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Evolution of deceased organ donation activity vs. efficiency over a 15 year period: an international comparison

April 2018
Transplantation 102(10):1

April 2018
102(10):1

DOI:10.1097/TP.0000000000002226

Authors:

Beatriz Mahillo

Ministry of Health, Social Servicies and Equality

Beatriz Dominguez-Gil

Organización Nacional de Trasplantes (O.N.T)

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Background: The donation rate (DR) per million population is not ideal for an efficiency comparison of national deceased organ donation programs. The DR does not account for variabilities in the potential for deceased donation which mainly depends on fatalities from causes leading to brain death. In this study, the donation activity was put into relation to the mortality from selected causes. Based on that metric, this study assesses the efficiency of different donation programs. Methods: This is a retrospective analysis of 2001-2015 deceased organ donation and mortality registry data. Included are 27 Council of Europe countries, as well as the USA. A donor conversion index (DCI) was calculated for assessing donation program efficiency over time and in international comparisons. Results: According to the DCI and of the countries included in the study, Spain, France, and the USA had the most efficient donation programs in 2015. Even though mortality from the selected causes decreased in most countries during the study period, differences in international comparisons persist. This indicates that the potential for deceased organ donation and its conversion into actual donation is far from being similar internationally. Conclusions: Compared with the DR, the DCI takes into account the potential for deceased organ donation, and therefore is a more accurate metric of performance. National donation programs could optimize performance by identifying the areas where most potential is lost, and by implementing measures to tackle these issues.

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Transplantation Publish Ahead of Print

DOI: 10.1097/TP.0000000000002226

Evolution of deceased organ donation activity vs. efficiency over a 15 year

period: an international comparison

Julius Weiss, MA1, Andreas Elmer, MSc1, Beatriz Mahíllo, MD2,

Beatriz -Gil, MD, PhD3, Danica Avsec, MD4, Alessandro Nanni Costa, MD5,

Bernadette J.J.M. Haase-Kromwijk, MD6, Karim Laouabdia, MD7, Franz F. Immer, MD1,

on behalf of the Council of Europe European Committee on Organ

Transplantation (CD-P-TO)**

1Swisstransplant, the Swiss National Foundation for organ donation and transplantation, Bern,

Switzerland

2Organización Nacional de Trasplantes. C/Sinesio Delgado 6, pabellón 3, 28029 Madrid,

Spain

3Director General. Organización Nacional de Trasplantes. C/Sinesio Delgado 6, pabellón 3,

28029 Madrid, Spain

4Institute for Transplantation of Organs and Tissues of the Republic of Slovenia, 1000



5 Italian National Transplant Centre, Via Giano della Bella 34, 00161 Roma, Italy

6Dutch Transplantation Foundation, Plesmanlaan 100, 2332 CB Leiden, Netherlands

7, 1, Avenue du Stade de France, 93212 St Denis la Plaine, France

Correspondence to: Franz F. Immer, MD, consultant cardiovascular surgeon FMH,

Swisstransplant, Effingerstrasse 1/ Postfach, CH-3011 Bern, Switzerland. ,

franz.immer@swisstransplant.org

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**Please refer to Appendix 1, SDC, http://links.lww.com/TP/B562 for information about

Council of Europe European Committee on Organ Transplantation (CD-P-TO) membership

Authors’ contributions

JW: acquired and analyzed data, reviewed the literature, wrote the manuscript; AE acquired

and analyzed data, contributed to the writing of the manuscript; BM, provided the donation

data from the Newsletter Transplant database; BDG, DA, ANC, BHK, KL: members of the

     -P-TO working group, participated in the study

design, revised the manuscript critically; FFI conceived the study, advised on its design and

revised the manuscript critically, member of the TO077 CD-P-TO working group.

Conflict of interest

The authors declare no conflicts of interest.

Funding

This study received no external funding.

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Abbreviations

ADD, actual deceased donors

BD, brain death

DBD, donation after brain death

DCD, donation after cardiocirculatory death

DCI, donor conversion index

DR, donation rate

ICD, International Classification of Diseases

MR, mortality rate

pcm, per cent mille population

pmp, per million population

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Abstract

Background: The donation rate (DR) per million population is not ideal for an efficiency

comparison of national deceased organ donation programs. The DR does not account for

variabilities in the potential for deceased donation which mainly depends on fatalities from

causes leading to brain death. In this study, the donation activity was put into relation to the

mortality from selected causes. Based on that metric, this study assesses the efficiency of

different donation programs.

Methods: This is a retrospective analysis of 20012015 deceased organ donation and

mortality registry data. Included are 27 Council of Europe countries, as well as the USA. A

donor conversion index (DCI) was calculated for assessing donation program efficiency over

time and in international comparisons.

Results: According to the DCI and of the countries included in the study, Spain, France, and

the USA had the most efficient donation programs in 2015. Even though mortality from the

selected causes decreased in most countries during the study period, differences in

international comparisons persist. This indicates that the potential for deceased organ

donation and its conversion into actual donation is far from being similar internationally.

Conclusions: Compared with the DR, the DCI takes into account the potential for deceased

organ donation, and therefore is a more accurate metric of performance. National donation

programs could optimize performance by identifying the areas where most potential is lost,

and by implementing measures to tackle these issues.

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Introduction

The organ donation rate (DR), expressed as the number of donors per million population

(pmp), is a convenient and widely used metric of the functioning of donation programs. The

               

available, and it can be utilized for comparing national or regional donation programs in a

standardized way.1,2 This metric, however, has also drawn some criticism of being

methodologically biased.17

It has been argued that the DR rather represents the activity (or volume) of a donation

program than its performance or efficiency.1,4 The DR disregards the potential for deceased

donation which ought to be taken into account when assessing the performance of a donation

program1,2,6,7, since the living population is hardly an adequate measurement parameter of

such potential.6

Many different methodologies have been proposed for a more realistic assessment of the

potential for deceased organ donation, and for a metric of the efficiency of donation

programs.24,725 Broadly summarized, these studies have 2 things in common. First, there is

widespread agreement that a more accurate assessment of the donor potential is needed, and

that it ought to focus on deaths from causes likely leading to brain death (BD). Second, no

consensus has been reached on how to best estimate or determine the potential for deceased

organ donation. Most studies have chosen different approaches for its assessment, due to

methodological and practical considerations (eg, data availability or comparability), or the

lack of generally accepted definitions.1,3,14,19

Despite the methodological issues, these studies have succeeded in drawing the attention to

the fact that there are considerable differences among regions or countries in terms of

mortality rates (MRs) from causes that likely lead to BD, and therefore also in the potential

for deceased organ donation.4,10,13,18,26,27 As fatalities from causes associated with BD

(broadly, cerebrovascular accidents, trauma and anoxia) vary internationally as well as in

countries over time, MRs from these causes most likely also have an impact on the potential.

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Consequently, it has been argued that an assessment of the performance or efficiency of

donation programs should account for such variabilities in the potential.10,11,13,18

In this paper, we present a comparison of donation activity and efficiency of donation

programs internationally, as well as in individual countries over time. For this comparison, we

used deceased organ donation and mortality registry data, from which we calculated a donor

conversion index (DCI) for each country and year. The aim of this retrospective data analysis

including 27 Council of Europe countries and the USA was threefold. First, we wanted to

assess the potential for deceased organ donation based on selected mortality data (which we

used as basis for the DCI). Second, we intended to assess whether there are differences

between DRs pmp and the DCI (activity vs. efficiency). Third, we aimed at providing an

overview of the evolution of the donation efficiency of different countries over time.

Materials and Methods

This is a retrospective analysis of 20012015 deceased organ donation and mortality data.

