As all healthcare professionals know, organ donation is an incredibly important source of life-restoring treatment for individuals across the country and the world. Each organ donor has the potential to restore health and extend the lives of eight people. Donated organs include the heart, lungs, pancreas, kidneys, liver and small intestines. And hospitals, first and foremost, work to save patient lives. When that isn’t possible, hospitals refer potential donors to Organ Procurement Organizations (OPOs) and work in partnership with them while they determine the medical suitability of a donor and secure authorization for donation. OPOs are the bridge between organ donors and recipients, working with donor families, hospitals and transplant programs to facilitate a successful donation and transplant matching process.
As the McLean, Va.-based Association of Organ Procurement Organizations (AOPO) explains on its website, “Organ Procurement Organizations (OPOs) represent a unique component of healthcare. By federal law, not-for-profit OPOs are the only organizations that can perform the life-saving mission and serve as the vital link between donors and patients waiting for life-saving organ transplants. OPOs work with donor families, hospitals and transplant programs to facilitate a successful donation and transplant matching process.” There are 57 OPOs nationwide.
And, as UNOS, the United Network for Organ Sharing, explains on its website, “Organ Procurement Organizations (OPOs) are not-for-profit organizations responsible for recovering organs from deceased donors for transplantation in the U.S. There are 57 OPOs, each mandated by federal law to perform this life-saving mission in their assigned donation service area. The OPO’s role is to assess donor potential, collect and convey accurate clinical information, and follow national policies for offering organs. (It is the transplant hospital’s role to review organ offers and decide whether they are suitable for their patients.) OPOs are on the front-line of organ procurement, and work directly with a decedent’s family during the emotional discussion about potential donation in order to facilitate the gift of life. For every successful match, the OPO facilitates authorization, testing, the recovery of donor organs and delivery to the transplant hospital.”
Further, UNOS notes: “The U.S. system for organ donation and recovery is among the best in the world. No nation recovers more organs from deceased donors than we do. As a result of innovation and continuous improvement by the nation’s OPOs: Deceased donation has increased 10.1 percent over the 2020 total, the eleventh consecutive record year. Organ donation from deceased donors has doubled over the last 19 years. More than 41,350 total transplants were performed in 2021, exceeding the 40,000 threshold for the first year ever. Forty-nine OPOs increased the total number of donors in 2021 over the previous year. Forty-five OPOs set all-time records in 2021 for donors recovered in a single year. The increases are significant given that fewer than one percent of people die in a way that allows for organ donation.”
Further, UNOS notes, “The National Organ Transplant Act of 1984 (NOTA) was enacted to help ensure the organ allocation process is carried out in a fair and efficient way, leading to an equitable distribution of donated organs. This legislation established a national computer registry, called the Organ Procurement and Transplantation Network, for matching donor organs to waiting recipients. The OPTN is managed by UNOS, and all 57 OPOs use the UNOS proprietary computer system to match and place the organs that they procure. UNOS provides tools, resources, and expertise to help OPOs improve the quality of service they provide, in order to achieve our joint goal of placing donated organs equitably and efficiently and saving more lives.”
One of the 57 OPOs nationwide is the Tempe-based Donor Network of Arizona. The Donor Network of Arizona is the federally designated organ procurement organization for Arizona. The Donor Network is involved in the full recovery of life-saving organs, as well as life-healing tissue and ocular (corneas, bone). Donor Network encompasses 250 staff, half of whom are clinicians, and the other half of whom work in such areas as donor program development, quality, IT, donor referral services, finance, and public education. The organization was founded in 1986. It broke its record, facilitating 924 organ donations from 315 donors, and saving 786 lives in 2021.
One of the challenges facing OPOs nationwide has been the fact that the COVID-19 pandemic has negatively impacted organ transplantation rates and organ procurement organizations (OPOs); however, telehealth has played a critical role in helping to facilitate the availability of organ donations for those in need, and continues to do so, dramatically improving organ transplantation rates across the United States despite COVID-19-related disruptions.
The professionals at Donor Network of Arizona have been partnering with the Henderson, Nev.-based telehealth-solutions provider Specialist Direct in order to facilitate a better process. “This innovative telepathology solution from Specialist Direct has enabled us to rapidly implement OPO biopsy best practices,” says Wendy Van Kirk, R.N., B.S.N., CPTC, director of organ recovery at Donor Network of Arizona, on Specialist Direct’s website. “Having expedited pathology interpretations and real-time sharing of biopsy images enables us to transplant more lifesaving organs.” Another customer, Joey Boudreau, chief clinical officer of the Louisiana Organ Procurement Agency, says in his testimonial that “The ability for us to have near immediate, high-quality interpretations of biopsies 24/7/365, as well as real-time sharing of the results with transplant surgeons and key partners through smart phones via Specialist Direct’s OPO solution has been a game changer.”
