Increasing organ donation: a successful new concept

BACKGROUND: Organ donation rates nationally have changed little in the last 15 years, despite a growing waiting list. About 6000 patients die each year for lack of a donated organ. South Carolina's organ procurement organization, LifePoint, recently restructured itself in an effort to increase donation and transplantation rates. The main change was division of the procurement coordinator position into five new positions. A unique innovation was the creation of a bereavement counseling and education service to provide families of potential donors emotional support and education regarding brain death and the value of transplantation. METHODS: We retrospectively reviewed data of the Association of Organ Procurement Organizations and LifePoint's in-house databases, covering the period from 1997 to 2001. RESULTS: From 1997 to 2001, the donation rate within LifePoint's service area increased from 18.2 to 33.6 donors per million of population (83%), and transplantation rate increased from 54.8 to 108.6 transplants per million of population (97%), while the national rates were virtually unchanged (P<0.01 and P<0.001, respectively). CONCLUSIONS: Division of procurement function into several separate positions, including family bereavement counseling and education, can substantially increase donation and transplantation rates. If these innovations could be effectively adapted by other organ procurement organizations, the number of patients nationally who die on waiting lists could be substantially reduced.     

A 5-year analysis of organ donors and recipients in Italy

This article describes the improvement of organ donation and transplantation in Italy during 1995-1999. In 1999, the mean number of donors per million population reached 13.7 in Italy. In addition, an analysis regarding major characteristics of donors and recipients is presented, focusing particularly on donor characteristics that have changed in the past 5 years. Despite the encouraging results, further efforts are required to reach the European mean, which still remains higher than the Italian national mean. In particular, an increase of organ donation and procurement in regions with a poor activity in this field is crucial. A 1999 law on donation and transplantation should help in solving problems that continue to affect part of the nation, especially preparing the healthcare staff dedicated to organ retrieval to promote organ procurement.     

A marked increase in organ donation in Puerto Rico

During its first years of existence, the Puerto Rico Transplant Program barely reached 18 to 20 renal transplants per year. A brain death amendment to the law improved the numbers but only to a stable thirty/year. Polls and studies showed that, although people knew about transplantation and expressed willingness to donate, the powerful emotional grief reaction, as well as a peculiar decision-making process, all militated against effective donation. In 1995, LifeLink of Puerto Rico was created as part of the very successful LifeLink Foundation of Tampa, staffed by local professionals. Cadaveric donation increased exponentially by 1227% and in 2004, 22.4 donors per million population were recovered, up from 1.5, one of the steepest growth curves in the United States. As a result, kidney transplantation increased, a cardiac transplant program was inaugurated, a pancreas transplant program has started, and liver will follow. The success is the result of well-trained, culturally sensitive coordinators and requestors; continuous education to the public, hospitals, administrators, neurospecialists, and critical care units; hospital development; implementation of federal law; and a sensitive approach the deceased donor family, and not only to the waiting list patients. The results demonstrate that organizational and educational factors can override cultural obstacles.     

An educational intervention on organ and tissue donation for first-year medical students

CONTEXT: Medical students and medical professionals have knowledge deficits related to organ and tissue transplantation. OBJECTIVE: To implement and evaluate a medical education intervention on organ and tissue donation designed for first-year medical students. STUDY DESIGN: Independent sample pretest and posttest design. SETTING AND PARTICIPANTS: First-year medical students attending University at Buffalo School of Medicine during fall 2005 and fall 2006 terms. INTERVENTION: A 1-hour lecture on the background of organ donation, donor eligibility (eg, living vs deceased donation), policies and roles during transplantation (eg, role of physician and organ procurement organization), and the organ-matching process. After the lecture, students participated in a small-group interaction that used standardized patients who role-played 1 of 2 scenarios designed to test students' knowledge and communication about organ and tissue donation. OUTCOME MEASURES: Knowledge, self-efficacy, family discussion, and enrollment into state organ and tissue registry. RESULTS: Significant increases from pretest to posttest in medical students' knowledge, self-efficacy, and family notification of donation intentions were found. The intervention was successful in increasing students' knowledge and awareness about organ and tissue donation. Future research should implement and evaluate a course-long curriculum on donation.     

