Causes of Failure during the Management Process from Identification of Brain-Dead Potential Organ Donors to Actual Donation in Korea: a 5-Year Data Analysis (2012–2016)

BACKGROUND: This retrospective study analyzed the causes of failure in the management process from the identification of brain-dead potential organ donors to actual donation in Korea over the past 5 years. METHODS: Data of 8,120 potential brain deaths reported to the Korea Organ Donation Agency were used, including information received at the time of reporting, donation suitability evaluation performed by the coordinator after the report, and data obtained from interviews of hospital medical staff and the donor's family. RESULTS: From January 2012 to December 2016, the total number of brain-dead potential organ donors in Korea was 8,120, of which 2,348 (28.9%) underwent organ procurement surgery with designated recipients. While the number of transplant donors has increased over time, the ratio of transplant donors to medically suitable brain-dead donors has decreased. The common causes of donation failure included donation refusal (27.6%), non-brain death (15.5%), and incompatible donation (11.6%); 104 potential donors (7.8%) were unable to donate their organs because they were not pronounced brain dead. CONCLUSION: The rate of successful organ donation may be increased by analyzing the major causes of failure in the brain-dead organ donation management process and engaging in various efforts to prevent such failures.

Status of Organ Donation and Solution of Organ Shortage in Korea / 대한이식학회지

Deceased organ donation in Korea has increased steadily after legislation of transplantation law. Since last year, however, several obstacles resulting in a decrease in organ donation have been experienced. Among them, the reduced reporting of potential brain death from large size hospitals and reduced consent rate of medically available deceased donors are two main hurdles. The consent rate of organ donation was 41.9% in 2017 but has dropped to approximately 10% than 2016. Other strong family members overrode approximately 10% of donations initially consented by their next of kin. In addition to the medical points, difficulties in labor shortage are being experienced during donor management, testing and organ recovery in the hospital. Some end stage patients who are candidates as organ donor give up further management and decide to withdrawing life sustaining treatment, which deprive the chance of donation. Moreover, the national mortality rate of cerebrovascular and traffic accidents, which occupy a major part of brain death, have decreased over the recent 10 years. All of these events can cause a decrease in brain death development so it is important to find solutions to overcome all of them. Revising transplant law and donation system should be led by government. Efforts to increase the consent rate, procurement rate, and transplant rate and decrease the organ discard rate are all the responsibility of the medical team. Public awareness and a positive attitude towards organ donation are the most important basic requirements for increasing organ donation. A comprehensive task force team to overcome all of these problems is requested.

Comparison of clinical outcomes between ABO-compatible and ABO-incompatible spousal donor kidney transplantation

BACKGROUND: Kidney transplantation (KT) is the treatment of choice for end-stage renal disease patients. The spouse is a major donor in living KT. Clinical outcomes of spousal donor KT are not inferior to those of living related donor KT. In this study, we compared clinical outcomes between ABO-compatible (ABOc) and ABO-incompatible (ABOi) spousal donor KTs. METHODS: Thirty-two cases of spousal donor KT performed from January 2011 to August 2013 were analyzed retrospectively. Twenty-one ABOc KTs and 11 ABOi KTs were performed. We investigated patient survival, graft survival, acute rejection, graft function, and complications. RESULTS: During follow-up, patient and graft survival rates were 100% in both groups. There were no significant differences in the incidence of delayed graft function, acute rejection, and the change in graft function between the 2 groups. Medical and surgical complications were not significantly different between the groups. CONCLUSION: The clinical outcomes of ABOc and ABOi spousal donor KTs were equivalent. In ABOi KT, an emotionally motivated spousal donor KT may be a good alternative to the problem of the absolute shortage of kidney donations.

