Organ Procurement for Transplantation

Aditya K. Kaza and Max B. Mitchell

This chapter is relevant to all surgeons caring for victims of trauma because traumatic injury is a leading cause of brain death and subsequent organ donation. Because of the severe shortage of organ donors, it is critical that traumatologists recognize potential organ donors as early as possible and care for these patients assuming that organ donation may occur. It is important for physicians to understand the criteria for brain death and the local requirements for the pronunciation of brain death.

This chapter provides an overview of the procurement organization and how organs are allocated. The responsibilities of the local organ procurement organizations (OPOs) are underscored in this chapter (i.e., community education, evaluation and screening of potential donors, local hospital coordination, and family counseling). The trauma team’s role is to resuscitate the patient and maintain perfusion of the organs. Once a potential donor is identified the trauma team must coordinate its efforts with the OPO. Once a patient is declared brain dead the trauma team’s role does not end. Cooperation between the trauma team and representatives of the OPO will help to maximize donation of organs and is important for preserving the function of donated organs.

INTRODUCTION

The combined developments of effective immunosuppressant therapy and sophisticated surgical techniques have made organ transplantation very successful in treating the end-stage failure of most solid organs. Transplantation is now the treatment of choice for end-stage heart, lung, liver, and renal disease for patients who have no contraindications to transplantation. Pancreas transplantation has also proven successful in the treatment of diabetes mellitus. In addition, there is increasing demand for bone, skin, and other tissues used in the treatment of other disease processes. Despite advances in living-related solid organ transplantation,¹ the majority of transplant recipients remain dependent on cadaveric organ donors.² Improved supportive care for patients with advanced organ failure and expanded indications for transplantation have increased the numbers of patients waiting for organs. In contrast, efforts at increasing the pool of suitable organ donors have had comparatively little success in increasing the supply of organ donors; however, there is a slow increase in living donors as noted from 1988 to 2005 (Fig. 50-1). Consequently, the number of patients on the various transplant waiting lists continues to outpace the available donor pool. In the year 2000, an average of 114 patients were placed on waiting lists each day while an average of 63 patients per day received organ transplants.³ During the same year, an average of 16 patients per day died awaiting transplantation.³

FIGURE 50-1 Total patients in the United States who underwent organ transplantation from deceased and living donors from 1988 to 2005. (Reproduced with permission from United Network for Organ Sharing website. Accessed February 2005. http://www.unos.org/Data.)

Traumatic brain injury is the most common cause of death leading to cadaveric solid organ donation.⁴ Clinicians caring for severely injured patients necessarily play a key role in the initiation and implementation of the transplantation process. Early recognition of potential organ donors is critical to maximizing the available pool of donor organs and the number of transplantable organs per donor. It is essential for those caring for potential organ donors to be knowledgeable about the criteria and process for declaring brain death and the physiologic effects of brain death. Familiarity with local OPOs is important because of the vital role they play in counseling the families of potential organ donors and coordinating the transplant process. Lastly, following the declaration of brain death, treatment priorities aimed at minimizing brain injury require adjustment. Physiologic support directed at maintaining perfusion of potentially transplantable organs assumes priority, and timely initiation of this support is crucial to increasing the probability of successful transplantation.

ORGAN DONATION AND ALLOCATION

Under the National Organ Transplant Act (Pub. L. No. 98-507, Title I, 1984), the U.S. Congress established The Organ Procurement and Transplantation Network (OPTN). The OPTN is a unique public–private partnership linking professionals involved in the organ donation and transplantation system. Subsequent federal legislation mandated that all U.S. transplant centers and OPOs must be members of the OPTN to receive any funds through Medicare or Medicaid (H. Rep. No. 100-383, 1987, and Pub. L. No. 100-607, Title IV, 1988). Other members of the OPTN include independent histocompatibility laboratories involved in organ transplantation; relevant medical, scientific, and professional organizations; voluntary health and patient advocacy organizations; and members of the general public with a particular interest in organ transplantation.

