Advancing the science of organ donor management

Research and Innovation in Organ Donation: Recommendations From an International Consensus Forum

This report provides recommendations from the Research and Innovation domain as part of the International Donation and Transplantation Legislative and Policy Forum (hereafter the Forum) to provide expert guidance on the structure of an ideal organ and tissue donation and transplantation system. The recommendations focus on deceased donation research and are intended for clinicians, investigators, decision-makers, and patient, family, and donor (PFD) partners involved in the field.

Methods

We identified topics impacting donation research through consensus using nominal group technique. Members performed narrative reviews and synthesized current knowledge on each topic, which included academic articles, policy documents, and gray literature. Using the nominal group technique, committee members discussed significant findings, which provided evidence for our recommendations. The Forum's scientific committee then vetted recommendations.

Results

We developed 16 recommendations in 3 key areas to provide stakeholders guidance in developing a robust deceased donor research framework. These include PFD and public involvement in research; donor, surrogate, and recipient consent within a research ethics framework; and data management. We highlight the importance of PFD and public partner involvement in research, we define the minimum ethical requirements for the protection of donors and recipients of both target and nontarget organ recipients, and we recommend the creation of a centrally administered donor research oversight committee, a single specialist institutional review board, and a research oversight body to facilitate coordination and ethical oversight of organ donor intervention research.

Conclusions

Our recommendations provide a roadmap for developing and implementing an ethical deceased donation research framework that continually builds public trust. Although these recommendations can be applied to jurisdictions developing or reforming their organ and tissue donation and transplantation system, stakeholders are encouraged to collaborate and respond to their specific jurisdictional needs related to organ and tissue shortages.

Examining consent for interventional research in potential deceased organ donors: a narrative review

In the last decade, research in transplant medicine has focused on developing interventions in the management of the deceased organ donor to improve the quality and quantity of transplantable organs. Despite the promise of interventional donor research, there remain debates about the ethics of this research, specifically regarding gaining research consent. Here, we examine the concerns and ambiguities around consent for interventional donor research, which incorporate questions about who should consent for interventional donor research and what people are being asked to consent for. We highlight the US and UK policy responses to these concerns and argue that, whereas guidance in this area has done much to clarify these ambiguities, there is little consideration of the nature, practicalities and context around consent in this area, particularly regarding organ donors and their families. We review wider studies of consent in critical care research and social science studies of consent in medical research, to gain a broader view of consent in this area as a relational and contextual process. We contend a lack of consideration has been given to: what it might mean to consent to interventional donor research; how families, patients and health professionals might experience providing and seeking this consent; who is best placed to have these discussions; and the socio-institutional contexts affecting these processes. Further, empirical research is required to establish an ethical and sensitive model for consent in interventional donor research, ensuring the principles enshrined in research ethics are met and public trust in organ donation is maintained.

Identification of Hemodynamic Risk Factors for Apnea Test Failure During Brain Death Determination

OBJECTIVE

An apnea test is essential step for diagnosing brain death and is known to be relatively safe. However, various complications such as hypoxia, arrhythmias, and hypotension could occur. Herein, we identified risk factors of failed apnea test and determined their optimal cutoff values.

METHODS

We retrospectively analyzed 512 patients of apnea test to diagnose brain death and classified them into 2 groups according to success or failure of the test. Demographic characteristics, value of arterial blood gas analysis, and systolic blood pressure (SBP) were collected, and alveolar-arterial gradient (A-a gradient) and Pao₂/fraction of inspired oxygen ratio were calculated to evaluate the respiratory status.

RESULTS

A total of 484 patients completed the apnea test, and the test was aborted in 28 patients because of hypotension or refractory hypoxemia. The SBP, pH, Pao₂, and Pao₂/fraction of inspired oxygen ratio were higher in success group, whereas A-a gradient was lower. In multivariate analysis, low SBP (odds ratio [OR], 0.976; 95% CI, 0.958-0.994; P = .01), low pH (OR, 0.004; 95% CI, 0.000-0.184; P = .005), and elevated A-a gradient (OR, 1.005; 95% CI, 1.003-1.008; P = .001) were associated with apnea test failure. The optimal cutoff values to predict the test failure were 105.0 mm Hg for pretesting SBP, 7.326 for pretesting pH, and 556.4 mm Hg for pretesting A-a gradient.