The analysis includes 27 Council of Europe        

efficiency r  et al.18 as a model which we adapted slightly for the

calculation of the DCI, and the assessment of donation program performance over time and in

international comparisons. Our slightly adapted model indicates how many actual deceased

donors (ADDs) resulted from 100 deaths from the causes associated with potentially

devastating cerebral lesions related to BD.8,11

Data sources and definitions

Donation data



Council of Europe Newsletter Transplant database. All deceased donation figures presented in

this study are ADDs, defined as deceased persons from whom at least 1 organ has been

recovered for the purpose of transplantation.28 DRs pmp presented in this study may vary

slightly from figures published elsewhere as they were calculated from the annual number of

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ADDs reported by each country to the Newsletter Transplant, and from Eurostat and United

States Census Bureau population data for each corresponding year.29,30 If donation after

cardiocirculatory death (DCD) country data in the Newsletter Transplant database was either

blank or zero for all years during the entire study period, a country was categorized as not

having had an active DCD program. In the Newsletter Transplant database, DCD data for

20012002 was not reported separately.

Demographic data

European population data was extracted from the Eurostat database.29 US population data

was extracted from the United States Census Bureau database.30 The data used was the

resident population on 1 January of each year, except for 20012009 US data (1 July).

Mortality data

European mortality data (absolute number of fatalities per year and country; all ages, not age

standardized) was extracted from the Eurostat database.29 Corresponding US mortality data

was extracted from the National Center for Health Statistics database.31

The selection of mortality data relevant for deceased organ donation was based on the

European Directorate for the Quality of Medicines & HealthCare (EDQM) 

         -10 codes of diseases

associated with potentially devastating cerebral lesions related to brain death).8 For the

purpose of the DCI calculation, the following ICD-10 codes32 were used:

I69 (cerebrovascular diseases). Covers cerebrovascular accidents (I60I66).

 H95 (other diseases of the nervous system and the sense organs), excluding G20

(Parkinson disease) and G30 (Alzheimer disease). Covers all cerebral damages (anoxic brain

damage, compression of brain, cerebral edema, and infections of the central nervous system

(meningitis)).

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 V99, Y85 (transport accidents) was used as a substitute for trauma since the

corresponding ICD-10 codes (S02, S06) were not available.

Cerebral neoplasms were excluded due to a relatively high number of fatalities out of which

only a small percentage are relevant for deceased organ donation. Moreover, data on the

relevant causes (C71, D33) was only available as part of larger packages of aggregated data

including various other fatalities.

Handling of missing data

Missing mortality data was imputed using the TREND function in Microsoft Excel 2013

(method of least squares). If no preceding data was available (first year of the study period),

the 3 subsequent values were used. If there was a data gap, the 3 preceding and the 3

subsequent values were included and the mean of the 2 predicted values was taken.

Calculation of donor conversion index

The DCI expresses the absolute number of ADDs per country and year as a percentage of the

absolute number of fatalities belonging to the selected ICD-10 codes per country and year.

The DCI indicates how many ADDs resulted from 100 deaths from the causes associated with

potentially devastating cerebral lesions related to BD.8 For example, a 3% DCI equals 3

ADDs that resulted from 100 fatalities from the selected causes.

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Results

Table 1 shows 20012015 data (DCI, DR, and MR from the selected causes) for the 28

countries included in the study. Figure 1 illustrates the differences when comparing the 2015

country rankings by DRs and DCI. An overview on the evolution and significance of

individual national DCD programs is presented in Table 2. Figure 2 shows the development of

donation efficiency according to the DCI over time by country.

Donor conversion index

The DCI indicated that there were differences in donation efficiency between the countries as

well as in individual countries during the 15 years analyzed (Table 1, Figure 2).

In 2015, the DCI was highest by far in Spain (5.0%), followed by France and the USA (3.9%

both), Belgium (3.7%), Ireland (3.1%), and Austria (3.0%). According to the DCI, these

programs were the most efficient of all countries included in the study. Figure 2 shows that

there were considerable differences in efficiency not only between the countries, but also in

individual countries over time. The countries with the highest DCI increase (2001 vs. 2015)

were Spain (+2.1 percentage points), France (+1.9 percentage points), and Belgium (+1.8

percentage points).

Mortality rates

The MR per 100,000 population from the causes associated with BD decreased in most

countries during the study period, however to different degrees (Table 1). Estonia and

Portugal were among the countries that showed the most considerable reduction in MRs over

time. Notable exceptions were Bulgaria, Lithuania, and Slovakia where MRs increased when

comparing 2001 with 2015 data.

Donation rates

DRs showed sizeable differences in international comparisons. The DR increased in a

majority of countries during the evaluation period, however to different degrees (Table 1).

DRs increased substantially during the evaluation period in Croatia, Portugal, and Slovenia.

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Countries with the highest DRs at the end of the study period included Croatia, Spain,

Belgium, Portugal, the USA, and France.

Donation activity vs. efficiency

Figure 1 shows the differences when comparing the 2015 country rankings by DR and DCI.

Countries are ordered based on the difference when ranked according to DR versus DCI. The

figure illustrates that the DR can fail to represent performance, particularly for countries in

which the mortality relevant for organ donation is low or high. Countries on the left side of

the chart (positive rank difference) were ranked higher by DCI than by DR. For example,

Ireland was on position 5 (5th highest) of the countries ranked by DCI, but only on position 16

ranked by DR. This comparison shows that in countries with a large positive or negative

ranking difference, there is a disparity between the donation activity and the efficiency.

Countries with a high DR pmp but only an intermediate DCI in 2015 included Croatia (40.0

pmp DR, 2.0% DCI) and Portugal (30.7 pmp DR, 2.3% DCI). In these 2 countries, only a

moderate proportion of the supposed potential for deceased organ donation was actually

converted into actual donation, regardless of the fact that the DRs were among the highest in

international comparisons. In contrast, there were national donation programs with an

intermediate DR but a relatively high DCI. In 2015, these included Austria (23.2 pmp DR,

3.0% DCI), Ireland (17.5 pmp DR, 3.1% DCI), and Switzerland (17.4 pmp DR, 2.7% DCI). In

these countries, the potential was transformed quite efficiently, even though they did not

belong to the nations with the highest DRs.

Donation after cardiocirculatory death

Table 2 shows that 17 out of 28 countries reported DCD donors during the evaluation period.

It shows the absolute number of DCD donors per year as well as a percentage of the total

number of ADDs. Countries with the most active DCD programs at the end of the study

period were the Netherlands, the United Kingdom, Latvia, Belgium, Spain, the USA, and

Switzerland.

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The Netherlands, Latvia, and Belgium showed virtually no or little increase in the conversion

of donation after brain death (DBD) over the study per

increase was mainly due to the considerable growth of DCD. In the USA, the introduction of

DCD in 2011 led to a subsequent decrease of the DBD portion of the DCI.

Discussion

The data presented in our study suggest that there are considerable differences in the potential

and the efficiency of donation programs among countries as well as over time in individual

countries. While it is widely publicized that DRs vary substantially between countries, the

differences in MRs from causes relevant to the potential for deceased organ donation usually

draw much less attention. However, our figures show that large differences in MRs exist

between the countries, even though most succeeded in reducing fatalities relevant to the

potential for deceased organ donation during the 15 years analyzed.

When comparing DRs and DCI data (ie, donation activity vs. efficiency) in 2015, there were

also notable differences among the national donation programs. In our study we found that

Spain has been and continues to be at the forefront of countries with both the most active and

efficient deceased organ donation programs. France, the USA, Belgium, Ireland and Austria

also have efficient donation programs according to the DCI. We also found that, with a few

exceptions, most countries succeeded in increasing the donation efficiency over time, even

though to different degrees.

Donor conversion index

The DCI puts the number of ADDs (donation activity or volume) in relation to the

approximated potential for deceased organ donation (number of fatalities from causes

associated with BD).8 As such,            

performance. The efficiency can increase if there is a reduction of MR (while keeping the

donation activity stable), or an increase of the donation volume (if the mortality is stable), or a

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combination of both. Most countries in our study succeeded in increasing the donation

efficiency, however by different means and measures.10,20,3341

Factors with a possible influence on the DCI

Clearly, there are many crucial steps in the donation process between the potential for

deceased organ donation and the final result, ie, ADDs. These steps include (but are not

limited to) the detection and referral of possible donors, organizational structures, and

obtaining consent to donation.11,15,17,38,39,4245 Therefore, many factors may influence the

donation efficiency. For example, a lack of (in- or out-of-hospital) infrastructure,

neurosurgical facilities, or a lack of financial or human resources, and the absence of training

or accountability.

