Organ procurement center allows for daytime liver transplantation with less resource utilization: May address burnout,pipeline, and safety for field of transplantation

Abdominal organ transplantation faces several challenges: burnout, limited pipeline of future surgeons, changes in liver allocation potentially impacting organ procurement travel, and travel safety. The organ procurement center (OPC) model may be one way to mitigate these issues. Liver transplants from 2009 to 2016 were reviewed. There were 755 liver transplants performed with 525 OPC and 230 in‐hospital procurements. The majority of transplants (87.4%) were started during daytime hours (5 am ‐7 pm ). Transplants with any portion occurring after‐hours were more likely to have procurements in‐hospital (P < .001). Daytime cases (n = 400) had more OPC procured livers and hepatitis C recipients and were less likely to have a donation after circulatory death donor (all P < .05). In adjusted analyses, daytime cases were independently associated with extubation in the operating room and less postoperative transfusion. There were no significant differences in short‐ or long‐term postoperative outcomes. For exported livers, 54.3% were procured by a local team, saving 137 flights (151 559 miles). The OPC resulted in optimally timed liver transplants and decreased resource utilization with no negative impact on patient outcomes. It allows for ease in exporting organs procured by local surgeons, and potentially addresses provider burnout, the transplant surgery pipeline, and surgeon travel.     

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.     

Changing Metrics of Organ Procurement Organization Performance in Order to Increase Organ Donation Rates in the United States

The shortage of deceased‐donor organs is compounded by donation metrics that fail to account for the total pool of possible donors, leading to ambiguous donor statistics. We sought to assess potential metrics of organ procurement organizations (OPOs) utilizing data from the Nationwide Inpatient Sample (NIS) from 2009–2012 and State Inpatient Databases (SIDs) from 2008–2014. A possible donor was defined as a ventilated inpatient death ≤75 years of age, without multi‐organ system failure, sepsis, or cancer, whose cause of death was consistent with organ donation. These estimates were compared to patient‐level data from chart review from two large OPOs. Among 2,907,658 inpatient deaths from 2009–2012, 96,028 (3.3%) were a “possible deceased‐organ donor.” The two proposed metrics of OPO performance were: (1) donation percentage (percentage of possible deceased‐donors who become actual donors; range: 20.0–57.0%); and (2) organs transplanted per possible donor (range: 0.52–1.74). These metrics allow for comparisons of OPO performance and geographic‐level donation rates, and identify areas in greatest need of interventions to improve donation rates. We demonstrate that administrative data can be used to identify possible deceased donors in the US and could be a data source for CMS to implement new OPO performance metrics in a standardized fashion.     

Regional Differences in Communication Process and Outcomes of Requests for Solid Organ Donation

Although federal mandate prohibits the allocation of solid organs for transplantation based on “accidents of geography,” geographic variation of transplantable organs is well documented. This study explores regional differences in communication in requests for organ donation. Administrative data from nine partnering organ procurement organizations and interview data from 1339 family decision makers (FDMs) were compared across eight geographically distinct US donor service areas (DSAs). Authorization for organ donation ranged from 60.4% to 98.1% across DSAs. FDMs from the three regions with the lowest authorization rates reported the lowest levels of satisfaction with the time spent discussing donation and with the request process, discussion of the least donation‐related topics, the highest levels of pressure to donate, and the least comfort with the donation decision. Organ procurement organization region predicted authorization (odds ratios ranged from 8.14 to 0.24), as did time spent discussing donation (OR = 2.11), the number of donation‐related topics discussed (OR = 1.14), and requesters’ communication skill (OR = 1.14). Standardized training for organ donation request staff is needed to ensure the highest quality communication during requests, optimize rates of family authorization to donation in all regions, and increase the supply of organs available for transplantation.     

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.     

Importance of incorporating standardized,verifiable, objective metrics of organ procurement organization performance into discussions about organ allocation

Identifying and supporting specific organ procurement organizations (OPOs) with the greatest opportunity to increase donation rates could significantly increase the number of organs available for transplant. Accomplishing this is complicated by current Scientific Registry of Transplant Recipients/Centers for Medicare & Medicaid Services metrics of donation rates and OPO performance that rely on eligible deaths. These data are self‐reported and unverifiable and have been shown to underestimate potential organ donors. We examine the limitations of current OPO performance/donation metrics to inform discussions related to strategies to increase donation. We propose changing to a simple, verifiable, and uniformly applied donation metric. This would allow the transplant community to (1) better understand inherent differences in donor availability based on geography and (2) identify underperforming areas that would benefit from systems improvement agreements to increase donation rates.     

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.     

