CATEGORY III DONATION AFTER CIRCULATORY DEATH LUNG DONORS FOR PAEDIATRIC LUNG TRANSPLANTATION (PLTX): INCREASING THE DONOR POOL WITH EXCELLENT OUTCOMES
SNELL G 1
1Lung Transplant Service, Alfred Hospital, Melbourne, Australia
Introduction and Objectives: Access to timely suitably sized quality organs remains a challenge for pLTx. The utility and outcomes of the use of Donation after Circulatory Death (DCD) lungs for pLTx are rarely reported.
Methods: A review of the Alfred Hospital DCD and pLTx activity (≤age 18 years) and outcomes.
Results: Forty pLTx have been performed since 2006, nine utilising DCD and 31 DBD donors. There have been 21 pLTx done since 2012; nine DCD lung transplantations (LTx) included four paediatric DCD donors (mean age 8yrs), two adult bilobar (BLTx) and three adult BLTx DCD donors (mean age 43 years) with a mean wait-list (W/L) time of 78 days.
The other 12 pLTx utilised DBD donors- seven paediatric (mean age 9 years), two adult bilobar and three BLTx DBD (mean age 44 years) with a mean W/L time of 142 days. The nine pLTx recipients of DCD lungs had a median age 15 years. All survived one year, and seven of the nine7/9 DCD pLTx are alive at a mean of 1,140 days, with one death at 531 days from chronic lung allograft dysfunction (CLAD), one death from renal failure at 1,813 days. There have been two W/L paediatric deaths since 2006 at182 and 66 days.
Since 2006, 77 paediatric donors have been used for LTx. Fifteen of these were DCD donors (median age 16 years), 11 of the15 have been used for adult LTx (aLTx). The 11 adults had a mean age of 46 years and W/L time of 230 days. Ten of the 11 aLTx are alive at 2,264 days with one death at 2,444 days.
Conclusion: Controlled DCD provides a significant and quality donor lung pool to increase LTx opportunities for paediatric patients.
TEN YEARS ON: THE SIGNIFICANT IMPACT OF CONTROLLED DONATION AFTER CIRCULATORY DEATH (DCD) LUNG DONORS ON LUNG TRANSPLANT OPPORTUNITIES AND OUTCOMES
LEVVEY Bronwyn, A/Prof
Lung Transplant Service, Alfred Hospital, Melbourne, Australia
Introduction and objectives: This study evaluates waiting-list (W/L) and long-term outcomes of the 150 DCD and contemporaneous Donation after Brain Death (DBD) lung transplants (LTx) performed at the Alfred Hospital since 2006.
Methods: All LTx between May 2006 and February 2017 (n=696, 150 DCD LTx and 546 DBD LTx) were analysed, including W/L times/mortality, early outcome measures (Intensive Care Unit (ICU) & total length of stay (LOS)), survival and death due from chronic lung allograft dysfunction (CLAD).
Results: The use of DCD has resulted in 25% more LTx annually and reduced overall W/L times (245 days to135 days, p<0.001) and W/L mortality (29% to 5%, p<0.01) from 2006 to 2016 respectively.
Compared to DBD, DCD donors were intubated in ICU longer (115 vs 79 hours, p<0.001), older (45.6 vs 41.6 years, p<0.01), more frequently male (64% vs 51%, p<0.01), but distant donors (>300 kilometres) were less common for DCD than DBD (20% vs 35%, p<0.01).
DCD recipients, compared to DBD, had a reduced W/L time (101 days vs 120 days, p=0.03), longer cold graft ischaemic time (GIT) (323 vs 287 minutes, p<0.01) and more were bilobar lung transplantation (BLTx) (97% vs 90%, p<0.01). DCD lungs were used in six (4%) paediatric (5-17yrs) recipients vs 21(3.8%) paediatrics receiving DBD lungs.
The 5 and 10 year survival rates were similar (DCD 96%, 69% & 53% vs DBD 92%, 64% & 51%, p=ns). CLAD related deaths were no different between DCD & DBD (34% vs 40%, p=0.36).
Conclusions: Controlled DCD has significantly and safely increased overall LTx numbers, reduced W/L time and mortality, with excellent 1, 5 and 10 year LTx outcomes at the Alfred Hospital. Ex-vivo lung perfusion is not required for successful DCD LTx outcomes.
BRIEF NORMOTHERMIC MACHINE PERFUSION IS SUPERIOR TO COLD STORAGE ALONE - A PAIRED DISCARDED HUMAN KIDNEY ANALYSIS
HAMEED A1,2,3, LU D2, PATRICK E2, P’NG C1, GASPI R1, ZHANG C1, ROBERTSON P1, HU M2, CHEW Y2, MIRAZIZ R1, ALEXANDER S2,3,5, THOMAS G3,5, LAURENCE J1,3,4, DE ROO R1, WONG G1,2,3, YUEN L1,3, HAWTHORNE W1,2,3, ROGERS N1,2,3, and PLEASS H1,3,4
1Westmead Hospital, Westmead, Australia,2Westmead Institute for Medical Research, Westmead, Australia,3Sydney Medical School, University of Sydney, Australia,4Royal Prince Alfred Hospital, Camperdown, Australia,5The Children’s Hospital at Westmead, Westmead, Australia
Introduction: Normothermic machine perfusion (NMP) is a promising new modality that provides the potential for the resuscitation, repair and improved assessment of donor kidneys prior to transplantation.
Objectives: Using a series of discarded human kidneys, we aimed to investigate the mechanistic basis and translational potential of NMP as a viable and superior preservation strategy to the current gold standard of cold static storage (CS).
Method: Discarded deceased donor kidneys (n = 15) underwent brief (one hour) NMP after a period of CS during transportation. Renal perfusion, biochemical, and histologic parameters were recorded. Leukocyte efflux from the kidney was measured in selected grafts. NMP was directly compared to CS in paired donor kidneys using simulated transplantation with whole allogeneic blood, followed by assessment of perfusion and functional parameters, markers of ischemia-reperfusion injury (IRI), and ribonucleic acid (RNA) sequencing.
Results: All kidneys were successfully perfused, with demonstration of improving renal blood flows and resistance (median 260 ml/min and 0.29 mmHg/ml/min respectively), and urine output (median 21 ml), in all but one kidney. NMP completely resolved non-perfused regions in discarded Donation after Circulatory Death (DCD) kidneys. In paired kidneys, transcriptomic analyses showed induction of stress and inflammatory pathways in NMP kidneys, with upregulation of pathways promoting cell survival and proliferation. Furthermore, the NMP pairs had significantly better renal perfusion and functional parameters, and amelioration of cell death, oxidative stress, and complement activation by immunofluorescence.
Conclusion: NMP demonstrated multiple superior outcomes to CS, allowing for the rejuvenation of marginal kidneys. NMP has considerable potential to enhance early graft function in such kidneys, and also reduce organ discards in order to increase kidney transplantation rates.
TIME IS PRECIOUS – REDUCING THE TIME FROM CERTIFICATION OF DEATH TO COMMENCEMENT OF SURGERY IN DONATION AFTER CIRCULATORY DETERMINATION OF DEATH
1Royal North Shore Hospital (RNSH), Sydney, New South Wales (NSW), Australia
Introduction: Warm ischaemic time (WIT) during Donation after Circulatory Death Determination (DCDD) is a key factor in successful transplant outcomes. The RNSH DCDD Project commenced in 2018 with the primary aim of reducing the time from declaration of circulatory death to commencement of retrieval surgery. Key considerations were preserving the dignity of the patient, family experience and operating theatre (OT) staff comfort.
Method: The project introduced the practice of moving the patient onto a mobile operating table in the anaesthetic bay before withdrawal of cardiorespiratory support (WCRS) in the presence of the family. This removed the need for transfer to the operating table during the time-pressured period before retrieval commences. In-house simulation, planning and post donor reviews provided ongoing support of the process.
Results: The median time from WCRS to commencement of surgery for the first three DCDD patients was 3 minutes, compared to a median time for the previous 18 donations of 5 minutes. The dignified transfer of the mobile operating table into theatre was well received by both family and RNSH OT staff.
Conclusion: RNSH is the first hospital in Australia to introduce routine WCRS on a mobile operating table in the presence of the family. Our early results suggest that this simple intervention will contribute to significant reductions in WIT.
DONOR LUNG REFERRALS FOR LUNG TRANSPLANTATION: A VIEW FROM ‘THE OTHER SIDE’
SNELL G1, LEVVEY B1, HENRIKSEN A1, WHITFORD H1, LEVIN K1, PARASKEVA M1, WILLIAMS T1, WESTALL G1, and MCGIFFIN D1
1Lung Transplant Service, Alfred Hospital, Melbourne, Australia
Introduction: Australia’s increasing organ donor rate has translated to increased lung donor referrals and subsequent lung transplants (LTx). The LTx sector attempts to utilise as many organs as possible, but the reality is that some organs are not useable.
Objectives: This analysis aims to assess the utility and efficiency of donor lung referrals to the Alfred Hospital.
Method: As collated prospectively by the Alfred Hospital recipient coordination staff, all DonateLife lung referrals for 2017 were analysed.
Results: There were 440 referrals representing 220 [68% of these donation after circulatory death (DCD)] from Victoria and 220 (48% DCD) from the rest of Australia (ROA). There were 102 LTx performed: 31 from 21% of the 149 Victorian and 8% of the 106 ROA DCD donors, 71 from 54% of the Victorian and 24% of the ROA donation after brain death (DBD) donors.
Of all donors, 80% were aged <35 years and 30% >35 years, 4.4% (3/68) DCD and 13% (2/15) DBD donors aged >70 years were used. Logistical and resource considerations, particularly around the retrieval of older DCD lungs, are a significant issue. There is a considerable amount of time taken by transplant coordinators and physicians when assessing lung referrals. For lungs that were transplanted the time taken was a mean 23 hours (median 21 hours), and for those lungs not transplanted the average time taken was 7 hours in Victoria and 3 hours (ROA) (median 1 hour). The time at which referrals were made is another significant factor with 33% of referrals between 2000-0800 hours.
Conclusion: At 11.3 LTx per million population (PMP), the Alfred Hospital has one of the highest lung donor conversion and LTx activity rates in the world (United States of America 7.2, Europe 5.2, United Kingdom 2.6). However, this could be further extended by focusing effort, logistics and resources on optimising DCD recovery rates.
TILL DEATH DO US PART - POST MORTEM SPERM RETRIEVAL
HOLMAN J1, and GROOBY K2
1Royal North Shore Hospital, Sydney, Australia, 2New South Wales Organ & Tissue Donation Service Sydney, Australia
Introduction: Donating an organ to prolong life, and donating a gamete to create life are diametrically opposed. Post mortem sperm retrieval refers to the collection of sperm from a recently deceased person for the purpose of posthumous reproduction.
Family donation conversations are no longer limited to the organ and tissue donation wishes of a loved one and can reveal unparalleled appeals to extend life beyond death.
