OPTN/SRTR 2018 Annual Data Report: Deceased Organ Donation

SRTR uses data collected by OPTN to calculate metrics such as donation rate, organ yield, and rate of organs recovered for transplant but not transplanted. In 2018, there were 10,721 deceased donors, and this number has been increasing since 2010. The number of deceased donor transplants increased to 29,676 in 2018 from 28,582 in 2017, and this number has been increasing since 2012. The recent increase may be due in part to the rising number of deaths of young people due to the opioid epidemic. In 2018, 4994 organs were discarded, slightly more than 4813 in 2017. In 2018, 3755 kidneys, 278 pancreata, 707 livers, 3 intestines, 23 hearts, and 317 lungs were discarded. These numbers suggest an opportunity to increase numbers of transplants by reducing discards.     

OPTN/SRTR 2019 Annual Data Report: Deceased Organ Donors

SRTR uses data collected by OPTN to calculate metrics such as donation rate, organ yield, and rate of organs recovered for transplant but not transplanted. In 2019, there were 11,870 deceased donors, an increase from 10,721 in 2018; this number has been increasing since 2010. The number of deceased donor transplants increased to 32,313 in 2019, from 29,675 in 2018; this number has been increasing since 2012. The increase may be due in part to the rising number of deaths of young people due to the ongoing opioid epidemic. The number of organs transplanted included 17,425 kidneys, 1,018 pancreata, 8,275 livers, 81 intestines, 3,604 hearts, and 2,607 lungs. In 2019, 4,324 kidneys, 346 pancreata, 867 livers, 5 intestines, 31 hearts, and 148 lungs were discarded. These numbers suggest an opportunity to increase numbers of transplants by reducing discards.     

Organ donation and utilization in the United States, 2004

This article discusses issues directly related to the organ donation process, including donor consent, donor medical suitability, non-recovery of organs, organs recovered but not transplanted, expanded criteria donors (ECD), and donation after cardiac death (DCD). The findings and topics covered have important implications for how to evaluate and share best practices of organ donation as implemented by organ procurement organizations (OPOs) and major donor hospitals in the same donation service areas (DSAs). In 2002 and 2003, US hospitals referred more than one million deaths or imminent deaths to the OPOs of their DSA. Referrals increased by nearly 10% from 2002 to 2003 (1,022,280 to 1,121,392). Donor consents have increased by about 5% and the number of total deceased donors has risen from 6,187 to 6,455. Since multiple organs are recovered from most donors, this increase allowed more than 500 additional wait-listed candidates to receive an organ transplant than in the prior year. Non-traditional donor sources have experienced a large rate of increase; in 2003 the number of ECD kidney donors increased by 8% and the number of DCD donors increased by 43% , from 189 donors in year 2002 to 271 donors in 2003.     

Improving Organ Utilization to Help Overcome the Tragedies of the Opioid Epidemic

Death rates from drug overdoses have nearly doubled since 2003, with over 47 000 deaths in 2014. This is largely attributable to the opioid epidemic. If the unfortunate deaths of otherwise healthy people have yielded an increase in organ donors, then this might serve as perhaps the only comforting factor among this tragic and unnecessary loss of life. In this viewpoint, we present data from the Organ Procurement and Transplantation Network (OPTN) that show how the greatest relative increases in the mechanism of death among deceased donors from 2003 to 2014 were drug overdoses. Unfortunately, despite the absolute increase in the number of donors who died from a drug overdose, the mean organ yield was significantly lower than in other categories, in part due to concerns about disease transmission. In this paper, we present data on the changes in donation from donors with a drug overdose as a result of the opioid epidemic and discuss the need to educate transplant candidates and their physicians about the low risk of disease transmission compared to the greater risk of dying on a transplant waitlist.     

Organ donation in Hawaii: impact of the final rule

BACKGROUND: In an effort to increase organ donation, the Department of Health and Human Services issued the Final Rule in 1998. The Health Care Financing Administration (HCFA) later required hospitals to notify organ procurement organizations (OPO) of all deaths and imminent deaths in order to remain eligible for Medicare and Medicaid reimbursement. We set out to determine the impact of the Final Rule on organ donation in Hawaii. METHODS: Medical records of all deaths between January 1999 and December 2000 at 17 acute-care hospitals were reviewed to determine the number of medically suitable, potential organ donors. RESULTS: Of 9427 deaths, 144 were potential organ donors. In 1999, before the Final Rule, 60 of 75 (80%) potential donors were identified and 40 (53%) were referred to the OPO. In 2000, after the Final Rule, the identification rate was 83% and the referral rate was 70%. CONCLUSIONS: Although, the Final Rule increased the referral rate slightly, medical centres must continue to improve their identification of potential donors and prompt referral. This is not only to comply with the Final Rule, but ultimately to increase organ donation to meet the needs of the ever-expanding list of patients waiting for organs.     

