The real unmet need: A multifactorial approach for identifying sensitized kidney candidates with low access to transplant.

BACKGROUND: At the start of 2020, the kidney waiting list consisted of 2526 candidates with a calculated panel reactive antibody (CPRA) of 99.9% or greater, a cohort demonstrated in published research to have meaningfully lower than average access to transplantation even under the revised kidney allocation system (KAS). METHODS: This was a retrospective analysis of US kidney registrations using data from the OPTN [Reference (https://optn.transplant.hrsa.gov/data/about-data/)]. The period-prevalent study cohort consisted of US kidney-alone registrations who waited at least 1 day between April 1, 2016, when HLA DQ-Alpha and DP-Beta unacceptable antigen data became available in OPTN data collection, to December 31, 2019. Poisson rate regression was used to model deceased donor kidney transplant rates per active year waiting and using an offset term to account for differential at-risk periods. Median time to transplant was estimated for each IRR group using the Kaplan-Meier method. Sensitivity analyses were included to address geographic variation in supply-to-demand ratios and differences in dialysis time or waiting time. RESULTS: In this study, we found 1597 additional sensitized (CPRA 50-<99.9%) candidates with meaningfully lower than average access to transplant when simultaneously taking into account CPRA and other factors. In combination with CPRA, candidate blood type, Estimated Post-Transplant Survival Score (EPTS), and presence of other antibody specificities beyond those in the current, 5-locus CPRA were found to influence the likelihood of transplant. CONCLUSION: In total, this suggests approximately 4100 sensitized candidates are on the waiting list who represent a community of disadvantaged patients who may benefit from progressive therapies and interventions to facilitate incompatible transplantation. Though associated with higher risks, such interventions may nevertheless be more attractive than remaining on dialysis with the associated accumulation of mortality risk over time.

Geographic disparities in lung transplantation in the United States before and after the November 2017 allocation change.

BACKGROUND: The primary lung allocation unit was expanded from the donation service area to a 250-mile radius in 2017. Prior to the change, geographic disparities in donor lung availability impacted waitlist outcomes. We sought to determine if the new allocation system improved these disparities. METHODS: We conducted a retrospective cohort study comparing the 2-year period before and after the change. Donor lung availability was defined as the ratio of donor lungs to waitlist candidates in the primary allocation unit. Transplant centers were divided into quartiles by donor lung availability. Multivariable competing risk models were used to determine the association between lung availability and waitlist outcomes. Multivariable Cox proportional hazards models compared post-transplant survival. RESULTS: Prior to the allocation change, the unadjusted transplant rate at centers in the lowest and highest quartiles was 132 and 607 transplants per 100 waitlist years. Candidates in the lowest quartile of donor lung availability had a 61% adjusted lower transplantation rate compared to candidates in highest quartile (sub-hazard ratio [sHR]: 0.39, 95% confidence interval [CI]: 0.34-0.44). After the allocation change, the disparity decreased resulting in an unadjusted transplant rate of 141 and 309 among centers in the lowest and highest quartiles. Candidates in the lowest quartile had a 38% adjusted lower transplantation rate compared to those in the highest (sHR: 0.62, 95% CI: 0.57-0.68). There was no significant difference in 1-year post-transplant survival. CONCLUSIONS: Although the expansion of the primary allocation unit improved disparities in waitlist outcomes without any change in post-transplant survival, there still remain significant differences due to geography.

Overcoming Mismatch Concerns for Adult Recipients of Small Pediatric Deceased Donor Kidneys.

