Continuously evaluating performance in deceased donation: the Spanish quality assurance program

Meeting the Shortage of Human Cells and Tissues: The Andalusian Quality Assurance Programme for Tissue Donation

Background A quality assurance programme for the tissue donation process was launched in Andalusia in 2020 to facilitate the integration of tissue donation into end-of-life care, and to respond to the growing need for human tissue for therapeutic purposes. The results of this programme are presented here. Methods After identifying the hospital departments in which to intensify the detection of tissue donors, expanding training activities and designing a specific data collection system for possible tissue donors who do not donate their tissues, the results of the donation activity were quantified and the causes of non-donation were analysed by applying the critical pathway for deceased tissue donation methodology. Results After an initial drop in activity, which coincided with the coronavirus pandemic, the number of tissue donors increased by 48.4% in 2022 compared to 2019. From the eligible donors, 83% were actual tissue donors and 71% were utilised donors. The modifiable causes of tissue donation loss, in order of frequency, were family refusal, followed by organisational or logistical issues, failure to notify or failure to identify possible donors, and failure to complete donor evaluation. Conclusion As a result of the collaboration of the various professionals involved in the programme, tissue donation activity has increased remarkably, the potential and effectiveness of the donation process have been evaluated, and areas for improvement have been identified, which we hope will lead to continuous improvement of the process.

Donor audits in deceased organ donation: a scoping review

PURPOSE

We sought to collate and summarize existing literature on donor audits (DA) and how they have been used to guide deceased organ donation and transplantation system performance and quality assurance.

SOURCE

We searched MEDLINE, Cumulative Index of Nursing and Allied Health Literature, and Web of Science supplemented by Google to identify grey literature on 6 May 2022, to locate studies in English, French, and Spanish. The data were screened, extracted, and analyzed independently by two reviewers. We grouped the results into five categories: 1) motivation for DA, 2) DA methodology, 3) potential and actual donors, 4) missed donation opportunities, and 5) quality improvement.

PRINCIPAL FINDINGS

The search yielded 2,416 unique publications and 52 were included in this review. Most studies were from the UK (n = 13) and published between 2001 and 2006 (n = 15). The methodologies described for DA were diverse. Our findings showed that the primary motivation for conducting DA was to identify potential donors and the number of potential deceased organ donors is significantly higher than the number of actual donors. Among retrieved studies, the proportion of donation opportunities following neurologic determination of death was 95/222 (43%) compared with 25/181 (14%) for donation after cardiocirculatory death (DCD), suggesting that the missed donation rate is higher for DCD.

CONCLUSION

Donor audits help identify missed donation opportunities along the deceased donation pathway and can help support the evaluation of quality improvement initiatives.

Evidence-Based Checklist to Delay Cardiac Arrest in Brain-Dead Potential Organ Donors: The DONORS Cluster Randomized Clinical Trial

Importance

The effectiveness of goal-directed care to reduce loss of brain-dead potential donors to cardiac arrest is unclear.

Objective

To evaluate the effectiveness of an evidence-based, goal-directed checklist in the clinical management of brain-dead potential donors in the intensive care unit (ICU).

Design, Setting, and Participants

The Donation Network to Optimize Organ Recovery Study (DONORS) was an open-label, parallel-group cluster randomized clinical trial in Brazil. Enrollment and follow-up were conducted from June 20, 2017, to November 30, 2019. Hospital ICUs that reported 10 or more brain deaths in the previous 2 years were included. Consecutive brain-dead potential donors in the ICU aged 14 to 90 years with a condition consistent with brain death after the first clinical examination were enrolled. Participants were randomized to either the intervention group or the control group. The intention-to-treat data analysis was conducted from June 15 to August 30, 2020.

Interventions

Hospital staff in the intervention group were instructed to administer to brain-dead potential donors in the intervention group an evidence-based checklist with 13 clinical goals and 14 corresponding actions to guide care, every 6 hours, from study enrollment to organ retrieval. The control group provided or received usual care.

Main Outcomes and Measures

The primary outcome was loss of brain-dead potential donors to cardiac arrest at the individual level. A prespecified sensitivity analysis assessed the effect of adherence to the checklist in the intervention group.

Results

Among the 1771 brain-dead potential donors screened in 63 hospitals, 1535 were included. These patients included 673 males (59.2%) and had a median (IQR) age of 51 (36.3-62.0) years. The main cause of brain injury was stroke (877 [57.1%]), followed by trauma (485 [31.6%]). Of the 63 hospitals, 31 (49.2%) were assigned to the intervention group (743 [48.4%] brain-dead potential donors) and 32 (50.8%) to the control group (792 [51.6%] brain-dead potential donors). Seventy potential donors (9.4%) at intervention hospitals and 117 (14.8%) at control hospitals met the primary outcome (risk ratio [RR], 0.70; 95% CI, 0.46-1.08; P = .11). The primary outcome rate was lower in those with adherence higher than 79.0% than in the control group (5.3% vs 14.8%; RR, 0.41; 95% CI, 0.22-0.78; P = .006).

Conclusions and Relevance

This cluster randomized clinical trial was inconclusive in determining whether the overall use of an evidence-based, goal-directed checklist reduced brain-dead potential donor loss to cardiac arrest. The findings suggest that use of such a checklist has limited effectiveness without adherence to the actions recommended in this checklist.

Trial Registration

ClinicalTrials.gov Identifier: NCT03179020.

Recommendations for living donor kidney transplantation

This Guide for Living Donor Kidney Transplantation (LDKT) has been prepared with the sponsorship of the Spanish Society of Nephrology (SEN), the Spanish Transplant Society (SET), and the Spanish National Transplant Organization (ONT). It updates evidence to offer the best chronic renal failure treatment when a potential living donor is available. The core aim of this Guide is to supply clinicians who evaluate living donors and transplant recipients with the best decision-making tools, to optimise their outcomes. Moreover, the role of living donors in the current KT context should recover the level of importance it had until recently. To this end the new forms of incompatible HLA and/or ABO donation, as well as the paired donation which is possible in several hospitals with experience in LDKT, offer additional ways to treat renal patients with an incompatible donor. Good results in terms of patient and graft survival have expanded the range of circumstances under which living renal donors are accepted. Older donors are now accepted, as are others with factors that affect the decision, such as a borderline clinical history or alterations, which when evaluated may lead to an additional number of transplantations. This Guide does not forget that LDKT may lead to risk for the donor. Pre-donation evaluation has to centre on the problems which may arise over the short or long-term, and these have to be described to the potential donor so that they are able take them into account. Experience over recent years has led to progress in risk analysis, to protect donors' health. This aspect always has to be taken into account by LDKT programmes when evaluating potential donors. Finally, this Guide has been designed to aid decision-making, with recommendations and suggestions when uncertainties arise in pre-donation studies. Its overarching aim is to ensure that informed consent is based on high quality studies and information supplied to donors and recipients, offering the strongest possible guarantees.

