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Current risk-adjusted models for donor lung use and lung graft survival do not include donor critical care data. We sought to identify modifiable donor physiologic and mechanical ventilation parameters that predict donor lung use and lung graft survival. This is a prospective observational study of donors after brain death (DBDs) managed by 19 Organ Procurement Organizations from 2016 to 2019. Demographics, mechanical ventilation parameters, and critical care data were recorded at standardized time points during donor management. The lungs were transplanted from 1811 (30%) of 6052 DBDs. Achieving ≥7 critical care endpoints was a positive predictor of donor lung use. After controlling for recipient factors, donor blood pH positively predicted lung graft survival (OR 1.48 per 0.1 unit increase in pH) and the administration of dopamine during donor management negatively predicted lung graft survival (OR 0.19). Tidal volumes ≤8 ml/kg predicted body weight (OR 0.65), and higher positive end-expiratory pressures (OR 0.91 per cm H2 O) predicted decreased donor lung use without affecting lung graft survival. A randomized clinical trial is needed to inform optimal ventilator management strategies in DBDs.

Organ transplantation is a life-saving intervention for patients suffering from end-stage organ failure, but it relies on the availability of donor organs. However, even when donors are available, the brain-dead organ donor is a clinically complex patient who presents many management challenges. Donor management with a goal of optimization of organ function is essential to maximizing the number of patients who can be helped by each individual donor. Thoughtful critical care management of the potential organ donor, with a focus on meeting donor management goals, can lead to improved donation outcomes.

The shortage of organ donors remains the major limiting factor in lung transplant, with the number of patients on the waiting list largely exceeding the number of available organ donors. Another issue is the low utilization rate seen in some types of donors. Therefore, novel strategies are continuously being explored to increase the donor pool. Advanced age, smoking history, positive serologies, and size mismatch are common criteria that decrease the rate of use when it comes to organ utilization. Questioning these limitations is one of the purposes of this review. Challenging these limitations by adapting novel donor management strategies could help to increase the rate of suitable lungs for transplantation while still maintaining good outcomes. A second goal is to present the latest advances in organ donation after controlled and uncontrolled cardiac death, and also on how to improve these lungs on ex vivo platforms for assessment and future specific therapies. Finally, pushing the limit of the donor envelope also means reviewing some of the recent improvements made in lung preservation itself, as well as upcoming experimental research fields. In summary, donor lung optimization refers to a global care strategy to increase the total numbers of available allografts, and preserve or improve organ quality without paying the price of early-, mid-, or long-term negative outcomes after transplantation.

Lung transplantation (LTx) is the definitive treatment for select progressive end-stage lung disease patients despite being on optimum medical therapy. Asian countries like China, Japan and India have started LTx programmes despite various odds and challenges. Some of these challenges seem to be unique to developing countries. We have elaborated the challenges of LTx in India and their proposed solutions and shared our experience in setting up a successful LTx programme.

Background Little has changed in donor management and liver utilization rates in Brazil over the last decade. With a growing demand for liver donations, organ waste is an important obstacle toward better patient care. The study of discarded donors helps to shed light on the possibilities of increasing organ usage, including by using extended criteria donors. Methods We retrospectively analyzed all discarded liver donors in a high-volume Brazilian transplant center from January 2015 to December 2018. Pertinent clinical and laboratorial data were collected from the donors’ electronic health records. Results In our study period, there were 248 liver harvests, of which 67 (27.0%) were discarded. Most discarded donors were male (65.7%). More than three-quarters of donors were Caucasian (79.1%). Median donor body mass index was 26.27 kg/m2, and most discarded donors presented no comorbidities. Donor liver injury tests were abnormal in 56 (83.5%) out of 67 discarded donors. Forty-three (64.1%) donors presented elevated transaminases. Alanine aminotransferase levels were elevated in 35 (52.2%) discarded donors, with a median value of 38 U/L. Half of all discarded livers were due to graft-related issues. Twenty-eight organs (41.79%) presented external pathologic alterations. Organ refusal due to donor clinical and laboratorial condition was reported in 24 cases. Conclusion It is clear there is a considerable issue of organ waste in Brazil, with the subjective judgment of graft quality and inadequate interpretation of donor’s laboratorial exams leading to excessive denial of organs that could be fitted into extended criteria for donation.

BACKGROUND Delayed graft function (DGF) after kidney transplantation is a common occurrence and correlates with poor graft and patient outcomes. Donor characteristics and care are known to impact DGF. We attempted to show the relationship between achievement of specific donor management goals (DMG) and DGF. METHODS This is a retrospective case-control study using data from 14 046 adult kidney donations after brain death from hospitals in 18 organ procurement organizations (OPOs) which were transplanted to adult recipients between 2012 and 2018. Data on DMG compliance and donor, recipient, and ischemia-related factors were used to create multivariable logistic regression models. RESULTS The overall rate of DGF was 29.4%. Meeting DMGs for urine output and vasopressor use were associated with decreased risk of DGF. Sensitivity analyses performed with different imputation methods, omitting recipient factors, and analyzing multiple time points yielded largely consistent results. CONCLUSIONS The development of DMGs continues to show promise in improving outcomes in the kidney transplant recipient population. Studies have already shown increased kidney utilization in smaller cohorts, as well as other organs, and shown decreased rates of DGF. Additional research and analysis are required to assess interactions between meeting DMGs and correlation versus causality in DMGs and DGF.

Supplemental Digital Content is available in the text., Background. Early prediction of whether a liver allograft will be utilized for transplantation may allow better resource deployment during donor management and improve organ allocation. The national donor management goals (DMG) registry contains critical care data collected during donor management. We developed a machine learning model to predict transplantation of a liver graft based on data from the DMG registry. Methods. Several machine learning classifiers were trained to predict transplantation of a liver graft. We utilized 127 variables available in the DMG dataset. We included data from potential deceased organ donors between April 2012 and January 2019. The outcome was defined as liver recovery for transplantation in the operating room. The prediction was made based on data available 12–18 h after the time of authorization for transplantation. The data were randomly separated into training (60%), validation (20%), and test sets (20%). We compared the performance of our models to the Liver Discard Risk Index. Results. Of 13 629 donors in the dataset, 9255 (68%) livers were recovered and transplanted, 1519 recovered but used for research or discarded, 2855 were not recovered. The optimized gradient boosting machine classifier achieved an area under the curve of the receiver operator characteristic of 0.84 on the test set, outperforming all other classifiers. Conclusions. This model predicts successful liver recovery for transplantation in the operating room, using data available early during donor management. It performs favorably when compared to existing models. It may provide real-time decision support during organ donor management and transplant logistics.