BACKGROUND: Kidneys from very young pediatric donors continue to be underutilized. To reduce discard, the Organ Procurement and Transplantation Network (OPTN) policy was recently updated to allow kidneys from donors weighing <18 kg to be recovered en bloc. METHODS: We reviewed our center's experience with kidney transplantation in adult recipients of <18 kg pediatric donor kidneys to assess renal function outcomes specific to solitary vs en bloc usage. RESULTS: The majority of <18 kg donors were used en bloc (n = 39, 72.2% vs n = 15, 27.8%). Donor weight (kg) was similar between the 2 groups (12.3 ± 3.2 vs 14.1 ± 2.5, P = .05). Recipient weight was lower in the solitary kidney group (P = .01). Both groups had a similar donor-to-recipient body weight ratio (0.24 ± 0.3 vs 0.18 ± 0.3, P = .51). The solitary kidney group had a lower estimated glomerular filtration rate at 1 (56.9 ± 24.3 vs 81.8 ± 24.8, P = .01) and 2 years (72 ± 18.6 vs 93.7 ± 21.6, P = .03). By 2 years, both groups had an average estimated glomerular filtration rate >60 mL/min. Kidney allograft growth occurred in both groups, with the largest increase occurring the first month posttransplant (11.9%, 18.6%, P < .0001). CONCLUSION: For pediatric donors weighing <18 kg, improvements in renal function continue beyond the first posttransplant year. Risk for hyperfiltration injury appears low and renal mass-recipient mass matching is useful in guiding decision-making for solitary vs en bloc utilization.

Local versus distant lung donor procurement does not influence short-term clinical outcomes.

OBJECTIVE: The purpose of this study was to recognize clinically meaningful differences in lung transplant outcomes based on local or distant lung procurement. This could identify if the lung allocation policy change would influence patient outcomes. METHODS: This single-center retrospective cohort study analyzed adult patients who underwent lung transplant from 2006 to 2017. Donor and recipient data were abstracted from a collaborative, prospective registry shared by our local organ procurement organization, and tertiary medical center. Short-term outcomes, 1-year survival, and hospitalization costs were compared between local and distant lung transplants defined by donor service area. RESULTS: Of the 722 lung transplants performed, 392 (54%) had local donors and 330 (46%) had distant donors. Donors were similar in age and cause of death. Recipients were significantly different in diagnosis and local recipients had lower median lung allocation scores (local, 37.3 and distant, 44.9; P < .01). Distant lung transplants had longer total ischemic times (local, 231 ± 52 minutes and distant, 313 ± 48 minutes; P < .01). The rate of major complications, length of hospital stay, and 1-year survival were similar between groups. Distant lung transplants were associated with higher median overall cost (local, $183,542 and distant, $229,871; P < .01). Local lung transplants were more likely to be performed during daytime (local, 333 out of 392 [85%] and distant, 291 out of 330 [61%]; P < .01). CONCLUSIONS: Local lung transplants are associated with shorter ischemic times, lower cost, and greater likelihood of daytime surgery. Short- and intermediate-term outcomes are similar for lung transplants from local and distant donors. The new lung allocation policy, with higher proportion of distant lung transplants, is likely to incur greater costs but provide similar outcomes.

The general public new views on deceased organ donation in China.

BACKGROUND: The organ donation in China has developed rapidly since fully launched donations after citizens death in 2015. This study was conducted to evaluate how the Chinese general public views changed on deceased organ donation, and to improve the donation process. METHODS: A total of 110 eligible studies, including 103, 410 individuals, were selected to analyze through searching PubMed, CBMdisc, CQVIP, CNKI, and Wanfang Data from Jan 1, 1990 to May 31, 2019. The pooled proportions (and 95% CIs) of cognition, attitudes and willingness related to organ donation were calculated using the Freeman-Tukey double arcsine transformation. RESULTS: The pooled proportions of knowing about organ donation and willing to donate increased from 84.6% (73.0-93.4) and 32.4% (23.9-41.6) before 2015, to 86.4% (74.5-95.1) and 39.9% (32.8-47.2) after 2015, respectively. The willingness to posthumous organ donation for cornea, heart, kidney, and liver had a significant improvement. Especially, the proportion of willingness to donate cornea increased to 56.0% (43.3-68.3) after 2015, from 39.2% (31.2-47.4) before 2015. However, although 69.7% (62.7-76.4) of participants approved the deceased organ donation, only 35.6% (29.7-41.8) and 43.9% (37.2-50.8) were willing to donate their own and relatives organs postmortem, respectively. The leading reasons for refraining from donating organs postmortem were distrusting the medical professionals (49.8%, 35.2-64.4) and traditional Chinese values (40.6%, 32.4-49.0). Popularizing knowledge about organ donation (61.5%, 45.7-76.1), humanitarian aid (57.1%, 48.8-65.3), and priority of using donated organs for relatives (53.1%, 30.8-74.7) were the applauded strategies to improve the willingness to posthumous organ donation. CONCLUSIONS: The willingness toward posthumous organ donation has a significant improvement among Chinese general public since 2015, however, several important measures still need to be taken to promote the favorable attitudes and willingness toward organ donation.