CONCLUSION

Early recognition and aggressive management for the risk factors are important to reduce failure rates of apnea test and consequently improve outcomes of organ procurement.

Hormone replacement therapy in brain-dead organ donors: a comprehensive review with an emphasis on traumatic brain injury

BACKGROUND

Organ shortage is an ongoing problem in the United States. Most donor organs are procured following brain death and a significant portion of brain-dead donors result from devastating brain injury. Without a standard practice for hormone replacement therapy (HRT) in the setting of brain death, a comprehensive review of the literature was deemed necessary.

METHODS

A search of published literature was conducted with terms "TBI" or "brain injury" or "head injury" AND "hormone" or "management" AND "organ" AND "donor" or "donation." Abstracts and full texts were screened for relevance and inclusion of information on HRT. Additional studies were selected from references cited within these. Excluded studies were non-English, nonhuman based, or had small sample size, (i.e., case reports or series with fewer than five subjects).

RESULTS

Fifteen studies were selected for inclusion and contained Level III or Level IV evidence. Combinations of thyroid hormone, insulin, and corticosteroids were the most commonly cited HRT. Ninety-three percent of studies found a significant increase in organ procurement rate among donors who received HRT. Hormone replacement therapy was administered after brain death declaration in eight studies. Only two studies specifically explored the effects of starting HRT earlier and identified even greater procurement rates. Four studies were specific to traumatic brain injury (TBI); the remaining 11 studies involved TBI in 22% to 89% of the sample.

CONCLUSION

Organ shortage remains a growing problem in the United States. Donor management including HRT has been proposed to combat the endocrine derangement associated with brain death and, in particular, TBI. While the existing literature reported compelling outcomes using HRT, there remains a need for further Level I and Level II evidence studies to define optimal practice.

LEVEL OF EVIDENCE

Review article, level IV.

Hamilton-DONATE: a city-wide pilot observational study of the ICU management of deceased organ donors

PURPOSE

Improving the medical care of deceased organ donors to increase transplant rates and improve allograft function requires an understanding of the current epidemiology and clinical practices of deceased donation within intensive care units (ICUs). Herein, we report the results of our investigation into the feasibility of a multicentre prospective cohort study addressing the afformentioned issues.

METHODS

We conducted a 12-month prospective observational cohort study in six ICUs and one coronary care unit in Hamilton, Canada. We included consecutive children and adults following consent for deceased organ donation (including neurologic determination of death [NDD] or donation after circulatory death [DCD]). Intensive care unit research staff recorded donor management data from hospital records, extending from one day prior to the consent for organ donation up to the time of organ retrieval. The provincial Organ Donation Organization (ODO) supplemented these data and, additionally, provided data on corresponding organ recipients. We identified, evaluated, and measured three potential obstacles to the feasibility of a national cohort study: obtaining authorization to implement the study with a waiver of research consent, accessibility of transplant recipient data, and the time required to complete very detailed case report forms (CRFs), with valuable lessons learned for implementation in future projects.

RESULTS

The local Research Ethics Board and the ODO Privacy Office both authorized the recording of donor and recipient study data with a waiver of research consent. Sixty-seven consecutive consented donors were included (31 NDD and 36 DCD donors); 50 of them provided 144 organs for transplantation to 141 recipients. We identified the age and sex of the recipients as well as the location and date of transplant for all organ recipients in Ontario; however, we obtained no recipient data for six organs transported outside of Ontario. Intensive care unit research staff estimated that future CRF completion will require five to seven hours per patient.

CONCLUSION

The Hamilton-DONATE pilot study supports the feasibility of a larger cohort study to describe the epidemiology and clinical practices related to deceased donor care in Canada.

TRIAL REGISTRATION

wwwclinicaltrials.gov (NCT02902783). Registered 16 September 2016.

Deceased Organ Donation From Pediatric Donors: Does the Literature Really Help Us? Implication for More Powerful Guidelines

BACKGROUND

Brain-dead pediatric donors have always been the focus of attention because of the higher quality, utility, and possibility of their organ donation. However, donors under the age of 5 years always necessitate making more challenging management efforts, which are not clearly implied in most parts of the guidelines.

