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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2014  |  Volume : 25  |  Issue : 3  |  Page : 589-596
Potential brain death organ donors - challenges and prospects: A single center retrospective review

1 Department of Surgery, Qatar Center for Organ Transplantation, Hamad General Hospital, Doha, Qatar
2 Department of Urology, College of Medicine, Al Nahrain University, Baghdad, Iraq

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Date of Web Publication9-May-2014


Organ donation after brain death (BD) is a major source for obtaining transplantable organs for patients with end-stage organ disease (ESOD). This retrospective, descriptive study was carried out on all potential BD patients admitted in different intensive care units (ICUs) of the Hamad medical Corporation (HMC), Doha, Qatar during a period from January 2011 to April 2012. Our aim was to evaluate various demographic criteria and challenges of organ donation among potential BD organ donors and plan a strategy to improve the rate of organ donation in Qatar. Various aspects of BD patients in the ICUs and their possible effects on organ donation were studied. The time intervals analyzed to determine the possible causes of delay of organ retrieval were: time of diagnosing fixed dilated pupils in the ICU, to performing the first BD test, then to the second BD test, to family approach, to organ retrieval and/or circulatory death (CD) without organ retrieval. There were a total of 116 potential BD organ donors of whom 96 (82.75%) were males and 20 (17.25%) were females. Brain hemorrhage and head injury contributed to 37 (31.9%) and 32 (27.6%) BD cases, respectively. Time interval between diagnosing fixed dilated pupil and performing the first test of BD was delayed >24 h in 79% of the cases and between the first and second BD tests was >6 h in 70.8% of the cases. This delay is not compatible with the Hamad Medical Corporation (HMC) policy for BD diagnosis and resulted in a low number of organs retrieved. BD organ donation, a potential source for organs to save patients with ESOD has several pitfalls and every effort should be made to increase the awareness of the public as well as medical personnel to optimize donation efficacy.

How to cite this article:
Al-Maslamani Y, Abdul Muhsin AS, Mohammed Ali OI, Fadhil RA, Abu Jeish AR. Potential brain death organ donors - challenges and prospects: A single center retrospective review. Saudi J Kidney Dis Transpl 2014;25:589-96

How to cite this URL:
Al-Maslamani Y, Abdul Muhsin AS, Mohammed Ali OI, Fadhil RA, Abu Jeish AR. Potential brain death organ donors - challenges and prospects: A single center retrospective review. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2022 Jul 1];25:589-96. Available from: https://www.sjkdt.org/text.asp?2014/25/3/589/132198

   Introduction Top

Living organ donation is the most widely practiced type of donation in the Middle East, and includes kidney and partial liver. It has to be predominantly genetically related; however, non-genetically related and commercial living organ donations do exist. [1] Other sources of organ donation include organs obtained from a donor after brain stem death (BD), also called cadaveric heart beating donors, after BD criteria were defined and adopted in 1968 or donation after cardiac death (DCD) previously known as non-heart beating donation. [2],[3] Cadaveric donation is lower than expected due to cultural, legal and medical problems. [4]

Transplantation in the Middle East Society for Organ Transplantation (MESOT) region began as early as 1969, with a heart transplant in Turkey. In 1986, the Islamic theologians (Al Aloma) issued what became known as the Amman declaration, in which they clearly accepted BD and the retrieval and transplantation of organs from living and cadaveric donors. [5]

In Qatar, the Human Organs Transplants Law no. 21 enacted in the year 1997 was clear in defining the following. Transplantation of Organ: Removal of an organ of a human, dead or alive, and its implantation in a living human. Death: Irreversible cessation of the heart and respiratory system, or irreversible cessation of all functions of the brain (brain death). Thus, BD (deceased) kidney donation was established as another option for renal transplantation in addition to living donation. [6] The objectives of this study were assessment of the demographic criteria of potential BD donors, reviewing the pitfalls and procedural delays in the referral and performance of BD diagnostic tests in intensive care units (ICUs) and to have an idea on the ultimate effect of these factors on the final pool of organ donation within the study period and to discuss the best strategy to overcome the delays in the diagnosis and procurement of organs.

   Subjects and Methods Top

A retrospective review was carried out on all patients who were potential BD cases during their admission to ICUs of the Hamad Medical Corporation (HMC), Doha, Qatar between January 2011 and April 2012. Once BD diagnosis is labeled, they represented potential donors for organ transplantation. This study was exempted from review and approval by the Institutional Ethics Committee due to its retrospective, observational nature and is in accordance with the Helsinki Declaration of 1975 (as revised in 1983).

