Hormone replacement before brain death increases organ donation rate after catastrophic brain injury: An EAST multicenter trial.

BACKGROUND

One third of organ donors die due to catastrophic brain injury (CBI). CBI causes massive physiological derangements that can damage organs and prevent organ donation. Hormone replacement therapy (HRT) can mitigate this damage when given in the critical care setting, but no standardized protocol for use at trauma centers exists. Single-center studies show that HRT increases organ donation, but there has not been an investigation on which hormone combinations are most beneficial.

METHODS

This prospective, observational EAST multicenter trial included adult CBI patients at 38 Level I and II trauma centers from January 2022 to June 2025. CBI was defined as a brain injury causing loss of function above the brain stem and subsequent death. A generalized linear mixed model analyzed the association of HRT and organ donation.

RESULTS

Of 1,184 CBI patients, 704 received at least one hormone. There were 269 organ donors, and 227 received HRT. HRT patients were younger, more often male, sustained higher rates of penetrating brain injuries, and had lower rates of known comorbidities compared with non-HRT patients. HRT patients had higher ISS, but there was no difference in abbreviated injury scale-head scores between groups. GLMM analysis accounted for demographic and clinical differences between groups and found that single-hormone replacement with steroids, levothyroxine, vasopressin, dopamine, DDAVP, or insulin was associated with increased odds ratios of organ donation compared with no HRT. The combination of methylprednisolone and levothyroxine was associated with the greatest increased odds of donation.

CONCLUSIONS

When administered to CBI patients before brain death, HRT is associated with significantly increased odds of organ donation. A standardized protocol incorporating HRT should be utilized across trauma centers to maximize organ donation in patients who have suffered nonsurvivable head trauma. ( J Trauma Acute Care Surg . 2026;101: 619-631.).

LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level II.