Organ donation in Latin America

Recently in Latin America, there has been a strong influence of the "Spanish model" of organ procurement. In 2001, The "Punta Cana Group" was created by Latin American transplantation coordinators with the objective of registering and improving the system of donation and procurement. In many countries there is no universal financial support from the government for medical treatment, including dialysis and transplantation. In other countries there is complete financial support for all of the population, including immunosuppressive drugs. Practically all countries have transplantation laws that follow ethical concepts, such as brain death diagnosis criteria, forms of consent, criteria of allocation, and inhibition of commerce. The rate of potential donors notified in countries that perform transplantations with deceased donors varied from 6 to 47 per million population yearly (pmp/y); The rate of effective donors varied from 1 to 20 pmp. In 2004, the mean rate of effective donors in Latin America was 5.4 pmp. The family refusal rate for the donation of organs varied from 28% in Uruguay to 70% in Peru. In some countries, such as Puerto Rico, Uruguay, and Cuba, it was more than 15 pmp, whereas in others countries deceased donors were practically not used. The number of patients on the waiting list for solid organ transplants in 12 Latin American countries is 55,000. Although the donation rate has increased by 100% during the last 10 years, it is lower than that in Europe (15 pmm/y) or the United States (20 pmp/y).     

Aggressive organ donor management significantly increases the number of organs available for transplantation

BACKGROUND: The shortage of transplantable organs has become a national crisis. Despite various attempts to expand the donor pool, the difference between organ supply and organ demand continues to widen. With no foreseeable increase in the number of donors, it is necessary to maximize the utilization of organs from the existing donor pool. METHODS: Records of all patients referred to the regional organ procurement organization for possible organ donation over an 8-year period (1995-2002) were reviewed. A policy of aggressive donor management (ADM) by dedicated physicians was instituted in January 1999 involving intensive care unit admission, pulmonary artery catheterization, aggressive fluid resuscitation, early use of vasopressors, prevention and treatment of complications associated with brain death, and liberal use of thyroid hormone in hemodynamically unstable donors. Data regarding referrals for organ donation, actual organ donors, organs recovered, and donors lost due to cardiovascular collapse before organ donation were compared before (January 1995- December 1998) and after (January 1999- December 2002) ADM. RESULTS: There were 878 patients referred for organ donation during the 8-year period. Of those, 469 (53.4%) were confirmed as potential donors, but only 161 (34.3%) became actual donors. When compared with the period before ADM, the period after ADM showed a 57% increase in total referrals (p < 0.001), 19% increase in potential donors (p = 0.01), 82% increase in actual donors (p < 0.001), 87% decrease in the number of donors lost due to hemodynamic instability (p < 0.001), and a 71% increase in the number of organs recovered (p < 0.001). CONCLUSIONS: A policy of ADM increases the referral pool for organ donation and reduces the number of organ donors lost due to cardiovascular collapse. The net result is a significant increase in the number of organs available for transplantation.     

Donation education for medical students: enhancing the link between physicians and procurement professionals

PURPOSE: Increasing healthcare professionals' knowledge about organ and tissue donation; the national mandates regarding referral compliance; and the effect on donors, donor families, and transplant recipients is a challenging task. Physicians not routinely involved in organ donation or transplantation are some of the most difficult professionals for organ procurement organizations to access. A course for medical students was developed to initiate the transfer of information, comfort, and familiarity with the organ and tissue donation process. METHODS: Discussions with a local medical school revealed that little organized education on organ and tissue donation existed. An elective course was developed consisting of 2-hour lectures, once a week for 6 weeks. Topics included an overview of tissue and organ donation, history and significance of the current crisis, determination of brain death and its role in organ donation, tissue donation, pretransplant and posttransplant processes, ethical issues, and the donor family and recipient experience. RESULTS: A thorough course proposal was presented to the medical school's Chairman of Surgery and Chairman of Transplantation. The proposal was approved for first- and second-year medical students. CONCLUSION: Offering medical students a unique and comprehensive course may attract curious students who could become future champions for donation. This type of educational approach may significantly influence future interactions between physicians and organ procurement organizations. If more organ procurement organizations implement this type of program, the medical students' knowledge of donation will not only affect and benefit the local organ procurement organization's service area but other procurement organizations throughout the country as well.     