Remote Ischemic Preconditioning Enhances the Expression of Genes Encoding Antioxidant Enzymes and Endoplasmic Reticulum Stress-Related Proteins in Rat Skeletal Muscle

PURPOSE: Ischemic preconditioning (IPC), including remote IPC (rIPC) and direct IPC (dIPC), is a promising method to decrease ischemia-reperfusion (IR) injury. This study tested the effect of both rIPC and dIPC on the genes for antioxidant enzymes and endoplasmic reticulum (ER) stress-related proteins. MATERIALS AND METHODS: Twenty rats were randomly divided into the control and study groups. In the control group (n=10), the right hind limb was sham-operated. The left hind limb (IscR) of the control group underwent IR injury without IPC. In the study group (n=10), the right hind limb received IR injury after 3 cycles of rIPC. The IscR received IR injury after 3 cycles of dIPC. Gene expression was analyzed by Quantitative real-time polymerase chain reaction from the anterior tibialis muscle. RESULTS: The expression of the antioxidant enzyme genes including glutathione peroxidase (GPx), superoxide dismutase (SOD) 1 and catalase (CAT) were significantly reduced in IscR compared with sham treatment. In comparison with IscR, rIPC enhanced the expression of GPx, SOD2, and CAT genes. dIPC enhanced the expression of SOD2 and CAT genes. The expression of SOD2 genes was consistently higher in rIPC than in dIPC, but the difference was only significant for SOD2. The expression of genes for ER stress-related proteins tended to be reduced in IscR in comparison with sham treatment. However, the difference was only significant for C/EBP homologous protein (CHOP). In comparison with IscR, rIPC significantly up-regulated activating transcription factor 4 and CHOP, whereas dIPC up-regulated CHOP. CONCLUSION: Both rIPC and dIPC enhanced expression of genes for antioxidant enzymes and ER stress-related proteins.

The Effects of Normal Saline Solution versus Hartmann's Solution on the Acid-base and Electrolytes Status and Renal Function after Kidney Transplantation / 대한이식학회지

BACKGROUND: The purpose of this study was to elucidate the effects of fluid on the acid-base and electrolytes status and renal function after kidney transplantation (KT). METHODS: We retrospectively analyzed 103 patients who underwent KT. Analyses were performed separately according to the donor type (living, 52; deceased, 51). In the living donor KT group, 28 patients received normal saline solution (NS) and 24 patients received Hartmann's solution (HS). In the deceased donor KT group, 27 patients received NS, and 24 received HS. The acid-base and electrolyte status, urine volume, and renal function between patients receiving NS and patients receiving HS were compared in each group. RESULTS: Regardless of donor type, there were no differences in potassium, pH, base excess, PCO2 and HCO3 between HS and NS on immediate postoperative and postoperative day 1. However, changes to neutral acid-base balance in terms of pH, HCO3, and base excess were significantly higher in HS than in NS. In living donor KT, NS increased serum potassium and chloride significantly during fluid therapy. On postoperative day 7, renal function showed no difference between two groups but urine volume was significantly larger in NS than in HS. CONCLUSIONS: HS does not increase the incidence of hyperkalemia after KT. The use of HS resulted in less metabolic acidosis than the use of NS. Renal function was similar but polyuria was more severe in patients who received NS than in those who received HS.

Validation of the KDRI in Korean Deceased Donor Kidney Transplantation / 대한이식학회지

BACKGROUND: The United Network for Organ Sharing developed the continuous kidney donor risk index (KDRI) for measurement of the spectrum of risk associated with the various factors known to influence graft failure. This study was conducted in order to validate the KDRI in assessment of deceased donor kidney in Koreans. METHODS: Patients (n=404) who underwent kidney transplants performed at five transplantation centers from 2000 to 2010 were studied retrospectively. The distribution of the KDRI of donor kidneys was calculated and the distribution of kidney donors by standard criteria donor (SCD)/expanded criteria donor (ECD) and KDRI was compared. The KDRI were divided into five groups: or =1.4. Graft function and graft survival among KDRI groups were analyzed. RESULTS: The mean KDRI was 1.01 (range, 0.55~1.88). More than 90% of donors had KDRI or =1.4 were ECD. The estimated GFR at one-year in the KDRI groups was 72.2, 65.8, 63.2, 69.1, and 47.1 mg/dL, respectively. Graft function was significantly lower in those with KDRI > or =1.4 (P or =1.4 (P=0.001). CONCLUSIONS: The KDRI is a useful tool for estimation of posttransplant outcomes in the Korean population. The KDRI can be used by physicians as an additional assessment tool to assist in the decision making process regarding donor organ selection.

