Abstracts from the 12th Congress of the International Society for Organ Donation and Procurement November 21–24, 2013 / Sydney, Australia

doi: 10.1097/01.tp.0000438970.80290.d5
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130

Conscience-based refusal to participate in donation after cardiac death (DCD)

Mark Wicclair1,2

1Philosophy, West Virginia University, Morgantown, WV, United States; 2Center for Bioethics and Health Law, University of Pittsburgh, Pittsburgh, PA, United States

While conscientious objection has its historical roots in objections to military service, a growing number of health professionals have refused to provide a broad range of goods and services that violate their ethical beliefs. Such actions, clearly, can have a major impact on organ donation. Some ICU clinicians, for instance, have objected to participating in donation after cardiac death (DCD) because it is against their conscience. In this presentation, two extreme approaches to managing conscience-based objections to participating in DCD are identified and rejected and a more nuanced middle-ground is proposed.

One extreme is “conscience absolutism,” the view that clinicians should be exempted from performing any action, including participating in DCD, that is contrary to their conscience. The second extreme is the “incompatibility thesis,” the view that practitioners have an obligation to provide any good or service, including participating in DCD, that is legal, professionally accepted, and within the scope of their professional competence.

Neither of these extreme approaches is defensible. Conscience absolutism is indefensible because it fails to consider that clinicians have obligations to patients and their families, other professionals, institutions, and society. The incompatibility thesis is untenable because it fails to acknowledge the value of moral integrity, and it presupposes an indefensible conception of clinicians’ professional obligations.

An alternative to both extreme approaches is presented. It features the following guidelines: a) Clinicians should provide advance notification of a conscience-based objection to participating in DCD; b) accommodation should not result in a failure to inform surrogates of the DCD option in a timely manner; c) accommodation should not impede or unduly delay DCD; d) accommodation should not impose excessive burdens on other clinicians, administrators, or institutions.

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131

Legalizing HIV-positive organ donation to HIV-positive recipients: One giant leap toward addressing organ donation waiting list burden

Leslie Wolf, Rachel Hulkower

College of Law, Georgia State University, Atlanta, GA, United States

In the United States today, over 115,000 patients are waiting for organ transplantation, but, in 2012, only 28,051 organs were transplanted from living and deceased donors. The gap between the supply and demand continues to grow, while thousands of patients die annually awaiting organ transplantation.

US laws that ban transplantation of organs from donors who are HIV-infected, even when the recipient is HIV-infected, exacerbate this gap. Such limits may have been necessary early in the HIV/AIDS epidemic, when there were no effective treatments and patients typically died within a year or two of an AIDS diagnosis. Today, however, with access to effective antiretroviral therapies, people living with HIV have life expectancies similar to those without HIV and now also add to the number of patients awaiting organ transplantation.

Eliminating legal barriers to transplantation of organs from HIV-infected donors could alleviate the shortage of organs for both HIV-infected and non-infected transplantation candidates. This would occur by increasing the pool of organs available to HIV-infected transplantation candidates, moving them off the transplant list, and allocating remaining organs to those remaining on the list. This presentation will describe the laws and policies prohibiting organ donation by those who are HIV-infected, the need for and evidence supporting a policy change, and recommend ways to accomplish that policy change.

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132

Changing pattern of death cause and future source of organs in Korea

Won H Cho1,2, Ui J Park1, Jin S Yu2, Hyeung T Kim1,2

1Department of Surgery, Division of Transplantation, Keimyung University School of Medicine, Daegu, Korea; 2Vitallink Korea, Seoul, Korea

Required reporting system included in newly revised transplantation law increase deceased donor about 20% in recent 2 years. However, nobody can believe this amount of growth in the next year because we already sense a slowing of growth this year. In order to have a prospective possibility of organ donation from deceased donor, national statistics about changing pattern of death cause were reviewed. The Korea Network of Organ Sharing(KONOS) reported that number of living donor transplantation is decreasing from 53.3% in 2008 to 50.9% in 2012. Instead, proportion of deceased donor is increased from 35.3% to 45.7%.

Figure

Figure

Among these deceased donor, two most frequent cause of brain death were cerebrovascular disease and head trauma by traffic or other accident, which comprised 81.0%. But real problem in recent year is the changing pattern of death cause which reported by the Statistics Korea(national statistics). The death rate of cerebrovascular disease and head trauma are decreasing definitely and their reducing rate in 2012 are 31.2% and 39.6% compare to 2001. Even we don’t use all of the potential donor that developed at hospital right now, we easily expect the donor from deceased donor will be soon flat or decreasing. To solve this problem, we actively change our policy to use non-heart beating donor and aggressively use expanded criteria donor which were discarded previously. National consensus about changing the law for removing the life supporting system is also seriously considered.

Figure

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133

An exploration of consent issues in Victorian potential donors after brain death (DBD) and cardiac death (DCD)

Hugh Stephens1, David Pilcher2, Helen Opdam3, Gregory Snell4, Jeffrey Rosenfeld5

1MBBS/PhD Candidate, Monash University / The Alfred Hospital, Melbourne, Australia; 2Department of Intensive Care, Alfred Hospital, Melbourne, Australia; 3DonateLife Victoria, Melbourne, Australia; 4AIRmed Lung Transplant Service, Alfred Hospital, Melbourne, Australia; 5Department of Surgery, Alfred Hospital, Melbourne, Australia

Background & Aim: Consent remains one of the greatest barriers to increasing the donor pool [1]. International centres have found family consent rates to be associated with brain death status, age, and ethnicity [2].

Methods: From a database of 18,949 deaths occurring in 22 Victorian hospitals between 1 January 2010 and 30 June 2012, we selected cases where organ donation was discussed with the family or guardian. Examination of patient and family wishes; donor type and whether donation was successful was completed using univariate analysis.

Results: A total of 623 family discussions occurred. Of these, 115 were unsuitable for donation due to a medical contraindication, were considered unsupportable to facilitate donation or were not ventilated in the 6 hours prior to death. There were a total of 175 successful donations (130 DBD donations and 41 DCD donations (n=4 unknown), from 508 potential donors, 34%), and one patient survived to discharge (n=4 data missing). Donation was raised by staff in 73% (n=372) of cases and family in 24% of cases (n=123). The patient was recorded as a consent on the organ donation registry in 54 cases out of 256 checks (remainder not listed). In one of these cases, the family subsequently declined donation. Of those not listed on the registry, 45% of families subsequently consented to donation (n=201), with n=242 refusals and n=5 not asked. Family consent was more likely in patients with confirmed or probable brain death (50% vs 40%, p=0.03), whether the patient died of non-neurological causes (69% vs 50%, p=0.04) and whether families initially raised donation (76% vs 42%, p<0.01). This suggests a potential lack of understanding from patient families of DCD programs. There was no association with age (p=0.40) or gender (p=0.80).

Conclusions: Brain death status, cause of death and who initially raised organ donation were factors predicting consent.

References:

[1] National Health and Medical Research Council (NHMRC). National Protocol for Donation after Cardiac Death. Canberra: Australian Organ and Tissue Donation and Transplantation Authority (AOTDA); 2010.

[2] Brown, C. V., et al. (2010). “Barriers to obtaining family consent for potential organ donors.” J Trauma 68(2): 447-451.

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134

Body language of "blood owners" different cultural and legal frameworks need different family approaches in organ request

Masoud Mazaheri

Organ Procurement, Emam OPU, Tehran, Iran (Islamic Republic of)

In different countries, different legal systems regulate the whole process of organ donation and transplantation. This legal system has been influenced by many historical, traditional and even philosophical local factors and has always continual dialogue with social forces which represent those factors. The brain-dead’s family interview to request organ donation, where one proposes an emergent request to a still-unbeleiving family, reveals the hidden internal conflictions and challenges of this legal system. In countries like Spain, where the “individual will” is the most determining legal factor, the interview takes the shape of an detective mission to discover whether the brain-dead has had any dissagreement with organ donation in their lifetime or not. On the other hand, in countries influenced by Arabic-Islamic culture (including Iran) the family members’ final will is more important than the individual’s and in legal issues such as organ donation the next-of-kins decision (more specifically, the male relatives or “blood owners”) is what matters the most. In these countries, the family interview is not as easy and non-challenging as Spain model and one must struggle to convince a group of male relatives to give permission for someone-else organ donation! To do so, the organ procurement unit (OPU) coordinators must be aware of all communicative skills needed to manage a non-cooperative and heterogen group. To be familiar with “body language” is a good weapon in handling family interviews all over the world, but in a country like Iran, it is very vital and could avoid of many misundertandings and unwanted tensions, and could dramatically raise the rate of successful requests for organ donation.

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135

Getting to 96% family constant rate for organ donation by PEIP method

O. Ghobadi, K. Hadisadegh, S. Abdollahi, M. Mottaghi, M. Moftakhari, A. Jamali, K. Najafizadeh

Lung Transplantation Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Islamic Republic of)

Introduction: Taking brain dead family consent is one of the most important steps of organ donation process. In spite of extensive social awareness activities, rate of family consent was still about 32% in Iran. To increase the rate of consent, we started a project named PEIP (Persian educating interviewers’ project) which is presenting here:

Methods: 1- We learned brain dead family interview fundamentals from TPM (Transplant Procurement Management) of Spain as one of the most successful teams of the world in this subject. 2- By checking the causes of family refusal and considering the cultural differences, we adjusted this science with our culture 3- By an interview and exam we selected 6 out of 70 volunteer psychologists. 4- After educating these psychologists and our coordinators for brain dead family interview we selected the interviewers who could get to the consent rate of more than 60%. 5- The interviewers discussed about their cases and took the others comments every other week and their expert teacher guided them. 6- We changed the interviewer if the first one could not get the consent in 48 hour. 7- We didn’t give up until getting the family consent or until the case had cardiac arrest.

Results: Family consent rate increased from %32 to %96.3 one month after starting the project and stayed more than 85% until now. The duration of interview needed, decreased from 24 – 72 hours to less than 12 hours in 72%, 12-24 hours in 21% and more than 24 hours in 7%. Organ retrieval increased from 12 to 27 monthly.

Conclusion: Brain dead family interview is a science and with regular educating the interviewers by experts, consent rate can increase to near 100%. We advise PEIP to be used in another countries specially the ones with similar culture.

Keywords: Organ donation, Brain death, family consent

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137

Psychosocial impact of donation process on the living organ donors (FIS project)

Marti Manyalich Vidal1, Ana Menjivar1, Josep Maria Peri1, Xavier Torres1, Eva Oliver2, Nuria Masnou3, Teresa Rangil4, Maribel Delgado5, Antonio Fernandez6, Montserrat Martinez7, Ana Vila8, Chloe Balleste1, Jaume Grau1, Amado Andres5, Ana Zapatero9, Laura Cañas4, Ricardo Lauzurica4, M. Pilar Gracia9, Yolanda Diaz9, Josep Maria Puig9

1Hospital Clinic of Barcelona, Barcelona, Spain; 2Bellvitge Hospital, Barcelona, Spain; 3Vall d’Hebron Hospital, Barcelona, Spain; 4Germans Trias i Pujol Hospital, Barcelona, Spain; 5Hospital Universitario 12 de Octubre, Madrid, Spain; 6Complejo Universitario de A Coruña, A Coruña, Spain; 7Fundació Puigvert, Barcelona, Spain; 8Hospital Sant Joan de Deu, Barcelona, Spain; 9Hospital del Mar, Barcelona, Spain

Introduction: Living Donation has a positive impact on Living donors (LDs) in terms of their self-estimation and social value. However, an evaluated risk on their physical and psychosocial outcome is presented. Such risk appears to be linearly increased for a longer post donation time.

FIS project, 2011-2013, co-founded by European Regional Development Fund (FEDER), aims to evaluate the psychosocial outcome and the satisfaction level of Spanish kidney and liver living donors.

Objective: To analyze the impact of donation process on the LDs quality of life and psychological well-being and to evaluate the level of satisfaction received from the process.

Methodology: The population includes the LDs who donated in nine transplant centers all over Spain from year 2000 in continuity.

The project is developed in two simultaneous studies:

Prospective study- a longitudinal psychosocial follow-up of LDs, assessed in two moments pre and one year post donation.

Retrospective study- to evaluate the satisfaction level LDs received from the donation process. As assessment tool a new version of the EULID (European Living Donation and Public Health) satisfaction survey was designed.

The results are introduced in the database surged from EULID project, available on www.eulivingdonor.eu.

Results: The centers have adapted the methodology to their characteristics and resources. The studies are being developed independently and currently the project is in the data-analyses phase.

Nowadays, there are more than 400 LDs registered; respectively 90% are Kidney LDs and 10% Liver LDs.

Out of these approximately 214 LDs are included in the retrospective study and approximately 132 LDs in the prospective study.

Conclusion: Changes in the ability to manage or improve life stressors are fundamental for good psychosocial outcome on LDs. The LDs satisfaction is key point to ensure the overall quality and security of donation procedures.

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138

Correlation between potential donor age and family refusal rates in the State of Rio de Janeiro, Brazil

Janaina Lenzi1, Andreia Assis1, Márcia Ponte1, Priscila Paura2, André Albuquerque2, Rodrigo Sarlo3, Cláudia Araújo5, Eduardo Rocha4,5

1Family Services, State Organ Procurement Organization, Rio de Janeiro, Brazil; 2Education, State Organ Procurement Organization, Rio de Janeiro, Brazil; 3General Coordination, State Organ Procurement Organization, Rio de Janeiro, Brazil; 4Health Foundation, State Health Board, Rio de Janeiro, Brazil; 5COPPEAD, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil

Introduction: It is well known that potential donor (PD) age influences family decision on organ donation. Accepting the death of a child or young person often is very difficult and donation rates (DR) may vary according to cultural beliefs and general education on organ donation. Studies are contradictory to DR among the elderly. Our study aims to analyze the influence of age on family refusal, in order to help developing strategies to increase awareness on the subject and training of health professionals in charge of interviewing families of PD.

Methods: Data from the records of the Rio de Janeiro State Transplant Program (PET) from 2011 to 2012 were reviewed and expressed as percentual analysis (%). Family refusal (FR) rates for donation were organized according to PD’ age group as follows: children (<11), teenagers (12-17), adults (18-64) and seniors (>65).

Results: Our data show that in the period studied, among refusals 53% were associated to children, 51% to teenagers, 46% to adults, and 55% to senior PD. The main reason for children and teenager FR were misunderstanding of brain death and fear of body mutilation. These become to have a smaller participation as the potential donor age increases. Otherwise, absence of consensus among family members and first person refusal were the main reasons for FR in elderly PD.

Conclusion: Our study shows that FR occurred in over 50% of cases when a child, teenager or an elderly PD was involved. This result reinforces previous research and indicates that young donor age is associated with a reduced probability of donation. Furthermore, this research goes further by showing that seniors also have a lower likelihood of having their organs donated in RJ, Brazil. This means that health care professionals who interview families of PD should be trained to deal with these family questions, using different strategies according to the age of the deceased.

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141

Brain death impairs microcirculation with or without autonomic storm: an intravital microscopy study with thoracic epidural anesthesia in rats

Isaac Azevedo Silva, Rafael Simas, Laura Menegat, Cristiano de Jesus Correia, Sueli Gomes Ferreira, Paulina Sannomiya, Luiz Felipe Pinho Moreira

Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil

Introduction: Brain death (BD) is associated with hemodynamic instability, inflammation and mesenteric hypoperfusion[1]. In a previous study, thoracic epidural anesthesia (TEA) blocked the hypertensive crisis and the hemodynamic instability, without inflammatory response attenuation[2]. The present study aimed to evaluate the influence of sympathetic blockade in mesenteric perfusion in brain dead rats.

Methods: Male Wistar rats were anesthetized with isoflurane (5-2%) and underwent BD by intracranial catheter insufflation immediately after epidural infusion of bupivacaine (Bupi) or saline. Mean arterial pressure (MAP) was monitored over 3h. The mesenteric microcirculation was assessed by intravital microscopy. In the same time point, the expression of mesenteric ICAM-1 was quantified by immunohistochemistry and the serum corticosterone level was determined by ELISA. Sham-operated rats (SH group) was trepanned only. Results are presented as mean±SEM.

Results: The autonomic storm was abolished in Bupi group (p<0.001), however, the percentage of perfused mesenteric microvessels was similar between the study groups and significantly lower than SH (Bupi: 43±6%, saline: 39±7%; SH: 74±6%. p=0.002). The expression of ICAM-1 was similar between the study groups (Bupi: 21±5; Saline: 23±8), but higher than the SH (9±2 mean fluorescence intensity, p<0.001). Serum levels of corticosterone was lower in Bupi and Saline groups compared with SH (p=0.01).

Conclusions: TEA with bupivacaine was effective in abolishing the autonomic storm, however, tissue hypoperfusion, elevated expression of adhesion molecules, and the low serum corticosterone, triggered by BD remained in the animals independently to hemodynamic status. Therefore, inhibition of the hypertensive peak in BD does not improve mesenteric perfusion and does not modulate the endothelial activation.

Finnacial Support: FAPESP.

References:

[1] Simas, R.; Sannomiya, P.; Cruz, J. W. M. C.; Correia, C. J.; Zanoni, F L; Kase, M.; Menegat, L.; Silva,I. A.; Moreira, L. F. P. Paradoxical effects of brain death and associated trauma on rat mesenteric microcirculation: an intravital microscopic study. Clinics (USP. Impresso) JCR, v. 67, p. 69-75, 2012.

[2] Silva, I.A.; Correia, C.J.; Simas, R.; Cruz, J.W.M.C.; Ferreira, S.G.; Zanoni, F.L.; Menegat, L.; Sannomiya, P.; Moreira, L.F.P. Inhibition of Autonomic Storm by Epidural Anesthesia Does Not Influence Cardiac Inflammatory Response After Brain Death in Rats. Transplantation Proceedings JCR, v. 44, p. 2213-2218, 2012.

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142

Apnea testing for determination of brain death in children supported with veno-arterial ECMO

Thomas A. Nakagawa1, Rima J. Jarrah2, Samuel J. Ajizian3, Swati Agarwal5, Scott C. Copus

2Anesthesiology, Wake Forest Baptist Health, Brenner Children’s Hospital, Winston-Salem, NC, United States; 1Anesthesiology, Wake Forest Baptist Health, Brenner Children’s Hospital, Winston-Salem, NC, United States; 3Anesthesiology, Wake Forest Baptist Health, Brenner Children’s Hospital, Winston-Salem, NC, United States; 4Pediatrics, Section of Pediatric Critical Care, Inova Fairfax Hospital for Children, Falls Church, VA, United States; 5Respiratory Care, Wake Forest Baptist Health, Brenner Children’s Hospital, Winston-Salem, NC, United States

Introduction: The updated United States guideline for the determination of brain death in infants and children provides important direction for clinicians tasked with determining death.[1] The guideline unfortuantely lacks direction for apnea testing when a patient is supported on extracorporeal membrane oxygenation (ECMO), as no published literature exists for this clinical situation.

Methods: Retrospective observational case review.

Results: Three children ages 5 months, 2 years, and 14 years, supported on veno-arterial (VA) ECMO following cardiopulmonary arrest, developed a neurologic exam consistent with brain death. Apnea testing on VA ECMO was successfully performed using the following method:

  1. 1. PaCO2 was normalized by adjusting ECMO sweep gas flow and obtaining a baseline arterial blood gas (ABG) analysis.
  2. 2. Sweep gas FiO2 was increased to 1.0 to provide preoxygenation on VA-ECMO.
  3. 3. A flow-inflating bag system with continuous positive airway pressure and FiO2 1.0 was used after removing the patient from mechanical ventilation support.
  4. 4. Sweep gas flow was reduced to 0.1 L/min for smaller children and 1.0 L/min for larger children while maintaining sweep gas FiO2 at 1.0. Rate of PaCO2 rise was monitored using CDI blood parameter monitoring system and correlated with ABG analysis to confirm PaCO2 level reached the recommended threshold to support brain death determination.

In two cases, apnea testing was able to be successfully performed. In one case, the patient developed hemodynamic instability and hypoxia, and the apnea test was terminated.

Conclusions: This pediatric case series describes a method of conducting apnea testing for children supported with VA ECMO. We address an important clinical scenario that has not been previously described in children undergoing brain death testing.

Reference:

1. Nakagawa TA, Ashwal S, Mathur M, et al. Guidelines for the determination of brain death in infants and children: an update of the 1987 Task Force recommendations. Crit Care Med 2011,39(9):2139-2155.

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143

Impact of simultaneous administration of Furosemide and Desmopressin on hypernatremia in brain dead organ donors: A clinical trial

Sahar Sajedi, Katayoun Najafizadeh, Omid Ghobadi, Ali Khalili, Hamid Rashid, Meysam Mojtabaee, Javad Ghasemi

Lung Transplantation Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Islamic Republic of)

Background: Appropriate brain dead donor management is a critical issue and one of the most prominent problems the management team is facing is fluid and electrolyte disturbances specially hypernatremia. In this study we decided to treat hypernatremia with simultaneous administration of Desmopressin and furosemide to get advantage of natriuretic effect of Furosemide and water saving effect of Desmopressin. The result expected to be the correction of hypernatremia with smaller amount of fluid.

Methods: 45 brain dead donors with hypernatremia were selected and divided randomly to case and control groups. Every group further divided to 3 subgroups according to level of hypernatremia (150-159, 160-169 and higher than 170 meq/liter). Water deficit (according to the Na level) plus insensible water loss were calculated and every one hour beside previous hour urine volume, 10% of calculated fluid was given by IV fluids (half saline for two first subgroups and dextrose water for third subgroup) and 15% by simple water gavage for 3 hours.3 milligrams of furosemide and Desmopressin (0.5 microgram for two first subgroups and 1microgram for the third subgroup) were added simultaneously only in case group.

Results: A total of 30 controls and 15 cases were compared. Mean age was 34 (6-85 years) which was not significantly different between case and control groups and 57.8% of donors ware male. Sodium Correction progress in 3 hours were significantly different among the groups (p=0.02). Urea correction rate approached close to significance border (p=0.05). There was no significant difference in potassium and creatinine correction rates.

Conclusion: Simultaneous use of Desmopressin and Furosemide can correct hypernatremia and prerenal azotemia easier and faster and needs less fluid to be used. This method could be recommended specially for lung donor candidates.

Keywords: Brain death, hypernatremia, Desmopressin, Furosemide

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144

Brain death induces leucopenia and reduction in the number of bone marrow cells

Julia M. Caliman1, Laura Menegat1, Primavera Borelli2, Rafael Simas1, Luiz F. Ferraz da Silva3, Luiz F. Moreira1, Paulina Sannomiya1

1University of São Paulo, Sâo Paulo, Brazil; 2Faculty of Pharmaceutical Sciences, University of São Paulo, Sâo Paulo, Brazil; 3Department of Pathology, University of São Paulo Medical School, Sâo Paulo, Brazil

Introduction: Brain death (BD) is associated with increased inflammatory response in the different organs. In this study, we evaluated the recruitment of bone marrow cells to peripheral blood in rats submitted to BD compared with BD-associated trauma.

Methods: Male Wistar rats (250-350g) were anesthetized and mechanically ventilated. A balloon catheter was placed into intracranial cavity, through trepanation, and quickly inflated to induce BD. Sham operated rats (SH) were trepanned only. Bone marrow cells were obtained by flushing the femoral cavity with Iscoves medium 6 hours thereafter. White blood cell (WBC) counts in the peripheral blood were determined at baseline, and after 3 and 6 hours. Total bone marrow cells and WBC counts were determined using a hemocytometer. Differential counts were performed on smears stained with May-Grunwald Giemsa solution.

Results: BD rats exhibited a progressive leucopenia (Baseline: 13171±1377; 3 h: 11086±1779; 6 h: 8300±927 cells/mm3), in contrast with SH group (Baseline: 12863±1283; 3 h: 17013±6186; 6 h: 17353±8286 cells/mm3, p=0.012). The leucopenia observed in BD animals was also associated with lower values for neutrophil/lymphocyte ratio in comparison with the values observed in SH rats at 6 hours (p=0.004). BD rats showed a significant reduction in the total number of bone marrow cells (2.8±0.2 x107 cells/mL) compared with SH animals (4.9±0.9 x107 cells/mL, p=0.03), specially due to a significant reduction in the number of segmented cells (p=0.03), and lymphocytes (p=0.06). The cellularity reduced in BD group (p<0,0001).

Conclusions: Despite its pro-inflammatory effects, BD itself paradoxically induced progressive leucopenia and reduction in the number of bone marrow cells in this experimental model.

Grant #2011/22803-2, São Paulo Research Foundation (FAPESP)

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145

Final report of the Polish multicentre study for evaluation of computed tomographic angiography in the diagnosis of brain death

Romuald Bohatyrewicz1, Marcin Sawicki2, Anna Walecka2, Jerzy Walecki3, Olgierd Rowinski4, Joanna Solek-Pastuszka1, Zenon Czajkowski5, Maciej Zukowski1, Jaroslaw Zylkowski4, Piotr Skrzywanek11, Wojciech Kociemba9, Maciej Guzinski6, Malgorzata Burzynska7, Witold Manko10, Joanna Wojczal8

1Department of Anaesthesiology and Intensive Therapy, Pomeranian Medical University, Szczecin, Poland; 2Department of Diagnostic Imaging and Interventional Radiology, Pomeranian Medical University, Szczecin, Poland; 3The Centre of Postgraduate Medical Education, Warsaw, Poland; 42nd Department of Clinical Radiology, Medical University of Warsaw, Warsaw, Poland; 5Regional Joint Hospital, Szczecin, Poland; 6Department of General Radiology, Interventional Radiology and Neuroradiology, Wroclaw Medical University, Wroclaw, Poland; 7Department of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Wroclaw, Poland; 8Department of Neurology, Medical University of Lublin, Lublin, Poland; 9Department of Neuroradiology, University of Medical Science, Poznan, Poland; 10Department of Anaesthesiology and Intensive Therapy, University of Medical Science, Poznan, Poland; 11Department of Diagnostic Imaging, City Hospital, Poznan, Poland

Introduction: According to Polish brain death (BD) criteria instituted in 2007, confirmatory tests should be used in specific situations such as intoxication, infratentorial processes, extensive facial damage, in children up to one year of age and any case when clinical examination seems to be inadequate. These tests are often unavailable due to insufficient access to proper equipment and qualified specialists. Therefore, finding a confirmatory test, which would be widely available, simple to perform and easy to interpret became of fundamental importance. Computed tomographic angiography (CTA) seemed to be the test of choice for this purpose because new generation of CT scanners became widely available. The method is simple and relatively cheap. Despite of this fact, CTA was not included in Polish BD criteria because of limited expertise and lack of generally accepted criteria. In this situation, after approval of Bioethical Committee we organized Polish national multicentre trial for evaluation of CTA in the diagnosis of BD.

