In this episode, I’ll discuss IV levothyroxine in unstable brain-dead heart donors.
Observational data has been used to support giving hemodynamically unstable brain-dead organ donors high-dose infusions of levothyroxine. However a 2020 study cast some doubt on whether levothyroxine has the desired effect, giving support to the design of a randomized trial to examine this issue that was recently published in New England Journal of Medicine.
This was a multi-center trial that randomized over 800 hemodynamically unstable potential heart donors within 24 hours after declaration of death according to neurologic criteria to either an open-label infusion of intravenous levothyroxine at 30 mcg/hr or saline placebo.
The primary outcome was successful transplantation of the donor heart and a secondary safety outcome was graft survival after 30 days.
Hearts were transplanted from 54.9% of the donors in the levothyroxine group and 53.2% of the donors in the saline group. This difference was not statistically significant with the 95% confidence interval for the adjusted risk ratio ranging from 0.97 to 1.07.
Graft survival occurred in 97.4% of patients in the levothyroxine group and 95.5% of the placebo group, and this difference met criteria for non-inferiority.
When examining secondary outcomes the authors found no differences between groups in weaning from vasopressor therapy, ejection fraction on echocardiography, or organs transplanted per donor. The levothyroxine group did have more episodes of severe hypertension and tachycardia.
The authors concluded:
In hemodynamically unstable brain-dead potential heart donors, intravenous levothyroxine infusion did not result in significantly more hearts being transplanted than saline infusion.
Given that levothyroxine use is routine in donor protocols and the study results were contrary to contemporary practice, the journal editors invited expert commentary to be published in a letter to the editor in the same issue as this study to put results in context. The editorial is titled The Importance of Randomized, Controlled Trials in the Care of Organ Donors.
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