Uncontrolled Organ Donation After Circulatory Death
Uncontrolled Organ Donation After Circulatory Death
An uncontrolled DCD organ donation programme in the RIE might be able to enrol around four patients per year potentially allowing up to eight extra renal transplants per annum. With a steady rise of people on the ODR it is not unreasonable to anticipate that these numbers may increase in the future. Such programmes have been proven to be beneficial and sustainable in the long run. Spain for example, has been doing Category II DCD for years, and consistently reports success.
There are many ethical, legal and clinical challenges to setting up such an uncontrolled DCD organ donation programme; however, with the publication of two important Academy of Medical Royal Colleges documents, there is now some much needed UK guidance in the area of the diagnosis of death and DCD organ donation. The ethical, legal and clinical challenges of uncontrolled DCD will continually need to be reviewed as practices change and new interventions in the field of cardiac arrest such as extracorporeal membrane oxygenation and coronary angiography (and the evidence for them) become more widely available. Although currently there is little to support the use of these interventions on anything but a highly specific individual case basis, detailed protocols for their use will need to be drawn up as they become more widespread over the next decade.
There are many advantages that kidney transplantation has over renal dialysis. One advantage is the financial burden of dialysis. The average dialysis patient costs the NHS £30 800 per year. In the UK in 2006, over 44 000 patients were kept alive by renal replacement therapy and 1 in 10 000 adults were accepted for long-term dialysis. Factoring in the projected rise in patients with chronic kidney disease, the number requiring renal replacement therapy will grow and this will incur significant cost to the NHS each year. In contrast, kidney transplantation costs £17 000 per patient. The cost breaks even after a few months. In fact, after the first year, transplantation has a subsequent cost benefit of £25 800 per annum. Using our figures, an uncontrolled organ donation programme in our ED could potentially have saved £180 600 over a year.
We have chosen to accept only those aged 16 years to 60 years into our pilot programme as older kidneys usually fare worse after transplantation. During the first year of a similar programme in Leicester in the 1990s, donors aged 61–65 years were included, however a significant proportion within this age group had poor perfusion, and consequently poor post-transplantation outcomes. An area of concern is the quality of organs received from Maastricht Category II DCD donors. Several published studies have shown that while Maastricht Category II DCD organs fare worse in the short term, long-term outcomes are similar to that of organs derived from other Maastricht categories.
Our baseline of 564 cardiac arrests in 14 months may seem large; however, this does include some patients in whom resuscitation was terminated in the prehospital setting (included in the 127 who died outside the ED). Also, our hospital is the primary receiving hospital for cardiac arrests in the Lothian region, which has a population of around half a million. Our cardiac arrest improvement programme may in future consider early transfer on a mechanical compression device, of patients unable to be initially resuscitated. This may increase the number of patients who could become potential donors in future.
The time of arrival in the ED was limited to 9:00–17:00, because that is when the core ED and transplant team are available. Almost half the population was excluded based solely on this criterion. Since there are no current uncontrolled DCD programmes in the UK and none have ever been implemented in Scotland, jumping straight to setting up a dedicated after-hours team for Maastricht Category II DCD donation is unwise and potentially very costly. In the future this criteria can however be reconsidered.
This study was limited by difficulty in getting information about whether patients were on the ODR. Using a percentage obtained from the ODR enables estimation of the actual figure, but does not truly reflect the true potential number of Maastricht Category II DCD donors. It should also be noted that the percentage of the population on the ODR in Scotland is high compared with the UK. The retrospective nature of the study also meant that some data was unavailable. This may reflect data that would also not be available should a potential donor present to the ED; however, the number of potential donors may be higher than we have estimated if this information was available at the time of ED presentation. Finally, while legally, a patient determines whether they wish to become an organ donor by joining the ODR, family wishes should always be respected. All four patients may not have become donors because this assumes that relatives would consent to donation in each case. However, consent may be granted in only approximately 40% of cases. Although authorisation rates (the percentage of families approached who consent to donation) in our health region are around 55% for DCD, the conversion rate (the percentage of potential donors who became actual donors) is only around 40%. This would reduce the potential number of donors a year in our ED to only two.
