- Email: [email protected]
Current Status of Discarded Grafts in Korean Organ Transplantation
Current Status of Discarded Grafts in Korean Organ Transplantation Kil Hwan Kim, YoungRok Choi*, Jai Young Cho, Ho-Seong Han, Yoo-Seok Yoon, In Gun Hyun, Sunjong Han, and Bo-Ram Lee Department of Surgery, Seoul National University, College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
ABSTRACT Objectives. Despite the severe shortage of available organs, many are discarded after procurement. This study aims to analyze the current status of discarded organs (retrieved, but not transplanted organs) from deceased donors in Korea. Methods. Deceased donor organ and procurement data were collected from the Korean Network for Organ Sharing and Korea Organ Donation Agency database from 2013 to 2016. Results. Between 2013 and 2016, a total of 6315 deceased donor organ transplants were performed nationwide. A total of 63 organs were discarded. The most commonly discarded organs were kidney (n ¼ 24), followed by islet cell (n ¼ 23), lung (n ¼ 9), liver (n ¼ 6), and pancreas (n ¼ 1). The most common cause for discarding solid organs was poor organ condition (n ¼ 24). Other reasons included aggravation of donor condition, incidental cancer detection of the donor, and the abscence of matching recipient. Islet cells (n ¼ 23) were not used because of inadequate separation and purification. Conclusions. To reduce unnecessary graft discard in Korea, systems-based improvements in preprocurement organ evaluation and postprocurement preservation are imperative.
O
RGAN transplant is a lifesaving intervention to increase survival in end-stage organ disease and is being more commonly performed. Despite increasing demand for organs throughout the world, supply has been limited [1]. Despite an increase in expanded criteria donors and living donor use, supply cannot reach demand. There are organs that are discarded during the procurement despite the shortage of donors. The aim of this study is to understand the current status and causes of organ discard in Korea.
RESULTS Status of Deceased Donor Organ Transplants in Korea
MATERIALS AND METHODS
A total of 6315 cases of deceased donor organ transplant were performed in Korea from 2013 to 2016 (Fig 1). That increasing trend was affected by several causes: releasing informed consent of deceased donor families and reinforcing public relations and education through the media to improve public awareness of organ donation. Because of those efforts, the number of deceased organ donors in 2016 was 11.39 per million people in South Korea compared with 43.4 per million in Spain and 30.98 per million in the United States [2].
All deceased donor and procurement records were collected from the Korean Network for Organ Sharing and Korea Organ Donation Agency database from 2013 to 2016. The following organ types were selected for analysis: kidney, liver, heart, lung, and pancreas including islet cell. Patient clinical, histopathologic, and procurement discard data were abstracted and reviewed.
Disclosure: The authors have no conflict of interest to disclose. *Address correspondence to YoungRok Choi, 82 SNUBH, Gumi-ro 173 Beon-gil, Bundang-gu, Gyeonggi-do 13620, South Korea. Tel: þ82-31-787-7111; Fax: þ82-31-787-4055. E-mail: [email protected]
0041-1345/19 https://doi.org/10.1016/j.transproceed.2019.01.119
1478
ª 2019 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 51, 1478e1480 (2019)
DISCARDED GRAFTS IN KOREAN ORGAN TRANSPLANT
1479 Table 2. Multiple Reasons for Discarding Organs
2000
Kidney (n ¼ 24)
1800 1600 1400
Total
1200
Kidney Liver
1000
Pancreas
800
Islet cell
600
Heart Lung
400 200 0 2013
2014
2015
2016
Fig 1. Number of deceased donor organ transplants in Korea from 2013 to 2016.
