| Abstract|| |
Organ transplantation is the gold standard for treating end-stage organ diseases, many of whom are on waiting lists. The reasons for this include the nonavailability of suitable organs to be transplanted. In many nations, most of these challenges have been surmounted by the adoption of deceased donor program, which is not so in sub-Saharan countries such as Nigeria. This study is to audit the potentially transplantable organs available from potential deceased donors from a Nigerian tertiary hospital. This is a study of deaths in the intensive care unit (ICU) and the accident and emergency units of the University of Ilorin Teaching Hospital, Nigeria. Data included the biodata, social history, diagnosis or indications for admission, time of arrival and death, causes of death, associated comorbidities, potential organs available, social history, and availability of relations at the time of death. There were 104 deaths in the ICU and 10 patients in the accident and emergency unit. There were 66 males (57.9%) and 48 females (42.1%). Eighty patients were Muslims (70.2%) and 34 were Christians (19.8%). A total of 33 participants were unmarried (28.9%),whereas 81 (71.1%) were married. The tribes of the patients were Yoruba (105, 92.1%), Igbo (7, 6.1%), Hausa (1, 0.9%), and Nupe (1, 0.9%). The age range was 0.08-85 years. Twenty-two (19.3%) had primary and the remaining had at least secondary education. The causes of death were myriad, and there were relatives available at the times of all deaths. The Maastricht classification of the deaths were Class I - 1 (0.9%), Class II - 37 (32.2%), Class III - 9 (7.8%), Class IV - 20 (17.4%), and Class V - 47(40.9%). There were no transplantable organs in 42 (36.5%), one organ in eight (7%), two organs in two (7%), three organs in one (0.9%), four organs in 13 (11.3%), five organs in six (5.2%), six organs in 11 (9.6%), seven organs in 11 (9.6%), eight organs in five (13%), and nine organs in five (4.3%). Deceased donor sources of organs are worthy of being exploited to improve organ transplantation in Nigeria.
|How to cite this article:|
Popoola AA, Bolaji BO, Olanrewaju TO, Ajiboye TO. Deceased donor organ transplantation potential: A peep into an untapped gold mine. Saudi J Kidney Dis Transpl 2020;31:245-53
|How to cite this URL:|
Popoola AA, Bolaji BO, Olanrewaju TO, Ajiboye TO. Deceased donor organ transplantation potential: A peep into an untapped gold mine. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2020 Oct 31];31:245-53. Available from: https://www.sjkdt.org/text.asp?2020/31/1/245/279947
| Introduction|| |
Organ transplantation is the gold standard for treating end-stage organ diseases (ESRDs). However, there are organ shortages all over the world with several patients on the waiting list for transplantation. According to the Gift of Life, an organ procurement organization in the USA, the mean wait time before transplantation in the area under its jurisdiction in the USA is as follows: kidney - five years, heart - four months, lung - four months, simultaneous kidney and pancreas - one and half years, and pancreas - two years. While on this wait, these patients would require a form of organ replacement therapy or support. Patients with ESRD would require dialysis, whereas other organ failure patients would require various other forms of organ supports such as drugs and pacemakers. These nontransplant organ replacement therapies or supports are not optimal, and many patients develop several morbidities and soon die as a result of complications of these replacement interventions or from the inadequacies of the interventions to make up for the failed organs. The reasons for this long or endless wait for these patients are myriad. One major reason, globally, is the unavailability of suitable organs to be transplanted. In many developed nations, most of these challenges have been or are being surmounted. One major way of surmounting the challenges of organ shortages is the adoption of deceased donor program. In sub-Saharan countries such as Nigeria, with poor organ transplantation rate, deceased donor organ transplantation is not in existence, and the only form of organ transplantation that would be feasible is living donor kidney transplantation. Other organ transplantations are practically not feasible without a deceased organ transplantation program. In Port Harcourt, Nigeria, in a four-year retrospective study, 590 patients were admitted for renal diseases, about 20.3% died within the period of study, and this mortality was apart from those who left the hospital against medical advice. The story is similar across the country.
| Aim of the Study|| |
The aim of this study is to audit the trans- plantable organ availability from potential deceased donors from a Nigerian tertiary care hospital.
| Methods|| |
This is a prospective study of deaths in the intensive care unit (ICU) and the accident and emergency units of the University of Ilorin Teaching Hospital, Ilorin, Nigeria. Data extracted included the patients’ biodata, social history, diagnosis or indications for admission, time of arrival and time of death, cause of death, associated comorbidities, potential organs available for transplantation, social history, and availability of relations at the time of death. The data were analyzed using IBM SPSS Statistics version 20.0 (IBM Corp., Armonk, NY, USA).
| Results|| |
There were 114 patients, in which 104 patients died in the ICU of the hospital, whereas 10 patients in the accident and emergency department of the hospital. The diagnoses of the patients at admission into the facilities are described in [Figure 1]. Seventy-five percent of the patients had no associated chronic illness, for example, diabetes mellitus and hypertension. [Table 1] illustrates the comorbidities in the remaining 25%. Among these deaths, 66 (57.9%) were male, whereas 48 (42.1%) were female. Eighty (70.2%) of the patients were Muslims, whereas 34 (19.8%) were Christians; 81 patients (71.1%) were married. The tribes of the patients were Yoruba (105, 92.1%), Igbo (7, 6.1%), Hausa (1, 0.9%), and Nupe (1, 0.9%). The age ranged between about a month and 85 years, with a mean age of 36.6 years.