Recently, Wendy Van Kirk spoke with Healthcare Innovation Editor-in-Chief Mark Hagland regarding Donor Network of Arizona’s ongoing work, the challenges of the pandemic, and how technology, including information technology, is changing how OPOs operate. Below are excerpts from that interview.
Could you begin by explaining how Donor Network of Arizona works with hospitals?
We work very hand-in-glove with hospitals. They are experts in caring for patients; we are experts in donation. And our goal is always to preserve the option for donation, for families. Certainly, during this COVID environment, it’s been very trying, because the hospitals have been so overwhelmed. We work with five major transplant centers that are also trauma centers; and the burnout and other issues are pretty tough; but just allowing us the opportunity to talk with families about donation, has remained our focus. In general, we have two pathways for donation. We have the brain-dead pathway, which means that a patient is still on a ventilator—the person would appear alive, but has no blood flow to their brain, so they’re brain-dead; that’s 65 percent of our cases. The other 35 percent involves donation after circulatory death; the family has made the decision to withdraw life-saving efforts. And if we think there’s at least one life-saving organ that could help someone, we’ll talk to that family. Support is withdrawn in a controlled setting, the family is able to be with them, and if the patient passes within a certain time frame, then the surgeons are ready in the OR. Donation only occurs after death. And We’re starting to bridge looking at COVID donors, where they’re asymptomatic—but we test every single donor for COVID.
Some organs would still be useful even after a COVID-related death?
When we work with our transplant centers, they’re always trying to balance out the risk-benefit. Right now, we’re primarily focusing on abdominal organs. Our transplant centers are always trying to find lifesaving organs for their recipients, but must carefully weigh the risk case by case.
So there could be a concern over COVID in a transplanted organ?
Yes, you could transmit COVID; on the donor side, we test every single donor, and are very transparent with the transplant centers with all results. The final decision is made when the surgeon visualizes the intended organ.
How has the pandemic affected what you do?
It has been really trying, because unfortunately, the nurses and physicians are exhausted, and the hospitals are very overwhelmed. Multiple answers to that question: in some cases, the ICUs are running at 120 percent of census, and the families are limited with visitation and very stressed. We do a tremendous amount of workup—we’re looking at x-rays, CTs, MRIs, to see whether these organs are transplantable or not. Our average case probably takes 36 hours from start to finish. If you were to walk by a room, you would not be able to tell if that’s a donor or an ICU patient, because the organs have to stay profused and oxygenated. And that certainly takes time and staff in the ICU. Well, in a pandemic, we haven’t always had a lot of time or staff. Many senior staff at the bedside are leaving, and hospitals have a lot of very, very new nurses, who are very challenged in the ICU, which is tough. The good thing is that in general, people are very pro-donation; they understand its value, and those donor champions really make all the difference for us.
What would you like hospital leaders to understand?
I think that one of the most important things is allowing us the time and opportunity to speak with families about donation—people go into medicine and nursing because they want to save lives, to heal lives. And we’re not at cross purposes with them. And we’ve got phenomenal clinical leadership in Arizona, who are still supporting us our mission. What we see on the donor side is the healing that donation brings to the families. We hear from families all the time, that donation was the only positive thing that came out of their loved one’s death, that it helped to save lives. It saves recipients, but also brings healing to the donor family.
What are going to be your biggest challenges in the next few years?
Many things are happening in our industry. One thing is that CMS has really stepped in and challenged all of the OPOs to increase utilization of kidneys, and look at every possible way we can transplant kidneys. If you look at the list today, there are over 107,000 people on the transplant waiting list, with over 97,000 people waiting for kidneys—106,389, to be precise. And if you look daily, we have 17 people who die each day while waiting for an organ. Over 100,000 on the waiting list are for kidneys. The lion’s share is kidneys. If you look at why the federal government got involved in organ donation, the average person on dialysis costs the federal government over $1 million over the cost of a lifetime; if they get a kidney transplant, that figure gets cut in half. They’ve subsequently gotten involved and are challenging all the OPOs to increase kidney utilization.
Innovation and using different devices, and different systems, such as telehealth and telepathology, are changing how we work. And that’s how we got involved with Specialist Direct, in maximizing that. And innovation is accelerating in donation and transplantation. When we go to the operating room, if I run a donor at let’s say, St. Joseph’s Hospital in Phoenix, the surgeons all come to the hospital for procurement or recovery of organs (never harvest). Those teams come to St. Joseph’s Hospital. We historically flushed the organs and put them in triple sterile bags on ice and box them (cold storage), until the surgeon brought them back to their transplant center to transplant them. TransMedics is a tremendous company that had developed organ care systems (OCS) specific for lungs, heart, liver and kidneys. For example, if we are going to utilize the lung OCS, surgeons would take lungs out of the donor, put them on this device, and pump oxygenated blood and air into them, and basically tune them up even more before they transplant them into the recipient. That actually provides a safer way to test transplantability. Transplant centers are always trying to make the tough decision of, is this a good organ to transplant? Success is measured by six-month and one-year survivability. That’s one of the many metrics that they use. These devices hopefully help expand the pool of transplantable organs.
