Solid Organ Donors Research Articles

Retrospective screening of solid organ donors in Italy, 2009, reveals unpredicted circulation of West Nile virus

Since the occurrence of West Nile virus (WNV) infection in humans in 2008 in Italy, concerns have been raised about the potential risks associated with solid organ transplantation (SOT). A nationwide retrospective survey showed that 1.2% of SOT donors in 2009 were WNV-seropositive and demonstrated that human WNV infection is distributed throughout several Italian regions. Transmission of WNV or other arboviruses through SOT is a possibility and risk assessment should be carried out before SOT to avoid infection through transplantation.

Terlipressin as Rescue Therapy in Catecholamine-Resistant Hypotension in Solid Organ Donors: A Case Report

Objective The objective of this study was to report the effects of Terlipressin treatment in 2 potential organ donors with intractable, catecholamine-resistant hypotension. Design and Setting This study was based on case reports in the intensive care unit of a general hospital. Patients Patients included 2 adult patients with cerebral death and catecholamine-resistant hypotension. Interventions A low dose of Terlipressin (3.5 μg/kg) by intravenous bolus was added to the standard treatment. Measurement and Results In both cases, Terlipressin induced a rapid improvement in arterial pressure with a consequent increase in urine output and the appearance of diabetes insipidus. In 1 patient it allowed for the withdrawal of norepinephrine infusion. No related adverse effects were detected in either patient. Organ removal was not possible in the second case due to lack of family consent. Conclusions Terlipressin might be considered as a rescue therapy for potential organ donors with intractable, catecholamine-resistant hypotension. In spite of the positive results obtained here and by other authors in the treatment of septic shock, its judicious use is recommended, and an optimal administration schedule must still be elucidated.

Attitudes of Spanish and Mexican Resident Physicians Faced With Solid Organ Donation and Transplantation

Introduction The attitudes of specialist physicians toward organ donation and transplantation are of great interest because promotion of this activity depends on them. Our objective was to analyze the attitudes of residents in health centers in Spain (MIR) and in Mexico (ENARM). Materials and methods A random stratified sample was obtained in six teaching hospitals: two in Spain ( n = 246) and four in Mexico ( n = 139) as part of the International Collaborative Program “Proyecto Donante, Murcia.” The sample consisting of 385 trainee physicians completed a psychosocial questionnaire as the instrument to test their opinions. Results Most residents (93%; n = 359), were in favor of deceased organ donation with 90% ( n = 348) in favor of living kidney donation and 87% ( n = 335) in favor of liver donation. Attitudes toward donation were similar among Spanish and Mexican residents regarding deceased donation (93% vs 94%; P > .05), living kidney donation (88% vs 94%; P > .05), and living liver donation (86% vs 89%; P > .05). None of the attitudes toward donation was associated with the classic psychosocial factors related to attitudes toward donation or job factors. Discussion within the family was associated with more positive attitudes toward deceased donation ( P < .001), living donation of the kidney ( P = .01), and of the liver ( P = .019). Conclusion Attitudes toward various types of donation were favorable among both Spanish and Mexican trainee physicians, so that they could potentially act as a group to promote this activity, raising hopes for increased donation rates in the future.

Parasitic Infections in Solid Organ Transplant Recipients

Parasitic Infections in Solid Organ Transplant Recipients

Evaluation of the coagulation and inflammatory responses in solid organ transplant recipients and donors