Since the efficiency depends on the potential for deceased organ donation, success of

measures that enhance public health and road traffic safety, as well as progress in the

treatment of traumatic brain injury and cerebrovascular accidents may influence the DCI. The

data presented in our study suggests, however, that there is no direct connection between the

reduction of fatalities and the donation efficiency which is in line with findings in previous

studies.13,18

There are various factors that may influence the donation activity as well as the efficiency.

For example, the introduction of a DCD program, or an increased acceptance of extended

criteria and/or older donors.33,34,39,46,47 Recent studies show that in 2015, 10% of donors in

Spain were aged 80 and over, and that in Spain as well as in France a considerable proportion

of deceased donors .33,47

Another major reason for differences in DCI among donation programs are variations in

consent rates. However, there is no generally accepted formula for the calculation of the

consent rates, and only 14 of 28 countries included in this study are reporting consent rates to

the Newsletter Transplant.19,28 This makes an international comparison virtually impossible,

despite the fact that in countries with a low consent rate the negative impact on the DCI may

be very strong.4850

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Mortality rates

The differences in MRs among the countries show that the potential for deceased organ

donation is far from being the same everywhere. This points to the importance of taking into

account the potential when assessing the performance of donation programs, as emphasized

by previous studies.24,725

The reduction of deaths from the selected causes in most countries can likely be explained by

measures that enhance public health, and better prevention of transportation fatalities.18,27,5153

Such measures likely result in a reduction of the maximum potential for deceased organ

donation.1,12,13,27,51,52,54 Without going into detail, we found no apparent relation between a

reduction of the MRs and the performance of donation programs. In a broad way, this is in

line with previous findings, even if results are not directly comparable due to methodological

incongruence. However, high MRs may be an indicator for a not so well developed public

health service (likely due to a lack of resources) and therefore, organ donation and

transplantation might not be on top of the priority list.

Donation rates vs. donor conversion index

It is widely known that there are sizeable differences in DRs pmp between countries.28,37 In

our comparison of donation activity vs. efficiency, we found that some countries have a high

DR as well as a high DCI (eg, Spain, France, the USA, and Belgium). Generally speaking,

however, there was no direct relation between the DR and the DCI, since the latter takes into

account variabilities in mortality. As shown in the comparison of the 2015 DR vs. DCI

ranking, countries with a large number of donors (high activity) but also a large number of

fatalities from the selected causes (high potential) show the largest discrepancy between

activity and efficiency. A multitude of factors may have an impact on the donation activity as

well as efficiency. The primary scope of the DCI is to provide a benchmark for comparing the

efficiency of different programs. Differences in efficiency may be explained by various

reasons. These may include, among others, variances in access to healthcare in general, access

to intensive care and place of death, consent rates and modality, or organizational aspects of

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the organ donation and transplant programs. Further studies are required for an analysis of the

impact of such factors on the donation efficiency,

Donation after cardiocirculatory death

There is some controversy in the literature whether (or how) the promotion of DCD programs

is influencing the DBD activity.5559 The data presented in our study shows that in some

countries, the increase in the DCI resulted from an increase of both, DBD and DCD. In other

countries, the DBD efficiency remained mostly stable over time and the increase in DCI

resulted basically from DCD. Remarkably, the USA showed an unparalleled drop in DBD

performance after the introduction of DCD in 2011.

Because DCD may also result from deaths that are not included in the selected causes likely

leading to BD, the DCI for DCD must be interpreted with caution. Especially, this applies to

countries with a substantial proportion of DCD. In these donation programs, the total (DBD

and DCD) value of the DCI is likely overestimated. This is due to the fact that the DCI is

calculated based on mortality associated with BD. However, DCD may also result from

fatalities that are not covered by these selected causes of death.

Also, one should keep in mind that DCD is a resource-intensive process, and that the organ

yield per donor is lower than in DBD.34,5557,60 Therefore, the DCD potential should be

supplementary to the DBD potential.

Study strengths and limitations

The DCI used in this paper for an assessment of the donation efficiency has its strengths and

limitations. Compared with DRs, the main advantage of the DCI is that it takes into account

the potential for deceased organ donation (actual mortality from the selected causes).

Therefore, the DCI may be considered more suitable for a performance comparison of

donation programs. Yet, the DCI is not meant to replace the DR pmp but rather as a

complementary indicator of the efficiency of a program. We believe that the DCI can provide

important insight concerning the conversion of the potential into donors that may help donor

programs to improve the donation performance.

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(eg,

due to migration, and varying birth or overall MRs) which has no direct impact on neither the

donation activity nor efficiency.1,6          

increase of the DCI by 1 percentage point means that there was 1 more donor out of one

hundred deaths from the relevant causes.

Compared with alternative methods used in other studies to estimate or determine the

potential for deceased organ donation, the DCI has also some distinctions. In addition to

cerebrovascular disease and traffic accident mortality (used in some studies as a proxy), the

DCI also covers cerebral damages of other causes. Also, in contrast with studies that

determined the potential for donation by medical chart review, the DCI can be calculated from

standardized database information (IDC codes) readily available for many countries

worldwide.

Major limitations of the DCI include (i    

 mortality data used for

the DCI calculation allows only for an estimation of the potential for deceased organ

donation. In the online Eurostat database, some of the relevant ICD codes were only available

as part of larger groups (data packages) which may have resulted in an overestimation of the

potential. Conversely, there may be an additional potential from trauma related deaths not

included in the traffic accident mortality data such as work or leisure activity related

accidents. In addition, we occasionally had to extrapolate missing mortality data, since some

figures were unavailable).29 We consider it a minor limitation that the DCI does not account

for absolute or relative contraindications. Since the DCI is calculated based on national cause

of death registry data, it shares the general limitation concerning data reliability of all studies

using registry information.

We are aware that the selected causes of death and the corresponding mortality allows only

for an estimation of the potential for deceased organ donation. We do believe, however, that

the DCI which is based on the original idea by Coppen et al.18 is useful for a performance

ACCEPTED

comparison of deceased organ donation programs over time as well as internationally. In

addition, the DCI can be used as an indicator for the assessment of the efficacy of measures

implemented to increase organ availability. For this purpose, it is more suitable than the DR

pmp because the DCI accounts for the evolution of the potential over time.

Conclusions

The DCI indicates that, despite a reduction of the potential, it is possible to considerably

improve the efficiency of national donation programs through targeted measures. Compared

with the DR pmp (which should be considered a metric for the activity, not the performance),

the DCI takes into account the potential for deceased organ donation, and therefore is a more

          

optimize the performance by identifying the areas where most potential is lost, and by

implementing measures to tackle these issues.

ACCEPTED

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Figure legends

Figure 1: Difference in country ranking 2015; donor conversion index (DCI) vs. donation

rate (DR).

Figure 2: Donor conversion index (DCI) development by country, 20012015.

