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1.
Am J Transplant ; 20(11): 3081-3088, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32659028

RESUMO

The coronavirus disease 2019 (COVID-19) pandemic is a rapidly changing circumstance with dramatic policy changes and universal efforts to deal with the initial crisis and minimize its consequences. To identify changes to organ donation and transplantation during this time, an anonymous web-based survey was distributed to 19 select organ procurement organizations (OPOs) throughout the United States comparing 90-day activity during March-May 2020 and March-May 2019. Seventeen OPOs responded to the survey (response rate of 89.5%). Organ authorization decreased by 11% during the current pandemic (n = 1379 vs n = 1552, P = .0001). Organ recovery for transplantation fell by 17% (P = .0001) with a further 18% decrease in the number of organs transplanted (P = .0001). Donor cause of death demonstrated a 4.5% decline in trauma but a 35% increase in substance abuse cases during the COVID-19 period. All OPOs reported significant modifications in response to the pandemic, limiting the onsite presence of staff and transitioning to telephonic approaches for donor family correspondence. Organ donation during the current climate has seen significant changes and the long-term implications of such shifts remain unclear. These trends during the COVID-19 era warrant further investigation to address unmet needs, plan for a proportionate response to the virus and mitigate the collateral impact.

2.
Am J Transplant ; 20(7): 1795-1799, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32368850

RESUMO

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has rapidly become an unprecedented pandemic that has impacted society, disrupted hospital functions, strained health care resources, and impacted the lives of transplant professionals. Despite this, organ failure and the need for transplant continues throughout the United States. Considering the perpetual scarcity of deceased donor organs, Kates et al present a viewpoint that advocates for the utilization of coronavirus disease 2019 (COVID-19)-positive donors in selected cases. We present a review of the current literature that details the potential negative consequences of COVID-19-positive donors. The factors we consider include (1) the risk of blood transmission of SARS-CoV-2, (2) involvement of donor organs, (3) lack of effective therapies, (4) exposure of health care and recovery teams, (5) disease transmission and propagation, and (6) hospital resource utilization. While we acknowledge that transplant fulfills the mission of saving lives, it is imperative to consider the consequences not only to our recipients but also to the community and to health care workers, particularly in the absence of effective preventative or curative therapies. For these reasons, we believe the evidence and risks show that COVID-19 infection should continue to remain a contraindication for donation, as has been the initial response of donation and transplant societies.


Assuntos
Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Transplante de Órgãos/efeitos adversos , Transplante de Órgãos/tendências , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Doadores de Tecidos , Obtenção de Tecidos e Órgãos/ética , Obtenção de Tecidos e Órgãos/tendências , Ética Médica , Humanos , Unidades de Terapia Intensiva , Exposição Ocupacional , Equipamento de Proteção Individual , Alocação de Recursos , Risco , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Estados Unidos
3.
Transplantation ; 104(2): 343-348, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31283685

RESUMO

BACKGROUND: More people who have personally consented to organ donation via first person authorization (FPA) registration before death become organ donors than those not personally consenting. The majority of registrations occur at state-specific department of motor vehicle (DMV) and licensing offices, where people register their vehicles and obtain driver's licenses. METHODS: One organ procurement organization (OPO) ran 3 DMV offices and implemented an intervention: a donor-centric approach, including employee education, office decoration with donation materials, and customer experience improvements. Data about registry enrollment was collected before and during the 4-year OPO licensing office contract. A linear mixed model and interrupted time series analyses were performed to evaluate whether the intervention improved rates of registration. RESULTS: Preintervention registry enrollment rates per month were 10%-50%. Having the offices run by an OPO was associated with more enrollments independent of the increasing trend of enrollment (P < 0.001). Also, the DMV office with the lowest preimplementation registration rates had an immediate increase in enrollments after the intervention leading to higher registration rates (P < 0.001). CONCLUSIONS: A donor-centric OPO-managed DMV experience increases FPA registration, especially at offices with low initial registration rates. However, even at the office with the highest percentage of FPA registrations, rates were only 65% at intervention conclusion. The transplant community should consider other opportunities for FPA registration.


