CADAVER ORGAN DONATION and it's implications.pptx

Cadaver organ donation

1. CADAVER ORGAN DONATION

2. CONTENTS Introduction History of transplant Types of transplant Major organs and tissues transplanted Types of donor Heart transplant procedure Transplant rejection Immunosuppressive drugs Cost of transplants Conclusion References

3. INTRODUCTION An organ ( from the latin “ organum ” meaning an instrument or tool) is the collection of the tissues that structurally form a functional unit specialized to perform a particular function. Organ donation is the donation of biological tissue or an organ of the human body , from a living or dead person to a living recipient in need of a transplantation. Organ donation day is on 27 th of November Transplantation of human organs and tissue act was passed in 1994 and is aimed at regulation of removal, storage and transplantation of human organs for therapeutic purposes and for prevention of commercial dealings in human organs

4. History of organ transplantation Indian surgeon sushruta the father of surgery in the second century BC, who used auto graft skin transplantation in nose reconstruction rhinoplasty.

5. OBJECTIVES To have basic idea of solid organ transplantation To know about organ sources and donor types To know about brain death concept

6. OPT IN VS. OPT OUT SYSTEM These are two main default options for determining voluntary consent of organ donor – Opt in (explicit consent): only those who have given explicit consent are donors – Opt out (presumed consent): anyone who has not refused consent to donate is a donor.

7. Opt In (Explicit Consent) • Opt-in policy requires people have to actively register their consent to the posthumous donation of their bodily organs • If the deceased person’s organ donation wishes are unknown, the organ procurement organization will approach a family member to obtain consent to remove the organs . The family members with the authority to do so is generally determined by this hierarchy – Spouse. If no spouse, then – Adult child. If no adult children, then – Parent. If no parents, then – Adult sibling. If no siblings, then – Legal guardian

8. Opt Out (Presumed Consent) • In countries that favor opt-out policy the default position is that everybody is a donor posthumous unless he/she has registered an objection . • Advocates of a this approach might argues that it is every person’s civic duty to donate their organs once they no longer need them (i.e. after death) to those who do .

9. Some factors influencing refusal to consent by relatives Non acceptance of brain death Superstition relating to being reborn with a missing organ A delay in funeral Lack of consensus within family members Dissatisfaction with a hospital staff Religious beliefs

10. SOLID ORGAN TRANSPLANTATION DEFINITION:- AUTOGRAFT :- the transfer of tissue or organ from one part of body to another within the same person ALLOGRAFT :- the transfer of tissue or organ from one individual to another individual. ISOGRAFT :- a subset of allograft from the donor to a genetically identical recipient (e.g. identical twin) XENOGRAFT :- a transplant of an organ or a tissue from one species to another e.g. porcine heart valve transplant

11. ORGANS THAT CAN BE TRANSPLANTED kidney heart lung liver pancreas intestines TISSUE THAT CAN BE TRANSPLANTED Cornea heart valves Skin Bone Bone marrow Tendon Cartilage Veins

12. ORGAN DONORS LIVING Relative Stranger 2. CADAVER

13. Types of living donor transplants Kidney ( entire organ) Liver (segment) Lung(lobe) Intestines( portion) Pancreas( portion )

14. After brain death (heart beating donors) Kidney Heart liver Lungs Pancreas Intestines Heart valves After Circulatory death( non heart beating donor ) After natural death Cornea Bone Skin Blood vessels

15. LIVING VS DECEASED TRANSPLANT Improved graft survival Less recipient morbidity Early function and easier to manage Avoidance long waiting time for transplant Less aggressive immunosuppressive regimen Relatively inferior graft survival More immunogenic Surgery of recipient is unscheduled More likely to need future transplant Waiting time is more

16. BRAIN DEATH IMPLICATIONS Heart beating brain dead donors provide majority of organs for transplant Extended time within terminal brain stem herniation, declaration of brain death and organ recovery risk loss of organs because of refractory cardiopulmonary instability Cost of intensive care

