Objectives: In Iran, each medical university can have one organ procurement unit for its own hospital. If the family consents, all patients with brain death must be transferred to the organ procurement unit. When brain death is officially confirmed and the family gives the second consent, the organs are then retrieved in the operating room.
Materials and Methods: To minimize the number of “failed donations” (and to reduce their related costs), we studied 685 patients with brain death who were transferred to the Masih Daneshvari Organ Procurement Unit (Tehran, Iran) from 2016 to 2018 in terms of their outcomes. Of these, 623 led to (at least one) organ donation, whereas the remaining 62 had different causes for unsuccessful organ retrieval and donation.
Results: Two causes (not officially confirmed and family withdrawal) were responsible for 4 failed donations (0.5%). We focused on the remaining 58 cases, which had principally medical grounds for unsuccessful organ retrieval and donation. These were further subcategorized into 3 groups: expired, unacceptable laboratory results, and exclusion in the operating room. We compared these groups versus the successful donation group in terms of average age, male-to-female ratio, average body mass index, pace of brain death occurrence, and days of hospitalization. Results showed that age, body mass index, and cause of brain death are important predictive factors in differentiating successful and failed donations, whereas sex and days of hospitalization are not so decisive.
Conclusions: Special precautions must be considered before transfer of brain dead donors who are overweight, are of older age, and have nonhemorrhagic causes of brain death. Stricter criteria are needed to control psychologic and financial burdens of failed transfers of deceased donors to the organ procurement unit.
Key words : Brain death, Family consent, Organ retrieval
Over the past few decades, there have been gains over several obstacles to make organ transplant an effective life-saving treatment for many patients. Among them are the refinement of surgical techniques and the availability of effective immuno-suppressive regimens against rejection, which have both played major roles.1,2
The present increased organ shortages no longer depend on the location of the country. In a Middle Eastern country with a growing population like Iran, it is disappointing to witness unsuccessful retrieval of organs from deceased donors. In our center, if the family consents, all deceased potential donors are transferred from their original hospital to the organ procurement unit (OPU) hospital. When primary case selection results in questionable quality due to abnormal laboratory results or lowered quality because of past history, both the organ donation and transplant teams have already put in great efforts and thus become worn out for nothing. Even in well-developed countries, the organ and tissue donation process has special complexities for relatively newer centers. The classical framework in which brain death, referral, consent, and organ recovery procedures are clearly structured3 looks like a dream for us. Indeed, we have advanced our own donation processes by creativity and gaining from international experts.
In Iran, each medical university can have one OPU for its own hospital. If the family consents, all potential brain-dead donors are transferred from their original hospital to the OPU hospital. When brain death is officially confirmed and the family gives the second consent, the organs will be recovered in the OPU operating room. In other words, we transfer only deceased donors to the OPU when we are 100% sure they are going to operating room.
The OPU process takes 12 to 24 hours, and all efforts are done to maximize the quantity and quality of transplantable organs. Some deceased donors, however, may have no transplantable organs; in addition, the heart may stop beating before organ donation, and we have no donation after cardiac death facilities. Therefore, efforts are focussed on the conversion of possible donors to actual ones.4 Here, we discuss successful and unsuccessful organ donations and their processes after transfer to our OPU.
Materials and Methods
In this retrospective study, all potential brain-dead donors who were transferred to the OPU from 2016 to July 2018 were included. If potential candidates did not make it to organ recovery, reasons were recorded, as shown in Table 1. Demographics of potential donors, cause of brain death, and hospitalization duration were also recorded.
We examined a total of 685 brain-dead patients in terms of their outcomes. Of these, 623 led to (at least one) organ donation, whereas the remaining 62 were unsuccessful because of multiple causes (Table 1).
Our results showed that age (P = .02) and cause of brain death (P = .01) were important influencing factors in differentiating successful and unsuccessful donations, whereas sex, body mass index, and days of hospitalization were not so decisive.
Two potential causes (not official brain death confirmation and family withdrawal) comprised 4 failed donations (0.5%). We then focused on the remaining 58 candidates, which had principally medical grounds for unsuccessful donations. These were further subcategorized into 3 groups: expired, unacceptable laboratory results, and exclusion in the operating room. We compared the successful donation group versus these groups in terms of average age, male-to-female ratio, average body mass index, pace of brain death occurrence, and days of hospi-talization. These results are shown in Table 2.
After specialized intensive care unit hospitalization, proper considerations regarding management of potential donors are critical to achieve optimum donation targets. In the literature, investigations have reported substantial benefits with specific donor management procedures,5 with less favorable results shown with rushing of organ recovery efforts,1,2 which can affect transplant outcomes.
Jansen and associates6 expressed that, after family rejection (57% to 62%), donor management problems and surgical techniques (38% to 43%) were barriers to conversion of potential donors into actual ones.6
Increasing donor age may be a relatively new difficulty for our OPU, as we have had a history of organ procurement from young trauma donors. Najafizadeh and associates reported a mean age of 31.7 ± 15.5 years for their potential brain-dead donors.7 In Kazemeyni and associates, the mean age was 29 years in their population of donors.8 Presently, many potential donors have cerebro-vascular accident as the cause of brain death, with our numbers getting close to those of developed countries.9 Elderly donors, which are starting to be the leading group of candidates for deceased donation,10 can have additional negative factors, including cardiovascular risk factors and history of ischemic heart disease. However, toxicity has also been seen in a relatively high proportion of potential (unsuccessful) candidates, with an overall mean age equal to actual donors; indeed, the mean age of poisoned candidates was 26.7 years. Acute poisoning involving different agents may be responsible for a greater incidence of certain conditions such as metabolic acidosis. These explanations leave elderly and poisoned potential organ donation candidates more prone to loss before organ donation surgery.
We divided the different causes of brain death into slow-paced and fast-paced categories. Fast-paced causes include head trauma, intracranial hemorrhage, and rupture of aneurysm, whereas slow-paced causes include nonhemorrhagic ischemia, complications after cardiopulmonary resuscitation, drug toxicities, brain tumors, convulsions, and infections of the central nervous system, which all have slower brain deterioration. This classification of course is not exact but does arrive from clinical experience. Because of harsher factors, hemodynamic instability seems to be more in line with the first category. Therefore, the legal and medical processes should be optimized for these donors. However, these strategies may influence organ quality.
Special precautions must be considered before transfer of brain-dead candidates with older age and with nonhemorrhagic causes of brain death (particular with complication after cardiopulmonary resuscitation and drug toxicities) to the operating room for organ recovery. Stricter criteria are needed for these groups to control psychologic and financial burdens of failed transfers.
Volume : 17
Issue : 1
Pages : 128 - 130
DOI : 10.6002/ect.MESOT2018.O79
From the Organ Procurement Unit (OPU), Lung Transplantation Research Center
(LTRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD),
Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
Acknowledgements: The authors declare that they have no sources of funding for this study, and they have no conflicts of interest to declare.
Corresponding author: Farahnaz Sadegh Beigee, Organ Procurement Unit (OPU), Lung Transplantation Research Center (LTRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences (SBMU), Darabad, Niavaran, Tehran, Iran 19569-44413
Phone: +98 2127122103
Table 1. Outcomes of Potential Brain-Dead Donors Transferred to the Masih Daneshvari Organ Procurement Unit From 2016 to 2018
Table 2. Comparison of Successful Versus Unsuccessful Donations