Aggressive management of lung donors classified as unacceptable: excellent recipient survival one year after transplantation

OBJECTIVE: A dire shortage of lungs for transplantation exists. We hypothesized that aggressive organ procurement organization management of lungs usually rated as unacceptable (ratio of Pao(2) to inspired oxygen fraction <150) might make them acceptable for transplantation. We also hypothesized that lungs from donors who died of trauma could be used for transplantation with recipient survival comparable with that seen with lungs from donors who died of nontraumatic causes. METHODS: From January, 1, 1995, through August 31, 2000, a total of 194 donors resulted in 228 lung transplants. Of these, 27 donors were deemed unacceptable for lung transplantation according to organ procurement organization protocol. We used the California Transplant Donor Network database to conduct a retrospective review of all 194 donors, including the 27 supposedly unacceptable donors who were treated with invasive monitoring (central venous pressure), methylprednisolone, fluid restriction, inotropic agents, bronchoscopy, and diuresis. We evaluated survivals at 30 days and 1 year of patients who received lungs rated as unacceptable and acceptable. In addition, we compiled data on recipient survival for a subgroup of 122 recipients with lungs from donors who died of trauma and compared these data with those of recipients who received lungs from donors who died of nontraumatic causes to see whether the donor's death by trauma resulted in higher recipient mortality. RESULTS: After aggressive organ procurement organization management, ratios of Pao(2) to inspired oxygen fraction, central venous pressures, fluid balances, dopamine requirements, and chest radiographs of unacceptable donors according to organ procurement organization criteria were comparable with those of acceptable donors. There were no significant differences in recipient mortality between groups at 30 days or 1 year after transplantation. Moreover, no significant difference was found in mortalities of recipients who received lungs from donors who died of traumatic and nontraumatic causes. CONCLUSION: Aggressive organ procurement organization management of donors initially considered unacceptable may increase the number of lungs available for transplantation.     

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.     

Increasing organ recovery from level I trauma centers: the in-house coordinator intervention

PURPOSE: Daily presence of organ procurement organization staff in level I trauma centers combined with early family contact and interaction can increase donation rates. METHODS: A successful in-house coordinator program already in place at 2 level I trauma centers in Houston was replicated in 6 other level I trauma centers in New York City, Los Angeles, and Seattle. Organ procurement organization staff were placed inside the 8 trauma centers to provide early family support in potential donor situations and day-to-day donation system management. Comparison data were obtained on 83 level I trauma centers nationally. Data from 1999 to 2000 were compared with data from 2001 to 2002. RESULTS: Despite demographic differences, the 8 centers with in-house coordinators had higher consent rates (60% vs 53%) and conversion rates (55% vs 45%) than centers without them. Conversion of potential to actual donors was 22% higher in centers with in-house coordinators than in centers without them. Donation rates were affected by donor age, ethnicity, previous family discussion of donation, the family's initial reaction to the request (favorable, unfavorable, undecided), amount of time family spent with the in-house coordinator, presence of the in-house coordinator during explanation of brain death, whether the request was made at the same time as the brain-death explanation, and, in cases where donation was mentioned to the family before the formal request, who first mentioned donation to the family. CONCLUSIONS: In-house coordinators improve the donation process by interacting with families and staff earlier and more often during potential organ donations and improving donation systems through closer relationships with hospital staff.     

