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 2017 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 2017, 1,085,646 death and imminent death referrals were made to organ procurement organizations, of which 22,265 met the definition of eligible (11,673) or imminent neurological (10,592) deaths per OPTN policy. There were 10,286 deceased donors, and this number has been increasing since 2010. The number of organs authorized for recovery has also continued to increase since 2010. The recent increase may be in part due to the rising number of deaths of young individuals due to the opioid epidemic. In 2017, 4813 organs were discarded, including 3542 kidneys, 309 pancreata, 742 livers, 4 intestines, 33 hearts, and 272 lungs. These numbers suggest a need to reduce the number of organs discarded.     

A 10-year analysis of organ donation after cardiac death in the United States

BACKGROUND: The greatest challenge facing transplantation today is how to increase the number of organ donors. Patients with severe brain injury who are not brain-dead can donate organs after they are removed from a ventilator and allowed to die, termed donation after cardiac death (DCD). METHODS: We analyzed the database of all organs recovered from deceased donors in the United States from 1994 through 2003 to determine DCD trends in the United States. The database was obtained from the United Network for Organ Sharing (UNOS). RESULTS: There were 57,681 deceased donors reported from 1994 through 2003. Of these, 1,177 were donors without a heartbeat (DWHB), 55,206 were brain dead donors, and 1,298 were unspecified donors. At least one organ was transplanted from 1010 of the 1177 DWHB. Organ procurement organizations (OPOs) reported 0-212 DWHB accounting for up to 12.3 percent of deceased donors. There was a steady annual increase in the number of DWHB, but in 2003 there were still 19 of 59 OPOs that recovered no DWHB. A total of 2,231 organs were transplanted from the 1,177 DWHB donors, and another 665 organs were recovered for transplantation but not transplanted. The transplanted organs included 1,779 kidneys, 395 livers, 54 pancreata, 2 lungs, and 1 heart. Organs from DWHB can be successfully transplanted. CONCLUSIONS: Wider use of DWHB has the potential to greatly increase the number of organ transplants performed each year in the United States.     

The First 2 Years of Activity of a Specialized Organ Procurement Center: Report of an Innovative Approach to Improve Organ Donation

The number of patients requiring organ transplants continues to outgrow the number of organs donated each year. In an attempt to improve the organ donation process and increase the number of organs available, we created a specialized multidisciplinary team within a specialized organ procurement center (OPC) with dedicated intensive care unit (ICU) beds and operating rooms. The OPC was staffed with ICU nurses, operating room nurses, organ donor management ICU physicians, and multidisciplinary staff. All organ donors within a designated geographic area were transferred to and managed within the OPC. During the first 2 years of operation, 126 patients were referred to the OPC. The OPC was in use for a total of 3527 h and involved 253 health workers. We retrieved 173 kidneys, 95 lungs, 68 livers, 37 hearts, and 13 pancreases for a total of 386 organs offered for transplantation. This translates to a total of 124.6 persons transplanted per million population, which compares most favorably to recently published numbers in developed countries. The OPC clearly demonstrates potential to increase the number of deceased donor organs available for transplant. Further studies are warranted to better understand the exact influence of the different components of the OPC on organ procurement.     

Organ utilization among deceased donors in Canada, 1993–2002

BACKGROUND: Optimizing organ utilization from consented donors is a critical need, given a static organ donation rate. We report changes in the characteristics of donors and organ utilization patterns in Canada over a ten-year period. METHODS: For the decade spanning the years 1993-2002, data were extracted from the Canadian Organ Replacement Register (CORR), the national transplant registry. A donor was defined as a deceased person from whom at least one vital organ was retrieved and transplanted. RESULTS: The donor pool is aging (median age of donors increased eight years over the decade), with proportionately fewer donors dying from head trauma (motor vehicle collisions) and proportionately more from cerebrovascular accidents. At least four organs were utilized from approximately half the donors. These donors were significantly younger every year over the sampling period when compared with donors where < or = three organs were utilized. In 2002, utilization rates were: 87.0% (kidneys), 85.0% (livers), 42.2% (hearts), 30.6% (pancreata), 28.3% (lungs), and < or = 1% (intestines). There was increased utilization of donor pancreata, lungs and liver over the decade, but a flat utilization pattern for hearts, and a small decline in kidney utilization. Utilization rates vary from province to province. CONCLUSIONS: Trends in the Canadian organ donor pool are characterized by an increasing age and a shift towards cerebrovascular diseases as primary causes of death. In order to improve organ utilization and understand regional variability, the scope of data provided to the national registry requires enhanced detail to address the factors that lead to non-utilization. Addressing the low utilization rates for hearts and lungs is especially critical, given the need for thoracic transplantation in Canada.     

