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Improving organ utilization and the role of surgeons in the process
Efforts to maximize organ utilization include increasing the pool of potential donor organs through more rigorous evaluation of donation after circulatory death (DCD) and advances in organ preservation, broadening donor criteria, and applying new technologies for better organ recovery, rehabilitation, and preservation.
Willingness to accept high-risk donors and recipients
As a gap exists between organ supply and demand, marginal organs are increasingly being considered, but this approach requires transplant centers to be willing to take on more risk.
“By being more proactive in inviting donors and looking at marginal donors, we can help people get organs sooner and reduce deaths on the waiting list,” said Jordan Hoffman, MD, FACS, director of heart and lung transplant surgery at the University of Colorado at Denver.
Larger transplant centers tend to take a more aggressive approach than smaller centers because they have the resources and infrastructure to provide individualized, intensive patient care before and after transplant, Dr. Stewart said. Still, transplant centers should be prepared to evaluate organs more closely and expand their acceptance criteria.
“Give every organ a chance,” Dr. Stewart said.
Reducing risk and rewarding innovation
Transplant centers would be more likely to accept marginal donors if outcome metrics were less stringent, Dr. Stewart said. Transplant centers are expected to maintain outcomes of 96 percent or higher for one-year transplant and patient survival, he said. “Any deviation from these strict regulatory standards will have regulatory consequences for your program,” he said.
The United States has one of the best organ donation and transplant systems in the world, but it may be too strict when it comes to outcome monitoring policies, Dr. Mathur said, “which can hinder the practice of medicine. We need to be more responsive to innovation.”
Reducing the risk of regulatory discipline for transplant centers could potentially reduce the risk of patients dying on the waiting list.
“We need a more holistic approach to risk management,” Dr. Stewart said. “We can't let people on transplant waiting lists die because transplant centers are too selective about which organs they accept.”
Significant increase in use of DCD organs
DCD organs can be affected by hypoxic-ischemic brain injury because they cannot be harvested until the donor has been declared dead, which in the United States is typically done after the donor's pulse has stopped for five minutes.11 For many years, DCD has been associated with lower yields of transplantable organs, reduced patient and graft survival, higher complication rates, and increased delays in graft function when compared with organ donation after brain death (DBD).
In 2010, about 85 percent of transplanted organs were DBD organs and 15 percent were DCD organs, Dr. Stewart said. Since then, advances in perfusion technology have made DCD organs a more viable option. DCD hearts have increased the donor heart pool by about 20% to 30%, and complication rates have decreased to the point where DCD organs are comparable to DBD organs.
“We use modified pumps to perfuse organs that we use for transplant,” Dr. Hoffman said, “and while we do this, we are also testing the function and physiology of these organs.”
What's more, transplant teams can travel to the donor's location to perfuse the organ, a technique called normothermic regional perfusion (NRP), which provides results comparable to extracorporeal perfusion, said Dr. Hoffman, who called NRP a “game-changing technology” for hearts, lungs, livers and kidneys.
In Dr. Stewart's clinic, 50% of livers became DCD organs in the past six months, compared with 0% in the year prior.
Unfortunately, DCD lungs have not caught on as quickly as other organs, and because lung transplant recipients generally have a limited lifespan (average survival is around six years), surgeons want to ensure that donor lungs are in the best possible condition and do not develop complications.
The main limitation of perfusion is cost, meaning transplant programs need to find ways to recoup costs, and Dr. Hoffman says NRP in particular is more economically feasible than any other procurement technique, including extracorporeal perfusion.
