Outcomes of a High-Volume Organ Procurement Organization in the Era of Increasing Donation After Circulatory Death.

Introduction: Donation after circulatory death (DCD) is rapidly increasing in the United States. Detailed data outlining the process from referral to organ transplantation is lacking. Project Aims: We sought to quantify differences at each stage along the referral to donation pathway by donor type. Additionally, we examined factors associated with successful DCD organ utilization. Design: This program evaluation analyzed data from a single organ procurement organization in 2018 to assess demographic and clinical predictors of progression through the donation process, including the role of first-person authorization in DCD. Descriptive statistics were examined by donation stage for demographic characteristics using chi-square; univariate and multivariate logistic regression was used to model predictors of utilization and authorization by organ type, respectively. Results: There were 2466 organ donation referrals during 2018, including 575 donations after brainstem death (DBD), 1890 controlled DCD referrals, and 1 uncontrolled DCD referral. Univariate and multivariate logistic regression models highlighted differences in authorization rates by donor type (DCD vs DBD) and by age, race, and ethnicity. Next-of-kin authorization was declined in 23% of first-person authorized potential DCD, highlighting issues related to the role of donor registration in DCD. Pre-mortem heparin administration was predictive of DCD organ utilization; donor age and warm ischemia time of less than 30 min was statistically significantly associated with DCD extra-renal organ utilization. Conclusion: These results provided insight into strategies for increasing authorization and transplantation of organs from DCD donors and identified areas of improvement for process standardization and policy development.

National Landscape of Human Immunodeficiency Virus-Positive Deceased Organ Donors in the United States.

BACKGROUND: Organ transplantation from donors with human immunodeficiency virus (HIV) to recipients with HIV (HIV D+/R+) presents risks of donor-derived infections. Understanding clinical, immunologic, and virologic characteristics of HIV-positive donors is critical for safety. METHODS: We performed a prospective study of donors with HIV-positive and HIV false-positive (FP) test results within the HIV Organ Policy Equity (HOPE) Act in Action studies of HIV D+/R+ transplantation (ClinicalTrials.gov NCT02602262, NCT03500315, and NCT03734393). We compared clinical characteristics in HIV-positive versus FP donors. We measured CD4 T cells, HIV viral load (VL), drug resistance mutations (DRMs), coreceptor tropism, and serum antiretroviral therapy (ART) detection, using mass spectrometry in HIV-positive donors. RESULTS: Between March 2016 and March 2020, 92 donors (58 HIV positive, 34 FP), representing 98.9% of all US HOPE donors during this period, donated 177 organs (131 kidneys and 46 livers). Each year the number of donors increased. The prevalence of hepatitis B (16% vs 0%), syphilis (16% vs 0%), and cytomegalovirus (CMV; 91% vs 58%) was higher in HIV-positive versus FP donors; the prevalences of hepatitis C viremia were similar (2% vs 6%). Most HIV-positive donors (71%) had a known HIV diagnosis, of whom 90% were prescribed ART and 68% had a VL <400 copies/mL. The median CD4 T-cell count (interquartile range) was 194/µL (77-331/µL), and the median CD4 T-cell percentage was 27.0% (16.8%-36.1%). Major HIV DRMs were detected in 42%, including nonnucleoside reverse-transcriptase inhibitors (33%), integrase strand transfer inhibitors (4%), and multiclass (13%). Serum ART was detected in 46% and matched ART by history. CONCLUSION: The use of HIV-positive donor organs is increasing. HIV DRMs are common, yet resistance that would compromise integrase strand transfer inhibitor-based regimens is rare, which is reassuring regarding safety.

Decellularization of Whole Human Heart Inside a Pressurized Pouch in an Inverted Orientation.

The ultimate solution for patients with end-stage heart failure is organ transplant. But donor hearts are limited, immunosuppression is required, and ultimately rejection can occur. Creating a functional, autologous bio-artificial heart could solve these challenges. Biofabrication of a heart comprised of scaffold and cells is one option. A natural scaffold with tissue-specific composition as well as micro- and macro-architecture can be obtained by decellularizing hearts from humans or large animals such as pigs. Decellularization involves washing out cellular debris while preserving 3D extracellular matrix and vasculature and allowing "cellularization" at a later timepoint. Capitalizing on our novel finding that perfusion decellularization of complex organs is possible, we developed a more "physiological" method to decellularize non-transplantable human hearts by placing them inside a pressurized pouch, in an inverted orientation, under controlled pressure. The purpose of using a pressurized pouch is to create pressure gradients across the aortic valve to keep it closed and improve myocardial perfusion. Simultaneous assessment of flow dynamics and cellular debris removal during decellularization allowed us to monitor both fluid inflow and debris outflow, thereby generating a scaffold that can be used either for simple cardiac repair (e.g. as a patch or valve scaffold) or as a whole-organ scaffold.