Objectives: To present a case in context with current literature and reveal an important disparity that exists between Australian states and territories in the ability to retrieve gametes and the inability to bring them to full humanity.
Conclusion: The ties that bind families are some of the strongest bonds. When life does not go as we had planned and the man in a relationship suffers a catastrophic unsurvivable injury, it is devastating. The surviving partner has a window of opportunity to retrieve that man’s sperm for storage and possible future use to create a child that they had once thought was possible before tragedy struck.
Protocols may provide clarity in guiding the appropriate and timely management of these requests. Should we do this? Can we do this? Who decides this and what is the basis surrounding these decisions?
This complex request is fraught with uncertain legal obligations and clouded ethics. Our response was not simple, straight forward or timely.
ESTABLISHING ORGAN AND TISSUE DONATION IN A SMALL COUNTRY TOWN
CAMPBELL Ms Mary
NSW Organ and Tissue Donation Service (NSW OTDS), Grafton Base Hospital (GBH)
Introduction: The New South Wales (NSW) Agency for Clinical Innovation - Intensive care service model – states that “where feasible, NSW residents should have access to intensive care services close to where they live.” Prior to 2014 patients from GBH requiring critical care support were transferred to the nearest intensive care facility, 135 kilometres away.
Objectives: Between 2014-2017, four patients were transferred from GBH to Lismore Base Hospital (LBH) for the purpose of organ donation, resulting in loved ones being deprived of the support of family during their time of grief. During this same period of time three families at GBH declined organ donation due to the need to transfer their family member to LBH.
Method: In 2016 preliminary discussions took place to determine the feasibility of establishing organ donation at GBH, in view of its service classification. Thereafter an executive meeting took place between the NSW OTDS and GBH resulting in a consensus to work towards the capacity for GBH to facilitate organ and tissue donation.
Results: A comprehensive educational plan was developed for all clinical areas involved in the organ donation process. Obstacles were identified during the implementation of the education plan resulting in the formation of a working party with representation from all clinical areas, an executive lead from GBH and executive representation from the NSW OTDS.
Conclusion: In September 2018, GBH successfully facilitated its first organ and tissue retrieval, with family members extremely grateful for being able to proceed with donation in their home town.
INTRODUCTION OF AN AUTOMATIC DEATH NOTIFICATION SYSTEM WITHIN TWO PRIVATE WESTERN AUSTRALIAN HOSPITALS
THOMAS L1, SHAHIB N1, and KIRK-BURNNAND E1
1DonateLife WA, Perth, Australia
Introduction: DonateLife Western Australia (WA) receives automatic, electronic notifications of all public hospital deaths within WA, which allows all deaths to be assessed as potential tissue donors and therefore provides families with the opportunity to consider tissue donation. The placement of DonateLife WA Clinical Nurse Specialists within the Western Australian private hospital sector identified many unrealised, potential tissue donors due to deaths not routinely reported to DonateLife WA. In order to enable all deaths within two large metropolitan private hospitals to be assessed as potential tissue donors, an automatic death notification system was introduced.
Objectives: To allow all deaths to be assessed as potential tissue donors and provide families with the opportunity to consider the possibility of tissue donation
Method: Information Services guided the development of the Automatic Death Notification System (ADNS) which generates an email to the on-call DonateLife WA Donor Coordinator when a death is electronically recorded at the hospitals. The ADNS was introduced at the two hospitals in July 2014.
Results: Prior to implementing the ADNS, one hospital site had no tissue donors recorded during the preceding months with four tissue donors recorded in the year post implementation. The other hospital recorded one tissue donor in the months prior to implementation and three tissue donors in the year post implementation.
Conclusion: The implementation of the ADNS within the two, large metropolitan private hospitals has provided more families with the opportunity to consider tissue donation and increased the number of tissue donors at each site.
BARWON HEALTH BONE BANK; 30 YEARS’ EXPERIENCE IN A REGIONAL AUSTRALIAN FEMORAL HEAD BANK
VAN DER MEER Gavin, WILLIAMS Simon, and PAGE Richard
University Hospital Geelong, Ryrie Street, Geelong, Victoria, 3220, Australia.
Objective: To report the evolution and activity of the Barwon Health Bone Bank (BHBB) through 30 years of operation as a unique, regional repository of fresh frozen, non-irradiated bone allograft for clinical implantation (1986 to 2016)
Background: The BHBB was established in 1986 to provide bone graft material for orthopaedic patients in the Greater Geelong region. Bone donations are sourced from screened living donors, scheduled for elective total hip replacement patients and released after quarantine.
Clinical Indications: Reconstruction of bone defects such as revision of hip, knee or shoulder replacement, primary joint replacement, fracture non-union and fusion of the foot and ankle.
Fresh frozen bone allograft is preferred as there is strong evidence that irradiating bone causes structural and biological deterioration that affects its ability to function.
Method: Compilation of data through an audit of existing bone bank donor and recipient databases, performance indictor reports and quality/management reviews.
Results: • 2,501 femoral head donations collected from 2,343 donors
• 821 discarded for quality and safety
• 1,680 grafts produced for clinical use
• 1,546 grafts implanted into 952 recipients across 1,077 procedures
• 40 grafts transferred for further processing (as milled bone)
• Zero (0) reported instances of adverse recipient outcomes.
Conclusions/Outcomes: There are advantages to retaining an ‘on-site’ bone bank in a regional centre;
• availability of fresh frozen, non-irradiated bone graft
• confirmation of the need for graft can be made during surgery
• graft wastage is rare
• graft can be delivered within 20 minutes
• confidence in quality, safety and reliable supply
• compliment the national supply
PREGNANCY AND ORGAN DONATION: A CASE STUDY
1DonateLife Victoria, Carlton, VIC
Introduction: On average an organ donation case can take between 24 to 48 hours from consent to conclusion of retrieval theatre. However there are special circumstances where a donation case may be on hold for a number of days or weeks until retrieval can occur. In this case study we will explore the circumstances of a pregnant donor who was able to be supported in the intensive care unit (ICU) for 7 weeks before retrieval surgery.
Case study: A 42 year old female complained of a sudden headache and collapsed at home. Past history (PHx): depression, urinary tract infection (UTI), Gravida 3 Para 2 (26/40 weeks gestation at time of presentation).
On arrival at the local emergency department (ED), Glasgow Coma Scale (GCS) of 3, intubated for airway protection and urgent transfer to neurosurgical centre.
Computerised Tomography-Brain (CTB): Grade V Subarachnoid Haemorrhage with early hydrocephalus
Theatre: emergency craniotomy with external ventricular drain (EVD) insertion for evacuation of bleed
Day Three: Pupils remain fixed and dilated, nil spontaneous breaths, absent cough and gag reflexes. Absent corneal reflexes. Brain death testing completed via nuclear medicine scan and confirmed by two intensive care specialists. Death declared.
Organ donation was raised with the next of kin (domestic partner) who was very supportive and completed the formal consent the same day.
Their one request was to deliver the baby when he/she was viable and healthy.
The patient was supported for six weeks in ICU with multidisciplinary team input- including obstetrics and gynaecology, infectious diseases, ICU and general medicine. Multiple nursing teams were involved in the care of the patient as well as social work involvement.
Successful retrieval of heart, lungs, liver, pancreas, kidneys and eyes, helping to improve the lives of 8 recipients.
Conclusion: A large multidisciplinary team was involved in the care of this patient and provided support to her and her family to ensure that her previously documented wish of becoming an organ donor was honoured, as well as her family’s wish of a healthy outcome for the baby. Not only was she able to help many others through the gift of organ and tissue donation, the safe delivery of her baby provided much needed comfort for her family during this very difficult time.
DONOR FAMILY INTERVIEW TRAINING VIDEO
AMSDEN J1, and PLAS M1
1DonateLife Victoria, Melbourne, Australia
Introduction: In four years, DonateLife Victoria (DLV) has trained 46 staff in the donor family interview and consent process. The traditional method of training (observing a role-play) was inadequate which led to the development of a video training resource
Objectives: The primary aim of developing this resource was to provide novice and experienced donation specialists with a resource they could utilise repeatedly to develop, refine and further consolidate their donor family interviews.
Method: The DLV education team worked with a local film company to develop the material and casting for actors. Additional support in developing the material was provided by experienced colleagues within the DonateLife Network. Health professional roles were played by experienced DLV staff. Filming occurred over two days.
The resource consists of seven vignettes including a complete donor family interview inclusive of the medical/social history and seven additional vignettes demonstrating how to navigate specific elements of the formal consent interview e.g. Donation after Circulatory Death (DCD) processes and exploring viral risk in a paediatric donor
Results: The resource has been utilised by 12 training donation specialists. Within simulations, specialists have demonstrated accurate content delivery and have been able to demonstrate appropriate application of communication techniques.
Conclusion: The development of the resource has provided 12 novice donation specialists the opportunity to successfully complete their training in a more streamlined and efficient manner. There has been a demonstrated higher standard in the initial ‘mock’ donation conversations by these staff following use of this resource. Experienced coordinators have also acknowledged the benefit to their communication and practice.
CLINICAL CHAMPIONS: CATALYSTS FOR CHANGE IN THE WORLD OF DONATION AND TRANSPLANT
PENNA K1,2, and MCGUIGAN C1,2
1Austin Health, Melbourne, Australia, 2DonateLife Victoria, Melbourne, Australia
Introduction: Austin Health has developed the role of Clinical Champion for Organ and Tissue Donation across our Intensive Care Unit (ICU) and Palliative Care unit. Nurses have been recruited to educate, advocate and facilitate organ and tissue donation across the hospital to ensure that donation is discussed as part of routine end-of-life care at Austin Health.
Objectives: 1. Train, equip and support registered nurses to provide organ and tissue donation expertise to their unit
2. Influence clinicians regarding donation processes at end of life and effect referral rates of patients at end-of-life care
3. Contribute to evolving and improving Austin Health end-of-life care practices.
4. Aim for 100% referral rate for all patients at end of life in ICU.
Method: Nursing staff were recruited to the roles through expression of interest and interview process. Formalised training involved one-on-one teaching, donation process study days, practical workshops and online learning. Preceptorship programs were commenced to support, encourage and train these clinicians in this specialty.
Results: The Clinical Champions program has been running for 11 months and data has shown that referral rates have increased by 66% and organ donation rates are consistently high. Austin Health has increased its yearly rate of corneal donation by 114% and staff engagement has been consistently evident.
Conclusion: The initial phase of the Clinical Champions program has shown that the presence of trained advocates on the ward impacts end-of-life processes enables discussion around organ and tissue donation and improves referral and consent rates.
YOU CAN’T CLOSE THE WINDOW: PREVALENCE OF OPEN NUCLEIC ACID TESTING WINDOW PERIODS IN A COHORT OF AUSTRALASIAN POTENTIAL ORGAN DONORS
DUTCH M1, and PILCHER D2
1Royal Melbourne Hospital, Melbourne, Australia, 2The Alfred Hospital, Melbourne, Australia
Introduction: Demand for solid organ donation within Australasia continues to outstrip supply. To expand the donor pool, potential donors with increased viral risk are increasingly being considered.