Status of Discarded Organs
A total of 63 organs were discarded during the study period, most commonly kidney (n ¼ 24), representing a discard rate of 0.68% over 4 years (Table 1). Islet cells were the second most common discarded organ (n ¼ 23, 71.88%). Lungs were discarded in only 9 cases; however, the discard rate was relatively high at 3.42%. Livers were discarded in 6 cases at a steady year-over-year rate. Pancreas was discarded in only 1 case in 2014 because of partial duodenal infarction after procurement. There were no discarded hearts during the study period. Reasons for Organ Discard
Table 2 shows the reasons listed for discarding organs. Of 63 discarded organs, the reason in 13 cases (20.6%) was recipient-related. Three kidneys were discarded because of the refusal of the matched recipients for transplant. Ten other organs were discarded at the time of procurement because the recipient’s medical condition was worsening and inappropriate for transplant. The listed reasons for the remaining 50 cases (79.4%) were donor-related. In detail, the most common reason was unsuitable organs for transplanting, including vessel Table 1. Current Status of Discard Organs From 2013 to 2016
Kidney, No. (%) (n ¼ 24, 0.68%) Liver, No. (%) (n ¼ 6, 0.34%) Pancreas, No. (%) (n ¼ 1, 0.41%) Islet cell, No. (%) (n ¼ 23, 71.88%) Heart, No. (%) (n ¼ 0) Lung, No. (%) (n ¼ 9, 3.42%)
2013 N ¼ 19
2014 N ¼ 11
2015 N ¼ 19
2016 N ¼ 14
6 (0.79)
6 (0.74)
9 (0.99)
3 (0.28)
2 (0.54)
1 (0.25)
0 (0.0)
3 (0.59)
0 (0.0)
1 (1.79)
0 (0.0)
0 (0.0)
8 (72.73)
2 (100.0)
7 (63.64)
6 (75.0)
0 (0.0) 3 (6.12)
0 (0.0) 1 (1.79)
0 (0.0) 3 (4.48)
0 (0.0) 2 (2.20)
% discard rate ¼ discarded organs/(transplanted organs þ discarded organs) * 100.
Recipient, No. (%) N ¼ 13 Refusal 3 (n ¼ 3) Patient’s 2 condition (n ¼ 10) Donor, No. (%) N ¼ 50 Donor’s condition (n ¼ 1) Organ 18 condition (n ¼ 24) Cancer (n ¼ 2) 1 Technique (n ¼ 23)
Liver Pancreas Islet Cell Heart Lung (n ¼ 6) (n ¼ 1) (n ¼ 23) (n ¼ 0) (n ¼ 9)
(4.7)
0
0
0
0
0
(3.2)
3 (4.7)
0
0
0
5 (7.9)
0
1 (1.5)
0
0
0
0
0
0
4 (6.3)
0 23 (36.5)
0 0
0 0
(28.6) 1 (1.5) 1 (1.5)
(1.5) 0
1 (1.5) 0
0 0
problems (n ¼ 24, 38.1%). Among the 24 kidney cases, 4 were not used because of severe arterial thrombosis or intimal injuries. Five kidneys were discarded because of poor perfusion. The 1 case of discarded liver was because of graft-patient size mismatch. The sole case of discarded pancreas was because of partial duodenal infarction. Two discarded lungs had severe pulmonary edema. After organ condition, failure of appropriate separation of islet cell (n ¼ 23, 36.5%) was the second most common cause. Among them, 13 cases were discarded because the number of isolated islet cells was too few to be transplanted. The other 8 cases were discarded because of low purity. The discard rate for lung (3.42%) was higher than for other organs. Five cases were associated with recipient’s poor medical condition at the operating room, so ischemia time was much longer. Also, malignant neoplasms were incidentally found in 2 cases, which were diagnosed as renal cell carcinoma by frozen biopsy. Reasons for Discontinuation of Procurement at the Operating Room
Among 45 total cases discontinued during procurement, poor organ condition was the most common cause (n ¼ 30, Table 3. Reasons for Discontinuation of Procurement at Operating Room
2013 (n ¼ 13) 2014 (n ¼ 10) 2015 (n ¼ 11) 2016 (n ¼ 11) Total, No. (%) (N ¼ 45)
Poor Organ Condition
Infection
Incidental Cancer
Death of Donor
No Matching Recipient
11 4 8 7 30 (66.7)
0 4 2 2 8 (17.8)
1 0 0 1 2 (4.4)
0 1 1 1 3 (6.6)
1 1 0 0 2 (4.4)
1480
KIM, CHOI, CHO ET AL Table 4. Discard Rate of Other Countries in 2014
Kidney, % Liver, % Pancreas, % Heart, % Lung, %
Korea
USA
Eurotransplant†
UK
0.7 0.2 5.2* 0 1.8
18.5 9.6 24.1 1.2 3.9
9.9 17.1 50.1 14.1 27.6
2.9 1.6 13.3 0.6 6.9
*Pancreas þ islet cell. † Austria, Belgium, Croatia, Germany, Luxembourg, Hungary, Netherlands, and Slovenia.