Clinico-radiological related to early brain death factors

OBJECTIVE

To identify clinical and radiological factors associated to early evolution to brain death (BD), defined as occurring within the first 24 h.

DESIGN

A retrospective cohort study was made covering the period 2015-2017.

SETTING

An adult Intensive Care Unit (ICU).

PATIENTS/METHODS

Epidemiological, clinical and imaging (CT scan) parameters upon admission to the ICU in patients evolving to BD.

RESULTS

A total of 166 patients with BD (86 males, mean age 62.7 years) were analyzed. Primary cause: intracerebral hemorrhage 42.8%, subarachnoid hemorrhage 18.7%, traumatic brain injury 17.5%, anoxia 9%, stroke 7.8%, other causes 4.2%. Epidemiological data: arterial hypertension 50%, dyslipidemia 34%, smoking 33%, antiplatelet medication 21%, alcoholism 19%, anticoagulant therapy 15%, diabetes 15%. The Glasgow Coma Score (GCS) upon admission was 3 in 68.8% of the cases in early BD versus in 38.2% of the cases in BD occurring after 24 h (p = 0.0001). Eighty-five patients presented supratentorial hematomas with a volume of 90.9 ml in early BD versus 82.7 ml in BD > 24 h (p = 0.54). The mean midline shift was 10.7 mm in early BD versus 7.8 mm in BD > 24 h (p = 0.045). Ninety-one patients presented ventriculomegaly and 38 additionally ependymal transudation (p = 0.021). Thirty-six patients with early BD versus 24 with BD > 24 h presented complete effacement of basal cisterns (p = 0.005), sulcular effacement (p = 0.013), loss of cortico-subcortical differentiation (p = 0.0001) and effacement of the suprasellar cistern (p = 0.005). The optic nerve sheath measurements showed no significant differences between groups.

CONCLUSIONS

Early BD (>24 h) was associated to GCS < 5, midline shift, effacement of the basal cisterns, cerebral sulci and suprasellar cistern, and ependymal transudation.

Design and implementation of the European-Mediterranean Postgraduate Programme on Organ Donation and Transplantation (EMPODaT) for Middle East/North Africa countries

This prospective study reports the design and results obtained after the EMPODaT project implementation. This project was funded by the Tempus programme of the European Commission with the objective to implement a common postgraduate programme on organ donation and transplantation (ODT) in six selected universities from Middle East/North Africa (MENA) countries (Egypt, Lebanon and Morocco). The consortium, coordinated by the University of Barcelona, included universities from Spain, Germany, Sweden and France. The first phase of the project was to perform an analysis of the current situation in the beneficiary countries, including existing training programmes on ODT, Internet connection, digital facilities and competences, training needs, and ODT activity and accreditation requirements. A total of 90 healthcare postgraduate students participated in the 1-year training programme (30 ECTS academic credits). The methodology was based on e-learning modules and face-to-face courses in English and French. Training activities were evaluated through pre- and post-tests, self-assessment activities and evaluation charts. Quality was assessed through questionnaires and semi-structured interviews. The project results on a reproducible and innovative international postgraduate programme, improvement of knowledge, satisfaction of the participants and confirms the need on professionalizing the activity as the cornerstone to ensure organ transplantation self-sufficiency in MENA countries.

Critical pathway for deceased tissue donation: a novel adaptative European systematic approach

A ‘Critical pathway for deceased tissue donation’ was developed by the European Committee on Organ Transplantation of the Council of Europe (CD‐P‐TO) with the aim of providing a common systematic approach to the deceased tissue donation process. Definitions of tissue donors according to the donation stage have been developed so that they can be adapted to different local scenarios. This critical pathway can be used retrospectively to evaluate the potential of tissue donation, assess performance in the tissue donation process and identify areas for improvement. It sets the basis to build indicators to compare organizations, regions and countries. The critical pathway can also be used prospectively to promote good practices in tissue donation programmes aimed at covering the tissue transplantation needs of patients.

Defining Quality Criteria for Success in Organ Donation Programs: A Scoping Review

Background

Well-established performance measures for organ donation programs do not fully address the complexity and multifactorial nature of organ donation programs such as the influence of relationships and organizational attributes.

Objective

To synthesize the current evidence on key organizational attributes and processes of international organ donation programs associated with successful outcomes and to generate a framework to categorize those attributes.

Design

Scoping Review using a mixed methods approach for data extraction.

Setting

Databases included PubMed, CINAHL, Embase, LILACS, ABI Business ProQuest, Business Source Premier, and gray literature (organ donation association websites, Google Scholar-first 8 pages), and searches for gray literature were performed, and relevant websites were perused.

Sample

Organ donation programs or processes.

Methods

We systematically searched the literature to identify any research design, including text and opinion papers and unpublished material (research data, reports, institutional protocols, government documents, etc). Searches were completed on January 2018, updated it in May 2019, and lastly in March 2020. Title, abstracts, and full texts were screened independently by 2 reviewers with disagreements resolved by a third. Data extraction followed a mixed method approach in which we extracted specific details about study characteristics such as type of research, year of publication, origin/country of study, type of journal published, and key findings. Studies included considered definitions and descriptions of success in organ donation programs in any country by considering studies that described (1) attributes associated with success or effectiveness, (2) organ donation processes, (3) quality improvement initiatives, (4) definitions of organ donation program effectiveness, (5) evidence-based practices in organ donation, and (6) improvements or success in such programs. We tabulated the type and frequency of the presence or absence of reported improvement quality indicators and used a qualitative thematic analysis approach to synthesize results.

Results

A total of 84 articles were included. Quantitative analysis identified that most of the included articles originated from the United States (n = 32, 38%), used quantitative approaches (n = 46, 55%), and were published in transplant journals (n = 34, 40.5%). Qualitative analysis revealed 16 categories that were described as positively influencing success/effectiveness of organ donation programs. Our thematic analysis identified 16 attributes across the 84 articles, which were grouped into 3 categories influencing organ donation programs' success: context (n = 39, 46%), process (n = 48, 57%), and structural (n = 59, 70%).

Limitations

Consistent with scoping review methodology, the methodological quality of included studies was not assessed.

Conclusions

This scoping review identified a number of factors that led to successful outcomes. However, those factors were rarely studied in combination representing a gap in the literature. Therefore, we suggest the development and reporting of primary research investigating and measuring those attributes associated with the performance of organ donation programs holistically.

Trial Registration

Not applicable.