The education level of the study patient showed that 22 (19.3%) had less than primary level while the others had education up to secondary level. The admission times into the facilities are shown in [Figure 1], and [Figure 2] shows the times of death. The causes of death are shown in [Figure 1]. At the time of death, there was at least one significant relative available in the hospital. [Figure 3] shows a description of the type of relatives. The Maastricht classification of the deaths were Class I - one (0.9%), Class II - 37 (32.2%), Class III - nine (7.8%), Class IV - 20 (17.4%), and Class V - 47 (40.9%). There were no potentially transplantable organs in 42 (36.5%); [Figure 4] describes the number of transplan- table organs per potential donor: one organ in eight (7%), two organs in two (7%), three organs in one (0.9%), four organs in 13 (11.3%), five organs in six (5.2%), six organs in 11 (9.6%), seven organs in 11 (9.6%), ;eight organs in five (13%), and nine organs in five (4.3%), with an average of 3.6 organs per potential donor. The time of arrival or admission into the facilities and the time of death are represented in [Figure 4] and [Figure 5].
|Figure 2: The time of admission of the potential donors to the facilities.|
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| Discussion|| |
A major challenge with organ replacement therapy is the availability of suitable organs for transplantation. This is responsible for the long waiting list. Many patients have died while on the waitlists. This scenario is global, but various countries have found means to improve on the situations.
Donor register is a means of having potential donors signed on in the event that they become braindead or sustain irreversible brain damage. Furthermore, patients who developed irrecoverable cardiac arrest within a facility could also be donors. In the UK, and the US, the register system is the “opt-out” system, whereby potential donors get on the register voluntarily. The Netherlands, until few years ago, provided the opportunity for most adults who, on application for a driver’s license, are encouraged to state whether they would like to be potential deceased donors or not. This opportunity at enrollment for donation along with a driver license application helps the citizen to make an early decision. However, countries such as Spain, France, and Belgium presume every citizen to be a potential donor unless the citizen formally opts out of this. The “opt-out” system, therefore, has more proportion of the citizens as potential deceased donors on the register than the opt-in system. The “opt-out” system and the placement of physicians as transplant coordinators in the ICU are the cardinal aspects of the successful Spanish model. Nigeria has no donor register. Either of the two register systems is the basis of deceased donor program in those countries. The deceased donor program is an integral part in many countries that have a significant improvement in their transplantation rate. However, many countries in sub-Saharan Africa have no deceased donor program, hence the dismal outlook of their transplantation program. The lack of a transplantation program also puts limitations on their program; hence, heart and lung and other organ transplantations which are only feasible with deceased donation are not possible in these countries.
Iran is reported to be one of the very few countries to have virtually no one on transplant wait list. This is largely attributed to a government-controlled donor compensation program that involves the recipient paying the donor with some government subsidy. This removes occult or black market and all such ills that come with “middlemanship.” This ensures that ethically minded practitioners are able to carry out the transplantation in an open manner without feeling they have contravened any law. There are still some gray areas of ethical dilemma. Although this may still not be acceptable in many Western nations, it has helped ESRD patients across socioeconomic status to receive kidney transplant.
In the year 2013, the death rate from road crashes estimated by the WHO for Nigeria was 20.5/100,000, 9th position worldwide, i.e., about 35,000 deaths in a population of about 175 million in a year. Many of these victims get to the hospitals alive, but because of the severity and irreversibility of their injuries such as head injury, they eventually succumb. One major source of deceased donor organ supply is from the victims of road crashes who have suffered irreversible brain damage. An improved prehospital transportation of these victims is very important for their possible survival or being suitable as a potential organ donor. In Nigeria it is still not adequate, and transportation is made largely by passersby and in just any vehicle that is available. Prompt transportation of these victims who may suffer irreversible cardiac arrest within a few minutes of arrival can still make them potential organ donors. Adoption of a deceased donor program would need an expansion of the ICU beds and training of transplant personnel. The success of the Spanish model can be attributed largely to having the ICU physicians double as transplant coordinators. Many of the deaths in the ICU and the accident and emergency unit are potential deceased donors.
