Children as donors: a national study to assess procurement of organs and tissues in pediatric intensive care units

Organ Donation in Canadian PICUs: A Cross-Sectional Survey, 2021-2022

OBJECTIVES

To understand contemporary pediatric organ donation programs in Canadian PICUs, including: policies and practices, data collection and reporting, and system and process barriers.

DESIGN

A cross-sectional survey carried out 2021-2022.

SETTING

Canadian PICUs affiliated with a donor physician network.

SUBJECTS

Pediatric intensivists identified as the donation program lead, or most knowledgeable about donation for their institution.

MEASUREMENTS AND MAIN RESULTS

A 19-item survey was developed through collaboration with stakeholders from the organ donation and transplantation community within Canada. Domains and items were generated and reduced iteratively during an in-person workshop. Pretesting and pilot testing were completed to ensure readability, flow, clinical sensibility, and construct validity. Fifteen of 16 (94%) invited Canadian PICUs from seven provinces completed the survey representing 88% (15/18) of all noncardiac Canadian PICUs. Surveys were completed between June 2021 and September 2022. All units support donation after death by neurologic criteria (DNC); 14 of 15 indicated donation policies were in place and 1 of 15 indicated no policy but the ability to facilitate donation. Thirteen of 15 units (87%) support donation after death by circulatory criteria (DCC) with policies in place, with 11 of 13 of these indicating routine support of donation opportunities. The majority (13/15) of units identified a donation champion. Of the 16 identified champions across these centers, 13 were physicians and were registered nurses or nurse practitioners. Eight of 13 units (62%) with donation champions had positions supported financially, of which 5 units came from the Organ Donation Organization and the other 3 came from the provincial health authority. Finally, only 3 of 15 PICU donation programs have a pediatric donation committee with family involvement. Variability exists in identification (including determination of death practices), referral, and approach for donation between units.

CONCLUSIONS

Although all Canadian PICUs support donation after DNC donation, and most support donation after DCC, variability exists in the identification, referral, and approach of potential donors. There is a notable lack of family involvement in pediatric donation programs. There are many opportunities for standardization of PICU donation programs which may result in improved rates of pediatric organ donation in Canada.

Paediatric organ donation following neurological determinants of death in intensive care units in Saudi Arabia: a retrospective cross-sectional study

OBJECTIVES

The aim of this retrospective cross-sectional study was to assess the performance of paediatric organ donation in intensive care units following neurological determinants of death in Saudi Arabia.

DESIGN

Retrospective cross-sectional study.

SETTING

Paediatric intensive care units at three tertiary centres over 5 years.

PARTICIPANTS

423 paediatric deaths (<14 years) from January 2017 to December 2021.

PRIMARY OUTCOME

Patients were identified as either possible, potential, eligible, approached, consented or actual donors based on organ donation definitions from the WHO, Transplantation Society and UK potential donor audit.

SECONDARY OUTCOME

Secondary outcome was causative mechanisms of brain injury in possible donors. Demographics of the study cohort (age, sex, hospital length of stay (LOS), paediatric intensive care unit LOS, pre-existing comorbidities, admission type and diagnosis category) were compared between possible and non-possible donors. Demographics were also compared between patients who underwent neurological determination of death and patients who did not.

RESULTS

Among the 423 paediatric deaths, 125 (29.6%) were identified as possible donors by neurological criteria (devastating brain insult with likelihood of brain death, Glasgow Coma Score of 3 and ≥2 absent brainstem reflexes). Of them, 41 (32.8%) patients were identified as potential donors (neurological determination of death examinations initiated by the treating team), while only two became actual donors. The eligible death conversion rate was 6.9%. The reporting rate to organ procurement organisation was 70.7% with a consent rate of 8.3%. The most common causes of brain insult causing death were cardiac arrest (44 of 125 patients, 35.2%), followed by traumatic brain injury and drowning (31 of 125 patients, 24.8%), and intracranial bleeding (13 of 125 patients, 11.4%).

CONCLUSION

Major contributors to low actual donation rate were consent, donor identification and donor referral.