Objectives: This study aims to estimate the prevalence of open Nucleic Acid Testing (NAT) windows for Human Immunodeficiency Virus (HIV), Hepatitis B virus (HBV) and Hepatitis C virus (HCV) within an Australasian cohort of potential organ donors.
Method: This study employed a previously published methodology to identify a cohort of potential organ donors from the Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient database.
The study used a prospective NAT turn-around-time of 4 hours, and NAT window periods of 5.9, 15.1, and 2.6 days for HIV, HBV and HCV respectively.
The percentage of patients with an Intensive Care Unit (ICU) length of stay (LOS) shorter than the relevant NAT window period for each virus was calculated. For patients with an open NAT window, the percentage of the NAT window period spent in ICU was calculated.
Results: Between January 2008 and June 2018, 14,807 patients were identified as possible organ donors. These patients had a median length of stay (LOS) of 2.2 days [Interquartile range (IQR) 1 – 4.4].
The prevalence of open NAT windows was 84%, 98% and 58% for HIV, HBV and HCV respectively. For patients with open windows, the median percentage of the NAT window spent in ICU was 28%, 14% and 40%.
Conclusion: Due to the short LOS for potential organ donor patients, the majority will have open NAT windows for HIV, HBV and HCV. This study highlights the importance pre-transplantation vaccination, and relative proportion of the window period spent in ICU away from viral risk behavior when considering transmission risk.
ESTABLISHING THE AUSTRALIAN TRANSPLANTATION BIOBANK
GORDON Claire L1,2, OPDAM Helen1,3, JONES Robert1, STARKEY Graham1, D’COSTA Rohit3, and GRAYSON M. Lindsay1
1Austin Health, Melbourne, Australia, 2Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Australia, 3DonateLife Victoria, Melbourne, Australia
Introduction: Immune responses occur in diverse anatomical sites, including protective immune responses to infection and cancer, and dysregulated immune responses in autoimmune and inflammatory diseases. However, our knowledge of human immunity is largely derived from the sampling of blood. Although immune cell locations and functions have been mapped in mice, translating this knowledge to humans is an ongoing challenge.
Objectives: The major barrier to translating research discoveries from animal studies to humans is the difficulty in obtaining human tissue. We aim to bridge this barrier by establishing a national human donor tissue repository (the Australian Transplantation Biobank). Our research also aims to determine how immune responses in tissues relate to the subsequent risk of infections in transplant recipients.
Method: We will collect blood, lymphoid tissues (bone marrow, spleen, lymph nodes and thymus), skin, lung, gut and liver from organ donors at the time of organ procurement. Tissues will be processed and stored for subsequent high-content analysis of immune cells in the tissues.
Results: This project is in the planning phase.
Conclusion: The importance of tissue immune responses in health and disease is only now emerging. Organ donor tissue has the potential to advance our understanding of tissue immune responses and lead to new treatments for infections, cancer, autoimmune and inflammatory diseases, and better transplant outcomes.
THE DESKTOP COORDINATOR: A RETROSPECTIVE ANALYSIS OF HOSPITAL DEATHS ASSESSED USING ELECTRONIC MEDICAL RECORDS
Queensland Tissue Bank (QTB), Brisbane, Australia
Introduction: To facilitate tissue donation, QTB staff assess all public hospital deaths in South-East Queensland (SEQ). Staff efficiently identify suitable donors utilising access to electronic medical records and an automatic death notification system. A total of 16 SEQ hospitals facilitate eye donation of which seven (44%) have electronic medical records accessible by QTB staff. Additionally, QTB staff access several databases covering pathology results and all presentations/admissions to any Queensland public hospital. This efficiency is vital in the setting of limited resources and significant time constraints inherent to tissue donation.
Objectives: Limited to eye tissue, to analyse the outcomes of hospital deaths assessed in 2017.
Method: Retrospective one year analysis.
Results: On average, automatic notifications were received three hours after death and a consent outcome obtained 5.5 hours after QTB receiving the notification. Of a total of 7,213 hospital death notifications, 5,298 (73%) patients were assessed as unsuitable to donate, 1,199 (17%) were not assessed due to resource capacity and 716 (10%) were identified as potentially suitable. Of the potentially suitable patients, 50 (7%) families were unable to be contacted, 209 (29%) did not consent and 457 (64%) consented to eye donation. Of the patients where family consent was obtained, 89% were identified as medically suitable resulting in 407 eye donors in 2017.
Conclusion: QTB’s automatic notification system and electronic access to medical records allows staff to rapidly gather relevant information to quickly identify suitable eye donors. In the future, this review could be expanded to include other tissue types and deaths referred to the Coroner.
IS THERE A CEILING FOR DONOR CONSENT? A COMPARISON OF CONSENT RATES FROM 2005 TO 2015 AT THE NEW SOUTH WALES (NSW) TISSUE BANKS
HODGE C1,2, GEORGES P1, LAWLOR M2, TRELOGGEN J1, PETSOGLOU C1,2, and SUTTON G1,2
1NSW Organ & Tissue Donation Service (NSW OTDS), Sydney, Australia 2The University of Sydney, Save Sight Institute, Sydney Medical School, Sydney, Australia
Introduction: Organ donation is a precious gift. Although Australia continues to meet demands it is essential to optimise the possible opportunity provided by donors and their families.
Objectives: To determine the rate of eye donation and compare the result to historical findings within the same eye bank to determine change across time.
Method: Retrospective review
Results: Across a 12-month period in 2015, 318 of 503 donor conversations resulted in a consent decision, leading to an equivalent overall consent rate of 63.2%. Of the families that were approached by our coordinators to consider donation on behalf of the deceased, a statistically significant higher percentage of families provided consent when the donor had previously registered their intent to donate on the Australian Organ Donation Register (AODR) as against those donors who had not previously registered a decision (78.5% vs 51.5%, p = 0.000). In a previous report from the same eye bank (2004-2005) 529 out of 837 eligible approaches resulted in donation consent (63.2%).
Conclusion: Against the backdrop of a significant federal initiative to increase donor awareness and consent, we have found no difference in the overall percentage of familial donor consent over time for eye donation at our location. This has been ameliorated by an increase in the acceptable donor pool through the introduction of alternative storage techniques which currently allows the eye bank to meet growing requirements. The development of a donation-positive culture is difficult and undoubtedly a long-term project. Targeting the donation registration process and the eventual family conversation may be key to improvement.
AMNION: THE SWISS ARMY KNIFE OF TISSUES
MCKEOWN H1 , TRELOGGEN J1 , and PETSOGLOU C1,2
1New South Wales Organ & Tissue Donation Service (NSW OTDS), Sydney, Australia, 2The University of Sydney, Save Sight Institute, Sydney Medical School, Sydney, Australia
Introduction: Amniotic membrane, or amnion, is the innermost layer of the placenta, and acts as a natural scaffold with multiple clinical applications. It is translucent, avascular, anti-inflammatory and has low immunogenicity. Amnion is widely available and normally considered a by-product of delivery. It is these properties that lead to its long history of use, initially as a skin substitute back in the early 1900s.
Since that time its specific properties of cell differentiation into a variety of cell types has stimulated a flurry of research aimed at evaluating its use in regenerative medicine. This has been primarily focused on tissue engineering, cell replacement, cell protection and stimulating repair of injured tissues.
The NSW Tissue Banks are licensed to retrieve, store and release amniotic membrane for surgical use. Initially to be used for ophthalmic use for non-healing ulcers and/or ocular surface reconstruction, it has a wide range of other surgical subspecialties.
At the outset amnion donation will be sourced from one hospital from full term elective caesarean deliveries by obstetricians and evaluated by the NSW Tissue Banks Living Donor Coordinators. It is expected 20-30 pieces of amniotic tissue from one donor can be provided for clinical use.
Objectives: To describe the introduction of amnion tissue collection to the NSW OTDS.
Conclusion: The NSW Tissue Banks seek to provide ethically sourced, reliable, quality tissue that meets clinical and surgical requirements in a timely manner.
THE CREATION AND OPERATIONS OF THE NEW SOUTH WALES ORGAN & TISSUE DONATION SERVICE RESEARCH STEERING COMMITTEE
TRELOGGEN J1 , GHABCHA M1 , and SUTTON G1,2
1NSW OTDS, Sydney, Australia, 2The University of Sydney, Save Sight Institute, Sydney Medical School, Sydney, Australia
Introduction: The ethical responsibility the donation sector has to donors and retrieved tissue is one of stewardship. The NSW Organ and Tissue Donation Service (OTDS) has sought to embody this ethical principle by formalising the process of allocating and releasing tissue for research.
With the support of the South Eastern Sydney Local Health District Research Support Office the NSW OTDS Research Steering committee has been created and has developed research protocols and instigated the use of material and data transfer agreements to clarify the ethical and legal responsibilities of researchers.
Objectives: To outline the process and responsibilities of the NSW OTDS Research Steering Committee
Results: Since it formed in 2015, the committee has enabled 23 projects involving data, ocular tissue and solid organs.
Conclusion: The Research Steering Committee facilitates the review of all applications for access to retrieved tissue and data collated as part of the donation for transplantation process; oversees the governance of the Australian Ocular Biobank; and monitors the annual reports from researchers concerning the use of data and/or tissue and outcomes of research.
BEYOND THE DONATELIFE AUDIT
DonateLife Tasmania (DLT)
Introduction: The DonateLife Audit provides valuable information at a national and jurisdictional level to reflect progress, outcomes and provide direction in practice improvement.
To support the integration of the Clinical Practice Improvement Program (CPIP) Phase 3, DLT undertake additional ‘Greenfile’ reviews of:
• Donation requests with variances from the best practice requesting model
• Non referred patients, excluded by audit criteria, where there may have been benefit of discussing donation, or the potential for eye donation.
Objectives: • To best realise any donation opportunities, thus maximising our donor pool
• To track the uptake of having donation being considered as routine in planned end-of-life care
• To optimise our consent rate
Method: To capitalise on Donation Specialist Medical (DSM) expertise at quarterly jurisdiction audit meetings, Greenfiles are reviewed to analyse non-referred patients that were identified as having a benefit to considering donation, or donation discussions that did not reflect the best-practice requesting model. An action from the case review may be created.
Results: This young initiative has positive outcomes, including:
• Recent examples to support case studies and education
• Ability to track practice improvements
• Additional outcomes from audit meetings
• Identify barriers to organ donation or system challenges.
Conclusion: These extended criteria for reviewing potential cases will continue to provide value insight to the DLT team of activity ‘on the ground’ and anecdotal advice on embedding routine referral and the best practice model for requesting organ donation. Such case reviews will support optimising consent of our true donor pool, and alterations to the DonateLife Audit could be considered.