Improved severe hepatopulmonary syndrome after liver transplantation in an adolescent with end-stage liver disease secondary to biliary atresia

Hepatopulmonary syndrome (HPS) is a serious complication of end-stage liver disease, which is characterized by hypoxia, intrapulmonary vascular dilatation, and liver cirrhosis. Liver transplantation (LT) is the only curative treatment modality for patients with HPS. However, morbidity and mortality after LT, especially in cases of severe HPS, remain high. This case report describes a patient with typical findings of an extracardiac pulmonary arteriovenous shunt on contrast-enhanced transesophageal echocardiography (TEE), and clubbing fingers, who had complete correction of HPS by deceased donor LT. The patient was a 16-year-old female who was born with biliary atresia and underwent porto-enterostomy on the 55th day after birth. She had been suffered from progressive liver failure with dyspnea, clubbing fingers, and cyanosis. Preoperative arterial blood gas analysis revealed severe hypoxia (arterial O2 tension of 54.5 mmHg and O2 saturation of 84.2%). Contrast-enhanced TEE revealed an extracardiac right-to-left shunt, which suggested an intrapulmonary arteriovenous shunt. The patient recovered successfully after LT, not only with respect to physical parameters but also for pychosocial activity, including school performance, during the 30-month follow-up period.

Evaluation of the Korean Network for Organ Sharing Expanded Donor Criteria in Deceased Donor Renal Transplantation / 대한이식학회지

BACKGROUND: This study was conducted in order to evaluate the propriety of expanded donor criteria in Korea and to identify the preoperative factors influencing allograft survival and function. METHODS: We studied 404 patients who received deceased renal transplants from five transplantation centers of 2, 3 territory from 2000 to 2010. Differences in 1-year graft function, delayed graft function (DGF) rate, and graft survival rate between the standard criteria donor (SCD) and expanded criteria donor (ECD) were compared retrospectively. The preoperative factors influencing graft function and graft survival were analysed. RESULTS: SCD showed significantly better 1-year graft function than ECD (P=0.011). No differences in 1-year acute rejection rate were observed between SCD (13.2%) and ECD (16.9%) (P=0.449). Significantly higher DGF rate was observed for ECD (25.4%) than for SCD (14.1%) (P=0.022). Graft type had no significant influence on 5-year graft survival (SCD 94.5% vs. ECD 93.7%) (P =0.835). Advanced donor age (P=0.001), donor hypertension history (P=0.047), high serum creatinine (P=0.002), and cerebral infarction as cause of death (P=0.004) had a negative influence on 1-year allograft function. Significantly low graft survival was observed for advanced donor age (P =0.002). CONCLUSIONS: Graft function, DGF rates of ECD were poorer than those of SCD. Graft survival rate of ECD was comparable to that of SCD kidney. Korean Network for Organ Sharing expanded criteria may underestimate the organ quality of deceased kidney and modification may be needed in order to expand the potential donor pool through nationwide study.

Careful Physical Examination Saves Unnecessary Duplex Ultrasonogram in Patients Who Need Vascular Access for Hemodialysis in Korea / 대한혈관외과학회지

PURPOSE: About 30% of the cause of admission of the patient with end-stage renal disease is reported to be related with complications of vascular access (VA). To achieve good outcome after VA surgery, routine mapping of artery and vein is recommended for the patients who are planned to have vascular access surgery. But evidence supporting routine application of ultrasonogram (USG) is scarce and the situation in Korea is different from western countries where most of the guidelines are produced. We compared the results of the vascular access surgery after physical examination only with those after selective examination with USG. METHODS: Two hundred and forty eight consecutive patients who received VA surgery in Dongsan Medical Center from Jun 2010 to May 2011 were included. Clinical data were retrospectively analyzed and the immediate postoperative failure and early suitability of hemodialysis were compared. RESULTS: One hundred eight patients (group 1) received VA without USG, 140 after USG study. Overall 13 failures were developed. There was no difference between the two groups in terms of early failure (5.6% vs. 5.0%). CONCLUSION: Selective application of duplex sonographic evaluation of vascular status in the patients who need vascular access surgery in Korea is a reasonable policy to save the limited health financial source with acceptable results.

