Donor heart and lung procurement: A consensus statement

Heart and lung procurements are multiphased processes often accompanied by an array of complex logistics. Approaches to donor evaluation and management, organ procurement, and organ preservation vary among individual procurement teams. Because early graft failure remains a major cause of mortality in contemporary thoracic organ transplant recipients, we sought to establish some standardization in the procurement process. This paper, in this vein, represents an international consensus statement on donor heart and lung procurement and is designed to serve as a guide for physicians, surgeons, and other providers who manage donors to best optimize the clinical status for the procurement of both heart and lungs for transplantation. Donation after brain death (DBD) and donation after circulatory determination death (referred to as donation after circulatory death [DCD] for the remainder of the paper) for both heart and lung transplantation will be discussed in this paper. Although the data available on DCD heart donation are limited, information regarding the surgical technique for procurement is included within this consensus statement. Furthermore, this paper will focus on adult DBD and DCD heart and lung procurement.Currently, no certification, which is either recognized and/or endorsed by the transplant community at large, exists for the training of a cardiothoracic procurement surgeon. Nevertheless, establishing a training curriculum and credentialing requirements are beyond the scope of this paper. Heart and lung procurements are multiphased processes often accompanied by an array of complex logistics. Approaches to donor evaluation and management, organ procurement, and organ preservation vary among individual procurement teams. Because early graft failure remains a major cause of mortality in contemporary thoracic organ transplant recipients, we sought to establish some standardization in the procurement process. This paper, in this vein, represents an international consensus statement on donor heart and lung procurement and is designed to serve as a guide for physicians, surgeons, and other providers who manage donors to best optimize the clinical status for the procurement of both heart and lungs for transplantation. Donation after brain death (DBD) and donation after circulatory determination death (referred to as donation after circulatory death [DCD] for the remainder of the paper) for both heart and lung transplantation will be discussed in this paper. Although the data available on DCD heart donation are limited, information regarding the surgical technique for procurement is included within this consensus statement. Furthermore, this paper will focus on adult DBD and DCD heart and lung procurement. Currently, no certification, which is either recognized and/or endorsed by the transplant community at large, exists for the training of a cardiothoracic procurement surgeon. Nevertheless, establishing a training curriculum and credentialing requirements are beyond the scope of this paper. Evaluation of donor heart and lungs is a multistep process that begins many hours or even days before the surgical procurement. Initial assessment includes a review of the donor history, cause of death, laboratory results, and imaging including both computed tomography scan and echocardiography. The procuring surgeon may use a donor checklist to prevent glaring omissions (Figure 1).1Loor G Shumway SJ McCurry KR et al.Process improvement in thoracic donor organ procurement: implementation of a donor assessment checklist.Ann Thorac Surg. 2016; 102: 1872-1877Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Any relative contraindications to transplantation should be ruled out, such as transmission of an infectious disease.2Nalesnik MA Woodle ES Dimaio JM et al.Donor-transmitted malignancies in organ transplantation: assessment of clinical risk.Am J Transplant. 