17. PATHOPHYSIOLOGY OF BRAIN INJURY Damages of neuronal tissues associated with traumatic brain injury fall into two category Primary injury, which is directly caused by mechanical forces during the initial insult Secondary injury, which refers to further tissue and cellular damages following primary insult

18. PATHOPHYSIOLOGY OF BRAIN INJURY

19. PATHOPHYSIOLOGY OF BRAIN INJURY Terminal brain stem herniation is often the final stage in refractory brain injury caused by trauma, ischemia or infarction, haemorrhage, intracranial tumours and infectious processes such as encephalitis and meningitis Progression of injury follows a cranio - caudal path

20. DONATION AFTER BRAIN DEATH Brain injury is refractory to aggressive management and is considered non survivable with loss of consciousness and brain stem reflexes, brain death protocol may be initiated to determine death according to neurological criteria Brain death is defined as the irreversible cessation of brain function including the brain stem

21. The clinical diagnosis of brain death consists of current clinical practice Establishment of proximate cause of neurologic insult Utilization of ancillary tests, such as electroencephalography (EEG), cerebral angiography in patients who do not meet clinical criteria Appropriate documentation Clinical examinations to determine coma, absence of brain stem reflexes, and apnea

22. CLINICAL TESTING OF BRAIN STEM DEATH

23. CONFOUNDING FACTORS IN BRAIN DEATH Spinal cord injury Movements in brain death complex spinal reflexes, muscle fasciculation, ventilator auto-triggering) Medical conditions such as drug over dose, hypothermia, hypoglycaemia Transient brain stem depression after cardiopulmonary arrest

24. DONORS AFTER CIRCULATORY DEATH Due to shortage of donor organs, donation after cardiac death(DCD) also known as donation by non heart beating donors (NHBDs)- was introduced to the transplant community. Category for donation after cardiac death (Maastricht classification) is as follows:- Type -1 dead on arrival (irreversible cardiac arrest on the street ) Type -2 unsuccessful resuscitation (includes pts brought into the emergency room while being resuscitated by the ambulance crew ) Type-3 imminent cardiac arrest in intensive care (ventilator switch off) Type -4 cardiac arrest during or after the brain death diagnostic procedure type- 5 unexpected cardiac arrest in intensive care

25. After the consent for donation is obtained from next of kin, the donors life support is removed After the cessation of cardiac and respiratory function, organ procurement starts With cardiac death ( as opposed to brain death), warm ischemic injury to organs can occur during the period between circulatory cessation and rapid core cooling through perfusion of preservation solution. Difference in long term outcomes is negligible for recipients of organs from either type of donor. Significant percentage of liver grafts procured after cardiac death, especially those with more than 25 minutes of warm ischemic time, develop devastating ischemic cholangiopathy and fail.

26. A new development to minimize ischemic injury to organs procured after cardiac death has been the application of extra corporeal membrane oxygenation (ECMO). With the ECMO, DCD differs in two keys ways A. cannulation occurs before withdrawal of life support B. organs are perfused via ECMO with warm oxygenated blood after declaration of cardiac death

27. EVALUATION OF DECEASED DONOR once the diagnosis of brain death h as been established the local organ procurement organizations assumes the care of potential donor and initiate the process of donor evaluation and organ donation Has to be assessed in view of transmissible infectious agents Malignancy HIV HBV HCV for kidney- adequate urine output, serum creatinine level and blood urea level For liver – liver function test For heart – ecg For lungs – chest x ray, gas exchange,

28. MANAGEMENT OF DECEASED DONORS Maintain electrolytes and fluid balance Vasopressin- to allow reduction or cessation of catecholamines pressor to treat diabetes insipidus Methylprednisolone- for fluid and metabolic management T3- for cardiovascular instability

29. RECOVERY OF MULTIPLE ORGANS FROM DECEASED DONORS Surgeons who perform multiple organ retrieval should be familiar and experienced with supra rapid technique described by Pittsburgh group. Preferably, NHBDs undergo withdrawal of life support in the operating room after the surgical site is prepared and draped, as soon as surgical team is ready.

