New challenges and opportunities in
organ donation
Dr Paul Murphy
National Clinical Lead for Organ Donation
NHS Blood and Transplant
1
Outline
• Performance 2013/14
• Updates
– Ante mortem interventions
– DCD heart retrieval
– Extended DCD
– Anencephaly
– Neurological determination of death in
infants < 2 months
– Challenges to neurological determination of
death
• Current strategies
– Family refusal
– DCD triage
– Organ utilisation
– Regional Collaboratives
Deceased donors and transplants in UK
4000
Donors
Transplants
3509
3500
2916
3000
2500
2242
2197
2386
2384
2559
2655
3341
3118
2706
2000
1500
1000
751
765
793
809
899
959
1010
1088
1212
1320
1282
500
0
2004/05
2005/06
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
Trends in UK donation
Rolling 12 month numbers of DBD and DCD donors, 2008- to date
1400
Total
1200
DBD
DCD
800
600
400
200
ar
-0
8
Se
p08
M
ar
-0
9
Se
p09
M
ar
-1
0
Se
p10
M
ar
-1
1
Se
p11
M
ar
-1
2
Se
p12
M
ar
-1
3
Se
p13
M
ar
-1
4
Se
p14
M
ar
-1
5
0
M
number
1000
Eligible donors
Eligible DBD donors
Eligible DCD donors
Eligible DBD or DCD donors
3000
2500
number
2000
1500
1000
500
0
Apr 10 - Oct 10 - Apr 11 - Oct 11 - Apr 12 - Oct 12 - Apr 13 - Oct 13 - Apr 14 - Oct 14 Sep 10 Mar 11 Sep 11 Mar 12 Sep 12 Mar 13 Sep 13 Mar 14 Sep 14 Mar 15
Progress against PDA metrics
Referral and BSD testing
DBD
DCD
100
Referral
90
Referral rate (%)
80
70
60
50
40
30
20
10
BSD testing
BSD testing rate (%)
0
2007-8
2008-9
2009-10 2010-11 2011-12 2012-13 2013-14 2014-15*
2007-8
2008-9
2009-10 2010-11 2011-12 2012-13 2013-14 2014-15*
100
90
80
70
60
50
20
14
/1
5*
20
13
/1
4
20
12
/1
3
20
11
/1
2
20
10
/1
1
20
09
/1
0
20
08
/0
9
20
20
07
/0
8
30
20
06
/0
7
20
05
/0
6
20
04
/0
5
20
03
/0
4
consent / authorisation rate (%)
Progress against PDA metrics
Consent / authorisation
80
70
60
50
40
DBD
DCD
10
0
Age of deceased DCD donors
•
•
•
Proportionally fewer
donors are aged 70+
For kidneys, there
appears to be less
appetite to use the
higher risk donors in the
most recent year, while
for livers there is no
such trend.
Kidney offer decline
rates are higher in the
last two years for
extended criteria
donors.
100
90
3
15
3
14
3
13
3
17
5
15
80
70
25
26
22
60
26
24
8
10
11
12
16
18
20
23
22
22
24
24
50
40
30
49
50
53
48
50
0
8
7
8
5
7
22
70+
25
26
22
25
6069
46
42
38
37
37
39
4
4
4
3
4
3
20
10
11
2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15
2014/15 Based on activity to 1 March
Some features of current position
• 7% fall in donor numbers from peak
– Both DBD and DCD
• No substantial deterioration in donor pool, referral or testing
– Possible small fall in DBD pool
– 25% of potential DCD not referred
• Little progress with consent / authorisation
– Slight fall in both DBD and DCD in 2014/15
• More cautious approach to older / higher risk kidney donors
– Kidney offer decline rates are higher in the last two years for extended
criteria donors
DRAFT
Update: ante mortem interventions in DCD
• Legal guidance issued in 2009 - 11
– Conservative
– Effective prohibition on ante-mortem heparin
• Call for revision in 2012 / 2013 by UK DEC
– Generic overarching guidance
– Separate documents covering specific interventions
(e.g. heparin, extubation)
– Specific recommendations regarding heparin
• Further evidence required by Department of Health
– Risks and benefits
– Clinical and public acceptability
– NHSBT asked to conduct this review
Physiological changes following treatment
withdrawal
• Can a point of ‘no-return’ be identified following
treatment withdrawal?