EFFECT OF LANGUAGE AND COUNTRY OF BIRTH ON MEDICAL SUITABILITY AND CONSENT IN SOLID ORGAN DONOR REFERRALS IN NEW SOUTH WALES 2010-2015 – A LINKED-DATA COHORT STUDY
ROSALES B1, HEDLEY J1, DE LA MATA N1, WYBURN K2,3, KELLY P1, O’LEARY M4, CAVAZZONI E4, and WEBSTER A1,5
1Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia, 2Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia 3Renal Department, Royal Prince Alfred Hospital, Sydney, Australia 4New South Wales Organ and Tissue Donation Service, Sydney, Australia 5Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia
Introduction: Culturally and linguistically diverse populations in Australia are over-represented on transplant waiting lists but under-represented in actual organ donor populations.
Objectives: We sought to compare medical suitability and family consent outcomes between donor referrals based on primary language and country of birth.
Method: We used linked-data from the NSW Biovigilance Register. This Register linked NSW donor referrals from 2010-2015 with the NSW Admitted Patient Data Collection and Emergency Department Data Collection. Effects of primary language (English vs non-English) and country of birth (Australian vs overseas born) on referral outcomes were determined using logistic regression (odds ratios with 95%CI).
Results: Of 2,977 referrals, 1,097 (37%) were medically suitable for donation. There were no differences in the proportion of referrals deemed medically suitable for English versus non-English speakers (p=0.7) or those born in Australia versus overseas (p=0.3). Medical suitability was slightly lower in referrals where language and country of birth were not reported (Table 1). Of 1,427 (48%) cases where consent was sought, 899 (63%) consented. Consent was less likely to be sought from families of non-English speakers [Odds ratio (OR) 0.68, 95%CI 0.50-0.92, p=0.01], and less likely to be given in families of non-English speakers (OR 0.50; 95%CI 0.31-0.81, p=0.005) and those born overseas (OR 0.47; 95%CI 0.34-0.65, p<0.001). There were no interaction effects (p>0.1).
Conclusion: Language and birth country impacted on family refusal for organ donation but not medical suitability
"THE CATCH-UP GROUP" - REGIONAL TRANSPLANT RECIPIENTS RECEIVING EDUCATION AND SOCIAL SUPPORT IN THEIR LOCAL COMMUNITY
Ballarat Health Services, Ballarat, Australia
Introduction: The Ballarat Transplant Recipient Catch-Up Group was formed in March 2017 to provide local transplant recipients and their carers the opportunity to come together with others who know better than anyone the ups and downs of the transplant journey. It also provides a forum for information sharing with health professionals in a relaxed, informal group environment in their local area.
Objectives: The idea for the group came from the recipients themselves, expressing the need for support and education closer to home. The ideas and themes for each catch-up are driven by the recipients and organised and coordinated by a local nurse specialist. The Catch-Up Group decreases the travel burden for regional transplant recipients who already go to the city for so much.
Method: Topics already covered included skin care, medication guidance and nutrition. Local experts volunteer their time to provide the education and advice is always sought from metropolitan transplant services when required. Based on feedback from the recipients, future sessions will include emotional/mental health and well-being support as well a focus on carer and relationship support.
Results: The Ballarat Transplant Recipient Catch-Up Group is the only group of its kind in Australia that is, a regional, community based group for transplant recipients and their carers that provides social support and education close to home. The feedback from all recipients who attend is overwhelmingly positive and they see it as a vital component of their ongoing well-being.
Conclusion: The group continues to expand its membership and aims to carry on providing quality education, support and socialisation for transplant recipients within the local community.
COMORBIDITIES INFLUENCING THE OUTCOME OF ORGAN DONOR REFERRALS IN NEW SOUTH WALES: COHORT STUDY 2010-2015
THOMSON I1, ROSALES B1, KELLY P1, WYBURN K1,2, O’LEARY M3,4, and WEBSTER A1,5,6
1Sydney Medical School, School of Public Health, University of Sydney 2Renal Department, Royal Prince Alfred Hospital, 3Intensive Care Unit, Royal Prince Alfred Hospital, 4New South Wales Organ and Tissue Donation Service (NSW OTDS), 5Centre for Transplant and Renal Research, Westmead Hospital, 6Centre for Kidney Research, Children’s Hospital at Westmead
Introduction: Efforts to increase organ donation rates in Australia have led to a rise in potential donor referrals. When assessing medical suitability for donation, donor comorbidities are an increasingly significant consideration.
Objectives: To quantify the impact of comorbidities on referral outcome, and to identify a means of eliminating potential organ donors who are unlikely to donate early in the referral process
Method: We reviewed NSW OTDS referral logs 2010-2015, considering the presence or absence of cardiac disease, vascular disease, chronic liver disease (CLD), chronic kidney disease (CKD), respiratory disease, cerebrovascular disease (CVD), hypertension, hyperlipidaemia, diabetes, malignancy, age >65 and hospital location. Outcomes were donating (donors) and not donating (non-donors). Non-donors whose families declined to consent for donation were excluded. Logistic regression [odds ratio (OR), 95% confidence intervals (95%CI)] was used to identify comorbidities significantly influencing referral outcome, and to predict the probability of becoming a donor given comorbidities.
Results: Of 2,977 referrals, family refusals excluded 669 (22%) non-donors, leaving 2,310 (78%) referrals in our analysis, of whom 668 (29%) donated and 1,642 (71%) did not. Comorbidities (Table 1), in addition to non-metropolitan hospital and absence of hyperlipidaemia, were significantly (P<0.01) associated with a referral not donating. Of these, malignancy (OR 3.91, 95%CI 2.71-5.66) and CKD (OR 3.45, 95%CI 1.99-5.98) had the greatest impact.
Conclusion: Donor comorbidities significantly influence referral outcome. Key elements of this model could be used to identify referrals unlikely to become donors, and improve the efficiency of the donor referral process in NSW.
CKD: chronic kidney disease, CLD: chronic liver disease, CVD: cerebrovascular disease.
INFORMATION TECHNOLOGY (IT) CONNECTIONS FOR A MORE EFFICIENT WORKPLACE
1DonateLife South Australia (SA), Adelaide, Australia
Introduction: Technological advancements have become part of our everyday lives; despite this, our ways of working are not always congruent with the technology available to us. Developing a custom software solution to store, manage and report data was pertinent to address short comings with out-dated approaches to data management. The development of a Structured Query Language (SQL) database to fulfil the administrative functions of a Donate Life Agency ensued.
Objectives: The key objectives of this project are quality improvement, service improvement, operational risk mitigation, and compliance:
• Quality Improvement – improved documentation and report abilities
• Service Improvement – increased accessibility and report production for communication with specific groups. Increased ability for information production/reporting
• Operational risk mitigation – minimise risk of data loss, inaccuracy and storage requirements
• Compliance – allows the organisation safe and reliable storage of information for the required timeframes set by the General Disposal Schedule and legislation compliance.
Method: Development of an SQL database in consultation with a government Information and Communications Technology (ICT) department to replace outdated Microsoft excel and access databases.
Results: Since 2017, SA Health ICT designed and supported the SQL database; the database records all referrals and all cases. The database is able to receive Australia and New Zealand Organ Donation (ANZOD) imports from the Electronic Donor Record (EDR) for actual donor cases.
Conclusion: The database has fundamentally changed the ways that staff interact with data and made the process more efficient, safe and accurate. The use of contemporary data management software can provide significant improvements for the way that Donate Life Agencies conduct daily operations.
BLOODBORNE VIRUS INFECTIONS IN NEW SOUTH WALES ORGAN DONOR REFERRALS: THE SAFE-BOD COHORT 2010-2015
DE LA MATA NL1, WALLER K1, Hedley JH1, ROSALES B1, O’LEARY M4, CAVAZZONI E4, KELLY PJ1, WYBURN K2,3, and WEBSTER AC1,5
1School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia, 2Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia, 3Renal Unit, Royal Prince Alfred Hospital, Sydney, Australia, 4New South Wales Organ and Tissue Donation Service, Sydney, Australia, 5Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia
Introduction: Misclassification of bloodborne viruses (BBV) may lead to potential donors being unnecessarily declined, or to infected donor organs being used.
Objectives: To compare perceived BBV risk at referral with verified BBV risk using linked health datasets
Method: We included all donor referrals 2010-2015 from the NSW Biovigilance Public Health Register (SAFEBOD). This Register linked organ donor referrals and transplant recipients in NSW to administrative health databases, including the hospital admissions data and notifiable conditions information management system. Perceived BBV risk was based on information available at referral, including serology, nucleic acid testing, and high-risk history. Verified BBV risk was based on ICD-10-AM codes indicating active infection, past infection and exposure to Human Immunodeficiency Virus (HIV), Hepatitis B virus (HBV) and Hepatitis C virus (HCV) in the Register. We used cross tabulations and Cohen’s Kappa to compare perceived and verified BBV risk.
Results: Of 2,934 donor referrals, 1,990 were either not medically suitable or their family declined consent. Among 944 remaining referrals, agreement between perceived and verified BBV risk occurred for 807 persons (789 baseline BBV risk; 14 active BBV infection; 4 past BBV infection) (Table 1). The agreement for any active BBV infection was 93% (Kappa=0.27, p value<0.001). Ten referrals perceived to have baseline risk were verified with active BBV infection (1 HIV; 3 HBV; 3 HCV; 3 HBV and HCV). Perceived high risk behaviour (n=27) and active infection (n=2) were not verified.
Conclusion: Data linkage to existing administrative health data can aid assessment of donor referrals, revealing unrealised biovigilance risk to recipients and potential additional donor opportunities.
EXAMINING THE INCREASED RATES OF DECEASED DONOR KIDNEY NON-UTILISATION IN AUSTRALIA: WHAT HAS CHANGED?
SYPEK Matthew P1,2,3, ULLAH Shahid1,4,5, HUGHES Peter D2,3, CLAYTON Philip A1,4,5,6, and MCDONALD Stephen P1,4,5,6
1Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia, 2Dept of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia, 3Dept of Nephrology, Royal Melbourne Hospital, Australia, 4South Australian Health and Medical Research Institute, Adelaide, Australia, 5Adelaide Medical School, University of Adelaide, Australia, 6Central and Northern Renal and Transplantation Services, Central Adelaide Local Health Network, Adelaide, Australia
Background: From 2013, Australia has experienced a sustained increase in the proportion of deceased donor kidneys that are retrieved but not utilised for transplantation. We aimed to determine whether this could be explained by changes in donor characteristics over time.
Methods: Registry data were used to examine predictors of kidney non-utilisation over the period 2005-2017. Multi-level mixed effect logistic regression modelling and propensity score analysis were used to determine if era of donation (2013-2017 vs 2005-2012) was an independent predictor of organ non-utilisation after controlling for donor characteristics.
Results: A total of 7,810 kidneys were retrieved for the purpose of transplantation with 334 (4.3%) not utilised. The non-utilisation rate was 5.8% in 2013-2017 compared to 2.7% in 2005-2012. Despite adjustment for donor characteristics, donation in the more recent era remained a significant predictor of kidney non-utilisation [adjusted odds ratio (OR) 1.98, 95%CI 1.54-2.54, p<0.001]. This finding was confirmed in the propensity score analysis.
