Organ Transplant Programs Research Articles

Organ donation after cardiac death: donor and recipient outcomes after the first three years of the Ontario experience

The aim of this study was to explore donor and recipient outcomes from organ donation after cardiac death (DCD) in Ontario and to examine the impact of DCD on deceased donation rates in Ontario since its implementation. Donor data were obtained from the Trillium Gift of Life Network (TGLN) TOTAL database from June 1, 2006 until May 31, 2009. All DCDs were tracked, including unsuccessful DCD attempts during that time. For the first 36months after DCD implementation, all Ontario solid organ transplant programs that utilized organs from DCD provided clinical outcome data at one year. Total DCD activity until December 1, 2010 was also tracked. In addition, we compared organ donation and DCD rates across all Canadian jurisdictions and the USA. For the first 36months of DCD activity in Ontario, June 1, 2006 to May 31, 2009, there were 67 successful DCDs out of 87 attempted DCDs in 18 Ontario hospitals, resulting in 128 kidney, 41 liver, and 21 lung transplants. The one-year kidney patient and death-censored allograft survivals were 96 and 97%, respectively. Mean (SD) creatinine at 12months was 150 (108) μmol·L(-1). In 26 (20%) extended criteria donors (ECD-DCD), the one-year creatinine was 206 (158) μmol·L(-1) vs 137 (80) μmol·L(-1) in 102 standard criteria donors (SCD-DCD) (P=0.002). The one-year liver and lung allograft survivals were 78% and 70%, respectively. Since its implementation four and a half years ago, DCD has accounted for 10.9% of deceased donor activity in Ontario. In 2009, Ontario had a record number of organ donors. Of the 221 deceased donors, 37 (17%) donors were DCD. By December 1, 2010 there were 121 DCD Ontario donors resulting in>300 solid organ transplants and accounting for 90% of all DCD activity in the country. The rapid update of DCD in Ontario can be attributed to strong proponents in the critical care and transplantation communities with continued support from Trillium Gift of Life Network (TGLN). Ontario is the only province to demonstrate growth in deceased donor rates over the last decade (25% over the last four years), which can be attributed primarily to the success of its DCD activity.

Organ procurement: Spanish transplant procurement management

Transplantation is an accepted therapeutic option to save or improve the quality of life when organ failure occurs or tissue replacements are needed. However, the lack of organs is the major limitation. The deceased organ procurement organization and professionals provide the solution to this international problem. In this review, we identify the elements involved in the organ procurement management process to analyze the possibility of implementation of deceased organ procurement for a transplantation program. While the donation rates are subject to several negative factors including religious, economic, cultural, and legal issues, the existence of well-trained professionals may considerably increase them. Professional training in organ donation along with the establishment of a solid organizational system has been identified as the crucial factor in developing efficient organ donation and transplantation programs.

Recommendations for management of Chagas disease in organ and hematopoietic tissue transplantation programs in nonendemic areas

The substantial immigration into Spain from endemic areas of Chagas disease such as Latin America has increased the number of potential donors of organs and tissues. In addition, an increasing number of patients with advanced Chagas heart disease may eventually be eligible to receive a heart transplant, a universally accepted therapeutic strategy for the advanced stages of this disease. Therefore, it is necessary to establish protocols for disease management. This document is intended to establish the guidelines to be followed when a potential donor or a tissue or organ recipient is potentially affected by Chagas disease and summarizes the action criteria against the possibility of Chagas disease transmission through the donation of organs, tissues, or hematopoietic stem cells and aims to help professionals working in this field. A single registry of transplants in Trypanosoma cruzi infected donors and/or recipients will provide and disseminate experience in this area, which has shown a low recorded incidence to date.

