Ontario's policy on organ donation after circulatory death boosts transplants

Last Updated: 2017-09-25

By Marilynn Larkin

NEW YORK (Reuters Health) - Implementing a "donation after circulatory determination of death" (DCD) policy in Ontario led to more transplants of solid organs, except the heart, researchers in Canada say.

The DCD policy was introduced in Ontario in 2006 to increase the available pool of organ donors, according to Dr. Vivek Rao of the University of Toronto and colleagues. Other areas of Canada reported a decline in donations involving neurologic determination of death (NDD) after implementing DCD, with a drop in organ yield and quality.

To investigate, the team examined the DCD policy's effect on overall transplant activity in Ontario. They looked at deceased donor and organ transplants during three 4-year periods: pre-DCD (2002-03 to 2005-06); early DCD (2006-07 to 2009-10); and recent DCD (2010-11 to 2013-14).

As reported in CMAJ, online September 25, organ donations increased by 57% overall, from 578 donors in the pre-DCD period to 905 donors in the recent DCD era, with DCD accounting for 21% of donor activity in the recent era. NDD donation also increased, overall, during the 12-year period.

The mean length of hospital stay before declaration for NDD was 2.7 days, with an average organ yield of 3.73, versus 6.0 days for DCD, with an average yield of 2.58 organs.

All organs from DCD donors, except for hearts, were successfully transplanted. Nonetheless, transplant activity increased from the pre-DCD to the recent DCD era for all solid-organ recipients, including heart (from 158 to 216), kidney (821 to 1,321), liver (477 to 657) and lung (160 to 305).

"One concern the heart transplant group has was that the practice of DCD was encroaching on the number of NDD donors and thus actually reducing the eligible number of cardiac donors," Dr. Rao told Reuters Health by email.

"This study clearly refutes that concern," he said. "Not only has NDD donation increased, but the characteristics between NDD and DCD donors are clearly different." For example, NDD donors were more likely to have experienced an embolic or hemorrhagic neurologic event, whereas DCD donors were more likely to have experienced anoxic brain injury.

Also, death was being declared for potential DCD donors well after the time window for potential NDD donation, with little overlap, according to the authors. "This result contradicts a widely held notion that organs are recovered from DCD donors before they become eligible for traditional NDD donation."

With respect to the lower yield from DCD heart donors than NDD donors, the authors note that "the continued development of mechanical assist devices, which are increasingly being offered as an alternative to transplant" could be a factor.

"The introduction of ex vivo perfusion technologies has affected the number of DCD lung transplants," they observe, "and we suspect that the same will occur with heart transplants once ex vivo cardiac perfusion becomes widely available."

Dr. Rao noted that, in addition to DCD, factors such as increased community awareness of the benefits of organ donation and increased investment in hospital resource to promote donation contributed to the increase in overall transplant activity.

Dr. Sam Shemie of McGill University in Montreal, author of a related editorial, said in an email to Reuters Health that "donation-focused intensive care physicians drive all forms of deceased donation, including NDD, by identifying and managing patients who are likely to die after a devastating brain injury and may thus become organ donors."

In his editorial, Shemie writes, "The 2015 rate of 18.2 donors per million population remains well below estimates of donor potential . . ." He notes that data about evolving trends will be "informative for future investment in the (organ donation) system by health care organizations, funders and policy-makers."

SOURCES: http://bit.ly/2ftKXQR and http://bit.ly/2wgo1YF

CMAJ 2017.