Uncontrolled donors with controlled reperfusion: Reliable recourse of kidney transplantation
Andrey Skvortsov, Denis Kuzmin, Alexey Tutin, Alexey Kutenkov, Irina Ulyankina, Alexey Ananyev, Igor Loginov, Oleg Reznik
Department of Transplantation and Organ Donation, Saint-Petersburg I. I. Dzhanelidze Research Institute of Emergency Medicine, Saint-Petersburg, Russian Federation.
Background: The global critical organ shortage leads to use of kidney from the donors after sudden cardiac death, or uncontrolled donors (UDCDs). The purpose of our clinical investigation was to define the clinical applicability of kidney obtained from UDCDs and resuscitated by extracorporal perfusion technology in situ after 60 minutes of asystole.
Methods: Between 2009 and 2012, organ procurement service of St Petersburg, Russia, performed the transplantation of kidneys (KTx) obtained from 23 UDCDs. All donors died as ICU patients after sudden irreversible cardiac arrest and failed cardiopulmonary resuscitation. The mean warm ischemic time, or asystole (WIT) was 61.3±3.8 minutes. For kidney resuscitation was employed the subnormothermic (27-32˚C) extracorporeal isolated abdominal perfusion with thrombolytics (Streptokinase) and leukocyte depletion by a leukofilter. The outcome of the extracorporeal perfusion resuscitated kidneys transplanted into 46 recipients was compared with outcome of 92 KTx from 74 brain death donors (BDDs).
Results: Immediate functioning of kidney grafts was observed in 23 of the 46 cases; there was no one PGNF. Only 8 episodes of rejection were observed to the end of first year after surgery (17.4%), and 27 episodes of acute cellular rejection at the end of the twelfth month in group from BDD (29.3%). The actuarial 1-year graft survival rate was 95.7% (n=44) in UDCD group, 93.5% (n=86) in BDD group. The mean creatinine level at the end of the first year of observation was 0.113±0.003 mmol/l (UDCD), 0.115±0.004 mmol/l (BDD).
Conclusions: Kidneys from uncontrolled deceased donors with critically prolonged warm ischemic time could be successfully used for transplantation if the resuscitation perfusion procedure in situ is implemented in organ procurement protocol. This approach could substantially expand the pool of the organ donors.
SEUSA Program, an international collaborative strategy to increase deceased organ donor activity
Maria Paula Gómez Gómez1, Martí Manyalich1, Xavier Guasch1, José Manuel García Buitron2, Antonio Fernández2, Lesley Roberts3, José Ignacio Sánchez4, Antoine Stephan5, Farida Younan5, Francesco Paolo Schena6
1DTI Foundation, Barcelona, Spain; 2Juan Canalejo Hospital, A Coruña, Spain; 3National Organ Transplant Unit (NOTU), Port of Spain, Trinidad and Tobago; 4 Regional Coordination of Transplantations of Aragon, Zaragoza, Spain; 5National Organization for Organ and Tissue Donation and Transplantation (NOOTDT), Beirut, Lebanon; 6Apulia Transplant Regional Center, Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy.
Objective: The SEUSA is a program to improve the organ donation and transplant system based on the best practices of the Spanish, European and USA models. The objective of the present study is to collect evidence of the effectiveness of the SEUSA increasing the deceased organ donation from the experience of implementation in three regions, the South of Italy (La Puglia), Lebanon and Trinidad and Tobago.
Method: The SEUSA includes: 1) Diagnose of the organ donation and transplantation activity through the “Organ Donation Diagnosis Survey” (ODDS); 2) Establishment of the Transplant Procurement Management Team; 3) Implementation of the “Deceased Alert System” (DAS); 4) Application of the “Essential in Organ Donation” (EOD) and 5) Hospital Audit. Monthly monitoring meetings to make needed adjustments based on the specific characteristics of the country are done. The program also contributes with the definition of specific economic funds direct to the procurement system.
Results: SEUSA-Apulia started in 2007 and after three years of implementation, comparing to the data from the three previous years of the project (2005-2006-2007) we found an increase of 36.5% of brain death diagnose (83 vs. 113.3) and the total number of donors increased to 47% (89 vs. 131). SEUSA-Lebanon started in 2009. So far, SEUSA has increased Lebanon’s donation rate from 0 to 2.5 PMP and it has been possible to implement the cornea donation program, obtaining 90 cornea donors. SEUSA-Trinidad and Tobago is currently being implemented and started on July 2010. During the first year of DAS 161 alerts of possible DBD and DCD happened, from them 17 Brain death were diagnosed.
Conclusion: The SEUSA has contributed to the improvement of the organ donation/transplant system in the three regions. In addition, it may represent an example of valuable and replicable strategy to ameliorate organ and tissue activity in other countries.
Meeting donor management goals maximizes organ recovery in children
Thomas Nakagawa1, Susan Galbraith2, Jim Quetschenbach3, Ginger DeLario3
1Anesthesiology, Wake Forest Baptist Health, Winston-Salem, NC, United States; 2 LifeShare of the Carolinas, Charlotte, NC, United States; 3Carolina Donor Services, Durham, NC, United States.
Introduction: There is a clear need to reduce the gap between donors and patients awaiting transplant.
Achieving donor management goals (DMGs) results in more organs transplanted per donor (OTPD) in adults. We sought to determine if meeting DMGs in pediatric donors resulted in more OTPD in addition to other factors that might influence organ recovery and transplantation.
Methods: Data from 2 Organ Procurement Organizations (OPO) were retrospectively reviewed from 2007 through 2012 for pediatric donors age 0–18 years meeting brain death criteria. The time period corresponds with implementation of electronic medical record systems within each organization. DMGs included: systolic blood pressure appropriate for age, central venous pressure 4-12 cm H2O, arterial pH 7.3-7.5, PaO2>80 mm Hg on FiO2≤.4, serum Na+ ≤160 meq/L, serum glucose <200 mg/dL, single vasopressor agent at low dose, and urine output 0.5-7 cc/kg/hour in the 4 hours prior to recovery. We reviewed number of organs recovered, transplanted, discarded and organs used for research.
Results: 148 brain dead pediatric donors had 673 organs recovered for transplantation. 605 organs were transplanted (4.09 OTPD). 102 donors had 4.39 OTPD when >80% of the DMGs were achieved. 46 donors had 3.37 OTPD when <80% of the DMGs were met. 24 organs were discarded and 42 organs were used for research. Surgical damage or damage to organs due to traumatic cause of death occurred in 2 cases. Medical examiner restriction (thoracic organs only) occurred in 4 cases resulting in 8 organs not recovered for transplant. Discarded organs occurred more frequently in donors <1 year of age despite exhausting match runs and, in most cases, were pancreata. The youngest brain dead donor was 9 days old (2 organs recovered). A total of 29 donors were <1 year of age.
Conclusions: Meeting >80% of DMG’s before organ recovery in children resulted in more OTPD. Other factors influencing organ recovery and organ transplanted included donor age and medical examiner restriction.
Evidence-based guideline for the hormone modulation of the adult brain-dead organ donor: Vasopressin, corticosteroids and thyroid hormones use
Vilma Inés Brunetti1, Pablo Centeno2, Ernesto Germán Monteagudo2, Rogelio Matías Anchorena2
1Laboratory, HZGA Simplemente Evita, Gonzalez Catàn, Argentina; 2 Intensive Care Unit, HZGA Simplemente Evita, Gonzalez Catán, Argentina.
Background: There is disagreement about the best hormone treatment indicated for the brain-dead (BD) organ donor (OD), maybe because there is no high-quality guideline published.
Aims and Objectives: Establishing hormone modulation strategies to optimize: circulatory function, organ procurement, graft survival, benefits and costs. These outcomes were used to formulate PICO questions for every hormonal treatment. Target population: BD people and possibly OD older than 14 years old, in intensive care units. Target group: OD manager physicians.
Methods: Systematic literature search in PubMed using keywords of the PICO questions added to a Google search of the references of interest. FLCritica 1.1.1 (Osteba) was used for the critical appraisal of literature. Evidence grading system, and grading system for recommendations: SIGN. Agreement method: nominal group.
Brief Summary of Key Recommendations: We recommend administering methilprednisolone (1 gr bolus) soon after BD, repeating doses every 24 hours, recommendation grade (RG): A. Both in case of haemodynamic impairment (HI) or diabetes insipidus (DI), we recommend using vasopressin (AVP) as first choice, RG: B, starting with 1 U bolus, followed by infusion (maximum dose: 2.4 U/h), RG: D. We suggest using norepinephrine as a second choice to treat HI, RG: B. We suggest using desmopressin as a second choice to treat DI or to enhance AVP use, RG: D. We suggest treating hypernatremia, RG: D. We do not recommend the use of thyroid hormones.
Implementation and Monitoring of Guideline: Several indicators were developed for monitoring the described outcomes. A check list and a quick consult guideline stands out. Update: every 2 years.
External assessment by using the AGREE instrument. Domain scores: each of the six are independently above 80 %.
Conclusions: The present guideline simplifies the access to data based on evidence which might improve the standardizing criteria and outcomes.
Heart donation in Japan before and after revision of Japanese Transplantation Act
Norihide Fukushima1, Minoru Ono2, Yoshikatsu Saiki3, Takeshi Nakatani4, Satoshi Saito5, Suguru Kubota6, Juntaro Ashikari7
1Department of Therapeutics for End-Stage Organ Dysfunction, Osaka University, Suita, Japan; 2Department of Cardiothoracic Surgery, Tokyo University, Tokyo, Japan; 3Department of Cardiovascular Surgery, Tohoku University, Sendai, Japan; 4Department of Transplantation, National Cardiovasuclar Center, Suita, Japan; 5Department of Cardiovascular Surgery, Tokyo Women’s Medical College, Tokyo, Japan; 6Department of Cardiovacular Surgery, Hokkaido University, Sapporo, Japan; 7Head Quarter, Japan Organ Transplant Network, Tokyo, Japan.
After revision of Organ Transplant Act in July 2010, brain dead organ donation increased from 13 to 45 in a year and heart donation increased. The purpose of this study is to review consecutive 163 brain dead heart donors to evaluate our special strategies to identify and manage organ donors.
Method: Consecutive 163 brain dead heart donors since the Act was issued were reviewed. While 69 heart donations were performed between October 1997 and July 2010 before revision of the Act, 97 heart donations were done for 3 years after revision.
Donor Evaluation and Management System: Since November in 2002, special transplant management doctors were sent to donor hospitals in order to assess donor’s organ function and to identify which organ could be transplanted. They also intensively cared the donor to stabilize hemodynamics and to improve cardiac function by intravenously giving anti-diuretic hormone and pulmonary toileting by broncho-fiberscope.
Results: A mean donor age of heart donor was increased from 41.0 to 43.9 years. Especially 11 hearts from a donor older than 60 years were transplanted successfully. Before revision, the cause of death was 37 in cerebrovascular disease (SAH 34, stroke 1, bleeding 2), 18 in head trauma, 13 in asphyxia, and 2 in post-resuscitation brain damage. After revision, that was 49 in cerebrovascular disease (SAH 37, stroke 2, bleeding 16 and other 4), 17 in head trauma, 10 in asphyxia, and 11 in post-resuscitation brain damage. 58 donors had a history of cardiac arrest. 58 required high dose of cathecholamine drip infusion. Only one recipients died of primary graft dysfunction (PGD). Patient survival rate after heart Tx at 3 years was not different before and after revision of the Act (95.2 % vs 94.2%).
Conclusion: Although donor age was increased and donor who died of cerebral bleeding or post-resuscitation after the revision of Act, the outcome after heart transplantation was not changed.
Deceased donor transplantation programme in Andhra Pradesh - a Southeastern State in a developing country India
Nephrology, Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad, India .
In developing country like India the prevalence of end stage organ disease is increasing due to shift in health related problems from communicable diseases to chronic diseases. Though transplantation has been in practice in India for more than 3 decades, it has been grossly inadequate in terms of actual numbers, due to a shortage of resources and organs. The only solution for the shortage of organs is deceased donor transplantation.
Globally, Spain has highest rate of deceased donor transplantation rate of 32 per million population per year. The deceased donor transplantation in USA is 20.7 per million population per year, Europe 15.9 per million populations per year and Asia 1.1 per million population per year. Deceased donor transplantation rate in India is 0.08 per million population that accounts to 2 % of total transplantation.
In India the Human Organs Transplantation Act, was enacted in 1994 with the objective of promoting and regulating the transplantation of human organs like kidney, liver and heart - both live as well as deceased donor. There was no significant increase in deceaseddonor transplantation over the past two decades for various reasons. India follows “opt in” system and brain death declaration is not mandatory. Andhra Pradesh is one of the 28 states of India, situated on the country’s southeastern coast. It is India’s fourth largest state by area and fifth largest by population. Government of Andhra Pradesh, considering the shortage of organs and increasing burden of end stage organ failure in the state, has come up with a Government Order1 called “Jeevandan” to streamline the procedure for facilitating and regulating the cadaver transplantations on an end-to-end basis. The word “Jeevanadan” means “to donate life.” We present our experience of deceased donor transplantation programme initiated by government of Andhra Pradesh, India.
Jeevandan program practically came into force from 1st January 2013. Since the inception of deceased donor transplantation (Jeevandan) program in the Andhra Pradesh, there have been 23 deceased donations. Male donors were 16 and female 7:; female to male ratio being 1: 2.28. The mean age of deceased donors was 33.88 years (range 8 to 72). Fifteen (65.12%) donors were educated and 8 (34.78%) were uneducated. Most common Blood group was B positive in 11 (47.82%) donors followed by A positive and O positive in 5 (21.73%) donors each. AB positive bllod group was in 2 (8.69%) donors only. Total 102 organs were retrieved from 23 deceased donors; 41 kidneys, 20 livers, 22 heart valves 18 corneas and 1 lung.
Total deceased donor renal transplantations during this period were 41. Out of 23 donors, Kidneys were not utilized from 2 donors; as one donor had chronic kidney disease with serum creatinine of 4.5 mg/dl and other donor was 72 year old female with hypertension, diabetic and had diabetic nephropathy. Both the kidneys from a 8 year old male donor were placed in single recipient. Mean age of renal recipients was 41.35 years (range 13 to 63). There were 12 females and 29 males, female to male ratio being 1:2.41. Among deceased donor renal transplant recipients, B positive blood group was most common, seen in 19(46.34%) followed by O positive in 10 (24.39%) A positive in 8 (18.51%) and AB in 4 (9.75%) recipients. Among 41 renal transplant recipients eleven patients (26.82%) had delayed graft function. One (2.43%) patient underwent graft nephrectomy due to candida fungal infection. One (2.43%) patient developed humoral mediated rejection which responded to plasmapheresis and rituxibmab therapy and one (2.43%) patient expired due to infection. Graft function in rest of the renal transplant recipients was good with mean serum creatinine of 1.45mg/dl.
Submitted on be half of Government of Andhra Pradesh, India
Reference: G.O.MS.NO. 184 HM&FW (M1) Department, dated 16-08-2010, Government of Andhra Pradesh, India
Organ donor screening by serology and NAT allows immediate diagnosis of blood-borne viruses and safer use of organs from increased risk donors
Chee Choy Kok1, Cristina Baleriola2, Sanghamitra Ray3, Peter Robertson4, William Rawlinson5
1Microbiology, South eastern Area Laboratory Services, Randwick, Australia; 2 Microbiology, South Eastern Area Laboratory Services, Randwick, Australia; 3Microbiology, South eastern Area Laboratory Services, Randwick, Australia; 4Microbiology, South Eastern Area Laboratory Services, Randwick, Australia; 5Microbiology, South Eastern Area Laboratory Services, Randwick, Australia .
Serology and nucleic acid test (NAT) screening for HBV, HCV and HIV are key steps to prevent blood-borne-virus (BBV) transmission from organ donors. We assessed optimal use of NAT in the solid organ transplant setting for 4 years through evaluation of requests and results for NAT and serology testing in routine and increased risk donors (IRD).
Review of NAT and serology results for donor screening from October 2009 to July 2013 showed NAT was performed on a total of 422 donors; 100 performed prospectively while 322 performed retrospectively. There were 295 organs (3.0 organs/donor) retrieved from IRD and 1,121 organs retrieved from 322 average-risk donors (3.5 organs/donor).
NAT screening of 42 serology positive (1 HIVAb+, 11 HCVAb+, 30 HBV HBcAb or HBsAg+) donors resulted in transplantation of 67 additional organs that without NAT screening would either have not been used or used with restrictions. The NAT assays demonstrated the HIV donor was NAT positive, the HCV donors were 9/11 NAT positive, and the HBV donors were 3/30 NAT positive. Of the HBV donors, 27/30 were HBcAb positive and 0/27 NAT positive, and 3/30 HBsAg with 3/3 NAT positive. Donors accepted for transplantation were HIV 0/1, HCV 3/11 (all of whom were NAT positive and transplanted into HCV RNA positive recipients) and 19/27 HBcAb positive donors transplanted. Most transplanted organs with positive serology and negative NAT were from HBcAb positive donors (n=19 donors with 63 organs transplanted) and 4 organs retrieved from 3 HCV positive donors.
The availability of a 24/7 NAT screening service for organ donors provides diagnosis within 8 hours of blood delivery. This enabled the use of organs from donors with positive serology but inactive viral infection and donors with false positive serology results. This algorithm allowed use of organs from IRD with safer expansion of the donor pool.
Information sources, donation knowledge and attitudes towards transplant recipients in Australia
Melissa Hyde, Suzanne Chambers
Behavioural Basis of Health, Griffith Health Institute, Griffith University, Mt Gravatt, No, Australia .
Background: Knowledge is linked consistently with organ donation attitudes, willingness, and consent. Negative information about donation and the recipients of donation can affect public opinion and donation willingness. However, it is unclear which information sources are most important in forming knowledge, particularly in Australia where little prior research exists. In this regard, we aimed to identify information sources that may inform Australian’s organ donation knowledge and attitudes towards transplant recipients.
Methods: 1487 Australian residents aged 18 years or older completed an online survey. Self-reported knowledge, information sources, and attitudes toward transplant recipients were assessed.
Results: Participants felt fairly well informed about organ donation; particularly if they registered donation wishes, were female and older. Over half reported their driver’s license, news on TV, and discussion with family/friends, as donation information sources. However, information sources contributing to knowledge were personal experience, online, hospital, Government campaign, discussion with family/friends, Medicare, doctor’s surgery, and the newspaper. Differences based on registration status, sex, and age, were found. Discussion with family/friends and movies/TV shows, as well as not having seen information in a newspaper or doctor’s surgery, contributed to positive attitudes towards recipients; although the variance explained was small.
Conclusion: People felt more informed by personal, medical, and government information sources compared to mass media. Family discussion was not only a common information source but also contributed significantly and positively to both donation knowledge and attitudes towards recipients. Further exploration of information sources contributing to young male’s donation knowledge and community attitudes toward transplant recipients is needed.
Creation of a donation after circulatory death (DCD) training DVD
Kathryn Coumans2, Helen Opdam1, Nicole Gauthier1, Elizabeth Treasure1
1DonateLife Victoria, Melbourne, Australia; 2Barwon Health, Geelong, Australia .
DonateLife Victoria (DLV) has developed a unique model for the implementation of donation after circulatory death (DCD). With support from the DonateLife Victoria Agency, hospital donation specialist staff develop a local DCD protocol and undertake other activities such as education of ICU and operating theatre personnel and run a mock DCD case. This process achieves engagement of key hospital stakeholders and provides strong local ownership by clinical staff, vital for subsequent success in undertaking DCD.
