Disposal of donor livers in Brazil: how to optimize their utilization rate in transplants?

Yuri Longatto Boteon Corresponding author: Yuri Longatto Boteon Avenida Albert Einstein, 627/701 – Morumbi Zip code: 05652- 900 – São Paulo, SP, Brazil. Phone: (55 11) 2151-7100 E-mail: yuri.boteon@einstein.br

Instituto Israelita de Ensino e Pesquisa Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.

http://orcid.org/0000-0002-1709-9284

Corresponding author: Yuri Longatto Boteon Avenida Albert Einstein, 627/701 – Morumbi Zip code: 05652- 900 – São Paulo, SP, Brazil. Phone: (55 11) 2151-7100 E-mail: yuri.boteon@einstein.br

Conflict of interest:

none.

AUTHORS´ CONTRIBUTION

Yuri Longatto Boteon: designed the study. Yuri Longatto Boteon and Júlia Porto de Oliveira Drezza: performed the literature review and prepared the questionnaire. Yuri Longatto Boteon, Júlia Porto de Oliveira Drezza, Amanda Pinter Carvalheiro da Silva Boteon, Igor Lepski Calil, Raoni Salomão Sant Anna, Marcelo de Melo Viveiros, Marcelo Bruno de Rezende and Rafael Antonio Arruda Pecora: interpreted the results. Yuri Longatto Boteon, Júlia Porto de Oliveira Drezza, Amanda Pinter Carvalheiro da Silva Boteon, Igor Lepski Calil, Raoni Salomão Sant Anna, Marcelo de Melo Viveiros, Marcelo Bruno de Rezende and Rafael Antonio Arruda Pecora: wrote the article. Yuri Longatto Boteon: critically revised the article. All authors contributed to editing and approved the final version of the article.

Figures (3)
Tables (4)

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Figure 1
Respondents’ opinions regarding their perception of the utilization rate of deceased donor livers (ratio between the number of organs offered and the number of organs transplanted) in Brazil

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Figure 2
Participants’ perceptions of the negative influence of the expansion of the extended criteria donor population on the utilization rate of livers from deceased donors

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Figure 3
Participants’ answers regarding the main categories of reasons for refusing a deceased donor liver for transplantation

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Table 1
Demographic characteristics of the 42 study participants

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Table 2
Main reasons in clinical practice selected by participants for refusing a deceased donor liver, in order of frequency

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Table 3
List, by order of relevance, as per participants, of the main measures to optimize the use of deceased donor livers