Preliminary Results of Donor Action in Korea / 대한이식학회지

BACKGROUND: Donor Action (DA) is a well-known program used to evaluate the potential of organ donors and to survey hospital attitudes toward organ donation in a region or nation. DA has not yet been fully implemented in Korea. METHODS: We collected medical information on expired patients from 9 hospitals in Yeoung-nam province. We also passed out Hospital Attitude Survey questionnaires in those same 9 hospitals. We reviewed the medical records of the expired patients in the neurological and neurosurgical critical care units from January 1, 2009 to December 31, 2009. Data was analyzed with a DA system database. RESULTS: A total of 704 patients were enrolled. Altogether, 307 patients (43.6%) were potential donors, and 26 patients (6.5%) were reported to an to organ procurement organization. Among the potential donors, a family approach was taken with 33 patients (10.7%), and family consent was obtained in 26 cases (8.5%). Organ donation was done with 24 patients (7.8%). Among the potential donors, 88.6% of them were not identified as potential donors. Hospital attitude surveys were given to 417 hospital staff members. A positive attitude towards organ donation was shown in 85%. However, only 55.4% of hospital staff agreed on the concept of brain death. CONCLUSIONS: Among the processes of organ donation, identifying a potential donor is a critical step to increase organ donation.

Type I Endoleak Five Year after Endovascular Repair of Abdominal Aortic Aneurysm / 대한혈관외과학회지

Endovascular aneurysm repair (EVAR) surgery has become a more prevalent in recent years, as it is less invasive and requires a shorter hospital stay and recovery time, in addition to resulting in lower mortality. However, EVAR has the disadvantage of increased numbers of reintervention incidents, need of regular follow up, and uncertainty of long-term stability. Type II endoleak is the most common endoleak, but it mostly seals without intervention. Type I endoleak is a sealing failure around the graft and proximal neck or distal landing zone and usually occurs during the initial procedure, which can be corrected by ballooning, an additional stent (bare or graft), or surgery. Late type I endoleak can develop by migration of the graft or shrinkage or progression of aneurysm. Here we report a case of distal type I endoleak found 5 years after EVAR which was corrected by additional endovascular grafts.

Optimal System for Deceased Organ Donation and Procurement in Korea / 대한이식학회지

Since the first deceased donor kidney transplantation in 1979, continuous efforts have been made to increase deceased organ donation in Korea. However, a critical shortage of human organs for transplant is still a serious problem and is partly caused by the absence of a system to actively identify and properly manage deceased donors in Korea. Considering this, Korea needs to create a new national system for deceased donor identification, management, and organ procurement. There are three kinds of organ procurement systems in the world: The "Spanish model", the "United States model", and the "other European model". We reviewed each system and suggested the optimal organ procurement system for Korea. We also proposed requirements for operating an organ procurement organization and increasing deceased organ donation. Further improvements in the organ procurement system will contribute to improve the current organ shortage.

Analysis of the Potential Deceased Donors in the Neurosurgical Intensive Care Units of Korea / 대한이식학회지

BACKGROUND: The shortage of donor organs is the main problem that needs to be solved in Korea as well as in other countries. To expand the donor pool, we retrospectively reviewed the brain-dead patients who expired without organ donation in the neurosurgical intensive care units (NICU) and evaluated the potential deceased donors (PDDs). METHODS: Between January 2008 and December 2008, PDDs who expired without organ donation in the NICU were recruited from 52 secondary or tertiary referral hospitals in Korea. The data of a total 2,288 PDD cases were collected from the questionnaire. Of these, 1,980 cases were eligible for analysis. RESULTS: There were 1,166 males (58.9%) and 793 females (40.1%) with a mean age of 57.6+/-18.0 years (21.2% in the 5th decade; 21.0% in the 6th decade). The most common cause of death of PDDs was cerebrovascular accident (n=1,034; 52.2%). Glasgow Coma scale was 3 in 23.1% and 4 in 12.1% of the PDDs. Craniotomy was performed in 996 patients (50.3%). Sepsis developed in 276 patients (14.0%) among the total PPDs. Diagnostic procedure for assessment of brain death was performed in 194 patients (9.8%). The seroprevalence of HBsAg and HCVAb was 1.7% and 0.6%, respectively. The mean AST/ALT level on admission and after brain death were 80.9+/-344.9/49.0+/-162.19 and 308.6+/-1,485.2/142.5+/-596.27 IU/L, respectively. Uriney protein level was normal in 1,221 patients (61.7%) after brain death. Of the 1980 PDDs, 19 patients (1%) donated their organs for transplantation. CONCLUSION: Only a small percentage (1%) of PDDs in the NICU donated their organs in Korea. We suggest that continuous and active donor action is needed to increase organ donation from the potential deceased donors.

