Factors Affecting the Time Taken to Determine Brain Death in Patients with Impending Brain Death

Background@#and Purpose: The increased demand for donor organs has made it crucial to keep the organs of patients with impending brain death (PWIBDs) suitable for transplantation during the process of determining brain death. This study aimed to identify the time taken to determine brain death (TT-BD) in PWIBDs and the associated influencing factors. @*Methods@#This study analyzed data collected by the Korean Organ Donation Agency from 15 hospitals in the Yeongnam region of South Korea. There were 414 PWIBDs eligible for inclusion in this study. The data consisted of the TT-BD for PWIBDs and the potential variables influencing the TT-BD. @*Results@#The mean age of the 414 PWIBDs was 48.9 years, and 120 of them were female (29.0%). The mean TT-BD was 8.5 days. The presence of spontaneous movements (SMs) and craniotomy significantly affected the TT-BD. The mean TT-BDs were 13.9 and 8.2 days in the PWIBDs with and without SMs, respectively, and 9.8 and 8.0 days in the PWIBDs with and without craniotomy, respectively. @*Conclusions@#The SMs in PWIBDs and a craniotomy performed immediately before starting the process of determining brain death seem to be related to lengthening the TT-BD.

Reflex and Spontaneous Movements in Adult Patients during the Process of Determining Brain Death in Korea

BACKGROUND: Brain death is a clinical diagnosis that implies irreversible loss of function of the entire brain, including the brainstem and both hemispheres. Based on previous reports, it is not rare for reflex and spontaneous movements to occur in patients during the process of determining brain death. However, reports of the frequency and common types of these movements vary from study to study. Thus, we evaluated adult patients with impending brain death in Korea to determine the frequency and characteristics of reflex and spontaneous movements.METHODS: Brain dead patients who were admitted to 15 hospitals in the Yeongnam region (Southeast) of Korea were recruited prospectively from January 2013 to September 2016. All patients met the criteria for brain death as established by the Korea Medical Association. All body movements occurred during the process of diagnosing brain death and were assessed by physicians and trained organ transplant coordinators. The frequency and characteristics of these movements were identified and the demographic and clinical factors of impending brain dead patients with and without these movements were compared.RESULTS: A total of 436 patients who met the criteria for brain death were enrolled during the study period. Of these patients, 74 (17.0%) exhibited either reflex or spontaneous movements. Of this subset, 45 (60.8%) exhibited reflex movements only, 18 (24.3%) exhibited spontaneous movements only, and 11 (14.9%) exhibited both reflex and spontaneous movements. The most common reflex movements were the flexor/extensor plantar response and spinal myoclonus. Of the 74 patients, 52 (70.3%) exhibited one movement of the same pattern and 22 (29.7%) exhibited two or more different movement patterns. In addition, 45 (60.8%) exhibited these movements only on a limited area of the body with the leg being most common (n = 26, 57.8%). Patients with hypoxic brain damage and a higher systolic blood pressure exhibited significantly more reflex or spontaneous movements.CONCLUSION: Movements associated with brain dead patients are not rare and thus an awareness of these movements is important to brain death diagnosis. Physicians who perform brain death examinations should understand the frequency and characteristics of these movements to reduce delays in determining brain death.

Reflex and Spontaneous Movements in Adult Patients during the Process of Determining Brain Death in Korea