66.67%, Table 3). Procurements were stopped in 7 cases because peritonitis was identified (eg, bowel perforation, necrosis) during the operation. There were 2 incidental cancers (renal cell carcinoma, gallbladder cancer) that were not detected during the preoperative evaluation process. DISCUSSION
A significant number of organs have been discarded in deceased donor organ transplants every year. To minimize the discard rate, we should understand the reasons for discard. First of all, preoperative tests of donors are not enough to evaluate organs accurately. As commented above, operations were discontinued because peritonitis was identified in 7 cases. In most of the centers, only preoperative basic tests such as laboratory findings and ultrasonography including echocardiography have been performed; physicians should retrieve organs with subjective inspection and objective findings (eg, frozen biopsy). The donor’s medical condition is usually poor, and the cost is expensive for accurate and time-consuming screening tests. Through appropriate evaluations such as Doppler ultrasonography, high-resolution computed tomography, and nonenhanced abdominal computed tomography, incidental carcinoma, hidden trauma, and organ worsening could be detected preoperatively, possibly decreasing the discard rate. For 4 years, the discard rate of islet cell (71.88%) was significantly higher than other organs. Human islet isolation remains a challenging process, with only about 50% of optimal pancreases achieving transplantable islet yields in the leading isolation centers worldwide [3]. The reasons for this are multiple, but the insufficient consistency of enzyme blends is one of the main reasons for the low standardization of enzymatic isolation of human islets [4]. In Korea, there were no hearts discarded for 4 years. We have used criteria for acceptability of a donor heart that would be stricter than those of other organs [5]. The 8 cases of discarded kidneys were related to massive vascular thrombosis and intimal injury leading to poor perfusion. It is unknown whether the thrombosis and intimal injury existed preoperatively or intraoperatively. If those
occurred during procurement, we could improve organ quality by insisting more experienced physicians perform the procurement and require regular education and/or certification for procuring physicians. We compared the discard rate for 2014 in each country (Table 4) [6e8]. Although there will be differences from year to year, South Korea had a lower discard rate than other countries in 2014. We suggest 2 reasons: first, procurement from donation after circulatory death is relatively rare in Korea, and brain death donors are highly selected. Second, the distance to procurement and donor wait time are relatively short. Even though the Korean discard rate is low, we must try to reduce this rate with optimal preoperative donor selection, monitoring, and management. CONCLUSIONS
It is obvious that the shortage of organ donors continues to increase. While discarding a small fraction of organs procured from donors may be inevitable, discarding potentially transplantable organs needs to be avoided. To reduce unnecessary procurement and organ discarding, we need to more extensively evaluate donor organs prior to procurement and intensively monitor and manage deceased donors. ACKNOWLEDGMENT The authors would like to thank the Korean Network for Organ Sharing (KONOS) and the Korea Organ Donation Agency (KODA) for their kindness in furnishing us with data from the national deceased donor registry. A sincere thank you to Jonathan Sham for his diligent proofreading of this paper.
REFERENCES [1] Saidi RF, Hejazii Kenari SK. Challenges of organ shortage for transplantation: solutions and opportunities. Int J Organ Transplant Med 2014;5:87e96. [2] International Registry in Organ Donation and Transplantation. IRODaT Newsletter 2016. http://www.irodat.org/img/database/pdf/ IRODaT%20newletter%20Final%202016.pdf [Accessed April 10, 2019]. [3] Johnson PR, Jones KE. Pancreatic islet transplantation. Semin Pediatr Surg 2012;21:272e80. [4] Brandhorst H, Asif S, Andersson K, et al. The effect of truncated collagenase class I isomers on human islet isolation outcome. Transplantation 2010;90:334e5. [5] Aliabadi-Zuckermann AZ, Gokler J, Kaider A, et al. Donor heart selection and outcomes: an analysis of over 2,000 cases. J Heart Lung Transplant 2018;37:976e84. [6] OTPN/SRTR Annual Data Report, USA. 2014. [7] Activity Report, Organ donation and transplantation, NHS Blood and Transplant, UK. 2014/15. [8] Eurotransplant Annual Report. 2015.
