Brain death diagnoses and evaluation of the number of potential organ donors in Québec hospitals

PURPOSE

Faced with our inability to respond to the growing number of Quebec patients waiting for organ transplants, we sought to determine the number of potential organ donors (OD) in acute care hospitals.

METHODS

A retrospective chart review of all acute care, in-hospital deaths in Quebec in the year 2000 was undertaken. Hospital record librarians provided statistics and completed questionnaires on each chart after applying exclusion and inclusion criteria.

RESULTS

There were 24,702 acute care in-hospital deaths reported by 83 hospitals participating in the study on a voluntary basis. Analyzing 2,067 files meeting inclusion criteria, we identified 348 potential OD (1.4% of deaths). In hospitals not providing tertiary adult trauma care, the potential donor rate was 0.99% of all deaths. There were 4.5 times more potential donors in tertiary care adult trauma centers. Brain death was formally diagnosed in 268/348 patients, and organ donation discussed as an option with 230/268 families. Consent for donation was given in 70% of cases, although not all these patients proved to be suitable after evaluation. There were 125 actual donors in Quebec in the year 2000 (18 per million population).

CONCLUSIONS

The gap between used and potential donors can be explained by several factors including failure to approach families for organ donation, family refusal, incomplete neurological assessment of patients, and medical unsuitability of some consented donors. There is room for improvement in the identification of potential donors and in the presentation of organ donation as an end of life option to families.

Strategies for Establishing Organ Transplant Programs in Developing Countries: The Latin America and Caribbean Experience

The Latin America and Caribbean region is composed of 39 countries. It is remarkable the progress of transplantation in the region in despite of the low economic resources when compared to other regions. The criteria for brain death are well established and culturally accepted. The consent for retrieval is based on required family consent in most countries. The regulations for living donors are also well established, with restrictions to unrelated donors and prohibition of any kind of commerce. The access to transplant is limited by the model of public financing by each country, and those with public universal coverage have no financial restrictions to cover the costs for any citizen; in countries with restricted coverage, the access is restricted to the employment status. There is a progressive increment in the annual number of solid organ transplants in Latin America, reaching near 10,000 in 2004, accomplished by adequate legislation that is also concerned with the prohibition of organ commerce.

[Skin tumors in organ-transplant recipients]

Skin cancers are a significant medical problem for organ-transplant recipients. Squamous cell carcinoma and basal cell carcinoma are most common tumors. An increasing incidence of melanoma, Kaposi sarcoma, Merkel cell carcinoma, as well as uncommon skin malignancies, is also seen. Predisposing factors include cumulative sun exposure, cumulative immunosuppression, age, gender, skin type, virus detection and genetic alterations. Skin tumors grow rapidly and their number continues to increase in the years following transplantation. Large numbers of tumors, aggressive courses and appearance in young patients are other characteristics of these skin tumors. More general awareness of the need for preventive measures and regular dermatological examinations is desirable. In addition standardized registries are needed to assure the comparability of data, to better correlate immunosuppression with skin tumors and to plan therapeutic studies.

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.

Changes in cross-sectional area of hamstring anterior cruciate ligament grafts as a function of time following transplantation

PURPOSE

To measure the cross-sectional area (CSA) of hamstring anterior cruciate ligament (ACL) grafts in humans up to 2 years postoperatively and to estimate the appropriate graft-notch distance (the distance between ACL graft and roof or wall of the notch) at surgery.

TYPE OF STUDY

Case series.

METHODS

Fifty-nine patients, who had consented to have a magnetic resonance imaging (MRI) evaluation postoperatively, underwent endoscopic ACL reconstruction using 3- to 5-strand autogenous hamstring tendons. Intraoperatively, the CSA of the graft was measured using a custom-made area micrometer. Postoperatively, 115 axial MRIs of the grafts (48 at 3 months, 44 at 12 months, and 23 at 24 months) were obtained. They were transmitted to a personal computer and the CSAs of the grafts' midsubstance were calculated. To evaluate the accuracy of the MRI measurement, another 15 patients who consented to have MRI 2 days after surgery were selected and intraoperative graft CSA measurements and graft axial MRI were performed 2 days after surgery.

RESULTS

The CSAs of the grafts measured by MRI 2 days after surgery were well correlated with those directly measured intraoperatively (gamma = 0.905). The CSA of the grafts measured intraoperatively was 43 +/- 5 mm2, and those estimated by MRI at 3, 12, and 24 months were 50 +/- 9 mm2, 54 +/- 9 mm2, and 48 +/- 12 mm2, respectively. The increase in graft diameter at 3, 12, and 24 months was 9% +/- 8%, 13% +/- 10%, and 7% +/- 12%, respectively.