Blue bars, donation after brain death (DBD); purple bars, donation after cardiocirculatory

death (DCD); grey bars, no distinction between DBD and DCD in Newsletter Transplant

database (no bars: missing donor data or no donors reported)

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Figure 1

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Figure 2

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Tables

Table 1: Donor conversion index (DCI), deceased donation rate (DR), mortality rate (MR) per country

and year

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Austria*

DCI

2.0%

2.1%

2.5%

2.9%

2.7%

2.5%

3.2%

3.0%

3.3%

3.0%

3.2%

3.3%

3.0%

DR (pmp)

23.8

24.2

23.1

22.4

24.5

24.6

21.7

20.3

25.6

23.5

23.8

23.1

24.0

24.5

23.2

MR (pcm)

119

123

112

Belgium*

DCI

1.9%

2.0%

2.1%

2.4%

2.8%

3.0%

2.7%

2.9%

2.3%

3.5%

3.3%

3.2%

3.7%

DR (pmp)

21.6

22.9

21.8

23.7

26.8

28.2

25.7

26.5

20.4

30.1

29.4

29.0

26.7

31.8

MR (pcm)

115

111

107

102

Bulgaria

DCI

0.0%

0.1%

0.0%

0.1%

0.0%

0.1%

0.0%

0.1%

0.2%

DR (pmp)

0.2

1.0

1.5

0.9

0.8

2.5

1.2

1.1

1.5

2.7

0.5

0.3

2.9

5.2

6.2

MR (pcm)

281

300

293

288

309

322

326

320

303

313

291

312

296

328

317

Croatia

DCI

0.3%

0.4%

0.7%

0.5%

0.6%

0.9%

1.6%

1.7%

1.9%

1.8%

1.9%

2.0%

DR (pmp)

7.4

9.5

9.1

13.7

10.2

13.2

13.4

19.2

18.1

31.4

34.5

35.8

33.8

35.6

40.0

MR (pcm)

217

215

218

207

211

209

216

211

206

196

197

193

190

199

Czech Republic*

DCI

0.9%

n.a.

1.0%

1.3%

1.2%

1.6%

1.5%

1.4%

1.6%

1.5%

1.7%

1.8%

2.3%

2.1%

DR (pmp)

16.8

n.a.

18.7

20.7

20.3

18.9

21.2

19.1

19.2

19.7

17.6

20.6

20.7

24.8

23.3

MR (pcm)

188

187

190

165

156

132

130

133

125

121

120

116

108

111

Denmark

DCI

1.1%

1.2%

1.1%

1.4%

1.3%

1.6%

1.7%

1.8%

1.4%

1.9%

2.0%

DR (pmp)

13.1

13.6

13.9

11.9

11.6

11.4

13.2

11.9

14.0

13.2

13.1

13.6

10.4

14.2

15.4

MR (pcm)

115

121

118

112

105

102

Estonia

DCI

0.4%

0.9%

0.4%

0.0%

1.3%

0.3%

1.1%

1.6%

2.0%

1.4%

1.5%

2.5%

2.1%

1.9%

DR (pmp)

10.1

21.0

10.2

0.0

25.8

6.7

18.6

23.2

24.7

17.3

16.5

24.1

24.2

17.5

16.0

MR (pcm)

232

235

227

203

201

198

168

141

125

119

113

Finland

DCI

1.5%

0.9%

1.9%

1.5%

1.9%

1.6%

1.5%

1.7%

1.9%

1.7%

2.1%

2.3%

DR (pmp)

17.0

17.1

10.2

20.9

16.2

20.7

17.2

15.3

17.6

17.2

17.3

20.0

17.7

22.2

23.2

MR (pcm)

117

116

110

109

106

103

104

101

102

106

104

105

103

France*

DCI

1.9%

2.2%

2.1%

2.7%

2.8%

3.0%

3.4%

3.3%

3.5%

3.6%

3.9%

DR (pmp)

17.5

19.5

18.1

20.7

21.8

22.8

25.2

24.0

23.8

25.1

25.2

25.5

24.8

27.2

MR (pcm)

Germany

DCI

1.2%

1.1%

1.3%

1.5%

1.6%

1.7%

1.6%

1.7%

1.6%

1.4%

1.2%

DR (pmp)

13.0

12.1

13.7

13.0

14.8

15.3

16.0

14.6

14.8

15.8

15.0

13.0

10.9

10.4

10.8

MR (pcm)

112

110

108

Greece

DCI

0.1%

0.3%

0.5%

0.4%

0.3%

0.5%

0.4%

0.3%

0.5%

0.4%

0.3%

0.2%

DR (pmp)

3.0

6.0

6.5

6.0

8.1

7.2

5.8

8.9

6.4

4.0

7.1

6.9

5.6

4.6

3.6

MR (pcm)

197

195

192

185

180

178

170

167

161

154

162

154

151

156

Hungary

DCI

0.6%

0.8%

0.7%

0.8%

1.0%

0.9%

0.8%

1.0%

0.9%

1.1%

1.4%

1.6%

DR (pmp)

13.4

16.4

15.9

15.8

17.9

17.6

15.0

14.7

14.0

15.9

13.1

14.4

15.6

20.6

23.9

MR (pcm)

213

214

203

182

172

173

165

161

154

152

148

144

147

Ireland*

DCI

2.1%

2.5%

2.7%

3.1%

2.6%

3.6%

3.2%

2.9%

3.4%

2.2%

3.6%

3.0%

3.3%

2.5%

3.1%

DR (pmp)

17.7

20.5

20.2

21.3

17.3

21.6

20.3

18.2

19.9

12.7

20.3

17.0

18.7

13.7

17.5

MR (pcm)

Italy*

DCI

1.2%

1.3%

1.2%

1.4%

1.5%

1.6%

1.7%

1.8%

1.9%

2.0%

1.8%

DR (pmp)

17.3

17.9

18.2

20.9

20.7

21.3

20.5

21.6

21.9

22.3

22.5

22.2

22.8

22.5

MR (pcm)

141

148

150

135

130

132

130

125

124

126

119

115

124

Latvia*

DCI

0.5%

0.7%

0.5%

0.6%

0.7%

0.5%

0.7%

0.8%

0.7%

0.6%

0.5%

0.7%

DR (pmp)

17.4

24.1

17.0

18.0

20.4

19.3

19.5

13.7

15.7

16.0

19.3

18.6

16.8

14.5

18.6

MR (pcm)

325

326

322

300

305

289

272

254

236

242

231

256

263

267

283

Lithuania

DCI

0.0%

0.6%

0.0%

0.1%

0.5%

0.7%

0.5%

0.8%

0.6%

0.7%

0.8%

0.5%

0.9%

DR (pmp)

0.0

11.3

0.0

2.1

1.5

10.2

14.9

10.4

15.9

11.8

13.0

13.8

17.0

10.6

19.7

MR (pcm)

176

185

184

188

197

220

215

209

213

211

212

221

209

217

Luxembourg

DCI

1.6%

0.2%

0.6%

0.0%

0.3%

2.4%

0.0%

0.7%

2.3%

1.1%

2.2%

1.2%

0.9%

DR (pmp)

18.2

2.3

6.7

0.0

2.1

18.6

0.0

6.0

17.6

7.6

14.9

7.3

5.3

MR (pcm)

110

114

106

Netherlands*

DCI

1.3%

1.4%

1.7%

1.9%

1.7%

2.3%

1.8%

2.0%

2.1%

2.3%

2.2%

2.3%

2.2%

DR (pmp)

11.7

12.5

14.8

15.2

14.7

12.9

16.9

12.8

13.8

13.7

13.6

15.3

15.9

16.8

MR (pcm)

Poland

DCI

0.9%

1.0%

1.1%

1.2%

1.1%

0.8%

0.9%

1.0%

1.2%

1.3%

1.5%

1.6%

1.4%

DR (pmp)

11.8

12.8

13.7

14.7

14.6

13.0

9.2

11.2

11.0

13.4

14.5

16.2

15.6

13.8

MR (pcm)

133

131

128

127

124

122

120

115

112

113

109

104

Portugal

DCI

0.8%

1.0%

0.9%

1.2%

1.0%

1.2%

1.5%

1.7%

2.0%

1.6%

2.1%

2.3%

DR (pmp)

19.6

20.9

18.2

21.2

18.1

19.1

23.9

26.8

31.1

30.5

28.5

23.9

28.1

27.7

30.7

MR (pcm)

234

216

209

184

176

155

160

155

153

154

143

145

135

132

133

Romania*

DCI

0.0%

0.1%

0.2%

0.1%

0.3%

0.2%

DR (pmp)

0.9

0.6

0.4

0.5

1.0

1.7

2.9

2.1

3.4

3.8

3.2

6.6

6.9

5.7

MR (pcm)

258

275

277

273

283

278

264

259

261

262

253

246

241

240

Slovakia

DCI

1.0%

0.6%

0.7%

0.9%

1.2%

1.6%

1.0%

1.2%

1.3%

1.1%

1.0%

1.5%

DR (pmp)