Twelve hospitals in the metropolitan and greater Melbourne area currently have active DCD programs, with the aim now to expand DCD capability to include rural and smaller Victorian hospitals. DLV identified a lack of resource material for training staff specifically in DCD donation, and wanted to fill this gap. We will demonstrate how a group of dedicated professionals were able to create a DVD of a mock DCD case for use within Victoria and nationally to train staff with no or minimal exposure to DCD.
The process of creating the video included:
1. Formation of a DCD DVD working group consisting of DLV Agency and hospital staff, transplant surgeons, operating theatre staff, and a filmmaker
2. Identifying target audience information needs and key elements of the DCD process
3. Developing a script which accurately illustrates the organ donation process from the first family conversation to the family viewing after surgery
4. Casting roles using members of the working group and actors
5. Undertaking the filming at Geelong Hospital within the ICU and operating theatre
6. Review and editing of scenes with the film company
Conclusion: The DCD DVD working group has successfully created a high quality training resource available to educate hospital staff in Victoria and Australia about the DCD process. The resource achieves the goal of providing clear, accurate and relevant information to staff in an engaging way.
Source of Funding: DonateLife Victoria
Effects of a modified education program in organ donation in Norway
Käthe Meyer1,2, Ingebjørg Kvangarsnes1,2, Pål Foyn Jørgensen1,2, Per Arne Bakkan1,2, Urs Christen1,2, Stein Foss1,1,2
1Transplantation, Oslo University hospital, Oslo, Norway; 2Norwegian resource group for organ donation, Oslo, Norway.
Background: Competence in the organ donor process is known to be essential for high rates in organ donation, low refusal rate and organs available for transplantation. Two Norwegian surveys investigating intensive care personnel’s knowledge and attitudes revealed a deficiency in communicative skills and cognition of the organ donor process. The educational program, organised as a two days seminar by the Norwegian Resource Group for Organ Donation (Norod), did not fulfil physicians’ and nurses’ perceived needs.
Method and materials: In 2009 we initiated a modification of our program. A revised program with uniform lectures focusing on communication training was introduced in 2011.
Concomitantly we started systematically evaluation. An evaluation form was filled in by the participants at the end of each seminar. The items covered all lectures and the learning effect employing a Likert-like scale as well as an evaluation in own words. The results were analysed by frequency, and the previous and present program were compared by t-test. The written evaluation was assessed by text analysis to describe participants’ opinions about the program and their suggestions for improvement.
Results: A total of 275 participants evaluated the seminars. The participants in the present education program scored high on most themes, mean 4.18-4.74 (range1-5), and the learning effect was higher in the present than in the previous program. More interactive lectures were requested and the communication training was much appreciated. The donation rate has increased from 21.14 pmp in 2009 till 23.27 pmp in 2012. In the same period the refusal rate declined from 26 % to 17%.
Conclusion: Participants of the Norod seminars seemed more satisfied with the new educational program. We will continue to refine the program and highlight the interactive educational method. Modifications of the donor hospitals educational program according to reported needs may increase the donation rate significantly.
Analysis of social awareness of organ donation in the secondary school population in Galicia
Jacinto Sanchez-Ibañez1, Marta Alvarez Vazquez1, Encarnacion Bouzas Caamaño1, Anton Fernandez Garcia2, Maria Valentina Fernandez Lopez2, Enrique Alemparte Pardavila3
1Regional Transplant Coordination, Galician health Service, Santiago de Compostela, Spain; 2Hospital Transplant Coordination Office, Complejo Hospitalario universitario A Coruña, A Coruña, Spain; 3Hospital Transplant Coordination Unit, Complejo Hospitalario Pontevedra, Pontevedra, Spain.
Introduction: The family refusal rate in Galicia is traditionally higher than that of Spain as a whole. To change this attitude it is important to work with the young population in school. We analyse the results of a program designed by the Transplant Coordination Office in Galicia to introduce organ donation to students over 14 years old.
Material and Methods: From 2007 until June 2013, 531 talks were given at schools in Galicia by hospital transplant coordinators together with organ recipients about all aspects of donation and transplantation. We analysed the answers to the five questions included in the questionnaire given out at the end of each talk.
Results: 27,850 students attended the talks. The mean age was 17.3 ± 4.4 years old; 56.7% were female and 43.3% male. Q1: Would you like to be transplanted? Yes: females 97.4% vs males 94.1% (p=0.000). Q2: Will you donate your organs? Yes: females 89.2% vs males 81.2% (p=0.000); population of the municipality >10,000 inhabitants (86.2%) vs <10,000 (83,8%) (p=0.000); students >15 years old (86.2%) vs <15 (84,4%) (p=0,001). Q3: Would you donate the organs of a relative who doesn’t manifest his or her wish in life? Yes: females 46.6% vs males 43.3% (p=0.000); population of the municipality >10,000 inhabitants (45.9%) vs <10,000 (42.4%) (p=0.000); students >15 years old (46.5%) vs <15 (41,6%) (p=0.000). Q4: Will you respect a relative’s decision to donate? Yes: females 98.3% vs males 96.1% (p=0.000); population of the municipality > 10,000 inhabitants (97.5%) vs <10,000 (96.7%) (p=0.002); students >15 years old (97.6%) vs <15 (96.8%) (p=0.000). Q5: Is brain death the death of the person? No difference between genders, greater acceptance when the population >10.000 (69%) vs <10,000 (63.5%) (p=0.000) and when the age is >15 years old (69.2%) vs <15 (64.1%) (p=0.000). The mean score for student assessment of the talks was 8.5/10.
Conclusion: After the talks we observed a positive attitude towards donation, although the understanding of the concept of brain death shows room for improvement. We observed differences according to gender, age, and population of the municipality.
Training course in donation for hospital nursing staff in Galicia: Analysis and results before and after the course
Jacinto Sanchez-Ibañez1, Marta Alvarez Vazquez1, Encarnacion Bouzas Caamaño1, Carlos Leon Vara Perez2, Juan Cortes Cañones3, Maria Isabel Alvarez Dieguez4, Francisco Garcia Novio5, Luis Amador Barciela2
1Regional Transplant Coordination, Galician health Service, Santiago de Compostela, Spain; 2Hospital Transplant Coordination Unit, Complejo Hospitalario Universitario Vigo, Vigo, Spain; 3Hospital Transplant Coordination Unit, Complejo Hospitalario Ourense, Ourense, Spain; 4 Hospital Transplant Coordination Unit, Complejo Hospitalario Ferrol, Ferrol, Spain; 5 Hospital Transplant Coordination Unit, Complejo Hospitalario Lugo, Lugo, Spain .
Background: The level of knowledge of donation and transplantation together with that of hospital nursing staff awareness is crucial in improving the positive atmosphere around donation.
Aim: We designed in Galicia training courses for nursing staff in all the hospitals authorized for donation and compared their knowledge of and attitude to the donation and transplantation process before and after the course.
Material and Methods: 55 accredited courses were held between 2008 and the 1 of June 2013. A questionnaire was completed before and after the course and the answers were analyzed. The variables studied were: gender, age, type of hospital (only procurement or procurement and transplant); type of unit (donor’s unit or not)
Results: 1,697 health professionals took part in the courses, of whom 75.8% completed the questionnaire before and after the course. 95.7% were female and 4.3% male. The average age was 41.8 years (S.D. 9.3 years).. 96.5% of the participants had a positive attitude before the course. Before the course 61.7% recognized the diagnosis of brain death as the death of the patient, this figure rising to 95.6% (p<0,000) after the course. Before the course only 49,5% were familiar with Spanish legislation on consent, changing after the course to 89.8% (p<0.000). The most appropriate moment to talk about donation was recognized before the course by 80,4% of participants, and afterwards by 93.9% (p<0,000).
Conclusion: Hospital staff’s awareness in donation is important to avoid misunderstandings with relatives and to create a positive environment. The results show that training courses for hospital nursing staff should be part of any action plan.
The influence of Transplant Procurement Management (TPM) training program in organ and tissue donation and transplantation
Tyler R. Harrison1, Melania G. Istrate2, Susan E. Morgan1, Gloria Paez2, Maria Paula Gomez2, Quan Zhou1, Ricard Valero2,3, Marti Manyalich2,3
1Brian Lamb School of Communication, Purdue University, West Lafayette, IN, United States; 2TPM-DTI Foundation, Barcelona, Spain; 3Hospital Clínic de Barcelona, Barcelona, Spain.
Background: Training on organ donation/ transplantation (D&T) is relevant for transplantation improvement . TPM has been providing training on organ D&T [2-3] in compliance with the agreed professional requirements.
Methods: Considering that micro level change practices can have macro level influences, a survey was developed assessing the impact of training on development of policies, practice, career choices, leadership, and knowledge dissemination. Thus a new type of evaluation was designed focusing on how different groups perceive training benefits. It was translated into five languages (Spanish, English, Italian, French, and Portuguese). Individuals who participated in TPM training courses were sent a recruitment letter and link to an online survey. Additionally, links were posted on Facebook and handed out at organ donation meetings and congresses. Potential participants and key individuals were asked to forward the link to individuals active in D&T. Respondents were required to rate on a scale of 1-5 (1- no influence and 5- a great deal of influence) the influence of trainings on 12 items to answer the following Research question: What is the perceived influence of specialized training programs on career, collaboration, and skills in D&T?. Institutional review boards at the University of Barcelona and Purdue University (USA) approved the study.
Results: 1102 participants agreed to take the survey, 87% reported participating in a TPM course, out of which 95% selected TPM courses as most influential. Specifically, 98% reported influence on knowledge [score 4.45/5], 93% on technical [4.15] and communication [4.14] skills, 89% on attitude toward D&T [4.08], 92% on motivation to work [4.23], 91% on desire to innovate [3.98], 87% and 79% on ability to change D&T practices [3.85] and policies [3.51], respectively.
Conclusion: Participation in TPM training courses has positive perceived benefits.
 Manyalich M, Guasch X, Paez G, Valero R, Istrate M and the ETPOD partner consortium: ETPOD (European Training Program on Organ Donation): a successful training program to improve organ donation. Transpl Int 2013 Apr;26(4):373-84
 Communication from the Commission. Action plan on Organ Donation and Transplantation (2009-2015): Strengthened Cooperation between Member States. Available at: http://ec.europa.eu/health/ph_threats/human_substance/oc_organs/docs/organs_action_en.pdf (last review 16 July 2013).
 Paez G, Valero R, Manyalich M. Training of health care students and professionals: a pivotal element in the process of optimal organ donation awareness and professionalization. Transpl Proc 2009; 41: 2025.
Estimating differential renal function using ellipsoid approximation of renal volume on CT scan
Laura Nguyen, Fadi Kamal, Brian Blew
University of Ottawa/The Ottawa Hospital, Ottawa, ON, Canada.
Background: Living renal donors must undergo extensive medical investigations in order to be approved for the donor program. Among other testing, this includes both computed tomography (CT) scans to evaluate vascular anatomy and nuclear medicine renal scans to assess for differential renal function.
Complex models have been used to calculate precise radiographic measurement of renal volume on CT to estimate differential renal function based on differential renal volumes. Thus, the necessity of the nuclear medicine renal scan can be eliminated, reducing the radiographic burden and time commitment of the potential donor and addressing the ongoing scarcity of necessary radionucleotides. However, these models are rarely used as they are often cost-prohibitive due to the need for proprietary software and they are labor-intensive for radiologists.
Methods: We examined whether a simplified estimation of differential renal volumes based on the ellipsoid formula (renal volume = πldw/6, where l, d, and w represent dimensions of the kidney) using CT scans, may also adequately estimate differential renal function.
Results: Consecutive living renal donors were reviewed retrospectively (n=79). The volume-based estimations of differential renal volume were correlated to differential renal function on nuclear medicine scans (r=0.29, p<0.01). We were able to identify the kidney with the greater function in 53 (67%) of the 79 cases, and in all 8 (100%) of 8 cases in which the difference in differential renal function was clinically significant (>10% difference between kidneys).
Conclusions: These findings support removal of the nuclear medicine scan from routine assessment of potential kidney donors without the need for expensive radiologic software. Further research looking specifically at potential donors with clinically significant differential renal function between kidneys is required to confirm our findings.
Use of kidneys with small renal tumors for transplantation: Potential benefits of organ recycling for high-risk dialysis patients
Yoshihide Ogawa1, Keimei Kojima2, Rensuke Mannami2, Makoto Mannami2, Keiichi Kitajima3, Mitsuo Nishi4, Hisaaki Afuso5, Seiichi Ito6, Naoki Mituhata6
1Urology, Tokyo-West Tokushukai Hospital, Akishima, Japan; 2 Urology, Uwajima Tokushukai Hospital, Uwajima, Japan; 3Urology, Kagoshima Tokushukai Hospital, Kagoshima, Japan; 4Urology, Saint Martin’s Hospital, Sakaide, Japan; 5 Urology, Chubu Tokushukai Hospital, Okinawa, Japan; 6Urology, Kure Kyosai, Kure, Japan .
Objectives: Buell, Mannami, Nicol, Masquera, and He respectively reported 14, 8, 31, 7, and 19 transplant cases using kidneys after resection of RCC. Donor-transmitted renal cell carcinoma in transplant is unavoidable but guidelines were issued to optimize organ usage. To balance the risk of dying on dialysis against cancer transmission, high-risk recipients are suggested best to deserve the procedure. Utilizing these discarded kidneys may help to suppress the rise of organ trafficking and transplant tourism. Therefore, we performed a prospective open trial that utilizes resected kidneys for transplant into third-party recipients after restoration.
Subjects and Methods: Our clinical trial (stage 1 and 2) consisted of 5 cases each has been completed after one year of follow-up. Donors were recruited from 6 donor-harvesting hospitals and subsequently selected from among patients who opted to undergo nephrectomy for small RCC (<4 cm) after extensive discussion of other treatment modalities. The recipient selection was mainly based on ABO compatibility and clinical scores, and immunological data (PRA and HLA mismatch) were added to the selection criteria in the extended trial (stage 2).
Results: In the stages1 and 2, five male patients and 3 male & 2 female patients were the donors with T1a RCC, respectively. The nephrometry RENAL scores for their renal tumors were of low and moderate complexity. A total of 56 dialysis patients and 76 patients were enrolled as candidate recipients for the stages 1 and 2, respectively. Five recipients aged 47–66 and 46–65 years were selected in either stage 1 or 2, respectively. Two recipients had a history of kidney transplant in each stage. Four recipients in each stage have experienced rejection so far and the latest serum creatinine levels range from 1.10 to 5.55 mg/dl without recurrence of RCC after 17 to 43 months of follow-up.
Conclusions: Restored kidney transplant led to achieving good renal function without recurrence of RCC at 17–43 months. The procedure appears technically demanding, however, with expertise hands selected candidates can benefit from accepting these discarded kidneys.
 Buell JF, Hanaway MJ, Thomas M, Munda R, Alloway RR, First MR, Woodle ES. Donor kidneys with small renal cell cancers: can they be transplanted? Transplant Proc. 2005 Mar;37(2):581–2.
 Mannami M, Mannami R, Mitsuhata N, Nishi M, Tsutsumi Y, Nanba K, Fujita SLast resort for renal transplant recipients, ‘restored kidneys’ from living donors/patients. Am J Transplant. 2008 Apr;8(4):811–8.
 Nicol DL, Preston JM, Wall DR, Griffin AD, Campbell SB, Isbel NM, Hawley CM, Johnson DW. Kidneys from patients with small renal tumours: a novel source of kidneys for transplantation. BJU Int. 2008 Jul;102(2):188–92
 Musquera M, Perez M, Peri L, et al Kidneys from donors with incidental renal tumors: should they be considered acceptable option for transplantation? Transplantation 2013 Feb 14
 He B, Mitchell A, Lim W, Delriviere L. Restore kidney graft from urologist referrals for renal transplant. 24th Int Congr Transpl Society July 19, 2012, Berlin, Germany (Transplantation: 27 November 2012 - Volume 94 - Issue - p 1093
Australian Supporting Leave for Living Organ Donors ‘‘Scheme” An innovative example of successful advocacy
Luke Toy1, Tim Mathew2, Anne Wilson3, Marie Ludlow2
1Kidney Health Australia, Canberra, Australia; 2Kidney Health Australia, Adelaide, Australia; 3Kidney Health Australia, Melbourne, Australia .
Every year in Australia more than 200 healthy people undergo an invasive, voluntary surgical procedure to become a live kidney donor. Those willing to donate a kidney are subjected to a number of out of pocket expenses for the cost of the procedure. In addition, some are unable to secure paid leave from their employment, compounding their financial situation or presenting a potential reason to withdraw from the procedure. Australian live donors are characterised by a significant under-representation in the lower socio-economic quintiles.
Financial hardship for live donors is an issue that Kidney Health Australia has been advocating for, both on behalf of and with, living donors, those with kidney disease, their families and carers. On 7 April 2013 the Federal Minister for Health announced with Kidney Health Australia, a two year pilot of a ‘Supporting Leave for Living Organ Donors’ Scheme. The pilot commenced on 1 July 2013, covering live kidney and partial liver donations.
The Scheme is not an incentive to donate, but is designed to help support those people who wish to donate but cannot afford to due to loss of income. By extension it will assist to offset the financial stress on the donor’s family. Under the initiative, people who are employed or self-employed can, with the support of their employer, seek reimbursement of up to the minimum wage rate per week, for a period of six weeks, including time off taken for both work-up periods and recovery.
The success of the Scheme depends on a comprehensive communication, media and support strategy to ensure potential donors and recipients, their employers, and hospital staff are confident in accessing the Scheme. Although modelling suggests the Scheme may pay for itself over time, the strongest justification is its potential in correcting the current burdens borne by live donors.
Hypertension does not negatively impact post living kidney donor residual GFR
Hatem Amer1, Hisham Elsherbini1, Harini Chakkera2, Andrew Rule1
1Nephrology and Hypertension and The William J von Liebig Transplant Center, Mayo Clinic, Rochester, MN, United States; 2Transplant Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.
Introduction: Hypertension is considered a contraindication to live kidney donation by some centers. The objective of this study was to examine the impact of pre-existing hypertension on post donation renal function.
Methods: We studied 902 living kidney donors who donated at our center. Renal function was assessed at the time of evaluation by iothalamate clearance. Blood pressure was measured by in office measurements as well as automated ambulatory blood pressure monitoring. Hypertension was defined as a previous diagnosis with ongoing antihypertensive therapy at the time of evaluation and/or average awake ambulatory blood pressure >135/85 mmHg. Our center accepts donors with mild hypertension controlled by a single agent with or without a diuretic. Post donation renal function was measured by repeat iothalamate clearance post donation. Residual GFR was defined as (Post Donation GFR/Pre donation GFR)*100. Higher numbers indicating greater post nephrectomy compensation.
Results: 789 (87.5%) of donors were normotensive (NT) and 113 (12.5%) were hypertensive donors. Hypertensive donor were older 55.1±9.1 vs. 43.8±10.8 years p<0.001. Equal proportion of females 56% vs. 58% p=0.6 and Caucasian race 95% vs. 97% p 0.2 (hypertensive vs. normotensive respectively). For all donors, residual GFR after donation was 65.2±11.8% of pre donation levels. Age was the strongest predictor of lower residual renal function −0.12 per year p=0.017. Hypertensive donors had lower residual GFR 62±14 vs. 66±11% p 0.03. Adjusted for age there was no difference p=0.15. Nocturnal dipping status could be assessed in 845 donors. 62% were dippers (>=10% decrease in systolic blood pressure during sleep), 37% non-dippers and 1% were reverse dippers (nocturnal increase in blood pressure). Dipping status did not have an impact on residual GFR.
