Local Organ Procurement Organization Research Articles

No difference in clinical transplant outcomes for local and imported liver allografts

In the United States, liver allograft allocation is strictly regulated. Local centers have the first option to accept a donor liver; this is followed by regional allocation for those donor livers not used locally and then by national allocation for those donor livers not accepted regionally. This study reviews the outcomes of all liver allografts used over 6 years (2001-2007) and evaluates initial and long-term function stratified by the geographic source of the donor liver allograft. The records for 845 consecutive deceased donor liver transplants at a single center were reviewed. The geographic origin of the allograft was recorded along with donor and graft characteristics to determine the probable reason for graft refusal. Within our local organ procurement organization, there is 1 liver transplant center, and within the region, there are 8 active centers. Early graft failure included any graft loss within 7 days of transplant, and initial function was measured with liver enzymes 30 days post-transplant. Graft survival and patient survival were evaluated with Kaplan-Meier and Cox survival modeling. Median follow-up was 43 months. The geographic distribution of organs included local organs (562, 66%), regionally imported organs (126, 15%), and nationally imported organs (157, 19%). There were no differences between the 3 groups in initial graft function, intraoperative death, or early graft loss. Survival curves for the 3 study groups demonstrated no difference in survival up to 5 years post-transplant. In conclusion, liver allografts rejected for use by a large number of transplant centers can still be successfully used without early graft function or long-term survival being affected.

Use of Recombinant Factor VIIa to Facilitate Organ Donation in Trauma Patients with Devastating Neurologic Injury

Organ donation serves a public health function but is also an important part of end-of-life care. Nearly 40% of organ donors are the victims of traumatic brain injury (TBI). We report on a series of patients with nonsurvivable TBI and severe coagulopathy or active hemorrhage who went on to successful organ donation with the use of recombinant factor VIIa (rFVIIa). Organ donors from a 6-year period were identified from the local Organ Procurement Organization (OPO). Medical records were reviewed, and demographics, injury-specific data, coagulation profiles, and medications administered were abstracted. Outcomes data on early graft function after transplantation were obtained. One hundred forty-eight patients had organ recovery after either brain death or withdrawal of care. Twenty-nine patients received rFVIIa and 119 patients did not. rFVIIa was administered before determination of nonsurvivability or brain death in 21 patients. In eight patients, rFVIIa was administered as a specific salvage therapy to allow donation. Mean Injury Severity Score in the rFVIIa group was 43.4 (+/-14.8) versus 34.0 (+/-13.3) in the group that did not receive rFVIIa (p = 0.001). Organs transplanted per donor were no different in the 2 groups (3.5 versus 3.6; p = 0.7). There were nearly twice as many successfully recovered lungs from the donors who received rFVIIa (44.1% versus 26.2%; p = 0.04). There was no difference in early graft function in the two groups when recipient outcomes were compared. Use of rFVIIa facilitated donation in patients with multisystem injuries who otherwise might have been ineligible for organ donation. Use of rFVIIa did not affect early graft function, although longterm outcomes are unknown. Recombinant factor VIIa is expensive, but its use is justified if the donor organ supply can be increased.

Regarding unexpected severe and life-threatening donor-transmitted viral infections and use of high-risk behavior donors

Regarding unexpected severe and life-threatening donor-transmitted viral infections and use of high-risk behavior donors

Controversy and Consensus on Pediatric Donation After Cardiac Death: Ethical Issues and Institutional Process

Donation after cardiac death (DCD) remains controversial in some pediatric institutions. An evidence-based, consensus-building approach to setting institutional policy about DCD can address the controversy openly and identify common ground. To resolve an extended internal debate regarding DCD policy at Children's Hospital Boston, a multidisciplinary task force was commissioned to engage in fact finding and deliberations about clinical and ethical issues in pediatric DCD, and attempt to reach consensus regarding the development of a protocol for pediatric DCD. Issues examined included values and attitudes of staff, families, and the public; number of possible candidates for DCD at the hospital; risks and benefits for child donors and their families; and research needs. Consensus was reached on a set of foundational ethical principles for pediatric DCD. With assistance from the local organ procurement organization (OPO), the task force developed a protocol for pediatric kidney DCD which most members believed could meet all the requirements of the foundational ethical principles. Complete consensus on the use of the protocol was not reached; however, almost all members supported initiation of kidney DCD for older pediatric patients who had wished to be organ donors. The hospital has implemented the protocol on this limited basis and established a process for considering proposals to expand the eligible donor population and include other organs.