Operational and Regulatory System Requirements for Pursuing Self-sufficiency in Deceased Donor Organ Transplantation Program in Korea

Myung-Gyu Kim, M.D., Jong Cheol Jeong, M.B., Eun Jin Cho, M.B., Kyu Ha Huh, M.D., Jaeseok Yang, M.D., Nyeon Im Byeon, R.N., Jin Sook Yu, R.N., Ki Tae Bang, M.D., Heoung Soo Chung, Jong Won Ha, M.D., Soon Il Kim, M.D., Won Hyun Cho, M.D. and Curie Ahn, M.D. Transplantation Center, Seoul National University Hospital, Departments of Internal Medicine, Surgery, Seoul National University College of Medicine, Vitallink, Department of Internal Medicine, Eulji University School of Medicine, Korean Network for Organ Sharing, Department of Surgery, Yonsei University College of Medicine, Seoul, Keimyung University School of Medicine, Daegu, Korea

Challenges in diagnosing brain death

Recognizing that the nature of the practice of clinical medicine involves areas of uncertainty, death is one diagnosis that doctors must not be allowed to miss. The concept of brain death, which originates from the Harvard Criteria, has allowed development of cadaveric organ transplantation programs. Over the years, the definition of brain death and the criteria for the neurological determination of death (NDD) have been updated. The Universal Determination of Death Act provides a definition of death but leaves the determination process to accepted medical standards (national, provincial, or even local), which can entail a high variability. In April 2003, in response to a perceived need in the general medical and critical care community, the Canadian Council for Donation and Transplantation (CCDT) held a national forum to revisit the process of declaring brain death and to propose updated recommendations. These are the current guidelines used by organ donation and transplantation organizations across Canada. The CCDT recommendations have the virtue of having brought uniformity to the process of NDD. Still, several of its recommendations are somewhat vague and open the door to clinical judgement and interpretation, a situation that is highly undesirable when facing potential organ donation. In this issue of the Journal, Roberts et al. report two cases where experienced physicians faced challenges in the clinical NDD. In both cases, it appears that several of the criteria for NDD were either misinterpreted or overlooked. Although they are usually not reported in the medical literature, similar incidents occur more than occasionally. This is somewhat disturbing. The existence of cadaveric organ donation and transplantation programs relies on the Dead Donor Rule that dictates that a patient’s death must be confirmed before any attempt at organ preservation or harvesting for the purpose of transplantation. Before a patient is dead, ethical principles mandate that medical care must be directed toward the sole and only benefit of this patient, even in a situation that could be perceived as ‘‘almost dead’’. Brain death is a complex concept that is very difficult for the general public to understand. Patients and their families place their trust in their treating physician. In organ donation, they trust that physicians will strictly abide by the Dead Donor Rule. Therefore, the process for NDD must be watertight. The CCDT recommendations define neurological death as the irreversible loss of all brain stem functions. The minimum criteria for clinical NDD are: 1) an established etiology capable of causing neurological death in the absence of reversible conditions capable of mimicking neurological death; 2) a deep unresponsive coma with bilateral absence of motor responses (excluding spinal reflexes); 3) absent brain stem reflexes, as defined by absent gag and cough reflexes, and the bilateral absence of corneal responses, pupillary responses to light (with pupils at mid-size or greater), and vestibulo-ocular responses; 4) absent respiratory effort based on the apnea test; and 5) absence of any confounding factors. Minimum means that at least all of these criteria must be met for clinical NDD. Confusion may arise regarding the first criterion. An etiology ‘‘capable of causing’’ neurological death is not the same as ‘‘sufficient to account for’’ the absence of clinical signs of brain function. For example, brain trauma is an M. R. Lessard, MD (&) J. G. Brochu, MD Department of Anesthesia and Critical Care, Centre hospitalier affilie universitaire de Quebec, Universite Laval, 1401, 18e rue, Quebec, QC G1J 1Z4, Canada e-mail: martin.lessard@anr.ulaval.ca