Methods: In 7 cooperating centres, we examined 82 patients, which fulfilled standard clinical BD criteria. In a first step CTA was performed, followed by CT perfusion, and finally verified by conventional angiography. The lack of cerebral blood flow in CTA was defined as the absence of opacification of M4 segments of the middle cerebral artery (M4-MCA) and deep cerebral veins, the same as in criteria of French Society of Neuroradiology [1].

Results: In 76 patients, CTA revealed the absence of opacification of M4-MCA segments and deep cerebral veins. This met the French diagnostic criteria of cerebral circulatory arrest. In 62 out of 64 examined patients (96.9%), subsequent CT perfusion revealed zero values of cerebral blood volume and flow in the whole brain. In the remaining 2 cases CT perfusion showed very low values of perfusion parameters in small cortical regions at the site of decompressive craniectomy. Conventional angiography confirmed cerebral circulatory arrest in all 82 cases. CTA achieved the sensitivity of 92.7%. Additionally we identified potential points of pitfalls, which will be mentioned in currently elaborated Polish instruction.

Conclusions:

1. CTA is a valuable confirmatory test for BD diagnosis.

2. Polish instruction will be compatible with French protocol published in 2011.

The study was supported by a grant from the State Committee for Scientific Research of Poland No KBN-N 403 171 137.

Reference:

[1] Societe Francaise de Neuroradiologie, Societe Francaise de Radiologie, Agence de la Biomedecine. [Recommendations on diagnostic criteria of brain death by the technique of CT angiography]. J. Neuroradiol. 2011. 38(1):36-9.

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146

Role of CT angiography in confirmation of brain death

Subhash Arora, Gopal Taori

Intensive Care, Monash Health, Melbourne, Australia

Confirmation of brain death requires demonstration of intracranial circulatory arrest, especially when clinical assessment is not possible due to presence of confounding factors. The ANZICS guideline accepts conventional 4 vessel cerebral angiography and cerebral perfusion scintigraphy as “gold standard” to make such diagnosis. However these procedures are disadvantaged by invasiveness, limited availability, operator dependence and sometimes substantial delay.

Around the world, various other technical aids are used to confirm the diagnosis of brain death. These include somatosensory evoked potential (SSEP), electroencephalography (EEG) and transcranial doppler ultrasonography (TCD). These often yield discordant results necessitating interpretation by expert examiners.

In recent times, CT angiography (CTA) with CT brain perfusion study, is emerging as a viable alternative and has been licensed for use in some countries. While the results of studies so far, comparing conventional cerebral angiography and CTA with or without CT perfusion favour using the later as a rapid method for confirmation of diagnosis of brain death, larger studies are needed to validate their findings further.

In our presentation, we describe the various technical aids used to determine the diagnosis of brain death, provide information that will be useful in deciding which of the available techniques to use and compare the results of CT angiography available so far with those of other forms of examination. We also discuss the ethical and practical issues around a proposed study comparing CT angiography using a new 320-slice CT scanner and conventional cerebral angiography.

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147

A new method to increase brain dead potential donor detection rate

O. Ghobadi, M. Dargahi, M. Hazrati, M. Mazlum, K. Najafizadeh

Lung Transplantation Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Islamic Republic of)

Background: Brain dead potential donor detection which is one of the most important steps of organ donation process has 3 different methods: Administrative, Active, Passive. Active method has been known the best way for detecting all possible donors. Our OPU in Tehran covers 112 hospitals. Because it is not practical to have this much in-hospital coordinators, we designed a new project for detecting all possible donors.

Methods: 112 hospitals were divided to 4 groups according to the number of ICU beds and having the neurosurgery ward. 6 expert nurses were chosen as inspectors. Hospitals were screened by 3 complementary methods: PPDDP (Persian potential donor detection project), TDDP (Telephone donor detection project), HR (hospital reporting). A schedule was designed for detection according to the hospital group. Inspectors should visit the hospitals in specific times according to the schedule. Telephone detection had to cover the other times. Hospital report could be done in any time of the day. Special forms were designed for: 1-GCS 3 brain dead; 2- GCS 3, not brain dead; 3- GCS 4 and 5 and 4- unacceptable donors. Group 1 were followed by coordinators, group 2 and 3 were followed by TTDP group and group 4 were just recorded for statistics.

Findings: The rate of detection increased from 50 to 475 per month. Eight out of 40 group 2 and 12 out of 260 group 3 were brain dead in follow up and 6 and 8 were actual donors respectively. 12 out of 80 group 1 donated their organs.

Conclusion: In the OPUs with high number of hospital, PPDDP is an effective method to detect all possible donors. This study showed that close following the GCS 3 non brain dead and GCS 4, 5 cases are very important.

Keywords: Organ donation, brain death, brain dead donor, detection rate

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148

Potential pitfalls and problems during implementation of CT angiography for national brain death diagnosis protocol in Poland

Romuald Bohatyrewicz1, Marcin Sawicki2, Anna Walecka2, Jerzy Walecki3, Olgierd Rowinski4, Joanna Solek-Pastuszka1, Zenon Czajkowski5, Maciej Zukowski1, Jaroslaw Zylkowski4, Piotr Skrzywanek11, Wojciech Kociemba9, Maciej Guzinski6, Malgorzata Burzynska7, Witold Manko10, Joanna Wojczal8

1Department of Anaesthesiology and Intensive Therapy, Pomeranian Medical University, Szczecin, Poland; 2Department of Diagnostic Imaging and Interventional Radiology, Pomeranian Medical University, Szczecin, Poland; 3The Centre of Postgraduate Medical Education, Warsaw, Poland; 42nd Department of Clinical Radiology, Medical University of Warsaw, Warsaw, Poland; 5Regional Joint Hospital, Szczecin, Poland; 6Department of General Radiology, Interventional Radiology and Neuroradiology, Wroclaw Medical University, Wroclaw, Poland; 7Department of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Wroclaw, Poland; 8Department of Neurology, Medical University of Lublin, Lublin, Poland; 9Department of Neuroradiology, University of Medical Science, Poznań, Poland; 10Department of Anaesthesiology and Intensive Therapy, University of Medical Science, Poznan, Poland; 11Department of Diagnostic Imaging, City Hospital, Poznan, Poland

In 2007, new Polish code of practice reversed brainstem death criteria to whole brain death criteria. At this occasion there was extensive discussion about usefulness of CT angiography as a confirmatory test for cessation of cerebral perfusion. Finally the method was not recommended at this occasion because of no experience in Poland and lack of widely accepted criteria in international literature.

Careful analysis of scientific publications was rather confusing. Every center elaborated different examination protocol and evaluation criteria. Therefore the reports were difficult to compare. Only the French Society of Neuroradiology published detailed national instructions in 2007 and 2011[1].

In this situation, after approval of Bioethical Committee we organized multicenter trial in order to determine the accuracy of CT angiography and CT perfusion for the confirmation of BD. Our protocol for CT angiography was similar to French one and evaluation criteria were the same. The study was performed in 7 cooperating centers in 122 patients, which fulfilled standard clinical BD criteria. Unfortunately we had to exclude 40 cases because of protocol violations.

During the study we organized meetings and discussions concerning protocols and diagnostic criteria. Finally we identified following potential pitfalls and problems during implementation of CT angiography for BD diagnosis protocol:

1. failure to comply with the examination protocol,

2. misinterpretation of opacification of the proximal segments of cerebral arteries as indicative of persistent cerebral circulation,

3. false interpretation of SAH or pseudoSAH sign as real vascular opacification,

4. the apprehension of establishing the diagnosis, which is equivalent to the declaration of death.

Conclusions:

1. The introduction of CT angiography to the panel of tests confirming cerebral circulatory arrest should be preceded by an educational campaign with particular emphasis on radiological, neurological, neurosurgical and intensive care community.

2. Instruction, in addition to a detailed methodology should include information about the causes of potential errors and interpretation problems.

The study was supported by a grant from the State Committee for Scientific Research of Poland No KBN-N 403 171 137.

Reference:

[1] Societe Francaise de Neuroradiologie, Societe Francaise de Radiologie, Agence de la Biomedecine. [Recommendations on diagnostic criteria of brain death by the technique of CT angiography]. J. Neuroradiol 2011. 38(1):36-9.

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151

Auto-resuscitation and circulatory death in potential organ donors

David Pilcher1,3, Shena Graham1,2, Hayley Furniss2, Steven Philpot1,3

1Department of Intensive Care Medicine, The Alfred Hospital, Melbourne, Australia; 2DonateLife in Victoria, Melbourne, Australia; 3Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia

Background and Aims: Return of spontaneous circulation (auto-resuscitation) during donation after circulatory death (DCD) has significant implications, and has been rarely described. The Alfred Hospital has a controlled DCD program which mandates a five minute period of cessation of circulation prior to declaration of death. Our aim was to investigate cases where auto-resuscitation may have occurred in patients considered for DCD, to identify risk factors and highlight processes which may assist identification of future episodes.

Results: Between 2006 and 2012, 60 patients have undergone controlled withdrawal of cardio-respiratory support (WCRS) in the Intensive Care Unit in anticipation of DCD. 38 patients (63%) have died within acceptable time frames and become organ donors. There have been 2 possible auto-resuscitation episodes. Both patients had non-neurological causes of death.

Case one: A 57 year woman with end stage pulmonary fibrosis had WCRS. Six minutes later, invasive arterial monitoring became unavailable due to signal alarms. After this no arterial waveform analysis could be obtained. ECG activity ceased at 8 minutes. After an absence of 3 minutes, ECG activity returned for 3 minutes before permanently stopping.

Case two: A 41 year old man with extensive spinal, chest, abdominal and pelvic injuries lost ECG and arterial pulsation 5 minutes and 47 seconds after WCRS. One minute and 42 seconds later, ECG and arterial pulsation returned for a further one minute and 48 seconds before permanently stopping.

In both cases, 5 minutes of absence of ECG and arterial pulsatility was subsequently observed before death was declared and donation of kidneys proceeded.

Conclusions: Auto-resuscitation may be more common in non-neurologicalDCD cases. These possible auto-resuscitation cases highlight need for accurate monitoring and documentation. We recommend invasive arterial waveform analysis for all DCD cases.

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152

Donation after cardiac death category II in the emergency department: What is the impact?

Danielle Nijkamp1, Marije Smit2, Marc Seelen3, Bas Bens4, Christina Krikke5, Michiel Erasmus6

1Surgery, Division of Organ Donation, University Medical Center Groningen, Groningen, Netherlands; 2Critical Care Medicine, University Medical Center Groningen, Groningen, Netherlands; 3Nephrology, University Medical Center Groningen, Groningen, Netherlands; 4Emergency Room, University Medical Center Groningen, Groningen, Netherlands; 5Surgery, Division of Organ Donation and Transplantation, University Medical Center Groningen, Groningen, Netherlands; 6Cardiothoracic Surgery and Lung Transplantation, University Medical Center Groningen, Groningen, Netherlands

Background: Donation after cardiac death category II (DCD II) in patients after unsuccessful cardiac resuscitation could expand the existing donor pool for lung and kidney transplantation.

Aim: To assess the size of the potential DCD II donor pool for lung and kidney transplantation in a large university hospital, in which yearly on average 20 organ donation procedures are being performed.

Methods: A prospective database was retrospectively analyzed to identify potential DCD II donors among patients who were admitted to the emergency department (ER) from 2010 until 2012. Data on cardiac resuscitation, age, medical history, and national donor registry status were collected.

Results: In total, 298 patients had out of hospital cardiac arrest; 98 (32.8%) died in hospital and met the medical and age inclusion criteria for both lung (age ≤65) and kidney donation (age ≤50).

Forty-two patients (42/98; 42.8%) died in the ER of which 14 (33.3%) could have been both DCD II lung and kidney donor, and 11 (26.2%) only DCD II lung donor.

Fifty-three patients (53/98; 54.1%) died in the intensive care unit (ICU) and could have been a DCD III donor. Two out of 53 (3.8%) patients had a second episode of cardiac arrest and could have been a DCD II donor in the ICU.

Three out of 98 (3.1%) patients died in the cardiac catheterization unit and could have been a DCD II lung donor.

Conclusions: In three years time in the emergency department of a university hospital, 25 patients proved to be potential DCD II lung or kidney donors after unsuccessful resuscitation for cardiac arrest, 2 patients proved to be potential DCD II donor in the ICU, and 3 patients at the cardiac catheterization unit.

This programme of lung and kidney donation could be an important source of donor organs to expand the existing donor pool by 50%.

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153

A single centre retrospective review of selection criteria for donation after circulatory death liver transplantation

Georgina E Riddiough1, Michael A Fink1,2, Graham Starkey1, Bao Z Wang1, Adam G Testro1, Paul Gow1, Rhys B Vaughan1, Robert M Jones1

1Liver Transplant Unit, Austin Hospital, Melbourne, Australia; 2Department of Surgery, University of Melbourne, Melbourne, Australia

Introduction: Ongoing demand for liver transplantation in addition to ongoing limited organ availability has led to increased use of organs from donation after circulatory death (DCD) donors. Due to concerns over the success of such grafts related to prolonged warm ischaemia time careful selection of DCD grafts is imperative.

Methods: We retrospectively assessed the number of DCD liver offers made between 1 October 2007 and 7 February 2013. We reviewed our selection criteria for DCD liver grafts and examined reasons for declining such livers both immediately and at hepatectomy. Data was extracted from our liver transplant database.

Results: In total 86 DCD liver offers made to the Austin hospital in Victoria between 1 October 2007 and 7 February 2013. 52% (n = 45) of offers were declined immediately and 47% (n = 40) provisionally accepted, the remaining graft was exported to Queensland. 20% (n = 17) of grafts were transplanted; 9 grafts were declined at hepatectomy (reasons included hypoperfusion [n=2], hepatosteasosis [n=6]; one graft was declined when intraoperative findings indicated transplantation was no longer required). Reasons for immediately declining a DCD liver offer were varied, most commonly donor age >60 years (n=10). In 25 cases a combination of factors such as alcohol consumption, obesity, diabetes mellitus, unknown viral status, down time and abnormal pathology results led to immediate graft rejection.

Conclusion: One fifth of DCD liver grafts offered to the Austin were finally implanted. In this group of DCD liver transplant recipients 1-year patient survival was 82% and 1-year graft survival was 71%.

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154

The differences between donors after cardiac death and donors after brain death in 22 Victorian hospitals

Hugh Stephens1, David Pilcher2, Helen Opdam3, Gregory Snell4, Jeffrey Rosenfeld5

1MBBS/PhD Candidate, Monash University / The Alfred Hospital, Melbourne, Australia; 2Department of Intensive Care, Alfred Hospital, Melbourne, Australia; 3DonateLife Victoria, Melbourne, Australia; 4AIRmed Lung Transplant Service, Alfred Hospital, Melbourne, Australia; 5Department of Surgery, Alfred Hospital, Melbourne, Australia

Background & Aim: Since 2008, donation after cardiac death (DCD) programs across Australia have been increasing the donor pool by providing an alternative pathway to donation after brain death (DBD) [1]. As yet, little research has been conducted comparing the characteristics of these two donor types.

Methods: We analysed data from the DonateLife Audit database for 22 Victorian hospitals from 1 January 2010 through 30 June 2012 (n=18,949 deaths) to compare characteristics between donor types using ANOVA testing.

Results: 140 DBD and 51 DCD successful donors’ data was analysed. There was no significant difference in the proportion of donors that were DCD compared to DBD across the 3 years studied (p=0.85). No significant difference was found in age (p=0.20), location of death (p=0.24), or patient and family wishes (p=0.88, p=0.16 respectively). More DCD donors were male (75% vs 54%, p=0.01). DCD donors were less likely to die from a neurological cause of death (p<0.01, although both DBD and DCD donors more commonly died of neurological causes), although for those with neurological causes of death, there was no significant difference between groups (p=0.16). DBD donors more commonly met the DonateLife trigger criteria on admission to the emergency department (32% vs 8%, p<0.01). While more DCD donors came from tertiary centres (where DCD is facilitated) compared to metropolitan, pediatric, private or regional hospitals, the difference was not significant (p=0.07).

Conclusions: DCD donors appear to have different characteristics to DBD donors, particularly regarding cause of death, meeting trigger criteria in emergency departments and being male.

Reference:

[1] National Health and Medical Research Council (NHMRC). National Protocol for Donation after Cardiac Death. Canberra: Australian Organ and Tissue Donation and Transplantation Authority (AOTDA); 2010.

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155

The impact of changing Donation after Cardiac Death criteria on available potential donors: A study of 22 Victorian hospitals

Hugh Stephens1, David Pilcher2, Helen Opdam3, Gregory Snell4, Jeffrey Rosenfeld5

1MBBS/PhD Candidate, Monash University / The Alfred Hospital, Melbourne, Australia; 2Department of Intensive Care, Alfred Hospital, Melbourne, Australia; 3DonateLife Victoria, Melbourne, Australia; 4AIRmed Lung Transplant Service, Alfred Hospital, Melbourne, Australia; 5Department of Surgery, Alfred Hospital, Melbourne, Australia

Background: Australian Donation after Cardiac Death (DCD) protocol requires all potential donors to die within 90 minutes of withdrawal of life-sustaining therapy and be aged less than 65 years. International centres have reported favourable outcomes from donors outside this time limit [1] or from those older than 65 [2].

Methods: We analysed a database of 18,949 deaths in Victorian hospitals from 1 January 2010 to 30 June 2012 to determine the impact of adjusting these criteria on potential donor numbers. We defined a potential donor as a death in ED, ICU or operating theatre, ventilated in the 6 hours prior to death, not having active cancer, unlikely to become brain dead, and having a cardiorespiratory system supportable for long enough to facilitate donation.

Results: There were 257 potential DCD donors using existing parameters. 89% (n=228) died in ICU, 11% (n=27) in the emergency department and 2 in operating theatre. 42 (16%) subsequently donated organs. Increasing the maximum age limit to 70 would result in 71 additional potential donors, and a further 71 were aged 71-75 but were otherwise eligible. During the study period, 6 patients donated organs aged 67 to 72, so increasing formal age criteria to 70 or 75 may be already feasible in the Australian context.

339 deaths had time until death recorded with (aged under 65). 51% (n=184) died within 30 minutes, 14% (n=52) within 60 and 5.8% (n=21) within 90 minutes (i.e. matched existing criteria). Increasing the time limit to 120 minutes could provide an additional 11 donors, or 150 minutes a further 18 donors.

Conclusions: Modifying age criteria appears to have the most significant impact on increasing the number of potential DCD donors, while modifying time to death having a minor effect.

References:

[1] Moers C, Leuvenink HGD, Ploeg RJ. Donation after cardiac death: evaluation of revisiting an important donor source. Nephrol Dial Transplant. [Editorial Review]. 2010 Mar; 25(3):666-73

[2] Frei U, Noeldeke J, Machold-Fabrizii V, Arbogast H, Margreiter R, Fricke L, Voiculescu A, Kliem V, Ebel H, Albert U, Lopau K, Schnuelle P, Nonnast-Daniel B, Pietruck F, Offermann R, Persijn G, Bernasconi C. Prospective age-matching in elderly kidney transplant recipients–a 5-year analysis of the Eurotransplant Senior Program. Am J Transplant 2008; 8(1):50-7.

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156

Development of a competence based training programme for perioperative practitioners undertaking in-situ normothermic regional preservation in DCD donors

John Stirling, Pamela Stenhouse, Graham Johnston, Ian Currie, Gabriel Oniscu

Scottish Organ Retrieval Team, NHS Lothian, Edinburgh, United Kingdom

Normothermic Regional Perfusion (NRP) is a new approach to DCD organ retrieval involving normothermic oxygenated blood perfusion rather than cold perfusion. This may improve organ viability and quality and potentially increase the number of organs recovered.

In Scotland, there is a unified multi-organ retrieval team, the Scottish Organ Retrieval Team (SORT). This includes perioperative practitioners responsible for multi-organ perfusion and preservation. Traditionally, this involves hypothermic preservation and packing the organs for cold storage. NRP requires greater specialist knowledge of physiology, biochemistry and organ assessment. In conjunction with the lead clinician for the NRP project, it was identified that the senior perioperative practitioners from SORT would undertake an education and training programme followed by competence assessment. This was developed in collaboration with the practice development team using a Standard Operating Procedure (SOP). This training programme was divided into four distinct phases: theoretical learning, practical observation, experiential learning and competence assessment. The theoretical learning component included education sessions (anatomy, physiology, biochemistry and the components of the console, circuit and pump). Practical observation included visiting centres using NRP in clinical practice and attending practical workshops. The experiential learning component involved animal labs sessions and repetition of the practical steps laid out in the SOP. The final competence assessment was undertaken once the education and training components had been completed. The lead clinician for the NRP project carried out the competence assessments. Four practitioners have successfully undergone competence assessment and are involved with NRP in clinical practice.

This approach could serve as a model for future development in organ retrieval and preservation and the expansion of the role of transplant theatre practitioners.

Submitted on behalf of the Scottish Organ retrieval Team (SORT)

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157

Implementing donation after cardiac death in hospital: barriers and their resolution

Gopal Taori, Subhash Arora, Nicola Stitt, Bridget O’Bree

Intensive Care, Monash Health, Melbourne, Australia.

Objective: To report three year experience of successful implementation of donation after cardiac death (DCD) programme in a metropolitan teaching hospital.

Background: As a part of National reforms agenda for organ and tissue donation, there has been a significant focus on organ donation by DCD pathway. However hospital based organ donation teams often face many difficulties in it’s successful implementation. These range from attitudes of the clinical and support staff to logistical problems. Key barriers include a lack of knowledge about DCD, psychological barriers for DCD versus brain death, concerns about whether death has been reached, beliefs about saving versus killing patients, trust in the organ donation team, moving from saving patients to being a donation advocate and concerns with the DCD process particularly time taken for the process and conflict of interest in assigning priority to management of potential donor versus other critically ill patients.

Methods: We describe our experience with regards to changing attitudes towards DCD, overcoming potential barriers and creating opportunities and strategies for gaining support, which included education initiatives, a cultural shift, a consistent DCD protocol separating care from recovery, process monitoring, and a strong sense of teamwork.

Conclusion: Our findings provide a better understanding of potential barriers, critical to the implementation of strategic plans for DCD programme in the hospital setting. Communication efforts that are able to educate healthcare professionals and eliminate misconceptions will increase support for DCD. Key to future success requires confident committed and well-trained team.

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158

Excellence in organ donor coordination at La Raza General Hospital of Mexico City during 2013

Cesar Villasenor-Colin, Mariano Hernandez-Dominguez, Marlene Santos-Caballero, Guillermo Careaga-Reyna, Roberto Ortiz-Lerma, Karla Verdiguel, Arturo Robledo-Martinez, Israel Pagola-Quintero, Jaime Zaldivar-Cerverra, Armando Soberanes-Hernandez

Transplant Surgery, La Raza General Hospital, Mexico City, Mexico.

Introduction: Decisions in Organ Donor Coordination ODC are based on personal experience. The reasoning in ODC often obeys a process not systematic and empiric. A high percentage of the decisions in ODC do not have a scientific solid foundation and it is estimated that less than the 20 % are well-founded. The results of ODC should be analysed in relation with their importance and application. The recognition of potential donors implies the need to count on truthful information provided by the experience in the selection of the optimal multi-organic donors understanding that experience is valid when it results in the decrease of errors.

Objective: Presenting the evidence of excellence in ODC at La Raza General Hospital during the first six months of the year 2013.

Material and Methods: By means of a descriptive and prospective study, there were a total of 156 cases.

Results: A total of 48 hearts, 40 livers, 26 kidneys and 48 corneas were offered; 92 from male and 64 from female.

Findings: There were 13 heart transplants, 7 liver transplants, 10 kidney transplants and 32 corneal transplants, which consolidates our hospital as the main transplant centre of excellence at Mexico during the first six months of 2013.

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159

The critical pathway of Deceased Organ Donation in KSA: 2001-2010

Faissal A.M. Shaheen, Besher Al Attar, Abdulla Al Sayyari, Michael Abeleda, Elsayed Gadallah

Medical Department, Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia.

Objective: Organ transplantation is the best existing method for the treatment of end-stage organ failure. However, the need for viable organ supply limits its progress; thus, we studied the algorithm of process for deceased heart beating donors with the rate of adapting the critical pathways of organ donation from possible to potential to eligible to consent and to actual deceased donors (DD) in the kingdom.

Methods: A retrospective study comparing the nationwide figures and composition of the Critical Pathway of DD cases in a decade from 2001-2005 vs. 2006-2010 to Saudi Center for Organ Transplantation (SCOT).

Results: The Study showed a remarkable increase in the total number of Possible Deceased Donor cases from 1827 of 2001-2005 to 2651 (+45%) of 2006-2010. The mean possible case per year in relation to the number of population for the first half of the decade is 16 PMP as compared to 22 PMP in the last 5 years of the decade. The rate of conversion from possible to potential is 63% (1151 and 1674 respectively). Moreover, Eligible Donors ascends its number from 956 to 1336 (+39%) of which 270 (28% with 2.2 PMP) and 511 (38% with 4.1PMP) respectively were consented for organ donation. The Actual DD for the year 2001-2005 was 248 and 453 for the year 2006-2010. As a result, the number of Utilized DD organs increased from 244 to 441(+81%) cases.

Conclusion: There is a notable increase in the number of Possible DD reported and consented in the second half of the decade. There is also a significant increase in the Actual DD. In relation to this, the various strategies being implemented to promote organ donation in every region of the kingdom are relatively effective in applying the critical pathways of deceased organ donation.