Organ donation and transplantation: a multi-stakeholder call to action

Although overall donation and transplantation activity is higher in Europe than on other continents, differences between European countries in almost every aspect of transplantation activity (for example, in the number of transplantations, the number of people with a functioning graft, in rates of living versus deceased donation, and in the use of expanded criteria donors) suggest that there is ample room for improvement. Herein we review the policy and clinical measures that should be considered to increase access to transplantation and improve post-transplantation outcomes. This Roadmap, generated by a group of major European stakeholders collaborating within a Thematic Network, presents an outline of the challenges to increasing transplantation rates and proposes 12 key areas along with specific measures that should be considered to promote transplantation. This framework can be adopted by countries and institutions that are interested in advancing transplantation, both within and outside the European Union. Within this framework, a priority ranking of initiatives is suggested that could serve as the basis for a new European Union Action Plan on Organ Donation and Transplantation.

Survey of Canadian critical care physicians' knowledge and attitudes towards legislative aspects of the deceased organ donation system

PURPOSE

We surveyed Canadian critical care physicians who may care for patients who are potential organ donors to understand their attitudes and knowledge of legislation governing the deceased organ donation system.

METHODS

We used a web-based, self-administered survey that included questions related to opt-out consent and mandatory referral legislation. Potential participants were identified through membership lists of professional societies and manual searches. We designed our survey using standardized methods and administered it in February and March 2018.

RESULTS

Fifty percent (263/529) of potential participants completed the questionnaire. A majority (61%; 144/235) supported a change towards an opt-out consent model, and 77% (181/235) stated they believe it would increase donation rates. Asked if opt-out consent would change their practices, 71% (166/235) stated an opt-out model would not change how or if they approach families to discuss donation. Fifty-six percent (139/249) supported mandatory referral laws, while only 42% (93/219) of those working in provinces with mandatory referral correctly stated that such laws exist in their province. Respondents gave variable responses on who should be accountable when patients are not referred, and 16% (40/249) believed no one should be held accountable.

CONCLUSIONS

While a majority of critical care physicians supported opt-out consent and mandatory referral, many were neutral or against it. Many were unaware of existing laws and had variable opinions on how to ensure accountability. Efforts to increase understanding of how legislative models influence practice are required for any law to achieve its desired effect.

Clinico-radiological related to early brain death factors

OBJECTIVE

To identify clinical and radiological factors associated to early evolution to brain death (BD), defined as occurring within the first 24 hours.

DESIGN

A retrospective cohort study was made covering the period 2015-2017.

SETTING

An adult Intensive Care Unit (ICU).

PATIENTS/METHODS

Epidemiological, clinical and imaging (CT scan) parameters upon admission to the ICU in patients evolving to BD.

RESULTS

A total of 166 patients with BD (86 males, mean age 62.7 years) were analyzed. Primary cause: intracerebral hemorrhage 42.8%, subarachnoid hemorrhage 18.7%, traumatic brain injury 17.5%, anoxia 9%, stroke 7.8%, other causes 4.2%. Epidemiological data: arterial hypertension 50%, dyslipidemia 34%, smoking 33%, antiplatelet medication 21%, alcoholism 19%, anticoagulant therapy 15%, diabetes 15%. The Glasgow Coma Score (GCS) upon admission was 3 in 68.8% of the cases in early BD versus in 38.2% of the cases in BD occurring after 24 h (p = 0.0001). Eighty-five patients presented supratentorial hematomas with a volume of 90.9 ml in early BD versus 82.7 ml in BD >24 h (p = 0.54). The mean midline shift was 10.7 mm in early BD versus 7.8 mm in BD >24 h (p = 0.045). Ninety-one patients presented ventriculomegaly and 38 additionally ependymal transudation (p = 0.021). Thirty-six patients with early BD versus 24 with BD >24 h presented complete effacement of basal cisterns (p = 0.005), sulcular effacement (p = 0.013), loss of cortico-subcortical differentiation (p = 0.0001) and effacement of the suprasellar cistern (p = 0.005). The optic nerve sheath measurements showed no significant differences between groups.

CONCLUSIONS

Early BD (>24 h) was associated to GCS < 5, midline shift, effacement of the basal cisterns, cerebral sulci and suprasellar cistern, and ependymal transudation.

Uncontrolled Donation After Circulatory Death: A Unique Opportunity

Uncontrolled donation after circulatory death (uDCD) refers to donation from persons who die following an unexpected and unsuccessfully resuscitated cardiac arrest. Despite the large potential for uDCD, programs of this kind only exist in a reduced number of countries with a limited activity. Barriers to uDCD are of a logistical and ethical-legal nature, as well as arising from the lack of confidence in the results of transplants from uDCD donors. The procedure needs to be designed to reduce and limit the impact of the prolonged warm ischemia inherent to the uDCD process, and to deal with the ethical issues that this practice poses: termination of advanced cardiopulmonary resuscitation, extension of advanced cardiopulmonary resuscitation beyond futility for organ preservation, moment to approach families to discuss donation opportunities, criteria for the determination of death, or the use of normothermic regional perfusion for the in situ preservation of organs. Although the incidence of primary nonfunction and delayed graft function is higher with organs obtained from uDCD donors, overall patient and graft survival is acceptable in kidney, liver, and lung transplantation, with a proper selection and management of both donors and recipients. Normothermic regional perfusion has shown to be critical to achieve optimal outcomes in uDCD kidney and liver transplantation. However, the role of ex situ preservation with machine perfusion is still to be elucidated. uDCD is a unique opportunity to improve patient access to transplantation therapies and to offer more patients the chance to donate organs after death, if this is consistent with their wishes and values.

The potential for organ donation in Iceland: A nationwide study of deaths in intensive care units

BACKGROUND

The deceased organ donation rate in Iceland has been low compared with other Western countries. The aim of this study was to explore the potential for organ donation after brain death in Iceland.

METHODS

Observational cohort study of patients with catastrophic brain injury who died in intensive care units (ICUs) at hospitals in Iceland in 2003-2016. Medical records were retrospectively reviewed to identify potential donors (PDs), using the WHO Critical Pathway for Deceased Donation. Trends in annual incidence of PDs, conversion to actual donors, and family refusals were assessed.

RESULTS

Among 1537 patients who died in the ICU, 125 (8.1%) were identified as PDs. Of 103 PDs who were declared brain dead, consent for organ donation was pursued in 84 cases and granted in 63. Fifty-six became actual donors. The annual donation rate averaged 13 per million population (pmp), but rose abruptly in the final 2 years to 36 and 27 pmp, respectively. This was paralleled by an increase in annual incidence of PDs from an average of 28 pmp to 54 and 42 pmp, respectively. The donor conversion rate increased during the study period (P = .026). Twenty-three PDs (18%) were not pursued without an apparent reason.