The OPTN is administered by the United Network for Organ Sharing (UNOS). UNOS is a private nonprofit charitable organization contracted by the Health Resources and Services Administration of the U.S. Department of Health and Human Services (DHHSS) to develop organ transplantation policy.⁵ Policy recommendations are then adopted and enforced by the DHHSS. UNOS facilitates organ transplantation by organizing the medical, scientific, public policy, and technologic resources required to maintain an efficient national transplantation system. UNOS is responsible for developing recipient priority policies and for managing the national transplant waiting lists. UNOS also sets professional standards for efficiency and patient care for transplant centers. UNOS maintains the national transplant database, plays a very important role in raising public awareness of the importance of organ donation, and helps to keep patients informed about transplant issues and policy.⁶

Organ donation, allocation, and procurement require a closely coordinated and complex series of efforts. In the United States, this process is coordinated by independent local OPOs. OPOs employ specially trained professionals who assist with the evaluation of potential organ donors, the declaration of brain death, counseling of donor family members, management of the donor, organ allocation, and the procurement process. When an organ donor is identified, the local OPO serves to ensure that brain death has been established and assists in obtaining consent for organ donation. Thereafter, coordination of organ placement and the procurement of the organs are facilitated by the OPO. There are currently 51 cooperating OPOs in the United States, distributed among 11 geographic regions. The regional system plays a pivotal role in the current process of allocating organs for transplantation. It was established to help reduce organ preservation time and improve organ quality and survival outcomes. In addition, it was intended to reduce the costs of organ transplantation and provide equal access to transplantation for patients regardless of where they live.

Donor organs are matched to individual patients according to waiting lists developed and coordinated by UNOS. Each organ waiting list incorporates specific criteria to establish individual patient ranking on the list. All lists incorporate patient waiting time and patient ABO blood grouping. For lung transplantation, these are the primary factors. The kidney waiting list also incorporates the degree of human lymphocyte antigen matching so that top priority is given to patients with a perfect human leukocyte antigens (HLA) match. This is not done for other organs. The heart and liver waiting lists differ by including organ-specific criteria to establish severity of illness prioritizing the sickest patients. All lists are patient specific so that organs are offered to an individual patient on a center’s list as opposed to the center. Organs are first offered locally within the boundaries of the involved OPO. If the organ is declined by all local centers, it is then offered regionally followed by national offers. There has been significant recent debate regarding the current allocation system with some parties advocating a nationally based system.⁷ Such a system would be predicated primarily on the severity of illness followed by waiting time while eliminating consideration of the region from which the organ originates. At this time, no changes in this system have been adopted.

DONOR SCREENING

The screening process for organ donors begins when a potential organ donor is identified. All patients who have suffered severe brain injuries and are either brain dead or likely to progress to brain death should be considered for organ donation regardless of their age, underlying cause of illness, and overall social history. Although perceived contraindications to donation may exist, they should be discussed with a representative of the local OPO before concluding that a given patient is not a candidate for organ donation (Table 50-1). The physician caring for the patient is responsible for notifying the local OPO of such patients. In many states physicians are legally required to notify the local OPO of each in-hospital death. All OPOs employ personnel who are responsible for advising health care providers on the suitability of an individual patient for organ donation. Communication with local forensic authorities is extremely important. The OPO will contact the medical examiner or coroner in order to obtain permission to proceed with organ donation. Once a donor is identified, the OPO is responsible for obtaining family consent for organ donation. Organ procurement specialists are trained in counseling families about the importance and process of organ donation, and it is advisable to refer families to these specialists when potential organ donation is discussed. These individuals also perform a careful review of the potential donor’s social and past medical history. The circumstances leading to brain death are very important, as is any history of the occurrence and duration of cardiopulmonary arrest. Screening also includes an extensive laboratory and serologic evaluation to exclude chronic disease and transmissible infections. A donor profile is then generated and includes current hemodynamics as well as an assessment of current organ function. The assessment of organ function is individualized to the donor based on the donor profile, the specific organs under consideration, and the level of medical support required to maintain the donor. The overall profile that is generated is crucial for transplant physicians who must evaluate the suitability of a given organ donor for the individual recipient.

TABLE 50-1 Contraindications to Organ Donation^a

DECLARATION OF BRAIN DEATH

Ethical standards in the United States mandate that all organ donors must be declared dead before organ donation can proceed. Brain death must therefore constitute a sufficient basis on which to declare a person legally dead. Despite continued interest in non-heart beating donors, the vast majority of cadaveric organs are procured from donors whose deaths are declared on the basis of brain death. Consequently, cadaveric solid organ donation is dependent on the ability to reliably determine that a patient is brain dead.⁸

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