Continuously evaluating performance in deceased donation: the Spanish quality assurance program

The Spanish Quality Assurance Program applied to the process of donation after brain death entails an internal stage consisting of a continuous clinical chart review of deaths in critical care units (CCUs) performed by transplant coordinators and periodical external audits to selected centers. This paper describes the methodology and provides the most relevant results of this program, with information analyzed from 206,345 CCU deaths. According to the internal audit, 2.3% of hospital deaths and 12.4% of CCU deaths in Spain yield potential donors (clinical criteria consistent with brain death). Out of the potential donors, 54.6% become actual donors, 26% are lost due to medical unsuitability, 13.3% due to refusals to donation, 3.1% due to maintenance problems and 3% due to other reasons. Although the national pool of potential donors after brain death has progressively decreased from 65.2 per million population (pmp) in 2001 to 49 pmp in 2010, the number of actual donors after brain death has remained at about 30 pmp. External audits reveal that the number of actual donors could be 21.6% higher if all potential donors were identified and preventable losses avoided. We encourage other countries to develop similar comprehensive approaches to deceased donation performance.

Expanded Donor Criteria Due to Age: An Effort Rewarded

The life expectancy of the current Spanish population is 78 years, with some 20% of the population aged over 65 years. The continuing increase in the demand for transplants has led to widening of the criteria for acceptance of donors without worsening the results, but without reducing transplant waiting lists or mortality. This has resulted in the need to include the concept of the expanded criteria donor (ECD). We undertook a retrospective study of 77 donors from a hospital with no neurosurgery service from January 2000 to December 2005. Four of the donors younger than 60 years of age (n = 38) were not appropriate (10.5%), whereas five of the donors older than 60 years of age (n = 39) were not appropriate (12.8%; P = NS). The older donors provided 47 used kidneys (60.2%) and 22 livers (56.4%), slightly fewer than those obtained from the younger donors, though the difference was not significant. Thus, ECDs, those older than 60 years of age, did not result in a significant loss of kidneys or livers available for transplantation. Other factors associated with systemic vascular disease and accompanying disorders could be determinant when predicting the usefulness of organs for transplantation.

Prostate-specific antigen in the assessment of organ donors

Transplantation is limited worldwide by the shortage of organs, thus, donors of older ages are necessary to be used to meet the increasing demand for transplants. To minimize the transmission of cancer from this population, it is mandatory to rule out the presence of neoplasms. We present our experience with analysis of the prostate-specific antigen (PSA) for male donors older than 50 years of age. Eleven (5.9%) had PSA levels >6 ng/mL, 2 had prostate cancer. In 7 donors with high PSA levels postextraction study of the whole prostate gland showed carcinoma in 1 and prostate infarction in 1; the other 5 were reported as normal or having benign prostatic hypertrophy (BPH). Donors with high PSA levels are suitable for transplantation if urgent pathological studies do not find prostate cancer. Nevertheless, in most donors, increased PSA levels are secondary to causes other than malignant tumors, thus, the risk of transmission of prostate cancer with transplants is minimal. In conclusion, measurements of PSA levels alone prior to extraction are not sufficient to diagnose cancer in organ donors. We conclude that this analysis must be restricted to donors with a past history of prostate disease. Meanwhile, better tests to avoid false-positive results are required.

Histochemical and chemical demonstration of reactive aldehyde groups in elastin

To ascertain the presence of free aldehyde radicals in elastic fibers, a histochemical method using the Sawicki reagent (N-methyl-benzothiazolone hydrazone) was employed. Three separate studies were conducted on the elastic tissue of bovine ligamentum nuchae. The elastic fibers were tested (a) in native state, (b) after extraction using an autoclave method and (c) after hot NaOH treatment. Free aldehyde radicals were detected histochemically in native and treated fibers, indicating a close attachment of the carbonyl groups to the fibrous-protein component of the elastic material. Pretreatment of the sections with NaBH4 or with NaHSO3 abolished the staining, indicating that the aldehydes in elastin can be reduced or blocked by the addition of bisulfite compounds. The presence of free carbonyl compounds in elastin was confirmed by chemical data with a new chromatographic technique. Using QAE Sephadex column pretreated with sodium bisulfite, aldehyde-bearing peptide fractions could be isolated from the elastin fibers.