References:

• SCOT DATA. Annual Report 2008 – 2010 Ministry of Health, Kingdom of Saudi Arabia. www.scot.org.sa

• B.Dominguez-Gil, F.L. Delmonico, F. AM Shaheen, et al. The Critical Pathway for Deceased Donation: 3rd W.H.O Global Consultation on Organ Donation and Transplantation, March 2010.

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163

A quality of life survey following kidney transplant using a graft after excision of a small tumour

Siva Sundararajan, Luc Delriviere, Bulang He

Western Australia Liver and Kidney Transplant Service, Sir Charles Gairdner Hospital, Perth, Australia.

Background: It is well recognised that renal transplantation improves the quality of life of patients in end stage renal disease (ESRD). The aim of this study was to investigate the quality of life of renal transplant recipients who received a tumour resected kidney graft (TRK).

Methods: A strategy has been implemented in our transplant service for using kidney graft after excision of a small renal tumour since February 2007. Patients were given the SF-36 questionnaire to assess their quality of life pre and post-transplantation. Additional information regarding concerns about tumour recurrence and whether they would choose a TRK transplant again or prefer to stay on dialysis was obtained. Renal function was also obtained at regular intervals.

Results: Twenty-four patients received kidney transplant under this programme. Of them, 20 returned the questionnaire. The mean scores in all 8 domains of the SF-36 were higher post-transplantation. The differences were statistically significant. Ninety-five percent of patients would prefer to have the transplant again. Eighty percent of patients did not have any significant concerns regarding tumour recurrence. There is no tumour recurrence on median 27 months follow-up. Mean creatinine before transplantation was 740.55 ± 240.72μmol/L. At 6 months post-transplantation, mean creatinine was 160 ± 69.81μmol/L.

Conclusion: Renal transplantation by using tumour resected kidney grafts result in improved quality of life. Patients prefer transplant to staying on dialysis and concerns regarding recurrence of tumour are minimal. Kidney transplantation by using the kidneys after excision of the known tumour is an important novel solution in the context of organ shortage with excellent quality of life and biochemical outcomes.

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165

Outcomes following transplantation: preferences and priorities of kidney transplant recipients

Martin Howell1,2, Germaine Wong1,2,4, Allison Tong1,2, John Rose3, Jonathan Craig1,2, Kirsten Howard2

1Centre for Kidney Research, Westmead, Australia; 2School of Public Health, University of Sydney, Sydney, Australia; 3Institute of Transport and Logistics, University of Sydney, Sydney, Australia; 4Centre for Transplant and Renal Reseacrh, Westmead Hospital, Westmead, Australia.

Background: Knowledge of the extent to which recipients would be willing to trade the risk of adverse outcomes for graft survival should be taken into account when considering expansion of the organ donor pool.

Aim: To evaluate transplant recipient preferences and trade-offs for adverse outcomes after transplantation.

Methods: Kidney transplant recipients were presented a survey that contained a list of nine outcomes including; graft survival and the risk of dying before graft failure; serious adverse events; and drug related side effects. The survey instrument assessed the participants’ preferences of the best and worst outcomes for each scenario. The questionnaires were sent and returned by post or completed on the Web. Responses were analysed using multinominal logit models to evaluate relative importance and trade-offs between outcomes. Interviews were conducted with selected participants to evaluate understanding of the survey.

Results: Of the 83 eligible participants, 35 recipients (42%) (35–73 years) participated. Graft survival was the most important outcome, followed by cancer, cardiovascular disease and serious infection. Modelling suggested that participants were willing to forgo 4.5 to 5 years of graft survival to prevent a 10% increased risk of cancer, cardiovascular disease or serious infection. In contrast participants were willing to forgo only 2.6 years of graft survival to prevent a 10% increase in the risk of dying with a functioning graft.

Conclusion: Transplant recipients are willing to accept a high probability of serious outcomes and side effects to maximize graft survival. Aversion of returning to dialysis was reflected in the relatively low importance placed on the probability of dying with a functioning graft.

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166

The joint impact of donor and recipient parameters on the outcome of heart transplantation in Germany after donor selection

Carl-Ludwig Fischer-Fröhlich1, Irene Schmidtmann3, Marcus Kutschmann2, Sylke R Zeissig3, Nils R Frühauf5, Frank Polster4, Gunter Kirste1

1Region Baden-Württemberg, Deutsche Stiftung Organtransplatnation,Stuttgart, Germany BQS Institute for Quality and Patient Safety, Düsseldorf, Germany; 3Institute for Medical Biometrics, Epidemiology and Informatics (IMBEI), Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany; 4Deutsche Gesellschaft für Gewebespende gGmbH, Hannover, Germany; 5Landesärztekammer Niedersachsen, Hannover, Germany.

Background: Organ shortage in heart-transplantation (HTx) results in increased use of grafts from donors with substantial risk factors. It is discussed controversially which donor characteristics may be detrimental. Therefore, we evaluated the joint impact of donor and patient related risk factors in HTx on patient survival by multiple analysis in a nationwide multicenter study after donor selection was carried out.

Methods: The research database consists of data concerning hearts donated and transplanted in Germany between 2006 and 2008 as provided by Deutsche Stiftung Organtransplantation and the BQS-Institute. Multiple Cox regression (significance level 5%, hazard ratio [95%-CI]) was conducted (n=774, recipient age ≥18 years).

Results: Survival was significantly decreased by donor-age (1.021 [1.008-1.035] per year), non-traumatic cause of death (1.481 [1.079-2.034]), Troponin >0.1 ng/ml (2.075 [1.473-2.921]), ischemia time (1.197 [1.041-1.373] per hour), recipient-age (1.017 [1.002-1.031] per year) and in recipients with pulmonary vascular resistance ≥320 dyn*s*cm-5 (1.761 [1.115-2.781]), with ventilator dependency (3.174 [2.211-6.340]) or complex previous heart surgery (1.763 [1.270-2.449]).

Conclusion: After donor selection had been conducted, multiple Cox regression revealed donor-age, -non-traumatic cause of death, -Troponin and ischemia time as well as recipient-age, -pulmonary hypertension, -ventilator dependency and -previous complex heart surgery as limiting risk factors concerning patient survival.

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167

Acute rejection requiring T cell depletive antibodies is associated with a higher risk of incident cancer after kidney transplantation

Wai Lim1, Robin Turner2, Jeremy Chapman3, Angela Webster2,3,4, Jonathan Craig2,3,4, Germaine Wong2,3,4

1Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia; 2 Sydney School of Public Health, University of Sydney, Sydney, Australia; 3Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, Australia; 4Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia.

Background: Induction therapy with T cell depletive antibodies is an established risk factor for incident cancers, especially post-transplant lympho-proliferative disease (PTLD). However, the relationship between the use of T cell depletive antibodies for rejection (AR-T) and cancer risk after transplantation is unknown. We aimed to determine if AR-T post-transplant was associated with the risk of site specific and overall incident cancers after kidney transplantation.

Methods: Using the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA), we assessed the association between rejection stratified by use (AR-T) or non-use (AR) of T cell depletive antibodies for all cancers (except for non-melanocytic skin cancers) as well as site-specific cancer incidence using adjusted Cox proportional hazard and competing risk models.

Results: Over a median follow-up of 4.6 years, 551/7237 (7.6%) kidney transplant recipients developed incident cancers. Compared with no rejection, AR-T but not AR was associated with a higher risk of incident cancer in the adjusted model (HR 1.54, 95%CI 1.51-2.05, p=0.004). There was an excess risk of PTLD in recipients who had experienced rejection. In the competing risk model, there was an excess risk of incident cancers in AR-T compared to no rejection or AR groups, particularly beyond 14-years post-transplant.

Conclusion: Acute rejection requiring T cell depletive antibodies is a significant risk factor for cancers in kidney transplant recipients independent of competing events such as age and cardiovascular deaths. Strategies to improve cancer surveillance among these recipients who have experienced rejection requiring T cell depletive antibodies may be warranted.

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168

Older deceased donor kidneys are associated with an increased risk of incident cancer in renal transplant recipients

Wai Lim1, Robin Turner2, Jeremy Chapman3, Angela Webster2,3,4, Jonathan Craig2,3,4, Germaine Wong2,3,4

1Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia; 2 Sydney School of Public Health, University of Sydney, Sydney, Australia; 3Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, Australia; 4Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia.

Background: Inflammation has long been associated with the development of cancer. We hypothesize the greater inflammatory response associated with older deceased donor (DD) kidney transplants may contribute to an increased risk of cancer following kidney transplantation. Our study aims to determine the association between donor types and the risk of overall incident cancers after transplantation.

Methods: Using the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) between 1997 and 2009, we assessed the association between donor type and overall cancer incidence using adjusted Cox proportional hazard models.

Results: Over a period follow-up time of 83,535 patient-years, a total of 563 patients developed cancers. Of the 7,252 renal transplant recipients, 37%, 6%, 44% and 13% received kidneys from young living, old living, standard criteria and extended criteria deceased donors (ECD), respectively. There was a significant association between donor type and the risk of incident cancer after transplant (p-value for trend 0.007). Compared with recipients who received young living donors (defined as donor age less than 60 years), recipients of ECD kidneys were associated with a greater risk of incident cancer (adjusted HR 1.49, 95%CI 1.14, 1.95), after adjusted for donor gender, recipient characteristics (age, gender, race, cause of end-stage renal disease, time on dialysis), immunological factors (HLA-mismatches, panel reactive antibodies) and transplant era and initial immunosuppression. There was no significant difference in the risk of site-specific cancers among the different donor groups.

Conclusion: Recipients of ECD kidneys appear to be associated with an increased risk of cancer, independent of recipient age and immunosuppression. Strategies to improve cancer surveillance among recipients who had received ECD kidneys may be warranted.

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169

The impact of nosocomial infections for generating an organ donor center of high complexity

Gustavo Melgarejo

1Department of Donation Y Transplant, Ips, Asuncion, Paraguay.

Introduction: Paraguay is a country with a population of 6,672,631 inhabitants. The Central Hospital of Security Social is the most complex center with 68 adult ICU beds. It introduces the concept of hospital coordinator in September 2011 with which you start a program of active enforcement records and cadaveric donors allow us to analyze the statistics of 2012. The average age of the patients was 51 years. The main hospital is the first in the country to introduce the model of Hospital Transplant Coordination. The idea is to create strategies to reduce medical contraindications and to allow the Hospital of greater complexity of the country is also an important source of cadaveric donors.

Objective: Prove that hospital infections in patients in critical care, prevents further generation of donor organs.

Material and Methods: The statistics are taken as HCIPS records of 2012, in Excel format. We performed a retrospective cross-sectional study, which evaluates potential donor cases detected in ICU. Sample:60cases. Inclusion criteria: patients entering a critical care hospitalization period longer than 8 hours. Exclusion criteria: patients with admission diagnosis of infectious process.

Results: The study is evaluated 60 patients. We had 17 cases EVR and KPC infections, 6 cases by virus > Dengue. Other causes are two SLE, Degenerative disease, glioblastoma, and lung cancer. The > cause of death was due to stroke 39 %, 28 % Brain Injury Trauma and other in 27% diagnosed with Brain Death 67 %.

Period of acquisition of infections was 5 days. Hospital infections comprise 38% of medical contraindications, which would give a loss of 23 Donors cadaveric.

Conclusion: Hospital Infections in most cases is the cause of medical contraindications to donation, this result in lower number of organ donation

It is important to develop strategies to reduce the incidence of multiresistant bacterial infections.

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170

Estimating differential renal function using ellipsoid approximation of renal volume on CT scan

Laura N. Nguyen, Fadi Kamal, Brian Blew

Division of Urology, The Ottawa Hospital/University of Ottawa, 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 differential renal function.

Extensive research has been done using complex models to calculate precise radiographic measurement of renal volume on CT in order 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 the necessary radionucleotide. 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: In this study, 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 three dimensions of the kidney) using CT scans, may also adequately estimate differential renal function.

Results: Charts of 79 consecutive living renal donors were reviewed retrospectively. The differential renal volumes measured on CT scans were reliable between operators (p<0.05). We found that the volume-based estimations of differential renal volume were in fact 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: Findings support removal of the nuclear medicine scan from routine assessment of potential kidney donors without the need for expensive radiologic software.

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230

Donation after cardiac death following withdrawal of veno-venous extracorporeal membrane oxygenation

Brett Sampson1,2, Ubbo Wiersema1, Philippa Jones2, Gerry O’Callaghan1

Intensive and Critcal Care Unit, Flinders Medical Centre, Adelaide, Australia; 2DonateLife, SA, Australia.

Donation after cardiac death (DCD) has rapidly increased throughout Australia in recent years [1,2]. Over the same period there has been increased availability of extracorporeal membrane oxygenation (ECMO); a legacy of the 2009 Influenza A (H1N1) pandemic [3,4]. With growing experience in these two practices, a new pool of potential organ donors is likely to be realised. In Australia, ECMO is only initiated for severe cardiorespiratory failure when spontaneous recovery is expected, or as a bridge to heart (&/or lung) transplantation. Unfortunately, ECMO is not always lifesaving and sometimes it must be withdrawn to enable end of life care. It is in this cohort of patients that a new pool of potential organ donors may exist. We present a case of a sixty year old man with severe community acquired pneumonia, complicated by acute respiratory distress syndrome, who donated both kidneys through DCD after withdrawal of veno-venous ECMO. We discuss how ECMO might influence the identification of potential organ donors, its impact on the withdrawal of life sustaining treatments and how it might be used to minimise ischaemic injury to donated organs. The international practice of initiating veno-arterial ECMO after cardiac death, solely to facilitate DCD, is not practiced in Australia and therefore is not discussed.

References: [1] Sampson BG, O’Callaghan GP, Russ GR: Is donation after cardiac death reducing the brain-dead donor pool in Australia? Crit Care Resusc. 2013 Mar;15(1):21–7.

[2] Opdam H: The rise and rise of donation after cardiac death: a solution to the shortfall in organs for transplantation? Crit Care Resusc. 2013 Mar;15(1):3–4.

[3] Bishop JF, Murnane MP, Owen R. Australia’s winter with the 2009 pandemic influenza A (H1N1) virus: N Engl J Med. 2009 Dec 31;361(27):2591–4.

[4] ANZIC Influenza Investigators, Webb SA, Pettilä V, Seppelt I et al. Critical care services and 2009 H1N1influenza in Australia and New Zealand: N Engl J Med. 2009 Nov12;361(20):1925–34.

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231

Current situation of donation after cardiac death in Poland

Edyta Skwirczynska-Szalbierz, Adam Nowacki, Marek Ostrowski

Department of General Surgery and Transplantation, Autonomous Public Clinical Hospital No. 2 of Pomeranian Medical University, Szczecin, Poland.

The demand for organ donation in Poland is three times greater compared to the number of transplant procedures performed in our country. In 2012 there has been 615 donations, which accounted for 16 donors per 1 million inhabitants (pmp). In Spain this rate exceeded 30. There are significant regional differences in the number of harvested organs in Poland. In 2012, in the northwest region there has been 28 donors pmp and in the southern region only 5.8 donors pmp. The deepening organ shortage crisis leads inevitably to the increase in the number of patients dying while awaiting for organ transplantation. The appropriate utilization of DCD donors seems to be one of the solutions for this crisis.

Despite existing regulations there are no separate development strategies for DCD donation in Poland. There were no DCD donations in this country to date.

Purpose: To specify the reason for total lack of identification of DCD donors in the northwest region of Poland despite the highest donation rate in this country.

Methods: In 2013 a questionnaire survey was carried out among the staff in intensive care units, cardiology and cardiac surgery departments. It consisted of 23 questions divided into 3 sections which tested respondents for DCD donation knowledge, respondents’ involvement in the process of DCD identification and asked for suggestions to increase the number of donations from deceased donors, including DCD donors.

Results: 70% of respondents did not know the definition of DCD, 54% deemed that DCD donation is prohibited in Poland, 90% did not know the classification of DCD, 75% consider neurological criteria to be sufficient for determination of death in organ donation.

Conclusions: There is no sufficient knowledge among the hospital staff involved in donation process regarding DCD donation.

An implementation of appropriate educational and psychological workshops regarding DCD donation is required.

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232

Extended Criteria Donors (ECD) - expanding the boundaries for donation after cardiac death

Nicola Stitt1,2, David Pilcher2,3,4, Tim Crozier1

1Intensive Care Unit, Monash Health, Melbourne, Australia; 2 Donatelife Victoria, Melbourne, Australia; 3Dept of Intensive Care, The Alfred Hospital, Melbourne, Australia; 4Department ofEpidemiology and Preventative Medicine, Monash University, Melbourne, Australia .

Introduction: The upper age limit for lung donation via the Donation after Cardiac Death (DCD) pathway has generally been considered to be 65 years. We report a case of a 73 year old patient who was able to donate his lungs for transplantation.

Case Description: A 73 yr old male ex-smoker was admitted to the Intensive Care Unit (ICU) following an out-of-hospital cardiac arrest due to myocardial infarction. The likelihood of neurological recovery was poor and during end of life discussions the family raised the possibility of organ donation with the Intensivist. As he was unlikely to progress to brain death the only option was the DCD pathway. However current guidelines suggested that he was over the age limit for lungs, liver and kidney donation, with the previous oldest DCD lung donor being 65 years old.

Upon consideration the Intensivist engaged the help of the Nurse Donation Specialist who investigated the possibility of donation with Donatelife Victoria (DLV). The initial response received was that he was too old for DCD. The family were disappointed with this outcome. Further discussions between the Intensivist and Organ Donor Coordinator (ODC) at DLV led to another approach to the lung transplant team for reconsideration.

Arterial Blood Gas (ABG) on 100% oxygen. pH 7.35, pCO2 42.3, pO2 458, BE -2. Chest X- ray & bronchoscopy were clear. Ventilation requirements were FiO2 = 0.30, PEEP 10cm, PS 12.*

After reviewing the patients’ current condition it was decided that he would be accepted as potential lung donor.

Following withdrawal of life sustaining therapy the patient died peacefully within the timeframe required for DCD. This resulted in successful lung donation, with subsequent successful bilateral lung transplantation.

Conclusion: Exploring the possibility of extended criteria donation in carefully selected patients may result in more organs being available for transplant.

*PEEP: Positive End Expiratory Pressure PS: Pressure Support

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236

Paediatric donation after cardiac death: The Story of Max

Anne-Maree Holmes

Nambour Hospital- Intensive care, Nambour Hospital/ Donatlife Queensland, Nambour, Australia.

Only a small percentage of the organ donor pool is from the paediatric population approximately ten percent of donors were paediatric in 2010. Still in the early stages of the introduction of the Donation after Cardiac Death (DCD) process a 3yr old boy MAX was admitted with severe hypoxia to the Paediatric Intensive care unit with a grossly abnormal MRI and a GCS of 3. Overtime his parents were given a poor prognosis and unlikely survivability. Discussions moved to focus on withdrawal of life supporting therapies.

Max’s parents introduced the idea of organ and tissue donation. A perfusion scan showed limited perfusion to the brain. Donation form cardiac death would be the pathway to facilitate max becoming an organ donor.

The decision to follow the DCD pathway was easy as Max’s parents were highly motivated they wanted Max to be able to help other children and to prevent another family having to deal with the loss of a child. Both the State medical director and the Director of Genetics were engaged where no reason was found for donation after cardiac death not to proceed.

With supportive enthusiastic staff we were able to proceed with the donation after cardiac death. Many staff had limited or no experience and sop were wary of the process ofDCD but with small education sessions and support from the donatelife staff everyone worked well and the donation was a success.

Max was extubated at 04:19 and death was declared at 04:27. Max donated both his kidneys to recipients who now 3 years later are doing well and his heart valves that were donated have also been used.

References: Australian and New Zealand Intensive Care Society.The ANZICS Statement on Death and Organ Donation. 3rd ed. Melbourne: ANZICS; 2008.

NSW Health. Organ Donation after Cardiac Death: NSW Guidelines. Sydney: NSW Health; 2007.

ANZOD Registry Report 2012

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237

Results of kidney transplantation from controlled donors after cardio-circulatory death: A single center experience

Hieu LE DINH1, Laurent Weekers2, Catherine Bonvoisin2, Jean-Marie Krzesinski2, Josée Monard3, Arnaud de Roover4, Olivier Detry4, Jean-Paul Squifflet4, Michel Meurisse4

1University of Medicin Pham Ngoc Thach, Ho Chi Minh city, Viet Nam; 2Department of Nephrology, University Hospital of Liège, Liège, Belgium; 3Transplant Coordinator, University Hospital of Liège, Liège, Belgium; 4Department of Abdominal Surgery and Transplantation, University Hospital of Liège, Liège, Belgium.

Background: The aim of this study was to determine results of kidney transplantation (KT) from controlled donation after cardio-circulatory death (DCD). Primary end-points were graft and patient survival, and post-transplant complications. The influence of delayed graft function (DGF) on graft survival and DGF risk factors were analyzed as secondary end-points.

Material and Methods: This is a retrospective mono-center review of a consecutive series of 94 DCD-KT performed between 2005 and 2012. Mean patient follow-up was 33.1 months.

Results: Overall and death-censored graft survival rates were 93.6% and 93.6% at 3 months, 89.2% and 93.6% at 1 year, 86% and 91.6% at 3 years, and 78.9% and 91.6% at 5 years, respectively. Main cause of graft loss was patient’s death with a functioning graft. Global patient survival rates at the corresponding time points were 97.9%, 93.3%, 92%, and 84.8%. No primary non-function grafts. DGF was observed in 36% of all DCD-KT. Renal graft function was suboptimal at hospital discharge, but nearly normalized at 3 months. DGF significantly increased post-operative length of hospitalization (18.2 ± 5.3 versus 13.2 ± 4.1 days, p <0.000) but had no deleterious impact on graft function or survival, neither on 3-month acute rejection rate nor on early post-operative complications (p = ns). However, overall patient survival rate in kidney transplants with DGF was significantly lower than in those without DGF (p = 0.039). Recipient BMI ≥30 kg/m2 and pre-transplant dialysis duration significantly increased the risk of DGF in a multivariate logistic regression analysis (p = 0.036 and p = 0.004, respectively).

Conclusions: Despite a higher rate of DGF, controlled DCD-KT offers a valuable contribution to the pool of deceased donor kidney grafts, with comparable mid-term results to those procured after brain death.

Figure

Figure

Keywords: brain death, organ preservation, primary graft dysfunction, risk assessment, treatment outcome, warm ischemia.

References:

[1] Akoh JA, Denton MD, Bradshaw SB, Rana TA, Walker MB. Early results of a controlled non-heart-beating kidney donor programme. Nephrol Dial Transplant. 2009; 24: 1992–6.

[2] Doshi MD, Hunsicker LG. Short- and long-term outcomes with the use of kidneys and livers donated after cardiac death. Am J Transplant. 2007; 7: 122–9.

[3] Locke JE, Segev DL, Warren DS, Dominici F, Simpkins CE, Montgomery RA. Outcomes of kidneys from donors after cardiac death: implications for allocation and preservation. Am J Transplant. 2007; 7: 1797–807.

[4] Sudhindran S, Pettigrew GJ, Drain A, et al. Outcome of transplantation using kidneys from controlled (Maastricht category 3) non-heart-beating donors. Clin Transplant. 2003; 17: 93–100.

[5] Ledinh H, Bonvoisin C, Weekers L, et al. Results of kidney transplantation from donors after cardiac death. Transplant Proc. 2010; 42: 2407–14.

[6] Moers C, Leuvenink HG, Ploeg RJ. Donation after cardiac death: evaluation of revisiting an important donor source. Nephrol Dial Transplant. 2010; 25: 666–73.

[7] Snoeijs MG, Winkens B, Heemskerk MB, et al. Kidney transplantation from donors after cardiac death: a 25-year experience. Transplantation. 2010; 90: 1106–12.

[8] Squifflet JP. Why did it take so long to start a non-heart-beating donor program in Belgium? Acta Chir Belg. 2006; 106: 485–8.

[9] Van Gelder F, Delbouille MH, Vandervennet M, et al. An 11-Year Overview of the Belgian Donor and Transplant Statistics Based on a Consecutive Yearly Data Follow-up and Comparing Two Periods: 1997 to 2005 Versus 2006 to 2007. Transplant Proc. 2009; 41: 569–71.

[10] Van Gelder F, Delbouille MH, Vandervennet M, et al. Overview of the Belgian donor and transplant statistics 2006: results of consecutive yearly data follow-up by the Belgian Section of Transplant Coordinators. Transplant Proc. 2007; 39: 2637–9.

[11] Ledinh H, Meurisse N, Delbouille MH, et al. Contribution of Donors After Cardiac Death to the Deceased Donor Pool: 2002 to 2009 University of Liege Experience. Transplant Proc. 2010; 42: 4369–72.

[12] Detry O, Laureys S, Faymonville ME, et al. Organ donation after physician-assisted death. Transpl Int. 2008; 21: 915.

[13] Ysebaert D, Van Beeumen G, De Greef K, et al. Organ procurement after euthanasia: Belgian experience. Transplant Proc. 2009; 41: 585–6.

[14] Bernat JL, D’Alessandro AM, Port FK, et al. Report of a National Conference on Donation after cardiac death. Am J Transplant. 2006; 6: 281–91.

[15] Moers C, Smits JM, Maathuis MH, et al. Machine perfusion or cold storage in deceased-donor kidney transplantation. N Engl J Med. 2009; 360: 7–19.

[16] Smits JM, Persijn GG, van Houwelingen HC, Claas FH, Frei U. Evaluation of the Eurotransplant Senior Program. The results of the first year. Am J Transplant. 2002; 2: 664–70.

[17] Yarlagadda SG, Coca SG, Garg AX, et al. Marked variation in the definition and diagnosis of delayed graft function: a systematic review. Nephrol Dial Transplant. 2008; 23: 2995–3003.

[18] Houillier P, Froissart M. [Elevated serum creatinine]. Rev Prat. 2005; 55: 91–6.

[19] Flamant M, Boulanger H, Azar H, Vrtovsnik F. [Plasma creatinine, Cockcroft and MDRD: validity and limitations for evaluation of renal function in chronic kidney disease]. Presse Med. 2010; 39: 303–11.