CONCLUSIONS

In humans, the increase in CSA of the ACL graft was smaller compared with previous animal studies. The graft CSA increased up to 29% (13% in diameter) 12 months after surgery. When a 95% confidence interval was used, the percent increase in diameter of the reconstructed graft was estimated to be less than 32% in 95% of the cases. When the graft diameter was 7, 8, or 9 mm, a 1.1-, 1.3-, or 1.4-mm graft-notch distance, respectively, was suitable for impingement-free graft during postoperative periods with 95% of probability.

LEVEL OF EVIDENCE

Level IIII.

Are we frozen in time? Analysis of the utilization and efficacy of pulsatile perfusion in renal transplantation

Preservation techniques are crucial to deceased donor kidney transplantation (DDTx), but the efficacy of pulsatile perfusion (PP) versus cold storage (CS) remains uncertain. We describe patterns of PP use and explore four fundamental questions. What kidneys are selected for PP? How does PP affect utilization of donated kidneys? What effect does PP have on outcomes? When does PP appear to be most efficacious? We examined rates of PP in DDTx in the United States from 1994 to 2003. We generated models for organ utilization, delayed graft function (DGF) and for the use of PP. We analyzed the long-term effect of PP with multivariate Cox models. The utilization rates for non-expanded criteria donors (ECDs) were similar by storage type, but for ECDs there was a significantly higher utilization rate with PP (70% with PP vs. 59% with CS, p < 0.001). Use of PP was widely variable across transplant centers. DGF rates were significantly lower with PP (27.6% vs. 19.6%). PP was associated with a mild benefit on death censored graft survival (adjusted hazard ratio = 0.88, 95% CI 0.85-0.91). Reduced DGF and significantly lower discard rates of ECDs associated with PP suggest an important utility of PP in renal transplantation. Additional evidence of improvement in graft survival, particularly in more recent years, provides further encouraging evidence for the use of PP.

Missile-caused median nerve injuries: results of 81 repairs

BACKGROUND

Missile-caused median nerve injuries have rarely been reported in current literature. We present repair outcome for all median nerve injuries in which the median nerve was severed either by missile injury or secondarily in the subsequent resection of a neuroma in continuity.

METHODS

Prospective study included 81 casualties with proximal, intermediate, or distal complete median nerve lesions, repaired by nerve graft or direct suture. Final outcome was defined at least 4 years postoperatively, on the basis of motor recovery, sensory recovery, neurophysiological recovery, and patient's judgment on the outcome, each estimated by 0 to 5 points and according to the total sum, as poor, insufficient, good, or excellent. The last 2 modalities were considered to be successful.

RESULTS

Successful outcome was obtained in 68.7% of distal, in 33.3% of intermediate, and in 10% of proximal repairs. Average outcomes were good, insufficient, and poor, respectively (P < .001). Nerve defect and preoperative interval were both significantly shorter on average for patients with successful outcome than for those with unsuccessful outcome (P < .001 and P = .007, respectively), but only preoperative interval and height of repair were independent predictors for successful outcome. Age of patient, associated ulnar nerve complete lesion, and manner of repair did not influence the outcome significantly (P > .05).

CONCLUSIONS

The level of repair, duration of preoperative interval, and length of nerve defect significantly influence outcome after median nerve repair, but only level of repair and duration of preoperative interval were independent predictors for successful outcome.

Infections and severe sepsis in solid-organ transplant patients admitted from a university-based ED

The objective was to provide a descriptive analysis of infectious processes in transplant patients admitted from the emergency department (ED). A database of all adult transplant patients at a university medical center was cross-referenced with a computerized record of all ED visits over an 18-month period. ED charts, inpatient records, and microbiology data were retrospectively reviewed. Final diagnoses and outcomes were analyzed. There were 352 ED visits by transplant patients (kidney 66%, kidney/pancreas 15%, liver 13%, lung 3%, heart 3%). Infections were the most common indications for admission (77/217, 35%). Urinary tract infection and pneumonia were the most common infections. Nine of 77 patients (11.7%) with documented infections developed severe sepsis, which was the most common reason for ICU utilization. Thirty-five percent of transplant patients admitted from the ED had acute infections, and 11.7% of these patients had severe sepsis. The emergency physician must have a high index of suspicion for infections when evaluating organ transplant recipients.