CONCLUSIONS

The donation rate increased markedly in the last 2 years of the study period after remaining low for more than a decade. This change can largely be explained by a high incidence of PDs and a low family refusal rate. Missed donation opportunities suggest a potential to maintain a high donation rate in the future.

Loss of Potential Donors Due to Hemodynamic Maintenance

BACKGROUND

Statistics indicate low utilization of potential donors, where only about one-third are converted into actual donors. In this context, it is plausible to argue that many potential donors are not hemodynamically stable for harvesting multiple organs since the procedures for maintaining parameters of stability may not be a priority in all critical care units in the country. Thus, it is necessary to identify losses of potential donors due to hemodynamic maintenance since reversing this situation enable minimizing mortality on waiting lists.

METHODS

This was a retrospective quantitative study, based on information sent to Notification, Organ Procurement, and Distribution Centers by reporting hospitals in the state of São Paulo, using the Death Information Form regarding the specifics of each death registered in their intensive care units and emergency rooms.

RESULTS

Hemodynamic instability contributed to a loss of 537 potential donors, corresponding to 61.9% of failures to obtain potentially transplantable organs.

CONCLUSION

Of the 33,175 cases of death reported, 867 fulfilled the criteria to be possible and potential donors (ie, patients diagnosed with brain death). Among these cases, 38.1% fulfilled Criterion 3 (ie, they were hemodynamically stable and in ideal organ donation condition). Therefore, this study concludes that losses due to maintenance occurred in 537 brain dead patients. This finding highlights the importance of investing in the development of competencies of professionals who work in critical care units to increase the number of multiple organ and tissue donors and reduce waiting lists.

Survey of Canadian intensivists on physician non-referral and family override of deceased organ donation

PURPOSE

Intensive care physicians play an important role in the identification and referral of potential organ donors in Canada. Nevertheless, little is known about intensivists' attitudes or behaviours in situations where families override previously expressed consent to donate; nor why physicians elect not to refer patients who are potential donors to provincial organ donation organizations (physician non-referral).

METHODS

We integrated questions regarding family override and physician non-referral into an online, self-administered survey of Canadian intensivists. We report results descriptively.

RESULTS

Fifty percent of targeted respondents (n = 550) participated. Fifty-five percent reported having witnessed family override situations and 44% reported having personally not referred patients who were potential donors. Fifty-six percent of respondents stated they would not pursue donation in the face of family override; 2% stated they would continue with the donation process. Fear of loss of trust in the donation system (81%) and obligation to respect the grief and desires of surrogate decision makers (71%) were frequently reported reasons to respect family override requests. Respondents who chose not to refer patients often did so based on organ dysfunction they assumed would preclude donation (59%), or a perception that the family was too distressed to consider donation (42%). No respondents reported that personally held beliefs against organ donation influenced their decision.

CONCLUSION

Physicians caring for patients who are potential organ donors commonly encounter both family override and physician non-referral situations. Knowledge translation of optimal practices in identification and referral could help ensure that physician practices align with legal requirements and practice recommendations.

Criteria to Identify a Potential Deceased Organ Donor: A Systematic Review

OBJECTIVES

To systematically review the global published literature defining a potential deceased organ donor and identifying clinical triggers for deceased organ donation identification and referral.

DATA SOURCES

Medline and Embase databases from January 2006 to September 2017.

STUDY SELECTION

All published studies containing a definition of a potential deceased organ donor and/or clinical triggers for referring a potential deceased organ donor were eligible for inclusion. Dual, independent screening was conducted of 3,857 citations.

DATA EXTRACTION

Data extraction was completed by one team member and verified by a second team member. Thematic content analysis was used to identify clinical criteria for potential deceased organ donation identification from the published definitions and clinical triggers.

DATA SYNTHESIS

One hundred twenty-four articles were included in the review. Criteria fell into four categories: Neurological, Medical Decision, Cardiorespiratory, and Administrative. Distinct and globally consistent sets of clinical criteria by type of deceased organ donation (neurologic death determination, controlled donation after circulatory determination of death, and uncontrolled donation after circulatory determination of death) are reported.

CONCLUSIONS

Use of the clinical criteria sets reported will reduce ambiguity associated with the deceased organ donor identification and the subsequent referral process, potentially reducing the number of missed donors and saving lives globally through increased transplantation.

The implementation and utilization of an organ donation dedicated medical advisory service: A descriptive study

BACKGROUND

Obstacles encountered during the organ donation process may result in the loss of organs. A centralized medical advisory service (MAS), providing a 24/7/365 service, was established in 2007 to respond to queries from healthcare professionals regarding organ safety, brain death (BD) determination, and donor management.

METHODS

Data collected from 2007 to 2017 included the number and context of the queries and the mean number of organs transplanted/donor. Since 2012, the number of six donor management goals (DMGs) met at the time of consent has been monitored.

RESULTS

The number of queries relative to the number of potential donors increased from 12.4% (n = 78 queries) in 2007 to 48.2% (304 queries) in 2009 and has remained widely utilized, with most queries consistently related to organ safety. The context of the queries informed the formulation of protocols relating to donor infections and malignancy and identified difficulties regarding BD determination and subsequent implementation of solutions. A mean of 5.0 ± 0.7 DMGs was achieved, while the number of organs transplanted/donor increased from 3.4 in 2007 to 4.0 in 2017.

CONCLUSION

We suggest that this model may provide a valuable resource to improve the safety, standardization, and quality of the donation process.

Summary of Spanish recommendations on intensive care to facilitate organ donation

With the aim of consolidating recommendations about the practice of initiating or continuing intensive care to facilitate organ donation (ICOD), an ad hoc working group was established, comprising 10 intensivists designated by the Spanish Society of Intensive Care and Coronary Units (SEMICYUC) and the Spanish National Transplant Organization (ONT). Consensus was reached in all recommendations through a deliberative process. After a public consultation, the final recommendations were institutionally adopted by SEMICYUC, ONT, and the Transplant Committee of the National Health-Care System. This article reports on the resulting recommendations on ICOD for patients with a devastating brain injury for whom the decision has been made not to apply any medical or surgical treatment with a curative purpose on the grounds of futility. Emphasis is made on the systematic referral of these patients to donor coordinators, the proper assessment of the likelihood of brain death and medical suitability, and on transparency in communication with the patient's family. The legal and ethical aspects of ICOD are addressed. ICOD is considered a legitimate practice that offers more patients the opportunity of donating their organs upon their death and helps to increase the availability of organs for transplantation.

Measures influencing post-mortem organ donation rates in Germany, the Netherlands, Spain and the UK : A systematic review

BACKGROUND

German post-mortem organ donation rates have been declining since 2010. Several transplantation scandals led to a negative portrayal of organ donation in the media. Spain, the UK and the Netherlands achieved a rise in organ donation rates while retaining organ donation legislation.