Figure

Figure

[20] Brook NR, White SA, Waller JR, Veitch PS, Nicholson ML. Non-heart beating donor kidneys with delayed graft function have superior graft survival compared with conventional heart-beating donor kidneys that develop delayed graft function. Am J Transplant. 2003; 3: 614–8.

[21] Renkens JJ, Rouflart MM, Christiaans MH, van den Berg-Loonen EM, van Hooff JP, van Heurn LW. Outcome of nonheart-beating donor kidneys with prolonged delayed graft function after transplantation. Am J Transplant. 2005; 5: 2704–9.

[22] Kokkinos C, Antcliffe D, Nanidis T, Darzi AW, Tekkis P, Papalois V. Outcome of kidney transplantation from nonheart-beating versus heart-beating cadaveric donors. Transplantation. 2007; 83: 1193–9.

[23]Chapman J, Bock A, Dussol B, et al. Follow-up after renal transplantation with organs from donors after cardiac death. Transpl Int. 2006; 19: 715–9.

[24] Keizer KM, de Fijter JW, Haase-Kromwijk BJ, Weimar W. Non-heart-beating donor kidneys in the Netherlands: allocation and outcome of transplantation. Transplantation. 2005; 79: 1195–9.

[25] Brook NR, Waller JR, Richardson AC, et al. A report on the activity and clinical outcomes of renal non-heart beating donor transplantation in the United Kingdom. Clin Transplant. 2004; 18: 627–33.

[26] Ojo AO, Hanson JA, Meier-Kriesche H, et al. Survival in recipients of marginal cadaveric donor kidneys compared with other recipients and wait-listed transplant candidates. J Am Soc Nephrol. 2001; 12: 589–97.

[27] Snoeijs MG, Schaubel DE, Hene R, et al. Kidneys from donors after cardiac death provide survival benefit. J Am Soc Nephrol. 2010; 21: 1015–21.

[28] Chudzinski RE, Khwaja K, Teune P, et al. Successful DCD kidney transplantation using early corticosteroid withdrawal. Am J Transplant. 2010; 10: 115–23.

[29] Barlow AD, Metcalfe MS, Johari Y, Elwell R, Veitch PS, Nicholson ML. Case-matched comparison of long-term results of non-heart beating and heart-beating donor renal transplants. Br J Surg. 2009; 96: 685–91.

[30] Rudich SM, Kaplan B, Magee JC, et al. Renal transplantations performed using non-heart-beating organ donors: going back to the future? Transplantation. 2002; 74: 1715–20.

[31] Saeb-Parsy K, Kosmoliaptsis V, Sharples LD, et al. Donor type does not influence the incidence of major urologic complications after kidney transplantation. Transplantation. 2010; 90: 1085–90.

[32] Droupy S, Blanchet P, Eschwege P, et al. Long-term results of renal transplantation using kidneys harvested from non-heartbeating donors: a 15-year experience. J Urol. 2003; 169: 28–31.

[33] Khairoun M, Baranski AG, van der Boog PJ, Haasnoot A, Mallat MJ, Marang-van de Mheen PJ. Urological complications and their impact on survival after kidney transplantation from deceased cardiac death donors. Transpl Int. 2009; 22: 192–7.

[34] Ridgway D, White SA, Nixon M, Carr S, Blanchard K, Nicholson ML. Primary endoluminal stenting of transplant renal artery stenosis from cadaver and non-heart-beating donor kidneys. Clin Transplant. 2006; 20: 394–400.

[35] Nicholson ML, Metcalf MS, White SA, et al. Comparison of the results of renal transplantation from non-heartbeating, conventional, cadaveric and living donors. Kidney International 2000; 58: 2585–91.

[36] Kootstra G. The asystolic, or non-heartbeating, donor. Transplantation. 1997; 63: 917–21.

[37] Wells AC, Rushworth L, Thiru S, et al. Donor kidney disease and transplant outcome for kidneys donated after cardiac death. Br J Surg. 2009; 96: 299–304.

[38] D’Alessandro AM, Fernandez LA, Chin LT, et al. Donation after cardiac death: the University of Wisconsin experience. Ann Transplant. 2004; 9: 68–71.

[39] Kootstra G, van Heurn E. Non-heartbeating donation of kidneys for transplantation. Nat Clin Pract Nephrol. 2007; 3: 154–63.

[40] Sanchez-Fructuoso AI, Marques M, Prats D, et al. Victims of cardiac arrest occurring outside the hospital: a source of transplantable kidneys. Ann Intern Med. 2006; 145: 157–64.

[41] Sanchez-Fructuoso AI, Giorgi M, Barrientos A. Kidney transplantation from non–heart-beating donors: a Spanish view. Transplant Rev. 2007; 21: 249–54.

[42] Cohen B, Smits JM, Haase B, Persijn G, Vanrenterghem Y, Frei U. Expanding the donor pool to increase renal transplantation. Nephrol Dial Transplant. 2005; 20: 34–41.

[43] Brook NR, Nicholson ML. Kidney transplantation from non heart-beating donors. Surgeon. 2003; 1: 311–22.

[44] Saidi RF, Bradley J, Greer D, et al. Changing pattern of organ donation at a single center: are potential brain dead donors being lost to donation after cardiac death? Am J Transplant. 2010; 10: 2536–40.

[45] Watson CJE, Wells AC, Roberts RJ, et al. Cold machine perfusion versus static cold storage of kidneys donated after cardiac death: a UK multicenter randomized controlled trial. Am J Transplant. 2010; 10: 1991–9.

[46] Wight JP, Chilcott JB, Holmes MW, Brewer N. Pulsatile machine perfusion vs. cold storage of kidneys for transplantation: a rapid and systematic review. Clin Transplant. 2003; 17: 293–307.

47] Schold JD, Kaplan B, Howard RJ, Reed AI, Foley DP, Meier-Kriesche HU. Are we frozen in time? Analysis of the utilization and efficacy of pulsatile perfusion in renal transplantation. Am J Transplant. 2005; 5: 1681–8.

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238

A step forward to reduce organ shortage in Malaysia

Farah Salwani muda Ismail

Faculty Syariah and Law, Islamic Science University Malaysia, Nilai, Malaysia.

Organ transplantation has always been seen as a miracle in the modern medical world. It is not just the hope that it brings to patients in need of those precious organs, but it indirectly promotes helping hands and brotherhood ties to be extended even across total strangers. Nevertheless, despite the huge benefit and inspiration that it brings, a lot of countries including Malaysia suffer from a severe shortage of these donated organs. Supply of organs like kidneys, livers, hearts and many more are scarce, though the demand for it is endlessly shooting high.This problem has been going on for quite some time and needs to be addressed urgently in an effective manner.Therefore, this paper will thoroughly highlight this issue and discuss immediate steps that should be taken by Malaysia, towards eliminating organ shortage through social and legal strategic planning. Suggestions including fully utilizing fatal road accident victims and introducing a family support system for new organ pledgers, while still maintaining the opting in system will hopefully assist in providing new frontiers in law and its application, to effectively address and solve organ shortage issues in Malaysia.

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239

Postmortal organ donation in pediatric patients - general aspects and single center experience

Sivatharsiny Thavarajah1, Nagoud Schukfeh1, Thomas Breidenbach2, Jutta Weiss2, Martin Metzelder1, Carmen Kirchner1, Andreas Paul1, Gernot Kaiser1

1General-, Visceral- and Transplantsurgery, University Hospital Essen, Essen, Germany; 2 Deutsche Stiftung Organspende, Frankfurt, Germany.

Background: In times of urgent need for pediatric transplantations the shortage of adequate organs is still challenging. In comparison to adult transplantations the problem of proper size of the organ is a major limiting factor in pediatric transplantation. At all there is no age-restriction for organ donation in Germany.

Methods: The organ donors after brain death in Germany up to the age of 15 between 2007 and 2012 were analyzed. 2012 there was a further division into three age groups (< 2 years, 2 – 5 years, 6 – 15 years) with evaluation of the number of realized organ donations out of the potential organ donors and the results of the discussions with the relatives/parents. Additionally we analyzed the pediatric livers transplanted at our center between 2007 and 2012 independently to the age of the recipient.

Results: The overall percentage of pediatric organ donation was 3,2% (2007 – 2012) in Germany. 2012 only 55% of potential pediatric organ donors became realized as donors, which is significantly lower comparison to adults (donors > 15 years: 66,4%). The discussions with the relatives of the potential organ donors lead to a clearly higher rate of refusal for pediatric organ donors (42%) than adult donors (28%). At our center we received 42 livers from pediatric donors (2007 – 2012) with a median age of 5 (range 0 – 15) resulting in promising long-term results.

Conclusion: Although children only are a small percentage among the potential organ donors, there is a special need for pediatric recipients. To increase the comparatively low rate of consent in the age group under 16 years, a better education of the relatives as well as the medical staff seems to be necessary.

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240

Is there a limit for expanding criteria of kidney donors? How far can we go?

Piotr Domagala, Artur Kwiatkowski, Rafal Kieszek, Michal Wszola, Jakub Drozdowski, Piotr Diuwe, Andrzej Chmura Department of General Surgery and Transplantology, Medical University of Warsaw, Warszawa, Poland.

Introduction: The lack of organs for transplantation has forced the transplant community to expand the pool of donors. Using expanded criteria donor (ECD) organs is one of the strategies for making more transplants available. Although there are organs that do not fit into definition of ECD and remains controversial for transplantation. The aim of this paper is to report the criteria of discharging kidney from transplantation.

Patients and Methods: Four hundred and sixteen patients received cadaveric renal transplants between January 1, 2010 and June 31, 2013. In this time seventy one kidneys were discharged from the transplantation – thirty eight kidneys (nineteen referred potential donors) were disqualified before organ procurement and thirty three kidneys were rejected from transplantation during organ storage. Data on donors and preservation parameters were collected. Causes of organ refusal were analysed.

Results: Two the most common causes of kidney rejection from transplantation were malignancy or strong suspicion of malignancy in donor body as well poor donor kidney parameters with probability of kidney irreversible injury.

Table

Table

Conclusion: Careful kidney selection is recommended in cases of expanded criteria donor kidneys in order to diminish factors that can negatively affect graft function and survival.

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241

En-bloc kidneys transplanted from infant donors less than 5 kg into school age recipients

Li Zeng, Wen-Yu Zhao, Lei Zhang, You-Hua Zhu, Yu Chen, Fan-Yuan Zhu

Organ Transplantation Institute of PLA, Changzheng Hospital, Second Military Medical University, Shanghai, People’s Republic of China.

Background: Kidney transplantation is currently the best treatment option for children with end-stage renal disease. Given the shortage of donor kidneys in China, the use of grafts from deceased infant donors (weight < 5kg) is a potential approach to expand the donor pool. In this study we reviewed the results of the first cohort of en bloc kidney transplantation of infant donors to pediatric recipients in our center.

Methods: From February, 2012 to March, 2013, four infant en bloc kidney transplants in pediatric recipients were performed in our center. The en bloc graft was implanted extraperitoneally in the right iliac fossa. The distal end of the donor aorta was anastomosed end-to-end to the internal iliac artery, while the donor vena cava was anastomosed (end-to-side) to the external iliac vein. Both ureters were anastomosed individually to the bladder, with the exception of one case, in which a donor bladder patch was anastomosed to the bladder. After the operation, the recipients received basiliximab as induction therapy followed by tacrolimus and mycophenolic acid for immunosuppression. Prophylactic anticoagulation with heparin was used for the first week after transplantation.

Results: Recipients included 2 females and 2 males with age ranging from 4.6 to 11.6 yr. Donor age ranged from 33 to 56 days with weight ranging from 2.5 to 5.0 kg. After a follow up of 2-14 months, patient and graft survivals were 100% and 75% respectively. Complications included delayed graft function in 1 patient, urine leak in 1, and anticoagulation-related hemorrhage in 1. One graft was lost early from vascular thrombosis. The remaining 3 recipients had excellent graft function with median serum creatinine of 1.1mg/dL (range, 0.8-1.3mg/dL) at last follow-up.

Conclusion: Based on our initial experience, we conclude that favorable outcomes can be obtained from en bloc transplantation from infant donors. The use of this donor population for pediatric recipients should be encouraged.

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242

Influence of interleukin 12B, interleukin 16 and interleukin 18 genes polimorphisms on delayed graft function and rejection episodes in patients after kidney transplantation

Jan Pawlus1, Anita Sierocka1, Karol Tejchman1, Zbigniew Ziętek2, Maciej Romanowski1, Andrzej Pawlik3, Jerzy Sieńko1, Maciej Żukowski4, Kazimierz Ciechanowski5, Marek Ostrowski1, Tadeusz Sulikowski1

1Department of General Surgery and Transplantation, Pomeranian Medical University, Faculty of Medicine, Szczecin, Poland; 2Chair and Department of Anatomy, Pomeranian Medical University, Faculty of Medicine, Szczecin, Poland; 3Department of Experimental and Clinical Pharmacology, Pomeranian Medical Uniwersity, Faculty of Medicine, Szczecin, Poland; 4Clinic of Anaesthesiology and Intensive Care, Pomeranian Medical University, Faculty of Medicine, Szczecin, Poland; 5Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, Faculty of medicine, Szczecin, Poland.

Background: Inflammatory mediators have an important role in kidney graft outcomes. The cytokine and chemokine gene polymorphisms are associated with variable production,activity, expression or ligand-receptor affinity[1]. Genetic variation in the DNA sequence of the interleukin 12B (IL-12B), interleukin 16 (IL-16) and interleukin 18 (IL-18) genes may lead to altered cytokine production and activity. These variations can lead to changes in individual’s patient outcome after kidney transplantation. That is know,the polymorphisms of interleukins influence on inflammatory diseases, e.g. diabetes, asthma or periodontopathy. Nevertheless there were only few publications about their role in kidney graft outcome [2,3,4].

Aim: The aim of this study was to evaluate the correlation between IL-12B, IL-16 and IL-18 genes polimorphisms with graft function (delayed graft function-DGF) and rejection episodes-acute(AR), chronic(CR).

Materials and Methods: 267 (38,6% women, 61,4% men) recipients were included to the study. The polymerase chain reaction was used to determine gene polymorphisms of IL-12B(rs3212227), IL-16(4778889), IL-18(rs1946518,rs187238) in serum. Statistical sihnificance (p<0,05) was analised by logit regression (Pearson Chi2, M-L Chi2, Phi, Kendall’s test, Gamma test, Spearman Rank R), ANOVA - Tukey’s post-hoc test, Odds Ratio (OR)-Chi2 with Yates correction (CI-95%).

Results: Regression analysis revealed no significance between AR/DGF/CR and IL-12B (p=,176/p=,328/p=,438), IL-16 (p=,231/p=,784/p=,287), IL-18-rs1946518 (p=,582/p=,279/p=,084), IL-18-rs187238 (p=,285/p=,279,p=,303). CR group-AAvsCC genotype (IL-18,rs1946518) OR=2,35 (p=,040).

Conclusion: There was no statistical significance between IL-12B, IL-16 and IL-18 gene polimorphisms and kidney graft outcomes after transplantation. Presence of AA genotype IL-18 (rs1946518) is connected with 2,35 higher risk of CR occurence.

Source of Funding: NCN:2013/B/P01/2011/40

References:

[1] Nankivell BJ, Alexander SI: Rejection of the kidney allograft. N Engl J Med 2010, 363: 1451–1462.

[2] Trinchieri G, Pflanz S, Kastelein A: The IL-12 family of heterodimeric cytokines: new player in the regulation of T cell responses. Immunity 2003, 19:641–644.

[3] Wang S, Diao H, Guan Q, Cruishank WW, Delovitch TL, Jevnikar M, Du C: Decreased renal ischemia-reperfusion injury by IL-16 inactivation. Kidney Int 2008, 73: 318–326.

[4] Wu H, Craft ML, Wang P, Wyburn KR, Chen G, Ma J, Hambly B, Chadbon SJ: IL-18 contributes to renal damage after ischemia-reperfusion. J Am Soc Nephrol 2008, 19:2331–2341.

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243

Improvement of the system for request for organ donation in brain death patients

Sakuntala Rodmai

Co-ordination Organ Transplant, Sunpasitthiprasong Hospital, Ubonratchatani, Thailand.

Background: The system for request for organ donation in brain death patients has been in place since 2001. However, a significant number of relatives of brain death patients considered potential organ donors were not approached for request for organ donation. In 2001, only 13 from 94 brain death patients completed the organ donation. This may be due to hard workload of critical care units, which might in turns prevent them from timely notifying an organ donation unit concerning potential organ donors. We hypothesized that if potential candidates for organ donation were approached promptly, the number and successful rates of organ donation would be improved.

Objectives: To increase the rates of organ donation in brain death patients

Methods: Between October 2011 and September 2012, attempts to increase the number and rates of organ donation of brain death patients in the Sunpasitthiprasong Hospital, a 1,200-bed regional hospital, were taken. This included 1) improving the coordination of departments involved in organ donation procedures, 2) regular morning and afternoon nurse rounds to all critical care units, 3) prompt assessment of brain death patients and relevant laboratory test results, 4) provision of direct contact to responsible nurses in the organ donation unit, and 5) feedback of the results to stakeholders for further and continuous improvement. We compared the numbers and rates of organ donation before and after the implementation of the new system.

Results: After the implementation of a new system for request for organ donation, the number of registered cases of brain deaths increased from 94 case in 2011 to 152 case in 2012. The rates of organ donation increased from 13.8% (13 out of 94 cases) to 23.7% (36 out of 152 cases) in 2011 and 2012, respectively.

Discussion: Improvement of the system for request for organ donation in brain death patients through fostering effective co-ordination and communication between departments and units involved leads to prompt negotiation with relatives about the possibility of organ donation and helps enhance the rates of organ donation. Further implication is to improve the methods to care for subjects with brain death.

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244

The role of recruitment maneuver in improving the marginal lungs donors

Sareh Parto, Shadi Shafaghi, Seyyed Shahabeddin Mohammad Makki, Farahnas Sadeghbeygi, Hamid Reza Khoddami Vishteh, Katayoun Najafizadeh

Lung Transplantation Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Islamic Republic of).

Background: Lung transplantation is limited by shortage of suitable donors. To overcome this problem, Recruitment maneuver have been used in marginal lungs donors. Recruitment maneuver is a strategy aimed at re-expanding collapsed and edematous lung tissue. This study was conducted to assess the efficacy of this maneuver on improving marginal lungs for transplantation.

Methods: All brain-dead donors of Shahid Beheshti University of Medical Sciences Organ Procurement Unit (SBMU-OPU) of Tehran, Iran were evaluated for lung transplantation from May 2010-2013. Then, those who had marginal donor’s criteria (patients with normal Chest X Ray or bilateral infiltration and PaO2/FIO2 200-300 mmHg) were selected. The recruitment maneuver was performed and arterial blood gas was obtained before and after maneuver. The recruitment maneuver was performed for two hours with pressure control of 25-30 cmH2O and Positive End Expiratory Pressure of 10-15 cmH2O. O2 saturation and patients hemodynamic were checked continuously. Finally patients with normal bronchoscopy and PaO2/FIO2≥300 mmHg were considered suitable for lung transplantation.

Results: Of 259 brain-dead donors which were assessed for lung donation, 45 (17%) had marginal lungs for transplantation. Recruitment maneuver which was carried out in all of these cases could increase PaO2 to more than 300 in 14 (31%) which 8 of them were transplanted. In these patients the mean of PaO2/FIO2 was significantly increased from 253 to 344 mmHg by recruitment maneuver (P=0.006, Wilcoxon test).

Conclusions: The results of this study showed that Recruitment maneuver could increase PaO2 more than 300 mmHg and it could convert marginal lungs to appropriate ones in one third of brain-dead donors. So, it is recommended that this maneuver is considered in the assessment protocol of lungs for donation.

Keywords: Marginal donor lungs, Recruitment maneuver, Lung transplantation

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246

The Islamic founding principles on organ transplantation and evolution of the collective scholarly Islamic opinion on the subject

Ruhul Kuddus

Biology, Utah Valley University, Orem, UT, United States.

Background: Muslims constitute one-fifth of the humanity and a significant fraction of the organ recipients identify themselves as Muslims. A large fraction of Muslim population is devout but unaware of the religious principles on organ donation and transplantation and depends on scholars’ (among Sunnis) and imams’ (among Shias) opinions on the matter.

Methods: The Qur’an, the authentic Traditions and expert collective opinions on the subject were investigated.

Results: The founding principles on transplantation medicine are from the Qur’an (for example, sacredness of life and the human body, and some infractions are allowed to preserve life), the Traditions (such as, sanctity of the corpse, prophet’s allowing of a mutilated male subject transplanting with a prosthetic nose made of noble i.e. forbidden metals, and prophet’s forbidding of the use of wigs; etc.) and maslaha (the principles of public interest deduced by the scholars to protect a person’s religion, life, reason, lineage and property). In general and briefly, Muslim scholars, particularly the scholars of Indian subcontinent, initially attempted to establish that organ donation and transplantation is prohibited. Thereafter, many Arab and Iranian scholars and Muslim scholars (including those from Indian subcontinent) settled in the western hemisphere opined that organ donation and transplantation are permitted but organ donation must be a voluntary act of charity. Of late, the Iranian scholars (and imams) have recognized that the government but not any private parties may acquire organs for an established uniform compensation and equitably distribute the acquired organs.

Conclusions: The current Islamic working principles on transplantation medicine have remained somewhat transitory, emerging if not confusing, and detached from the bulk of the Muslim population. The effect of such a status on transplantation medicine, particularly on organ donation, needed to be investigated.

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247

A questionnaire survey on cognition and intention towards organ donation in driving license holders of mainland China

Lulin M1, Lei Zhao1, Lixin Yu2, Tongyi Men27, CHangxi Wang3, Linhui Wang4, Ye Tian5, Yaowen Fu6, Long Liu7, Youhua Zhu8, Xuren Xiao9, Genfu Zhang10, Wei Zhang11, Heng Li12, XiaotongWu13, Shunliang Yang14, Tao Lin15, Huanqing Yang16, Qingguo Zhu17, Jianlin Yuan18, Zhenli Gao19, Wenke Han20, Jun Dong21, Sen Xie22, Ming Cai23, Wujun Xue24, Zhangqun Ye25, Nan Li26

1Urology, Peking University Third Hospital, Beijing, People’s Republic of China; 2Department of Kidney Transplantation, South Hospital Affiliated to Southern Medical College, Guangzhou, People’s Republic of China; 3Department of Organ Transplantation, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People’s Republic of China; 4Department of Urology, Shanghai Changhai Hospital Affiliated to the Second Military Medical University, Shanghai, People’s Republic of China; 5Department of Urology, Beijing Friendship Hospital, Beijing, People’s Republic of China; 6Department of Urology, the First Hospital of Jilin University, Jilin, People’s Republic of China; 7Department of Urology, the General Hospital of Shenyang Military Region, Shenyang, People’s Republic of China; 8Department of Organ Transplantation, Shanghai Changzheng Hospital Affiliated to the Second Military Medical University, Shanghai, People’s Republic of China; 9Department of Urology, Beijing General Hospital of Armed Police Forces, Beijing, People’s Republic of China; 10 Department of Urology, Xinqiao Hospital, the Third Military Medical University, Chongqing, People’s Republic of China; 11Department of Urology, Jiangsu Province Hospital, Nanjing, People’s Republic of China; 12Department of Urology, Union Hospital of Tongji Medical College, Wuhan, People’s Republic of China; 13Department of Kidney Transplantation and Dialysis, Second People’s Hospital of Shanxi Province, Taiyuan, People’s Republic of China; 14Department of Urology, Fuzhou General Hospital of Nanjing Military Command, Fuzhou, People’s Republic of China; 15Department of Urology, West China Hospital of Sichuan University, Chengdu, People’s Republic of China; 16 Department of Urology, Guangdong General Hospital, Guanzhou, People’s Republic of China; 17 Department of Urology, the 2nd Affiliated Hospital of Harbin Medical University, Harbin, People’s Republic of China; 18Department of Urology, Xijing Hospital, the Fourth Military Medical University, Xian, People’s Republic of China; 19Department of Urology, Yantai Yuhuangding Hospital Affiliated to Qingdao University Medical College, Yantai, People’s Republic of China; 20Department of Urology, Peking University First Hospital, Beijing, People’s Republic of China; 21Department of Urology, General Hospital of Chinese People’s Liberation Army, Beijing, People’s Republic of China; 22 Department of Urology, Wuhan General Hospital of Guangzhou Military, Wuhan, People’s Republic of China; 23Department of Organ Transplantation, the 309th Hospital of Chinese People’s Liberation Army, Beijing, People’s Republic of China; 24Department of Kidney Transplantation, First Affiliated Hospital of Xi’an Medical University, Xian, People’s Republic of China; 25Department of Urology, Tongji Hospital, Tongji Medical College of Huazhong University of science & technology, Wuhan, People’s Republic of China; 26Clinical Epidemiology Research Center, Peking University Third Hospital, Beijing, People’s Republic of China; 27Department of Urology, Qianfoshan Hospital Affiliated to Shandong University, Jinan, People’s Republic of China.

A questionnaire survey was conducted to investigate the cognition towards organ donation, definition of death, transplantation and willingness to donate in driving license holders in China. From Jan 2013 to Mar 2013, 25,000 questionnaires were distributed to 25 transplant centers in China which were the member units of the Kidney Transplantation Group of Chinese Urological Association and the survey on local driving license holders was performed by each center randomly. The questions in the questionnaires included demographic characteristics of respondents as well as their understanding of kidney transplantation and organ donation and personal willingness. All the questionnaires were collected to Peking University Third Hospital for statistics and the results were analyzed by epidemiology experts. Total 25,000 questionnaires were distributed and 12,807 collected (51.2%).The effective response rate of questionnaires was 95.5% (12228/12807). 74.4% respondents approved voluntary organ donation, 64.0% advocated organ donation after death and 48.4% wanted to be volunteers of organ donation. It can be seen from the results that most of the respondents approve organ donation, but only less than half wants to be the organ donation volunteers. The reasons for this are various and more propaganda will be needed to promote the voluntary organ donation in China.

References: [1] Huang J, Mao Y, Millis JM. Government policy and organ transplantation in China [J]. Lancet, 2008, 372(9654):1937–1938.