Assuntos
Veículos Automotores/legislação & jurisprudência , Transplante de Órgãos/tendências , Sistema de Registros , Doadores de Tecidos/provisão & distribução , Obtenção de Tecidos e Órgãos/organização & administração , Humanos , Estados Unidos
4.
Am J Transplant ; 19(8): 2241-2251, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30809941

RESUMO

The use of procurement biopsies in deceased donor kidney acceptance is controversial. We analyzed Scientific Registry of Transplant Recipients data (n = 59 328 allografts, 2014-2018) to describe biopsy practices across US organ procurement organizations (OPOs) and examine relationships with discards, using hierarchical modeling to account for OPO and donor factors. Median odds ratios (MORs) provide the median of the odds that allografts with identical reported traits would be biopsied or discarded from 2 randomly drawn OPOs. Biopsies were obtained for 52.7% of kidneys. Biopsy use rose in a graded manner with kidney donor profile index (KDPI). Biopsy rates differed significantly among OPOs (22.8% to 77.5%), even after adjustment for KDPI and other donor factors. Discard rates also varied from 6.6% to 32.1% across OPOs. After adjustment for donor factors and OPO, biopsy was associated with more than 3 times the likelihood of discard (adjusted odds ratio [95%LCL aOR95 %UCL ], 3.29 3.513.76 ). This association was most pronounced for low-risk (KDPI <20) kidneys (aOR, 5.45 6.477.69 ), with minimal impact at KDPI >85 (aOR, 0.88 1.151.51 ). Adjusted MORs for kidney discard and biopsy were greatest for low-risk kidneys. Reducing the rate of unnecessary biopsy and improving the accuracy of histologic assessments in higher KDPI organs may help reduce graft discard rates.


Assuntos
Seleção do Doador/métodos , Transplante de Rim/métodos , Doadores de Tecidos/provisão & distribução , Obtenção de Tecidos e Órgãos/métodos , Biópsia , Seleção do Doador/normas , Seguimentos , Humanos , Transplante de Rim/normas , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Obtenção de Tecidos e Órgãos/normas , Transplantados
5.
Am J Transplant ; 19(8): 2164-2167, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30758137

RESUMO

Organ allocation for transplantation aims to balance the principles of justice and medical utility to optimally utilize a scarce resource. To address practical considerations, the United States is divided into 58 donor service areas (DSA), each constituting the first unit of allocation. In November 2017, in response to a lawsuit in New York, an emergency action change to lung allocation policy replaced the DSA level of allocation for donor lungs with a 250 nautical mile circle around the donor hospital. Similar policy changes are being implemented for other organs including heart and liver. Findings from a recent US Department of Health and Human Services report, supplemented with data from our institution, suggest that the emergency policy has not resulted in a change in the type of patients undergoing lung transplantation (LT) or early postoperative outcomes. However, there has been a significant decline in local LT, where donor and recipient are in the same DSA. With procurement teams having to travel greater distances, organ ischemic time has increased and median organ cost has more than doubled. We propose potential solutions for consideration at this critical juncture in the field of transplantation. Policymakers should choose equitable and sustainable access for this lifesaving discipline.


Assuntos
Transplante de Pulmão/normas , Regionalização/normas , Alocação de Recursos/legislação & jurisprudência , Doadores de Tecidos/provisão & distribução , Obtenção de Tecidos e Órgãos/organização & administração , Listas de Espera/mortalidade , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Obtenção de Tecidos e Órgãos/tendências
6.
Am J Transplant ; 19(5): 1296-1304, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30247814

RESUMO

Abdominal organ transplantation faces several challenges: burnout, limited pipeline of future surgeons, changes in liver allocation potentially impacting organ procurement travel, and travel safety. The organ procurement center (OPC) model may be one way to mitigate these issues. Liver transplants from 2009 to 2016 were reviewed. There were 755 liver transplants performed with 525 OPC and 230 in-hospital procurements. The majority of transplants (87.4%) were started during daytime hours (5 am-7 pm). Transplants with any portion occurring after-hours were more likely to have procurements in-hospital (P < .001). Daytime cases (n = 400) had more OPC procured livers and hepatitis C recipients and were less likely to have a donation after circulatory death donor (all P < .05). In adjusted analyses, daytime cases were independently associated with extubation in the operating room and less postoperative transfusion. There were no significant differences in short- or long-term postoperative outcomes. For exported livers, 54.3% were procured by a local team, saving 137 flights (151 559 miles). The OPC resulted in optimally timed liver transplants and decreased resource utilization with no negative impact on patient outcomes. It allows for ease in exporting organs procured by local surgeons, and potentially addresses provider burnout, the transplant surgery pipeline, and surgeon travel.


