Key words : Caribbean procurement, Deceased donor, Quality indicators, Religious leader education, Resource allocation

The Republic of Trinidad and Tobago (T&T) located in the southern Caribbean Sea has a multiethnic and multireligious population of 1.399 million people (census 2020)¹ and is the only English-speaking Caribbean country with an established kidney transplant program from living donors (LD) and deceased donors (DD). The country has a public health care system administered via 8 hospitals. Since 2006, there is a single transplant agency, the National Organ Transplant Unit (NOTU) located at the Eric Williams Medical Sciences Complex, where both kidney retrieval and transplant are performed.2 The NOTU operations are governed by the Human Tissue Transplant Act No 13 of 2000 and the Human Tissue Transplant Regulations 2004.² Governmental regulatory involvement conceptualized an “OPT-IN” donation policy whereby one can opt to become a donor. Deceased donor organ procurements/retrievals occur at 3 other hospitals: Port of Spain General, San Fernando General, and Sangre Grande Hospitals. The structure of the transplant system in T&T is based on the Spanish model of universal coverage, free access, and hospital-based transplant procu-rement managers (TPMs),³ but extended criteria donors (ECD), death by circulatory criteria donors, and recipient waiting lists for ECD are not currently implemented. Since 2010, the Donation and Transplantation Institute and the Refinería Española de Petróleo Sociedad Limitada (REPSOL) have partnered the implementation of SEUSA program, the Donation and Transplantation Institute foundation consultancy program, with support from NOTU and the Ministry of Health of T&T.⁴ The SEUSA program, an international development tool used successfully in Spain, Europe, and USA (SEUSA) to increase organ donation and transplantation rates, includes (1) diagnosis of the current situation using organ donation diagnostic surveys, (2) creation of a human resources structure through TPMs, (3) detection of all brain and cardiac deaths in the hospitals implementing the Deceased Donor Alert System, (4) in-hospital awareness based on the Essentials in Organ Donation, and (5) external hospital audits.⁴ Thanks to the implementation of the program, health care professionals have been exposed to training programs in organ donation and transplant (ODT), the LD kidney program has been maintained, and the structure of the deceased donation network has been strengthened. In a retrospective analysis of kidney transplants performed within 5.5 years (January 2006 to June 2011) at the NOTU reported by Roberts and colleagues,^{5 73} kidney transplants were performed, with only 3 from DDs. Recipient survival rates were 91.5%, 89.5%, and 86.3% at 1, 3, and 5 years after transplant, respectively. Infections and cardiovascular disease were the most common complications, with most occurring at 12 months posttransplant.⁵ In another study, Sanchez and colleagues⁶ reviewed the determinants of quality of life for patients on renal replacement therapy in T&T (100 transplants, 80 peritoneal dialyses, 350 hemodialysis) using different survey instruments. The group showed that kidney transplant recipients enjoyed the best quality of life, supporting increasing patient’s access to kidney transplant for markedly improving health status of dialysis patients. We conducted this study to report data of a 15-year experience of kidney transplant in T&T. For this study, we reviewed national transplant outcomes and procurement quality at the main DD procurement hospital (Port of Spain General Hospital) using some DOPKI⁷ and ODEQUS⁸ quality indicators. Moreover, we examined the role of education of health care professionals and religious leaders for promoting organ donation at the end of life and facilitating a change in community values regarding organ transplant decisions. We also investigated whether national budgetary allocation for organ procurement and NOTU’s policies were aligned with the goal of a sustained organ donation strategy.

