Urgencias Médicas de Madrid SUMMA112, Spain Coordinación de trasplantes, Hospital Universitario 12 de Octubre, Madrid, Spain

a r t i c l e

i n f o

a b s t r a c t
Objective: This study aims to determine the failure rate of transplanted kidney grafts in recipients of organs from non-heart beating donors (NHBDs) who have had mechanical chest compressions to maintain a circulation before organ retrieval. Methods: A retrospective observational study based on review of the emergency medical service database and case histories of NHBDs, and information periodically sent by transplant units about donors and organs. The following variables were studied: age, sex, transfer hospital, time to arrival on the scene of cardiopulmonary arrest, time to arrival in hospital, number and type of organs retrieved, use of mechanical chest compression devices, and kidney function in graft recipients. The study covered the period between January 2008 and November 2009. During 2008 standard manual chest compressions were used and during 2009 mechanical chest compression devices were used. Results: In 39 transplanted kidneys from donors receiving mechanical chest compressions primary failure was documented in recipients on two occasions (5.1%). Kidneys transplanted from donors who had manual chest compressions resulted in three primary failures in recipients (9.1%). The difference between the two groups was not significant (p = 0.5). Three patients achieved successful return of spontaneous circulation in the mechanical chest compression group after initiation of the NHBD donor protocol. Conclusion: We have described our experience and protocol for non-heart beating donation using victims of out-of-hospital cardiac arrest in whom cardiopulmonary resuscitation has been unsuccessful as donors. Primary kidney graft failure rates in organs from non-heart beating donors is similar when manual or mechanical chest compression devices are used during cardiopulmonary resuscitation. © 2010 Elsevier Ireland Ltd. All rights reserved.

Article history: Received 10 February 2010 Received in revised form 12 April 2010 Accepted 28 April 2010 Keywords: Non-heart beating donors Emergency medical services Transplantation

1. Introduction Non-heart-beating donors (NHBDs) have to meet predefined criteria for organ donation1 including death from irreversible cessation of the beating heart. In 1995 the Maastricht conference2 defined four NHBD categories to differentiate their viability, and provide ethical and legal support.3 Type I donors (admitted to the centre after death) and type II donors (resulting from unsuccessful cardiopulmonary resuscitation (CPR) attempts) are referred to as uncontrolled donors, since the precise duration of warm ischaemia is not known in these donors. In Spain, NHBDs who originate from the out-hospital setting correspond to type II donors. These are

patients who have suffered a cardiac arrest outside hospital, and after failed CPR attempts are then transferred with continued CPR to hospital for organ donation. Mobile Emergency Unit doctors are legally and ethically enabled to diagnose (but not certify) the death of the patient and activate the donor protocol. In Spain all individuals whose views on organ donation are not known are considered as organ donors.4 In spite of this family permission is also obtained. This is regulated by the Royal Decree 2070/1999 relating to the donation and transplantation of organs and tissues.5 This allows the diagnosis of death after cardiorespiratory arrest according to the following: • The unequivocal confirmation of the absence of a heart beat, diagnosed by the absence of a central pulse or asystole on the electrocardiogram, and the absence of spontaneous breathing—being observed for a period of at least 5 min. • The irreversibility of the cessation of cardiorespiratory function must be confirmed after an adequate period of advanced CPR. This period, and CPR interventions should be appropriate for the age of

A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2010.04.024. ∗ Corresponding author at: C/ Antracita 2 bis, 28045 Madrid, Spain. Tel.: +34 607110309. E-mail address: amateo.summa@salud.madrid.org (A. Mateos-Rodríguez). 0300-9572/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2010.04.024