Conclusion: Kidneys retrieved in Australia since 2013 were more likely not to be utilised for transplantation even after adjusting for changes in donor characteristics. The abrupt increase may be explained by increased clinical risk aversion, changes in unmeasured donor factors or logistical issues. Although non-utilisation rates in Australia remain low by international standards, further clinical auditing of the reasons for offer decline may help to optimise resource utilisation and maximise transplant opportunities.
USING BEHAVIOURAL INSIGHTS TO TEST MESSAGE EFFECTIVENESS IN VICTORIA
JONES A1, and STOREY P2
1Behavioural Insights Unit, Public Sector Innovation, Department of Premier and Cabinet, Melbourne Australia
Introduction: DonateLife Victoria worked collaboratively with the Department of Premier and Cabinet’s Behavioural Insights Team and VicRoads to test the effectiveness of various messages about organ donation, against a control message.
Objectives: The project objectives were to identify which message:
1. will encourage the most people to click-through to the DonateLife website
2. has the best conversion to registrations.
Method: The messages were displayed as side banner ads on the ‘Renew your license’ webpage. The page randomly displayed two variants of the banner ad at one time, with a ‘winner stays on’, A/B model adopted for this trial. Five trial blocks ran for a total of seven weeks each.
Five messages were tested:
1. Control message: Click here to join the Australian Organ Donor Register today.
2. Reciprocity: If you’d say yes to a lifesaving transplant, have you said yes to being an organ donor?
3. Priming: Did you tick the organ donor box on your driver’s license? It’s time to confirm your registration.
4. Image: Using an image of young transplant recipient, with the control message.
5. Gain frame: One organ and tissue donor can save more than 10 lives.
Results: The ‘priming’ message was the most successful in attracting click-throughs.
The ‘gain frame’ message delivered the most registrations; however the results were not statistically significant and this could be entirely due to chance.
Conclusion: Using the context from the ‘priming’ message on the VicRoads site was the most successful way to engage the audience on this particularly site.
USING VOLUNTEERS TO INCREASE ORGAN DONATION REGISTRATION IN VICTORIA
STOREY P1, and JONES A2
Introduction: DonateLife Victoria (DLV) has more than 80 active, trained volunteers, supported by a full-time Community Engagement Coordinator. The Coordinator recruits and trains volunteers and works to keep them engaged in the program.
The program has been used for more than ten years to increase Australian Organ Donor Register (AODR) registrations. In 2018, we used this workforce to attend the Royal Melbourne Show – our biggest event ever.
Objectives: The show runs for 10 hours a day, for 11 days. We wanted to attend this event using almost entirely volunteers.
Method: Due to the size and complexity of this event, a tailored approach was required. This included:
- gauging volunteer interest and availability
- developing a comprehensive roster, including allocated break times
- hosting a tailored training session to prepare volunteers for the event
- giving the volunteers tailored tools and resources for the show, and consistent language
- asking the volunteers to track results, so that we could easily evaluating the success of the show.
Results: Eighteen volunteers, supported by six staff, contributed 221 hours, averaging 12 hours per volunteer.
Based on Australian Bureau of Statistics figures, volunteers are worth $41.72 per hour; making these shifts worth $9,220.
If DLV paid staff for these hours, it would have cost more than $18,000.
With at least three people at our stand at all times, we registered 950 new AODR registrations, with 350+ checks. The following month saw more than 5,000 new registrations – a clear flow-on from this event.
Conclusion: Investing in a volunteer program saves money, time and resources, and delivers outstanding results when supported properly.
FACILITATING ORGAN DONATION IN EXPEDITED TIME FRAMES: THE VICTORIAN EXPERIENCE
D’COSTA RL1,2, RADFORD S1,3, OPDAM H3,4, MCEVOY L3, MCDONALD M4, and BELLOMO R3
1Donatelife Victoria Carlton, 2The Royal Melbourne Hospital, Parkville, 3The Austin Hospital, Heidelberg, 4Organ and Tissue Authority, Canberra
Introduction: With the expansion of the donor pool, organ donation coordination has become increasingly complex, requiring collaboration to support families, obtain consent, organise risk assessment, organ allocation and coordination of retrieval surgery. Typically these aspects require around 24 hours of work-up prior to retrieval; however physiological instability or family circumstances may require an expedited process.
Objectives: (1) To describe trends over time in numbers of donors via the expedited pathway relative to the broader donor pool and describe the demographic, clinical and donation details of this group.
(2) To describe operational requirements for expedited donation.
Method: A retrospective audit of the Electronic Donor Record (EDR) was undertaken for Victorian actual and intended donors between 1 April 2014 and 30 March 2018. Those who donated (or died without donating) within 6 hours of formal consent were considered to represent the expedited donor group.
Results: A total of 30 solid organ donors met the expedited criteria within the study period. Of the expedited group, 23 were due to physiologic instability, and seven were due to family circumstances. The majority of the physiologically unstable group were on high doses of vasoactive agents: 22/23 on Noradrenaline (mean dose 0.85 mcg/kg/min), 12/23 on adrenaline (mean 0.82 mcg/kg/min) and 11/23 on arginine-vasopressin (mean 0.06 Units/kg/hr). Two patients deteriorated to cardiac arrest prior to retrieval and in one cardiopulmonary resuscitation (CPR) was attempted (unsuccessfully). In both, a retrieval team was rapidly assembled and donation proceeded. Twenty-nine of the 30 expedited donors had kidney retrieval with 86% of these organs were transplanted.
Conclusion: Donation in expedited timeframes is feasible and represents an important part of donor pool expansion in Victoria.
DONOR REFERRALS WITH PRIMARY BRAIN TUMOUR – PERCEIVED VS VERIFIED RISK
HEDLEY J1, THOMSON I2, DE LA MATA N1, ROSALES B1, O’LEARY M3, CAVAZZONI E3, KELLY P1, WYBURN K2,4, and WEBSTER A1,5
1Sydney School of Public Health, Faculty of Health and Medicine, University of Sydney, Sydney, Australia, 2Sydney Medical School, Faculty of Health and Medicine, University of Sydney, Sydney, Australia 3New South Wales (NSW) Organ and Tissue Donation Service, Sydney, Australia, 4Renal Unit, Royal Prince Alfred Hospital, Sydney, Australia, 5Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia
Introduction: In Australia, organ donation is not contraindicated for referred donors with most types of primary brain tumour (PBT). However, the perceived risk of transmission is based only on information available at referral, which may be incomplete or inaccurate.
Objectives: We sought to determine the accuracy of perceived risk of PBT transmission at the time of referral compared to verified risk using linked-data.
Method: We used organ donor referrals 2010-2015 from the NSW Biovigilance Register. This Register linked NSW organ donor referrals and transplant recipients to NSW Admitted Patient Data Collection and the Central Cancer Registry. We classified risk based on tumour type using the Transplant Society of Australia and New Zealand (TSANZ) guidelines. Perceived risk was determined from referral logs, with verified risk based on the NSW Biovigilance Register.
Results: We analysed 2,934 people referred for donation and identified 78 (3%) with PBT; 11 (14%) from referral logs, five (6%) from other health records, and 62 (79%) from both. The perceived risk agreed with verified risk in 66 referrals (85%), was higher than the verified risk in nine (12%), and lower in three (4%). Cohen’s Kappa was 0.83 (p<0.001) suggesting good agreement. All 11 (14%) who became actual donors were verified to be minimal risk with disagreement in one (9%) perceived low risk.
Conclusion: Assessment of PBT transmission risk cannot always be determined accurately at referral. Perceived risk is more frequently overestimated than verified risk, suggesting risk adverse decision-making. Evidence-based decision support may have a future role.
PAEDIATRIC LUNG TRANSPLANTATION AT THE ALFRED: THE CHALLENGES OF SMALL PATIENTS IN A BIG COUNTRY
Bourne B1 , PARASKEVA M1,2 , WESTALL G1,2 , SNELL G1,2 , and LEVVEY B1,2
1The Alfred Hospital, Melbourne, Australia, 2Monash University, Melbourne, Australia
Introduction: The Alfred Hospital (AH), in collaboration with the Royal Children’s Hospital (RCH) Melbourne, has hosted the nationally funded centre (NFC) Paediatric Lung Transplantation (pLTx) program since its development in 2011. Prior to this, pLTx were performed infrequently at both RCH and AH.
Objectives: To review the activity and challenges of pLTx at the AH
Method: Data was included from all AH pLTx recipients aged ≤18years at the time of transplant. Paediatric lung transplantation matching, surgery and recovery out to 3 months was all undertaken at AH. Interstate patients then return home and Victorian recipients continue to be followed at the AH for life.
Results: Between 1996 and 2018, 52 pLTx have been performed, 35 of those females, mean age 13.5 (range 5-18), mean weight 38kg (range16-70kg). Their home states were Victoria 38%, New South Wales 15%, Queensland 15%, Western Australian 14%, South Australia 12% and Tasmania 6%. There were 6 heart-lung transplants and 46 bilateral lung transplants. Mean waiting time was 146 days (range 0-777). Mean donor age was 24.6 years (range 3-61).
Conclusion: The AH NFC pLTx service provides timely access to pLTx for all Australian children, with outcomes comparable to international benchmarks.
INCIDENCE OF HEPATITIS C VIRUS IN INCREASED RISK POPULATIONS WITHIN AUSTRALIA: IMPLICATIONS FOR ORGAN DONATION
DUTCH M1, ARMSTRONG E2, MALCHER K1, and ALLAN W3
1Royal Melbourne Hospital, Melbourne, Australia, 2Austin Hospital, Melbourne, Australia, 3Ambulance Victoria, Melbourne, Australia
Introduction: As part of initiatives to improve access to organ donation, elevated risk populations for Hepatitis C (HCV) may be considered for donation to HCV negative recipients. The risk of transmission of window-period HCV infection from these donors can be estimated from the incidence of Human Immunodeficiency Virus (HIV) in the donor population.
Objectives: This study aims to identify HCV incident rates within elevated risk populations within the Australian context and calculate the associated risk of disease transmission for each group.
Method: A structured literature review was undertaken to identify studies of Australian populations which reported incident rates for HCV. Incident rates and risk of transmission are reported for individual studies and when possible on pooled cohorts.
Results: The search strategy identified 98 articles, of which 39 met the inclusion criteria. The studies reported incident rates in 85 selected populations and subpopulations. When data was pooled for elevated risk groups, transmission rates were lowest in men who have sex with men, and highest in intravenous drug users. Pooled incident rates varied between 0.1 and 18.4 per 100 person years respectively. This equated to window period transmission risks of between 1 in 320,000 and 1 in 1,980 per day.
Conclusion: This review describes the incidence of HCV infection in various Australian populations, including a number of novel evolving risk cohorts (eg. direct acting antivirals treated cohorts). The low risks of transmission from many elevated risk group cohorts supports attempts to implement routine referral of all potential organ donors regardless of social and behaviour risk factors for HCV.