[2] UNOS.OPTN/UNOS Transplant Trends.[EB/OL]. http://optn.transplant.hrsa.gov/data/

[3] Song YG. Analysis of issues related to organ transplantation [J]. Chinese Medical Theory and Practice, 2005, 14(2):199.

[4] Huang JF. A key measure to promote the sound development of organ transplantation in China-Thoughts on principles of donation after cardiac death pilot [J]. Chin J Organ Transplant,2011,32(1):1–4.

[5] Grewal HP, Willingham DL, Nguyen J, et al. Liver transplantation using controlled donation after cardiac death donors:an analysis of a large single-center experience [J]. Liver Transpl,2009,15(9):1028–1035.

[6] Ming YZ, Ye QF, Shao MJ, et al. Clinical analysis of 48 cases of kidney transplantation from cardiac death donors [J]. J Cent South Univ(Med Sci),2012,37(6):598–605.

[7] Xian YX, Chen GD. Advances in DCD donor kidney quality assessment and improvement methods [J]. Organ Transplantation, 2013, 4(2):113–116.

[8] Reich DJ, Mulligan DC, Abt PL, et al. ASTS recommended practice guidelines for controlled donation after cardiac death organ procurement and transplantation [J]. Am J Transplant,2009,9:2004-2011.

[9] Wang HY, Béatrice SENEMAUD, Chen ZH. Management and standards of organ donation and transplantation in France [J]. Chin J Transplant (Electronic Edition), 2012, 6(1):59–64.

[10] Hou FZ. Introduction of organ donation and transplantation administrative system in the United States [J]. Chin J Transplant (Electronic Edition), 2011, 5 (4):330–336.

[11] Medical Service Supervision Division of the Ministry of Heath, the People’s Republic of China. Notification of the General Office of the Ministry of Heath about launching the donation after cardiac death pilot (Attachment1:Classsification of Donation after Cardiac Death in China)

[12] Organ Transplantation Association. Guide for donation after cardiac death in China [J]. Chin J Organ Transplant, 2010, 31(7):436–437.

[13] He XS, Guo ZY. Standardized management to promote the orderly development of human organ donation in China [J]. Chin J Transplant (Electronic Edition), 2010, 4(1):7–9.

[14] Yao Y, Gu JX. Discussion on ethical principles of donation after cardiac death in China [J]. Chinese Medical Ethics, 2012, 25(5):569–571.

[15] Yao Y. Ethical reflection and practical exploration on donation after cardiac death [J]. Medicine and Philosophy, 2012, 33:23–25.

[16] Zhang R, Li C, Li ZW, et al. Development status and prospect of transplantation and donation after cardiac death[J]. Chin J Bases and Clinics in General Surgery,2012,5,19:493–497.

[17] Dong Q, Li C, Wang YJ, et al. Feasibility analysis of donation after cardiac death in China [J]. Chin J Bases and Clinics in General Surgery, 2012,5,19:498–501.

[18] Wang YJ, Li C, Zhang R. Survey on factors affecting organ donation willingness. Organ Transplantation, 2013, 4(2):75–78.

[19] Yin ZK, Yan J. Predicament of donation after cardiac death and its countermeasures [J]. Medicine and Philosophy, 2012, 33(1A):28–32

[20] http://news.sina.com.cn/c/2011-04-26/004522356616.shtml

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250

Online solicitation of organ donors: An analysis of a living donor online forum (preliminary findings)

Dominique Martin1, Rebecca Ritte1,2

1Centre for Health and Society, The University of Melbourne, University of Melbourne, Australia; 2Onemda, VicHealth Koori Health Unit, The University of Melbourne, University of Melbourne, Australia.

Little is known about the mechanisms by which individuals may solicit or offer organs for transplantation on the internet, despite widespread recognition of the ethical concerns raised by online solicitation of unrelated living organ donors. In this paper, we present the preliminary findings of the Online Solicitation of Organ Donors (OSOD) study in the context of a multinational living donor online forum.

Methods: A forum dedicated to communication between potential donors and recipients within an international online community website with a prohibition on commercial activity was analysed. Publicly presented personal information was extracted from all threads initiated during a six week period (1 June 2013 – 14 July 2013 inclusive). Openly posted names, usernames, email addresses and phone numbers were used to trace any further evidence of online activity elsewhere.

Results: From a total of 45 individual user profiles identified, four user categories were defined: offerers (n=20); solicitors (n=20); brokers (n=1) and other (n=4). Approximately 89% of solicitors and offerers were concerned with obtaining or donating livers (n=18) and/or kidneys (n=22). Ten countries were identifiable with 36 of the user profiles; 29% were associated with the USA and 27% with India. Of the offerers, 50% were identified offering their organs in a variety of unrelated internet forums, with at least 7 of the 10 seeking monetary payment.

Conclusion: Nominally altruistic organ donation online forums appear to provide a platform for individuals to solicit and offer organs across the world. Participation in such forums is one of the strategies prospective organ vendors, buyers and brokers may use to arrange sales. Greater knowledge of these online interactions will inform efforts to prevent harmful practices and assist in the evaluation of illicit organ trade in the international setting.

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251

“Suffering and urgent needs” - online solicitation of Sri Lankan kidney donors

Prabhathi Basnayake1, Dominique Martin1, Rebecca Ritte1,2

1Centre for Health and Society, The University of Melbourne, University of Melbourne, Australia; 2Onemda, VicHealth Koori Health Unit, The University of Melbourne, University of Melbourne, Australia.

The rising burden of chronic kidney disease in Sri Lanka has led to increasing demand for transplantation, with needs predominantly met by living donors. In the setting of widespread reports of organ trading and an extraordinary national reputation for altruistic corneal donation, the regular solicitation of unrelated kidney donors in online Sri Lankan newspapers raises intriguing questions and serious concerns. We report the results of a study of kidney donor solicitation advertisements in Sri Lankan newspapers published online in Sinhalese and English. We completed a thematic and content analysis of solicitation advertisements in 3 online newspapers over a six week period (1 May 2013 – 14 June 2013).

The analysis of the 15 posted advertisements revealed themes of social and health status; medical urgency; donor qualities; and healthcare providers. The brief advertisements sought to stimulate interest from prospective donors by painting a picture of need, appealing to virtue and providing contact details for further information. The online advertisements were consistent with findings from international research investigating solicitation of organ donors and donors of other human biological materials in a variety of media.

Reviewed in the context of current donation policy and practice, our results provide some important insights into the challenges and opportunities of organ donor recruitment in Sri Lanka.

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252

Living Donor Observatory (LIDOBS community)

Marti Manyalich1,2, Ana Menjivar2, Xavier Torres2, Josep M. Peri2, Ignacio Revuelta2, Fritz Diekmann2, Constantino Fodevila2, Santiago Sanchez2, David Paredes1,2, Chloë Balleste1

1 School of Medicine, University of Barcelona, Barcelona, Spain; 2 Hospital Clinic of Barcelona, Barcelona, Spain.

Introduction: LIDOBS is a multidisciplinary community composed by international experts on Living Donation interested to join efforts to improve the quality of the procedures and to establish international consensus in order to protect Living donors’ (LD) health and safety through the development of registries and follow-up the living donation impact on donors’ life.

Objective: To promote a High Quality of Living Donation programs offering a scientific platform that will help to assure transparency, quality and safety of the programmes.

Methodology:LDs’ protection: by providing detailed information about the process, detecting new ethical dilemmas and being coherent on legislation issues.

Registry: Implement a database model for LD registration and data analysis. The model is created based on three levels: mandatory, recommended and excellence.

Follow-up: Detect the key points for the outcome, donors’ satisfaction and mid to long-term impact of donation process on donor’s quality of life and their psychological well-being.

Research: Continuous scientific researches to identify the best practices, to develop quality indicators and make recommendation for LD safety.

Results:On-line database registry: Currently there are more than 1600 registered LDs with mandatory data from 19 centres in 13 European countries. The actual registry is improving and enhanced with data from other countries. Such registry will help the research and the quality of the procedure.

LDs assessment/follow-up surveys (tools surged by EULID and ELIPSY projects available in several EU languages): LIDOBS enable the continuity of their application.

Conclusion: Promoting LD follow-up and international registration practices through research and data analysis, and establishing a consensus among professionals will benefit transplant professionals and the quality of LD programs. The centres that accomplish the LIDOBS recommendations should be considered as excellence centres.

A great gratitude goes to all professionals that were involved in all the stages of the following projects: - ELIPSY project - EULID project - FIS project (Co-founded by European Regional Development Fund FEDER).

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253

Community perspectives on the allocation of deceased donor organs for transplantation: 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; 2Centre for Kidney Research, Children’s Hospital Westmead, Westmead, Australia; 3The George Institute for global health, Camperdown, Australia; 4Central Clinical School, Bosche Institute, University of Sydney, Sydney, Australia; 5Dept of Renal Medicine, Royal Prince Alofred Hospital, Camperdown, Australia; 6 Menzies School of Health Research, Northern Territory, Australia.

Aim: Deceased donated organs are a community held resource yet little is known about community views on organ allocation. We aimed to determine community preferences for organ allocation.

Methods: Thirteen 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 influential in their decision-making about organ allocation. A mean importance score was determined for all the factors. Transcripts were analysed thematically to identify reasons for their choices.

Results: Medical urgency or need was considered to be the most important factor, followed by ability to survive the surgery. Other factors ranked highly included: time on the waiting list, the age of recipient, life expectancy after transplant and compatibility. Younger participants valued time on waiting list; compatibility and lifestyle greater and older participants valued life expectancy after transplant greater. Participants were relieved that health professional made ultimate decision. We identified three major themes underpinning their preferences for allocation: save and improve as many lives as possible, fairness, and minimising lost opportunities for patients on the waiting list.

Conclusion: The community prioritise medical need, waitlisting time for organ allocation. While these broadly reflect attributes in the current allocation algorithm in Australia, there needs to be a more explicit process of incorporating community values into organ allocation policies.

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254

The enlightening lectures to the ordinary people and medical stuffs about the organ donation on the neurosurgeon’s neutral standpoint are effective for the futural development of the transplantation medicine

Shun-ichi Yoshikai

Department of Neurosurgery, Shin-Kokura Hospital, Kitakyushu, Japan.

The number of the organ donations is quite unsatisfactory and the announcement about the donation is still poor in Japan. One of the major reasons is that the almost Japanese people including medical doctors have longstanding misunderstandings about the donation due to the negative campaigns of the mass media since the first cardiac transplantation in 1968 in Japan and also due to the incorrect or malicious information about donation widely spread through the internet. The typical misunderstandings are: the donor’s body is brought away for months or never returns, and the body is cut in pieces at the organ extractions, the agreement of the donation is forced and pressed by the transplantation coordinators, the cost of the transplantation is huge and the fundraising activities are necessary even in the domestic transplantation etc.. In order to resolve these issues, the Japanese transplantation academic meetings and networks have tried to announce the correct information, however, the discussions remain stopped at the very beginning issue, the brain death is really an individual’s death or not. In addition, the emergency room doctors hesitate the confirmation of the patient’s donor-card possession or the proposal of the option because of their personal prejudices to the organ donation. The author is a neurosurgeon with many experiences of the patients’ cadaveric donations, and has promoted the enlightenment activities and published a book especially about the organ donations on a neutral standpoint. For example, the author does not accept the brain death is the individual’s death medically, however, the author accepts it legally. According to these neutrality and objectivity, the author’s lectures are easily acceptable to the audience. The enlightening activities do not bring any quick effects, however, it is important to educate them to be involved in the organ donation on the neutrally and objectively.

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255

Are there barriers which prevent family discussion about their organ donation wishes?

Mary Campbell

Nursing, Northern NSW Local Health District, Tweed Heads, Australia.

Background: Organ transplantation is the definitive treatment for many patients with end-stage organ failure. Australia however, has a persistently low donation rate, which results in many Australian’s dying before transplantation.

In New South Wales (NSW) in 2011, 31% of families for whom consent was requested, declined permission for their loved one to become an organ donor. However, evidence suggests that when families have had a memorable discussion about their organ donation wishes, they are more likely to support their loved ones wish to become an organ donor.

Aims

1. To identify if barriers exist which prevent or inhibit families from holding a memorable discussion about their organ donation wishes.

2. To identify factors that facilitates organ donation discussions within families.

Methods: Four focus groups were conducted in rural NSW, incorporating a continuum of ages from senior school children to retired seniors. The focus groups included year 10 and 11 students, sterilisation technicians employed in the Central Sterilizing Supply Unit (CSSU) of a local hospital, university lecturers from Southern Cross University (SCU) and members from the University Third Age (U3A).

The senior students and the sterilisation technicians had been involved in an organ donation education session prior to participating in the focus group, while the university lecturers and members of U3A had not been involved in an educational session prior to participating in the focus group. The focus group data was transcribed and coded to identify key themes using an interpretative phenomenology process.

Results: The identified barriers were lack of knowledge, geographical distribution, hectic pace of family life and age. The findings also showed that school children and adults were able to initiate family discussion with ease once they had been involved in an education session.

Conclusion: Despite the barriers, family discussions are facilitated when individuals have participated in an education session and given the opportunity to ask questions.

NSW Organ and Tissue Donation Service,Health Education Training Institute

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257

Discussing donation: educational DVD resource

Sarah Aranha1, Steve Philpot1,2

1DonateLife Victoria, Melbourne, Australia; 2Intensive Care Unit, Alfred Health, Melbourne, Australia.

In 2011 DonateLife Victoria (DLV) formed the Communication Skills Working Group (CSWG) to develop, implement and evaluate strategies within the DLV network to improve the quality of family donation conversations. The group developed a DVD resource to support the provision of education for health professionals who are involved in family donation conversations. The resource was designed to assist education facilitators who are already skilled and knowledgeable in donation conversations.

The DVD contains 16 vignettes showing various elements of the donation conversation, contrasting skilful communication techniques with poor techniques. The vignettes were partially scripted prior to filming to ensure that each vignette highlighted one to two key learning points. For instance vignette one shows the doctor discussing brain death with a family using technical jargon, and vignette two shows the doctor providing the family with more appropriate information by using simple language. Filming was completed by an external production company, with members of the CSWG in the role of health professionals and paid actors in the role of family members.

The DVD resource is accompanied by a written facilitator’s guide containing teaching points, learning objectives and suggested questions for participants. The resource has been designed so that each vignette may be used as a standalone teaching tool, or multiple vignettes may be used to facilitate a comprehensive organ donation conversation workshop. The Australian Organ and Tissue Authority have incorporated the resource into a national training program.

The development of this resource was the first project completed by the CSWG and met its purpose in providing health professionals and educators with a teaching resource to improve the quality of organ donation conversations. It is hoped that this will ensure that families of potential organ donors are supported to make an enduring, informed and value-driven decision regarding donation.

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258

“You say you are doing your job but it feels like so much more…” An exploration of the intensive care nurse and organ donation

Sharella Robinson, Fiona Cox

ICU, Alfred, Melbourne, Australia.

The Alfred Intensive Care Unit is a fast paced, dynamic unit. The nursing staff is remarkably adaptable, resilient and work under high levels of stress. When a life cannot be saved, the focus changes to end of life care. Organ and tissue donation offers loved ones the opportunity to salvage something positive from the tragedy of loss. The bedside nurse is crucial in supporting families though this process. It is highly complex and emotionally taxing, yet so rewarding and a privilege to be a part of. This study was inspired by the title of the abstract, a statement from the wife of a patient who became an organ donor.

The role of the bedside nurse in organ donation was explored though surveying ICU nurses. Consisting of 11 questions, the results provided insight into the perception ICU nurses have of donation and how confident they are in this role. The majority of respondents were Clinical Nurse Specialists (CNS) with 5–10 years of ICU experience. It was described as a “mostly positive” experience with 81% reporting being comfortable caring for this patient group. When given a list of words to describe the process, Brain Death (BD) donation was described as respectful, compassionate, rewarding and professional. Donation after Cardiac Death (DCD) was described as challenging, demanding and emotive. It was evident that the DCD process was more stressful and confronting. Three quarters of nurses surveyed felt confident in supporting families through this time, the main barriers noted as being “caught up in emotions” and “it’s the questions that throw me..... I feel as their nurse I should have all the answers” as well as a lack of rapport with family.

The survey demonstrated nursing staff developing a bond with their patients and loved ones that is unique to organ donation. It often becomes difficult to simply “switch off” emotions. These patients often stay with us long after the shift is over. It’s a privilege to be a part of this process, hence why being involved with this special group of patients is more than just a job.

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259

Factors influencing on families’ refusal for organ donation in Korea

Jaesook Oh1, Sungae Cheon2, Boosun Park2, Ohyuk Yun2, Jeongrim Lee2, Kyungsook Jang3, Sunhee Kim4, Jongwon Ha5,6

1Information Education, Korea Organ Donation Agency, Seoul, Korea; 2Donation Management, Korea Organ Donation Agency, Seoul, Korea; 3Donation Support, Korea Organ Donation Agency, Seoul, Korea; 4Secretary General, Korea Organ Donation Agnecy, Seoul, Korea; 5President, Korea Organ Donation Agency, Seoul, Korea; 6Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.

Although the number of deceased donor organ donation is increasing in Korea, we still face many cases of unutilized donors because of family refusal. Increasing conversion rate is another important way to increase donor number. We analyzed factors related donors and tried to find out important factors which influence on the donation.

Method: Donor records of Korea Organ Donation Agency (KODA) were analyzed. In 2012, 1,126 patients were reported to KODA. Among them, family consent was obtained from 446, and family refusal was 343 among eligible donors. Factors of each group such as sex, age group (0˜19, 20˜39, 40˜59, more than 60 years old), causes of the brain-death, trauma / non-trauma, marital state, duration of hospital stay and region of living were used for analysis. Direct KODA coordinator approaches were performed in 216 out of 343 and these cases were analyzed to see causes of donation refusal. Statistical analysis was performed using 2-tailed χ2test, t-test and logistic regression analysis (SPSS ver. 18).

Results: The agreement from the men showed 1.3 times more than that from the women in logistic analysis over the key factors as above although it was not statistically significant. In an age group, it was indicated as they get older, the donation also increases to 1.3 times (p=0.014). Family living in Seoul agreed with the organ donation 3 times more than that of other area families (p=0.000), and those who have a spouse agreed with the donation 0.35 times lower than the opposite (p=0.000). The causes of the 66 refusal cases (30.6%) were related to disagreement from the rest of the family other than the one who favorably consulted first. The 56 cases (25.9%) of the emotional rejection of the family come second. The other reasons were the denial of the brain-death (9.7%), never thought about the donation (8.3%), and belief in peaceful death (6%).

Conclusion: Public education to increase positive support for the deceased donor organ donation is important to increase conversion rate.

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260

Providing support to donor families: Evaluation and challenges

Minsun Kang1, Sanghyoung Yoon2, Gahee Kim2, Eunyoung Heo2, Sunny Kim3, Jongwon Ha4,5

1Management Support Team, Korea Organ Donation Agency, Seoul, Korea; 5Department of Surgery, Seoul National University College of Medicine, Seoul, Korea; 2Family Care, Korea Organ Donation Agency, Seoul, Korea; 3Chief Operating Officer, Korea Organ Donation Agency, Seoul, Korea; 4President, Korea Organ Donation Agency, Seoul, Korea.

Background and Objective: Various bereavement support programs have been provided through Korea Organ Donation Agency (KODA) to assist families of a brain-dead organ donor. This study aimed to understand the decision-making process of donor family members, and evaluate their experience of the organ donation process.

Methods: Face-to-face interviews were performed using ten structured questions and four unstructured questions with nineteen family members who completed the organ donation process. Information about family members’ depression was evaluated using the Center for Epidemiological Studies-Depression (CES-D) scale.

Results: Thirteen participants (68%) were aware of the possibility of organ donation and ten families (53%) decided by themselves to donate their deceased relatives’ organs even before they were approached to consider it. The process of reasoning behind agreeing to organ donation of the deceased by participants was ‘meaningful death for their relatives’ mostly, and some of them agreed to donate organs because of either fulfilling the wishes of the deceased or receiving government compensation of funeral costs and the donor’s medical costs. During the organ donation process, ten participants (53%) had felt difficult to understand entire donation process. Overall the study results indicated that participants were satisfied with the service provided to them by KODA and twelve participants (63%) were willing to donate their own organs after death. Twelve participants (70%) scored 25 and higher and only five (30%) scored 15 or lower on the CES-D scale, which means that many left experience depression.

Conclusion: Most family members felt that they were given enough information to make an informed decision about donation and the study results indicated a positive attitude towards the organ donation process among family members. However, majority of participants were struggling with severe or mild depression after donation and these findings suggests that developing grieving or counseling programs would be essential throughout and after the donation process.

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261

Longevity of an organ donor coordinator, a personal perspective

Andrew Young, Kelly Rogerson

DonateLife Victoria, Melbourne, Australia.

Body of Abstract: The role of the organ donor coordinator at DonateLife Victoria (DLV) is a critical component of the organ donation process. The involvement of experienced and efficient organ donor coordinator (ODC) is integral to successful organ and tissue donation outcomes.

I have been in this privileged role since July 2007 and believe that the role of the ODC will continue to expand and become even more complex. My role over this time has progressed from a case related focus to also leading portfolios that align with the national priorities.

During these last 6 years, and more recently, the challenge I find is to maintain my focus on ensuring organ and tissue cases progress in a timely, effective and professional manner, while also expanding my skills to ensure I remain a valuable team member.

My aim with this abstract is to highlight methods and strategies that I have found beneficial to ensure my position as an ODC remains satisfying, from a professional and personal viewpoint while I continue to evolve in an advanced practice nursing role.

These strategies include:

1. Setting personal goals and recognizing values

2. Developing and maintaining relationships with members of the DLV network

3. Regular review of current workload

4. Planning and maintaining professional portfolios

5. Setting boundaries

6. Recognizing that personal ideals and choices do have a professional impact

7. Undertaking professional development opportunities

These strategies are completely subjective in nature, however I believe that they may have some relevance for other ODC’s to assist in their own personal development. This can only lead to a more experienced and competent ODC workforce.

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262

Education, social communication/cooperation with patient

edyta skwirczyńska-szalbierz

Department of General Surgery and Transplantation, Independent Public Clinical Hospital No. 2, Pomeranian Medical University in Szczecin, Szczecin, Poland.

Cooperation is common affair, based on division of mastery and authority. Cooperation is not hierarchic. Its mastery is based on knowledge and experience, which is opposite to mastery based on role or position.

In Poland, there is no obligation of having family’s agreement for taking organs from dead relative, because there is obligation of alleged agreement. In practice we are striving to get this agreement. If family is against transplantation we dissent from taking organs.

Positive attitude to medical care results in potential agreement for taking organs from dead relative.

The point is to answer the questions

1. Does the way of caring about still living patient, and relation between doctor and patient’s family has influence on family’s agreement for taking organs after death?

2. Does the way of caring about respondents has influence on their agreement for taking organs?

Research Methods

1. Questionnaire made of 18 questions

2. In research participated 173 people

Summary: Thirty two percent of people are satisfied with level of medical care. Majority of them are of the opinion that doctors are treating them without expected carefulness. Thirty eight percent believes that doctors are capable to stop the therapy to get organs for transplantation.

Conclusions: There is necessity to recognize correlation between correct relation doctor-patient, trust gain and reliability of doctor’s opinions. Patient’s conviction that they are well treated may regain belief in straightforwardness of doctor’s opinions, less dissatisfaction and criticism for medical care.

References

[1] W. Kraus Collaboralion in Organizations

[2] Ostrowska A.:Doctor patient relationships - new quality. Health Promotion. Social Science and Medicine, 2001, 21, 109–121

[3] The Cell, Tissue and Organ Recovery, Storage and Transplantation Act 1)2) of July 1st, 2005 (the Official Journal of Acts Dziennik Ustaw 05.169.1411, as amended)

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263

Implementation of educational programs for Russian speaking countries.

Sergey Trushkov, Janis Jushinskis

Paul Stradin University Hospital, Department of Transplantation, Riga, Latvia.

There are many large geographical regions speaking the same language for different historical and political reasons. In European Union it is English with the main educational programs using this language. The same situation is observed in transplantation, where the modern destinations in transplantation law, donation aspects, donor family approach, etc. being presented in English.

In the former USSR territory Russian was used as international language and this situation remains in many countries where Russian is more popular than English. At the same time they have big interest in the development of local transplantation programs that needs participation in education programs in transplantation. Latvian transplantation center in cooperation with Riga Stradins University and local authorities have started educational program in transplantation for Russian speaking countries, which was started as the separate lectures and presentations performed locally and presently processed to specialized educational 7- day program including both theoretical and practical issues in transplantation. In the result of this educational program presently there are already some changes in Kazakhstan national transplant legislation and deceased donation was started.

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264

The role of trust and hope in organ donation decisions

Holly Northam, Mary Cruickshank, Gylo Hercelinskyj

Disciplines of Nursing and Midwifery, University of Canberra, Canberra, Australia.

Introduction: Transplantation is the therapy of choice for most patients with end stage organ failure; however access to transplantation is limited by the shortage of medically suitable donor organs. Increasing family agreement to organ donation requests is key to increasing national and international transplantation rates. Despite widespread community acceptance of the benefits of donation, less than 60% of Australian families will agree to donate their deceased relatives’ organs.

Objectives: To present findings of a qualitative study designed to examine the factors that contribute to family deceased organ donation for transplantation decisions.

Methods: A PhD study entitled “The factors that influence families to decline organ donation” has been conducted. This project has used an exploratory case study approach with a qualitative snowball sampling recruitment strategy. Following ethics approval, family members who had made an organ donation decision for a deceased relative within the previous three years were invited to participate in the study. Twenty two participants from nine families were interviewed between 2011–2012. The interviews were transcribed and thematic analysis was performed. The Precaution Adoption Process Model of Decision making was used to propose that trust, hope and deep hope underpin family organ donation decisions.

Results: Data analysis has revealed strong themes around hope, trust and care for the deceased, the influence of time, information, suffering and organs.

Conclusion: The findings have implications for consent and non-consent decisions in both organ and tissue donation circumstances.

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265

The collaborative development of continuing education targeted to funeral professionals delivered by a national professional association.