10.6

6.9

8.6

10.2

11.9

19.9

14.3

16.0

16.9

12.8

13.1

11.1

11.8

17.3

MR (pcm)

111

115

111

103

101

121

138

129

126

118

120

109

113

119

Slovenia

DCI

1.0%

1.4%

1.1%

1.5%

1.0%

1.5%

1.1%

1.6%

1.3%

1.8%

1.4%

2.1%

1.9%

2.3%

DR (pmp)

11.6

17.6

14.0

18.0

10.5

15.0

11.4

18.4

16.7

20.0

15.1

22.9

23.3

21.3

26.2

MR (pcm)

121

124

122

118

106

107

117

125

113

108

111

109

110

113

Spain*

DCI

2.9%

3.1%

3.0%

3.4%

3.5%

3.6%

3.7%

4.0%

4.2%

4.0%

4.6%

4.4%

4.7%

4.8%

5.0%

DR (pmp)

32.8

34.3

34.5

35.1

35.7

34.3

34.6

34.5

34.7

32.3

35.7

35.1

35.4

36.2

39.8

MR (pcm)

114

111

113

102

101

Sweden

DCI

0.9%

1.0%

1.2%

1.3%

1.4%

1.5%

1.4%

1.3%

1.6%

1.8%

2.1%

2.2%

DR (pmp)

12.2

11.0

12.8

13.7

14.2

15.1

14.6

16.6

13.8

12.6

15.5

15.1

15.9

17.2

17.3

ACCEPTED

MR (pcm)

129

128

123

118

109

107

103

108

102

Switzerland*

DCI

1.6%

1.3%

1.6%

1.7%

1.5%

1.6%

2.0%

1.9%

1.8%

2.1%

2.3%

2.7%

DR (pmp)

13.2

10.3

13.0

12.4

10.7

10.8

11.9

13.4

12.6

12.7

12.1

13.7

14.4

17.4

MR (pcm)

United Kingdom*

DCI

1.0%

0.9%

1.1%

1.2%

1.4%

1.6%

1.7%

2.0%

2.2%

2.6%

2.5%

DR (pmp)

13.2

12.9

11.9

13.6

12.5

12.9

13.0

14.4

15.0

16.2

16.8

18.3

20.7

20.3

20.2

MR (pcm)

131

132

129

118

113

109

105

104

United States*

DCI

2.6%

2.8%

3.2%

3.4%

3.7%

3.8%

4.0%

3.9%

4.0%

3.9%

4.0%

3.9%

DR (pmp)

21.3

21.5

22.3

24.4

25.7

26.9

26.3

26.1

25.7

26.2

26.0

26.2

27.1

28.4

MR (pcm)

* Country with an active donation after cardiocirculatory death program

Abbreviations: DCI, donor conversion index; DR (pmp), deceased donation rate per million population; MR (pcm), selected mortality rate per 100,000 of population; n.a.,

not available

((TABLE 1, CONTINUED FROM PREVIOUS PAGE))

ACCEPTED

Table 2: Countries with an active donation after cardiocirculatory death (DCD) program; actual

deceased donors (ADD) and proportion of DCD

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Austria

ADD (n)

189

185

203

207

185

172

214

196

205

198

208

212

205

DCD (n)

DCD (% of

ADD)

1.1%

1.6%

1.0%

1.9%

2.7%

1.7%

0.5%

0.0%

2.9%

2.0%

2.4%

1.9%

2.9%

Belgium

ADD (n)

237

227

248

282

298

274

285

221

331

326

324

299

357

DCD (n)

117

DCD (% of

ADD)

5.9%

2.2%

4.0%

11.7

13.1

15.3

21.4

22.6

19.3

21.8

24.1

27.8

32.8%

Croatia

ADD (n)

135

148

153

144

151

169

DCD (n)

DCD (% of

ADD)

0.0%

2.3%

0.0%

Czech

Republic

ADD (n)

191

211

207

193

217

198

200

206

185

216

218

261

246

DCD (n)

DCD (% of

ADD)

1.0%

0.9%

1.4%

1.0%

0.9%

0.5%

0.0%

1.0%

0.5%

0.9%

0.5%

1.5%

3.3%

Finland

ADD (n)

109

108

121

127

DCD (n)

DCD (% of

ADD)

0.0%

4.6%

0.0%

France

ADD (n)

1119

1291

1371

1443

1601

1610

1543

1538

1630

1642

1673

1635

1809

DCD (n)

DCD (% of

ADD)

0.0%

0.1%

5.9%

2.9%

4.0%

3.6%

3.2%

2.4%

3.0%

Greece

ADD (n)

DCD (n)

DCD (% of

ADD)

0.0%

4.5%

0.0%

Ireland

ADD (n)

DCD (n)

DCD (% of

ADD)

0.0%

1.1%

3.8%

7.0%

6.3%

4.9%

Italy

ADD (n)

1042

1203

1197

1234

1194

1201

1273

1298

1325

1337

1323

1384

1369

DCD (n)

DCD (% of

ADD)

0.0%

0.2%

0.5%

0.4%

0.2%

0.1%

0.6%

Latvia

ADD (n)

DCD (n)

DCD (% of

ADD)

0.0%

36.6

21.7

0.0%

27.9

36.7

38.2

32.4

32.5

39.5

38.2

31.0

29.7%

Netherlands

ADD (n)

239

247

239

211

277

210

227

256

267

282

284

DCD (n)

111

120

100

114

117

128

160

132

156

DCD (% of

ADD)

41.0

44.9

50.2

47.4

41.2

43.3

42.3

37.0

51.5

50.0

59.9

46.8

54.9%

Poland

ADD (n)

525

562

556

496

352

427

420

509

553

615

593

594

526

DCD (n)

DCD (% of

ADD)

0.0%

2.0%

0.0%

0.6%

Romania

ADD (n)

132

138

113

DCD (n)

DCD (% of

ADD)

0.0%

1.7%

0.0%

3.9%

1.5%

0.0%

Spain

ADD (n)

1443

1495

1546

1509

1550

1577

1606

1502

1667

1643

1655

1682

1851

DCD (n)

107

130

117

161

159

193

314

DCD (% of

ADD)

3.9%

4.7%

4.6%

5.0%

5.7%

4.9%

6.7%

8.7%

7.0%

9.8%

9.6%

11.5

17.0%

Switzerland

ADD (n)

103

100

110

117

143

DCD (n)

DCD (% of

ADD)

6.3%

6.6%

2.2%

0.0%

3.0%

7.3%

10.9

15.4

11.2%

United

Kingdom

ADD (n)

710

813

753

779

793

885

931

1015

1056

1164

1323

1309

1311

DCD (n)

121

146

186

264

318

373

405

504

544

505

548

DCD (% of

ADD)

9.3%

10.7

16.1

18.7

23.5

29.8

34.2

36.7

38.4

43.3

41.1

38.6

41.8%

United States

ADD (n)

6455

7150

7593

8024

8089

7984

8021

7943

8126

8143

8268

8596

9079

DCD (n)

1055

1106

1205

1291

1494

DCD (% of

ADD)

0.0%

13.0

13.6

14.6

15.0

16.5%

Abbreviations: ADD, actual deceased donors; DCD, donation after cardiocirculatory death

ACCEPTED

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Full-text available

Feb 2024

Objectives This study aims to investigate factors with a significant influence on deceased organ donation rates in Organisation for Economic Co-operation and Development (OECD) countries and determine their relative importance. It seeks to provide the necessary data to facilitate the development of more efficient strategies for improving deceased organ donation rates. Design Retrospective study. Setting Publicly available secondary annual data. Participants The study includes 36 OECD countries as panel members for data analysis. Outcome measures Multivariable panel data regression analysis was employed, encompassing data from 2010 to 2018 for all investigated variables in the included countries. Results The following variables had a significant influence on deceased organ donation rates: ‘opt-in’ system (β=−4.734, p<0.001, ref: ‘opt-out’ system), only donation after brain death (DBD) donors allowed (β=−4.049, p=0.002, ref: both DBD and donation after circulatory death (DCD) donors allowed), number of hospital beds per million population (pmp) (β=0.002, p<0.001), total healthcare employment pmp (β=−0.00012, p=0.012), World Giving Index (β=0.124, p=0.008), total tax revenue as a percentage of gross domestic product (β=0.312, p=0.009) and percentage of population aged ≥65 years (β=0.801, p<0.001) as well as high education population in percentage (β=0.118, p=0.017). Conclusions Compared with the promotion of socioeconomic factors with a positive significant impact on deceased organ donation rates, the following policies have been shown to significantly increase rates of deceased organ donation, which could be further actively promoted: the adoption of an ‘opt-out’ system with presumed consent for deceased organ donation and the legal authorisation of both DBD and DCD for transplantation.

