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Donor Management: Past, Present and Future

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David P. Nelson, MD
Integris Baptist Medical Center
Oklahoma City, OK, USA

Once upon a time procurements went like this: Guys with knives showed up and management decisions were the products of competing interests contested by alpha dogs. There were no OPOs, no UNOS, and transplant center surgeons and coordinators ran the show. Then, federal regulation structured the process and, buffered by OPO personnel, transplanters gradually disengaged from donor management. A modern transplanter's procurement focus is A) Deciding if and for whom to accept an organ, B) Coordination of two surgeries, and C) Preoperative preparation of the recipient.

Outsourcing donor management is an efficiency with a cost: Organ wastage and suboptimal organs.

Organ wastage: Young healthy kid becomes a donor, EF is 25% and not improving. The OPO is juggling its usual flaming balls, weather, growing impatience of the grieving family and host hospitals rapidly approaching morning OR schedule. Board question: "What donor management changes should be made and what biomarkers/metrics predicting reversibility can the OPO invoke to justify its delay to interested parties?" Answer: None. The answer does not currently exist.

Suboptimal organs: It is no mystery that hemodynamic, inflammatory and coagulopathic derangements affect short and long-term organ function in the living, so it is not a reach to speculate that these events in the donor affect graft function and survival. However, the U.S. transplanter's current donor role pre-implant is limited to selection, explant, and delivery.

Several U.S. initiatives reengaging ISHLT members in donor management are ongoing. These include the DMRCC (Donor Management Research Consensus Conference), which is now named DIREP (Donor Intervention Research Expert Panel) and the Donor Management Task Force (DMTF) "Metrics Project".

The DIREP continues to develop donor and recipient consent algorithms for donor research, and is mapping out the blueprints for a national oversight body to regulate the research. Timeline for first draft deliverables are January 1, 2015. The "Metrics Project" establishes monitoring guidelines for non-targeted organs of donor research. Its thoracic goal is to identify unintended adverse (or potentially beneficial) consequences to hearts and lungs of donor interventions directed at abdominal organs. The AST Board has approved same-purposed metrics for liver and kidney. ISHLT metrics were developed by ISHLT task forces of both the Heart and Lung Scientific Councils and are currently under review by the Standards and Guidelines Committee. Personally I envision the metrics being used by a National Oversight Body with elements selectively required on a study-by-study basis.

For decades, transplant research and management has been a postoperative enterprise. Reconnecting with our historical roots in donor management is an opportunity begging to be seized. Redirecting clinical and scientific acumen to the pre-explant timeline is an investment we cannot afford to miss. ■

Disclosure Statement: The author has no conflicts of interest to disclose.

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