Surgical strategies for vertebral osteomyelitis and epidural abscess

Pyogenic vertebral discitis and osteomyelitis (PVDO) has become an increasing problem for the spine surgeon. Despite recent advances in medical care and improved diagnostic neuroimaging, PVDO remains a major cause of illness and death in the elderly population. Infection of the spinal column often presents insidiously; however, if not treated appropriately and in a timely manner it can lead to severe neurological impairment, systemic septicemia, and progressive spinal deformity. In this paper the authors review the epidemiological and pathophysiological features and the clinical presentation of PVDO. Conventional medical therapy is described, with a particular focus on the methods of diagnosis. Surgical strategies for PVDO are then presented based on the literature and according to the practice of the senior author (S.L.O.), with an emphasis placed on structural considerations, implant selection, and techniques for augmenting vascular tissue to the site of infection.

TUBERCULOSIS IN THE TRANSPLANT CANDIDATE: IMPORTANCE OF EARLY DIAGNOSIS AND TREATMENT

BACKGROUND

Transplantation is contraindicated in candidates with active tuberculosis. The present study was undertaken to determine the clinical manifestations of tuberculosis in the transplant candidate and the prognosis of cases that inadvertently undergo transplantation.

METHODS

This study was a retrospective study of tuberculosis cases diagnosed among 3,889 transplant candidates. All cases were diagnosed from respiratory or tissue samples obtained in the pretransplant period or during transplantation.

RESULTS

We observed 7 cases (0.18%) of active tuberculosis among 3,889 candidates. Two patients had a history of tuberculosis. Tuberculosis was frequently asymptomatic. Three patients had extrapulmonary tuberculosis. Chest radiographs showed residual fibrotic lesions in three patients and noncavitated consolidation in two patients. All of the patients in which the purified protein derivative test was performed were anergic. All patients that inadvertently underwent transplantation were cured.

CONCLUSIONS

Aggressive management is required to prevent tuberculosis in transplant candidates. Patients that inadvertently undergo transplantation can be effectively treated when diagnosed early.

Identifying the potential organ donor: an audit of hospital deaths

OBJECTIVE

To quantify the potential for organ donation in Victoria and identify missed opportunities for organ donation.

DESIGN AND SETTING

Prospective medical record audit of all deaths in 12 Victorian hospitals.

MEASUREMENTS

Data on deaths, total potential donors, organ donors and outcome of requests for organ donation were collected. Patients in whom brain death was confirmed or likely to occur and in whom organ donation was not requested (unrealised potential donors) were classified by an independent panel. Rates of organ donation and unrealised donors were determined as a proportion of total potential donors and hospital deaths and the maximal potential organ donor rate was estimated.

RESULTS

Of 5551 deaths, there were 112 potential donors, with 66 requests for organ donation resulting in 39 consents (consent rate of 59%) and 37 organ donors (33% of total potential donors; 0.7% of hospital deaths). Two consented potential donors did not donate due to failed physiological support (5%). There were 46 medically suitable unrealised potential donors; 3 with confirmed brain death. Approximately half of these patients had treatment withdrawn in the intensive care unit and half in the Emergency Department. The estimated maximal potential donor rate was 30 per million population.

CONCLUSIONS

The potential for organ donation in Victoria is relatively low compared with previous estimates in Australia and overseas. An increase in the organ donation rate may be possible through increasing consent and the identification and support of potential donors. This would require substantial changes in clinical practice that have resource and ethical implications.

Selecting the best heart valve for your patient: mechanical or tissue

This review provides general guidance for heart valve selection. Mechanical heart valves exhibit excellent durability and hemodynamic performance but require anticoagulation to reduce thromboembolism, and therefore risk of anticoagulation-related hemorrhage is increased. Tissue valves were introduced to avoid anticoagulation, but in fact often do not, and lack durability. A literature review was performed to compare the complications of thromboembolism, anticoagulation-related hemorrhage, reoperation structural valve deterioration, and reoperative mortality associated with mechanical and tissue valves. The thromboembolism rates for mechanical and tissue valves are equivalent. During their lives, many recipients of tissue valves receive anticoagulation therapy due to comorbid conditions. The anticoagulation-related blood loss rates associated with mitral mechanical valves and mitral tissue valves are equivalent, whereas the blood loss rates associated with aortic tissue valves are less than those associated with aortic mechanical valves.