2011; 11: 1140-1147Crossref PubMed Scopus (135) Google Scholar, 3Seem DL Lee I Umscheid CA Kuehnert MJ United States Public Health ServicePHS guideline for reducing human immunodeficiency virus, hepatitis B virus, and hepatitis C virus transmission through organ transplantation.Public Health Rep. 2013; 128: 247-343Crossref PubMed Scopus (163) Google Scholar, 4Kim E Ko HH Yoshida EM A concise review of hepatitis C in heart and lung transplantation.Can J Gastroenterol. 2011; 25: 445-448Crossref PubMed Scopus (22) Google Scholar, 5Gottlieb RL Sam T Wada SY et al.Rational heart transplant from a hepatitis C donor: new antiviral weapons conquer the Trojan horse.J Card Fail. 2017; 23: 765-767Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Blood group and chest size are first determined to be compatible, and the tissue types acceptable for transplantation. If the donor has been designated as an increased risk, the recipient or the recipient's proxy is informed, and separate informed consent is duly obtained. Certain causes of brain death may directly affect the thoracic organs. Table 1 lists the causes of brain death with specific risks that are best addressed at the procurement center. The ultimate goals of donor management are to preserve the donation opportunity and to maximize the number and quality of donor organs for transplantation. Equally important is maintaining an unbiased and collaborative approach without prioritizing 1 organ over another. Timely and frequent communication among the surgeons and other team members is thus essential both within and between the procuring teams.Table 1Causes of Death Affecting the Thoracic Organ DonorCauseDescriptionTraumaCardiac and pulmonary contusions, myocardial stunning, neurogenic pulmonary edemaCVAIndication of possible hypertension in the donor, left ventricular hypertrophy, coronary artery disease, peripheral arterial diseaseAsphyxiaPrimary respiratory failure, if unwitnessed unknown downtimeDrug intoxicationPossible drug-induced problems. That is, cocaine, methamphetamines—coronary artery disease—indicates the need for possible left heart catheterization; heroine—high-risk contractible disease potentiallyMalignancyCentral nervous system malignancy not necessarily a contraindication to donationAbbreviation: CVA, cerebral vascular accident. Open table in a new tab Abbreviation: CVA, cerebral vascular accident. The goals of management of the donation after brain death (DBD) donor include optimizing cardiac filling pressures, maintaining adequate arterial pressure for donor organ perfusion, ensuring a patent airway and maintaining protective ventilation strategies, and maintaining metabolic homeostasis.6Rosendale JD Kauffman HM McBride MA et al.Aggressive pharmacologic donor management results in more transplanted organs.Transplantation. 2003; 75: 482-487Crossref PubMed Scopus (242) Google Scholar, 7Venkateswaran RV Patchell VB Wilson IC et al.Early donor management increases the retrieval rate of lungs for transplantation.Ann Thorac Surg. 2008; 85: 278-286Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar, 8Wheeldon DR Potter CD Oduro A Wallwork J Large SR Transforming the “unacceptable” donor: outcomes from the adoption of a standardized donor management technique.J Heart Lung Transplant. 1995; 14: 734-742PubMed Google Scholar The recommended approach to the management of the DBD donor is summarized in Figure 2, Figure 3.9Available at:https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/17645/identification-and-referral-of-potential-organ-donors-18072019.pdfGoogle ScholarFigure 3Brain death donor management pathophysiological management.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4DCD lung procurement procedure. CIT, cold ischemic time; DCD, donation after circulatory death; OR, operating room; TIT, total ischemic time; WIT, warm ischemic time.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Arterial and central venous lines are required to allow continuous monitoring of the donor hemodynamic status. In donors with a low mean arterial pressure (MAP) (i.e., MAP < 60 mm Hg) despite adequate central venous pressure (CVP) (i.e., CVP of 6–10 mm Hg), a pulmonary artery (PA) catheter is also desirable.8Wheeldon DR Potter CD Oduro A Wallwork J Large SR Transforming the “unacceptable” donor: outcomes from the adoption of a standardized donor management technique.J Heart Lung Transplant. 