A. Mateos-Rodríguez et al. / Resuscitation 81 (2010) 904–907

905

the individual and the circumstances leading to cardiorespiratory arrest. At all times current advanced life support guidelines must be followed. • If the cardiac arrest victim’s body temperature is less than 32 ◦ C, the victim should be warmed before establishing the irreversibility of cardiac arrest, and thus the diagnosis of death. This study describes the role of mechanical chest compression devices in our service and determines if recipients of organs from NHBDs who have had mechanical chest compressions have improved kidney graft function compared with those recipients from NHBDs who have had manual chest compressions. 2. Material and methods 2.1. Study setting Madrid, Spain has 6 million inhabitants. The emergency medical service (EMS) is the Service of Medical Emergencies of Madrid, SUMMA112. This provides a comprehensive service including the use of two helicopters, 26 mobile intensive care units, 17 rapid intervention vehicles, a truck for major incidents, and another for special situations. Emergency vehicles have emergency trained doctors and nurses—and one or two emergency care technicians. During 2008 the service received about one million calls and attended 400,000 incidents including 78,000 by emergency care vehicle. 2.2. Resuscitation and donor protocol The inclusion criteria for the NHBD protocol of the Madrid Emergency Medical Service SUMMA112 are: absence of neoplastic, systemic or transmissible diseases (including no HIV infection); an age of between 1 and 55 years; a known time of cardiac arrest; a time interval from cardiac arrest to the start of advanced CPR of less than 15 min; hospital arrival in less than 90 min after cardiopulmonary arrest; a known or easily diagnosable cause of death, with no suspected abdominal or chest bleeding, and a healthy external appearance. When the EMS attends a cardiac arrest they begin CPR. If after 30 min of advanced CPR, there is no return of spontaneous circulation the victim is assessed as a potential NHBD. If the victim fulfills the NHBD criteria the protocol is activated, and ventilation and chest compressions (but not drugs) are continued while the patient is transferred to the transplant hospital. Resuscitation is not stopped during this assessment process. Death is diagnosed and certified after hospital arrival by a doctor who is not a member of the transplant team. This is usually an ICU doctor. CPR is stopped and the patient is assessed and the signs of death must be observed for at least 5 min to confirm death. The transplant surgical team than connect the donor to an extracorporeal circulation (bypass) machine to maintain a circulation. The process and timings are summarized in Table 1. There are two public hospitals in this programme: San Carlos University Clinic Hospital and Doce de Octubre Hospital. At present, the following organs are retrieved for transplantation from NHBDs identified by this program: kidneys, lungs, liver, corneas and bone tissue. We report here data from one of these two centres (Doce de Octubre Hospital). The study covered the period from January 2008 to November 2009. During the first year of the study mechanical chest compression devices were not used. Since 2009 mechanical chest compression devices have been included in the protocol. Specifically, use has been made of the Lucas©(Physio-Control) and Autopulse©(Zoll) compression devices (Fig. 1). In the case of helicopter transfer, where the Autopulse©was used. The analysis was limited to those cases in which one or two kidneys were retrieved and transplanted. 2.3. Data collection A retrospective observational study based on review of emergency medical service database, case histories of NHBDs, and information provided by transplant units on the validity of donors and organs. The following variables were entered into a database: age, sex, transfer hospital, time to arrival on the scene of cardiopulmonary arrest, time to arrival in hospital, number and type of organs retrieved, use of mechanical chest compression devices, and kidney function in graft recipients. 2.4. Statistical analysis The SPSS©version 16.0 was used for statistical analysis. Quantitative variables are expressed as the mean ± standard deviation (SD). Qualitative variables are reported as percentages. For the comparison of qualitative variables, the Chi-squared test or its Fisher f correction was used. Comparison of quantitative variables was made with the Student’s t-test. 3. Results During 2009, 28 NHBD candidates were transferred to the Doce de Octubre Hospital with the use of one of the mechanical chest compression devices. Of these 28 cases, 85% were males, with a mean age of 39 ± 10 years. The mean time for EMS arrival to the scene of the cardiopulmonary arrest was 12 ± 8 min, and the interval from the initial alert for the cardiac arrest and hospital arrival was 97 ± 53 min. There was no significant difference with the data from 2008 when manual chest compressions were used (Table 2). The cause of death in the 28 patients who had mechanical chest compressions was: cardiac arrest (15 cases), neurological (5 cases), respiratory (1 case) and unknown (information missing from clinical record in 7 cases). Thirty-nine kidneys were transplanted from the 28 NHBDs in 2009, representing 70% of the total potential kidneys. Kidneys were not transplanted because of: legal objection in one case (two kidneys), family refusal in three cases (6 kidneys), failure to establish an extracorporeal circulation in 1 case (two kidneys) and microscopic and macroscopic defects in 7 kidneys. During the manual chest compression period in 2008, 33 kidneys were transplanted from 20 NHBDs (83% of the potential organs). The difference between both groups in proportion of donor kidneys transplanted was not significant (p = 0.23).
Fig. 1. Mechanical cardiac compressors used in the program, Lucas©from PhysioControl and Autopulse©from Zoll.

