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Non-Heart Beating Donors - an Untapped Resource
Please note, this page is a summary of the full conference speech (click here for the full transcript).
David Talbot
David Talbot graduated from the University of Newcastle up Tyne with an MBBS in 1982. He gained an MD in 1988 and became a Fellow of the Royal College of Surgeons in 1989. His present appointment is that of consultant hepatobiliary and transplant surgeon at the Freeman Hospital in Newcastle, a position he has held since 1995.
Kidneys from non-heart beating donors are giving excellent results comparable to those from ordinary heart-beating donors and are beginning to make a substantial contribution to the supply of donors, Mr Talbot told the conference.
More and more centres were doing this type of transplant - Leicester, Newcastle, three in London - St George's, St Mary's, and King's Hospital, Bristol, Cambridge, Oxford and Leeds. Nottingham wanted to start and it looked as if a problem with the slightly different law in Scotland would be sorted out and Edinburgh and Glasgow would be able to start too. From January, Newcastle would starting a donor programme at Sunderland hospital which had a large accident and emergency department.
The main differences between a non-heart beating donor and a heart-beating donor related to primary warm ischaemic time, the time between the heart stopping to the perfusion of the organs with a cold solution.
Mr Talbot detailed the four categories of non-heart beating donors, defined from a meeting in Maastricht:
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Uncontrolled: Patients who were dead on arrival and because of the unknown time since death they did not work very well. Virtually no centre actually used them.
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Uncontrolled: Patients brought into the accident and emergency department whom the team failed to resuscitate. These you could actually use.
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Controlled: Patients in the intensive care unit who were not fully brain dead but had cardiac arrest.
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Patients very close to normal donors. Cardiac arrest during or after brain death diagnosis.
The Newcastle team in 1998 had introduced a retrieval protocol to improve results in category 2 patients in the accident and emergency department. This category also needed a machine perfusion system to test the kidneys. With the help of a very enthusiastic Pam Buckley, they had designed a machine using a disused dialysis machine that cost nothing, two dialysis pumps and a pump from a garden centre. The total cost was £45, plus £90 for the solution.
They also devised a system of testing how badly damaged the kidney was by measuring the amount of an enzyme Gluthathione S Transferase (GST). A high level of GST showed that the kidney was damaged, and a cut off point of a GST level of 200 was set.
Since 1998 the unit has had 71 donors, producing 142 kidneys, out of which 90 kidneys have been transplanted and 50 discarded. Category 3 had been the best donors, and there were 11 discards and 46 transplants, roughly one in four.
"If you have that sort of donor you don't throw many kidneys away", said Mr Talbot.
"But if you have a donor from the accident and emergency department, it's roughly 50/50 because these kidneys have been damaged far more with the initial insult".
The actual kidney and patient survival rates were about 90 per cent for the first year and the same for the third year.
The kidneys that were not used were returned to the body from whence they had come. In Newcastle, Leicester and Spain it was around 30 per cent. The Americans used very young excellent donors because they had a lot of shooting, and in Japan, where they had a big problem with the concept of brain death, they put cannulas in but didn't touch the organs until the heart stopped, giving a very low discard rate.
Non-heart beating kidneys tended to have delayed graft function, so the hospital stay was slightly longer, but the graft failure rate was very similar to heart beating kidneys. After three months the creatinine levels were the same for both types.
To solve the problem of introvascular coagulation because of clotting when the heart was not working, the unit had developed the use of streptokinase, a thrombolytic, and now routinely used it.
Another future development would be to get a perfusion system from a firm called Organ Recovery Systems which was much simpler and cheaper than the American system and better than the unit's Heath Robinson approach.
Please note, this page is a summary of the full conference speech (click here for the full transcript).
Sue
Lyon - Patient Presentation 3
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