1995; 14: 734-742PubMed Google Scholar,10Zaroff JG Rosengard BR Armstrong WF et al.Consensus conference report: maximizing use of organs recovered from the cadaver donor: cardiac recommendations, March 28-29, 2001, Crystal City, Va.Circulation. 2002; 106: 836-841Crossref PubMed Scopus (346) Google Scholar If a PA catheter is not used, direct intraoperative measurement of pressures of the PA and left atrium is recommended.11Al-Khafaji A Murugan R Wahed AS et al.Monitoring Organ Donors to Improve Transplantation Results (MOnIToR) trial methodology.Crit Care Resusc. 2013; 15: 234-240PubMed Google Scholar Potential lung donors require continuous oxygen saturation and end-tidal carbon dioxide monitoring (where available) at regular intervals (at least daily or more frequently at the discretion of the donor management team), arterial blood gases and daily chest radiographs, and computed tomography scans of the thorax. A PaO2:FiO2 (P/F) ratio >300 mm Hg (40 kPa) generally indicates that the lungs are suitable for transplantation, although a lower value does not necessarily indicate that the organ(s) is unsuitable for donation.12Shemie SD Ross H Pagliarello J et al.Organ donor management in Canada: recommendations of the forum on Medical Management to Optimize Donor Organ Potential.CMAJ. 2006; 174: S13-S32Crossref PubMed Scopus (148) Google Scholar All potential heart donors require a transthoracic echocardiogram or transesophageal echocardiogram (TEE) to evaluate ventricular function and left ventricular wall thickness so as to rule out major valvular or structural heart diseases. Wall motion abnormalities that do not correspond with any particular coronary artery distribution are common after brain death.13Berman M Ali A Ashley E et al.Is stress cardiomyopathy the underlying cause of ventricular dysfunction associated with brain death?.J Heart Lung Transplant. 2010; 29: 957-965Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 14Maréchaux S Fornes P Petit S et al.Pathology of inverted Takotsubo cardiomyopathy.Cardiovasc Pathol. 2008; 17: 241-243Crossref PubMed Scopus (42) Google Scholar, 15Zaroff JG Rordorf GA Ogilvy CS Picard MH Regional patterns of left ventricular systolic dysfunction after subarachnoid hemorrhage: evidence for neurally mediated cardiac injury.J Am Soc Echocardiogr. 2000; 13: 774-779Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar In addition, ventricular dysfunction and hemodynamic optimization, particularly in pediatric donors, may improve with time.16Borbely XI Krishnamoorthy V Modi S et al.Temporal changes in left ventricular systolic function and use of echocardiography in adult heart donors.Neurocrit Care. 2015; 23: 66-71Crossref PubMed Scopus (35) Google Scholar,17Krishnamoorthy V Borbely X Rowhani-Rahbar A Souter MJ Gibbons E Vavilala MS Cardiac dysfunction following brain death in children: prevalence, normalization, and transplantation.Pediatr Crit Care Med. 2015; 16: e107-e112Crossref PubMed Scopus (21) Google Scholar However, the heart may not necessarily recover, and repeated echocardiograms as frequently as every 12 hours may be indicated. Donor coronary angiography should be performed in potential heart donors with risk factors for coronary artery disease (CAD)—such as those with hypertension; a history of cocaine, heroin, or amphetamine use; significant smoking history or current smoker; age > 40 years; hyperlipidemia; pre-mature CAD; or who have regional wall motion abnormalities on echocardiography.18Grauhan O Siniawski H Dandel M et al.Coronary atherosclerosis of the donor heart–impact on early graft failure.Eur J Cardiothorac Surg. 2007; 32: 634-638Crossref PubMed Scopus (43) Google Scholar,19Grauhan O Wesslau C Hetzer R Routine screening of donor hearts by coronary angiography is feasible.Transplant Proc. 2006; 38: 666-667Crossref PubMed Scopus (17) Google Scholar All diagnostic studies should be carefully reviewed at the procurement hospital and evaluated in conjunction with donor physiologic status such as inotrope and/or pressor support