Pediatric transplantation: An international perspective

The international practice of transplant in the pediatric population is heterogenous. Global trends in pediatric transplant activity are increasing, with diffusion of transplant activities into developing and emerging economies. There have been impacts of the COVID-19 pandemic which have in the earlier part of the pandemic caused a decrease in the number of transplants. While deceased donor programs are well established in advanced economies, emerging and developing countries rely heavily on live donor programs. Prioritization of organs for children exists in different forms throughout the world. Pediatric transplantation as a sub-specialty is young but growing around the world with a need to train surgeons and physicians in this discipline. Outreach efforts with multi-national and multi-institutional partnerships have enabled resource poor countries to establish new transplant programs for children. Further international collaboration, good quality data collection and audit, prospective research and ongoing mentorship and education are needed to further improve outcomes of all children receiving solid organ transplants.

Whole liver transplantation in children under 10 kg: How to minimize the high risks of a still challenging procedure

BACKGROUND

Whole liver transplantation in infants <10 kg is a rare procedure with moderate outcomes (67%-79% graft survival at 1 year) and high rates of vascular complications (hepatic artery thrombosis 5-26%).

METHODS

Retrospective single-center analysis of whole liver transplantation in infants <10 kg and systematic review of the literature focused on survival rates and surgical complications.

RESULTS

Between January 2005 and December 2020, 175 liver transplantations in 173 children were performed at our center. A total of 92 (53%) children weighed less than 10 kg; 19 (21%) of them underwent WLT and constitute the study population. Median age of the recipients was 10 months (21 days-24 months) and median body weight 6.5 (3.1-9.8) kg. Median age of the donors was 5 (1-84) months and median body weight 6.1 (4-21) kg. Median donor-to-recipient body weight ratio was 1.2 (range: 0.6-4.5). Postoperatively, neither hepatic artery nor portal vein thrombosis occurred. A biliary complication occurred in 4 cases: 1 bile leak (early), 3 anastomotic stenoses (1 delayed and 2 late), and 1 non-anastomotic stenosis (late). Patient survival rate at 1, 5, and 10 years was 100%, 92%, and 92%, respectively. Overall, death-censored graft survival after 1, 5, and 10 was 100%.

CONCLUSION

Our results are excellent in terms of complications and graft and patient survival. This involves not only high-end surgical performance but also close interdisciplinary perioperative cooperation based on strong standard operating procedures and mainly focused on fluid management, hemostasiology, and strict monitoring of vessel patency.

Neonatal donation: are newborns too young to be recognized?

Neonatal organ and tissue donation is not common practice in the Netherlands. At the same time, there is a transplant waiting list for small size-matched organs and tissues. Multiple factors may contribute to low neonatal donation rates, including a lack of awareness of this option. This study provides insight into potential neonatal organ and tissue donors and reports on how many donors were actually reported to the procurement organization. We performed a retrospective analysis of the mortality database and medical records of two largest neonatal intensive care units (NICUs) in the Netherlands. This study reviewed records of neonates with a gestational age >37 weeks and weight >3000g who died in the period from January 1, 2005 through December 31, 2016. During the study period, 259 term-born neonates died in the two NICUs. In total, 132 neonates with general contra-indications for donation were excluded. The medical records of 127 neonates were examined for donation suitability. We identified five neonates with documented brain death who were not recognized as potential organ and/or tissue donors. Of the remaining neonates, 27 were found suitable for tissue donation. One potential tissue donor had been reported to the procurement organization. In three cases, the possibility of donation was brought up by parents.Conclusion: A low proportion (2%) of neonates who died in the NICUs were found suitable for organ donation, and a higher proportion (12%) were found suitable for tissue donation. We suggest that increased awareness concerning the possibility of neonatal donation would likely increase the identification of potential neonatal donors. What is Known: • There is an urgent need for very small organs and tissues from neonatal donors What is New: • A number of neonates who died in the NICU were suitable organ or/and tissue donors but were not recognized as donors. • Knowledge on neonatal donation possibilities is also important for proper counseling of parents who sometimes inquire for the possibility of organ and tissue donation.

Lack of knowledge and experience highlights the need for a clear paediatric organ and tissue donation protocol in the Netherlands

Aim

This study explored the attitudes of medical professionals to organ and tissue donation in paediatric intensive care units (PICUs) and neonatal intensive care units (NICUs) in the Netherlands. It also examined their compliance with the existing Dutch donation protocol and assessed whether a paediatric donation protocol was needed.