Providing Support to Families considering the Option of Organ Donation: An Innovative Training Method

Families must make decisions about organ donation for a loved one during intensely emotional circumstances in the hospital, where support from others is crucial to their coping. Research about families' experiences during the decision-making process regarding donating their loved ones' organs has shown that quality of hospital care and receiving psychosocial support are important factors influencing their decision. Typically, a donation coordinator from the local organ procurement organization approaches the family about the option of donation, whereas the role of medical and nursing staff is to convey diagnostic and prognostic information to the family. Currently, no requirement is in place for training of professional staff in communication skills for approaching and interacting with families about organ donation. This article discusses a simulated training method in empathic communication used for supporting families who are approached about organ donation. This innovative method can be adapted to and should be tested with professional audiences.

Providing support to families considering the option of organ donation: an innovative training method

Families must make decisions about organ donation for a loved one during intensely emotional circumstances in the hospital, where support from others is crucial to their coping. Research about families' experiences during the decision-making process regarding donating their loved ones' organs has shown that quality of hospital care and receiving psychosocial support are important factors influencing their decision. Typically, a donation coordinator from the local organ procurement organization approaches the family about the option of donation, whereas the role of medical and nursing staff is to convey diagnostic and prognostic information to the family. Currently, no requirement is in place for training of professional staff in communication skills for approaching and interacting with families about organ donation. This article discusses a simulated training method in empathic communication used for supporting families who are approached about organ donation. This innovative method can be adapted to and should be tested with professional audiences.

Internet Organ Solicitation, Explained

The growth of internet-based communications and the increasing demand for living organ donors are resulting in more use of Web sites for organ solicitation. Web resources have the capacity to improve public awareness about both organ donations and transplant outcomes. Rules for organ donation and fair allocation must follow legal principles regarding organ solicitation. Categories of internet recipient/donor matching services include "clearing house," "membership," and "individual" sites. All these raise ethical concerns related to the individual recipient/donor relationship and to the current system of organ allocation. However, a lack of rules and regulations regarding internet solicitation exists. Several pragmatic steps are proposed.

Patient-Initiated Request for Donation Information

Physicians are urged to help patients address their concerns about organ donation by providing educational literature and facilitating discussions with the local organ procurement organization. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

Donation education for medical students: enhancing the link between physicians and procurement professionals

Increasing healthcare professionals' knowledge about organ and tissue donation; the national mandates regarding referral compliance; and the effect on donors, donor families, and transplant recipients is a challenging task. Physicians not routinely involved in organ donation or transplantation are some of the most difficult professionals for organ procurement organizations to access. A course for medical students was developed to initiate the transfer of information, comfort, and familiarity with the organ and tissue donation process. Discussions with a local medical school revealed that little organized education on organ and tissue donation existed. An elective course was developed consisting of 2-hour lectures, once a week for 6 weeks. Topics included an overview of tissue and organ donation, history and significance of the current crisis, determination of brain death and its role in organ donation, tissue donation, pretransplant and posttransplant processes, ethical issues, and the donor family and recipient experience. A thorough course proposal was presented to the medical school's Chairman of Surgery and Chairman of Transplantation. The proposal was approved for first- and second-year medical students. Offering medical students a unique and comprehensive course may attract curious students who could become future champions for donation. This type of educational approach may significantly influence future interactions between physicians and organ procurement organizations. If more organ procurement organizations implement this type of program, the medical students' knowledge of donation will not only affect and benefit the local organ procurement organization's service area but other procurement organizations throughout the country as well.