Deceased organ donation in Brazil: how can we improve?

METHODS: We retrospectively analyzed the registry data from one organ procurement organization obtained between January 1 and December 31, 2005. RESULTS: Among the 378 potential deceased donors, 182 (48.2%) were lost, mainly due to clinical conditions (27%) or cardiac arrest (19.3%). Of the remaining 196 (51.8%) potential donors, family consent was obtained in 94 cases (48%). Family refusal was higher for potential donors aged between 18 and 59 years (70%). Of the 94 donors, 72 (77%) had their organs harvested. Cardiac arrest before harvesting (56.5%) and positive viral serology (26%) were the main reasons for further losses. The mean donor age was 40 years and 51% were men. Causes of death were cerebral vascular accidents (55.5%), cranium encephalic traumas (29%), and gun shot wounds (8%). The rate of organ donation was 100% for kidneys and livers, 96% for hearts, 86% for pancreatas, 76% for lungs, and 74% for corneas. After assessment of organ viability, 94% of corneas, 91% of kidneys, and 88% of livers were transplanted, but only 52% of pancreata and 42% of hearts. The most frequent causes of discarded organs were age and concomitant donor infection. CONCLUSION: Areas for potential improvements are: (1) earlier identification and adequate maintenance of potential donors; (2) campaigns for organ donation; and (3) careful evaluation of donated organs and selection of a suitable population to increase utilization of expanded criteria organs.     

Vascularized composite allotransplantation in the United States: A descriptive analysis of the Organ Procurement and Transplantation Network Data

On July 3, 2014, the Organ Procurement and Transplantation Network/United Network for Organ Sharing was charged with the oversight of vascularized composite allograft (VCA) procurement and transplantation in the United States. As of December 31, 2017, 61 VCA programs at 27 centers were approved in the United States. Fifty candidates have been added to the waiting list at 15 centers. Twenty‐eight VCA transplants have been performed at 14 programs (10 upper limb, 10 uterus, 5 craniofacial, 1 scalp, 1 abdominal wall, and 1 penile). Twenty‐two VCAs were procured from 21 deceased donors, resulting in 109 non‐VCA organs transplanted (15 hearts, 3 intestine, 40 kidney, 20 livers, 24 lungs, and 7 pancreata). Six uterus transplants were performed from living donors. Fourteen candidates were still waiting at 9 centers on December 31, 2017. Two of the 10 uterus recipients had live births and 3 still had viable grafts. Seventeen of 18 nonuterus recipients had functioning grafts. At present, VCA is an emerging field with a small number of patients transplanted. Data on posttransplant survival and functional outcomes continue to be collected to further the understanding of this complex and evolving field. Further systematic data are important for policy refinement and assurance of patient safety.     

Intensivist‐Led Management of Brain‐Dead Donors Is Associated with an Increase in Organ Recovery for Transplantation

The disparity between the number of patients in need of organ transplantation and the number of available organs is steadily rising. We hypothesized that intensivist‐led management of brain dead donors would increase the number of organs recovered for transplantation. We retrospectively analyzed data from all consented adult brain dead patients in the year before (n = 35) and after (n = 43) implementation of an intensivist‐led donor management program. Donor characteristics before and after implementation were similar. After implementation of the organ donor support team, the overall number of organs recovered for transplantation increased significantly (66 out of 210 potentially available organs vs. 113 out of 258 potentially available organs, p = 0.008). This was largely due to an increase in the number of lungs (8 out of 70 potentially available lungs vs. 21 out of 86 potentially available lungs; p = 0.039) and kidneys (31 out of 70 potentially available kidneys vs. 52 out of 86 potentially available kidneys; p = 0.044) recovered for transplantation. The number of hearts and livers recovered for transplantation did not change significantly. Institution of an intensivist‐led organ donor support team may be a new and viable strategy to increase the number of organs available for transplantations.     