Methods

We invited 966 professionals working in all eight PICUs and the two largest NICUs to complete an online survey from December 2016 until April 2017.

Results

A quarter (25%) took part and they included PICU intensivists, neonatologists, nurses and other health and allied professionals. Most were female and nurses. More than half (54%) of the PICU respondents considered paediatric organ donation to be very important and 53% supported tissue donation. In contrast, only 22% of the NICU respondents believed that both neonatal organ and tissue donation were very important. Familiarity and compliance with the existing national donation protocol were low. PICU nurses had significantly less experience than PICU intensivists and felt less comfortable with the donation process. None of the NICU respondents had prior donation experience.

Conclusion

Paediatric intensive care units and NICU professionals lack specialised knowledge and experience on organ and tissue donation. A comprehensive and clear paediatric donation protocol is clearly needed.

Assessing comfort level of organ donation competencies among pediatric intensivists in Saudi Arabia: a national survey

BACKGROUND

As increasing the number of organ donations presents a global challenge, Saudi Arabia is no different. Intensivists can play a major role in maximizing the organ donation process and minimize the challenges. The purpose of this study was to investigate Saudi pediatric intensivists' comfort and importance levels of organ donation competencies.

METHODS

We conducted a cross-sectional survey whose sampling frame included 100 pediatric intensivists. The pediatrician intensivists were identified through an updated list provided by the Saudi Critical Care Society. We assessed 14 competencies categorized into four domains: the general donation, donation after brain death (DBD), neurological determination of death, and medicolegal, religious, and ethical domains. Then we investigated the association between these competencies and physicians' characteristics.

RESULTS

With a response rate of 76%, we found that 40-60% of the surveyed pediatric intensivists rated their comfort in 6 out of 14 competencies as high or very high. There was a statistically significant gap in the intensivists' rating of 10 competencies (i.e., high importance but low comfort levels). Ordinal regression showed that comfort levels with the general donation, neurological determination of death, and medicolegal, religious, and ethical domains were higher in intensivists who were frequently involved with DBD than those who had never been exposed.

CONCLUSIONS

Pediatric intensivists expressed low comfort levels to organ donation competencies that are essential for maximizing donation rates. Adapting mandatory comprehensive donation education programs and dedicated physician specialists may be beneficial in critical care units aiming to increase donation rates.

Dot blots of solubilized extracellular matrix allow quantification of human antibodies bound to epitopes present in decellularized porcine pulmonary heart valves

BACKGROUND

The present study reports the development of a sensitive dot blot protocol for determining the level of preformed antibodies against porcine heart valve tissue derived from wild-type (WT) and α-Gal-KO (GGTA1-KO) pigs in human sera.

METHODS

The assay uses decellularized and solubilized heart valve tissue; antibody binding found in this dot blot assay could be correlated with antibody titers of preformed anti-α-Gal and anti-Neu5Gc antibodies detected by a sensitive ELISA.

RESULTS

The ultimate protocol had an inter-assay variance of 9.5% and an intra-assay variance of 9.2%, showing that the test is reliable and highly reproducible. With the aid of this dot blot assay, we found significant variation with regard to antibody contents among twelve human sera. Binding of preformed antibodies to WT tissue was significantly higher than to GGTA1-KO tissue.

CONCLUSIONS

The dot blot assay described herein could be a valuable tool to measure preformed antibody levels in human sera against unknown epitopes on decellularized tissue prior to implantation. Ultimately, this prescreening may allow a matching of the porcine xenograft with the respective human recipients in demand and thus may become an important tool for graft long-term survival similar to current allotransplantation settings.

Literature overview highlights lack of paediatric donation protocols but identifies common themes that could guide their development

AIM

Paediatric donation is a unique and extremely sensitive process that requires specific knowledge and competencies. Most countries use protocols for organ and tissue donation to ensure optimal care for the donor and family, but these mainly focus on adults. However, the donation process for children differs from adults in many ways. An overview of the literature was performed to identify protocols for the paediatric population.

METHODS

PubMed, Web of Science, EMBASE and the Internet were searched up to March 2016 for papers or other sources in English related to specific organ and tissue donation protocols for children and neonates. This comprised title, abstract and then full-text screening of relevant data.

