Post-Brain Death Donor Management

Clinical Overview

Post-brain death donor management (PBDM) refers to the comprehensive physiological optimisation of the potential organ donor following declaration of brain death. Brain death triggers a catastrophic autonomic storm characterised by catecholamine surge, followed by profound hypopituitarism and systemic inflammatory response. Without active management, this physiological cascade results in rapid deterioration of organ function, rendering organs unsuitable for transplantation. [1,2]

The goal of PBDM is to maintain homeostasis and optimise end-organ perfusion to maximise the number of viable organs transplanted per donor while respecting ethical, legal, and cultural considerations. Effective donor management can convert up to 25% of initially marginal donors into suitable organ providers. [3]

In Australia and New Zealand, donor management is governed by the ANZICS Statement on Death and Organ Donation (Edition 4, 2021) and implemented through the DonateLife network. The "Rule of 100s" provides a framework for physiological targets, though organ-specific protocols take precedence when donor intent targets particular organs. [4]

Exam Detail: Pathophysiology of the Catecholamine Storm

Brain death typically results from severe intracranial pathology causing massive intracranial hypertension. The Cushing reflex initially produces severe hypertension and bradycardia. This is followed by the autonomic storm characterised by massive catecholamine release (up to 10-fold increase) leading to:

• Left ventricular dysfunction (neurogenic stunning)
• Pulmonary edema (neurogenic pulmonary edema)
• Systemic vasoconstriction and end-organ ischemia
• Disseminated intravascular coagulation
• Electrolyte disturbances

This storm is rapidly followed by hypopituitarism as the hypothalamic-pituitary axis infarcts, resulting in deficiency of TSH, ACTH, ADH, and gonadotropins. The combination of inflammatory mediator release (IL-6, TNF-α) and endocrine collapse produces the "donor collapse" phenomenon. [5-7]

Epidemiology

In Australia and New Zealand, approximately 500-600 organ donors are identified annually, of which 80-85% are donors after brain death (DBD). The national conversion rate (number of actual donors per million population) is approximately 20-25 donors per million, which ranks among the highest globally. [8]

The average organs transplanted per DBD donor in Australia is 3.8-4.2 organs, with kidneys and livers being the most frequently transplanted. Lung and heart transplantation rates have increased significantly over the past decade, driven by improved donor management protocols and acceptance of marginal donors. [9]

Key demographic factors influencing donation rates:

• Age: Optimal donors aged 18-50 years. Donors over 60 years are considered "extended criteria donors" (ECD).
• Cause of death: Trauma accounts for 40-50% of DBD donors, with intracranial hemorrhage (30-40%) and hypoxic brain injury (15-20%) comprising the remainder.
• Donor type: Standard criteria donors (SCD) vs. expanded criteria donors (ECD) defined by age greater than 60 years, hypertension, diabetes, cerebrovascular accident as cause of death, or terminal creatinine greater than 1.5 mg/dL. [10]

Pathophysiology

Neurogenic Storm Phase

The initial phase of brain death is characterised by massive sympathetic discharge resulting from brainstem herniation. This typically occurs 5-10 minutes before circulatory collapse if untreated and is characterised by:

Cardiovascular effects:

• Severe hypertension (systolic pressures often greater than 200 mmHg)
• Tachycardia followed by bradycardia (Cushing's triad)
• Direct myocardial injury with histological evidence of contraction band necrosis
• Left ventricular ejection fraction often depressed to 25-40% during this phase [14]

Pulmonary effects:

• Neurogenic pulmonary edema from increased pulmonary capillary permeability
• Severe ventilation-perfusion mismatch
• Hypoxia often refractory to conventional ventilation strategies

Systemic effects:

• Peripheral vasoconstriction leading to end-organ ischemia
• Disseminated intravascular coagulation (DIC) in 30-40% of donors
• Metabolic acidosis from tissue hypoperfusion

Hypopituitarism Phase

Following the autonomic storm, infarction of the hypothalamic-pituitary axis occurs due to loss of cerebral perfusion pressure. This results in:

TSH deficiency (70-80% of donors):

• Decreased conversion of T4 to T3
• Reduced myocardial contractility
• Impaired thermogenesis
• Contribution to systemic inflammatory response

ACTH deficiency (60-70% of donors):

• Cortisol deficiency leading to refractory hypotension
• Impaired vascular responsiveness to catecholamines
• Exacerbated inflammatory response

ADH deficiency (diabetes insipidus in 70-90% of donors):

• Polyuria (often greater than 5-6 mL/kg/hr)
• Hypernatremia (greater than 150 mmol/L)
• Volume depletion exacerbating hypotension
• Worsening of cerebral edema if brain tissue remains present

Gonadotropin deficiency:

• Limited clinical significance in the acute donor phase [15-17]

Systemic Inflammatory Response

Brain death triggers a massive systemic inflammatory response independent of infection:

• IL-6 levels typically 50-100× normal
• TNF-α elevation
• Activation of coagulation cascade
• Endothelial activation and increased vascular permeability
• Priming of innate immune system leading to increased graft immunogenicity

This inflammatory milieu contributes to primary graft dysfunction and early graft rejection. Corticosteroid administration directly targets this inflammatory cascade. [18-20]

Presentation and Recognition

Indications for Brain Death Testing

The decision to proceed with brain death testing is made when:

1. Irreversible catastrophic brain injury is identified
2. No reversible causes contributing to coma can be identified
3. Prognostication indicates no possibility of recovery
4. Family has been informed of the patient's condition and poor prognosis

Common clinical scenarios requiring brain death testing:

• Massive intracranial hemorrhage (especially with intraventricular extension)
• Severe traumatic brain injury with herniation
• Hypoxic-ischemic brain injury after cardiac arrest (GCS ≤5 and absent pupillary reflexes at ≥72 hours)
• Large ischemic stroke with mass effect and herniation
• Intracranial tumors with herniation

Brain Death Criteria

In Australia and New Zealand, brain death is defined as "the irreversible loss of all functions of the entire brain, including the brainstem." Testing requires [21]:

Prerequisites:

1. Exclude reversible causes:

   • Hypothermia (core temperature must be ≥36.5°C)
   • Drug intoxication (including sedatives, paralytics, alcohol)
   • Metabolic derangements (severe acid-base disturbance, severe electrolyte abnormalities)
   • Severe hypotension or shock

2. Identify cause of coma:

   • Must be a known, irreversible structural brain injury

Clinical testing:

1. Coma: Unresponsive to all stimuli
2. Absent brainstem reflexes:
   • Pupillary light response (fixed, dilated or mid-position pupils)
   • Corneal reflexes absent bilaterally
   • Oculocephalic reflexes absent (doll's eye)
   • Oculovestibular reflexes absent (no eye movement after ice water calorics)
   • Gag and cough reflexes absent
3. No respiratory effort: Apnea test (PaCO2 greater than 60 mmHg or greater than 20 mmHg above baseline without respiratory movement)

Confirmatory testing (required if clinical testing cannot be performed):

• Cerebral angiography: No intracranial arterial or venous flow
• Computed tomography angiography: No intracranial perfusion
• Transcranial Doppler: Oscillating flow, small systolic spikes, or no flow
• Electroencephalogram: Isoelectric brain activity

Exam Detail: Apnea Testing Technique

1. Ensure patient is haemodynamically stable (MAP ≥60 mmHg)
2. Pre-oxygenate with 100% FiO2 for 10-15 minutes (target PaO2 greater than 200 mmHg)
3. Set ventilator to provide no breaths (CPAP 5 cmH2O mode)
4. Insert oxygen catheter into endotracheal tube (6 L/min)
5. Disconnect ventilator from circuit (or change to CPAP mode)
6. Observe for respiratory movement for 8-10 minutes
7. Measure ABG after 8-10 minutes
   • If PaCO2 ≥60 mmHg (or ≥20 mmHg above baseline) and no respiratory effort → positive apnea test
   • If PaCO2 below 60 mmHg and no respiratory effort → continue observation for additional 5 minutes
8. Reconnect to ventilator and return to pre-test settings

Safety considerations:

• Maintain SpO2 monitoring throughout
• Have vasopressors prepared and available
• Consider arterial line monitoring for MAP
• Stop test if severe hypotension, desaturation, or arrhythmias develop
• For potential lung donors, perform apnea testing with CPAP rather than complete disconnection to prevent alveolar collapse [22]

Family Communication During Brain Death Determination

Communication with families during brain death determination is a critical process requiring:

Principles of communication:

• Use clear, unequivocal language: "I need to tell you that [patient name] has died"
• Avoid ambiguous terms like "brain-dead" (the hyphen can be misinterpreted as a qualification) or "passed away" (can imply a process rather than an event)
• Prepare family for testing: "We need to perform formal testing to confirm that death has occurred"
• Explain the tests and their meaning clearly

Common challenges:

• Families may experience "brain death" as a diagnosis rather than death
• Confusion between persistent vegetative state and brain death
• Difficulty understanding that the ventilator supports oxygenation, not life
• Religious or cultural beliefs about when death occurs
• Disagreement among family members

Supportive strategies:

• Offer family presence during bedside testing if appropriate and safe
• Provide continuous nursing support throughout the process
• Allow time for questions and repeated explanations
• Use visual aids (diagrams showing herniation or brain anatomy)
• Arrange for spiritual or cultural support if requested

Documentation: Brain death declaration must be documented in the medical record with:

• Time of death (completion of all brain death testing)
• Names of two medical practitioners who performed testing (at least one must be a specialist with ≥5 years post-fellowship experience)
• Specific tests performed and results
• Confirmation that reversible causes were excluded
• Signature of both practitioners [23,24]

Investigations

Baseline Assessment Following Brain Death

Immediate investigations (within 1 hour of brain death declaration):

Haematology:

• FBC: Assess for anaemia (Hb target 70-100 g/L) and coagulopathy
• Coagulation profile: PT/INR, APTT, fibrinogen (DIC correction often required)
• Blood group and cross-match: Essential for organ allocation

Biochemistry:

• Urea, electrolytes, creatinine: Baseline renal function and monitor DI management
• Liver function tests: ALT, AST, ALP, GGT, bilirubin (assess hepatic injury)
• Serum amylase/lipase: Pancreatic injury (relevant for pancreas donation)
• Thyroid function: Free T3, free T4, TSH (often abnormal; hormone replacement therapy indicated)
• Cortisol: Random level or cortisol response to ACTH stimulation
• Blood glucose: Target 6-10 mmol/L (stress hyperglycaemia common)
• Serum lactate: Marker of tissue hypoperfusion

Immunology:

• Infectious disease screen: HIV, Hepatitis B and C, syphilis, EBV, CMV, HTLV
• Blood group: ABO typing
• HLA typing: For kidney and pancreas transplantation
• Panel reactive antibodies (PRA): If recipient-specific screening required

Microbiology:

• Blood cultures (×2 sets)
• Sputum/tracheal aspirate cultures
• Urine culture
• Wound cultures if present
• Specific cultures if infection suspected: CSF, peritoneal fluid, etc.