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Section I – Demographic factors 1. In which region of Brazil is your transplant center located? a) North b) Northeast c) South d) Southwest e) Midwest 2. How many years have you been working specifically with liver transplantation? a) <5 years b) 5-10 years c) 10-15 years d) >15 years 3. How many liver transplants are performed at your center annually? a) <30 b) 30-60 c) >60 Section II – Perception of the use of livers from deceased donors 4. How do you consider the utilization rate of livers from deceased donors (ratio between the number of organs offered and the number of organs transplanted) today in Brazil? a) High. b) Appropriate (all organs possible are utilized). c) Low (it would be possible to optimize the utilization of donor organs). d) Very low (many organs that could be utilized are discarded). 5. Do you think it is possible to increase the utilization rate of livers from deceased donors currently practiced in Brazil? a) Yes b) No 6. Do you believe that over the past few years there has been a higher prevalence of marginality criteria among organ donors offered for transplantation? a) Yes b) No 7. Do you believe the expansion of the extended criteria donor population has directly affected the utilization rate of donor livers? a) Yes b) No Section III – Reasons for discarding donor livers for transplantation 8. Into which of the following categories do your reasons for not accepting a donor organ for transplantation most commonly fall? a) Donor related conditions (e.g., doubts regarding function, age, and obesity). b) Conditions related to the transplant center (for example, logistics, and lack of blood components). c) Recipient-related conditions (e.g., severity of the recipient's liver disease). 9. Among the reasons below for not accepting an organ (liver) from a deceased donor, which do you consider the major factor, in your clinical practice? a) Prolonged estimated cold ischemia time (due to the long distance from the organ procurement hospital to the transplant center). b) Difficulty in making a good match between donor and recipient (balance between the recipients’ liver disease severity and donor/organ characteristics). c) Donor past medical history data (including laboratory tests) - doubts regarding organ function. d) Findings during harvesting (steatosis, anatomical abnormalities, injuries during the surgery, unsatisfactory organ perfusion, and organ size - donor/recipient disproportion). e) Donor organ biopsy findings. 10. Among the reasons below for not accepting an organ (liver) from a deceased donor, which do you consider the second major factor in your clinical practice? a) Prolonged estimated cold ischemia time (due to the long distance from the organ procurement hospital to the transplant center). b) Difficulty in making a good match between donor and recipient (balance between the liver disease severity of recipients and donor/organ characteristics). c) Donor past medical history data (including laboratory tests) - doubts regarding organ function. d) Findings during the extraction (steatosis, anatomical abnormalities, injuries during extraction, unsatisfactory organ perfusion, and organ size - donor/recipient disproportion). e) Donor organ biopsy findings. 11. Among the reasons below for not accepting an organ (liver) from a deceased donor, which do you consider the third major motive in your clinical practice? a) Prolonged estimated cold ischemia time (due to the long distance from the organ procurement hospital to the transplant center). b) Difficulty in making a good match between donor and recipient (balance between the recipients’ liver disease severity and donor/organ characteristics). c) Donor past medical history data (including laboratory tests) - doubts regarding organ function. d) Findings during the harvesting (steatosis, anatomical abnormalities, injuries during the surgery, unsatisfactory organ perfusion, and organ size - donor/recipient disproportion). e) Donor organ biopsy findings. 12. In your opinion, are there any other reasons for not accepting an organ (liver) from a deceased donor that are not listed in the options above? If yes, please specify. Answer:_________________________________________________ Section IV – Measures to favor the use of livers from deceased donors 13. Among the measures below, which do you think would be the primary action to optimize the use of livers from deceased donors? (Select two alternatives) a) Offers only from donors within more restrictive criteria (for example, maximum age limit, serum sodium level at or near normal limits, and body mass index limits). b) Development of an organ allocation system that already considers donor and recipient characteristics prior to donation. c) Development/investment in new technologies to improve preservation and perform function evaluation of donor organs before transplantation (machine perfusion of the liver). d) Better training of intensive care unit teams in organ donor care. e) Allocation of organs only regionally (allocation zones), imposing distance limits for organ supply. 14. Among the measures below, which do you think would be the second major action to optimize the use of livers from deceased donors? (Select two alternatives) a) Offers only from donors within more restrictive criteria (e.g., maximum age limit, serum sodium level at or near normal limits, and body mass index limits). b) Development of an organ allocation system that already considers donor and recipient characteristics prior to donation. c) Development/investment in new technologies to improve preservation and perform function evaluation of donor organs before transplantation (liver perfusion machine). d) Better training of intensive care unit teams in organ donor care. e) Procurement of organs only regionally (procurement zones), imposing distance limits for organ supply. 15. Do you believe that the implementation of the ex situ machine perfusion of the liver will positively affect liver transplantation, favoring a greater use of donor livers? a) Yes b) No c) I do not have an opinion. 16. Are there other strategies that you think could further improve the donor utilization rate? a) Yes b) No 17. If you answered yes to the previous question, please specify which strategy you think would also contribute: Answer:____________________________________________________

Characteristics		n (%)
Region of the transplant center
	North	2 (4.76)
	Northeast	7 (16.67)
	South	6 (14.29)
	Southeast	26 (61.90)
	Midwest	1 (2.38)
Working with liver transplantation, years
	<5	4 (9.52)
	5-10	13 (30.95)
	10 -15	10 (23.81)
	>15	15 (35.72)
Transplants/year at the service
	<30	11 (26.19)
	30-60	7 (16.67)
	>60	24 (57.14)

Reason	n (%)
Findings during harvesting (steatosis, anatomical abnormalities, injuries during harvesting, unsatisfactory organ perfusion, and organ size - donor/recipient disproportion)	19 (46.0)
Prolonged estimated cold ischemia time (due to the long distance from the organ procurement hospital to the transplant center)	14 (34.0)
Difficulty in making a good match between donor and recipient (balance between the severity of liver disease of the recipient and characteristics of the donor/organ)	15 (37.0)

Measure	n (%)
First measure: better training of intensive care unit staff in organ donor care	22 (53.66)
Second measure: development/investment in new technologies to improve preservation and perform function evaluation of donor organs before transplantation (machine perfusion of the liver)	22 (53.66)

