the changing scenario for organ...
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THE CHANGING SCENARIO FOR ORGAN DONATIONElisabeth Coll Torres MD PhD
Organización Nacional de Trasplantes, Spain
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AUT
BEL
BGR
CYP
CZE
DEU
DNK
ESP
EST
FIN
FRA
GBR
GRC
HRV
HUN
IRL
ITA
LTU
LUX
LVA
MLT
NLD
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1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012
…and Spain is here© World Health Organization 2015
SDR, cerebrovascular diseases, all ages, per 100 000
SDR, motor vehicle traffic accidents, all ages, per 100 000
65.2 64.4 63.461.1 60.7
55.5 56.0 55.553.4
49.151.0
47.6
32.0 32.5 32.5 33.0 33.4 32.1 32.3 32.5 32.029.2
32.8 31.4
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2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Do
nan
tes
en
ME
pm
p
Donantes potenciales en ME pmp Donantes reales en ME pmp
De la Rosa et al. Am J Transplant 2012; 12:2507
Potential DBD pmp Real DBD pmp
pm
p
‘(…) The second concept isbased on the principle of non-maleficience and justice. Thetreating physician is not obligedto perform or continue withfutile treatments, these beingthose which do not achievetheir expected objective.
In this sense, continuing futiletreatments is considered a badclinical practice since it is notrespectful with human dignity; on the other hand, theunnecessary use of health careresources is against the pricipleof distributive justice’.
Monzón JL, et al. Med Intensiva 2008;32(3):121-33.
ETHICUS STUDYICU DEATHS 18% WSLT
EPIPUSE STUDYICU DEATHS 34% WSLT
Sprung et al, 2003; JAMA 290. Hernandez-Tejedor et al, 2015; Med Intensiva:395
EXPANSION DONOR POOL40 pmp DONOR PLAN
OBJECTIVE: Donor rate 40 pmp
• DBD Optimization
• DCD
• Living Donation
• Expanded criteria/ NSR donors
• Donation in minorities
• Special Surgical TechniquesMatesanz R, et al. Transplantation proceedings, 2009
Donor Pool
Donation after
circulatory death
Living donation
Old
donors
Brain Death
optimization
Special surgical techniques (liver split and domino. double
kidney)
Transmissible
diseases
- Neoplasias
- Infections
Other
pathologies:
- HTA. DM
- Intoxications
- Rare diseases…
Donation in
minorities
Expanded criteria
Non standard risk donors
40 pmp DONOR PLAN OBJECTIVE: Donor rate 40 pmp
Brain death Optimization
QUANTITATIVE PHASE
INDICATORS
1. REFERRAL OF POTENTIAL DONORS TO CU
2. MANAGEMENT OF POTENTIAL DONORS
INSIDE CU
3. OBTAINING CONSENT TO ORGAN DONATION
QUALITATIVE PHASE
VISIT TO BPH
• STRUCTURED INTERVIEW
• TRANSPLANT COORDINATORS
• OPENED QUESTIONS
IDENTIFICATION OF BEST
PERFORMER HOSPITALS (BPH)
IDENTIFICATION AND
DESCRIPTION OF BEST PRACTICES
Matesanz R, et al. Am J Transplant 2012;12(9):2498-506
WHO IS THE
BEST?
HOW DO THEY DO IT?
Matesanz R et al. Lancet 2012Number of donors within the 12 previous months at a given date
GOOD PRACTICES GUIDELINEAVAILABLE IN SPANISH, ENGLISH, GERMAN AND ITALIAN
http://www.ont.es/publicaciones/Paginas/Publicaciones.aspx
Brain death Optimization
TRAINING PROGRAMMESONT–SEMES
Available at http://www.ont.es
COMMON RESEARCH PROJECTS
RECOMMENDATIONS/DOCUMENTS
Brain death Optimization
FROM 2008, COLLABORATION AGREEMENT
WITH SPANISH INTENSIVE CARE SOCIETY (SEMICYUC)
• Training Programme (+ 1000 youngintestivists trained)
• Research projects• Recommendations
Escudero D, et al. Intensive care practices in brain death diagnosis and organ donation. Anaesthesia. 2015 Oct;70(10):1130-9
Brain death Optimization
INDICATOR SD
ORGAN DONATION
Nº Donors ---------------------------------------x 100
Nº BD people in CU
60%
Nº people in BD correctly monitored---------------------------------------------------------------------x 100
Nº BD people in CU
100%
Nº confirmed BD-------------------------------------------------x 100
Nº CU Deaths
5-30%
http://www.semicyuc.org/sites/default/files/actualizacion_indicadores_calidad_2011.pdf
Brain death Optimization
- small interventions in deceased donation through PDSA cycles in 40
donor hospitals
Proactive follow-up system for patientswith catastrophic brain injuries – ICD-10 codified mortality, neuroimages, etc. –discusion with treating physicians.