Assuntos
Esgotamento Profissional , Transplante de Fígado/métodos , Transplante de Fígado/estatística & dados numéricos , Alocação de Recursos , Obtenção de Tecidos e Órgãos/métodos , Adulto , Agendamento de Consultas , Criança , Isquemia Fria , Sobrevivência de Enxerto , Acesso aos Serviços de Saúde , Hepatite C/complicações , Hospitais , Humanos , Transplante de Fígado/educação , Pessoa de Meia-Idade , Preservação de Órgãos , Avaliação de Resultados em Cuidados de Saúde , Segurança do Paciente , Admissão e Escalonamento de Pessoal , Qualidade de Vida , Estudantes de Medicina , Cirurgiões , Doadores de Tecidos , Viagem
7.
J Am Coll Surg ; 226(5): 909-916, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29505825

RESUMO

BACKGROUND: Donation after cardiac death (DCD) is one method of organ donation. Nationally, more than half of evaluated DCD donors do not yield transplantable organs. There is no algorithm for predicting which DCD donors will be appropriate for organ procurement. Donation after cardiac death program costs from an organ procurement organization (OPO) accounting for all evaluated donors have not been reported. STUDY DESIGN: Hospital, transportation, and supply costs of potential DCD donors evaluated at a single OPO from January 2009 to June 2016 were collected. Mean costs per donor and per organ were calculated. Cost of DCD donors that did not yield a transplantable organ were included in cost analyses resulting in total cost of the DCD program. Donation after cardiac death donor costs were compared with costs of in-hospital donation after brain death (DBD) donors. RESULTS: There were 289 organs transplanted from 264 DCD donors evaluated. Mean cost per DCD donor yielding transplantable organs was $9,306. However, 127 donors yielded no organs, at a mean cost of $8,794 per donor. The total cost of the DCD program was $32,020 per donor and $15,179 per organ. Mean cost for an in-hospital DBD donor was $33,546 and $9,478 per organ transplanted. Mean organ yield for DBD donors was 3.54 vs 2.21 for DCD donors (p < 0.0001), making the cost per DBD organ 63% of the cost of a DCD organ. CONCLUSIONS: Mean cost per DCD donor is comparable with DBD donors, however, individual cost of DCD organs increases by almost 40% when all costs of an entire DCD program are included.


Assuntos
Custos e Análise de Custo , Morte , Doadores de Tecidos , Obtenção de Tecidos e Órgãos/economia , Feminino , Humanos , Masculino
8.
Sci Immunol ; 2(10)2017 Apr 21.
Artigo em Inglês | MEDLINE | ID: mdl-28567448

RESUMO

Obesity-related insulin resistance is driven by low-grade chronic inflammation of metabolic tissues. In the liver, non-alcoholic fatty liver disease (NAFLD) is associated with hepatic insulin resistance and systemic glucose dysregulation. However, the immunological factors supporting these processes are poorly understood. We found that the liver accumulates pathogenic CD8+ T cell subsets which control hepatic insulin sensitivity and gluconeogenesis during diet-induced obesity in mice. In a cohort of human patients, CD8+ T cells represent a dominant intrahepatic immune cell population which links to glucose dysregulation. Accumulation and activation of these cells are largely supported by type I interferon (IFN-I) responses in the liver. Livers from obese mice upregulate critical interferon regulatory factors (IRFs), interferon stimulatory genes (ISGs), and IFNα protein, while IFNαR1-/- mice, or CD8-specific IFNαR1-/- chimeric mice are protected from disease. IFNαR1 inhibitors improve metabolic parameters in mice, while CD8+ T cells and IFN-I responses correlate with NAFLD activity in human patients. Thus, IFN-I responses represent a central immunological axis that governs intrahepatic T cell pathogenicity during metabolic disease.