requirements at the time of procurement. One of the most important goals in maintaining organ perfusion during donor management is achieving euvolemia. Most organ donors are at risk of intravascular volume depletion to loss of vascular tone and increased capillary permeability. Diabetes insipidus (DI) and hyperglycemia may also compound further losses, increasing the risk for hypovolemic shock.20Munshi L Murugan L Intensive care of the deceased multiorgan donor: one donor, nine lives.in: Subramanian K Sakai T Anesthesia and perioperative care for organ transplantation. Springer, New York2017: 51-61Crossref Google Scholar In donors with decreased pre-load, crystalloid solutions (0.9% sodium chloride or Ringer's lactate) are the preferred choices for fluid repletion and maintenance.21Kotloff RM Blosser S Fulda GJ et al.Management of the potential organ donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement.Crit Care Med. 2015; 43: 1291-1325Crossref PubMed Scopus (189) Google Scholar,22McKeown DW Bonser RS Kellum JA Management of the heartbeating brain-dead organ donor.Br J Anaesth. 2012; 108: i96-107Abstract Full Text Full Text PDF PubMed Scopus (169) Google Scholar Dextrose containing fluids or hypotonic solutions, such as 0.45% sodium chloride, may be used in patients with hypernatremia (Serum Na+ > 145 mmol/liter) after correction of hypovolemia. Sodium bicarbonate may be added to treat metabolic acidosis.23Wood KE Becker BN McCartney JG D'Alessandro AM Coursin DB Care of the potential organ donor.N Engl J Med. 2004; 351: 2730-2739Crossref PubMed Scopus (290) Google Scholar Careful fluid management avoids massive crystalloid infusion, which has a detrimental effect on arterial oxygenation. Surgeons should evaluate the lungs for pulmonary edema at the donor hospital. Rapid increases in intravascular volume may adversely affect right ventricular function as well as potentiate acute kidney injury.21Kotloff RM Blosser S Fulda GJ et al.Management of the potential organ donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement.Crit Care Med. 2015; 43: 1291-1325Crossref PubMed Scopus (189) Google Scholar, 22McKeown DW Bonser RS Kellum JA Management of the heartbeating brain-dead organ donor.Br J Anaesth. 2012; 108: i96-107Abstract Full Text Full Text PDF PubMed Scopus (169) Google Scholar, 23Wood KE Becker BN McCartney JG D'Alessandro AM Coursin DB Care of the potential organ donor.N Engl J Med. 2004; 351: 2730-2739Crossref PubMed Scopus (290) Google Scholar Protective lung ventilation strategies may prevent additional lung injury. This is achieved by limiting tidal volumes lowering driving pressures and optimizing positive end-expiratory pressure (PEEP)24Botha P Rostron AJ Fisher AJ Dark JH Current strategies in donor selection and management.Semin Thorac Cardiovasc Surg. 2008; 20: 143-151Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 25Mascia L Pasero D Slutsky AS et al.Effect of a lung protective strategy for organ donors on eligibility and availability of lungs for transplantation: a randomized controlled trial.JAMA. 2010; 304: 2620-2627Crossref PubMed Scopus (249) Google Scholar, 26Van Raemdonck D Neyrinck A Verleden GM et al.Lung donor selection and management.Proc Am Thorac Soc. 2009; 6: 28-38Crossref PubMed Scopus (170) Google Scholar, 27Miñambres E Pérez-Villares JM Chico-Fernández M et al.Lung donor treatment protocol in brain dead-donors: a multicenter study.J Heart Lung Transplant. 2015; 34: 773-780Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar (Figure 2). Gentle recruitment maneuvers are ideally performed after tracheal suctioning or temporary disconnection of the ventilator circuit.28Philpot SJ Pilcher DV Graham SM Snell GI Lung recruitment manoeuvres should be considered when assessing suitability for lung donation.Crit Care Resusc. 