BACKGROUND@#Brain death is a clinical diagnosis that implies irreversible loss of function of the entire brain, including the brainstem and both hemispheres. Based on previous reports, it is not rare for reflex and spontaneous movements to occur in patients during the process of determining brain death. However, reports of the frequency and common types of these movements vary from study to study. Thus, we evaluated adult patients with impending brain death in Korea to determine the frequency and characteristics of reflex and spontaneous movements.@*METHODS@#Brain dead patients who were admitted to 15 hospitals in the Yeongnam region (Southeast) of Korea were recruited prospectively from January 2013 to September 2016. All patients met the criteria for brain death as established by the Korea Medical Association. All body movements occurred during the process of diagnosing brain death and were assessed by physicians and trained organ transplant coordinators. The frequency and characteristics of these movements were identified and the demographic and clinical factors of impending brain dead patients with and without these movements were compared.@*RESULTS@#A total of 436 patients who met the criteria for brain death were enrolled during the study period. Of these patients, 74 (17.0%) exhibited either reflex or spontaneous movements. Of this subset, 45 (60.8%) exhibited reflex movements only, 18 (24.3%) exhibited spontaneous movements only, and 11 (14.9%) exhibited both reflex and spontaneous movements. The most common reflex movements were the flexor/extensor plantar response and spinal myoclonus. Of the 74 patients, 52 (70.3%) exhibited one movement of the same pattern and 22 (29.7%) exhibited two or more different movement patterns. In addition, 45 (60.8%) exhibited these movements only on a limited area of the body with the leg being most common (n = 26, 57.8%). Patients with hypoxic brain damage and a higher systolic blood pressure exhibited significantly more reflex or spontaneous movements.@*CONCLUSION@#Movements associated with brain dead patients are not rare and thus an awareness of these movements is important to brain death diagnosis. Physicians who perform brain death examinations should understand the frequency and characteristics of these movements to reduce delays in determining brain death.

Reflex and Spontaneous Movements in Adult Patients during the Process of Determining Brain Death in Korea

BACKGROUND@#Brain death is a clinical diagnosis that implies irreversible loss of function of the entire brain, including the brainstem and both hemispheres. Based on previous reports, it is not rare for reflex and spontaneous movements to occur in patients during the process of determining brain death. However, reports of the frequency and common types of these movements vary from study to study. Thus, we evaluated adult patients with impending brain death in Korea to determine the frequency and characteristics of reflex and spontaneous movements.@*METHODS@#Brain dead patients who were admitted to 15 hospitals in the Yeongnam region (Southeast) of Korea were recruited prospectively from January 2013 to September 2016. All patients met the criteria for brain death as established by the Korea Medical Association. All body movements occurred during the process of diagnosing brain death and were assessed by physicians and trained organ transplant coordinators. The frequency and characteristics of these movements were identified and the demographic and clinical factors of impending brain dead patients with and without these movements were compared.@*RESULTS@#A total of 436 patients who met the criteria for brain death were enrolled during the study period. Of these patients, 74 (17.0%) exhibited either reflex or spontaneous movements. Of this subset, 45 (60.8%) exhibited reflex movements only, 18 (24.3%) exhibited spontaneous movements only, and 11 (14.9%) exhibited both reflex and spontaneous movements. The most common reflex movements were the flexor/extensor plantar response and spinal myoclonus. Of the 74 patients, 52 (70.3%) exhibited one movement of the same pattern and 22 (29.7%) exhibited two or more different movement patterns. In addition, 45 (60.8%) exhibited these movements only on a limited area of the body with the leg being most common (n = 26, 57.8%). Patients with hypoxic brain damage and a higher systolic blood pressure exhibited significantly more reflex or spontaneous movements.@*CONCLUSION@#Movements associated with brain dead patients are not rare and thus an awareness of these movements is important to brain death diagnosis. Physicians who perform brain death examinations should understand the frequency and characteristics of these movements to reduce delays in determining brain death.

Reflex and Spontaneous Movements of Patients in the Process of Determining Brain Death

Brain death is a clinical diagnosis that implies irreversible loss of function of the entire brain, including the brainstem and both hemispheres. It is not uncommon for reflex and spontaneous movements to occur in patients with impending brain death during the process of determining brain death. When physicians charged with judging brain death witness such movements during this period, unless they know how common these movements are and what they mean, it will be difficult for them to make an appropriate determination of brain death. Movements following brain death have been reported in previous studies of various types, including cohort studies and case series or reports. However, only a few studies have employed verified diagnostic tools and neurological examinations as a standard protocol when diagnosing brain death. According to previous reports, the frequency of these movements ranges from 19.2% to 75.0% of all brain death cases. These reports have also described which movements are commonly seen. However, it is difficult to determine conclusively where these movements originate, i.e., in the spinal cord or in the cerebral motor cortex, and how such information should be considered in determining brain death. Although limited information is available on the characteristics and pathophysiological mechanism of these movements, it will help physicians to diagnose brain death correctly if they obtain sufficient knowledge about them.

