Donor Management Protocols Research Articles

Does the use of double hormone replacement therapy for trauma patient organ donors improve organ recovery for transplant.

With an ongoing demand for transplantable organs, optimization of donor management protocols, specifically in trauma populations, is important for obtaining a high yield of viable organs per patient. Endocrine management of brain-dead potential organ donors (BPODs) is controversial, leading to heterogeneous clinical management approaches. Previous studies have shown that when levothyroxine was combined with other treatments, including steroids, vasopressin, and insulin, BPODs had better organ recovery and survival outcomes were increased for transplant recipients. To determine if levothyroxine use in combination with steroids in BPODs increased the number of organs donated in trauma patients. A retrospective review of adult BPODs from a single level 1 trauma center over ten years was performed. Exclusion criteria included patients who were not solid organ donors, patients who were not declared brain dead (donation after circulatory death), and patients who did not receive steroids in their hospital course. Levothyroxine and steroid administration, the number of organs donated, the types of organs donated, and demographic information were recorded. Univariate analyses were performed with P < 0.05 considered to be statistically significant. A total of 88 patients met inclusion criteria, 69 (78%) of whom received levothyroxine and steroids (ST/LT group) vs 19 (22%) receiving steroids without levothyroxine (ST group). No differences were observed between the groups for gender, race, pertinent injury factors, age, or other hormone therapies used (P > 0.05). In the ST/LT group, 68.1% (n = 47) donated a high yield (3-5) of organ types per donor compared to 42.1% (n = 8) in the ST group (P = 0.038). There was no difference in the total number of organ types donated between the groups (P = 0.068). This study suggests that combining levothyroxine and steroid administration increases high-yield organ donation per donor in BPODs in the trauma patient population. Limitations to this study include the retrospective design and the relatively small number of organ donors who met inclusion criteria. This study is unique in that it mitigates steroid administration as a confounding variable and focuses specifically on the adjunctive use of levothyroxine.

Microfilariae Prevalence and its Association with Anemia Among First-time Blood Donors in Lambaréné, Gabon

Anemia remains a significant public health concern in Gabon, particularly among children, adolescents, and females. Gabon is also home to two major species of filarial worms, Loa and Mansonella spp., which cause microfilaremia. The epidemiological nexus between hemoglobin (Hb) concentrations and microfilaremia in Gabonese first-time blood donors remains unknown. To understand better the epidemiological relationship between anemia and microfilaremia to improve donor selection and management protocols. A retrospective cohort study. This study was conducted among first-time blood donors in Lambaréné between March 2018 and October 2019. Participants aged 16-65 years old and weighing a minimum of 50 kg were enrolled using standard donor selection criteria. An automatic hematological analyzer was used to quantify Hb concentrations, and microscopy techniques were used to detect the presence of microfilariae. Microfilariae were found in 4.8% (35/723) of the 723 first-time blood donors from Lambaréné. Anemia was classified as mild in 35.5% (257/723) and moderate in 1% (7/723). No significant associations were found between the distribution of microfilariae and variables such as age, sex, socioprofessional classification, marital status, or residence. Blood group O donors had a higher prevalence of microfilariae (6%) than non-O donors (2.7%). However, the observed difference was not statistically significant (AOR =2.3, p = 0.052). Furthermore, microfilariae were associated with increased moderate anemia (3.7% vs. 29%, AOR =15.6, p = 0.003). Our findings highlight microfilaremia as a possible etiological cause of anemia among Gabonese blood donors, emphasizing the need for further research and a potential review of donor management strategies.

115.5: Impact of implementation standard donor management protocol on the organ donation and procurement in a large tertiary care hospital in United Arab Emirates: Lessons learnt.

115.5: Impact of implementation standard donor management protocol on the organ donation and procurement in a large tertiary care hospital in United Arab Emirates: Lessons learnt.

Starting at the Source: Donor Research, Done Right.