Successful Renal Transplantation in Patients with Polycystic Kidneys after Renal Contraction by Renal Artery Embolization: Report on 2 Cases / 대한이식학회지

Autosomal polycystic kidney disease is responsible for about 10% of the cases of end stage renal disease. The increase in kidney size is usually proportional to the degree of deterioration in renal function. At the time of transplantation, these nonfunctional kidneys can be massively enlarged and nephrectomy is required before renal transplantation. However, pretransplantation nephrectomy of polycystic kidneys has the potential risk of surgical complications, including ileus, hernias, infection, excessive bleeding and/or intestinal injury. We report here on two cases successful renal transplantation in patients with polycystic kidneys after renal contraction by renal artery embolization and without nephrectomy. The volume reduction was evaluated by CT before and 3 months after renal artery embolization and the reduction in volume was 48% and 44% in each case, respectively. The embolization was well tolerated in both cases without immediate or delayed complications except for fever and lumbar flank pain. Four months after renal artery embolization, both of the patients successfully received a transplant from living donors.

Comparison of Mid-term Results of Surgical and Endovascular Treatment for TASC C & D Lesions of the Iliac Artery

PURPOSE: In order to establish therapeutic guidelines for TASC C & D iliac lesions, we compared outcomes of surgical and endovascular treatment. METHODS: From May 2002 to April 2007, 27 limbs of 18 patients underwent bypass operation and 23 limbs of 21 patients underwent stent placement for TASC C & D iliac lesions at Dongsan Medical Center. Age, sex, risk factor, combined diseases, clinical symptoms, treatment method, and patency rate were reviewed retrospectively. RESULTS: Technical and clinical success was achieved in all patients of the bypass group and in 95.8% of patients in the stent group. There were no complications in the surgical group, but 4 major complications in the stent group: 3 distal embolizations, and 1 arterial rupture. The primary patency rates at 6 months, 1, 2, and 3 years were all 90% in the bypass group and 95%, 89%, 89%, and 89%, respectively, in the stent group (P=0.99). The respective secondary patency rates were all 90% in the bypass group and 100%, 94%, 94%, and 94% in the stent group (P=0.56). CONCLUSION: Arterial bypass and stent placement are technically safe and effective treatment modalities in TASC C & D lesions of the iliac artery. A liberal posture to open arterial reconstruction extends the ability to treat diffuse TASC C & D lesions via endovascular means.

The Role of NGO in Deceased Organ Transplantation / 대한이식학회지

Solid organ transplantations give end stage organ failure patients new, healthy and normal lives and have them return to their families, friends and communities. But, there has been a donor organ shortage and it has been considered a major obstacle. A national report in 2009 showed a severe disparity between the annual numbers of organ donors (1,787) and the number of patients (12,235) on the deceased donor waiting list. In terms of donor action, and to meet the demands of organs for transplantation, we need to educate the public on the need for organs, eye and tissue donations, and we need to motivate the public to make an actionable donor designation. The unification of non-governmental organization (NGO) is necessary to educate the public about organ, eye and tissue donations and to avoid duplication of effort.

Operational and Regulatory System Requirements for Pursuing Self-sufficiency in Deceased Donor Organ Transplantation Program in Korea / 대한이식학회지

Since beginning with the first organ transplantation from brain-dead donor in 1979, organ transplantation has been developing continuously in Korea. However, organ shortage still is a serious problem in the field of solid organ transplantation. For this reason, it is necessary to promote deceased donor organ transplantation and achieve self sufficiency. There are two system requirements managing deceased donor organ transplantation; operational and regulatory systems. In operational system, mutual and balanced cooperation between transplantation centers, organ procurement organism (OPO), registration/allocation system and NGOs is one of most important determinants to maximize brain dead donor. Especially, transplantation center and OPO need to improve in their organ donation process through evaluating donation practices and developing critical pathway for each step. In addition, public education program focusing on the hospital staff, the family of deceased donors and students should be enhanced to increase public awareness for organ donation. In regulatory system, national transplantation authority for the transplant coordination among various structures and policy-making on the issue of organ donation is necessary. For this purpose, Korean Network for Organ Sharing (KONOS) has to be improved into professional and authoritative body and establish more expanded national database network system. Further improvement in operational and regulatory systems to activate organ donation could enable to achieve the Asian leadership in the field of transplantation as well as self sufficiency for organ transplantation.