Evaluation of underidentification of potential organ donors in German hospitals.

BACKGROUND: Since 2010, the number of organ donations in Germany has decreased by one third, mostly due to undetected organ donors. It is unclear, how the undetected potential donor pool is distributed among the different German hospital categories (A = university hospital, B = hospitals with neurosurgery, C = hospitals without neurosurgery) and region types. METHODS: We performed a nationwide secondary data analysis of all German inpatient cases of the year 2016 (n = 20,063,689). All fatalities were regarded as potential organ donors, in which primary or secondary brain damage was encoded and organ donation was not excluded by a contraindication or a lack of ventilation therapy. RESULTS: In 2016, 28,087 potential organ donors were identified. Thereof 21% were found in category A, 28% in category B and 42% in category C hospitals. The contact rate (= organ donation related contacts/ potential organ donors) and realization rate (= realized organ donations/ potential organ donors) of category A, B and C hospitals was 10.6% and 4.6%, 10.9% and 4.8% and 6.0% and 1.7%, respectively. 58.2% of the donor potential of category C hospitals was found in the largest quartile of category C hospitals. 51% (n = 14,436) of the potential organ donors were treated in hospitals in agglomeration areas, 28% (n = 7,909) in urban areas and 21% (n = 5,742) in rural areas. The contact- and realization rate did not significantly differ between these areas. CONCLUSIONS: The largest proportion of potential organ donors and the lowest realization rate are found in category C hospitals. Reporting and donation practice do not differ between urban and rural regions.

Comercialización social de la donación de órganos en Colombia: un estudio exploratorio.

Resumen Este estudio tiene como objetivo determinar las actitudes, creencias y aspectos culturales que motivan a los familiares de las personas fallecidas a donar sus órganos, a través de los cuales el marketing social puede desarrollar acciones que promuevan cambios de comportamiento. Se realizó un estudio de investigación descriptivo exploratorio a través del método de recopilación de información cualitativa con entrevistas en profundidad utilizando un cuestionario semiestructurado, procesado por el software NVivo 11. Descubrimos que las razones por las cuales los miembros de la familia donaron órganos fueron principalmente manifestaciones durante la vida del donante, el deseo de las familias de poder ayudar a otras personas (altruismo) y creencias religiosas.

Living Donor Versus Deceased Donor Liver Transplantation for HCC.

INTRODUCTION: Liver transplantation is the definitive treatment modality of the patients having an end-stage liver disease with hepatocellular carcinoma. DISCUSSION: The number of living donor liver transplantations has been increased because of the deceased donor organ shortage, especially in Asian countries. CONCLUSION: Reports of different clinics about the postoperative course and tumor recurrence rates comparing living donor versus deceased donor liver transplantations, besides patient selection criteria, are reviewed along with our clinic's experiences.

The need for a living donor wellness program.

PURPOSE OF REVIEW: Living donation has a tremendous impact in bridging the gap between the shortage of organs and the growing list of transplant candidates but remains underutilized as a percentage of total transplants performed. This review focuses on obesity and social determinants of health as potential barriers to the expansion of living kidney donation. RECENT FINDINGS: The growing rate of obesity and associated metabolic syndrome make many potential donors unacceptable as donor candidates because of the future risk for developing chronic health conditions, such as hypertension and diabetes. There is also increasing evidence demonstrating socioeconomic differences and racial disparities potentially limit access to living donation in certain populations. These potentially modifiable factors are not exclusive of each other and together serve as significant contributing factors to lower rates of living donation. SUMMARY: Living donors make sacrifices to provide the gift of life to transplant recipients, despite the potential risks to their own health. Studies describing risk factors to living donation call attention to the overall need for more action to prioritize and promote the health and well being of living donors.