In reality, a large majority of the domestic commercial flights include boxed kidneys in the cargo area. There’s a cold ischemic time that’s tolerable (by hours) for different organs. Hearts and lungs within 4-6 hours. Liver, pancreas, intestines, somewhere between 6 and 12. Kidneys can go to 36 hours or even more; that’s why we can commercially fly those. But with this new technology, we can pump kidneys, which will allow them to be optimized before transplant. TransMedics has a heart device, liver device, lung device, where they can oxygenate those organs, change the Ph, pump blood through them, and potentially take organs that in the past would not have been marginal and possibly not transplantable, and make them transplantable. There’s also a safety factor there. In the past, speaking of lungs, you could potentially have lungs where you take a chance—now, you can put them on a device and determine that they can’t be tuned up and aren’t transplantable and minimize the risk to the recipient.
One thing that we’ve done from a technology standpoint on an everyday basis has been working with Specialist Direct. A very big part of evaluating kidneys, as well as livers, is that when someone has hypertension or diabetes, we know that those kidneys, all your vasculature and all your organs, have been stressed. We biopsy kidneys regularly, unless it’s really a young donor. Anybody with hypertension or diabetes, over 50, we’ll biopsy the kidney or liver. The surgeons will take a small sample, prepare the slide, and will look at what percentage of glomeruli are sclerosed or healthy. What has always been taxing for us is that we used to have to physically transport those slides to the transplant centers to look at. At the donor hospital, we would have the pathologist to do the read. But if you’re not at a hospital that is used to doing kidney biopsies and looking for the specifics that we look for, we don’t always get accurate results. Now, as part of the equipment we bring to the operating room, we bring a microscope from Specialist Direct, and once we get that slide back, we put it in the microscope, the microscope scans and digitizes it. From there we can send the slide to Specialist Direct to have one of their transplant pathologist read the slide and then upload those results to UNOS, the United Network of Organ Sharing. From there, any center that has accepted the organ has access to those images, and can make a final decision on whether they will accept the kidney for transplant.
Has the percentage increase in usable organs been changing of late?
We’re doing a study on that right now. We’re having the donor hospital pathologist read the kidney slides, and having an Specialist Direct transplant pathologist read the slide and are comparing results. We’re seeing some definite differences. We’re not done with the study, but are very pleased with preliminary results.
In other words, by using technology, you’re able to access the work of experienced pathologists who can read slides digitally, rather than relying on pathologists at smaller community hospitals, who might not have the level of expertise needed to judge accurately whether certain organs that might not seem promising initially, might be useful after all?
Yes; there are two elements there. So, let me give you an example. Mayo Clinic in Phoenix is one of our big transplant centers. Let’s say we want biopsies on kidneys that they have preliminarily accepted. And maybe a pathologist at a donor hospital isn’t experienced; now, the slides are being uploaded to UNOS, and a Mayo’s pathologist can look at them directly on his/her laptop at home by downloading the images. That process allows all the transplant centers to have their own pathologists do the read review the slides. And if maybe the donor hospital is not experienced doing them, we can have Specialist Direct do the read. Right now, we’re doing a 100-percent overread using the Specialist Direct pathologists as part of our study, it will be interesting to see the comparative results. This concept is revolutionizing things for us. Honestly, we spent years having slides brought all over the state, then waiting for reads and decisions, which caused organs to be cold stored for extended times. Now you scan it and upload it in ten minutes and they can do their own reads. The portability of it is tremendous. We want to simply transplant, that’s always our goal.
What does the next few years look like for your organization?
We’ve just seen the tip of the iceberg around donation. There’s going to be a lot more device use for organs. We’re taking more calculated risks. Seventeen years ago, we would never, ever have looked at a hepatitis C-positive donor, ever. But the pharmacological advances with drugs like Harvoni, with antivirals specific to hepatitis C have been a game changer. If the donor is hep C, you can do what’s called seroconverting them. You can give them the series of that medication—sometimes it’s three injections, or possibly oral, and when they’re done, they will not no longer have hep C afterwards.
Both medicine and technology are advancing, correct?
Yes, and we are casting a much wider net around organ donation, and what qualifies someone to be a donor hoping to save as many lives as possible.