Conclusion: Mild hypertension that is treated by a simple antihypertensive regimen did not have a negative impact on the compensatory increased function of the remaining kidney.
Living kidney donor assessment: Challenges, uncertainties and controversies among transplant nephrologists and surgeons
Allison Tong1,2, Jeremy Chapman3, Germaine Wong1,2,3, Jonathan Craig1,2
1Sydney School of Public Health, The University of Sydney, Sydney, Australia; 2Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, Australia; 3Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia.
Background: The assessment of living kidney donors presents unique ethical challenges and complex psychosocial implications. This study aimed to ascertain the perspectives of transplant nephrologists and surgeons on living kidney donor assessment.
Methods: Semi-structured, face-to-face interviews were conducted with 110 transplant nephrologists and surgeons from 43 transplant units in 12 countries from Europe, Australasia, and North America.
Results: The challenge of defining acceptable risk to the donor was central to five themes identified (Figure): burden of responsibility (personal accountability, policing morality, democratic decision making, meeting legal obligations, optimizing outcomes and innovation, relinquished control); medical protectiveness (prognostic uncertainty, scepticism of donor risk perception, avoidance of undue coercion, concerns for dubious motivations and coercion, safeguard donor well-being, ethical information disclosure); respecting donor autonomy (facilitate informed-decision making, concede to donor risk acceptance, benefit of the doubt, donor mandate to maintain health, acceptable altruism); driving ideologies (preserving equity, championing living donation, cognisance of anti-paternalism); and contextual pressures (evolving donor demographic, resource limitations).
Conclusions: Living kidney donor assessment involves complex interactions between safeguarding the donors’ welfare and respecting their autonomy. In our opinion, authoritative and well-described transplant unit and public policy positions that make explicit the considerations which are often implicit, may reduce the uncertainty within which donors are assessed.
Assessment of potential renal donors using principles of the Amsterdam Forum: A single centre review
Andrew Emerson, Lincoln Dealtry, Philip O’Connell, Henry Pleass, Jeremy Chapman
Westmead Hospital, Westmead, Australia.
We reviewed the reasons for living renal donor exclusion at our centre following implementation of recommendations for assessment made at the Amsterdam forum. A retrospective audit was therefore undertaken of all 577 potential renal donors considered by our centre between 6 April 2004 and 20 September 2012. Potential renal donors were 18-70 years of age, and were all assessed to have an altruistic motivation for donating, and being able to consent for the procedure.
Results: 53 donors were rejected for non-medical reasons and 186 for medical reasons. The three most common single criteria reasons for donor exclusion were HLA sensitisation/incompatibility (15%), impaired renal function (13%) and impaired glucose tolerance (10%). Hypertension was the most common reason for donor exclusion when paired with other assessment criteria. There was an equal gender balance with 52% of actual donors being female. Assessed first degree relatives were less likely to proceed to donation than more distant relatives and spouses.
Conclusions: Introduction of the paired kidney exchange program and approaches to transplantation of ABO incompatible kidneys may reduce donor exclusion by 15%, but data on long term follow up of donors with marginal medical criteria for acceptance will be required before liberalising acceptance criteria could be considered.
Organ donation and transplantation - in the focus between medicine, ethics and law
Helmut Arbogast1, Hans Neft2, Detlef Bösebeck3
1Department of Surgery, University of Munich, Munich, Germany; 2 Bavarian State Ministry of Health, Government of Bavaria, Munich, Germany; 3 Deutsche Stiftung Organtransplantation, Berlin, Germany.
Introduction: With the aim of increasing the awareness for the necessity of organ donation and transplantation, in November 2001, in cooperation between the Transplant Centre of the University of Munich, the Bavarian State Ministries of Social Affairs, Education and Health and the German Foundation of Organ Transplantation (DSO), an educational project for schools was launched.
Materials and Methods: After first promising events with intense discussions with students age 16 to 18, before graduation from high school, we expanded the invitations to junior high school students and introduced special events for teachers, which we see as effective multiplicators of the educational contents. The activity, scheduled for approximately 4.5 hours, begins with a display of the legal basics of organ donation and transplantation, followed by a vivid interactive presentation of the work of the organ procurement organisation DSO, ending with a quiz. A representative of the transplant centre demonstrates the milestones of transplantation, initially in a historical, chronologic way. Interposed are personal presentations of transplanted patients. The audience gets emotionally involved, by listening to their mostly touching fate on the waiting list, but also by their successful transplant story. Ethical questions related to the topic of organ donation and transplantation form a final discourse at the end of the clinical presentation. A 20-minute movie summarizing the tasks of the Eurotransplant foundation is completing the event.
Results: Meanwhile, in 110 performances, issued monthly during schooldays, more than 6.000 students and more than 500 teachers have been involved. The excellent feedback for this event is mirrored in the first “price for enhancing organ donation”, awarded by the German Transplant Society (DTG), in 2005 Its attraction is uncompromised, even in its 12th year after launching the activity, stressed by the fact of the monthly events being booked out already at the beginning of the new year. Additionally, the most important topics are available in PDF format, intended for download for teachers and use in their classrooms, thus further spreading the open discussion about organ donation and transplantation. Occasional participation of celebrities, politicians and broadcasters further enhance the attractivity of the event.
Conclusions: The project presented demonstrates a promising way, how to deal with a frequently tabooed, ethically explosive topic, by information without indoctrination and thus leads to a positive resonance in favor of organ donation and transplantation, and promotes the evolution of students into responsible individuals.
The motivation of organ donation among college students in the United States
Ruhul Kuddus1, Reza Sanati-Mehrizy2, Afsaneh Minaie2
1Biology, Utah Valley University, Orem, UT, United States; 2 Computer Science, Utah Valley University, Orem, UT, United States.
Background: Majority of the patients waiting for an organ is waiting for a kidney. Living persons can safely donate a kidney and donation of a kidney by about 1% of the adult population would completely eliminate kidney shortage. Current laws of the western nations allow organ donation only as a charity and prohibit compensation. We investigated comprehension and concerns of college students towards charitable and compensated organ donation.
Methods: A 40-question survey approved by the Institutional Review Board was conducted to collect the data. The respondents were students of biological sciences. The data was tabulated and analyzed.
Results: The participants (n=320) include 47% males, 53% females, 47% Caucasian and 53% other races, 44% married and 56% unmarried or divorced with an annual household income of <30,000. 48 % of the participants had at least one person in the family with some healthcare needs and 22% of the participants had a family member or a friend who is waiting for an organ or had an organ transplanted. 95% of the respondents support organ donation but most have little or no idea of the current system of organ procurement and distribution. 48% of the participants thought that transplantation benefits organ recipients and 39% believed that the donors should be compensated in some form. 64% of the participants thought that compensation would increase organ donation. Opinion of the participants on the ethical issues of compensated organ donation, organ theft rumors, brain death issues, organ harvest from comatose patients and from prisoners and organ harvest in the developing countries have been analyzed. Correlation of age, sex, ethnic background and other aspects of the participants with their motivation to organ donation are currently being analyzed.
Conclusions: A large fraction of young participants supports compensated organ donation and considers that compensation will increase organ donation.
International Registry in Organ Donation and Transplantation
Martí Manyalich2, Maria Paula Gómez Gómez1, Blanca Pérez Gavalda1
1DTI Foundation, Barcelona, Spain; 2Hospital Clínic de Barcelona, Barcelona, Spain.
Background: IRODaT is the first registry in this field, which contains statistics of deceased/living donors and transplants. Out of the 105 countries with organ donation or transplantation activity, 86 national reporters submit data to IRODaT during 15 years.
Methods: IRODaT is a friendly, easy to use database. Reporters introduce the figures of their countries directly to the webpage. Experts validate and update the data. IRODaT staff process the information and produce different materials to meet users’ needs and requirements. Internet users’ also may consult information by IRODaT website.
Results: During the first six month of 2013 IRODaT collected the 2012 year data from more than 56 countries. Information on donation and transplantation activity is analyzed and it is noticed an improved of the actual deceased donor rates in some countries around the world (see Fig 1). The great numbers are detected in Finland, which its rate increases from 17,3 in 2011 to 20.5 pmp in 2012. Belgium, increase from 29.3 pmp in 2011 to 32.9 pmp in 2012; Estonia had 19.4 in 2011 and 24.3 pmp in 2012, and finally the most significant rise is located in Slovenia, which increase from 15.5 pmp in 2011 to 23 pmp in 2012.
Conclusions: IRODaT is able to provide statistics within a short timeframe, based on a worldwide network of experts involved in organ donation and transplantation. The data have proved to be of an extreme value to scientific programs, social and governmental bodies.
Development and the global diffusion of transplantation activities
Sarah White1,2, Richard Hirth1,2,3, Beatriz Mahillo4, Beatriz Dominguez-Gil4, Mar Carmona4, Marina Alvarez4, Jose Ramon Núñez4, Rafael Matesanz4, Francis Delmonico5,6, Alan Leichtman1,2
1Department of Medicine, Division of Nephrology, University of Michigan, Ann Arbor, MI, United States; 2Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI, United States; 3Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, United States; 4Organización Nacional de Trasplantes, Madrid, Spain; 5The Transplantation Society, Montreal, QC, Canada; 6Department of Surgery, Harvard University, Boston, MA, United States .
Background: Organ transplantation is now a global practice, performed across high- to low-income countries. The interaction between economic, technical, socio-cultural, administrative and/or political factors influencing supply and demand, and the diffusion of transplantation technology has not been investigated in detail.
Materials and Methods: Data were obtained from the Global Observatory on Donation and Transplantation, World Bank, World Health Organization, and the World Values Survey. Two models were fitted: a logit model in which the dependent variable was any reported organ transplantation activity from 2006-2011, and a linear regression model in which the dependent variable was the log-transformed rate of solid organ transplantation in 2011.
Results: In a multivariate logit model, education (index combining years of schooling, secondary/tertiary enrollment; odds ratio [OR] per standard deviation [SD] increase=9.2, 95% CI 1.9 - 43.2), private sector indicators (index combining ease of doing business, logistics performance; OR=12.5, 95% CI 2.5 - 63.6), and life expectancy (OR=3.2, 95% CI 0.84 - 12.3) were positively associated, and mortality from cardiovascular disease and diabetes (ages 30-70) negatively associated (OR=0.3, 95% CI 0.1 - 1.1), with the existence of any transplantation activity after adjustment for population size. In a multivariate linear regression model, health expenditure from external sources >5% (b= -1.4, 95% CI -2.0 - -0.8), rate of scientific publications (b=0.9, 95% CI 0.5 - 1.2), and values orientation (self-expression vs. survival, b=0.5, 95% CI 0.1 - 0.9) were significant predictors of volume.
Conclusion: Economic development per se is not the principal determinant of transplantation availability: instead, uptake of transplantation was predicted by educational attainment, health outcomes, and private sector indicators. Higher transplant volumes were predicted by self-sufficiency with respect to health resources, scientific research output, and values orientation emphasizing quality of life and altruism. A limitation of this analysis is the inability to consider all possible factors influencing the availability of transplantation, in particular the impact of regional/international cooperation.
The analysis of discarded deceased organs in KSA
Faissal A.M. Shaheen, Besher Al Attar, Abdulla Al Sayyari, Mohamed Kamal, Michael Abeleda
Medical Department, Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia.
Objective: To evaluate the rate and causes of unused organs in ten-year period.
Methods: A retrospective study was done during the period of 2000-2009, comprising the eligible, the actual, the utilized deceased organ donor cases and consented not harvested cases. Organs involve were kidneys, livers and hearts.
Results: From the total of 4227 reported cases as Possible Deceased Donors (DD), 2162 (51.1%) were approached for organ donation after declaration of Death, and 702 (32.5%) were consented for organ donation with 635 (90.5%) harvested, while 67 (9.5%) were rejected. From the 635 actual cases, 98% were consented for kidney donation including cases from organ sharing program with GCC countries and Spain. There were 1066 kidneys retrieved locally, 1009(94.7%) of them were utilized, and 57 (5.3%) were not used. All in all, 653 (93%) cases were eligible for liver donation, 249 (38.1%) of which were rejected for utilizing mainly due to hypernatremia and elevated liver enzymes, 422 (64.6%) cases were harvested while 323(76.5% from the harvested cases) were utilized with 99 (23.5%) unused. There were 596 (84.9%) eligible for heart donation with only 84 (14.1%) were used as whole heart and 296 used as a source for valves.
Conclusion: The rate of rejection to harvest were 10.13% for kidneys, 34.41% for liver and 36.92% for heart, mainly as a result of the donor qualities, while the rate of unused organ after harvesting is around 19.14%, usually due to characteristics itself. Still, we could lessen the rate of rejection by preventing technical reasons and the much needed improvement in the area of donor management.
Keywords: Deceased Donors, Unused Organs, Rejection Rate, Saudi Arabia
 Int J Org Transplant Med 2012; Vol. 3 (4)
 Rao P. et. al. Donor Factors affecting Graft Outcome: the Kidney Donor Risk Index.
 SRTR database 69,440 transplant. Transplantation 2009; 88:231-6
 Tuttle-Newhall J. et.al., Increasing Demand Necessitates the Use of More Expanded Criteria Donors. 2008 OPTN/SRTR Annual Report
 SCOT DATA. Annual Report 2008-2010 Ministry of Health, Kingdom of Saudi Arabia. http://www.scot.org.sa
Living Donor Registry (LIDOBS Community)
Ana Menjivar2, Xavier Torres2, Josep M. Peri2, Ignacio Revuelta2, Fritz Diekmann2, Constantino Fondevila2, Santiago Sanchez2, David Paredes1,2, Chloe Balleste1, Marti Manyalich1,2
1School of Medicine, University of Barcelona, Barcelona, Spain; 2Hospital Clinic of Barcelona, Barcelona, Spain.
Introduction: Nowadays, there is no any central database for Living Donation practices in Europe. Living Donor Observatory (LIDOBS) a multidisciplinary team of international experts in the field, is concerned into developing a central database for these practices.
Such registry will ensure a rich resource of information for European transplant community and will be very useful for all the centers applying Living donors (LDs) practices.
Objective: To develop an on-line simplified registry model for LDs with central database reports to an international level.
Methods: LIDOBS registry use the database created previously during EULID project (European Donation and Public Health) and tested for EULID participating countries.
The registry data are classified in three levels:
1st Transparency: Include the mandatory data.
2nd Security: Include the recommended data of clinical pre and post donation parameters.
3rd Quality of donation programs: Include excellence data representing the quality of donation programs. All these data are collected by the application of the questionnaires for LD satisfaction and psychosocial follow-up.
Results: LIDOBS registry is active and being used for the research projects European and Spanish that LIDOBS group is running out.
Currently there are more than 1600 registered LDs with mandatory data from 19 centers in 13 European countries. 1461 out of these are Kidney LDs and 162 are liver LDs. This divergence is due to the superiority in number and operative centers for Kidney LDs programs.
Conclusions: An online database is useful to simplify the registration and analysis processes, increasing the quality of the disposable information on LDs as well increasing the quality of the programs.
All registries offer the opportunity to promote results and experiences on donation and transplantation activity development.
A great gratitude goes to all the professionals from all the participant centres that were involved in the following projects: ELIPSY project EULID project FIS project (co-founded by European Regional Development Fund FEDER).
Patients’ attitudes towards living kidney donation: Systematic review and thematic synthesis of qualitative research
Camilla S. Hanson1,2, Steven Chadban3, Jeremy R. Chapman2,4, Jonathan C. Craig1,2, Germaine Wong1,2,4, Allison Tong1,2
1Sydney School of Public Health, The University of Sydney, Sydney, Australia; 2Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, Australia; 3Transplantation, Royal Prince Alfred Hospital, Sydney, Australia; 4 Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia.
Living donor kidney transplantation can offer optimal clinical outcomes for recipients compared with dialysis or deceased donor transplants. However, decision-making can be complex for patients, given the medical and psychosocial risks to donors. This study aimed to describe the beliefs, attitudes, and expectations of patients with chronic kidney disease (CKD) towards living kidney donation. We conducted a systematic review of qualitative studies of patients’ attitudes towards living kidney donation using a comprehensive literature search to February 2013. Thematic synthesis was used to analyse the findings. Thirty-seven studies involving 1732 patients with CKD (stages 1–5) were included. We identified five major themes: prioritising health (better graft survival, urgency and desperation, resuming normal life, accepting risk, active self-advocacy); burden of responsibility (jeopardising donor health, anticipated donor regret, fear of graft failure, donor inconvenience); sensitive and cautious communication (donor initiation, respectful communication, decisional pressure, donor unsuitability, lacking self-efficacy, emotional vulnerability); shifting relationship dynamics (strengthened bonds, tension and conflict, unrelenting indebtedness, maintaining self-reliance, renegotiating relationship roles); and support structures (religious altruism, family loyalty, limited professional support). Patients believed a living kidney donation could offer a lifesaving treatment with minimal medical risk to themselves or donors. However, patients felt accountable for potential adverse outcomes like graft failure and donor health complications, and feared their donor would regret their decision to donate. Initiating discussions with potential donors was emotionally challenging for patients. Clarifying, validating and addressing these concerns, coupled with education and psychosocial support can empower patients to make informed decisions about living kidney donation.
European living donor psychosocial follow-up (Elipsy Project)
Marti Manyalich1, Ana Menjivar2, Ingela Ferhman-Ekholm3, Christian Hiesse4, Leonidio Dias5, Christina Papachristou7, Niclas Kvarnström3, Levent Yucetin, Xavier Torres2, Josep M. Peri2, Inês Carvalho2, Fritz Diekmann2, Ignacio Revuelta2, David Paredes2, Constantino Fondevila2, Entela Kondo2
1School of Medecine, University of Barcelona, Barcelona, Spain; 2 Hospital Clinic of Barcelona, Barcelona, Spain; 3Karolinska Universitetssjukhuset, Stockholm, Sweden; 4Hôpital Foch, Paris, France; 5Centro Hospitalar do Porto, Porto, Portugal; 6Charité University Hospital Berlin, Berlin, Germany; 7Medical Park Antalya Hospital Complex, Antalya, Turkey.
Introduction: ELIPSY project, co-funding by EAHC aims to develop a common methodology for EU countries to assess/follow-up the psychosocial sphere of Living Donor (LD).
Objective: To contribute guaranteeing high quality living organ donation programs, by creating a follow-up model for LDs psychological well-being, Quality Of Life (QOL) and the impact of recipients’ outcome on the donor and donors’ perception of donation process.
1. Current psychosocial follow-up practices: LD’s assessment/follow-up methodology among partner’s centers.
2. Donor follow-up methodology: Evaluate the psychosocial well-being, QOL of LD before and after donation and the impact of donation process.
3. Recipient follow-up: Design a recipient follow-up methodology to correlate recipients’ outcome with the LDs psychosocial sphere.
1. Prospective: Assessing short-term outcome (percentage of change between pre-donation and one year after) of LDs to detect and characterize worsening of psychosocial status.
2. Retrospective: Identifying long-term impact (up to five years) of living donation and recipient/graft outcome in LDs psychosocial sphere.
Results: Survey about current psychosocial assessment/follow-up practices was conducted in 52 centres from 10 countries. Results show no consensus among the centres.
Prospective study shows no changes in the psychosocial outcome of 87 LDs assessed before and after donation, within the range of healthy general population.