Donör bakımı, son yıllarda “organ yönetimi” olarak adlandırılan yoğun bakımda beyin ölümü tanısı konulmuş hastalara uygulanan tedaviden oluşur. Beyin ölümünde donör adayının kardiak arrestine yol açabilecek hemodinamik, hormonal ve inflamatuvar bozukluklar görülebilir. Bu bozukluklar tedavi edilmezse transplante edilebilecek organ sayısı ve kalitesi düşebilir. Ayrıca donör bakımında hangi organın transplante edilmesi planlanıyorsa ona yönelik tedavi ve bakım uygulanmalıdır. Her biri ayrı öneme sahip bu bozukluklar son literatür taranarak incelenmiştir.

Optimizing the management of deceased organ donors focuses on providing critical care that prevents, mitigates, or repairs the pathophysiologic sequelae of brain death. This review discusses protocol-based care; approaches to monitoring, resuscitation, hormone replacement therapy, and respiratory management; and the potential of various additional donor therapies.Protocol-based critical care after the determination of brain death has the potential to substantially increase the quantity and improve the quality of organs available for transplantation. Close hemodynamic monitoring with timely resuscitation using isotonic fluid replacement as well as adjunctive vasoactive and hormone replacement therapy in the persistently hemodynamically unstable donor is recommended. Convincing evidence suggests that mild therapeutic hypothermia of the donor can be adopted to reduce delayed graft function in the renal transplant recipient.There continues to be a limited number of current published reports pertaining to deceased organ donor management, with many practices still based on consensus statements. Recent endorsement and recommendations for conducting donor intervention research have provided a framework for future studies, which have potential to lead to the publication of quality results so that more evidence-based guidelines can be developed.

Introduction: Rates of successful organ donation vary between otherwise comparable intensive care units (ICUs). The ICU staff have a unique perspective into the facilitators and barriers underlying this variation in successful deceased organ donation. Research Question: What do ICU staff perceive to be the most meaningful facilitators and barriers to deceased organ donation? Design: We designed and conducted a survey of all disciplines working in the ICU to ascertain the perceived facilitators and barriers to donation in an academic tertiary care hospital. Survey reliability was assessed using Cronbach α. Factor analysis was used to assess construct validity and identify potentially redundant survey items. Results: We had responses from 108 ICU staff, including nurses (n = 75), respiratory therapists (n = 14), physicians (n = 12), chaplains (n = 2), as well as social work, pharmacy, physiotherapy, and occupational therapy (n = 1 each). Perceived facilitators included availability of organ donation organization coordinators, explicit institutional support for donation, ICU staff culture toward donation, standardized order sets for donation, presence of ICU staff with donation experience, and bedside nurse presence at discussions about donation. Perceived barriers included ICU staff ruling out potentially suitable donors before consulting a donor coordinator, physician communication skills, low priority for organ donation among operating room staff, limited family understanding of patient prognosis and organ donation, and limited emotional readiness of families to discuss donation. Discussion: Several staff-perceived facilitators and barriers to deceased organ donation were identified in the ICU. Future research could identify strategies to promote these facilitators and overcome barriers.

Introduction:A recent study of pediatric organ donation after the neurologic determination of death (DNDD) demonstrated an association between the use of donor management goals (DMGs) by organ procurement organizations (OPOs) and organ yield.Objective:To describe the pediatric DMGs used by OPOs and any association between specific DMGs and organ yield.Design:Query of US OPOs who utilized DMGs in the care of pediatric DNDD organ donors from 2010 to 2013.Results:All 23 OPOs using DMGs for pediatric DNDD organ donors during the study period participated (100%). The OPOs pursued an average 9.6 goals (standard deviation: 3.9; range: 5-22) with 113 unique definitions that targeted 33 aspects of donor hemodynamics, gas exchange/mechanical ventilation, electrolytes/renal function, blood products, thermoregulation, and infection control. The DMGs used by >50% of OPOs included blood pressure, oxygenation (partial pressure of arterial oxygen (PaO2), oxygen saturation of hemoglobin by pulse oximetry, or PaO2/fractional concentration of inspired oxygen [FiO2] ratio), pH, central venous pressure, serum sodium, urine output, limitations on inotropic support, and serum glucose. There was no significant correlation between the number of DMGs pursued by OPOs and organ yield. There was a difference in the observed/expected organs transplanted in the 0- to 10-year age-group for OPOs that included serum creatinine among their DMGs ( P = .046).Conclusions:The pediatric DMGs used by OPOs were generally measurable but diverse in definition and the number of goals pursued. There was no benefit in organ yield from larger DMG bundles. There may be a benefit in organ yield through the use of serum creatinine as a DMG in pediatric donors aged 0 to 10 years.

Background Brain death frequently induces hemodynamic instability and cardiac stunning. Impairments in cardiac performance are major contributors to hearts from otherwise eligible organ donors not being transplanted. Deficiencies in pituitary hormones (including thyroid-stimulating hormone) may contribute to hemodynamic instability, and replacement of thyroid hormone has been proposed as a means of improving stability and increasing hearts available for transplantation. Intravenous thyroxine is commonly used in donor management. However, small controlled trials have not been able to demonstrate efficacy. Methods This multicenter study will involve organ procurement organizations (OPOs) across the country. A total of 800 heart-eligible brain-dead organ donors who require vasopressor support will be randomly assigned to intravenous thyroxine for at least 12 h or saline placebo. The primary study hypotheses are that thyroxine treatment will result in a higher proportion of hearts transplanted and that these hearts will have non-inferior function to hearts not treated with thyroxine. Additional outcome measures are the time to achieve hemodynamic stability (weaning off vasopressors) and improvement in cardiac ejection fraction on echocardiography. Discussion This will be the largest randomized controlled study to evaluate the efficacy of thyroid hormone treatment in organ donor management. By collaborating across multiple OPOs, it will be able to enroll an adequate number of donors and be powered to definitively answer the critical question of whether intravenous thyroxine treatment increases hearts transplanted and/or provides hemodynamic benefits for donor management. Trial registration ClinicalTrials.govNCT04415658. Registered on June 4, 2020

