No Stone Left Unturned: Utilization of an Organ Procurement Organization Donor Surgeon at Procurement Reduces Discards of Marginal Liver Allografts.

BACKGROUND: The recent trend of organ procurement organizations (OPOs) employing independent surgeons for organ procurement has been developed with the goal of improving the supply of suitable organs for transplantation. We investigated the effects that the addition of an OPO-employed, organ-procurement specialist has on liver allograft discard rate, marginal organ utilization, and graft survival. METHODS: Organ Procurement and Transplant Network and OPO data were retrospectively studied between April 1, 2014' and July 31, 2019' within the Southwest Transplant Alliance donor service area. Liver procurements with an OPO-surgeon present (OPO-Present) were compared to those without the involvement of an OPO surgeon (OPO-Absent). Donor and recipient characteristics as well as outcomes were analyzed across groups using propensity score matching. RESULTS: In total 869 OPO-Present liver allografts had similar rates of discard (5.2%) compared to 771 OPO-Absent livers (5.8%). However, after adjusting for donor risk, OPO-Present livers had a lower propensity of discard compared to OPO-Absent (3.4% versus 7.6%, P < 0.05). OPO-Present livers were more likely to be shared nationally (11.0% versus 4.8%, P < 0.001). Outcome analysis showed allograft survival of OPO-Present livers at 5 y was comparable to OPO-Absent livers (79.5% versus 80%, P = 0.34). CONCLUSIONS: The presence of an OPO surgeon was associated with decreased liver allograft discard and increased utilization of marginal donor organs. The OPO surgeon's presence represents a potential strategy to increase organ utilization nationally.

Maximizing the use of potential donors through increased rates of family approach for authorization.

In the United States, a small proportion of potential deceased organ donor referrals lead to donation and recovery. Understanding variation in the processes involved between organ procurement organizations (OPOs) may help increase deceased donation and reduce the organ shortage. We studied 103 923 referrals from 10 OPOs from 2018 to 2019, of which 14.4% led to approach for authorization, 8.2% led to authorization, 5.1% led to organ recovery, and 4.8% led to transplantation. First-person authorization (FPA) was associated with threefold higher odds of donation (OR = 2.83 3.02 3.22 , p < .001). Female referrals had 11% lower odds of approach; when approached, Black and Hispanic referrals had 46% and 35% lower odds of authorization, respectively (all p < .001). There was substantial OPO-level variation in rates of approach, authorization, and organ recovery, which persisted after adjusting for age, sex, race, and FPA status. An OPO's relative rate of approach correlated strongly with its relative rate of donation among all referrals (ρ = 0.43). Correlation between an individual OPO's authorization rate among approached families, and overall rate of donation, was negative, suggesting that high authorization rates may be the result of selective approach practices. Therefore, approaching a higher proportion of families for authorization may lead to higher donation rates.

Variation in donation after circulatory death hospital policies in a single donor service area.

BACKGROUND: Historically, there has been wide variation among hospital policies for donation after circulatory death (DCD) processes. With more DCD donors as well as more organs from DCD donors being utilized, it is time to revisit the variability in DCD hospital policies. METHODS: Collection of hospital characteristics, DCD referrals and completions, and DCD policies from the Southwest Transplant Alliance Donor Service Area. Content analysis of DCD hospital policies. RESULTS: We found variability in referral requirements, discussion elements for authorization, pre-mortem interventions and process elements. Most policies allow prepping and draping (84.7% [83 of 98]) and premortem heparin administration (78.6% [77 or 98]). A minority allow femoral cannulation prior to extubation (19.4% [19 of 98]) or during the hands-off period (15.3% [15 of 98]). CONCLUSIONS: We recommend a national effort to achieve consistency and clarity in DCD hospital policies based on our findings of continued variability in DCD hospital policies.

Short Report: Evaluating the Effects of Automated Donor Referral Technology on Deceased Donor Referrals.