Transplant research needs to start at the source. Optimizing graft function to ameliorate ischemia-reperfusion needs to occur before the injury occurs to protect organs and prevent graft failure. The aim of donor management is to optimize perfusion and oxygen delivery to the grafts by maintaining favorable hemodynamics, intravascular volume, and metabolic states while averting the pathophysiological derangements that occur with death by neurological criteria. Defining specific donor management goals a priori and implementing standardized interventions to meet these goals improve organ yield1 and are widely put in practice by organ procurement organizations. Achieving the hemodynamic goals (usually mean arterial pressure between 60 and 110 mm Hg) to maintain organ perfusion is considered particularly important; however, it is controversial what interventions are best suited to reach that goal. The study by van Bakel et al2 studied almost 200 organ donors who were randomized to receive either high-dose methylprednisolone, levothyroxine, both, or neither before organ procurement. Although the study was not powered to detect a difference in organ yield or quality, the authors found that methylprednisolone either alone or in combination with levothyroxine (but not levothyroxine alone) reduced vasopressor requirements. Administration of methylprednisolone further reduced a number of inflammatory markers, specifically of interleukin-6, interleukin-12p40, and tumor necrosis factor-alpha, potentially an indication that the reduction of vasopressors may actually improve organ perfusion. Vasopressors are a double-edged sword that may—in the vasodilated state—restore vascular tone and organ perfusion and can also decrease graft perfusion and cause ischemia. Nevertheless, use of high-dose vasopressors in donors has consistently been associated with worse outcome, and reduction of vasopressor requirements should probably be considered beneficial. A number of studies have demonstrated that bundles of hormone replacement (steroids, thyroid hormone, vasopressin) improve organ yield and function,3 but which component of the bundle is beneficial has been unknown. Based on the results of the present study, administration of steroids should be considered part of donor management protocols. Unfortunately, this study was not powered to actually detect the difference in outcomes and therefore does not provide the conclusive, strong evidence needed to unequivocally support wide spread use of steroids in all donors. There is scant evidence for any donor interventions before procurement to a large degree because of the logistical difficulties of organ donor research. A landmark study by Niemann et al4 demonstrated the benefit of mild donor hypothermia to prevent delayed graft function in kidney recipients. More importantly, this study provided a blueprint on how to conduct large, randomized studies of transplant donors. Ethical considerations are real: studying donors who are dead by neurological criteria is not human subject research. But any (randomized) intervention applied to the donor can affect up to 8 solid organ recipients. True equipoise is essential for donor research to avoid biases and potential harm to recipients. Some interventions that may be favorable for 1 organ may harm others, and coordination of organ donor intervention research may be needed. The National Academies of Sciences, Engineering, and Medicine recognized the need for more donor research and provided a broad framework in their 2017 consensus study report “Opportunities for Organ Donor Intervention Research: Saving Lives by Improving the Quality and Quantity of Organs for Transplantation.”5 This report delineates a process to address the ethical concerns of donor research and recommends the institution of a single institutional review board, a Donor Research Oversight Committee, to coordinate different projects and data and the institution of safety monitoring boards to oversee the conduct of these studies. This is a great step in the right direction to create a scaffolding to support studies that further our knowledge about donor management and may help us improve organ yield, graft function, and outcomes after transplantation.

Thyroid Hormone Improved Heart Transplant Recipient Survival

Purpose Studies have shown that thyroid hormone results in a higher number of organs available for transplant. The purpose of this study was to evaluate the effects of triiodothyronine (T3) and/or thyroxine (T4) on heart transplant recipient (HtxR) survival. Methods The United Network for Organ Sharing (UNOS) database was retrospectively reviewed from March 1994 to March 2018 for donor hearts. After exclusions for multiorgan transplant and age (donor Results Donor age ranged from 15-73 y (mean 32y, median 30y), 70% were male. The mean donor ejection fraction (EF) was 61.6% (median 60%). The ischemic time ranged from 0.22-12 hours (h) (mean3.16h, median 3.13h). 37307 patients had T3/4 data available. 24358 (65%) patients were given T3 or T4 within 24h of procurement and 12949 (35%) were given neither. Donors who received T3/4 had 15% higher odds of 30 day survival (OR=1.15; p=0.033), translating adjusted 30 day survival probabilities into 95.8% for those receiving neither and 96.2% for those receiving either T3/4. However, 1 year survival was not significantly different (OR=1.06; p=0.123; 89.8% vs. 90.3%). Over more than 10 years there was a long-term survival benefit for recipients whose donors had received T3/4 within 24 hours of procurement (HR=0.95, p=0.009). The same effect was present for post-transplant rejection, although with a higher degree of uncertainty (HR=0.96, p=0.050). Conclusion Thirty day and long-term HtxR survival is improved when T3/4 is given to the donor within 24 hours of procurement. T3/4 should be a considered as an additional component of a donor management protocol.