METHODS

A systematic review of publications focusing on (1) organ donation legislation, (2) data on post-mortem organ donation rates and (3) measures to increase post-mortem organ donation rates in Europe was conducted in November 2017 in PubMed, PsycINFO and Web of Science. Quality parameters of the World Bank and the World Health Organization (WHO) were studied to analyze national health services, frequent causes of death and life expectancy.

RESULTS

Quality parameters of national health services were similar in all countries. The Netherlands and Germany have an opt in system. An increase of 37.4% in post-mortem organ donation rates from 2008 to 2015 in the UK was accomplished through the establishment of a donation task force, adopting parts of the Spanish model, while maintaining an opt in system. Spain has the highest organ donation rate worldwide (39.7 per million persons in 2015). The implementation of transplantation coordinators and the change in legislation in Germany in 2012 has so far shown no effect. Public awareness of organ donation in the Netherlands increased following various information campaigns.

CONCLUSION

Donation after cardiac death (DCD), expanded donor criteria, increasing public awareness and introduction of an organ donor register should be discussed as measures to increase organ donation rates in Germany.

Development of a multinational registry of pediatric deceased organ donation activity

BACKGROUND

There are no currently agreed upon international standards for reporting of pediatric deceased organ donation activity. This leads to difficulty in comparisons between jurisdictions for both researchers and policy stakeholders. The goal of this project was to develop and test a standardized registry for pediatric deceased donation activity.

METHODS

Four countries (Canada, Spain, USA, and the UK) with geographical and practice diversity were approached to participate. Iterative exchanges were used to create data fields and definitions that were acceptable to all participants. Data from 2011 to 2015 (inclusive) were requested from national health databases and analyzed on a secure, web-based survey platform.

RESULTS

Data were obtained from three of the four countries (Canada unable to provide). Total pediatric donation rates were stable over the 5-year period, but with variation between countries. pDCD rates were the most variable, representing 32.2% of total pediatric donation in the UK, 14.4% in the United States, and 2.6% in Spain during the studied period. Most organs from pediatric donors were allocated to adult recipients, though the rates of allocation of pediatric kidneys to pediatric recipients ranged from 7% in the United States to 40% in Spain.

DISCUSSION

In this limited cohort of three countries, we demonstrated substantial variation in pediatric donation rates and practice. These data highlight opportunities for practice improvement such as the development of rigorous clinical practice guidelines. Future development of this registry will seek to engage more countries, and address barriers that prevented full participation of approached jurisdictions.

Evolution of Deceased Organ Donation Activity Versus Efficiency Over a 15-year Period: An International Comparison

BACKGROUND

The donation rate (DR) per million population is not ideal for an efficiency comparison of national deceased organ donation programs. The DR does not account for variabilities in the potential for deceased donation which mainly depends on fatalities from causes leading to brain death. In this study, the donation activity was put into relation to the mortality from selected causes. Based on that metric, this study assesses the efficiency of different donation programs.

METHODS

This is a retrospective analysis of 2001 to 2015 deceased organ donation and mortality registry data. Included are 27 Council of Europe countries, as well as the United States. A donor conversion index (DCI) was calculated for assessing donation program efficiency over time and in international comparisons.

RESULTS

According to the DCI and of the countries included in the study, Spain, France, and the United States had the most efficient donation programs in 2015. Even though mortality from the selected causes decreased in most countries during the study period, differences in international comparisons persist. This indicates that the potential for deceased organ donation and its conversion into actual donation is far from being similar internationally.

CONCLUSIONS

Compared with the DR, the DCI takes into account the potential for deceased organ donation, and therefore is a more accurate metric of performance. National donation programs could optimize performance by identifying the areas where most potential is lost, and by implementing measures to tackle these issues.

Management of donation after brain death (DBD) in the ICU: the potential donor is identified, what's next?

The success of any donation process requires that potential brain-dead donors (PBDD) are detected and referred early to professionals responsible for their evaluation and conversion to actual donors. The intensivist plays a crucial role in organ donation. However, identification and referral of PBDDs may be suboptimal in the critical care environment. Factors influencing lower rates of detection and referral include the lack of specific training and the need to provide concomitant urgent care to other critically ill patients. Excellent communication between the ICU staff and the procurement organization is necessary to ensure the optimization of both the number and quality of organs transplanted. The organ donation process has been improved over the last two decades with the involvement and commitment of many healthcare professionals. Clinical protocols have been developed and implemented to better organize the multidisciplinary approach to organ donation. In this manuscript, we aim to highlight the main steps of organ donation, taking into account the following: early identification and evaluation of the PBDD with the use of checklists; donor management, including clinical maintenance of the PBDD with high-quality intensive care to prevent graft failure in recipients and strategies for optimizing donated organs by simplified care standards, clinical guidelines and alert tools; the key role of the intensivist in the donation process with the interaction between ICU professionals and transplant coordinators, nurse protocol managers, and communication skills training; and a final remark on the importance of the development of research with further insight into brain death pathophysiology and reversible organ damage.

Donation after circulatory death and its expansion in Spain

PURPOSE OF REVIEW

Donation after circulatory death (DCD) is still performed in a limited number of countries. This article summarizes the development of DCD in Spain and presents recent Spanish contributions to gain knowledge on the potential benefits and the practical use of normothermic regional perfusion (nRP).

RECENT FINDINGS

DCD now contributes to 24% of deceased donors in Spain. The development of DCD has been based on an assessment of practices in the treatment of cardiac arrest and end-of-life care to accommodate the option of DCD; the creation of an adequate regulatory framework; and institutional support, professional training and public education. Appropriate posttransplant outcomes have been obtained with organs from both uncontrolled and controlled DCD donors. nRP is increasingly used, with preliminary data supporting improved results compared with other in-situ preservation/recovery approaches. Mobile teams with portable extracorporeal membrane oxygenation devices are making nRP possible in hospitals without these resources. To avoid the possibility of reestablishing brain circulation after the determination of death, a specific methodology has been validated.

SUMMARY

DCD has been successfully developed in Spain following a streamlined process. nRP may become a standard in DCD, although further evidence on the benefits of this technology is eagerly awaited.

Development of a national minimum data set to monitor deceased organ donation performance in Canada

Purpose

Deceased donation data requires standardization to enable accurate interprovincial and international comparisons of deceased donation performance. In Canada, most provincial organ donation organizations (ODOs) have developed different processes and infrastructures for referring potential donors and subsequent data collection. This has led to differing definitions of the performance measures used for each step in the donation process, from potential donor identification to consent to transplantation. The Deceased Donation Data Working Group (DDDWG), comprised of representatives from ODOs across Canada, was therefore convened by Canadian Blood Services to develop a national, comprehensive, standardized deceased donation minimum data set.