Jim Mohr, Kim Young, Mathias Haun, Ken Lotherington

Organs and Tissues, Canadian Blood Services, Ottawa, ON, Canada.

Funeral professionals indicate that 50% of all funerals are pre-planned, presenting a logical opportunity to initiate a donation discussion with clients.

In 2008, governments gave Canadian Blood Services a mandate for organ and tissue donation and transplantation to support system performance improvement. In 2012 the Funeral Services Association of Canada (www.fsac.ca) was engaged as a national donation partner in the development of an on-line donation course targeted to funeral professionals to advance donation opportunities and improve relationships with recovery organizations.

Experts in on-line learning solutions were retained to manage the development and implementation of the course. The course content was informed by a panel of five experts representing funeral home/medical examiner liaisons, an eye bank, a tissue bank, a provincial donation organization and an expert in organ donation. The course was developed over six months and launched June 2013. It has been implemented in both English and French and upon completion of the course participants can receive Continuing Education Units towards their ongoing funeral professional education.

Module 1 introduces the concept of dual advocacy and provides funeral professionals with knowledge and motivation to appropriately and positively raise the opportunity for donation during pre-planned funeral conversations and to direct clients to provincial donation organizations and donation intent registries to action their wishes or obtain additional information.

Module 2 addresses the surgical aspect of organ and tissue recovery, encourages the development of collaborative working relationships with recovery organizations and provides guidance on expected practice of recovery organizations in body reconstruction.

Links to all Canadian donation and recovery organizations’ websites and intent-to-donate registries are provided to facilitate and encourage communication and relationship development. Each course participant is asked to complete a course evaluation to compare their level of confidence in discussing organ and tissue donation with clients before and after completing the course.

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266

Collaborating with medical examiners and coroners to increase donation

Christina Parsons, Kimberly Young, Jim Mohr, Ken Lotherington, Mathias Haun

Organs and Tissues, Canadian Blood Services, Ottawa, ON, Canada.

Approximately 50% of deaths in Canada occur outside the hospital environment with most falling under medical examiner or coroner jurisdiction. In 80% of Canada’s tissue banks, less than 5% of donors are identified from death investigation cases, identifying a significant opportunity for improvement.

In August 2008, the federal, provincial and territorial (F/P/T) governments gave Canadian Blood Services a mandate to work with the tissue donation and transplantation communities to develop leading practices and recommendations in support of system performance improvement.

One national partner organization engaged early on by Canadian Blood Services was the Canadian Conference of Chief Coroners and Chief Medical Examiners, which led to the development of a Reference Manual for Donation for Canadian coroners and medical examiners as well as an initiative to implement practical steps to increase tissue donations from deaths outside the hospital environment.

Canadian Blood Services is facilitating collaborative workshops with medical examiners and coroners in the Provinces of Manitoba, Ontario, New Brunswick, Saskatchewan and Nova Scotia, and in each province tissue recovery and organ procurement organizations, pathologists, funeral professionals and governments officials are joining these process improvement workshops, with a goal of increasing the identification and referral of donors. A panel of Canadian and international tissue banking and death investigation experts has also been convened to support this initiative. The first provincial workshops are taking place in 2013, the others will follow in 2014.

To-date, participants in the provincial workshops have identified several local opportunities for improvement and are improving or creating new functional linkages between organizations to realize more tissue donations. Knowledge gained through these provincial collaborations will be detailed in a report and shared with the broader Canadian donation community.

Medical examiners and coroners can be engaged as key partners to support increasing tissue donation from deaths that occur outside the hospital.

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270

Pharmacological conditioning with GTN and Cariporide at cardioplegia activates cardioprotective signaling targeting mitochondria in a model of donor heart preservation

Mark Hicks1,2, Jair Kwan2,4, Ling Gao2, Peter Macdonald2,3

1Clinical Pharmacology & Toxicology, St Vincent’s Hospital, Darlinghurst, Australia; 2Division of Cardiac Physiology and Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, Australia; 3Heart Lung Transplant Unit, St Vincent’s Hospital, Darlinghurst, Australia 4Free Radical Group, Heart Research Institute, Newtown, Australia.

Background: Storage of donor hearts in cardioplegic solutions supplemented with agents that mimic ischemic preconditioning enhanced their post-reperfusion function. The present study examines the association of functional recovery produced by glyceryl-trinitrate (GTN), a nitric oxide donor and cariporide, (a sodium-hydrogen exchange inhibitor), with activation of pro-survival signaling pathways.

Methods: After baseline functional measurement, isolated working rat hearts were arrested and stored for 6h in either Celsior, Celsior containing 0.1mg/ml GTN, 10μM cariporide or both agents. After reperfusion, function was remeasured, then tissue processed for immunoblotting or histology.

Results: Recovery was significantly improved by these supplements alone or combined (cardiac output 69 vs 20% GTN+cariporide vs Celsior; P<0.05). Necrotic and apoptotic markers in the Celsior group post-reperfusion were abolished by GTN, cariporide or both. Increased phosphorylation of ERK and Bcl2, after reperfusion was seen in groups stored in GTN, cariporide or both along with increased phospho-STAT3 levels in the GTN/Cariporide group. Inhibition of STAT3 phosphorylation blocked recovery. No phospho-Akt increase was seen in any treatment.

Conclusions: Functional cardiac recovery produced by GTN and cariporide was accompanied by activation of signaling pathways consistent with mitophagy activation (phosphorylation of ERK and Bcl2 [1]), and maintenance of mitochondrial transition pore closure after reperfusion via the interaction of phospho-STAT3 with cyclophyllin D [2]. Both processes are crucial for functional recovery of the heart after ischemia reperfusion injury.

References

[1] Kang R, Zeh HJ, Lotze MT, Tang D: The beclin 1 network regulates autophagy and apoptosis. Cell Death Differ 2011, 18: 571–580.

[2] Boengler K, Hilfiker-Kleiner D, Heusch G, Schulz R: Inhibition of mitochondrial transition pore opening by mitochondrial STAT3 and its role in myocardial ischemia reperfusion. Basic Res Cardiol 2010, 105:771–785.

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272

Is there a limit for expanding criteria of kidney donors? How far can we go?

Piotr Domagala, Artur Kwiatkowski, Rafal Kieszek, Michal Wszola, Jakub Drozdowski, Piotr Diuwe, Andrzej Chmura

Department of General Surgery and Transplantology, Medical Univeristy of Warsaw, Warsaw, Poland.

Introduction: The lack of organs for transplantation has forced the transplant community to expand the pool of donors and to use expanded criteria donor(ECD) organs. Although there are organs that do not fit into definition of ECD and remains controversial for transplantation. The aim of this paper is to report the criteria of discharging kidney from transplantation.

Patients and Methods: Four hundred and sixteen patients received cadaveric renal transplants between January 1, 2010 and June 31, 2013. In this time seventy one nine kidneys were discharged from the transplantation – thirty eight kidneys (nineteen referred potential donors) were disqualified before organ procurement and thirty three kidneys were rejected from transplantation during organ storage. Data on donors and preservation parameters were collected. Causes of organ refusal were analysed.

Results: Two the most common causes of kidney rejection from transplantation were malignancy or strong suspicion of malignancy in donor body as well poor donor kidney parameters with probability of kidney irreversible injury.

No caption available

No caption available

Conclusion: Careful kidney selection is recommended in cases of expanded criteria donor kidneys in order to diminish factors that can negatively affect graft function and survival.

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273

“Pharmacological conditioning” improves recovery of hearts from brain dead rats after prolonged hypothermic storage

Gayathri Kumarasinghe, Ling Gao, Mark Hicks, Aoife Doyle, Padmashree Rao, Arjun Iyer, Alisdair Watson, Andrew Jabbour, Christopher Hayward, Peter Macdonald

Cardiac Physiology and Transplantation Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia.

Aim: Cold storage of hearts from brain dead (BD) donors is still the mainstay in cardiac transplantation, however ischaemia-reperfusion injury (IRI) and primary graft failure (PGF) are significant disadvantages[1]. We found that the addition of ‘conditioning’ agents–Glyceryl trinitrate (GTN), Erythropoietin (EPO) and Zoniporide (ZON) to standard preservation solutions attenuates IRI in rat hearts[2–4]. We aimed to test their efficacy under conditions of BD and prolonged cold storage.

Methods: Male Lewis rats were subjected to BD by inflation of a subdural embolectomy catheter. Invasive haemodynamic changes were measured in BD and sham groups. Cardiac output (CO) was then assessed on an isolated working heart model (IWHM) and hearts arrested and preserved in 4°C using either Celsior preservation solution for 1, 3 or 6 hours, or Celsior supplemented with GTN, EPO and ZON for 3 or 6 hours (n=6 each sub-group). Post-storage CO was reassessed on an IWHM.

Results: Hearts from BD rats showed inferior recovery of CO compared with shams. Supplementing Celsior preservation solution with GTN+EPO+ZON significantly improved CO in hearts from BD rats.

No caption available

No caption available

Conclusion: Pharmacological conditioning agents GTN, EPO & ZON significantly improve recovery of hearts from BD rats after prolonged cold storage. This shows promising potential for application in clinical cardiac transplantation.

References

[1] 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

[2] 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

[3] Gao L, Tsun J, Sun L, Kwan J, Watson A, Macdonald PS, Hicks M. Critical role of STAT3 pathway in cardioprotective efficacy of Zoniporide in a model of myocardial preservation – the rat isolated working heart. Br J Pharmacol 2011 Feb;162(3):633–47

[4] Hicks M, Hing A, Gao L, Ryan J, Macdonald PS. Organ preservation. Methods Mol Biol. 2006;333:331–74

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274

The I Now Know (iNK) PROjECT- a pilot education program and video competition to engage secondary schools students to create a one minute video that reflects their perception and understanding of organ and tissue donation

Annie Jarvie-Cross, Catherine Chanter

Nurse Donation Specialist, Northeast Health, Wangaratta, Victoria, Australia.

As part of the Victorian DonateLife Rural Special Interest Group (RSIG), Nurse Donation Specialist (NDS) from Northeast health Wangaratta (NHW) were successful in attaining a Grant from the Canberra DonateLife Authority. To promote community awareness of Organ and tissue donation for DonateLife 2013.

Utilizing the 2013 theme “Make you wishes count”, NHW NDS initiated an innovative pilot project to engage young adults to increase their awareness of organ and tissue donation. The I Now Know (iNK) PROjECT - education program and video competition was conceptualized and developed by the NHW NDS as part of a collaborative engagement involving three regional secondary schools.

Eligibility to enter the competition saw 350 students participate in education sessions based on “The Last Race” education package endorsed by DonateLife. Students were invited to create a one minute video about their perceptions and understanding on any aspect of organ and tissue donation and how they would share their thoughts.

Evaluations by the students written on DonateLife postcards were photographed for The iNK PROjECT face book page. A total of 50 students elected to submit, producing 19 individual or group videos for judging.

A judging DVD was collated for a panel of seventeen national and state DonateLife representatives as well as the NHW executive and regional community leaders. Winners were selected using a specific judging criteria based questionnaire developed by the NDS using survey monkey as a response tool.

Funding provided the platform for the Awards Event, prizes and DonateLife branded photo booths. Over 500 students viewed the winning videos that were also featured in television news coverage. Success of the project has not only been measured by the high standard and quality of the videos, but in the ongoing community engagement and requests for further activities and discussions about Organ and Tissue Donation.

DonateLife

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275

Transplanting the transplanted

Andree Gould, Mary Lynch, Nicola Fletcher, Sarah Kelley, Kylie Monk, Sarah Markham, Rebecca Reid, Marie Schaumann, Melissa Smith

DonateLife WA, DonateLife WA, Perth, Australia.

Presented is a case of a successful donation of a previously transplanted kidney.

Mr X. was a 60 year old male who unfortunately had a catastrophic intracranial haemorrhage which despite treatment resulted in progression to brain death. During conversations of prognosis and poor outcome his family raised the potential for organ donation. He had received a kidney transplant 7 years previously from a living relative for polycystic renal disease.

While it is accepted that a transplant recipient can be an organ donor the question arose – which organs could we consider for donation?

During investigation and consideration for organ donation it was determined that the gentleman’s heart was not medically suitable due to his cardiac history. His lungs were not medically suitable due to poor oxygenation and infection. His liver was not medically suitable due to the presence of multiple hepatic cysts and his pancreas was declined due to his complex medical history. The organ considered medically suitable for donation was his previously transplanted kidney.

In this paper we outline the challenges to achieve a successful donation outcome in this case, including consent from the original living donor and tissue typing considerations.

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276

Scoping study into the potential eye and tissue donor pool at the Royal Melbourne Hospital

Martin Dutch1,2, Tracey Mackay2

1Emergency Department, Royal Melbourne Hospital, Melbourne, Australia; 2Organ and Tissue Donation Team, Royal Melbourne Hospital, Melbourne, Australia.

Introduction: Eye and Tissue donation has the capacity to significantly improve the quality of life for recipients, and in some cases is a live saving intervention. Improvements in public health have seen a reduction in the amount of banked tissue from traditional coronial sources. Non-Coronial eye and tissue donations are thus an increasingly important source for tissue within the state of Victoria, Australia.

Methods: The Royal Melbourne Hospital (RMH) is a tertiary, teaching, referral hospital that provides general medical, surgical and specialist services A retrospective scoping study was undertaken to analyse the size of the potential, isolated eye and tissue donor pool within RMH. The last 5 years of hospital deaths were electronically reviewed. For each in hospital death, all separations which occurred over the preceding 5 years were screened using International Classification of Disease codes. Cases were screened positive for potential eye or tissue donation if they met both age criteria (<80yrs), and had no record of specific exclusion diagnoses. Results: Between 2008–2012, 5,091 patients died in the hospital. Deaths most commonly occurred in the ICU and pallative care wards. Approximately 32% of all deaths occured “in hours” (M-F, 8am-4pm). The screening tool identified 2231 potential isolated eye donors, and 930 potential isolated tissue donors. A random selection of identified patients were audited (n=24). The positive predictive value (PPV) for the eye screening tool was 71%, the PPV for the tissue screening tool was 25%. Discussion: Each year over 1000 patients die at the RMH. The screening tool identified 9 eye, and 4 tissue potential donors/wk. An in hours, eye and tissue donor referral program, with a consent rate of 50%, could realise approximately 50 eye donors and 7 tissue donors each year. This increased, non-coronial source of tissue could significantly bolster banked tissue stores.

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277

Improving Corneal Referrals from Palliative Care Services

Nigel Palk1, Margaret Philpott2

1DonateLife SA, Adelaide, Australia; 2Eye Bank of South Australia, Flinders Medical Centre, Adelaide, Australia.

Eye donation gives many people the opportunity upon death to become organ donors, even when collecting solid organs is not an option due to age or other factors. Families are often under great stress when their loved one dies. They may be unable to make clear decisions or even remember a previous conversation about donation (1). We propose that if stronger links are established with Adelaide’s metropolitan palliative care services, more referrals will be made to the Eye Bank prior to death. The referrals will allow more informed decisions to be made by the family, including the patient. Palliative care services in Australia had a 50% increase in admissions from 2001 to 2010. Nearly half the admissions were people over the age of 75 and 85% of those were admitted to public hospitals (2).

The increased number of referrals to the Eye Bank over the last two years suggests that eye donation education aimed at palliative care nursing staff and allied health workers is effective.

We are developing an easy-to-understand guide on the facilitation of corneal donation in the setting of palliative care. The guide will include the contraindications to eye donation, common questions and answers, and a sticker that is placed in the case notes after the initial referral identifying the patient as a potential eye donor. Through the guide and a simplified referral process, we expect to see an increase in palliative care referrals to the Eye Bank.

We believe that approaching palliative care services for eye donation will decrease the need for ‘cold calls’ to families. This improvement will be the result of an increasing number of palliative care donors, their potential incorporation into the Advance Care Directive, the empowerment of patients and families, and the further education of palliative care staff.

References:

[1] Verbal & Worth White paper 2013 http://www.verbleworthverble.com/wp-content/uploads/2013/04/Framing-the-Donation-Question3.pdf

[2] Palliative Care Services in Australia Report 2012 http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737423346

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278

Graphical approach in the risk factor analysis for the death with functioning graft in kidney transplantation from Japanese registry data

Makiko Mieno1, Takashi Yagisawa2, Kenji Yuzawa3, Shiro Takahara4

1Department of Medical Informatics, Center for Information, Jichi Medical University, Shimotsuke, Japan; 2Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Shimotsuke, Japan; 3Department of Transplant Surgery, National Hospital Organization Mito Medical Center, Ibaraki, Japan; 4Department of Advanced Technology for Transplantation, Osaka University Graduate School of Medicine, Suita, Japan.

Background: Death with functioning graft has been a common cause of graft failure in kidney transplantation. We investigated the impact of the risk factors associated with the death with functioning graft or the other competing causes of graft failure graphically.

Methods: By using the kidney transplantation registry data in Japan from 1992 to 2009, we analyzed first-time kidney-only adult (20-year-old or more) transplants: 9,203 living donor transplants and 2,616 deceased donor transplants. The recipient’s sex, recipient’s age, donor’s age, the number of HLA-mismatches, pre-transplant dialysis, primary cause of end-stage renal disease (specifically, diabetes or not) and the year of the transplantation performed were examined for living donor transplants. The warm ischemia time and the total ischemia time were also included for deceased donor transplants analysis. We examined possibly non-linear relation between the covariates and outcome, such as the hazard ratio of the competing events, non-parametrically with restricted cubic splines with extended Cox regression analysis.

Results: For death with functioning graft, older recipient and longer pre-transplant dialysis were the significant risk factors (the importance of recipient’s factor), whereas for the other causes of graft failure, male recipient, older donor, increasing HLA mismatches and longer ischemia time were more important (relatively donor’s factor).

Conclusion: When calculating the graft survival, the difference between the death with functioning graft and the other causes of graft loss should be considered, and graphical approach might help well.

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279

Challenges and progress of eye banking in Bangladesh

Mir Rahman

Eye Bank, Chittagong Eye Infirmary and Training Complex (CEITC), Chittagong, Bangladesh.

Introduction: In Bangladesh, thousands of people suffer from corneal diseases and await corneal transplantation. Eye banks throughout the country are working towards collecting donor cornea to reduce cornea blindness. Though the eye donation program is not yet popular in Bangladesh, eye banks have been trying to maintain standard practice of cornea collection since inception.

Objective: Understanding the challenges of eye banking system in Bangladesh with primary focus on the functioning of eye banks. This will also include the willingness of eye donation, donor selection criteria, quantity of quality cornea and follow up procedure of cornea transplantation.

Method: In the history of almost a decade, eye banking system has changed significantly in terms of collection of quality corneas, preservation system, cornea distribution policy and follow up procedure of the patient.

Results: The Eye Banking Pilot Project in 2004 has set the standards for quality cornea collection, processing and preservation system, follow up of cornea distribution in Bangladesh. The Project has developed skilled manpower, technical lab, SOP and has also initiated educational program, grief counseling.

Conclusions: With elaborate and efficient planning for grief counseling and public awareness program on eye donation, the numbers of cornea donation in Bangladesh are likely to increase significantly. Sufficient financial and technical support from donor side can help to face such eye banking challenges in Bangladesh.

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281

Prognostic impact of kidney volume and early kidney resistance index on graft and patient survival in 1-year observation

Anita Sierocka1, Jan Pawlus1, Karol Tejchman1, Maciej Romanowski1, Jerzy Sieńko1, Maciej Żukowski3, Kazimierz Ciechanowski2, Aleksander Falkowski4, Marek Ostrowski1, Tadeusz Sulikowski1

1Department of General Surgery and Transplantation, Pomeranian Medical University, Szczecin, Poland; 2Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, Faculty of Medicine, Szczecin, Poland; 3Clinic of Anaesthesiology and Intensive Care, Pomeranian Medical University, Faculty of Medicine, Szczecin, Poland; 4II Department of Radiological Diagnostics, Pomeranian Medical University, Faculty of Medicine, Szczecin, Poland.

Background: Resistance index (RI) is measured by Doppler sonography during the early posttransplant period. RI reflects vascular susceptibility connected with interstitial kidney oedema. RI>0,8 is identified as a powerfull predictor for worse kidney function [1,2,3]. Kidney graft volume seems to have importance in a matter of adjusting number of active nephrons to the recipient. However mentioned correlation was confirmed by only a few publications [4]. There are allocation protocols which includes adjusting kidney mass to the body weight of the recipient, neverthelles those procedures seem not to have sufficient scientific confirmation.

Aim: The aim of this study was to evaluate the correlation between kidney volume as well as early kidney resistance index (RI) and graft outcome and patient survival.

Material and methods: 66 recipients were included to the study. Kidney volume was determined before graft implantation, RI was measured in the first day after surgery. Statistical analysis was performed to adjust for demographic and clinical variables. Statistical significance was analised with T-Student test and Spearman-R correlation (p<0,05).

Results: Kidney volume (Vk) was correlated with graft function, acute rejection episodes (AR), eGFR and graft survival with no statistical significance. We observed statistical significance between Vk and diuresis 1 month after transplantation (Tx) (p=.01). There was significant correlation between RI and DGF (p=.02), AR (p=.02), diuresis during 1 week after Tx (p<.05), creatinine during 1 month after Tx (p<.05) and eGFR 3 month after Tx (p=.0009).

Conclusion: Vk has no influence on graft function. Higher RI values in the early post-transplant period are correlated with higher DGF occurence, higher AR episodes occurence 1 year after Tx, higher creatinine serum concentration 1 month after TX, lower eGFR 3 month after Tx.

Source of Funding: NCN:2013/B/P01/2011/40

References:

[1] Kolonko A, Chudek J, Zejda JE, Więcek A: Impact of early kidney resistance index on kidney graft and patient survival during 5-year follow-up. Nephrol Dial Transplant 2012; 27:1225-1231.

[2] Knemann R, Frank D, Brendenburg UM, Heussen N, Takahama J, Krüger T, Riehl J, Floege J: Prognostic impact of renal arterial resistance index upon renal allograft survival: the time point matters. Nephrol Dial Transplant 2012; 27: 3958-3963.

[3] Bigé N, Lévy P, Callard P, Faiutuch JM, Chigot V, Jousselin V, Rouco P, Poffa JJ: Renal arterial resistance index is associated with severe histological changes and poor renal outcome during chronic kidney disease. Nephrol DIal Transplant 2006, 21:2916-2920.

[4] Hugen CM, Polcari AJ, Faroog AV, Fitzgerald MP, Holt DR, Milner JE: Size does matter: donor renal volume predicts recipient function following live donor renal transplantation. The Journal of Urology 2011, 185:605-609.

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282

Diseased kidney transplantation from expanded criteria donors

Faissal A.M. Shaheen, Besher Al Attar, Muhammad Ziad Souqiyyeh, Abdulla Al Sayyari, Zayed Ibrahim

Medical Department, Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia.

Objective: To identify and analyze the use of Expanded Criteria Donors (ECD) and the outcome of kidney transplantation in the Kingdom of Saudi Arabia.

Methods: This is a retrospective study of all deceased donor transplantation from the year 2008 to 2010 investigating the impact on graft, patient survival and graft function of ECD kidneys compared to Standard Criteria Donors (SCD).

Results: Out of the 433 kidney transplants in the year 2008-2010, the number of ECD kidneys transplanted were 68 (16%), out of which 7 kidneys were from ≥60 years old donors; 43 kidneys from serum creatinine ≥133 umol/L or 50-59 years old with CVA/HTN and 18 kidneys were from donors with serum creatinine doubled at harvesting with cases of CVA/HTN. Moreover, it showed significant difference in the mean age group (39 years vs. 48 years). Furthermore, as the causes of brain insult, 38% of SCD were due to trauma while only 1 case (.02%) for ECD. There was increase number of days from the mean period of transplantation to discharge from 19 days for SCD and 32 days with ECD. The mean serum creatinine at discharge was doubled between the 2 groups. In comparison kidney recipients, who had delayed graft function also doubled between SCD 16% and ECD 36%. On the other hand, episodes of acute rejection are significantly increased from 5% in SCD to 20% in ECD group.

Conclusion: The use of Expanded Criteria Donors is an acceptable method to use in specified category for kidney transplantation in Saudi Arabia. The outcome of marginal kidney transplantation is comparable to international data.

References:

[1] PORT F, et al. UNOS Expanded Criteria, SRTR. Transplantation 2002;74:1281-6.

[2] Rao P, et al. Donor Factors affecting Graft Outcome: The Kidney Donor Risk Index. SRTR database. 69,440 transplant. Transplantation 2009; 88:231-6

[3] Tuttle-Newhall J, et al. Increasing Demand Necessitates the Use of More Expanded Criteria Donors. 2008 OPTN/SRTR Annual Report. Am J Transplant 2009;9 (Pt 2.): 879-93

[4] Colins M, et al. Outcomes of Expanded Criteria Grafts: ANZDATA Analysis. Transplantation 2009;87:1201-9

[5] SCOT DATA. Annual Report 2008 – 2010 Ministry of Health, Kingdom of Saudi Arabia. http://www.scot.org.sa

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283

Increased donor rates - the hidden impact on coordination workload

Victoria Dale1, Jessica Amsden1, Kelly Rogerson1, David Pilcher2,3

1DonateLife, Melbourne, Australia; 2Department of Intensive Care, The Alfred Hospital, Prahran, Australia; 3Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia.

Background: Since the implementation of the National Health Reform in 2009, Victoria has seen a 63% increase in donation cases (to December 2012). Strategies utilised to achieve this include education around donor identification, communication training, and broadening of the donor pool. These strategies have led to increased referrals to organ donor coordinators (ODCs), and the impact of this increased workload has not been measured.

Objective: Our aim was to describe the number and duration of referrals to DonateLife Victoria in July 2011 - June 2013, and to determine the relative proportion of these, which led to attendance of an ODC at a hospital to facilitate actual or intended donation.

Methods: The number of referrals and the time spent on each were extracted from the DonateLife Victoria referral database. Trends over time were analysed.

Results: Over the 2 year period, there were 664 referrals, which incurred a total duration of 677 hours (average 1.01 hours per referral).