“A Delicate balance”—Perceptions and Experiences of ICU Physicians and Nurses Regarding Controlled Donation After Circulatory Death. A Qualitative Study

Article

Full-text available

Sep 2022
TRANSPL INT

Controlled donation after circulatory death (cDCD) is considered by many as a potential response to the scarcity of donor organs. However, healthcare professionals may feel uncomfortable as end-of-life care and organ donation overlap in cDCD, creating a potential barrier to its development. The aim of this qualitative study was to gain insight on the perceptions and experiences of intensive care units (ICU) physicians and nurses regarding cDCD. We used thematic analysis of in-depth semi-structured interviews and 6-month field observation in a large teaching hospital. 17 staff members (8 physicians and 9 nurses) participated in the study. Analysis showed a gap between ethical principles and routine clinical practice, with a delicate balance between end-of-life care and organ donation. This tension arises at three critical moments: during the decision-making process leading to the withdrawal of life-sustaining treatments (LST), during the period between the decision to withdraw LST and its actual implementation, and during the dying and death process. Our findings shed light on the strategies developed by healthcare professionals to solve these ethical tensions and to cope with the emotional ambiguities. cDCD implementation in routine practice requires a shared understanding of the tradeoff between end-of-life care and organ donation within ICU.

Exploring the Potential of an Eye Tissue Donor Reporting App in Enhancing the Procurement of Corneal Donors: Mixed Methods Observational Study

Article

Full-text available

May 2024

Background The availability of donated eye tissue saves and enhances vision in transplant recipients; however, the current demand for tissue surpasses the available supply. Corneal donor shortages lead to increased wait times, delayed surgeries, prolonged visual impairment, and increased inconvenience to patients requiring eye tissue transplantation. A web-based application was previously developed to facilitate easy and intuitive submission of potential donor information. Objective The primary objectives of this study were to assess health care professionals’ attitudes toward the potential application and evaluate its effectiveness based on user feedback and donor registrations through the application. Methods Researchers used a mixed methods approach, commencing with a literature review to identify challenges associated with donor procurement. Stakeholder interviews were conducted to gauge health care professionals’ perspectives regarding the application. User feedback was collected through questionnaires, surveys, and interviews to assess the application’s usability and impact. An assessment of the reported potential donors and questionnaire responses were analyzed. Results The final version of the application successfully reported 24 real cornea donors. Among 64 health care providers who used the application to communicate about potential donors, 32 of them submitted trial entries exclusively for testing purposes. The remaining 8 health care professionals reported potential donors; however, these individuals did not meet the donor qualification criteria. The majority of participants found the application user-friendly and expressed their readiness to use it in the future. Positive ratings were assigned to the layout, appearance, purpose, and specific features of the application. Respondents highlighted the automatic sending of notifications via SMS text messages and the integration of all necessary documents for donor qualification and tissue collection as the most valuable functions of the application. Conclusions The study indicates that donor reporting applications offer promising solutions to enhance tissue donor procurement. This application streamlined the reporting process, reduced paperwork, facilitated communication, and collected valuable data for analysis.

Living-donor lobar lung transplantation for pulmonary hypertension: living on the edge?

Article

Mar 2023
EUR J CARDIO-THORAC

‘Living on the Edge’ is the first studio album by Stéphane Pompougnac, a French psychotherapist and dental surgeon [1]. The expression is used to indicate someone is taking a risk above and beyond what most people would do, to have a lifestyle in which one tends to engage in dangerous or risky behaviour. The majority of lung transplantation (LTx) worldwide is performed with lungs from deceased donors declared death on neurologic or circulatory criteria [2]. A very small proportion of patients though receive a lobe from a living donor, mainly in countries with a very low deceased donor conversion rate such as Japan [3]. The largest experience with living-donor lobar LTx has been reported by the groups at Okayama University and Kyoto University with remarkable results. Compared to other diagnoses, patients with end-stage lung disease related to pulmonary arterial hypertension (PAH) form a difficult population with the highest post-transplant mortality [4]. It is believed that PAH patients need perfect lungs to accommodate the enhanced pulmonary blood flow resulting from an acute change in cardiopulmonary physiology with a decrease in right ventricular afterload and an increase in left ventricular preload during the first post-transplant days. Donor to recipient size matching based on donor height or total lung capacity is a parameter of special importance when choosing the best donor for PAH patients as their postoperative risk is reduced when transplanted with an oversized lung with a large pulmonary vascular bed [5].

Expanding heart transplantation in 2022 and beyond

Article

Jan 2023

Purpose of review: Despite advances in the technology of mechanical circulatory support, the need for heart transplantation continues to grow. The longevity of heart transplants continues to be superior to mechanical solutions, though the short-term differences are shrinking. In this review, we cover three timely developments and summarize the recent literature. Recent findings: After stagnant rates of heart transplant activity for some years, recently, transplant volume has increased. The developments that have ignited interest have been the use of hepatitis C infected donors, which can now be safely transplanted with the advent of curative oral regimens, and the worldwide use of donors following withdrawal of life support as opposed to traditional brain death donors. In addition, the recent experience of human cardiac xenotransplantation has been very exciting, and though it is not of clinical utility yet, it holds the promise for a virtually unlimited supply of organs at some time in the future. Summary: Much work remains to be done, but together, all three of these developments are exciting and important to be aware of in the future. Each will contribute to additional donors for human heart transplantation and hopefully will alleviate suffering and death on the waiting list.

Extended-criteria donors in lung transplantation in Switzerland: an evaluation of two adapted lung donor scores

Article

Full-text available

Apr 2018
SWISS MED WKLY

AIM Various scoring systems aim to assess the quality of organs donated for transplantation on the basis of patient characteristics, clinical examination and laboratory results. How well such scoring systems reflect the practice in lung transplantation in Switzerland has never been studied. Therefore, we evaluated two scoring systems for their ability to predict whether or not donor lungs are accepted by the two Swiss lung transplant centres. METHODS We retrospectively analysed patient data of adult deceased organ donors in Switzerland between 1 July 2007 and 30 June 2014. Included were all donors from whom at least one organ was transplanted. We evaluated two lung donor quality scores, the multicentre-developed Eurotransplant donor score (EDS), and the single-centre-developed Zurich donor score (ZDS). Both scores were slightly adapted to be applicable to Swiss deceased organ donor data. We evaluated whether these scores can predict whether lungs were transplanted or refused by Swiss transplant centres, using univariate logistic regression. We further assessed their discriminative power by calculating the area under the receiver operating characteristic curve (AUC). RESULTS Of the 635 donors included in our analysis, 295 (46%) were accepted as lung donors by one of the two lung transplant centres in Switzerland. Our analysis showed that both scores can predict whether or not a donor lung is likely to be accepted for transplantation in Switzerland. As the score value of a donor increases, the odds of the lung being transplanted significantly decreases (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.51–0.65 for the adapted EDS; OR 0.35, 95% CI 0.28–0.43 for the adapted ZDS). This effect is slightly more pronounced in the adapted ZDS than in the adapted EDS. The discriminatory power of the scores from the AUC was 0.719 (95% CI 0.680–0.758) for the adapted EDS, and 0.723 (95% CI 0.681–0.760) for the adapted ZDS, which for both was deemed fair discrimination. CONCLUSIONS Both scoring systems are able to predict whether or not donor lungs are accepted by the two Swiss lung transplant centres. As an alternative to adapting an established scoring system, a national lung quality score could be derived de novo. This could be based on a logistic regression analysis including the most relevant donor characteristics. However, such a new score would need to be validated on an independent sample and ideally tested for its predictive value in terms of post-transplantation outcome.

