Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London, UK.
Organización Nacional de Trasplantes, C/Sinesio Delgado 6, Pabellón 3, Madrid, Spain.
Intensive Care Med. 2019 Mar;45(3):310-321. doi: 10.1007/s00134-019-05533-0. Epub 2019 Feb 6.
The continuing shortage of deceased donor organs for transplantation, and the limited number of potential donors after brain death, has led to a resurgence of interest in donation after circulatory death (DCD). The processes of warm and cold ischemia threaten the viability of DCD organs, but these can be minimized by well-organized DCD pathways and new techniques of in situ organ preservation and ex situ resuscitation and repair post-explantation. Transplantation survival after DCD is comparable to donation after brain death despite higher rates of primary non-function and delayed graft function. Countries with successfully implemented DCD programs have achieved this primarily through the establishment of national ethical, professional and legal frameworks to address both public and professional concerns with all aspects of the DCD pathway. It is unlikely that expanding standard DCD programs will, in isolation, be sufficient to address the worldwide shortage of donor organs for transplantation. It is therefore likely that reliance on extended criteria donors will increase, with the attendant imperative to minimize ischemic injury to candidate organs. Normothermic regional perfusion and ex situ perfusion techniques allow enhanced preservation, assessment, resuscitation and/or repair of damaged organs as a way of improving overall organ quality and preventing the unnecessary discarding of DCD organs. This review will outline exemplar controlled and uncontrolled DCD pathways, highlighting practical and logistical considerations that minimize warm and cold ischemia times while addressing potential ethical concerns. Future perspectives will also be discussed.
由于可供移植的已故供体器官持续短缺，而且脑死亡后的潜在供体数量有限，因此人们对循环死亡后捐献（DCD）重新产生了兴趣。热缺血和冷缺血过程会威胁 DCD 器官的活力，但通过精心组织的 DCD 途径以及原位器官保存和离体复苏和修复的新技术，可以将这些影响降到最低。尽管原发性无功能和延迟移植物功能的发生率较高，但 DCD 后移植的存活率与脑死亡后捐献相当。成功实施 DCD 计划的国家主要通过建立国家伦理、专业和法律框架来解决 DCD 途径各个方面的公众和专业关切，从而实现了这一目标。仅扩大标准 DCD 计划可能不足以解决全球供体器官短缺的问题。因此，很可能需要依靠扩展标准供体，同时必须将候选器官的缺血性损伤降至最低。常温区域灌注和离体灌注技术允许对受损器官进行增强保存、评估、复苏和/或修复，以提高整体器官质量并防止不必要地丢弃 DCD 器官。这篇综述将概述典型的对照和非对照 DCD 途径，重点介绍了在解决潜在的伦理问题的同时，尽量减少热缺血和冷缺血时间的实际和后勤考虑因素。还将讨论未来的展望。