New strategies that modify the coagulation/inflammatory cascades may be applicable to solid organ transplant (SOT) recipients in the treatment of complications. However, data on kinetics of post-SOT cascades are needed before considering these strategies. Prospectively collected pre-transplant serum measurements of inflammatory (high-sensitive C-reactive protein, HS-CRP) and coagulation (d-Dimer, DD; protein C, PC) markers were compared to post-operative (day 1-90) values in deceased-donor liver (DDLT) and renal (DDRT) transplant recipients, living-related renal recipients (LRT) and donors (LRD). A total of 85 SOT were enrolled: 25 DDLT, 32 DDRT/LRT, 28 LRD. HS-CRP increased in all groups, mainly immediate post-SOT and in LRDs. DD had a similar pattern mainly in LRT and LRD. PC increased significantly over time in the DDLT group ( p < 0.01). Compared to those with no complications (infection, rejection or thrombosis), day 30 HS-CRP (p = 0.04) and DD (p = 0.06) were elevated in the DDRT/LRT group with complications; PC was decreased at day 7 (p = 0.04) and day 30 (p = 0.009) in DDLT and DDRT/LRT groups with complications, respectively. In conclusion, activation of the inflammatory/coagulation cascades occurs after SOT and is least pronounced in DDLT. This activation diminishes over time unless transplant complications occur. Our results support further research in approaches to altering these cascades in SOT recipients.

The Importance of Emergency Medicine in Organ Donation: Successful Donation Is More Likely When Potential Donors Are Referred From the Emergency Department

This study sought to identify factors that are associated with successful organ retrieval among patients referred to organ procurement services for potential organ donation. Particular attention was paid to the frequency, patient characteristics, and outcomes of patients referred for donation from the emergency department (ED). For this retrospective cohort study, data were collected on all solid-organ donor referrals made to a single organ procurement organization serving 78 hospitals over a 45-month period. Data retrieved included patient age, sex, race, referral site (ED vs. inpatient), and mechanism of injury. Outcome of referral (organs retrieved or not) was the primary outcome variable. Pearson chi-square and Student's t-tests were used for bivariate statistical analysis. Multiple logistic regression analysis was used to determine which variables remained associated with organ retrieval after controlling for potential confounders. A total of 6,886 donor referrals were made in the study population. Of these, 155 were excluded due to incomplete data, leaving 6,731 subjects for analysis. Using bivariate statistical analysis, we found that successful organ retrieval was associated with younger age (donor mean age 40.8 years, 95% confidence interval [CI] = 39.1 to 42.5 vs. nondonor mean age 59.4, 95% CI = 58.9 to 59.9), mechanism of injury (p < 0.001), and referral from the ED (ED 15.5% retrieved, inpatient 5.9%, odds ratio [OR] = 2.92, 95% CI = 2.32 to 3.67). After controlling for potential confounders with multiple logistic regression, referral from the ED remained significantly associated with successful organ retrieval (OR = 1.52, 95% CI = 1.18 to 1.97), as did age (OR = 0.96, 95% CI = 0.96 to 0.97) and mechanism of injury (p < 0.001). On regression analysis, race emerged as a significant predictor of organ retrieval (p < 0.001). Medically suitable patients referred from the ED were significantly more likely on bivariate analysis to have consent for donation granted compared to patients referred from inpatient settings (OR = 1.48, 95% CI = 1.03 to 2.12), but this association was not found to be significant on regression analysis (OR = 1.37, 95% CI = 0.93 to 2.02). Referral of potential organ donors from the ED is associated with an increased likelihood of successful organ retrieval. The authors conclude that further attention and resources should be directed toward the role of emergency medicine (EM) in the organ procurement process, owing to the relatively high likelihood of successful organ retrieval among patients referred from the ED.

Impact of a Bereavement and Donation Service incorporating mandatory ‘required referral’ on organ donation rates: a model for the implementation of the Organ Donation Taskforce’s recommendations

In 2008 the Organ Donation Taskforce published its recommendations for increasing organ donation in the UK by 50% over 5 years. Bolton NHS Trust has addressed the problem of low rates of organ donation by amalgamating Bereavement and Donation Services and introducing a trigger to refer automatically all potential organ donors to the regional transplant donor co-ordinators. We audited the ability of the new service to deliver the aims and recommendations of the Organ Donation Taskforce. Following the changes in service provision the number of tissue donors rose from six in 2002 to 246 in 2007. In the same period solid organ donation rates remained unchanged. The introduction of an automatic trigger for referral of potential donors in 2007 resulted in 31 referrals and 11 successful multi-organ donors. The current service exceeds the aims of the Taskforce and offers the potential to meet UK organ donation targets without resorting to an 'opt out' system of presumed consent.

