Estimation of Potential Deceased Organ Donors in Canada

High-Functioning Deceased Donor Kidney Transplant System Characteristics: The British Columbia Experience With an Opt-In System

Rationale & Objective

A high level of cooperation between organ procurement organizations and transplant programs may help maximize use of deceased donor kidneys. The practices that are essential for a high functioning organ donation and transplant system remain uncertain. We sought to report metrics of organ donation and transplant performance in British Columbia, Canada, and to assess the association of specific policies and practices that contribute to the system's performance.

Study Design

A retrospective observational study.

Setting & Participants

Referred deceased organ donors in British Columbia were used in the study from January 1, 2016, to December 31 2019.

Exposures

Provincial, organ procurement organization, and center level policies were implemented to improve donor referral and organ utilization.

Outcomes

Assessment of donor and kidney utilization along steps of the critical pathway for organ donation.

Analytical Approach

Deceased donors were classified according to the critical pathway for organ donation and key donation and transplant metrics were identified.

Results

There were 1,948 possible donors referred. Of 1,948, 754 (39%) were potential donors. Of 754 potential donors, 587 (78%) were consented donors. Of 587 consented donors, 480 (82%) were eligible kidney donors. Of 480 eligible kidney donors, 438 (91%) were actual kidney donors. And of 438 actual kidney donors, 432 (99%) were utilized kidney donors. One-year all-cause allograft survival was 95%. Practices implemented to improve the system's performance included hospital donor coordinators, early communication between the organ procurement organization and transplant nephrologists, dedicated organ recovery and implant surgeons, aged-based kidney allocation, and hospital admission of recipients before kidney recovery.

Limitations

Assignment of causality between individual policies and practices and organ donation and utilization is limited in this observational study.

Conclusions

In British Columbia, consent for donation, utilization of donated kidneys, and transplant survival are exceptionally high, suggesting the importance of an integrated deceased donor and kidney transplant service.

Outcomes following heart or bilateral-lung transplantation from donors who died of drug toxicity in British Columbia, Canada

INTRODUCTION

The illicit drug toxicity (overdose) crisis has worsened across Canada; between 2016 and 2021, more than 28,000 individuals have died of drug toxicity. Organ donation from persons who experience drug toxicity death (DTD) has increased in recent years. This study examines whether survival after heart or bilateral-lung transplantation differed by donor cause of death.

METHODS

We studied transplant recipients in British Columbia who received heart (N = 110) or bilateral-lung (N = 223) transplantation from deceased donors aged 12-70 years between 2013 and 2019. Transplant recipient survival was compared by donor cause of death from drug toxicity or other. Five-year Kaplan-Meier estimates of survival and 3-year inverse probability treatment weighted Cox proportional hazards models were conducted.

RESULTS

DTD donors made up 36% (40/110) of heart and 24% (54/223) of bilateral-lung transplantations. DTD donors were more likely to be young, white, and male. Unadjusted 5-year recipient survival was similar by donor cause of death (heart: 87% for DTD and 86% for non-DTD, p = .75; bilateral- lung: 80% for DTD and 76% for non-DTD, p = .65). Adjusted risk of mortality at 3-years post-transplant was similar between recipients of DTD and non-DTD donor heart (hazard ratio [HR]: .94, 95% confidence interval (CI): .22-4.07, p = .938) and bilateral-lung (HR: 1.06, 95% CI: .41-2.70, p = .908).

CONCLUSION

Recipient survival after heart or bilateral-lung transplantation from DTD donors and non-DTD donors was similar. Donation from DTD donors is safe and should be considered more broadly to increase organ donation.

Observational Study Examining Kidney Transplantation Outcomes Following Donation From Individuals That Died of Drug Toxicity in British Columbia, Canada

Background:

The illicit drug toxicity (overdose) crisis has worsened across Canada, between 2016 and 2021 more than 28 000 individuals have died of drug toxicity. Organ donation from persons who experience drug toxicity death has increased in recent years.