The process of donation after cardiac death: a US perspective

Donation after cardiac death (DCD) has the potential to significantly increase the number of organ donors nationwide by at least 10%, which is the current goal of the National Organ Donation and Transplantation Collaboratives. Several organ procurement organizations in the United States currently exceed this goal with nearly 20% of their organ donors being DCD donors. With the Joint Commission on Accreditation of Healthcare Organizations asking all hospitals in the United States to have a policy on DCD donation, the number of DCD donors nationwide is expected to increase. Likewise, the numbers of organs transplanted from DCD donors is expected to increase since transplantation results with kidneys, pancreata, livers, lungs, and, in two cases, heart transplantation, have been similar to results from brain-dead donors. Equally, if not more important, is the ability to offer the opportunity of organ donation as part of the continuum of care at the end of life for patients and families. The comfort and healing nature of being able to leave a legacy of life through organ donation is well known and should never be underestimated whether donation occurs in the DCD or brain-death setting.     

Kidney and pancreas transplantation

Data from the Scientific Registry of Transplant Recipients offer a unique and comprehensive view of US trends in kidney and pancreas waiting list characteristics and outcomes, transplant recipient and donor characteristics, and patient and allograft survival. Important findings from our review of developments during 2002 and the decade's transplantation trends appear below.
The kidney waiting list has continued to grow, increasing from 47 830 in 2001 to 50 855 in 2002. This growth has occurred despite the increasing importance of living donor transplantation, which rose from 28% of total kidney transplants in 1993 to 43% in 2002.
Policies and procedures to expedite the allocation of expanded criteria donor (ECD) kidneys were developed and implemented during 2002, when 15% of deceased donor transplants were performed with ECD kidneys. Unadjusted 1- and 5-year deceased donor kidney allograft survivals were 81% and 51% for ECD kidney recipients, and 90% and 68% for non-ECD kidney recipients, respectively.
Although more patients have been placed on the simultaneous kidney-pancreas waiting list, the number of these transplants dropped from a peak of 970 in 1998 to 905 in 2002. This decline may be due to competition for organs from increasing numbers of isolated pancreas and islet transplants.     

Impact of US Public Health Service increased risk deceased donor designation on organ utilization

Under US Public Health Service guidelines, organ donors with risk factors for human immunodeficiency virus (HIV), hepatitis B virus (HBV), or hepatitis C virus (HCV) are categorized as increased risk donors (IRD). Previous studies have suggested that IRD organs are utilized at lower rates than organs from standard risk donors (SRD), but these studies were conducted prior to universal donor nucleic acid test screening. We conducted risk‐adjusted analyses to determine the effect of IRD designation on organ utilization using 2010‐2017 data (21 626 heart, 101 160 kidney, 52 714 liver, and 16 219 lung recipients in the United States) from the Organ Procurement and Transplantation Network. There was no significant difference (P < .05) between risk‐adjusted utilization rates for IRD vs SRD organs for adult hearts and livers and pediatric kidneys, livers, and lungs. Significantly lower utilization was found among IRD adult kidneys, lungs, and pediatric hearts. Analysis of the proportion of transplanted organs recovered from IRD by facility suggests that a subset of facilities contribute to the underutilization of adult IRD kidneys. Along with revised criteria and nomenclature to identify donors with HIV, HBV, or HCV risk factors, educational efforts to standardize informed consent discussions might improve organ utilization.     

Present Data on Organ Donation and Transplantation in Poland

At present, organ transplantation activity in Poland is located in the middle among European Union countries. There are appropriate law regulations, well-organized legal structures, well-educated transplant teams, good transplantation results, and case registries. There are 24 organ transplant teams in 20 centers, including 46 programs. Since 1966, over 18,000 organs have been transplanted 14,300 kidneys; 1800 livers; 1700 hearts; 250 kidney/pancreases and 30 lungs. Every year almost 1500 organs are procured from about 500 cadaveric heart-beating donors (9–14 per million people [pmp]) with 50 from living donors: 800 to 1000 kidneys (21–28 pmp); over 200 livers (5–6 pmp); and 60 to 100 hearts (1.6–2.7 pmp). National transplant registries are maintained in Poltransplant including a central registry of refusals (the policy of presumed consent with registered objection on donation after death is implemented), waiting lists, a cadaveric and living donor registry, and a transplant registry. There are still some actions that should be undertaken to strengthen the transplantation system in Poland, to increase organ availability, to enhance the efficiency and accessibility of transplantation systems, and to improve quality and safety: namely, increasing deceased donations to their full potential, appointing transplant coordinators in every hospital where there is the potential for organ donation, promoting quality improvement programs, and promoting living donation.     