Donation Education for Medical Students: Enhancing the Link between Physicians and Procurement Professionals

Increasing healthcare professionals' knowledge about organ and tissue donation; the national mandates regarding referral compliance; and the effect on donors, donor families, and transplant recipients is a challenging task. Physicians not routinely involved in organ donation or transplantation are some of the most difficult professionals for organ procurement organizations to access. A course for medical students was developed to initiate the transfer of information, comfort, and familiarity with the organ and tissue donation process. Discussions with a local medical school revealed that little organized education on organ and tissue donation existed. An elective course was developed consisting of 2-hour lectures, once a week for 6 weeks. Topics included an overview of tissue and organ donation, history and significance of the current crisis, determination of brain death and its role in organ donation, tissue donation, pretransplant and posttransplant processes, ethical issues, and the donor family and recipient experience. A thorough course proposal was presented to the medical school's Chairman of Surgery and Chairman of Transplantation. The proposal was approved for first- and second-year medical students. Offering medical students a unique and comprehensive course may attract curious students who could become future champions for donation. This type of educational approach may significantly influence future interactions between physicians and organ procurement organizations. If more organ procurement organizations implement this type of program, the medical students' knowledge of donation will not only affect and benefit the local organ procurement organization's service area but other procurement organizations throughout the country as well.

Potential Suitability for Transplantation of Hearts From Human Non–Heart-Beating Donors: Data Review From the Gift of Life Donor Program

Organ availability limits use of heart transplantation for treatment for end-stage heart disease. Hearts are currently obtained from donors declared brain dead (heart-beating donors [HBDs]). Although use of hearts from non-heart-beating donors (NHBDs) could reduce the shortage, they are considered unusable because of possible peri-mortem ischemic injury. To project how use of NHBD hearts could increase heart donation, we retrospectively reviewed donor databases from the Gift of Life Donor Program (GLDP), our local organ procurement organization, from 2001 through 2003. We screened the NHBD population using conservative donor criteria, assuming an acceptable hypoxic/ischemic time (time from withdrawal of care to cross-clamp) of 30 minutes. During the study period, there were 894 HBDs, 334 heart transplants and 119 NHBDs. NHBDs were similar to HBDs with respect to gender and ethnicity, but NHBDs were proportionately younger. Of 119 NHBDs, 55 did not meet the age criteria (< or =45 years) and 20 were eliminated because of incomplete data. Eighty-two NHBDs were cross-clamped within 30 minutes of care withdrawal. Twenty NHBDs met all cardiac donor criteria, and 14 of these 20 had hypoxic/ischemic times < or =30 minutes. Pro rata estimation for the 20 NHBDs with incomplete data suggested 7 potential additional donors. Based on our assumptions, 12% to 18% of NHBDs in the study period (14 to 21 of 119 total) were potential heart donors, representing a 4% to 6% increase over of the number of heart transplants performed during the same time interval.

Organ donation rates in a neurosurgical intensive care unit.

The number of patients waiting for organ transplantation continues to grow, while organs are donated by very few of the thousands of potential donors who die every year. The authors' neurosurgical intensive care unit (NICU) has worked closely with coordinators from the local organ procurement organization (OPO) for many years. In this study, the authors analyze donation rates in the NICU and discuss factors that may be important in maximizing these rates. All referrals from the NICU to the OPO from 1996 to 1999 were analyzed. Of the 180 referrals, 98 patients were found to be medically suitable as potential donors. Another 15 patients died of hemodynamic collapse shortly after admission to the NICU. If one assumes that all 15 patients would have been suitable donors, the unsuccessful resuscitation rate becomes 15 (13.3%) of 113. Of the 98 eligible donors, consent was obtained and organs or tissue were recovered in 72, yielding a successful organ procurement rate of 73.5%. Close working relationships among physicians, nurses, and OPO coordinators can result in higher donation rates than have been reported previously. Aggressive resuscitation and stabilization of all patients, early identification of potential organ donors, prompt declaration of brain death, and attempts by the OPO coordinator to build rapport with families are all important factors that may increase donation rates. Because most organ donors have sustained catastrophic intracranial events, neurosurgeons are uniquely positioned to influence organ donation policies at their hospitals and thus to salvage some benefit from tragic cases of overwhelming brain injury.