Objective:

This study examines whether graft loss after kidney transplantation differed by donor cause of death.

Design:

Retrospective cohort.

Setting:

Provincial transplant program of British Columbia, Canada.

Patients:

Transplant recipients who received kidney transplantation from deceased donors aged 12 to 70 years between 2013 and 2019 (N = 1012).

Measurements:

Transplant recipient all cause graft loss (graft loss due to any cause including death) was compared by donor cause of death from drug toxicity or other.

Methods:

Five-year Kaplan-Meier estimates of all-cause graft survival, and 3-year complete as well as stratified inverse probability of treatment weighted Cox proportional hazards models were conducted.

Results:

Drug toxicity death donors donated to 25% (252/1012) of kidney transplantations. Drug toxicity death donors were more likely to be young, white, males, with fewer comorbidities such as diabetes or hypertension but were more likely to have a terminal serum creatinine ≥1.5 mg/dL or be hepatitis C virus (HCV) positive. Unadjusted 5-year estimate of all-cause graft survival was 97% for recipients of drug toxicity donor kidneys and 83% for recipients of non-drug toxicity donor kidneys ( P < .001). Recipients of drug toxicity death donor kidneys had decreased risk of all cause graft loss compared to recipients of non-drug toxicity death donor kidneys (hazard ratio [HR]: 0.30, 95% confidence interval [CI]: 0.12-0.77, P = .012). This is primarily due to the reduced risk of all-cause graft loss for recipients of younger (≤35 years) drug toxicity death donor kidneys (HR: 0.05, 95% CI: 0.00-0.55, P = .015).

Limitations:

Potential selection bias, potential unmeasured confounding.

Conclusions:

Donation after drug toxicity death is safe and should be considered more broadly to increase deceased donor kidney donation.

Israeli Medical Experts’ Knowledge, Attitudes, and Preferences in Allocating Donor Organs for Transplantation

Medical advancement has increased the confidence in successful organ transplants in end-stage patients. As the waitlist of organ demand is multiplying, the organ allocation process is becoming more crucial. In this situation, a transparent and efficient organ allocation policy is required. This study evaluates the preferences of medical experts to substantial factors for allocating organs in different hypothetical scenarios. Twenty-five medical professionals with a significant role in organ allocation were interviewed individually. The interview questionnaire comprised demographic information, organ donation status, important organ allocation factors, public preference knowledge, and experts’ preferences in different hypothetical scenarios. Most medical experts rated the waiting time and prognosis as the most important, while the next of kin donor status and care and contribution to the well-being of others were the least important factors for organ allocation. In expert opinion, medical experts significantly considered public preferences for organ allocation in making their decisions. Altogether, experts prioritized waiting time over successful transplant, age, and donor status in the hypothetical scenarios. In parallel, less chance of finding another organ, donor status, and successful transplant were prioritized over age. Medical experts are the key stakeholders; therefore, their opinions are substantial in formulating an organ allocation policy.

Comparing Deceased Organ Donation Performance in Two Countries that Use Different Metrics: Comparing Apples With Apples

Organ donation networks audit and report on national or regional organ donation performance, however there are inconsistencies in the metrics and definitions used, rendering comparisons difficult or inappropriate. This is despite multiple attempts exploring the possibility for convergently evolving audits so that collectives of donation networks might transparently share data and practice and then target system interventions. This paper represents a collaboration between the United Kingdom and Australian organ donation organisations which aimed to understand the intricacies of our respective auditing systems, compare the metrics and definitions they employ and ultimately assess their level of comparability. This point of view outlines the historical context underlying the development of the auditing tools, demonstrates their differences to the Critical Pathway proposed as a common tool a decade ago and presents a side-by-side comparison of donation definitions, metrics and data for the 2019 calendar year. There were significant differences in donation definition terminology, metrics and overall structure of the audits. Fitting the audits to a tiered scaffold allowed for reasonable comparisons however this required substantial effort and understanding of nuance. Direct comparison of international and inter-regional donation performance is challenging and would benefit from consistent auditing processes across organisations.