OPTN/SRTR 2019 Annual Data Report: Lung

The number of lung transplants performed continues to increase annually and reached an all-time high in 2019, with decreasing waitlist mortality. These trends are attributable to an increasing number of candidates listed for transplant each year and a continuing increase in the number of donors. Despite these favorable trends, 6.4% of lungs recovered for transplant were not transplanted in 2019, and strategies to optimize use of these available organs may reduce the number of waitlist even further. Time to transplant continued to decrease, as over 50% of candidates waited 3 months or less in 2019, yet regional heterogeneity remained despite policy changes intended to improve allocation equity. Small gains continued in posttransplant survival, with 1-year survival at 88.8%; 3 year, 74.4%; 5 year, 59.2%, and 10 year, 33.1 %.     

Neoplasia in solid organ transplant recipients: single-center experience

The incidence of neoplasms among transplanted patients is increasing, being estimated at between 4% and 18% (mean = 6%). In this article we review the neoplasms in 2514 patients who underwent transplantation in our hospital between 1981 and 2002 including 1579 kidneys, 418 hearts, 430 livers, 70 lungs, and 17 pancreas. We observed 170 tumors in 117 patients. The most frequent neoplasm was skin and lip carcinoma (30 patients) followed by PTLD (18 patients). Our results concur with the literature with one exception, a low incidence of PTLD in heart transplants, which may only be explained due to the use of preventive therapy with antiretroviral drugs.     

Organ donor management and organ outcome: a 6-year review from a Level I trauma center

A retrospective review of 114 solid organ donors over a 6-year period (1982-1987) was undertaken to identify problems in organ donor management and determine outcome of donated organs. Admission GCS was less than or equal to 4 in 84% of the donors. Complications included hypotension (81%), multiple transfusion requirements (63%), diabetes insipidus (53%), DIC (28%), arrhythmias (27%), cardiac arrest requiring CPR (25%), pulmonary edema (19%), hypoxia (11%), acidosis (11%), seizures (10%), and positive bacterial cultures (10%). Only 18% of organs were procured within 3 hours of brain death; 23% were procured more than 6 hours later. Six patients excluded from this study suffered cardiovascular collapse before their organs could be retrieved. From 114 organ donors, consent was obtained to procure 224 kidneys, 77 livers, 62 hearts, 35 pancreata, and ten heart-lung units. All 224 donated kidneys were procured and 202 were ultimately transplanted. Of 77 donated livers, 32 were procured; 31 transplanted. Of 62 donated hearts, 38 were procured; 29 transplanted and nine used for valves. Ten heart-lung units were donated; six were procured and transplanted. Of 35 donated pancreata, 11 were procured; only five were transplanted. Reasons for failure of donated organs to be procured or transplanted included abnormal organ characteristics, lack of compatible recipients, unavailability of surgical teams, organ injury during procurement, intraoperative arrest, and anatomic limitations precluding multiple organ procurement. This study identifies characteristics of organ donors and common organ-threatening complications. Rapid and continuing resuscitation of clinically brain dead trauma victims is mandatory.(ABSTRACT TRUNCATED AT 250 WORDS)     

Recovery and Utilization of Deceased Donor Kidneys from Small Pediatric Donors

The optimal use of kidneys from small pediatric deceased donors remains undetermined. Using data from the Scientific Registry of Transplant Recipients, 2886 small (< 21 kg) pediatric donors between 1993 and 2002 were identified. Donor factors predictive of kidney recovery and transplantation (1343 en bloc; 1600 single) were identified by logistic regression. Multivariable Cox regression was used to assess the risk of graft loss. The rate of kidney recovery from small pediatric donors was significantly higher with increasing age, weight and height. The odds of transplant of recovered small donor kidneys were significantly higher with increasing age, weight, height and en bloc recovery (adjusted odds ratio = 65.8 vs. single; p < 0.0001), and significantly lower with increasing creatinine. Compared to en bloc, solitary transplants had a 78% higher risk of graft loss (p < 0.0001). En bloc transplants had a similar graft survival to ideal donors (p = 0.45) while solitary transplants had an increased risk of graft loss (p < 0.0001). En bloc recovery of kidneys from small pediatric donors may result in the highest probability of transplantation. Although limited by the retrospective nature of the study, kidneys transplanted en bloc had a similar graft survival to ideal donors but may not maximize the number of successfully transplanted recipients.     