The Organ Transplant Debate in Egypt: a Social Anthropological Analysis

In this paper, I take the heated debate about the ethics of organ transplantation in Egypt, to ask why Egypt is the only Muslim country in the world that has, for the past three decades, been unable to pass legislation for a national organ transplant program. Why is it that patients and even physicians articulate their antipathy to organ transplantation in terms of “Islam” when most Muslim scholars of Islamic law have argued that the donation of organs is permissible? I argue that we cannot reduce the question of the ethics of organ donation in Egypt to abstract Islamic legal categories (permissible (mubâh) or impermissible (harâm) – as analysts both within and outside the Muslim world are apt to do. Doing so overlooks the pervasive problem of social inequalities that persist in the Egyptian medical system. In the context of vast discrepancies in health status and health care delivery, ordinary Egyptians are wary of medical institutions’ claims of re-using body parts for the common good.

The D&T Report

The D&T Report

Parasitic Infections in Solid Organ Transplant Recipients

Parasitic Infections in Solid Organ Transplant Recipients

Nursing personnel faced with living kidney donation in a Spanish hospital with a living‐donor kidney transplant program

AbstractOBJECTIVETo analyze attitudes toward living‐kidney donation among nursing personnel in a Spanish hospital with a living kidney transplant program and to analyze the influence of different types of variables on such attitudes.METHODSThis was a descriptive transversal study. The study was carried out in a Spanish third‐level hospital with an organ transplant program (kidney, liver, pancreas, and heart) and a living‐donation program (kidney and liver). A random sample (n = 305) was taken and was stratified by type of service among nursing personnel. Attitude was evaluated using a validated survey. It was completed anonymously and was self‐administered.RESULTSThe questionnaire completion rate was 95% (n = 289). Of these respondents, 86% (n = 248) were in favor of living‐related kidney donation. The following were found to be factors that were significantly related to attitude toward living kidney donation: (1) attitude toward deceased donor donation (p = .002); (2) a respondent's belief in the possibility of needing a transplant in the future (p = .002); and (3) a respondent's willingness to accept a living donated kidney (p < .0005).DISCUSSIONOur hospital nursing personnel have a favorable attitude toward living‐related kidney donation, and this attitude is mainly determined by reciprocity.

Use of neurodevelopmental delay in pediatric solid organ transplant listing decisions: Inconsistencies in standards across major pediatric transplant centers

Children with NDD present for organ transplant evaluation, but the role of NDD as a listing criterion itself is poorly described. Therefore, we sought to investigate how major pediatric solid organ transplant programs use NDD as a criterion in their listing decisions. We developed a survey that was sent via post to active pediatric solid organ transplant programs across the United States investigating transplant listing decision-making for neurodevelopmentally delayed children. Respondents were medical/surgical directors and transplant coordinators. Descriptive statistics summarize the findings. Programs inconsistently use NDD in listing decisions. Thirty-nine percent of programs stated that they "rarely" or "never" consider NDD in their decisions, whereas 43% of programs "always" or "usually" do. Sixty-two percent of programs report that informal processes guide their use of NDD, and no programs describe their process as "formal, explicit, and uniform." The degree of delay is an additional source of discordance among programs, with 14% of programs reporting mild or moderate NDD as a relative contraindication to listing and 22% reporting that NDD was "irrelevant" to the listing decision. The use of NDD in pediatric solid organ transplant listing decisions is varied and inconsistent across active programs.

Training of Health Care Students and Professionals: A Pivotal Element in the Process of Optimal Organ Donation Awareness and Professionalization