ABSTRACT Objectives. Despite the severe shortage of available organs, many are discarded after procurement. This study aims to analyze the current status of discarded organs (retrieved, but not transplanted organs) from deceased donors in Korea. Methods. Deceased donor organ and procurement data were collected from the Korean Network for Organ Sharing and Korea Organ Donation Agency database from 2013 to 2016. Results. Between 2013 and 2016, a total of 6315 deceased donor organ transplants were performed nationwide. A total of 63 organs were discarded. The most commonly discarded organs were kidney (n ¼ 24), followed by islet cell (n ¼ 23), lung (n ¼ 9), liver (n ¼ 6), and pancreas (n ¼ 1). The most common cause for discarding solid organs was poor organ condition (n ¼ 24). Other reasons included aggravation of donor condition, incidental cancer detection of the donor, and the abscence of matching recipient. Islet cells (n ¼ 23) were not used because of inadequate separation and purification. Conclusions. To reduce unnecessary graft discard in Korea, systems-based improvements in preprocurement organ evaluation and postprocurement preservation are imperative.
O
RGAN transplant is a lifesaving intervention to increase survival in end-stage organ disease and is being more commonly performed. Despite increasing demand for organs throughout the world, supply has been limited [1]. Despite an increase in expanded criteria donors and living donor use, supply cannot reach demand. There are organs that are discarded during the procurement despite the shortage of donors. The aim of this study is to understand the current status and causes of organ discard in Korea.
RESULTS Status of Deceased Donor Organ Transplants in Korea
MATERIALS AND METHODS
A total of 6315 cases of deceased donor organ transplant were performed in Korea from 2013 to 2016 (Fig 1). That increasing trend was affected by several causes: releasing informed consent of deceased donor families and reinforcing public relations and education through the media to improve public awareness of organ donation. Because of those efforts, the number of deceased organ donors in 2016 was 11.39 per million people in South Korea compared with 43.4 per million in Spain and 30.98 per million in the United States [2].
All deceased donor and procurement records were collected from the Korean Network for Organ Sharing and Korea Organ Donation Agency database from 2013 to 2016. The following organ types were selected for analysis: kidney, liver, heart, lung, and pancreas including islet cell. Patient clinical, histopathologic, and procurement discard data were abstracted and reviewed.
Disclosure: The authors have no conflict of interest to disclose. *Address correspondence to YoungRok Choi, 82 SNUBH, Gumi-ro 173 Beon-gil, Bundang-gu, Gyeonggi-do 13620, South Korea. Tel: þ82-31-787-7111; Fax: þ82-31-787-4055. E-mail: [email protected]
0041-1345/19 https://doi.org/10.1016/j.transproceed.2019.01.119
1478
ª 2019 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 51, 1478e1480 (2019)
DISCARDED GRAFTS IN KOREAN ORGAN TRANSPLANT
1479 Table 2. Multiple Reasons for Discarding Organs
2000
Kidney (n ¼ 24)
1800 1600 1400
Total
1200
Kidney Liver
1000
Pancreas
800
Islet cell
600
Heart Lung
400 200 0 2013
2014
2015
2016
Fig 1. Number of deceased donor organ transplants in Korea from 2013 to 2016.
