Pediatric Organ Donation and Transplantation

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Pediatric Organ Donation and Transplantation Powered By Docstoc
					                              Planning the Way
                                  Forward

 Pediatric Organ Donation
   and Transplantation
               Patricia A Webster, MD
       The Children’s Mercy Hospital and Clinics
                   Kansas City, MO


                 Workplace Partnership for Life, U.S. Department of Health & Human Services




         Understanding Where We Are

Where do we stand                              Do we have
in 2007 with pediatric                         enough donors?
organ donation?
                         Is pediatric DCD
What is the consent      a viable option?
rate for pediatric
organ donation?     Is organ allocation
                    fair and efficient?

     What can we do to end deaths
          on the waiting list?
                 Workplace Partnership for Life, U.S. Department of Health & Human Services




       Where do we find the answers?

• Literature for pediatric donation
  – Limited number of articles
• No comprehensive national database for
  pediatric donation
  – Number of donors is known (OPTN)
  – But not the number of potential donors
• Limited national emphasis on pediatric
  donation

                 Workplace Partnership for Life, U.S. Department of Health & Human Services




                                                                                              1
                                                      Objectives
 • Describe the available donor pool on a
   national level
 • Look at consent rates across a broad range
   of ages
 • Describe the setting in which pediatric
   donation occurs
 • Consider strategies for increasing consent
   and organ recovery

       Goal is to decrease or eliminate
         deaths on the waiting list
                     Workplace Partnership for Life, U.S. Department of Health & Human Services




                   Pediatric Consent Study
            Calendar Year 2005
• Survey sent out to all 58 OPO’s
  –   Number of brain dead donors (CMS criteria)
  –   Age of donors (0-11 or 12-17)
  –   Number of DCD donors
  –   Number of lost donors (ME or organ instability)
  –   Location of donors (PICU vs non-PICU)
  –   Quality of interaction with donor hospitals
• 100% response to survey (lots of prodding)
• 100% response for additional information (lots
  of begging)

                     Workplace Partnership for Life, U.S. Department of Health & Human Services




                   Pediatric Consent Study
       Hospital Characterization
 • How many PICU beds in the hospital?
 • Did the hospital have a pediatric critical
   care fellowship program?
 • Was the hospital designated as a Level I
   trauma center? (adult or peds)
 • Did the hospital have active pediatric
   solid organ transplant programs?
Information collected from web sites and by telephone calls

                     Workplace Partnership for Life, U.S. Department of Health & Human Services




                                                                                                  2
                                               Study Findings
  The OPO community is fabulous!
 • 1330 eligible brain dead donors
 • 920 consented brain dead donors
 • 849 recovered donors
 • Consent rate for all ages = 69%
 • Conversion rate for all ages = 64%
 • 37 DCD donors

                      Workplace Partnership for Life, U.S. Department of Health & Human Services




                          Lost Pediatric Donors
                      1

                  1
ME Declines                                                 1       1                        1
   43                                               4                          4
                                                                                         2
                                           2                            1 2                      1
              4                                                 1             1
 26 OPO’s                     1                                             1            2
                                       1                3                            1
  affected                                                                 3
                                                   2            2




                      Workplace Partnership for Life, U.S. Department of Health & Human Services




                          Lost Pediatric Donors

      Other causes of donor loss
• Multi-organ system dysfunction ≥ 11
• Cardiac arrest prior to recovery regardless
  of consent status = 51
   – Occurred in 29/58 OPO’s
   – Highest number of arrests in one OPO =7
   – 33% of potential donors for this OPO
• Were these losses avoidable?

                      Workplace Partnership for Life, U.S. Department of Health & Human Services




                                                                                                     3
                      Lost Pediatric Donors
          How many organs could
           have been recovered?
  • 17 ME denials had family consent for
    donation
  • 11 lost to MOSF were consented
  • Assuming 69% consent rate for remaining
    lost donors – 53 additional consented
    donors
  • Assuming 3.75 organs per donor

                304 Organs Lost
                     Workplace Partnership for Life, U.S. Department of Health & Human Services




                                          Pediatric DCD
    Is Pediatric DCD a viable option?
  • 37 DCD donors identified in 2005
     – OPTN data = 39
  • 12 donors were less than 12 years of age
  • Youngest donor was 9 months
  • DCD took place in 18 of 58 OPO’s
  • 103 organs recovered in 2005
  • Increasing yearly, 78 donors in 2006

 ~460 organs recovered in 4 years
                     Workplace Partnership for Life, U.S. Department of Health & Human Services




           Age Distribution of Donors
• 0-11 Years
   – 687 Potential Donors
                                       800
   – 438 Consented Donors
   – 64% Consent Rate *                600
                                                                          75%
• 12-17 Years                                             64%                        Total Donors

   – 643 Potential Donors              400                                           Consented
                                                                                     Donors
   – 483 Consented Donors
                                       200
   – 75% Consent Rate *
• Corroborates previous                    0
  studies                                           0-11            12-17
                * p=0.0001                          Years           Years

 Initially looked at 0-11 and ≥12 years
                     Workplace Partnership for Life, U.S. Department of Health & Human Services




                                                                                                    4
           Age Distribution of Youngest Donors

150
125
100
75
50
25
 0
      <1    1       2        3       4        5        6        7         8         9      10       11