9.
J Am Coll Surg ; 222(4): 591-600, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26947113

RESUMO

BACKGROUND: A new era in organ donation with national redistricting is being proposed. With these proposals, costs of organ acquisition are estimated to more than double. Traditionally, organ recoveries occur in the donor hospital setting, incurring premium hospital expenses. The aim of the study was to determine organ recovery costs and organ yield for donor recoveries performed at an organ procurement organization (OPO) facility. STUDY DESIGN: In 2001, we established an OPO facility and in 2008 began transferring the donor expeditiously when brain death was declared. The OPO donor and hospital costs on a per donor basis were calculated. Donation after cardiac death donors cannot be transferred and were included in the hospital cost analysis. RESULTS: From January 2009 to December 2014, nine hundred and sixty-three donors originating in our OPO had organs recovered and transplanted. Seven hundred and sixty-six (79.5%) donors were transferred to the OPO facility 8.6 hours (range 0.6 to 23.6 hours) after declaration of brain death. Donor recovery cost was 51% less when donors were transferred to the OPO facility ($16,153 OPO recovery vs $33,161 hospital recovery; p < 0.0001). Organ yield was 27.5% better (3.43 organs) from OPO-recovered donors vs an organ yield of 2.69 from hospital-recovered donors (p < 0.0001). Standard criteria donor organ yield from our OPO was 6% higher than the national average (3.92 vs 3.7 nationally; p = 0.012) and expanded criteria donor organ yield was 18% higher (2.2 vs 1.87 nationally; p = 0.03). CONCLUSIONS: An OPO facility for donor organ recovery increases efficiency and organ yield, reduces costs, and minimizes organ acquisition charge. As we face new considerations with broader sharing, increased efficiencies, cost. and organ use should be considered.


Assuntos
Obtenção de Tecidos e Órgãos/organização & administração , Bancos de Espécimes Biológicos/economia , Morte Encefálica , Controle de Custos , Arquitetura de Instituições de Saúde/economia , Custos Hospitalares , Humanos , Transferência de Pacientes/economia , Estudos Retrospectivos , Coleta de Tecidos e Órgãos/economia
10.
J Crit Care ; 28(1): 111.e1-7, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-22762934

RESUMO

PURPOSE: Corticosteroids are used to promote hemodynamic stability and reduce inflammatory organ injury after brain death. High-dose (HD) methylprednisolone has become the standard regimen based on comparisons to untreated/historical controls. However, this protocol may exacerbate hyperglycemia. Our objective was to compare a lower-dose (LD) steroid protocol (adequate for hemodynamic stabilization in adrenal insufficiency and sepsis) to the traditional HD regimen in the management of brain-dead organ donors. METHODS: We evaluated 132 consecutive brain-dead donors managed before and after changing the steroid protocol from 15 mg/kg methylprednisolone (HD) to 300 mg hydrocortisone (LD). Primary outcome measures were glycemic control, oxygenation, hemodynamic stability, and organs transplanted. RESULTS: Groups were balanced except for nonsignificantly higher baseline Pao(2) in the LD cohort. Final Pao(2) remained higher (394 mm Hg LD vs 333 mm Hg HD, P=.03); but improvement in oxygenation was comparable (+37 mm Hg LD vs +28 mm Hg HD, P=.43), as was the proportion able to come off vasopressor support (39% LD vs 47% HD, P=.38). Similar proportions of lungs (44% vs 33%) and hearts (31% vs 27%) were transplanted in both groups. After excluding diabetics, median glucose values at 4 hours (170 mmol/L vs 188 mmol/L, P=.06) and final insulin requirements (2.9 U/h vs 8.4 U/h, P=.01) were lower with LD steroids; and more patients were off insulin infusions (74% LD vs 53% HD, P=.02). CONCLUSIONS: A lower-dose corticosteroid protocol did not result in worsened donor pulmonary or cardiac function, with comparable organs transplanted compared with the traditional HD regimen. Insulin requirements and glycemic control were improved. High-dose methylprednisolone may not be required to support brain-dead donors.


Assuntos
Anti-Inflamatórios/administração & dosagem , Hidrocortisona/administração & dosagem , Hiperglicemia/prevenção & controle , Metilprednisolona/administração & dosagem , Obtenção de Tecidos e Órgãos , Adulto , Anti-Inflamatórios/efeitos adversos , Morte Encefálica , Feminino , Transplante de Coração , Humanos , Hidrocortisona/efeitos adversos , Hiperglicemia/induzido quimicamente , Transplante de Pulmão , Masculino , Metilprednisolona/efeitos adversos , Pessoa de Meia-Idade , Estudos Prospectivos , Análise de Regressão
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