Critical care management of the potential organ donor : Current recommendation for adults

The shortage of donor organs has not improved in recent years. To increase the number and success of transplantation it is crucial to optimize the processes of early identification of potential organ donors and structured critical care management. The therapy starts long before brain death is diagnosed. Structured in-house organ donor management protocols ensure ahighly qualified critical care that has adirect impact on the transplantation outcome. The therapy is based on the established standards. The main focus is on differentiated catecholamine and volume therapy. Vasopressin, in combination with norepinephrine, is effective for both treating vasoplegia and electrolyte disturbances. Despite poor evidence, steroids are useful for stabilizing hemodynamics and treating the consequences of neuroendocrine dysfunction. Overall, prospective studies are required to give general recommendations for critical care.

A Impact of Radial Score Combined with Advanced Donor Management Protocols on Primary Graft Dysfunction Rates after Heart Transplant in India

scholarly articles on cardiology Journal of Cardiology & Cardiovascular Therapy is an Open Access, international peer reviewed journal launched from Juniper Publishers. Cardiology is a branch of medicine deals with the disorders of heart that keeps cardiologists up to date with advances in the diagnosis and treatment of cardiovascular diseases.

Time Dependent Changes in Thyroid Hormone Levels During Donor Management

Brain Death (BD) is associated with severe perturbations in thyroid hormone (TH) levels leading to euthyroid sick syndrome (ESS) in animal models, but human studies have shown mixed results. Despite this, TH replacement is widely used in organ donor management protocols. High dose glucocorticoids, also widely administered to organ donors, suppress TSH and reduce the T3/T4 ratio, suggesting altered conversion of T4 to T3. We investigated the change in TH levels from initiation of active donor management through procurement, with and without high dose glucocorticoids.

Organ-Protective Intensive Care in Organ Donors.

The ascertainment of brain death (the irreversible, total loss of brain function) gives the physician the opportunity to limit or stop further treatment. Alternatively, if the brain-dead individual is an organ donor, the mode of treatment can be changed from patient-centered to donationcentered. Consensus-derived recommendations for the organ-protective treatment of brain-dead organ donors are not yet available in Germany. This review is based on pertinent publications retrieved by a selective search in PubMed, and on the authors' clinical experience. Brain death causes major pathophysiological changes, including an increase in catecholamine levels and a sudden drop in the concentration of multiple hormones, among them antidiuretic hormone, cortisol, insulin, and triand tetraiodothyronine. These changes affect the function of all organ systems, as well as the hemodynamic state and the regulation of body temperature. The use of standardized donor management protocols might well increase the rate of transplanted organs per donor and improve the quality of the transplanted organs. In addition, the administration of methylprednisolone, desmopressin, and vasopressin could be a useful supplement to treatment in some cases. Randomized controlled trials have not yet demonstrated either improved organ function or prolonged survival of the transplant recipients. The evidence base for organ-protective intensive care is weak; most of the available evidence is on the level of expert opinion. There is good reason to believe, however, that the continuation of intensive care, in the sense of early donor management, can make organ transplantation more successful both by increasing the number of transplantable organs and by improving organ quality.

Cardiac Donor Risk Factors Predictive of Short-Term Heart Transplant Recipient Mortality: An Analysis of the United Network for Organ Sharing Database

IntroductionTo address the shortage of donor hearts for transplantation, there is significant interest in liberalizing donor acceptance criteria. Therefore, the aim of this study was to evaluate cardiac donor characteristics from the United Network for Organ Sharing (UNOS) database to determine their impact on posttransplantation recipient outcomes. MethodsAdult (≥18 years) patients undergoing heart transplantation from July 1, 2004, to December 31, 2012, in the UNOS Standard Transplant Analysis and Research (STAR) database were reviewed. Patients were stratified by 1-year posttransplantation status; survivors (group S, n = 13,643) and patients who died or underwent cardiac retransplantation at 1-year follow-up (group NS/R = 1785). Thirty-three specific donor variables were collected for each recipient, and independent donor predictors of recipient death or retransplantation at 1 year were determined using multivariable logistic regression analysis. ResultsOverall 1-year survival for the entire cohort was 88.4%. Mean donor age was 31.5 ± 11.9 years, and 72% were male. On multivariable logistic regression analysis, donor age >40 years (odds ratio [OR] 1.44, 95% confidence interval [CI] 1.27 to 1.64), graft ischemic time >3 hours (OR 1.32, 1.16 to 1.51), and the use of cardioplegia (OR 1.17, 1.01 to 1.35) or Celsior (OR 1.21, 1.06 to 1.38) preservative solution were significant predictors of recipient death or retransplantation at 1 year posttransplantation. Male donor sex (OR 0.83, 0.74 to 0.93) and the use of antihypertensive agents (OR 0.88, 0.77 to 1.00) or insulin (OR 0.84, 0.76 to 0.94) were protective from adverse outcomes at 1 year. ConclusionsThese data suggest that donors who are older, female, or have a long projected ischemic time pose greater risk to heart transplant recipients in the short term. Additionally, certain components of donor management protocols, including antihypertensive and insulin administration, may be protective to recipients.