Evaluation of underidentification of potential organ donors in German hospitals

Background

Since 2010, the number of organ donations in Germany has decreased by one third, mostly due to undetected organ donors. It is unclear, how the undetected potential donor pool is distributed among the different German hospital categories (A = university hospital, B = hospitals with neurosurgery, C = hospitals without neurosurgery) and region types.

Methods

We performed a nationwide secondary data analysis of all German inpatient cases of the year 2016 (n = 20,063,689). All fatalities were regarded as potential organ donors, in which primary or secondary brain damage was encoded and organ donation was not excluded by a contraindication or a lack of ventilation therapy.

Results

In 2016, 28,087 potential organ donors were identified. Thereof 21% were found in category A, 28% in category B and 42% in category C hospitals. The contact rate (= organ donation related contacts/ potential organ donors) and realization rate (= realized organ donations/ potential organ donors) of category A, B and C hospitals was 10.6% and 4.6%, 10.9% and 4.8% and 6.0% and 1.7%, respectively. 58.2% of the donor potential of category C hospitals was found in the largest quartile of category C hospitals. 51% (n = 14,436) of the potential organ donors were treated in hospitals in agglomeration areas, 28% (n = 7,909) in urban areas and 21% (n = 5,742) in rural areas. The contact- and realization rate did not significantly differ between these areas.

Conclusions

The largest proportion of potential organ donors and the lowest realization rate are found in category C hospitals. Reporting and donation practice do not differ between urban and rural regions.

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.

Criteria to Identify a Potential Deceased Organ Donor: A Systematic Review

OBJECTIVES

To systematically review the global published literature defining a potential deceased organ donor and identifying clinical triggers for deceased organ donation identification and referral.

DATA SOURCES

Medline and Embase databases from January 2006 to September 2017.

STUDY SELECTION

All published studies containing a definition of a potential deceased organ donor and/or clinical triggers for referring a potential deceased organ donor were eligible for inclusion. Dual, independent screening was conducted of 3,857 citations.

DATA EXTRACTION

Data extraction was completed by one team member and verified by a second team member. Thematic content analysis was used to identify clinical criteria for potential deceased organ donation identification from the published definitions and clinical triggers.

DATA SYNTHESIS

One hundred twenty-four articles were included in the review. Criteria fell into four categories: Neurological, Medical Decision, Cardiorespiratory, and Administrative. Distinct and globally consistent sets of clinical criteria by type of deceased organ donation (neurologic death determination, controlled donation after circulatory determination of death, and uncontrolled donation after circulatory determination of death) are reported.

CONCLUSIONS

Use of the clinical criteria sets reported will reduce ambiguity associated with the deceased organ donor identification and the subsequent referral process, potentially reducing the number of missed donors and saving lives globally through increased transplantation.

Deceased organ donation potential in Canada: a review of consecutive deaths in Alberta

BACKGROUND

Transplantation is the most effective treatment for many patients with end-stage organ failure. There is a gap between the number of patients who would benefit from transplantation and availability of organs. We assessed maximum potential for deceased donation in Alberta and barriers to increasing the donation rate.

METHODS

All deaths that occurred in Alberta in 2015 in areas where mechanical ventilation could be provided were retrospectively identified using administrative data. Medical records were reviewed by donation coordinators and critical care physicians with expertise in donation, using a standardized tool to determine whether deceased patients could potentially have been organ donors.