Notification criteria with supportingmaterial
New systems of notification
Protocols on Elective Non TherapeuticIntensive Care to facilitate organ donation
Daily review of deaths
Training sessions and feed-back activities
EMERGENCY CARENEUROLOGY/NEUROSURGERY
INTERNAL MEDICINEINTENSIVE CARE
27.4
4.7
10.2
18.8
39.0
0
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30
35
40
45
A: Active treatment inthe ICU until brain
death (n=539)
B: Active treatment inthe ICU until the
patient suffers anunexpected CA from
which the patientcannot not be
resuscitated (n=92)
C: Admission to ICU toincorporate the optionof organ donation into
end-of-life(n=200)
D: Active treatmentinthe ICU until thedecision is made to
WLST(n=370)
E: Not admitted intoICU (n=769)
%
1 out of 4 actual donors in Spain have been admitted to the ICU to enable organ donation
N=1970 possible donorsaged ≤85
11/1/2014-4/30/2015
24% ACTUAL DONORS
Domínguez-Gil B, et al. Med. Intensiva 2016
Domínguez-Gil B, et al. Transplantation 2017
Possible organ donors notadmitted into the ICU
1970 Possible donors
769 Not admitted into the ICU (39%)
427 No medical contraindications (56%)
49 Intubated– 39 dead ≤ 3 days378 Not intubated– 226 dead ≤ 3 days
342 NEVER REFERRED TO THE DONOR COORDINATOR
Patients dead as a result of a devastating brain injury (possible donors) ≤ 85 years
68 hospitals
1st November 2014 – 30th April 2015
Domínguez-Gil B, et al. Med Intensiva 2016
Mean age78 years
Legal, deontological and ethical framework
Identification of possible donors
Research of the will of donation. Care and
communication with the family of the
possible donor
Critical Unit management
Recommendation to implement a ICOD
program
Outcomes evaluation
EXTERNAL REVIEW PHASE
Brain death Optimization
Donor Pool
Donation after
circulatory death
Living donation
Old
donors
Brain Death
optimization
Special surgical techniques (liver split and domino. double
kidney)
Transmissible
diseases
- Neoplasias
- Infections
Other
pathologies:
- HTA. DM
- Intoxications
- Rare diseases…
Donation in
minorities
Expanded criteria
Non standard risk donors
1. Creation of new DCD programs – uDCD & cDCD
2. Increase the effectiveness of DCD - utilization rate and
number of organs recovered & transplanted per donor
3. Evaluate post-transplant outcomes with organs from DCD-
strategies for improvement
AIMS
Donation after Circulatory Death
1. Introduction
2. Glossary & classification of DCD
3. Determination of death by circulatory criteria
4. Uncontrolled DCD
a. Out-of-hospital logistics. Donor selection criteria
b. In-hospital logistics. Donor selection criteria
c. Preservation. recovery and organ viability
d. Family approach
5. Controlled DCD
a. Donor selection criteria
b. WLST
c. Family approach
d. Extubation. cardiac arrest and death determination
e. Preservation. recovery and organ viability
f. Requisites for starting a controlled DCD program
6. Recipient selection criteria & peritransplant management. Information
to the potential recipient
7. Communication with the media
8. Ethical & legal aspects
DCD in Spain: state of the art and
recommendations
National ConsensusDocument 2012
Donation after Circulatory Death
• Training courses
Controlled and uncontrolled DCD
New scenarios for family interview
Normothermic Abdominal Perfusion
• Annual Report DCD activity in Spain
Description of procedures and trends
Outcomes: organ recovery, transplantation and post
transplant results
• National protocols on:
Liver Donation and Transplantation (2015)
Lung Donation and Transplantation (2017)
Donation after Circulatory Death
869 932 1002 997 1112 1214 1302 1313 1317 1360 1387 1424 1475 1433 1462 1500 14981372
1550 1482 1496 1489 1537 15240
2835 35
4336
32 32 18 49 56 71 71 76 88 77 108130
117 161 159 193314
495
22.625
27 26.829
31.533.6 33.9
32.5 33.7 33.8 34.6 35 33.8 34.3 34.2 34.432
35.3 34.8 35.1 36
39.7
43.4
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1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