Automation of deceased donor referrals with standardized clinical triggers allows organ procurement organizations to be rapidly aware of medically eligible potential donors without the need for manual reporting and subjective decision-making of otherwise very busy hospital staff. In October 2018, 3 Texas hospitals (pilot hospitals) began using an automated referral system; our goal was to evaluate the impact of this system on eligible donor referral. Methods: We studied ventilated referrals (n = 28 034) in a single organ procurement organization from January 2015 to March 2021. We estimated the change in referral rate in the 3 pilot hospitals due to the automated referral system using a difference-in-differences analysis with Poisson regression. Results: Ventilated referrals from the pilot hospitals increased from mean 11.7 per month pre-October 2018 to 26.7 per month post-October 2018. The difference-in-differences analysis estimated that automated referral was associated with a 45% increase in referrals (adjusted incidence rate ratio [aIRR] = 1.30 1.45 1.62), an 83% increase in approaches for authorization (aIRR = 1.34 1.83 2.48), a 73% increase in authorizations (aIRR = 1.18 1.73 2.55), and a 92% increase in organ donors (aIRR = 1.13 1.92 3.09). Conclusions: Following deployment of an automated referral system that did not require any actions by the referring hospital, referrals, authorizations, and organ donors increased substantially in the 3 pilot hospitals. Broader deployment of automated referral systems may lead to increases in the deceased donor pool.

Differences in Organ Donation and Transplantation in States Within the United States and in European Countries: Is There a Benefit to Opting Out?

BACKGROUND: Organ donation in the United States currently requires explicit consent by an "opt-in" approach. Some European countries have reported an increase in donation rates with an "opt-out" strategy. We hypothesized that regional differences in decision making affect organ donation rates in different countries and suggest no single approach will reliably increase organ donation rates. METHODS: Donation and transplantation rates in European countries and states within the United States with populations of >10 million and a minimum organ donation rate of 10 donors per million were compared. 2016 International Registry in Organ Donation and Transplantation data and the 2016 Scientific Registry of Transplant Recipients annual report were used for European countries and US states, respectively. Comparisons by region and donation model were made. RESULTS: Deceased organ donor rates and transplants did not differ between opt-in and opt-out models. Living donation was increased in all opt-in entities. When comparing European countries, there was a trend toward higher organ donation rates in opt-out countries than in opt-in countries. Donation and transplantation rates of US states were higher than both European opt-in and opt-out countries. CONCLUSION: There were no differences in deceased donor organ donation when considering the donation consent model. These data do not support that an opt-out approach will increase the number of transplants in the United States.

Early Experiences With COVID-19 Testing in Transplantation.

BACKGROUND: The early effects of coronavirus disease 2019 (COVID-19) on transplantation are dramatic: >75% of kidney and liver programs are either suspended or operating under major restrictions. To resume transplantation, it is important to understand the prevalence of COVID-19 among transplant recipients, donors, and healthcare workers (HCWs) and its associated mortality. METHODS: To investigate this, we studied severe acute respiratory syndrome coronavirus 2 diagnostic test results among patients with end-stage renal disease or kidney transplants from the Johns Hopkins Health System (n = 235), and screening test results from deceased donors from the Southwest Transplant Alliance Organ Procurement Organization (n = 27), and donors, candidates, and HCWs from the National Kidney Registry and Viracor-Eurofins (n = 253) between February 23 and April 15, 2020. RESULTS: We found low rates of COVID-19 among donors and HCWs (0%-1%) who were screened, higher rates of diagnostic tests among patients with end-stage renal disease or kidney transplant (17%-20%), and considerable mortality (7%-13%) among those who tested positive. CONCLUSIONS: These findings suggest the threat of COVID-19 for the transplant population is significant and ongoing data collection and reporting is critical to inform transplant practices during and after the pandemic.

Improving oxygenation when conventional ventilation fails: a case study.

Long periods of significant hypoxia do not disqualify a patient from becoming an organ donor. As the management of organ donor patients becomes more complex, recovery coordinators often have to change their thinking and resort to nonconventional means of management. This case study presents a hypoxic donor and how using pressure-control inverse ratio ventilation improved oxygenation in this donor. Before changing ventilator modes, the transplant surgeons were concerned about the long periods of hypoxia the patient had experienced during her hospitalization. After making the change, improving oxygenation, and demonstrating an improved oxygen state, 4 organs were recovered and subsequently transplanted. All the recovered organs functioned immediately after transplantation without any signs of poor performance. Although this treatment modality is not available at every institution, it can be used to improve oxygenation problems in organ donors.