Identificação dos potenciais doadores de órgãos no Paraná (2011-2019) em razão dos óbitos hospitalares

Article

Full-text available

Apr 2022

Milhares de pessoas aguardam a disponibilização de órgãos para transplante. Estima-se que 2,2% dos óbitos hospitalares são potenciais doadores de órgãos, razão adotada como padrão ouro pelo modelo espanhol, benchmark mundial dos sistemas de busca de órgãos para transplante. Estudo transversal da razão entre os óbitos hospitalares e potenciais doadores identificados no Paraná de 2011 a 2019, assim denominada Índice Paraná. A média do índice em 2019 foi de 1,34±0,98. Inicialmente 13,63% e ao fim do período 59,09% das Regionais de saúde superavam o padrão-ouro, não havendo diferença no número de leitos hospitalares disponíveis entre as regionais. Todas as Organizações de Procura de Órgãos do Paraná apresentaram Índices Paraná semelhantes, sendo o maior (1,78±0,57) atingido pela OPO Cascavel. Concluímos que sob a métrica do Índice Paraná, o estado suplanta o padrão ouro preconizado pelo modelo espanhol.

Evolving Characteristics of Heart Transplantation Donors and Recipients: JACC Focus Seminar

Article

Mar 2022

Although the burden of end-stage heart failure continues to increase, the number of available organs for heart transplantation (HT) remains inadequate. The HT community has been challenged to find ways to expand the number of donor hearts available. Recent advances include use of hearts from donors infected with hepatitis C virus as well as other previously underutilized donors, including those with left ventricular dysfunction, of older age, and with a history of cocaine use. Concurrently, emerging trends in HT surgery include donation after circulatory death, ex vivo normothermic heart perfusion, and controlled hypothermic preservation, which may enable procurement of organs from farther distances and prevent early allograft dysfunction. Contemporary HT recipients have also evolved in light of the 2018 revision to the U.S. heart allocation policy. This focus seminar discusses recent trends in donor and recipient phenotypes and management strategies for successful HT, as well as evolving areas and future directions.

Critical pathways for controlled donation after circulatory death in France

Article

Feb 2022

Introduction In 2015, France authorised controlled donation after circulatory death (cDCD) according to a nationally approved protocol. The aim of this study is to provide an overview from the perspective of critical care specialists of cDCD. The primary objective is to assess how the organ donation procedure affects the withdrawal of life-sustaining therapies (WLST) process. The secondary objective is to assess the impact of cDCD donors’ diagnoses on the whole process. Material and methods This 2015-2019 prospective observational multicentre study evaluated the WLST process in all potential cDCD donors identified nationwide, comparing 2 different sets of subgroups: 1- those whose WLST began after organ donation was ruled out vs. while it was still under consideration; 2- those with a main diagnosis of post-anoxic brain injury (PABI) vs. primary brain injury (PBI) at the time of the WLST decision. Results The study analysed 908 potential cDCD donors. Organ donation remained under consideration at WLST initiation for 54.5% of them with longer intervals between their WLST decision and its initiation (2 [1–4] vs. 1 [1–2] days, P < 0.01). Overall, 60% had post-anoxic brain injury. Time from ICU admission to WLST decision was longer for primary brain injury donors (10 [4–21] vs. 6 [4–9] days, P < 0.01). Median time to death (agonal phase) was 15 [15–20] minutes. Conclusions French cDCD donors are mostly related to post-anoxic brain injury. The organ donation process does not accelerate WLST decision but increases the interval between the WLST decision and its initiation.

OPTN/SRTR 2015 Annual Data Report: Deceased Organ Donation

Article

Full-text available

Jan 2017

SRTR uses data collected by OPTN to calculate metrics such as donation/conversion rate, organ yield, and rate of organs recovered for transplant but not transplanted. In 2015, 1,072,828 death and imminent death referrals were made to Organ Procurement Organizations, of which 21,559 met the definition of eligible (9793) or imminent (11,766) deaths per OPTN policy. The number of deceased donors was 9080, and this number has been increasing since 2010. The number of organs authorized for recovery increased slightly to 65,086 in 2015, and the number recovered increased slightly to 25,762. In 2015, 4370 organs were discarded, including 3157 kidneys, 311 pancreata, 703 livers, 30 hearts, and 214 lungs. These numbers suggest a need to reduce the number of organs discarded.

Time trends in organ donation after neurologic determination of death: a cohort study

Article

Full-text available

Jan 2017

Background: The cause of brain injury may influence the number of organs that can be procured and transplanted with donation following neurologic determination of death. We investigated whether the distribution of causes responsible for neurologic death has changed over time and, if so, whether this has had an impact on organ quality, transplantation rates and recipient outcomes. Methods: We performed a cohort study involving consecutive brain-dead organ donors in southern Alberta between 2003 and 2014. For each donor, we determined last available measures of organ injury and number of organs transplanted, and compared these variables for various causes of neurologic death. We compared trends to national Canadian data for 2000-2013 (2000-2011 for Quebec). Results: There were 226 brain-dead organ donors over the study period, of whom 100 (44.2%) had anoxic brain injury, 63 (27.9%) had stroke, and 51 (22.6%) had traumatic brain injury. The relative proportion of donors with traumatic brain injury decreased over time (> 30% in 2003-2005 v. 6%-23% in 2012-2014) (p = 0.004), whereas that with anoxic brain injury increased (14%-37% v. 46%-80%, respectively) (p < 0.001). Nationally, the annual number of brain-dead donors with traumatic brain injury decreased from 4.4 to less than 3 per million population between 2000 and 2013, and that with anoxic brain injury increased from 1.1 to 3.1 per million. Donors with anoxic brain injury had higher concentrations of creatinine, alanine aminotransferase and troponin T, and lower PaO2/FIO2 and urine output than donors with other diagnoses. The average number of organs transplanted per donor was 3.6 with anoxic brain injury versus 4.5 with traumatic brain injury or stroke (p = 0.002). Interpretation: Anoxic brain injury has become a leading cause of organ donation after neurologic determination of death in Canada. Organs from donors with anoxic brain injury have a greater degree of injury, and fewer are transplanted. These findings have implications for availability of organs for transplantation in patients with end-stage organ failure.

How Spain Reached 40 Deceased Organ Donors per Million Population

Article

Full-text available

Jan 2017
AM J TRANSPLANT

With 40 donors and more than 100 transplant procedures per million population in 2015, Spain holds a privileged position worldwide in providing transplant services to its patient population. The Spanish success derives from a specific organizational approach to ensure the systematic identification of opportunities for organ donation and their transition to actual donation and to promote public support for the donation of organs after death. The Spanish results are to be highlighted in the context of the dramatic decline in the incidence of brain death and the changes in end-of-life care practices in the country since the beginning of the century. This prompted the system to conceive the 40 donors per million population plan, with three specific objectives: (i) promoting the identification and early referral of possible organ donors from outside of the intensive care unit to consider elective non-therapeutic intensive care and incorporate the option of organ donation into end-of-life care; (ii) facilitating the use of organs from expanded criteria and non-standard risk donors; and (iii) developing the framework for the practice of donation after circulatory death. This article describes the actions undertaken and their impact on donation and transplantation activities.