Research to practice: a national consensus conference

PURPOSE: To gain consensus on aspects of the process of gaining consent for organ donation that should be mainstream daily practice. METHODS: A 3-day consensus conference of transplant professionals that provided a forum for research and innovative ideas about gaining consent for organ donation. Four work groups were assembled to address issues of gaining consent from organ and tissue donors: (1) demystifying first-person consent (donor authorization): is it a matter of law?, (2) recovery coordinators: getting from green to great, (3) maximizing the process: old views and new, and (4) donor family support: mother or smother? RESULTS: Participants reached a consensus about major consent-related practices, identified areas of practice variance, and defined topics in need of further research. CONCLUSIONS: The conference participants agreed that (1) the primary role of the organ procurement organization is to recover organs for transplantation from deceased donors and to facilitate distribution of those organs to the appropriate recipients; (2) early referral of potential donors from the hospital to the organ procurement organization is desirable; (3) a score less than 5 on the Glasgow Coma Scale should initiate end-of-life discussions with family members; a procurement coordinator from the organ procurement organization who is physically housed within the hospital is the most successful model for accommodating early referral of potential donors and optimizing family support practices; and (3) a decedent's right to donate should take precedence in the donation process and such designation by the donor before death is irrevocable and does not require the consent or concurrence of any person after the donor's death.     

Psychosocial profile in favor of organ donation

INTRODUCTION: The lack of organ donation continues to be a major limiting factor in transplantation. Our aims are: (1) to define the psychosocial profile against organ donation, and (2) to determine the impact of a law on the procurement and transplantation of organs based on "presumed consent" in the population. MATERIALS AND METHODS: The population in this study (n = 2000) was randomly selected and stratified according to sex, age, and geographic localization. The attitude toward organ donation and transplantation was evaluated according to a questionnaire that probed psychosocial aspects of donation. Statistical comparisons were performed using the chi2 and logistic regression tests. RESULTS: The population attitude toward organ donation was favorable in 63% of subjects, unfavorable in 31%, and 6% did not respond. With regard to the law based on "presumed consent," only 24% of the population agreed with the law; 53% thought it was an abuse of authority. The population subgroup with a negative attitude to the law was characterized by: age over 40 years, low educational level, no previous experience with organ donation or transplant, no experience in prosocial activities, a refusal to accept cadaver manipulation or mutilation, and lack of knowledge of the brain-death concept. CONCLUSIONS: The psychosocial profile against donation is a person above 40 years with a low level of education who has never performed prosocial activities, did not have previous experience with organ donation or transplantation, displays no knowledge of the brain-death concept, and rejects cadaver manipulation. For these people a law based on "presumed consent" is considered an abuse of authority.     

Coordinating organ transplantation in Turkey: effects of the National Coordination Center

In January 2001, the National Coordination Center, which brought tissue and organ procurement and transplantation under the Turkish Health Ministry, was established in Turkey. The main aims of this organization are to expand cadaveric donation and increase the number of transplantable organs supplied by cadaveric donors. We compared the proportions of cadaveric organ transplantations that were performed in Turkey before and after the national coordination system was established. Of all the cadaveric transplantations completed to date, 91.6% of kidney and 71.5% of liver procedures were done before implementation of the new system, and 8.4% and 28.5%, respectively, were performed after the system was established. The data show that the frequency of cadaveric donation has increased, as well as the number of cadaveric organ transplantations performed annually. The new national transplantation coordination system is making a good start at increasing cadaveric transplantation in Turkey. This system will hopefully lead to a larger organ pool and shorter waiting lists in future.     

Organ transplantation laws in Asian countries: a comparative study

Legal tools are a necessity in organ procurement to allow transplant surgeons to remove organs from potential sources. In some countries the organ transplantation law may not only increase the organ retrieval rate, but may also decrease the number of transplantations. Reassessing the impact of organ transplantation laws on the application of transplant technology is therefore an emerging issue. This article discusses organ transplantation laws in eight Asian countries: Japan, Korea, India, Iran, Philippines, Saudi Arabia, Singapore, and Turkey. The organ transplantation laws of each of these countries were compared in terms of how they address the issues of definition of death; donor consent; the role of family and surrogate decision making; age limitation for organ donation; organ trade and donor compensation; and the organ procurement model.     

