Do NICU Deaths Represent a Source for Organ Donors?

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Anne Hansen, MD, MPH, of Children's Hospital Boston, and colleagues wanted to try to answer the question. The researchers conducted a retrospective study to determine the percentage of deaths in level III neonatal intensive care unit (NICU) settings that theoretically have been eligible for donation after cardiac death (DCD).

The answer to the question “do NICU deaths represent a source for organ donors” is very important. The need for infant organs continues to increase as more are placed on waiting lists for transplantation. These small infants need organs which match their size. At the end of October 2009, there were 441 infants added to the waiting list for organs, compared with just 109 donors.

The results of their study and an accompanying editorial have been published in the January issue of the Journal of Pediatrics.

The retrospective study reviewed all deaths in 3 Harvard Program in Neonatology NICUs between 2005 and 2007. The NICUs were at Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, and Children's Hospital Boston.

Eligibility of the potential donors was based on criteria developed with transplantation surgeons and the local organ procurement organization.

Of the 192 deaths in infants who had reached at least 23 weeks of gestation that occurred during the study period, 161 were excluded, leaving 31 theoretically eligible donors. Only 16 patients (8%) had a warm ischemic time of

These 16 potential donors would have provided 14 livers and 18 kidneys. Of the 16, 14 patients had a warm ischemic time of

Eligibility criteria for donation after cardiac death were developed by transplant surgeons in collaboration with the New England Organ Bank. Exclusion criteria were as follows:

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Postmenstrual age at death of less than 37 weeks
Weight at death of less than 3 kilograms
Active infection
Known HIV-positive status
Active malignancy, excluding a primary brain tumor
Encephalopathy of unknown etiology
Brain death
No requirement for mechanical ventilation when life support is withdrawn

The study authors conclude that “Based on the size of the potential donor pool, establishing an infant DCD protocol for level III NICUs should be considered.”

In an accompanying editorial, Lainie Friedman Ross, MD, PhD, of the University of Chicago, and Joel Frader, MD, of Northwestern University in Chicago, wrote that the study raises important clinical controversies, including whether organs can be collected in infants as small as those deemed eligible by the study authors, tension exists between the delivery of optimal end-of-life care and the preparations necessary for efficiently procuring organs, and the doubt many pediatricians have that infants who are candidates for organ donation after cardiac death are really dead.

The editorial also notes that most pediatric organs are transplanted into adult recipients, so using NICUs as a donor source for organs might not reduce the waiting list for pediatric recipients.

Two issues must be addressed before implementing newborn donation-after-cardiac-death programs, Ross and Frader argued.

"First, we need to ensure that donation-after-cardiac-death protocols conform to quality end-of-life care for all concerned: patients, parents, and healthcare professionals," they wrote.

"Second, allocation policies should be designed to promote broader geographic sharing of infant organs so these small-size organs are distributed to children who might otherwise die on the deceased donor wait list."

Source reference:
Donation after cardiac death: The potential contribution of an infant organ donor population; Labrecque M, Parad R, Gupta M, Hansen A; J Pediatr 2011; 158: 87-92.

Are we ready to expand donation after cardiac death to the newborn population?; Ross L, Frader J; J Pediatr 2011; 158: 6-8.

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