NICUs Untapped Source for Organ Transplants

Jan. 4, 2011— -- Today in the United States 100 babies are waiting for new kidneys, livers and hearts—donor organs that will allow them to grow into healthy children, perhaps even save their lives. Research from a team of Harvard doctors may ease provide new hope for these tiniest patients.

Dr. Anne Hansen of Children's Hospital Boston and colleagues say that infants who die of heart-related causes in the nation's neonatal intensive care units may represent a new source of donor organs for babies awaiting transplantation.

There are currently an estimated 200,000 Americans who are awaiting organ transplants, and 100 of them have not yet celebrated a first birthday.

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As it now stands, transplantation rules only allow infants and young children to receive transplants from older children or from an adult, which makes it almost impossible for babies to receive transplants since it is very difficult to make larger organs fit into an infant's body.

Hansen and colleagues analyzed records from Harvard-affiliated hospitals and discovered that of192 infants who died over a three-year period in one of three Boston NICUs, 16 would h were deemed candidates for organ donation after cardiac death. Those 16 could have donated 18 kidneys, 14 livers, and 10 hearts.

"The need to increase the pool of organ donors is clear," Hansen wrote in the January issue of the Journal of Pediatrics. For example, through the end of October 2009, there were 441 infants added to the waiting list for organs, compared with just 109 donors.

"The discrepancy between the number of possible recipients and donors underscores the importance of understanding the potential role of an infant donation-after-cardiac-death program in maximizing the donor pool for this population," Hansen and her colleagues wrote.

Changing Donor Criteria

Since organ transplant programs began decades ago, donor organs have usually come from brain-dead patients—those with no evidence of brain activity, but with still beating hearts.

Recently, the focus has turned to donations following cardiac death as a means of expanding the number of available donor organs. In 1997, the Institute of Medicine approved the practice as ethically acceptable and medically useful. In 2007, the Joint Commission required all of its accredited hospitals to develop a donation-after-cardiac-death policy.

To see how many deaths in a level III NICU would be theoretically eligible for donation after cardiac death, the researchers analyzed records of all deaths in three Harvard Program in Neonatology NICUs — at Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, and Children's Hospital Boston — between 2005 and 2007.

Over the study period, there were 192 deaths in infants who had reached at least 23 weeks of gestation.

A total of 31 infants who died during the study were considered eligible for organ donation. Only 16, however, had a warm ischemic time of less than one hour, and were classified as potential donor candidates for kidney and liver transplantation. Of those, 14 had an interval of less than 30 minutes, and also qualified as donors for heart transplantation.

In an accompanying editorial, Dr. Lainie Friedman Ross of the University of Chicago and Dr. Joel Frader of Northwestern University in Chicago wrote that the study raises important clinical controversies, including whether organs can be collected in infants as small as those deemed eligible by the study authors.

Ethical controversies around procuring organs from infants who die of cardiac causes remain as well, they said.

Many pediatricians are not confident that infants who are candidates for organ donation after cardiac death are really dead, "a problem not helped by the variability in practices on how long one waits to certify death after circulatory arrest or subsequently how long surgeons must wait to ensure lack of 'auto-resuscitation' after the pronouncement of death," they wrote.

When Timing is Everything

Also, the editorialists wrote, tension exists between the delivery of optimal end-of-life care and the preparations necessary for efficiently procuring organs.

"Donation after cardiac death almost always challenges standard, even when unproven, end-of-life practices that allow families to have substantial time alone with the patient immediately after death."

Two issues must be addressed before implementing newborn donation-after-cardiac-death programs, Ross and Frader argued.

"First, we need to ensure that donation-after-cardiac-death protocols conform to quality end-of-life care for all concerned: patients, parents, and health care professionals," they wrote.

"Second, allocation policies should be designed to promote broader geographic sharing of infant organs so these small-size organs are distributed to children who might otherwise die on the deceased donor waitlist."