1. 43% (285/664) of referrals resulted in an ODC hospital attendance

2. Referrals which led to an attendance had a longer duration than those where there was no hospital attendance (<P=0.001).

3. The average number of referrals/month was 28

4. A rise was seen from 17 in the July-September(1st quarter) 2011 to 36 in the Mar-June 2013 (last quarter), which is equivalent to 3 additional referrals every 2 months (P<0.001).

5. There has been a trend to a reduction in the proportion of referrals which have led to ODC hospital attendances from 54% in the first quarter to 37% in the final quarter (P=0.054).

Conclusion: There has been an increase in referrals over the past 2 years which reflects increased awareness and a desire to check medical suitability in patients who would not have previously been referred. This results in a significant increase in workload associated with initial referrals, and should be considered when planning service delivery models.

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284

Oral history and a history trip - tools supporting transition: The South Australian Organ Donation Agency (SAODA) to DonateLife South Australia (DLSA)

Sally Tideman1, Tim Dalmau2, Johanna Kijas3

1DonateLife, DonateLife South Australia, SA, Australia; 2Dalmau Network, Brisbane, Australia; 3Kijas Histories, Lismore, Australia.

With the introduction of a ‘World’s Best Practice Approach to Organ and Tissue Donation for Australia’ DLSA acknowledged that the reform brought with it complex change and transition challenges. The State Medical Director held the view that leaders within the organisation had the responsibility to ensure staff were skilled and supported through the change, transition and into the future. The theoretical models of organisational psychology and the academic body of work on ‘followership’ and ‘leadership’ ignited by Grint 2006 [1] underpin the DLSA attention to organisational development and to sustaining a high- performing clinical service for optimising all aspects of organ donation for transplantation.

During four years of sector reform in Australia DLSA has used and reported on a range of organisational development ‘tools’ including:

- Values in Action

- Totems, Taboos and Repetitive Interactions

- Behaviourally Specific Feedback

- The Six Circle Lens

Two additional tools used by DLSA in the ongoing development program ‘Change Conversations’ are described. The foundation is in the fields of history, story-telling and psychology and share the principle that the act of sharing information builds stronger relationships and aids in forming a stronger identity.

The first, ‘The SA Organ Donation Oral History Project ‘ used the skills of an historian Dr Kijas, to interview and record the oral testimony [2] of individuals closest to the establishment and development of SAODA through to DLSA.

The second, ‘The History Trip’ enabled staff to recall events that symbolised (more than any other event) the essence of ‘who we are and why we are here’as DLSA.

In conclusion the additional tools described brought context and clarity to the identity and the future of DLSA.

References:

[1] Grint K:Followership:the anvil of leadership, in Grint K, Jupp,J (eds), Beyond Command.London:HMSO

[2] Perk R, Thomson A eds.,: The Oral History Reader London: Routledge, 2003

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285

Donor evaluation for lung transplantation in Iran

Sareh Parto, Seyyed Shahabeddin Mohammad Makki, Shadi Shafaghi, Abolghasem Daneshvar, Kambiz Sheykhi, Hamid Reza Khoddami Vishteh, Masoureh Vahdati, Katayoun Najafizadeh

Lung Transplantation Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Islamic Republic of).

Introduction: Transplantation has evolved as the treatment of choice for many patients with end-stage organ disease. But it is limited by the availability of transplantable donor lungs. So, assessment of lungs in brain dead donors is very important. The aim of this study was to assess the lungs of brain dead donors in Masih Daneshvari organ procurement unit which is one of the most active ones in the Middle East.

Materials & Methods: This prospective study was performed on all of brain dead donors who were transferred to this center from May 2010 to 2013. Evaluation was carried out in 4 steps including history taking and physical examination, chest-x-ray (CXR), O2 challenge test and bronchoscopy. Finally, patients with normal CXR, normal bronchoscopy and PaO2/FIO2≥300 mmHg were considered as standard candidates for lung transplantation.

Result: From 259 brain-dead donors 162 were males (63%), mean age of 32.5±15.1 years. The most common cause of brain death was Trauma (46%). 17% of cases had chest trauma according to history, physical examination and/or chest x ray. 43% of donors had history of smoking more than 20 packs per year and 49% had turbid tracheal secretion. Abnormal CXR in 64%, abnormal bronchoscopy in 50% and PaO2/FIO2 more than 300 mmHg in 25% of all cases have been reported.

Conclusion: Findings of this study showed that the majority of cases had unsuitable lungs (81.5%). This study illustrate that lung is as a very damageable organ in brain dead cases. So, it is recommended that strategies like use of methylprednisolone, endotracheal suctioning, changing the position, antibiotic therapy if necessary and recruitment maneuver in potential brain dead donors has an essential role in improving lungs donors which reducing the number of inadequate donor lungs, increasing the overall donor pool and organ availability.

Keywords: Lung evaluation, Brain dead donors, Lung transplantation

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286

Main causes of lung transplant mortality in Iran

Shadi Shafaghi, Seyyed Shahabeddin Mohammad Makki, Sareh Parto, Majid Marjani, Kambiz Sheikhy, Tahereh Parsa, Hamid Reza Khoddami Vishteh, Katayoun Najafizadeh

Lung Transplantation Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Islamic Republic of).

Introduction: Lung transplantation is an effective treatment for a variety of end-stage lung diseases. Although transplant can significantly improve the quality of life and prolong survival, complex complications may result in morbidity and mortality especially in learning curve of a center. The recognition and early treatment of these complications is important for optimizing outcomes. This article provides an overview of the causes that led to mortality in Masih Daneshvari Hospital lung transplant patients.

Method: In this retrospective study, all complications of 67 patients who were transplanted during 2000 and 2013 were collected and main causes of early and late mortality categorized into 4 groups: 1. hemodynamic instability, 2. Any kind of infections (bacterial, fungal and viral infection), 3. Any type of rejection (acute and/or chronic) and 4. others.

Result: In this study 56% of mortality was early (during 3 weeks after transplant) and 44% was late. Early mortality causes were hemodynamic instability in 68% of patients, acute bacterial and/or fungal and/or viral infection in 20%, pulmonary emboli in 4% and other causes in 8%. Infection made 42%, rejection 38%, hemodynamic instability 5% and other causes 15% of all causes of late mortality.

Conclusion: Recognition of these main factors for lung transplant mortality, and decision making directed to prevent these complications, may lead to reduce morbidity and mortality in patients who have undergone lung transplant. Early hemodynamic instability as one of the main reasons of early mortality in our center needs changes in peri-operative protocols, especially selection of patients in better condition and also using different instruments like extra corporeal membrane oxygenation (ECMO) to manage intraoperative complications. High infection rate (especially fungal and bacterial resistant infections) needs serious consideration and may also more aggressive anti-fungal therapies even for prophylaxis regimen.

Keywords: Lung transplantation, Mortality cause, Infection, Rejection, Hemodynamic instability

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287

13 Years of lung transplantation in Iran: Experience of the National Research Institute of Tuberculosis and Lung Diseases

Shadi Shafaghi1, Seyyed Shahabeddin Mohammad Makki1, Abolghasem Daneshvar1, Shideh Dabir1, Majid Marjani2, Sareh Parto1, Zahra Ansari1, Kambiz Sheikhy3, Hamid Reza Khoddami Vishteh1, Katayoun Najafizadeh1

1Lung Transplantation Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Islamic Republic of); 3Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran; 2Mycobacteriology Research Center, Masih Daneshvari Hospital, Shaheed Beheshti University of Medical Sciences, Tehran, Iran .

Introduction: Lung transplantation is the ultimate treatment in many patients with advanced stages of pulmonary disease. Complexity, lack of donors, lack of specialized centers and cost of the procedure are some problems for its expansion. This study was conducted to describe our 12-year center experience in lung transplantation.

Materials and Methods: We used the database of lung transplantation research center of Masih Daneshvari Hospital, Tehran, Iran and extracted all cases of lung transplantation during 2000-2013 periods. Masih Daneshvari Hospital is a university based hospital and the referral center for lung transplantation. We analyzed the survival of the patients using life table and Kaplan-Meier method.

Results: Lung transplantation undergone in 67 patients that one of them was re-transplantation, and heart lung transplantation in one patient during this period. Fifty one patients (76%) were male and the mean age was 34±13 yr. The causes of transplantation were pulmonary fibrosis (45%), bronchiectasis (22%), COPD (15%), cystic fibrosis (11%), and others (7%). Lung transplantation was double-sided in 38 (57%) and single-sided in 29 (43%) patients. One and three-year survivals of the lung transplanted patients were 51% and 40%, and the mean and median of patients’ survival were 44 and 22 months, respectively. In patients who were alive after two weeks of transplantation, one and three-year survivals were 68% and 56% and the mean and median of patients’ survival were 61 and 67months, respectively.

Discussion: Although lung transplant is a complex procedure, our experiences show that it can be performed in developing countries such as Iran. According to our previous report, the survival of our patients improved gradually mainly due to long term post-operation follow up alongside other factors such as better candidate selection, improvement of experiences of our surgeons, using ECMO and higher standards of patients management at time of transplantation.

Keywords: Lung transplantation, Pulmonary fibrosis, COPD, Bronchiectasis, Cystic fibrosis, Survival

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290

Awareness and knowledge of eye and tissue donation amongst emergency department registered nurses

Bridget O’Bree, Nina Mao, Nicola Stitt

Monash Health, Melbourne, Australia.

Introduction: Monash Health (MH), which is Victoria’s largest health service, has experienced a threefold increase in organ donation since the implementation of the national reform agenda in 2009. However eye and tissue donation has not seen the same increases especially from the Emergency Departments (ED). MH has three ED’s within the organisation.

Objectives: To determine the level of awareness and knowledge of eye and tissue donation in order to meet the learning needs of RN’s from the ED’s within MH.

Methods: The survey was developed and consisted of ten components with an overall total of 20 questions. It was sent to all ED nursing staff via email. A total of 75 responses were received during the two weeks the survey was open, which was a 24% response rate. One ED had a response rate of 49%.

Results: A total of 91% of respondents were supportive of eye and tissue donation. The majority of respondents (93%) thought that less than 50% of the Australian population were willing to become eye and tissue donors, with over half of respondents (63%) believing that less than 25% of the Australian population were willing to become eye and tissue donors. The majority of nurses (84%) were comfortable supporting grieving families and felt the most appropriate time to raise the subject of eye and tissue donation with the family was during end-of-life care discussions (76%). Over half (57%) did not feel they had the necessary skills and knowledge to introduce tissue donation to a family nor did they feel competent to explain tissue donation to a family (64%), although the majority (76%) felt comfortable to notify the appropriate personnel or agency when a potential donor was identified.

Conclusions: RNs working in ED were supportive of eye and tissue donation and were comfortable notify the appropriate personnel or agency when a potential donor was identified. The ED RNs were not comfortable to converse with a family about eye and tissue donation.

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291

Corneal donation, when 1 + 1 = 3

Andrew Young1, Prema Finn, Graeme Pollock, Kelly Rogerson1

DonateLife Victoria, Melbourne, Australia.

Body of Abstract: Corneal donation is an important transplant procedure which restores eyesight to people with severally effected vision. The value of a solid organ donor in facilitating this for a number of transplant recipients will be a focus of this presentation. Our focus is on the initial setting where a gentleman died as a result of a severe neurological injury. His family were approached and consent to the donation of his eye tissue for the purpose of both research and transplantation.

The donation highlights how the generosity of the families’ consent led to a successful donation outcome for 5 recipients related to this eye tissue alone. This included 3 recipients who required urgent corneal transplants and 2 recipients who received scleral transplants.

Relevant details which will be covered include:

1. why there were 3 recipients;

2. how 2 corneas were able to be donated to 3 recipients;

3. recipient outcome;

4. informing the family of this outcome;

5. family opinion of this outcome;

6. long term recipient outcomes;

7. learnings for donor coordinators and Lions scientists and surgeons.

The surgical technicality/techniques of obtaining 3 transplants from a single cornea will be discussed, highlighting the use of both the anterior and posterior keraoplasty from a single cornea.

This outcome resulted in improved quality of life for these 3 corneal recipients. All cases were deemed emergencies/urgent cases, with tight associated time frames which is unusual for this type of transplantation. Two of these recipients had severely impaired vision while the third recipient had suffered an acute eye injury. This recipient was at significant risk of losing his eyesight without this precious transplant. His surgery went extremely well and the risk of him losing his eyesight was averted by this corneal transplant.

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292

Time Delays in the organ allocation process a South Australian perspective

Renee Chambers, Tricia Williams

DonateLife SA, DonateLife SA, Adelaide, Australia.

The organ donation process is a complex task with multiple clinical and logistical components that require time critical coordination if the process is to proceed smoothly [1]. Organ donation can take on average 16 to 24 hours with the biggest proportion of time taken for the allocation of organs. Anecdotally there was a perception that transplant teams were causing delays in the organ allocation process by not adhering to the nominated times as outlined in the Transplant Society of Australia and New Zealand, Consensus Statement on Eligibility Criteria and Allocation Protocols to accept or decline organ offers [2]. As a continual quality improvement activity DonateLife SA, identified a need to examine the length of time taken for the organ allocation process. The review was particularly focused on the length of time transplant teams deliberated prior to acceptance or decline of an organ offer and how often agreed organ offer response times were not observed. This would determine a baseline for future practice improvements.

DonateLife SA undertook an audit of all organ donor case files for a 12 month period to establish if transplant teams were delaying the organ offering process by accepting or declining an offer outside the nominated time frames. Forty six donor case files were reviewed, with a total of 305 organ offers made. Responses outside the nominated time frames for organ offers ranged from 6-9% for kidneys, 10% for pancreas, 13% for lungs, 19% for heart, 25% for livers, and 45% for heart and lungs.

In conclusion, non-adherence to agreed criteria has had a demonstrated impact on organ donation timelines with flow-on effects for families, clinicians (Intensive Care Units, Theatres, retrieval teams) Intensive Care Units bed utilisation and the overall cost associated with organ procurement.

References:

[1] Aldea A, Lopez B, Moreno A, Riano D and Valls A 2001, “A Multi Agent System for Organ Transplant Co-ordination’, Artificial Intelligence in Medicine, 2101, pp. 413-416.

[2] Organ Transplantation from Deceased Donors 2012, Consensus Statement on Eligibility Criteria and Allocation Protocols, Version 1.2, 16th May, Transplant Society of Australia and New Zealand, Australian Government, Organ and Tissue Authority, viewed 9 July 2013, http://www.tsanz.com.au/organallocationprotocols/.

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296

Process mapping the donation pathway: What can we learn?

Kelly Rogerson

DonateLife Victoria, Carlton, Australia.

Organ donation has increased by 85% in Victoria since the implementation of the National health reform in 2009. The services provided have evolved and the care of the donor and family form an essential focus in facilitating the family’s wishes. Staffing models have changed to meet the increasing demands and to enable service delivery. Process mapping was used to document (or review) the donation process and activities from a quality and risk perspective to ensure consistent and robust practice.

Over the last eighteen months, the DonateLife Victoria team led by the nursing workforce have process mapped both pathways by which an individual can donate their organs and tissues. While process mapping is not new, understanding the nuances and practices that have evolved to ensure donation proceeds and capturing them in a timeline, is new. Some initial work was undertaken during the Donation collaborative in 2007, but this work no longer reflects the practices of today.

The early outcomes of the mapping identified clear changes in practice that would benefit both the staff involved and overall donation process. As the mapping process evolved, significant changes in practice have been implemented, documented and evaluated.

A positive outcome of this work has been the ability to capture the complexity of the donation process. Areas which were initially identified as minor have evolved into areas of great cost savings and risk reduction. The benefits of taking the time to reflect and review the activities of your service can lead to cultural, budgetary and risk reduction benefits.

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297

Admission to intensive care for consideration of organ donation in Australia and New Zealand

Andrew P Melville1, David V Pilcher1,2,3, Joanna Mitropoulos1, Steve J Philpot1,3

1Intensive Care Unit, Alfred Hospital, Melbourne, Australia; 2 Australian & New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Melbourne, Australia; 3Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia .

Background: ICU admission for consideration of organ donation remains controversial in some contexts. Limited data is available on the frequency and outcomes of this practice.

Aim: To define epidemiology of patients admitted to ICU for consideration of organ donation and identify factors associated with outcome.

Methods: Retrospective analysis of data from the Australian and New Zealand Intensive Care Society Adult Patient Database between 2007 and 2012.

Results: Between 2007 and 2012, there were 467 admissions to ICU for consideration of organ donation (0.08% of total ICU admissions), and these numbers are increasing, with 118 in 2012. Median length of ICU stay was 25.7 hours (IQR 15.3-41.9). The most common diagnosis was intracerebral haemorrhage. Hospital mortality was 97.2%. 9 patients (1.9%) were discharged home and 4 (0.9%) to a chronic care or rehab facility. No data was available on the proportion that became organ donors. Factors independently associated with survival were increasing age (OR 1.05, 95% CI 1.01–1.10, p=0.012), not being intubated and ventilated (OR 8.1, 95% CI 2.2-29.8, p=0.002) and non-neurological diagnoses (OR 14.2, 95% CI 3.8–53.4, p<0.0001).

Discussion: Admission to ICU for consideration of organ donation is an uncommon but increasing occurrence and most patients die. Non-neurological diagnoses were associated with survival.

Conclusion: More work is required to establish the accuracy of these results and extent of possible data error. Survival may represent a failure to identify patients appropriately and assessment of events during ICU stay and functional status of survivors is needed.

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298

Donors and reason behind decline in transplantation: Oman experience

Isa Al Salmi, Abdul Massieh Youssef

Renal Medicine, Royal Hospital, Muscat, Oman.

Objectives: Relatives of patients with endstage kidney disease(ESKD) are generally very willing to get their loved well a kidney transplant. Relatives as Kidney donors are worked up thoroughly to ensure the best care given for both donor and recipient. We will evaluate the reasons for decline to go ahead with kidney donation.

Method: We review all cases that being worked up for the period from 2009 till 2012 to evaluate the reasons for decline to go ahead with kidney donation. All cases attend the kidney donor clinic as the main service for the country for people interested to undergo transplantation. Kidney donor clinic worked every day and provide all type of clinical care and investigational procedures.

Results: The number of new cases worked up as kidney donors, for their relatives who suffer with ESKD, has increased progressively from 116 on 2009 to 132 case in 2012. Similarly, the number of recipients with ESKD cases worked up for kidney transplant has increased from 60 cases in 2009 to 80 cases during 2012. However, the number of transplant done at the hospital was 23 on 2009 and only 14 cases in 2012. The drop of number of cases that have been transplanted does not go in parallel to the number of cases and donor that been worked up.

In fact, the transplanted cases decrease significantly from 2009 to 2012 by almost 50%. In parallel, the cases of commercial transplantation continued at a high rate. Out of all the total number of 483 cases, 74 cases went ahead with their donation. One hundred and fifty two out of 483 (31%) declined because of medical reasons. Almost 20% changed their mind to go ahead with transplantation.

Conclusion: Few cases of all worked up go ahead with their donation process. There are many reasons including medical but social reason play a major part. Similarly, easy access to commercial transplantation plays a major effect as well. In addition, lack of national cadaveric programe contributes significantly to this matter.

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299

Extending the search for the missed potential organ donor: A six-month audit of deaths in a large Australian teaching hospital

Jonathan Gatward, Michael O’Leary, Myra Sgorbini

Intensive Care Service, Royal Prince Alfred Hospital, Sydney, Australia.

The DonateLife Audit (DLA) is a review of all deaths that occurred in the Intensive Care Unit (ICU) and Emergency Department (ED) of selected New South Wales hospitals, and those who died due to an irrecoverable brain injury within 24 hours of leaving these areas, to measure organ donation (OD) activity. A 6 month retrospective audit of all in-hospital deaths was conducted at Sydney’s Royal Prince Alfred Hospital to establish whether potential organ donors were being missed by the DLA. Neonates and patients with oncological diagnosis, for palliative care, failed resuscitation in ED and over 80 years were excluded from a total number of 429 deaths. The remaining 119 deaths were subdivided by age: 65 years and under (41/119) and over 65 years (78/119). Three OD Specialists reviewed the deaths and found that nearly half of all deaths (58/119) and the majority of deaths under 65 years (31/41) occurred in ICU with only a small proportion dying in ED (6/119). Over 65s were deemed not medically suitable (NMS) if they had a non-neurological diagnosis (57/119). Of the 21 patients over 65 years with a neurological diagnosis, 12 were NMS, 1 was assessed for OD and 7 were set aside for further discussion. Of the 12 patients under 65 years with a neurological diagnosis, 3 were NMS and 9 were assessed for OD (resulting in 3 donors). Of 29 patients with a non-neurological diagnosis, 25 were NMS, 1 was assessed for OD and 2 were set aside for further discussion. The 9 identified patients were discussed at a multidisciplinary meeting of OD experts. It was decided that 1 ICU patient should have been considered for OD, but the remaining 8 patients would not have been considered for OD for various valid reasons.

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300

IMPETRO: The IMProvEmentTs in Live ORgan DOnations project in South Auckland

Mark Marshall, Denise Beechey, Michael Lam Po Tang

Renal Services, Counties Manukau DHB, Auckland, New Zealand.

Counties Manukau DHB serves South Auckland with a high prevalence of indigenous peoples (NZ Maori & Pasifika). This group have a disproportionately higher rate of End Stage Kidney Disease and lower rate of kidney transplantation, unexplained by medical co-morbidities. They also have greater social deprivation and lower literacy skills. Barriers to transplantation/organ donation include: access to understandable information, lack of cultural skills in health providers, over-emphasis on dialysis decision-making, and insufficient resources/operational support for work-up.

The IMPETRO Study is a joint venture with the Kidney Society Auckland, a patient support group. It aims to increase live kidney donation rates in South Auckland over 3 years using a multi-faceted health service delivery improvement project to educate, encourage and facilitate live donation.

Interventions include:

Development of culturally- and health literacy-appropriate educational resources on live kidney transplantation and organ donation.

Local implementation of a “Home & Kidney first” policy to focus on transplantation (& home therapies) as the treatment of choice.

Formation of culture-specific health educators aimed at building individual and Whaanau health literacy skills.

Development of a community engagement framework aimed at community/religious leaders as well as specific communities through educational sessions.

Development of an educational programme aimed at primary care providers to enable them to support patients and donors.

Year 1(2013) of the project involves the development of the resources listed above with year 2 and 3 being the implementation period.

The primary outcome is the number of potential live kidney donors who offer, and the main secondary outcome, the number who convert into successful donation. Subgroup analyses of outcomes in indigenous groups will be conducted. Initial results are expected in late 2014.

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301

Analysis of reasons for family refusal on organ donation in the State of Rio de Janeiro, Brazil

Janaina Lenzi1, Andreia Assis1, Márcia Ponte1, Priscila Paura2, André Albuquerque2, Rodrigo Sarlo3, Cláudia Araújo5, Eduardo Rocha4,5

Family Services, State Organ Procurement Organization, Rio de Janeiro, Brazil; 2 Education, State Organ Procurement Organization, Rio de Janeiro, Brazil; 5 COPPEAD, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; 3 General Coordination, State Organ Procurement Organization, Rio de Janeiro, Brazil; 4 Health Foundation, State Health Board, Rio de Janeiro, Brazil .

Introduction: Family Refusal (FR) to organ donation is well-known as a major barrier to transplantation worldwide. In recent years we observed a drop in FR rates in the State of Rio de Janeiro (RJ). Comparing 2011 to 2012, FR went from 51.9% to 44%. Our study aims to analyze FR in this region of Brazil in order to formulate strategies for public awareness, as well as to improve interviewers’ qualification.

Methods: Donation interviews occurring in 2011 and 2012 were reviewed and reasons for FR were classified in the following categories: first person refusal (FPR), family misunderstanding of brain death (FMBD), lack of familial consensus (LFC), religion issues (RI), others (O) and unknown reason (UR). Data were extracted from the Transplant State Program data base and are expressed as percentage (%).

Results: Respectively in 2011 // 2012, the reasons for FR were: LFC 21% // 25%, FPR 19% // 14%, FMBD 14% // 23%, RI 6% // 3%, O 8% // 10% and UR 32// 25%.

Conclusion: Our numbers indicates that the main reasons for FR were FPR, FMBD and LFC as shown in previous research by others. In our series, religion issues were not identified as an important reason for FR in RJ. Noteworthy is the large number of cases of FR for UR, which clearly demonstrates a need for educational efforts toward the health care team, in order to identify and clarify families’ reasons. Findings related to LFC and FPR point to the importance of previous discussing the subject with the society in order to decrease the conflict and the emotional instability of families at the decision-making moment. Furthermore, considering FMBD, it is important that bereaved families have a better understanding of what brain death means. It’s difficult for members of a family to understand and accept brain death if there is miscommunication with physicians and nurses. Therefore, these themes should be the focus of awareness campaigns and reinforced in the training of health professionals.

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302

Profile of family member responsible for organ and tissue donation in the State of Rio de Janeiro

Andreia Assis1, Janaina Lenzi1, Márcia Ponte1, Priscila Paura2, André Albuquerque2, Rodrigo Sarlo3, Cláudia Araújo5, Eduardo Rocha4,5

1Family Services, State Organ Procurement Organization, Rio de Janeiro, Brazil; 2 Education, State Organ Procurement Organization, Rio de Janeiro, Brazil; 3 General Coordination, State Organ Procurement Organization, Rio de Janeiro, Brazil; 4 Health Foundation, State Health Board, Rio de Janeiro, Brazil; 5 COPPEAD, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil .

Introduction: In Brazil, there is a shortage of organs to be donated and study the profile of families who consent to donation may help to increase the number of transplantations. In this sense, this study aims to investigate the gender and degree of kinship of who authorizes the donation in Rio de Janeiro (RJ), in order to improve the communication strategy with families of potential donors. There is no consensus on the influence of gender on the decision to donate or not to donate an organ of a family member. According to Breitkopf (2009), women are more likely to consent to donation than are men. On the other hand, Morais et al. (2012) analyzed Brazilian families of potential donors who did not choose to donate organs in the period from January 1997 to December 2004 and the results indicated that most family members responsible for refusing donation were women; regarding the degree of kinship, the family members were offspring (34%), spouses (25%), parents (23%) or siblings (18%).

