Q J Med 1999; 92: 415-418
© 1999 Association of Physicians
Correspondence |
Organ donation after fatal poisoning
Department of Intensive Care, Cliniques Universitaires St-Luc, Brussels, Belgium
Sir,
We were particularly interested by the commentary published by Jones et al. about organ donation after fatal poisoning.1 We share the authors' opinion that poisoned donors are a neglected source of organ procurement. Since the time of our first review, we extended our experience, and we have now a series of 21 poisoned donors corresponding to more than 60 grafts transplanted.2 The results remain excellent and no death can be related to a toxic origin. Organ donation after poisoning is difficult for several reasons. The medico-legal issue should not be a problem. It is possible to obtain an accurate diagnosis of brain death even in the case of acute poisoning. As numerous substances may affect the electroencephalogram, other techniques that are also available in the ITU should be preferred to make a correct diagnosis in this particular setting. Angiography is often considered as the method of choice, but we propose to use multimodality evoked potentials as a first-line and valuable technique.3 In our opinion, the main problem remains insufficient knowledge of organ-specific toxicity, leading to the premature exclusion of organ procurement. We have conducted a survey among people directly involved in transplantation or organ procurement (members of European and US transplantation co-ordination centres or organ procurement organizations) and people working in the field of clinical toxicology (members of European or US poison control centres). The objective was to obtain the a priori opinion of specialists concerning the possibility of donation of specific organs after exposure to some specific toxins. About 500 questionnaires were sent, but probably due to the specificity of this topic, the response rate was relatively low (64 responses were analysed); some relevant data are presented in Table 1
. Nevertheless, this survey clearly shows that transplantation specialists seem to have more experience than appears in the literature, but that they need more information (13.3–55.6% have no opinion in some situations). For some toxic substances, like opiates, barbiturates and benzodiazepines, a consensus exists among transplantation specialists and toxicologists, but fatalities due to benzodiazepine overdose are exceptional. The risk of heart donation after exposure to carbon monoxide, tricyclic antidepressants or cocaine is identified by both specialists. Cyanide poisoning is considered by the transplantation teams, but also by the toxicologists, as an absolute or relative contraindication to organ procurement, even though positive results have been repeatedly published with this toxin.2,4,5 Kidney donation (but not heart donation) following paracetamol overdose seems also to be a matter of concern for the toxicologists. Finally, organ donation after methanol poisoning is not usually accepted by the transplantation specialists, while the toxicologists have a less restrictive opinion. In our experience, seven cases of fatal methanol poisoning have led to successful renal transplantation in 13 cases, liver transplantation in three cases, double-lung transplantation in one recipient and heart transplantation in one case.2,6
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We suggest that the transplantation co-ordination centres should collect more information on the referred poisoned patients who are not accepted as suitable candidates and that these data (toxicokinetics, histological features ... ) should be discussed in collaboration with clinical toxicologists.
References
1.
Jones AL, Simpson KJ. Drug abusers and poisoned patients: a potential source of organs for transplantation?Q J Med 1998; 91:589–92.
2. Hantson P, Mahieu P, Hassoun A, Otte J-B. Outcome following organ removal from poisoned donors in brain death status: a report of 12 cases and review of the literature. J Toxicol Clin Toxicol 1995; 33:709–12.[Medline]
3. Hantson Ph, Mahieu P, de Tourtchaninoff M, Guérit JM. The problem of `brain death' and organ donation in poisoned patients. In: Recent developments in neurology. Brain Death Machado C, ed. Elsevier, Amsterdam, 1995;119–26.
4. Swanson-Biearman B, Krenzelok EP, Synder JW, Unkle DW, Nathan HM, Yang S-L. Successful donation and transplantation of multiple organs from a victim of cyanide poisoning. J Toxicol Clin Toxicol 1993; 31:95–9.[Medline]
5. Puig JM, Lloveras J, Knobel H, Nogues X, Aubia J, Masramon J. Victims of cyanide poisoning make suitable organ donors. Transpl Int 1996; 9:87–8.[Medline]
6. Hantson P, Kremer Y, Lerut J, Squifflet JP, Mahieu P. Successful liver transplantation with a graft coming from a methanol-poisoned donor. Transpl Int 1996; 9:437.[Medline]
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