Organ donation rates during the COVID-19 pandemic: Comparing the approach taken during the first two waves

Introduction: In response to the COVID-19 pandemic the many UK transplant units had to close or reduce activity, with deceased donation and transplantation down 80% in March-May 2020. Donor age criteria were reduced in the first wave to protect ICU capacity, and donation after brain death (DBD) was prioritised over donation after cardiac death (DCD). From June onwards, an NHSBT recovery plan aimed to reopen programmes, with the aim to return to a position of exploring all eligible donors and reviewing their potential on a case-by-case basis,1 but the ability of such programmes was impacted by a further rise in COVID-19 cases (second wave). Objectives: We aimed to compare the performance of NHSBT referral, donation, and transplantation strategies during the first two waves of COVID-19. Wave one was defined as 11/3/20 to 10/8/20, and wave two 11/8/20 to 10/3/21. Methods: Mortality and transplant data were acquired from the Potential Donor Audit (PDA) and national transplant registries. COVID-19 healthcare utilisation data was acquired via the PHE API. Correlation between features were assessed using Pearson's product-moment correlation coefficient and means compared using Student's t-test. Results: Weekly referral rates during the first wave were strongly inversely correlated to COVID-19 critical care utilisation (r=-0.82, 95%CI -.93 to -0.60) but moderately positively correlated during the second (r=0.61, 95%CI 0.31 to 0.80). Total transplanted organs were inversely correlated throughout (r=-0.64, 95%CI -0.78 to -0.44) with no difference between waves (p=0.055), although renal transplants were less effected during the second wave (p<0.001). The mean transplant gap (difference between organs retrieved and transplanted) was significantly higher in the second wave (5.9 per week, 95%CI 3.4 to 8.5, p<0.001). The DBD/DCD ratio was significantly lower in the second wave (reduced from 3.3 to 2.0, 95%CI for reduction 0.5-2.1, p=0.001). Conclusion: Referral rates to NHSBT improved during the second wave, and the ratio of DBD to DCD fell, both reflecting positively on the change of approach taken. Although total organ transplants fell during both waves, this is strongly correlated to critical care utilisation by COVID-19 patients, suggesting an impact on the ability for transplant centres to access critical care resources post-operatively. The relative sparing of renal transplants (who rarely require critical care post-operatively) and increasing transplant gap in the second wave fits with this assessment, although concerns regarding risks of COVID-19 in transplant recipients -especially in renal patients2-during periods of high burden of disease in hospital likely also contributed to reduced transplant rates,3 and the higher transplant gap could additionally be associated with the increase in DCD donation during the second wave.4.

