Expanding the donor pool: regional variation in pediatric organ donation rates

Organ donation by children in Australia, 2000-2019: impact of the 2009 National Reform Program. A population-based registry data study

OBJECTIVES

To assess the impact of the 2009 National Reform Program for organ donation in Australia on the number and characteristics of organ donors under 16 years of age.

DESIGN, SETTING, PARTICIPANTS

Retrospective observational time series study; analysis of Australia and New Zealand Organ Donation (ANZOD) registry data for all consented potential deceased organ donors under 16 years of age during 2000-2019, and of numbers of donors aged 16 years or more reported in ANZOD annual reports.

MAIN OUTCOME MEASURES

Difference between 2000-2008 (pre-reform) and 2009-2019 (reform period) in annual organ donor rates (donors per million population), by age group (under 16 years, 16 years or more), reported as incidence rate ratio (IRR).

SECONDARY OUTCOMES

Differences in child donor characteristics during 2000-2008 and 2009-2019.

RESULTS

During 2000-2019, 400 children under 16 years of age were consented potential deceased organ donors, of whom 374 were actual deceased donors (94%): 146 during 2000-2008, 228 during 2009-2019. The median annual rate was 3.3 (interquartile range [IQR], 3.0-4.3) actual donors per million population during 2000-2008 and 4.2 (IQR, 3.6-5.2) donors per million population during 2009-2019 (IRR, 1.15; 95% confidence interval [CI], 0.93-1.42). In contrast, the difference between the two periods was statistically significant for donors aged 16 years or more, rising from 11.7 (IQR, 11.2-11.8) to 19.9 (IQR, 18.3-24.4) actual donors per million population (IRR, 1.75; 95% CI, 1.66-1.85). The median age of actual organ donors under 16 was similar during 2000-2008 (11 years; IQR, 7-14 years) and 2009-2019 (10 years; IQR, 4-14 years), as was the proportion of donors in this age group under 10 kg (2000-2008: four of 146, 3%; 2009-2019: 14 of 228, 6%).

CONCLUSIONS

Despite its overall effect on organ donation rates, the National Reform Program was not effective in increasing the numbers of donors under 16 years of age. Relying on broad initiatives for adult donors may not be appropriate for achieving this aim.

Perceptions of pediatric deceased donor consent: A survey of organ procurement organizations

BACKGROUND

Children awaiting transplantation face a high risk of waitlist mortality due to a shortage of pediatric organ donors. Pediatric donation consent rates vary across Organ Procurement Organizations (OPOs), suggesting that some OPOs might utilize more effective pediatric-focused donor recruitment techniques than others. An online survey of 193 donation requestor staff sheds light on the strategies that OPO staff utilize when approaching potential pediatric deceased organ donors.

METHODS

In collaboration with the Association of Organ Procurement Organizations, the research team contacted the executive directors and medical directors of all 57 of the OPOs in the US. Of these, 51 OPOs agreed to participate, and 47 provided contact information for donation requestor staff. Of the 379 staff invited to participate in the survey, 193 provided complete responses.

RESULTS

Respondents indicated more comfort approaching adult donors than pediatric donors, and they endorsed approach techniques that were interpersonal and emotional rather than professional and informative. Respondents were accurate in their perceptions about which donor characteristics are associated with consent. However, respondents from OPOs with high consent rates (according to data from the Scientific Registry of Transplant Recipients), and those from OPOs with low consent rates were very similar in terms of demographics, training, experience, and reported techniques.

CONCLUSIONS

Additional research is needed to better determine why some OPOs have higher consent rates than others and whether the factors that lead to high consent rates in high-performing OPOs can be successful when implemented by lower-performing OPOs.

Variability of Care and Access to Transplantation for Children with Biliary Atresia Who Need a Liver Replacement

Background & Aims: Biliary atresia (BA) is the commonest single etiology indication for liver replacement in children. As timely access to liver transplantation (LT) remains challenging for small BA children (with prolonged waiting time being associated with clinical deterioration leading to both preventable pre- and post-transplant morbidity and mortality), the care pathway of BA children in need of LT was analyzed—from diagnosis to LT—with particular attention to referral patterns, timing of referral, waiting list dynamics and need for medical assistance before LT. Methods: International multicentric retrospective study. Intent-to-transplant study analyzing BA children who had indication for LT early in life (aged < 3 years at the time of assessment), over the last 5 years (2016−2020). Clinical and laboratory data of 219 BA children were collected from 8 transplant centers (6 in Europe and 2 in USA). Results: 39 patients underwent primary transplants. Children who underwent Kasai in a specialist -but not transplant- center were older at time of referral and at transplant. At assessment for LT, the vast majority of children already were experiencing complication of cirrhosis, and the majority of children needed medical assistance (nutritional support, hospitalization, transfusion of albumin or blood) while waiting for transplantation. Severe worsening of the clinical condition led to the need for requesting a priority status (i.e., Peld Score exception or similar) for timely graft allocation for 76 children, overall (35%). Conclusions: As LT currently results in BA patient survival exceeding 95% in many expert LT centers, the paradigm for BA management optimization and survival have currently shifted to the pre-LT management. The creation of networks dedicated to the timely referral to a pediatric transplant center and possibly centralization of care should be considered, in combination with implementing all different graft type surgeries in specialist centers (including split and living donor LTs) to achieve timely LT in this vulnerable population.