Successes in organ donation and transplantation programs are directly evidence-based education. Transplant Procurement Management (TPM) is an international educational project on organ donation and transplantation. Our purpose was to evaluate the TPM educational project. We compared the data of 17 years of experience, strategies, and methods. We retrospectively performed a descriptive analysis of all educational activities developed between 1991 and 2008. We identified 7 crucial points. (1) In 1991, TPM was started under the auspices of the University of Barcelona (UB) and the National Spanish Transplant Organization (ONT; national training, face-to-face). (2) In 1994, TPM became international (international advanced training and country-based). (3) Since 1997 in Italy and 2006 in France, national training courses were organized adapting the same methodologies as the advanced international TPM courses. TPM also implemented short (1-3 days) introductory courses worldwide. (4) In 2002, the e-learning platform program was launched to facilitate the education of professionals. (5) In 2005, an international master's degree was created at UB under the Life-Long Learning Institute (IL3). (6) In 2006, the courses were expanded to include pregraduate health science faculties with the International Project on Education and Research in Donation at University of Barcelona (PIERDUB). (7) In 2007, the European-funded European Training Program on Organ Donation (ETPOD) project was started. Currently, TPM offers face-to-face, e-learning, and blended international courses. As of 2008, TPM has trained 6498 professionals in 89 countries on 5 continents. TPM has impacted positively on the various essential levels in the process of organ donation and transplantation, with lifelong follow-up and an international network through the capacity to adapt to specific country needs as well as continuous quality improvement thanks to the collaboration of expert teachers and consultants.

Pediatric organ donation: A national survey examining consent rates and characteristics of donor hospitals*

To characterize the eligible pediatric donor pool in the United States by age, consent rate, location, and cause of donor loss. Survey. Organ procurement organizations in the United States. Pediatric patients who suffered brain death in the United States in 2005 and who were medically suitable for organ donation. None. We determined the number of patients, age < or =17 yrs, who were eligible for organ donation and the consent rate by age. Each hospital in which donation occurred was characterized by the presence of a pediatric intensive care unit (PICU), a pediatric critical care medicine (PCCM) fellowship, solid organ transplant programs, and level I trauma programs. Additional information was obtained on the number of donation after cardiac death donors and eligible donors lost due to medical examiner refusals and deterioration before organ recovery. The number of reported eligible pediatric donors in 2005 was 1330. The consent rate was 69.2% with higher consent rates in eligible donors 12 yrs of age and older. Eligible donors were spread across a large number of hospitals with few having ten or more eligible donors. Variability exists among hospitals in consent rate and number of donors per 100 PICU beds. The presence of a level I trauma program and/or a PCCM fellowship was associated with higher numbers of donors per 100 PICU beds. Ninety-four eligible donors were lost before recovery of organs due to medical examiner denials or cardiac arrest. Donation after cardiac death accounted for 37 donors. Overall pediatric consent rates were 69.2% but varied by age. Eligible donors were found most often in hospitals with level I trauma programs or PCCM fellowship programs. Few hospitals had >10 eligible donors in a 12-month period. This study is the first to describe in detail the U.S. pediatric donor population.

Organ and Tissue Transplantation

There could not have been a more appropriate time as now for a special issue of the Annals dedicated to transplantation. The topic is in the lay press everyday for both the right and the wrong reasons. This special issue covers not only the science and art of transplantation but also many of the ethical and social issues that are inherent in this field of medicine. The issue provides an overview of the Singapore experience in transplantation of various organs and tissues and has also been enriched by the contributions from world leaders in the field. One common theme in this issue of the Annals is the success of the various solid organ transplant programmes in Singapore. Indeed, the results of renal (both adult and paediatric) and heart transplants in Singapore, as reported by Vathsala and Chow; 1 Ng and colleagues; 2 and Sivathasan, 3 are comparable to if not better, than those reported from North American or International Registries. The review of liver transplantation in Asia by Ng and Lo 4 further highlights the innovative techniques that have evolved specifically to address the problem of organ shortage and the high prevalence of hepatocellular carcinoma in Asia. Indeed, Asia is considered the world leader in liver transplantation with many centres in the Far East having pioneered these techniques. The reviews by Hwang and Ong 5 and Tan et al 6 on advances in haematopoietic stem cell and cornea transplantation respectively, further attest to the advancing field of tissue transplantation. In total, transplantation has come of age in Singapore, is no more an experimental form of therapy but is instead the standard of care for many life-threatening conditions. A second fact highlighted in this issue are the similarities in complications of transplantation across all solid organs. Infectious complications were the leading cause of death among both adult and paediatric renal transplants as well as heart transplant recipients. 1,2 On the contrary, chronic rejection and chronic allograft vasculopathy were the leading causes of graft failure for renal and heart transplants respectively. As suggested by Sir Roy Calne 7 in this issue, continued research in strategies to ameliorate chronic graft