Organ Donation in the 50+ Age Demographic: Survey Results on Decision Rationale and Information Preferences.

The rate of organ donation by older potential donors is significantly declining even though recent studies show positive clinical outcomes with organs transplanted from older donors. This study examined the 50+ age demographic to identify the rationale for donation decisions, preferred media methods of donation information delivery, and responsiveness to an age-tailored donation message. Results from 579 surveys, 87% from the 50+ age demographic, found respondents prone to self-select themselves as medically ineligible based on current medication and health status, even though they might be medically suitable donors. Their incentive to pursue additional information on donation is limited except when motivated by personal accounts within their families and communities. In addition, even when computer literate, they continue to favor the printed or spoken word for donation information delivery. The results suggest an opportunity for those working with older adults to develop more personalized, localized donation education programs targeting this age demographic.

Family responses to donor designation in donation cases: a longitudinal study.

CONTEXT: A 2001 state law reinforced donors' rights by mandating that donor consent be strictly honored. One concern was the potentially negative impact of donor designation notification on donor families. OBJECTIVES: To examine donor families' responses to donor designation. DESIGN: Descriptive nonexperimental design spanning July 1999 to September 2004. SETTING: State served by organ procurement organization. DATA: Results from surveys completed by 569 donor families, including 162 surveys from designated donor families. MAIN OUTCOME MEASURES: Previous discussions, designation awareness, information helpful, information stress, awareness of meaning of donation, and comfort with designation decision. RESULTS: The majority (79%) of designated donor families reported their loved ones had discussed donation with them; of these families, 86% were aware of donor designation, and 83% understood what donation entailed. The majority (75%) thought information about loved ones' donor designation was helpful, and only 8% found it stressful. In contrast, 18% of families of nondesignated donors said being approached about donation was stressful after the law was strengthened. However, over 80% of all donor families were comfortable with the donation decision. CONCLUSIONS: The results fail to support the assumption that donor families perceive donor designation notification as negative and stressful. The majority of designated donor families report relief and reduced stress, compared to families approached for donation. The findings suggest that strengthening donor designation legislation can lead to positive results for donor families and donation recipients.

The distal metatarsal osteotomy for the treatment of hallux valgus.

This article discusses various forms of distal metatarsal osteotomy for the treatment of hallux valgus. The techniques for the various osteotomies have evolved over the years to allow the surgeon to match a procedure and its modifications to the individual patient's deformity, thus optimizing outcomes. Fixation techniques continue to evolve, and meticulous surgical technique to prevent complications remains a must. Regardless of the osteotomy used, the authors believe that adherence to the techniques laid out in current literature will provide gratifying results for the surgeon and the patient.

Unintended consequences: the impact of protocol change on critical care nurses' perceptions of stress.

CONTEXT: The Family Communication Coordinator protocol was implemented to facilitate effective communications during potential organ donation cases. Previous research records its effectiveness relative to donor outcome measures. By redefining and clarifying role responsibilities, the protocol may be associated with reduced job stress for those caring for potential donors. OBJECTIVES: To determine the relationship of the Family Communication Coordinator protocol on the role stress of critical care nurses. To examine role stress in terms of role ambiguity, role conflict, and role overload within the context of potential organ donation cases. DESIGN: Retrospective nonexperimental descriptive design. SETTING: Critical care units of an academic teaching hospital. PARTICIPANTS: Nineteen critical care nurses with experience before and after implementation of the Family Communication Coordinator protocol. MAIN OUTCOME MEASURES: Job dimensions, role stress, job satisfaction, and commitment, measured using surveys. These data were supplemented with interviews and hospital records. RESULTS: The findings demonstrate that the Family Communication Coordinator protocol is associated with reduced role stress. More specifically, the nurses perceived significant reductions in role ambiguity and role conflict, and some reduction in role overload. The findings highlight high satisfaction with the protocol, as well as improved job satisfaction, and professional and organizational commitment. CONCLUSIONS: The results suggest that reduced role stress among critical care nurses is associated with implementation of a protocol already associated with improved organ donation outcomes. The findings suggest positive outcomes also may impact other staff, multidisciplinary functions, and the organization. Similar protocols may be appropriate in other end-of-life situations to reduce uncertainty and stress among critical care professionals.