Background Efforts to ameliorate the organ shortage have predominantly focused on improving processes and interventions at multiple levels in the organ donation process, but no comprehensive review of hospital-level features contributing to organ donation exists. We undertook a systematic review of the literature to better understand current knowledge and knowledge gaps about hospital-level metrics and interventions associated with successful organ donation. Methods We searched six electronic databases (PubMed, Embase, CINAHL, Web of Science, Health Business Elite, and Google scholar) and conference abstracts for articles on hospital-level features associated with the final outcome of organ donation (PROSPERO CRD42020187080). Editorials, letters to the editor, and reviews without original data were excluded. Our main outcomes were conversion rate, donation rate, number of organs recovered, number of donors, and authorization rate. Results Our search yielded 2177 studies, and after a thorough assessment, 72 articles were included in this systematic review. Studies were thematically categorized into 1) Hospital-level interventions associated with metrics of organ donation; these included patient- and family-centric measures (i.e. standardized interviews, collaborative requesting and decoupling, and dedicated in-house coordinators), and donor management goals that significantly increased conversion rates by up to 64%; 2) Hospital-level multi-stage programs/policies; which increased authorization rates between 30 and 50%; and 3) Hospital characteristics and qualities; being an academic center, trauma center and larger hospital correlated with higher authorization and conversion rates. Most studies had considerable risk of bias and were of low quality. Conclusions There is a lack of well-designed studies on hospital-level metrics and interventions associated with organ donation. The use of thoughtful, patient- and family-centric approaches to authorization generally is associated with more organ donors. Future work can build on what is known about the hospital role in organ donation to improve the entire organ donation process.

Drug overdoses have tripled in the United States over the last two decades. With the increasing demand for donor organs, one potential consequence of the opioid epidemic may be an increase in suitable donor organs. Unfortunately, organs from donors dying of drug overdose have poorer utilization rates than other groups of brain-dead donors, largely due to physician and recipient concerns about viral disease transmission. During the study period of 2011 to 2016, drug overdose donors (DODs) account for an increasingly greater proportion of the national donor pool. We show that a novel model of donor care, known as specialized donor care facility (SDCF), is associated with an increase in organ utilization from DODs compared to the conventional model of hospital-based donor care. This is likely related to the close relationship of the SDCF with the transplant centers, leading to improved communication and highly efficient donor care.

Background Over the last decade two alternative models of donor care have emerged in the United States: the conventional model, whereby donors are managed at the hospital where brain death occurs, and the specialized donor care facility (SDCF), in which brain dead donors are transferred to a SDCF for medical optimization and organ procurement. Despite increasing use of the SDCF model, its cost-effectiveness in comparison to the conventional model remains unknown. Methods We performed an economic evaluation of the SDCF and conventional model of donor care from the perspective of U.S. transplant centers over a 2-year study period. In this analysis, we utilized nationwide data from the Scientific Registry of Transplant Recipients and controlled for donor characteristics and patterns of organ sharing across the nation's organ procurement organizations (OPOs). Subgroup analysis was performed to determine the impact of the SDCF model on thoracic organ transplants. Results A total of 38,944 organ transplants were performed in the U.S. during the study period from 13,539 donors with an observed total organ cost of $1.36 billion. If every OPO assumed the cost and effectiveness of the SDCF model, a predicted 39,155 organ transplants (+211) would have been performed with a predicted total organ cost of $1.26 billion (-$100 million). Subgroup analysis of thoracic organs revealed that the SDCF model would lead to a predicted 156 additional transplants with a cost saving of $24.6 million. Conclusions The U.S. SDCF model may be a less costly and more effective means of multi-organ donor management, particularly for thoracic organ donors, compared to the conventional hospital-based model.

Organ transplantation is a recognized treatment for many critical organ insufficiencies. One of the main problems in transplantation is the mismatch between organ donation and demand. It is very important to improve donor eligibility after brain stem death and to minimize insult to donatable organs by appropriate donor management. We present prone positioning as an effective supportive method of organ optimization in patients with acute respiratory distress syndrome with severe hypoxemia and hemodynamic instability.

Background Ex vivo lung perfusion (EVLP) is a widespread accepted platform for preservation and evaluation of donor lungs prior to lung transplantation (LTx). Standard lungs are ventilated using volume-controlled ventilation (VCV). We investigated the effects of flow-controlled ventilation (FCV) in a large animal EVLP model. Fourteen porcine lungs were mounted on EVLP after a warm ischemic interval of 2 h and randomized in two groups (n = 7/group). In VCV, 7 grafts were conventionally ventilated and in FCV, 7 grafts were ventilated by flow-controlled ventilation. EVLP physiologic parameters (compliance, pulmonary vascular resistance and oxygenation) were recorded hourly. After 6 h of EVLP, broncho-alveolar lavage (BAL) was performed and biopsies for wet-to-dry weight (W/D) ratio and histology were taken. The left lung was inflated, frozen in liquid nitrogen vapors and scanned with computed tomography (CT) to assess regional distribution of Hounsfield units (HU). Results All lungs endured 6 h of EVLP. Oxygenation was better in FCV compared to VCV (p = 0.01) and the decrease in lung compliance was less in FCV (p = 0.03). W/D ratio, pathology and BAL samples did not differ between both groups (p = 0.16, p = 0.55 and p = 0.62). Overall, CT densities tended to be less pronounced in FCV (p = 0.05). Distribution of CT densities revealed a higher proportion of well-aerated lung parts in FCV compared to VCV (p = 0.01). Conclusions FCV in pulmonary grafts mounted on EVLP is feasible and leads to improved oxygenation and alveolar recruitment. This ventilation strategy might prolong EVLP over time, with less risk for volutrauma and atelectrauma.

Purpose of review Ex-vivo perfusion has emerged in recent years as an alternative to cold static preservation of organs harvested for transplant. Normothermic ex-vivo perfusion, the subject of this review, maintains the donor heart in a near physiologic state, and allows the transplant team to monitor and control perfusion to the organ prior to implantation. A growing body of evidence has established the safety and viability of this technique, which may improve on current standards of donor management. Recent findings Following initial single-arm studies over a decade ago, ex-vivo perfusion has been studied in a prospective, randomized fashion in standard donor hearts (PROCEED II trial). The short and intermediate-term results demonstrated similar outcomes compared with cold storage with significantly shorter cold ischemic time. Since then, ex-vivo perfusion has been studied in extended-criteria donor hearts, first in observational studies, and currently in randomized, prospective fashion in the recently completed EXPAND-Heart trial, which is anticipated to be reported in 2020. Summary Normothermic ex-vivo perfusion has an established literature base and holds promise for changing current practices of heart preservation. Results of forthcoming pivotal studies will help determine its role in more widespread clinical adoption.

Rationale: Previous studies have shown that a lung-protective strategy, which aims at minimizing ventilator-induced lung injury (with low Vt/high positive end-expiratory pressure as the main pillar...

Lung transplantation provides the prospect of improved survival and quality of life for patients with end stage lung and pulmonary vascular diseases. Given the severity of illness of such patients at the time of surgery, lung transplant recipients require particular attention in the immediate post-operative period to ensure optimal short-term and long-term outcomes. The management of such patients involves active involvement of a multidisciplinary team versed in common post-operative complications. This review provides an overview of such complications as they pertain to the practitioners caring for post-operative lung transplant recipients. Causes and treatment of conditions affecting early morbidity and mortality in lung transplant recipients will be detailed, including primary graft dysfunction, cardiovascular and surgical complications, and immunologic and infectious issues. Additionally, lung donor management issues and bridging the critically ill potential lung transplant recipient to transplantation will be discussed.

Optimal management of pediatric cardiac donors is essential in order to maximize donor heart utilization and minimize the rate of discarded organs. This review was performed after a systematic literature review and gives a detailed overview on current practices and guidelines. The review focuses on optimal monitoring of pediatric donors, donor workup, hormonal replacement, and obliterating the adverse effects of brain death. The current evidence on catecholamine support and thyroid hormone replacement is also discussed. Recognizing and addressing this shall help in a standardized approach toward donor management and optimal utilization of pediatric heart donors organs.

Mortality remains high for patients on the waiting list for organ transplantation. A marked imbalance between the number of available organs and recipients that need to be transplanted persists. Organs from deceased donors are often declined due to perceived and actual suboptimal quality. Adequate donor management offers an opportunity to reduce organ injury and maximise the number of organs than can be offered in order to respect the donor's altruistic gift. The cornerstones of management include: correction of hypovolaemia; maintenance of organ perfusion; prompt treatment of diabetes insipidus; corticosteroid therapy; and lung protective ventilation. The interventions used to deliver these goals are largely based on pathophysiological rationale or extrapolations from general critical care patients. There is currently insufficient high-quality evidence that has assessed whether any interventions in the donor after brain death may actually improve immediate post-transplant function and long-term graft survival or recipient survival after transplantation. Improvements in our understanding of the underlying mechanisms following brain death, in particular the role of immunological and metabolic changes in donors, offer promising future therapeutic opportunities to increase organ utilisation. Establishing a UK donor management research programme involves consideration of ethical, logistical and legal issues that will benefit transplanted patients while respecting the wishes of donors and their families.

Multiple investigations have documented the health-related quality-of-life (HRQoL) and donation-related experiences of unrelated donors (URDs), but similar investigations of the related donor (RD) experience have been less common. The central goal of this study was to longitudinally examine and compare HRQoL of RD and URD hematopoietic stem cell (HSC) donors from predonation through 1 year postdonation. This prospective investigation included adult HSC donors ages 18 to 60 years who donated bone marrow or peripheral blood stem cells at one of 48 geographically diverse US transplant/donor centers and completed HRQoL interviews at predonation and 4 weeks and 1 year postdonation. At predonation, related donors were less ambivalent about donation (t = –3.30; P = .001), more satisfied with their decision to donate (t = 2.65; P = .009), and more likely to define themselves as donors (t = 2.94; P = .004) than were URDs. However, related donors were more concerned about the use of needles (odds ratio [OR] = 2.19; P = .012), about who would pay for the procedure (OR = 2.80; P = .011), and the possibility that they would feel responsible if the transplant failed (t = 2.31; P = .022). Shortly postdonation, related donors were more likely to report donation-related pain (t = 2.50; P = .013) and lightheadedness (OR = 3.63; P = .028). At 1 year postdonation, related donors were less likely to be fully recovered from donation (OR = 0.10; P = .010) and more likely to report a longer recovery period following donation (t = 2.57; P = .011), although this latter finding was primarily due to the percentage of related versus unrelated donors not fully recovered at 1 year postdonation (10% versus 1%). Taken together, these findings suggest that current related donor management practices may be sufficient in preparing related donors for the psychological aspects of donation but that there may be more to do in terms of calibrating the description of donation-related experiences and recovery time to the related donor group (i.e., descriptions of donation experiences based on unrelated donation may not provide best estimates of experience for this group).

Donation after circulatory death (DCD) provides the option of organ donation for patients who are not brain-dead, but for whom ventilator support will be removed for the purpose of death. With over 112,000 people waiting for a life-saving transplant, it is crucial that organ procurement organizations determine opportunities for the greatest potential for growth. For many, it is DCD donation. It is possible for DCD donors to donate the liver, kidneys, pancreas, lungs, and even the heart, but the most common organs recovered and transplanted from this donor population remain the liver and kidneys.

Due to loss of several regulating entities in case of brain death, the management of optimal organ function in the potential organ donor is challenging. This chapter provides the reader with a systematic walk-through on how to do this.

Abstract: The authors give a short introduction of the Hungarian and the international history of adult heart transplantation, and highlight the similarities in the evolution of the two programs. Their aim was to show how the Hungarian post-transplant survival changed in the last five years. They wanted to investigate how all the changes they had made in the program affected the post-transplant results. They investigated 496 heart transplantation data and compared to international data. Orv Hetil. 2018; 159(46): 1869–1875.