Opportunity to increase deceased donation for United States veterans

Recent changes to organ procurement organization (OPO) performance metrics have highlighted the need to identify opportunities to increase organ donation in the United States. Using data from the Organ Procurement and Transplantation Network (OPTN), Scientific Registry of Transplant Recipients (SRTR), and Veteran Health Administration Informatics and Computing Infrastructure Clinical Data Warehouse (VINCI CDW), we sought to describe historical donation performance at Veteran Administration Medical Centers (VAMCs). We found that over the period 2010–2019, there were only 33 donors recovered from the 115 VAMCs with donor potential nationwide. VA donors had similar age-matched organ transplant yields to non-VA donors. Review of VAMC records showed a total of 8474 decedents with causes of death compatible with donation, of whom 5281 had no infectious or neoplastic comorbidities preclusive to donation. Relative to a single state comparison of adult non-VA inpatient deaths, VAMC deaths were 20 times less likely to be characterized as an eligible death by SRTR. The rate of conversion of inpatient donation-consistent deaths without preclusive comorbidities to actual donors at VAMCs was 5.9% that of adult inpatients at non-VA hospitals. Overall, these findings suggest significant opportunities for growth in donation at VAMCs.     

Organ Donation and Utilization in the United States, 1997–2006

Deceased organ donation has increased rapidly since 2002, coinciding with implementation of the Organ Donation Breakthrough Collaborative. The increase in donors has resulted in a corresponding increase in the numbers of kidney, liver, lung and intestinal transplants. While transplants for most organs have increased, discard and nonrecovery rates have not improved or have increased, resulting in a decrease in organs recovered per donor (ORPD) and organs transplanted per donor (OTPD). Thus, the expansion of the consent and recovery of incremental donors has frequently outpaced utilization. Meaningful increases in multicultural donation have been achieved, but donations continue to be lower than actual rates of transplantation and waiting list registrations for these groups. To counteract the decline in living donation, mechanisms such as paired donation and enhanced incentives to organ donation are being developed. Current efforts of the collaborative have focused on differentiating ORPD and OTPD targets by donor type (standard and expanded criteria donors and donors after cardiac death), utilization of the OPTN regional structure and enlisting centers to increase transplants to match increasing organ availability.     

Increasing the Number of Organ Transplants in the United States by Optimizing Donor Authorization Rates

While recent policies have focused on allocating organs to patients most in need and lessening geographic disparities, the only mechanism to increase the actual number of transplants is to maximize the potential organ supply. We conducted a retrospective cohort study using OPTN data on all “eligible deaths” from 1/1/08 to 11/1/13 to evaluate variability in donor service area (DSA)‐level donor authorization rates, and to quantify the potential gains associated with increasing authorization rates. Despite adjustments for donor demographics (age, race/ethnicity, cause of death) and geographic factors (rural/urban status of donor hospital, statewide participation in deceased‐donor registries) among 52 571 eligible deaths, there was significant variability (p < 0.001) in donor authorization rates across the 58 DSAs. Overall DSA‐level adjusted authorization rates ranged from 63.5% to 89.5% (median: 72.7%). An additional 773–1623 eligible deaths could have been authorized, yielding 2679–5710 total organs, if the DSAs with authorization rates below the median and 75th percentile, respectively, implemented interventions to perform at the level of the corresponding reference DSA. Opportunities exist within the current organ acquisition framework to markedly improve DSA‐level donor authorization rates. Such initiatives would mitigate waitlist mortality while increasing the number of transplants.     