Estimating the Number of Organ Donors in Australian Hospitals—Implications for Monitoring Organ Donation Practices

Article

Full-text available

Apr 2015
TRANSPLANTATION

Background The Australian DonateLife Audit captures information on all deaths which occur in emergency departments, intensive care units and in those recently discharged from intensive care unit. This information provides the opportunity to estimate the number of donors expected, given present consent rates and contemporary donation practices. This may then allow benchmarking of performance between hospitals and jurisdictions. Our aim was to develop a method to estimate the number of donors using data from the DonateLife Audit on the basis of baseline patient characteristics alone. Methods All intubated patient deaths at contributing hospitals were analyzed. Univariate comparisons of donors to nondonors were performed. A logistic regression model was developed to estimate expected donor numbers from data collected between July 2012 and December 2013. This was validated using data from January to April 2014. Results Between July 2012 and April 2014, 6861 intubated patient deaths at 68 hospitals were listed on the DonateLife Audit of whom 553 (8.1%) were organ donors. Factors independently associated with organ donation included age, brain death, neurological diagnoses, chest x-ray findings, PaO2/FiO2, creatinine, alanine transaminase, cancer, cardiac arrest, chronic heart disease, and peripheral vascular disease. A highly discriminatory (area under the receiver operatory characteristic, 0.940 [95% confidence interval, 0.924-0.957]) and well-calibrated prediction model was developed which accurately estimated donor numbers. Three hospitals appeared to have higher numbers of actual donors than expected. Conclusions It is possible to estimate the expected number of organ donors. This may assist benchmarking of donation outcomes and interpretation of changes in donation rates over time.

Swiss Monitoring of Potential Organ Donors (SwissPOD): a prospective 12-month cohort study of all adult ICU deaths in Switzerland

Article

Full-text available

Oct 2014

Background: The Swiss Monitoring of Potential Organ Donors (SwissPOD) was initiated to investigate the causes of the overall low organ donation rate in Switzerland. The objective of our study was an assessment of the donation after brain death (DBD) process in Swiss adult intensive care units (ICUs), and to provide an overview of the donation efficiency as well as of the reasons for non-donation. Methods: SwissPOD is a prospective cohort study of all deaths in Swiss ICUs and accident and emergency departments. This study is an analysis of SwissPOD data of all patients who deceased in an adult ICU between 1 September 2011 and 31 August 2012. Results: Out of 3,667 patients who died in one of the 79 adult ICUs participating in SwissPOD, 1,204 were possible, 198 potential, 133 eligible, and 94 utilised DBD donors. The consent rate was 48.0% and the conversion rate 47.5%. In 80.0% of cases, the requests for donation took place before brain death was diagnosed, resulting in a similar proportion of consents and objections as when requests were made after brain death diagnosis. Conclusions: Despite the low donation rate, Swiss adult ICUs are performing well in terms of the conversion rate, similar to major European countries. The refusal rate is among the highest in Europe, which clearly has a negative impact on the donation rate. Optimising the request process seems to be the most effective means of increasing the donation rate.

Organ Donation in Switzerland - An Analysis of Factors Associated with Consent Rate

Article

Full-text available

Sep 2014
PLOS ONE

Background and Aim Switzerland has a low post mortem organ donation rate. Here we examine variables that are associated with the consent of the deceased’s next of kin (NOK) for organ donation, which is a prerequisite for donation in Switzerland. Methods and Analysis During one year, we registered information from NOK of all deceased patients in Swiss intensive care units, who were approached for consent to organ donation. We collected data on patient demographics, characteristics of NOK, factors related to the request process and to the clinical setting. We analyzed the association of collected predictors with consent rate using univariable logistic regression models; predictors with p-values <0.2 were selected for a multivariable logistic regression. Results Of 266 NOK approached for consent, consent was given in 137 (51.5%) cases. In multivariable analysis, we found associations of consent rates with Swiss nationality (OR 3.09, 95% CI: 1.46–6.54) and German language area (OR 0.31, 95% CI: 0.14–0.73). Consent rates tended to be higher if a parent was present during the request (OR 1.76, 95% CI: 0.93–3.33) and if the request was done before brain death was formally declared (OR 1.87, 95% CI: 0.90–3.87). Conclusion Establishing an atmosphere of trust between the medical staff putting forward a request and the NOK, allowing sufficient time for the NOK to consider donation, and respecting personal values and cultural differences, could be of importance for increasing donation rates. Additional measures are needed to address the pronounced differences in consent rates between language regions.

Effect of organ donation after circulatory determination of death on number of organ transplants from donors with neurologic determination of death

Article

Sep 2017

Background: To increase the available pool of organ donors, Ontario introduced donation after circulatory determination of death (DCD) in 2006. Other jurisdictions have reported a decrease in donations involving neurologic determination of death (NDD) after implementation of DCD, with a drop in organ yield and quality. In this study, we examined the effect of DCD on overall transplant activity in Ontario. Methods: We examined deceased donor and organ transplant activity during 3 distinct 4-year eras: pre-DCD (2002/03 to 2005/06), early DCD (2006/07 to 2009/10) and recent DCD (2010/11 to 2013/14). We compared these donor groups by categorical characteristics. Results: Donation increased by 57%, from 578 donors in the pre-DCD era to 905 donors in the recent DCD era, with a 21% proportion (190/905) of DCD donors in the recent DCD era. However, overall NDD donation also increased. The mean length of hospital stay before declaration for NDD was 2.7 days versus 6.0 days before withdrawal of life support and subsequent asystole in cases of DCD. The average organ yield was 3.73 with NDD donation versus 2.58 with DCD (p < 0.001). Apart from hearts, all organs from DCD donors were successfully transplanted. From the pre-DCD era to the recent DCD era, transplant activity in each era increased for all solid-organ recipients, including heart (from 158 to 216), kidney (from 821 to 1321), liver (from 477 to 657) and lung (from 160 to 305). Interpretation: Implementation of DCD in Ontario led to increased transplant activity for all solid-organ recipients. There was no evidence that the use of DCD was pre-empting potential NDD donation. In contrast to groups receiving other organs, heart transplant candidates have not yet benefited from DCD.

Organ Transplantation in France

Article

Mar 2017

Factors influencing the family consent rate for organ donation in the UK

Article

Jul 2016

The refusal rate for organ donation in the UK is 42%, among the highest in Europe. We extracted data on every family approach for donation in UK ICUs or Emergency Departments between 1st April 2012 and 30th September 2013, and performed multiple logistic regression to identify modifiable factors associated with consent. Complete data were available for 4703 of 4899 approaches during the study period. Consent for donation after brain death was 68.9%, and for donation after circulatory death 56.5% (p < 0.0001). Patient ethnicity, knowledge of a patient's wishes and involvement of a specialist nurse in organ donation in the approach were strongly associated with consent (p < 0.0001). The impact of the specialist nurse was stronger for donation after circulatory death than for donation after brain death, even after accounting for the impact of prior knowledge of patients' wishes. Involvement of the specialist nurse in the approach, encouraging family discussions about donation wishes and promotion of the organ donor register are key strategies to increase UK consent rates, and are supported by this study.

Changing Patterns of Organ Donation: Brain Dead Donors Are Not Being Lost by Donation After Circulatory Death

Article

Oct 2015
TRANSPLANTATION

The clinical characteristics of all New England Organ Bank (NEOB) donors after circulatory death (DCD) donors were analyzed between July 1, 2009, and June 30, 2014. During that 5-year period, there were 494 authorized medically suitable potential DCDs that the NEOB evaluated, constituting more than 30% of deceased donors coordinated annually by the NEOB. From the cohort of 494 authorized potential DCDs, 331 (67%) became actual DCD, 82 (17%) were attempted as a DCD but did not progress to donation, and 81 (16%) transitioned to an actual donor after brain death (DBD). Two hundred seventy-six organs were transplanted from the 81 donors that transitioned from DCD to actual DBD, including 24 heart, 70 liver, 12 single and 14 bilateral lung, and 12 pancreas transplants. When patients with devastating brain injury admitted to the intensive care units are registered donors, the Organ Procurement Organization staff should share the patient's donation decision with the health care team and the patient's family, as early as possible after the comfort measures only discussion has been initiated. The experience of the NEOB becomes an important reference of the successful implementation of DCD that enables an expansion of deceased donation (inclusive of DBD).

Evolution of deceased organ donation activity vs. efficiency over a 15 year period: an international comparison

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