Abdominal organ procurement in the Netherlands – an analysis of quality and clinical impact

Between March 2012 and August 2013, 591 quality forms were filled out for abdominal organs in the Netherlands. In 133 cases (23%), there was a discrepancy between the evaluation from the procuring and transplanting surgeons. Injuries were seen in 148 (25%) organs of which 12 (2%) led to discarding of the organ: one of 133 (0.8%) livers, five of 38 (13%) pancreata and six of 420 (1.4%) kidneys (P < 0.001). Higher donor BMI was a risk factor for procurement‐related injury in all organs (OR: 1.06, P = 0.011) and donor after cardiac death (DCD) donation in liver procurement (OR: 2.31, P = 0.034). DCD donation is also associated with more pancreata being discarded due to injury (OR: 10.333, P = 0.046). A higher procurement volume in a centre was associated with less injury in pancreata (OR = −0.95, P = 0.013) and kidneys (OR = −0.91, P = 0.012). The quality form system efficiently monitors the quality of organ procurement. Although there is a relatively high rate of organ injury, the discard rate is low and it does not significantly affect 1‐year graft survival for any organ. We identified higher BMI as a risk factor for injury in abdominal organs and DCD as a risk factor in livers. A higher procurement volume is associated with fewer injuries.     

Deceased donors with a past history of malignancy: an organ procurement and transplantation network/united network for organ sharing update

Approximately 2% of deceased donor organ transplants result from donors with a past history of cancer. An analysis of Organ Procurement and Transplantation Network/United Network for Organ Sharing data on 39,455 deceased donors from 2000 to 2005 showed 1069 donors had a PHC, resulting in 2508 transplants, including 1236 kidneys, 891 livers, 199 hearts, 100 lungs, and 82 miscellaneous organs. The most common type of previous cancer in the donor was nonmelanoma skin cancer (n=776) followed by central nervous system malignancies (n=642) and carcinoma of the uterine cervix (n=336). One donor with a glioblastoma multiforme transmitted fatal tumors to three recipients. One donor with a history of melanoma 32 years earlier transmitted a fatal melanoma to a single recipient and, therefore, donors with a history of melanoma should not be used. Donors with a past history of cancer who have a nontraumatic cerebral hemorrhage cause concern because this hemorrhage may be the result of an unrecognized metastatic tumor.     

Non-utilization of hearts and lungs after consent for donation: a Canadian multicentre study

PURPOSE: To identify reasons why hearts and lungs from consented adult organ donors are not transplanted and identify changes in practice aimed at increasing their utilization rates. A greater potential may exist in Canada to improve utilization rates for hearts and lungs given their comparatively suboptimal rates (kidneys 85%, livers 84%, hearts 35% and lungs 23% reported in 2001). METHODS: Four Canadian organ procurement organizations participated. All adult organ donation cases for the calendar year 2002 were reviewed and included if consent for organ donation was obtained. An organ donation framework was established to highlight key areas where organs are lost from the transplantation stream. Organ donor cases were analyzed through this framework. RESULTS: A utilization rate of 39% (42/107) for heart and 28% (29/105) for lung donors was found, comparable to Canadian and international rates. Organ function was the most frequently cited reason for non-utilization, followed by donor characteristics and logistical issues. Suggestions for alternate management, potentially resulting in organ utilization, were made in 20 of 65 (31%) hearts and 28 of 156 (18%) lungs. Variable practices, around consent for individual organs and offering of organs consented, remained significant barriers to successful transplantation. CONCLUSION: Target areas for changes in practice included consenting and offering of all organs. Management of "marginal" organs should include resuscitation and reevaluation thus allowing potential organ rescue and utilization. Although there is considerable pressure to increase organs for transplantation, any such mechanism will not be judged successful unless recipient graft survival rates remain acceptable.