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Saudi Journal of Kidney Diseases and Transplantation
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SPECIAL ARTICLE Table of Contents   
Year : 1999  |  Volume : 10  |  Issue : 2  |  Page : 175-182
Organization of Organ Donation and Role of Coordinators: Transplant Procurement Management


Chief Coordinacio de Transplanaments, Hospital Clinic, Director TPM Project, Formacio Continuada Les Heures, Universitat de Barcelona, Spain

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How to cite this article:
Manyalich M. Organization of Organ Donation and Role of Coordinators: Transplant Procurement Management. Saudi J Kidney Dis Transpl 1999;10:175-82

How to cite this URL:
Manyalich M. Organization of Organ Donation and Role of Coordinators: Transplant Procurement Management. Saudi J Kidney Dis Transpl [serial online] 1999 [cited 2019 Aug 20];10:175-82. Available from: http://www.sjkdt.org/text.asp?1999/10/2/175/37227

   Introduction Top


Scientific, technical and organizational advances in transplantation have made it a daily practice, allowing more and more patients to be treated using this therapeutic modality. For those patients suffering end­stage organ failure, transplantation is the best and in some cases the only option. Without organs there are no transplants.

The best transplant teams, trained at great expenses, using the most up-to-date methods and equipment, can only perform transplants if they have an adequate supply of viable organs.

This basic and essential concept is usually not concentrated on during the design of a new project of organ transplantation. Trans­plant teams usually start with a very expensive training program of physicians, surgeons and nurses on the techniques and follow-up of transplantation and develop up-to-date equipment in immunology. However, most of the groups don not take into account the importance of establishing an organization to promote donation and a good organ and tissue procurement team to assure the quality and number of grafts to be implanted. This phenomenon is what we refer to as "The Pittsburgh or Necher Syndrome" which means that many new groups seek excellence matching the performance of these well known transplant centers by focusing on surgical techniques of transplantation while neglecting issues related to organ donation and procurement.

Living and cadaveric donors form the source of organ and tissue donation. In Europe and in United States of America (USA) the principal source of organs for donation is the brain-dead-donors, only 10­20% of kidney transplants (KT) being from living donors. In some European countries, e.g. Sweden, the living donor represents 23% of all donors, and in Greece 40%. [1] In Saudi Arabia the figure could be 66% and in some Latin American and Asiatic countries could be 50% or more of all donors (e.g. 78.84% in Philippines). [3],[4],[5]

In recent years, organ procurement from cadaver donors has increases world-wide, with a mean donation rate of 15 donors per million population (pmp) in Europe, 22 donors pmp in the United States, 8-10 in Latin-America and 2-4 in other countries like Saudi Arabia. [1] Spain has a preferential place in the world, with a donor's rate of 31.5 pmp with some interregional variations like those of Catalonia where the donor's rate is 39 pmp. [6],[7] Nevertheless, these numbers are insufficient to meet the increased demand for organs, considering the need is around 50 donors pmp with the current waiting lists. [8]

This shortage of organs could be solved with the development of a solid collaborative network of health professionals with a common goal: increase organ and tissue donation. The elements of a system model of transplant coordinators (Transplant Procurement Managers), [9],[10],[11] in order to increase detection of potential brain-dead donors will be described in the following paragraphs.


   Organ Donation Top


There is a new cycle of life via organ donation and transplantation "vital cycle" [Figure - 1]. This cycle starts with the solidarity of society assured by donation of organs. This donation is based on an adequate social attitude achieved through continuous education and dissemination of information about organ donation and transplantation. This should start early in school and to be reinforced by favorable ethics and religious concepts, appropriate mass-media communi­cation, and supported by auspicious legi­slation. The cycle continues with organ and tissue procurement organized in five successive steps:

  1. Donor detection
  2. Death diagnosis (cardiac arrest or brain death)
  3. Donor maintenance
  4. Viability studies
  5. Family consent


Once all these steps have been completed the Extraction of the organs and tissues is performed. Simultaneously, after the family consent is obtained the process of Organ Sharing starts to find the best recipient on the waiting list following previously established distribution criteria, which are mainly realized by the transplant center. When all the organs are allocated Transplantation is performed. It allows closing the cycle by turning to the society a gift of life each time an organ or a tissue is engrafted.

Medical centers have to follow the recipients through a registry to evaluate the success of the transplant serving as a database for studies of survival and quality of life. The favorable results of studies on transplantation presented to the society support and perpetuate the vital Cycle.

In reference to the organs such as (heart, lung, liver, kidney and pancreas) this new Vital cycle occurs about 250 times per year in our hospital, 600 times per year in Catalonia, 4000 times per year in Spain and thousands of times all over the world. [1],[2],[3],[4],[5],[6] In relation to tissues (Corneas, bones, cartilage, arteries, heart valves, skin and pancreatic islets) this Cycle occurs more often that with whole organs. At present, organ donation is provided by only 2-5% of all the deaths that occur inside the hospitals. In contrast, a larger pool of donors provides tissue donation, since time is not relatively a limiting factor as in whole organ donation.