Noneligible Donors as a Strategy to Decrease the Organ Shortage

Organ procurement organization (OPO) performance is generally evaluated by the number of organ procurement procedures divided by the number of eligible deaths (donation after brain death [DBD] donors aged <70 years), whereas the number of noneligible deaths (including donation after cardiac death donors and DBD donors aged >70 years) is not tracked. The present study aimed to investigate the variability in the proportion of noneligible liver donors by the 58 donor service areas (DSAs). Patients undergoing liver transplant (LT) between 2011 and 2015 were obtained from the United Network for Organ Sharing Standard Transplant Analysis and Research file. LTs from noneligible and eligible donors were compared. The proportion of noneligible liver donors by DSA varied significantly, ranging from 0% to 19.6% of total liver grafts used. In transplant programs, the proportion of noneligible liver donors used ranged from 0% to 35.3%. On linear regression there was no correlation between match Model for End‐Stage Liver Disease score for programs in a given DSA and proportion of noneligible donors used from the corresponding DSA (p = 0.14). Noneligible donors remain an underutilized resource in many OPOs. Policy changes to begin tracking noneligible donors and learning from OPOs that have high noneligible donor usage are potential strategies to increase awareness and pursuit of these organs.     

Deceased Organ Donor Characteristics and Clinical Interventions Associated with Organ Yield

While the function of each organ is used by each transplant team to assess suitability for transplantation, little is known about the donor characteristics and clinical interventions that contribute toward overall organ transplantation potential. We conduct a retrospective review of United Network for Organ Sharing (UNOS) deceased donor registry data from January 2005 to December 2006. This registry contains all deceased donors from whom organs were recovered during this time period (n = 15  601). Ordinary least-squares (OLS) regression models using variables in the registry are estimated to predict the number of organs transplanted. Outcome is the number of organs transplanted per donor. Organ yield is found to depend significantly on donor age, anoxia as cause of death, history of myocardial infarction (MI), hypertension and/or diabetes, body mass index (BMI), B or AB blood type, cocaine and/or cigarette use and hepatitis infection (p < 0.01). In addition, the clinical interventions of steroid administration, desmopressin (DDAVP) and diuretic usage, as well as oxygenation, are associated with organ yield. Both intrinsic donor characteristics and medical management practice are observed to be highly variable across organ procurement organizations (OPOs). These findings may provide important information to explore and assess the efficacy of clinical interventions, compare OPO performance and point to best practices.     

Change of focus: from intensive care towards organ donation.

To progress from identifying a potential organ donor to implementing the actual organ donation effectively is a challenging process for all involved. The nurses might find the change of focus difficult, as the donor organ acquisition process often starts before the relatives had been informed and have had the time to reorient themselves about the severe situation of the patient and have been briefed on the option of organ donation. The purpose was to investigate the hospital-based education in organ donation at the 28 Norwegian donor hospitals, and elicit the needs of the intensive care nurses for imparting of required knowledge and support in shifting their focus from intensive care towards the process of organ procurement. Hospital-based education and guidelines in organ donation were analyzed by scrutinizing the documents available. Eleven units were found to have their own guidelines and only three hospitals had organ donation in their educational programme. Intensive care nurses at three hospitals participated in focus groups. The main finding was the need for collaboration and mutual understanding within the treatment team. Nurses expounded the multiple responsibilities that they discharged during the course of intensive care. In reorienting their focus from intensive care to donor organ procurement, the time of death was explained as the crucial turning point. The knowledge of intensive care staff and professional competence were crucial in winning the relatives' trust and were central in the communication processes. Donor hospitals should implement systematic training and debriefing, where both nurses and physicians contribute to this process. Well-prepared protocols for organ donation at hospitals can define responsibilities assigned to different members of the donor organ acquisition team.     

Implementing an innovated preservation technology: The American Society of Transplant Surgeons’ (ASTS) Standards Committee White Paper on Ex Situ Liver Machine Perfusion

The pervasive shortage of deceased donor liver allografts contributes to significant waitlist mortality despite efforts to increase organ donation. Ex vivo liver perfusion appears to enhance preservation of donor organs, extending viability and potentially evaluating function in organs previously considered too high risk for transplant. These devices pose novel challenges for organ allocation, safety, training, and finances. This white paper describes the American Society of Transplant Surgeons’ belief that organ preservation technology is a vital advance, but its use should not change fundamental aspects of organ allocation. Additional data elements need to be collected, made available for organ assessment by transplant professionals to allow determination of organ suitability in the case of reallocation and incorporated into risk adjustment methodology. Finally, further work is needed to determine the optimal strategy for management and oversight of perfused organs prior to transplantation.     