Status of Discarded Organs
A total of 63 organs were discarded during the study period, most commonly kidney (n ¼ 24), representing a discard rate of 0.68% over 4 years (Table 1). Islet cells were the second most common discarded organ (n ¼ 23, 71.88%). Lungs were discarded in only 9 cases; however, the discard rate was relatively high at 3.42%. Livers were discarded in 6 cases at a steady year-over-year rate. Pancreas was discarded in only 1 case in 2014 because of partial duodenal infarction after procurement. There were no discarded hearts during the study period. Reasons for Organ Discard
Table 2 shows the reasons listed for discarding organs. Of 63 discarded organs, the reason in 13 cases (20.6%) was recipient-related. Three kidneys were discarded because of the refusal of the matched recipients for transplant. Ten other organs were discarded at the time of procurement because the recipient’s medical condition was worsening and inappropriate for transplant. The listed reasons for the remaining 50 cases (79.4%) were donor-related. In detail, the most common reason was unsuitable organs for transplanting, including vessel Table 1. Current Status of Discard Organs From 2013 to 2016
Kidney, No. (%) (n ¼ 24, 0.68%) Liver, No. (%) (n ¼ 6, 0.34%) Pancreas, No. (%) (n ¼ 1, 0.41%) Islet cell, No. (%) (n ¼ 23, 71.88%) Heart, No. (%) (n ¼ 0) Lung, No. (%) (n ¼ 9, 3.42%)
2013 N ¼ 19
2014 N ¼ 11
2015 N ¼ 19
2016 N ¼ 14
6 (0.79)
6 (0.74)
9 (0.99)
3 (0.28)
2 (0.54)
1 (0.25)
0 (0.0)
3 (0.59)
0 (0.0)
1 (1.79)
0 (0.0)
0 (0.0)
8 (72.73)
2 (100.0)
7 (63.64)
6 (75.0)
0 (0.0) 3 (6.12)
0 (0.0) 1 (1.79)
0 (0.0) 3 (4.48)
0 (0.0) 2 (2.20)
% discard rate ¼ discarded organs/(transplanted organs þ discarded organs) * 100.
Recipient, No. (%) N ¼ 13 Refusal 3 (n ¼ 3) Patient’s 2 condition (n ¼ 10) Donor, No. (%) N ¼ 50 Donor’s condition (n ¼ 1) Organ 18 condition (n ¼ 24) Cancer (n ¼ 2) 1 Technique (n ¼ 23)
Liver Pancreas Islet Cell Heart Lung (n ¼ 6) (n ¼ 1) (n ¼ 23) (n ¼ 0) (n ¼ 9)
(4.7)
0
0
0
0
0
(3.2)
3 (4.7)
0
0
0
5 (7.9)
0
1 (1.5)
0
0
0
0
0
0
4 (6.3)
0 23 (36.5)
0 0
0 0
(28.6) 1 (1.5) 1 (1.5)
(1.5) 0
1 (1.5) 0
0 0
problems (n ¼ 24, 38.1%). Among the 24 kidney cases, 4 were not used because of severe arterial thrombosis or intimal injuries. Five kidneys were discarded because of poor perfusion. The 1 case of discarded liver was because of graft-patient size mismatch. The sole case of discarded pancreas was because of partial duodenal infarction. Two discarded lungs had severe pulmonary edema. After organ condition, failure of appropriate separation of islet cell (n ¼ 23, 36.5%) was the second most common cause. Among them, 13 cases were discarded because the number of isolated islet cells was too few to be transplanted. The other 8 cases were discarded because of low purity. The discard rate for lung (3.42%) was higher than for other organs. Five cases were associated with recipient’s poor medical condition at the operating room, so ischemia time was much longer. Also, malignant neoplasms were incidentally found in 2 cases, which were diagnosed as renal cell carcinoma by frozen biopsy. Reasons for Discontinuation of Procurement at the Operating Room
Among 45 total cases discontinued during procurement, poor organ condition was the most common cause (n ¼ 30, Table 3. Reasons for Discontinuation of Procurement at Operating Room
2013 (n ¼ 13) 2014 (n ¼ 10) 2015 (n ¼ 11) 2016 (n ¼ 11) Total, No. (%) (N ¼ 45)
Poor Organ Condition
Infection
Incidental Cancer
Death of Donor
No Matching Recipient
11 4 8 7 30 (66.7)
0 4 2 2 8 (17.8)
1 0 0 1 2 (4.4)
0 1 1 1 3 (6.6)
1 1 0 0 2 (4.4)
1480
KIM, CHOI, CHO ET AL Table 4. Discard Rate of Other Countries in 2014
Kidney, % Liver, % Pancreas, % Heart, % Lung, %
Korea
USA
Eurotransplant†
UK
0.7 0.2 5.2* 0 1.8
18.5 9.6 24.1 1.2 3.9
9.9 17.1 50.1 14.1 27.6
2.9 1.6 13.3 0.6 6.9
*Pancreas þ islet cell. † Austria, Belgium, Croatia, Germany, Luxembourg, Hungary, Netherlands, and Slovenia.
