Recently, continuous nonoxygenated hypothermic machine perfusion (HMP) has been implemented as standard preservation method for deceased donor kidneys in the Netherlands. This study was designed to ...assess the effect of the implementation of HMP on early outcomes after transplantation.
Kidneys donated in the Netherlands in 2016 and 2017 were intended to be preserved by HMP. A historical cohort (2010-2014) preserved by static cold storage was chosen as the control group. Primary outcome was delayed graft function (DGF). Additional analyses were performed on safety, graft function, and survival up until 2 y after transplantation.
Data were collected on 2493 kidneys. Analyses showed significantly more donation after circulatory death, preemptive transplantation, and retransplants in the project cohort. Of the 681 kidneys that were transplanted during the project, 81% were preserved by HMP. No kidneys were discarded due to HMP-related complications. DGF occurred in 38.2% of the project cohort versus 43.7% of the historical cohort (P < 0.001), with a significantly shorter duration within the project cohort (7 versus 9 d, P = 0.003). Multivariate regression analysis showed an odds ratio of 0.69 (95% confidence interval, 0.553-0.855) for the risk of DGF when using HMP compared with cold storage (P = 0.001). There was no significant difference in kidney function, graft survival, and recipient survival up until 2 y posttransplantation.
This study showed that HMP as a standard preservation method for deceased donor kidneys is safe and feasible. HMP was associated with a significant reduction of DGF.
The donation rate (DR) per million population is not ideal for an efficiency comparison of national deceased organ donation programs. The DR does not account for variabilities in the potential for ...deceased donation which mainly depends on fatalities from causes leading to brain death. In this study, the donation activity was put into relation to the mortality from selected causes. Based on that metric, this study assesses the efficiency of different donation programs.
This is a retrospective analysis of 2001 to 2015 deceased organ donation and mortality registry data. Included are 27 Council of Europe countries, as well as the United States. A donor conversion index (DCI) was calculated for assessing donation program efficiency over time and in international comparisons.
According to the DCI and of the countries included in the study, Spain, France, and the United States had the most efficient donation programs in 2015. Even though mortality from the selected causes decreased in most countries during the study period, differences in international comparisons persist. This indicates that the potential for deceased organ donation and its conversion into actual donation is far from being similar internationally.
Compared with the DR, the DCI takes into account the potential for deceased organ donation, and therefore is a more accurate metric of performance. National donation programs could optimize performance by identifying the areas where most potential is lost, and by implementing measures to tackle these issues.
Summary
This paper addresses ethical, legal, and psychosocial aspects of Global Kidney Exchange (GKE). Concerns have been raised that GKE violates the nonpayment principle, exploits donors in low‐ ...and middle‐income countries, and detracts from the aim of self‐sufficiency. We review the arguments for and against GKE. We argue that while some concerns about GKE are justified based on the available evidence, others are speculative and do not apply exclusively to GKE but to living donation more generally. We posit that concerns can be mitigated by implementing safeguards, by developing minimum quality criteria and by establishing an international committee that independently monitors and evaluates GKE’s procedures and outcomes. Several questions remain however that warrant further clarification. What are the experiences and views of recipients and donors participating in GKE? Who manages the escrow funds that have been put in place for donor and recipients? What procedures and safeguards have been put in place to prevent corruption of these funds? What are the inclusion criteria for participating GKE centers? GKE provides opportunity to promote access to donation and transplantation but can only be conducted with the appropriate safeguards. Patients’ and donors’ voices are missing in this debate.
The wait time for deceased‐donor kidney transplantation has increased to 4–5 years in the Netherlands. Strategies to expand the donor pool include a living donor kidney exchange program. This makes ...it possible that patients who cannot directly receive a kidney from their intended living donor, due to ABO blood type incompatibility or a positive cross match, exchange donors in order to receive a compatible kidney. All Dutch kidney transplantation centers agreed on a common protocol. An independent organization is responsible for the allocation, cross matches are centrally performed and exchange takes place on an anonymous basis. Donors travel to the recipient centers. Surgical procedures are scheduled simultaneously. Sixty pairs participated within 1 year. For 9 of 29 ABO blood type incompatible and 17 of 31 cross match positive combinations, a compatible pair was found. Five times a cross match positive couple was matched to a blood type incompatible one, where the recipients were of blood type O. The living donor kidney exchange program is a successful approach that does not harm any of the candidates on the deceased donor kidney waitlist. For optimal results, both ABO blood type incompatible and cross match positive pairs should participate.
Background
The aim of this nationwide observational study is to identify modifiable factors in communication about organ donation that influence family consent rates.
Methods
Thirty-two intensivists ...specialized in organ donation systematically evaluated all consecutive organ donation requests with physicians in the Netherlands between January 2013 and June 2016, using a standardized questionnaire.
Results
Out of 2528 consecutive donation requests, 2095 (83%) were evaluated with physicians. The questionnaires of patients registered with consent or objection in the national donor registry were excluded from analysis. Only those questionnaires, in which the family had to make a decision about donation, were analyzed (
n
= 1322). Independent predictors of consent included: requesting organ donation during the conversation about futility of treatment (OR 1.8;
p
= 0.004), understanding of the term ‘brain death’ by the family (OR 2.4;
p
= 0.002), and consulting a donation expert prior to the donation request (OR 3.4;
p
< 0.001).
Conclusions
Our study showed that decoupling the organ donation conversation from the conversation about futility of treatment was associated with lower family consent rates. Comprehension of the concept of brain death by the family and consultation with a transplant coordinator before the organ donation request by the physician could positively influence consent rates.