Research in deceased organ donor management offers an opportunity to increase the quantity and quality of organs available for transplantation. This article aims to appraise the current literature with a focus on reviewing deceased donor intervention trials. Aggressive critical care management after determination of brain death resulting in meeting of a donor management goal bundle has consistently demonstrated an association with significantly more organs transplanted per donor as well as improved graft outcomes. Although there is a dearth of experience with randomized donor intervention studies, dopamine and targeted mild therapeutic hypothermia have been found to significantly reduce delayed graft function in kidney recipients. Progress in understanding the ethical, legal, regulatory, policy, and organizational elements of organ donor research has provided a mechanism that allows for the endorsement of potentially impactful donor management studies. Ongoing trials should incorporate methods to ensure safety to all organs donated from donors enrolled in interventional trials.

Objectives To describe important considerations during the process of caring for critically ill children who may be potential organ donors and supporting the family during the death of their child. Design Literature review and expert commentary. Measurement and main results Medical literature focusing on pediatric donation, best pediatric donation practices, donor management, and factors influencing donation were reviewed. Additional pediatric data were obtained and reviewed from the U.S. Organ Procurement and Transplantation Network. Achieving successful organ donation requires the coordinated efforts of the critical care team, organ donation organization, and transplant team to effectively manage a potential donor and recover suitable organs for transplantation. Collaboration between these teams is essential to ensure that all potential organs are recovered in optimal condition, to reduce death and morbidity in children on transplantation waiting lists as well as fulfilling the family's wishes for their dying child to become a donor. Conclusions Organ donation is an important component of end-of-life care and can help the healing process for families and medical staff following the death of a child. The process of pediatric organ donation requires healthcare providers to actively work to preserve the option of donation before the death of the child and ensure donation occurs after consent/authorization has been obtained from the family. Medical management of the pediatric organ donor requires the expertise of a multidisciplinary medical team skilled in the unique needs of caring for children after neurologic determination of death and those who become donors following circulatory death after withdrawal of life-sustaining medical therapies.

False positive (FP) viral marker results in blood donors continue to pose many challenges. Informing donors of FP results and subsequent deferral can result in stress and anxiety for donors and additional complexity and workload for blood services. Donor management strategies need to balance the requirement to minimise donor anxiety and inconvenience while maintaining sufficiency of supply. Decisions about how and when to inform donors of FP results and determine deferral periods can be difficult as FP results, while often transitory, can take up to several years to resolve. Additional complexities include the interpretation of indeterminate serological confirmatory testing without detectable viral RNA or non-discriminated NAT results with concomitant anti-HBc reactivity - both may be due to FP results, but the former may also represent past infection and the later may represent occult hepatitis B infection. In this review we discuss strategies to minimise indeterminate serological confirmatory results, possible donor deferral policies and the impact on donors when notified of FP results. We also provide some new data from Australia that address the challenge of interpreting non-discriminated NAT results with concomitant anti-HBc reactivity. Ultimately, the challenge is for each blood service to develop appropriate strategies for donor management, taking into account local information and requirements.

Changes in the causes of brain death may influence the numbers of hearts that can be procured and transplanted. We retrospectively investigated whether the distribution of causes responsible for brain death have changed over a 15-year period in a cohort of 1286 potential heart donor (aged ≤ 60), and whether it influenced heart procurement. Between 2001 and 2016, the age of potential donors significantly increased (p

Assessment of potential donors is an essential part of heart transplantation. Despite the shortage of donor hearts, donor heart procurement from brain-dead organ donors remains low in France, which may be explained by the increasing proportion of high-risk donors, as well as the mismatch between donor assessment and the transplant team's expectations. Improving donor and donor heart assessment is essential to improve the low utilization rate of available donor hearts without increasing post-transplant recipient mortality. This document provides information to practitioners involved in brain-dead donor management, evaluation and selection, concerning the place of medical history, electrocardiography, cardiac imaging, biomarkers and haemodynamic and arrhythmia assessment in the characterization of potential heart donors.

Background Deferral for low hemoglobin (Hb) increases the likelihood that donors do not return for future donations. Zinc protoporphyrin (ZPP) has been described as a sensitive marker of iron-deficient erythropoiesis, before Hb decreases. It is a relatively cheap, rapid, and easy-to-perform measurement in a drop of whole blood. To assess the utility of ZPP measurement in donor management we examined whether ZPP and Hb levels among first-time donors differ from repeat donors. We further explored whether ZPP increases over subsequent donations at a donor population level and whether increasing ZPP levels coincide with decreasing Hb levels and donor deferral. Study design and methods We included first-time (n = 4983) and repeat (n = 3533) whole blood donors from the ZPP and Iron in the Netherlands Cohort (ZINC) study. ZPP and Hb were measured at each subsequent donation during a 4-year period after inclusion in the study. Results Median ZPP levels were higher in repeat than in first-time donors. In first-time donors, especially women, ZPP levels were increased with a corresponding decline in Hb levels over subsequent donations. ZPP levels were increased among first-time donors deferred for low Hb. Conclusion Our results suggest that adding ZPP to Hb measurements in the daily blood collection setting, especially for first-time donors and first-time female donors may add to the identification of a donor subpopulation with low functional iron stores.

Despite major advances in our understanding of the physiopathology of brain death (BD), there are important controversies as to which protocol is the most appropriate for organ donor management. Many recent reviews on this subject offer recommendations that are sometimes contradictory and in some cases are not applied to other critically ill patients. This article offers a review of the publications (many of them recent) with an impact upon these controversial measures and which can help to confirm, refute or open new areas of research into the most appropriate measures for the management of organ donors in BD, and which should contribute to discard certain established recommendations based on preconceived ideas, that lead to actions lacking a physiopathological basis. Aspects such as catecholamine storm management, use of vasoactive drugs, hemodynamic objectives and monitoring, assessment of the heart for donation, and general care of the donor in BD are reviewed.

