The critical pathway for deceased donation: reportable uniformity in the approach to deceased donation.

The critical pathway of deceased donation provides a systematic approach to the organ donation process, considering both donation after cardiac death than donation after brain death. The pathway provides a tool for assessing the potential of deceased donation and for the prospective identification and referral of possible deceased donors.

Diagnosing the Decades-Long Rise in the Deceased Donor Kidney Discard Rate in the United States.

BACKGROUND: The proportion of deceased donor kidneys recovered for transplant but discarded increased steadily in the United States over 2 decades, from 5.1% in 1988 to 19.2% by 2009. Over 100 000 patients are waiting for a kidney transplant, yet 3159 kidneys were discarded in 2015. METHODS: We evaluated trends in donor characteristics, discard reasons, and Organ Procurement Organization-specific discard rates. Multivariable regression and propensity analysis were used to estimate the proportion of the discard rate rise in the 2000s attributable to changes in donor factors and decisions to biopsy and pump kidneys. RESULTS: This study found that at least 80% of the discard rate rise can be explained by the recovery of kidneys from an expanding donor pool and changes in biopsy and pumping practices. However, a residual discard rate increase could not be explained by changes in these factors. From 1987 to 2009, median donor age rose from 26 to 43 years; median Kidney Donor Risk Index increased from 1.1 in 1994 to 1.3 in 2009. Our findings suggest that the increase from 10% to 30% in the proportion of kidneys pumped during the 2000s served as a buffer, keeping the discard rate from rising even higher than it did. CONCLUSIONS: The majority of the kidney discard rate rise can be explained by the broadening donor pool. However, the presence of an unexplained, residual increase suggests behavioral factors (eg, increased risk aversion) and/or allocation inefficiencies may have played a role. Reducing risk aversion, improving allocation, and more often pumping less-than-ideal, yet potentially transplantable kidneys, may help reverse the trend.

Hormonal therapy of the brain-dead organ donor: experimental and clinical studies.

Experiments in Cape Town in the 1980s demonstrated that acute brain death is followed by massive catecholamine release resulting in systemic hypertension, acute left ventricular failure, and multiple cardiac arrhythmias along with substantial decreases in cortisol, insulin, thyroid, and antidiuretic hormone levels, a change from aerobic to anaerobic metabolism, and increases in inflammatory cytokines. Hormonal replacement results in rapid recovery of cardiac function in both experimental animals and humans and enables significantly more organs to be transplanted. Organ Procurement and Transplantation Network/United Network for Organ Sharing multivariate studies on hormonal treatment of brain-dead donors revealed significant increases in organs transplanted and in one-year survival of kidneys and hearts.

Aggressive pharmacologic donor management results in more transplanted organs.

BACKGROUND: Brain death results in adverse pathophysiologic effects in many cadaveric donors, resulting in cardiovascular instability and poor organ perfusion. Hormonal resuscitation (HR) has been reported to stabilize and improve cardiac function in brain-dead donors. The goal of this study was to examine the effect of HR on the brain-dead donor on the number of organs transplanted per donor. METHODS: A retrospective analysis of all brain-dead donors recovered in the United States from January 1, 2000, to September 30, 2001, was conducted. HR consisted of a methylprednisolone bolus and infusions of vasopressin and either triiodothyronine or L-thyroxine. Univariate analyses and multivariate logistic regression analyses were used to detect differences between the HR group and those donors who did not receive HR. RESULTS: Of 10,292 consecutive brain-dead donors analyzed, 701 received three-drug HR. Univariate analysis showed the mean number of organs from HR donors (3.8) was 22.5% greater than that from nonhormonal resuscitation donors (3.1) (P <0.001). Multivariate analyses showed that HR was associated with the following statistically significant increased probabilities of an organ being transplanted from a donor: kidney 7.3%, heart 4.7%, liver 4.9%, lung 2.8%, and pancreas 6.0%. Extrapolation of these probabilities to the 5,921 brain-dead donors recovered in 2001 was calculated to yield a total increase of 2,053 organs. CONCLUSION: HR stabilizes certain brain-dead donors and is associated with significant increases in organs transplanted per donor.

Hormonal resuscitation yields more transplanted hearts, with improved early function.