Predictors of Deceased Organ Donation in the Pediatric Population

BACKGROUND

A shortage of donor organs represents the major barrier to the success of solid organ transplantation. This is especially true in the pediatric population for which the number of organ donors has decreased over time. With this study, we aimed to assess the factors associated with deceased organ donor consent in the pediatric population and determine the variability in consent rates across organ procurement organizations (OPOs).

METHODS

All eligible pediatric deaths were identified from the Scientific Registry of Transplant Recipients (2008-2019). The rate of organ donor consent was determined, and multivariable logistic regression was used to assess the factors independently associated with successful donor recruitment. The probability of donor consent was determined for each OPO after adjusting for patient demographics.

RESULTS

A total of 11 829 eligible pediatric deaths were approached to request consent for organ donation. Consent was successful in 8816 (74.5%) subjects. Consent rates are lower in the pediatric population compared with young adults and are directly related to patient age such that eligible infant deaths have the lowest rate of successful donor consent. There is significant variability in donor consent rates across OPOs, independent of population demographic differences.

CONCLUSIONS

OPO is predictive of pediatric deceased organ donor consent independent of demographic differences, with some regions having consistently higher consent rates than others. Sharing best practices for pediatric deceased donor recruitment may be a strategy to increase organ availability in the pediatric population.

Neonatal heart transplant outcomes: A single institutional experience

OBJECTIVE

Neonatal orthotopic heart transplantation was introduced in the 1980s as a treatment for complex congenital heart disease. Progress in single-ventricle palliation and biventricular correction has resulted in a decline in neonatal heart transplant volume. However, limited reports on neonatal heart transplants have demonstrated favorable outcomes. We report the long-term outcomes of patients with neonatal heart transplants at our institution spanning nearly 30 years.

METHODS

A retrospective analysis of neonatal heart transplants and neonates listed for transplant was performed at Children's Hospital Colorado. Primary outcomes were early and late survival. Secondary outcomes were rejection episodes, retransplantation, and development of cardiac allograft vasculopathy or post-transplant lymphoproliferative disease.

RESULTS

A total of 21 neonates underwent orthotopic heart transplantation at our institution. Among these, 10 neonates were transplanted from 1991 to 2000, 8 neonates were transplanted from 2001 to 2010, and 3 neonates were transplanted from 2011 to 2020. The average age of these patients was 17 days, and the average weight was 3.43 kg. Early survival was 95.2%. Survival at 1 and 5 years was 85.7% (confidence interval [CI], 61.9%-95.2%) and 75% (CI, 45.6%-85.5%), respectively. Of eligible patients, the 10-year and 20-year survival was 72.2% (CI, 45.1%-85.3%) and 50% (CI, 25.9%-70.1%), respectively.

CONCLUSIONS

Our institution reports favorable outcomes of neonatal heart transplantation. These results should be considered within the context of outcomes for patients awaiting transplant and the limited donor availability. However, the successful nature of these procedures suggest it may be necessary to reevaluate the indications for neonatal heart transplantation, particularly where risk of mortality and morbidity with palliative or corrective surgery is high.

Neonatal donation: are newborns too young to be recognized?