A list of patients with imminent death as defined by the HMC policy [6] was obtained from the inhouse transplant coordinator and crosschecked with the central hospital patient registry. The following data of the patients were recorded: Age, sex, nationality, religion, blood group, the referred ICU type in HMC namely trauma (TICU), medical (MICU), surgical (SICU), pediatric (PICU), coronary care unit (CCU) and Al Khour Hospital (AKH ICU). The cause of death and the time period between diagnosing fixed dilated pupil of patient and performing first and second confirmatory testing of BD, then, family approach, family decision for consent for organ donation and, finally, organ retrieval were studied. The BD was diagnosed as per The Qatar National Protocol Regulation which is followed in all ICUs. After the declaration of BD has been made, the transplant coordinator will approach the family of BD patient regarding organ donation and will proceed with the necessary steps for obtaining a written consent by the donor's next of kin.

   Statistical Analysis Top

Categorical and continuous values were to be expressed as frequency (percentage) and mean ± SD. Descriptive statistics were used to summarize all demographic and other clinical characteristics of the participants. Associations between two or more qualitative or categorical variables were assessed using the chi-square test. For small cell frequencies, chi-square test with continuity correction factor was used. Pictorial presentations of the key results were made using appropriate statistical graphs. A two-sided P-value <0.05 were considered to be statistically significant. All statistical analyses were performed using statistical packages SPSS 19.0.

   Results Top

File records of 116 potential BD organ donor patients admitted between January 2011 and April 2012, were reviewed, retrospectively. There were 96 (82.75%) males and 20 (17.25%) females. The mean age ± SD was 43.56 ± 18.41 (range, 5-81) years. [Table 1] shows age distribution, blood group, nationality and religious affiliation of the potential BD organ donors. The distribution of 116 potential BD patients, among the ICUs of the HMC was as follows: TICU 39 (33.6%), MICU 35 (30.1%), SICU 22 (18.9%), AKH ICU 11 (9.4%), PICU 7 (6%) and CCU 2 (1.7%) patients. The two main causes of potential BD were brain hemorrhage [both intra-cerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH)] and head injury in 37 (31.9%) and 32 (27.6%) cases, respectively. Road traffic accidents (RTAs) contributed to 11/32 (34.3%) cases of head injury admissions to ICU. [Table 2] shows the causes of potential BD.
Table 1: Demographic Data of potential BD organ donors.

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Table 2: Cause of death in potential BD organ donors (N = 116).

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Statistical analysis of the time interval between the diagnosis of fixed dilated pupil and performing the first BD test is shown in [Table 3]. Of 116 potential BD patients in various ICUs, 46 (39.6%) patients were not subjected to the first BD test and in another eight (6.8%) patients, the first BD test was carried out but the above time interval was not reported. Both groups were excluded from the statistical analysis. The above time interval in the remaining 62 potential BD patients was classified into two groups: ≤24 h and >24 h according to the HMC BD policy. In 13/62 (20.9%) patients the interval was ≤24 h, (compatible with HMC policy for potential BD donors). while in 49/62 (79%) patients the interval was >24 h (not compatible with HMC policy). There was no statistical significance regarding an association of an ICU type with the interval delay (>24 h).
Table 3: The time interval between fixed dilated pupil and first BD test (N = 116).

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Similarly, the time interval between performing the first and second BD tests was studied as shown in [Table 4]. Of 116 patients, this interval was analyzed in 70 patients as 46 patients did not have the first BD test. Of the 70 patients subjected to the first BD test, the second BD test was not carried out in 9/70 (12.8%) patients and the above time interval was not reported in 13/70 (18.5%) patients. Both groups were excluded from statistical analysis. The time interval between the first and second BD tests in the remaining 48 adult patients diagnosed with BD was classified in two groups (≤6 h and >6 h) based on the HMC policy for the interval between the first and second BD tests. Of 48 BD patients, only 14 (29.1%) patients had the mandatory 6-h interval between the first and second BD tests. In the other 34 (70.8%) patients, the above-mentioned interval was >6 h. Again, there was no statistical significance regarding an association of an ICU type with the above time interval delay (>6 h).
Table 4: The time interval between the first and second BD tests (N = 70).

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Of the total 116 potential BD patients, the diagnosis of BD was established in 61 patients (who represented potential BD organ donors) Unfortunately, 13/61 BD patients were not fit for organ donation due to one or more contra-indication(s) such as cancer, hepatitis…etc. In 2/61 BD cases, no immediate family contact/or poor registration followed by cardiac arrest was encountered. The families of all remaining 46/61 potential BD donors were informed about BD and then were approached by the organ transplantation coordinator(s) team taking the best efforts to overcome the language barrier for possible organ donation. The family refused organ donation in 37/46 (80.4%) cases, accepted organ donation in 8/46 (17.3%) cases, and cardiac arrest was encountered before final family decision in 1/46 (2.1%) of the cases. Family refusal was due to denial state of BD diagnosis in 8/37 (21.6%) cases, relatives asking to take their patient to another medical places while in the remaining 29/37 (78.3%) cases organ donation was refused due to religious and cultural reasons (fear of body disfigurement). Some relatives asked for economic compensation before thinking of organ donation of their BD patients. Among the eight BD cases in whom the families accepted organ donation, the written consent for organ donation could be obtained only from seven because one patient developed cardiac arrest before the consent. Further, organ retrieval could be carried out only in 5/7 patients (10 kidneys, two livers) since one more patient developed cardiac arrest before retrieval and cancellation of retrieval in another, due to fever and altered liver function tests.

   Discussion Top

In Qatar, organ transplantation started in 1986 with the first kidney transplantation. Since then, lack of living donors was the major obstacle limiting number of kidney transplantations. The Human Organs Transplant Law no. 21 enacted in the year 1997 was clear in defining and regulating organ donation (from living and brain dead patients) and transplantation in Qatar. This was followed by the official declaration to establish the Qatar Center for Organ Transplantation (QCOT) in November 2011 and then the Qatar Center for Organ Donation (Hiba) in August 2012.

The TICU and MICU units were the major source of potential BD referral contributing 63.8% of the cases. Thus, every effort should be made to supplement such busy units with the necessary number of qualified staff with implementing measures to increase the awareness of management and referral of BD cases. The main two causes of potential BD in HMC, brain hemorrhage (both ICH and SAH) and head injury, contributed collectively for 59.5% of the cases. This underlies the need to adopt more education campaigns among the public to explain the risks, causes and possible medical strategy to avoid fatal brain hemorrhage and increase governmental efforts to reduce head injury, particularly due to avoidable RTAs. In most Western countries, approximately 80-90% of BD patients suffer from aneurysmal SAH, traumatic brain injury (TBI) or ICH. Progress made in the prevention and treatment of these three conditions has led to a steady decline in the pool of potential heart-beating organ donors over the past few decades. [7] The variation in nationality of potential BD organ donors in Qatar shown in [Table 1] reflects different religious and cultural education and attitude toward organ donation. The most common nationalities were Qatari 21.5%, Indian 18.9%, Nepalese 12% and Filipino 11.2%. In addition, there were 16 other reported nationalities. Therefore, organ donation educational efforts and campaigns in Qatar should concentrate on such nationalities, explaining the life-saving benefits of organ donation. The QCOT includes Arabic, Indian and Filipino transplant coordinators to optimize family approach and counseling regarding organ donation.

The religious affiliation of BD patients was as follows: Muslim 45.6%, Hindu 8.6% and Christian 6%. However, religion was not recorded in 38.7% of the patients mainly due to the fact that majority of the patients admitted to the ICUs are critical and have impaired consciousness and the health card issued in Qatar does not refer to the religious affiliation. The effect of religious beliefs on organ donation is well known and, many people refuse organ donation due to the misunderstanding of religious thoughts. Therefore, a successful organ donation education program has to consider the help and guidance of the religious authorities.

In order for the BD organ donation program to be highly effective, there are two strategies to be encouraged and supported independently. The first one is the appropriate education of the public about the merits of organ donation following BD and the second is to improve awareness of various ICU staff and upgrade the standards of medical management of BD patients in the ICUs. The ICU staff should also be educated about the importance of timely referral to organ transplant coordinator who should then ensure appropriate response from neurologists to perform the necessary tests and document BD.

Of the 116 patients with fixed dilated pupils in the ICUs, the first BD test was not carried out in 46 (39.6%) patients. Unfortunately, there were no accurate documents explaining the reasons for not performing this test, but there was a suggestive presence of contraindication(s) for organ donation, development of cardiac arrest, poor recording or physician delay to perform the test. In eight (6.8%) other patients, the interval between dilated fixed pupil and first BD test was not reported in the Registry. There is no justification of not reporting or even a delayed or defective reporting of BD tests in the ICUs, whatever is the bulk of daily work load.

Among the 70 potential BD patients who had the first BD test, the above-mentioned interval was not reported in eight (6.8%) patients and the remaining 62 patients were classified into two groups. The first group interval (≤24 h, which is compatible with the standards of the HMC policy - Policy No.: CL 7213/Sheet No. 4 of 11) was reported in 13 (20.9%) patients and the second group interval (>24 h, which is beyond the HMC policy) in 49 (79%) patients. Delaying the first BD test in most patients in this study is the first pitfall of efficient BD organ donation, and it has to addressed and prevented.

Similar analysis of the time interval between performing the first and second BD tests was carried out. Among the 70 patients subjected to the first BD test, nine patients did not have the second BD test, with no clear documentation of the reason(s), and 13 patients had it, but with no record of time interval. The remaining 48 patients was classified into two groups according to relevant HMC policy, ≤6 h (compatible with the HMC policy) and >6 h, (incompatible with the HMC policy), Only 14 (29%) patients had the correct interval between the first and second BD tests, while the other 34 (70.8%) patients exceeded the 6-h threshold. The unnecessary delay of completing the second BD test and consequently that of declaring BD status will definitely affect the time of approaching the family and consequently the retrieval of organs. This will then act as an impediment to the progress of organ donation from BD patients.

There was no statistically significant difference between ICUs indelaying the performance of first and second BD tests. This may be due to the relatively small number (116) of patients studied. However, the transplantation team has to interact more with ICU authorities to encourage the staff for timely declaration of BD and perform confirmatory tests.

Retrieval of organs from BD patients requires the absence of a contraindication(s) for organ donation, such as cancer, and the family acceptance and consent, which is another hard task for the transplantation team particularly when the religious/or cultural beliefs and education oppose such agreement.

In this study, from 116 potential BD patients, the diagnosis of BD was reported only in 61 (52.5%) patients, whereas, BD was diagnosed in 60% of patients in Saudi Arabia (5 year/ 1834 potential BD cases). [8]

The family was approached in 46 medically fit potential BD organ donors. One/46 (2.1%) patients had cardiac arrest even before the family decision. Organ donation was accepted by 8/46 (17.3%) families, from whom we could obtain only seven written consents because one patient from this group also developed cardiac arrest before the consent could be obtained. Eventually, organ retrieval was successfully achieved only in five cases. This clearly shows the need of awareness of urgency needed to approach the families of BD patients for their written consent without any delay and quick retrieval of organs by the surgical team.

Family refusal of BD organ donation was reported in 37/46 (80.4%) cases. Indeed, family refusal of organ donation after BD is a universal problem, ranging in the literature from 25% up to 95% in literature. [4] Family refusal of organ donation was due to refusal of the diagnosis of BD status (denial state), religious and cultural (fear of body disfigurement) factors as well as demand by some family relatives for economic compensation. The causes of refusal were not statistically compared, with other variables such as the nationality or religion due to the wide nationality spectrum of people living in Qatar. Future studies involving a larger number of BD patients may show a correlation with certain nationality or religion.

Every day, a large number of patients die in controlled circumstances in the hospitals. But, the vast majority of these organs is buried or burned. [9] The QCOT in its continuous and ever hardwork to improve organ donation from all possible sources (living related and BD donors) adopted a new strategy in July 2011 to approach living donors and brain dead patient's families by recruiting two organ procurement coordinators (OPC) of the same religion and nationality as the BD patient to overcome the language barrier.

In Qatar, a study showed that 69.1% of the surveyed subjects were aware of organ donation. [10] In another survey in the HMC, physicians (23.9%) and nurses (61.3%) agreed that they lacked sufficient information about organ donation and that many physicians (72.4%) and nurses (74.7%) did not know that BD can be described as death. [11] Lack of adequate public knowledge regarding organ transplantation from deceased donors is also shared by other societies in the Arab gulf countries. [12] The best strategy to overcome this problem is adequate and continuous public education and organ donation campaigns for adults as well as educating high school and university students (medical and non-medical), to promote a positive attitude toward organ donation. The attitude of teachers [13] and high school students [14],[15] towards organ donation was assessed in some countries as part of the above-mentioned strategy.

Another effective tool to strengthen the BD organ donation program is the issuing of donor cards, which will document the willingness of people wishing to donate organs when BD is established. Some Middle East countries published their experience in this respect. [16] In Qatar, the organ donation campaign released in July-August 2012 succeeded to collect 2434 consents for organ donation after BD from different social classes.