Methods

The DDDWG’s scope encompassed considering all potential deceased organ donation data elements, including operational and performance data collected along the deceased donor pathway from donation potential to donation and disposition of organs. An environmental scan was conducted of other existing deceased donation registries from the Canadian and the international community. The DDDWG then engaged in regular face-to-face meetings and teleconferences to develop recommendations for the minimum data set that would satisfy key considerations, including the impact on existing ODO data collection processes, financial impact on stakeholders, the clinical and operational needs of multiple healthcare professionals involved in the deceased donation pathway, and availability of other existing national data sets that could be leveraged to reduce data collection burden.

Results

The key deceased donation data elements identified by the DDDWG are contained in an inverted pyramid framework that was derived from similar work conducted in other countries.

Conclusion

The DDDWG developed recommendations for proposed definitions and data sources that should be adopted nationally to guide the collection of deceased donation data. The ultimate purpose of the final minimum data set is to harmonize and standardize donation data definitions in Canada and align with international standards; inform the development of operational and clinical practice standards at the provincial and national levels; develop a framework for deceased donation performance measures; and advance the science of deceased donation.

[Organ donation: Lessons to be learned from abroad?]

The profound and ongoing crisis of organ donation and transplantation medicine in Germany urges for swift and sustainable improvement. Over the last few decades, various European countries have introduced national action plans and have efficiently begun to tap into their national potential for organ donation. Our paper sheds light on a variety of measures that have proven successful in different countries. Careful evaluation and comprehensive debate in public and professional bodies may warrant a tailor-made approach towards successful, albeit fundamental, changes in Germany's organ donation system.

Impact of Educational and Organizational Initiatives in Organ Donation in a Southern Brazilian State in the Last Decade

BACKGROUND

The unbalance between the demand and supply of organs for transplant is a universal phenomenon. This study shows Santa Catarina's experience with educational and organizational initiatives in the state's transplant system to describe the result of such actions in increasing donation rates.

METHODS

This is a before and after study. Medical data on potential organ donors, listed in the Santa Catarina Transplant Registry between January 2004 and December 2017, were analyzed. This 13-year period was divided into 3 phases. Phase 1, from 2005 to 2007, corresponds to the organization of the program without specific measures. Phase 2, from 2008 to 2011, is associated with theoretical/practical training on family interviews. Phase 3, from 2012 to 2017, is related to the implementation of a protocol for the management of potential deceased donors.

RESULTS

Referrals grew from 35.1 per million population (pmp) (phase 1) to 49.4 pmp (phase 1) and 74.0 pmp (phase 3), translating into a 110.8% (P < .001) increase. Lack of family consent dropped from 39.8% to 27.8% in phase 3, a global reduction of 30.1% (P < .001). Loss of donors to cardiac arrest were reduced from 51.9% to 23.3% to 12.2%. Effective donors, which varied from 12.0 pmp to 20.0 pmp and 32.7 pmp, increased by 172.5% (P < .001).

CONCLUSIONS

This study demonstrates the positive association between articulated educational initiatives and improvements in potential donors' identification, which, associated with cardiac arrest loss control and increased family consent, brought about significantly better results in organ donation.

Donor referral from outside the intensive care unit: A multidisciplinary cooperation model using communication apps and redefining refereal criteria

OBJECTIVE

We evaluate the impact of a web-based collaborative system on the referral of possible organ donors from outside of the intensive care unit (ICU).

STUDY DESIGN

Cohort prospective study.

SETTINGS

University hospital.

PATIENTS AND INTERVENTION

In 2015 a virtual collaborative system using a cross-platform instant messaging application replaced the previous 2014 protocol for the referral of patients outside of the ICU with a severe brain injury in whom all treatment options were deemed futile by the attending team to the donor coordination (DC). Once the DC evaluated the medical suitability and likelihood of progression to brain death (BD), the option of intensive care to facilitate organ donation (ICOD) was offered to the patient's relatives. This included admission to the ICU and elective non-therapeutic ventilation (ENTV), where appropriate.

RESULTS

A two-fold increase of referrals was noted in 2015 [n=46/74; (62%)] compared to 2014 [n=13/40; (32%)]; p<0.05. Patients were mostly referred from the stroke unit (58.6%) in 2015 and from the emergency department (69.2%) in 2014 (p<0.01). Twenty (2015: 42.5%) and 4 (2014: 30.7%) patients were discarded as donors mostly due to medical unsuitability. Family accepted donation in 16 (2015: 62%) and 6 (2014: 66%) cases, all admitted to the ICU and 10 (2015: 62.5%) and 3 (50%) being subject to ENTV. Ten (2015: 66.6%) and 5 (2014: 83.3%) patients progressed to BD, 60.5±20.2 and 44.4±12.2h after referral respectively. Nine (2015) and 4 (2014) of these patients became utilized donors, representing 29.0% (2015) and 13.0% (2014) of the BD donors in the hospital during the study period (p<0.05).

CONCLUSION

The implementation of a virtual community doubled the number of patients whose families were presented with the option of donation prior to their death.

Current opinions in organ allocation

Existing methods of academic publication provide limited opportunity to obtain stakeholder input on issues of broad interest. This article reports the results of an experiment to produce a collaborative, crowdsourced article examining a current controversial issue in transplant medicine (hereby referred to as the "C4 Article"). The editorial team as a whole selected the topic of organ allocation, then divided into six sections, each supported by an individual editorial team. Widely promoted by the American Journal of Transplantation, the C4 Article was open for public comment for 1 month. The nonblinded editorial teams reviewed the contributions daily and interacted with contributors in near-real time to clarify and expand on the content received. Draft summaries of each section were posted and subsequently revised as new contributions were received. One hundred ninety-four individuals viewed the manuscript, and 107 individuals contributed to the manuscript during the submission period. The article engaged the international transplant community in producing a contemporary delineation of issues of agreement and controversy related to organ allocation and identified opportunities for new policy development. This initial experience successfully demonstrated the potential of a crowdsourced academic manuscript to advance a broad-based understanding of a complex issue.

How Spain Reached 40 Deceased Organ Donors per Million Population

With 40 donors and more than 100 transplant procedures per million population in 2015, Spain holds a privileged position worldwide in providing transplant services to its patient population. The Spanish success derives from a specific organizational approach to ensure the systematic identification of opportunities for organ donation and their transition to actual donation and to promote public support for the donation of organs after death. The Spanish results are to be highlighted in the context of the dramatic decline in the incidence of brain death and the changes in end-of-life care practices in the country since the beginning of the century. This prompted the system to conceive the 40 donors per million population plan, with three specific objectives: (i) promoting the identification and early referral of possible organ donors from outside of the intensive care unit to consider elective non-therapeutic intensive care and incorporate the option of organ donation into end-of-life care; (ii) facilitating the use of organs from expanded criteria and non-standard risk donors; and (iii) developing the framework for the practice of donation after circulatory death. This article describes the actions undertaken and their impact on donation and transplantation activities.