– Does the patient always die if BP goes below a certain level?
– Does donation always happen if BP goes below a certain level?
• Is there time to give heparin once point of no return is
identified for it to have a systemic effect?
• What happens to non-proceeding DCD donors?
– Do all potential DCD donors die following treatment withdrawal?
Systolic BP in proceeding DCD donors, all regions
350
systolic BP (mmHg)
300
250
200
150
100
50
0
0
20
40
60
80
100
120
140
time after treatment withdrawal (minutes)
160
180
200
Timings in proceeding DCD donors
Systolic BP of 50 mmHg to asystole (minutes)
Minimum
Maximum
Mean
5.9
8.1
Median
5
6
Range
1 – 56
Systolic BP of 90 mmHg to asystole (minutes)
Minimum
Maximum
Mean
12.8
16.2
Median
8
12
Range
1-86
Minimum: time from first recording below selected BP to asystole
Maximum: time from last recording over selected BP to asystole
Systolic BP, non-proceeding donors, n=153
300
systolic BP
250
200
150
c
100
50
0
0
20
40
60
80
100
120
minutes after treatment withdrawal
140
160
180
Non-proceeding DCD donors with one or more
SBP < 90 mmHg (n=13)
300
270
240
died 13 hours
died 31 hours
died 8 hours
210
systolic BP
died 29 hours
died 3 hours
180
died 7 hours
died 4 hours
150
died 5 hours
died 1.5 hours
120
died 114 hours
died 120 hours
90
died 12 hours
died 7 hours
60
30
0
0
20
40
60
80
100
120
140
160
time after treatment withdrawal (minutes)
180
200
Time to death in non-proceeding DCD donors
(n=153, data on three patients missing)
60
52
50
number
40
30
23 22
17
20
8
7
2
1
0
0
0
0
0
0
1
1
0
day 17
day 18
day 19
day 20
day 21
day 22
day 23
day 11
0
day 16
2
day 15
2
day 14
1
day 13
0
day 10
3
day 9
5
day 8
10
3
0
Home
day 12
day 7
day 6
day 5
day 4
day 3
day 2
13-24 hours
0 - 12 hours
time after treatment withdrawal
Update: Heart retrieval from DCD donors
UK pilots
• 2 pilots
• Normothermic regional perfusion
assisted
– Papworth
– 3 centres in Eastern region
– 2 successful transplants to date
• Standard DCD retrieval
– Papworth and Harefield
– Eastern and South East regions
– Transthoracic echo (Harefield)
Update: extended DCD pilot
• Andre Vercueil, King’s; Roberto Cacciola, Royal
London
• NRP to support abdominal organ retrieval for up
to 9 hours after stand down
• Cannulae sited on ICU after death
• No ante mortem interventions
• 1 proceeding case so far
– Organs poorly perfused and so rejected after
retrieval
– Family grateful for extended opportunity
– Positive staff feedback
• ?? Benefits of
– Heparin
– Femoral guidewires
Update: organ donation from babies with
anencephaly
• Twin pregnancy
• Successful donation of kidneys and heart
valves from an anencephalic infant in April
14
• Delivery ≡ treatment withdrawal
• Baby died after 100 minutes
– Death diagnosed after 5 minutes asystole
• Assessment of renal function limited to
size on USS and lack of oligohydramnios
• Media coverage at baby’s anniversary
– c.15 000 on-line registrations
National CLOD in Big Brother Chair
Update: organ donation from babies with
anencephaly
• Twin pregnancy
• Successful donation of kidneys and heart
valves from an anencephalic infant in April
14
• Delivery ≡ treatment withdrawal
• Baby died after 100 minutes
– Death diagnosed after 5 minutes asystole
• Assessment of renal function limited to
size on USS and lack of oligohydramnios
• Media coverage at baby’s anniversary
– c.15 000 on-line registrations
Update: diagnosis of death by neurological criteria
in infants < 2 months
• AoMRC (2008) applies from 37
weeks gestation to 2 months, with
two additional cautions
• Available at
http://www.rcpch.ac.uk/system/files/p
rotected/page/DNC%20Guide%20FI
NAL.pdf
Update: DNC in infants < 2 months
Additional cautions
• In post-asphyxiated infants, or those receiving intensive care after
resuscitation, a period of at least 24 hours of observation during
which the preconditions necessary for assessment for DNC should
be continuously present, should elapse before clinical testing for
DNC. If there are concerns about residual drug-induced sedation,
then this period of observation may need to be extended
• A stronger hypercarbic stimulus is used to establish respiratory
unresponsiveness. Specifically, there should be a clear rise in
PaCO2 levels of >2.7kPa (>20 mm Hg) above the base line with no
respiratory response at that level.