Effects of broader geographic distribution of donor lungs on travel mode and estimated costs of organ procurement

On November 24, 2017, US lung transplant policy replaced donor service area with 250-nautical-mile radius as the first unit of allocation. Understanding this policy's economic impact is important, because the United States is poised to adopt the broadest feasible geographic organ distribution. All lung transplant recipients from January 1, 2015, to December 31, 2018, in the Scientific Registry of Transplant Recipients, were included. Recipients before and after November 24, 2017 were in the donor service area-first and 250-nautical-mile donor service area-free periods, respectively. Travel time was estimated using a Google application; mode was assigned as flying when driving time was longer than 60 min. Travel costs were estimated by mode and distance. Travel distance and time for organ procurement increased under the policy change. The estimated proportion of organs traveling by air increased from 61% to 76%. Estimated average costs increased by $14 051 if travel mode changed to flying, resulting in an average increase of $1264 for all transplants. Travel costs were highest for candidates <18 years and adults with high lung allocation scores. Broader geographic distribution increased estimated organ procurement costs for a small percentage of lung transplants. Further analysis should elucidate the broad economic impact of such policies.     

Deceased Donor Intervention Research: A Survey of Transplant Surgeons,Organ Procurement Professionals,and Institutional Review Board Members

Innovative deceased donor intervention strategies have the potential to increase the number and quality of transplantable organs. Yet there is confusion over regulatory and legal requirements, as well as ethical considerations. We surveyed transplant surgeons (n = 294), organ procurement organization (OPO) professionals (n = 83), and institutional review board (IRB) members (n = 317) and found wide variations in their perceptions about research classification, risk assessment for donors and organ transplant recipients, regulatory oversight requirements, and informed consent in the context of deceased donor intervention research. For instance, when presented with different research scenarios, IRB members were more likely than transplant surgeons and OPO professionals to feel that study review and oversight were necessary by the IRBs at the investigator, donor, and transplant center hospitals. Survey findings underscore the need to clarify ethical, legal, and regulatory requirements and their application to deceased donor intervention research to accelerate the pace of scientific discovery and facilitate more transplants.     

The organ procurement costs of expanding deceased donor organ acceptance criteria: Evidence from a cost function model

A potential solution to the deceased donor organ shortage is to expand donor acceptability criteria. The procurement cost implications of using nonstandard donors is unknown. Using 5 years of US organ procurement organization (OPO) data, we built a cost function model to make cost projections: the total cost was the dependent variable; production outputs, including the number of donors and organs procured, were the independent variables. In the model, procuring one kidney or procuring both kidneys from double/en bloc transplantation from a single-organ donor resulted in a marginal cost of $55 k (95% confidence interval [CI] $28 k, $99 k) per kidney, and procuring only the liver from a single-organ donor results in a marginal cost of $41 k (95% CI $12 k, $69 k) per liver. Procuring two kidneys for two candidates from a donor lowered the marginal cost to $36 k (95% CI $22 k, $66 k) per kidney, and procuring two kidneys and a liver lowers the marginal cost to $24 k (95% CI $17 k, $45 k) per organ. Economies of scale were observed, where high OPO volume was correlated with lower costs. Despite higher cost per organ than for standard donors, kidney transplantation from nonstandard donors remained cost-effective based on contemporary US data.     

The Life-Years Saved by a Deceased Organ Donor

Understanding the additional life-years given to patients by deceased organ donors is necessary as substantial investments are being proposed to increase organ donation. Data were drawn from the Scientific Registry of Transplant Recipients. All patients placed on the wait-list as eligible to receive or receiving a deceased donor solid organ transplant between 1995 and 2002 were studied. The benefit of transplant was determined by the difference in the expected survival experiences of transplant recipients and candidates expecting transplant soon. An average organ donor provides 30.8 additional life-years distributed over an average 2.9 different solid organ transplant recipients, whereas utilization of all solid organs from a single donor provides 55.8 additional life-years spread over six organ transplant recipients. The relative contribution of the different organs to the overall life-year benefit is higher for liver, heart and kidney, and lowest for lung and pancreas. The life-year losses from unprocured and unused organs are comparable to suicide, congenital anomalies, homicide or perinatal conditions and half that of HIV. Approximately 250,000 additional life-years could be saved annually if consent for potential deceased donors could be increased to 100%. Therefore, increasing organ donation should be considered among our most important public health concerns.     