Exploring Transplant Opportunities in Hmong Culture: A Case Report

A clinical case is used to explore the ethical complexities of solid organ donation and transplantation within the Hmong community in the United States. Although many cultures can present various ethical issues, the challenges of the Hmong belief system are unique and distinctly complex. Ways for the medical team to integrate with the Hmong value system to attempt to create an environment of transcultural respect and appreciation are described.

Exploring transplant opportunities in Hmong culture: a case report

A clinical case is used to explore the ethical complexities of solid organ donation and transplantation within the Hmong community in the United States. Although many cultures can present various ethical issues, the challenges of the Hmong belief system are unique and distinctly complex. Ways for the medical team to integrate with the Hmong value system to attempt to create an environment of transcultural respect and appreciation are described.

National Survey of Potential Heart Beating Solid Organ Donors in Sweden

Sweden has about 135 heart beating solid organ donors per year among 9.2 million inhabitants. Earlier estimations have suggested that 250–300 of potential heart beating donors might be available in the country annually. The present study is the first nationwide survey to establish the number of potential heart-beating donors, based on all patient deaths in Swedish intensive care units (ICUs). In the present study, a potential heart-beating solid organ donor was strictly defined as “a patient in an ICU on mechanical ventilation with the diagnosis of brain death.” All 85 eligible ICUs reported all patient deaths over a 3 month period of October through December 2007. The instrument consisted of 10 questions. The majority of data were entered electronically by the ICU staff into the “Swedish Intensive Care Registry.” The total number of reported patient deaths was 875 with 7.4% of patients who died meeting the criteria for a potential heart-beating solid organ donor. Actually 51% of them became donors. Reasons for not becoming a donor were refusals in 31%, medical reasons in 14%, impossibility to obtain consent in 1.5%, and no suitable recipient in 3%. Furthermore, 1.5% of patients did not become donors because of preferential forensic examinations. The main conclusion of the study was that the actual number of potential heart-beating solid organ donors in Sweden seems to be less than earlier estimates. Another interesting observation is the existence of a group of artificially ventilated, brain injury patients in whom the death was diagnosed by cardiac arrest. We think that this group of patient deaths deserves further investigation in future projects.

Communicating effectively about donation: an educational intervention to increase consent to donation

Families' refusal to consent to solid organ donation is a major contributor to the organ deficit in the United States. Previous research has identified organ procurement coordinators as best able to obtain consent from families; however, few studies have examined the effects of coordinator training programs on consent rates. To test the effects of the Communicating Effectively About Donation intervention on the rate of family consent to solid organ donation. A nonrandomized repeated measures design. Participants included 17 hospitals, 502 donor-eligible patients and their families, and 22 coordinators from an organ procurement organization in Ohio. Coordinators were given in-service training on the use of effective relational and affective communication techniques through a day-long interactive workshop and simulated donation scenarios. Families' final donation decision and coordinators' donation-related behaviors. Training of coordinators was associated with increases in coordinators' comfort speaking with patients' families about donation and answering donation-related questions, in the amount of time coordinators spent discussing donation with family members, and in the number of donation-related topics discussed with families. Consent rates increased from 46.3% to 55.5% after the intervention. The results suggest that improving coordinators' communication skills may be a fruitful avenue for increasing the rate of family consent to donation; however, a more definitive test of the training is needed to confirm the intervention's effectiveness.

Communicating Effectively about Donation: An Educational Intervention to Increase Consent to Donation

Families' refusal to consent to solid organ donation is a major contributor to the organ deficit in the United States. Previous research has identified organ procurement coordinators as best able to obtain consent from families; however, few studies have examined the effects of coordinator training programs on consent rates. To test the effects of the Communicating Effectively About Donation intervention on the rate of family consent to solid organ donation. A nonrandomized repeated measures design. Participants included 17 hospitals, 502 donor-eligible patients and their families, and 22 coordinators from an organ procurement organization in Ohio. Coordinators were given in-service training on the use of effective relational and affective communication techniques through a day-long interactive workshop and simulated donation scenarios. Families' final donation decision and coordinators' donation-related behaviors. Training of coordinators was associated with increases in coordinators' comfort speaking with patients' families about donation and answering donation-related questions, in the amount of time coordinators spent discussing donation with family members, and in the number of donation-related topics discussed with families. Consent rates increased from 46.3% to 55.5% after the intervention. The results suggest that improving coordinators' communication skills may be a fruitful avenue for increasing the rate of family consent to donation; however, a more definitive test of the training is needed to confirm the intervention's effectiveness.