Neonatal organ and tissue donation is not common practice in the Netherlands. At the same time, there is a transplant waiting list for small size-matched organs and tissues. Multiple factors may contribute to low neonatal donation rates, including a lack of awareness of this option. This study provides insight into potential neonatal organ and tissue donors and reports on how many donors were actually reported to the procurement organization. We performed a retrospective analysis of the mortality database and medical records of two largest neonatal intensive care units (NICUs) in the Netherlands. This study reviewed records of neonates with a gestational age >37 weeks and weight >3000g who died in the period from January 1, 2005 through December 31, 2016. During the study period, 259 term-born neonates died in the two NICUs. In total, 132 neonates with general contra-indications for donation were excluded. The medical records of 127 neonates were examined for donation suitability. We identified five neonates with documented brain death who were not recognized as potential organ and/or tissue donors. Of the remaining neonates, 27 were found suitable for tissue donation. One potential tissue donor had been reported to the procurement organization. In three cases, the possibility of donation was brought up by parents.Conclusion: A low proportion (2%) of neonates who died in the NICUs were found suitable for organ donation, and a higher proportion (12%) were found suitable for tissue donation. We suggest that increased awareness concerning the possibility of neonatal donation would likely increase the identification of potential neonatal donors. What is Known: • There is an urgent need for very small organs and tissues from neonatal donors What is New: • A number of neonates who died in the NICU were suitable organ or/and tissue donors but were not recognized as donors. • Knowledge on neonatal donation possibilities is also important for proper counseling of parents who sometimes inquire for the possibility of organ and tissue donation.

Deceased Donor Predictors for Pediatric Liver Allograft Utilization

BACKGROUND

The number of pediatric deceased organ donors has recently declined, and the nonutilization of pediatric liver allografts has limited the development of liver transplantation. We determined the utilization rate of pediatric livers and identified risk factors for graft discard.

METHODS

We used data from the Scientific Registry of Transplant Recipients database from January 1, 2000, to December 31, 2012. The trends of pediatric liver donors and utilization rates were analyzed. Donor risk factors that impacted the graft use of pediatric livers were measured. Logistic regression modelling was performed to evaluate graft utilization and risk factors.

RESULTS

A total of 11,934 eligible pediatric liver donors were identified during this period. A total of 1191 authorized liver grafts did not recover or recovered without transplantation. Factors including pediatric donors >1 year of age (odds ratio [OR] = 2.956, 95% confidence interval [CI] 2.494-3.503, P < .001), nonhead trauma (OR = 2.243, 95% CI 1.903-2.642, P < .001), lack of heartbeat (OR = 7.534, 95% CI 5.899-9.623, P < .001), hepatitis B surface antigen positivity (OR = 4.588, 95% CI 1.021-20.625, P = .047), anti-hepatitis C virus positivity (OR = 4.691, 95% CI 1.352-16.280, P = .015), total bilirubin >1 mg/dL (OR = 1.743, 95% CI 1.469-2.068, P < .001), and blood urea nitrogen >21 mg/dL (OR = 1.941, 95% CI 1.546-2.436, P < .001) were significantly related to graft nonutilization. Steroids or diuretics administered prerecovery were significantly related to graft utilization (OR = 0.684, 95% CI 0.581-0.806, P < .001; OR = 0.744, 95% CI 0.634-0.874, P < .001; respectively).

CONCLUSIONS

The pediatric liver allograft utilization rate and risk factors for nonutilization of grafts were determined.

Behavioral economics-A framework for donor organ decision-making in pediatric heart transplantation

The high discard rate of pediatric donor hearts presents a major challenge for children awaiting heart transplantation. Recent literature identifies several factors that contribute to the disparities in pediatric donor heart usage, including regulatory oversight, the absence of guidelines on pediatric donor heart acceptance, and variation among transplant programs. However, a likely additional contributor to this issue are the behavioral factors influencing transplant team decisions in donor offer scenarios, a topic that has not yet been studied in detail. Behavioral economics and decision psychology provide an excellent foundation for investigating decision-making in the pediatric transplant setting, offering key insights into the behavior of transplant professionals. We conducted a systematic review of published literature in pediatric heart transplant related to behavioral economics and the psychology of decision-making. In this review, we draw on paradigms from these two domains in order to examine how existing aspects of the transplant environment, including regulatory oversight, programmatic variation, and allocation systems, may precipitate potential biases surrounding donor offer decisions. Recognizing how human decision behavior influences donor acceptance is a first step toward improving utilization of potentially viable pediatric donor hearts.

ISHLT consensus statement on donor organ acceptability and management in pediatric heart transplantation

The number of potential pediatric heart transplant recipients continues to exceed the number of donors, and consequently the waitlist mortality remains significant. Despite this, around 40% of all donated organs are not used and are discarded. This document (62 authors from 53 institutions in 17 countries) evaluates factors responsible for discarding donor hearts and makes recommendations regarding donor heart acceptance. The aim of this statement is to ensure that no usable donor heart is discarded, waitlist mortality is reduced, and post-transplant survival is not adversely impacted.