2012; 14: 244-245PubMed Google Scholar In addition, limiting PaO2 to <500 mm Hg potentially limits subsequent bronchiolitis obliterans in lung recipients.29Hennessy SA Hranjec T Swenson BR et al.Donor factors are associated with bronchiolitis obliterans syndrome after lung transplantation.Ann Thorac Surg. 2010; 89: 1555-1562Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Decreasing the FiO2 once an evaluation is completed may mitigate any inadvertent collateral damage to the lungs. If the patient is PEEP-dependent, tracheal suctioning is performed only in the presence of airway secretions to avoid derecruitment and to evaluate for endobronchial lesions.30Mascia L Mastromauro I Viberti S Vincenzi M Zanello M Management to optimize organ procurement in brain dead donors.Minerva Anestesiol. 2009; 75: 125-133PubMed Google Scholar The endotracheal tube cuff is inflated to a pressure high enough to prevent aspiration.31Lorente L Blot S Rello J New issues and controversies in the prevention of ventilator-associated pneumonia.Am J Respir Crit Care Med. 2010; 182: 870-876Crossref PubMed Scopus (85) Google Scholar Bronchoscopy is performed early for an accurate evaluation of bronchitis, aspiration, obtaining sputum samples, and possibly bronchoalveolar lavage if an infection is suspected, and to clear stagnant secretions that may cause atelectasis32Gabbay E Williams TJ Griffiths AP et al.Maximizing the utilization of donor organs offered for lung transplantation.Am J Respir Crit Care Med. 1999; 160: 265-271Crossref PubMed Scopus (220) Google Scholar or inhalation injury. In DBD donors, regional differences in perfusion and gas distribution may occur owing to obstruction by excessive secretions, atelectasis, infection, inflammation, bronchospasm, and gravitational forces resulting in ventilation-perfusion mismatch and/or dead space ventilation, which may result in hypoxemia. Specific treatments include mucolytic therapy, antibiotics as guided by sputum microbiology, and steroids. Higher PEEP in combination with recruitment maneuvers, use of protective strategies, and judicious use of diuretics may be necessary to further reduce ventilation-perfusion mismatching and diffusion abnormalities, thereby increasing the P/F ratio.33Powner DJ Hewitt MJ Levine RL Interventions during donor care before lung transplantation.Prog Transplant. 2005; 15: 141-148Crossref PubMed Scopus (8) Google Scholar Intraoperative measurement of the CVP and PA pressure guides diuretic therapy. Bronchoscopy should be repeated at procurement and findings should be compared with previous findings. Bronchoscopic biopsies, sputum sampling and/or bronchoalveolar lavages, and cultures are important options to assess for infection and malignancy. Approximately 90% of brain-dead donors develop progressive hypotension despite adequate fluid resuscitation, necessitating vasopressor support.20Munshi L Murugan L Intensive care of the deceased multiorgan donor: one donor, nine lives.in: Subramanian K Sakai T Anesthesia and perioperative care for organ transplantation. Springer, New York2017: 51-61Crossref Google Scholar,34Baroldi G Di Pasquale G Silver MD Pinelli G Lusa AM Fineschi V Type and extent of myocardial injury related to brain damage and its significance in heart transplantation: a morphometric study.J Heart Lung Transplant. 1997; 16: 994-1000PubMed Google Scholar There is no consensus regarding the vasopressor of choice. Observational studies have suggested that the use of catecholamines may result in divergent effects on different organs. One large retrospective analysis reported that administration of catecholamines was associated with improved post-transplant outcomes for renal recipients but with worse outcomes for cardiac recipients.35Schnuelle P Berger S de Boer J Persijn G van der Woude FJ Effects of catecholamine application to brain-dead donors on graft survival in solid organ transplantation.Transplantation. 