Minors as Living Solid-Organ Donors

In the past half-century, solid-organ transplantation has become standard treatment for a variety of diseases in children and adults. The major limitation for all transplantation is the availability of donors, and the gap between demand and supply continues to grow despite the increase in living donors. Although rare, children do serve as living donors, and these donations raise serious ethical issues. This clinical report includes a discussion of the ethical considerations regarding minors serving as living donors, using the traditional benefit/burden calculus from the perspectives of both the donor and the recipient. The report also includes an examination of the circumstances under which a minor may morally participate as a living donor, how to minimize risks, and what the informed-consent process should entail. The American Academy of Pediatrics holds that minors can morally serve as living organ donors but only in exceptional circumstances when specific criteria are fulfilled.

Ethics and Apheresis: What Choice is There?

By comparison with many other procedures in medicine, apheresis for collection of haematopoietic progenitor cells (HPC) is a relatively innocuous process. The procedure itself is straightforward, serious adverse effects are rare and many donors experience real benefits. But the apparent simplicity of HPC harvest is misleading as apheresis raises substantial issues of consent, risk assessment and conflict of interest. G-CSF primed apheresis is associated with a number of predictable shortterm risks and unpredictable long-term risks, particularly in those who submit to a second or third donation. Donors are often coerced by the very nature of their relationship to the recipient and by expectations of altruism and are infrequently offered a true choice between bone marrow harvest and peripheral HPC harvest. And, as is the case in solid organ donation, HPC donors may consent to HPC collection for a number of different reasons, some of which may negatively impact upon their experience of apheresis and may give rise to concerns regarding late withdrawal from donation. While these issues are complex enough where competent adults are the donors, they are more difficult again where the ‘donor’ in not competent, is mentally ill or is a child. In this paper I will review the ethics of apheresis, critique the concept of informed consent and the disproportionate concern with unrelated donors, and consider whether current practices are ethically justifiable.

An Empirical Investigation of Physicians’ Attitudes Toward Intrasibling Kidney Donation by Minor Twins

A United States consensus group on the live donor concluded that minors (<18 years) can ethically serve as live solid organ donors in exceptional circumstances. More recent international guidelines reject this position. Recent United Network of Organ Sharing data show that minors serve as living donors, albeit infrequently. We examined the attitudes of US physicians toward minors as living donors. Four hundred members of the American Society of Transplantation and 160 physicians from the American Academy of Pediatrics Section of Nephrology or Bioethics were surveyed. The physicians were asked whether minors should be permitted to serve as living donors and how their opinion would change depending on the twins' zygosity, age, and increased waitlist time. One hundred seventy of 436 eligible participants (39%) returned surveys. Thirty-two and 39% of respondents would permit a kidney donation between 15-year-old fraternal and identical twins, respectively (P=NS). If the wait time increased from 1 to 6 years, willingness increased to 39% and 45%, respectively (P=NS). Pediatric bioethicists were the most reluctant to prohibit minors as living donors. Approximately one-third of US physicians would permit children to serve as donors. Lengthening the wait time is associated with a trend toward greater willingness to permit minor donations. Current policies that give preferential status for a deceased donor organ to minors may help minimize donations by their minor siblings. Nontransplant physicians need education about donor risks to ensure that donations are in the best interest of pediatric donors and recipients.

The live organ donor's consent: is it informed and voluntary?

Live organ donors represent nearly 50% of the solid organ donors in the United States. This unique population of individuals accepts risk for the benefit of another. The main justification by the medical community for permitting such risk to live donors has been respect for their autonomy, realized through the practice of informed consent. This article examines the key criteria of informed consent--understanding and non-control (voluntariness)--in the context of live organ donation. It concludes that more prospective studies are needed to improve the process of informed consent in this population.