Kidney graft outcome using an anti-Xa therapeutic strategy in an experimental model of severe ischaemia-reperfusion injury.

Deceased after cardiac death donors represent an important source of organs to reduce organ shortage in transplantation. However, these organs are subjected to more ischaemia-reperfusion injury (IRI). Reducing IRI by targeting coagulation is studied here in an experimental model. The effect of an anti-Xa compound (fondaparinux) was evaluated using an autotransplanted kidney model in pigs. Kidneys were clamped for 60 min (warm ischaemia) and then preserved for 24 h at 4 °C in University of Wisconsin solution (UW). The anti-Xa compound was injected intravenously before warm ischaemia and used during cold storage, and its effects were compared with those of intravenous injection of unfractionated heparin (UFH) before warm ischaemia and use during cold storage, or use of UW alone during cold storage. At 3 months after transplantation, anti-Xa treatment improved recovery of renal function and chronic serum creatinine levels compared with UW and UFH (mean(s.e.m.) 89(4), 250(4) and 217(8) µmol/l respectively). The anti-Xa treatment also reduced fibrosis, and decreased tissue expression of markers of the epithelial-mesenchymal transition compared with UW and UFH. Cleaved protease-activated receptor 2 was overexpressed in the UW group compared with the anti-Xa and UFH groups. Leucocyte infiltrates were decreased in the anti-Xa group compared with the UW and UFH groups. Macrophage invasion was also decreased by anticoagulation treatment. Peritransplant anticoagulation therapy was beneficial to graft outcome, in both the acute and chronic phases. Moreover, specific inhibition of coagulation Xa protease further protected kidney grafts, with better recovery and decreased expression of chronic lesion markers. Surgical relevance The increasing use of marginal donors highlights the importance of organ quality in transplantation. Renal ischaemia-reperfusion injury (IRI), which includes a deleterious activation of coagulation, plays a central role in determining graft quality and outcome. Using an established porcine renal autotransplantation preclinical model with high clinical relevance, the benefits of anticoagulation therapy using an antifactor Xa molecule were evaluated. Peritransplantion anticoagulation treatment, specifically with an anti-Xa compound, protected marginal kidney grafts, improving functional recovery and reducing chronic lesions. This study demonstrates the benefits of anticoagulation therapy at the time of organ collection, particularly for marginal organs, encountered in cases of extended criteria and deceased after circulatory death donors. This anticoagulation strategy could be an important addition to current donor and organ management protocols in order to limit IRI and improve outcome.

Effect of a Specific Lung Donor Management Protocol On Lung Donation Rate and Recipient Outcome: A Multicenter Study.

Background: We previously demonstrated that an intensive lung donor management protocol increased the lung procurement rate. Our aim was to confirm this observation in other centers. Methods: A multicenter study.Lung management protocol for donors after brain death (DBD) was sent to 6 Spanish centers. The centers were selected for having more than 20 DBDs per year and lung donation rate similar to the Spanish one. No training was previously carried out in any center. Lung donors during 2013 were the prospective cohort, and those from 2010-2012 the control group. There were no changes in donor selection criteria between the two periods. Lungs were offered by the Spanish procurement organization (ONT) to all Spanish lung transplant programs, and those made the final decision on the suitability of the lungs. Lungs available for transplantation were the main outcome measure. For recipients, early survival and the rate of primary graft dysfunction (PGD) were the main outcome measures. Basic descriptive analysis is presented, comparing qualitative variables in both groups with Chi-square test. T test for paired samples was used for analyzing gasometrical evolution. Results:The study group had 45 lung donors from 114 DBDs ≤ 70 years old while the control group (2010-2012) had 59 from 326 DBDs (lung donation rate 39.5% vs 18.1% respectively;p<0.001). We increased annual recovered lungs from 37 (average 2010-2012) to 84 (2013;p<0.001) and annual lung transplants (from 19 to 41;p<0.001).Protocol development showed a significant increase in PaO2/FiO2 before initiation and before grafts retrieval (335±108 vs 416±87;p<0.001). No differences were observed in the early recipients’ survival (87.8% vs 84.5%;p=0.773) nor in the rate of PGD (42.1% vs 44.6%;p=0.835). Conclusion: This protocol may be easily implemented without previous training. This lung donor-management protocol increases lung procurement rates without negative impact on early lung recipients’ survival nor on the rate of PGD. This work was supported by the Fundacion Mutua Madrileña