Retrospective study shows no significant differences in the psychosocial outcome of 302 assessed LDs compare to the healthy general population.
Conclusions: LDs assessed by ELIPSY methodology go well both at short and long term follow-up.
ELIPSY project contributes for the harmonization of LDs psychosocial follow-up practices promoting high quality LD programs.
A great acknowledgement goes to all the professionals from the six participants centers that were involved in all the stages of the project.
Mortality in patients with potential living donor liver awaiting liver transplantation
Hussien Elsiesy, Rania Alarieh, Zohor Mubaraki, Faisal Abaalkhail, Almoutaz Hashim, Hamad Albahili, Waleed Alhamoudi, Mohamed Alsebayel
Liver transplantation, KFSH&RC, Riyadh, Saudi Arabia.
Background: Living donor liver transplantation has the advantage of avoiding the long waiting time for cadaveric liver transplantation with possibility of decreasing mortality before liver transplantation.
Objective: To identify the mortality in patients with decompensated cirrhosis with potential living donor during the evaluation process for both donors and recipients before liver transplantation.
Methods: We retrospectively reviewed our records for patients with liver cirrhosis requiring liver transplantation that has a potential donor, the number of donors evaluated for each candidate, the mortality during the evaluation process either related to complication of liver disease or progression of hepatocellular carcinoma (HCC).
Results: Out of 370 liver cirrhosis patients with potential living donor for liver transplantation, 102 died (27.6%), 79 died related to complication of liver disease and 23 related to HCC progression.
The mortality increased as the number of donors evaluated increase, it was 27.6% for patients with one or two donors (86 out of4=311), 37% for patients with 3 donors evaluated (13 out of 35), and 50% with five or seven donors evaluated (2 out of 4). We do not have a MELD limit for living donor and patients with MELD >25 are discussed in case to case bases, and the donor work up time from 2 to 18 days (average 10 days).
Conclusion: The mortality is high in patients with potential living donor liver transplantation, with increase in mortality as the number of potential donors increase.
This may be explained by the time needed for the donor evaluation as well as late referral.
King Faisal Liver Group
A prospective audit of 50 retrievals in 12 months by a single surgeon: The good, the bad and the ugly
Henry Pleass, Lawrence Yuen, Vincent Lam, Brendan Ryan, Wayne Hawthorne, Richard Allen
Westmead, Westmead Hospital, Sydney, Australia.
Over a 12 month period all deceased organ donor procedures performed by a single surgeon were prospectively recorded. In total 50 deceased donor procedures were attempted during this time.
Of these 38 were brain dead donors (DBD) and 12 were DCD donors. Looking at the DBD donors more closely only 1 was a Kidney only donor, the other 37 being multi organ procedures. 6 Livers were split in situ in addition to kidney and Pancreas retrieval. There were 19 Liver Kidney retrievals, 7 Liver Kidney Pancreas and 2 Liver only retrievals where the kidneys had no suitable recipients. 4 livers were deemed unusable because of either severe steatosis or fibrosis (11%).
There were 12 DCD donors and of these, only 2 failed to progress during the 60 minute time frame. 2 DCD donors were deemed suitable Liver donors although only 1 was subsequently transplanted. The remainder was Kidney DCD donors, with or without Lung retrieval.
Over 12 months no Livers were deemed unusable because of retrieval injury. All split Liver procedures resulted in the Transplantation of both an adult and child in each case. Only 1 kidney was deemed untransplantable because of an intimal tear within the renal artery, although the kidney itself had been well perfused in the donor.
In conclusion deceased donor procedures remain complex, largely multi organ and mainly DBD donors within NSW. As only 1 procedure was a Kidney only donor during this study period, this has cost implications for providing a skilled readily available retrieval service, capable of retrieving all abdominal organs and splitting Livers to maximise organ utilisation. This remains a vast and largely untapped training opportunity for surgeons within NSW. Organ quality is fed back to the retrieval surgeon by way of an organ retrieval report form, filled out by the recipient surgeon. These forms are reviewed in NSW, by the state Transplant Advisory Committee and also by the Deceased donor organ procurement service committee to ensure optimum outcomes and the prevention of iatrogenic organ injury.
A review of perioperative staffing and competence levels for national organ retrieval teams in the United Kingdom
John Stirling, Ian Currie
Scottish Organ Retrieval Team, NHS Lothian, Edinburgh, United Kingdom.
Organ retrieval from cadaveric donors in the United Kingdom is undertaken by National Organ Retrieval (NORS) teams. Organ preservation techniques are developing rapidly, with new technologies including Normothermic Regional Preservation and ex-situ normothermic preservation now emerging into clinical practice. Currently organ preservation is often undertaken by Specialist Nurses in Organ Donation who already have significant other commitments during the organ retrieval process. Increased complexity in surgical retrieval and organ preservation requires highly trained individuals working to a national competence framework to undertake these roles. As workload increases, and roles become more complex, Specialist Practitioners in Organ Retrieval and Transplantation are emerging. Adequate staffing numbers and competence levels are critical for quality in organ retrieval and preservation. The staffing levels recommended in the NORS standards fall below that required by the Association for Perioperative Practice. Additionally, new competencies need to be developed to support staff from different disciplines that are developing specialist knowledge in organ retrieval and preservation. The composition and competence levels of NORS teams should therefore be reviewed to ensure cadaveric organ donors receive the same level of care as other patients in the operating room.
Submitted on behalf of the Scottish Organ Retrieval Team
Donor action per Vital-Link in Korea
Surgery, Yonsei University Health System, Seoul, Korea.
Since the establishment of government driven organ donation network (KONOS) and deceased donor organ transplantation Acts for organ transplantation in 2000, the patients on deceased organ donor waiting list were increased more than 6 folds for the last decade in Korea. To increase the numbers of deceased organ donor per sophisticate donor action and public education, the members of “The Korean Society for Transplantation” embarked Vital-Link Korea in October, 2009. After then, Vital-Link Korea had made a lot of efforts for publishing books and booklets relevant to organ donation and transplantation for public education as well as hosted many domestic and international forums to establish a solid supporting system in organ and tissue transplantations in Korea. Per the effort of Vital-Link Korea, we had 2nd renewed version of deceased donor organ transplantation Acts in May, 2010 and we had 409 deceased organ donors in 2012 when compared to 261 in 2009 and 52 in 2000.
Changes of public recognition for organ donation in Korea
Kyung Sook Jang1, Eun Joo Lee2, Han Duk Jung3, Sun Hee Kim2, Jon Won Ha5,6
1Donation Support Deptartment, Korea Organ Donation Agency (KODA), Seoul, Korea; 2Public Relations Department, Korea Organ Donation Agency, Seoul, Korea; 3Division of Donation Support Director, Korean Network for Organ Sharing, Korean Center for Disease Control, Seoul, Korea; 4Chief Operating Officer, Korea Organ Donation Agency, Seoul, Korea; 5Department of Surgery, Seoul National University College of Medicine, seoul, Korea; 6President, Korea Organ Donation Agency, Seoul, Korea.
To increase the organ donation, public awareness for brain death and organ donation is important. We analyzed survey data to find out what is the effective public promotion method and direction.
Method: Two surveys were performed in 2009 (1,346 answers) and 2012 (1,002 answers) including donor family, medical professionals, and general public. The proportion of general public was more in 2012.
Result: Knowing the concept of organ donation increased mildly (from 93.4% to 97%). However, the proportion of having only basic knowledge of organ donation was 62.1% in 2009, which increased to 73.8% in 2012. Those who know the whole procedure of organ donation also increased from 3.3% to 23.2%. Most of information was obtained through TV and it was more in 2012 (from 84.6% to 89.4%). Information posted in hospital (31.1%), friends and colleagues (29.2%), newspapers (24.5%), and internet (14.6%) followed next in 2012. However, dependence on newspaper decreased from 35.1% in 2009 and hospital information was another major source of information in 2012.
Conclusion: Ratio of people with full knowledge on organ donation and its process increased 20%, which reflects the effect of public education as well as medical professional education. General public acquire information mainly via TV, the strategy to use multimedia such as TV and newspapers should be developed.
Characteristics and preliminary determinants of family consent regarding organ donation from 4 Melbourne hospitals
Claudia Marck1, Sandra Neate2, Michelle Skinner3, Bernadine Dwyer3, Tracey Weiland1, George Jelinek1
1Emergency Practice Innovation Centre, St Vincent’s Hospital, Melbourne, Australia; 2Emergency Department, St Vincent’s Hospital, Melbourne, Australia; 3DonateLife Victoria, Melbourne, Australia.
Family consent rates for deceased organ donation (OD) are below 60% in Australia. To better understand the experiences and decision making process when next of kin (NOK) of potential donors are asked to consent for OD we are collecting data from 4 hospitals in Melbourne with the aim of interviewing 30-40 NOK. Data is collected if OD was discussed with the NOK of a potential donor, except for cases where donation was considered unlikely to proceed due to lack of medical suitability or the patient was unlikely to die in the required timeframe for donation after cardiac death (DCD). NOK receive information about the study 6 weeks after the death and are invited to participate by phone 2 weeks later. Data collection is ongoing, but preliminary analysis shows that of the 108 potential donors identified for inclusion in the study, 59% were eligible for DCD, most were identified in the ICU (83%), 61 were male and the median age at death was 59 years. Of the 53% (57) where consent for OD from NOK was obtained, 7 were “intended donors”, organ retrieval did not commence; 10 were “planned DCD”, DCD did not occur; and 40 were “organ donors” of which 35% DCD donors. 51 were “non-consent” where the NOK declined consent, of which 70% potential DCD donors. Consent was not related to gender, age, or religiosity, but was significantly related to country of birth, with those born in Asia or Oceania less likely to consent (8%) compared to those born in Europe (55%) or Australia (68%, p = 0.001). Non-English speaking families were also less likely to consent for OD compared to English speaking (8% vs 61% p < 0.001). Of those 63 invited, 35 agreed (including 12 non-consenting NOK) to be interviewed to explore their experiences and decision making related to the consenting and OD (qualitative data presented elsewhere). Interviews took place on average 91 days after the death. Additional data collection and analysis will provide further understanding of factors related to family consent.
 Opdam, H.I. and W. Silvester: Potential for organ donation in Victoria: an audit of hospital deaths. Med J Aust 2006, 185(5): 250-254.
Introducing simulation training to improve the organ donation conversation
Ellie McCann, Jonathan Gatward
NSW Organ and Tissue Donation Service, Sydney, Australia.
Simulation training within a protected learning environment provides unique opportunities for clinicians to rehearse realistic clinical scenarios and actively participate in role playing within a team setting. Key to the simulation learning experience is a facilitated debriefing session where examples of good practice and areas for improvement are discussed. Together, these processes trigger ongoing reflection about participants’ knowledge, skills and attitudes.
We developed a simulation course to consolidate skills acquired from the National Education Program, as part of the overall training required to become a Designated Requestor: the specially trained clinician that will conduct the sensitive organ donation conversation and provide information and support to families considering the opportunity to donate.
Our course gives participants the opportunity to rehearse, review and reflect on the difficult ‘family conversation’ in a simulation setting, using professional actors. The aim of the course is to increase participants’ confidence in undertaking the family conversation in clinical practice and to better support families through the decision making process.
Real scenarios are used with professional actors in the role of family members. The debriefing process is led by qualified experts and utilises video review and feedback from the actors, both ‘in’ and ‘out-of-character’.
This program was piloted in 2012 and formally commenced in January 2013. To date, one pilot and five training sessions have been conducted with 35 participants. Further sessions are scheduled for 2013 and it is anticipated that the program will continue to develop beyond this time.
Evaluations have been overwhelmingly positive with 70% of participants rating the training as outstanding, with requests to provide it regularly as a ‘refresher’ course.
Our presentation will highlight the value of simulation training in improving end of life conversations including those involving organ donations.
The Royal Prince Alfred Hospital, Sydney
ETPOD dissemination: The transferability of a successful European training program
Gloria Paez1, Marti Manyalich1,2, Xavier Guasch3, Ricard Valero1,2, Melania G. Istrate1
1TPM-DTI Foundation, Barcelona, Spain; 2Hospital Clínic de Barcelona, Barcelona, Spain; 3Hospital de la Plana, Villarreal, Spain.
Background: The European Training Program on Organ Donation (ETPOD) is a successful educational initiative addressing 3 different professional levels in organ donation that achieved a significant improvement in both numbers of utilized donors and organs recovered . One training program developed is “Training for Trainers” that aims at providing key donation professionals with the skills required to replicate the “Essentials in Organ Donation Training seminars” (EOD).
Objectives: The aim of this study is to ensure the continuity and transferability of the ETPOD training program, disseminate the educational tools created and analyze dissemination impact.
Methods: A dissemination strategy was developed to ensure ETPOD continuity and transferability. Due to its successful outcomes, ETPOD participants were encouraged to continue the implementation of EODs.
Moreover, participants from 22 countries, belonging to the European Transplant Network (ETN) and the Mediterranean Transplant Network (MTN), benefitted from Training for Trainers Programs and implemented EODs.
The impact of ETPOD results reached non-participating countries and due to its feasibility, new organizations expressed their interest to implement the training program in their countries.
A database was created (http://www.etpod-dissemination.eu) to follow up the EODs carried out.
Results: Since 2009 when ETPOD finished, a total of 172 EOD seminars have been carried out and 8477 healthcare professionals trained as following: 71 EODs and 4223 professionals trained by ETPOD participants, 98 EODs and 4195 professionals trained in the ETN and MTN countries, 3 EODs and 59 professionals trained by Life’s Donor, São Paulo, Brazil.
Conclusions: ETPOD, a successful training that produced significant improvements in organ donation, has been continued reaching out a high number of professionals worldwide.
 Manyalich M, Guasch X, Paez G, Valero R, Istrate M and the ETPOD partner consortium: ETPOD (European Training Program on Organ Donation): a successful training program to improve organ donation. Transpl Int 2013 Apr;26(4):373–84
Create an interactive eLearning portal to increase staff knowledge and understanding of the organ and tissue donation process.
Karli Brkljacic1, Kelly Rogerson2, Nicola Stitt1,2
1Intensive Care Unit, Monash Health, Melbourne, Australia; 2 Donatelife Victoria, Melbourne, Australia.
Introduction: A key activity of the Australian Organ and Tissue Authority (The Authority) 2009 health reform was employing specialist donation staff (SDS) dedicated to improving organ and tissue donation processes in hospitals. Monash Health (MH) which is Victoria’s largest health service has experienced a threefold increase in Organ donation since the implementation. Alternative methods of education delivery have eventuated to meet staff need. The paper reports on the development of an E Learning Portal to deliver interactive accessible education to staff.
Methods: SDS utilised a strong knowledge base, and linked with an external IT consultant to place clinical knowledge in a usable interactive format. Four modules were proposed by the SDS. The first was the National Clinical (GIVE) trigger. This module was launched in February 2012.The GIVE Trigger is used in all Emergency Departments and Intensive Care units to identify potential donors. This was subsequently followed by the second module, Eye and Tissue donation, which was launched in October 2012. This module was designed for all medical and nursing staff.
Results: 1000 MH staffs have completed the online modules. Organ and tissue donation recognition, approach and consent rates are at an all-time high for the organisation which can be partly attributed to an increased awareness and understanding formed from the E Learning portal.
Conclusions: Due to the success of the E Learning Portal in MH, Donatelife Victoria has engaged with the SDS to launch both modules across Victoria and New South Wales. E learning activities are now strategic activities at a National Level.
How eLearning is utilized to augment the classroom training of donation professionals
Robert J. Norden, Cherry P. Wise, Theresa A. Daly, Patricia A. Mulvania, Howard M. Nathan
Gift of Life Institute, Philadelphia, PA, United States.
Background: For nearly ten years, an international training institute for donation professionals has offered interdisciplinary resources for skill-based learning. Recognizing that its training audience is increasingly digital-native, the institute offers eLearning—a tool that provides anywhere, anytime instruction over the web—to augment its traditional classroom-based model.
Aim: By offering eLearning as a tool to provide fundamental concepts prior to classroom training, instructors can better manage time to engage learners through skill-building and problem-solving.
Results: Since July 2012, eLearning has been utilized in five separate on-site trainings, resulting in classroom sessions more focused on practical application. Facilitators spend significantly less time lecturing and more on deepening the understanding of complex donation-related issues. As testament to the effectiveness of eLearning, of the 54 participants who responded to a survey, 89% stated they Strongly Agree/Agree that they Would like to see more eLearning modules in the future; 9% Neither Agree or Disagree; 2% Disagree. When the same learners were asked if they Would recommend these modules to others, 91% either Strongly Agree/Agree and 9% Neither Agree or Disagree.
Materials and Method: To establish a base knowledge among participants prior to classroom training, the institute offers 15 self-directed modules on donation-related topics. To maximize learner engagement, instruction is provided through text, audio, and video. Knowledge checks and a final assessment are used to gauge comprehension, with results documented in a learning management system.
Conclusion: In addition to the inherent benefits of providing on-demand training and the ability for learners to revisit training topics on an ongoing, as-needed basis, eLearning offers classroom participants with more skill-practice and problem-solving opportunities.
One OPO’s experience using online role-play tool to increase donation professionals’ skill and confidence level in leading family conversations for organ donation
Theresa A. Daly1, Patricia Mulvania2, Robert Norden1, Howard Nathan1
1Gift of Life Institute, Philadelphia, PA, United States; 2 Gift of Life Donor Program, Philadelphia, PA, United States.
Background: Int’l training institute uses medical school online role-play tool to augment donation professionals (DP) family donation conversation (FDC) training, provide focused feedback and improve skill and confidence. Training institute offered tool to OPO to do same with its DPs and assess for ongoing use.
Aim: Increase skill and confidence levels of DPs leading FDCs as research indicates improved DP confidence in leading FDCs is associated w/higher authorization rates.
Materials and Methods: Tool offered opportunity for interactive skills practice and to assess, coach and improve staff judgment and communications skills. OPO leadership trialed use of tool to augment workshop training and increase skill and confidence through one-on-one remediation.
Results: Initial feedback from coaches, leadership and DPs was positive and indicated improved skill and confidence levels. When DPs were asked about impact on confidence levels leading FDCs AFTER using tool, 80% said Very Good-Good; 80% reported Extremely to Very Satisfied when asked to rate his/her experience using the tool; and 80% reported the feedback received from the coach was Extremely to Very Valuable. The OPO determined tool important enough to integrate into existing formal training program. Tool will be used for orientation sign off, annual training, improvement plan and staff requested practice. It is too early to measure impact on long term authorization rates.
Conclusion: Research indicates that higher confidence levels leading a FDC correlate to higher authorization rates. Confidence comes from experience and practice. OPOs are challenged to provide adequate one-on-one training opportunities to strengthen skill and build confidence.  Based on a survey of initial use of the online role-play tool, confidence levels in leading family donation conversations increased and the OPO is formally integrating this tool into its training with expectation that it will contribute to long term increased skill and authorization rates.
 Siminoff L, Gordon N, Hewlett J, Arnold R: Factors influencing families’ consent for donation of solid organs for transplantation. JAMA 2001, 286(1):71-77.
Trial of education program of in-hospital coordinators in Japan
Norihide Fukushima1, Setsuko Konaka1, Mayumi Yasuhira2
1Department of Therapeutics for End-Stage Organ Dysfunction, Osaka University, Suita, Japan; 2West Japan Branch, Japan Organ Transplant Netwrok, Osaka, Japan.