Discussion
An uncontrolled DCD organ donation programme in the RIE might be able to enrol around four patients per year potentially allowing up to eight extra renal transplants per annum. With a steady rise of people on the ODR it is not unreasonable to anticipate that these numbers may increase in the future. Such programmes have been proven to be beneficial and sustainable in the long run. Spain for example, has been doing Category II DCD for years, and consistently reports success.
There are many ethical, legal and clinical challenges to setting up such an uncontrolled DCD organ donation programme; however, with the publication of two important Academy of Medical Royal Colleges documents, there is now some much needed UK guidance in the area of the diagnosis of death and DCD organ donation. The ethical, legal and clinical challenges of uncontrolled DCD will continually need to be reviewed as practices change and new interventions in the field of cardiac arrest such as extracorporeal membrane oxygenation and coronary angiography (and the evidence for them) become more widely available. Although currently there is little to support the use of these interventions on anything but a highly specific individual case basis, detailed protocols for their use will need to be drawn up as they become more widespread over the next decade.
There are many advantages that kidney transplantation has over renal dialysis. One advantage is the financial burden of dialysis. The average dialysis patient costs the NHS £30 800 per year. In the UK in 2006, over 44 000 patients were kept alive by renal replacement therapy and 1 in 10 000 adults were accepted for long-term dialysis. Factoring in the projected rise in patients with chronic kidney disease, the number requiring renal replacement therapy will grow and this will incur significant cost to the NHS each year. In contrast, kidney transplantation costs £17 000 per patient. The cost breaks even after a few months. In fact, after the first year, transplantation has a subsequent cost benefit of £25 800 per annum. Using our figures, an uncontrolled organ donation programme in our ED could potentially have saved £180 600 over a year.
We have chosen to accept only those aged 16 years to 60 years into our pilot programme as older kidneys usually fare worse after transplantation. During the first year of a similar programme in Leicester in the 1990s, donors aged 61–65 years were included, however a significant proportion within this age group had poor perfusion, and consequently poor post-transplantation outcomes. An area of concern is the quality of organs received from Maastricht Category II DCD donors. Several published studies have shown that while Maastricht Category II DCD organs fare worse in the short term, long-term outcomes are similar to that of organs derived from other Maastricht categories.
Our baseline of 564 cardiac arrests in 14 months may seem large; however, this does include some patients in whom resuscitation was terminated in the prehospital setting (included in the 127 who died outside the ED). Also, our hospital is the primary receiving hospital for cardiac arrests in the Lothian region, which has a population of around half a million. Our cardiac arrest improvement programme may in future consider early transfer on a mechanical compression device, of patients unable to be initially resuscitated. This may increase the number of patients who could become potential donors in future.
The time of arrival in the ED was limited to 9:00–17:00, because that is when the core ED and transplant team are available. Almost half the population was excluded based solely on this criterion. Since there are no current uncontrolled DCD programmes in the UK and none have ever been implemented in Scotland, jumping straight to setting up a dedicated after-hours team for Maastricht Category II DCD donation is unwise and potentially very costly. In the future this criteria can however be reconsidered.
Limitations
This study was limited by difficulty in getting information about whether patients were on the ODR. Using a percentage obtained from the ODR enables estimation of the actual figure, but does not truly reflect the true potential number of Maastricht Category II DCD donors. It should also be noted that the percentage of the population on the ODR in Scotland is high compared with the UK. The retrospective nature of the study also meant that some data was unavailable. This may reflect data that would also not be available should a potential donor present to the ED; however, the number of potential donors may be higher than we have estimated if this information was available at the time of ED presentation. Finally, while legally, a patient determines whether they wish to become an organ donor by joining the ODR, family wishes should always be respected. All four patients may not have become donors because this assumes that relatives would consent to donation in each case. However, consent may be granted in only approximately 40% of cases. Although authorisation rates (the percentage of families approached who consent to donation) in our health region are around 55% for DCD, the conversion rate (the percentage of potential donors who became actual donors) is only around 40%. This would reduce the potential number of donors a year in our ED to only two.
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