Organ Donation and Elective Ventilation: A Necessary Strategy

Organ transplantation is the sole treatment to improve or save the life of patients with final-stage organ failure. The shortage of available organs for transplantation constitutes a universal problem, estimating that 10% of patients on waiting lists die. Brain death is an undesirable result; nevertheless, it has beneficial side-effects since it is the most frequent source of organs for transplantation. However, this phenomenon is relatively uncommon and has a limited potential. One of the options that focuses on increasing organ donation is to admit patients with catastrophic brain injuries (with a high probability of brain death and nontreatable) to the Intensive Care Unit, with the only purpose of donation. To perform elective nontherapeutic ventilation (ENTV), a patient's anticipated willingness to donate organs and/or explicit acceptance by his/her relatives is required. This process should focus exclusively on those patients with catastrophic brain injuries and imminent risk of death which, due to its acute damage, are not considered treatable. This article defends ENTV as an effective strategy to improve donation rate, analyzing its ethical and legal basis.

Identifying opportunities to increase organ donation after brain death. An observational study in Sweden 2009-2014

BACKGROUND

There is a wide gap between the number of organ donors and patients on waiting lists for transplantation. The purpose of this Swedish nationwide study of the critical pathway for organ donation after brain death (DBD) was to identify missed opportunities for organ donation.

METHODS

We performed a prospective, observational study of all ICU deaths in Sweden from Jan 1, 2009 to Dec 31, 2014. The protocol structure followed the critical pathway for organ donation, which was developed and tested during 2008. We analysed differences in donation incidences between healthcare providers (counties) and patient characteristics using descriptive statistics and logistic regression.

RESULTS

The number of DBD per million population (pmp) was 14.9, varying almost 10-fold from 4.3 to 40.6 DBD pmp between counties. Regional variation in DBD decreased when we assigned the donor to the place of residence (from 6.9 to 27.7 DBD pmp). Women were more likely to become donors compared to men [crude odds ratio (OR) 1.60, 95% confidence interval (CI) 1.38-1.85, P < 0.001]. The increased likelihood remained after adjusting for age, comorbidity, and main diagnostic categories (OR 1.49, 95% CI 1.25-1.77, P < 0.001). An end-of-life decision was found in 50.9% of possible organ donors.

CONCLUSIONS

Regional differences in DBD were considerable, and women were more likely to become donors than men. There is a need for increased awareness of the potential for organ donation as an integral part of end-of-life clinical care. In-depth analysis of these differences may reveal opportunities for action that could lead to increased DBD.

Practices Around Communication About Organ Donation in Hungary

BACKGROUND

One obstacle to organ donation is the high proportion of relatives who refuse consent in presumed-consent countries. The aim of this study was to survey the features of family approaches and to identify those that may have significant impact on family refusals.

METHODS

A 46-item validated questionnaire was designed and used in 2011 and 2012 to investigate factors around all family communications about brain death and organ donation. The data of 188 cases were collected by telephone calls. We asked for the demographic data of donors; place, timing, duration, type, and result of approach; number, age, gender, and qualification of the staff; affinity, gender, age, education, and religion of the involved relatives; and finally the applied method to treat family refusal if it existed.

RESULTS

Usually 1 physician talked with 2 relatives. Timing had significant impact on objection rate (χ² = 0.044). Single-discussion meetings (56.38%) were an average 1 hour 13 minutes before the brain death declaration, and they were initiated an average 19 hours 49 minutes before brain death when more than one meeting took place (43.62%). Conversations lasted for 11-22 minutes. Mann-Whitney U test revealed association between duration of donor family communication and occurrence of refusal (P = .021). It was found that the relatives' education level, the number of staff, and the number of family members strongly influenced the occurrence of refusals.

CONCLUSIONS

The careful preparation, organized direction, and support by intensive care unit staff can decrease the number of family refusals.

Deceased organ donation for transplantation: Challenges and opportunities

Organ transplantation saves thousands of lives every year but the shortage of donors is a major limiting factor to increase transplantation rates. To allow more patients to be transplanted before they die on the wait-list an increase in the number of donors is necessary. Patients with devastating irreversible brain injury, if medically suitable, are potential deceased donors and strategies are needed to successfully convert them into actual donors. Multiple steps in the process of deceased organ donation can be targeted to increase the number of organs suitable for transplant. In this review, after describing this process, we discuss current challenges and potential strategies to expand the pool of deceased donors.

Liver transplantation in Spain

Liver transplantation (LT) activity started in Spain in 1984 and has exceeded 23,700 interventions, with more than 1000 transplants performed yearly. Every hospital needs official authorization to perform a LT, which implies the obligation to register all patients on the national waiting list. The Spanish National Transplant Organization (ONT) provides essential support for organ procurement, allocation, and management of the waiting list at a national level. Liver allocation is center-oriented as all available organs are referred to the ONT for the whole country. The allocation rules for LT are made according to disease severity after consensus among professionals from every transplant center and ratified by representatives of the regional health authorities. Authorization and location/distribution of transplant centers are regulated by the country (Spain) and by the different regions according to the Real Decreto 1723/2012. For a total population of 47,850,795 inhabitants, there are 24 centers for LT for adults (1 team/2 million people) and 5 for LT for children (1 team/9.5 million people). Nonbiliary cirrhosis, particularly alcohol- and hepatitis C virus-related cirrhosis (60%), and tumors, mainly hepatocellular carcinoma (19%), are the most common indications for LT in Spain. Unusual causes of LT include metabolic diseases like Wilson's disease, familial amyloid polyneuropathy and hyperoxaluria type I, polycystic kidney and liver disease, and some tumors (epithelioid hemangioendothelioma and neuroendocrine tumors). Important efforts are now being undertaken to improve the quality and transplantability of extended criteria livers, in particular those arising from DCD, which represent the greatest opportunity to expand the donor pool. These efforts have to be addressed to adapt the organ preservation procedures, be it through the application of regional perfusion in situ or the use of machine perfusion preservation ex situ. Liver Transplantation 22 1259-1264 2016 AASLD.