This was a retrospective review of a 15-year experience of kidney transplantation in T&T. Our analysis included all single kidney transplants performed between 2006 and 2020. There were no exclusion criteria. Data were obtained from the patients’ medical records at NOTU and the Eric Williams Medical Sciences Complex. This retros-pective study was approved by the Ethics Committee of the North West Regional Health Authority (NWRHA), and informed consent was waived as information was collected from the NOTU and Eric William Medical Sciences Complex databases, with information accessible only to the investigators involved in the research. However, all participants in the 2 surveys especially designed for the purpose of the study gave verbal informed consent to complete the study questionnaires. Participation was voluntary, anonymous, and unpaid. Other data sources included quality indicators, such as DOPKI and ODEQUS, which were collected from a single procurement center (Port of Spain General Hospital) for the period from 2018 through 2020. The Port of Spain General Hospital provides about 57% of all DDs nationally and 59% of all DD kidneys for transplant by NOTU. National budgetary allocations for ODT and dialysis services were also recorded.⁹ Two surveys were conducted. In one survey, health care workers, health care staff professionals, and students in the final year of medical or nursing studies from 2 hospitals of the NWRHA were invited to complete an 8-item questionnaire on ODT immediately after having received face-to-face educational ODT sessions. Questions regarding knowledge, attitudes, and behavioral beliefs of organ transplant and brain death were selected from a validated questionnaire on ODT described by Singh and associates.¹⁰ For the other survey, leaders of the main religious denominations (Roman Catholic, Anglican, Hindu, Muslim, Orisha, Baptist, Pentecostal/Evangelical, Methodist, Presbyterian, Seventh Day Adventist, Sai Baba, Hare Krishna, Mormon, and Jehovah’s Witnesses) were approached via telephone to obtain permission to conduct a voluntary and anonymous survey involving the completion of a 20-item Google form before and after viewing and listening to a PowerPoint audio slideshow video. The main topics presented in this 25-slide video included the need and concerns of ODT, the beliefs of organ donation under the viewpoints of different religions, the importance of becoming a donor to save lives, and the legal normative for organ donor registration. The inclusion criterion for both surveys was that participants had to be 18 years of age or older.

The following recipient and donor data were collected: demographics (sex, age at transplant, date of transplant, ethnicity); donor relationship with the recipient; cause of death of DD; outcome of recipients and grafts with survival rates from 1 to 15 years post-transplant; quality indicators of kidney procurement performance at the Port of Spain General Hospital for the years 2018, 2019, and 2020; budgetary alignment with quality improvement in DD transplants; and results of the surveys of the health care workers and religious leaders.

In the survey of the religious leaders, a sample size of 80 participants would be required for 95% power and a difference of 2 standard deviations (SD) for 98% of persons to change their beliefs in a hypothesized direction. The 20 Faith-Based Organizations (FBOs) in T&T that received funding from the government to assist in providing food and other COVID-19 pandemic relief to vulnerable individuals and families across the country¹¹ were selected; thus, 4 leaders from each of the 20 FBOs would provide a sample size of 80 participants. Categorical data are expressed as frequencies and percentages and continuous data as means and SD. Survival rates are reported as percentages and standard error (SE). The primary data obtained from the Google forms collected before and after the video presentation were exported to an Excel spreadsheet for analysis. Survival estimates were obtained with the Kaplan-Meier method. Data were analyzed with the Statistical Package for the Social Sciences (SPSS) version 27 for Windows.

Demographics and transplant characteristics

During the 15-year study period, 195 single kidney transplants were performed, with 149 (76.4%) from LDs and the remaining 46 (23.6%) from DDs. Salient characteristics and outcomes are shown in (Table 1). There was a similar distribution of male and female patients among LD recipients (55.7% males, 44.3% females), whereas males accounted for 76.1% among DD recipients. The mean ages of LD recipients and DD recipients were 37.8 and 40.2 years, respectively, with a range from 9 to 70 years and 19 to 66 years respectively. Deceased donors had a mean age of 32.8 years, with a range from 16 to 60 years. Most LD recipients were Indian (56.4%), whereas Africans represented the largest ethnicity among deceased donors (42.9%). Regarding the relationship between donors and recipients of living donor transplant, 72.5% were genetically related, mainly sibling-sibling, and 27.5% were emotionally related, mainly friends. In relation to the cause of death for DD, forensic deaths (assaults, road/motor accidents, falls, and gunshot wounds) accounted for 60.7% of the cases and natural deaths for 32.1%. Outcomes were somewhat better for DD recipients compared with LD recipients (78.2% vs 64.4% with functional grafts). The percentage of recipients on dialysis was lower for DD recipients than for LD recipients (8.7% vs 14.7%). In addition, the percentages of recipients dead with graft functional or on dialysis were somewhat lower among DD recipients (Table 1). The national rates of donation from LD ranged from 2.9 to 12.1 per million population (pmp) and from DD from 0.71 to 3.6 pmp (Figure 1, top). The corresponding national rates for kidney transplant ranged from 2.9 to 12.1 pmp for LD transplants and from 0.71 to 7.1 pmp for DD transplants (Figure 1, bottom).