The Use of Donor and Recipient Screening for Toxoplasma in the Era of Universal Trimethoprim Sulfamethoxazole Prophylaxis

Toxoplasmosis is a serious complication of solid organ transplantation. The highest risk of infection and disease occurs in heart recipients with primary infection transmitted by a seropositive donor to a seronegative recipient (donor-recipient mismatch). Toxoplasmosis has been reported to occur in noncardiac transplant recipients; however, no large studies examining the frequency of such events or the need for serologic screening exist. A retrospective cohort study of 1,006 solid organ transplant recipients transplanted in our center between 1984 and 1997 was performed to examine the incidence of Toxoplasma seroconversion, reactivation, and clinical toxoplasmosis and to evaluate the impact of trimethoprim sulfamethoxazole (TMP/SMX) prophylaxis on these outcomes. Pretransplant Toxoplasma seroprevalence was 13.4% in donors and 17.8% in recipients. The incidence of Toxoplasma donor-recipient mismatch was 9.5% during the 14-year study period, and only 39.1% of mismatched recipients received TMP/SMX prophylaxis. Only four patients seroconverted, of whom two had received prophylaxis. There were no cases of clinical disease; either primary or reactivation. We therefore conclude that in transplant centers with low Toxoplasma seroprevalence, routine screening for Toxoplasma in solid organ donors and recipients is not necessary, particularly in the era of routine TMP/SMX prophylaxis.

Serological Profile of Potential Solid Organ Donors in Santa Catarina, Brazil

Objectives Serological tests are essential for the donation process. We performed a study to identify the seroprevalence of cytomegalovirus (CMV), toxoplasmosis, HIV, Chagas disease, HTLV, hepatitis B virus (HBV), hepatitis C virus (HCV) and Lues among our potential donors. Methods Among sera of 233 potential donors tested between January 2006 and April 2007, only 97 resulted in effective donation. Results The seroprevalence of CMV immunoglobulin G (IgG) was 89.3%. Anti-HBc was positive in 63 samples (27%) and just three people were HBsAg antigen-positive. HIV, HCV, HTLV, and Chagas disease showed low prevalence among the potential donors. Toxoplasmosis IgG antibody had a high prevalence in the tested group. Conclusion CMV and toxoplasmosis were prevalent in the whole sample.

Infant Heart Transplant From Non-Heart Beating Donors

This is a pilot study designed to address the need for organ donation for a group of patients at greatest risk for death while awaiting heart transplantation. The study is sponsored by a grant from the Department of Health and Human Services, Transplant Division. Currently, organs for heart transplant come from individuals who meet brain death criteria, “traditional donor.” Successful transplant of the kidney and liver has been reported utilizing the non-heart beating donor (NHBD). With an NHBD, donation of solid organs occurs following removal of life support and after the heart has stopped beating.

Opportunities not taken: Successes and shortcomings in the Institute of Medicine's report on organ donation

The Institute of Medicine's recent report, Organ Donation: Opportunities for Action, studies the current problems facing organ donation in the USA, making suggestions for quality improvement and analyzing various proposals of incentivized donation and presumed consent (PC). Although the report deals with the donation of several solid organs, this mini review examines the findings from the perspective of kidney transplantation. The committee's recommendations to move from circulatory to neurologic criteria for cadaveric donation and to increase opportunities for donor decision making are prudent. We agree with the committee's arguments against providing incentives for donation because of the inherent distributional inequalities and imperfect information; the intrinsic difficulties in establishing market equilibrium for such heterogeneous and perishable goods; the implied commoditization of the human body; and the inadequate data regarding the long-term risks of living donation. However, we question the committee's firm opposition to PC, especially given recent data from 22 European countries showing a 25-30% increase in organ supply attributable to a PC policy. If this simple change in the default position on donation has the potential to increase organ supply, decrease the need for living donation, reduce the burden on grieving families, maintain familial authority over the deceased, and respect patient autonomy, at least a pilot program of PC seems warranted.