Effect of an intensive lung donor-management protocol on lung transplantation outcomes

An intensive lung donor-management protocol based on a strict protocol would increase the lung procurement rate. The aim of this study was to determine the effect of such a protocol on the rate of lung grafts available for transplant. A lung-management protocol for donors after brain death (DBD) was implemented in 2009. Lung donors from 2009 to 2011 were the prospective cohort, and those from 2003 to 2008 formed the historical control. We analyzed the synergic effect of several measures, such as protective ventilation, ventilator recruitment maneuvers, high positive end-expiratory pressure, fluid restriction with reduced extravascular lung water values, and hormonal resuscitation therapy in multiorgan DBD. The number of lungs available for transplantation was the main outcome measure. For recipients, early survival and the rate of primary graft dysfunction (PGD) grade 3 were the main outcome measures. The DBD rate was more than 40 donors per 1 million population in both periods. The rate of lung donors increased from 20.1% to 50% (p < 0.001), quadrupling the number of lung donors (p < 0.001), grafts retrieved (p = 0.02), and patients who received a lung transplant (p < 0.01). No differences were observed in the survival of early recipients (p = 0.203) or in the rate of PGD grade 3 (p = 0.835). The management of multiorgan DBDs should be approached as a global treatment requiring attentive bedside management. Implementing an intensive lung donor-management protocol based on synergic measures increases lung procurement rates, negative effect on early survival of lung recipients or PGD grade 3.

Deceased Organ Donor Research: The Last Research Frontier?

Deceased Organ Donor Research: The Last Research Frontier?

The Reward is Worth the Wait: A Prospective Analysis of 100 Consecutive Organ Donors

Aggressive donor management protocols have evolved to maximize the number of procured organs. Our study assessed donor management time and the number and types of organs procured with the hypothesis that shorter management time yields increased organ procurement and transplant rates. We prospectively analyzed 100 donors managed by a regional organ procurement organization (OPO) during 2007 to 2008. Data included patient demographics, number and types of organs procured and transplanted, patient management time by the OPO, and achievement of donor preprocurement goals. One hundred consecutive organ donors were managed with a mean age 41 ± 18 years and mean management time 23 ± 9 hours; 376 organs were procured and 327 successfully transplanted. Donors managed greater than 20 hours yielded significantly more heart (5 vs 26, P < 0.01) and lung (6 vs 40, P < 0.01) procurements, more organs procured per donor (3.2 ± 1.4 vs 4.2 ± 1.6, P < 0.01), and more organs transplanted per donor (2.6 ± 1.5 vs 3.7 ± 1.8, P < 0.01) than those managed 20 hours or less. No difference in the attainment of donor management goals was observed between these populations. Contrary to our initial hypothesis, donor management times greater than 20 hours yielded increased organ procurement and transplant rates, particularly for hearts and lungs, despite no differences in the achievement of donor preprocurement management goals.

Lung Transplantation

First performed in 1963, lung transplantation is approaching the half-century mark. With more than 32,000 procedures having been performed worldwide, lung transplantation has become the standard of care for select patients with advanced lung diseases of various nonmalignant etiologies. Indications for transplantation have broadened over the years, and selection criteria have become less restrictive. A relatively scarce donor pool limits wider application of this therapy, but this is being addressed in part through relaxation of donor selection criteria, donor management protocols that preserve and optimize lung function, and development of ex vivo perfusion techniques to "recondition" suboptimal organs. Bilateral lung transplantation has become the procedure of choice for most indications, although its preferential use in patients with idiopathic pulmonary fibrosis remains controversial. Post-transplantation survival has steadily improved, but significant constraints on long-term survival persist as evidenced by a median survival rate that currently stands at 5.7 years. This has brought into focus the question of whether and for whom transplantation actually confers a survival advantage, a question that in the absence of randomized trials can only be answered with statistical modeling. Primary graft dysfunction, infection, and bronchiolitis obliterans syndrome are common complications encountered by the lung transplant recipient and are major impediments to long-term survival. This review provides an overview of the current status of lung transplantation, highlighting both the many advances that have taken place and the challenges that remain.

