Resuscitation 81 (2010) 904–907

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Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

Short communication

Kidney transplant function using organs from non-heart-beating donors

maintained by mechanical chest compressions夽
Alonso Mateos-Rodríguez a,∗ , Luis Pardillos-Ferrer a , José María Navalpotro-Pascual a ,
Carlos Barba-Alonso a , María Eugenia Martin-Maldonado a , Amado Andrés-Belmonte b
a
Servicio de Urgencias Médicas de Madrid SUMMA112, Spain
b
Coordinación de trasplantes, Hospital Universitario 12 de Octubre, Madrid, Spain

a r t i c l e i n f o a b s t r a c t

Article history: Objective: This study aims to determine the failure rate of transplanted kidney grafts in recipients of organs
Received 10 February 2010 from non-heart beating donors (NHBDs) who have had mechanical chest compressions to maintain a
Received in revised form 12 April 2010 circulation before organ retrieval.
Accepted 28 April 2010
Methods: A retrospective observational study based on review of the emergency medical service database
and case histories of NHBDs, and information periodically sent by transplant units about donors and
Keywords:
organs. The following variables were studied: age, sex, transfer hospital, time to arrival on the scene of
Non-heart beating donors
cardiopulmonary arrest, time to arrival in hospital, number and type of organs retrieved, use of mechan-
Emergency medical services
Transplantation
ical chest compression devices, and kidney function in graft recipients. The study covered the period
between January 2008 and November 2009. During 2008 standard manual chest compressions were
used and during 2009 mechanical chest compression devices were used.
Results: In 39 transplanted kidneys from donors receiving mechanical chest compressions primary failure
was documented in recipients on two occasions (5.1%). Kidneys transplanted from donors who had man-
ual chest compressions resulted in three primary failures in recipients (9.1%). The difference between
the two groups was not significant (p = 0.5). Three patients achieved successful return of spontaneous
circulation in the mechanical chest compression group after initiation of the NHBD donor protocol.
Conclusion: We have described our experience and protocol for non-heart beating donation using victims
of out-of-hospital cardiac arrest in whom cardiopulmonary resuscitation has been unsuccessful as donors.
Primary kidney graft failure rates in organs from non-heart beating donors is similar when manual or
mechanical chest compression devices are used during cardiopulmonary resuscitation.
© 2010 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Non-heart-beating donors (NHBDs) have to meet predefined
criteria for organ donation1 including death from irreversible ces-
sation of the beating heart. In 1995 the Maastricht conference2
defined four NHBD categories to differentiate their viability, and
provide ethical and legal support.3 Type I donors (admitted to the
centre after death) and type II donors (resulting from unsuccessful
cardiopulmonary resuscitation (CPR) attempts) are referred to as
uncontrolled donors, since the precise duration of warm ischaemia
is not known in these donors. In Spain, NHBDs who originate from
the out-hospital setting correspond to type II donors. These are
夽 A Spanish translated version of the abstract of this article appears as Appendix
in the final online version at doi:10.1016/j.resuscitation.2010.04.024.
∗ Corresponding author at: C/ Antracita 2 bis, 28045 Madrid, Spain.
Tel.: +34 607110309.
E-mail address: amateo.summa@salud.madrid.org (A. Mateos-Rodríguez).
patients who have suffered a cardiac arrest outside hospital, and
after failed CPR attempts are then transferred with continued CPR
to hospital for organ donation.
Mobile Emergency Unit doctors are legally and ethically enabled
to diagnose (but not certify) the death of the patient and activate
the donor protocol. In Spain all individuals whose views on organ
donation are not known are considered as organ donors.4 In spite
of this family permission is also obtained. This is regulated by the
Royal Decree 2070/1999 relating to the donation and transplanta-
tion of organs and tissues.5 This allows the diagnosis of death after
cardiorespiratory arrest according to the following:
• The unequivocal confirmation of the absence of a heart beat,
diagnosed by the absence of a central pulse or asystole on the elec-
trocardiogram, and the absence of spontaneous breathing—being
observed for a period of at least 5 min.
• The irreversibility of the cessation of cardiorespiratory function
must be confirmed after an adequate period of advanced CPR. This
period, and CPR interventions should be appropriate for the age of