Objectives: Although the Japanese Organ Transplant Act was revised in 2010 and brain dead organ donation increased from 13 to 45 cases in a year, the number was still extremely smaller than other developed countries. In these circumstances, In-Hp Cos may play great roles in increasing organ donation and making procurement procedure smooth. In the present study, our Education Program of In-HpCos is described and the future of education program of In-Hp Cos in Japan is discussed.
Materials and Methods: In May 2012, our Department started the Education Program of In-Hp Cos. In the first semester, two-hour lecture are provided every two weeks for 5 months to 10 to 20 In-Hp-Cos. Most of them are working near Osaka. In the second semester, twenty lectures were provided for continuous three days to 32 In Hp Cos. Two third of them are working far from Osaka,
The topics of lectures are history of Organ transplantation in Japan and in the world, the current status of organ donation and transplantation in Japan, the social regulation of organ donation, care of transplant recipients, overall procedures of organ donation (brain dead and donation after cardiac death), the role of In-Hp Co, donor family care, and donor indications, and donor assessment and management. There are also simulation of organ donation process in which every participant play their special role and group discussion of family care.
Results: Regards to opinion survey of participants after the program, most of participants were satisfied with the program, topics and duration. As most of them are not a full-time In-Hp, they prefer to attend 3-day program. Although not so many organ donations have not been performed in hospital in which the participants are working, many participants are now working main In-Hp Cos and establishing their own organ donation system in their hospital.
Conclusions: To establish organ procurement system and increase organ donation, In-Hp Cos have great roles in Japan. However, none was a full-time In-Hp Cos and most In-Hp Cos required more professional education. This program may help to establish systematic education program for each occupation in Japan.
Potential and evolution of organ donation in Galicia (Spain) 2006-2011
Jacinto Sanchez-Ibañez, Marta Alvarez Vazquez, Encarnacion Bouzas Caamaño
Regional Transplant Coordination, Galician health Service, Santiago de Compostela, Spain.
Aim: To describe the potential for donation in Galicia and to study its evolution in the last 6 years,
Material and methods: We analyzed all ICU deaths (ICUDs) from 2006-2011, specifically all with intracranial diseases (ICDs) that can develop brain death (BD), their evolution to BD and to donor. We evaluated the age impact and the cause of death in the total number of BDs and organ donors.
Results: We analyzed 9,280 ICUDs where we knew the cause of death (98.7% of the total number of ICUDs from all the authorized hospitals). 27.4% died from ICDs, of whom 37.8% developed BD, 52.8% of these finally becoming organ donors. The median age of ICUDs was 71 years old, 68 years old for the ICDs. The most frequent causes of death in the ICD group were cerebrovascular accident (59.2%), non traffic brain trauma (15.2%) and anoxia (14.4%). During 2006-2011 the ICUD percentage decreased by 11%, ICDs decreased by 12.8%, especially cerebrovascular accident and traffic brain trauma. Nevertheless the total number of BDs and donors has been maintained. The median age of ICUDs and ICDs was maintained but BD increased from 61 to 71 years old and actual donors from 58 to 60 years old. These figures varied slightly between hospital with or without neurosurgery but the trend was the same.
Conclusion: ICUDs is decreasing progressively, including from ICDs in all the hospitals. Nevertheless the total number of BDs and organ donors remain constant, probably due to the ongoing improvement in the work done by hospital transplant coordinators.
Educational efforts impacting on critical care staff’s attitudes towards donation: Donor action data from Korea and Japan
Beatrice Pelleriaux1, Jongwon Ha2, Tomonori Hasegawa3, Jacqueline Smits4, Leo Roels1
1Donor Action Foundation, Linden, Belgium; 2Korea Organ Donation Agency, Seoul, Korea; 3Toho University School of Medicine, Tokyo, Japan; 4Eurotransplant International Foundation, Leiden, Netherlands .
Background: Critical Care (CC) staff’s attitudes towards donation vary between professional categories, hospitals and countries, depending, amongst other co-factors, on educational efforts, and, hence, may influence donation rates.
Methods: 17,860 Donor Action (DA) Hospital Attitude Survey (HAS) questionnaires (Korea: n=1,454, Japan: n=16,406), collected between January 1, 2010 and December 31, 2012, were entered into the DA database to compare CC staff’s attitudes towards donation as well as their confidence levels with donation related tasks and their training needs. In Korea, a governmentally supported educational program by skilled transplant coordinators (81 training sessions in 27 hospitals) preceded this survey.
Results: General support for donation was higher amongst Korean medical/nursing (M/N) staff (87.3%) compared to their Japanese colleagues (73.1%, P <.0001). Whilst 52.3% of Korean M/N staff would donate their own organs, only 41% of Japanese colleagues would do so (P<.0001). In Japan, 22.3% of M/N staff would object to donating their relative’s organs, versus only 15.4% in Korea (P<.0001). Confidence levels with referring a potential donor, explaining brain death (BD) or introducing the subject of donation were 66.9, 48.3 and 31.7% respectively amongst Korean staff, against only 9.5, 2.9 and 2.6% in Japan (P<.0001). BD was accepted as a valid determination of death by 84.6% of medical and 63.3% of nursing staff in Korea, versus only 60.9 and 32.9% in Japan (P<.0001). In Korea, 27% of medical and 17% of nursing staff on average had received specific training on organ donation related issues vs. only 6.5 and 4.5% in Japan (P<.01).
Conclusions: Data presented suggests a strong correlation between self-reported attitudes, skills and confidence levels and specific education received in 2 neighbouring Asian countries with an otherwise comparable socio-economic, technical level and religious background. Further investigations to understand the subtle cultural disparities that may explain diverging relationships amongst CC and transplant professionals may help to adapt and export the ‘Korean model’ of targeted training of CC staff to other Asian countries and will ultimately increase donation rates in these countries.
Kidney transplantation from donors with acute kidney failure receiving haemofiltration.
Jo Sanders1, Hayley Furniss1, Helen Opdam1, Daryl Jones1,2
1DonateLife Victoria, DonateLife, Carlton, Australia; 2Intensive Care Unit, Austin Health, Heidelberg, Australia.
Acute kidney failure (AKF) is common in critically ill patients but generally resolves with non invasive treatment. Some patients may require haemofiltration to ensure adequate renal function during the acute kidney impairment episode. More than 90% of acute renal failure resolves with resolution of critical illness. Despite this, kidneys from potential donors with renal impairment have traditionally been considered unsuitable for transplantation due to the concern of poor renal recovery and function post transplantation.
We aim to report the Victorian experience of facilitating cadaveric donation in patients with established acute kidney failure requiring haemofiltration, to demonstrate that such donations can result in successful kidney transplantation. A retrospective analysis of all organ donors from 2008 to 1st July 2013 was undertaken to identify the number and outcomes, of renal donations in the context of acute kidney failure.
625 donors were reviewed, identifying 293 who had at least one episode of oliguria (oliguria = <20ml/hr UO) throughout admission. Of these oliguric donors, eight donors were identified to have received haemofiltration for renal impairment treatment during their hospital admission prior to donating their kidneys. Fifteen successful kidney transplants resulted, with one kidney not transplantable due to surgical complications. The kidney recipients were followed up for one year to five years post transplant and have shown favourable outcomes.
As there is a widening gap between the number of patients needing kidney transplantation and number of kidneys available for transplantation, strategies should be developed to expand the kidney donor pool. We have demonstrated that utilising kidneys from deceased donors with established AKF requiring haemofiltrtion should be considered as one strategy to overcome the current shortage of kidneys.
A 17 year summary of one OPO’s changing pool of potential donors
Gweneth O‘Shaughnessy, Sharon West, Richard Hasz, Howard M. Nathan
Gift of Life Donor Program, Philadelphia, PA, United States.
Purpose: Study characterizes one organ procurement organization’s (OPO) evolving donor demographics and donation outcomes over a 17 year period of time.
Methods: Characterizing donor demographics and donation outcomes allows the OPO to understand its pool of potential donors, and align strategies/resources. Characteristics examined: cause of death, mechanism of death, ethnicity, gender, and age. Outcomes examined: organ referrals, potential donors, actual donors (brain dead and donors after circulatory death), and conversion rates (actual donors as a percentage of potential donors).
Results: Organ referrals among anoxic patients increased from 24% (200) of total referrals to 57% (2093) in 2012. In 1995, anoxic potential donors represented 15% of the donor pool vs 44% of the donor pool in 2012. Organ donors in the anoxic pool increased from 12% (27) of total donors in 1995 to 41% (171) in 2012. DCD donors represented 46% of all DCD donors in 2012 (n = 65). The primary mechanism of injury was cardiovascular (50% in 1995; 71% in 2012). Conversion rates are higher in the ‘other’ cause of death category.
Conclusion: There has been a dramatic increase in the overall volume of referrals, potential, and donors in the anoxic population. These patients are typically cared for in medical/cardiac intensive care units (ICUs) vs other ICUs. To ensure that there is an optimal donation process in place, OPOs should evaluate the impact of shifting hospital development (HD) staffing resources to these areas. Although conversion rates in the anoxic donor pool improved to 50%, other strategies should be considered to improve consent and conversion.
Family perspectives on organ and tissue donation for transplantation: Thematic synthesis of qualitative studies
Angelique Ralph1,2, Jeremy Chapman3, Jonathan Gillis4, Jonathan Craig1,2, Phyllis Butow5, Kirsten Howard1, Michelle Irving1,2, Bernadet Sutanto1,2, Allison Tong1,2
1Sydney School of Public Health, The University of Sydney, Sydney, Australia; 2Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, Australia; 3Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia; 4Centre for Values, Ethics and Law in Medicine, The University of Sydney, Sydney, Australia; 5Centre for Medical Psychology & Evidence-based Decision-making, The University of Sydney, Sydney, Australia .
Background: A contributing factor to the critical shortage of deceased organ donors is family refusal to give consent, or veto a prior decision of the donor. We aimed to describe the beliefs and views of donor families on organ and tissue donation.
Methods: We conducted a systematic review and synthesis of qualitative studies on family perspectives on organ and tissue donation for transplantation. Electronic databases were searched to September 2012.
Results: Thirty-four studies involving 1,035 participants were included. We identified seven themes: comprehension of unexpected death (including sub-themes of accepting finality of life, ambiguity of brain death); finding meaning in donation (altruism, letting the donor live on, fulfilling a moral obligation, easing grief); fear and suspicion (financial motivations, unwanted responsibility of death, medical mistrust); decisional conflict (pressured decision-making, family involvement and consensus, internal dissonance, adhering to religious beliefs); vulnerability (valuing sensitivity and rapport, overwhelmed and disempowered); respecting the donor (honouring the donor wishes, preserving body integrity); and needing closure (appreciating acknowledgement, regret over refusal, unresolved decisional uncertainty, feeling dismissed).
Conclusions: Bereaved families can derive emotional benefit from the “lifesaving” act of donation but also report a sense of uncertainty about death and the donation process, vulnerability, an acute emotional and cognitive burden, and pre- and post-decisional dissonance. Education and counselling strategies are needed to help families understand and accept death in the context of donation, address anxieties about organ procurement, foster trust in the donation process, resolve insecurities and tensions in their decision-making, and gain a sense of closure after donation. This may improve family experiences and decision making in organ donation.
Facilitating donation after circulatory death subsequent to withdrawal of extracorporeal membrane oxygenation support
Alice Coulson1, Hazel Christine1, Carrie Alvaro1, Robert Herkes1,2
1NSW Organ and Tissue Donation Service, Sydney, Australia; 2Intensive Care Services, Royal Prince Alfred Hospital, Sydney, Australia.
Patients dependent on extracorporeal membrane oxygenation (ECMO) for cardio-respiratory support are rarely considered for donation after circulatory death following agreement to withdraw treatment. In NSW, management of these potential organ donors typically involves complex medical suitability assessment and logistical planning for withdrawal of treatment.
The referral database at the NSW Organ and Tissue Donation Service was reviewed from 2007 to 2013. Five ECMO-dependent patients were identified. Four patients were supported with veno-venous ECMO for respiratory failure and the other with veno-arterial ECMO for cardiac failure from idiopathic cardiomyopathy.
Consent for organ donation was obtained in four cases. The family declined donation in the remaining case. Of those consented hospital length of stay ranged from 8 to 60 days, and ECMO duration ranged from 12 to 43 days. Unexpectedly, the patient supported with veno-arterial ECMO did not die within the required sixty minutes. The remaining three cases successfully donated kidneys, resulting in six kidneys being available for transplantation. Liver donation was considered in two of the donors but was ultimately not possible due to timeframes within which the patients died. Medical suitability determination in all cases required thorough evaluation of admission history and multiprofessional consultation, including transplant professionals.
The logistics of ceasing ECMO as part of withdrawing treatment are complex. While the process of withdrawing treatment remains the responsibility of the treating Intensive Care team, collaboration and guidance from donation and retrieval staff was required to ensure that management of the cannulae and circuit did not inhibit organ retrieval.
Patients dependent on ECMO for cardiorespiratory support can be successful kidney donors with thorough assessment of suitability and collaborative planning of withdrawal and retrieval. Liver donation may be feasible, but cessation of ECMO was not consistent with a rapid progression to death making retrieval of the liver possible.
State-wide organ donation project of Western Australia
Teik Oh, Bruce Powell
DonateLife WA, Perth, Australia.
The OTA Australia identified six strategic priorities. DonateLife WA embarked on a project to implement the first: Develop a clinical governance framework to support and guide DonateLife Network staff in the provision of quality organ and tissue donation services within the broader health system.
SWOT analysis explored possibilities for new initiatives, and a plan, the “State-wide Organ Donation Project” was conceived. This parent project begets projects (below) to be developed, all with one goal - to improve organ donation services in WA.
Projects: A framework of the process state-wide, agreed to by all key stakeholders, standardises and clarifies step-by-step interactions to improve communications, ownership, and responsibilities, thus minimising misunderstandings and subsequent loss of organ donation opportunities.
Organ donation is relevant to all health sectors in the State but only three major metropolitan hospitals undertake organ retrieval. Engagement of regional general hospitals in the State to retrieve organs will benefit the donation rate and engage health care professionals outside the metropolitan area.
Collaboration with community groups in partnerships in fund raising, education, and PR ventures aims to increase public awareness of organ donation and raise funds for projects to be undertaken.
Although all health professionals support organ donation, the support is not comprehensive. Engagement of key medical professionals with closer ties to DonateLife WA, is envisaged with a Council of Experts that is a resource to promote clinical interactions. More frequent workshops related to Medical ADAPT are intended to inform junior ICU and ED doctors about the importance of organ donation.
Desirable outcomes are increased involvement of regional centres and Teaching Hospital doctors, increased referral and consent rates, improved awareness of organ donation in the WA community, and better data capture.
The importance of sound management and organizational culture in donation and transplantation: A single center organ procurement organization experience in the US
Joseph Ferreira, Simon Keith, John st John, Dr. John Ham, Karen Hess, Kathy Crabtree, Barry Grace, Carrie Deese
Nevada Donor Network, Las Vegas, NV, United States.
Introduction: The Nevada Donor Network (NDN) is federally designated by the US Department of Health and Human Services as the Organ Procurement Organization (OPO) which covers approximately 80% of the total population in the State of Nevada. The NDN coverage area is comprised of a population of approximately 2.1 million people according to the 2012 census report. In June of 2011, NDN was declared as a “Member Not in Good Standing” by the Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) based on a regulatory peer review process which revealed underperformance and compliance violations.
Methods: The Board of Directors of NDN took decisive action based on these findings and recruited new leadership to transform the culture of the organization. The culture deployed by the new leadership was based on a blend of sound management principles and entrepreneurial concepts from the private sector of business.
Results: During the second quarter of 2012, the organization began to experience significant growth in organ donation. In 2011, prior to the cultural changes by new management, the organization recovered organs for transplantation from 53 donors. This equates to 25 donors per million population which ranked NDN 30th out of the 58 OPOs in the US. In 2012, the number of donors recovered increased to 75 which translates to 36 donors per million population which improved NDN’s ranking to 12th out of the 58 OPOs. Year to date in 2013, NDN has recovered organs from 56 donors. This equates to 53 donors per million which ranks NDN 1st out of the 58 OPOs in the US.
Conclusion: The resultant increase in the number of donors per million population at NDN denotes the importance of effective leadership and organizational culture in the donation mission. It also emphasizes the value of regulatory oversight and peer review of the OPTN/UNOS in the US to maximize OPO performance.
Submitted on behalf of the entire team at Nevada Donor Network and our community partners in Nevada for their hard work and dedication which led to these results.
Doha Donation Accord (DDA) on the trail of the Declaration of Istanbul (DOI): A local implementation of an international framework to improve organ donation and combat commercialism
Riadh A. Fadhil, Hanan Alkuwari, Yousef Almaslamani, Abdalla Alansari, Hassan Almaliki, Hatem Khalaf, Omar Ali
Qatar Organ Donation Center & Qatar Center for Organ Transplantation, Hamad Medical Corporation, Doha, Qatar.
Qatar is a small Gulf state of 1.7million multicultural society(1), Renal Transplantation in Qatar started 1986, but the number of transplants remained low because of lack of donors that pushed most of the ESRD patients to seek commercial transplantation abroad and return back with high complications and mortality(2,3). All liver transplantations average 15/year, used to be done abroad.
In order to combat commercial transplantation and to develop organ donation and transplantation, HMC the main tertiary health care facility adopted the recommendations of DOI and WHO guiding principles, and extracted what is compatible from the Qatari laws and regulations to launch the DDA in 2010 (4,5,6,7).
The Principles of the DDA include; Equity & Fairness in access to organs, Extra care of Donors and recipients, community education, development of Donor Registry. And no financial incentives to donors or families, instead it is a community focused removal of disincentives scheme with the leaders’ inspirational vision that poor and underprivileged communities will donate organs if they sense fairness, respect, dignity and freedom to donate(8).
Since the implementation of the DDA early 2011 There has been increase in the consents rate gradually to 3/year in 2010, and to 1 or 2/month since January 2013, seekers of transplant abroad dropped 69% in 2012, 80 % of the native ESRD ready for transplantation have registered for transplant in Doha, Kidney transplants done abroad to those done in Qatar decreased tremendously in 2012 to 1/1 as compared to 30/1 in 2008.No liver transplantation done abroad since April 2012, While four successful Liver transplantations were done in HMC so far.
Conclusion: DDA has succeeded to increase organ donation, and develop transplantation, We recommend it to countries that have comparable demography and socioeconomic status. local factors should be taken in consideration in implementing the DOI recommendations.
 Population statistics: http://www.qsa.gov.qa/eng/PopulationStructure.htm
 Riadh A.S. Fadhil, y.moslemani, A.Alansari, O.Alani. The outcome of commercial kidney transplantation : A Qatari study on preoperative and post-transplant follow –up records of patients having commercial renal transplantation abroad. Transplantation Journal July 27,2008. volume 86. Number 2S.
 Riadh A.S. Fadhil, H.Althani, Y. Almaslamani, O.Alani. Trichosporon Fungal Arteritis Causing Rupture of Vascular Anastamosis After Commercial Kidney Transplantation: A Case Report and Review of Literature. Transplantation Proceedings, (2011) 43, 657–659
 Organ trafficking and transplant tourism and commercialism: the Declaration of Istanbul. The Lancet, Volume 372, Issue 9632, Pages 5–6, 5 July 2008
 WHO Guiding Principles on Human cell, Tissue and Organ Transplantation. Transplantation. 2010 Aug 15;90(3):229–33
 Qatari Organ Donation and transplantation Law 21/1997 in http://www.gcc-legal.org/MojPortalPublic/LawAsPDF.aspx?opt&country=3&LawID=2838
Organ donation in different health regions in Rio de Janeiro State
Priscila Paura1, Rodrigo Sarlo4, Janaína Lenzi3, Andreia Assis3, André Albuquerque1, Tereza Guimarães1, Claudia Araújo2, Eduardo Rocha1
1Education, Transplant State Program, Rio de Janeiro, Brazil; 2COPPEAD, UFRJ, Rio de Janeiro, Brazil; 3Family Coordination, Transplant State Program, Rio de Janeiro, Brazil; 4General Coordination, Transplant State Program, Rio de Janeiro, Brazil.