Section I – Demographic factors
1. In which region of Brazil is your transplant center located?
	a) North
	b) Northeast
	c) South
	d) Southwest
	e) Midwest
2. How many years have you been working specifically with liver transplantation?
	a) <5 years
	b) 5-10 years
	c) 10-15 years
	d) >15 years
3. How many liver transplants are performed at your center annually?
	a) <30
	b) 30-60
	c) >60
Section II – Perception of the use of livers from deceased donors
4. How do you consider the utilization rate of livers from deceased donors (ratio between the number of organs offered and the number of organs transplanted) today in Brazil?
	a) High.
	b) Appropriate (all organs possible are utilized).
	c) Low (it would be possible to optimize the utilization of donor organs).
	d) Very low (many organs that could be utilized are discarded).
5. Do you think it is possible to increase the utilization rate of livers from deceased donors currently practiced in Brazil?
	a) Yes
	b) No
6. Do you believe that over the past few years there has been a higher prevalence of marginality criteria among organ donors offered for transplantation?
	a) Yes
	b) No
7. Do you believe the expansion of the extended criteria donor population has directly affected the utilization rate of donor livers?
	a) Yes
	b) No
Section III – Reasons for discarding donor livers for transplantation
8. Into which of the following categories do your reasons for not accepting a donor organ for transplantation most commonly fall?
	a) Donor related conditions (e.g., doubts regarding function, age, and obesity).
	b) Conditions related to the transplant center (for example, logistics, and lack of blood components).
	c) Recipient-related conditions (e.g., severity of the recipient's liver disease).
9. Among the reasons below for not accepting an organ (liver) from a deceased donor, which do you consider the major factor, in your clinical practice?
	a) Prolonged estimated cold ischemia time (due to the long distance from the organ procurement hospital to the transplant center).
	b) Difficulty in making a good match between donor and recipient (balance between the recipients’ liver disease severity and donor/organ characteristics).
	c) Donor past medical history data (including laboratory tests) - doubts regarding organ function.
	d) Findings during harvesting (steatosis, anatomical abnormalities, injuries during the surgery, unsatisfactory organ perfusion, and organ size - donor/recipient disproportion).
	e) Donor organ biopsy findings.
10. Among the reasons below for not accepting an organ (liver) from a deceased donor, which do you consider the second major factor in your clinical practice?
	a) Prolonged estimated cold ischemia time (due to the long distance from the organ procurement hospital to the transplant center).
	b) Difficulty in making a good match between donor and recipient (balance between the liver disease severity of recipients and donor/organ characteristics).
	c) Donor past medical history data (including laboratory tests) - doubts regarding organ function.
	d) Findings during the extraction (steatosis, anatomical abnormalities, injuries during extraction, unsatisfactory organ perfusion, and organ size - donor/recipient disproportion).
	e) Donor organ biopsy findings.
11. Among the reasons below for not accepting an organ (liver) from a deceased donor, which do you consider the third major motive in your clinical practice?
	a) Prolonged estimated cold ischemia time (due to the long distance from the organ procurement hospital to the transplant center).
	b) Difficulty in making a good match between donor and recipient (balance between the recipients’ liver disease severity and donor/organ characteristics).
	c) Donor past medical history data (including laboratory tests) - doubts regarding organ function.
	d) Findings during the harvesting (steatosis, anatomical abnormalities, injuries during the surgery, unsatisfactory organ perfusion, and organ size - donor/recipient disproportion).
	e) Donor organ biopsy findings.
12. In your opinion, are there any other reasons for not accepting an organ (liver) from a deceased donor that are not listed in the options above? If yes, please specify.
Answer:_________________________________________________
Section IV – Measures to favor the use of livers from deceased donors
13. Among the measures below, which do you think would be the primary action to optimize the use of livers from deceased donors? (Select two alternatives)
	a) Offers only from donors within more restrictive criteria (for example, maximum age limit, serum sodium level at or near normal limits, and body mass index limits).
	b) Development of an organ allocation system that already considers donor and recipient characteristics prior to donation.
	c) Development/investment in new technologies to improve preservation and perform function evaluation of donor organs before transplantation (machine perfusion of the liver).
	d) Better training of intensive care unit teams in organ donor care.
	e) Allocation of organs only regionally (allocation zones), imposing distance limits for organ supply.
14. Among the measures below, which do you think would be the second major action to optimize the use of livers from deceased donors? (Select two alternatives)
	a) Offers only from donors within more restrictive criteria (e.g., maximum age limit, serum sodium level at or near normal limits, and body mass index limits).
	b) Development of an organ allocation system that already considers donor and recipient characteristics prior to donation.
	c) Development/investment in new technologies to improve preservation and perform function evaluation of donor organs before transplantation (liver perfusion machine).
	d) Better training of intensive care unit teams in organ donor care.
	e) Procurement of organs only regionally (procurement zones), imposing distance limits for organ supply.
15. Do you believe that the implementation of the ex situ machine perfusion of the liver will positively affect liver transplantation, favoring a greater use of donor livers?
	a) Yes
	b) No
	c) I do not have an opinion.
16. Are there other strategies that you think could further improve the donor utilization rate?
	a) Yes
	b) No
17. If you answered yes to the previous question, please specify which strategy you think would also contribute:
Answer:____________________________________________________

[1] Corresponding author: Yuri Longatto Boteon Avenida Albert Einstein, 627/701 – Morumbi Zip code: 05652- 900 – São Paulo, SP, Brazil. Phone: (55 11) 2151-7100 E-mail: yuri.boteon@einstein.br

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Disposal of donor livers in Brazil: how to optimize their utilization rate in transplants?

ABSTRACT

Objective:

Methods:

Results:

Conclusion: