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DONOR MANAGEMENT:
US Perspective
CCCFOctober 26, 2015
Darren Malinoski, MD, FACSAssistant Chief of Surgery
Portland VA Medical CenterAssociate Professor of Surgery
Oregon Health & Science University*My views may not
represent those of
the U.S. Government
BACKGROUND
Shortage of organs for transplantation
National average of three organs transplanted per donor (OTPD)
30% of hearts utilized
Inconsistent donor management practices
BACKGROUND
Checklists have demonstrated utility in
several arenas
Standardized critical care endpoints
Donor Management Goals (DMGs)
OTPD and DMGs
UNOS Region 5 DMGs
Step 1 – retrospective – 2007-2008
Achieving Donor Management Goals (DMG) Prior to Deceased Donor Procurement is Associated with More Organs Transplanted per Donor
Primary outcome measure: > 4 OTPD
DMG/Variable OR 95% CI p value
Continuous Variables
Age (years) 0.944 0.923 – 0.966 < 0.001
Creatinine (mg/dL) 0.636 0.409 – 0.987 0.044
Categorical Variables
Thyroid Hormone use 1.969 1.082 – 3.582 0.026
CVP 4 – 10 mmHg 1.897 1.021 – 3.527 0.043
EF > 50% 3.988 2.095 – 7.592 < 0.001
P:F > 300 on PEEP 5 4.591 2.478 – 8.506 < 0.001
Na 135 – 160 mEq/L 3.352 1.141 – 9.851 0.028
“Goals met” 4.394 2.497 – 7.732 < 0.001
UNOS Region 5 DMGs
Step 2
Prospective
Three time points
At authorization for donation
12-18 hours later – organ offers being made
Prior to organ recovery
Modified DMGs
June 2008 – January 2009
UNOS Region 5 DMGs
Prospective Data 380 SCDs
The Impact of Meeting Donor Management Goals on the Number of Organs Transplanted per Donor Primary outcome measure: > 4 OTPD
Results confirmed findings of retrospective study
BACKGROUND
Organs transplanted per donor is not an
ideal outcome measure
Graft function is a better endpoint
Variable OR 95% CI p
Age (per year) 1.02 1.01-1.03 0.003
Creatinine prior to recovery (per mg/dL)
1.4 1.1-1.6 0.001
ECD 0.9 0.5-1.5 0.664
Cold ischemia time (per hour) 1.03 1.01-1.05 0.011
DMGs met at authorization 0.5 0.3-0.9 0.019
- 2013 American Journal of Transplantation
UNOS DMG Web PortalLaunched in March 2012 – supported by Tii
Forced field
entry
Linked to
UNet
Recipient
data added
Fields for
study data
Funded by
OPOs
SRTR SAF
merger *Now includes 14 OPOs from 7 UNOS Regions
Other recent publications from
the DMG Web Portal
Optimal Glucose Threshold = < 180 mg/dL
DMGs in ECDs
Propensity Analyses:
Hespan Use in the Donor on Recipient DGF
*Blood Transfusions in the Donor on DGF
*Predictors of cardiac graft outcomes
RCT:
Impact of Therapeutic Mild Hypothermia Prior to Organ Recovery on DGF
The Transfusion Effect Revisited: Impact of
Blood Transfusions in Deceased Organ
Donor on the Outcomes of 1884 Renal
Grafts from UNOS Region 5
J Salvador de la Cruz, John Zatarain, Mitch Sally,
Megan Crutchfield, Katrina Ramsay, Jodi Lapidus,
Susann Orloff, Darren Malinoski
Portland Veterans Affairs Medical Center
Oregon Health & Science University
Pre-Transplant Blood
Transfusion Historically: Kidney recipients given blood
transfusions prior to transplantation
Blood Transfusion and Kidney Transplant:
Results of Two Independent Studies
Patients without
Transfusion
Patients with
Transfusions
Year of Study 1 Year Graft
Survival
1 Year Graft
Survival
P value
1974 32% 53% 0.02
1976 31% 49% 0.01
Opelz G, Terasaki PI. Prog Clin Biol Res. 1976;11:133-40.