Rehabilitation of Transplantee and Transplant Games / 대한이식학회지

Many transplant recipients believe that exercise or physical activity after transplantation will have adverse effects on the body and the grafted organ, and even more, some of them believe that the grafted organ will tear off from the vascular bed inside of the abdominal cavity. As a result, many recipients are isolated from social life even after successful recovery of the grafted organ function. However, rehabilitation by physical exercise and activity is essential to return to normal social life. In 1978, a transplantee's sport game known as the Transplant Olympics, which later changed to the World Transplant Games, was started to improve the quality of life and develop friendships between transplant recipients globally. This event promotes improvement of recipient's life quality while delivering an important message to the public. This is because by engaging in sports activities, transplantees can show their healthy life after transplantation to the public. This can also improve self-esteem of the family of organ donors and allow them to verify that their decision to donate was not in vain. Additionally, the public can realize the benefits of transplantation and necessity for organ donation. Finally, the early return to social life and normal family life after transplantation will also reduce the national budget for health insurance. Although sports clubs are located in all transplant centers in Korea, no continuous athletic meetings or transplant sport organization exist nationwide. This problem is exacerbated by the lack of concern that transplant physicians and surgeons show toward recipients' physical activity and exercise. Therefore, in this study, we reviewed the significance of physical activity after transplantation and describe the world transplant games and domestic games to enable development of a recipient rehabilitation plan.

Factors Influencing Family's Organ Donation Decision / 대한이식학회지

BACKGROUND: The main factor limiting the increase in brain dead organ donors is low consent rates for organ donation. METHODS: This study is a retrospective analysis of donor records of Korea Organ Donation Agency from 2013 to 2015. Factors related before providing information about organ donation and process of explaining organ donation were analyzed. RESULTS: Donor gender, marital status, religious affiliation, residence area, knowledge of patients' wishes, understanding of brain death status, and the referring system, providing initial information about donation and initial medical staff providing information about donation had a significant influence on decision to donate. Organ donation greatly increased when the donor family knew the patient's intent to donate. As the degree of family understanding of brain death status and the referring system increased, organ donation rate significantly increased. CONCLUSIONS: Providing sufficient information about brain death during the period of delivering medical services as well as activating campaign and public education are essential to improving the positive attitude toward organ donation.

Clinical Outcomes between Living Related and Living Unrelated Kidney Transplantation in ABO-Incompatible Kidney Transplant Recipients / 대한내과학회지

BACKGROUND/AIMS: Kidney transplantation (KT) is the best treatment for end-stage renal disease patients. Although previous studies have demonstrated that the clinical outcome following living related (LR) KT is better than that following unrelated (LUR) KT in ABO-compatible KT recipients, recent studies showed no differences in clinical outcomes between the two treatments. In this study, we compared the clinical outcomes of LR and LUR KT in ABO-incompatible KT recipients. METHODS: From January 2011 to August 2013, 19 cases of ABO-incompatible KT were analyzed retrospectively. Eight kidneys (7 cases of parent-offspring and 1 case of siblings, Group 1) were donated from living-related donors and 11 (all spousal donors, Group 2) from living-unrelated donors. We investigated patient survival, graft survival, acute rejection, graft function, and complications. RESULTS: On Kaplan-Meier analysis, patient and graft survival during follow-up were 87.5% and 87.5% in Group 1; both were 100% in Group 2. Acute rejection, graft function, and medical and surgical complications were not significantly different between the two groups. CONCLUSIONS: The short-term clinical outcomes between LR and LUR KT in ABO-incompatible KT recipients were equivalent. Most domestic cases of LUR KT are from spousal donors and the spousal donor will be a major donor in ABO-incompatible KT patients.