RESULTS

We included 12 papers and two electronic sources that were mainly from North America and Europe. Most discussed donations after cardiac death. The recurring themes included identifying potential donors, approaching parents, palliative care and collaboration with organ procurement organisations. Most papers called for paediatric donation policies to be standardised.

CONCLUSION

Scientific publications in English on paediatric donation protocols are very scarce. No comprehensive paediatric donation protocol was found. We identified several recurring themes in the literature that could be used to develop such protocols.

Pediatric transplantation: An international perspective

Abdominal solid-organ transplantation has revolutionized the life of children with end-stage organ failure. The international practice of transplant in the pediatric population is heterogeneous. Global trends in pediatric transplant activity are increasing, with diffusion of transplant activities into developing and emerging economies. The organization of deceased donor programs varies internationally (with strong association to a country's gross domestic product (GDP) per capita and health spending). While deceased donor programs are well established in advanced economies, emerging and developing countries rely heavily on living donor programs. There are efforts underway to increase availability of pediatric and neonatal donor organs. Prioritization of organs for children exists in different forms throughout the world. Pediatric transplantation as a subspecialty is young but growing around the world with a need to train surgeons and physicians in this discipline. Outreach efforts with multinational and multi-institutional partnerships have enabled resource poor countries to establish new transplant programs for children. Further international collaboration, good quality data collection and audit, prospective research and ongoing mentorship, and education are needed to further improve outcomes of all children receiving solid-organ transplants.

Challenges of paediatric organ donation

Paediatric organ donation represents a small fraction of overall organ donation in Australia and New Zealand and indeed world-wide. Many factors contribute to low donation rates including low paediatric intensive care mortality, consent rates and medical suitability relating to disease, age and size. In the past decade, the re-emergence of donation after circulatory death has changed the landscape for the paediatric population. This article reviews the current status and challenges of organ donation for the paediatric population.

Pediatric Deceased Donation-A Report of the Transplantation Society Meeting in Geneva

The Ethics Committee of The Transplantation Society convened a meeting on pediatric deceased donation of organs in Geneva, Switzerland, on March 21 to 22, 2014. Thirty-four participants from Africa, Asia, the Middle East, Oceania, Europe, and North and South America explored the practical and ethical issues pertaining to pediatric deceased donation and developed recommendations for policy and practice. Their expertise was inclusive of pediatric intensive care, internal medicine, and surgery, nursing, ethics, organ donation and procurement, psychology, law, and sociology. The report of the meeting advocates the routine provision of opportunities for deceased donation by pediatric patients and conveys an international call for the development of evidence-based resources needed to inform provision of best practice care in deceased donation for neonates and children.

A Comparison of the Request Process and Outcomes in Adult and Pediatric Organ Donation

BACKGROUND AND OBJECTIVES

Although existing studies suggest that factors affecting families' decisions regarding pediatric organ donation mirror those for adult patients, health professionals working in this area maintain that pediatric and adult decision-makers differ in significant ways. This study compared the request process, experiences, and authorization decisions between family decision-makers (FDMs) of adult and pediatric donors and nondonors.

METHODS

Perceptions of the donation request were collected via telephone interviews with 1601 FDMs approached by staff from 9 US organ procurement organizations (OPOs). Authorization regarding donation (ie, authorized/refused) was obtained from FDM reports and verified by using OPO records. Tests of association were used to estimate differences between FDMs of adult and pediatric patients. A logistic regression analysis was conducted to identify variables predicting FDM authorization.

RESULTS

FDMs of children were significantly more likely to authorize donation than were FDMs of adults (89.7% vs 83.2%; χ(2) = 6.2, P = .01). Differences were found between pediatric and adult families' initial feelings toward donation, donation-related topics discussed, communication behaviors and techniques used, perceptions of the request, and receipt and preference of grief information. The likelihood of FDM authorization increased with the number of topics discussed and communication skills employed during requests. Authorization was not predicted by patient age (ie, adult versus pediatric).

CONCLUSIONS

FDMs of children are willing to donate and experience no more psychological distress from the request for donation than do FDMs of adults. Communication emerged as a critical factor of family authorization, reinforcing its importance in requests for donation.