DMG Web Portal Update
UNOS Region 5 Meeting
March 18, 2015
Darren Malinoski, MD
Mitch Sally, MD
Megan Crutchfield, MPH
INTRODUCTION

Shortage of organs available for
transplantation

Efforts needed to increase number and
quality of organs from donors after
neurologic determination of death
(DNDDs)
INTRODUCTION

Donor Management Goals (DMGs)



Checklist of critical care endpoints
Standardize care of potential organ donors
Normal cardiovascular, respiratory,
endocrine, renal, and acid-base
parameters
INTRODUCTION
DMG Web Portal Update
Total Number of Donors
n=4,094
SCD
n=2,714
66%
DCD
n=553
14%
ECD
n=827
20%
From March 15, 2012 to March 11, 2015
DMG Web Portal Update
Number of Donors by Region and OPO
Region 4 (n=351) (since January 2014)
n=351
9%
Donor Network of Arizona (AZOB)
n=409
10%
California Transplant Donor Network (CADN)
n=891
22%
Golden State Donor Services (CAGS)
One Legacy (CAOP)
n=180
n=1234
n=293
n=118
n=245
n=274
4%
30%
7%
3%
6%
7%
Life Gift of Texas (TXGC)
Region 5 (n=3,644)
Lifesharing (CASD)
New Mexico Donor Services (NMOP)
Nevada Donor Network (NVLV)
Intermountain Donor Services (UTOP)
Region 6 (n=99) (since November 2013)
Pacific Northwest Transplant Bank (ORUO)
n=99
2%
DMG Web Portal Update
Organs Transplanted per Donor (OTPD)
OTPD Overall
SCD
DCD
ECD
Mean + SD
3.18 + 3.00
3.76 + 4.00
1.95 + 2.00
2.08 + 2.00
DMG Web Portal Update
Individual Organs Transplanted by Donor Type
Heart
Left
Lung
Right
Lung
Left
Kidney
Right
Kidney
Liver
Pancreas
Intestines
All
Donors
(n=4094)
1380,
(34%)
914,
(22%)
891
(22%)
3248
(79%)
3177
(78%)
2870
(70%)
433
(11%)
32
(<1%)
SCD
(n=2714)
1338
(51%)
792
(29%)
769
(28%)
2339
(86%)
2302
(85%)
2147
(79%)
427
(16%)
32
(1%)
DCD
(n=553)
0
469
(85%)
440
(53%)
451
(82%)
425
(51%)
138
(25%)
585
(71%)
0
42
(5%)
8
(1%)
114
(14%)
6
(1%)
ECD
(n=827)
8
(1%)
114
(14%)
0
0
DMG Web Portal Update
Number of Donors That Met the DMG Bundle
All DNDDs
(n=3541)
SCD
(n=2714)
ECD
(n=827)
Referral
Authorization
12-18 Hours
Prior to OR
588 (17%)
804 (23%)
1657 (47%)
2279 (64%)
444 (16%)
641 (24%)
1371 (51%)
1863 (69%)
144 (17%)
163 (20%)
286 (35%)
416 (50%)
DMG Web Portal Update
Percent DMGs Met at Each Time Point
Referral
Authorization
12-18 Hours
Prior to OR
MAP (60-110 mmHg)
84%
91%
91%
91%
CVP (4-12mmHg)
10%
28%
49%
50%
EF (>50%)
10%
15%
43%
62%
pH (7.3-7.5)
65%
78%
87%
90%
PF Ratio (>300)
43%
39%
46%
56%
Sodium (<155)
92%
71%
79%
86%
Glucose (<180 mg/dL)
55%
76%
68%
81%
Urine (0.5 cc/kg/h over 4 hours)
86%
83%
83%
81%
Pressors (<1 and low dose)
75%
66%
84%
92%
DMG Web Portal Update
Met DMG Bundle
OPO 1
OPO 2
OPO 3
OPO 4
OPO 5
OPO 6
OPO 7
OPO 8
OPO 9
OPO 10
Average
Referral
Authorization
12-18 Hours
Prior to the OR
15%
21%
13%
24%
20%
13%
16%
25%
11%
18%
19%
26%
27%
31%
29%
25%
22%
16%
31%
17%
32%
26%
59%
56%
55%
57%
46%
42%
32%
37%
56%
56%
53%
68%
79%
58%
59%
55%
46%
46%
46%
61%
66%
64%
DMG Web Portal Update
OTPD when bundle met v. not met
Referral
All
DNDDs
SCD
(n=2714)
ECD
(n=827)
Authorization
12-18 Hours
Prior to OR
Met
Not Met
Met
Not Met
Met
Not Met
Met
Not Met
3.44
3.12
3.64
3.04
3.77
2.71
3.75
2.35
4.09
3.69
4.28
3.60
4.23
3.28
4.16
2.87
2.36
2.02
2.34
2.02
2.39
1.92
2.44
1.72
Lactate Levels as Predictors of
Organ Transplantation Rates after
Neurologic Determination of Death
UNOS Region 5 Meeting
March 18, 2015
Mitchell Sally, MD
Darren Malinoski, MD, FACS
VA Portland Healthcare System
Oregon Health & Science University
Portland, OR
LACTATE


Peripheral biomarker
Common use in trauma, burns, critical
illness, and sepsis to guide resuscitation




SvO2, ScvO2
CVP
UOP
BP
LACTATE





End product of anaerobic
metabolism (glycolysis)
Usually in skeletal muscle,
bowel, brain and RBC
Taken up and converted to
glucose (gluconeogenesis)
by liver
Marker for adequacy of
resuscitation
Normal levels: < 2 mmol/L
Curr Opin Crit Care, 2012 Jun; 18 (3): 267-272
GUIDING RESUSCITATION
Living Patient
DNDD