Eccentrically Punched Descemet Membrane Endothelial Keratoplasty Grafts Expand the Descemet Membrane Endothelial Keratoplasty Donor Pool: One Eye Bank's Reappraisal of the Central Clear Zone Convention.

PURPOSE: To ascertain whether offsetting the Descemet membrane endothelial keratoplasty (DMEK) punch can expand the donor pool in conjunction with prepunched and preloaded services by recapturing the corneas otherwise excluded by the conventional central clear zone criteria. METHODS: In this retrospective review of corneas recovered and processed for DMEK by a single eye bank between March 2017 and October 2018, corneas failing to meet the conventional central clear zone requirement during initial evaluation (defined as an area in the central cornea where an 7.5- to 8.0-mm diameter graft can be obtained free of previous surgical scars, Descemet tears, or confined areas of endothelial defects) were further evaluated for offset punching. Corneas with a central endothelial cell density of at least 2000 cells/mm at the initial screening (average of 3 specular images assessed with the center dot method) that had a clear zone of 7.5- to 8.0-mm diameter where a graft could be obtained were designated as eligible for offset punching for either prepunched or preloaded DMEK. RESULTS: A total of 2607 corneas were found to be suitable for DMEK using the conventional central clear zone criteria. An additional 62 corneas were deemed DMEK suitable by offsetting the punch, yielding a 2.4% increase in the availability of DMEK suitable corneas. CONCLUSIONS: Offsetting the DMEK punch can recapture corneas otherwise excluded from the DMEK donor pool because of a failure to meet the conventional central clear zone criteria, and by our estimation may help eye banks meet the growing demand for DMEK tissue while maximizing the transplant potential of every cornea.

Assessment of Organ Donation Potential From Brain-Dead Donors in Polish Hospitals Using Quality Systems: System Of Donor Hospital Transplant Coordinators and Web-Tooled System of Monitoring Intensive Care Unit Deaths.

INTRODUCTION: In 2010 Poltransplant organized a national network of donor hospital transplant coordinators involved in the recruitment of potential deceased organ donors. One of the employed coordinators' tasks is monitoring donation potential at hospitals and reporting their results with the use of a tele-information tool www.koordynator.net. BACKGROUND: The aim of our study was to evaluate the organ donation potential at hospitals in 2018 based on the analysis of reports and on the comparison of these results with organ donation indicators elaborated within the European Commission project entitled Improving the Knowledge and Practices in Organ Donation (DOPKI). METHODS: Reports concerning deaths were applied to a retrospective analysis regarding a possibility to diagnose deaths according to neurologic criteria and to detect possible donations. In total, 1214 reports from 116 hospitals were delivered to the tele-information system during 2018. The analysis was made based on 840 full monthly reports from 70 hospitals. Numbers and indicators connected to the organ donation potential, both in the hospital and the intensive care unit (ICU) scales, have been calculated: numbers of beds and admissions, total number of deaths, deaths due to reasons frequently leading to death according to neurologic criteria, number of brain death diagnoses, and number of organ donations. RESULTS: In the scales of hospital and ICU the studied indices showed the following: 1. distinctly lower ratios related to brain death determination in the total number of beds, admissions, deaths, and deaths with selected International Classification of Diseases and Related Health Problems (ICD) codes in comparison with DOPKI results and 2. distinctly higher ratio of donations in the total number of brain deaths confirmed (69%) in comparison with DOPKI (42%). CONCLUSIONS: Based on obtained data from respective hospitals, the analysis showed the following in comparison with data coming from international European study (DOPKI): 1. low frequency of brain death determination procedures in the total number of deaths in Polish hospitals and ICUs, probably also in cases where such mechanism of death has occurred (the discrepancy may reach 1974 cases per year) and 2. high percentage of donations in the total number of brain-dead persons (conversion index), which may be caused by successful authorization of donation and acceptance of risky donors and organs by transplant teams but (what is more probable) may be explained by the ICUs' habit that procedures of brain death protocol is implemented only in cases when donation is expected.

Current status of liver transplantation in North America.