Introduction: The State of Rio de Janeiro (RJ) has 16 million inhabitants and had a significant increase in the number of actual donations (AD = 176%) in the last 3 years. This increase was both through the number of brain death notifications (BDN = 38%) and the rate of effectiveness (RE = 93%). This study analyzed the results of the RJ, to support performance management strategies considering the different health regions. Methods: This was a retrospective study from 2011–2012. Data were collected in reports of BDN from Transplant State Program (PET-RJ) and analyzed by health regions. The numbers of BDN and AD were computed per million population (pmp) and RE in percentage (%). Results: The RJ received 559 (35 pmp) and 693 (43.4 pmp) BDN, respectively, in 2011 and 2012. Of these, 121 (8 pmp) and 221 (13.4 pmp) resulted in AD. The data in the North and Central South regions were: decreased BDN (37–22 // 50–25 pmp) and AD (9–8 // 15–10 pmp), but an increase in RE (25–37 // 30-40%), both RE higher than the state (31%). Metropolitan and Lagos regions increased BDN by 38 to 49 and 10 to 27 pmp, AD by 8 to 15 and 0 to 8 pmp, RE by 21 to 30 and 0 to 28%, however the MR’s RE has some raise and as LR, despite having considerable proportional performance when compared to the last year, was still below the average of RJ (31%). There was a reduction of BDN in the Middle Paraíba (29–26 pmp), nevertheless had better numbers than State’s AD (9–12 pmp) and RE (31-46%). The Northwest region also decreased the BDN (33–24 pmp) and AD (27–21 pmp), but had a superior RE (82-86%). The Serrana Region has improved the BDN (17–23 pmp), but remains at low RE (33-19%). Conclusion: Regional differences point to the need of different action plans addressing educational and logistical aspects, especially in regions with high BDN, but low AD. Also, the regions which still showed low BDN and AD, need to intensify training in various stages of organ donation.
Success and challenges of deceased donation and transplantation
Sunil Shroff, Sumana Navin, Lalitha Raghuram, Pallavi Kumar
MOHAN Foundation, Chennai, India.
India started deceased donation programme after its law accepted brain death as form of death in 1995. The programme has been slow to take off, however significant strides have been made in a few states in the country and these success stories could be duplicated in other regions. Six of the 28 states have done better than rest in promoting the programme and have done 90% of the deceased donations in last 17 years. Similar is the state with corneal donations and of 45,000 donations last year. The current donation rate in India still remains below 1 per million population however 2012 was a landmark year for the programme with almost 196 donations (Fig.1) in the country. The successful model of the state of Tamil Nadu which has a donation rate that is 10 times the national average could be duplicated in some of the other states provided the state government works together with other stake holders such as public, private hospitals and NGO’s. The overall potential of deceased donation is extremely high as the number of fatal deaths due to road traffic accidents every year exceeds 140,000 and head injury occurs in over 60% of such deaths. The current donation rate, if pushed to 3 per million, would take care of all the current requirements of organs. The recent amendments bringing in the required request law to ask for organs in event of brain death and compulsory appointment of transplant coordinator may give the required momentum to the programme.
A critical discourse analysis of the introduction of an embedded, dedicated nursing role supporting organ and tissue donation in Victoria, Australia
Damien W. Hurrell1, Kathleen Tori2
1Nurse Donation Specialist, Medical & Critical Care Services, Bendigo Health, Bendigo, Victoria, Australia; 2Lecturer/Emergency Nurse Practitioner, Department of Rural Nursing and Midwifery, Rural Health School, Faculty of Health Sciences, Latrobe University, Bendigo, Victoria, Australia.
Background: As part of Australian Organ and Tissue Donation (OTD) reforms introduced in 2009, embedded, dedicated nursing roles (initially titled Hospital Senior Nurse, Organ and Tissue Donation (HSNOTD); since renamed Nurse Donation Specialist (NDS)) with responsibility for supporting OTD were created in 76 Australian hospitals. There is little information in the professional literature about these roles and their specific responsibilities.
Method: Documents such as position descriptions, codes of conduct, training materials, evaluation templates, government policy documents, acts of parliament, scholarly publications and media articles were collected and analysed using Critical Discourse Analysis.
Results: HSNOTD roles were introduced into a complex system of Australian Organ and Tissue Donation stakeholders including a newly established national authority, established state level government departments and non-government authorities, local general health services, transplant services, advocacy groups, and persons who had received or were waiting for organ and tissue transplants. This complex context resulted in multiple lines of formal and informal responsibility and accountability. HSNOTD responsibilities included auditing, professional and community education, policy development and implementation, and support of donation processes and donor families. Emphasis on various responsibilities varied between different stakeholder groups.
Conclusion: This study describes the context for and responsibilities of the HSNOTD as envisioned in the available documents establishing the role. Further studies are required to explore aspects of the role such as the challenges faced during the implementation of the role and strategies used to overcome them, development and evolution of the roles since implementation, and differences between the evolved roles in different contexts.
Organ donation: New hope through the expected amendment in Germany?
Gernot M. Kaiser1, Radunz Sonia1, Ulrike Wirges2, Andreas Paul1, Matthias Heuer1
1General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany; 2Region Northrhinr-Westphalia, DSO, Essen, Germany.
Introduction: The current organ donor shortage in Germany results in the death of 1,000 patients on the transplant waiting list every year. In response, a recent amendment to the German Transplant Act aiming to increase donor rates was passed in 2012. The objective of this study was to collect and evaluate data on the public’s attitude toward organ donation prior to the amendment.
Methods: A survey on the subject of organ donation was conducted in 2011 among clients of a public pharmacy in a major city in the federal state North Rhine-Westphalia, Germany. Data regarding gender, age, health behavior and attitude toward the amendment were collected and analyzed in comparison to whether or not the individual possessed an organ donor card.
Results: A total of 1,485 questionnaires were evaluated. Of those surveyed, only 14.1% had an organ donor card. No statistically significant associations between gender (p-value 0.3045), age (p-value 0.1453) and the possession of a donor card were observed. 72.5% of respondents stated that they appreciated the expected amendment, and in the case of implementation, 83.4% would obtain an organ donor card.
Discussion: The future success of transplantation medicine relies on an increase in the public’s overall willingness to donate organs. Educating the public and ensuring transparency in transplantation medicine are necessary to achieve higher donation rates. It remains to be seen whether the amendment to the German Transplantation Act will bring the desired results. At the very least, the measure signifies action to address the organ donor shortage.
Regional variation in organ donation in Saudi Arabia
Hussien Elsiesy, Mohamed Al Sebayel, Almoataz Hashim, Waleed Al-hamoudi Al-hamoudi, Hamad Albahili, Faisal Abaalkhail Abaalkhail
Liver transplantation, KFSH&RC, Riyadh, Saudi Arabia.
Background and Aim: Cadaveric organ donation started in 1986, out of 8820 cases reported, 4661 cases documented, and 1384 donors harvested since the program inception until the end of 2011, with conversion rate of 29.7%. There is marked regional variation in organ donation among different region of Saudi Arabia. Our aim is to study the reasons for this variation in order to improve organ donation in areas of low donation rate.
Method: Saudi Center for organ transplantation (SCOT) data for cadaveric organ donation from 2006–2011 detailing the number of cases reported, documented, consented and harvested, as well as the distribution by region (central 29.4% of the total population Saudi Arabia, western 32%, eastern 15%, northern 8%, southern 15.6%). The number of contributing ICU stratified by size of ICU and the region was also reviewed.
The overall donation rate as well as the percentage of harvested cases per region as well as the conversion rate (harvested/Documented) was reviewed.
Results: Between 2006–2011, 448 cases procured form Saudi Arabia, of which 343 where procured for central region representing 76.5% coming from 30 out of 97 contributing ICU’s (31%), the eastern region came second with 49 cases (11%) followed by the western region with 35 cases (7.8%) while northern and southern region had 12 and 9 cases (2.7&2%) respectively. The conversion rate followed a similar trend. This is related to the presence of active mobile donor team in Riyadh (the capital) as well as active transplant centers.
Conclusion: There is marked variation with regards of contribution to organ donation in different regions in Saudi Arabia from 2% in the southern area to 76.5% in central area. This is related to the presence of active mobile donor team in the central region. A similar trend towards increasing number of cases and conversion rate was observed in the eastern region after having a new mobile donor team. We suggest that having active well trained mobile donor team in each region will increase the number of cadaveric donor at least 3 folds in the next 3–5 years.
Keywords: Cadaveric organ donation, Regional variation, Donor team
King Faisal Liver Group
In-house coordination for organ donation - single center experience in a pilot project in Germany
Gernot M. Kaiser1, Claas Baier2, Sonia Radunz1, Holger Krauss3, Andreas Paul1
1General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany; 2Administration, University Hospital Essen, Essen, Germany; 3NRW, DSO, Essen, Germany.
The most urgent challenge for solid organ transplantation in Germany is the shortage of organs. Recent data demonstrate a consistently low donation rate in Germany (less than 15 organ donors per million) compared to the rest of the world. In an effort to increase donation rates, some federal states mandated that hospitals install transplantation officers to coordinate, evaluate, and enhance the donation and transplant processes.
In 2009 the German Foundation for Organ Transplantation (DSO) implemented the so called “In-house Coordination Project,” which includes retrospective, quarterly, IT-based case analyses of all deceased patients with primary or secondary brain injury in regard to the organ donation process. From 2006 to 2008 an analysis of potential organ donors was performed in our hospital using a time consuming, complex method that of questionnaires, hand-written patient files, and the hospital IT documentation system (standard method). Analyses in the In-house Coordination Project are instead carried out by a proprietary semi-automated IT Tool called Transplant Check, which uses easily accessible standard data records of the hospital controlling and accounting unit. The aim of our study is to compare the results of the standard method and Transplant Check in detecting and evaluating potential donors. To do so, the same period of time (2006 to 2008) was re-evaluated using the IT Tool.
In the comparison of both investigation methods during the same time period, Transplant Check was able to record significantly more patients who fulfilled the criteria for inclusion (641 vs. 424). The methods displayed a wide overlap, apart from 22 patients who were only recorded by the standard method (see figure 1). In these cases, the accompanying brain injury diagnosis was not recorded in the controlling and accounting unit data records due to little relative clinical significance. None of the 22 patients fulfilled the criteria for brain death.
The IT Tool detected a greater number of deaths, which included those who eventually became organ donors and who qualified as potential donors. Therefore, Transplant Check is an easy to use, reliable, and valid tool for evaluating donor potential in a maximum care hospital. Therefore from 2010 on, analyses were performed exclusively with Transplant Check.
Interventions to increase willingness for deceased organ donation: A systematic review
Andrew Li1,2, Michelle Irving1,2, Stephen Jan3, Germaine Wong2, Kirsten Howard1
1School of Public Health, University of Sydney, Sydney, Australia; 2Centre for Kidney Research, The Children‘s Hospital at Westmead, Sydney, Australia; 3The George Institute for Global Health, Sydney, Australia.
Aims: The shortage of deceased donor organs for transplantation may be explained by community unwillingness to donate. We aimed to evaluate the effectiveness of interventions to increase willingness for deceased organ donation.
Methods: Medline, Embase, PsycINFO and CINAHL were searched to December 2012 for analytic studies that evaluated any intervention targeting the willingness of the general public to become solid organ donors after death. Risk of bias was assessed, and data was collected for rates of registration and intention to donate. A descriptive synthesis of the results was undertaken, and where possible, the results were compared quantitatively.
Results: 46 studies were included and incorporated over 50 000 participants. Interventions varied greatly in their approaches, e.g. advertising, community partnerships, educational materials and structured educational interventions. Most studies exhibited a low or unclear risk of bias. Due to the heterogeneity in participants, methods and outcome metrics, no one approach could be definitively identified as the most effective. However, a greater general trend towards significant increases in intention to donate was seen in interventions that included emotive components and/or interpersonal contact with participants, and a greater general trend towards significant increases in registration rates was seen in interventions that included interpersonal contact with participants.
Conclusion: Interventions to increase community willingness for deceased organ donation varied in their approach and effectiveness, with no one approach definitively emerging as the most effective, although it seems that interventions that include emotive components and/or interpersonal contact with individuals or groups may help increase willingness for deceased organ donation.
Edutainment on nursing students by “One’s Gift of Life to Many” Programme
Organ Donation Centre, Thai Red Cross Society, Bangkok, Thailand.
Introduction: Nowadays organ shortage is a crucial obstacle for organ and tissue transplantation in Thailand. “One’s Gift of Life to Many” Programme is a programme for organ and tissue donation which is created by the Organ Donation Centre Thai Red Cross Society. It has been done continuously for 15 years in various activities in order to enhance knowledge and correct missed understanding and reinforce positive attitudes about organ and tissue donation.
Material and Method: This is a retrospective descriptive analysis of “One’s Gift of Life to Many” Programme from 2010-2013. We organized activities such as walk rally in order to give knowledge about organ and tissue donation, brain dead criteria, transplantation and coordination to nursing students. Participants were divided into groups. Each group had activities as they rotated to each knowledge stations. Awards or points were given to participants.
Results: After nursing students finished the edutainment activities, they understood and had good attitude towards organ donation. After the 1st programme in 2010 nursing student became donor pledgers 38 (20.88%) from 182. The 2nd programmes in 2011 turned nursing students to be donor pledgers 215 (54.99%) from 391. In 2012 we got donor pledgers 207 (64.29%) from 322. And this year, 2013 there were donor pledgers 242 (65.41%) from 370. Totally there are donor pledgers 702 (55.19%) from 1,265.
Discussion: The superstitious misconception must be clarified by appropriate discussion by scientific facts and religious doctrine. “One’s Gift of Life to Many” Programme has been organized for 4th year nursing students that will be in medical team and play major role in the national health care system. They can provide accurate information to create awareness, understanding and good attitudes towards organ donation.sz.
On behalf of The Organ Donation Centre Thai Red Cross Society
Master in donation and transplantation of organs, tissues and cells: The second edition results
Chloë Ballesté1,2, Ricard Valero1,2, David Paredes1, Gloria Páez2, Ana Menjívar, Melania Istrate2, Martí Manyalich1,2
1Surgery Department, School of Medecine, University of Barcelona, Barcelona, Spain; 2Transplant Procurement Management, Donation and Transplantation Institute, Barcelona, Spain.
Introduction: The Master´s degree in Donation & Transplantation of organs, tissues and cells is offered by the University of Barcelona. Its second edition was held during years 2011-2012. The Master’s degree was structured in 3 common modules: Research in donation, Research in organ transplantation, Research in tissues, cells & hematopoietic progenitor’s transplants and 2 specialized: Research & Professional Path.
Objectives: Evaluate the efficiency of the teaching programme through student’s feedback analyses.
Methodology: We evaluated following aspects: experience and motivation of the students; participation; material´s content; way of presenting; way of running question/answer minutes; personal benefits from the participation in the class.
Results: Participant’s profile: 28 participants, with a heterogeneous cultural and professional profile background; 12 Medical Doctors, 12 Nurses, 1Biologists, 1 Bacteriologists and 1 Pharmacists. All of them did graduate. Internal subjects evaluations: The evaluation showed the following scores: Content of the materials (4,40±0.28); presentation (4,37±0.34); Questions/answers minutes (4,41±0.29);Personal benefits (4,10±0.29) On- line results: Online learning system was used. The evaluation was a summary of student activities and the tasks fulfilled by them. Research projects: Divided in 2 different fields: Research & Investigation (48% of the participants) and Professional Practice (42 % of the participants). 100% of the participants fulfilled the study on time. All were considered as adequate by the ad-hoc tribunal.
Conclusions: This Master offers the possibility to enlarge know ledges and skills of a large number of foreign professionals providing them with an official degree, known in the scientific and academic community. This programme achieved the expectations.
Community attitudes towards the provision of information regarding organ & tissue donation & end of life care in critical care waiting rooms
Carol Woeltjes1, Shena Graham1, Belinda Heasman1, Joanne Matchado2, David Pilcher1,3, Asim Shah1, Steve Philpot1,3
1ICU, The Alfred Hospital, Melbourne, Australia; 2Patient and Family Services, The Alfred Hospital, Melbourne, Australia; 3Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
Introduction: Limited literature exists relating to the acceptability and impact of providing information on organ and tissue donation, death and end of life care in Intensive Care Unit (ICU) waiting rooms. Presently no such information is provided in the ICU waiting room at The Alfred Hospital. Our aim was to determine attitudes to provision of information about death and organ donation amongst family members of patients who have previously been admitted to ICU.
Method: Family members of patients who had been admitted to ICU were identified from the ICU database. Potential participants were contacted by telephone. Those who agreed to participate were then sent a questionnaire regarding acceptability, usefulness and appropriateness of information about death and organ donation, if it were made available in the ICU waiting room.
Results: 161 families were contacted by telephone of whom 100 agreed to participate in the survey. Reasons for non-participation included: not contactable (n=34, 21.1%); excluded for both no response and English being a second language (n=62, 38.5%); “wished to move on” and “limited experience of ICU waiting room” (n=33, 20.5%). Preliminary analysis of the first 10 of 59 surveys returned, suggest that 9/10 respondents thought it was acceptable to have information about organ and tissue donation and all 10 thought it appropriate to have information about death in the ICU waiting room.
Conclusion: If responses to this survey reflect general public opinion, it is likely that future provision of information about death and organ donation within the ICU waiting room will be acceptable to family members of patients. Further analysis of all surveys is required to confirm these findings. If information is provided, its impact will be assessed in a future study.
Successful international collaboration improves family donation conversations resulting in 29% increase in organ donations.
Patricia Mulvania1, Cherry Wise1, Yael Cass2, Eva Mehakovic2, Theresa A. Daly1, Howard Nathan1, Robert Norden1
1Gift of Life Institute, Philadelphia, PA, United States; 2Organ & Tissue Authority, Canberra, Australia.
Background: A country’s donation leaders concluded that to increase organ donations, health professionals (HPs) conducting family donation conversations (FDC) required support & training. An int’l training institute w/programs based on proven results was engaged to create and implement customized training program to influence change in FDC practice & culture.
Aim: Increase donation rates by developing & implementing customized, self-sustaining training program to enhance HP’s FDC practices. Provide training & communications skills to lead FDC, support families to make enduring decisions & influence HPs to adopt practice as FDC cultural norm.
Materials and Methods: Planning meetings assured thoughtful development and customization. To gain support and determine program suitability, two 1-day pilot trainings were provided to 45 donation leaders in 2011. Training was further customized w/emphasis on creating change that would achieve/sustain desired results. Comprehensive nat’l training plan was implemented over 18 months. Eighteen 2-day FDC training workshops were held in 8 cities w/492 participants. Program evaluations and debriefings showed distinct shifts in perspectives and enthusiasm to implement new process. Between 2012-2013, instructor program was developed to transition training facilitation. Training institute remains involved in development and training to build and sustain skill and expertise.
Results: Total organ donors 2011-337; Jan-June 2013-216; on pace for 432, represents 29% increase.