Methods: Analysis of the donation rates by gender and kinship of the family member responsible for authorizing donation. Data were collected from medical records of the donors filed at the Transplant State Program for the year of 2012.

Results: Women were responsible for 55.46% of consent for organ donation of the family member, of which 33.33% were mothers, 27.78% daughters, 23.81% spouses or partners, and 15.08% sisters.

Conclusion: These results differ from the findings of Morais et al. (2012), whose data were from 1997 to 2004, and suggest that, in Rio de Janeiro, women have an important role in the process of organ donation since they are more likely to consent to donation. Therefore, the findings highlight that women may serve as an excellent bridge between healthcare providers and families to increase the number of donations in Rio.

References:

[1] Breitkopf, C.R. (2009). Attitudes, beliefs and behaviors surrounding organ donation among Hispanic women. Current Opinion in Organ Transplantation, 14(2): 191–195.

[2] Morais et al. (2012). Families Who Previously Refused Organ Donation Would Agree to Donate in a New Situation: A Cross-sectional Study. Transplantation Proceedings, 44: 2268–2271.

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303

Development of Facts & Tips sheets for point-of-care medical suitability assessment for the potential organ donor

Carrie Alvaro, Alice Coulson, Leslie Johnson, Trevor Rock, Adam Roshan, Deborah Verran, McKay Leigh

DonateLife, NSW Organ and Tissue Donation Service, Sydney, Australia.

Despite a significant increase in organ donation, the disparity between organ supply and demand continues to grow. This disproportion and changing of donor demographics has led to reassessing thresholds for acceptable risk and to re-consider the use of organs from donors with characteristics once thought to preclude donation. During the past 5 years, the proportion of extended criteria donors (ECD) in NSW has increased 2-fold.

To address this issue and to encourage the referral of ECDs, DonateLife New South Wales (NSW) has developed 20 Facts and Tip Sheets. The Tip Sheets have been developed since November 2012 as a point-of-care tool for donation clinicians to provide them with a brief overview of medical conditions known to require further evaluation for donation suitability. Topics cover a vast range including congenital disorders, malignancies and infectious risks. Specific to the Tip Sheets are ‘red-flag alerts’ and special investigations required to assist with the assessment of medical suitability. The Fact Sheets have been developed to assist with implementation into the wider hospital community.

All donation specialists (medical and nursing) within NSW have been provided with the Facts and Tip Sheets for point-of-care use as well as being a resource reference tool. The Facts and Tip Sheets can also be accessed from the DonateLife Portal.

To date, there have been at least 10 incidences where the Tip Sheets were used. In all of these cases they were used as an adjunct to assist with the determination of donor suitability for organ donation.

In conclusion this new information tool has provided staff with a sound scientific rationale for enabling the final decisions made relating to the assessment of donor suitability. It is planned for DonateLife NSW to continue to develop additional Facts & Tips Sheets.

Reference:

ANZOD Registry Report 2010

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305

Progressing towards an Asian Transplant Registry - Indian transplant registries can show the way forward

Sunil Shroff

MOHAN Foundation, Chennai, India.

National or regional Transplant registries have distinct advantages in looking at various parameters of graft outcomes both in short and long term. In Asian sub-continent very little effort has been made in this front. The UNOS and Euro-transplant registry have over the years set the benchmark for the western countries. We in Asia are dependent on these registries for all our information related to transplants and their outcomes. Efforts have been made in the past to form an Asian transplant registry but this has failed to live up to its expectations. With Internet becoming easily available and with no shortage of knowledgeable manpower in our sub-continent it is time to start our efforts in the direction of creating a viable transplant registry for the Asian region. There have been some efforts in China, Japan, Singapore and Taiwan in this direction but no long term strategy has been formulated. In this respect two organisations in India have made significant progress in this direction and can offer valuable inputs in making the dream of Asian Transplant registry a reality. The Indian Society of Organ Transplantation formed a national registry [1] and has fast track data and a full version available. MOHAN Foundation (an NGO) has to helped with state transplant registries for deceased donation and transplantation [2]. These registries are fully functional and will be demonstrated (Fig.1). An Asian fast track model would be presented too for adoption by the Asian Transplant Society.

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References:

[1] www.transplantindia.com

[2] www.tnos.org

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306

Creating sustainable and consistent community engagement through corporate outreach and the development of effective partnerships

Simone McMahon

Organ Donation & Transplant Foundation of WA, Perth, Australia.

Title: Creating sustainable and consistent community engagement through corporate outreach and the development of effective partnerships

Background: Effective community engagement strategies play an integral part in encouraging family discussion and raising community awareness about organ and tissue donation, directly impacting on donation and consent rates.

In 2008 Simone McMahon AM founded the Organ Donation & Transplant Foundation of WA (ODAT) as a result of returning from a Winston Churchill Fellowship. As part of the fellowship, she travelled to the US, UK and Spain where she studied the Internationals models of organ and tissue donation and the educational and promotional strategies used to increase organ and tissue donation awareness and community engagement.

As a result of findings from this Fellowship, in 2009 ODAT established the “Workplace Partnerships for Life Program”

Aim of the Workplace Partnerships for Life Program

1. To provide encouragement and support to employers in educating their staff about the life-saving and life-enhancing benefits of organ and tissue donation.

2. To facilitate in the dissemination of accurate information about organ and tissue donation via workplaces.

Outline Summary: This program provides employers of WA workplaces with access to accurate information required to enable their staff to make an informed decision about donation for themselves or their loved ones.

This is achieved through;

1. Appointment of Project Officer

2. Onsite Education Seminars

3. Networking Events

4. eNewsletter

Since its establishment 2009, this corporate outreach program has evolved to become a proven successful mechanism in building partnerships and creating sustainable and consistent community engagement reaching over 10,000 employees within its first year.

Acknowledgements: The Organ and Tissue Authority and DonateLife WA

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310

Over 1,400 DCD organs transplanted in 18 years: An effective organ procurement organization’s DCD program increases the donor pool

Howard M. Nathan, Richard D. Hasz, John D. Abrams, Sharon M. West, Michael J. Moritz, MD

Gift of Life Donor Program, Philadelphia, PA, United States.

Aim: Demonstrate an effective DCD program increases organ donor pool & provides lifesaving transplants to those on the waiting list.

Methods: A single OPO, multi-center study evaluating the recovery & utilization of DCD donor organs. Ongoing hospital education on early referral & DCD protocols were initiated prior to DCD donor recoveries. Transplant outcomes were evaluated using the Kaplan-Meier method.

Results: Since implementation of its DCD program (Jun 1995 - Dec 2012), OPO has procured 806 DCD organ donors. DCDs increased the donor pool by 13% resulting in the transplant of 1,468 organs. Mean donor age was 39 yrs (r=0.5-76). Mean time from donor extubation to cross-clamp, or warm ischemic time (WIT), for kidneys transplanted (n=1,272) was 32 minutes (r=2-214). Mean WIT for livers transplanted (n=175) was 19 minutes (r=2-69). Of the 806 DCD organ donors, 658 (82%) were Maastricht Category 3; 74 were Category 2; & 74 were Category 4. Kidney ATN rate was 46% & kidney graft survival was 86% at 1 yr, 75% at 3 yrs & 64% at 5 yrs. Liver graft survival was 72% at 1 yr, 63% at 3 yrs & 56% at 5 yrs.

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Conclusion: An effective DCD program and clinical practice can lead to an increase in the availability of transplantable organs. Properly implemented OPO donor referral protocols can result in an increase in procurement of DCD organ donors. Further research should be considered to identify ways to increase DCD liver, lung and pancrease utilization.

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311

One OPO’s 17 year experience with uncontrolled DCD donors

Richard D. Hasz, Howard M. Nathan, John D. Abrams, Sharon M. West, Michael J. Moritz, MD

Gift of Life Donor Program, Philadelphia, PA, United States.

Aim: To show that uncontrolled DCD organ donation can lead to successful retrieval of tx organs & to evaluate kidney & liver tx outcomes for recipients of organs from uncontrolled donors

Methods: Single OPO, multi-center retrospective study evaluating the procurement and utilization of organs from uncontrolled DCD donors. Graft survival was evaluated using the Kaplan-Meir method.

Results: Between 1996 and 2012, 290 kidneys, 33 livers & 3 pancreata were recovered for tx from 148 uncontrolled DCD donors resulting in the tx of 198 kidneys, 12 livers, and 2 pancreata. Mean donor age was 31 yrs (r=05-76). Mean warm ischemic time (WIT) of 66 mins (r=9-214) for the 74 Maastricht Category (MC) II donors was significantly higher than the mean WIT of 45 mins (r=2-177) for the 74 brain dead donors recovered subsequent to unexpected arrest (MC IV). Kidney utilization rate was 65% for MC II donors and was 72% for MC IV donors and the liver utilization rate was 58% for MC II donors and 24% for MC IV donors. The ATN rate for kidney recipients was not significantly different between the 2 categories (53% ATN rate for MC II & a 56% ATN for MC IV). Kidney graft survival for MC IV was 86% at 6 mos, 80% at 1 yr, 72% at 3 yrs and 61% at 5 yrs. Kidney graft survival for MC II was 80% at 6 mos, 74% at 1 yr, 65% at 3 yrs and 59% at 5 yrs. Of the 7 livers txd from MC II, 6 failed within 60 days of tx and the 7th functioned for 12 years, 7 mos post-tx. Of the 5 livers txd from MCIV, 3 failed within 65 days of tx and 2 are functioning at 11 yrs and 5 yrs post-tx.

Conclusion: Uncontrolled DCDs provide acceptable kidney graft survival outcomes and represnt a pool of organs that should be pursued for transplantation. Results from the small number of liver tx are disappointing.

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312

What is the potential source of heart allografts from Donation after Circulatory Death (DCD) donors?

Arjun Iyer1,2, Ben Wan2, Gayathri Kumarasinghe1,2, Michelle Harkess1, Bronwyn Levvey3, Greg Snell3, Paul Jansz1, Emily Granger1, Phil Spratt1, Kumud Dhital1,2, Allan Glanville1, Peter Macdonald1,2

1Heart Lung Transplant Unit, St Vincent’s Hospital, Darlinghurst, Australia; 2 Heart Transplantation Lab, Victor Chang Cardiac Research Institute, Darlinghurst, Australia; 3 Lung Transplant Service, Alfred Hospital, Melbourne, Australia.

Aim: Heart Transplantation (Tx) remains the gold standard treatment of ESHF, however is limited by the shortage of donor cardiac allograft availability. Our group has been investigating the viability of hearts from DCD donors, and have demonstrated recovery of hearts post 30 minutes warm ischaemic time (WIT) in pre-clinical studies. In this review, we aim to investigate the potential increase in available heart allografts for Tx from DCD donors.

Methods: We retrospectively reviewed the DCD donor database for Lung Tx across the two highest volume transplant institutions in Australia & New Zealand (St Vincent’s Hospital, Sydney & The Alfred Hospital, Melbourne). Inclusion criteria were WIT ≤30 minutes, donor age <50, and donor inotropes (Noradrenaline (NA)<0.2 mcg/kg/min), being evaluated between 2007 and 2013.

Results: 115 DCD lung donors were reviewed between November 2007 and April 2013. During this period, 38/115 (33%) DCD donors met the criteria of age <50 & WIT ≤30 minutes. This amounts to an additional 7 donors per year, or a 17% increase in donors (38/223 heart Tx at the 2 institutions during this period). Inotrope data was available for St Vincent’s Hospital DCD donors. Incorporating donor NA dose <0.2 mcg/kg/min, there were 11/39 DCD donors suitable for heart donation. At this institution, this amounts to an additional 9% (11/122) of donors for cardiac Tx.

Conclusion: Based on this review of the data, viable cardiac allografts from DCD donors may allow an increase in heart Tx by up to 17%, a significant increase especially considering the 10% mortality on the waiting list. This review was limited to DCD accepted lung donors, therefore likely to be underestimating the potential – evaluation of the entire (all organs) DCD pool is underway to gauge the true potential.

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313

Case report of cardiac allografts retrieved from Human Donation after Circulatory Death (DCD) donors - assessment on ex vivo Organ Care System

Arjun Iyer1,2, Ling Gao1, Mark Hicks1, Padmashree Rao1, Ben Wan1, Gayathri Kumarasinghe1,2, Andrew Jabbour1,2, Anders Aneman4, Michael O’Leary6, Arvind Rajamani8, Matthew MacPartlin10, Peter Saul11, Gordon Flynn7, Andrew Cheng9, Dani Goh12, Ray Raper5, Suhel Al Soufi3, Emily Granger2, Paul Jansz2, Phil Spratt2, Kumud Dhital1,2, Peter Macdonald1,2

1Heart Transplantation Lab, Victor Chang Cardiac Research Institute, Darlinghurst, Australia; 2Heart Lung Transplant Unit, St Vincent’s Hospital, Darlinghurst, Australia; 3 Intensive Care Unit, St Vincent’s Hospital, Darlinghurst, Australia; 4Intensive Care Unit, Liverpool Hospital, Liverpool, Australia; 5Intensive Care Unit, Royal North Shore Hospital, St Leonards, Australia; 6Intensive Care Unit, Royal Prince Alfred Hospital, Camperdown, Australia; 7 Intensive Care Unit, Prince of Wales, Randwick, Australia; 8Intensive Care Unit, Nepean Hospital, Kingswood, Australia; 9Intensive Care Unit, St George Hospital, Kogarah, Australia; 10 Intensive Care Unit, Wollongong Hospital, Wollongong, Australia; 11Intensive Care Unit, John Hunter Hospital, New Lambton Heights, Australia; 12Intensive Care Unit, Westmead Hospital, Westmead, Australia .

Aim: Hearts from DCD donors are not used clinically due to concern of warm ischaemic (WI) injury. Our preclinical studies have shown that, using pharmacological post-conditioning and ex vivo normothermic perfusion, WI times (WIT) of ≤30 minutes demonstrate good recovery. We report the first two cases of cardiac allograft resuscitation from human DCD donors using this strategy.

Methods: Donor 01 was a 62 y.o male with Guillain Barre Syndrome. WIT (b/w extubation & organ preservation) was 32 mins. Donor 2 was a 39 y.o male, with hypoxic encephalopathy. He was declared brain death (BD), but subsequently was exposed to 30 minutes WIT for the study. Hearts were flushed with Celsior solution supplemented with post-conditioning agents, before being cannulated and reperfused on a Transmedics OCS device for 7-8 hrs of beating heart assessment - functional, metabolic & biochemical parameters were evaluated with hearts in resting mode for 4 hrs, & working mode for 3 hrs.

Results: During resting perfusion, heart 1 had favourable lactate profiles (lactate extraction) suggestive of viable myocardium. Heart 2 had adverse lactate profiles (lactate production) suggestive of ischaemic myocardium. In a loaded working state, undergoing a left atrial pressure challenge, heart 1 functioned better than heart 2 (figure 1 - cardiac output & generated pressure). The inferiority of Heart 2 was likely the result of dual BD & DCD insult, decreased post-conditioning activation, and an undiagnosed patent foramen ovale (PFO).

Conclusion: We report the first 2 DCD human hearts recovered on the Transmedics OCS. Despite not being ideal donors for DCD heart donation (donor 1 – age>50, WIT>30 mins; Donor 2 – BD+DCD, & PFO), both demonstrated viability & the potential for DCD cardiac allografts. Further studies of ideal criteria DCD donors are underway.

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314

Draft copy more than 20% increase in deceased-donor organ procurement and transplantation activity following the use of Donation after Cardiac Death: Single centre experience

Hieu LE DINH1, Josée Monard2, Marie-Hélène Delbouille2, Marie-France Hans2, Laurent Weekers3, Catherine Bonvoisin3, Jean-Marie Krzesinski3, Jean Joris4, Séverine Lauwick4, Abdour Kaba4, Pierre Damas5, Didier Ledoux5, Arnaud de Roover5, Pierre Honoré5, Olivier Detry5, Jean-Paul Squifflet5, Michel Meurisse5

1University of Medicin Pham Ngoc Thach, Ho Chi Minh city, Viet Nam; 2 Transplant Coordinators, University Hospital of Liège, Liège, Belgium; 3 Department of Nephrology, University Hospital of Liège, Liège, Belgium; 4 Department of Anesthesia and Intensive Care Medicine, University Hospital of Liège, Liège, Belgium; 5Department of Abdominal Surgery and Transplantation, University Hospital of Liège, Liège, Belgium.

Background: We evaluated organ procurement and transplant activity from controlled donation after cardiac death (DCD) at our institution over an 11-year period in order to determine whether this program influenced the transplant program and donation after brain death (DBD) activity.

Material and Methods: Deceased donor (DD) procurement and transplant data were prospectively collected in a local database for retrospective review.

Results: There was an increasing trend in the potential and actual DCD number over time. Mean conversion rate turning potential into effective donors was 47.3%. DCD accounted for 21.9% of the DD pool over 11 years. Mean donor age was 54.6 years (3-83). Donors ≥60 years old made up 44.1% of the DCD pool. Among referred donors, reasons for non-donation were medical contra-indications (33.7%) and family refusals (19%). Mean organ yield per DCD donor was 2.3 organs. Mean total warm ischemia time was 19.5 min (6-39).

The number of DCD kidney and liver transplants has progressively risen over time. DCD- KT and LT represented 23.7% and 24.2% of the DD kidney and liver pool, respectively, over 11 years. The DBD retrieval and transplant activity increased during the same time period. In 2012, 17 DCD and 37 DBD procurements were performed in Liège region with a little >1 million habitants.

Conclusions: The implementation of the DCD program at our institution enlarged the DD pool and did not compromise the development of DBD programs. The potential DCD pool is still underused and appears as a valuable donor source for transplantation.

Keywords: brain death, cardiac death, deceased donors, organ procurement, kidney transplantation, liver transplantation

References:

[1] Ledinh H, Bonvoisin C, Weekers L, et al. Results of kidney transplantation from donors after cardiac death. Transplant Proc. 2010; 42: 2407-14.

[2] Le Dinh H, de Roover A, Kaba A, et al. Donation after cardio-circulatory death liver transplantation. World J Gastroenterol 2012; 18: 4491-506.

[3] Salvalaggio PR, Davies DB, Fernandez LA, Kaufman DB. Outcomes of pancreas transplantation in the United States using cardiac-death donors. Am J Transplant. 2006; 6: 1059-65.

[4] Muthusamy AS, Mumford L, Hudson A, Fuggle SV, Friend PJ. Pancreas transplantation from donors after circulatory death from the United kingdom. Am J Transplant. 2012; 12: 2150-6.

[5] Mason DP, Brown CR, Murthy SC, et al. Growing single-center experience with lung transplantation using donation after cardiac death. The Annals of thoracic surgery. 2012; 94: 406-11; discussion 11-2.

[6] Brook NR, Nicholson ML. Kidney transplantation from non heart-beating donors. Surgeon. 2003; 1: 311-22.

[7] Cohen B, Smits JM, Haase B, Persijn G, Vanrenterghem Y, Frei U. Expanding the donor pool to increase renal transplantation. Nephrol Dial Transplant. 2005; 20: 34-41.

[8] Summers DM, Counter C, Johnson RJ, Murphy PG, Neuberger JM, Bradley JA. Is the increase in DCD organ donors in the United Kingdom contributing to a decline in DBD donors? Transplantation. 2010; 90: 1506-10.

[9] Squifflet JP. Why did it take so long to start a non-heart-beating donor program in Belgium? Acta Chir Belg. 2006; 106: 485-8.

[10] Le Dinh H. Extending Donor Pool with Donation after Cardiac Death in Kidney and Liver Transplantation: What is the Price to Pay? Faculty of Medicine. University of Liège, Liège - Belgium, 2012: 206 pages, http://orbi.ulg.ac.be/handle/2268/139275.

[11] Detry O, Le Dinh H, Noterdaeme T, et al. Categories of donation after cardiocirculatory death. Transplant Proc. 2012; 44: 1189-95.

[12] Colloque Liégeois de Coopération (CLIC) - Don d’Organes. http://www.nicolas-sottiaux.be/ULG/ULG.html. Centre Hospitalier Universitaire de Liège, Liège - Belgique, 2011 et 2012.

[13] Kootstra G, Kievit J, Nederstigt A. Organ donors: heartbeating and non-heartbeating. World J Surg. 2002; 26: 181-4.

[14] Matesanz R, Marazuela R, Dominguez-Gil B, Coll E, Mahillo B, de la Rosa G. The 40 donors per million population plan: an action plan for improvement of organ donation and transplantation in Spain. Transplant Proc. 2009; 41: 3453-6.

[15] Kootstra G, van Heurn E. Non-heartbeating donation of kidneys for transplantation. Nat Clin Pract Nephrol. 2007; 3: 154-63.

[16] Lamy FX, Atinault A, Thuong M. [Organ procurement in France: new challenges]. Presse Med. 2013; 42: 295-308.

[17] Dominguez-Gil B, Haase-Kromwijk B, Van Leiden H, et al. Current situation of donation after circulatory death in European countries. Transpl Int. 2011; 24: 676-86.

[18] Saidi RF, Bradley J, Greer D, et al. Changing pattern of organ donation at a single center: are potential brain dead donors being lost to donation after cardiac death? Am J Transplant. 2010; 10: 2536-40.

[19] Moers C, Leuvenink HG, Ploeg RJ. Donation after cardiac death: evaluation of revisiting an important donor source. Nephrol Dial Transplant. 2010; 25: 666-73.

[20] Terasaki PI, Cho YW, Cecka JM. Strategy for eliminating the kidney shortage. Clin Transplant. 1997: 265-7.

[21] Chaib E, Massad E. The potential impact of using donations after cardiac death on the liver transplantation program and waiting list in the state of Sao Paulo, Brazil. Liver Transplant. 2008; 14: 1732-6.

[22] Noterdaeme T, Detry O, Hans MF, et al. What is the potential increase in the heart graft pool by cardiac donation after circulatory death? Transpl Int. 2013; 26: 61-6.

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315

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).

FIGURE 1

FIGURE 1

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.

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316

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.

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317

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.

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318

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.

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319

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.

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320

Deceased donor transplantation programme in Andhra Pradesh - a Southeastern State in a developing country India

Swarnalatha Guditi

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

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321

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.

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325

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.

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326

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

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327

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.

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328

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.

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329

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.

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330

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 [1]. 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.

References:

[1] 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

[2] 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).

[3] 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.

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335

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.

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336

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.

References:

[1] 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.

[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.

[3] 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

[4] 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

[5] 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

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337

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.

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338

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.

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339

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).

Figure

Figure

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.

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340

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.

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400

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.

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401

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.

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417

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.

Figure

Figure

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.

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418

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.

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419

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.

Figure

Figure

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.

Figure

Figure

Keywords: Deceased Donors, Unused Organs, Rejection Rate, Saudi Arabia

References:

[1] Int J Org Transplant Med 2012; Vol. 3 (4)

[2] Rao P. et. al. Donor Factors affecting Graft Outcome: the Kidney Donor Risk Index.

[3] SRTR database 69,440 transplant. Transplantation 2009; 88:231-6

[4] Tuttle-Newhall J. et.al., Increasing Demand Necessitates the Use of More Expanded Criteria Donors. 2008 OPTN/SRTR Annual Report

[5] SCOT DATA. Annual Report 2008-2010 Ministry of Health, Kingdom of Saudi Arabia. http://www.scot.org.sa

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420

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).

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421

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.

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422

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.

Methodology:

Working tasks:

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.

Studies:

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.

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423

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

Reference:

None

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424

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.

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425

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

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430

Donor action per Vital-Link in Korea

Soon Kim

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.

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431

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.

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432

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[1]. 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.

Reference:

[1] 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.

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433

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

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434

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 [1]. 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.

Reference:

[1] 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

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435

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.

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436

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.

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437

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.[1]

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. [1] 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.

Reference:

[1] 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.

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438

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.

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445

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.

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446

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.

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448

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.

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450

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.

Figure

Figure

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.

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452

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.

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453

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.

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460

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.

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461

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.

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462

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.

References:

[1] Population statistics: http://www.qsa.gov.qa/eng/PopulationStructure.htm

[2] 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.

[3] 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

[4] Organ trafficking and transplant tourism and commercialism: the Declaration of Istanbul. The Lancet, Volume 372, Issue 9632, Pages 5–6, 5 July 2008

[5] WHO Guiding Principles on Human cell, Tissue and Organ Transplantation. Transplantation. 2010 Aug 15;90(3):229–33

[6] Qatari Organ Donation and transplantation Law 21/1997 in http://www.gcc-legal.org/MojPortalPublic/LawAsPDF.aspx?opt&country=3&LawID=2838

[7] http://www.qatarembassy.net/Qatar_Labour_Law.asp

[8]http://odc.hamad.qa/en/how_to_become_a_donor/doha_donation_accord/doha_donation_accord.aspx

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463

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.

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464

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.

FIGURE 1

FIGURE 1

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465

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.

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466

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.

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467

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

Figure

Figure

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468

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.

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480

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.

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481

Edutainment on nursing students by “One’s Gift of Life to Many” Programme

Methikar Prapthanawatch

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

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482

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.

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483

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.

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484

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.

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486

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.

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487

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).

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488

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.

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495

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:

Figure

Figure

Figure

Figure

Continuous increase in organ and tissue donation in the last ten years. [1] 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%) [1]

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.

Reference:

National Information System of Procurement and Transplantation of the Republic Argentina.

https://cresi.incucai.gov.ar/IniciarCresiFromSintra.do

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496

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.

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497

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.

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498

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.

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499

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.

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500

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.

Table

Table

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501

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.

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502

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.

Table

Table

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.

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503

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.

Reference: None

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504

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.

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505

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.

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506

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.

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507

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.

Figure

Figure

Figure

Figure

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.

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508

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[1]. 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.

Table

Table

Conclusion: Despite increasing use of marginal donors and LVADs, supplementing Celsior with glyceryl trinitrate and erythropoietin allows excellent recovery of donor hearts.

References:

[1] 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

[2] 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

[3] 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

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509

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.

FIGURE 1

FIGURE 1

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.

FIGURE 2

FIGURE 2

Conclusion: Perfusion of a swine heart for 12 hours with maintenance of sinus rhythm is feasible.

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510

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.