30. Midline abdominal incision and median sternotomy are used to obtain access Organs to be recovered are perfused in situ The Heart is perfused via a cannula in ascending aorta The lungs are perfused via cannula in pulmonary artery Abdominal organs are perfused via aortic and portal cannula

31. Blood and perfusate are vented from left atrial appendage and inferior vana cava This produces rapid cooling of organs and thus reduce their metabolic activity and preserve their viability Additional surface cooling of abdominal organs may be achieved by application of saline ice slush

32. The heart and lungs are excised simultaneously with the liver and pancreas followed by kidney either en bloc or separately When removing the donor kidney care taken to ensure that any polar renal arteries are included in a aortic patch in a renal artery

33. In case of pancreas, Y-graft of donor iliac artery is excised and used it to reconstruct the divided splenic and superior mesenteric arteries of the graft before implantation

34. The liver from deceased is split and left lobe of left lateral segments are used for a child and the right lobe for an adult recipient during recovery care is taken to ensure that there is an aberrant hepatic artery arising from superior mesenteric artery included in the aortic patch

35. After removal from the donor the organs may undergo a further flush with chilled preservation solution before they are placed in double or triple sterile bags and stored at 4 degree Celsius by immersion in ice while they transported to the recipient center and await implantation. Once the donor organs have been excised, samples of donor spleen and mesenteric lymph nodes are obtained for confirmation of tissue type and the use in the cross match test.

36. Brain death may result in legal death, but still with the heart beating, and with mechanical ventilation all other vital organs may be kept completely alive and functional, providing optimal opportunities for organ transplantation. Most organ donation for organ transplantation is done in the setting of brain death. The non-living donor is kept on ventilator support until the organs have been surgically removed. If a brain-dead individual is not an organ donor, ventilator and drug support is discontinued and cardiac death is allowed to occur.

37. ORGAN PRESERVATION It extends the time that organs can be safely stored after procurement has enabled better organ utilization and better recipient outcomes Hypothermia and pharmacological inhibition are two most frequent methods. Both slow yet can not completely shut down the removed organ’s metabolic activity so the both have adverse effect such as cellular swelling and degradation.

38. Cold storage solutions were introduced to mitigate some of the adverse effect of hypothermia or pharmacologic inhibition alone. Such solutions help to prevent cellular swelling and loss of cellular potassium . Most effective preservation solution was developed at the university of Wisconsin and remains in the wide use. Its contents are Lactobionate ( which helps to prevent cellular swelling and reperfusion injury ) Raffinose and hydroxyethyl starch (which helps to reduce swelling of endothelial cells, there by decreasing edema) Histidine-tryptophan- ketoglutarate solution is also in wide use now a days

39. DISTRIBUTION Distribution varies slightly between different organs but is essentially very similar. When lists are generated many factors are taken into consideration these factors include: distance of transplant center from the donor hospital , blood type medical urgency wait time donor size tissue typing

40. TRANSPLANTATION GREEN CORRIDOR :- is a special route that is managed in a way that all traffic signals that come in the route of hospital where an organ is harvested and the hospital where it is to be transplanted are green and controlled manually. In this system the traffic department collaborates to transport a vital organ in less than 60-70% of the time that is usually taken to go from place A to place B Green corridor makes sure that there is no organ wastage In india concept of green corridor has been in use since 2014

41. TRANSPLANTATION Location of a transplant center with respect to a donor hospital is given priority due to the effects of Cold Ischemic Time (CIT ). Once the organ is removed from the donor, blood no longer perfuses through the vessels and begins to starve the cells of oxygen (ischemia ). Each organ tolerates different ischemic times. Hearts and lungs need to be transplanted within 4–6 hours from recovery, liver about 8–10 hours and pancreas about 15 hours; kidneys are the most resilient to ischemia . Kidneys packaged on ice can be successfully transplanted 24–36 hours after recovery Developments in kidney preservation have yielded a device that pumps cold preservation solution through the kidneys vessels to prevent Delayed Graft Function (DGF) due to ischemia.