Crude Incidence Rate of Malignancy after Kidney Transplantation / 대한이식학회지

BACKGROUND: The incidence pattern of malignancy after kidney transplantation is different from that of the general population. Because increased exposure to immunosuppressants results in an increased incidence of malignancy, institutional reports that do not consider duration of immunosuppression have limited value for providing future kidney recipients with the actual risk for malignancy or for developing a kidney allograft recipient surveillance program. Thus, we retrospectively analyzed our institutional data with regard to the duration of exposure to immunosuppressants. METHODS: A total of 757 patients who had kidney transplantation and were followed-up for at least 6 months at our hospital were reviewed retrospectively. The crude incidence rate (CI) was calculated by counting the days of exposure to immunosuppressants. RESULTS: Most malignancies after kidney transplantation were solid tumors (85.3%). The CI of malignancies was 641.1 in allograft recipients and 329.6 in the general population per 100,000 persons per year. Solid tumor cancers of the stomach, liver, lung, breast, cervix, and pancreas showed an increased CI in the allograft recipient group than the general population but cancers of the thyroid and colon did not. Based on the type of immunosuppressive agent, the CI was highest in the cyclosporine group (866/12 months/100,000 persons) than the other groups. CONCLUSIONS: We have provided the CIs of cancers after kidney transplantation at our institute. The pattern of post-transplant malignancy is different from that of western countries. Nationwide registration is needed to provide a more rational approach to post-transplant cancer surveillance in Korea.

A Proposal to Activate Organ Donation: Report of Organ Allocation Study Group / 대한이식학회지

Organ shortage is a serious problem in the field of solid organ transplantation. Increasing number of death on the waiting list, transplant tourism, black market for organ selling are all caused by organ shortage and these eventually causing poor quality of life for patient and family, and may give rise to a serious confusion in domestic transplant system. Since the KONOS launched in the year 2000, some portion of the illegal side of organ supply were corrected but the number of organ donor was hardly to increase. In order to search any solution for this problem, organ allocation study group under the Korean society for organ transplantation was actively worked from August 2008 through February 2009, and got some solution. Among them, amendment of the transplantation law including brain death committee, reporting system of suspected brain dead patients, and set up an independent organ procurement organization system for an effective organ procurement. Organ donation and increasing the number of donor is not a task only for transplant society, but is closely related with quality of life for peoples. This also can change the execution of budget of national medical health insurance. To give a correct understanding about this and activate the nationwide organ donation, the transplant society should have a key role with various medical and nursing society, hospital association, government, national assembly and every voluntary groups.

Factors Affecting the Result of Kidney Retransplantation / 대한이식학회지

BACKGROUND: As the result of renal transplantation improving, also increasing the number of graft failure which will be a candidate for second renal transplantation. The purpose of this study is to evaluate the factors that influence the survival of retransplanted kidney. METHODS: Among 775 renal transplantations that have been performed in Dongsan Medical Center until August 2007, 225 cases were failed their graft function and 59 of them were retransplanted during their follow up period. Graft survival of retransplanted kidney was compared with primary renal transplantation and factors that affecting the survival of kidney retransplantation were evaluated. RESULTS: Main causes of graft failure of first kidney transplantation were chronic rejection, followed by recurrence of original disease of recipient and acute vascular rejection. Mean survival time was 72.6 months (15 days~161 months). One and 5 years graft survivals were 94.6%, 90.7%, and patient survivals were 100.0%, 97.8%, respectively. Among the factors which showed significance in univariate analysis, short interval between failure of first transplantation and retransplantation, and graft failure due to chronic rejection were statistically significant unfavorable factors for survival of retransplanted kidney. CONCLUSIONS: Kidney retransplantation showed similar graft and patient survival compare to the first one. However, retransplantation should be performed after enough time after graft failure and should be cautious in a patient who lost their graft due to chronic rejection.