Influence of surgeons' specialty on the selection of vascular access for hemodialysis treatment

BACKGROUND/AIMS

Various patient-related factors could not explain the variability of access types across facilities in the published literature. The aim of this study was to investigate the influence of surgeons' specialty on access type selection for hemodialysis treatment.

METHODS

The directors (nephrologists) of all renal units in Greece (n = 92) were surveyed by a closed questionnaire.

RESULTS

The response rate was 75%. There was no statistically significant difference in the percentage of patients predominantly with autologous arteriovenous fistulae between units where only vascular surgeons were performing access surgery and those where either general surgeons or transplant surgeons were operating (mean value in all renal units 80.8%, range 43-97%). However, the difference between the three groups of renal units regarding their surgeons' ability to create complex access procedures and to correct complications (as an index of surgeons' skill) was statistically significant (p < 0.001).

CONCLUSION

The general surgeons of the new generation are not often using vascular surgical techniques and may have less opportunities to develop expertise in vascular access creation.

Longitudinal study of cryptococcosis in adult solid-organ transplant recipients

While studies in kidney recipients have found meningitis to be the most common clinical manifestation of cryptococcosis (Cry), it is unclear if the clinical presentation of Cry differs among various solid-organ transplant (SOT) recipients and whether the serum cryptococcal antigen (SCA) might predict the site of infection. We report the clinical manifestations and the correlation with a positive SCA among 55 consecutive SOT recipients diagnosed with Cry at the University of Pittsburgh Medical Center. These included: heart (n=13), lung (n=4), liver (n=28), kidney (n=9) and small bowel (n=1) recipients. While there were no significant differences in the manifestations of Cry in heart and lung recipients, kidney recipients had disseminated disease as the most common presentation (P=0.02). In contrast, pneumonia (P=0.003) and meningitis (P=0.02) were more frequent than disseminated disease in liver recipients. Positive SCA was higher in patients with disseminated disease and meningitis than in patients with isolated pneumonia (P=0.0001). Significant differences in the manifestations of Cry were observed among types of SOT populations. A positive SCA may be predictive of dissemination and meningitis, but it may not be sensitive for pulmonary disease.

The supply of organs for transplantation: issues and challenges

The success of organ transplantation has been well documented, with improvements in quality of life and cost-effectiveness being notable outcomes of the therapy. In this paper, we focus on the major issues and challenges related to the shortage of solid organs available for transplantation. The reasons for the organ shortage are complex and multifaceted. Fewer motor vehicle accident deaths, public perceptions about organ donation, attitudes of health professionals, knowledge of health professionals regarding organ donation, donor identification processes, family consent rates, and ethnocultural considerations are all issues that are important to consider in addressing the shortage.

Grafts of BDNF-producing fibroblasts rescue axotomized rubrospinal neurons and prevent their atrophy

We have reported that intraspinal transplants of fibroblasts genetically modified to express brain-derived neurotrophic factor (BDNF) promote rubrospinal axon regeneration and functional recovery following subtotal cervical hemisection that completely ablated the rubrospinal tract. In the present study we examined whether these transplants could prevent cell loss and/or atrophy of axotomized Red nucleus neurons. Adult rats received a subtotal spinal cord cervical hemisection followed by a graft of unmodified fibroblasts or fibroblasts producing BDNF into the lesion cavity. One or 2 months later, fluorogold was injected several segments caudal to the lesion-transplant site to retrogradely label those Red nucleus neurons whose axons have regenerated. Unmodified fibroblasts failed to protect against either cell loss or atrophy. Neuron counts and soma-size measurements in Nissl-stained preparations showed a 45% loss of recognizable neurons and 40% atrophy of the surviving neurons in the injured Red nucleus. Grafts of BDNF-producing fibroblasts reduced neuron loss to less than 15% and surviving neurons showed only a 20% decrease in mean soma size. Soma size analysis of fluorogold-labeled Red nucleus neurons indicated that the Red nucleus neurons whose axons regenerated caudal to the graft did not atrophy. We conclude that fibroblasts engineered ex vivo to secrete BDNF and grafted into a partial cervical hemisection promote axon regeneration while reducing cell loss and atrophy of neurons in the Red nucleus. These results suggest that transplants of genetically engineered cells could be an important tool for delivery of therapeutic factors that contribute to the repair of spinal cord injury.

Effects of disc height and distractive forces on graft compression in an anterior cervical discectomy model

STUDY DESIGN

An in vitro biomechanical study using a calibrated distractor and a subminiature load cell in a cadaver anterior cervical discectomy construct was conducted.