Successful organ donation and transplantation require continuous cooperation between the procurement tram, the transplant team and the transplant center. [6],[7] [Figure - 2] shows the structure of the Catalan health system as an example. When consent of donation is obtained, these teams have to act promptly and in harmony whatever the situation, time or place. The procurement hospital with its own procurement team and teams of several transplant hospitals, according to the type of contemplated transplants, and a network of various transplant offices at local, regional and national levels work together in order to accomplish one task. A center that works at a national level supervising all these teams and ensuring equity of distribution and sharing of organ may be indispensable. The Saudi Center for Organ Transplantation (SCOT) in Saudi Arabia, the Organizacio'n Nacional de Trasplantes (ONT) in Spain, Organitzacio' de Trasplantaments (OCATT) in Catalina, the United Network for Organ Sharing (UNOS) in United States, and Eurotransplant in Belgium, Holland and Luxembourg, are examples of such centers.

In Spain, organ distribution follows geo­graphic criteria. Procured organ share offered first to the waiting list of the procurement hospital. In case of no available recipients, regional, national or international waiting lists are sought until a transplant team accepts the organ. [6],[7] Once the organ is accepted, the transplant team should move for procure­ment in the donating hospital. Afterwards, choosing the appropriate recipient varies according to the organ. For example, matching the donor and recipient for the kidney is based in the compatibility of blood group, HLA and negative cross-match. Other criteria such as weight, body surface area, age, donor and recipient previous pathologies are also considered in the matching. [6],[7]

This system is intended to stimulate the procurement and transplant activities in the centers through the idea that each donating hospital is able to implant the organs procured in it. The only exception to this rule is the presence of either a pediatric recipient or a case fulfilling urgent criteria for liver, lung or heart transplantation such as acute severe hepatitis, refractory cardiac failure, etc.

There are various scientific committees and commissions that establish the distribution criteria organize the waiting list, define the priority criteria, promote clinical or basic studies for each type of transplant and solve any difficulties between the teams. [6],[7] Adjuvant to the system, there are tissue­typing laboratories that are available on a regional or a national basis are responsible for the HLA determination and cross-match examination necessary for donor-recipient matching.


   Coordination Top


Traditionally, hospitals and health authorities are accustomed to offer health services to patients but nor to procure their organs when they die. At the beginning of the transplant era, nephrologists or transplant surgeons started searching for donors of kidneys. The scope of transplantation expanded later to include other organs. This mandated the presence of coordinators of donation. Procure­ment teams started to become a regular feature of health care, and their role in coordination became more defined.

There are three different types of coordinators in our system:

  1. Procurement Coordinator: for organ and tissue procurement.
  2. Sharing Coordinator: for exchange of organs and tissues.
  3. Clinical Coordinator: for recipients care.


In the following paragraphs the goals and task of each type of coordinators will be defined.


   Procurement Coordinator Top


Transplant Procurement Management­-TPM- is a total system approach to the problem of organ shortage. The principal goal of the TPM is to provide all the necessary services related to cadaver organ donation and distri­bution of procured organs and tissue through established sharing organizations to the most appropriate recipients [Figure - 3]. TPM serves the purpose of procuring the greatest number of organs and tissues with optimal organ viability in a cost-effective way, thereby facilitating transplantation and work of the transplant teams. [9],[10],[11]

Goals

  1. To ensure that all-potential cadaveric donors are properly recognized and evaluated, and their families are approached for donation. [11],[12],[13]
  2. Integrated management of the whole procurement process to assure quality and consistency of all performed procedures. [9],[10],[14],[15],[16],[17],[18]


Tasks

1. Clinical tasks include:

  • Detection, identification and evaluation of donors.
  • Facilitation of diagnosis of brain death
  • Donor maintenance and viability studies
  • Family and social relations-Family Consent
  • Procurement and distribution of organ and tissues.


2. Research: includes studies to improve organ viability, different experimental protocols for non-heart beating donors, and on how to expand the donor pool.

3. Training: training and continuous education of medical (transplant coordinators, trans­plant teams, intensive care units and other specialties) and related health professional. This is accomplished by means of specialized courses in the field of organ and tissues procurement in order to increase the rate of cadaveric donation to solve shortage of organ donors. [9],[10] It also includes public education starting at school-children level and continuing to cover interaction with the general public to increase awa4eness about organ donation and transplantation.

4. Management: responsibility for, and control over, all aspect of the process of donation. This implies deciding upon allocation of the available human, material and economic resources with the aim of optimizing the procurement process.

