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Volume: 17 Issue: 1 January 2019 - Supplement - 1

FULL TEXT

Demographic Differences Between Two 7-Year Periods of Organ Donation in Iran: A Single-Center Experience

Objectives: Donor characteristics can directly affect transplant outcomes. In this study, we examined donor patterns in an organ procurement unit, which covered one-third of the population in Tehran, Iran over the past 12 years (2005 to 2018).

Materials and Methods: Demographic data of donors, including sex, age, cause of death, blood group, outcome of donation, number of organs per donor, and comorbidities (including diabetes mellitus and hypertension), were assessed.

Results: Our analyses included 1848 deceased donors from 2005 to 2018; of these, 649 were female donors (35.11%), and mean age was 37.11 years old. During the study period, donor age significantly increased. The number of pediatric donors under 15 years old decreased from 11.11% to 7.44%, whereas the number of donors under 5 years old significantly increased during the later period. Cause of death shifted to cerebral hemorrhage rather than trauma. We observed a significant increase in donors with diabetes mellitus and hypertension. In the early study period, 16% of the donors had these comorbidities; however, in the later period, 31% of the donors had at least 1 risk factor, including diabetes mellitus or hypertension. Number of organs per donor was steady over the study period.

Conclusion: Because donors with brain death are the only source for heart, lung, and liver transplants, it is necessary to determine weak points to reduce lost transplant opportunities.


Key words : Brain death, Cardiac death, Extended-criteria donor, Trauma

Introduction

The greatest hurdle facing organ recovery from deceased donors is ways to increase the number of available organs for transplant.1 In this regard, a variety of approaches have been employed to extend the donor organ pool. Utilization of extended-criteria donors, efforts to increase society awareness, utili-zation of all brain death sources to detect potential donors, methods to improve the rate of obtaining consent from families and next of kin, national sharing models, and optimization of organ allocation are some activities to overcome the limitations of accessible organs.2-4 Consequently, organ procurement has improved over time due to increases in awareness and positive attitudes toward organ donation among health care staff and society.5 In some countries, significant changes in donor characteristics over the past decade have been detected. Increases in donor age and donor body mass index have indicated a shift in the preference of transplant teams against donors with comorbidities.6-8 In addition, the number of donations after cardiac death has significantly jumped by 2.6-fold,8 with quantity of deceased donors only slightly increasing. Another notable revision in organ procurement is donation from human immuno-compromised virus-infected donors.9 From an ethical point of view, these types of donors must be discarded; however, the willingness of potential recipients along with the presence of patients who are human immunodeficiency virus positive on organ transplant wait lists have opened new windows.10

In Iran, organ procurement after cardiac death is not a possible consideration, and deceased donors are the only sources for organs such as heart, lung, liver, and pancreas.11 Moreover, additional psycho-social supportive directives are needed for both society and medical professionals to improve organ utilization from deceased donors. Indeed, all parts of the organ donation process from detection to donation require close observations to prevent any failures.

It is known that donor characteristics can directly affect transplant outcomes12; therefore, their consi-deration in the organ donation and transplant process is crucial. In this study, we examined donation patterns in an organ procurement unit that covered half of the population in Tehran, Iran over the past 12 years (2005 to 2018).

Materials and Methods

This study was approved by the National Research Institute of Tuberculosis and Lung Diseases. We performed a retrospective analysis of our center’s database to obtain information on donors consented for organ donation between December 2005 and October 2018. The retrieved records were then categorized into 2 time periods, from 2005 to December 2011 and from 2012 to 2018.

Demographic data of donors, including sex, age, cause of death, blood group, outcomes after donation, number of organ per donor, and some comorbidities (diabetes mellitus and hypertension), were assessed.

Data were exported to SPSS software (SPSS: An IBM Company, version 21, IBM Corporation, Armonk, NY, USA) from the center’s database. According to normal distribution of quantitative date, t tests were conducted for analysis and for nominal variables. Statistical comparisons were made using chi-square test. P < .05 was considered statistically significant.

Results

From 2005 to 2018, there were 1848 deceased donors; of these, 649 were female (35.11%), and the mean age was 37.11 years. Over the study years investigated here, we observed a change in the demographics of organ donors. As shown in Table 1, age of male donors significantly increased, with mean age increasing from 31.51 ± 15.28 years in the early period to 40 ± 22.3 years in the later period. However, the proportion of female and male donors was steady, with 60% to 65% of donors who were male.