Variability in donor selection among pediatric heart transplant providers: Results from an international survey

There is considerable variability in donor acceptance practices among adult heart transplant providers; however, pediatric data are lacking. The aim of this study was to assess donor acceptance practices among pediatric heart transplant professionals. The authors generated a survey to investigate clinicians' donor acceptance practices. This survey was distributed to all members of the ISHLT Pediatric Council in April 2018. A total of 130 providers responded from 17 different countries. There was a wide range of acceptable criteria for potential donors. These included optimal donor-to-recipient weight ratio (lower limit: 50%-150%, upper limit: 120%-350%), maximum donor age (25-75 years), and minimum acceptable left ventricular EF (30%-60%). Non-US centers demonstrated less restrictive donor selection criteria and were willing to accept older donors (50 vs 35 years, P < 0.001), greater size discrepancy (upper limit weight ratio 250% vs 200%, P = 0.009), and donors with a lower EF (45% vs 50%, P < 0.001). Recipient factors were most influential in the decision to accept marginal donors including recipients requiring ECMO support, ventilator support, and highly sensitized patients with a negative XM. However, programmatic factors impacted the decision to decline marginal donors including recent programmatic mortalities and concerns for programmatic restrictions from regulatory bodies. There is significant variation in donor acceptance practices among pediatric heart transplant professionals. Standardization of donor acceptance practices through the development of a consensus statement may help to improve donor utilization and reduce waitlist mortality.

Primary Transplantation for Congenital Heart Disease in the Neonatal Period: Long-term Outcomes

BACKGROUND

Primary transplantation was developed in the 1980s as an alternative therapy to palliative reconstruction of uncorrectable congenital heart disease. Although transplantation achieved more favorable results, its utilization has been limited by the availability of donor organs. This review examines the long-term outcomes of heart transplantation in neonates at our institution.

METHODS

The institutional pediatric heart transplant database was queried for all neonatal heart transplants performed between 1985 and 2017. Follow-up was obtained from medical records and an annually administered questionnaire. Overall survival and time to development of complications were estimated using the Kaplan Meier method. Univariate and multivariate analyses were performed to identify independent predictors of survival.

RESULTS

Heart transplantation was performed in 104 neonates. Median age was 17 days. Hypoplastic left heart syndrome (classic or variant) was the primary diagnosis in 77.8% of patients. Survival at 10 years and 25 years was 73.9% and 55.8%, respectively. At 20 years, freedom from allograft vasculopathy and lymphoproliferative disease was 72.0% and 81.9%, respectively. Freedom from re-transplantation was 81.4% at 20 years. Eight patients (7.6%) developed end-stage renal disease. By multivariate analysis, lower glomerular filtration rate and allograft vasculopathy were the only significant predictors of death.

CONCLUSIONS

Neonatal heart transplantation remains a durable therapy with very acceptable long-term survival. Children transplanted in the newborn period have the potential to reach adulthood with minimal need for reintervention.

Pediatric Donor Management Goals in Use by US Organ Procurement Organizations

INTRODUCTION

A recent study of pediatric organ donation after the neurologic determination of death (DNDD) demonstrated an association between the use of donor management goals (DMGs) by organ procurement organizations (OPOs) and organ yield.

OBJECTIVE

To describe the pediatric DMGs used by OPOs and any association between specific DMGs and organ yield.

DESIGN

Query of US OPOs who utilized DMGs in the care of pediatric DNDD organ donors from 2010 to 2013.

RESULTS

All 23 OPOs using DMGs for pediatric DNDD organ donors during the study period participated (100%). The OPOs pursued an average 9.6 goals (standard deviation: 3.9; range: 5-22) with 113 unique definitions that targeted 33 aspects of donor hemodynamics, gas exchange/mechanical ventilation, electrolytes/renal function, blood products, thermoregulation, and infection control. The DMGs used by >50% of OPOs included blood pressure, oxygenation (partial pressure of arterial oxygen (PaO₂), oxygen saturation of hemoglobin by pulse oximetry, or PaO₂/fractional concentration of inspired oxygen [FiO₂] ratio), pH, central venous pressure, serum sodium, urine output, limitations on inotropic support, and serum glucose. There was no significant correlation between the number of DMGs pursued by OPOs and organ yield. There was a difference in the observed/expected organs transplanted in the 0- to 10-year age-group for OPOs that included serum creatinine among their DMGs ( P = .046).

CONCLUSIONS

The pediatric DMGs used by OPOs were generally measurable but diverse in definition and the number of goals pursued. There was no benefit in organ yield from larger DMG bundles. There may be a benefit in organ yield through the use of serum creatinine as a DMG in pediatric donors aged 0 to 10 years.