Analysis permits differentiation of each task involved in procurement, to calculate the cost for each task and compare these costs with transplant results so as to compute cost-effectiveness. Furthermore, coordinators should evaluate quality of life after trans­plantation in comparison with other organ replacement therapies. This process enables the evaluation of relevant technology, faci­litating decision-making on the adequacy of therapies and activities.

2. Sharing Coordinator

Goals


  1. Allocate maximum number of organs and tissues provided by each donation.
  2. Control the efficiency, harmony and legality of the whole donation and sharing process.


Tasks

  1. Donors Data: to ensure collection of all the donor data that are necessary for the transplant team to decide whether to accept or refuse an organ.
  2. Waiting Lists: to control all the waiting lists generated by the transplant teams and the lists of recipients of all the organs procured, especially live, heart, lung and pancreas. The following characteristic should be registered: age, gender, HLA typing, weight, height, body surface area, blood group, city of residence of donor and recipients, etc.
  3. Allocation Criteria: to control allocation procedure according to local, regional and national criteria.
  4. Operative Support: to offer technical and operative support to all procurement and transplant teams to facilitate the procure­ment distribution process. These include telephones, fax machines, e-mail, Internet, transportation of the teams (regular coaches, ambulances, airplanes the use of all airport facilities, etc.)
  5. Packing and transportation: All the organs and tissues must be securely and safely carried and transported with the adequate identification to prevent mis­placement.
  6. Regulatory Affairs: to regulate the whole process through different committees established for this goal with the parti­cipation of different members of the donation-transplant communities, these affairs also include international relations and sharing.


1. Clinical Coordinator

Goals


  1. To prepare and evaluate the recipient before transplantation, to be sure that he/she has been properly selected an included in the waiting lists. After trans­plantation the clinical coordinator usually participates in the clinical evaluation and follow-up of the patient.


Task

  1. Locating the recipient.
  2. Transportation of the recipient the hospital.
  3. Check the evaluation list: to ensure that the recipient is in optimal condition for transplantation.
  4. Matching with donor: this includes the appropriate serum-tissue cross-match, and the proper match in weight, height, blood group, etc. between the donor and the recipient.
  5. Preconditioning for transplantation: this includes performing basic blood test, electrocardiogram, X-rays, etc. In renal patients also includes the planning of a pretransplant dialysis session.
  6. Implantation
  7. Follow-up of the recipient
  8. Inform the coordination center about the transplantation to remove the patient's name form the waiting list
  9. Help and support of the relatives of the recipient.


2. 4. Location and Structure

Profile and Location of Transplant Procurement (TP) Manager:
A TP manager is a full-time senior hospital doctor working round the clock on promoting organ donation in his/her hospital. [6],[9],[10] The sum of respon­sibilities entitled by the different functions of TP manger requires good human relation­ships, respect for team-work, leadership and interest in training others. To ensure efficacy of their role, Transplant Procurement Manage­ment (TPM) members should be able to work independently of, but with continuous cooperation with, the transplant teams. Furthermore, it is advisable to be independent of the medical director to avoid any inter­ference in their tasks. The specialty of the TPM implies working with a complete dedication, as a career and not only as a temporary or occasional job. The doctors could come from many different sources related with the donation-transplantation process, like ICU, anesthesiology, nephrology, surgery, emergency doctors.

The size of TPM team necessary in a hospital depends on the types and number of transplantation to be performed. For 6-12 donors per year (equivalent to a donation rate of 1-5 donors per million inhabitants), it is necessary to have at least one full-time TPM member (TP Manager). [9]

The payment has to be based on salary system and according to their specialty with incentives dependent on their results. This system could stimulate a more continuous and dedicated search of donors.


   Comment Top


To increase the number of cadaveric donors it is advisable to implement a full­time procurement organization with the participation of highly skilled professional individuals dedicated to organs and tissue procurement. Additionally, the system must have the support of a well-organized laboratory to perform all the hematological, biochemical, toxicological, immunological and micro­biological determinations necessary to evaluate the potentials donors. The capability of the pathology laboratory to perform frozen biopsies and autopsies is a crucial step in this process. In the same context, continuous cooperation of other services of the hospital, such as radiology, echocardiography and nuclear medicine, improves the success of organ donation programs. We should remember that as immunosuppression is the treatment of rejection in transplantation, TPM is the treatment of "The Pittsburgh or Necher Syndrome".

The donation-transplantation process carries with it a progressive change in the health culture. The multi-disciplinary approach of different specialties in this process should improve the performance of these services. At the same time, there is close relation­ship, based on solidarity and generosity, between different procurement and transplant hospitals inside their regions or with others from different regions or countries in organ sharing.