The age of donors is very important in the outcome in the recipients after transplan- tation. It is one of the criteria in classifying the donors to standard criteria donors (SCDs) or extended criteria donors (ECDs). The standard criteria are, therefore, set to ensure that the recipients receive optimal functioning organs in order to achieve the best results. However, in view of the shortage of trans- plantable SCDs, the criteria have been relaxed to allow for inclusion of some fringed quality donor organs. Recipients of ECD kidneys generally have improved survival compared with wait-listed dialysis patients, thus encouraging the pursuit of this type of kidney transplantation., The age range of these deaths varied widely from less than a year to 85 years. However, at least 72.8% of these, on account of their ages, are within the standard donor criteria. Hence, about two-thirds of the deaths were potential donors based on the age.
The study also revealed that in 65% of the deaths, the potential deceased donors had no associated comorbidities that could disqualify them from being SCD. Furthermore, some comorbidities are not absolute contraindications to being potential donors. Very few comorbid conditions are absolute contraindications. They include human immunodeficiency virus disease, active septicemic conditions, Creutzfeldt-Jakob disease More Details, uncontrolled infection (donor sepsis), metastatic or non- curable malignancy, and past history of some malignancies which pose risk for transmission, no matter how long the apparent disease-free period (e.g., melanoma and choriocarcinoma).
The deceased donor transplantation provides multiple organs from the same potential donor to multiple recipients. Some types of organ transplantation are only possible with deceased donor organs. Our study revealed that on average, each of the potential donors would have provided about four organs which could go to several recipients apart from tissues such as cornea and bone marrow. Even in situations when solid organs are not suitable for transplantation, tissues such as cornea are available for transplantation.
Family consent is very important in many countries, especially in countries where the “opt-in” deceased donor registration is the practice, especially in The Netherlands, Germany, and the UK., In view of this importance, availability of family members is very important not just at the time of death but also from when the potential donor is admitted into the facility. However, adequate training is necessary for transplant personnel in obtaining family consent. A declined consent when the patient is braindead does not preclude consent after the same patient has suffered cardiac arrest. In the USA and the UK, family consent is reported at 54% and 60%. In our study, all the patients had at least one significant member of the family present within the hospital before and at the time of death. [Figure 6] shows who these family members or relatives were. This is positive for deceased donor program. There is a great need for training for transplant coordinators, ICU personnel, and others who will need to relate with family members of potential donors right from the time of admission into the facility through when the patient is considered a potential donor and at the time of death. A relationship of trust must be developed with the patient relatives right from the start of admission into the facility. The patients must be given and be seen by the relatives to have been given the best of care, and regular update about the care of the patients must be imparted. One of the reasons for family refusal of consents is mistrust. Therefore, an essential part of training for personnel to be involved in organ training, especially deceased donor transplantation, should be trust building. This makes regular communication between transplant coordinators and the family of a potential deceased donor very important. A study in The Netherlands is optimistic that there may be increased family consent by exploring the possibility of consent for donation after circulatory death if families refuse consent for donation after braindeath.
The deaths were mainly uncontrolled DCD which are the Maastricht Classes I, II, and V [Figure 7]. These constituted about 75% of all the deaths. These were unexpected deaths and therefore present with the challenges of unpre- paredness. At present, no center in Nigeria has the capacity for deceased donor transplantation. For the country to exploit the gold mine of deceased donor transplantation, a lot needs to be done. Prehospital transportation of road traffic victims in Nigeria needs a lot of improvement in order to improve on the outcome of the care for these victims. Arriving at the hospital alive and on time for resuscitation is crucial, and if they eventually die in the process, perfusion could be started while the organs are still transplantable to preserve the organs while trying to obtain consent from the family members. The organs of many of these Class I victims may not be transplantable because of delay in arriving at the hospital. Proper training should be imparted on the transplant personnel on how to identify suitable potential donors and communicate with patients’ relatives gaining their confidence.
|Figure 7: Estimated number of transplantable organs per potential donor.|
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The country needs to improve on the portion of the Nigeria Health Bill on organ transplantation to include deceased donor organ transplantation and include definition of deaths and braindeath.
In view of the fact that the living donor pool in Nigeria is not likely to expand significantly to offset the growing number of patients with end-stage organ failure, there is a need for alternative source of organs. In Nigeria, the only solid organ transplantation program is that of the kidney. Even this is slow in developing countries, and the major challenges are those of cost and availability of willing living donors. Deceased donor transplantation will help to expand the donor pool and make possible other organ transplantations that are not possible with living donors such as heart and lung transplantation.
| Conclusion|| |
In Nigeria and many countries in sub- Saharan Africa, transplantation rate is low and most of these countries do not have a deceased donor program. Deceased donor sources of transplantable organs are worthy of being exploited to improve organ transplantation in Nigeria. This study showed that there are great potentials for deceased donor organ transplantation, but several steps including having the right legislation, facilities, and personnel are needed.
Conflict of interest: None declared.
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Ademola Alabi Popoola
Department of Surgery, University of Ilorin, University of Ilorin Teaching Hospital, Ilorin
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]