Active Critical Care Can Increase Number Of Transplant Organs Per Donor

Darren J. Malinoski, MD, FACS Assistant Chief of Surgery – Research and Education Chief, Section of Surgical Critical Care Portland VA Medical Center Associate Professor of Surgery Oregon Health & Science University Portland, OR 97207MedicalResearch.com Interview with:
Darren J. Malinoski, MD, FACS
Assistant Chief of Surgery – Research and Education
Chief, Section of Surgical Critical Care
Portland VA Medical Center Associate Professor of Surgery
Oregon Health & Science University
Portland, OR 97207

Medical Research: What are the main findings of the study? 

Dr. Malinoski: Our two main findings are that the status of the DMG Bundle prior to organ recovery, at the end of the OPO donor management process, is the most predictive of the number of organs that will be transplanted per expanded criteria donor (ECD) and that the absolute increase in the number of individual DMG elements achieved over time also appears to be relevant.  Taken together, these two findings suggest that the number of organs that will be transplantable from each donor is not necessarily predetermined by their age, comorbidities, and pre-neurologic death condition, but that active critical care management has the ability to affect outcomes and reassessing each donor’s condition over time is necessary.

Medical Research: What was most surprising about the results?

Dr. Malinoski: Our prior study that examined the relationship between meeting Donor Management Goals (DMGs) in standard criteria donors (SCDs), who are younger and have fewer comorbidities than the expanded criteria donors (ECDs) who were the focus of this study, found that meeting the DMG Bundle at two time points was associated with more organs transplanted per donor (OTPD):

1. At the time of authorization for donation, which reflects the care provided by donor ICU providers prior to handing the care of the potential organ donor over to the organ procurement organization (OPO), and

2.  immediately prior to organ recovery, at the end of the organ procurement organization donor management process.  In contrast, this study involving only Expanded Criteria Donors found that only meeting the Bundle prior to organ recovery had a statistically significant association with increased organ utilization rates.  This may reflect the fact that the older and sicker Expanded Criteria Donor needs more optimization performed due to the chronic nature of their underlying conditions.

Medical Research: What should clinicians and patients take away from your report?

Dr. Malinoski: In addition to the comments about the main findings of the study, it is worth noting that, even though meeting the Donor Management Goals Bundle at the time of authorization for donation was not an independent predictor of the number of OTPD in this analysis, the absolute increase in the number of individual endpoints achieved from the time of donor hospital referral to organ recovery was significant.  This implies that the critical care provided by hospital staff prior to handing a donor over to the organ procurement organization has the potential to impact the gift that each patient and family are able to make.

Also, many people ask if it is possible to tell which of the DMGs is/are most important in improving the number of organs transplanted.  Our first retrospective analysis, published in 2011, was designed to identify the specific critical care endpoints to be included in our subsequent prospective studies that implemented the Donor Management Goals Bundle at the bedside of each donor after neurologic determination of death (DNDD).  The multivariate analysis in that study identified the central venous pressure (CVP), ejection fraction (EF), PaO2:FiO2, and serum sodium goals to be independent predictors of an SCD having >/= 4 OTPD.  Since that time, we have intentionally not examined the independent effect of each Bundle element, for, when they are all applied as a single checklist, many of them interact and their isolated impact cannot really be teased out.  For example, if one is trying to increase the urine output by giving a diuretic, the CVP may be lowered and the PaO2:FiO2 might be increased.  Similarly, the vasopressor requirements might also go up in this situation, depending on the donor’s underlying intravascular volume status.  Another example could include the common practice of giving a DNDD steroids to help with both oxygenation and hemodynamic stability, a side effect of which could be an increase in serum glucose above the DMG target of 150 mg/dL.  This is not to say that we do not continue to try to modify the individual Donor Management Goals elements based on evolving literature or focused analyses with our own data, just that it is difficult to determine the relative impact of one endpoint over another.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Malinoski: We have consistently shown that donors who have the Donor Management Goals bundle met have more organs transplanted per donor, but there are only limited data on the impact of meeting these goals on recipient graft outcomes.  While we have analyzed the association between the DMGs and both renal and liver graft outcomes, further analyses are needed.  In addition, it is will continue to be important to look for other biomarkers that may be useful additions to the DMG Bundle moving forward.

Citation:
The Impact of Meeting Donor Management Goals on the Number of Organs Transplanted per Expanded Criteria Donor: A Prospective Study From the UNOS Region 5 Donor Management Goals Workgroup

Madhukar S. Patel, MD, MBA, ScM; John Zatarain, MD; Salvador De La Cruz, MD; Mitchell B. Sally, MD; Tyler Ewing, BS; Megan Crutchfield, MPH; C. Kristian Enestvedt, MD; Darren J. Malinoski, MD

JAMA Surg. 2014; doi: 10.1001/jamasurg.2014.967