Modernization of the Organ Transplantation Program in China

Modernization of the Organ Transplantation Program in China

Living Related Kidney Transplantation in Libya: A Single Center Experience

Objective The aim of this study was to establish a successful living related kidney transplantation program in Libya and to bring down health care costs in management of patients with end-stage renal disease. Patients and Methods Since the transplantation program was launched on August 17, 2004, 135 patients have been transplanted up to August 17, 2007. The donors and recipients were screened prior to transplantation. Our immunosuppressive protocol was cyclosporine-based. Both donors and recipients were followed in the transplant outpatient clinic. Results Among 135 accepted pairs, 133 cases (98.5%) were genetically related donors and recipients and 2 cases were emotionally related. Mean donor age was 37 ± 9.5 years (range, 18–56 years). Recipient age was significantly lower, namely, 37 ± 13.6 years (range, 7–67 years). Among the recipients, 95 (70.4%) were males and 40 (29.6%) females, while among the donors, 102 (75.6%) were males and 33 (24.4%) females. The most common donor-recipient relationship was brother-to-brother. There was no early or late surgical mortality among donors. Delayed graft function was observed in 3 patients (2.2%), acute rejection in 6 (4.4%), and posttransplantation infections in 8 (5.9%). Urinary tract infections were diagnosed in 6 patients (4.4%) and pneumonia in 3 (2.2%). Postsurgical complications included ureteric kink in 2 patients (1.5%) and an anastomotic urine leak in 4 (3.0%). At 36 months, graft survival was observed in 130 patients (96.3%) and patient survival in 126 (93.3%). Conclusion The Libyan National Organ Transplant Program has been successful with results comparable to international levels.

Healthcare assistants faced with cadaveric organ donation in a hospital with a solid organ transplant program

Healthcare assistants faced with cadaveric organ donation in a hospital with a solid organ transplant program

The D&amp;T Report

The D&amp;T Report

Abstract CN09-02: Cancer and infection: lessons from immune deficient populations

Abstract CN09-02 Immune deficiency offers an informative window through which to examine the infection-cancer relationship. Simply stated, if a cancer is caused by infection, then it is likely to occur at increased rates in people with immune deficiency. The HIV epidemic, and the expansion of organ transplantation programs, have led to the creation of large cohorts with immune deficiency. In this talk, I will review recent findings on cancer occurrence in these populations. People with HIV are at increased risk for a wide range of cancers, but there has been debate about whether this is due to immune deficiency, or due to exposure to cancer risk factors such as smoking, alcohol intake, and sexually transmitted and blood-borne pathogens. New light has been shed on these relationships by work on cancer in kidney transplant recipients. As transplant recipients have little in common with people with HIV apart from immune deficiency, shared patterns of cancer occurrence would likely be explained by immune deficiency. We conducted a retrospective cohort study of 28,855 end stage renal disease patients in Australia. Incident cancers diagnosed between 1982 and 2003 were ascertained by record linkage. Standardised incidence ratios (SIRs) were calculated in transplant recipients. Cancer rates were increased after transplantation for all infection-related cancers, including those related to KSHV (KS); EBV (NHL, Hodgkin lymphoma); HPV (anogenital cancers and head and neck cancers); HBV and HCV (liver cancer) and helicobacter pylori (stomach cancer). Rates were not increased for most epithelial cancers common in the general population. We also conducted a meta-analysis comparing cancer risks in population-based studies of solid organ transplant recipients and in people with HIV infection. This revealed that the pattern of increased cancer incidence was strikingly similar in the two populations. These data suggest that most infection-associated cancers occur at increased rates related to immune deficiency in people with HIV and in transplant recipients. A key question that remains is whether reversal of immune deficiency can reduce cancer risk. Our analysis of cancer risk in people who cease immune suppression because their kidney transplant fails suggests that cancer risk does rapidly return to baseline. In chronic HIV disease, reversal of immune suppression due to treatment is more gradual and less complete, and the increased rates of some but not all infection-related cancers appear to decrease towards normal levels. Describing cancer rates by current level of immune function is an important research priority among people with HIV. Infection-related cancer is caused by the interplay between immune function and infection. For many of these cancers, the raised risk associated with immune deficiency can be reversed by a return to normal immunity. These findings have implications for the management of long term mild immune deficient states, and also for the prevention of infection-related cancer in the general population. Citation Information: Cancer Prev Res 2008;1(7 Suppl):CN09-02.