Increasing Organ Yield through a Lung Management Protocol

Gift of Life Michigan determined that the largest gap between the number of organ donors and the number of organs transplanted has been in the number of lungs transplanted. The literature was reviewed for lung donor management strategies and other organ procurement organizations were surveyed for existing donor management guidelines to improve lung function. On the basis of pulmonary physiology and the knowledge gained from the literature search, Gift of Life Michigan developed a lung donor management protocol that has been very effective. In 4 years, the number of lungs transplanted has increased from 37 to 135, representing a 265% improvement.

Organ Transplantation in the Madrid Autonomous Region

The Madrid Autonomous Region, a Spanish area with 6,200,000 inhabitants, has 7 hospitals authorized for organ transplantation, with 25 active programs for carrying out various transplantations: 18 for adults and 7 for children. Most of these hospitals are reference transplant centers for other Spanish regions. Between 715 and 760 transplantations are performed annually, which represents between 19% and 22% of Spanish activity. During 2007, 395 kidney, 220 liver, 55 heart, and 35 lung transplantations were performed, as well as 23 isolated or combination transplantations of other abdominal organs (pancreatic, intestinal, or multivisceral). Kidney, liver, heart, and children's intestinal transplant activity in 2007 represented 37%, 63%, 80%, and 100%, respectively, of all pediatric national activity. The Madrid Autonomous Region has a donation rate of 34.2 donors per million inhabitants. Of these, 30% are from non-heart-beating donors (NHBD), Maastrich criteria category 1 or 2. Various hospitals perform kidney, liver, and lung transplantations with these organs, representing 11% of the lung transplantations carried out in recent years, with this being a pioneer procedure worldwide. Despite the important transplant activity, we are working to increase donations, to improve organ donor detection and management protocols, as well as to reach a consensus on criteria to decrease the nonviability rates of potential transplant organs.

Aggressive Organ Donor Management Protocol

As of August 2007, 96 900 people are awaiting organ transplantation in the United States, while only 28 930 transplants were performed in 2006. With such a large gap between organ need and organ availability, it is inevitable that many will die while awaiting transplantation. This organ shortage has become a national public health crisis, and as a response, the United States Department of Health and Human Services launched the Organ Donation Breakthrough Collaborative, an ambitious campaign to dramatically increase the number of transplantable organs. One of the suggested strategies involves maximizing the number of organs obtained from the available cadaveric "brain dead'' donor pool by using donor management protocols that optimize and treat the profound physiological disturbances that are associated with brain death. The use of these standardized and aggressive donor management protocols has been shown to increase the number of transplanted organs and prevent the number of donors lost due to medical failures. A protocol-driven approach by a dedicated organ donor management team should be considered a key component of any program designed to bridge the gap between organ supply and demand.

“Non‐heart‐beating,” or “cardiac death,” organ donation: Why we should care

Organ donation after cessation of cardiac pump activity is referred to as non-heart-beating organ donation (NHBOD). NHBOD donors can be neurologically intact; they do not fulfill the brain death criteria prior to cessation of cardiac pump activity. For hospitals to participate in NHBOD, they must comply with a newly introduced federal requirement for ICU patients whose deaths are considered imminent after withdrawal of life support. This report describes issues related to NHBOD. A nonstructured review of selected publications and Web sites was undertaken. Scientific evidence from autoresuscitation and extracorporeal perfusion suggests that verifying cardiorespiratory arrest lasting 2-5 minutes does not uniformly comply with the dead donor rule, so that the process of organ procurement can be the irreversible event defining death in organ donors. The interest of organ procurement organizations and affiliates in maximizing recovery of transplantable organs introduces self-serving bias in gaining consent for organ donation and abandons the basic tenet of obtaining true informed consent. The impact of donor management and procurement protocols on end-of-life (EOL) care and the potential trade-off are not disclosed, raising concern about whether potential donors and their families are fully informed before consenting to donation. The use of comprehensive quality indicators for EOL care can determine the impact of NHBOD on care offered to donors and the effects on families and health care providers. Detailed evaluation of NHBOD will enable the public to make informed decisions about participating in this type of organ donation.