Cause of death and consent rates during the COVID-19 pandemic

Introduction: The COVID-19 pandemic of 2020-21 impacted all aspects of the UK health service. Organ donation acceptance criteria were initially revised to safeguard critical care resources, and prioritised younger donors and donation after brain death (DBD) over donation after circulatory death (DCD).1 These were later returned to the original criteria prior to the second wave in September 2020;yet referrals and donation numbers remained below pre-pandemic levels throughout 2020. This data was further confounded by England changing from an opt-in model to presumed consent for donation.2 Objectives: We aimed to assess the impact of the COVID-19 pandemic on causes of death, and the subsequent effect on numbers of potential donors, referral rates (adjusted for the altered referral criteria during the first wave), and consent rates for donation. Methods: Mortality, referral, and consent rate data were acquired from the Potential Donor Audit (PDA) database held by NHS Blood and Transplant. The two pandemic waves (defined as 11/3/2020-10/08/2020 and 11/08/2020-10/03/2021) were compared to their corresponding periods from 2019-20. Event counts were compared using exact Poisson tests, and proportions using two-sample z-tests. Results: All-cause mortality was higher during both waves (p<0.001) than the previous year, with excess in-ICU non-COVID-19 mortality during the second wave (p=0.024, see figure). Mortality from cardiac arrest (p<0.001), catastrophic brain injury (p<0.001), and head trauma (p=0.280) were reduced in both waves, and deaths in ICU from suicide and self-harm were reduced in the second wave (p=0.002). After accounting for COVID-19 positive patients and those outside of the adjusted age-criteria, there was no difference in referral rates for potential DBD patients (99% in all cases) but fewer DCD patients meeting criteria were referred during both waves (89% vs 93%, p=0.003, and 85% vs 92%, p<0.001). There were fewer eligible donors during both waves (p<0.001). Fewer eligible families were approached during the first wave (42% vs 58%, p<0.001) but more were approached during the second (58% vs 54%, p=0.001) than in the preceding twelve months. There was no significant difference in Specialist Nurse in Organ Donation (SNOD) presence during approaches, nor family consent rates. Additionally, there was no difference in the proportion of patients who subsequently went on to donate. Conclusions: The reduction in donations - and hence transplantation - during the COVID-19 pandemic was multifactorial. There was a significant reduction in causes of mortality that aremost associated with donation, likely driven by an increased number of deaths in the community who never 'made it' to hospital. Potential DCDs were referred less frequently during both waves, although this was secondary to the change in acceptance criteria during the first wave. Additionally, fewer eligible families were approached during the first wave, further reducing donation potential. Despite fewer eligible donors, consent rates, the relationship between SNOD presence and consent, and progression to donation remained unchanged, suggesting that the foundations underpinning the organ donation programme remained resilient. Future work should focus on validating factors predicting family consent3 in the context of COVID-19 and assessing the ongoing impact of presumed consent.

The impact of COVID-19 on organ donation and transplantation in the UK: lessons learned from the first year of the pandemic.

The COVID-19 pandemic had a major impact on UK deceased organ donation and transplantation activity. We used national audit data from NHS Blood and Transplant to explore in detail the effects of the pandemic in comparison with 12 months pre-pandemic, and to consider the impact of the mitigating strategies and challenges placed on ICU by 'waves' of patients with COVID-19. Between 11 March 2020 and 10 March 2021, referrals to NHS Blood and Transplant of potential organ donors were initially inversely related to the number of people with COVID-19 undergoing mechanical ventilation in intensive care (incident rate ratio (95%CI) per 1000 patients 0.93 (0.88-0.99), p = 0.018), although this pattern reversed during the second wave (additional incident rate ratio (95%CI) 1.12 (1.05-1.19), p < 0.001). Adjusted numbers of donors (incident rate ratio (95%CI) 0.71 (0.61-0.81), p < 0.001) and organs retrieved (incident rate ratio (95%CI) 0.89 (0.82-0.97), p = 0.007) were inversely dependent on COVID-19 workload, though weekly numbers of transplants were unrelated (incident rate ratio (95%CI) 0.95 (0.86-1.04), p = 0.235). Non-COVID-19 mortality fell from 15,007 to 14,087 during the first wave (rate ratio (95%CI) 0.94 (0.92-0.96), p < 0.001) but climbed from 18,907 to 19,372 during the second wave (rate ratio (95%CI) 1.02 (1.00-1.05), p = 0.018). There were fewer in-hospital deaths from cardiac arrest and intracranial catastrophes throughout (rate ratio (95%CI) 0.83 (0.81-0.86), p < 0.001 and rate ratio (95%CI) 0.88 (0.85-0.91), p < 0.001, respectively). There were overall fewer eligible donors (n = 4282) when compared with pre-pandemic levels (n = 6038); OR (95%CI) 0.58 (0.51-0.66), p < 0.001. The total number of donations during the year fell from 1620 to 1140 (rate ratio (95%CI) 0.70 (0.65-0.76), p < 0.001), but the proportion of eligible donors who proceeded to donation (27%) was unchanged (OR (95%CI) 0.99 (0.91-1.08), p = 0.821). The reduction in donations and transplantation during the pandemic was multifactorial, but these data highlight the impact in the UK of a fall in eligible donors and an inverse relationship of referrals to COVID-19 workload. Despite the challenges faced, the foundations underpinning the UK deceased organ donation programme remained strong.