Imaging:

• Chest X-ray: Assess for pulmonary edema, contusions, aspiration
• CT chest/abdomen/pelvis: Evaluate organ anatomy, assess for occult pathology, identify malignancy
• Echocardiography: Essential for cardiac donation assessment (EF greater than 45% target)
• CTA or MRA: Vascular anatomy for organ procurement planning
• Brain imaging (CT/MRI): Document cause of death, assess for intracranial pathology that may contraindicate donation [25,26]

Organ-Specific Assessment

Cardiac assessment:

• Transthoracic echocardiography (TTE) or transoesophageal echocardiography (TOE)
• Left ventricular ejection fraction (LVEF): Target greater than 45% for standard donors, greater than 40% for marginal donors
• Wall motion abnormalities: Document regional dysfunction
• Right ventricular function: Assess for right heart strain
• Valvular pathology: Significant stenosis or regurgitation may contraindicate
• Cardiac catheterisation: If donor greater than 50 years or CAD risk factors (age, diabetes, hypertension, smoking, family history)

Lung assessment:

• Chest X-ray: Clear lungs preferred, but mild infiltrates may be acceptable
• Bronchoscopy: Evaluate for aspiration, infection, mucosal injury
• Arterial blood gas: PaO2/FiO2 ratio greater than 300 mmHg on PEEP 5 cmH2O ideal
• Mechanical ventilation assessment: Lung compliance, airway pressures
• CT thorax: Detailed assessment of parenchymal disease

Liver assessment:

• LFTs: ALT/AST preferably below 200 U/L (higher levels may be acceptable)
• INR: below 2.0 preferred, greater than 3.0 concerning for synthetic dysfunction
• Serum bilirubin: below 50 μmol/L preferred
• Imaging: Assess for steatosis (CT attenuation), focal lesions
• Consider liver biopsy: For extended criteria donors

Kidney assessment:

• Baseline creatinine: below 150 μmol/L ideal, greater than 200 μmol/L concerning
• Urine output: greater than 0.5 mL/kg/hr
• Proteinuria: Assess urine protein/creatinine ratio
• Imaging: Kidney size (rule out chronic kidney disease), assess for cysts, stones, or masses

Pancreas assessment:

• Amylase/lipase: Assess for pancreatic injury
• Blood glucose: Diabetic donors may be considered for pancreas donation under specific protocols
• Imaging: Assess for pancreatic anatomy, calcifications, or inflammation [27,28]

Management

Donor Stabilisation: The "Rule of 100s"

Following brain death declaration, systematic donor optimisation targets multiple physiological parameters. The "Rule of 100s" provides a memorable framework:

• MAP 100 mmHg (or 60-80 mmHg minimum)
• SPO2 100% (or PaO2 greater than 100 mmHg)
• CVP 10 cmH2O (or 4-10 mmHg range)
• Urine output 100 mL/hr (or 0.5-2.0 mL/kg/hr)
• Hb 100 g/L (or 70-100 g/L range)
• Temperature 37°C (or 36.0-37.5°C range)

These targets are general guidelines and must be individualised based on organ donation intent, donor comorbidities, and recipient requirements. [29,30]

Exam Detail: Hemodynamic Targets and Monitoring

Mean Arterial Pressure (MAP):

• Target: 60-80 mmHg (ideal 70-75 mmHg)
• Rationale: Adequate perfusion pressure for end-organs without excessive vasoconstriction
• Monitoring: Arterial line mandatory for continuous monitoring
• Management:
  • Fluid bolus (250-500 mL crystalloid) for volume depletion
  • Noradrenaline 0.05-0.5 μg/kg/min as first-line vasopressor
  • Vasopressin 0.03-0.04 units/min if noradrenaline greater than 0.1 μg/kg/min required (reduces catecholamine requirement)
  • Adrenaline 0.02-0.1 μg/kg/min for refractory hypotension (use cautiously due to increased graft dysfunction)

Central Venous Pressure (CVP):

• Target: 4-10 mmHg
• Rationale: Euvolaemia for optimal organ perfusion without pulmonary congestion
• Monitoring: Central venous catheter
• Caution: High CVP (greater than 12-15 mmHg) associated with worse lung graft outcomes
• Fluid choice: Balanced crystalloid (Plasma-Lyte or Hartmann's) preferred; albumin 4-5% may be used for severe hypoalbuminaemia

Cardiac Output (if monitored):

• Target: Cardiac index greater than 2.1 L/min/m²
• Monitoring: Pulmonary artery catheter or oesophageal Doppler
• Consider inotropic support: Dobutamine 2-10 μg/kg/min if EF below 45% despite adequate volume and vasopressor support

Blood Pressure Management Pearls:

• Avoid rapid blood pressure fluctuations (greater than 20 mmHg MAP changes)
• Prioritise maintaining MAP greater than 65 mmHg during apnea testing
• Consider dopamine 2-10 μg/kg/min for renal protection in donors with marginal renal function (controversial) [31,32]

Fluid Management

Goals:

• Maintain euvolaemia
• Avoid hypovolaemia (worsens hypotension and end-organ ischemia)
• Avoid hypervolaemia (worsens pulmonary edema, impairs lung procurement)

Fluid composition:

• Balanced crystalloid: Plasma-Lyte, Hartmann's (or Ringer's lactate) preferred over normal saline
• Albumin 4-5%: Considered for severe hypoalbuminaemia or large-volume resuscitation
• Packed red blood cells: Target Hb 70-100 g/L, transfuse if below 70 g/L or if symptomatic anaemia

Fluid assessment:

• Dynamic parameters: Stroke volume variation, pulse pressure variation if patient ventilated
• Static parameters: CVP, urine output, lactate clearance
• Clinical assessment: Peripheral perfusion, lung auscultation, chest X-ray

Special considerations:

• Diabetes insipidus causes massive volume depletion and hypernatremia
• Replace urine output mL-for-mL initially, then titrate based on sodium and hemodynamics
• Avoid large boluses (greater than 1000 mL crystalloid) unless clearly hypovolaemic

Hormone Replacement Therapy (HRT)

Corticosteroids (Methylprednisolone):

Indication: Recommended for ALL brain-dead donors

Dose: 15 mg/kg IV (maximum 1,000 mg) or flat dose 1,000 mg IV

Mechanism: Suppression of inflammatory cytokine storm (IL-6, TNF-α), stabilisation of endothelial membranes, improved response to catecholamines

Timing: As soon as possible after brain death declaration (preferably within 6 hours)

Evidence:

• Improves lung oxygenation and increases lung procurement rates
• Reduces primary graft dysfunction in cardiac and liver transplantation
• Meta-analyses demonstrate increased organs transplanted per donor [33,34]

Vasopressin (Antidiuretic Hormone):

Indications:

1. Treatment of diabetes insipidus (urine output greater than 3-4 mL/kg/hr or greater than 300-400 mL/hr)
2. As second-line vasopressor to reduce catecholamine requirements
3. Management of hypernatraemia

Dose:

• Diabetes insipidus: Desmopressin (DDAVP) 1-4 μg IV every 8-12 hours
• Hemodynamic support: Vasopressin 0.01-0.04 units/min continuous infusion

Mechanism: V1 receptor-mediated vasoconstriction (reduces catecholamine requirement); V2 receptor-mediated water reabsorption

Target: Urine output 0.5-3.0 mL/kg/hr; Serum sodium below 150 mmol/L

Evidence:

• Reduces noradrenaline requirement by 30-50%
• Improves renal graft outcomes by reducing catecholamine exposure
• Early use (within 2 hours of brain death) associated with increased organ yield

Caution: Rapid sodium shifts with desmopressin may affect liver graft function; correct sodium slowly (below 12 mmol/L per 24 hours) [35,36]

Thyroid Hormone (T3/T4):

Indication: CONTROVERSIAL. Consider if:

1. Cardiac donor with EF below 45% or hemodynamic instability despite adequate volume and catecholamines
2. High-dose vasopressor requirement (noradrenaline greater than 0.1 μg/kg/min)
3. Cardiac arrest prior to brain death or post-brain death arrhythmias

Dose:

• T3 (liothyronine): 4 μg bolus, then 3 μg/hr infusion
• T4 (levothyroxine): 20 μg bolus, then 10 μg/hr infusion
• Duration: Typically 6-12 hours until procurement

Mechanism: Restoration of myocardial metabolic function, improvement of beta-adrenergic receptor sensitivity, improved myocardial contractility

Evidence - The Controversy:

• Early observational studies (1990s-2000s) suggested increased heart procurement rates
• Pfeifer et al. (2023) NEJM RCT (1,121 donors): No significant difference in organs transplanted per donor with levothyroxine vs. placebo
• No difference in number of hearts transplanted or post-transplant graft function
• No reduction in vasopressor requirement
• Current recommendation: Selective use rather than routine administration [37-39]

Insulin:

Indication: All donors with blood glucose greater than 10 mmol/L

Dose: Titrate insulin infusion to target blood glucose 6-10 mmol/L

Rationale: Hyperglycaemia impairs immune function, increases infection risk, exacerbates endothelial dysfunction

Evidence: Tight glycaemic control (4.4-6.1 mmol/L) associated with increased hypoglycaemia in donors; moderate control (6-10 mmol/L) provides best risk-benefit balance

Lung Protective Ventilation

Rationale:

• Brain death causes neurogenic pulmonary edema and increased alveolar-capillary permeability
• Lungs highly susceptible to ventilator-induced lung injury (VILI)
• Systemic inflammation from injured lungs damages other organs (heart, liver, kidneys)
• Lung protective strategy increases procurement rates from 27% to 54% (Mascia et al. 2010)

Ventilator Settings:

Tidal Volume (VT):

• Target: 6-8 mL/kg predicted body weight (PBW)
• PBW calculation:
  • "Male: 50 + 0.91 × (height in cm - 152.4)"
  • "Female: 45.5 + 0.91 × (height in cm - 152.4)"
• Rationale: Prevents volutrauma from overdistension

PEEP:

• Target: 8-10 cmH2O (higher than standard ICU practice)
• Rationale: Prevents atelectrauma, maintains functional residual capacity, recruits atelectatic lung zones
• Monitor for decreased venous return and hypotension (may require fluid or vasopressor adjustment)

FiO2:

• Target: Lowest possible to maintain PaO2 greater than 100 mmHg (or SpO2 greater than 95%)
• Rationale: Minimises oxygen toxicity, prevents absorption atelectasis

Respiratory Rate:

• Target: 10-16 breaths/min, titrated to PaCO2 35-45 mmHg
• Allow permissive hypercapnia (PaCO2 up to 60 mmHg) if needed to limit driving pressure

Driving Pressure:

• Target: below 15 cmH2O (plateau pressure - PEEP)
• Rationale: Independent predictor of lung injury and mortality

Recruitment Maneuvers:

Indications:

• After any circuit disconnection (suctioning, transport, repositioning)
• Declining PaO2/FiO2 ratio
• Before final assessment for lung donation

Techniques:

1. Sustained inflation:

   • CPAP 40 cmH2O for 40 seconds
   • Most commonly used due to simplicity

2. Incremental PEEP:

   • Gradually increase PEEP by 5 cmH2O increments to 20-25 cmH2O
   • Hold for 2 minutes at each level
   • Gradually decrease to baseline

3. Pressure control recruitment:

   • PCV mode: PEEP 25 cmH2O, driving pressure 15 cmH2O for 2 minutes
   • Return to baseline settings

Post-recruitment:

• Maintain PEEP at 8-10 cmH2O to prevent de-recruitment
• Re-check ABG within 30 minutes
• Consider repeat recruitment if PaO2 declines

Special Considerations:

Apnea Testing for Lung Donors:

• Perform with CPAP 5-10 cmH2O rather than complete disconnection
• Use T-piece with CPAP if possible
• Maintain PEEP throughout test to prevent alveolar collapse

Tracheobronchial Toilet:

• Suction gently and judiciously
• Avoid aggressive deep suctioning that causes mucosal injury
• Consider bronchoscopy if secretions or aspiration suspected

Prone Positioning:

• Consider for severe hypoxaemia refractory to conventional management
• May improve oxygenation in donors with neurogenic pulmonary edema
• Requires careful planning to maintain vascular access and lines

Evidence:

• Mascia et al. (2010) JAMA: Lung protective strategy increased lung procurement from 27% to 54%
• Multiple systematic reviews confirm reduced primary graft dysfunction with protective ventilation
• ISHLT guidelines recommend LPV as standard of care for potential lung donors [40,41]

Renal Support

Indications for Renal Replacement Therapy (RRT):

Absolute indications:

• Severe hyperkalaemia (K+ greater than 6.5 mmol/L) refractory to medical management
• Refractory metabolic acidosis (pH below 7.1, HCO3- below 10 mmol/L)
• Volume overload with pulmonary edema (impairing lung procurement)
• Severe oliguria/anuria with fluid intolerance (unable to meet renal perfusion goals)

Relative indications:

• Acute kidney injury with rapidly rising creatinine
• Uraemic complications (pericarditis, encephalopathy, bleeding)
• Dialysis requirement prior to brain death (ESKD patients as donors)

RRT Modality Selection:

Continuous Renal Replacement Therapy (CRRT):

• Preferred modality for unstable donors
• CVVHDF (continuous veno-venous haemodiafiltration) most common
• Provides steady haemodynamic control
• Allows gradual correction of electrolyte abnormalities
• Typically 20-25 mL/kg/hr effluent dose

Intermittent Haemodialysis (IHD):

• May be appropriate for haemodynamically stable donors
• Faster correction of electrolyte abnormalities
• Risk of intradialytic hypotension (may compromise organ perfusion)
• Shorter duration than CRRT, but less physiologic

RRT Prescription Goals:

Sodium correction:

• Correct hypernatraemia gradually (below 12 mmol/L per 24 hours)
• Target sodium 135-145 mmol/L (avoid rapid correction)
• Rationale: Rapid sodium shifts cause osmotic stress on hepatocytes (worsens liver graft outcomes)

Acid-base balance:

• Target pH 7.35-7.45, HCO3- 22-28 mmol/L
• Use bicarbonate-based dialysate when possible
• Avoid excessive buffer (risk of post-transplant metabolic alkalosis)

Fluid management:

• Ultrafiltration rate titrated to achieve euvolaemia
• Goal CVP 4-10 mmHg
• Avoid negative fluid balance (may compromise renal perfusion and other organs)

Electrolyte management:

• Potassium: Target 3.5-5.0 mmol/L
• Magnesium: Target 0.75-1.0 mmol/L
• Phosphate: Target 0.8-1.5 mmol/L (CRRT often causes hypophosphataemia; prophylactic replacement required)

Anticoagulation:

Regional citrate anticoagulation (RCA):

• Preferred for most donors
• Reduces bleeding risk vs. heparin
• Monitor ionised calcium (target 1.0-1.2 mmol/L)
• Ca:iCa ratio greater than 2.5 suggests citrate accumulation

Heparin:

• Used if RCA contraindicated
• Target APTT 40-60 seconds
• Bleeding risk increases in setting of DIC (common in brain-dead donors)

No anticoagulation:

• May be appropriate for short runs (below 4 hours) or if severe coagulopathy
• Shorter filter life (typically below 24 hours)

Special Considerations:

Timing of RRT:

• Initiate early when indications develop (don't wait for severe abnormalities)
• Continue throughout donor management phase
• Discontinue just prior to procurement surgery (often last 2-3 hours)

Renal function markers:

• Donor creatinine greater than 200 μmol/L associated with increased delayed graft function in recipients
• Biomarkers (NGAL, KIM-1) may provide early AKI detection but not routinely used clinically
• Urine output greater than 0.5 mL/kg/hr remains important prognostic marker

Evidence:

• Early RRT initiation improves renal graft outcomes
• CRRT provides superior haemodynamic stability compared to IHD
• Gradual sodium correction critical for liver graft preservation [42,43]

Temperature Management

Target: 36.0-37.5°C

Hypothermia (below 36°C):

• Common due to hypothalamic dysfunction (loss of thermoregulation)
• Causes: Coagulopathy, cardiac arrhythmias, impaired drug metabolism, reduced immune function
• Management:
  • Forced-air warming blankets (Bair Hugger)
  • Warm IV fluids (warmer set to 40-42°C)
  • Increase ambient room temperature
  • "Consider active core warming if severe (below 34°C):"
    • Forced-air warming device
    • Warm intravascular devices (Coolgard, Thermogard)
    • Peritoneal lavage (rarely required)
    • Consider ECMO for refractory severe hypothermia (below 30°C)

Hyperthermia (greater than 37.5°C):

• Less common but can occur (infection, autonomic instability)
• Increases metabolic rate and oxygen demand
• Management:
  • Paracetamol 1 g IV/PO
  • Surface cooling devices if needed
  • Identify and treat infection if source identified

Temperature Monitoring:

• Core temperature (oesophageal, bladder, or rectal probe)
• Continuous monitoring preferred
• Document temperature hourly during donor management phase

Electrolyte Management

Sodium:

• Target: 135-145 mmol/L
• Common abnormalities:
  • Hypernatraemia (greater than 150 mmol/L) due to diabetes insipidus (70-90% of donors)
  • Hyponatraemia (below 135 mmol/L) due to fluid overload or SIADH (rare in brain death)
• Management:
  • "Hypernatraemia: Desmopressin 1-4 μg IV every 8-12 hours; replace free water deficits (0.5 L 5% dextrose for every 5 mmol/L above 150 mmol/L in 70 kg adult)"
  • "Hyponatraemia: Fluid restriction, hypertonic saline 3% if severe (below 120 mmol/L)"
• Critical: Correct slowly (below 12 mmol/L per 24 hours) to avoid osmotic stress on hepatocytes

Potassium:

• Target: 3.5-5.0 mmol/L
• Hyperkalaemia (greater than 5.5 mmol/L) common causes:
  • Tissue breakdown (rhabdomyolysis)
  • Renal failure
  • Massive transfusion
  • Metabolic acidosis
• Management:
  • Calcium gluconate 10% 10-30 mL IV (cardiac membrane stabiliser)
  • Insulin 10 units IV + 50 mL 50% dextrose
  • Salbutamol 5 mg nebulised (shifts K+ intracellularly)
  • Sodium bicarbonate 150 mL IV if acidosis present
  • Potassium-free IV fluids
  • RRT if refractory

Magnesium:

• Target: 0.75-1.0 mmol/L
• Hypomagnesaemia common with CRRT
• Management: Magnesium sulphate 5-10 mmol IV/PO
• Avoid hypermagnesaemia (greater than 1.2 mmol/L) - causes muscle weakness, respiratory depression

Phosphate:

• Target: 0.8-1.5 mmol/L
• Hypophosphataemia very common with CRRT (greater than 80% of patients)
• Severe hypophosphataemia (below 0.3 mmol/L) causes:
  • Respiratory muscle weakness
  • Myocardial dysfunction
  • Haemolysis
• Management: Sodium or potassium phosphate 10-30 mmol IV over 2-4 hours (monitor calcium during replacement)

Calcium:

• Ionised calcium target: 1.0-1.25 mmol/L
• Hypocalcaemia common with citrate anticoagulation on CRRT
• Management: Calcium gluconate or chloride 10% 10-20 mL IV
• Hypercalcaemia (greater than 1.4 mmol/L): Hydration, consider bisphosphonates if severe

Blood Product Management

Red Blood Cells:

• Transfusion threshold: Hb below 70 g/L (or below 80 g/L if cardiac donor)
• Target: Hb 70-100 g/L
• Consider higher threshold (greater than 90 g/L) for cardiac donor with marginal EF
• Leukocyte-depleted, irradiated products preferred

Platelets:

• Target: greater than 50,000 × 10^9/L
• Higher threshold (greater than 100,000 × 10^9/L) if invasive procedures planned or ongoing bleeding
• Indicated for ongoing DIC or thrombocytopenia from massive transfusion

Fresh Frozen Plasma:

• Target: INR below 2.0
• Higher target (below 1.5) for liver donor or if invasive procedures planned
• Indicated for DIC with bleeding or before organ procurement

Cryoprecipitate:

• Target: Fibrinogen greater than 1.5 g/L
• Indicated for fibrinogen below 1.0 g/L or DIC with bleeding
• Each unit typically raises fibrinogen by ~0.1 g/L

Massive Transfusion Protocol:

• Activate if greater than 4 units RBC transfused or active bleeding
• 1:1:1 ratio (RBC:FFP:Platelets) associated with improved survival in trauma
• Consider in donors with active bleeding or requiring massive transfusion
• Monitor for transfusion reactions, hyperkalaemia, citrate toxicity

Contraindications to Donation

Absolute Contraindications

Malignancy:

• Metastatic malignancy (any organ)
• Active hematologic malignancy (leukemia, lymphoma, multiple myeloma)
• High-grade primary CNS tumors with risk of extraneural spread (glioblastoma multiforme, medulloblastoma)
• Melanoma (even if "cured"
• high risk of late recurrence)
• Choriocarcinoma

Infection:

• Viral: HIV (if recipient is HIV-negative), rabies, Ebola, Creutzfeldt-Jakob disease (CJD) or other prion diseases
• Active systemic infection: Uncontrolled sepsis, multi-organ failure from infection
• Active tuberculosis: Untreated or disseminated TB

Organ-Specific Contraindications:

• Severe chronic organ disease precluding transplantation
• Active severe infection of organ (e.g., pneumonia for lung donation, hepatitis for liver donation)
• Severe structural abnormality (e.g., severe COPD for lungs)

Other:

• Unknown cause of death (risk of undetected transmissible disease)
• Toxic ingestion or poisoning where organs may be contaminated (case-by-case basis)
• Transmissible spongiform encephalopathies (CJD, variant CJD)

Relative Contraindications

Malignancy (acceptable for specific recipients or with longer disease-free interval):

• Non-melanoma skin cancers (basal cell, squamous cell carcinoma) - generally acceptable
• Carcinoma in situ (e.g., cervical CIS) - generally acceptable
• Low-grade primary CNS tumors that rarely metastasise (e.g., meningioma, low-grade astrocytoma) - may be acceptable
• Treated malignancy with greater than 5 years disease-free interval - may be acceptable

Infection (often acceptable for specific recipients):

• HIV-positive donors → HIV-positive recipients (HOPE Act in USA; similar policies emerging elsewhere)
• Hepatitis B-positive donors → Hepatitis B-positive recipients or to HBV-negative recipients with prophylaxis
• Hepatitis C-positive donors → Hepatitis C-positive recipients or to HCV-negative recipients with direct-acting antiviral (DAA) therapy post-transplant
• Treated bacteremia → Acceptable if donor received appropriate antibiotics for 24-48 hours and haemodynamically stable
• Bacterial meningitis → Acceptable if treated and no evidence of organ infection

Medical Comorbidities:

• Age greater than 60 years → "Extended criteria donor" (ECD) - acceptable for appropriate recipients
• Diabetes mellitus → May affect organ quality (kidneys, pancreas) but not absolute contraindication
• Hypertension → Acceptable, but assess end-organ damage
• Obesity (BMI greater than 30) → May affect surgical access but not contraindication

Donor Factors:

• Prolonged cardiac arrest before brain death → Case-by-case based on organ function assessment
• Significant substance abuse → Screen for transmissible diseases; assess organ function

Extended Criteria Donors (ECD)

Donors who meet one or more of the following criteria are considered "extended criteria" or "marginal":

1. Age greater than 60 years (or greater than 50 years with 2 of: hypertension, diabetes, creatinine greater than 1.5 mg/dL, or cerebrovascular accident as cause of death)
2. Cerebrovascular accident as cause of death
3. Hypertension (long-standing)
4. Diabetes mellitus
5. Terminal creatinine greater than 1.5 mg/dL (greater than 130 μmol/L)
6. Significant steatosis on liver imaging
7. LVEF 40-45% for cardiac donation
8. Active smoking history greater than 20 pack-years for lung donation

Management of ECD:

• Aggressive optimisation to maximise organ function
• Early organ allocation to appropriate recipients
• Consider machine perfusion (NMP) for organ preservation and assessment
• Detailed discussion with recipient teams about organ quality and risks

Contraindications by Organ

Kidney:

• Absolute: Chronic kidney disease stage 4-5 (eGFR below 30 mL/min/1.73 m²), focal segmental glomerulosclerosis (high recurrence risk)
• Relative: Hypertension, diabetes, age greater than 60, proteinuria greater than 1 g/day

Liver:

• Absolute: Cirrhosis (Child-Pugh C), advanced fibrosis, severe steatosis (greater than 60% macrovesicular)
• Relative: Mild-moderate steatosis, elevated transaminases (ALT/AST 200-500 U/L), INR greater than 2

Heart:

• Absolute: Severe CAD not amenable to revascularisation, severe cardiomyopathy (EF below 35%), significant valvular disease
• Relative: Mild-moderate CAD, EF 40-45%, mild valvular disease, age greater than 50

Lung:

• Absolute: Severe COPD (FEV1 below 50% predicted), pulmonary fibrosis, active pneumonia, severe aspiration
• Relative: Smoking history greater than 20 pack-years, mild COPD, age greater than 50

Pancreas:

• Absolute: Diabetes mellitus (if organ for Type 1 diabetes recipient), severe chronic pancreatitis
• Relative: Mild pancreatic steatosis, elevated amylase/lipase without clinical pancreatitis

Ethics of Consent

Legal Framework (Australia)

Organ Donation Laws in Australia:

• Opt-in system across all states and territories (adults must explicitly consent to donation)
• Donor registration: Australians can register donation intent via the Australian Organ Donor Register (AODR)
• Next-of-kin consent: Even if donor is registered, family must provide consent before organs can be retrieved
• Authority to consent: Next-of-kin hierarchy:
  1. Spouse or de facto partner
  2. Adult son or daughter
  3. Adult parent
  4. Adult brother or sister
  5. Guardian or person in a close personal relationship

Brain Death Legal Status:

• Brain death is legally equivalent to death in all Australian jurisdictions
• Declaration of brain death must follow established protocols (ANZICS guidelines)
• Two medical practitioners (at least one specialist with ≥5 years post-fellowship) must certify brain death
• Once brain death declared, ventilator support can be withdrawn; organ donation request can proceed

Ethical Principles

Autonomy:

• Respect donor's prior wishes (AODR registration, documented decision)
• Respect family's decision-making role in consenting
• Ensure family understands donation is voluntary and their decision will be respected

Beneficence:

• Maximise benefit from donation (optimise donor management to increase organs transplanted per donor)
• Benefit to recipients (life-saving or life-enhancing transplantation)
• Benefit to donor family (sense of purpose from donation)

Non-Maleficence:

• Avoid harm to donor (dignity maintained during procurement)
• Avoid harm to recipients (ensure organs are safe and suitable)
• Avoid harm to donor family (appropriate support and communication)

Justice:

• Equitable allocation of organs (organ allocation systems based on medical need, waiting time, and compatibility)
• Fair access to donation regardless of socioeconomic status, geography, or cultural background
• Consider special populations (Indigenous, rural/remote, children)

Consent Process

Optimal Consent Process Elements:

1. Separation of Roles:

   • Treating medical team declares death and provides medical information
   • Organ donation coordinator (DonateLife) discusses donation options
   • This "decoupling" of death notification and donation request improves consent rates

2. Timing of Request:

   • Must occur after brain death declared and family understands death
   • Allow time for family to process grief before donation request (typically 30 minutes to 2 hours)
   • Identify "emotional readiness"

• family asking "what happens next?" or "can we do anything?" signals readiness
  • Consent rates: 60% with decoupling vs. 18% with simultaneous death notification and request (Gortmaker et al.)

3. Setting:

   • Private, quiet room away from the bedside
   • All family members present who wish to be involved
   • Sufficient time allocated (not rushed)
   • Support persons available (spiritual, cultural, social work)

4. Information Provided:

   • Clear explanation of death and brain death
   • Which organs are suitable for donation
   • What donation involves (surgery, timing, impact on funeral arrangements)
   • Recipient outcomes (transplant success rates)
   • Address specific concerns (body appearance, timing, religious considerations)
   • Option to specify which organs/tissues to donate (or decline)

5. Documentation:

   • Written consent obtained
   • Specific organs/tissues documented
   • Family sign consent form
   • Family receive copy of consent form for their records

Exam Detail: The Decoupled Approach: Evidence and Implementation

Evidence:

• Gortmaker et al. (JAMA): Consent rates 60% with decoupling vs. 18% with simultaneous approach
• Siminoff et al.: OPO coordinators obtain consent 70-80% of time vs. 30-40% for treating physicians
• Key principle: Families must accept death before donation request is made

Implementation:

1. Treating team provides death notification:

   • "I need to tell you that [patient name] has died"
   • Allow time for questions and emotional processing
   • Assess family's understanding of death

2. Transition to donation request:

   • "Would you like me to invite our organ donation coordinator to speak with you about options for donation?"
   • Or: "Our organ donation coordinator is available if you'd like to discuss donation options"

3. Organ donation coordinator:

   • Reconfirms death and ensures family understands
   • Explains donation process, options, and impact
   • Asks: "Would you consider allowing [patient name] to become an organ donor?"
   • Respects family's decision (whether yes or no)
   • Provides ongoing support

Common Challenges:

• Family requesting donation while death notification ongoing (delay request)
• Family unable to understand brain death (may need extended explanation)
• Disagreement among family members (facilitate discussion, support consensus)
• Religious or cultural objections (provide appropriate support and information)

Professional to Make Request:

• Optimal: Trained OPO coordinator or DonateLife coordinator
• Acceptable: Treating physician if properly trained and using decoupled approach
• Suboptimal: Treating nurse or allied health (lack training in donation communication) [44,45]

Special Considerations

Pediatric Donation:

• Consent obtained from parents or legal guardians
• Special emphasis on age-appropriate communication
• Consider child's own wishes (especially for older children/adolescents)
• Parents may experience profound guilt; extra support required
• Higher consent rates for pediatric donors (70-80%)

Pregnant Donors:

• Consideration of maintaining support for fetus if viable age (greater than 22-24 weeks)
• Ethical: Autonomy of donor vs. potential life of fetus
• Legal: Varies by jurisdiction; often requires ethics committee consultation
• Possible scenario: Support donor for fetal delivery, then proceed with organ donation

Undocumented or Homeless Individuals:

• No known next-of-kin → state public advocate may authorise donation
• Efforts to locate family members made (often through police)
• Longer time to identification may delay donation

Foreign Nationals or Tourists:

• Consent from family in home country may be required
• Embassies or consulates may assist with communication
• Consider international organ transport logistics

Refusal of Donation

Reasons for Family Refusal:

• Lack of understanding of brain death
• Religious or cultural beliefs
• Concern about mutilation or disfigurement of body
• Fear that proper care wasn't provided
• Guilt or feeling "abandoning" their loved one
• Disagreement among family members

Management of Refusal:

• Respect decision immediately (no pressure)
• Provide support and resources for grieving
• Offer referral to grief counselling or support services
• Document refusal in medical record
• Do not revisit donation request (unless family initiates)
• Maintain professional relationship and support throughout hospital stay

Debrief and Quality Improvement:

• Review cases where donation was refused to identify system improvements
• Did family understand brain death?
• Was timing of request appropriate?
• Was setting appropriate?
• Was communication clear and empathetic?
• Can staff training be improved?

Family Communication

Principles of Effective Communication

Key Elements:

1. Clear, unambiguous language about death
2. Empathy and compassion
3. Patience and time
4. Honesty and transparency
5. Respect for cultural and religious beliefs
6. Appropriate support (social work, spiritual care, AHWs/ALOs)

Structured Approach

STEPWISE Model for Donation Conversations:

S - Setting:

• Private, quiet room
• Away from bedside
• All key family members present
• Support persons available
• Adequate time allocated (at least 30 minutes)

T - Timing:

• After brain death declared
• Family understands death
• Family shows signs of emotional readiness (asking "what happens next?")
• No other critical medical information pending

E - Explanation:

• Reconfirm understanding of death
• Explain donation process clearly
• Describe which organs are suitable
• Explain what donation involves (timing, surgery, impact on body, funeral arrangements)

P - Permission:

• Ask permission to discuss donation: "Would you be open to discussing organ donation?"
• Listen to concerns and questions
• Address specific concerns empathetically
• Ask: "Would you consider allowing [patient name] to become an organ donor?"

W - Waiting:

• Allow time for decision-making
• Don't rush family
• Offer support while they discuss among themselves
• Return when requested or check back at agreed time

I - Implementation:

• Obtain written consent if family agrees
• Document specific organs/tissues consented
• Explain next steps (organ retrieval, coordination, follow-up)
• Provide resources and support (counselling, bereavement support)
• Express gratitude (without creating obligation)
• Offer ongoing support (liaison nurse, contact information)

S - Support:

• Provide ongoing support throughout hospital stay
• Offer bereavement counselling
• Offer opportunity to meet transplant recipients (in the future, at family's request)
• Provide information about donation outcomes (if requested by family)
• Offer support groups for donor families

Common Difficulties and Strategies

Family Doesn't Understand Brain Death:

Challenge: Family may understand "coma" but not "brain death," believing patient will "wake up" eventually.

Strategies:

• Use clear language: "All functions of the brain, including the brainstem, have permanently stopped. This is death."
• Explain brain death vs. persistent vegetative state
• Use visual aids (brain diagrams showing herniation)
• Allow time for questions and repeated explanations
• Consider second medical opinion if family still uncertain

Family Believes Treatment Was Withdrawn Prematurely:

Challenge: Family may feel medical team "gave up" too early.

Strategies:

• Provide detailed explanation of injury and why recovery was impossible
• Show imaging or other objective evidence of catastrophic brain injury
• Explain that treatment was aggressive but the injury was beyond repair
• Validate family's emotions: "It's completely understandable that you want everything possible done"
• Consider ethics or palliative care consultation for support

Family Disagreement About Donation:

Challenge: Some family members support donation, others oppose.

Strategies:

• Facilitate discussion among family members
• Allow each person to express their views without judgment
• Encourage decision based on what donor would have wanted
• Consider donor's prior wishes (AODR registration)
• Ultimately, family consensus required; if unable to reach consensus, respect refusal
• Don't take sides or pressure family

Religious or Cultural Objections:

Challenge: Family's religious or cultural beliefs may conflict with organ donation.

Strategies:

• Respect family's beliefs and objections
• Offer to discuss with religious or spiritual leader
• Provide information about donation from religious perspective (many religions support donation)
• Consider cultural liaison or support person
• Don't pressure if donation conflicts with core beliefs

Grief Reactions:

Challenge: Family's grief may manifest as anger, denial, or withdrawal.

Strategies:

• Validate emotions: "I can see this is incredibly difficult for you"
• Don't take anger personally
• Offer appropriate support (social work, chaplaincy, counselling)
• Recognise that grief is normal and expected
• Provide information about grief support services

Body Appearance Concerns:

Challenge: Family concerned about disfigurement or impact on funeral viewing.

Strategies:

• Explain that organs are removed surgically with respect
• Explain that incisions are closed carefully and will be covered by clothing
• Offer opportunity for open-casket viewing (always possible)
• Discuss timing of funeral arrangements (can proceed normally)
• Show photos or diagrams if helpful

Post-Decision Support

If Family Consents:

• Express gratitude (without creating obligation)
• Explain organ allocation process (how recipients are chosen)
• Offer opportunity for follow-up communication about donation outcomes
• Provide bereavement support resources
• Explain liaison nurse role
• Address any ongoing concerns or questions

If Family Refuses:

• Accept decision immediately without pressure
• Validate emotions and concerns
• Provide bereavement support resources
• Explain next steps (end of life care, funeral arrangements)
• Maintain supportive relationship
• Don't revisit donation request

For All Families:

• Offer grief counselling
• Provide information about bereavement support groups
• Offer contact information for hospital support services
• Document communication in medical record

Organ Allocation Systems

Australia: National Organ Allocation Scheme

National Authority:

• Organ and Tissue Authority (OTA), Australian Government Department of Health
• DonateLife network coordinates donation and allocation
• Organ Procurement Organisations (OPOs): State-based DonateLife agencies

Allocation Principles:

• Clinical urgency (sickest first)
• Tissue compatibility (blood group, HLA matching for kidneys)
• Geographic proximity (minimise cold ischemia time)
• Waiting time (in cases of equivalent urgency)
• Paediatric priority (children prioritised for pediatric-sized organs)

Organ-Specific Allocation:

Kidneys:

• ANZOD (Australia and New Zealand Organ Donor Registry)
• Waitlist prioritised by:
  1. Blood group compatibility
  2. HLA matching (0 mismatches > 1-2 mismatches > 3-6 mismatches)
  3. Highly sensitised patients (high PRA, cPRA)
  4. Waiting time
  5. Geographic proximity
• Paediatric recipients prioritised for pediatric donors
• Extended criteria donors (ECD) allocated to recipients who consent to ECD kidneys

Livers:

• MELD-Na score (Model for End-Stage Liver Disease with Sodium) used for prioritisation
• MELD-Na calculation:
  • Based on bilirubin, INR, creatinine, and sodium
  • Higher score = higher priority (sickest patients)
• Status 1 a: Acute liver failure (highest priority)
• Status 1 b: Paediatric acute liver failure
• Geographic considerations: Cold ischemia time below 12 hours critical

Hearts:

• Urgency tiers (1A, 1B, 2, 3, 4)
• Status 1A: Life support, high-dose inotropes, mechanical circulatory support
• Status 1B: Continuous intravenous inotropes, sometimes with home support
• Status 2: All other transplant candidates
• Geographic constraints: Cold ischemia time below 4-6 hours critical
• Size matching: Donor weight within 20% of recipient weight

Lungs:

• Lung Allocation Score (LAS) - United States system, adapted for Australia/NZ
• LAS based on:
  • Age and diagnosis
  • Functional status (6-minute walk distance)
  • Lung function (FVC, FEV1)
  • Oxygen requirements
  • Pulmonary artery pressure
  • Diabetes/BMI status
• Blood group compatibility required
• Height matching (donor lung size must fit recipient thoracic cavity)

Pancreas:

• Allocation primarily by waiting time
• Blood group compatibility required
• Often allocated with kidney for simultaneous pancreas-kidney (SPK) transplantation

Intestines:

• Rare transplant, centralised to few centres
• Allocation by clinical urgency and waiting time
• Blood group compatibility required

Geographic Distribution:

Transplant centres in Australia:

• Heart: St Vincent's Hospital (Sydney), Prince Charles Hospital (Brisbane), Alfred Hospital (Melbourne)
• Lung: St Vincent's Hospital (Sydney), Alfred Hospital (Melbourne), Prince Charles Hospital (Brisbane)
• Liver: Austin Hospital (Melbourne), Royal Prince Alfred Hospital (Sydney), Princess Alexandra Hospital (Brisbane), Flinders Medical Centre (Adelaide)
• Kidney: Multiple centres in all states (every major hospital with transplant program)

Allocation algorithm:

1. National waiting list (maintained by OTA)
2. Organ offer based on allocation criteria
3. Transplant centre accepts or declines offer
4. If declined, organ offered to next recipient on list
5. Cross-regional allocation considered if local no suitable recipient

Special Allocation Programs:

Paediatric Allocation:

• Paediatric recipients prioritised for pediatric donors
• Age matching considerations (donor age within 10-15 years of recipient age)
• Size matching critical (donor weight within 20% of recipient weight)
• Urgent cases (pediatric acute liver failure, pediatric heart failure) prioritised

Highly Sensitised Patients:

• High PRA (panel reactive antibody) or cPRA (calculated PRA) patients
• HLA matching prioritised for these patients
• Special allocation programs to increase transplantation access
• Desensitisation protocols available at specialised centres

Extended Criteria Donors (ECD):

• Older donors, donors with comorbidities
• Separate allocation track for recipients who consent to ECD organs
• Shorter waiting times for recipients accepting ECD organs
• Increased risk of delayed graft function but acceptable for many patients

Disease-Specific Programs:

Hepatitis C:

• HCV-positive donors → HCV-positive recipients
• Increasing: HCV-positive donors to HCV-negative recipients with DAA therapy post-transplant
• Increases donor pool significantly

HIV:

• HIV-positive donors → HIV-positive recipients (HOPE Act model)
• Limited centres perform this
• Requires specialised protocols

Cross-Match Allocation:

• Donor-specific antibodies (DSA) may prevent transplantation
• Virtual crossmatch (using HLA typing and antibody screening)
• Physical crossmatch (mixing donor lymphocytes with recipient serum)
• Positive crossmatch: Risk of hyperacute rejection, organ not allocated to that recipient

New Zealand Allocation

Integrated with Australia:

• ANZOD registry covers both Australia and New Zealand
• Organ sharing across trans-Tasman when needed
• Geographic considerations for organ transport (ferry or flight required)

Differences:

• Smaller population, fewer transplant centres
• Different ethnic demographics (higher Māori and Pasifika populations)
• Allocation prioritised within NZ first, then offer to Australia if no NZ recipient suitable

International Allocation

Rare circumstances:

• International organ exchange when no local recipient suitable
• Highly sensitised patients (rare HLA types)
• Specialised procedures (small bowel transplant not performed locally)

Regulations:

• Requires government approval
• Must follow allocation protocols
• Donor family consent required for international allocation

Retrieval Coordination

Organ Retrieval Team Coordination

The Retrieval Process:

Pre-Retrieval Phase:

1. Initial contact: DonateLife coordinator contacts transplant centres when suitable donor identified
2. Organ allocation: National allocation system identifies recipients
3. Team assembly: Retrieval teams from each recipient hospital assembled
4. Transport coordination: Ground ambulance or flight arrangements
5. Operating theatre booking: Donor hospital OR scheduled
6. Logistics: Preservation solution, equipment, blood products prepared

Retrieval Phase:

1. Donor preparation: Final optimisation, last-minute investigations, antibiotics, steroids
2. Multiple-team coordination: Retrieval teams arrive and coordinate with donor ICU
3. Surgical timeout: Joint briefing, confirm identity, verify allocation
4. Sequential or simultaneous retrieval: Depends on number of organs and donor stability
5. Organ preservation: Cold flush with preservation solution, packaging, transport
6. Transport: Cold storage (or machine perfusion) to recipient hospital

Post-Retrieval Phase:

1. Donor theatre: Closure, preparation for funeral
2. Organ transport: Coordination with recipient teams
3. Recipient coordination: Recipient preparation for transplantation
4. Documentation: Retrieval forms, organ allocation records, consent documentation
5. Family follow-up: Liaison nurse contacts family for grief support

Coordination Roles

DonateLife Coordinator:

• Primary point of contact for all stakeholders
• Coordinates donor optimisation with ICU team
• Liaises with transplant centres
• Coordinates retrieval team logistics
• Supports family communication

ICU Medical Team:

• Ongoing donor management and optimisation
• Medical assessment of donor suitability
• Communicates with transplant teams about donor status
• Attends surgical timeout and provides handover

ICU Nursing Team:

• Hourly monitoring and documentation of donor parameters
• Preparation for retrieval (lines, equipment, blood products)
• Support to retrieval teams
• Continues family support

Retrieval Surgeons:

• Assess organ suitability in OR
• Perform organ retrieval
• Communicate with recipient teams during retrieval
• Package organs for transport
• Document organ condition and findings

Transplant Recipient Coordinators:

• Recipient preparation
• Communication with retrieval teams
• Coordinate recipient theatre timing
• Organ transport logistics

Preservation Solutions and Techniques

Static Cold Storage (SCS):

• Standard preservation technique for most organs
• Organs flushed with cold (4°C) preservation solution
• Stored in sterile container with ice and preservation solution
• Simple, cost-effective, widely available

Preservation Solutions:

University of Wisconsin (UW / Viaspan):

• High potassium, high viscosity
• Contains hydroxyethyl starch, lactobionate, raffinose
• Gold standard for liver, kidney, pancreas
• Ideal for long cold ischemia times
• Cons: Viscosity requires thorough flushing; high potassium risk if not rinsed before heart reperfusion

Histidine-Tryptophan-Ketoglutarate (HTK / Custodiol):

• Low potassium, low viscosity
• Histidine buffer, tryptophan, ketoglutarate
• Rapid cooling and flushing
• Widely used for heart, multi-organ retrieval
• Good for liver and kidney
• Cons: May be inferior to UW for very long CIT for liver

Celsior:

• Hybrid between UW and HTK
• Low viscosity, moderate potassium
• Histidine buffer
• Designed for cardiac preservation
• Validated for multi-organ retrieval
• Cons: Less commonly used for isolated kidney/liver

Organ-Specific Cold Ischemia Time Limits:

• Heart: below 4-6 hours (preferably below 4 hours)
• Lung: below 6-8 hours (preferably below 6 hours)
• Liver: below 12 hours (preferably below 8 hours)
• Kidney: below 24-36 hours (though DGF increases after 18-24 hours)

Machine Perfusion:

Normothermic Machine Perfusion (NMP):

• Organs maintained at 37°C with oxygenated blood
• Allows ex vivo assessment of organ function
• Extends allowable transport time
• Can rehabilitate marginal organs
• Evidence: Improves outcomes for ECD kidneys, DCD livers
• Cons: Expensive, requires specialised equipment and expertise

Hypothermic Machine Perfusion (HMP):

• Organs maintained at 4-8°C with perfusate solution
• Commonly used for kidneys
• Reduces delayed graft function
• Allows assessment of perfusion parameters
• Less expensive than NMP
• Cons: Limited availability

Oxygenation Techniques:

Ex Vivo Lung Perfusion (EVLP):

• Lungs maintained at 37°C with ventilatory support
• Allows assessment and rehabilitation of marginal lungs
• Evidence: Increases lung utilization rate by up to 30%
• Requires specialised equipment and expertise

Machine Perfusion Selection:

• ECD kidneys → HMP considered
• DCD livers → NMP considered
• Marginal lungs → EVLP considered
• Standard donors → Cold storage generally adequate

Transport Logistics

Modes of Transport:

Ground Ambulance:

• Local retrievals (below 100 km)
• Most kidneys, some livers
• Cost-effective, flexible timing
• Cons: Traffic delays, longer journey times

Fixed-Wing Aircraft:

• Inter-city or interstate retrievals
• Longest distances (greater than 500 km)
• Rapid transport, controlled environment
• Cons: Expensive, weather-dependent, airport logistics

Helicopter:

• Medium distance retrievals (50-200 km)
• Rapid, can land near hospitals
• Cons: Weather-dependent, expensive, limited cargo space

Transport Considerations:

Temperature Control:

• Organs maintained at 4°C during transport
• Continuous temperature monitoring
• Ice replenishment if needed
• Avoid temperature fluctuations

Packaging:

• Sterile containers, double-bagged
• Ice preservation system
• Clear labelling (organ type, blood group, donor ID)
• Documentation attached

Communication:

• Regular updates between retrieval and recipient teams
• GPS tracking for organ containers (increasingly used)
• Real-time temperature monitoring
• Contingency planning for delays

Documentation:

• Chain of custody documentation
• Organ assessment forms
• Preservation solution type and time
• Transport logs (temperature, timing)
• Recipient handover documentation

Cold Ischemia Time (CIT) Management:

• Start time: Organ flush and cooling in donor OR
• End time: Organ reperfusion in recipient
• Critical to minimise CIT for heart, lung, liver
• Kidneys more tolerant but DGF increases after 18-24 hours

Exam Detail: Retrieval Phase Timeline (Example for Multi-Organ Retrieval):

T-12 hours:

• Donor optimisation continues
• Retrieval teams notified and mobilised
• Transport arranged
• OR booked for retrieval

T-6 hours:

• Retrieval teams travelling to donor hospital
• Recipient teams prepare recipients
• Donor continues optimisation
• Blood products prepared

T-2 hours:

• Retrieval teams arrive at donor hospital
• Surgical timeout and briefing
• Final assessment of donor suitability
• Antibiotics administered (e.g., cefazolin 2 g IV)
• Methylprednisolone administered (if not previously given)

T-1 hour:

• Donor transferred to OR
• Lines secured
• Monitoring confirmed
• Anesthesia administered (no paralysing agents)

T-0:

• Surgical incision
• Sequential organ retrieval begins
  1. Heart and lungs (often first due to time sensitivity)
  2. Liver and pancreas
  3. Kidneys

T+2-4 hours:

• All organs retrieved
• Cold flush and packaging
• Documentation completed

T+4-6 hours:

• Organs in transport to recipient hospitals
• Donor theatre closure
• Donor prepared for funeral
• Family updated

T+6-12 hours:

• Organs arrive at recipient hospitals
• Recipient surgery begins
• Organ implantation

Timeline Variations:

• Shorter retrieval times for single-organ retrievals
• Longer for multi-organ retrievals
• Dependent on organ allocation distance
• Dependent on weather and transport delays [48,49]

Quality Assurance and Documentation

Donor Assessment Documentation:

• Medical history, cause of death, brain death certification
• Investigations: Bloods, imaging, cultures, cardiac assessment
• Hemodynamic parameters throughout donor management
• Hormone replacement therapy administered
• Ventilation strategy and ABGs
• Renal function and RRT details
• Temperature management
• Electrolyte management

Retrieval Documentation:

• Organ allocation decisions and recipient details
• Surgical timeout documentation
• Organ-specific assessment findings (surgeon notes)
• Preservation solution used
• Organ condition and any abnormalities noted
• Cold ischemia times documented
• Chain of custody documentation

Post-Retrieval Documentation:

• Donor closure and preparation for funeral
• Family communication and support
• Transport logs and times
• Recipient handover documentation
• Allocation audit trail