The Changes of Graft Survival and Causes of Graft Failure after Kidney Transplantation / 대한이식학회지

BACKGROUND: The incidence of acute rejection has decreased with the introduction of new immunosuppressive agents. However, several studies have shown that allograft survival has not clearly improved over the past few decades. METHODS: We reviewed patients who underwent kidney transplantation between 1982 and 2007. We compared the causes of graft loss for three decades: 1982~1990 (period I),1991~2000 (period II), and 2001~2007 (period III), with the clinical characteristics of patients with functioning grafts and patients who lost their allografts. RESULTS: There were 785 recipients with a mean age of 36.1 years, and 65.2% were male. Graft loss occurred in 329 patients (41.9%), and the most common cause of graft loss was chronic allograft nephropathy (CAN, 52.0%), followed by patient death (17.6%), post-transplant glomerulonephritis (12.8%), and non compliance (7.9%). During the three time periods, 129, 172, and 28 patients lost their grafts, respectively. Five-year graft survival was 61.5%, 78.4%, and 90.8%, respectively, and increased significantly (P<0.000). CAN, as a cause of graft loss, fell from 65.1% (period I) to 32.1% (period III, P<0.000), but patient death increased from 12.4% to 32.1% (P=0.034). A multivariate analysis revealed that significant risk factors for graft loss included an older donor, transplantation at period I, and dual immunosuppression. Use of tacrolimus and mycophenolate mofetil was associated with a significantly reduced risk of graft loss. CONCLUSIONS: Graft survival has increased over the last three decades whereas the proportion of CAN, the most common cause of graft loss, has decreased. Attention to the main causes of graft loss, CAN, and patient death will offer potential improvement in graft survival.

Current Management for Patients on the Waiting List of Deceased Donor Kidney Transplantation in Korea / 대한이식학회지

BACKGROUND: Health maintenance and monitoring of transplant candidates, the great majority of whom are undergoing chronic dialysis, can be a determinant of post-transplant prognosis. New issues such as malignancy, inflammation, cardiovascular disease, and psychosocial problems might arise among potential recipients, which may lead to cancellation of the transplantation. METHODS: A questionnaire, including questions regarding follow-up monitoring, was sent to 66 transplant centers, and responses to the survey were obtained from 35 centers (53%). A similar questionnaire was sent to 217 wait-listed patients, and 164 (76%) responded. RESULTS: Regular contact between the transplant center and patients was maintained by only 37% of the centers. No consistent pattern of contact was observed for 11%. Sixty percent of the centers monitored patients by telephone. Three-fourths of the transplant centers monitored their patients annually or every 6 months. A cancer screening program was run by only 17% of the centers, and 29% did not routinely request cardiac screening. Most centers (83%) informed their patients of the features of marginal kidneys. However, many patients (69%) reported not hearing about marginal kidneys, and 43% indicated that a cadaver transplant was cancelled because of a cadaver donor problem. CONCLUSIONS: Our survey indicates that the necessity for routine follow-up monitoring is broadly recognized by 86% of transplant centers and 78% of wait-listed patients However, no formal monitoring guidelines currently exist for wait-listed patients in Korea. Therefore, guidelines are absolutely necessary for improving the quality of post-transplant life.

Effect of Perioperative Management on 1 Year Patency of Internal Arteriovenous Fistula

