Expanding the Organ Donor Pool in Michigan

Educational Objectives

The goal of this program is to improve management of organ donation. After hearing and assimilating this program, the clinician will be better able to:

1. Elaborate upon recent trends in organ donation in the United States.
2. Compare normothermic machine perfusion vs normothermic regional perfusion for use in organ donation.

Summary

Factors contributing to growth: utilization of high-risk donors has increased; various programs consider donors with, eg, age ≥70 yr, hepatic steatosis, death due to cardiac causes, significant medical comorbidities; the Scientific Registry of Transplant Recipients (SRTR) allows patients and providers to view the outcome measures of various transplantation programs; insurance companies use the SRTR to determine who gets insurance contracts to ensure that transplantation centers are providing optimal patient care; the growth in the number of total donors in the United States (US) has been primarily attributed to the expansion of donation after cardiac death (DCD); donation after brain death (DBD) has slightly increased; DCD has significantly increased; donors ≥70 yr of age are increasing; donors <18 yr of age have remained stable; recruitment and conversion efforts among patients ≥18 yr of age for organ donation are improving

Hepatic steatosis: often reverses ≤6 mo following liver transplantation (LT); the use of these livers has significantly increased across the US over the last few years

DBD vs DCD: donors with brain death are declared dead because of brain injury, but their heart and lungs are kept alive through ventilation for donation; donors with cardiac death have brain injuries and are typically on a ventilator, and families decide to discontinue ventilation and permit natural passing, after which organs are procured for donation; data from the SRTR show an increasing rate of DCDs vs DBDs (traditional); compared with livers obtained through DCD, livers obtained through DBD undergo a smoother reperfusion and better outcomes from a biliary standpoint in the recipient (eg, less renal failure); unlike DBD livers, DCD livers are procured and flushed with cold preservation solutions following a period of warm ischemia

Organ perfusion: normothermic machine perfusion (NMP) — involves removing the liver from the donor body, placing it on a pump, pumping oxygenated blood through the hepatic artery and portal vein, and allowing the liver to remain outside the body for a period of time to measure clearance of lactate and bile production; NMP permits better management of livers between the donor and recipient, provides additional time to consider higher risk factors for the recipient, and makes LT safer and more reasonable for everyone who is involved; normothermic regional perfusion (NRP) — a donor who experiences cardiac death is placed on extracorporeal membrane oxygenation, permitting the organs to live inside the donor body while assessing functionality; this is an ethically controversial issue, as cannulas can restart the heart, making the patient seem alive but not alive at the same time; recently, a governmental body has written to the organ transplant network to ensure NRP does not harm potential donors; benefits — NMP can reduce intensive care unit length of stay by 50% and reduces use of blood products in the operating room; patients are no longer required to visit the hospital to check whether a donor dies from cardiac causes; despite the higher cost, the technology seems to be saving money because patients experience better outcomes

Modernization and increasing donations: Securing the US Organ Procurement and Transplantation Network Act — targets the United Network for Organ Sharing (UNOS) and authorizes the Health Resources and Services Administration to break up the UNOS monopoly into 5 groups and award contracts to different companies to manage the groups; regional collaboration — organs traditionally remained within a specific organ procurement organization (OPO); to address this, organs are now shared across multiple OPOs within a geographic region; however, some people argued about unfairness because of the differences in Model for End-stage Liver Disease scores within the OPOs; liver acuity circles — replaces regional collaboration; concentric circles are drawn with radii of 150, 250, and 500 nautical miles from the donor location to prioritize LT access for the sickest patients within that proximity; increased the availability of livers in various locations

Readings

Feng S, Roll GR, Rouhani FJ, et al. The future of liver transplantation. Hepatology. 2024;80(3):674-697. doi:10.1097/HEP.0000000000000873; Linares I, Hamar M, Selzner N, et al. Steatosis in liver transplantation: current limitations and future strategies. Transplantation. 2019;103(1):78-90. doi:10.1097/TP.0000000000002466; Longchamp A, Nakamura T, Uygun K, et al. Role of machine perfusion in liver transplantation. Surg Clin North Am. 2024;104(1):45-65. doi:10.1016/j.suc.2023.07.001; Seth R, Andreoni KA. Changing landscape of liver transplant in the United States — time for a new innovative way to define and utilize the “non-standard liver allograft” — a proposal. Front Transplant. 2024;3:1449407. doi:10.3389/frtra.2024.1449407; Terrault NA, Francoz C, Berenguer M, et al. Liver transplantation 2023: status report, current and future challenges. Clin Gastroenterol Hepatol. 2023;21(8):2150-2166. doi:10.1016/j.cgh.2023.04.005; Torabi J, Todd R, van Leeuwen LL, et al. A decade of liver transplantation in the United States: drivers of discard and underutilization. Transplant Direct. 2024;10(6):e1605. doi:10.1097/TXD.0000000000001605; Truog RD, Flescher A, Ladin K. Normothermic regional perfusion — the next frontier in organ transplants? JAMA. 2023;329(24):2123-2124. doi:10.1001/jama.2023.9294; Wang BK, Shubin AD, Harvey JA, et al. From patients to providers: assessing impact of normothermic machine perfusion on liver transplant practices in the US. J Am Coll Surg. 2024;238(5):844-852. doi:10.1097/XCS.0000000000000924.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Waits was recorded at the 13th Annual Western Michigan Liver Round-Up, held on October 11, 2024, in Grand Rapids, MI, and presented by the University of Michigan Health. For information on upcoming CME activities from this presenter, please visit https://medschool.umich.edu/offices/cme. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

GE390402

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.