906

A. Mateos-Rodríguez et al. / Resuscitation 81 (2010) 904–907

Table 1 Timing and interventions for out-hospital NHBD program. Pre-hospital setting 0–15 min 15–30 min 30–90 min Arrive at scene and start CPR If no ROSC and fulfill NHBD criteria actived protocol NHBD alert and transfer to hospital with CPR on going (manual or mechanical compressiions) Hospital setting Legal actions

Hospital organ retrieval team alerted

Diagnosis of death and certification by hospital doctor on arrival Legal request for catheterization for preservation purposes Legal request for organ retrieval

90–120 min 120–240 min ROSC = return of spontaneous circulation. NHBD = non-heart beating donor.

Extracorporeal bypass circulation Ask family if they agree with organ donation

Table 2 Description of the cases studied. Manual chest compressions (n = 20 patients) Age ± SD (years) Males (%) Time to arrival on scene of cardiopulmonary arrest (min) Cardiac arrest alert to hospital arrival interval (min) Kidneys transplanted (% versus potential number) Primary graft failure in recipient 41 ± 9 85% 15 ± 7 99 ± 24 33 (82%) 3 (9.1%) Mechanical chest compressions (n = 28 patients) 39 ± 10 95% 12 ± 8 97 ± 53 39 (70%) 2 (5.1%) p = 0.38 p = 0.19 p = 0.89 p = 0.23 p = 0.50

Among the 39 transplanted kidneys from NHBDs who had mechanical chest compressions in 2009, primary graft failure was documented in recipients on two occasions (5.1%). In the manual chest compression period there were three primary graft failures in recipients of the 33 kidneys (9.1%). The difference between the two groups was not significant (p = 0.62). We were also made aware of a further three cases who had mechanical chest compressions as part of the NHBD protocol where there was a return of spontaneous circulation during transport to the transplant centre. One of these cases made a good recovery with neurological function.

4. Discussion Mechanical chest compression devices are a feasible alternative to manual compressions during transport of patients in whom our NHBD protocol is activated. The program was started in the year 2004, and since then over 500 organs from 170 patients transferred to the transplant units have been transplanted. The non-primary function rate in kidney recipients from donors of this kind is about 10%.6–8 Although larger studies are needed to confirm this, our observational study shows that the use of mechanical chest compression devices used to maintain a circulation during transport of patients who have had a failed CPR attempt does not significantly improve the primary graft function of donated kidneys. Graft function is dependent on a large number of factors, and cannot be established by improved perfusion in the context of cardiopulmonary arrest alone. Primary kidney graft failure is usually due to microcoagulation within the renal parenchyma, and this phenomenon is difficult to resolve and even more difficult to detect prior to transplantation. Mechanical chest compression devices likewise do not seem to offer an important improvement in the number of viable organs for transplantation, though here again further studies are needed. Mechanical chest compression devices do make patient transport easier for the medical team, decreasing the physical work required for manual chest compressions and minimizing injuries to rescuers from performing chest compressions during ambulance during transfer. Also, while these devices have not shown