Conclusion: When existing donation conversation processes do not yield desired results, change is needed. Integration of another organization’s process poses distinct challenges; however, thoughtful collaboration, sensitive to cultural aspects and family care, communication and donation practices, can result in successful training that shifts perspectives, provides new skills and achieves/sustains an increase in organ donation rates.
The Robyn Hookes Shield: An organ and tissue donation community education event in regional Victoria, Australia
Damien W. Hurrell
Nurse Donation Specialist, Medical & Critical Care Services, Bendigo Health, Bendigo, Victoria, Australia.
Background: DonateLife week is Australia’s annual organ and tissue donation awareness week, held annually towards the end of February. As community education is an important part of the role of Nurse Donation Specialists in Australia, Nurse Donation Specialists in regional areas have since 2009 staged events to raise awareness of organ and tissue donation during the week.
Method: A cricket match between a team of transplant recipients from the Australian Transplant Cricket Club and an invited team, comprising community members, local celebrities, and state and international representative cricketers was staged in Bendigo, a regional city in Victoria, Australia, on February 24, 2013: the first day of DonateLife Week. The teams competed for the Robyn Hookes Shield, named in honour of the wife of David Hookes, an international cricketer who donated his organs after his death in 2004. Multiple strategies were used to generate interest in the match, which was free to attend, and leverage that interest into communicating the key organ and tissue messages of DonateLife Week.
Results: The two teams played a close and exciting match on a very hot day in front of a crowd of over 300 people. Over 120 radio advertisements, 5 radio interviews, local television news coverage, multiple local press stories and a radio broadcast of the match on a community radio station increased the reach of the event, and hundreds of posters and flyers containing key messages were distributed. Trained organ and tissue donation volunteers and health professionals provided information and merchandise to attendees, while fun, non-cricket related activities ensured the event had broad appeal to the community. Lessons for the future include ensuring tasks are distributed amongst multiple staff, everything must be checked at least twice, and strategies to attract celebrities to play.
Conclusion: The inaugural Robyn Hookes Shield was a successful community education event, with significant potential to grow into the future.
This Project was funded by a DonateLife Community Education Grant from the Australian Commonwealth; a community grant from the City of Greater Bendigo, and sponsorships from a number of local businesses.
A systematic review of family influence on consent decisions for deceased organ donation
Melissa Hyde1, Suzanne Chambers1, Jason Siegel2
1Behavioural Basis of Health, Griffith Health Institute, Griffith University, Mt Gravatt, Australia; 2School of Behavioral and Organizational Sciences, Claremont Graduate University, Claremont, CA, United States.
Family typically have the final say as to whether their loved one’s organs are donated. However, the extent to which research has considered family influence on consent decisions for donation is unclear. A framework including family attitude, family norm, and family efficacy was developed to describe evidence of family influence on consent decisions in two contexts: 1) prior to a critical incident via a donor registry or family discussion, and 2) at the time of a loved one’s death. Evidence for family attitude, norm, and efficacy on consent decisions was described and compared across contexts. Medline and PsycINFO were searched for peer-reviewed articles published in English after 1st January 1970 and prior to 31st December 2012. Inclusion criteria were: individuals eligible to consent to donation via a donor register or family discussion, and/or family asked to consent to donate a loved one’s organs/tissue for transplantation from countries with opt-in consent systems; and focused on deceased donation for transplantation; and discussed family influence on consent decisions. 47 articles met all criteria and considered family influence on consent decisions for donation prior to a critical incident (n = 19) and for a deceased loved one (n = 28). Studies were mostly quantitative, cross-sectional, used convenience samples, conducted in the United States, and published from 2001 onwards. Although understudied and rarely the primary focus of studies reviewed, there was some evidence for family influence on consent decisions. However, evidence was indirect; more often reported family influence on decision-making at the time of loved one’s death; and was more consistent for family attitude and norms than efficacy. A future focus on family influence more broadly is needed including family attitudes towards communicating consent; the discrepancy between perceived and actual family reaction; and family capabilities (e.g. communication style).
Exploring next-of-kin perceptions of optimal strategies to request family consent for organ donation in a hypothetical scenario
Melissa Hyde1, Renata Meuter2
1Behavioural Basis of Health, Griffith Health Institute, Griffith University, Mt Gravatt, Australia; 2School of Psychology and Counselling, Queensland University of Technology, Kelvin Grove, Australia.
Next-of-kin refusal for donation is a key factor preventing recovery of organs. Conversations with Organ Procurement (Donor) Coordinators (OPCs)/health professionals can impact on next-of-kin consent. While common consent gaining strategies have been identified, it is less well known whether next-of-kin find these strategies acceptable. Identifying optimal request strategies may ultimately improve the request process and subsequent family consent rates. We used a scenario based-study conducted in a non-clinical setting to explore potential donor families’ likelihood of consent to and perceived acceptability of 12 strategies which are used by OPCs/health professionals to request organ donation. A convenience sample of 163 participants completed an online survey containing one of four scenarios manipulating next-of-kin’s prior knowledge of their loved one’s donation wishes (wishes known/unknown) and the sex of their loved one (Mother/Father). Using MANOVA we explored differences in participants’ ratings of consent and acceptability of request strategies across scenarios. There were significant differences in consent and acceptability ratings based on prior knowledge of loved one’s donation wishes only (not across the four scenarios). Strategies least likely to gain consent or acceptance included mentioning well known others who support donation (wishes unknown), making next-of-kin aware their parent needs an autopsy, and explaining the donation process. Strategies most likely to gain consent and acceptance included informing next-of-kin their parent had joined the donor register and ask for permission (wishes unknown) or support (wishes known) to donate. Consent and acceptance of request strategies may vary based on next-of-kin’s prior knowledge of their loved one’s donation wishes. Optimal request strategies tailored to next-of-kin’s prior knowledge of loved one’s donation wishes may facilitate consent.
Hospital model development donor in a public hospital in Argentina
Pablo Centeno1,2, Matias Anchorena1,2, Julian Juarez1,2, Marco Flores1,2, Matias Willig1,2, Leonardo Del Rio1,2, Adrian Tarditti2, Mariana Casalins1,2
1HZGA Simplemente Evita, Gonzalez Catàn, Argentina; 2CUCAIBA, INCUCAI, Buenos Aires, Argentina.
Because efforts to increase organ and tissue donation in Argentina, growth in donation rate has increased slowly but steadily in recent years. However, it is observed that not all health centers participating in the activity and that most of those who develop donor policies tend to complete a cycle of increase, plateau, decline and disappearance in the generation of donors. This cycle lasts about five years.
A medium-complexity hospital located in an area of extreme poverty and history contrary to the donation has developed a program based on quality of care, collaboration with the bereaved family, specially trained human resources and focus in the intensive care unit as the key to detect potencial donnors.
The result was:
Continuous increase in organ and tissue donation in the last ten years.  Annual donors fivefold in ten years, while growth in the country was fifty percent.
Negative to donation rate less than 3% in last two years (In the same period, national rate was close to 35%) 
Loss of donors due to missed detections close to 10%, including cardiac arrest deceased. The estimated national rate of missed detection is over 50% for potential beating heart donors and over 90% for post cardiac arrest.
Supporting these results over time despite a turnover of health personnel for a period of ten years, maximizing donation rate the last four.
These results have led the national procurement and transplantation to use (the Catan’s Model) as a role model for the rest of the country’s institutions.
National Information System of Procurement and Transplantation of the Republic Argentina.
Family approach - retrospective analysis of 6617 donation requests
Franz Schaub1, Carl-Ludwig Fischer-Froehlich1, Guenter Kirste2
1Deutsche Stiftung Organstransplantation (DSO), Frankfurt am Main, Germany; 2 Universitätsklinik Freiburg, Freiburg, Germany.
Introduction: The German Transplantation-Legislation was modified in November 2012 with promoting voluntary decision of people about organ donation. Despite the current national transplantation-scandal, citizens have a positive attitude towards organ donation. Even though the law now requires every citizen to enter their decision about organ donations in the minutes, the decedent’s written consent is missing most of times. Therefore donor families have to be approached about this specific issue. Thereby the refusal rate of 40% exceeds the ones of other countries. It was evaluated which factors might influence consent rate beyond personal decisions during donation requests.
Methods: 6.617 documented donation requests between the years 2009 and 2011 were analysed for factors that could influence the decisions beyond personal values.
Results: The decedent’s was often unknown (67.4%) and then the family’s decision was based on assumptions about the patient’s will. This resulted in 4.097 (61.9%) consents and 2.520 (38.1%) refusals. 4.669 (70.6%) of these donation-requests were done by the physician in charge only and 1.948 (29.4%) with a coordinator present additionally. Predictive (p<0.001) for consent were the presence of a specially trained transplantation coordinator and the timing of the request for organ donation (especially when the donation request was initiated in the time period when measures for certifying death by neurologic criteria were started, p<0.001).
Conclusion: There is a big difference between the attitude displayed in surveys and the real rate of consent to organ donation. The major challenge is that improved caregiving of donor family members is required. Donation requests should be done by trained physician as well as coordinators. Waiting until the finalized certification of brain death may not be appropriate nowadays: A transparent description of all detail contributes to build up a therapeutic relation to donor families and this allows them to have a proper timeframe for a stable decision about organ donation.
Web-net tool based and nationwide system for referring and monitoring serious adverse events and reactions in the area of organ transplantation
Jarosław Czerwiński1,3, Piotr Kaliciński2, Roman Danielewicz1,3
1Dep. of Surgical and Transplant Nursing, Medical University of Warsaw. Poltransplant, Warsaw, Poland; 2Dep. of Pediatric and Transplant Surgery, Children’s Memorial Health Institute, Warsaw, Poland; 3Polish Transplant Coordinating Center, Poltransplant, Warsaw, Poland.
Following Directive 2010/53/UE serious adverse events (SAEs) and reactions (SARs) alerting system in the area of organ transplantation was implemented in Poland on technical basis of web-net platform connecting all transplant centers.
Substantial issue of this system, distinctly problematic and widely discussed among professionals and decision makers was the catalog of events and reactions must be referred.
Finally constructed catalog consists of:
1. Events related to organ recipients: transplantation from the donor with incomplete or incorrect characteristic, transplantation of organ after abnormal or too long preservation, absence of valid potential recipient’s plasma for cross-match, organ transplantation from a donor with a viral infection (unrelated to the rules of allocation), severe and uncontrolled bacterial, fungal or protozoan infection, transplantation form a donor with cancer, unintentional transplantation from a donor with non-identical or incompatible blood group ABO.
2. Reactions related to organ recipients: resignation from transplantation due to organ damage at the time of donation, storage and implantation, transmission from a donor viral infection (unrelated to the rules of allocation), organ lost due to the absence of proper recipient, transmission of cancer, never function of the graft, recipient’s death within 30 days after transplantation or during the initial hospitalization graft loss within 30 days of transplantation or during the initial hospitalization, HIV transmission from the donor, severe bacterial, fungal, or protozoan infection.
3. Events related to living organ donor: organ procurement from the donor with incomplete or incorrect characteristic.
4. Reactions related to living organ donor: serious health consequences (illness, serious complications) in the donor associated with the donation.
In the year of 2012 the total number of 51 SARs and 6 SAEs was documented in the system with regards of 1653 totally transplanted organs.
System of donor hospital transplant coordinators maintained and financed by national transplant organization improves donation rates, but it is effective only in a half of hospitals
Jarosław Czerwiński1,2, Teresa Danek2, Adam Parulski3, Monika Trujnara4, Roman Danielewicz1,2
1Dep. of Surgical and Transplant Nursing, Medical University of Warsaw. Poltransplant, Warsaw, Poland; 2Polish Transplant Coordinating Center, Poltransplant, Warsaw, Poland; 3 Dep. of Cardiosurgery, The Cardinal Stefan Wyszyński Institute of Cardiology, Warsaw, Poland; 4 Dep. of Anaesthesiology and Intensive Care, Międzyleski Specialistic Hospital, warsaw, Poland.
Coordinators in the number of 218 trained professionals (134 doctors and 84 nurses) are employed by Poltransplant in 200 hospitals (ca 50% of total number of hospitals with potential of donation). This resulted, after 21 months of work, compared to 21 month period prior to their employment in changes of the following hospital donation indicators:
• Increasing the number of reported potential deceased donors by 27%
• Increasing the number of actual deceased organ donors by 24%
• increasing the percentage of multiorgan donation from 54% to 56%
• increasing the number of transplanted organs by 20%
• increasing the percentage of family refusals to donation from 8.5% to 9.3%
• reducing the rate of utilized organs per actual donor from 2.65 to 2.57
The desired effect of the employment of hospital donor coordinators to improve organ procurement rates was reached in 102 (51%) hospitals; in this group there were hospitals where there was no pre-employment donations and they took place after the employment, where the number of donations has increased or remained the previous level. In 98 (49%) hospitals had no procurements before or after the employment of coordinators, were before hiring them, but there was no after or the number of actual donors has decreased. Pronounced effect was observed in hospitals:
• located in regions with low baseline rate of donation (59%)
• academic hospitals (63%) and multi-profile hospitals in large cities (77%)
• hospitals, where a team of two coordinators was set up (67%)
• hospitals for adults (52%)
• hospitals, where doctors were assigned coordinators (55%)
The annual formal analysis of activity of donor hospital coordinators gives to national transplant organization a rational basis for their employment taking into account the characteristics of hospitals and the characteristics of hospital coordination team.
Argentine training program for transplant coordinators in the framework of presumed consent
Rogelio M Anchorena1,2, Ricardo Ibar1, Carlos Soratti1, Alejandro Yankowsky1, Maria E Barone1, Martin Torres 1, Roxana Fontana1, Alberto Maceira1, Adriana Carballa1, Hector Iudicsissa1, Rodrigo Salas1, Monica Juarez1, Vilma Brunetti2
1National Institute for Organ Donation and Transplantation INCUCAI, Buenos Aires, Argentina; 2Hospital Simplemente Evita, Gonzalez Catan, Argentina.
Background: In recent years, Argentina improved the donation rate. Reached in 2012 15.7 donors PMP, however the family interview is a major and critical point in this process. Since 2006 in Argentina has been incorporated presumed consent in the law. This changed the way of doing the family interview. In this framework should be prioritized the donor decision upon the family decision. It was necessary develop tools to train transplant coordinators. In 2011 began the “Argentine training program for transplant coordinators in the framework of presumed consent”.
Material and Method: National System of Procurement and Transplantation in Argentina (SINTRA) collects one hundred percent of the donation process including family interview data. 115 professionals were trained divided into four theoretical and practical courses. By SINTRA analyzed the results of interviews before and after training.
Results: There was a statistically significant impact on communication processes, decreasing the chance that the result is negative (OR: 0.55, 95% CI: 0.39 to 0.78, p = 0.00045).
The study evidence a individually improvement in the family interview after training (p=0.0059).
Conclusion: Communication after training for the use of presumed consent showed a statistically significant reduction of the risk of negative results during the family interview with a consequent increase in the number of donors.
Deciding to donate a family member’s organs: What factors are most important to the community? Results of a best-worst scaling study
Kirsten Howard1, Stephen Jan2, John M. Rose3, Michelle Irving1,4, Germaine Wong1,4, Allison Tong1,4, Jonathan C. Craig1,4, Steven Chadban5,6, Richard D. Allen6, Alan Cass2,7
1School of Public Health, University of Sydney, Sydney, Australia; 2The George Institute for International Health, Sydney, Australia; 3Institute for Transport and Logistics Studies, University of Sydney, Sydney, Australia; 4Centre for Kidney Research, The Children’s Hospital Westmead, Westmead, Australia; 5Central Clinical School, Bosch Institute, University of Sydney, Sydney, Australia; 6Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia; 7 Menzies School of Health Research, Casuarina, Australia.
Background: Despite broad public support for organ donation, there is a chronic shortage of deceased donor organs. The final decision on organ donation is made by donor’s families. We aimed to identify the key factors influencing decisions to donate a family member’s organs.
Methods: A best-worst-scaling method was used where policies/services are described by factors presented with varying levels. Community respondents were recruited from an existing internet panel; quota sampling ensured they were broadly representative of the adult Australian age distribution. Participants answered 30 online scenarios presenting eight factors (Table1), and chose, in each, the factor that made them most likely, and least likely, to agree to donate their family member’s organs. Using MNL regression we calculated: the importance of each factor, and the contribution each factor made to overall utility of a policy.
Results: There were 2002 respondents with a mean age of 44.9 (range18-84); 51.9% were female. The importance ranking of attributes is shown below (Table1), with knowing a family member’s preference ranked highest. The largest gains in overall utility of a policy could be achieved from: knowing a family member’s preferences, by telling the family how death is defined, by giving family priority for organs in the future, and provision of direct payments. There were some differences in the valuation of attributes with respondent age, with respondents <50 yrs valuing financial mechanisms more highly than older people.
Conclusions: Knowing a family member’s wishes about donation was the most important factor. Conversely, less important attributes such as funeral expense reimbursement and direct payments contributed positively to overall policy utility, suggesting the Australian public is open to donation policies that include financial mechanisms.
Becoming an organ donor - what are the most influential factors for the general community when considering deceased organ donation? A nominal group study
Michelle Irving1,2, Allison Tong1,2, Stephen Jan3, Alan Cass6, Steve Chadban4,5, Richard Allen5, Jonathan Craig1,2, Germaine Wong2, Kirsten Howard1
1School of Public Health, University of Sydney, Sydney, Australia; 2 Centre for Kidney Research, Children’s Hospital Westmead, Westmead, Australia; 3 The George Institute, Camperdown, Australia; 4Central Clinical School, Bosche Institute, University of Sydney, University of Sydney, Australia; 5Dept of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, Australia; 6Menzies School of Health Research, Northern Territory, Australia.
Aim: The observed donation rate in Australia appears substantially lower than the high level of community support for the principle of organ donation would suggest. We aimed to identify factors perceived by the community to be influential on their willingness to register as a deceased organ donor.
Methods: Thirteen community nominal groups involving 114 participants from the general community were conducted in New South Wales, Victoria, Queensland and South Australia. Participants identified, ranked and discussed reasons for factors they believed were important in decision-making about organ donation. A mean importance score was determined for all the factors. Transcripts were analysed thematically to identify reasons for their choices.
Results: 38 factors were identified with “saving life” being the highest ranked. Secondly, families should not be able to veto the decision to donate. Highly ranked factors also included clarity about the consent process, that families should not be able to overrule an individual’s preference, the benefits of organ donation for the recipients, the organ donation process and benefits of positive media coverage. Younger participants particularly indicated that compulsory choice or opt-out consent systems were acceptable and older groups viewed incentives such as the payment of funeral expenses quite favourably. Themes underpinning their choices included; core beliefs, external and emotional influences and the need for a simpler consent system.
Conclusion: The general community tends to hold a complex range of personal reasons for becoming organ donors. Continuation and expansion of current community education is recommended and should include: organ donation procedure, consent process and recipient benefits. A policy review may be undertaken with community input regarding potential incentives and families’ power to veto prior decisions.
I’d register, but I’ve never been asked! Key factors influencing decisions about whether to register as an organ donor
Kirsten Howard1, Stephen Jan2, John M. Rose3, Michelle Irving1,4, Germaine Wong1,4, Allison Tong, 1,4, Jonathan C. Craig1,4, Steven Chadban5,6, Richard D. Allen6, Alan Cass2,7
1School of Public Health, University of Sydney, Sydney, Australia; 2The George Institute for International Health, Sydney, Australia; 3Institute for Transport and Logistics Studies, University of Sydney, Sydney, Australia; 4Centre for Kidney Research, The Children’s Hospital Westmead, Westmead, Australia; 5Central Clinical School, Bosch Institute, University of Sydney, Sydney, Australia; 6Department of Renal Medicine, Royal Prince Alfred Hopspital, Sydney, Australia; 7Menzies School of Health Research, Casuarina, Australia.