Family and transplant professionals’ views of organ recovery before circulatory death for imminently dying patients: A qualitative study using semistructured interviews and focus groups

Donation before circulatory death for imminently dying patients has been proposed to address organ scarcity and harms of nondonation. To characterize stakeholder attitudes about organ recovery before circulatory death we conducted semistructured interviews with family members (N = 15) who had experienced a loved one's unsuccessful donation after circulatory death and focus groups with professional stakeholders (surgeons, anesthesiologists, critical care specialists, palliative care specialists, organ procurement personnel, and policymakers, N = 46). We then used qualitative content analysis to characterize these perspectives. Professional stakeholders believed that donation of all organs before circulatory death was unacceptable, morally repulsive, and equivalent to murder; consent for such a procedure would be impermissible. Respondents feared the social costs related to recovery before death were too high. Although beliefs about recovery of all organs were widely shared, some professional stakeholders could accommodate removal of a single kidney before circulatory death. In contrast, family members were typically accepting of donation before circulatory death for a single kidney, and many believed recovery of all organs was permissible because they believed the cause of death was the donor's injury, not organ procurement. These findings suggest that definitions of death and precise rules around organ donation are critical for professional stakeholders, whereas donor families find less relevance in these constructs for determining the acceptability of organ donation. Donation of a single kidney before circulatory death warrants future exploration.     

Improving Organ Procurement Practices in Michigan

Travel to procure deceased donor organs is associated with risk to transplant personnel. In many instances, multiple teams are present for a given operation. We studied our statewide experience to determine how much excess travel this redundancy entails, and generated alternate models for organ recovery. We reviewed our organ procurement organization's experience with deceased donor operations between 2002 and 2008. Travel was expressed as cumulative person-miles between procurement team origin and donor hospital. A model of minimal travel was created, using thoracic and abdominal teams from the closest in-state center. A second model involved transporting donors to a dedicated procurement facility. Travel distance was recalculated using these models, and mode and cost of travel extrapolated from current practices. In 654 thoracic and 1469 abdominal donors studied, the mean travel for thoracic teams was 1066 person-miles and for abdominal teams was 550 person-miles. The mean distance traveled by thoracic and abdominal organs was 223 miles and 142 miles, respectively. Both hypothetical models showed reductions in team travel and reliance on air transport, with favorable costs and organ transport times compared to historical data. In summary, we found significant inefficiency in current practice, which may be alleviated using new paradigms for donor procurement.     

Organ Donor Screening Practices for Trypanosoma cruzi Infection among US Organ Procurement Organizations

Donor‐derived Trypanosoma cruzi infection in solid organ transplant recipients is associated with significant morbidity and mortality. Little is known about T. cruzi screening practices among U.S. organ procurement organizations (OPOs). We distributed a questionnaire to all U.S. OPO directors, requesting data on T. cruzi screening strategies, laboratory methods, number of donors screened, disposition of organs from positive donors and attitudes toward screening. Fifty‐eight (100%) U.S. OPOs responded to the survey. Donor screening began in 2002 and is presently performed by 11 (19%) OPOs. Among screening OPOs, four screen all donors and seven use a risk‐based strategy. Three different T. cruzi serology tests are used for donor screening. During 2008, 9/993 (0.9%) donors screened positive by a T. cruzi screening test, 6/9 (66%) had confirmatory tests performed and 4/6 (66%) had positive confirmatory tests. These results led to the nonuse of five donors and 17 organs. Five organs from three seropositive donors were transplanted in 2008 without recognized disease transmission. Variability of T. cruzi donor screening strategies, laboratory methods and disposition of organs from positive donors currently exists. Further research is needed to identify the risk of donor‐derived T. cruzi infections to help inform the best screening strategy.     

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 COVID‐19 outbreak in Italy: Initial implications for organ transplantation programs

The spread of Coronavirus Disease 2019 (COVID‐19) has already reached a pandemic dimension within a few weeks. Italy has been one of the first countries dealing with the outbreak of COVID‐19, and severe measures have been adopted to limit viral transmission. The spread of COVID‐19 may have several implications in organ transplant activity that physicians should be aware of. The initial experience gained during the COVID‐19 outbreak shows that around 10% of infected patients in Italy need intensive care management to overcome the acute respiratory distress syndrome. Due to the exponential rise of infected patients we are now facing an actual risk of saturation of intensive care unit (ICU) beds. A restriction in the number of ICU beds available for both donors and transplant recipients may unfavorably influence the overall donation activity, and eventually lead to a reduced number of transplants. Preliminary Italian data show that a 25% reduction of procured organs has already occurred during the first 4 weeks of COVID‐19 outbreak. This underlines the need to closely monitor what will be further happening in ICUs due to the COVID‐19 spread in the attempt to preserve transplant activity, especially in Western countries where deceased donors represent the major organ resource.