Urine output
Normal BP
Normal CVP
ScvO2

Lactate







Diabetes insipidus
Vasopressor use
Multiple organ issues
No brain oxygen extraction
Unaffected by exterior
pressures
LACTATE



Not currently part of the DMG Bundle
Recorded only sporadically
Utility in guiding donor management has
not been examined
DMG Web Portal Update
Lactate Levels Present at Each Time Point
TXGC (n=295)
AZOB (n=312)
CADN (n=828)
CAGS (n=156)
CAOP (n=1105)
CASD (n=227)
NMOP (n=118)
NVLV (n=244)
UTOP (n=209)
ORUO (n=68)
TOTAL (n=3562)
Referral
Authorization
12-18 Hours
Prior to OR
n=19 (6%)
n=14 (5%)
n=10 (3%)
n=7 (2%)
n=32 (10%)
n=27 (9%)
n=15 (5%)
n=7 (2%)
n=168 (20%)
n=253 (31%)
n=363 (44%)
n=351 (42%)
n=75 (48%)
n=71 (45%)
n=86 (55%)
n=65 (42%)
n=283 (26%)
n=708 (64%)
n=1007 (91%)
n=996 (90%)
n=30 (13%)
n=27 (12%)
n=29 (13%)
n=25 (11%)
n=38 (36%)
n=14 (13%)
n=9 (8%)
n=8 (7%)
n=12 (5%)
n=4 (2%)
n=6 (2%)
n=6 (2%)
n=101 (48%)
n=134 (64%)
n=110 (53%)
n=103 (49%)
n=13 (19%)
n=9 (13%)
n=5 (7%)
n=3 (4%)
n=771 (22%)
n=1261 (35%)
n=1640 (46%)
n=1571 (44%)
OBJECTIVES/HYPOTHESIS
To determine the association between
blood lactate levels and organ
transplantation rates.
We hypothesized that normal lactate
levels would be associated with more
OTPD.
METHODS

Prospective, observational study




1.
2.
3.
All DNDDs
10 OPOs, UNOS Regions 4, 5, and 6
March 2012 - August 2014
Three standard time points:
Authorization for donation
12-18 hours after authorization
Prior to organ recovery
METHODS


Primary outcome: achieving ≥ 4 OTPD
Secondary outcomes: individual organ
transplantation rates
RESULTS




1351 donors
3.4 ± 1.8 OTPD
45% ≥ 4 OTPD
Lactate values recorded:



831/1351 (61.5%) at Authorization
1090/1351 (80.7%) at 12-18 Hours
1045/1351 (77.4%) Prior to recovery
RESULTS – LACTATE

Mean lactate levels (mmol/L):





2.5 + 3.1 overall
2.5 + 3.0 at Authorization
2.6 + 3.0 at 12-18 Hours
2.1 + 2.8 Prior to organ recovery
2,008/2,966 (67.7%) levels were < 2
mmol/L.
RESULTS – UNIVARIATE
Continuous
OTPD < 4
OTPD > 4
p
3.11
2.88
< 0.01
3.01
2.45
< 0.01
2.96
2.58
< 0.01
2.78
2.08
< 0.01
Authorization Lactate < 2 mmmol/L
60.3%
70.1%
< 0.01
12-18 Hours Lactate < 2 mmol/L
OR Lactate < 2 mmol/L
54.3%
66.5%
< 0.01
71.8%
85.0%
< 0.01
1 measurement (n=116)
18.2%
17.3%
0.76
2 measurements (n=147)
20.5%
24.6%
0.22
3 measurements (n=316)
44.3%
52.7%
0.03
Overall Mean
Authorization Mean
12-18 Hrs Mean
Terminal Mean
Categorical
# Lactates < 2 mmol/L (n=579)
RESULTS - MULTIVARIABLE
Continuous
Overall Mean
Authorization Mean
12-18 Hrs Mean
Terminal Mean
Categorical
Authorization Lactate < 2 mmmol/L
12-18 Hours Lactate < 2 mmol/L
OR Lactate < 2 mmol/L
# Lactates < 2 mmol/L (n=579)
1 measurement (n=116)
2 measurements (n=147)
3 measurements (n=316)
OR
0.92
0.90
0.94
0.88
95% CI
0.86-0.99
0.83-0.98
0.87-1.03
0.79-0.97
p
0.02
0.01
0.06
0.02
1.37
1.33
1.93
0.90-2.08
0.93-1.89
1.19-3.11
0.14
0.11
<0.01
1.35
1.14
1.22
0.79–2.32
0.71–1.85
0.81-1.84
0.27
0.58
0.35
*Results controlled for with known predictors of > 4 OTPD: age, weight, BMI, terminal creatinine, donor
management bundle met at all 3 time points, standard criteria status, gender, thyroid hormone
administration, and CDC high risk status.
RESULTS – INDIVIDUAL
ORGANS

Lower mean lactate levels found in
DNDDs whose organs were utilized:
Used
Not Used
p
Hearts
2.6 + 2.9
3.1 + 3.2
< 0.01
Lungs
2.4 + 3.0
3.1 + 3.1
< 0.01
Livers
2.7 + 2.9
3.6 + 3.7
< 0.01
CONCLUSIONS




Lactate measurements are inconsistently
drawn in DNDDs during donor management
Lower mean lactate levels remained
independent predictors of ≥ 4 OTPD
Terminal lactate < 2 mmol/L: independently
associated with > 4 OTPD
Inclusion of a lactate level < 2 mmol/L into
existing DMG Bundles should be considered
QUESTIONS