The shortage of suitable organs is the biggest obstacle for transplants. At present, most organs for transplant in the United States are from donation after neurologic determination of death (brain death). Potential organs for transplant need to maintain their viability during a series of insults, including the original disease, physiologic derangements during the dying process, ischemia, and reperfusion. Proper donor management before, during, and after procurement has potential to increase the number and quality of organs from donors. Anesthesiologists need to understand the physiologic derangements associated with brain death and the updated donor management during the periprocurement period.

Background Left ventricular systolic dysfunction (LVSD) accounts for almost 25% of nonacceptance of potential donor hearts. Previous smaller, single-center studies showed that LVSD following brain death may be transient, and such hearts can be successfully resuscitated with resolution of LVSD, then transplanted. Objectives This study evaluated outcomes of donor hearts with LVSD on initial transthoracic echocardiogram (TTE) that resolved during donor management. Methods We reviewed echocardiograms of all cardiac donors in the United Network of Organ Sharing database that were transplanted from January 1, 2007, to September 30, 2015, and identified 472 donor hearts with LVSD (left ventricular ejection fraction [LVEF] ≤40%) on initial TTE that resolved (LVEF ≥50%) during donor management on a subsequent TTE. These patients comprised the improved donor LVEF group. These were compared with donor hearts with normal LVEF (LVEF ≥55%) on the initial TTE for recipient mortality, cardiac allograft vasculopathy (CAV), and primary graft failure (PGF). Results There was no significant difference in recipient mortality at 30 days, 1 year, 3 years, and 5 years of follow-up, nor any difference in rates of PGF at 90 days and CAV at 5 years between recipients of donor hearts with improved LVEF and recipients of donor hearts with initially normal LVEF. Post-transplant length of stay was also similar between the 2 groups. Using propensity scores, 461 transplants in the improved-donor LVEF group were matched to 461 transplants in the normal-donor LVEF group. There was no significant difference in PGF at 90 days or recipient mortality after up to 5 years of follow-up. Conclusions In the largest analysis of donor hearts with transient LVSD, we found that such hearts can be successfully resuscitated and transplanted without increasing recipient mortality, CAV, or PGF. These results underscore the importance of appropriate donor management and should help to increase utilization of donor hearts with transient LVSD.

Background The Alliance of Blood Operators initiated a project labelled ‘Donor of the Future’. This study gives an overview of the project results, in particular with regard to country differences. Study Design and Methods A large survey (N = 7663) among blood donors in six countries was conducted to analyse the effects of five global areas of change: (1) demographic change; (2) technological developments; (3) health innovations; (4) public, behavioural and attitudinal aspects; and (5) political, economic and environmental issues. Results The main results exhibited similarities and differences between blood donors of the participating countries. Greater differences were found, for example, regarding technological developments. Whereas only blood donors from the UK and Australia would like to be informed via SMS, blood donors from all countries would like to be informed via email. Conclusion Different priorities of donors have been uncovered. These differences give suggestions to improve the country-specific donor management. Furthermore, the key findings provide a comprehensive overview of major future research domains.

Despite important advances in the care of postcardiac arrest patients, severe brain injury remains one of the major causes of death in the cardiac intensive care unit. Neurological prognostication after cardiac arrest has evolved significantly since the introduction of therapeutic hypothermia. It now relies on a multimodal approach and a minimal observation period of 72 hours is usually advocated. However, when brain injury is severe and the prognosis considered dismal, patients become eligible for organ donation. Patients with severe anoxic encephalopathy might evolve toward brain death and be candidates for donation after brain death. In the presence of severe brain injury without brain death criteria, when withdrawal of life-sustaining therapy is considered, patients might be eligible for donation after cardiocirculatory death. The diagnosis of brain death, the differences between donation after brain death and donation after cardiocirculatory death, family approach, and donor management in the intensive care unit are discussed. Because these are increasingly encountered situations in the cardiac intensive care unit, it is essential that physicians involved in cardiac critical care be familiar with these concepts.

Background No standard exists for the use of deceased donor liver biopsy during procurement. We sought to evaluate liver biopsy and the impact of findings on outcomes and graft utilization. Methods A prospective observational study of donors after neurologic determination of death was conducted from 02/2012-08/2017 (16 OPOs). Donor data were collected through the UNOS Donor Management Goals Registry Web Portal and linked to the Scientific Registry of Transplant Recipients (SRTR) for recipient outcomes. Recipients of biopsied donor livers (BxDL) were studied and a Cox proportional hazard analysis was used to identify independent predictors of 1-year graft survival. Results Data from 5449 liver transplant recipients were analyzed, of which 1791(33%) received a BxDL. There was no difference in graft or patient survival between the non-BxDL and BxDL recipient groups. On adjusted analysis of BxDL recipients, macrosteatosis (21%-30%[n = 148] and >30%[n = 92]) was not found to predict 1-year graft survival, whereas increasing donor age (HR1.02), donor Hispanic ethnicity (HR1.62), donor INR (HR1.18), and recipient life support (HR2.29) were. Conclusions Excellent graft and patient survival can be achieved in recipients of BxDL grafts. Notably, as demonstrated by the lack of effect of macrosteatosis on survival, donor to recipient matching may contribute to these outcomes.

Maintenance of physical infrastructure transitioned from donor management to national ownership has been a challenge in the health sector leading to a considerable number of physical infrastructure dilapidating to a deplorable state. This study investigated the causes of deterioration for Health Physical Infrastructure Transitioned from Donor to National Management in Zambia. A mixed method approach was adopted for the study. Qualitative and quantitative data was collected through interviews and questionnaires respectively. The findings revealed that there was lack of onsite maintenance technicians in the health centres. Further, that though maintenance plans were in place in most urban facilities as compared to rural health facilities adherence to such plans was hindered due to lack of funding. The study therefore, recommends improved budget allocation for maintenance activities to the Ministry of Health, assigning of qualified maintenance technicians in health centres. Further, that Government should consider having a maintenance policy to achieve sustainability for built assets transferred from donor to national management.