The rise of organ donation after circulatory death: a narrative review

Solid organ transplantation saves and transforms lives. The original type of organ donation from deceased patients was controlled donation after circulatory death, previously referred to as non-heart beating organ donation. The rise of donation after circulatory death in the UK came about through advances in critical care and transplant medicine and support from several key organisations in developing a robust ethical, legal and professional framework. The transplant waiting list reached a historic peak in 2009–2010 of 8000 patients, but fell by 25% to 6000 in 2017–2018. There has also been a steady rise in the number of deceased donors and the number of donations after circulatory death. The contribution of donation after circulatory death to the total number of donations rose steadily between 2000 and 2012 and has remained about 40% since. Although the situation has improved for patients waiting for a transplant, deaths and long waits remain common. Changes to legislative, technical and peri-mortem procedures may greatly change future practices in donation after circulatory death in the UK.     

Regional Variability in Liver Waiting List Removals Causes False Ascertainment of Waiting List Deaths

Inconsistent identification of reasons for removal from the liver transplant waiting list by Organ Procurement and Transplantation Network (OPTN) regions may contribute to regional variability in wait‐list death rates. We analyzed OPTN and Social Security Administration (SSA) reported deaths of 103 364 liver transplant candidates listed May 8, 2003–April 17, 2011, and determined regional variability in risk of death attributable to differences in use of OPTN removal codes. Only 26% of candidates removed as “too sick” died within 90 days of delisting; 6335 deaths after delisting were not reported to OPTN. The ratio of number of candidates removed as “too sick” to number who died on the waiting list varied by region from 0.23 to 0.94, indicating substantial variability in use of removal codes. Including SSA‐reported deaths within 90 days of delisting reduced regional variability in risk of death by 48% compared with deaths on the list alone, and by 35% compared with deaths plus the “too sick” designation. Codes for delisting liver transplant candidates are inconsistently applied among OPTN regions, spuriously elevating estimated regional variability in risk of wait‐list death. This variability is ameliorated by including SSA‐ reported deaths within 90 days of delisting.     

Poor organ quality and donor–recipient age mismatch rather than poor donation rates account for the decrease in deceased kidney transplantation rates in a Germany Transplant Center

Kidney transplantation is limited not by technical or immunological challenges but by lack of donor organs. Whereas the number of patients on waiting list increased, the transplantation rate decreased. We analyzed the development of decline rates and reasons as well as the fate of declined organs. In total, 1403 organs offered to 1950 patients between 2001 and 2010 were included. Of 440 organs offered between 2009 and 2011 that were declined, we investigated whether these organs were transplanted elsewhere and requested delayed graft function, creatinine, graft and patient survival. Data were compared to results of transplantations at the same time at our center. Decline rate increased from 47% to 87%. Main reasons were poor organ quality and donor–recipient age or size mismatch. Of the rejected organs, 55% were transplanted at other centers with function, graft and patient survival equivalent to patients transplanted at our center during that period. The number of decline has increased over time mainly due to a growing number of marginal donors accounting for poor organ quality or a mismatch of donor and recipient. If proper donor–recipient selection is performed, many organs that would otherwise be discarded can be transplanted successfully.     

Thoracic organ transplantation in the United States, 1994–2003

Using OPTN/SRTR data, this article reviews the state of thoracic organ transplantation in 2003 and the previous decade. Time spent on the heart waiting list has increased significantly over the last decade. The percentage of patients awaiting heart transplantation for >2 years increased from 23% in 1994 to 49% by 2003. However, there has been a general decline in heart waiting list death rates over the decade. In 2003, the lung transplant waiting list reached a record high of 3,836 registrants, up slightly from 2002 and more than threefold since 1994. One-year patient survival for those receiving lungs in 2002 was 82%, a statistically significant improvement from 2001 (78%). The number of patients awaiting a heart-lung transplant, declining since 1998, reached 189 in 2003. Adjusted patient survival for heart-lung recipients is consistently worse than the corresponding rate for isolated lung recipients, primarily due to worse outcomes for heart-lung recipients with congenital heart disease. A new lung allocation system, approved in June 2004, derives from the survival benefit of transplantation with consideration of urgency based on waiting list survival, instead of being based solely on waiting time. A goal of the policy is to minimize deaths on the waiting list.     

