P1633STANDARDIZED REVIEW OF DONOR AFTER BRAIN DEATH KIDNEY OFFERS; A QUALITY IMPROVEMENT PROJECT

Background and Aims

Transplanting renal centres have a duty to use the finite resource of the deceased-donor kidney pool to benefit potential recipients without exposing them to excessive risk. However, there is known variation in centre and clinician practice. This may relate to clinicians’ attitude to risk, knowledge of the recipient and unit culture. Centre differences in acceptability of donor organs is evidenced by variation in NHS blood and transplant registry data. Use of marginal donors has become more frequent, especially for older recipients with higher comorbidity. In the UK this year we will see whether switching to an ‘opt out’ donation law further increases this proportion of donors.

We developed a systematic method to retrospectively review donation after brain death (DBD) kidney offers declined by our centre, with the intention of reducing variation in practice between clinicians, and identifying cases where offer acceptance may have been appropriate

Method

All DBD kidney offers declined by the Richard Bright Renal Service between June 2018 and May 2019 were reviewed. Data were collected by casenotes review and by contact with other transplanting units to establish the outcome of donor kidneys and recipient progress. Reasons for offer decline were recorded. Donor and recipient risk indices (DRI and RRI) were calculated. For patients now transplanted, the DRI of the declined offer was compared to the DRI of the transplanted kidney.

Results

During the study period, 98 DBD kidneys were declined. A donor organ identifier was not available in 8 cases, so 90 are considered here. Average donor age was 57 years with 52% having a Donor Risk Index (DRI) score of 4, and 74.7% a DRI score ≥3. The most common reasons for organ decline were donor related (65%), of which 27% were due to poor kidney function and 22% age mismatch; or recipient related (35%), where 30% were deemed inadequate quality for the recipient and 30% were unavailable or unwell. Of those kidneys which were transplanted elsewhere, 88% were functioning at 6 months with a median creatinine of 119 (IQR 106-148).

There were 60 potential recipients, 61% of whom had a RRI score ≥3; 44% had a RRI equal to or less than the DRI of the declined organ. Those who have still not been transplanted have accrued a median of 352 extra days on dialysis. 31 recipients (52%) have been transplanted since their declined offer. The median change in DRI score from the declined offer to the accepted offer was -1 (IQR -2 to 1), and offers were accepted after a median of 45 (IQR 14-143) additional dialysis days. Of those who were transplanted after declining a donor offer, 11 (39%) received a kidney from a donor with equal or worse DRI than the original offer, after a median of 49 further days on dialysis.

Conclusion

This review process highlights the effect of kidney offer decline on future progress of the potential recipient, as well as differences in our centre practice compared to other centres. Key to this review is to highlight the risks involved with DBD organ decline- 18% of recipients ultimately received an equal or inferior kidney while accruing additional time on dialysis. Alongside this review we have implemented strategies including a policy on AKI in donors and monthly multidisciplinary meetings to discuss individual DBD decline cases. We aim to standardize decision making and increase our utilization of all as well as marginal DBD organs, and expect to show a reduction in variation in practice in future reviews. Use of this process in other units or at a national level could reduce unwarranted variation in the utilization of the donor organ pool.

The effect of compression rate and slope on the incidence of symptomatic Eustachian tube dysfunction leading to middle ear barotrauma: a Phase I prospective study

INTRODUCTION

Symptomatic Eustachian tube dysfunction (ETD) and middle ear barotrauma (MEB) are the most common reported complications during hyperbaric oxygen (HBO2) treatment. There is no standardized rate of compression (ROC) reported to decrease the incidence rates of ETD and MEB during hyperbaric treatments. Few studies actually demonstrate that the ROC decreases the incidence of ETD or MEB.

METHODS

Our study was designed to determine an optimal hyperbaric chamber compression rate that might reduce the incidence of symptomatic ETD leading to MEB during the compression phase of treatment in a multiplace hyperbaric chamber. Data was collected prospectively over 2,807 elective patient treatments compressed using a U.S. Navy Treatment Table 9 (USN TT9) with a modified ROC. ROC was assigned using two variables, time (10 vs.15 minutes) and slope (linear vs. non-linear compression). Patients were exposed to all four compression schedules in a consecutive daily fashion. We recorded any patient requiring a stop during initial compression due to ear discomfort. Anyone requiring a stop was evaluated post treatment for MEB. Findings were compared to our standard 10-minute linear ROC. Evaluation of the tympanic membrane was accomplished using video otoscopy. Barotrauma when present was classified using both the Teed and O'Neill grading systems. Data was analyzed using basic statistical methods.

RESULTS

When comparing four different rates of compression during an elective USN TT9 in a multiplace (Class A) chamber there is a decreased incidence for symptomatic ETD when using a 15-minute linear compression schedule (p-value ⟨0.05).

CONCLUSION

Using a 15-minute linear compression schedule is associated with less symptomatic ETD and less MEB when performing an elective 45 fsw (USN TT9) hyperbaric treatment in a Class A chamber. Asymptomatic ETD and MEB were not considered in this study.

Biochemical and molecular diagnosis of glutaric aciduria type 1 in a black South African male child: case report

Glutaric aciduria type 1 (GA-1) is an inborn error of metabolism caused by a deficiency of the mitochondrial enzyme glutaryl-Co enzyme A dehydrogenase. GA-1 is not uncommon amongst Caucasians but to the best of our knowledge, it has previously not been reported in black African children. We present a case of GA-1 in a black South African boy who was referred to hospital at the age of five years and ten 10 months with dyskinesia and dystonia accompanied by chorea and athetosis. Radiological examination revealed enlarged basal cisterns with bilateral fluid collection around the sylvian fissures suggestive of GA-1. Analysis of urine showed raised levels of glutaric acid at 520 micromol/mmol creatinine (normal <2.0), 3-hydroxyglutaric acid at 113 micromol/mmol creatinine (normal <3.0) and a low blood carnitine level of 31.5 micromol/l (normal 35-84). A definitive diagnosis was reached through DNA analysis which revealed homozygosity for an A293T mutation in the glutaryl-Co-enzyme A dehydrogenase (GCDH) gene.