RESULTS

There were 2,706 deaths occurring in either an intensive care unit or emergency department, of which 1,252 were attributable to a non-neurologic cause: 946 involved cardiac arrests with unsuccessful resuscitation, and 57 were not mechanically ventilated. Of the remaining 451 deaths, 117 (28 donors per million population [dpmp]) either were, or could potentially have been, organ donors after neurologic determination of death (NDD). Of these, 19 (4.5 dpmp) were not appropriately identified or referred, and 45 approached families (10.8 dpmp) did not provide consent. Non-identified NDD cases accounted for a larger proportion of deaths due to neurologic causes in emergency departments (18%) than in intensive care units (2%) (P < 0.0001) and in rural (9%) compared with urban centres (3%) (P = 0.05). If routinely available, donation after circulatory death (DCD) could potentially have been possible in as many as 113 (27 dpmp) cases.

CONCLUSIONS

Maximum deceased organ donation potential in Alberta is approximately 55 dpmp. The current donation rate has potential to increase with more widespread availability of DCD and a higher consent rate.

Predicting Expected Organ Donor Numbers in Australian Hospitals Outside of the Donate-Life Network Using the ANZICS Adult Patient Database

Background

The majority of organ donations in Australia occur in the DonateLife Network of hospitals, but limited monitoring at other sites may allow donation opportunities to be missed. Our aim was to estimate expected donor numbers using routinely collected data from the Australian and New Zealand Intensive Care Society Adult Patient Database and determine whether unrecognized potential donors might exist in non-DonateLife hospitals.

Methods

All deaths at 150 Australian intensive care units (ICUs) contributing to the Australian and New Zealand Intensive Care Society Adult Patient Database were analyzed between January 2010 and December 2015. Donor numbers were extracted from the Australian and New Zealand Organ Donor registry. A univariate linear regression model was developed to estimate expected donor numbers in DonateLife hospitals, then applied to non-DonateLife hospitals.

Results

Of 33 614 deaths at 71 DonateLife hospitals, 6835 (20%) met criteria as “ICU deaths potentially suitable to be donors,” and 1992 (6%) were actual donors. There was a consistent relationship between these groups (R² = 0.626, P < 0.001) allowing the development of a prediction model which adequately estimated expected donors. Of 8077 deaths in 79 non-DonateLife ICUs, 452 (6%) met criteria as potentially suitable donors. Applying the prediction model developed in DonateLife hospitals, the estimated expected donors in non-DonateLife hospitals was 130. However, there were only 75 actual donors.

Conclusions

It is possible to estimate the expected number of Australian organ donors using routinely collected registry data. These findings suggest that there may be a small but significant pool of underutilized potential donors in non-DonateLife hospitals. This may provide an opportunity to increase donation rates.

This retrospective analysis of the Australian and New Zealand Intensive Care Society Adult Patient Database data registry suggests that it is possible to estimate the expected number of organ donors and recognizes the existence of a small but significant pool of under-utilised potential donors. Supplemental digital content is available in the text.

Current opinions in organ allocation

Existing methods of academic publication provide limited opportunity to obtain stakeholder input on issues of broad interest. This article reports the results of an experiment to produce a collaborative, crowdsourced article examining a current controversial issue in transplant medicine (hereby referred to as the "C4 Article"). The editorial team as a whole selected the topic of organ allocation, then divided into six sections, each supported by an individual editorial team. Widely promoted by the American Journal of Transplantation, the C4 Article was open for public comment for 1 month. The nonblinded editorial teams reviewed the contributions daily and interacted with contributors in near-real time to clarify and expand on the content received. Draft summaries of each section were posted and subsequently revised as new contributions were received. One hundred ninety-four individuals viewed the manuscript, and 107 individuals contributed to the manuscript during the submission period. The article engaged the international transplant community in producing a contemporary delineation of issues of agreement and controversy related to organ allocation and identified opportunities for new policy development. This initial experience successfully demonstrated the potential of a crowdsourced academic manuscript to advance a broad-based understanding of a complex issue.

