Impact of high-dose inotropic donor support on early myocardial necrosis and outcomes in cardiac transplantation.

BACKGROUND: Cardiac donors routinely require vasoactive agents for circulatory stability after brain death. Nevertheless, inotropes have been associated with direct cardiac toxicity. Our study evaluated whether the use of high-dose inotropic support in potential donors was associated with increased early myocardial necrosis (MN) and worse clinical outcomes after cardiac transplantation. METHODS: The UTAH Cardiac Transplant Program (UCTP) and Intermountain Donor Services databases were queried for records between 1996 and 2009. The high-dose donor inotropic support (HDIS) group was defined as patients on dopamine >10 µg/kg/min. The incidence of early MN, intensive care unit (ICU) length of stay, length of ventilator support, and mortality was evaluated. RESULTS: Two hundred and forty-four recipients undergoing transplant met study criteria. The average donor age was 27 yr. The incidence of MN in the HDIS (n=29) and non-HDIS (n=204) groups was 14.8% and 6.7%, respectively, OR 2.67. Total ischemic time, ventilator support time, ICU stay, and actuarial survival were similar between both groups. CONCLUSION: The use of high-dose inotropic support to maintain donor stability appears to have a higher trend for early post-transplant MN without an impact on clinical outcomes. With the current growing shortage of organ donors, it appears reasonable to use donors on high-dose inotropic support.

Informed consent to tissue donation: policies and practice.

Nearly 10 years ago, the tissue industry's informed consent practices with donor families in the United States were criticized. In response, the industry, along with the Inspector General of the Department of Health and Human Services, suggested elements to be included in the informed consent process. This study examines which of these elements were present in the informed consent documents of 45 (78%) of the nation's 58 Organ Procurement Organizations (OPOs). Some elements, such as involvement of for-profit companies, were present in almost all. Others, such as labeling tissue as a gift from donor families, never were. The authors conclude that the time is ripe for reexamination of the informed consent process with an eye to meaningful consent that promotes the benefits of tissue transplantation and at the same time protects the rights and interests of donor families; can be realistically implemented; and, maintains the trust of the American public.

The Ohio study in light of national data and clinical experience.

The Siminoff, Burant, and Youngner study in Ohio is strikingly consistent with data from a national study. Both suggest that there might be significant public acceptance of future policies that violate the dead donor rule, or that further extend the boundary between life and death to include brain-damaged patients short of "brain death." Experience with donation suggests that many individuals would donate their loved ones' organs when they have concluded that the brain injury is not survivable, even if all the criteria for "brain death" are not met. It would be very helpful to have research on those who have gone through the real-life clinical situation. Based on the findings of this study and the increasing demand for organs, it may be appropriate for public policy to allow for ways to increase organ procurement from individuals who are not fully "brain dead" beyond the current method of procurement after cardiac death, but any change in this area should go slowly and with significant public input.