pm
p
Ab
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ten
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ber
Brain Death Donors Circulatory Death Donors Rate pmp
12 5
2351 84
211
370
24.5%
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2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
%
Ab
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um
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IV III IIb IIa % DCD/Total Actual donors
> 3 PMP1-3 PMP< 1 PMP
EN 3 (0.1)4 (0.9) 548 (8.5)
55 (0.9)
156 (9.2)
110 (9.7)
16 (1.9) 6 (0.7)
8 (0.8)
11 (5.5)
8 (0.1)
73 (0.5)
314 (6.8)
U.S.A.: 1494 (4.6)
6 (1.2)
IN 2015, SPAIN WAS THE 3rd COUNTRY IN ABSOLUT NUMBERS,
AFTER USA AND UK
495 (10.6) 2016
+ 3500 from thebeggining
From 24 to 838 tx / year
Donor Pool
Donation after
circulatory death
Living donation
Old
donors
Brain Death
optimization
Special surgical techniques (liver split and domino. double
kidney)
Transmissible
diseases
- Neoplasias
- Infections
Other
pathologies:
- HTA. DM
- Intoxications
- Rare diseases…
Donation in
minorities
Expanded criteria
Non standard risk donors
PROGRESSIVE CHANGE IN ELEGIBILITY
CRITERIA FOR ORGAN
DONATION
CHANGES IN THE PROFILE OF POTENTIAL
ORGAN DONORS
IMPROVEMENTS IN THE CARE OF NEUROCRITICAL
PATIENTS
DECLINE IN MORTALITY
RELEVANT TO ORGAN DONATION
Information on the quality and safety of transplants performed with organs from these donors is ESSENTIAL to guide risk-benefit assessments in the future
• All NSRD since 01/01/2013
• Utilization NSRD
• Follow-up recipients
Donors with an increased risk of
donor related disease in the
recipient, assumed before
transplantation.
Non Standard Risk Donors
Infections:
• CNS infections
• TBC
• Emerging infections
• Bacteriemias
• Endocarditis
Malignancies:
Prior or present history of malignancy
Poisoning:
• Cocaine
• Ecstasy
• Hydrocarbons
• Mushrooms
• Organophosphates
• Ethylene glycol Methanol
• Rodenticide
• Other
Other diseases:
• Myeloproliferative disorders
• Amyotrophic lateral sclerosis
• Systemic lupus erythematosus
• Multiple Sclerosis
• Other (rare diseases)
3 months
6-12-24 months
3 months
12-24 months
176 actual donors
155 utlized donors
430 transplants
1Transmission*/Relatedproblem 84% follow-up
TRANSPLANT RESULTS
No Graftloss/Patient death
attributable to NSRD
*cardiacrecipient HCV
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
≥80 0.9 0.7 1 1.2 1.7 2.1 2 2.4 3 3.7 4.9 6.5 7.5 8.4 8.9 9.7 9.8
70-79 11.4 12.7 13.7 15.2 16.5 16.1 17.6 18.6 20.4 21.7 20.6 25.8 22.8 23.1 21.2 22.5 22.6
60-69 19.2 20.4 19.7 17.5 20 19.8 19.2 21.9 20.9 19.5 21.1 21.4 20.5 20.9 23.7 21 22.1
45-59 28 28.8 30 28.7 30 29.2 29 29.1 28.7 29.8 32.4 28 28.4 30.5 28.8 31 29.4
30-44 16.9 16.3 15.5 16.2 14.7 15.9 16.7 16.1 15.9 14.8 12.7 12.7 13.5 10.8 11.8 10.3 9.8
15-29 19.8 17.8 15.3 16.6 12.9 13 12.5 9.3 8.8 7.2 6.6 4.1 5.7 3.7 4 3.9 4.5
0-14 3.7 3.2 4.8 4.5 4.2 3.9 3 2.6 2.3 3.4 1.7 1.6 1.7 2.5 1.5 1.6 1.8
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
≥80 70-79 60-69 45-59 30-44 15-29 0-14
>50%
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1
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10
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2
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12
10
13
7
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12
8
11
15
14
19
0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0
CY (n=5)
EL (n=50)
MK (n=10)
BG (n=38)
TR (n=407)
RO (n= 138)
LU (n=4)
IS (n=3)
LT (n=31)
DE (n=864)
SK (n=64)
IE (n=63)
DK (n=80)
LV (n=29)
PL (n=594)
NL (n=282)
SE (n=166)
EE (n=23)
EU28 (n=10033)
HU (n=203)
UK (n=1309)
SI (n=44)
NO (n=114)
FI (n=121)
IT (n=1384)
CZ (n=261)
AT (n= 212)
FR (n=1635)
BE (n=299)
PT (n=289)
MT (n=12)
HR (n=151)
ES (n=1682)
Actual Total ≤ 60 years PMP Actual Total > 60 years PMP
2014 data
‘(…)the number of donors >70 years increased from 3.8 to 8.8 pmp (a 132% increase) in Spain and they now constitute 25.4% of all Spanish organ donors.
