Reducing Organ Wastage

A F O C U S O N C O M M I T T E E S
Reducing Organ Wastage
OAC ANALYZES USE AND DISCARD DATA, SUGGESTS IMPROVEMENTS

25September–October 2007UNOS Update
BY KAREN SOKOHL

Every transplant surgeon would like to consider organ
offers from a near-perfect donor. But with an aging
population and a steadily growing list of transplant candidates,
there continues to be a gap between the number of donor
organs and the number of people who need them.
Painfully aware of that gap and the fact that about
17 transplant candidates die every day on the waiting list,
OPTN/UNOS committees continue to examine ways to better
use less-than-perfect organs —and no committee is more
dedicated to that effort than the OAC, or OPTN/UNOS organ
availability committee.
Today, an increasing number of organs available for
transplant fit the description of “expanded criteria donors”
(ECD), which means, for example, that they are older than 60
or had a history of vascular disease, intracranial hemorrhage,
diabetes, high-blood pressure, or combinations of these and
other illnesses.
In addition, HRSA’s various Breakthrough Collaboratives have
inspired an increase in the recovery of organs from donation
after cardiac death (DCD) donors; those organs can sometimes be
less than optimal.
Members of the OAC have focused on these issues over
the past couple of years, and their efforts led to OPTN/UNOS
policy changes that have helped to eliminate some of the
unnecessary discarding of donated organs.

Better defining discards

“We wanted to precisely define the factors that put an organ
at a high risk for discard [HRD],” said David Hull, M.D., FACS,
acting chair of the OAC and director of the transplant
program at Hartford Hospital in Connecticut.
“As a community, we knew that there were certain types of
organs that frequently tended to be discarded,” Dr. Hull
added, “but we also knew that some centers were using these
same types of organs with success.
“We needed objective data to help communicate this
information to fellow professionals and to help ensure that
these types of organs were used when they could be.”
In reviewing data analyzed by the Scientific Registry of
Transplant Recipients (SRTR), the OAC determined that
organs discarded more than 50 percent of the time had
characteristics in common.
OPTN data from July 2004 to December 2006 indicated
that 25 percent of transplant programs did not transplant
kidneys with those characteristics, but that 29 programs did
transplant such kidneys.

Getting organs to centers that use them

At its meeting in October, the members of the OAC began
to discuss ways to get these HRD kidneys more quickly to the
programs that can and will use them. A future Update will
report on that progress.
“We also spent a lot of time this past year discussing DCD
procedures,” said Dr. Hull. “We discovered that DCD data
collection varied greatly from one operating room to the next.
“This made some surgeons wary of accepting DCD organs
that weren’t recovered by their own teams,” he explained.
The OAC is working to limit those variables so that
surgeons can be confident that a DCD organ removed in a
St. Louis operating room, for example, was handled the same
way it would have been handled in Los Angeles.
Historically, OPOs have collected minimal data specific to
DCD donors, such as whether the donor was controlled and
if core cooling was used.
OPOs also record the estimated warm ischemic time.
Because that value is calculated differently across different
DSAs, however, the data isn’t always meaningful to centers.

Differentiating DCD phases

The OAC committee determined that to make the data useful,
OPOs needed to differentiate between the two distinct phases
of the DCD recovery process —the withdrawal phase (the
interval when ventilator support is withdrawn and the heart-
beat stops) and the agonal phase (interval from cessation of
circulation to the start of cold perfusion).
At its June meeting, the OPTN/UNOS board of directors
approved the addition of these phases as elements on the
deceased donor registration forms. The online forms will
contain the fields before the end of the year.
“The information gained by having OPOs report these
additional elements will really help physicians in the long
run,” said Dr. Hull, “especially in terms of linking diagnosis
with anticipated transport times to the OR.”
Because many of the issues committees are struggling with
are so broad and interrelated, input from other committee
members is often indispensable to decision making.

Working closely with other committees

“The issues that the OAC is talking about, such as use of
DCD and expanded criteria kidney donors, is spurring a lot
of constructive discussions among many of the different
committees,” said Jeff Orlowski, M.S, CPTC, an OAC member
and also vice chair of the OPTN/UNOS organ procurement
organization (OPO) committee. The OAC reserves a standing at-
large position on its roster for the OPO committee vice chair.
“The OAC will often ask for input from the OPO committee,
and since I sit on both committees, I’m the one who can give
them answers,” Orlowski said.
“And, if the OPO committee asks something about the OAC,
I can respond not just with the factual content but with the
flavor of the discussion as well,” he added.
“It’s an effective way to share information between
committees, leading to more balanced discussions —and,
ultimately,” he added, “to more organs being transplanted into
the people who so desperately need them.”

Karen Sokohl is UNOS’ member communications specialist and
a contributing writer.

DONOR WHOSE ORGANS ARE AT HIGH RISK FOR DISCARD

• organs recovered after cardiac death (DCD)
• certain kidneys recovered that have not been pumped
and /or biopsied
• had history of diabetes
• organs with more than 5 percent glomerulosclerosis
• had presence of central nervous system tumor
• had history of hypertension
• was positive for hepatitis C virus
• was positive for hepatitis B core antibody
• had creatinine clearance less than 62
• organs pumped with a resistance greater than 0.349
• age 45 or more
• had creatinine levels greater than 2.0

A M AT T E R O F P O L I C Y

FINANCIAL ASPECTS OF ORGAN DONATION

Public misunderstanding exists surrounding the financial
aspects of organ donation and transplantation. The work that
organ recovery agencies perform is vital to the overall donation
and transplantation process; however, costs associated with
their work are subject to misinterpretation. Recent media
stories exposing the “high costs” of a particular organ may
have adverse effects on public perception of the altruistic gift
of organ donation.
• Organ recovery agencies bear the responsibility of
coordinating the organ donation process. All are nonprofit
501(c)(3) organizations, a federal designation indicating
that income covers expenses incurred, including but not
limited to salaries, medical supplies, hospital costs, medical
testing, public education campaigns and office operations.
• Donor families are never charged for costs associated with
donation or transplantation. Organ recovery agencies
absorb the costs of donation, generally beginning at the
declaration of brain death and extending through the
organ recovery process.
• All charges and expenses incurred by organ recovery
agencies are regulated and audited by the Centers for
Medicare and Medicaid Services (CMS).
• All organ recovery agencies undergo an audit process on
an annual basis.
• Most expenses are direct costs associated with recovery of
organs. The recovery hospital’s charges are billed to the
organ recovery agency. Those costs are combined with the
organ recovery agency’s recovery costs, and the
“acquisition costs” are subsequently billed to the
recipient’s transplant center.
• Transplant hospitals charge the recipient’s insurer for the
acquisition cost of the transplanted organ.
• Acquisition costs vary by organ and geographic area,
typically ranging from $20,000 to $35,000 per organ.
• Medicare generally covers the costs of kidney transplants
under the End Stage Renal Disease (ESRD) Program and
covers other transplants when the center is Medicare
certified. This applies only to Medicare patients. Other
patients rely on whatever health coverage they possess.
Questions can be directed to Joni Rosebrock, manager of
community relations, Indiana Organ Procurement
Organization, and chair of the AOPO’s public relations/public
education council, at (317) 685-0389 or jonir@iopo.org.
Reprinted with permission from the Association of Organ
Procurement Organizations (AOPO) and its public relations/public
education council. The original was written and distributed to AOPO
members and others in early 2007.