66.67%, Table 3). Procurements were stopped in 7 cases because peritonitis was identified (eg, bowel perforation, necrosis) during the operation. There were 2 incidental cancers (renal cell carcinoma, gallbladder cancer) that were not detected during the preoperative evaluation process. DISCUSSION
A significant number of organs have been discarded in deceased donor organ transplants every year. To minimize the discard rate, we should understand the reasons for discard. First of all, preoperative tests of donors are not enough to evaluate organs accurately. As commented above, operations were discontinued because peritonitis was identified in 7 cases. In most of the centers, only preoperative basic tests such as laboratory findings and ultrasonography including echocardiography have been performed; physicians should retrieve organs with subjective inspection and objective findings (eg, frozen biopsy). The donor’s medical condition is usually poor, and the cost is expensive for accurate and time-consuming screening tests. Through appropriate evaluations such as Doppler ultrasonography, high-resolution computed tomography, and nonenhanced abdominal computed tomography, incidental carcinoma, hidden trauma, and organ worsening could be detected preoperatively, possibly decreasing the discard rate. For 4 years, the discard rate of islet cell (71.88%) was significantly higher than other organs. Human islet isolation remains a challenging process, with only about 50% of optimal pancreases achieving transplantable islet yields in the leading isolation centers worldwide [3]. The reasons for this are multiple, but the insufficient consistency of enzyme blends is one of the main reasons for the low standardization of enzymatic isolation of human islets [4]. In Korea, there were no hearts discarded for 4 years. We have used criteria for acceptability of a donor heart that would be stricter than those of other organs [5]. The 8 cases of discarded kidneys were related to massive vascular thrombosis and intimal injury leading to poor perfusion. It is unknown whether the thrombosis and intimal injury existed preoperatively or intraoperatively. If those
occurred during procurement, we could improve organ quality by insisting more experienced physicians perform the procurement and require regular education and/or certification for procuring physicians. We compared the discard rate for 2014 in each country (Table 4) [6e8]. Although there will be differences from year to year, South Korea had a lower discard rate than other countries in 2014. We suggest 2 reasons: first, procurement from donation after circulatory death is relatively rare in Korea, and brain death donors are highly selected. Second, the distance to procurement and donor wait time are relatively short. Even though the Korean discard rate is low, we must try to reduce this rate with optimal preoperative donor selection, monitoring, and management. CONCLUSIONS
It is obvious that the shortage of organ donors continues to increase. While discarding a small fraction of organs procured from donors may be inevitable, discarding potentially transplantable organs needs to be avoided. To reduce unnecessary procurement and organ discarding, we need to more extensively evaluate donor organs prior to procurement and intensively monitor and manage deceased donors. ACKNOWLEDGMENT The authors would like to thank the Korean Network for Organ Sharing (KONOS) and the Korea Organ Donation Agency (KODA) for their kindness in furnishing us with data from the national deceased donor registry. A sincere thank you to Jonathan Sham for his diligent proofreading of this paper.
REFERENCES [1] Saidi RF, Hejazii Kenari SK. Challenges of organ shortage for transplantation: solutions and opportunities. Int J Organ Transplant Med 2014;5:87e96. [2] International Registry in Organ Donation and Transplantation. IRODaT Newsletter 2016. http://www.irodat.org/img/database/pdf/ IRODaT%20newletter%20Final%202016.pdf [Accessed April 10, 2019]. [3] Johnson PR, Jones KE. Pancreatic islet transplantation. Semin Pediatr Surg 2012;21:272e80. [4] Brandhorst H, Asif S, Andersson K, et al. The effect of truncated collagenase class I isomers on human islet isolation outcome. Transplantation 2010;90:334e5. [5] Aliabadi-Zuckermann AZ, Gokler J, Kaider A, et al. Donor heart selection and outcomes: an analysis of over 2,000 cases. J Heart Lung Transplant 2018;37:976e84. [6] OTPN/SRTR Annual Data Report, USA. 2014. [7] Activity Report, Organ donation and transplantation, NHS Blood and Transplant, UK. 2014/15. [8] Eurotransplant Annual Report. 2015.