                        Total Donors                Consented Donors
 <1    1        2       3        4       5        6         7         8         9       10        11
 64% 65%    63%     64%      70% 75% 47% 72% 58% 57% 61% 66%
                            Workplace Partnership for Life, U.S. Department of Health & Human Services




                            Where are the donors?
           PICU or Community Hospital
• Location of 0-11 age group
  – 95.3% in hospitals with PICU’s – consent rate 64.4%
  – 4.7% in community hospitals – consent rate 50.0%
• Location of 12-17 age group
  – 72.8% in hospitals with PICU’s – consent rate 74.1%
  – 27.2% in community hospitals – consent rate 76.5%
• Majority of donors (80%) are in hospitals
  with PICU’s

                            Workplace Partnership for Life, U.S. Department of Health & Human Services




                    Characteristics of PICU’s

  • PICU’s ranged in size from 3-45 beds
  • Half the PICU’s were 12 beds or larger and
    half were smaller than 12 beds
  • Largest number of potential donors = 25
  • Only 21 PICU’s out of 345 had 10 or more
    potential donors
      – Only 21% of the total donor pool
      – Consent rate 70% (range 31%-100%)



                            Workplace Partnership for Life, U.S. Department of Health & Human Services




                                                                                                         5
                             Impact of a Pediatric
               Critical Care Medicine Fellowship
               Does it help with consent rates?
      • 74 Hospitals with PCCM Fellowships
            – Consent rate for 0-11 = 60% *
            – Consent rate for 12-17 = 78%
            – Overall consent rate = 66%
      • Lower consent rates for 0-11
        approaches statistical significance
      • Fellowship had no impact on overall
        consent rates
                                                                                          * p = 0.07
                                    Workplace Partnership for Life, U.S. Department of Health & Human Services




                    Impact of Level I Trauma Designation

     • Included donor hospitals with adult or
       pediatric Level 1 trauma programs
     • Nearly twice as many potential donors in
       hospitals with trauma centers
        – 16.7/100 beds in hospitals without trauma centers
        – 31.4/100 beds in hospitals with trauma centers
     • Consent rates
        – 65% without trauma centers
        – 69% with trauma centers *


                                                                                        * p = 0.15
                                    Workplace Partnership for Life, U.S. Department of Health & Human Services




                                          Impact of PICU Size
                     Donors / 100 Beds

30                                                                 • Larger ICU’s trend to
                                                                     having fewer donors
25
                                   p=0.14        p=0.21            • 28 units with ≥ 20 beds
20                                                                   had only 0-4 potential
                                                                     donors
15
                                                                   • One 22 bed PICU had
10                                                                   no potential donors
                                                                   • Possible explanations?
5

0
       10-19 Beds     20-29 Beds   30-39 Beds     40-45 Beds



                                    Workplace Partnership for Life, U.S. Department of Health & Human Services




                                                                                                                 6
                  Solid Organ Transplant Programs
                                 Donors / 100 Beds
         35

         30

         25

         20
                                                                           *
         15
                  1         2               3          *4               5 or 6
   Hospitals with 5 or 6 solid organ transplant
    programs trend to lower potential donors

                                                                         * p = 0.10
                      Workplace Partnership for Life, U.S. Department of Health & Human Services




                  Solid Organ Transplant Programs

     Consent Rates for Hospitals with
     one or more transplant programs
                                 % Consent
   100
    80                                                                      *
    60                               *
    40                                                              ^
    20
    0
              1       2               3               4            5 or 6



                          * p = 0.02                      ^ p = 0.05
                      Workplace Partnership for Life, U.S. Department of Health & Human Services




                                      Moving Forward

• Pediatric donors are not found in a few
  large children’s hospitals
  – Approach will differ from the adult collaborative
  – Each OPO has to make pediatric donation a focus
• Improve consent rates
  – 13 ICU’s with ≥ 8 donors have ≥ 80% consent
  – Specifically target PICU’s with high volume and low
    performance
• Focus on Level I trauma centers
  – Significantly more donors in hospitals with
    trauma services

                      Workplace Partnership for Life, U.S. Department of Health & Human Services




                                                                                                   7
                                 Moving Forward

• Prevention of donor losses
  – Medical examiner issues
  – Maximize pre-brain death management
  – Improve care during the donation process to
    prevent loss and increase OTPD
  – Intensivist involvement in care
• Are we identifying all donor potential?
  – Why do large ICU’s have few potential donors?
  – Early withdrawal of therapy?
  – Survey of intensivist attitudes about donation


                 Workplace Partnership for Life, U.S. Department of Health & Human Services




                                 Moving Forward

• Transplant Centers
  – Engaging transplant physicians as advocates of
    donation
• Allocation issues
  – Recent focus of Dr. Sue McDiarmid, past-
    president of UNOS
  – Exhausting all possibilities before giving up
  – Use of aggressive transplant centers
• Pursuing all DCD opportunities
  – Assisting hospitals with DCD policy
    development

                 Workplace Partnership for Life, U.S. Department of Health & Human Services




                                     Moving Forward




                             Questions?
                 Workplace Partnership for Life, U.S. Department of Health & Human Services




                                                                                              8

				
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