Steven C. Stain, MD

Abstracts The Dr. Neil Lempert Professorship in Surgery serves as a tribute to the professional legacy of Neil Lempert, MD, who in 1969 became the capital region’s first transplant surgeon and led the team that performed the first kidney transplant in northeastern New York at Albany Medical Center. Lem-pert served as director of transplantation until 1992 and, in 1997, the Lempert professorship was established to honor his legacy as an exceptional medical leader. In his retirement, he continues to work closely with Albany Medical Center. At the time of his retirement as director of the transplant program at Albany Medical Center in 1992, the Organ Procurement Organization of Albany Medical College wrote: Neil Lempert, MD, has been part of one of the most exciting chapters in medicine at Albany Medical Center—organ transplantation. Dr. Lempert initiated the organ transplant program at the Medical Center in 1967, and performed the first transplant two years later. Under his leadership, the program has thrived. Since then, nearly 1,000 kidneys have been transplanted at Albany Medical Center . “Work with transplant patients provides gratification and satisfaction,” said Lempert. “We see patients whose existence surrounds their dialysis treatment. We have patients who frequently are so sick they are hardly able to walk. After surgery, they can resume normal life.” During the early years of the program, Lempert had to be on call 24 hours a day, ready to perform surgery whenever a kidney became available. “We still have a lack of suitable organs,” he said. “We need better use of available organs, better prevention and treatment of rejection.” Lempert received his MD at Albany Medical College and served as research fellow in surgery at Mary Imogene Bassett Hospital in Cooperstown from 1963–1964. There, his mentor was David Blumenstock, MD, chief of surgery, who was pioneering a program in transplantation. After a tour of duty in the army, Lempert returned to Albany Medical Center in 1967. He has been active in professional organizations, serving on the board of directors of the Kidney Foundation of Northeastern New York, the American College of Surgeons, the American Society of Transplant Surgeons, the United Network for Organ Sharing and the State of New York Commission on Quality of Care of the Mentally Disabled.

How can we achieve global equity in provision of renal replacement therapy?

There is a significant emerging burden of chronic and end-stage kidney disease in low- and middle-income countries, driven by population ageing and the global epidemic of type 2 diabetes. Sufferers of end-stage kidney disease require ongoing dialysis or kidney transplantation to survive; however, in many low- and middle-income countries, treatment options are strictly limited or unaffordable. Low numbers of maintenance dialysis patients and transplant recipients reflect profound economic and service provision challenges for health-care systems in low- and middle-income countries in sustaining renal replacement therapy programmes. Underdeveloped organ donor and transplant programmes, health system and financing issues, ethical regulation of transplantation and the cost of pharmaceuticals commonly pose additional barriers to the delivery of efficient and cost-effective renal replacement therapy. Development of locally appropriate transplant programmes, effective use of nongovernmental sources of funding, service planning and cost containment, use of generic drugs and local manufacture of dialysis consumables have the potential to make life-saving renal replacement therapy available to many more in need. Select low- and middle-income countries demonstrate more equitable provision of renal replacement therapy is possible outside high-income countries. For other low- and middle-income countries, education, the development of good public policy and a supportive international environment are critical. Prevention of end-stage kidney disease, ideally as part of an integrated approach to chronic vascular diseases, must also be a key objective.