BACKGROUND: Brain death results in cardiovascular instability and poor organ perfusion in many brain-dead donors. Hormonal resuscitation stabilizes certain brain-dead donors and is associated with significant increases in the numbers of organs transplanted per donor. The goal of this study was to examine the quality of hearts recovered from donors treated with hormonal resuscitation. METHODS: A retrospective analysis of 4,543 recipients of hearts recovered from brain-dead donors, reported to the United Network for Organ Sharing/Organ Procurement and Transplantation Network database between November 1, 1999, and December 31, 2001, was conducted. Hormonal resuscitation consisted of a methylprednisolone bolus and infusions of vasopressin and either triiodothyronine or l-thyroxine. Univariate and multivariate analyses were used to evaluate the quality of hearts from donors who received three-drug hormonal resuscitation (3HR) treatment versus donors who did not receive all three drugs (non-3HR). Death within 30 days and early graft dysfunction were used as endpoints. RESULTS: Hearts from 3HR donors demonstrated a 1-month survival rate of 96.2%, compared with a 92.1% survival rate for non-3HR donor hearts (P<0.01). Early graft dysfunction occurred in 5.6% of 3HR donor hearts and 11.6% of non-3HR donor hearts (P<0.01). Multivariate results demonstrated a 46% reduced odds of death within 30 days and a 48% reduced odds of early graft dysfunction. Steroids alone and steroids plus triiodothyronine/l-thyroxine also significantly reduced prolonged graft dysfunction. CONCLUSIONS: This study suggests that 3HR treatment of brain-dead donors results in increased numbers of transplanted hearts, with improved short-term graft function.

The role of procurement biopsies in acceptance decisions for kidneys retrieved for transplant.

BACKGROUND AND OBJECTIVES: There is a shortage of kidneys for transplant, and many patients on the deceased donor kidney transplant waiting list would likely benefit from kidneys that are currently being discarded. In the United States, the most common reason given for discarding kidneys retrieved for transplant is procurement biopsy results. This study aimed to compare biopsy results from discarded kidneys with discard attributed to biopsy findings, with biopsy results from comparable kidneys that were successfully transplanted. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this retrospective, observational, case-control study, biopsy reports were examined from 83 kidneys discarded in 2010 due to biopsy findings (cases), 83 contralateral transplanted kidneys from the same donor (contralateral controls), and 83 deceased donors randomly matched to cases by donor risk profile (randomly matched controls). A second procurement biopsy was obtained in 64 of 332 kidneys (19.3%). RESULTS: The quality of biopsy reports was low, with amounts of tubular atrophy, interstitial inflammation, arteriolar hyalinosis, and acute tubular necrosis often not indicated; 69% were wedge biopsies and 94% used frozen tissue. The correlation between first and second procurement biopsies was poor; only 25% of the variability (R(2)) in glomerulosclerosis was explained by biopsies being from the same kidney. The percentages of glomerulosclerosis overlapped substantially between cases, contralateral controls, and randomly matched controls: 17.1%±15.3%, 9.0%±6.6%, and 5.0%±5.9%, respectively. Of all biopsy findings, only glomerulosclerosis>20% was independently correlated with discard (cases versus contralateral controls; odds ratio, 15.09; 95% confidence interval, 2.47 to 92.41; P=0.003), suggesting that only this biopsy result was used in acceptance decisions. One-year graft survival was 79.5% and 90.7% in contralateral and randomly matched controls, respectively, versus 91.6% among all deceased donor transplants in the Scientific Registry of Transplant Recipients. CONCLUSIONS: Routine use of biopsies could lead to unnecessary kidney discards.

A review of studies relating to thyroid hormone therapy in brain-dead organ donors.

An acute decrease in cardiac performance can result from a reduced free triiodothyronine (FT3) level following (i) brain death (euthyroid sick syndrome), (ii) a period of cardiopulmonary bypass, and possibly (iii) regional or global myocardial ischemia. The two major pathophysiologic effects of brain death are (i) vascular injury associated with the hemodynamic consequences of the autonomic 'storm', and (ii) a generalized inhibition of mitochondrial function, which results in diminished organ function from the loss of energy stores from a rapid loss of circulating FT3. Deterioration of donor organ function can be reversed by hormonal replacement therapy, in which T3 plays a critical role. This results in (i) an increased number of organs being functionally acceptable, and (ii) increased early and intermediate graft survival. Cardiopulmonary bypass is associated with a reduction in the circulating level of FT3, and this can be associated with deterioration in cardiac function. The administration of T3 at the time of discontinuation of cardiopulmonary bypass reverses this state. In patients undergoing heart transplantation, T3 therapy to both donor and recipient is beneficial.

Organ donation in the United States: 1988-2003.

There were 6,457 deceased and 6,821 living donors recovered in 2003, a 58% and 274% increase over those recovered in 1988. The number of deceased donors aged 50 or older has increased from 12% of all donors in 1988 to 34% of all donors in 2003. The typical deceased donor in 2003 was a white male with ABO blood type O between the ages of 35-49. In 2003, a typical living donor was a white female with ABO blood type O between the ages of 35-49. Between 1988 and 2003, the percentage of minority donors increased for deceased donors (17% to 30%), and for living donors (24% to 30%). The number of living donors who were either spouses or unrelated to the recipient increased from 5% in 1988 to 33% in 2003. In 2003, California (10.2%) was most often listed as the state of residence for deceased donors, followed by Texas (7.9%) and Florida (6.9%). In 2003, deceased donors were recovered most often on Wednesdays (16.0%), followed by Tuesdays (15.2%) and Thursdays (14.7%). In 2003, living donors were recovered most often on Tuesdays (26.4%), followed by Wednesdays (25.5%) and Thursdays (20.7%). In 2003, deceased donors were recovered most often in October (9.0%), followed by January (8.6%), and July (8.6%). In 2003, living donors are recovered most often in July (10.2%), followed by October (8.9%) and June (8.6%).