PURPOSE: Early arteriovenous fistula (AVF) failure especially during the first several months after fistula creation makes the patient, physician and surgeon frustrated. To evaluate the patency rate of arteriovenous fistulas which were made for hemodialysis, we analyzed three different protocols pre- and peri-operatively in our hospital. METHOD: From January 1983 through December 1998, total 2,078 cases of AVF were done in 1,711 patients. During the first period (from 1983 to 1988, n=280), all of the AVFs were performed with naked eyes but during the second period (from 1989 to 1993, n=770), we used surgical loupe and microvascular anastomosing technique. During the third period (from 1994 to 1998, n=1,028), besides using surgical loupe, patients were treated peri-operatively with certain volumes of fluid to maintain the systolic blood pressure above 100 mmHg, venogram and duplex sonogram to identify an available vein before AVF creation, aggressive salvage procedures and use of aspirin after fistula creation. RESULT: There were no differences between each periods in their age distribution, sex ratio, serum creatinine level, associated diabetes mellitus and hemoglobin level except significantly low incidence of hypotension at the time of operation in period 3. The early fistula failure rate at 3 months decreased in period 2, 3 than period 1 (6.9%, 6.7% vs 12.7%) and showed statistical significance (p<0.05). The rate of fistulas that is patent more than 3 months and continued at the end of 12 months were no difference between the periods. Frequency of re-AVF within 3 months in period 1 was significantly higher than period 2, 3 which suggested improved early patency in later periods. The center ability to manage the created AVF checked by rate of re-AVF showed significant difference between our hospital and other local dialysis centers. The patency of primary AVF in each period was 69.7%, 75.2%, 77.5% at one year but that of re-AVF were 77.7%, 86.3% and 80.2%. CONCLLUSION: Microsurgical technic under surgical loupe improved primary AVF patency and decreased early failure rate. Also a protocoled perioperative management, improved management skill and experiences of dialysis center might decrease the re-AVF rate.

Cadaveric Donor Renal Transplantation; Review of 39 Cases / 대한이식학회지

To improve the graft survival in cadaveric donor renal transplantation, various factors that affect the results of allograft function has been analysed and reported. From January 1994 through December 1998, 39 cases of renal transplantation were performed using 20 cadaver donor. Thirty five of them were from brain dead donor and four from cardiac arrest donor. The most frequent cause of brain death was head injury by traffic accident, mostly autobicycle accident. Male donor ratio was 85.0% and their mean age were 29.3 years old. Mean cold ischemic time was 347.5 minutes and warm ischemic time of 4 cardiac arrest cases were 55-60 minutes. The number of HLA mismatch more than 4 were 64.1%. There were 8 cases of multiple renal arteries and 4 cases of double ureter. Donor hypotension during and before kidney procurement and warm ischemic time were factors that cause the delayed graft function in our cases. The number of HLA mismatch and use of Cellcept as immunosuppressant were two factors that affected the development of acute rejection during 6 months after renal allograft. Among the 39 kidneys of 20 donors, 12 paired kidneys showed different graft result in each recipient. Recipient age, number of HLA mismatch, cold ischemic time, duration of hemodialysis before transplantation, and level of hemoglobin were factors that cause the diffrerent result in paired kidney. One and two year graft survival rate were 89.6% and 76.5% respectively. In summary, the early results of our cadaver donor renal transplantation was comparable to living donor transplantation. Adequate donor management and HLA matching between donor and recipient are factors that can improve the graft result.

Cadaveric Donor Renal Transplantation; Review of 39 Cases / 대한이식학회지

To improve the graft survival in cadaveric donor renal transplantation, various factors that affect the results of allograft function has been analysed and reported. From January 1994 through December 1998, 39 cases of renal transplantation were performed using 20 cadaver donor. Thirty five of them were from brain dead donor and four from cardiac arrest donor. The most frequent cause of brain death was head injury by traffic accident, mostly autobicycle accident. Male donor ratio was 85.0% and their mean age were 29.3 years old. Mean cold ischemic time was 347.5 minutes and warm ischemic time of 4 cardiac arrest cases were 55-60 minutes. The number of HLA mismatch more than 4 were 64.1%. There were 8 cases of multiple renal arteries and 4 cases of double ureter. Donor hypotension during and before kidney procurement and warm ischemic time were factors that cause the delayed graft function in our cases. The number of HLA mismatch and use of Cellcept as immunosuppressant were two factors that affected the development of acute rejection during 6 months after renal allograft. Among the 39 kidneys of 20 donors, 12 paired kidneys showed different graft result in each recipient. Recipient age, number of HLA mismatch, cold ischemic time, duration of hemodialysis before transplantation, and level of hemoglobin were factors that cause the diffrerent result in paired kidney. One and two year graft survival rate were 89.6% and 76.5% respectively. In summary, the early results of our cadaver donor renal transplantation was comparable to living donor transplantation. Adequate donor management and HLA matching between donor and recipient are factors that can improve the graft result.