ORGAN DONATION AFTER VOLUNTARY ASSISTED DYING
1Organ and Tissue Authority, Canberra, Australia, 2Cabrini Hospital, Melbourne, Australia, 3Monash University, Melbourne, Australia 4Melbourne Law Masters, Melbourne, Australia
Introduction: On June 19, 2019, the Voluntary Assisted Dying (VAD) Bill Victoria will be enacted. Up to ten percent of people deemed eligible for VAD will be medically suitable for organ donation. There are important challenges to address for donation to be successful in this context.
Conclusion: There is an accepted precedent for nearly all aspects of donation after assisted dying, although there are a number of specific considerations. Firstly, the decision to be a donor will require that a health care team unknown to the person and their family supervises death, at a time which is influenced by the needs of the health care team and recipients, and in a hospital environment which may not have otherwise been the person’s choice. Secondly, consent for donation and also for ante mortem interventions will be first person contemporaneous consent. Third, there is a need to prevent the opportunity of organ donation contaminating assessment of eligibility for VAD. Finally, there is a possibility that someone deemed eligible for VAD will end their lives prematurely purely in order to support their wish to be a donor.
There is a need to identify and support the potential for organ donation after VAD, and it is timely to begin a conversation about how best to do this. We must develop appropriate processes for donation in this unique context, and we must inform and support health care professionals in order to enable their role.
THE PATHWAY FOR EFFICIENT, SUSTAINABLE AND SUFFICIENT TISSUE DONATION AND TRANSPLANTATION IN AUSTRALIA
HERSON M1, and MARTIN DE1
1Deakin University, Geelong, Australia
Introduction: Tissue donation changes the lives of thousands of Australians every year – from restoration of eyesight, to regained mobility, to survival from trauma. The community, including donors, their families and health professionals trust that the practice of donation, graft manufacturing and transplantation respects human dignity, reflects the values of altruism, solidarity and reciprocity and promotes equitable access to human tissues and tissue products. However the goal of meeting national demand for such medical products of human tissue origin is threatened by diverse challenges in the sector. These include insufficient national tissue donation rates, constrained tissue banking capacity and financial issues impacting on manufacture and distribution of tissue products, and on innovation. Some commercial practices jeopardise the altruistic values inherent to tissue donation and may potentially inhibit donation and future access to therapies.
Objectives: This presentation will review the elements that, based on agreed ethical principles, are required for an efficient, sustainable and sufficient tissue donation and transplantation program. These elements include the mechanism for monitoring demand and align supply, optimization of tissue donation, increased manufacturing efficiencies, cost transparency, resources towards innovation, regulation of commerce and controlled movement of tissues and tissue products across international borders.
Conclusion: Altruistic donation and ethical values entail the expectations of equitable and reliable access to the benefits of donated human tissues in Australia. An efficient, sustainable and sufficient tissue donation and manufacturing sector is essential to meet these expectations and will depend on effective policies, appropriate governance, and public support and investment in the sector.
CANCER INCIDENCE IN DONOR REFERRALS, A NEW SOUTH WALES COHORT STUDY 2010-2015 USING DATA LINKAGE
HEDLEY J1, DE LA MATA N1, ROSALES B1, O’LEARY M2, CAVAZZONI E2, KELLY P1, WYBURN K3,4, and WEBSTER A1,5
1Sydney School of Public Health, Faculty of Health and Medicine, University of Sydney, Sydney, Australia, 2NSW Organ and Tissue Donation Service, Sydney, Australia, 3Sydney Medical School, Faculty of Health and Medicine, University of Sydney, Sydney, Australia, 4Renal Unit, Royal Prince Alfred Hospital, Sydney, Australia, 5Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia
Introduction: Detailed medical history is not always available at donor referral, impeding suitability assessment. Donor referrals with possible cancer history may be rejected if details are uncertain. Timely cancer verification could reduce potential missed donor opportunities.
Objectives: We sought to determine cancer incidence in donor referrals by primary site, and to compare the information available at time of referral with linked administrative health-data.
Method: We used organ donor referrals 2010-2015 from the NSW Biovigilance Register. This Register linked donor referrals and transplant recipients to the NSW Admitted Patient Data Collection and Central Cancer Registry. Primary cancer site was grouped using ICD-10-AM codes.
Results: Of 2,934 people referred for donation, 433 (15%) had cancers reported at time of referral (458 cancers). Of these, 272 cancers (59%) were also reported in NSW health datasets. The most common cancers reported at time of referral were 76 (3%) brain, 44 (1%) colorectal, 42 (1%) breast, 34 (1%) leukaemia, 33 (1%) lung, 33 (1%) prostate, and 30 (1%) melanoma (Table 1). Among these 292 most common cancers, 191 (65%) were verified. Brain cancers were the most frequently unverified. Agreement was highest in cancers of the prostate (94%), colorectal (77%), melanoma (77%) and breast (74%). Lowest agreement was found in cancers of the brain (42%) and leukaemia (56%) (Table 1).
Conclusion: Cancers are quite commonly reported for donor referrals, but many cancers cannot be verified in the cancer registry, suggesting misclassification. Real-time health record access at referral could clarify uncertainty and potentially increase donation.
INCIDENCE, PREVALENCE AND RESIDUAL RISK OF BLOOD BORNE VIRUS INFECTION WHEN AUSTRALIAN ORGAN DONOR REFERRALS WITH INCREASED RISK TEST NEGATIVE: A SYSTEMATIC REVIEW AND META-ANALYSIS
WALLER K. 1, DE LA MATA N.1, KELLY P.1, RAMACHANDRAN V.2, RAWLINSON W.2, WYBURN K., and WEBSTER A.
1Sydney School of Public Health, Faculty of Health and Medicine, University of Sydney, Sydney, Australia, 2Serology and Virology Division, NSW Health Pathology, Prince of Wales Hospital, Sydney, Australia, 3Sydney Medical School, Faculty of Health and Medicine, University of Sydney, Sydney, Australia, 4Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, Australia, 5Centre for Renal and Transplant Research, Westmead Hospital, Sydney, Australia
Introduction: Donor referrals with increased risk behaviours who test negative for blood borne viruses are potential organ donors. However, window or eclipse period infections (between exposure and tests becoming positive) may pose risk to recipients.
Objectives: To estimate the incidence of Human Immunodeficiency Virus (HIV), Hepatitis C virus (HCV) and Hepatitis B virus (HBV) viruses, among increased risk groups in Australia, and hence infer the residual risk of window period infection for organ donors with negative testing.
Methods: We performed a systematic review and meta-analysis of studies in 2000-2017 that reported original estimates of Australian HIV, HCV or HBV prevalence or incidence in increased risk groups. Pooled incidence rates were estimated using random effects. The estimated probability of window period infection assumed days since infection followed an exponential distribution.
Results: Of the 55 studies, most reported HIV and HCV in MSM (men who have sex with men), IDU (intravenous drug users) and prisoners. The absolute residual risk of HIV infection remained low in all increased risk groups; the highest was MSM with 6.2 (95% CI 4.4–8.0) estimated window period infections per 10,000 not detected with negative enzyme immunoassay (EIA) testing (Table 1). HCV and HBV incidence were highest in IDU. For HCV, 330 (95% CI 198–459) window period infections are estimated per 10,000 IDU testing negative on enzyme immunoassay (EIA), reducing to 24 (95% CI 14-34) per 10,000 with negative Nucleic Acid Testing (NAT).
Conclusions: Local risk estimates of bloodborne virus window period infection risk can aid decision-making when considering donors from increased risk groups.
MALARIA TESTING: A BLESSING OR A CURSE
Queensland Tissue Bank (QTB), Brisbane, Australia
Introduction: The QTB assesses living and deceased donor patients against Therapeutic Goods Order (TGO) number 88. According to the TGO 88, patients who have lived in or visited a malaria endemic area in a defined time period require malaria testing to be completed in order to accept the donated tissue for transplant. Without this testing, patients who are in the malaria risk category are excluded from donation.
Objectives: To review the QTB malaria data captured over the last four years and determine if there is scope to eliminate malaria testing for a specific travel risk group
Method: Travel history for each donor patient is reviewed and collated along with malaria test results.
Results: Approximately 500 donors have been tested as part of the QTB screening process. Only 4.5% of those patients have returned a reactive malaria test result and have been excluded from donation. Less than 1% of patients who travelled to a malaria endemic area in the last 12 months returned a positive result.
Conclusion: Donor patients who have travelled to a malaria endemic area within the last 12 months represent an extremely low risk. Consideration should be given to removing the malaria testing requirement for these patients. For living donor patients who can be tested, there would be little change to the donation rate. However, for deceased donor patients where there is no ante mortem sample for testing, removing the requirement to test these patients could lead to increased donor numbers and increased tissue available for recipients.
A PROSPECTIVE GRADING SYSTEM FOR FAMILY DONATION CONVERSATIONS
RADFORD S 1,2,3, JONES D2,4, OPDAM H2,3,5, D’COSTA R1,3,6, MCDONALD M5, BAILEY M4,7, and BELLOMO R2,3,7
1DonateLife Victoria (DLV), Melbourne, Australia, 2Austin Health, Melbourne, Australia, 3University of Melbourne, Melbourne, Australia, 4Monash University, Melbourne, Australia, 5Organ and Tissue Authority, Canberra, Australia, 6Melbourne Health, Melbourne, Australia, 7Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Melbourne, Australia
Introduction: There is a substantial difference between levels of public support for organ donation (OD) and observed consent rates in Family donation Conversations (FDCs). We propose a simple grading to be used prior to FDCs to predict consent likelihood. This grading can ensure best trained requesters are utilised in FDCs predicted to have a low consent rate.
1) Demonstrate frequency and consent rates by FDC grade
2) Demonstrate consent rate by levels of training and FDC grade
Method: Permission to access 2017 Australian DonateLife Audit aggregate consent and training data obtained from all Australian states and territories.
All data was stratified into four grades of FDC:
Results: Grade I FDCs were relatively rare (7.7%, 109/1420) with a high consent rate of 95.4% (104/109). Grade IV FDCs made up the majority (60.4%, 857/1420) with the lowest consent rate of 41.4% (355/857).
Training was associated with marked differences in Grade IV FDC consent rate. Donation specialist consent rate of 53.5% (189/353) was substantially greater than both untrained requesters at 32.8% (78/238) (p <0.00005, OR 2.36, 95% CI 1.68-3.53) and FDC trained requesters at 33.1% (88/266) (p <0.00005, OR 2.33, 95% CI 1.68-3.24).
Conclusion: Clinicians embarking on an FDC can predict the likelihood of consent using two easily obtained variables to stratify into four grades. This allows prospective identification of Grade IV FDCs with a low but modifiable likelihood of consent. Grades I-III FDCs have high consent rates that were not modifiable with training. FDC training alone had minimal impact on consent rate in Grade IV FDCs.