Update: challenges to neurological determination
of death by organ retrieval teams
• 6 incidents reported Nov 14 – Feb 15
• Nature
–
–
–
–
Apnoea test (starting CO2)
Hypernatraeamia
Interval between testing
Lack of microbiological characterisation
• Outcome
– Retrieval delayed until tests repeated
– Considerable distress in donor hospitals
• Root cause analysis
– Education and training deficits
– Variation in practice in critical care
– Issues with documentation
Apnoea testing in Midlands, Jan-Mar 15
1st apnoea test
2nd apnoea test
16
14
12
PaCO2
PaCO2
10
8
6
4
2
0
Pre-disconnection
end of apnoea test
18 DBDs
6 forms had no CO2 data
7 tests completely compliant
4 tests partially compliant
1 set of tests non compliant
Pre-disconnection
end of apnoea test
National Standards for Organ Retrieval
5.11 Before embarking on the retrieval operation, the lead retrieval
surgeons must review the patient’s medical notes. In particular
they must:
•
Have a clear understanding of the donor information prior to the
start of the retrieval;
•
Check the identity, blood group and virology status of the donor;
•
Check that brain stem death or confirmation of cardiac death
has been confirmed and documented correctly;
•
Check that appropriate consent/authorisation has been
documented for the organs and tissues to be retrieved;
Interim proposal
• Additional form
• Completed by ICU consultant
• Confirmation that death has
been diagnosed and confirmed
by neurological criteria
• Cause, time and place of death
• No other clinical information
• Supported by NODC and NRG
• Consulting HTA
International family refusal rates, 2011
Consent / authorisation for DBD
Consent / authorisation for DBD
Collaborative requesting
Donation after brain-stem death
Donation after circulatory death
100
90
SNOD involvement
80
consent / authorisation
90
80
70
60
60
50
%
70
50
40
30
30
20
20
10
10
0
0
20
05
/6
20
06
/7
20
07
/8
20
08
/9
20
09
/1
0
20
10
/1
1
20
11
/1
2
20
12
/1
3
20
13
/1
4
20
14
/1
5*
40
20
05
/6
20
06
/7
20
07
/8
20
08
/9
20
09
/1
0
20
10
/1
1
20
11
/1
2
20
12
/1
3
20
13
/1
4
20
14
/1
5*
%
100
UK Overall SN-OD
consent/authorisation
rate, when not on ODR,
SNOD
consent rates
whitepatients,
adult patients
non-BAME
notonly
on ODR
1 Jan 2012 to 31 Dec 2013, where no doubt over SN-OD name
• • • • • • •
100
•
•
• •
•
• •
•
•
•
•
•
•
•
• •
•
•
•
•
• • •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
• • • •
•
•
•
•
•
• •
• •
•
• •
• •
• • • •
• • •
• •
•
•
•
•
•
• •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
80
Consent/authorisation rate (%)
•
60
40
20
• • •
0
0
•
•
5
10
15
20
25
30
35
Number of approaches
40
45
50
55
60
Outcome of family approach
Improving how we ask
Donation after brain-stem death
100
90
consent / authorisation
80
SNOD involvement
70
50
40
30
– Has to be the right SNOD
– Designated requester pilot in North West
and Yorkshire
20
10
– May require review of SN-OD deployment
0
20
05
/6
20
06
/7
20
07
/8
20
08
/9
20
09
/1
0
20
10
/1
1
20
11
/1
2
20
12
/1
3
20
13
/1
4
20
14
/1
5*
%
60
• Continued commitment to
collaborative requesting
• Values based cohort SNOD
recruitment
• Six-month pilot of ALS review of
refusals in Midlands, Yorkshire and
London teams
DCD triage?
