Who pays for failed organ procurement and what is the cost of altruism?

Costs related to obtaining organs for transplantation: A systematic review

INTRODUCTION

The number of transplants in the world is growing, although there is a demand that exceeds supply. It is worth mentioning that the costs for obtaining organs are considered high. However, few studies have been developed on analyzing the costs of obtaining organs and tissues for transplants in order to support the decision-making of managers and health professionals.

OBJECTIVE

To summarize the studies related to the cost of obtaining organs for transplants from a deceased donor.

METHOD

A systematic literature review was conducted in the following databases: PubMed, Cochrane Library CINAHAL, Virtual Health Library (BVS), SCOPUS, Web of Science and EMBASE, using the following descriptors: Costs and cost analysis; Donor Selection; Tissue and Organ Procurement; Tissue and Organ Harvesting; and Tissue Donors, in studies published until April 2021. The risk of bias assessment was performed using the Joanna Briggs Institute's Checklist for Economic Assessments. It was not possible to perform a meta-analysis due to the heterogeneity of the studies.

RESULTS

A total of 1731 studies were identified, of which 11 were analyzed. The cost of kidneys in US dollars (USD) ranged between USD $1672 and USD $25,058. Obtaining a liver ranged from USD $586 to USD $44,478. Heart procurement ranged from USD $633 to USD $24,264. The combined heart-lung transplant ranged from USD $860 to USD $23,203. Obtaining the pancreas ranged from USD $413 to USD $29,708.

CONCLUSIONS

Cost of obtaining organs for transplants from a deceased donor is substantial and varies widely across different studies. The overall cost of failures to obtain organs is currently unknown. Understanding organ procurement expenses can help clarify areas in which organ and tissue procurement can improve in cost and efficiency.

Innovations in organ donation

The growing disparity between organ availability for transplantation and the number of patients in need has challenged the donation and transplantation community of practice to develop innovative processes, ideas, and techniques to bridge the gaps. Advances in the sharing of best practices in the donation community have contributed greatly over the last 8 years. Broader sharing of updated guidelines for declaration of brain death in conjunction with improvements in deceased donor management have increased opportunities for organ donation. New techniques for organ preservation and organ resuscitation have allowed for better utilization of the potential donor pool. This review will highlight processes, ideas, and techniques in organ donation.

The consequences of noncompliance with guidelines for withholding or terminating resuscitation in traumatic cardiac arrest patients

BACKGROUND

The validity of current guidelines regarding resuscitation of patients in traumatic cardiopulmonary arrest (TCPA) and the ability of emergency medical services (EMS) to appropriately apply them have been called into question. The purpose of this study is to demonstrate the consequences of violating the current published guidelines and whether EMS personnel were able to accurately identify patients in TCPA.

METHODS

We conducted a retrospective review of our Level I trauma center's database that identified 294 patients over an 8-year period (January 1, 2003, to December 31, 2010) who suffered prehospital TCPA and met criteria for the withholding or termination of resuscitation based on current guidelines. Patient demographics, prehospital/emergency department physiology, survival, neurologic outcome, and hospital charges were analyzed.

RESULTS

One of 294 patients (0.3%) survived to reach hospital discharge with a Glasgow Coma Scale score of 6. The total costs incurred for these 294 patients meeting criteria for withholding or termination of resuscitation were $3,852,446.65. One hundred seventeen (39.8%) patients were evaluated by more than one EMS team. There was 100% agreement on the presence (15 of 15) or absence (102 of 102) of a pulse between the EMS teams.

CONCLUSIONS

Our data support the current guidelines regarding the withholding or termination of resuscitation of patients in prehospital TCPA and represent the largest series to date on this topic. EMS personnel were able to accurately determine traumatic cardiac arrest in the field in this series. Violation of the current guidelines resulted in six patients being resuscitated to a neurologically devastated state. No loss of neurologically intact survivors would have resulted had strict adherence to the guidelines been maintained.

Donor conversion and procurement failure: the fate of our potential organ donors

BACKGROUND

Donor availability remains the primary limiting factor for organ transplantation today. The purpose of this study was to examine the causes of procurement failure amongst potential organ donors.

METHODS

After Institutional Review Board approval, all surgical intensive care unit (SICU) patients admitted to the LAC+USC Medical Center from 01/2006 to 12/2008 who became potential organ donors were identified. Demographics, clinical data, and procurement data were abstracted. In non-donors, the causes of procurement failure were documented.

RESULTS

During the 3-year study period, a total of 254 patients were evaluated for organ donation. Mean age was 44.8±18.7 years; 191 (75.2%) were male, 136 (53.5%) were Hispanic, and 148 (58.3%) were trauma patients. Of the 254 patients, 116 (45.7%) were not eligible for donation: 34 had multi-system organ failure, 24 did not progress to brain death and had support withdrawn, 18 had uncontrolled sepsis, 15 had malignancy, 6 had human immunodeficiency virus or hepatitis B or C, and 19 patients had other contraindications to organ donation. Of the remaining 138 eligible patients, 83 (60.2%) did not donate: 56 because the family denied consent, 9 by their own choice. In six, next of kin could not be located, five died because of hemodynamic instability before organ procurement was possible, four had organs that could not be placed, and three had their organs declined by the organ procurement organization. The overall consent rate was 57.5% (n=67). From the 55 donors, 255 organs were procured (yield 4.6 organs/donor).

CONCLUSIONS

Of all patients screened for organ donation, only a fifth actually donated. Denial of consent was the major potentially preventable cause of procurement failure, whereas hemodynamic instability accounted for only a small percentage of donor losses. With such low conversion rates, the preventable causes of procurement failure warrant further study.

Kidney damage during organ retrieval: data from UK National Transplant Database. Kidney Advisory Group

BACKGROUND

Kidney damage at organ retrieval is believed to be an increasing problem that is under reported. We aimed to identify the true rate of such damage and assess the effects on transplant survival.

METHODS

Data from the UK National Transplant Database were analysed on all cadaveric kidneys donated over a 5-year period in the UK. Records indicated whether kidneys had been retrieved by a liver or renal surgical team and whether damage was noted at the time of retrieval or at the transplant procedure. Multivariate Cox's regression models were fitted to 1-year and 3-year transplant-survival data in those kidneys that were transplanted between 1992 and 1994.

FINDINGS

Of 9014 kidneys retrieved, 96 could not be transplanted because of damage sustained at retrieval. Damage was reported in 1726 (19%) kidneys although by both donor and recipient centres in only 270 (3%). 1070 (62%) of the damaged organs were from donors aged 40 years or older. Reported kidney damage was more likely for retrievals of kidney only by a renal team (503 [26%]) than for multiorgan retrieval (454 [21%]), the proportion was lower when a liver team retrieved both liver and kidneys (415 [17%]). 794 (14%) kidneys retrieved and retained locally were reported as damaged, compared with 932 (29%) kidneys which had been exported. Donors' age had a significant effect on both 1-year and 3-year transplant survival (p<0.01 for both) but kidney damage did not (1 year p=0.40; 3 year p=0.81).

INTERPRETATION

Despite the high rate of damage to kidneys at retrieval, most of the organs can be transplanted with no adverse effect on transplant survival. Kidney damage is least likely to occur with kidneys from young donors, and when liver teams or centres undertaking more than 50 retrievals per year do the retrieval.