Grade IV FDCs should be undertaken by donation specialists in order to achieve consent rates that best match Australian public opinion.
KNOWING THE RISK – BREAST CANCER AND ORGAN DONATION
HEALY C 1,2, DA COSTA R2,3, and PILCHER D1,2,3
1The Alfred Hospital, Prahran, Melbourne, Australia, 2DonateLife Victoria (DLV), Melbourne, Australia, 3The Royal Melbourne Hospital, Parkville, Victoria, Melbourne, Australia
Introduction: A history of breast cancer has traditionally been considered a contraindication for solid organ donation in Australia due to the risk of late disease recurrence in potential donors.
Objectives and methods: To describe a case of organ donation from a patient with a history of breast cancer
Results: A 54 year old woman with a history of breast cancer was referred for organ donation following admission with a non-survivable intracranial haemorrhage. Resolution of initial haemodynamic instability allowed time to investigate her cancer history further.
In 2006 she had been diagnosed with oestrogen receptor positive Tumour(T) 1, Node(N) 2, Metastasis(M) 0 invasive ductal carcinoma, with two out of 14 local nodes positive. She underwent wide local excision with adjuvant chemo-radiotherapy and bilateral oophorectomy. She was subsequently discharged well from regular oncology follow-up in 2011. In the Intensive Care Unit, she underwent clinical and ultrasound examinations of both breasts, and whole body computed tomography (CT) scan, which showed no evidence of malignancy. After review by three oncologists (two of whom were breast cancer specialists), heart, lungs, liver and kidneys were referred for transplantation. Donation surgery occurred seven days after admission to ICU and 12 years after her initial diagnosis of breast cancer. Lungs were transplanted into an interstate male recipient aged over 60 years. One kidney was transplanted into a young female interstate recipient, with the other kidney discarded due to anatomical abnormalities.
Conclusion: With careful work-up and risk assessment, patients with a distant history of breast cancer may be suitable for solid organ donation.
AVAILABILITY OF MUSCULOSKELETAL TISSUE FROM AUSTRALIAN DECEASED DONORS
1PlusLife (Perth Bone and Tissue Bank), Perth, Australia
Introduction: Anecdotal evidence suggests there is a significant shortfall of donated musculoskeletal tissue within Australia to meet the current surgical demand. Shortfall figures of greater than 30% have been used as a justification to import cadaveric tissue from outside Australia, but there is no published data to support it.
Objectives: To establish if there is evidence to support the premise that there is a shortfall of Australian sourced human tissue for implant within Australia that justifies the importation of unprocessed cadaveric tissue
Method: Records of deceased donation levels for the past 10 years were reviewed in conjunction with inventory levels of tissue held and incidents of ‘non-supply’ events, across the same time period.
Results: Records show that there has been a net increase in the level of donation of deceased tissue in Australia over the period and a disproportionate increase in the level of inventory of transplantable tissue held, indicating a diminished demand for Australian tissue.
Conclusion: The levels of donated tissue from Australian deceased donors are at levels where there is a surplus of supply over existing demand.
Our promise to donor families is that we will ensure the ethical use of their donated tissue. This surplus of supply presents tissue banks with the ethical dilemma of considering refusal of cadaveric donations if there is no realistic chance that the tissue will be utilised.
As the quantity of available tissue from deceased donations outweighs demand, it can be concluded that the supply of non-Australian sourced tissue is detrimental to the continued supply of Australian donated tissue by Australian tissue banks, threatening the viability of both the Australian tissue banks and the Australian tissue donor program.
BEYOND THE TRADITIONAL DONOR: FIRST PERSON CONSENT IN A PATIENT WITH A HIGH GRADE NEUROLOGICAL MALIGNANCY
HEDGES O 1,2, GANTNER D2, THOMPSON S1,2, HEALY C1,2, D’COSTA R1, and PILCHER DV1,2
1DonateLife Victoria (DLV), Australia, 2Department of Intensive Care, The Alfred Hospital, Commercial Road, Vic 3004, Australia
Introduction: Solid organ donation from patients with high grade neurological malignancy is rare, as is first person consent to donate.
Objectives and methods: We present a case of a patient with terminal neurological malignancy who expressed his wish to be a donor and went on to successfully donate.
Results: A 42 year old man with a known glioblastoma multiforme (GBM) was admitted to The Alfred Hospital. GBM had been diagnosed in 2016, when he underwent resection with adjuvant radiotherapy. Recurrence was noted in 2018 and he was subsequently admitted for palliative care.
While on the general ward, he and his wife raised the possibility of organ donation and he was referred to DonateLife. Specialist opinions from oncology, neurology and transplant units were sought. An Intensive Care Unit admission was discussed with the patient and his wife. He was intubated the following day. Two days later cardio-respiratory supports were electively withdrawn to facilitate controlled donation after circulatory death. Cessation of circulation occurred at 14 minutes. He went on to donate lungs, kidneys and eyes to seven recipients. At routine follow up five months later, all seven recipients were well.
Conclusion: This case highlights the potential for pursuing organ donation outside the traditional referral criteria. It suggests new possibilities for donation, not only for those with neurological malignancies but also for patients on the ward who are not typically seen as part of the donor pool.
TWELVE YEARS OF INCREASING ADMISSIONS FROM THE EMERGENCY DEPARTMENT TO INTENSIVE CARE UNIT FOR POTENTIAL ORGAN DONATION
PILCHER DV 1,2, DUTCH M3, and OPDAM H4,5
1The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resources Evaluation (CORE), Camberwell, Victoria, Australia, 2The Alfred Hospital, Prahran, Vic 3004, Australia, 3The Royal Melbourne Hospital, Parkville, Victoria, Australia, 4DonateLife Victoria, Australia, 5The Austin Hospital, Heidelberg, Victoria, Australia
Introduction: Potential organ donors are sometimes identified in the Emergency Department (ED). It is unknown if admissions to the Intensive Care Unit (ICU) from ED to facilitate organ donation over time have changed or whether there is significant variation throughout Australia.
Objectives: To assess temporal and regional differences in admission to ICU for organ donation from ED
Methods: Data on admissions to Australian ICUs between January 2007 and September 2018 were extracted from the ANZICS Adult Patient Database. Admissions for potential organ donation and their source of admission were identified. Smaller regions of Australia were collapsed into one group ‘Other’ to compare with Queensland, New South Wales and Victoria.
Results: Over the 12-year period, 1,444,625 admissions to 171 ICUs were identified of whom 371,151 (26%) were admitted from ED. There were 1,342 admissions for potential organ donation, of whom 1,037 (77%) were admitted from the ED. There was a progressive rise in the absolute number and proportion of patients admitted to ICU from ED for potential organ donation in all regions of Australia (P<0.001). Victoria had the highest number admitted for potential organ donation per 1000 admissions from the ED (Victoria 3.6 vs Queensland 2.5 vs NSW 2.3 vs Other 2.1, P<0.001).
Conclusion: Despite overall increases in admissions to ICU for potential organ donation, further work is required to determine whether regional variation implies additional potential for donation in EDs outside Victoria or whether this is explained by differences in baseline patient characteristics and timing of prognostication.
SHOULD CLINICAL SUSPICION OF ISCHAEMIC BOWEL PRECLUDE DONATION? A REVIEW OF TWO CASES
SILVESTER W 1, PLAS M1, and D’COSTA R1
1DonateLife Victoria, Melbourne, Australia
Introduction: Amongst the medical conditions that may preclude organ donation, ischaemic bowel in the donor is of great concern as it signifies suboptimal perfusion of abdominal organs. This possibility is considered in donors with hyperlactataemia and vasopressor dependence.
Objectives: To raise awareness that organ donation should be pursued in a clinical presentation consistent with ischaemic bowel until proven to be not medically suitable.
Method: Two recent potential donors in Victoria were processed along standard practice guidelines and proceeded to multiorgan donation. The clinical progress is presented.
Results: A 44 year-old and a 22 year-old, with cardiac arrest periods of 60 minutes in both, subsequently had lactate levels of 12.4 and 9.1 respectively, along with dependence on very high infusion rates of noradrenaline, adrenaline and vasopressin. Retrieval surgeons considered abdominal organs were likely to be not medically suitable but agreed to proceed with retrieval surgery. No ischaemic bowel was found, all four kidneys perfused well and all four recipients are off dialysis.
Conclusion: A clinical presentation of ischaemic bowel should not preclude workup for organ donation.
INCREASED VIRAL RISK DONORS - PRESENTATION OF FIRST EIGHT VICTORIAN CASES
SILVESTER W 1, PLAS M1, GRAMNEA I1, SENG N1, MCEVOY L1, and D’COSTA R1
1DonateLife Victoria (DLV), Melbourne, Australia
Introduction: In response to concern about viral transmission to kidney recipients a new parallel Victorian kidney waiting list has been established for those potential recipients who have consented to receive a kidney from an increased viral risk donor (IVRD). The first eight cases considered under the IVRD criteria are presented.
Objectives: To raise awareness about the Victorian IVRD protocol through practical presentation of cases, to complement presentation of the principles and theory (being presented by Dr J Whitlam)
Method: Prospective donor and recipient data has been collected and analysed since commencement of the protocol of the donors satisfying the criteria of:
1) increased risk behaviour
2) within the Nucleic Acid Testing (NAT) window period for Hepatitis B virus (HBV) and Hepatitis C virus (HCV) and Human Immunodeficiency Virus (HIV)
3) no evidence of active infection and 4) not meeting exclusion criteria.
Results: Between 19 August and 8 December 2018 there were eight donors satisfying the criteria. Their average age was 41 years, 63% were male, cause of death was drug overdose or hanging in 75% of cases, the median Kidney Donor Profile Index (KDPI) was 38. Sixty-three percent proceeded along the Donation following Circulatory Death (DCD) pathway. From seven actual donors, 13 kidneys, three lungs, one heart and one liver were retrieved. The increased risk behaviour was intravenous drug use in 75% of cases and sexual risk in 38%. To date there is no evidence of viral transmission to recipients.
Conclusion: The IVRD protocol thus far appears to be a safe protocol that enables the transplantation of higher risk organs to consenting recipients who would otherwise have remained on the waiting list.
THE CHALLENGES OF SUCCESS
1DonateLife Victoria (DLV), Melbourne, Australia, 2The Alfred Hospital, Melbourne, Australia, 3The Austin Hospital, Melbourne, Australia, 4Monash Medical Centre, Melbourne, Australia, 5The Royal Melbourne Hospital, Melbourne, Australia, 6Interstate transplant units, Sydney/ Brisbane, Australia, 7New South Wales Organ and Tissue Donation Service, Sydney, Australia, 8DonateLife Queensland, Brisbane, Australia
Introduction: Donation rates have increased significantly in Victoria in 2018 thanks to the generosity of donors and their families. This success has an impact on all of the stakeholders involved in facilitating donation. Coordinating donation cases has become increasingly complex with the diverse donors and competing requirements of all involved. As donor numbers continue to rise, dynamic solutions to resourcing and coordinating donation need to be explored.