Background
One of the most important bottlenecks in the organ donation process worldwide is the high family refusal rate.
Aims and objectives
The main aim of this study was to examine whether family ...guidance by trained donation practitioners increased the family consent rate for organ donation.
Design
This was a prospective intervention study.
Methods
Intensive and coronary care unit nurses were trained in communication about donation (ie, trained donation practitioners) in two hospitals. The trained donation practitioners were appointed to guide the families of patients with a poor medical prognosis. When the patient became a potential donor, the trained donation practitioner was there to guide the family in making a well‐considered decision about donation. We compared the family consent rate for donation with and without the guidance of a trained donation practitioner.
Results
The consent rate for donation with guidance by a trained donation practitioner was 58.8% (20/34), while the consent rate without guidance by a trained donation practitioner was 41.4% (41/99, P = 0.110) in those patients where the family had to decide on organ donation.
Conclusions
Our data suggest that family guidance by a trained donation practitioner could benefit consent rates for organ donation.
Relevance to clinical practice
Trained nurses play an important role in supporting the families of patients who became potential donors to guide them through the decision‐making process after organ donation request.
Dutch Law Approves Opt-out System Reinders, Marlies E J; Reiger-van de Wijdeven, Jeantine M M P J; de Jonge, Jeroen ...
Transplantation,
08/2018, Letnik:
102, Številka:
8
Journal Article
Living donor kidney exchange is now performed in several countries. However, no information is available on the practical problems inherent to these programs. Here, we describe our experiences with ...276 couples enrolled in the Dutch program.
Our protocol consists of five steps: registration, computerized matching, crossmatching, donor acceptation, and transplantation. We prospectively collected data of each step of the procedure.
Of the 276 registered pairs we created 183 computer-matched combinations. However, 62 of 183 recipients proved to have a positive crossmatch with their new donor, which was not predicted by the screening results of the recipient centers. Alternative solutions were found for 39 couples, resulting in a total of 160 new combinations with negative crossmatches. Thereafter, because of 22 individual clinical problems, the exchange procedure had to be discontinued for 51 couples while only for 19 of them alternative solutions were found. At the end of day, 128 patients had received exchange kidneys, 55 were transplanted outside the program, 59 are still on the crossover waitlist, and 34 had left the program for medical or psychological reasons.
A living donor kidney exchange program is a dynamic process. Many clinical hurdles and barriers are encountered that for a large part were not foreseen but should be taken into account when programs are initiated based on computer simulations. Success is dependent on a flexible organization able to create alternative solutions when problems arise. Centralized allocation and crossmatch procedures are instrumental in this respect.
Background. The Netherlands has a low number of deceased organ donors per million population. As long as there is a shortage of suitable organs, the need to evaluate the donor potential is crucial. ...Only in this way can bottlenecks in the organ donation process be detected and measures subsequently taken to further improve donation procedures. Methods. Within a time frame of 4 years, 2005–08, medical charts of all intensive care deaths in 64 hospitals were reviewed by transplant coordinators and donation officers. Data were entered in a web-based application of the Dutch Transplant Foundation, both to identify the number of potential organ donors (including donation after cardiac death), as well as to analyse the reasons for potential donor loss. Results. In total, 23 508 patients died in intensive care units, of which 64% were younger than 76 years. The percentage of all potential organ donors out of the total number of deaths decreased from 8.2% in 2005 to 7.1% in 2008. Donor detection increased from 96% in 2005 to 99% in 2008. Of the potential donors, 17–21% recorded consent and 17–18% recorded objection in the national Donor Register. If the Donor Register was not decisive, the consent rate of families approached for organ donation was 35% in 2005, 29% in 2006, 41% in 2007 and 31% in 2008. The overall conversion rate (the number of actual donors divided by the number of potential donors) was 30%, 26%, 35% and 29% in these years. In the group of potential donor losses, objection by families accounted for about 60% during this study. Conclusions. This study showed that the maximal number of potential organ donors is about three times higher than the number of effective organ donors. The main reason accounting for ∼60% of the potential donor losses was the high family refusal rate. The year 2007 showed that a higher percentage of deceased organ donors can be procured from the pool of potential donors. All improvements should focus on decreasing the unacceptably high family refusal rates.
The availability of donor organs is considerably reduced by relatives refusing donation after death. There is no previous large-scale evaluation of the influence of the Donor Register (DR) ...consultation and the potential donor's age on this refusal in The Netherlands.
This study examines 2101 potential organ donors identified in intensive care units between 2005 and 2008 and analyzes the association of DR consultation and subsequent refusal by relatives and the relationship with the potential donor's age.
Of the 1864 potential donor cases where the DR was consulted, the DR revealed no registration in 56%, 20% registration of consent, and 18% objection. In the other 6.5% of cases, where the DR indicated that relatives had to decide, the relatives' refusal rate was significantly lower than in the absence of a DR registration (46% vs. 63%). In 6% of the cases where the DR recorded donation consent, relatives still refused donation. DR registration, objection in the DR, and the relatives' refusal rate if the DR was not decisive increased with donor age.
Despite the introduction of a DR, relatives still play an equally important role in the final decision for organ donation. The general public should be encouraged to register their donation preferences in the DR and also to discuss their preferences with their families. The higher refusal rate of older potential donors means that this group should receive more information about organ donation, especially because the cohort of available donors is ageing.
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