Gift of Life Michigan

Normothermic regional perfusion (NRP) adoption for donation after circulatory death (DCD) liver transplantation in the United States has been growing, but there remains a higher rate of non-utilization of NRP DCD liver grafts as compared with donation after brain death liver grafts. Six transplant centers and 1 organ procurement organization (OPO) with substantial NRP liver procurement experience performed retrospective reviews of all NRP procurement attempts from September 1, 2021, until March 1, 2024, identifying opportunities for utilization. Five of the 6 transplant centers had prospectively collected data on all accepted livers with NRP intent. The transplant center's intention to utilize DCD donors included 329 livers accepted for transplantation before withdrawal, 252 (76.6%) potential donors expired within the hospital timeframe for donation, and 168 (66.7%) livers were transplanted. Fifty-seven opportunities for utilization were identified by transplant centers, plus 11 from the OPO: most were due to exceeding a functional warm ischemic time limit (n=26), other reasons (n=17), and functional assessment (n=16). The lessons learned by centers in this study provide guidance for newer NRP centers and for OPOs in identifying opportunities for utilization of NRP DCD grafts that have historically been declined.

Transplant centers hold the key to accelerating organ use and transplanting more patients more efficiently. However, not all transplant procedures are alike, as organ complexity and patient comorbidities can dramatically increase the risk of the procedures, demanding unique skills and more extensive resources to achieve good outcomes. What if transplant centers could emulate aspects of the trauma center model to ensure that necessary capabilities are consistently applied and uniformly available for all levels of organ risk and patient health? The proposed model recognizes that some transplant centers would have the capacity and aligned resources to care for the most complex patients and different types of organ transplants. Other transplant centers would leverage their available resources for less complex patients and organs. Importantly, this model also provides a template for regular stakeholder review of transplant program performance and episodic certification of transplant center resources. By moving to a tiered trauma center-like certification model, transplant centers, organ allocation policy, and patients could be triaged to the center most capable of providing them timely, effective care.

Introduction: Transplant systems are intricate dances between transplant centers (TC), organ procurement organizations (OPO), and regulatory bodies (RB), each with different goals, logistical needs, and interpretations of each other. Methods: Qualitative observations of the US transplant system by an experienced working transplant surgeon who has worked for different TC and OPOs in various roles over three decades and an experienced transplant nephrologist, both of whom are also health services researchers. Results: As allocation policy changed, TC and OPO logistical needs align less. Many TC are not so much afraid of risk, but rather unaccounted-for risk, as RB emphasized two high stakes metrics. These metrics resulted in riskier patients and donors being sidelined—particularly for those with poorly accounted-for risk in RB’s statistical models. Having learned those ramifications for TC, RB relaxed them, which allowed TC to more aggressively transplant those who historically had poor access due to risk. However, RB promptly imposed two high stakes metrics on OPOs. For kidneys, this change was contemporary with change in kidney allocation. While kidneys were more aggressively recovered, predictably unused rates increased. Organs typically underutilized in the past were often from older and riskier donors—increases in overall organ recovery would be expected to result from a relative expansion of these donors. Growth of rapid DCD and US health care consumers’ expectations of “a perfect organ” contribute to these ratios. These issues pose significant difficulty for OPOs, as they are pressured by RB to recovery more organs while at the same time unrealistically expected to decrease unused rates. For kidney, the process is hampered by volume and timing. TC get multiple offers at all times of the day. However, compared to extrarenal organs, TC don’ t follow kidney candidates that closely, as they are primarily cared for by their local nephrologist. Logistics are further hampered by high rates of ongoing complications in dialysis patients, resulting in a significant fraction being passed for a given offer. OPO need provisional yes’ s (PY) to be actual PYs, but given the volume of offers TC surgeons must face 24/7 for days on end, this expectation is unrealistic. When offers are not primary, it is not surprising that TC haven’t done patient checks, performed virtual XM, or otherwise processed offers—particularly for offers released overnight. Human physiology—even for MDs—isn’t compatible with such long-term sleep disruptions. Some OPO have started waiting to release kidney offers until after recovery, further pressuring the system. Conclusions: To prevent system instability, realistic quantitative and qualitative mutual understandings by TC, OPO, and RB are required for transplant systems to be optimized, or at least Pareto-optimized. Additionally, human physiology and logistics, particularly the impact of volume and time of offers, must be considered.

Organ, tissue, and eye donations provide opportunities to leave a legacy by saving and/or enhancing the quality of life of others. There has been little published related to tissue or eye donation in hospice/palliative care and few initiatives to facilitate donation among hospice patients/families. Donation myths, gaps in knowledge, and, most significantly, lack of donation referral processes result in missed opportunities for patient/families to consider donation. One donor has the potential to impact 75 lives or more through tissue donation and 2 lives through eye donation. Hospice/palliative care providers can play key roles related to education, advocacy, and collaboration. The support of hospice/palliative care organizations and the local Organ Procurement Organization/Tissue and Eye Recovery Agency are essential for facilitating donation opportunities. This article summarizes current literature, examines legislation and regulations related to donation, presents a case that illustrates an opportunity for hospice community based donation, and shares practices that support donation in hospice/palliative care organizations together with the local Organ Procurement Organization/Tissue and Eye Recovery Agency. This article will hopefully provide the impetus for further study and the development of practices to optimize donation in hospice/palliative care, thus providing more patients and families the opportunity to turn loss into legacy.