42. ISCHEMIA DURATION WARM ISCHEMIA TIME :- time an organ remains at body temperature between which the blood supply is cut off before cold perfusion. (within 30 mins ) COLD ISCHEMIA TIME :- the time between the chilling of organ, after blood supply has been cut off the time it is warmed by reconnection

43. Maximum and optimal cold storage times ( approximate ) Organ Optimal (hours) Safe Kidney < 18 36 hour Liver < 12 18 hours Pancreas < 10 18 hours Small intestines < 4 6 hours Heart <3 6 hours Lung <3 8 hours

44. PRINCIPLES OF TRANSPLANTATION TRANSPLANT IMMUNOLOGY The immune system recognizes graft from someone else as foreign and triggers response via immune cells or substances they produce cytokines and antibodies Responses are via; recognition, amplification and memory

45. Problems in organ transplantation Chronic graft rejection and side effect of non specific immunosuppression The shortage of organ for transplantation

46. ORGAN REJECTION Rejection of transplanted organ is a bigger challenge than technical expertise required to perform the surgery It results mainly from HLA and ABO incompatibility Hyper acute :- within seconds to minute Acute :- in first 6 months Chronic :- after 6 months

47. Rejection is controlled by immunosuppression given as Induction All of the induction immunosuppressive agents currently used are biological agents monoclonal (muromonab-CD3, daclizumab , basiliximab , alemtuzumab ) 2)polyclonal( antithymocyte globulin [equine] / [rabbit]) antibodies

48. Maintenance There are usually 4 classes of maintenance drugs : 1) Calcineurin Inhibitors: Tacrolimus and Cyclosporine. 2) Antiproliferative agents: Mycophenolate Mofetil, Mycophenolate Sodium and Azathioprine. 3)mTOR inhibitor(Mammalian target of rapamycin (mTOR): Sirolimus. 4)Steroids: Prednisone.

49. Each state has its own nodal agency in charge of the allocation of human organs. Each nodal agencies is connected to all the transplant hospital in the state All hospital require to have their own website linked to the state nodal agency so that the hospital waiting lists for all organs is automatically linked to state nodal agency State nodal agency needs to be needs to be linked to the concerned regional organ and tissue transplant organization (ROTTO) ROTTO are to be linked to be national organ and tissue transplant organization (NOTTO) This will inform the national waiting list registry

50. In the event of brain stem death, once the family has agreed to organ donation, the hospital informs its own nodal officer in charge of organ donation about the death and the willingness of family to donate Of the paired organs such as kidney and lungs, one each is used by hospital for its own patients on the waiting list and the other is given to the waiting pool and will be allocated by the nodal agency to one of the patients in the other hospitals.

51. As per the governments allocation policy, if organs are retrieved from government hospital and put into the common pool, then they will be offered to the government hospital and then to the private hospital in case there are no takers in the government hospital If the organs are retrieved from private hospital, then they will be offered to private hospital first.

52. COUNSELLING May involve professional counselor/psychotherapist Aimed at preventing /minimizing possible complication Need for adherence to post op maintenance medication Regular follow up with thorough evaluation Life style modification ; smoking, alcohol, sedentary life style, junks, excessive salt ingestion

53. ETHICAL CONCERNS The world heath organisation argues that transplantations promotes health but notion of “ transplantation tourism “ has the potential to violate human rights or exploit the poor There is also powerful opposing views that trade in organs, if properly regulated to ensure that the seller fully informed of all the consequences of donation, is mutually beneficial transaction between two consenting adults, and that prohibiting it would itself be a violation of articles 3 and 29 of the universal declaration of human rights.

54. THANK YOU

55. REFERENCES