Changing Epidemiology of Neurological Death and Implications for Organ Transplantation: A 12-Year Population-Based Cohort Study
CCCF ePoster library. Kramer A. Oct 26, 2015; 114764; P20
Dr. Andreas Kramer
Dr. Andreas Kramer
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Abstract
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P20


Topic: Retrospective or Prospective Cohort Study


Changing Epidemiology of Neurological Death and Implications for Organ Transplantation: A 12-Year Population-Based Cohort Study



Andreas Kramer, R. Baht

Critical Care Medicine, University of Calgary, Calgary, Canada | Southern Alberta Organ and Tissue Donation Program, Alberta Health Services, Calgary, Canada

Introduction:

With advances in neurocritical care, a smaller proportion of brain-injured patients are progressing to neurological determination of death (NDD) [1]. However, with improvements in resuscitation, more cardiac arrest victims are admitted to hospital with anoxic brain injury (ABI) [2]. We hypothesized that ABI has replaced traumatic brain injury (TBI) and stroke (subarachnoid hemorrhage, intracerebral hemorrhage, and ischemic stroke) as the predominant cause of NDD, and that this shift has affected organ transplantation rates.



Objectives: To determine whether the relative distribution of etiologies responsible for NDD has changed over time; and if so, whether this has had an impact on organ quality and transplantation rates.

Methods:

We assessed consecutive patients over a period of 12 years that were referred to our regional organ donation agency after NDD. For each donor, we determined the last available measures of organ function, as well as the number of organs procured and transplanted, and compared these variables for different etiologies of NDD. Donor characteristics were compared using chi-square analysis and ANOVA, with adjustment for multiple comparisons. Temporal trends were assessed using the Cochrane-Armitage test. Multivariable linear regression was used to adjust for other factors that may influence the number of organs procured per donor, including age, body mass index, hypertension, diabetes mellitus and the use of hormonal therapy (levothyroxine or methylprednisolone).



Results:

Between 2003 and 2014, 223 patients became organ donors following NDD. The cause of NDD was ABI in 99 (44%), stroke in 62 (28%), TBI in 50 (22%), and various other conditions in 12 (5%). Donors with ABI were significantly older than donors with TBI, and younger than those with stroke (Table 1). The proportion of donors with TBI decreased over time from 29-33% per year in 2003-2005 to 0-23% per year in 2012-2014 (p=0.002) (Figure 1). In contrast, the proportion with ABI increased from 14-37% per year in 2003-2005 to 46-80% per year in 2012-2014 (p=0.0001). The proportion with stroke remained relatively stable (p=0.23).

Immediately prior to organ procurement, donors with ABI had significantly higher concentrations of urea, creatinine, alanine aminotransferase, and troponin T, as well as lower P
aO2 to FIO2 ratios and urine output compared with donors with TBI or stroke (Table 1). The number of organs transplanted per donor was 3.6 in donors with ABI compared with 4.5 in donors with other diagnoses (p=0.002). The difference was most pronounced for lung transplantation (22% in donors with ABI vs. 47% with TBI or stroke, p=0.0001), but similar trends were observed with other organs (Table 1). After adjustment for other donor characteristics, the presence of ABI remained an independent predictor of fewer organs transplanted per donor (p=0.005).

The number of organs transplanted per donor decreased from 3.7-4.5 in 2003-2005 to 3.4-3.8 in 2012-2014. Despite significant population growth, the total number of organs transplanted from donors in our region decreased from 79-104 per year in 2003-2005 to 44-53 per year in 2012-2014 (Figure 2). Among donors with ABI, the mean number of organs transplanted was 3.2 when there had been a cardiac arrest > 30 minutes, compared with 3.9 per donor when the cardiac arrest had been more brief (p=0.14).



Conclusion: ABI has replaced severe TBI and stroke as the most common cause of NDD in our region. This demographic shift has resulted in fewer organs procured and transplanted per donor. Efforts aimed at maximizing the number of deceased organ donors, whenever appropriate, is only part of the solution for organ shortages. Health care systems should direct resources towards interventions that enable use of marginal organs, in order to maximize the number of organs procured and transplanted per donor.



References: 1. Kramer AH, Zygun DA, Doig CJ, Zuege DJ. Incidence of neurologic death among patients with brain injury: a cohort study in a Canadian health region. CMAJ 2013; 185: E838-45.
2. Chan PS, McNally B, Tang F, Kellermann A. Recent trends in survival from out-of-hospital cardiac arrest in the United States. Circulation 2014; 13): 1876-82.
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