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.

Optimized technique in needle biopsy protocol shown to be of greater sensitivity and accuracy compared to wedge biopsy.

BACKGROUND: Kidney biopsy is an important tool in determining allograft suitability for transplantation. Most deceased-donor renal biopsies performed today in the United States are wedge biopsies (WBs), with core needle biopsies being performed only by a minority of organ procurement organizations (OPOs). The lack of a gold standard in tissue sampling and tissue evaluation has prompted our OPO to find a more sensitive biopsy method as well as a more accurate pathology evaluation protocol to reassess expanded-criteria donor kidneys. METHODS: Between the months of March 2007 and June 2008, the New York Organ Donor Network OPO imported 226 kidneys. These kidneys had been previously biopsied by the originating OPOs utilizing the WB method. All 226 kidneys were rebiopsied by our preservation team using the optimized needle biopsy technique (ONBT) and then evaluated by the pathologists of the Transplant Pathology Laboratory of the Mount Sinai Hospital. RESULTS: Histologic findings from both types of biopsies were compared in the following parameters: glomerular yield, percentage of obsolete glomeruli, tubular interstitial scarring, arterial intimal fibrosis and acute tubular necrosis. Difference in glomerular yield between WB and ONBT was not statistically significant (P = .1736). ONBT detected more tubular interstitial scarring and arterial intimal fibrous narrowing than WB (P = .00). No statistical difference was found between the two biopsy methods in identifying acute tubular necrosis. CONCLUSION: The data suggest that there were no statistical differences in sample reliability between ONBT and WB. However, ONBT was found to be significantly more sensitive in identifying allograft tubular interstitial scarring as well as intimal fibrous narrowing. Overall this study provides proof that ONBT is a more reliable and accurate method compared to WB in identifying important parameters of renal allograft.

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.