Correspondence
Care of the Potential Organ Donor
N Engl J Med 2005; 352:1266-1267March 24, 2005
- Article
To the Editor:
In their review article on the care of the potential organ donor, Wood et al. (Dec. 23 issue)1 emphasize the importance of the correction of hypovolemia and recommend the use of sodium bicarbonate to treat acidosis. They also remind the reader that hypernatremia in the donor can adversely affect the function of the transplant.
Fluid administration, as part of an early, goal-directed therapy, is beneficial in critical care patients with shock.2 However, there is no evidence to support the use of bicarbonate therapy in the treatment of hypoperfusion-induced acidemia. Alkali therapy does not improve hemodynamics, does not reduce the vasopressor requirement, and may even be harmful.3 It can lead to hypernatremia and extracellular fluid volume overload.4 Hemodynamic management with the use of adequate fluid resuscitation, vasopressors, and inotropic therapy is probably the cornerstone of the treatment of the potential organ donor. The use of sodium bicarbonate as standard therapy in the case of acidosis may be more deleterious than beneficial, is highly questionable, and cannot be recommended.
4 ReferencesFrédéric M. Jacobs, M.D.
Hôpital Antoine Béclère, 92140 Clamart, France
frederic.jacobs@abc. ap-hop-paris. fr 1
Wood KE ,Becker BN ,McCartney JG ,D'Alessandro AM ,Coursin DB . Care of the potential organ donor. N Engl J Med 2004;351:2730-2739
Full Text | Web of Science | Medline2
Rivers E ,Nguyen B ,Havstad S , et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-1377
Full Text | Web of Science | Medline3
Dellinger RP ,Carlet JM ,Masur H , et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32:858-873[Erratum, Crit Care Med 2004;32:2169-70.]
CrossRef | Web of Science | Medline4
Mathieu D ,Neviere R ,Billard V ,Fleyfel M ,Wattel F . Effects of bicarbonate therapy on hemodynamics and tissue oxygenation in patients with lactic acidosis: a prospective, controlled clinical study. Crit Care Med 1991;19:1352-1356
CrossRef | Web of Science | Medline
To the Editor:
The review article by Wood and colleagues contains several puzzling statements. First, infection with the human T-cell leukemia–lymphoma virus (HTLV) is said to contraindicate donation, but an earlier report from the same institution recommended that HTLV-positive persons not be categorically excluded from donating organs.1 Second, colloid solutions are recommended for potential lung donors to minimize the formation of pulmonary edema. However, there are data indicating that “colloid-containing solutions are . . . not more effective [than crystalloids] in preserving pulmonary function”2 and they are much more expensive than crystalloids. Furthermore, the recent Saline versus Albumin Fluid Evaluation Study concluded that saline and albumin are equivalent for volume resuscitation in patients in the intensive care unit.3
Finally, although the value of hormonal therapy has not been clearly established, it has nevertheless been incorporated into the United Network for Organ Sharing critical pathway for the care of donors, which recommends that “hormonal resuscitation” be instituted when conventional management fails.4 In contrast, Wood and colleagues recommend trying other vasopressors first.
Many questions remain regarding optimal care of donors. Until they are answered, practice will be based primarily on experience, rather than hard science.
4 ReferencesAaron Spital, M.D.
New York Organ Donor Network, New York, NY 10001
aspital@nyodn.org 1
Shames BD ,D'Alessandro AM ,Sollinger HW . Human T-cell lymphotrophic virus infection in organ donors: a need to reassess policy? Am J Transplant 2002;2:658-663
CrossRef | Web of Science | Medline2
Rose BD, Post TW. Clinical physiology of acid-base and electrolyte disorders. 5th ed. New York: McGraw-Hill, 2001.
3
The SAFE Study Investigators
Full Text | Web of Science | Medline4
Rosengard BR ,Feng S ,Alfrey EJ , et al. Report of the Crystal City meeting to maximize the use of organs recovered from the cadaver donor. Am J Transplant 2002;2:701-711
CrossRef | Web of Science | Medline
Author/Editor Response
The goal of our review was to provide recommendations derived from the best existing evidence and our collective experience in the care of donors at a comprehensive organ transplantation center. Unfortunately, evidence-based guidelines supported by prospective, randomized, controlled trials in this population are virtually nonexistent. The United Network for Organ Sharing regards the use of organs from donors infected with HTLV-I or HTLV-II as a protocol violation, unless subsequent confirmatory testing unequivocally indicates that the initial test result was a false positive result.1 Given the low prevalence of HTLV-I and HTLV-II among donors and the potential for false positive results with the use of highly sensitive screening assays, Shames et al. have recommended that careful consideration be given to transplanting organs from these donors.2
The optimal use of colloid or crystalloid in selected populations is open to discussion. Colloid has been recommended and has been associated with higher rates of lung procurement than crystalloid.3
In the absence of randomized or controlled trials, the use and timing of hormonal resuscitation remain speculative. Our algorithm recommending early placement of a pulmonary-artery catheter is derived from an evolving literature and from experience that suggests that improved fluid and hemodynamic management result with this approach. Cardiac recommendations by the Crystal City Meeting Group, cited by Spital, suggest that aggressive hemodynamic management with a pulmonary-artery catheter be initiated simultaneously with hormonal resuscitation.4
The use of sodium bicarbonate remains controversial, and in that way is similar to many options in the complex care of this population. Its use should be undertaken on an individualized basis.
4 ReferencesKenneth E. Wood, D.O.
Douglas Coursin, M.D.
Anthony D'Alessandro, M.D.
University of Wisconsin Hospital and Clinics, Madison, WI 53792-9988
kew@medicine.wisc. edu 1
Policy 4.0. Acquired immune deficiency syndrome (AIDS) and human pituitary derived growth hormone (HPDGH) and human T-lymphotrophic virus type I (HTLV-I). (Accessed February 23, 2005, at http://www.unos.org/PoliciesandBylaws/policies/pdfs/policy_16.pdf.)
2
Shames BD ,D'Alessandro AM ,Sollinger HW . Human T-cell lymphotrophic virus infection in organ donors: a need to reassess policy? Am J Transplant 2002;2:658-663
CrossRef | Web of Science | Medline3
Follette D ,Rudich S ,Bonacci C ,Allen R ,Hoso A ,Albertson T . Importance of an aggressive multidisciplinary management approach to optimize lung donor procurement. Transplant Proc 1999;31:169-170
CrossRef | Web of Science | Medline4
Zaroff JG ,Rosengard BR ,Armstrong WF , et al. Consensus Conference Report: maximizing the use of organs recovered from the cadaveric donor: cardiac recommendations. Circulation 2002;106:836-841
CrossRef | Medline
- Citing Articles (1)
Citing Articles
1
Myung-Gyu Kim, Jong Cheol Jeong, Eun Jin Cho, Kyu Ha Huh, Jaeseok Yang, Nyeon Im Byeon, Jin Sook Yu, Ki Tae Bang, Heoung Soo Chung, Jong Won Ha, Soon Il Kim, Won Hyun Cho, Curie Ahn. (2010) Operational and Regulatory System Requirements for Pursuing Self-sufficiency in Deceased Donor Organ Transplantation Program in Korea. The Journal of the Korean Society for Transplantation 24:3, 147
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