METHODS

The data obtained from 79 brain-dead pediatric donors of the Organ Procurement Unit of Masih Daneshvari Hospital, Tehran, Iran, were assessed. The donors were divided into 2 groups, including donors under 5 years of age (group A) and those between 5 and 12 years of age (group B). Metabolic, hemodynamic, hematologic, and electrolyte status as well as the suitability for donation were compared in the study groups.

RESULTS

Of 1252 donors, 6.3% were under 12 years of age. Trauma and drug toxicity were the two primary causes of brain death in group A. In comparison, trauma and brain tumor were the leading causes of brain death in group B. The prevalence of both hyperglycemia and respiratory acidosis was significantly higher in group A (P < .05). However, severe anemia and coagulopathy were more prevalent in group B (P < .05). The high-dose inotropic administration was used for 42.4% of the donors in group A, whereas only 26% of the donors in group B needed a high dose of inotropes (P < .05). The mean quantity of organ harvested per donor was 2.1 and 2.25 in groups A and B, respectively. Furthermore, donor loss was not significantly different in both groups.

CONCLUSIONS

The occurrence of different complications in donors under the age of 5 years requires special treatment considerations that should be the center of attention in the related guidelines. Organ donation per donor indicates that donors under the age of 5 years are a valuable resource for organ procurement.

Organ-Protective Intensive Care in Organ Donors

BACKGROUND

The ascertainment of brain death (the irreversible, total loss of brain function) gives the physician the opportunity to limit or stop further treatment. Alternatively, if the brain-dead individual is an organ donor, the mode of treatment can be changed from patient-centered to donationcentered. Consensus-derived recommendations for the organ-protective treatment of brain-dead organ donors are not yet available in Germany.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed, and on the authors' clinical experience.

RESULTS

Brain death causes major pathophysiological changes, including an increase in catecholamine levels and a sudden drop in the concentration of multiple hormones, among them antidiuretic hormone, cortisol, insulin, and triand tetraiodothyronine. These changes affect the function of all organ systems, as well as the hemodynamic state and the regulation of body temperature. The use of standardized donor management protocols might well increase the rate of transplanted organs per donor and improve the quality of the transplanted organs. In addition, the administration of methylprednisolone, desmopressin, and vasopressin could be a useful supplement to treatment in some cases. Randomized controlled trials have not yet demonstrated either improved organ function or prolonged survival of the transplant recipients.

CONCLUSION

The evidence base for organ-protective intensive care is weak; most of the available evidence is on the level of expert opinion. There is good reason to believe, however, that the continuation of intensive care, in the sense of early donor management, can make organ transplantation more successful both by increasing the number of transplantable organs and by improving organ quality.

Canada-DONATE study protocol: a prospective national observational study of the medical management of deceased organ donors

INTRODUCTION

Research on the management of deceased organ donors aims to improve the number and quality of transplants and recipient outcomes. In Canada, this research is challenged by regionalisation of donation services within provinces and the geographical, clinical and administrative separation of donation from transplantation services. This study aims to build a national platform for future clinical trials in donor management. Objectives are to engage collaborators at donation hospitals and organ donation organisations (ODOs) across Canada, describe current practices, evaluate the effectiveness of donation-specific interventions and assess the feasibility of future clinical trials.

METHODS AND ANALYSIS

This ongoing prospective observational study of the medical management of deceased organ donors will enrol more than 650 consented potential donors from adult intensive care units at 33 hospital sites across Canada, each participating for 12 months. ODOs ensure enrolment of consecutive eligible participants. Research staff record detailed data about participants, therapies, organ assessments, death declaration procedures and adverse clinical exposures from the time of donation consent to organ recovery. ODOs provide reasons that organs are declined, dates and places of transplantation, and recipient age and sex.Descriptive analyses will summarise current practices. Effectiveness analyses will examine donation-specific interventions with respect to the number of transplants, using multilevel regression models to account for clustering by donor, hospitals and ODOs. Feasibility analyses will focus on acceptance of the research consent model; participation of academic and community hospitals as well as ODOs; and accessibility of recipient data.

ETHICS AND DISSEMINATION

This study uses a waiver of research consent. Hospitals will receive reports on local practices benchmarked to (1) national practices and (2) national donor management guidelines. We will report findings to donation and transplant collaborators (ie, clinicians, researchers, ODOs) and publish in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03114436.