Organ donation programs can also be improved by getting organs from DCD. During the last ten years, kidneys recovered/transplanted from DCD have significantly increased. [17] The most important problem with organs from DCD is their inferior outcomes compared with those from BD, particularly in liver transplantation. [18]

In conclusion, BD organ donation is a potential source for organs for patients with ESOD. Every effort is made to increase the awareness among medical personnel to avoid unnecessary delay of BD diagnosis. A multidirectional educational program of public and medical workers has to be adopted to encourage both living and BD organ donation in Qatar.

   References Top

1.Shaheen FA, Souqiyyeh MZ. How to improve organ donation in the MESOT countries. Ann Transplant 2004;9:19-21.  Back to cited text no. 1
2.Hernandez-Alejandro R, Caumartin Y, Chent C, et al. Kidney and liver transplants from donors after cardiac death: initial experience at the London Health Sciences Centre. Can J Surg 2010;53:93-102.  Back to cited text no. 2
3.Faraj W, Fakih H, Mukherji D, Khalife M. Organ donation after cardiac death in the Middle East. Transplant Proc 2010;42:713-5.  Back to cited text no. 3
4.Ghafari A, Taghizade Afshari A, Makhdoomi Kh, et al. Cadaveric renal transplantation: A single-center experience. Transplant Proc 2009;41:2775-6.   Back to cited text no. 4
5.Masri MA, Haberal MA, Shaheen FA, et al. Middle East Society for Organ Transplantation (MESOT) Transplant Registry. Exp Clin Transplant 2004;2:217-20.  Back to cited text no. 5
6.Human Organs Transplants Law no. (21) for the year 1997. Organ Donation and Procurement Policy/Procedure. HMC policy (CL 7224 - original date February 2005).  Back to cited text no. 6
7.de Groot YJ, Wijdicks EF, van der Jagt M, et al. Donor conversion rates depend on the assessment tools used in the evaluation of potential organ donors. Intensive Care Med 2011;37:665-70.  Back to cited text no. 7
8.Al-Attar B, Shaheen F, Salam MA, et al. Implications of ICU Stay After Brain Death: The Saudi Experience. Exp Clin Transplant 2006;4:498-502.  Back to cited text no. 8
9.Wilkinson D, Savulescu J. Should we allow organ donation euthanasia? Alternatives for maximizing the number and quality of organs for transplantation. Bioethics 2012;26:32-48.  Back to cited text no. 9
10.El-Shoubaki H, Bener A, Al-Maslamani Y. Factors influencing organ donation and transplantation in State of Qatar. Transplant Med 2006;18:97-103.  Back to cited text no. 10
11.Bener A, El-Shoubaki H, Al-Maslamani Y. Do we need to maximize the knowledge and attitude level of physicians and nurses toward organ donation and transplant? Exp Clin Transplant 2008;4:249-53.  Back to cited text no. 11
12.Mohsin N, Militsala E, Budruddin M, et al. Attitude of the Omani population toward organ transplantation. Transplant Proc 2010;42:4305-8.  Back to cited text no. 12
13.Khoddami-Vishteh HR, Ghorbani F, Ghasemi AM, Shafaghi S, Najafizadeh K. Attitudes toward organ donation: A survey on Iranian teachers. Transplant Proc 2011;43:407-9.  Back to cited text no. 13
14.Al-Ghanim SA. The willingness toward deceased organ donation among university students. Implications for health education in Saudi Arabia. Saudi Med J 2009;30:1340-5.  Back to cited text no. 14
15.Afshar R, Sanavi S, Rajabi MR. Attitude and willingness of high school students toward organ donation. Saudi J Kidney Dis Transpl 2012;23:929-33.  Back to cited text no. 15
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16.Najafizadeh K, Shiehmorteza M, Mohamad MM, et al. Issuing donor cards in a single center in Iran: Results of the first 3 years. Transplant Proc 2009;4:2711-4.  Back to cited text no. 16
17.Ausania F, White SA, Pocock P, Manas DM. Kidney damage during organ recovery in donation after circulatory death donors: Data from UK National Transplant Database. Am J Transplant 2012;12:932-6.  Back to cited text no. 17
18.Faraj W, Fakih H, Mukherji D, Khalife M. Organ donation after cardiac death in the Middle East. Transplant Proc 2010;42:713-5.  Back to cited text no. 18

Correspondence Address:
Dr. Omar I Mohammed Ali
Qatar Center for Organ Transplantation, Hamad General Hospital, Doha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.132198

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  [Table 1], [Table 2], [Table 3], [Table 4]

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