Background: There is no specific guidelines concerning intraoperative management of brain-dead donors (BDD) during organ procurement (OP). This study aimed at describing usual anesthetic practices for BDD during an OP procedure and to assess the knowledge and self-confidence of French anesthesiologists with this practice. Methods: An electronic, national and anonymous survey with closed-questions about anesthetic management of BDD was distributed to French anesthesiologists via the mailing list of the French Society of Anesthesiology and Intensive Care. The questionnaire included questions concerning monitoring, intraoperative resuscitation, anesthetic drugs use and confidence of the respondents. Results: 458 responses were analyzed. Respondents were mainly attending physicians with more than 10 years of professional experience, equally distributed between university and non-university centers. Seventy-eight percent of them declared knowledge about guidelines regarding ICU management of BDD. Advanced hemodynamic monitoring and endocrine substitution were poorly considered by respondents (31% and 35% of respondents, respectively). 98% of the respondents used crystalloids for fluid resuscitation. During the procedure, use of neuromuscular blockers, opioids and sedative agents were considered by respectively 84%, 61% and 27% of the respondents. A very high level of agreement (10 [8-10], on a ten-points Likert-style scale) was reported concerning the expected impact of intraoperative anesthetic management on the primary function of grafts. Conclusions: Declared anesthetic practice appeared in accordance with guidelines concerning ICU management of organ donors. Further studies are needed to evaluate the specific impact of intraoperative management during this procedure and thus the need for specific anesthetic guidelines.

OBJECTIVES To evaluate the improvement in lung donation and immediate lung function after the implementation of a 360° rotational positioning protocol within an organ procurement organization in the Midwest. DESIGN Retrospective observational study. SETTING The Midwest Transplant Network from 2005 to 2017. Rotational positioning of donors began in 2008. SUBJECTS Potential deceased lung donors. INTERVENTIONS A 360° rotational protocol. Presence of immediate lung function in recipients, change in PaO2:FIO2 ratio during donor management, initial and final PaO2:FIO2 ratio, and proportion of lungs donated were measured. Outcomes were compared between rotated and nonrotated donors. MEASUREMENTS AND MAIN RESULTS A total of 693 donors were analyzed. The proportion of lung donations increased by 10%. The difference between initial PaO2:FIO2 ratio and final PaO2:FIO2 ratio was significantly different between rotated and nonrotated donors (36 ± 116 vs 104 ± 148; p < 0.001). Lungs transplanted from rotated donors had better immediate function than those from nonrotated donors (99.5% vs 68%; p < 0.001). CONCLUSIONS There was a statistically significant increase in lung donations after implementing rotational positioning of deceased donors. Rotational positioning significantly increased the average difference in PaO2:FIO2 ratios. There was also superior lung function in the rotated group. The authors recommend that organ procurement organizations consider adopting a rotational positioning protocol for donors to increase the lungs available for transplantation.

Background Obstacles encountered during the organ donation process may result in the loss of organs. A centralized medical advisory service (MAS), providing a 24/7/365 service, was established in 2007 to respond to queries from healthcare professionals regarding organ safety, brain death (BD) determination, and donor management. Methods Data collected from 2007 to 2017 included the number and context of the queries and the mean number of organs transplanted/donor. Since 2012, the number of six donor management goals (DMGs) met at the time of consent has been monitored. Results The number of queries relative to the number of potential donors increased from 12.4% (n = 78 queries) in 2007 to 48.2% (304 queries) in 2009 and has remained widely utilized, with most queries consistently related to organ safety. The context of the queries informed the formulation of protocols relating to donor infections and malignancy and identified difficulties regarding BD determination and subsequent implementation of solutions. A mean of 5.0 ± 0.7 DMGs was achieved, while the number of organs transplanted/donor increased from 3.4 in 2007 to 4.0 in 2017. Conclusion We suggest that this model may provide a valuable resource to improve the safety, standardization, and quality of the donation process.

Delayed graft function (DGF) in kidney transplant significantly increases inpatient and outpatient cost. Targeted, mild hypothermia in organ donors after neurologic determination of death significantly reduced the rate of DGF in a recent randomized controlled clinical trial. To assess the potential economic benefit of national implementation of donor hypothermia, rates of reduction DGF were combined with estimates of the impact of DGF on hospital cost and total health expenditure for standard and extended criteria donor organs (SCD and ECD). DGF increases the cost of the transplant episode by $9487 for ECD transplant and $10 342 for SCD transplant. Medicare recipients with DGF incur an additional $18 513 spending for ECD and $14 948 in SCD transplants over the first year. An absolute reduction in DGF rate after kidney transplantation consistent with trial results (ECD 25%, SCD 7%) has the potential to lower annual hospital cost for kidney transplant by $13 178 746 and annual Medicare spending by $20 970 706 compared to standard donor management practice using static cold storage. Targeted mild hypothermia improves care of renal transplant patients by safely reducing DGF rates in both ECD and SCD transplant. Broader application of this safe, effective, and low-cost intervention could reduce healthcare expenditures for providers and insurers.