Potentiel de patients éligibles à un prélèvement d’organes de type Maastricht III dans le cadre du protocole de l’Agence de la biomédecine dans un service de réanimation polyvalente

ObjectiveBecause of graft shortages, an experimental programme of organ donation after Maastricht 3-type circulatory death (M3) has been proposed by the French organ procurement organization (Agence de la biomedicine: ABM). The aim of the study was to estimate how many potential patients were eligible for an M3-type organ donation, amongst deceased patients who have had life-support withdrawn.Patients and methodsWe conducted a retrospective study looking at the notes of deceased patients in a French general intensive care unit (ICU), where organ donation is arranged in DBD donors.ResultsOver the year 2013, 1475 patients were admitted in ICU and 215 died. One hundred and one patients were brain-injured and 26 of them died following a decision to withdrawn life-support and without contraindication to organ donation. Among them, 2 patients (8%) met the criteria for the French M3-type organ donation protocol. A 12.5% increase in organ donation activity of our team and five organ transplantations could have been considered.ConclusionIf M3 organ donation is considered, a significant increase in transplantation would be expected.     

美国器官捐献和移植管理体系简介

美国是世界上器官移植开展最早和数量最多的国家,1968年就出台了《联邦遗体捐献法》,1984年又出台了《国家器官移植法》,有较为完善的法律体系,成立了国家层面的器官捐献移植协调管理机构和分布在各州和地区的58个器官获取组织,建立了覆盖全国的网络,形成了有效的经济运行机制,能有效地开展工作,较好地解决了移植器官短缺的问题。这些实践对中国目前开展的器官捐献工作有重要的借鉴和参考意义。     

法国器官捐献和移植管理及规范

法国较早建立起国内统一的公平、公开、公正的组织器官捐献和移植体系,器官捐献率位于世界前列。2004年8月法国政府对生命伦理法规进行修订,创建了欧洲唯一的综合性的生物医学研究机构,业务涉及器官捐献与移植、组织和细胞、人类生育繁殖、胚胎学及人类遗传学4个领域。本文简要介绍法国生物医学研究所、器官捐献相关法律和捐献移植现状、器官获取与分配步骤等。     

Organ donation rates in a neurosurgical intensive care unit

OBJECT: The number of patients waiting for organ transplantation continues to grow, while organs are donated by very few of the thousands of potential donors who die every year. The authors' neurosurgical intensive care unit (NICU) has worked closely with coordinators from the local organ procurement organization (OPO) for many years. In this study, the authors analyze donation rates in the NICU and discuss factors that may be important in maximizing these rates. METHODS: All referrals from the NICU to the OPO from 1996 to 1999 were analyzed. Of the 180 referrals, 98 patients were found to be medically suitable as potential donors. Another 15 patients died of hemodynamic collapse shortly after admission to the NICU. If one assumes that all 15 patients would have been suitable donors, the unsuccessful resuscitation rate becomes 15 (13.3%) of 113. Of the 98 eligible donors, consent was obtained and organs or tissue were recovered in 72, yielding a successful organ procurement rate of 73.5%. CONCLUSIONS: Close working relationships among physicians, nurses, and OPO coordinators can result in higher donation rates than have been reported previously. Aggressive resuscitation and stabilization of all patients, early identification of potential organ donors, prompt declaration of brain death, and attempts by the OPO coordinator to build rapport with families are all important factors that may increase donation rates. Because most organ donors have sustained catastrophic intracranial events, neurosurgeons are uniquely positioned to influence organ donation policies at their hospitals and thus to salvage some benefit from tragic cases of overwhelming brain injury.     

Increasing organ donation and transplantation: the U.S. experience over the past decade

The growing gap between the need for and supply of transplantable organs in the U.S. led to several initiatives over the past decade. UNOS implemented policies intended to facilitate the use of expanded criteria donor kidneys with mixed success. The U.S. government sponsored several organ donation and transplantation collaboratives, leading to significant increases in organ donation over several years. The use of organs from donors dying from cardiac death has increased steadily over the past decade, with such donors now exceeding 10% of the total. Revisions of state anatomic death acts allowed persons to declare their intention to donate by enrolling in state donor registries, facilitating the identification of willing donors by organ procurement organization. Despite these initiatives, the disparity between organ demand and supply has continued to grow, primarily as a result of marked increase in the number of candidates awaiting kidney transplantation.     

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.