The Impact of Organ Procurement Injury on Transplant Organ Availability

Patients on the transplant waiting list continue to have a significant wait time as organ supply remains low. Many initiatives have been undertaken in the last few years to attempt to increase the organ allograft supply. As organ procurement organizations have attempted to increase their procurement of organs from deceased donors, emphasis has been placed on avoidance of injury to organs during procurement. To analyze the success of this attention, data were collected from 29 of 57 organ procurement organizations in the United States. Data collection was from November 2017 to January 2020. Total injury rate ranged from 6% (donation after brain death) to 8.4% (donation after circulatory death). Level 3 injuries, those resulting in loss of the allograft, ranged from 1.1% in donation after brain death to 1.6% in donation after circulatory death. The most likely injured organ resulting in loss of viability (level 3 injury) during procurement was the right kidney. We noted that among donors with procurement injuries, a higher number had no previous abdominal surgery and there were more injuries noted from attending surgeons (compared to trainees). Deceased donor procurement organ injuries, though rare, lead to substantial loss of transplantable organs every year. Given that the United Network for Organ Sharing has recorded >10,000 deceased donors yearly for the past few years, such injuries can result in hundreds of transplantable organs lost. In this article we detailed the incidence and degree of injury and some variables that may be associated with these injuries.     

Long-Term Graft Outcome Analyzed From a National Registry Point of View

It has been 10 years since the “Taiwan Organ Registry and Sharing Center” (TORSC) was founded by the Department of Health in June 2002. The mission of TORSC is to build a fair organ sharing and registration network and also a national database collection and analysis mechanism. TORSC is also dedicated to improving the organ donation rate and shortening the waiting times for patients to improve the effective usage of donated organs. The first organ was formally allocated on April 1, 2005. In this article, we will present the initial 8-year results of this allocation system focusing on kidneys. From the first organ shared on April 1, 2005 to March 31, 2013, there were 1502 donors allocated by TORSC. There were 1063 males and 439 females, with a mean age for males of 42.41 and for females of 41.99. Total organs they donated were hearts 642, livers 688, kidneys 1626, lungs 50, pancreas 88, and cornea 1973. The overall nation-wide 3-year survival rate of kidney recipients was 93.72% for patients and 83.08% for kidney grafts. In comparison, the 3-year graft survival rate presented in the 2008 Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients (OPTN/SRTR) annual report was 82.4% for kidney. According to our data, graft survival is not inferior to OPTN/SRTR, although the patient numbers are not comparable.     

Mandatory reporting of “imminent” death to identify organ donors: History, controversy, and potential solutions

PURPOSE: To review the history of mandatory reporting for the purpose of identifying potential organ and tissue donors, and the controversy around the terms, "imminent" or "impending" death, and to suggest a solution to this controversy. SOURCE: In this narrative review, published papers were retrieved based on a Medline search using the terms, "mandatory reporting" and "organ donation." In addition, unpublished data from the United Network for Organ Sharing and the Pennsylvania Gift of Life Program were reviewed. PRINCIPAL FINDINGS: There has been no demonstrable effect of mandatory reporting of "imminent" death independent of educational activities on numbers of organ donors or organs transplanted. Furthermore, mandatory reporting of "imminent" death does not meet criteria of an acceptable screening test. CONCLUSION: Education of health care providers about eligibility for organ and tissue donation and about whom to report as a potential donor will hopefully lead to identification of more individuals who meet criteria for organ donation and who will go on to donate organs to the many potential recipients.     

Improvements in organ donation: Riding the coattails of a national tragedy

The US organ donation system has received attention from the highest levels of government. It has been debated whether increased donation is attributable solely to the opioid epidemic, or to broader performance improvements of the 58 OPOs. We evaluated Organ Procurement and Transplantation Network (OPTN) data of all deceased donors from 1/1/2009 to 12/31/2018. We hierarchically created four categories: (a) donor's mechanism of death coded as “drug intoxication” by the OPO; or donor coded as another mechanism of death but his/her history noted (b) intravenous drug use, (c) non-intravenous drug use (eg, snorting), or (d) no drug use. The first three categories were grouped as “drug-related.” In 2018, there were 2700 more deceased donors than 2009. While the number of donors dying from a non–drug-related death decreased by 52, the number of drug-related deaths increased by 2752 (102% of increase from 2018 vs 2009). While there have been improvements in performance at some OPOs, based on these data it is indisputable that nationally the increased number of donors is almost wholly attributable to the drug epidemic, and reflects the byproduct of a national tragedy, rather than an improved system to be celebrated.     

