title: Comparison of high- and low-dose corticosteroid regimens for organ donor management.
abstract: OBJECTIVE
  Corticosteroids are used to promote hemodynamic stability and reduce inflammatory organ injury after brain death. High-dose (HD) methylprednisolone has become the standard regimen based on comparisons to untreated/historical controls. However, this protocol may exacerbate hyperglycemia. Our objective was to compare a lower-dose (LD) steroid protocol (adequate for hemodynamic stabilization in adrenal insufficiency and sepsis) to the traditional HD regimen in the management of brain-dead organ donors.
  
  
  METHODS
  We evaluated 132 consecutive brain-dead donors managed before and after changing the steroid protocol from 15 mg/kg methylprednisolone (HD) to 300 mg hydrocortisone (LD). Primary outcome measures were glycemic control, oxygenation, hemodynamic stability, and organs transplanted.
  
  
  RESULTS
  Groups were balanced except for nonsignificantly higher baseline Pao(2) in the LD cohort. Final Pao(2) remained higher (394 mm Hg LD vs 333 mm Hg HD, P=.03); but improvement in oxygenation was comparable (+37 mm Hg LD vs +28 mm Hg HD, P=.43), as was the proportion able to come off vasopressor support (39% LD vs 47% HD, P=.38). Similar proportions of lungs (44% vs 33%) and hearts (31% vs 27%) were transplanted in both groups. After excluding diabetics, median glucose values at 4 hours (170 mmol/L vs 188 mmol/L, P=.06) and final insulin requirements (2.9 U/h vs 8.4 U/h, P=.01) were lower with LD steroids; and more patients were off insulin infusions (74% LD vs 53% HD, P=.02).
  
  
  CONCLUSIONS
  A lower-dose corticosteroid protocol did not result in worsened donor pulmonary or cardiac function, with comparable organs transplanted compared with the traditional HD regimen. Insulin requirements and glycemic control were improved. High-dose methylprednisolone may not be required to support brain-dead donors.
authors: Division of Neurocritical Care, Department of Neurology, Washington University School of Medicine, Saint Louis, MO 63110, USA. dharr@neuro.wustl.edu.
authors: Rajat
authors: R
authors: Dhar
authors: Colleen
authors: C
authors: Cotton
authors: Jason
authors: J
authors: Coleman
authors: Diane
authors: D
authors: Brockmeier
authors: Dean
authors: D
authors: Kappel
authors: Gary
authors: G
authors: Marklin
authors: Robert
authors: R
authors: Wright
mesh_terms: D000328:Adult; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage* / Q000009:adverse effects; D001926:Brain Death; D005260:Female; D016027:Heart Transplantation; D006801:Humans; D006854:Hydrocortisone / Q000008:administration & dosage* / Q000009:adverse effects; D006943:Hyperglycemia / Q000139:chemically induced / Q000517:prevention & control*; D016040:Lung Transplantation; D008297:Male; D008775:Methylprednisolone / Q000008:administration & dosage* / Q000009:adverse effects; D008875:Middle Aged; D011446:Prospective Studies; D012044:Regression Analysis; D009927:Tissue and Organ Procurement
chemical_list: D000893:Anti-Inflammatory Agents; D006854:Hydrocortisone; D008775:Methylprednisolone