Current Topics and Controversies in Pediatric Heart Transplantation: Proceedings of the Pediatric Heart Transplantation Summit 2017

In October 2017, a pediatric heart transplant summit was held in Seattle-the first of its kind internationally-which focused solely upon controversies in pediatric end-stage heart failure management and pediatric heart transplantation. We selected five of the most popular and contentious topics and asked the speakers to provide a position paper. Worldwide, the vast majority of programs perform only a handful of pediatric heart transplants a year. Because of this, these "orphan" areas of investigation provide an opportunity for us as a community to aggregate our collective knowledge, which may represent the only viable way that we might sort through these complex and controversial issues in the field. We hope this represents the first of many such conferences and that this initial selection of papers encourages us to begin this collaborative process.

Mechanical circulatory support costs in children bridged to heart transplantation - analysis of a linked database

BACKGROUND

Pediatric mechanical circulatory support (MCS) has evolved considerably over the past decade. Though marked improvements in waitlist survival have been realized, costs have not been reassessed. This project aimed to assess contemporary MCS costs in children bridged to heart transplant (HT).

METHODS

All pediatric HT recipients (2002-2016) were identified from a unique, linked PHIS/SRTR dataset. Costs were calculated from hospital charges, inflated to 2016 Dollars and adjusted for patient-specific characteristics using generalized linear mixed-effects models. Costs and length of stay (LOS) were compared across support strategies at the time of HT (no MCS, VAD, or ECMO) with select subgroup analyses.

RESULTS

A total of 2873 pediatric HT recipients were included; no MCS: 2268 (78.9%), VAD: 470 (16.4%), and ECMO: 135 (4.7%). Both VAD and ECMO were associated with greater total hospitalization costs compared to no MCS ($755,345 and $808,771 vs. $457,086; P < .001). Total costs and LOS were similar between VAD and ECMO groups; however, costs and LOS were greatest for VAD-supported patients in the pre-HT period and greatest for ECMO-supported patients post-HT. Post-HT costs and LOS were similar between patients who did not require MCS and those supported with a VAD ($324,887 and 18 days vs. $329,198 and 18 days respectively, p = NS). Outpatients with VAD support at HT demonstrated significantly lower total costs compared to those who were inpatient with continuous flow devices ($552,222 vs. $663,071, P = .003).

CONCLUSIONS

MCS as a bridge to HT in children is associated with greater total costs. While costs are similar between VAD and ECMO groups, the majority of costs associated with VAD support is incurred pre-HT while ECMO costs are incurred primarily post-HT. Discharging patients on VAD support awaiting HT may represent a strategy to reduce costs in this population.

Organ and tissue donation in a regional paediatric intensive care unit: evaluation of practice

Approximately 2% of those on the organ transplant list in the UK are children. Early identification of donors and referral to organ donation teams (ODT) has proven to increase both the success rate of gaining consent and the number of organs actually retrieved. To evaluate the practice relating to organ donation for children receiving end-of-life care on a paediatric intensive care unit (PICU) measured against the National Guidelines. All children 0-18 who received their end-of-life care and died on the PICU. A retrospective cohort study of organ donation patterns including referral, approach, consent and donation. This involved a review of case notes on PICU between the years 2009 and 2014. One hundred five deaths were identified and 100 notes were examined and data analysed to ascertain if religion, age and length of stay on PICU impacted on practice. Eighty-six children met the early identification criteria for potential donors, 40 (46.5%) children were referred to the ODT and 33 (38.3%) families were approached regarding donation. Twenty-one (24.4%) families consented to donation. Seventeen donations took place with a total of 41 sets of organs/tissues retrieved. Despite the majority of children meeting early identification for potential donors, many were not being referred.

CONCLUSIONS

All children on end-of-life care should be referred for potential organ donation. Organ donation needs to be seen as a priority for hospitals as a part of routine end-of-life care to help increase referral rates and give families the opportunity to donate. Many paediatric deaths are not referred for consideration of organ donation, despite guidelines stating that this process should be standard of care. Further optimization of referral rates may aid in increasing the number of organs available for donation. What is Known: • Shortage of organs continues to be a national problem. • NICE guidelines state that all patients who are on end-of-life care should have the option of organ donation explored. • Required referral both increases the number of donors and organs donated. What is New: • The process of identifying and referring children for paediatric organ donation. • Identifies that children are still not being referred for organ donation. • Organ donation is still not a priority for hospitals.

Challenges of paediatric organ donation

Paediatric organ donation represents a small fraction of overall organ donation in Australia and New Zealand and indeed world-wide. Many factors contribute to low donation rates including low paediatric intensive care mortality, consent rates and medical suitability relating to disease, age and size. In the past decade, the re-emergence of donation after circulatory death has changed the landscape for the paediatric population. This article reviews the current status and challenges of organ donation for the paediatric population.