Over the study period, the number of pediatric donors under 15 years old decreased from 11.11% to 7.44%, whereas donors under 5 years old were significantly higher in the later period. In the later period, 3.18% of all donors were under 5 years old versus 2.04% in the early period (P = .03; Figure 1).

We also observed a change in donation outcomes. In the early period, among 538 deceased donors, 93.6% were successful, whereas 3.6% of donors had cardiac death before organ retrieval and the donation process was terminated. In the later period, the rate of cardiac death before organ recovery decreased to 2.03%.

The incidence of brain death due to head trauma decreased from 50.5% in the early period to 29% in the later period (P < .001). However, it was the most prevalent cause in both periods. Likewise, intra-cerebral hemorrhage as cause of death increased from 16.6% to 27.3% (P = .04). Furthermore, brain death after prolonged cardiopulmonary resuscitation was more prominent in the later period versus in the early period (10% vs 2.3%).

When we considered the use of extended-criteria donors, we observed a significant increase in donors with risk factors such as diabetes mellitus and hypertension. In the early period, 16% of donors had these comorbidities; however, in the later period, 31% of donors had at least 1 risk factor, including diabetes mellitus or hypertension (P = .01). Blood group patterns were equal during both periods of time (Figure 2), and no differences were detected among donors during the time period.

There were no significant differences in rate of organ procurement based on organs per donor. As indicated in Figure 3, rate of organs per donor was 2.91 ± 1.6 from 2005 to 2011 and remained similar over the later period (2.58 ± 1.38; P > .05). Furthermore, we observed no significant changes in body mass index of donors during the periods of observation.

Discussion

Organ transplant is the final therapeutic option in patients with organ failure and is a confirmed highly effective treatment. In this regard, donor charac-teristics can strongly impact future organ donation rates. Increased road safety, more obese donors, more elderly donors, and a tendency to use extended-criteria donors to shorten times on transplant wait lists are some changes seen in organ procurement and utilization.

In our center, we began from 5.8 ±1.9 organ retrievals per month in 2005 to 30.1 ± 7.6 organs per month in 2011. In 2018, the rate of organs retrieved per month was steady due to the increased number of extended-criteria donors, who only have one proper organ to transplant. Other organ procurement units have mentioned declines in standard criteria donors from 78% to about 65% during a decade-long period.8 Our study showed a 15% growth in utilization of donors with underlying disorders such as diabetes mellitus or hypertension. In addition, the average age of donors increased by about 21.56%, confirming increased utilization of elderly donors by transplant teams. Overall, donor age has progressively increased over recent decades. From 1994 to 2004, there has been about a 150% increase in liver transplant donors who are more than 50 years old.13

A positive attitude toward brain death among medical staff has resulted in improvements in donor management, with cardiac arrest before final donation reduced by 1.6%.

According to the United Network for Organ Sharing database, a history of cancer is notable in 2.7% of deceased donors.13 Our study revealed that less than 6% of the donors (in both time periods) had brain death due to primary brain tumor. Our transplant teams do not use organs procured from donors with malignancy, although in some societies donors with malignancies and donors with viral hepatitis are considered.6 In 2013, Routh and associates explored shifting patterns in donor selection criteria for liver transplant, which included use of obese donors.6 Our data showed no changes in body mass index criterion among donors. Ising and associates illustrated an increasing number of drug-intoxicated heart donors from 2% in 2005 to 13% in 2015.14 In our organ procurement unit, the rate of intoxicated donors ranged from 4.6% to 5.5% with no significant change.15 It is worth mentioning that donors with cardiac death and donors with viral hepatitis are not included in our organ procurement program. Nelson and associates emphasized that, of 27 000 deceased donors annually throughout the world, most are from brain death.13,16 However, the number of total deceased organ donors will not greatly change unless there is a significant expansion to donations after cardiac death. Therefore, it is necessary to determine weak points to reduce lost transplant opportunities. Because these weak points can vary from hospital to hospital and from one time point to another, standardized techniques and strict instructions can minimize loss of potential donors and allow appropriate marginal organs.

Conclusion

Because donors with brain death are the only source for heart and lung transplants in many countries without DCD program, it is necessary to determine weak points to reduce lost transplant opportunities. Demographic changes in donors in the last decade necessitate professionals to pay attention to new techniques in order to avoid more serious organ shortage.


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Volume : 17
Issue : 1
Pages : 242 - 245
DOI : 10.6002/ect.MESOT2018.P106


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From the 1Lung Transplantation Research Center (LTRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran; and the 2Tracheal Diseases Research Center (TDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, 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: Meysam Mojtabaee, 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
E-mail: Drmojtabaee@sbmu.ac.ir