Development of a culturally sensitive, locality-based program to increase kidney donation

Diabetic kidney disease has become an epidemic in American Indian communities. In Central Arizona, the Salt River Pima-Maricopa, Gila River, and Ak-Chin Indian communities have the highest incidence rate of diabetes in the world. Over 200 diabetic people in these communities receive dialysis because of kidney disease, a frequency that is 10 to 15 times the national average. Very few of these patients ever receive a kidney transplant. The communities formed the Organ Donation and Kidney Transplant Education Committee, which designed culturally sensitive educational materials and trained tribal members to disseminate the information. The goals were to educate tribal members about the choices they have when faced with kidney failure and to increase organ donation within the communities. The committee also produced a 10- to 15-minute educational video presentation for use at community district meetings, health fairs, and local health clinics in the communities. One unexpected early outcome has been the opportunity to reflect on some assumptions and stereotypes about American Indians and organ donation commonly held by health care providers. The local organ procurement organization plans to use the video in training hospital donor requestors. What difference would it make to educate the communities and not change the assumptions of those in the hospitals requesting donation?

Presentation and outcomes for organ donation in patients with cerebral gunshot wounds.

This study was undertaken to examine the presentation and outcomes relative to solid organ donation in patients with fatal cerebral gunshot wounds at a level I trauma center over a 7-year period. A retrospective chart review of patients with such wounds over the years 1993-99 was completed. Eighty (80) patients were considered potential solid organ donors. Of these, 28 (35%) became organ donors, yielding 97 transplantable organs. Ninety-six percent presented with a GCS of less than 6. Mean SBP on presentation was 130, ranging from 48 to 225. Median time from presentation to death was 18 hours. Intravenous fluids given over the first 6 hours averaged 4.3 liters. Pressors were required in 68% of cases, blood products in 34%. Consent rate for donation was 32% when requested by a physician and 59% when requested by an organ procurement organization (OPO) co-ordinator. No request was made in 15 cases. Patients with fatal cerebral gunshot wounds, but with solid organ donor potential, have a characteristic presentation. Those with hemodynamic stability and those whose hypotension responds promptly to treatment can be expected to have a donor potential despite their devastating brain injury. Minimal time and resources are required to support such patients. Additional organs may have been obtained if the request for donation was consistently separated from the families' notification of brain death, and if the request was initiated by an OPO coordinator rather than a physician. Further, all patients admitted with cerebral gunshot wounds and poor neurologic function should have local OPO referral, potential survival notwithstanding.

The Cost of Altruism: Patient Charges for Organ Donation After Traumatic Injury

OBJECTIVE: To determine the origin and extent of institutional charges incurred by lethally-injured patients while awaiting the diagnosis of brain death and organ procurement. DESIGN: Retrospective review. SETTING: Surgical Intensive Care Unit, Urban Tertiary Care Trauma Center. PATIENTS: 31 lethally-injured patients awaiting the diagnosis of brain death and subsequent organ procurement. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Itemized hospital financial and medical records were reviewed. Length of stay and major medical complications were abstracted and charges calculated for three overlapping time periods : total hospital stay, stay (period following documentation of a lethal injury until a second brain death exam was performed), and brain death stay (period between the first and second brain death exams). RESULTS: Multiple medical complications (3.2 +/0.2) and interventions occurred in all patients awaiting the diagnosis of brain death. The mean length of stay was 19 +/2 hours; the mean length of brain death stay was 12 +/1 hours. As a result, significant (lethal stay $20,902 +/1409 and brain death stay $16,645 +/1223) hospital charges were accrued. Even though a lethal injury had been documented, and care was targeted solely at maintaining organ function, these charges were not subsidized by the local organ procurement organization (OPO). CONCLUSIONS: 1. Numerous medical complications are common in the traumatized patient awaiting the declaration of brain death. These require aggressive critical care interventions and management. 2. Significant hospital charges are accrued by patients for the care necessary prior to organ procurement. 3. OPOs must consider and enact reimbursement policy change to cover the cost of care before brain death is declared in all organ donors.