2001; 72: 455-463Crossref PubMed Google Scholar More recently, vasopressin at the lowest dose necessary has emerged as the recommended first-line agent.12Shemie SD Ross H Pagliarello J et al.Organ donor management in Canada: recommendations of the forum on Medical Management to Optimize Donor Organ Potential.CMAJ. 2006; 174: S13-S32Crossref PubMed Scopus (148) Google Scholar,20Munshi L Murugan L Intensive care of the deceased multiorgan donor: one donor, nine lives.in: Subramanian K Sakai T Anesthesia and perioperative care for organ transplantation. Springer, New York2017: 51-61Crossref Google Scholar This V1 and V2 receptor agonist increases systemic vascular resistance, although simultaneously preventing DI. Its use has been associated with improved donor heart function (possibly by allowing withdrawal of catecholamine support) and increased recovery of donor organs.36Venkateswaran RV Steeds RP Quinn DW et al.The haemodynamic effects of adjunctive hormone therapy in potential heart donors: a prospective randomized double-blind factorially designed controlled trial.Eur Heart J. 2009; 30: 1771-1780Crossref PubMed Scopus (85) Google Scholar,37Plurad DS Bricker S Neville A Bongard F Putnam B Arginine vasopressin significantly increases the rate of successful organ procurement in potential donors.Am J Surg. 2012; 204: 856-861Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar Dopamine may be considered an alternative first-line agent, particularly in patients requiring inotropic support.21Kotloff RM Blosser S Fulda GJ et al.Management of the potential organ donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement.Crit Care Med. 2015; 43: 1291-1325Crossref PubMed Scopus (189) Google Scholar,23Wood KE Becker BN McCartney JG D'Alessandro AM Coursin DB Care of the potential organ donor.N Engl J Med. 2004; 351: 2730-2739Crossref PubMed Scopus (290) Google Scholar A large prospective, randomized, placebo-controlled trial of low-dose dopamine (4 µg/kg/min) demonstrated that dopamine administration to donors already receiving norepinephrine <0.4 µg/kg/min resulted in reduced requirements for post-transplant dialysis in both renal and heart transplant recipients from the same donor.38Schnuelle P Gottmann U Hoeger S et al.Effects of donor pretreatment with dopamine on graft function after kidney transplantation: a randomized controlled trial.JAMA. 2009; 302: 1067-1075Crossref PubMed Scopus (200) Google Scholar Moreover, overall survival was improved in the heart recipients.39Benck U Hoeger S Brinkkoetter PT et al.Effects of donor pre-treatment with dopamine on survival after heart transplantation: a cohort study of heart transplant recipients nested in a randomized controlled multicenter trial.J Am Coll Cardiol. 2011; 58: 1768-1777Crossref PubMed Scopus (57) Google Scholar Epinephrine and norepinephrine may also be used to achieve desired hemodynamic goals; however, their use may lead to downregulation of β-receptors in the donor's heart, which may affect contractility after transplantation.40D'Amico TA Meyers CH Koutlas TC et al.Desensitization of myocardial beta-adrenergic receptors and deterioration of left ventricular function after brain death.J Thorac Cardiovasc Surg. 1995; 110: 746-751Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar Higher doses of these agents (>0.2 µg/kg/min) have been reported to increase the risk of cardiac injury,35Schnuelle P Berger S de Boer J Persijn G van der Woude FJ Effects of catecholamine application to brain-dead donors on graft survival in solid organ transplantation.Transplantation. 2001; 72: 455-463Crossref PubMed Google Scholar,41Santise G D'Ancona G Falletta C et al.Donor pharmacological hemodynamic support is associated with primary graft failure in human heart transplantation.Interact Cardiovasc Thorac Surg. 2009; 9: 476-479Crossref PubMed Scopus (24) Google Scholar,42Stoica SC Satchithananda DK White PA Parameshwar J Redington AN Large SR Noradrenaline use in the human donor and relationship with load-independent right ventricular contractility.Transplantation. 2004; 78: 1193-1197Crossref PubMed Scopus (44) Google Scholar although in recent literature, the use of norepinephrine in the donor has been deemed safe. Angleitner et al43Angleitner P Kaider A Gökler J et al.High-dose catecholamine donor support and outcomes after heart transplantation.J Heart Lung Transplant. 