[Resumen] Introducción: La donación de órganos es un proceso complejo que nos permite sustituir un órgano enfermo por otro que desempeña sus funciones fisiológicas. España es actualmente el país con mayor número de donaciones de órganos y trasplantes anuales, gracias al “Modelo Español”. Los órganos pueden proceder de 3 fuentes principales, aunque la mayoría se obtienen de donantes en muerte encefálica. Para asegurar un manejo adecuado del donante potencial, es imprescindible que el equipo multidisciplinar conozca las alteraciones fisiopatológicas desencadenadas de la muerte encefálica, con el fin de optimizar la función de los órganos que se trasplantarán, intentando utilizar las menores medidas de soporte necesarias. • Objetivos: Conocer las alteraciones fisiopatológicas derivadas de la ME, así como agrupar las recomendaciones y la evidencia disponible necesaria para estandarizar los cuidados de los donantes. • Metodología: Se realiza una búsqueda bibliográfica en distintas bases de datos, fijándose unos criterios de selección y de exclusión que nos permitan limitar los resultados. • Discusión: No existe suficiente evidencia que respalde los cuidados llevados a cabo hoy en día. Las guías y artículos se basan principalmente en modelos animales y en opiniones de expertos, lo que supone una variabilidad interpersonal en el manejo del donante potencial. [Resumo] Introdución: A doazón de órganos é un proceso complexo que nos permite substituír un órgano enfermo por outro que desempeña as súas función fisiolóxicas. España é actualmente o país con maior número de doazóns de órganos e transplantes anuais, grazas ao “Modelo Español”. Os órganos poden proceder de 3 fontes principais, aínda que a maioría obtéñense de doantes con morte encefálica. Para asegurar un manexo adecuado do doante potencial, é imprescindible que o equipo multidisciplinario coñeza as alteracións fisiopatolóxicas desencadeadas da morte encefálica, co fin de optimizar a función dos órganos que se van a transplantar, intentando utilizar as menores medidas de soporte necesarias. • Obxectivos: Coñecer as alteracións fisiolóxicas derivadas da ME, así como agrupar as recomendación e a evidencia necesaria para estandarizar os coidados dos doantes. • Metodoloxía: Realízase una busca bibliográfica en distintas bases de datos, fixándose criterios de selección e de exclusión que nos permitan limitar os resultados. • Discusión: Non existe suficiente evidencia que respalde os coidados levados a cabo hoxe en día. As guías e artigos baséanse principalmente en modelos animais e opinións de expertos, o que supón una variabilidade interpersoal no manexo do potencial doante. [Abstract] Introduction: Organ donation is a complex process that allow us to replace an ill organ for another that performs his physiological functions. Actually, Spain is the country with de highest number of organ donors and transplants, due to “Spanish Model”. Organs can proceed from three main sources but most of them proceed of brain death donors. To assure a proper handling of potential organ donor, multidisciplinary team must know physiopathology alterations triggered from the brain death in order to optimize the function of the organs that are going to be transplanted, trying to use the least necessary support measures • Objectives: Know about the physiopathology alterations triggered from the brain death as well as join the recommendations and the evidence needed to standardize management of the donors. • Methodology: We search in different databases, establishing selection criteria and exclusion criteria to limit the results. • Discussion: There isn’t enough evidence to support management of potential donor that we are carrying out today. Guidelines and articles are based on animal models and expert opinions. That supposes an interpersonal variability in management of organ donor. Traballo fin de grao (UDC.ENFC). Enfermaría. Curso 2018/2019

Objective To illustrate the burden of inherited disease on donor-conceived offspring based on mode of inheritance and to provide guidance on methods of risk reduction. Design An 8.5-year retrospective review of outcome reports and donor management to summarize medical risks to donor-conceived offspring that presented after the sperm donors were qualified for participation in the donor program. Setting Not applicable. Patient(s) None. Intervention(s) None. Main Outcome Measure(s) Description of our experience with newly identified medical risks in donor-conceived offspring as well as how this information was ascertained and managed. Result(s) More than half of the indications to restrict donor specimen distribution were due to multifactorial disorders. Approximately one third of the restrictions involved autosomal recessive disorders. The remainder of the restrictions were due to the other indications, including autosomal dominant disorders. Conclusion(s) The risks for multifactorial disorders or undiagnosed autosomal dominant disease cannot be significantly reduced or eliminated with routine donor screening procedures. Ongoing risk assessment is essential to identify new genetic risks for autosomal dominant and multifactorial disorders. These assessments require an investment of resources and genetics professionals in the long-term management of changing health information as well as collaboration among gamete facilities, recipients, donors, and their health care providers.

BACKGROUND Understanding the effect of delayed processing of whole blood on plasma ferritin will inform the feasibility of both routine ferritin testing in donors and clinical research study design. STUDY DESIGN AND METHODS Whole blood tubes drawn from 16 donors were held at 4°C and centrifuged at 24-hour intervals to assess plasma ferritin concentration up to 5 days after draw. Intraindividual variation over time was measured in 21 healthy donors in blood samples collected weekly for 4 weeks and then at 12 weeks. RESULTS No significant variation in plasma ferritin concentration was observed in blood stored at 4°C for up to 5 days after draw (p = 0.32). The estimated loss of 4.75% ferritin over 5 days was within the reported 5% variation of the assay. Moderate intraindividual variation occurs over time in both sexes, with variability increasing with the mean. No difference was detected between men and women in the regression of standard deviation on mean ferritin (p = 0.43). CONCLUSIONS Ferritin is stable in whole blood up to 5 days, demonstrating operational feasibility of its use in monitoring donor iron stores. Moderate fluctuations over time occur, but ferritin measurements are sufficiently reliable to determine donor iron status on the day of donation.

We performed a prospective analysis of iron status in plateletpheresis donors, using whole blood donors as a control group, to assess the haematinic effects of regular anti-coagulated extracorporeal circulation and platelet collection.Ferritin levels were measured in samples from 31 regular male plateletpheresis donors and from 14 first time male whole blood donors, immediately before and immediately after donation, and immediately before the next donation. An additional 33 regular male plateletpheresis donors and 17 first time male whole blood donors had serum ferritin levels checked predonation.Male plateletpheresis donors had a statistically significant fall in serum ferritin after donation (P = 0.005)*. In addition, male platelet donors had significantly lower serum ferritin levels than first time male blood donors: ferritin20 µg/L was found in 6/64 (9%) of regular platelet donors and 1/31 (3%) of first time blood donors (P 0.001)*.Our studies support the value of serum ferritin measurement in apheresis donor management.

While standardized organ donor management has maximized the number of organs successfully transplanted in the past 10 years, organ donor management prior to the procurement operation does not typically include nutrition therapy. The value of providing nutrition therapy in critically ill patients relates to reductions seen in infection and multiple organ failure, especially with early enteral feeding. Preventing infection and maintaining organ function prior to organ transplantation are key strategies in the management of the donor population. This paper discusses the rationale for providing nutrition therapy to critically ill brain-dead organ donors, highlighting potential benefits, issues with implementation, the importance of timing, and the potential risks which may be involved. While little experience exists in the literature, the potential benefits which might be incurred warrant consideration for initiating nutrition therapy in this patient population.

Modifications in recipient and donor criteria and innovations in donor management hold promise for increasing rates of lung transplantation, yet availability of donors remains a limiting resource. Imaging is critical in the work-up of donor and recipient including identification of conditions that may portend to poor posttransplant outcomes or necessitate modifications in surgical technique. This article describes the radiologic principles that guide selection of patients and surgical procedures in lung transplantation.