Recipient and graft survival rates from LD and DD kidney transplants are shown in (Table 2). In LD transplants, the 1-, 3-, 5-, 10-, and 15-year survival rates for recipients were 94.3% (SE 0.020), 92.0% (SE 0.023), 88.7% (SE 0.028), 80.1% (SE 0.040), and 74.1% (SE 0.057), respectively. In DD transplants, the 1-, 3-, 5-, 10-, and 12-year survival rates for recipients were 94.7% (SE 0.020), 92.3% (SE 0.023), 89.8% (SE 0.027), 82.5% (SE 0.038), and 80.5% (SE 0.042), respectively. Kaplan-Meier estimates for patient and graft survival are shown in (Figure 2) for LD transplants and in (Figure 3) for DD transplants.

The distribution of quality indicators for kidney procurement performance at the Port of Spain General Hospital in 2018, 2019, and 2020 is shown in (Table 3). There was a notable decrease in bed capacity and hospital and intensive care unit (ICU) admissions in 2019 and 2020. The number of brain deaths and potential DDs was small, with only 2 in 2018 and 1 in 2019 and 2020 each, showing a reduced rate of DD effectiveness (2.6% in 2018, 1.5% in 2019, and 1.9% in 2020). In relation to ODEQUS indicators, 3 structure indicators (24/7 availability of the procurement team, donation process protocol, and donation
team with ICU background) met the target recommendations, as well as organ donation seminars and evaluation and management of possible donors in the group of process indicators. However, the conversion rate, which ranged from 4.1% to 13.3%, was clearly below the target of 75%. The annual cost of hemodialysis was estimated as 72 million T&T dollars (TTD) (ratio of TTD to US dollars is 7:1). This comprised 1.2% of the total $6084 million TTD health care budget of the country in 2019 and 2020. In sharp contrast, the annual budget to NOTU for all transplant activities was $0.75 million TTD, representing 1% of the hemodialysis budget or 0.01% of the health allocation.⁹

A total of 319 health care workers completed the survey on ODT; 232 (72.7%) were women, with a fairly even age distribution between 18 and 50 years (only 28 participants were over 50 years of age). Almost 50% (n = 156) were students, and the remaining surveyed people were staff professionals from 2 hospitals of the NWRHA. Attitudes about ODT were very positive, with 249 respondents (78.1%) indicating that they would accept an organ from a deceased person, 224 (70.2%) willing to donate their organs after death, and 295 (92.5%) willing to donate a loved one’s organs with prior discussion in life (and 167 [52.3%] without prior discussion). After the educational ODT session, however, only 211 (66.1%) understood that brainstem death meant that the patient was dead. Only 10 of the 20 FBOs approached agreed to take part in the study, with a total of 32 participants, 15 of whom completed the questionnaire before and after viewing the PowerPoint video, 9 who completed the survey before only, and 8 who completed the survey after only. Male leaders accounted for 61.5%, and 88.5% were older than 50 years of age. Among responders, 92% knew that ODT was being done in T&T and 70.6% knew a person who was awaiting or underwent a successful kidney transplant. Moreover, 72.5% thought their religion encouraged kidney donation from a LD, 66.7% believed their religion encouraged DD to save another’s life, and 100% would counsel a fellow believer to donate their organs as their religion supports it. Finally, the main Muslim FBO convened its scholars and issued an official fatwa in support of ODT.