Liver transplantation is continuing to grow and evolve in North America. Changes in organ availability, recipient selection, indications and progressive approaches to oncologic treatment have occurred in the last five years. Despite increased activity in deceased and living donation in North America, there continues to be a high mortality on the waitlist as the recipient indications have changed over time which has led to new approaches to help patients with end-stage liver disease.

Donation after circulatory death liver transplantation: What are the limits for an acceptable DCD graft?

The utilization of donation after circulatory death (DCD) livers has been growing over the last decade. In large-volume centers, survival outcomes have improved and are comparable to outcomes with brain death donor (DBD) liver transplantation (LT). The relatively concentrated success with DCD LT demonstrated by high-volume transplant centers has rekindled international enthusiasm. The combination of increasing expertise in DCD LT and ongoing shortage in transplantable organs has promoted expansion of the DCD donor pool with regards to donor age, body mass index and donor warm ischemia time. In this review, we focused on the practice patterns in DCD liver graft utilization in the last decade, along with the possibilities for further expansion of DCD liver graft utilization and new technologies, such as machine perfusion.

Current status of liver transplantation in Europe.

Liver transplantation (LT) in Europe became an established life-saving treatment for patients with end-stage liver disease, hepatocellular carcinoma, and acute liver conditions with life-threatening hepatic dysfunction. Although there are substantial disparities in donation and transplant rates among European countries, LT can be offered to almost every European citizen today. In order to maximize the LT benefit beyond national levels, many countries cooperate within transnational organizations including Eurotransplant, Scandiatransplant, and Southern Alliance for Transplantation. In the majority of European countries, liver allocation is based on the Model for End-Stage Liver Disease (MELD). Similar to North America, the ongoing extinction of hepatitis C and increase of non-alcoholic steatohepatitis are also a hallmark of change in LT indications in Europe. Apart from Turkey, the organ pool for LT in European countries is mainly based on organs from donors after brain death, although some countries retrieve a substantial proportion of organs from donors after circulatory death. According to the 2018 report of the European Liver Transplant Registry, 146,762 LT have been performed in Europe until 2016. In the most recent period, LT in Europe achieved respectable 1- and 5-year overall survival rates of 86% and 74%.

Organ Donation in Intensive Care Units of Hospitals in Warsaw.

BACKGROUND: In recent years a systematic decrease in donation activity in Poland (15.4 vs 13.0) has been observed. A significant reduction has been noticed in Warsaw (36.2 vs 19.2) as well. METHODS: Data on deaths of patients admitted to intensive care units (ICUs) of Warsaw hospitals in from 2014 to 2018 were analyzed. Analysis was conducted in compliance with the Helsinki Congress and the Istanbul Declaration. Population of the city during this period averaged 1,753,480, although specialized capital hospitals service substantially bigger area than Warsaw alone. There are 18,500 to 18,600 deaths affecting this population every year. A total of 333 patients diagnosed as having brain death were included in analysis. RESULTS: In 42 cases (12.7%) data collection was given up because of lack of authorization. In all donors, death was diagnosed according to neurologic criteria. The most common causes were vascular brain diseases (64.1%) and craniocerebral trauma (21.4%). In 14.5% brain death occurred from other reasons. There are 20 hospitals with ICUs in Warsaw, which totals 318 intensive care beds. Program of identification of deceased organ donors was active in only 14 hospitals. A total of 243 potential donors (73%) were identified in the 3 most active hospitals. CONCLUSION: Analysis of ICU deaths of Warsaw hospitals showed a gradual decrease in the number of reported donors (from 75 in 2014 to 46 in 2018), although the number of all deaths did not decrease (the number of deaths in ICUs was on average 2.571/y).

Expanding the donor pool for liver transplantation with marginal donors.

The current supply of acceptable donor livers is not sufficient to meet the demands of listed patients awaiting transplantation resulting in thousands of deaths each year. Increased utilization of marginal livers may help alleviate this supply/demand mismatch by expanding the donor liver pool. The current status of liver transplantation using marginal donor grafts and efforts to optimize usage are discussed with attention to elderly donors, steatotic livers, donors after circulatory death, and split liver grafts.