Investigating geographic variation in mortality in the context of organ donation.

Organ procurement organizations (OPOs) report a nearly fourfold difference in donor availability as measured by eligible deaths per million population (PMP) based on hospital referrals. We analyzed whether mortality data help explain geographic variation in organ supply as measured by the number of eligible deaths for organ donation. Using the 2007 National Center for Health Statistics' mortality data, we analyzed deaths occurring in acute care hospitals, aged ≤ 70 years from cerebrovascular accidents and trauma. These deaths were mapped at the county level and compared to eligible deaths reported by OPOs. In 2007, there were 2 428 343 deaths reported in the United States with 42 339 in-hospital deaths ≤ 70 years from cerebrovascular accidents (CVA) or trauma that were correlated with eligible deaths PMP (r(2) = 0.79.) Analysis revealed a broad range in the death rate across OPOs: trauma deaths: 44-118 PMP; deaths from CVA: 34-118 PMP; and combined CVA and trauma: 91-229 PMP. Mortality data demonstrate that deaths by neurologic criteria of people who are likely to be suitable deceased donors are not evenly distributed across the nation. These deaths are correlated with eligible deaths for organ donation. Regional availability of organs is affected by deaths which should be accounted for in the organ allocation system.

Derivation of the uncontrolled donation after circulatory determination of death protocol for New York city.

Evidence from Europe suggests establishing out-of-hospital, uncontrolled donation after circulatory determination of death (UDCDD) protocols has potential to substantially increase organ availability. The study objective was to derive an out-of-hospital UDCDD protocol that would be acceptable to New York City (NYC) residents. Participatory action research and the SEED-SCALE process for social change guided protocol development in NYC from July 2007 to September 2010. A coalition of government officials, subject experts and communities necessary to achieve support was formed. Authorized NY State and NYC government officials and their legal representatives collaboratively investigated how the program could be implemented under current law and regulations. Community stakeholders (secular and religious organizations) were engaged in town hall style meetings. Ethnographic data (meeting minutes, field notes, quantitative surveys) were collected and posted in a collaborative internet environment. Data were analyzed using an iterative coding scheme to discern themes, theoretical constructs and a summary narrative to guide protocol development. A clinically appropriate, ethically sound UDCDD protocol for out-of-hospital settings has been derived. This program is likely to be accepted by NYC residents since the protocol was derived through partnership with government officials, subject experts and community participants.

An approach to needle biopsy technique to improve glomerulus yield.

BACKGROUND: Recent literature has indicated that more than 25 glomeruli need to be visualized for accurate and reproducible assessment of kidney allograft pathology. PURPOSE: Concern was raised by the Kidney-Pancreas Committee of a large, urban Organ Procurement Organization (OPO) about the high variability of glomerulus yield and the increased propensity for cortical damage from wedge biopsies as compared with core biopsies. However, as of August 2006, average glomerulus yield using the needle technique failed to yield more than the suggested 25 glomeruli. The OPO instituted a process that would increase glomerulus yield while continuing to utilize the needle biopsy technique. METHODS: The OPO undertook an internal training program with its staff to improve biopsy technique, and initiated taking two cores from each kidney instead of one. RESULTS: With initial training in biopsy technique, glomerulus yield increased by 36% and also increased the size of the core (P < .01); however, 55% of biopsies still yielded fewer than 25 glomeruli. With an increase of biopsy core size to 14 gauge, mean glomerular yield approached 25 glomeruli per kidney, yet the majority of kidneys continued to have insufficient glomerulus yield. Over a period of 2 months, the biopsy procedure was modified to two 14-gauge cores per kidney, resulting in 91% of kidney biopsies yielding more than 25 glomeruli. CONCLUSION: Our data suggest that adequate kidney allograft assessment can be obtained with two 14-gauge biopsy cores.

Deceased organ donor characteristics and clinical interventions associated with organ yield.

While the function of each organ is used by each transplant team to assess suitability for transplantation, little is known about the donor characteristics and clinical interventions that contribute toward overall organ transplantation potential. We conduct a retrospective review of United Network for Organ Sharing (UNOS) deceased donor registry data from January 2005 to December 2006. This registry contains all deceased donors from whom organs were recovered during this time period (n = 15,601). Ordinary least-squares (OLS) regression models using variables in the registry are estimated to predict the number of organs transplanted. Outcome is the number of organs transplanted per donor. Organ yield is found to depend significantly on donor age, anoxia as cause of death, history of myocardial infarction (MI), hypertension and/or diabetes, body mass index (BMI), B or AB blood type, cocaine and/or cigarette use and hepatitis infection (p < 0.01). In addition, the clinical interventions of steroid administration, desmopressin (DDAVP) and diuretic usage, as well as oxygenation, are associated with organ yield. Both intrinsic donor characteristics and medical management practice are observed to be highly variable across organ procurement organizations (OPOs). These findings may provide important information to explore and assess the efficacy of clinical interventions, compare OPO performance and point to best practices.