0300-9572/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.resuscitation.2010.04.024
 A. Mateos-Rodríguez et al. / Resuscitation 81 (2010) 904–907
the individual and the circumstances leading to cardiorespiratory
arrest. At all times current advanced life support guidelines must
be followed.
• If the cardiac arrest victim’s body temperature is less than 32 ◦ C,
the victim should be warmed before establishing the irreversibil-
ity of cardiac arrest, and thus the diagnosis of death.
This study describes the role of mechanical chest compression
devices in our service and determines if recipients of organs
from NHBDs who have had mechanical chest compressions have
improved kidney graft function compared with those recipients
from NHBDs who have had manual chest compressions.
2. Material and methods
2.1. Study setting
Madrid, Spain has 6 million inhabitants. The emergency medi-
cal service (EMS) is the Service of Medical Emergencies of Madrid,
SUMMA112. This provides a comprehensive service including the
use of two helicopters, 26 mobile intensive care units, 17 rapid
intervention vehicles, a truck for major incidents, and another
for special situations. Emergency vehicles have emergency trained
doctors and nurses—and one or two emergency care technicians.
During 2008 the service received about one million calls and
attended 400,000 incidents including 78,000 by emergency care
vehicle.
2.2. Resuscitation and donor protocol
The inclusion criteria for the NHBD protocol of the Madrid
Emergency Medical Service SUMMA112 are: absence of neoplas-
tic, systemic or transmissible diseases (including no HIV infection);
an age of between 1 and 55 years; a known time of cardiac arrest;
a time interval from cardiac arrest to the start of advanced CPR of
less than 15 min; hospital arrival in less than 90 min after cardiopul-
monary arrest; a known or easily diagnosable cause of death, with
no suspected abdominal or chest bleeding, and a healthy external
appearance.
When the EMS attends a cardiac arrest they begin CPR. If after
30 min of advanced CPR, there is no return of spontaneous cir-
culation the victim is assessed as a potential NHBD. If the victim
fulfills the NHBD criteria the protocol is activated, and ventilation
and chest compressions (but not drugs) are continued while the
patient is transferred to the transplant hospital. Resuscitation is
not stopped during this assessment process. Death is diagnosed
and certified after hospital arrival by a doctor who is not a mem-
ber of the transplant team. This is usually an ICU doctor. CPR is
stopped and the patient is assessed and the signs of death must be
observed for at least 5 min to confirm death. The transplant sur-
gical team than connect the donor to an extracorporeal circulation
(bypass) machine to maintain a circulation. The process and timings
are summarized in Table 1.
There are two public hospitals in this programme: San Carlos
University Clinic Hospital and Doce de Octubre Hospital. At present,
the following organs are retrieved for transplantation from NHBDs
identified by this program: kidneys, lungs, liver, corneas and bone
tissue. We report here data from one of these two centres (Doce de
Octubre Hospital).
The study covered the period from January 2008 to Novem-
ber 2009. During the first year of the study mechanical chest
compression devices were not used. Since 2009 mechanical chest
compression devices have been included in the protocol. Specif-
ically, use has been made of the Lucas©(Physio-Control) and
Autopulse©(Zoll) compression devices (Fig. 1). In the case of heli-
905
Fig. 1. Mechanical cardiac compressors used in the program, Lucas©from Physio-
Control and Autopulse©from Zoll.
copter transfer, where the Autopulse©was used. The analysis was
limited to those cases in which one or two kidneys were retrieved
and transplanted.
2.3. Data collection
A retrospective observational study based on review of emer-
gency medical service database, case histories of NHBDs, and
information provided by transplant units on the validity of donors
and organs. The following variables were entered into a database:
age, sex, transfer hospital, time to arrival on the scene of cardiopul-
monary arrest, time to arrival in hospital, number and type of
organs retrieved, use of mechanical chest compression devices, and
kidney function in graft recipients.
2.4. Statistical analysis
The SPSS©version 16.0 was used for statistical analysis. Quan-
titative variables are expressed as the mean ± standard deviation
(SD). Qualitative variables are reported as percentages. For the com-
parison of qualitative variables, the Chi-squared test or its Fisher
f correction was used. Comparison of quantitative variables was
made with the Student’s t-test.
3. Results
During 2009, 28 NHBD candidates were transferred to the Doce
de Octubre Hospital with the use of one of the mechanical chest
compression devices. Of these 28 cases, 85% were males, with a
mean age of 39 ± 10 years. The mean time for EMS arrival to the
scene of the cardiopulmonary arrest was 12 ± 8 min, and the inter-
val from the initial alert for the cardiac arrest and hospital arrival
was 97 ± 53 min. There was no significant difference with the data
from 2008 when manual chest compressions were used (Table 2).
The cause of death in the 28 patients who had mechanical chest
compressions was: cardiac arrest (15 cases), neurological (5 cases),
respiratory (1 case) and unknown (information missing from clin-
ical record in 7 cases).
Thirty-nine kidneys were transplanted from the 28 NHBDs in
2009, representing 70% of the total potential kidneys. Kidneys were
not transplanted because of: legal objection in one case (two kid-
neys), family refusal in three cases (6 kidneys), failure to establish
an extracorporeal circulation in 1 case (two kidneys) and micro-