The Faltering Solid Organ Donor Pool in the United States (2001–2010)

Background

Organ shortage is the greatest challenge facing the field of organ transplantation today. Use of more organs of marginal quality has been advocated to address the shortage.

Method

We examined the pattern of donation and organ use in the United States as shown in the Organ Procurement and Transplantation Network/United Network for Organ Sharing database of individuals who were consented for and progressed to organ donation between January 2001 and December 2010.

Results

There were 66,421 living donors and 73,359 deceased donors, including 67,583 (92.1 %) identified as donation after brain death and 5,776 (7.9 %) as donation after circulatory death (DCD). Comparing two periods, era 1 (01/2001–12/2005) and era 2 (01/2006–12/2010), the number of deceased donors increased by 20.3 % from 33,300 to 40,059 while there was a trend for decreasing living donation. The DCD subgroup increased from 4.9 to 11.7 % comparing the two eras. A significant increase in cardiovascular/cerebrovascular disease as a cause of death was also noted, from 38.1 % in era 1 to 56.1 % in era 2 (p < 0.001), as was a corresponding decrease in the number of deaths due to head trauma (48.8 vs. 34.9 %). The overall discard rate also increased from 13,411 (11.5 %) in era 1 to 19,516 (13.7 %) in era 2. This increase in discards was especially prominent in the DCD group [440 (20.9 %) in era 1 vs. 2,089 (24.9 %) in era 2].

Conclusions

We detect a significant change in pattern of organ donation and use in the last decade in the United States. The transplant community should consider every precaution to prevent the decay of organ quality and to improve the use of marginal organs.     

Numbers of Brain Deaths and Deceased Donors in Hospitals in Istanbul Region That Have Transplantation Units: A Retrospective Analysis Between the Years 2005 and 2015

Background

Turkey is one of the countries facing a serious organ shortage problem, with thousands of patients with end-stage organ failure. The Social Security Institution started to increase the reimbursement for transplantation operations in 2007 to solve this problem, and this policy has continued since then. Although the number of transplantation centers and operations in Turkey increased in this term, according to organ donation and transplantation statistics from the Ministry of Health, the rate of organ retrieval from deceased organ donors has decreased.

Direction of the Organ Procurement and Transplantation Network and United Network for Organ Sharing Regarding the Oversight of Live Donor Transplantation and Solicitation for Organs

The Organ Procurement and Transplantation Network (OPTN) operated by United Network for Organ Sharing (UNOS) has taken recent steps to address public solicitation for organ donors and its oversight of live donor transplantation. This report provides the direction of the OPTN regarding deceased donor solicitation. The OPTN has authority under federal law to equitably allocate deceased donor organs within a single national network based upon medical criteria, not upon one's social or economic ability to utilize resources not available to all on the waiting list. The OPTN makes a distinction between solicitations for a live donor organ versus solicitations for directed donation of deceased organs. As to live donor solicitation, the OPTN cannot regulate or restrict ways relationships are developed in our society, nor does it seek to do so. OPTN members have a responsibility of helping protect potential recipients from hazards that can arise from public appeals for live donor organs. Oversight and support of the OPTN for live donor transplantation is now detailed by improving the reporting of live donor follow-up, by providing a mechanism for facilitating anonymous live kidney donation, and by providing information for potential live kidney donors via the UNOS Transplant Living website.     

Organ donation and utilization in the USA

The processes leading to donor identification, consent, organ procurement, and allocation continue to dominate debates and efforts in the field of transplantation. A considerable shortage of donors remains while the number of patients needing organ transplantation increases.
This article reviews the main trends in organ donation practices and procurement patterns from both deceased and living sources in the USA. Although there have been increases in living donation in recent years, 2002 witnessed a much more modest growth of 1%. Absolute declines in living liver and lung donation were also noted in 2002.
In 2002, the number of deceased donors increased by only 1.6% (101 donors). Increased donation from deceased donors provides more organs for transplantation than a comparable increase in living donation, because on average 3.6 organs are recovered from each deceased donor. The total number of organs recovered from deceased donors increased by 2.1% (462 organs). Poor organ quality continued to be the major reason given for nonrecovery of consented organs from deceased donors.
The kidney is the organ most likely to be discarded after recovery. Over the past decade the discard rate of recovered kidneys has increased from 6% to 11%. Many of these are expanded criteria donor kidneys.