CCTC Deceased Donor Evaluation and Brain Death Determination — Questions and Answers
Question 1: Which of the following best defines Donation after Circulatory Death (DCD)?
- Organ recovery from a donor who meets standard neurological brain death criteria
- Organ recovery following withdrawal of life-sustaining treatment and confirmation of circulatory arrest (Correct answer)
- Organ recovery from a living donor who undergoes planned cardiac arrest under anesthesia
- Organ recovery performed concurrently with active cardiopulmonary resuscitation efforts
Correct answer: Organ recovery following withdrawal of life-sustaining treatment and confirmation of circulatory arrest
DCD (previously called non-heart-beating donation) involves procurement after withdrawal of life-sustaining therapy and confirmation of circulatory death. Unlike standard brain death donors where the heart continues beating until surgical procurement, DCD donors experience cardiac arrest first, resulting in warm ischemia time that affects organ viability assessments.
Question 2: Most U.S. hospital protocols for declaring brain death require which of the following?
- One attending physician and written family consent
- Two independent physicians, with the transplant team explicitly excluded from making the determination (Correct answer)
- Three physicians including the transplant surgeon to confirm organ suitability
- A transplant coordinator and a neurologist acting together
Correct answer: Two independent physicians, with the transplant team explicitly excluded from making the determination
Brain death declaration requires two independent physicians (at minimum one with neurological expertise) to prevent conflicts of interest. The transplant team is specifically excluded from the determination to maintain the ethical separation between donor care and recipient care.
Question 3: The PHS Guideline for identifying 'increased infectious disease risk' donors primarily addresses transmission risk for which pathogens?
- CMV, EBV, and Toxoplasma
- MRSA, VRE, and Candida
- HIV, HCV, and HBV (Correct answer)
- West Nile Virus, Rabies, and Prion disease
Correct answer: HIV, HCV, and HBV
PHS guidelines identify donors with recent behaviors (e.g., IV drug use, incarceration, high-risk sexual contact) that increase the probability of HIV, HCV, or HBV infection in the window period before seroconversion. Recipients must receive informed consent acknowledging this increased risk before organs from such donors are transplanted.
Question 4: A potential deceased donor has a serum creatinine of 3.8 mg/dL on ICU admission secondary to hypotension-induced acute kidney injury. After aggressive fluid resuscitation and hemodynamic optimization, creatinine falls to 0.9 mg/dL. Which statement most accurately describes kidney transplant suitability?
- Kidneys are absolutely excluded due to the peak creatinine exceeding 2.0 mg/dL
- Kidneys may be suitable; acute kidney injury with functional recovery is not an absolute contraindication (Correct answer)
- Kidneys must be automatically classified as Expanded Criteria Donor (ECD) regardless of recovery
- A pre-procurement biopsy showing >20% global sclerosis is required before placement can be considered
Correct answer: Kidneys may be suitable; acute kidney injury with functional recovery is not an absolute contraindication
Acute kidney injury with documented functional recovery does not automatically exclude donor kidneys. Trajectory (improving vs. worsening), cause (reversible vs. chronic), and final function are the critical determinants. AKI from hemodynamic insult that resolves is fundamentally different from chronic kidney disease, and many programs successfully transplant these kidneys.
Question 5: The hormonal resuscitation protocol commonly applied to brain-dead deceased donors (the 'TVCI' or similar protocol) addresses which physiological consequence of brain death?
- Cerebral edema causing elevated intracranial pressure
- Hypothalamic-pituitary axis dysfunction causing multi-hormonal deficiency (Correct answer)
- Catecholamine storm causing refractory hypertension
- Hyperglycemia from corticosteroid pretreatment prior to brain death
Correct answer: Hypothalamic-pituitary axis dysfunction causing multi-hormonal deficiency
Brain death disrupts the hypothalamic-pituitary axis, leading to deficiencies in thyroid hormone, vasopressin, cortisol, and insulin. The TVCI protocol (Thyroid hormone, Vasopressin, Corticosteroids, Insulin) replaces these hormones to maintain hemodynamic stability, improving organ function and increasing the number and quality of organs procured.
Question 6: A potential donor has a positive nucleic acid test (NAT) for HCV. The intended kidney recipient has been waitlisted for 6 years and faces continued deteriorating health on dialysis. After thorough discussion, the recipient provides informed consent to accept the organ. Which statement is correct?
- Acceptance is prohibited; HCV-positive organs may only be transplanted into HCV-positive recipients
- The transplant must be reported to UNOS as a mandatory protocol violation
- With recipient informed consent and the availability of curative direct-acting antiviral (DAA) therapy, transplanting an HCV-NAT-positive organ into an HCV-negative recipient is an accepted and policy-compliant practice (Correct answer)
- Only centers with a specific HCV waiver from CMS may perform such transplants
Correct answer: With recipient informed consent and the availability of curative direct-acting antiviral (DAA) therapy, transplanting an HCV-NAT-positive organ into an HCV-negative recipient is an accepted and policy-compliant practice
The advent of highly effective pan-genotypic DAA therapies (>95% cure rates) has transformed HCV-positive donor organs from an absolute contraindication to an accepted practice. UNOS policy permits transplanting HCV-viremic organs into HCV-negative recipients with informed consent, significantly expanding the donor pool. Post-transplant DAA treatment reliably clears the infection.
CCTC Deceased Donor Evaluation and Brain Death Determination
Which of the following best defines Donation after Circulatory Death (DCD)?