Ethical Challenges and the Donation Physician Specialist: A Scoping Review

Deceased donation medicine involves unique ethical challenges. Physicians who are focused on deceased donation medicine as part of their practice can expect to encounter these challenges. The goal of this review is to identify and describe these challenges, highlight existing guidelines and policy regarding the management of these challenges and to describe how the donation physician role might promote ethical practice in deceased donation medicine. Themes of discussion include: communication with families, interprofessional conflict, donation physician personal characteristics, donation clinical processes, health resource allocation, research and education, and remuneration. The information presented in this review can be used to inform development of recommendations and guidelines for the management of ethical challenges encountered by donation physicians.

Effect of corticosteroid administration on neurologically deceased organ donors and transplant recipients: a systematic review and meta-analysis

OBJECTIVES

This review investigates the impact of corticosteroids on donation rates and transplant outcomes in light of findings from randomised controlled trials (RCTs) and to highlight the sources of uncertainty in this unresolved donor management issue.

DATA SOURCES

We searched electronic databases, trial registries and conference proceedings for RCTs evaluating corticosteroid therapy in neurologically deceased donors.

STUDY SELECTION AND DATA EXTRACTION

Independent reviewers assessed eligibility, evaluated risk of bias and abstracted data, including donor haemodynamic data, number of organs recovered and transplant outcomes. Where possible, we pooled results. For each outcome, we assessed the overall quality of evidence using The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

DATA SYNTHESIS

Eleven RCTs with different corticosteroid regimens were included. Most trials assessed a once-daily infusion of methylprednisolone. Aside from one study showing improved liver graft function, no individual study or pooled analysis showed benefit of corticosteroids for any outcome: vasopressor use (three trials; relative risk (RR) 0.96; 95% CI 0.89 to 1.05), multiple organs recovered (two trials; RR 0.82; 95% CI 0.61 to 1.11), acute graft rejection (three trials; RR 0.91; 95% CI 0.60 to 1.39) or graft dysfunction (eight trials; RR 1.01; 95% CI 0.83 to 1.24). Two trials investigated adverse effects and found similar rates between groups. Quality of evidence was moderate or low for all outcomes.

CONCLUSION

Current clinical trials are limited in numbers and size to identify benefits or harms of corticosteroid therapy for deceased organ donors. In the face of these results, administering or withholding steroids both appear reasonable courses of action.

Organ donation protocols

Organ transplantation improves survival and quality of life in patients with end-organ failure. Waiting lists continue to grow across the world despite remarkable advances in the transplantation process, from the creation of public engagement campaigns to the development of critical pathways for the timely identification, referral, approach, and treatment of the potential organ donor. The pathophysiology of dying triggers systemic changes that are intimately related to organ viability. The intensive care management of the potential organ donor optimizes organ function and improves the donation yield, representing a significant step in reducing the mismatch between organ supply and demand. Different beliefs and cultures reflect diverse legislations and donation practices amongst different countries, creating a challenge to standardized practices. Maintaining public trust is necessary for continued progress in organ donation and transplantation, hence the urge for a joint effort in creating uniform protocols that ensure transparent practices within the medical community.

Effect of sufentanil preconditioning on liver apoptosis induced by brain death in rats

AIM: To investigate the effect of sufentanil against liver apoptosis induced by brain death in rats.

METHODS: Eighteen SD rats were randomly divided into three groups: a sham operation group, a brain death group and a sufentanil group. Activation of cytochrome c (Cyt-c) and Caspase3 was examined by the immunohistochemical staining (IHC) and Western blot. Apoptosis was assessed by terminal deoxynucleotide transferase-mediated dUTP nick-end nick-end labeling assay (TUNEL). Brain death was induced by gradually increasing intracranial pressure (ICP). Sufentanil (10 μg/kg) was injected 1 h before induction of brain death.

RESULTS: Liver tissue samples harvested after brain death showed increased activation of Cyt-c and Caspase3 (P < 0.05). Consistent with this, TUNEL analysis confirmed apoptosis in the liver following brain death. Sufentanil significantly decreases levels of Cyt-c and Caspase3 compared to the brain death group (P < 0.05).

CONCLUSION: Sufentanil preconditioning has a protective effect in reducing liver apoptosis induced by brain death in rats.