Pediatric Deceased Donation-A Report of the Transplantation Society Meeting in Geneva

The Ethics Committee of The Transplantation Society convened a meeting on pediatric deceased donation of organs in Geneva, Switzerland, on March 21 to 22, 2014. Thirty-four participants from Africa, Asia, the Middle East, Oceania, Europe, and North and South America explored the practical and ethical issues pertaining to pediatric deceased donation and developed recommendations for policy and practice. Their expertise was inclusive of pediatric intensive care, internal medicine, and surgery, nursing, ethics, organ donation and procurement, psychology, law, and sociology. The report of the meeting advocates the routine provision of opportunities for deceased donation by pediatric patients and conveys an international call for the development of evidence-based resources needed to inform provision of best practice care in deceased donation for neonates and children.

Prospective validation of ab initio liver transplantation in hepatocellular carcinoma upon detection of risk factors for recurrence after resection

A decade ago we proposed to enlist for transplantation those patients with resected hepatocellular carcinoma in whom pathology registered pejorative histological markers (microvascular invasion and/or satellites; ab initio indication) and not wait for the appearance of recurrence. This study evaluates the outcome of this approach. From 1995 to 2012, 164 patients with hepatocellular carcinoma underwent resection. Eighty-five patients were potential candidates for liver transplantation and were considered for it upon detection of pejorative histological markers. Patients without these markers were followed, and salvage liver transplantation was considered upon development of tumor recurrence/liver function impairment. Thirty-seven patients were at high risk and 48 at low risk of recurrence at pathology. Twenty-three out of 37 high-risk patients recurred during follow-up, but in nine of them the tumor burden extent contraindicated liver transplantation. Seventeen were finally transplanted: 10 of them presented recurrence at imaging/explant. After a median posttransplant follow-up of 50.9 months, hepatocellular carcinoma had recurred in two patients and five patients had died, the 5-year survival being 82.4%. Twenty-six of the 48 low-risk patients developed recurrence, and 11 of them were transplanted. After a median posttransplant follow-up of 59 months, two patients developed recurrence and five died, their 5-year survival being 81.8%.

CONCLUSION

Enlistment of patients at high risk of HCC recurrence after resection but before recurrence development seems a valid strategy and is associated with excellent long-term outcome; as early (<6 months) recurrence reflects an aggressive tumor behavior leading to tumor extent exceeding transplant criteria, we propose to wait at least 6 months before enlistment; however, once included on the waiting list, priority strategies should be implemented in order to reach effective transplantation prior to the appearance of recurrence.

Estimating the Number of Organ Donors in Australian Hospitals--Implications for Monitoring Organ Donation Practices

The Australian DonateLife Audit captures information on all deaths which occur in emergency departments, intensive care units and in those recently discharged from intensive care unit. This information provides the opportunity to estimate the number of donors expected, given present consent rates and contemporary donation practices. This may then allow benchmarking of performance between hospitals and jurisdictions. Our aim was to develop a method to estimate the number of donors using data from the DonateLife Audit on the basis of baseline patient characteristics alone.

Australian audit of intubated deaths in 68 hospitals allowed development of a highly predictive model of organ donation that permits estimation of potential donor numbers.

Intensive care practices in brain death diagnosis and organ donation

We conducted a multicentre study of 1844 patients from 42 Spanish intensive care units, and analysed the clinical characteristics of brain death, the use of ancillary testing, and the clinical decisions taken after the diagnosis of brain death. The main cause of brain death was intracerebral haemorrhage (769/1844, 42%), followed by traumatic brain injury (343/1844, 19%) and subarachnoid haemorrhage (257/1844, 14%). The diagnosis of brain death was made rapidly (50% in the first 24 h). Of those patients who went on to die, the Glasgow Coma Scale on admission was ≤ 8/15 in 1146/1261 (91%) of patients with intracerebral haemorrhage, traumatic brain injury or anoxic encephalopathy; the Hunt and Hess Scale was 4-5 in 207/251 (83%) of patients following subarachnoid haemorrhage; and the National Institutes of Health Stroke Scale was ≥ 15 in 114/129 (89%) of patients with strokes. Brain death was diagnosed exclusively by clinical examination in 92/1844 (5%) of cases. Electroencephalography was the most frequently used ancillary test (1303/1752, 70.7%), followed by transcranial Doppler (652/1752, 37%). Organ donation took place in 70% of patients (1291/1844), with medical unsuitability (267/553, 48%) and family refusal (244/553, 13%) the main reasons for loss of potential donors. All life-sustaining measures were withdrawn in 413/553 of non-donors (75%).

Intensive care medicine and organ donation: exploring the last frontiers?

The main, universal problem for transplantation is organ scarcity. The gap between offer and demand grows wider every year and causes many patients in waiting list to die. In Spain, 90% of transplants are done with organs taken from patients deceased in brain death but this has a limited potential. In order to diminish organ shortage, alternative strategies such as donations from living donors, expanded criteria donors or donation after circulatory death, have been developed. Nevertheless, these types of donors also have their limitations and so are not able to satisfy current organ demand. It is necessary to reduce family denial and to raise donation in brain death thus generalizing, among other strategies, non-therapeutic elective ventilation. As intensive care doctors, cornerstone to the national donation programme, we must consolidate our commitment with society and organ transplantation. We must contribute with the values proper to our specialization and try to reach self-sufficiency by rising organ obtainment.

Brain death organ donation potential and life support therapy limitation in neurocritical patients

OBJECTIVE

To analyze the profile, incidence of life support therapy limitation (LSTL) and donation potential in neurocritical patients.

STUDY DESIGN

A multicenter prospective study was carried out.

SETTING

Nine hospitals authorized for organ harvesting for transplantation.

PATIENTS

All patients consecutively admitted to the hospital with GCS < 8 during a 6-month period were followed-up until discharge or day 30 of hospital stay.

STUDY VARIABLES

Demographic data, cause of coma, clinical status upon admission and outcome were analyzed. LSTL, brain death (BD) and organ donation incidence were recorded.

RESULTS

A total of 549 patients were included, with a mean age of 59.0 ± 14.5 years. The cause of coma was cerebral hemorrhage in 27.0% of the cases.LSTL was applied in 176 patients (32.1%). In 78 cases LSTL consisted of avoiding ICU admission. Age, the presence of contraindications, and specific causes of coma were associated to LSTL. A total of 58.1% of the patients died (n=319). One-hundred and thirty-three developed BD (24.2%), and 56.4% of these became organ donors (n=75). The presence of edema and mid-line shift on the CT scan, and transplant coordinator evaluation were associated to BD. LSTL was associated to a no-BD outcome. Early LSTL (first 4 days) was applied in 9 patients under 80 years of age, with no medical contraindications for donation and a GCS ≤ 4 who finally died in asystole.

CONCLUSIONS

LSTL is a frequent practice in neurocritical patients. In almost one-half of the cases, LSTL consisted of avoiding admission to the ICU, and on several occasions the donation potential was not evaluated by the transplant coordinator.