OBJECTIVE

To study the interrelations of preoperative disc height, graft height, and compressive and distractive forces in an anterior cervical discectomy model.

SUMMARY OF BACKGROUND DATA

The effects of graft size on compressive and distractive forces in a discectomy model remain unknown. Larger grafts afford neural decompression through anterior column distraction. This distraction may subject the graft and vertebral bodies to excessive loads, increasing graft fracture, and subsidence risk.

METHODS

Disc height was measured radiographically in 18 specimens. A Smith-Robinson discectomy was performed, and the superior and inferior ends of the specimens were embedded in polyester resin. Distraction was applied through a calibrated Caspar distractor to measure the distractive force applied while steel spacers rigidly fixed to a subminiature load cell were introduced. After distraction was removed, immediate compressive force was measured.

RESULTS

Distractive forces of 112.4 N and 189.9 N were required to insert the 6-mm and 8-mm grafts, respectively. When this distractive force was removed, immediate compressive loads of 8.8 N and 21.5 N on the graft were noted. When a compressive load of 45 N was applied in a loading frame, measured graft loads of 16.2 N and 29.2 N also increased. No statistically significant relation was observed between preoperative disc height and distractive force or compression of the graft. Significantly lower distractive and compressive forces were associated with insertion of the 6-mm rather than 8-mm graft.

CONCLUSIONS

Significantly higher distractive and compressive forces were recorded with larger grafts. Preoperative disc height was not an accurate predictor of graft loads.

Renal failure in the ICU: comparison of the impact of acute renal failure and end-stage renal disease on ICU outcomes

BACKGROUND

Acute renal failure (ARF) is associated with a persistent high mortality in critically ill patients in intensive care units (ICUs). Most studies to date have focused on patients with established, intrinsic ARF or relatively severe ARF due to multiple factors. None have examined outcomes of dialysis-dependent chronic renal failure [end-stage renal disease (ESRD)] patients in the ICU. We examined the incidence and outcomes of ARF in the ICU using a standard definition and compared these to outcomes of ICU patients with either ESRD or no renal failure. We sought to determine the impact of renal dysfunction and/or loss of organ function on outcome.

METHODS

We prospectively scored 1530 admissions to eight ICUs over a 10-month period for illness severity at ICU admission using the Acute Physiological and Chronic Health Evaluation (APACHE III) evaluation tool. Patients were defined as having ARF based on the definition of Hou et al (Am J Med 74:243-248,1983) designed to detect significant measurable declines in renal function based on serum creatinine. ESRD patients were identified as being chronically dialysis-dependent prior to ICU admission and the remainder had no renal failure. Clinical characteristics at ICU admission and ICU and hospital outcomes were compared between the three groups.

RESULTS

We identified 254 cases of ARF, 57 cases of ESRD and 1219 cases of no renal failure for an incidence of ARF of 17%. Roughly half the ARF patients had ARF at ICU admission and the remainder developed ARF during their ICU stay. Only 11% of ARF patients required dialysis support. ARF patients had significantly higher acute illness severity scores than those with no renal failure, whereas patients with ESRD had intermediate severity scores. ICU mortality was 23% for patients with ARF, 11% for those with ESRD, and 5% for those with no renal failure. There was no difference in outcome between patients who had ARF at ICU admission and those who developed ARF in the ICU. Patients with ARF severe enough to require dialysis had a mortality of 57%. APACHE III predicted outcome very well in patients with no renal failure and patients with ARF at the time of scoring but underpredicted mortality in those who developed ARF after ICU admission and overestimated mortality in patients with ESRD.

CONCLUSIONS

ARF is common in ICU patients and has a persistent negative impact on outcomes, although the majority of ARF is not severe enough to require dialysis support. The mortality of patients with ARF from all causes is almost exactly similar to that noted using the same criteria two decades ago. More profound ARF requiring dialysis continues to have an even greater mortality. Nevertheless, acute declines in renal function are associated with a mortality that is not well explained simply by loss of organ function. The majority of ARF patients who did not require dialysis still had a considerably higher mortality than the ESRD patients, all of whom required dialysis; while ARF patients who did require dialysis had a much higher morality than ESRD patients. APACHE III performs well and captures the mortality of patients with ARF at the time of scoring. Development of ARF after scoring has a profound effect on standardized mortality. We were unable to identify a unique mortality associated with ARF, but the presence of measurable renal insufficiency continues to be a sensitive marker for poor outcome.