The Cost of Altruism: Patient Charges for Organ Donation After Traumatic Injury

OBJECTIVE: To determine the origin and extent of institutional charges incurred by lethally-injured patients while awaiting the diagnosis of brain death and organ procurement. DESIGN: Retrospective review. SETTING: Surgical Intensive Care Unit, Urban Tertiary Care Trauma Center. PATIENTS: 31 lethally-injured patients awaiting the diagnosis of brain death and subsequent organ procurement. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Itemized hospital financial and medical records were reviewed. Length of stay and major medical complications were abstracted and charges calculated for three overlapping time periods : total hospital stay, lethal injury stay (period following documentation of a "lethal injury" until a second brain death exam was performed), and brain death stay (period between the first and second brain death exams). RESULTS: Multiple medical complications (3.2 +/0.2) and interventions occurred in all patients awaiting the diagnosis of brain death. The mean length of lethal injury stay was 19 +/2 hours; the mean length of brain death stay was 12 +/1 hours. As a result, significant (lethal injury stay $20,902 +/1409 and brain death stay $16,645 +/1223) hospital charges were accrued. Even though a "lethal injury" had been documented, and care was targeted solely at maintaining organ function, these charges were not subsidized by the local organ procurement organization (OPO). CONCLUSIONS: 1. Numerous medical complications are common in the traumatized patient awaiting the declaration of brain death. These require aggressive critical care interventions and management. 2. Significant hospital charges are accrued by patients for the care necessary prior to organ procurement. 3. OPOs must consider and enact reimbursement policy change to cover the cost of care before brain death is declared in all organ donors.

Double renal allografts successfully increase utilization of kidneys from older donors within a single organ procurement organization.

In 1994, a policy of double renal allografting (DUAL) was used at two centers within our local organ procurement organization to increase utilization of kidneys from older donors that would otherwise be discarded. Both kidneys from an older donor (age > 60 years) were selectively transplanted into a single adult recipient. The relative impact of a DUAL policy on the utilization of older donor kidneys is examined for the period of April 1994 to April 1996. Actual utilization is compared with the hypothetical case in which a DUAL policy is not present. In the actual setting, a total of 75 kidneys from older donors (> 60 years) were accepted for transplantation. Thirty-six kidneys were transplanted as singlets, and 16 additional kidneys were transplanted as DUAL renal allografts. Thus, a 44% increase in transplantable kidneys, and a 22% increase in patients transplanted with kidneys from older donors, was realized. In the actual setting, 23 older kidneys were discarded; without the DUAL policy, 39 kidneys would have been deemed untransplantable. When compared with the actual (n = 52) and hypothetical number of kidneys transplanted without a policy of DUAL transplantation (n = 36), the DUAL policy significantly increased the utilization of older donor kidneys (P = 0.01). The actuarial 1-year graft survival rate of the dual kidneys was 100%, with a mean follow-up of 11.1 +/- 2.9 months. Mean 6-month and 1-year serum creatinine level were 1.76 +/- 0.4 and 1.63 +/- 0.6 mg/dl, respectively. A DUAL policy significantly increased the number of older donor kidneys transplanted in a single organ procurement organization and reduced the rate of discard of older donor kidneys over a 2-year period. Long-term follow-up is necessary to substantiate satisfactory graft function in DUAL from older donors.

Obtaining organ donation: Who should ask?

To assess the impact of a decoupled presentation of the option of organ donation by an organ procurement organization representative on organ donation rates. Retrospective chart review. A tertiary care university medical center. Patients declared dead by neurologic criteria during the 2-year period January 1, 1992, through December 31, 1993. The addition, for the calendar year 1993, of an institutionally dedicated organ procurement organization representative to present the option of organ donation with the use of the technique of decoupling. The rate of donation increased from 38% to 59% with the addition of an institutionally dedicated organ procurement organization representative and the routine use of decoupling. When a dedicated representative from the local organ procurement organization, rather than the physician, presents the option of donation and decouples the discussion of death by neurologic criteria from the presentation of the option of donation, the rate of donation significantly increases.