Organ donation in the United States: 1988-2002.

1. There were 6,187 deceased and 6,618 living donors recovered in 2002, a 52% and 263% increase over those recovered in 1988. 2. The number of deceased donors aged 50 or older has increased from 12% of all donors in 1988 to 31% of all donors in 2002. 3. The typical deceased donor in 2002 was a White male with ABO blood type O between the ages of 18-34. In 2002, a typical living donor was a White female with ABO blood type O between the ages of 35-49. 4. Between 1988-2002, the percentage of minority donors increased among deceased donors (17% to 28%), and among living donors (24% to 29%). 5. The percentage of living donors who were either spouses or unrelated to the recipient increased from 5% in 1988 to 30% in 2002. 6. In 2002, California (10.2%) was most often listed as the state of residence for deceased donors, followed by Texas (7.9%) and Florida (6.7%). 7. In 2002, deceased donors were recovered most often on Tuesdays (15.7%), followed by Wednesdays (14.9%) and Thursdays (14.6%). 8. In 2002, living donors were recovered most often on Tuesdays (27.1%), followed by Wednesdays (26.8%) and Thursdays (20.3%). 9. In 2002, deceased donors were recovered most often in May (8.9%), followed by August (8.7%), and October (8.7%). 10. In 2002, living donors are recovered most often in July (10.0%), followed by June (9.0%) and May (8.8%).

Organ donation in the United States: 1988-2001.

Based upon information reported to the United Network for Organ Sharing (UNOS) as of December 12, 2002: 1. There were 6,082 cadaveric and 6,535 living donors recovered in 2001, a 49% and 258% increase over those recovered in 1988. 2. The number of cadaveric donors aged 50 or older increased from 12% of all donors in 1988 to 31% of all donors in 2001. 3. The typical cadaveric donor in 2001 was a white male with ABO blood type O between the ages of 35-49. In 2001, a typical living donor was a white female with ABO blood type O between the ages of 35-49. 4. Between 1988-2001, the percentage of minority donors increased for cadaveric donors (from 17% to 27%), and for living donors (from 24% to 30%). 5. The percentage of living donors who were either spouses or unrelated to the recipient increased from 5% in 1988 to 27% in 2001. 6. In 2001, California (10.2%) was most often listed as the state of residence for cadaveric donors, followed by Texas (7.9%) and Florida (7.2%). 7. In 2001, cadaveric donors were recovered most often on Tuesdays (15.1%), followed by Sundays (14.7%) and Mondays (14.6%). 8. In 2001, living donors were recovered most often on Wednesdays (28.7%), followed by Tuesdays (25.9%) and Thursdays (19.5%). 9. In 2001, cadaveric donors were recovered most often in October (9.2%), followed by May (9.0%), and August (8.8%). 10. In 2001, living donors were recovered most often in August (9.4%), followed by July (9.4%) and October (9.1%).

Benefit of child-to-parent kidney donation.

Use of child-to-parent (CTP) kidney donation may be limited because of ethical concerns as well as doubts about its effectiveness. We used the United Network for Organ Sharing database to examine the effectiveness of CTP kidney donation compared with other types of living-related (LD) kidney donation and to cadaveric kidney donation. Data from 56 873 kidney transplants performed between 1988 and 1998 showed significantly greater transplant and patient survival for CTP kidney transplants compared with cadaveric kidney transplants. The average gain in kidney transplant half-life is 3.6 years for a CTP compared with a cadaveric kidney transplant, and it is estimated that this gain for the recipient far outweighs the 1 in 3000 risk of death to the donor associated with kidney donation. We conclude that CTP kidney donation should not be discouraged, and represents a useful source of transplantable kidneys.

Increased transplanted organs from the use of a standardized donor management protocol.

The organ shortage has resulted in increasing recipient waiting lists and waiting-list deaths. The increased use of expanded donors has been associated with increased discarding of procured organs because of poor organ function. A structured donor management algorithm or critical pathway was tested to determine its effect on the donor management and procurement process. A pilot study examined donors from 88 critical care units in 10 organ procurement organizations managed under the critical pathway and compared them to retrospective data collected at those same pilot sites. The total number of organs both procured and transplanted per 100 donors was significantly greater (p <0.01) in the critical pathway group when compared to the control group. There was no significant difference in 1-year graft survival for any of the organs recovered, and no significant difference in the rate of delayed graft function in the kidneys transplanted. Use of a structured donor management algorithm results in significant increases in organs procured and organs transplanted without any reduction in the quality of the organs being transplanted.