Examination of the Brain-Dead Organ Donor Management Process at a Spanish Hospital

The number of donors and organs available has not increased at the same rate as the inclusion of new patients in the waiting lists. The aim of the present study was to analyze the quality of the detection process of potential brain-dead organ donors at the Hospital of León. For this, a cross-sectional prospective study was developed on a retrospective cohort of patients who were admitted or died by catastrophic brain damage with the potential for organs donation. Data were collected for six months using hospital records of admissions and exitus. For the statistical analysis, the free distribution software Epi Info 3.5.4 was employed. A total of 627 patients were studied: 550 were discharged and 77 died as potential donors. Of the potential donors, 65 died in asystole, but 60 of them had an absolute contraindication to donation and 20 died after limitation of life support therapy. Five cases with donor criteria in controlled asystole were detected. The analysis found that the detection process conformed to the regulatory framework stablished by the National Transplant Organization. However, population aging leads to a high rate of absolute contraindications among detected potential donors. The donation capacity of the hospital could therefore be increased with the implementation of a donor protocol in controlled asystole.

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.

An Exception to the Rule or a Rule for the Exception? The Potential of Using HIV-Positive Donors in Canada

Selected human immunodeficiency virus (HIV)-infected patients with end organ failure can safely receive an organ transplant from an HIV uninfected donor. Recent demonstration of the short term safety of organ transplantation between HIV-infected persons prompted a change in US American law to allow such transplantations. Prompted by the recent completion of the first organ transplantation between HIV-infected persons in Canada, we review Canadian law regarding the use of organs from HIV-infected donors, estimate the number of potential HIV-infected donors in Canada, and critically review considerations related to advancing organ transplantation from HIV-infected donors in Canada. Existing legislation allows organ transplantation from an HIV-infected donor under exceptional medical circumstances and therefore no change in legislation is required to increase utilization of organs from HIV-infected donors for transplantation in Canada. Among 335,793 hospital deaths between 2005 and 2009 in Canadian provinces excluding Quebec, 39 potential HIV-infected donors were identified. The actual number of HIV potential donors is estimated to be approximately 60% lower (3-5 potential donor per year), if the absence of viremia is required for transplantation. Although offering all Canadians the opportunity to donate organs is a laudable goal, further research to understand the need for HIV-positive donors and the willingness of HIV-positive recipients to accept organs from HIV-positive donors is needed to inform future policy regarding organ donation from HIV-infected persons in Canada.

Development of a Canadian deceased donation education program for health professionals: a needs assessment survey

PURPOSE

The purpose of this survey was to determine how Canadian healthcare professionals perceive their deficiencies and educational requirements related to organ and tissue donation.

METHODS

We surveyed 641 intensive care unit (ICU) physicians, 1,349 ICU nurses, 1,561 emergency room (ER) physicians, and 1,873 ER nurses. The survey was distributed by the national organization for each profession (the Canadian Association of Emergency Physicians, the Canadian Association of Critical Care Nurses, and the National Emergency Nurses Association). Canadian Blood Services developed the critical care physician list in collaboration with the Canadian Critical Care Society. Survey development included questions related to comfort with, and knowledge of, key competencies in organ and tissue donation.

RESULTS

Eight hundred thirty-one (15.3%) of a possible 5,424 respondents participated in the survey. Over 50% of respondents rated the following topics as highly important: knowledge of general organ and tissue donation, neurological determination of death, donation after cardiac death, and medical-legal donation issues. High competency comfort levels ranged from 14.7-50.9% for ICU nurses and 8.0-34.6% for ER nurses. Competency comfort levels were higher for ICU physicians (67.5-85.6%) than for ER physicians who rated all competencies lower. Respondents identified a need for a curriculum on national organ donation and preferred e-learning as the method of education.

CONCLUSIONS

Both ICU nurses and ER practitioners expressed low comfort levels with their competencies regarding organ donation. Intensive care unit physicians had a much higher level of comfort; however, the majority of these respondents were specialty trained and working in academic centres with active donation and transplant programs. A national organ donation curriculum is needed.