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Paediatric donation after cardiac death (DCD) liver transplantation
35.2 Defining dcd: Donation after cardiac death
35.3 Organ procurement and implantation
Liver transplantation has become an established treatment option for a variety of liver conditions in children. But the success of liver transplantation is limited by the lack of suitable organs for children and is the main determinant of death on the transplant waiting list, with waiting list mortality increasing for the younger child, <5 years [1,2]. This has driven the development of paediatric living donor liver transplant (LDLT) programmes throughout the world (see Chapter 37) and encouraged the need to explore all sources of potential organs for liver transplant.
35.2 DEFINING DCD: DONATION AFTER CARDIAC DEATH
In the West, deceased liver transplantation is the main source of organs, and it includes both donation after brainstem death (DBD) and donation after cardiac death (DCD) organs. An earlier alternative acronym used in the literature for DCD is non-heart-beating donation (NHBD). The diagnostic criteria for brainstem death were first described by the Harvard Medical School in 1964 [3]. In the United Kingdom, the original Code of Practice for the Diagnosis of Brainstem Death was published in 1976 [4] and is applicable to children more than 2 months of age [5].
DCD is further subdivided according to the Maastricht classification [6–8] as follows:
I – Brought into hospital dead (uncontrolled)
II – Unsuccessful resuscitation in hospital (uncontrolled)
III – Awaiting cardiac arrest (controlled)
IV – Cardiac arrest after brainstem death (controlled)
The experience in the use of DCD organs for liver transplant has been predominantly from the controlled DCD categories of III and IV [9]. Prior to the definition of brainstem death, DCD was the only source of organs for the pioneering programmes in liver transplantation [10,11]. In hindsight, those early donors were highly selected and belonged to DCD controlled Maastricht category IV, that is, brainstem dead.
As DBD became established in the 1970s and produced results better than those of DCD, in terms of graft and recipient survival, the enthusiasm for the latter declined. As overall outcomes in liver transplantation have continued to improve, the unmet need has continued to grow and has led to renewed interest in DCD as a viable organ source. In paediatric liver transplantation, an additional factor is the lack of size-matched good-quality organs. There is the potential to increase size-matched donation by 40% on paediatric intensive care units (PICUs) if DCD donation is considered, providing futility of care has been agreed upon with the family of the child donor [6,12,13].
35.3 ORGAN PROCUREMENT AND IMPLANTATION
Withdrawal of life support for DCD is either in the ICU or the anaesthestic room, depending on donor hospital preference. For both the adult and child DCD donor, the family has the choice to remain present. On declaration of death, which is certified by a doctor independent of the donor team, there is a 5-min stand-off (in the United Kingdom). The donor team is scrubbed and ready for when the donor is brought into theatre. A modified superfast Casavilla * technique is used [14].
Thus, after a rapid thoracoabdominal incision and venting of blood in the chest, the abdominal aorta is cannulated, followed by cross-clamp in the chest. The portal vein (PV) or superior mesenteric vein is cannulated. The perfusion fluid used is chilled (4°C) University of Wisconsin (UW) solution with 20,000 IU heparin/L; pressure bags are used if flow by gravity is insufficient (3 L via aorta and 2 L via PV). Topically, ice is placed around the liver. Attention is given to prompt flushing of the biliary tree with chilled normal saline, until it is completely clear of bile, which is then followed by a rapid hepatectomy. Ideally, the whole process is <30 min long. On the backbench, the PV, hepatic artery and bile duct are further flushed before cold static storage.
Critical times that are recognised to be determinants of outcome in DCD liver transplantation are the warm ischaemic time (WIT) and the cold ischaemic time
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