In contrast, the number of US donors >70 years increased from 1.0 to 1.3 pmp, and they constitute only 4.4% of total deceased donors’.
Halldorson J et al, . LiverTransplant 2013; 19
0
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20
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50
60
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80
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100
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Edad
máx
ima
del
do
nan
te
TX. RIÑÓN TX. HÍGADO TX. CORAZÓN TX. PULMÓN TX. PÁNCREAS
94
9079 86
55
66752648
1246
999
2478
1161
51
2921854
1218
18308 353
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Kidney (N=11315) Liver (N=5380) Heart (N=1297) Lung (N=1309)
=< 60 years > 60-70 years > 70-80 years > 80 years
• OLD FOR OLD
• BETTER THAN REMAINING ON DYALISIS
Donor age is not the only relevant factor in the outcome of LT, however, surgical factors such as IT or hemodynamic instability during surgery, and recipient factors, such as MELD score are also essential. Therefore, avoiding these factors as much as possible in LT performed with elderly donors may lead to outcomes similar to those with transplants performed with younger donors
RECIPIENT SELECTION
Donor Pool
Donation after
circulatory death
Living donation
Old
donors
Brain Death
optimization
Special surgical techniques (liver split and domino. double
kidney)
Transmissible
diseases
- Neoplasias
- Infections
Other
pathologies:
- HTA. DM
- Intoxications
- Rare diseases…
Donation in
minorities
Expanded criteria
Non standard risk donors
Information program to patients
Information and training professionals
Expand living donors pool: Crossover-Donor Kidney
program, good samaritan
Living Donation
16 15 15 2035
22 20 19 17 1931 34
60 61
87102
137156
235240
320
361
382
423
388
343
0
50
100
150
200
250
300
350
400
450
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
OBJECTIVE: > 10-15%KIDNEY TRASPLANTS
15%
Living Donation
0
500
1000
1500
2000
2500
3000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Living donor DCD DBD
DCD
LIVING
BRAIN DEATH
Living Donation
OBJECTIVE: FULL INTEGRATION OF IMMIGRANTS AND MINORITIES TO DONATION AND TRANSPLANTATION
POBLATIONAL SURVEY: ATTITUDES OF IMMIGRANT POPULATION TOWARDS ORGAN DONATION
(in collaboration with Faculty of Psychology, Universidad Autónoma de Madrid)
• Lack of information on donation and transplantation
• Family interview is essential
• Three collectives reluctant to donation:
North Africa
Sub-Saharan Africa
Asia
Specially for religious reasons- Muslims with strong religious beliefs.
Information and awareness of donation and
transplantation: Donación sin fronteras campaign,
En el lado de lado de la vida (silent short film)
Enhance collaboration between transplant
network and cultural mediators (Symposium,
workshops)
Strengthen relations with the most representative
social organizations of the different groups
• Muslims
• Gypsies
01
23334
56666
788
101011
11111112
1317
181818
202323
2526
353738
394040
43454546
485151
5353
5657
5862
6668
696970
7174
7577
8386
8789
9393
101
0 25 50 75 100 125
Luxembourg (n=0)
Armenia (n=6)
Malasya (n=97)
Dominicana (n=41)
Macedonia (n=12)
Venezuela (n=192)
Bosnia and Herzegovina (n=27)
Guatemala (n=135)
Russian Federation (n=1473)
Azerbaijan (n=110)
Greece (n=126)
Georgia (n=50)
Romania (n=345)
Chile (n=321)
Mexico (n=2960)
Colombia (n=1204)
Uruguay (n=119)
Estonia (n=49)
Latvia (n=79)
Iran (n=3370)
Germany (n=3668)
Hungary (n=479)
New Zealand (n=203)
Israel (n=433)
Ireland (n=266)
Australia (n=1485)
Finland (n=373)
Canada (n=2492)
Czech Republic (n=749)
Netherlands (n=1263)
Norway (n=430)
Belgium (n=987)
United States of America (n=29851)
Spain (n=4641)
Recipients of solid organs pmp
Recipients of organs from Deceased Donors pmp
Recipients of organs from Living Donors pmp
Patients transplanted pmp 2015
2016
104 pmp
The difficulty of changing "Because it has always been done like this“ is a challenge.
‘To improve is to change; to be perfect is to change often’
― Winston Churchill
‘Nothing happens until something moves’ ― Albert Einstein
THANK YOU VERY MUCH FOR YOUR
ATTENTION