2018; 37: 596-603Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar reported no significant differences in 30-day and 1-year mortality, primary graft dysfunction, and the need for renal replacement therapy after heart transplantation when heart donors who did not require vasopressors were compared against those who were on low-dose norepinephrine (0.01–0.1 µg/kg/min), or when those on low-dose norepinephrine (0.01–0.1 µg/kg/min) were compared with those on higher-dose norepinephrine (>0.1 µg/kg/min).43Angleitner P Kaider A Gökler J et al.High-dose catecholamine donor support and outcomes after heart transplantation.J Heart Lung Transplant. 2018; 37: 596-603Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Recipients who received hearts from donors on norepinephrine had prolonged intensive care unit (ICU) length of stay.43Angleitner P Kaider A Gökler J et al.High-dose catecholamine donor support and outcomes after heart transplantation.J Heart Lung Transplant. 2018; 37: 596-603Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Hence, echocardiograms should be interpreted in the context of vasopressor(s) support that the donor was receiving at the time of the study and may need to be repeated. Brain death results in a rapid decline in serum levels of cortisol, anti-diuretic hormone, thyroid hormones, and insulin.20Munshi L Murugan L Intensive care of the deceased multiorgan donor: one donor, nine lives.in: Subramanian K Sakai T Anesthesia and perioperative care for organ transplantation. Springer, New York2017: 51-61Crossref Google Scholar The role of steroid administration in multiorgan donors in combination with thyroid hormone and vasopressin administration has been studied.44Macdonald PS Aneman A Bhonagiri D et al.A systematic review and meta-analysis of clinical trials of thyroid hormone administration to brain dead potential organ donors.Crit Care Med. 2012; 40: 1635-1644Crossref PubMed Scopus (89) Google Scholar In animal studies, early administration of methylprednisolone has been associated with significant preservation of both systolic and diastolic cardiac function and a reduction in pro-inflammatory cytokines such as interleukin-6 and tumor necrosis factor-α.20Munshi L Murugan L Intensive care of the deceased multiorgan donor: one donor, nine lives.in: Subramanian K Sakai T Anesthesia and perioperative care for organ transplantation. Springer, New York2017: 51-61Crossref Google Scholar In lung transplantation, high-dose corticosteroid administration is associated with improved oxygenation and increased success rate of lung procurement when compared with controls.45Follette DM Rudich SM Babcock WD Improved oxygenation and increased lung donor recovery with high-dose steroid administration after brain death.J Heart Lung Transplant. 1998; 17: 423-429PubMed Google Scholar To achieve these benefits, methylprednisolone is best administered as soon as brain death is confirmed and the patient declared a potential organ donor. Recent studies suggest that low-dose corticosteroid replacement (e.g., 300 mg hydrocortisone) achieves similar improvements in hemodynamic stability and lung oxygenation with less hyperglycemia than high-dose methylprednisolone.46Dhar R Cotton C Coleman J et al.Comparison of high- and low-dose corticosteroid regimens for organ donor management.J Crit Care. 2013; 28 (111.e1-17)Crossref PubMed Scopus (37) Google Scholar,47Pinsard M Ragot S Mertes PM et al.Interest of low-dose hydrocortisone therapy during brain-dead organ donor resuscitation: the CORTICOME study.Crit Care. 2014; 18: R158Crossref PubMed Scopus (40) Google Scholar The use of vasopressin in the treatment of vasoparesis after brain death is well established.37Plurad DS Bricker S Neville A Bongard F Putnam B Arginine vasopressin significantly increases the rate of successful organ procurement in potential donors.Am J Surg. 2012; 204: 856-861Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar A decrease in anti-diuretic hormone leads to DI and rapid fluid shift which, when combined with decreased sympathetic vascular tone, dramatically increases the risk of hypotension, hypernatremia, and hemoconcentration. Approximately 80% of donors develop DI.20Munshi L Murugan L Intensive care of the deceased multiorgan donor: one donor, nine lives.in: Subramanian K Sakai T Anesthesia and perioperative care for organ transplantation. Springer, New York2017: 51-61Crossref Google Scho