1 April 2013 to 31 March 2014
Respiratory failure
245 referrals, 140 attendances
28 NORS attendances,
25 donors
37 kidneys, 1 liver transplanted
Cancer, other than brain tumour
280 referrals, 106 Attendances,
0 NORS attendances
0 donors
Renal Failure
30 referrals, 10 Attendances,
0 NORS attendances
0 donors
Multi Organ Failure
1113 referrals, 471 attendances,
3 NORS attendances
3 donors
5 kidney transplants
Septicaemia
247 referrals, 101 attendances,
3 NORS attendances,
3 donors, 1 kidney transplant
MOF/ Cancer/ Sepsis/Renal failure as a cause of death
688 SNOD attendances
6 NORS attendances
6 transplants
Improving donor / organ utilisation
• DCD heart retrieval
• Phase II of Scout project
• Ante-mortem interventions in DCD
– Heparin at point of no return
• Novel technologies
– In-situ normothermic regional
perfusion
– Ex-situ perfusion
100
90
80
70
60
50
40
30
20
10
0
16
24
53
7
20
22
51
7
3
16
28
50
4
3
17
31
44
6
7
15
9
15
16
25
28
26
23
23
25
22
33
31
31
29
33
3
3
3
3
3
21
23
24
13
15
26
25
22
47
8
43
4
24
• Peer review of transplant centres
• Accredited training for retrieval
surgeons
DRAFT
Initial UK framework
8000
7877
7997
7655
7000
7800
7288
6698
6000
NHS Blood and Transplant
7636
7219
7026
Donors
Transplants
Transplant list
6142
5673
Number
5000
National ODO
Employment of coordinators
Commissioning of retrieval
Audit
Public engagement
Education and training
Departments of Health
48%
Acute hospitals
More patients
having their
wishes to
donate
recognised,
fulfilled and
maximised
3514
2912
3000
Clinical leads
Embedded coordinators
Donation Committees
Funding
Resolution of ethical and
legal obstacles
Regulation
Public recognition
4000
2396
2241
2196
2385
2381
2552
2645
3112
2695
2000
1000
793
899
1088
764
959
751
809
1010
770
2003-04
2004-05
2005-06
2006-07
2007-08
2008-09
2009-10
2010-11
2011-12
1212
1320
2012-13
2013-14
0
The emerging UK framework for donation
NHS Blood and Transplant
National ODO
Employment of SNODs
Commissioning of retrieval
Audit
Public engagement
Education and training
CLODs
SNODs
Donation
Committees
Funding
Resolution of ethical and
legal obstacles
Regulation
Public recognition
Donor
hospitals
Departments of Health and
Professional Societies
Regional
Acute hospitals
Collaboratives
More patients
having their wishes
to donate
recognised, fulfilled
and maximised
Service improvement in deceased donation
• Timely identification and
referral
– Emergency Department
• Brain-stem death testing
• Collaborative requesting
• Streamlining DCD
What are we trying to
achieve?
How will we know that
change is an
improvement?
What changes can we
make that will result in
improvement?
• Physiological optimisation of
the DBD donor
act
plan
study
do