Background: Despite broad public support for organ donation, there is a chronic shortage of deceased donor organs. We aimed to identify the key factors that would influence the decision about whether to register as an organ donor
Methods: A best-worst-scaling method was used where policies/services are described by factors presented with varying levels. Community respondents were recruited from an existing internet panel; quota sampling ensured they were broadly representative of the adult Australian age distribution. Participants answered 30 online scenarios presenting 9 factors (Table1), and chose, in each, the factor that made them most likely, and least likely, to register to be a donor. Using MNL regression we calculated: the importance of each factor, and the contribution each factor made to overall utility of a policy
Results: There were 2041 respondents with a mean age of 45.4 (range18-87); 51.8% were female. The importance ranking of attributes is shown below (Table1), with the type of consent system ranking highest. The largest gains in overall utility of a policy could be achieved from: reimbursement of funeral expenses, family priority in the future, how death is defined and direct payment mechanisms. There were some differences in the valuation of attribute levels with respondent age, for example respondents <50yrs valuing financial mechanisms more highly than older people.
Conclusions: How donation intent is registered (ie the consent system in place) and the extent of family overrule were valued highly, as was ease of registration. Interestingly, less important attributes such as possible incentive mechanisms (funeral expense reimbursement, direct payment and family priority) all significantly contributed positively to overall policy utility, suggesting the Australian public is open to donation policies that include incentives, including financial mechanisms.
Donor organ shortage crisis: A case study review of an economic-incentive system
Mohamed Al Sebayel1, A Al Enazi, R Sabbagh, T Al Aqeel, M Al Enazi, Hamad Al Bahili1, Hussien Elsiesy1
1Liver transplantation, KFSH&RC, Riyadh, Saudi Arabia.
Introduction and Background: Gross disparity between organ demand and supply created a profound negative impact on organ transplantation. Organ supply system depends on altruistic non-coercive donation (ADS). Desperate demand for organs and the need to combat organ trafficking, transplant tourism and human exploitation have resulted in the search for effective alternatives. Financial incentives are one of them. Its feasibility is debatable as it relates to medical, ethical and economic dimensions.
In Riyadh, Saudi Arabia, organ shortage was approach by Incentive-based procurement system (IBPS) applied by Mobile Donor Action Team (MDAT). Aggressive approach towards incentives for donors’ families and health workers was associated with a threefold increase in donation rate.
The aim is to provide a qualitative review of a five-year IBPS and to assess medical, ethical, religious, cultural and economic issues that have, and may impact the system and to make recommendations to the transplant community and health authority in KSA and elsewhere regarding the transferability of the system and areas for further research.
Method: Is qualitative. Review of documents was used to create a chronological audit and to shape interview questions. Sampling was purposeful and inclusive of MDAT members. Semi-structured interviews were conducted. Findings were subjected to thematic analysis.
Result: Documents reflected evolution of MDAT. The essence of MDAT is field work and liberal use of financial incentive resulting in 3 fold increase in donation rate. MDAT members believed that IBPS is the reason behind this increase. Moreover, IBPS has been acceptable from moral, ethical and religious aspects with high degree of professional satisfaction.
Discussion: Theoretical assumptions doubted the feasibility of IBPS. This real-life experience with IBPS proved the contrary. The findings may be applicable only to the setting in Riyadh, KSA. Further research is needed to explore its transferability to other settings.
Conclusion: IBPS can be an alternative to ADS and should be piloted in different settings.
King Faisal Liver Group.
Rewarming to subnormothermia for DCD liver graft with machine perfusion preservation in pigs
Naoto Matsuno1,3, Hiromichi Obara1, Toshihiko Hirano2, Kiyoko Kubota3, Masako Fujiyama3, Shin Inosawa3
1 Mechanical Engineering, Tokyo Metropolitan University, Tokyo, Japan; 2 Clinical Pharmachology, Tokyo Unversity of Pharmacy and life Sicience, Tokyo, Japan; 3Transplantaton and innovative surgery, National Center for Child Health and Development, Tokyo, Japan.
Utilization of grafts from donors after cardiac death (DCD) would greatly contribute to the expansion of the donor organ pool. However, the implementation of such a strategy requires the development of novel preservation methods to recover from changes due to warm ischemia. To assess potential methods and effect, livers procured after 60 minutes of warm ischemic time (WIT) were perfused and preserved.
Methods: Porcine livers were perfused with newly developed machine perfusion (MP) system. The livers were perfused with modify UW-gluconate(UW-G) or amino solution(JPS). Euro-ollins (EC) was used for simple cold storage (CS). All grafts were procured after acute hemorrhagic shock and ventilator off. Group 1 (n=4): grafts were procured after WIT of 0 min and preserved with CS for 2 hrs. and hypothermic MP (HMP) with UW-G for 2 hrsas a positive control.. Group 2 (n=4): grafts were procured with WIT of 60 min and preserved with CS for 2 hrs and HMP with JPS for 2hrs. Group 3 (n=5): preserved with CS for 2 hrs and rewarming up to 25°C by MP with JPS for 2hrs. The preserved liver grafts were transplanted orthotopicaly.
Results: The release rate of AST, ALT and LDH in perfusate as the difference from initial value during MP maintained as low in Group 3. The serum AST and LDH levels in 2 hr after reperfusion were significantly lower in Group 1 and 3 than in Group 2, (AST; 596.0, 1203,3 and 535.5 IU/L, LDH;637.5, 1417.2, and 778.2 IU/Lin each group,). Histologically, the necrosis of hepatocytes were less severe in Group 3. Survival rate with good postop. in Group 1 and3 was 3/4 and 3/5 respectively, but 0/4 in Group 2.
Conclusion: Rewarming up to subnormothermia iby MP is expected to facilitate the recovery and resuscitating function of DCD liver grafts.
Safety and feasibility of modified histidine-tryptophan-ketoglutarate solution for liver preservation prior transplantation
Gernot M. Kaiser1, Matthias Heuer1, Renate Reinhardt1, Guntje Kneiseler2, Hideo Baba3, Phillip Würzinger1, Ursula Rauen4, Andreas Paul1, Thomas Minor
1General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany; 2Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany; 3Pathology, University Hospital Essen, Essen, Germany; 4Institute of Pysiological Chemistry, University Duisburg-Essen, Essen, Germany; 5Surgical Research Division, University Clinic of Surgery, Bonn, Germany.
Cold storage is still a major concern in liver transplantation. Previous animal studies pointed out better results for a modified Histidine-Tryptophan-Ketoglutarate solution (HTK) in heart, lung and kidney transplantation compared to previously used HTK. Aim of this study is to demonstrate safety and feasibility of the modified HTK solution in a large animal model.
20 female swine were randomized into two groups (n=10) each with 5 donors and 5 recipients. The solution used for each transplant was blinded and randomized to modified HTK and standard HTK as control group. Liver transplantations were performed with all anastomoses in an end-to-end fashion. Anesthesia was maintained by intravenous administration of fentanyl and propofol continuously. In each swine the observation period was 7 days, immunosuppression applied as cyclosporine A (8,5mg/kg BW/d) and prednisolone (500 mg intraoperative single dose).
Liver transplantations was performed after a mean cold ischemic time of 307±10 minutes. Mean warm ischemic time was 23.2±2.9 minutes. Mean total surgery time was 225±39 minutes. There were no significant differences in cold ischemic time (p=0,88), warm ischemic time (p=0,69), time of surgery (p=0,98), donor weight (p=0,69) and recipient weight (p=0,81) between the both groups. All animals survived 7 days after operation, although one swine in the standard HTK group showed secondary dysfunction of the transplanted liver. Laboratory analysis demonstrated a tendency to improved liver function or less reperfusion injury, but no significant differences between the groups. On POD 7 the Quick´s value in the test group was 116.6±5.6 (control group 82.2±37.9; p=0.08); mean serum creatinine was 1.03±0.22 (control group 2.54±1.73; p=0.09). Partial thromboplastin time, serum bilirubin, alanine transaminase, cholinesterase and μ-GT were equal.
Orthotopic liver transplantations seems to be feasible and safe using the modified HTK solution due to first results of this in this large animal model. The advantages of the modified solution shown for other organs and in rat liver transplantation could not be reproduced, possibly due to the small number of animals in our study.Further evaluation in clinical setting seems to be justified to confirm the positive results shown in previous studies.
Normothermic extracorporeal perfusion of porcine and human liver following donation after cardiac death
Michael A. Fink1,4, Rinaldo Bellomo2, Bruno Marino3, Graham Starkey4, Bao-Zhong Wang4, Nan Zhu4, Satoshi Suzuki2, Shane Houston2, Glenn Eastwood2, Paolo Calzavacca2, Neil Glassford, Brenton Chambers5, Alison Skene6, Antoine G. Schneider2, Daryl Jones2, Andrew Hilton2, Helen Opdam7, Stephen Warrillow2, Nicole Gauthier7, Lynne Johnson8, Robert M. Jones4
1Department of Surgery, Austin Hospital, The University of Melbourne, Melbourne, Australia; 2Department of Intensive Care, Austin Hospital, Melbourne, Australia; 3 Perfusion Services, Austin Hospital, Melbourne, Australia; 4Liver Transplant Unit, Austin Hospital, Melbourne, Australia; 5Faculty of Veterinary Science, The University of Melbourne, Melbourne, Australia; 6Department of Anatomical Pathology, Austin Hospital, Melbourne, Australia; 7DonateLife Victoria, Melbourne, Australia; 8Department of Radiology, Austin Hospital, Melbourne, Australia.
Donation after cardiac death (DCD) has increased the pool of potential donors for liver transplantation. However, DCD livers are at increased risk of primary graft dysfunction and biliary tract ischaemia. Normothermic extracorporeal liver perfusion (NELP) may increase the ability to protect, evaluate and transplant DCD livers. Proof-of-concept experiments using a DCD model in the pig and in a discarded DCD human liver were performed to assess the short-term (3–4 hours) feasibility, histological effects and functional efficacy of NELP. Using extracorporeal membrane oxygenation, parenteral nutrition, separate hepatic artery and portal vein perfusion, and physiological perfusion pressures, we achieved NELP and evidence of function (bile production, paracetamol removal, maintenance of normal ammonia and lactate levels) for 4 hours in the pig livers subjected to 15 and 30 minutes of cardiac arrest before explantation and for 3 hours in the human liver. There was essentially normal liver and biliary tract histology after 8 hours perfusion. Our experiments justify further investigations of the feasibility and efficacy of human DCD liver preservation by ex-vivo perfusion.
A donor whole blood-based perfusate provides superior preservation of myocardial function during ex vivo heart perfusion
Christopher W. White1,2, Paul Mundt1, Yun Li2, Devin Hasanally2, Bo Xiang2, Rakesh C. Arora1,2, Trevor W. Lee3, Amir Ravandi 2, Ganghong Tian4, Larry Hryshko2, Darren H. Freed1,2
1Cardiac Surgery, University of Manitoba, Winnipeg, MB, Canada; 2Institute of Cardiovascular Sciences, University of Manitoba, Winnipeg, MB, Canada; 3Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada; 4National Research Council Institute for Biodiagnostics, Winnipeg, MB, Canada.
Background: Discarded hearts from brain-dead and DCD donors represent unutilized organs for transplantation; however, demonstration of adequate function prior to transplant is necessary. Ex vivo heart perfusion (EVHP) facilitates such functional assessment. We sought to determine what type of oxygen carrier provides superior preservation of myocardial function during EVHP.
Methods: 27 pig hearts were procured and underwent EVHP for 6 hours. Hearts were allocated to 4 groups according to the composition of the perfusate solution. Donor red blood cell concentrate (RBC, N=6), donor whole blood (RBC+Plasma, N=6), an acellular hemoglobin based oxygen carrier (HBOC, N=8), or HBOC plus donor plasma (HBOC+Plasma, N=7) were added to STEEN solution to achieve a hemoglobin concentration of 40 g/L. Myocardial function was assessed in working mode using pressure-volume loop analysis. Oxidative stress was assessed through quantification of oxidized phosphatidylcholine (OxPC) compounds using mass spectrometry. Myocardial energetics was assessed using magnetic resonance spectroscopy.
Results: A hemoglobin concentration of 40 g/L preserved myocardial energetics. Systolic function was comparable between treatment groups. Diastolic function was assessed using the end-diastolic pressure-volume relationship (EDPVR) and was superior in RBC+Plasma hearts at 1, 3, and 5-hours of EVHP (Figure 1). Donor plasma reduced the generation of OxPC compounds (Figure 2) and the development of myocardial edema in HBOC perfused hearts (HBOC+Plasma 9.8±1.7 vs. HBOC 16.3±1.9 grams/hr, p=0.03) but not in RBC perfused hearts (RBC+Plasma 6.6±0.9 vs. RBC 6.6±1.2 grams/hr, p=0.98).
Conclusion: During EVHP a hemoglobin concentration of 40 g/L preserves myocardial energetics. Donor plasma minimizes oxidative stress and the development of myocardial edema, and a donor whole blood-based solution (RBC+Plasma) provides superior preservation of diastolic function.
Clinical experience supplementing celsior preservation solution with pro-survival kinase agents glyceryl trinitrate and erythropoietin demonstrates excellent myocardial recovery post cardiac transplantation
Gayathri Kumarasinghe1,2, Arjun Iyer1,2, Alasdair Watson1,2, Mark Hicks2, Ling Gao2, Aoife Doyle2, Padmashree Rao2, Anne Keogh1,2, Christopher Hayward1,2, Eugene Kotlyar1, Jabbour Andrew1,2, Emily Granger1, Kumud Dhital1,2, Paul Jansz1, Phillip Spratt1, Peter Macdonald1,2
1Heart and Lung Transplant Unit, St. Vincent’s Hospital, Sydney, Australia; 2Cardiac Physiology and Transplant Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia.
Aim: Primary graft failure (PGF) is the leading cause of early morbidity and mortality in cardiac transplantation. We have shown in animal models that myocardial recovery is significantly improved by supplementing preservation solutions with pro-survival kinase agents that reduce ischaemia-reperfusion injury[2,3]. We translated these findings into clinic practice by supplementing Celsior solution with two agents glyceryl trinitrate (G) and erythropoietin (E) and report our findings.
Methods: Cardiac transplants performed in our institution since June 2010 used Celsior+G+E for cardioplegia and hypothermic storage. Donor and recipient baseline data, ischaemic time and post-transplant outcomes were retrospectively compared with historical controls where hearts were procured using Celsior alone.
Results: Celsior+G+E was used for 51 transplants (June 2010-February 2013), and Celsior alone was used for 104 transplants (March 2005-June 2010). There was increased use of left ventricular assist devices (LVADs) and a trend towards higher numbers of marginal donors in the Celsior+G+E group. There was a trend towards reduced PGF (lower use of mechanical circulatory assist devices) and improved survival in this group.
Conclusion: Despite increasing use of marginal donors and LVADs, supplementing Celsior with glyceryl trinitrate and erythropoietin allows excellent recovery of donor hearts.
 Iyer A, Kumarasinghe G, Hicks M, Watson A, Gao L, Doyle A, Keogh A, Hayward C, Kotlyar E, Dhital K, Granger E, Jansz P, Pye R, Spratt P, Macdonald PS. Primary graft failure after heart transplantation. J Transplantation. 2011;2011:175768. doi: 10.1155/2011/175768. Epub 2011 Aug 1
 Watson AJ, Gao L, Sun L, Tsun J, Jabbour A, Ru Qiu M, Jansz PC, Hicks M, Macdonald PS. Enhanced preservation of the rat heart after prolonged hypothermic ischemia with Erythropoietin-supplemented Celsior solution. J Heart Lung Transplant 2013. 32 (6):633–40
 Watson AJ, Gao L, Sun L, Tsun J, Doyle A, Faddy S, Jabbour A, Orr Y, Dhital K, Hicks M, Jansz PC, Macdonald PS. Enhanced preservation of pig cardiac allografts by combining erythropoietin with Glyceryl trinitrate and Zoniporide. Am J Transplant 2013. 13(7): 1676–87
Prolonged Ex-Situ perfusion: Twelve hours of heart perfusion
Benjamin Bryner2, Alvaro Rojas-Peña1,2, Yao Nie2 , Cory Toomasian2, Robert Bartlett2, Martin Bocks2,3, Gabe Owens2,3
1General Surgery-Section of Transplantation, University of Michigan, Ann Arbor, MI, United States; 2General Surgery-Extracorporel Life Support Laboratory, University of Michigan, Ann Arbor, MI, United States; 3Pediatric and Cardiology, University of Michigan Congenital Heart Center, Ann Arbor, MI, United States.
Background: Ex situ organ perfusion can extend time before transplant, expand the donor pool, and allow for optimization of donor organs.
Methods: Forty-kilogram swine are used as heart and blood donors. The swine’s blood is centrifuged, and perfusate is created by reconstituting erythrocytes and plasma (leukocytes are discarded) with a target hemoglobin of 3–4 mg/dL. The perfusion circuit includes a membrane oxygenator, heat exchanger, collapsible rotary pump, pressure-release valve, and bubble trap (figure 1). Perfusate enters the aortic root at a goal pressure of 50-55mmHg, and drains passively into the reservoir. Once the heart is rewarmed, it is defibrillated to restore sinus rhythm, but is not continually paced. A portion of the perfusate is exchanged hourly to dilute out metabolic byproducts. A sampling catheter is placed in the coronary sinus, and EKG leads are placed in the myocardium. Perfusion pressure, flow, temperature, and blood gas measurements are monitored. Experiments were ended when resistance rose above a critical threshold, or at 12 hours.
Results: We perfused nine hearts ex situ at body temperature (37-39°C) and two at room temperature. Initial pathology results showed patchy hemorrhage within the myocardium, prompting us to decrease the target perfusion pressure in later experiments from 65mmHg to 55mmHg. The room-temperature hearts were perfused for 7 and 8.5 hours; the normothermic hearts for 9–12 hours. Normothermia was necessary for hearts to regain sinus rhythm (fig 2); this did not occur at lower temperatures despite defibrillation. Despite regular changes of perfusate, lactate increased significantly by the end of the perfusion in most experiments. Mean weight gain was 17% over the course of perfusion.
Conclusion: Perfusion of a swine heart for 12 hours with maintenance of sinus rhythm is feasible.
Ex-Situ Limb Perfusion System: 24hr preservation of limbs
Alvaro Rojas-Peña1,2, Benjamin Bryner2, Yao Nie2, Cory Toomasian2, Jeffrey Punch1,2, Robert Bartlett2, Kagan Ozer2,3
1General Surgery-Section of Transplantation, University of Michigan, Ann Arbor, MI, United States; 2General Surgery-Extracorporel Life Support Laboratory, University of Michigan, Ann Arbor, MI, United States; 3Orthopaedic Surgery, University Michigan, Ann Arbor, MI, United States.
Limbs used for transplantation or re-implantation are cold stored for 6-9hr before re-attachment. However, anaerobic metabolism waste products are released after reperfusion affecting recipient outcomes. The goal of this study was to develop and test a 25°C ex-situ limb perfusion system (ELiPS) that improves limb viability prior to transplantation in a porcine model.