The philosophy of the TPM is to repeat the New Vital Cycle as frequently as possible to transform the donation into something useful and special for the society. The last verse in a poem written by a recipient's mother during the night of his transplantation reads: "we will win the life, we will fight the death"

 
   References Top

1.International figures on organ donation and transplantation activities 1993-1997. Agreements of the select committee of experts on the organizational aspects of cooperation in organ transplantation 1997. Organs and Tissues 1998; 1:13-20.  Back to cited text no. 1    
2.SCOT Data: Organ donation and results in the Kingdom of Saudi Arabia. Saudi J Kidney Dis Transplant 1998;9(4):464-72.  Back to cited text no. 2    
3.Santiago-Delpin EA, Duro-Garcia V, Chameh O. Forty thousand organ transplants in Latin America. Transplant Proc 1997;29(1-2):1586-9.  Back to cited text no. 3    
4.Takagi H. Organ Transplants still too few in Japan and Asian countries. Transplant Proc 1997; 29(1-2):1580-3.  Back to cited text no. 4    
5.De Villah V, Alonxo H, Tejada F, et al. Characterization of kidney allograft donation in the Philippines. Transplant Proc 1997;29(1-2):1580-5.  Back to cited text no. 5    
6.Miranda B, Fernandez-Lucas M, de Felipe C, et al. Organ donation in Spain. Organ and Tissues 1998;1:13-20.  Back to cited text no. 6    
7.Matesanz R, Miranda B, de Felipe C, Naya MT. Ecolucion de la donacion y la actividad transplanstadora en Espan'a. In: Lopez­Navidad at al, editors. El donante de organos y tejidos Evaluacion y manejo, Barcelona: Springer Verlag Iberica 1997:42-57.  Back to cited text no. 7    
8.Miranda B, Fernandez LM, Matesanz R. The potential organ donor pool: International figures. Transplant Proc 1997;29(1-2):1604­-6.  Back to cited text no. 8    
9.Manyalich M, Cabrer CA, Garcia-Fages LC< Valero R, Salvador L, Sanchez J. Training the transplant procurement management (TPM) coordinator. In: Touraine JL, et al, editors Organ Shortage: The Solutions, Dordrecht: Kluwer Academic Publishers, 1995:191-95.  Back to cited text no. 9    
10.Miranda B, Matesanz R, Felipe C, Naya MT. Integrated ways to improve cadaveric donation. In: Touraine JL, et al, editors. Organ Shortage: The Solutions, Dordrechr: Kluwer Academic Publishers 1995:179-90.  Back to cited text no. 10    
11.Manyalich M, Cabrer C, Sanchez J, Valero R, Lopez-Coll S, Paredes D. Expanded donor pool. In JL Touranine et al (eds). Organ Allocation. Kluwer Academic Publishrs, Great Britain 1998;147-166.  Back to cited text no. 11    
12.Valero R, Manyalich M, Cabrer C, Garcia­Gages LC, Salvador L. Extraccion de organeos de donantes a carazon parado. In Matesanz R, Miranda B (eds). Coordinacion y Transplantes: El Modelo Espanol, Madrid; Grupo Aula Medica 1995:68-73.  Back to cited text no. 12    
13.Kootstra G. Expanding the donor pool; the challenge of non-heart beating kidneys Transplant Proc 1997;29:3620.  Back to cited text no. 13    
14.Beasley CL, Capossela CL, Brigham LE, Gunderson S, Weber P, Gortmaker SL. The impact of a compreshensive, hospital­focuused intervention to increase organ donation. J Transplant Coord 1997;7:6-13.  Back to cited text no. 14    
15.Comite Europeo de Salud Metodos de despistaje serologico de las mas relevantes enfermedades microbiologicas en los donantes de organos y tejidos. Rev Esp Trans 1996;5:177-80.  Back to cited text no. 15    
16.Eastlund T. Infectious disease transmission through cell, tissue, and orga transplantation reducing the risk thrugh donor selection. Cell Transplant 1995;4:445-77.  Back to cited text no. 16    
17.Matesanz R, Fernandez LM. Standardization of organ donor screening to prevent transmission of neoplastic diseases. Document submitted to the Select Committee of Experts on the Organizational Aspects of Cooperation in Organ Transplantation. Council of Europe ONT, Madrid, Spain 1996.  Back to cited text no. 17    
18.Rodicio JL, Morales JM. Liver disease in renal transplant patients. In: testbook of Nephrology, Massry & Glassock (eds), Williams & Wilkins, Baltimore 1995:1684­-89.  Back to cited text no. 18    

Top
Correspondence Address:
Marti Manyalich
Chief Coordinacio de Transplanaments, Hospital Clinic, Director TPM Project, Formacio Continuada Les Heures, Universitat de Barcelona, Villarroel, 170. 08036, Bercelona
Spain
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