Transplanted Kidneys1,884
26% DGF rate250/975
34% DGF rate309/909
p<0.001
Results
Donor after Circulatory Death : 223< 18 years old: 177Separate trial: 183No kidney donated: 283Missing outcome data: 80
Total Donors(n=1,952)
DNDDs with > 1 kidney transplanted
(n=1,006)
Donors excluded N=946
≥1 unit of blood transfused975 (52%)
No blood transfused909 (48%)
Results:
Univariate Analysis – DGF
Categories of Number of Units of Blood Transfused
VariableNo Units
(n=909)
1-5 Units
(n=605)
6-10 Units
(n=198)
>10 Units
(n=172)p-value
DGF rate 34% 27% 25% 21% <0.001
Variable OR 95% CI for OR p-value
Blood Transfusion Category
Zero Units of Blood Ref -- --
1 to 5 Units of Blood 0.79 0.60 - 1.02 0.077
6 to 10 Units of Blood 0.79 0.52 - 1.20 0.281
Greater than 10 Units of Blood 0.56 0.35 - 0.91 0.019
Results:
Multivariate Analysis – DGF with
Propensity Score Included
Results:
Univariate Analysis – DGF
Impact of Donor Demographics and
Critical Care Endpoints on Cardiac
Transplantation and Recipient Survival
3433
DNDDs
2299 (67%)
Heart NOTTransplanted
1134 (33%)
Heart Transplanted
158 (14%)
Dead / Re-Tx
976 (86%)
Alive
*Follow-up 684 + 392
days
Impact of Donor Demographics and
Critical Care Endpoints on Cardiac
Transplantation and Recipient Survival
3433
DNDDs
2299 (67%)
Heart NOTTransplanted
1134 (33%)
Heart Transplanted
158 (14%)
Dead / Re-Tx
976 (86%)
Alive
*Follow-up 684 + 392 days
Multivariate Analysis: Predictors of Heart Transplantation
Multivariate Analysis: Predictors of Heart Transplantation
Multivariate Analysis: Predictors of Heart Transplantation
Impact of Donor Demographics and
Critical Care Endpoints on Cardiac
Transplantation and Recipient Survival
3433
DNDDs
2299 (67%)
Heart NOTTransplanted
1134 (33%)
Heart Transplanted
158 (14%)
Dead / Re-Tx
976 (86%)
Alive
*Follow-up 684 + 392 days
SRTR Data
Added:
Elements of
risk-adjusted
1-year Recipient
Survival Model
Multivariate Analysis: Predictors of Heart Recipient Survival*
Impact of Donor Demographics and
Critical Care Endpoints on Cardiac
Transplantation and Recipient Survival
Thyroid hormone dose
5.6 mcg/hr
Heart NOTTransplanted
4.5 mcg/hr
Heart Transplanted
2.9 mcg/hr
Dead / Re-Tx
4.8 mcg/hr
Alive
p value =
0.005
p value =
0.001
*Follow-up 684 + 392 days
Impact of Donor Demographics and
Critical Care Endpoints on Cardiac
Transplantation and Recipient Survival
Thyroid hormone dose
5.6 mcg/hr
Heart NOTTransplanted
4.5 mcg/hr
Heart Transplanted
2.9 mcg/hr
Dead / Re-Tx
4.8 mcg/hr
Alive
p value =
0.005
p value =
0.001
*Follow-up 684 + 392 days
Summary
Predictors of heart utilization:
Donor age, SCD, male, BMI <30, DMGs,
creatinine, pressors, thyroid hormone [less]
Summary
less
Predictors of heart survival
Donor age, SCD, male, DMGs, creatinine,
thyroid hormone [more] RCT needed
Summary
less
more
Mild hypothermia does not affect cardiac
graft utilization or recipient survival