Quality Improvement:

• Audit of donor management goals achievement
• Audit of organs transplanted per donor
• Audit of consent rates and reasons for refusal
• Audit of cold ischemia times and transport delays
• Feedback to ICU teams on donor management quality
• Feedback to transplant centres on organ outcomes

Outcomes and Prognosis

Donor Management Goals (DMG) and Organ Yield

Key Donor Management Goals (ANZICS Guidelines):

1. MAP greater than 60 mmHg
2. CVP 4-10 mmHg
3. Lactate below 4 mmol/L
4. Urine output greater than 0.5 mL/kg/hr
5. PaO2/FiO2 greater than 300 mmHg
6. Ejection fraction greater than 45% (if cardiac donor)
7. Sodium 135-145 mmHg
8. Blood glucose 6-10 mmol/L
9. Temperature 36.0-37.5°C
10. Hb greater than 70 g/L

Malinoski et al. (2012):

• Multi-centre prospective study of 461 brain-dead donors
• Achieving ≥6 of 8 DMG associated with significantly increased organs transplanted per donor (3.9 vs. 2.8 organs)
• Achieving all 8 DMG associated with highest organ yield (4.5 organs per donor)
• Early achievement of DMG (within 3 hours of brain death) associated with best outcomes

Organ Yield Indicators:

• Optimal: 4-6 organs transplanted per donor
• Average: 3.8-4.2 organs per donor (Australia/NZ)
• Below average: below 3 organs per donor (opportunity for improvement)

Organ-Specific Outcomes

Kidney Transplantation from DBD Donors:

• 1-year graft survival: 95%
• 5-year graft survival: 80-85%
• Delayed graft function (DGF) rate: 20-25% (vs. 40-50% for DCD kidneys)
• Primary non-function (PNF) rate: 3-5%
• Factors associated with worse outcomes:
  • Donor age greater than 60 years
  • Prolonged cold ischemia time (greater than 24 hours)
  • High-dose catecholamine requirement (greater than 0.1 μg/kg/min noradrenaline)
  • Terminal creatinine greater than 200 μmol/L

Liver Transplantation from DBD Donors:

• 1-year graft survival: 85-90%
• 3-year graft survival: 75-80%
• Primary non-function rate: 5-8%
• Biliary complications rate: 10-15% (vs. 25-30% for DCD livers)
• Factors associated with worse outcomes:
  • Donor age greater than 60 years
  • Macrosteatosis greater than 30%
  • Cold ischemia time greater than 12 hours
  • Elevated transaminases (ALT/AST greater than 500 U/L)
  • Sodium greater than 150 mmol/L (hypernatraemia injures hepatocytes)

Heart Transplantation from DBD Donors:

• 1-year survival: 85-90%
• 5-year survival: 70-75%
• 10-year survival: 50-60%
• Primary graft dysfunction (PGD) rate: 15-20%
• Factors associated with worse outcomes:
  • Donor age greater than 50 years
  • LVEF below 45%
  • High-dose catecholamine requirement
  • Ischemic cardiomyopathy in donor
  • Prolonged cold ischemia time (greater than 4 hours)

Lung Transplantation from DBD Donors:

• 1-year survival: 85-90%
• 3-year survival: 70-75%
• Primary graft dysfunction (PGD) rate: 20-25%
• Factors associated with worse outcomes:
  • Smoking history greater than 20 pack-years
  • Abnormal chest X-ray
  • PaO2/FiO2 below 300 mmHg
  • Donor age greater than 50 years
  • Prolonged mechanical ventilation (greater than 7 days)

Impact of Donor Management Strategies

Corticosteroids (Methylprednisolone):

• Increases lung procurement rates by 30-50%
• Reduces primary graft dysfunction in heart, liver, lungs
• Reduces inflammatory markers (IL-6, TNF-α)
• Standard of care for all brain-dead donors

Vasopressin:

• Reduces catecholamine requirement by 30-50%
• Improves renal graft outcomes
• Associated with increased organs transplanted per donor
• Standard of care for donors with diabetes insipidus

Thyroid Hormone (T3/T4):

• Controversial based on Pfeifer et al. (2023) NEJM RCT
• No significant increase in organs transplanted per donor
• No improvement in heart procurement rates
• Current trend: Selective use (only if cardiac donor with EF below 45% and unstable)

Lung Protective Ventilation:

• Mascia et al. (2010): Increased lung procurement from 27% to 54%
• Reduces primary graft dysfunction
• Reduces systemic inflammatory response
• Standard of care for all potential lung donors

Early Hormone Replacement Therapy (within 3 hours of brain death):

• Associated with increased organ yield
• Associated with improved haemodynamic stability
• Reduced catecholamine requirement

Achievement of Donor Management Goals:

• Malinoski et al. (2012): Each additional DMG achieved increases organs transplanted by 0.4-0.6 organs
• Optimal donor management associated with 4-6 organs per donor vs. 2-3 organs per donor with suboptimal management

Family Outcomes

Family Satisfaction:

• Families who consent to donation report higher satisfaction with end-of-life care
• Donation provides sense of purpose and meaning for many families
• Bereavement support and follow-up critical for positive outcomes

Family Grief:

• No evidence that donation prolongs or worsens grief
• Some evidence of positive meaning-making from donation
• Ongoing support and communication important

Communication Quality:

• High-quality communication (clear, empathetic, decoupled approach) associated with higher consent rates and family satisfaction
• Poor communication (rushed, unclear, simultaneous death notification and request) associated with refusal and dissatisfaction

Healthcare System Outcomes

Organ Availability:

• Australia/NZ: 20-25 donors per million population (among highest globally)
• Transplant rates: Kidney ~70 per million, Liver ~15 per million, Heart ~8 per million, Lung ~8 per million
• Organ shortage: Significant gap between donor organs available and recipients waiting

Cost-Effectiveness:

• Donor management costs are offset by transplant benefits (life-years gained, quality of life improvement)
• Kidney transplantation cost-effective compared to dialysis
• Liver transplantation life-saving and cost-effective
• Heart and lung transplantation costly but life-saving with significant quality of life benefits

Quality Metrics:

• Conversion rate: Donors per million population
• Organ yield: Organs transplanted per donor
• Donor management goal achievement rate
• Consent rate (percentage of eligible families who consent)
• Cold ischemia times
• Graft survival rates
• Patient survival rates

SAQ Practice Questions

SAQ 1

Question: A 45-year-old male is declared brain dead following a subarachnoid hemorrhage. His blood pressure has fallen to 85/45 mmHg with a heart rate of 110 bpm. His urine output is 300 mL/hr for the past 3 hours. Serum sodium is 158 mmol/L.

A. List 5 immediate interventions required for donor optimisation (5 marks)

B. Explain your choice of vasopressors and the rationale for this choice (3 marks)

Model Answer:

A. Immediate interventions (1 mark each):

1. Fluid bolus (250-500 mL crystalloid)
2. Initiate noradrenaline infusion (0.05-0.5 μg/kg/min)
3. Desmopressin 1-4 μg IV
4. Methylprednisolone 1,000 mg IV
5. Arterial line placement for continuous MAP monitoring Alternative acceptable answers: Vasopressin infusion, blood glucose check and management, temperature check, check electrolytes and correct abnormalities

B. Vasopressor choice and rationale (3 marks):

• Noradrenaline first-line: Alpha-1 mediated vasoconstriction improves MAP, minimal tachycardia, standard first-line vasopressor for hypotension in ICU patients [1 mark]
• Add vasopressin if noradrenaline greater than 0.1 μg/kg/min required: Reduces catecholamine requirement (by 30-50%), V1 receptor vasoconstriction, V2 receptor effects help manage diabetes insipidus, reduces catecholamine toxicity to grafts (kidneys, heart) [1 mark]
• Avoid or minimise adrenaline: High doses associated with increased graft dysfunction (primary graft dysfunction in heart, delayed graft function in kidneys) due to intense vasoconstriction and beta-agonist effects [1 mark]

SAQ 2

Question: You are managing a potential lung donor, a 28-year-old female following traumatic brain injury. Initial assessment shows PaO2/FiO2 ratio of 250 mmHg on PEEP 5 cmH2O with bilateral infiltrates on chest X-ray.

A. Outline the lung protective ventilation strategy for this donor (5 marks)

B. Describe the recruitment manoeuvre you would perform and explain when it should be used (3 marks)

Model Answer:

A. Lung protective ventilation strategy (1 mark each):

1. Tidal volume: 6-8 mL/kg predicted body weight (calculate based on height, not actual weight)
2. PEEP: Increase to 8-10 cmH2O (higher than standard ICU practice)
3. FiO2: Titrate to lowest possible to maintain PaO2 greater than 100 mmHg (or SpO2 greater than 95%)
4. Target driving pressure: below 15 cmH2O (plateau pressure - PEEP)
5. Permissive hypercapnia: Allow PaCO2 up to 60 mmHg if needed to maintain lung-protective settings

B. Recruitment manoeuvre (3 marks):

• Technique: Sustained inflation with CPAP 40 cmH2O for 40 seconds (or incremental PEEP from 10 to 25 cmH2O in 5 cmH2O steps, holding 2 minutes at each level) [1 mark]
• When to use:
  • After any circuit disconnection (suctioning, transport, repositioning)
  • If PaO2/FiO2 ratio declines (greater than 50 mmHg decrease)
  • Before final lung donation assessment
  • After apnea testing (to prevent de-recruitment) [1 mark]
• Post-recruitment: Maintain PEEP at 8-10 cmH2O to prevent alveolar collapse, re-check ABG within 30 minutes [1 mark]

Viva Practice Questions

Viva 1

Candidate Instructions: This viva covers the management of a 52-year-old brain-dead donor with diabetes insipidus and hemodynamic instability.

Examiner: A 52-year-old male has been declared brain dead following a massive intracranial hemorrhage. He has severe diabetes insipidus with urine output of 500 mL/hr and serum sodium of 162 mmol/L. His blood pressure is 70/40 mmHg despite 2 litres of crystalloid resuscitation.

Candidate: I need to optimise this donor by addressing the diabetes insipidus and haemodynamic instability. I'll start with fluid resuscitation and hormone replacement therapy.

