BACKGROUND Donation after circulatory death (DCD) is a procedure in which after planned withdrawal of life-sustaining treatment (WLST), the dying process is monitored. A DCD procedure can only be continued if the potential organ donor dies shortly after WLST. This study performed an external validation of 2 existing prediction models to identify potentially DCD candidates, using one of the largest cohorts. METHODS This multicenter retrospective study analyzed all patients eligible for DCD donation from 2010 to 2015. The first model (DCD-N score) assigned points for absence of neurological reflexes and oxygenation index. The second model, a linear prediction model (LPDCD), yielded the probability of death within 60 min. This study determined discrimination (c-statistic) and calibration (Hosmer and Lemeshow test) for both models. RESULTS This study included 394 patients, 283 (72%) died within 60 min after WLST. The DCD-N score had a c-statistic of 0.77 (95% confidence intervals, 0.71-0.83) and the LPDCD model 0.75 (95% confidence intervals, 0.68-0.81). Calibration of the LPDCD 60-min model proved to be poor (Hosmer and Lemeshow test, P < 0.001). CONCLUSIONS The DCD-N score and the LPDCD model showed good discrimination but poor calibration for predicting the probability of death within 60 min. Construction of a new prediction model on a large data set is needed to obtain better calibration.

External Validation of the DCD-N Score and a Linear Prediction Model to Identify Potential Candidates for Organ Donation After Circulatory Death: A Nationwide Multicenter Cohort Study.

Controlled donation after circulatory death (DCD) has the potential to substantially increase the number of lung transplants thus offsetting some of the imbalance between need and organ availability. We examine the potential benefits associated with increased DCD utilization as well as the perceived barriers to the expansion of DCD. Solutions are offered as a means to expand DCD utilization across centers and nations. Controlled donation after circulatory death (DCD) has the potential to substantially increase the number of lung transplants thus offsetting some of the imbalance between need and organ availability. We examine the potential benefits associated with increased DCD utilization as well as the perceived barriers to the expansion of DCD. Solutions are offered as a means to expand DCD utilization across centers and nations. 

Controlled DCD lung transplantation: Circumventing imagined and real barriers-time for an international taskforce?

Heart Donation after Circulatory Death (DCD) has the potential to significantly increase the number of patients benefitting from heart transplantation. However, the expansion of DCD heart transplantation is currently limited by unanswered questions pertaining to best practices in DCD heart procurement. Additionally, significant variability exists within regulatory frameworks, professional guidelines, and published practices of DCD procurement processes. Here we describe the current practice and outstanding questions related to fundamental aspects of DCD heart procurement, including donor selection, premortem donor intervention, ischemic definitions, confirmation of circulatory death, and techniques for heart procurement and preservation. Addressing these key issues through research and consensus recommendations will facilitate the advancement of the field and ultimately expand the opportunity for heart transplantation to a greater number of patients. 

The future of heart procurement with donation after circulatory death: Current practice and opportunities for advancement.

According to China brain death determination standard, after reaching the clinical determination standard of brain death, potential brain death organ donation (DBD) donors must be conducted with confirmation examination. As one of the confirmatory tests, the application of median nerve short latency evoked potential (SLSEP) in primary brain stem injury or children is limited, and it is hard to be understand by patients' families and non-neurological healthy workers.

Identification of separation phenomenon during brain death determination of potential organ donor and analysis of relative factors

To the Editor A substantial proportion of potential donors do not arrest in time in controlled donation after circulatory death (cDCD). Patients with a short time to death are well described in previous studies in attempts to develop models to predict the time between treatment withdrawal and circulatory death. However, studies that aimed to describe the group that did not arrest within the predefined timeframe are lacking. We analyzed nationwide data of all 143 patients who entered the cDCD program, but in whom organs were not procured due to delayed circulatory death, in a period of 36 months. Additionally, we compared our cohort with the cohorts of five published studies on prognostic models predicting time to death in cDCD donors (Additional file 1: Table S1). The majority of patients were male; median age at death was 57 years. Brainstem reflexes were mostly present, and the median Glasgow Coma Scale (GCS) was 4. We found a variability in delayed death across countries. The UK and Australian cohorts showed the highest survival, and the cohort from China, the shortest [1, 3–5]. Such variation could be due to differences in palliative care provided. Patients could be under profound sedation which may directly affect (limit) the time period until death and hence the applicability of predictive models. All studies showed a wide variation in time to death. The effect of age was conflicting. Two studies found that older age was significantly associated to a longer survival [1, 5]. Two cohorts demonstrated a high prevalence of an extensor or absent motor response and is from a neuroanatomical perspective probably a more sensitive predictor than the GCS [2, 3]. The presence of gag or cough reflex was a protective factor for cardiac arrest [5]. Death was predominantly the resultant of neurologic injury; however, none of the diagnoses was associated with time to death [2, 4, 5]. A standardization of diagnostic categories was lacking across the studies making comparison difficult. The greatest strength of our analysis was the evaluation of consecutive patients minimizing selection bias. Additionally, this is the largest cohort of cDCD donors with delayed time to death. The main drawback was the missing data on physiological parameters. Based on our analysis, we recommend that age and brainstem reflexes should at least be studied in future studies on multimodal prediction models on time to death. There is an important knowledge gap in the effect of palliative practice on time to death.

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When circulatory death does not come in time in potential organ donors

Background The success or failure of donation after circulatory death depends largely on the functional warm ischemia time , which is closely related to the duration between withdrawal of life-sustaining treatment and circulatory arrest However, a reliable predictive model for the duration is absent We aimed to compare the performance of the Chinese Donation after Circulatory Death Nomogram (C-DCD-Nomogram) and 3 other tools in a cohort of potential donors Methods In this prospective, multicenter, observational study , data were obtained from 219 consecutive neurocritical patients in China The patients were followed until circulatory death after withdrawal of life-sustaining treatment Results The C-DCD-Nomogram performed well in predicting patient death within 30, 60, 120 and 240 minutes after withdrawal of life-sustaining treatment with c-statistics of 087, 088, 086 and 095, respectively The DCD-N score was a poor predictor of death within 30, 60 and 240 minutes, with c-statistics of 063, 069 and 059, respectively, although it was able to predict patient death within 120 minutes, with a c-statistic of 073 Neither the University of Wisconsin DCD evaluation tool (UWDCD) nor the United Network for Organ Sharing (UNOS) criteria was able to predict patient death within 30, 60, 120 and 240 minutes after withdrawal of life-sustaining treatment (UWDCD tool: 048, 045, 049 and 057; UNOS criteria: 050, 053, 051 and 063) Conclusion The C-DCD-Nomogram is superior to the other 3 tools for predicting death within a limited duration after withdrawal of life-sustaining treatment in Chinese neurocritical patients Thus, it appears to be a reliable tool identifying potential donors after circulatory death

Guixing Xu

Papers

Prediction of potential for organ donation after circulatory death in neurocritical patients