improvement in the survival of patients suffering cardiopulmonary arrest,9 the devices do improve brain perfusion and also help minimize interruptions in chest compressions.10 We are currently studying injuries to donor organs caused by chest compressions. The most frequent cause of death in our series was primary cardiac arrest. Trauma patients who have suffered cardiopulmonary arrest are often not good donor candidates as they have injuries to major vessels and establishing an extracorporeal circulation can be difficult. We also identified three patients who were entered into the NHBD protocol and received mechanical chest compressions who had a return of spontaneous circulation during transfer to the transplant hospital. If these individuals had not been included in the NHBD protocol, resuscitation would have stopped after 30 min and the patients would not have survived. We are investigating these cases in more detail. Ensuring that the guidance for diagnosing death is strictly followed on arrival at the transplant centre ensures that only those patients who have died become NHBDs. Family refusal for organ donation in this group of NHBDs is low in comparison to heart beating donors who have been diagnosed brain dead.11 We do not know the cause of this difference. One reason may be the relative speed of the NHBD process as opposed to asking family members who may have been at the bedside of their sick relative for a number of days in the case of brain dead donors. Awareness and support for organ donation in Spain is generally good. 5. Conclusions We have described our experience and protocol for non-heart beating donation using victims of out-of-hospital cardiac arrest in whom cardiopulmonary resuscitation has been unsuccessful as donors. Primary kidney graft failure rates in organs from non-heart beating donors is similar when manual or mechanical chest compression devices are used during cardiopulmonary resuscitation. Conflict of interest statement None to declare.

A. Mateos-Rodríguez et al. / Resuscitation 81 (2010) 904–907

907

References
1. Álvarez J, Sánchez Fructuoso A, del Barrio MR, et al. Donación de órganos a Corazón parado. Resultados del Hospital Clínico San Carlos. Nefrología 1998;XVIII:47–52. 2. Kootstra G, Daemen JHC, Oomen APA. Categories of non-heart beating donors. Transpl Proc 1995;27:2893–4. 3. Brook NR, Waller JR, Nicholson ML. Nonheart-beating donation: current practica and future developments. Kidney Int 2003;63:1516–29. 4. Law 30/1979 on extraction and transplants of organs of October 27. Article 5. BOE I number 266 of November 6; 1979. 5. Real Decreto 2070/1999, de 30 de diciembre, por el que se regulan las actividades de obtención y utilización clínica de órganos humanos y la coordinación territorial en materia de donación y trasplante de órganos y tejidos. Anexo 1 y Articulo 10. 6. Andres A. Resultados del donante de organos procedente de donante en asistolia. ˜ In: 3er Congreso de la Sociedad Madrilena de trasplantes. 2009.

7. Fieux F, Losser M-R, Bourgeois E, et al. Kidney retrieval after sudden out of hospital refractory cardiac arrest: a cohort of uncontrolled non heart betaing donors. Crit Care 2009;13:R141. 8. Sanchez-Fructuoso AI, Marques M, Prats D, et al. Victims of cardiac arrest ocurring outside the hospital: a source of trasnplantable kidneys. Ann Intern Med 2006;145:157–64. 9. Axelsson C, Nestin J, Svensson L, Axelsson AB, Herlitz J. Clinical consequences of the introduction of mechanical chest compression in the EMS system for treatment of out-of-hospital cardiac arrest—a pilot study. Resuscitation 2006;71:47–55. 10. Wigginton JG, Isaacs SM, Kay JJ. Mechanical devices for cardiopulmonary resuscitation. Curr Opin Crit Care 2007;13:273–9. 11. Andres A, Morales E, Vazquez S, et al. Lower rate of family refusal for organ donation in non heart beating donors versus brain dead donors. Transpl Proc 2009;41:2304–5.