Objectives: This presentation will explore the effects of success on the stakeholders, the impact of increased donor numbers on coordination of cases and look forward to pose the question of where to from here.
Method: Review of referrals, donation cases and transplants through the data collected and engaging with stakeholders both locally and Interstate.
Results: It is anticipated that this presentation will show that as a result of an increase in donor numbers there has been significant impact on stakeholders which leads to both increased donor numbers and increasing challenges in coordinating donation cases.
Conclusion: With donation rates increasing this review will explore the impacts on stakeholders, coordination of cases and how the donation and transplantation sectors can sustain growth into the future.
ORGAN DONORS WITH A HISTORY OF CANCER - A REVIEW OF 35 VICTORIAN CASES SINCE 2014
SILVESTER W 1, MCEVOY L1, and D’COSTA R1
1DonateLife Victoria (DLV), Melbourne, Australia
Introduction: DLV has proactively sought to consider all potential organ donors whilst not risking transmission of cancer to recipients. The consideration of donation from patients with a history of cancer is undertaken with advice from a panel of oncologists.
Objectives: To retrospectively review organ donation in all donors since 2014 with a history of cancer.
Method: Data collected from all Victorian donors from April 2014 to December 2018 including demographics and medical history for potential and actual donors and outcomes for recipients.
Results: There were 55 donors with a history of cancer with 35 actual donors and 82 organs transplanted. There were 15 different cancer types. Restrictions were applied to minimise transmission risk. These will be presented. To date there have been no cases of cancer transmission.
Conclusion: Some patients with a history of cancer can be considered for organ donation without increasing the risk of cancer transmission.
THE ROLE OF THE VICTORIAN DONATELIFE MEDICAL CONSULTANT
SILVESTER W1, PILCHER D1, RADFORD S1, MCEVOY L1, and D’COSTA R1
1DonateLife Victoria (DLV), Melbourne, Australia
Introduction: DLV has had a Consultant on Call (COC) service since inception. The COC advises on many aspects of the donation process from medical suitability through to coronial issues. DLV also consults a ‘Panel’ of independent specialists, predominantly nephrologists, oncologists and infectious diseases physicians.
Objectives: To raise awareness of the role and benefit of a COC and Panel for DLV activity.
Method: Data collected from all Victorian Electronic Donor Record (EDR) entries from 1 April 2016 to 31 March 2017 included potential donor demographics and outcomes and data regarding the COC role and contribution. The consultation reason was categorised and its ‘helpfulness’ was assessed based on whether it confirmed or changed the direction of the organ donation workup.
Results: There were 195 EDR entries and 129 organ donors [86 Donation after Brain Death (DBD)/43 Donation after Circulatory Death (DCD)]. The median age was 50 years, 56% were male and 89% were in metropolitan hospitals. The three commonest causes of death were cerebral hypoxia (43%), intracranial haemorrhage (31%) and brain trauma (18%).
The COC was consulted in 80% of referrals in the EDR, of which 92% of consultations were helpful. The reasons for consultation were donor or organ medical suitability (84%), Intensive Care Unit (ICU) management (18%), DBD diagnosis (9%) or issues concerning transplant units (8%), donor family/consent (8%), DCD (2%) or the Coroner (2%) with a miscellaneous group (4%). The Panel was consulted in 25% of referrals (predominantly nephrologists).
Conclusion: The availability of a COC and specialist Panel contributes significantly to optimising organ donation whilst safely minimising recipient organ failure and disease transmission.
GOING THE DISTANCE: UTILISATION OF THE DONATION AFTER CIRCULATORY DEATH DONOR POOL AND THE WESTERN AUSTRALIAN EXPERIENCE
SHIHAB N 1, KIRK-BURNNAND E1, and FLETCHER N1
1DonateLife Western Australia (WA), Perth, Australia - Donor Coordinators, Clinical Nurse Specialists
Introduction: Western Australian statistics on the utilisation of Donation after Circulatory Death (DCD) donors and DCD organs have been lower than the other states in the country. In an attempt to identify ways to increase the DCD donor pool, DonateLife WA established a working group in October 2016. This group consisted of eight Donor Coordinators and Clinical Nurse Specialists to identify the practices followed in other states. Based on their findings, various recommendations were made to the transplant teams in WA, which lead to some changes in practice.
Objectives: To identify ways to increase the DCD donor pool and increase the utilisation of the WA DCD organs by offering them interstate.
Method: The establishment of the working group identified that WA DCD was more restrictive than in other states. The following criteria were followed at the time and were recommended to change
• DCD age 65 years and lower
• No high-risk donors such as Hepatitis B and C positive donors
• DCD organs not accepted by WA or offered interstate due to the distance.
Results: The following changes have been made to the exclusion criteria over the last two years:
• DCD age for consideration is now 75 years for lungs and 70 years for kidneys
• WA now offers DCD lungs and kidneys interstate
• WA now accepts DCD kidneys from interstate
• WA now considers high risk kidney donors with Hepatitis C/ positive Nucleic Acid Testing (NAT) results for Hepatitis C.
The table below shows DCD donor statistics for WA for 2016 and 2017 following some of the changes in practice:
Conclusion: The above table shows a positive change before and after the changes made to the exclusion criteria for DCD donation. It is expected that the change in practice will increase the utilisation of the WA DCD donor pool.
PINNING DOWN THE CHALLENGES TO ORGAN DONATION IN THE NORTHERN TERRITORY
JONES S 1, CAIRNES S2, ANSTEY K2, and WOOD L2
1Royal Darwin Hospital, Darwin, Australia, 2DonateLife NT (DLNT), Darwin, Australia
Introduction: Organ donation in the Northern Territory (NT) remains infrequent despite extensive efforts to improve community education and awareness.
Objectives: We aimed to identify the challenges to donation occurring in the NT.
Method: All referrals to the DLNT Agency between January 2015 and December 2018 were reviewed. We looked at consent rates, ethnic group, registration on the Australian Organ Donor Register (AODR) and reasons for medical unsuitability.
Results: There were 150 referrals to DLNT over the four year period. The mean age was less than 50 years. Seventy one (47.3%) of all referrals were Aboriginal, 57 were Caucasian (38%) and 18 (12%) were from a culturally and linguistically diverse background. Of the 150 referrals, only 56 (37.3%) proceeded to the Family Donation Conversation (FDC). Consent for organ donation was obtained from 21 (37.5%), 17 of whom became organ donors. There were four intended donors. Only 12.5% (7) of all referrals that proceeded to FDC were registered on the AODR. Of the 94 referrals that did not proceed to FDC, over half were deemed either medically unsuitable or medically unsupportable. Northern Australia’s recognised high rates of chronic disease were common comorbidities amongst medically unsuitable patients.
Conclusion: There are many challenges to organ donation within the NT which require ongoing attention. Although the patients are young, medical suitability issues often prevent conversations about organ donation from taking place. Registration rates on the AODR are also low.
PAEDIATRIC SINGLE DONOR KIDNEY TRANSPLANTED INTO SMALL PAEDIATRIC RECIPIENT IN AUSTRALIA
CHRISTOFF A 1,2, PASFIELD J1,2, and THOMAS G1
1The Sydney Children’s Hospital Network, Sydney, Australia, 2The Organ and Tissue Donation Service, New South Wales, Australia
Introduction: We present a case of the first reported successful paediatric single donation after circulatory death determination (DCDD) kidney donor transplanted into a small (<10 kg) paediatric recipient in Australia. It has been well established that paediatric kidneys transplant successfully into adult recipients. Transplantation of small paediatric kidneys is more commonly performed in adult recipients due to risk of early graft failure, technical complications and thrombosis. In order to avoid some of the risk in adult recipients the donor weight has routinely been from donor >10kg with use of en bloc technique. The age of the paediatric donor and the type of transplant (en bloc or single) is important in determining outcomes. Recent studies have demonstrated that small paediatric donor grafts transplanted into paediatric recipients achieve similar outcomes to adult recipients. Our case illustrates an example of a good outcome in a small paediatric recipient with end stage renal disease who received a single DCDD kidney from a paediatric donor.
Objectives: To describe a case of a paediatric single DCDD kidney donor transplanted into small paediatric recipient with end stage renal disease.
Method: Case review
Result: The paediatric recipient had no surgical complications and has good graft function one year post transplantation.
Conclusion: Transplantation of small paediatric donor kidneys may achieve similar outcomes to adults in paediatric recipients if recipients are selected carefully and transplanted at centres with clinical expertise.
EX-VIVO PERFUSION OF A MARGINAL DONOR LIVER PRIOR TO TRANSPLANTATION
REILING J 1,2,3,4, HODGKINSON P1,4, BUTLER N1,4, and FAWCETT J1,2,3,4
1Faculty of Medicine, The University of Queensland, Brisbane, Australia, 2Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Australia, 3Princess Alexandra Research Foundation, Princess Alexandra Hospital, Brisbane, Australia, 4Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Australia
Introduction: The majority of livers Donated after Circulatory Death (DCD) are currently being declined for transplantation due to a perceived unacceptable risk of graft dysfunction and ischaemic type biliary stricture (ITBS) formation. Normothermic machine perfusion (NMP) provided an opportunity to assess graft function and has been used as a tool to determine if certain DCD livers could in fact be suitable for transplantation.
Objectives: This report described the first clinical application of NMP in Australasia.
Method: The liver was obtained from an obese DCD donor aged 38, who required 30 minutes of cardiopulmonary resuscitation following an out of hospital arrest. The liver was retrieved following 26 minutes of functional warm ischaemic time and stored on ice for 5 hours and 15 minutes. The liver was subsequently perfused under normothermic conditions on the OrganOx metra for 17.5 hours. The 54-year-old recipient had a MELD score of 27.
Results: The marginal liver graft cleared lactate within two hours of perfusion, pH was within physiological range and portal venous and hepatic artery flow remained stable. Throughout the perfusion, the glucose concentration fell steadily to below 10 mmol/L within four hours. Following transplantation, immediate graft function was observed and the recipient was discharged from hospital ten days post-transplant. Since his transplant six months ago, the recipient has not developed ITBS.
Conclusion: NMP was successfully used to assess graft function of a marginal graft prior to transplantation. We anticipate that this technique will greatly improve the utilisation of DCD livers in Australia.
ORGAN ALLOCATION & ACCEPTANCE
PALK N 1, and DATSON L 2
1DonateLife South Australia, 2New South Wales Organ and Tissue Donation Service
Introduction: Australia and New Zealand have offered and allocated all organs in the same manner since the late 1980’s when the basis for today’s nationally agreed documents were written. Since this time, there has been very little change in the way that offering and allocation occurs.
Objectives: To look for ways that improves the communication from the donation sector to the recipient units whilst ensuring that the system remains fair and equitable for all. This will involve the timing of notifications and how the information is delivered and in what format
Conclusion: The Organ and Tissue Authority has joined with Australasian Transplant Coordinators Association and Transplantation Society of Australia and New Zealand to explore possible solutions by forming a working group to investigate potential solutions.