Examiner: What specific hormone replacement would you give and why?

Candidate: I would give:

1. Methylprednisolone 1,000 mg IV - this is indicated for ALL brain-dead donors to suppress the inflammatory cytokine storm, stabilise endothelial membranes, and improve response to catecholamines.
2. Desmopressin 2 μg IV to treat the diabetes insipidus - this will reduce urine output and help correct the hypernatraemia.
3. Consider vasopressin infusion 0.03 units/min - this provides both antidiuretic effect and vasoconstriction, reducing catecholamine requirement.

I would also consider thyroid hormone, though the evidence is controversial. The recent Pfeifer et al. (2023) NEJM trial showed no benefit from routine levothyroxine, so I would reserve T3/T4 for cardiac donors with ejection fraction below 45% who remain haemodynamically unstable despite adequate fluid and catecholamine support.

Examiner: How would you manage the hypernatraemia?

Candidate: The target is to correct sodium gradually to avoid osmotic stress on hepatocytes, which worsens liver graft outcomes. I would aim to correct sodium by no more than 12 mmol/L per 24 hours.

Management steps:

1. Desmopressin 2 μg IV every 8-12 hours to reduce urine output
2. Replace urine output mL-for-mL initially with hypotonic fluids (5% dextrose or balanced crystalloid diluted with 5% dextrose)
3. Calculate free water deficit: For this patient at 162 mmol/L, approximately 10 litres of free water deficit
4. Replace gradually over 24-36 hours: Give 200-300 mL of free water per hour via IV fluids (5% dextrose)
5. Monitor sodium every 2-4 hours
6. Target sodium 135-145 mmol/L

Examiner: The family has consented to organ donation, but they're concerned about how this will affect the funeral. How would you address this?

Candidate: I would address their concerns by explaining that organ retrieval is performed with great respect and dignity. Key points to discuss:

• The surgery is performed in the operating theatre with sterile technique
• Organs are removed surgically through incisions similar to other abdominal or chest surgeries
• All incisions are carefully closed and dressed
• The body's appearance is preserved - open-casket viewing is always possible
• Funeral arrangements can proceed normally and without delay
• The family can request to see the body after surgery if they wish
• Organ donation does not prevent cultural or religious funeral rites

I would also involve the DonateLife coordinator and appropriate cultural or spiritual support if needed, especially if the family is Aboriginal and Torres Strait Islander or Māori, to ensure cultural protocols around death and body handling are respected.

Examiner: What are the donor management goals you would aim to achieve for this donor?

Candidate: The key donor management goals (based on ANZICS guidelines) are:

1. MAP 60-80 mmHg: Maintain adequate perfusion pressure for end-organs
2. CVP 4-10 mmHg: Achieve euvolaemia without pulmonary congestion
3. Lactate below 4 mmol/L: Ensure adequate tissue perfusion
4. Urine output 0.5-2.0 mL/kg/hr: Manage diabetes insipidus with desmopressin or vasopressin
5. PaO2/FiO2 greater than 300 mmHg: Use lung protective ventilation (tidal volume 6-8 mL/kg PBW, PEEP 8-10 cmH2O)
6. Sodium 135-145 mmol/L: Correct hypernatraemia gradually (below 12 mmol/L per 24 hours)
7. Blood glucose 6-10 mmol/L: Use insulin infusion if needed
8. Temperature 36.0-37.5°C: Use warming blankets and warmed IV fluids
9. Hb 70-100 g/L: Transfuse if below 70 g/L
10. Ejection fraction greater than 45% (if cardiac donor): Assess with echocardiography

Achieving these goals has been shown in the Malinoski et al. (2012) study to increase organs transplanted per donor from 2.8 to 3.9 organs when 6 or more goals are achieved, and up to 4.5 organs when all goals are met.

Viva 2

Candidate Instructions: This viva covers family communication and consent for organ donation, including ethical considerations and special populations.

Examiner: You have declared a 35-year-old female brain dead following a subarachnoid hemorrhage. Her husband and parents are present. How would you approach the conversation about organ donation?

Candidate: I would use a decoupled approach, which involves separating the death notification from the donation request.

Step 1: Death notification I would ensure both the husband and parents are together in a private room, and I would use clear, unequivocal language: "I need to tell you that [patient's name] has died." I would explain what brain death means - irreversible cessation of all brain functions - and allow time for questions to ensure they understand. I would not mention organ donation at this stage.

Step 2: Transition Once the family has had time to process the news (typically 30 minutes to 2 hours) and shows signs of understanding and acceptance, I would transition by saying: "Would you like me to invite our organ donation coordinator to speak with you about options for donation?" or "Our organ donation coordinator is available if you'd like to discuss donation options."

Step 3: Donation request The DonateLife coordinator would then speak with the family, explain donation options, and ask: "Would you consider allowing [patient's name] to become an organ donor?"

Evidence from Gortmaker et al. (JAMA) shows this decoupled approach increases consent rates from 18% (simultaneous approach) to 60%. The key is ensuring the family accepts death before the donation request is made.

Examiner: What if the family is Aboriginal and Torres Strait Islander and needs to consult with community members before making a decision?

Candidate: This is a common and important consideration. Aboriginal and Torres Strait Islander decision-making often involves extended family and community consultation, not just the nuclear family.

My approach would be:

1. Invite Aboriginal Health Workers (AHWs) or Aboriginal Liaison Officers (ALOs): Ask the family: "Is there anyone else you'd like us to involve in these discussions?"

• this is crucial for cultural safety and appropriate communication

2. Allow extended time: Recognise that family members may need to travel, elders may need to be consulted, and community decision-making processes take time
3. Respect cultural protocols: Ask: "Are there cultural or community protocols we should respect?"

• different communities have different protocols around death, body handling, and communication

4. Avoid pressure: Do not rush the decision; organ donation is voluntary and the family's decision will be respected
5. Provide support: Offer appropriate cultural support and resources throughout the process

I would document this need for extended consultation and ensure the donor optimisation continues during this time. There is no time limit for the consent process in brain-dead donors (unlike DCD donors where there are time constraints).

Examiner: The family consents to kidney, liver, and heart donation but declines lung donation because of concerns about how the body will look. How would you respond?

Candidate: I would acknowledge and respect the family's decision, explaining that they have the right to choose which organs to donate. Partial consent is common and completely acceptable.

To address their concerns about body appearance, I would:

• Explain that all surgeries are performed with respect and dignity
• Explain that incisions are carefully closed and will be covered by clothing
• Reassure them that open-casket viewing is always possible
• Offer to have the DonateLife coordinator or a surgeon explain what the surgery involves
• Ask if they have specific concerns about certain organs

The key is to respect their autonomy - if they wish to proceed with kidney, liver, and heart donation but decline lungs, I would document this clearly and thank them for their generous gift. I would not pressure them to consent to lungs.

Examiner: What are the absolute and relative contraindications to organ donation?

Candidate: Absolute contraindications:

• Metastatic malignancy (any organ)
• Active hematologic malignancy (leukemia, lymphoma, multiple myeloma)
• High-grade primary CNS tumors with risk of extraneural spread (glioblastoma multiforme)
• Melanoma (even if "cured"
• high risk of late recurrence)
• Choriocarcinoma
• HIV (if recipient is HIV-negative)
• Rabies, Ebola, Creutzfeldt-Jakob disease or other prion diseases
• Active systemic infection with uncontrolled sepsis
• Active tuberculosis (untreated or disseminated)
• Unknown cause of death

Relative contraindications (acceptable for specific recipients):

• Low-grade primary CNS tumors (meningioma, low-grade astrocytoma) that rarely metastasise
• Treated malignancy with greater than 5 years disease-free interval
• Non-melanoma skin cancers (basal cell, squamous cell carcinoma)
• Carcinoma in situ (e.g., cervical CIS)
• HIV-positive donors → HIV-positive recipients (HOPE Act)
• Hepatitis B/C-positive donors → Hepatitis B/C-positive recipients or to negative recipients with prophylaxis/therapy
• Treated bacteremia (24-48 hours of appropriate antibiotics, haemodynamically stable)
• Age greater than 60 years → Extended criteria donor (ECD) for appropriate recipients
• Diabetes, hypertension, obesity → May affect organ quality but not contraindications
• Cerebrovascular accident as cause of death → ECD

For marginal or extended criteria donors, allocation occurs to recipients who have consented to accept higher-risk organs, and the decision is made on a case-by-case basis balancing the potential benefits and risks for the recipient.

Examiner: How are organs allocated in Australia, and what are the key principles?

Candidate: Organ allocation in Australia is managed by the Organ and Tissue Authority through the DonateLife network, following national allocation guidelines.

Key allocation principles:

1. Clinical urgency: Sickest first (highest priority)
2. Tissue compatibility: Blood group matching required for all organs; HLA matching critical for kidneys
3. Geographic proximity: Minimise cold ischemia time
4. Waiting time: In cases of equivalent urgency
5. Paediatric priority: Children prioritised for pediatric-sized organs

Organ-specific allocation systems:

• Kidneys: ANZOD registry; prioritised by blood group, HLA matching (0 mismatches best), then waiting time
• Livers: MELD-Na score (based on bilirubin, INR, creatinine, sodium); higher score = higher priority
• Hearts: Status 1A (life support, MCS) > 1B (high-dose inotropes) > 2 (all others); geographic constraints critical (below 4-6 hours CIT)
• Lungs: Lung Allocation Score (LAS) adapted for Australia/NZ; based on diagnosis, functional status, lung function, oxygen requirements
• Pancreas: Primarily by waiting time and blood group compatibility; often allocated with kidneys for SPK transplants

The national allocation system ensures equitable access to organs based on medical need rather than socioeconomic status or location, though geographic considerations (cold ischemia time limits) may influence allocation.

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Author Note: This topic is designed for CICM Fellowship candidates, with comprehensive coverage of donor physiology, management strategies, ethics, family communication, organ allocation, and retrieval coordination. All recommendations are based on the ANZICS Statement on Death and Organ Donation (Edition 4, 2021) and current evidence from randomized controlled trials and systematic reviews. Indigenous health considerations are included throughout, with specific attention to Aboriginal and Torres Strait Islander, Māori, and rural/remote contexts relevant to Australia and New Zealand.