scopic and macroscopic defects in 7 kidneys.
During the manual chest compression period in 2008, 33 kid-
neys were transplanted from 20 NHBDs (83% of the potential
organs). The difference between both groups in proportion of donor
kidneys transplanted was not significant (p = 0.23).
906 A. Mateos-Rodríguez et al. / Resuscitation 81 (2010) 904–907
Table 1
Timing and interventions for out-hospital NHBD program.
Pre-hospital setting Hospital setting
0–15 min Arrive at scene and start CPR
15–30 min If no ROSC and fulfill NHBD criteria
actived protocol
30–90 min NHBD alert and transfer to hospital Hospital organ retrieval team alerted
with CPR on going (manual or
mechanical compressiions)
90–120 min Extracorporeal bypass circulation
120–240 min Ask family if they agree with organ
donation
ROSC = return of spontaneous circulation. NHBD = non-heart beating donor.
Table 2
Description of the cases studied.
Manual chest compressions
(n = 20 patients)
Age ± SD (years) 41 ± 9
Males (%) 85%
Time to arrival on scene of cardiopulmonary arrest (min) 15 ± 7
Cardiac arrest alert to hospital arrival interval (min) 99 ± 24
Kidneys transplanted (% versus potential number) 33 (82%)
Primary graft failure in recipient 3 (9.1%)
Among the 39 transplanted kidneys from NHBDs who had
mechanical chest compressions in 2009, primary graft failure was
documented in recipients on two occasions (5.1%). In the manual
chest compression period there were three primary graft failures
in recipients of the 33 kidneys (9.1%). The difference between the
two groups was not significant (p = 0.62).
We were also made aware of a further three cases who had
mechanical chest compressions as part of the NHBD protocol where
there was a return of spontaneous circulation during transport to
the transplant centre. One of these cases made a good recovery with
neurological function.
4. Discussion
Mechanical chest compression devices are a feasible alternative
to manual compressions during transport of patients in whom our
NHBD protocol is activated. The program was started in the year
2004, and since then over 500 organs from 170 patients transferred
to the transplant units have been transplanted.
The non-primary function rate in kidney recipients from donors
of this kind is about 10%.6–8 Although larger studies are needed
to confirm this, our observational study shows that the use of
mechanical chest compression devices used to maintain a cir-
culation during transport of patients who have had a failed
CPR attempt does not significantly improve the primary graft
function of donated kidneys. Graft function is dependent on a
large number of factors, and cannot be established by improved
perfusion in the context of cardiopulmonary arrest alone. Pri-
mary kidney graft failure is usually due to microcoagulation
within the renal parenchyma, and this phenomenon is difficult
to resolve and even more difficult to detect prior to transplan-
tation. Mechanical chest compression devices likewise do not
seem to offer an important improvement in the number of viable
organs for transplantation, though here again further studies are
needed.
Mechanical chest compression devices do make patient trans-
port easier for the medical team, decreasing the physical work
required for manual chest compressions and minimizing injuries
to rescuers from performing chest compressions during ambu-
lance during transfer. Also, while these devices have not shown
Legal actions
Diagnosis of death and certification by
hospital doctor on arrival
Legal request for catheterization for
preservation purposes
Legal request for organ retrieval
Mechanical chest
compressions (n = 28 patients)
39 ± 10 p = 0.38
95%
12 ± 8 p = 0.19
97 ± 53 p = 0.89
39 (70%) p = 0.23
2 (5.1%) p = 0.50
improvement in the survival of patients suffering cardiopulmonary
arrest,9 the devices do improve brain perfusion and also help min-
imize interruptions in chest compressions.10 We are currently
studying injuries to donor organs caused by chest compres-
sions.
The most frequent cause of death in our series was primary car-
diac arrest. Trauma patients who have suffered cardiopulmonary
arrest are often not good donor candidates as they have injuries to
major vessels and establishing an extracorporeal circulation can be
difficult.
We also identified three patients who were entered into the
NHBD protocol and received mechanical chest compressions who
had a return of spontaneous circulation during transfer to the trans-
plant hospital. If these individuals had not been included in the
NHBD protocol, resuscitation would have stopped after 30 min and
the patients would not have survived. We are investigating these
cases in more detail. Ensuring that the guidance for diagnosing
death is strictly followed on arrival at the transplant centre ensures
that only those patients who have died become NHBDs.
Family refusal for organ donation in this group of NHBDs is low
in comparison to heart beating donors who have been diagnosed
brain dead.11 We do not know the cause of this difference. One
reason may be the relative speed of the NHBD process as opposed to
asking family members who may have been at the bedside of their
sick relative for a number of days in the case of brain dead donors.
Awareness and support for organ donation in Spain is generally
good.
5. Conclusions
We have described our experience and protocol for non-heart
beating donation using victims of out-of-hospital cardiac arrest
in whom cardiopulmonary resuscitation has been unsuccessful as
donors. Primary kidney graft failure rates in organs from non-heart
beating donors is similar when manual or mechanical chest com-
pression devices are used during cardiopulmonary resuscitation.
Conflict of interest statement
None to declare.
 A. Mateos-Rodríguez et al. / Resuscitation 81 (2010) 904–907
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