This review presented data on kidney transplant in T&T over a 15-year period, representing a study of the longest time interval in the country on this subject. Previously, Roberts and colleagues⁵ reported the results of the SORTTT study (survival outcomes of kidney transplants in T&T) for a 5.5-year period (January 2006 to June 2011). The comparison of our study with data from the SORTTT study showed a remarkable increase in the number of LD kidney transplants, which increased from 70 to 149 (2.1-fold increase), and in DD kidney transplants, which greatly changed from 3 to 46 (15.3-fold increase). As shown in (Figure 4) and in relation to LD kidney transplants, there was an improvement over the years in patient survival rates at 1, 2, and 3 years posttransplant, probably as a result of the use of better immunosuppression regimens and advances in surgical techniques and experience. The DD registry has substantially increased from 300 cases in 2011 to over 2000 cases in 2020 but remains far from achieving 10% of the population. Overall, the DD rates increased from 0.71 to 3.6 pmp and DD kidney transplants from 0.71 to 7.1 pmp. Our transplant rate of 7.1 is similar to 8 pmp for Panama and higher than 0 to 6 pmp corresponding to 9 other countries included in the 2019 report of the Latin American Dialysis and Renal Transplantation Registry.¹² The patient and graft survival rates at 1, 5, and 10 years for both LD and DD kidney transplants are similar to those reported in a retrospective cohort study of 944 kidney transplants performed between 2002 and 2015 in one center in São Paulo, Brazil.¹³ Living donor recipients were younger than DD recipients, with mean age of 37.8 versus 40.2 years; the mean age of DDs was 32.8 years. Patient survival rates were consistently slightly higher for DD recipients than for LD recipients, whereas graft survival rates for LD transplants versus DD transplants were slightly higher at 1, 5, and 12 years. The age of the LDs was not recorded by NOTU; however, given that most LDs were siblings and friends, it may be assumed that they would be close in age to the LD recipients. The marked change in bed capacity from 662 in 2018 to 280 in 2019 and 329 in 2020 could be explained by particular circumstances in T&T. In August 2018, an earthquake caused significant structural damage to the main patient block at Port of Spain General Hospital, a fire destroyed the department of radiology in 2019, and reconstruction activities started amidst the COVID-19 pandemic and the uncontrollable bed shortages in 2020. All of these situations affected the number of hospital and ICU admissions. Assessment of quality indicators of kidney procurement at the Port of Spain General Hospital showed that some ODEQUS structural, process, and outcome indicators were met; however, the conversion rate was very low (13.3% in 2018) compared with the recommended percentage of 75%. The proportion of donation team members with an ICU background (78%-88%) was well above the recommended 50%. In addition, donation process procedures, proactive donor identification, and documentation of key points in the donation process were in line with standard operating procedures. However, since the training of one staff member as a TPM in 2011, there have been unfulfilled promises to recognize, compensate, and formally incorporate TPMs at peripheral retrieval hospitals into the NOTU organizational structure, with all TPMs supporting the work of a full-time key donation person and 24/7 availability of a procurement team at each peripheral retrieval hospital. Although indicators of evaluation and management of potential brain death donors were in agreement with recommendations, the documentation of a patient as a potential DD before diagnosis of brain death was seen as unethical and causing family anguish, resulting in ICU team distrust and outright antagonism to ODT. One of the greatest challenges in truly improving donor conversion rates, and subsequently increasing the number of organs available, is early identification of potential organ donors by the local organ procurement team.¹⁴ In a systematic review of studies on national estimations of potential donors for transplant, conversion rates of 47.5% were reported to lead to 86.4 transplanted organs pmp.¹⁵ Different assessment tools are also related to the donor conversion rate.¹⁶ In our study, deceased donation rates steadily improved, peaking at 5 donors in 2014, with 10 DD and 10 LD kidney transplants, with subsequent declines due to critical pathway gaps affecting quality of donation effectiveness and conversion rates. Budgetary allocation for NOTU was visibly inadequate and insufficient, with no allocation for organ procurement at any of the 3 peripheral donor retrieval hospitals, although these centers provided 76% of all DDs. The fact that funding for hemodialysis is 100 times larger compared with transplant is of major concern.² Other challenges include “the lack of full-time TPMs at retrieval hospitals and the situation of unpaid voluntary activities of goodwill by trained TPM health care professionals (physicians and nurses) with demanding full-time responsibilities.”² The survey of health care workers showed very positive attitudes about ODT, although the meaning of brainstem death was understood by only 66% of respondents after the educational ODT session. However, despite medical and legal acceptance globally of brain death, the concept of brain death or brainstem death is still unclear, and, with influence from sociocultural factors, it remains difficult for brain death to be accepted as true death.^17-19 Religious leaders also showed supportive positive attitudes to ODT, reflecting an opportunity for including ODT understanding as a pastoral aspect of bereavement counseling. Limitations include the small number of participants who completed the before and after questionnaire and the unfeasibility of personal interviews due to the COVID-19 pandemic.

The review of a 15-year experience in kidney transplant in T&T showed encouraging results with high patient and graft survival rates. There have been remarkable improvements in LD and DD transplant procedures as well as to the DD registry, although there are still important shortcomings for the full implementation of quality indicators in the health care system, NOTU, and all procurement hospitals. Enhancing both quality performance and donation effectiveness will require rebalancing and improving budgetary resource allocation from renal dialysis procedures to kidney transplant, funding deceased organ procurement, and facilitating ODT education for religious leaders and health care professionals for end-of-life care and change of community values in organ transplant decisions.

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