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DECEASED ORGAN DONATIONJUAN PAOLO DLC. LAGUNZAD, M.D.Philippine Society of NephrologyCommittee on Advocacy
06 May 2014
Session Objective:
To discuss the current status of deceased organ donation in the country and how internists can contribute.
Outline:
I. Introduction
II. Outcomes of cadaveric kidney transplants
III. Current status of deceased organ donation
IV.Challenges to developing deceased organ donation
V. The internist’s roles in deceased organ donation
TRANSPLANT
Which organs can be procured from a potential deceased
organ donor?
Deceased Organ & Tissue Donation
• Kidneys• Liver• Cornea• Bones• Heart• Lungs• Pancreas• Spleen• Intestines
• Other tissues: skin, tendon, menisci, heart valves, blood vessels
Intensive Care Society. Guidelines for Adult Organ and Tissue Donation. UK, 2005
Republic Act No. 7170: Organ Donation Act of 1991
An Act Authorizing the Legacy of Donation of All or Part of a Human Body After Death
for Specified Purposes
Congress of the Philippines, 07 January 1992.
Republic Act No. 7170: Organ Donation Act of 1991Congress of the Philippines, 07 January 1992.
• Any individual, at least 18 years of age may give by way of legacy all or part of his body
• Introduce the organ donation program in a humane manner to relatives of the potential donor
• Public information campaign
• DOH Secretary to make an appeal for human organ donation.
Republic Act No. 7170. Congress of the Philippines, 1992.
"Death”• irreversible cessation of
circulatory and respiratory functions; or,
• irreversible cessation of all functions of the entire brain, including the brain stem
Republic Act No. 7170. Congress of the Philippines, 1992.
Republic Act No. 7170: Organ Donation Act of 1991Congress of the Philippines, 07 January 1992.
• Government organ procurement organization established in 1983
• In earlier years, functions included both organ procurement and allocation
Human Organ Preservation Effort (HOPE)
DOH Administrative Order No. 2010-0019
Establishment of a National Program for Sharing of Organs from Deceased Donors
DOH Administrative Order No. 2010-0019 Republic of the Philippines
Objectives:
This order sets policies and guidelines for the efficient and equitable sharing of organs from deceased donors.
Specific Objectives:
1. To establish the Philippine Network for Organ Sharing (PHILNOS)
2. To initiate and maintain the Philippine Organ Donor and Recipient Registry System (PODRRS)
3. To promote organ donation from the deceased
Republic of the Philippines, Department of Health A.O. No. 2010-0019
DOH Administrative Order No. 2010-0019 Republic of the Philippines
• PHILNOS shall act as the central coordinating body for all deceased organ donation and transplantation activities
• The function of the PHILNOS shall be carried out through organ procurement organizations (OPO)
• All tertiary hospitals and trauma centers are required to have a procurement transplant coordinator
• All patients deemed to be brain dead must be referred to the transplant coordinator for evaluation as a potential organ donor
Republic of the Philippines, Department of Health A.O. No. 2010-0019
Republic of the Philippines, Department of Health A.O. No. 2010-0019
Niñalga, HD et al. Graft and Recipient Outcome of Cadaveric Transplantation at the National Kidney and Transplant Institute from 1995-2001. National Kidney and Transplant Institute Proceedings 2005;1:63-70.
Mallari, J et al. Graft and Recipient Outcome of the deceased Renal Transplantation Program at the National Kidney and Transplant Institute from 2002-2007.Overio, Y et al. Graft and Recipient Outcome of Cadaveric Renal Transplantation at NKTI from 2007 to 2010.
Niñalga, HD et al. Graft and Recipient Outcome of Cadaveric Transplantation at the National Kidney and Transplant Institute from 1995-2001. National Kidney and Transplant Institute Proceedings 2005;1:63-70.
Mallari, J et al. Graft and Recipient Outcome of the deceased Renal Transplantation Program at the National Kidney and Transplant Institute from 2002-2007.Overio, Y et al. Graft and Recipient Outcome of Cadaveric Renal Transplantation at NKTI from 2007 to 2010.
Knowledge, attitudes, perceptions of Filipinos on organ donation
(2001 vs 2005)2001 2005
Knew about kidney donation 82% 77%Donor source for transplant
Living donors onlyDeceased donors onlyBoth
49%14%37%
50%9%
41%Willing to become donors 64% 87%Willing to become deceased donors 16% 78%
Uriarte, RDB; Amarillo, MI; Ampil, RS; Manauis, MNT, Philippine Information Agency; Danguilan, RA; Ona, ET. Comparison of national survey on knowledge, attitudes, perceptions of Filipinos on organ donation 2001-2005. Berlin, 2009.
64%
36%
willing to become donorsnot willing to become donors
87%
13% 16%
84%
willing to become deceased donorsnot willing to become deceased donors
78%
22%2001 2005 2001 2005
Kidney Transplants and Donor Source2007
Global Observatory on Donation & Transplantation. Dec 2008.
0
10
20
30
40
50
60
70
80
90
SpainBelgiumFrancePortugalAustriaN
orway
EstoniaSlovakiaC
zech Republic
United States of Am
ericaIrelandFinlandLatviaG
ermany
Netherlands
Sweden
Uruguay
ItalyH
ungaryC
yprusLithuaniaLuxem
bourgU
nited KingdomC
anadaSw
itzerlandD
enmark
ArgentinaPolandAustraliaN
ew Zealand
SloveniaC
olombia
Croatia
Chile
Cuba
BrazilG
reeceKuw
aitIsraelVenezuela (Bolivarian R
epublic of)Panam
aR
epublic of KoreaTurkeyM
exicoSaudi ArabiaIran (Islam
ic Republic of)
Costa R
icaC
hinaR
omania
Guatem
alaSouthAfricaThailandBoliviaJapanBulgariaTunisiaM
alaysiaEcuadorParaguayPhilippinesD
ominican R
epublicIndiaViet N
amN
igeriaJordanSudanKenyaO
man
Libyan Arab Jamahiriya
Syrian Arab Republic
Georgia
Honduras
El SalvadorLebanonIceland
Deceased kidneys pmp Live kidneys pmp
Philippine Renal Disease Registry; PRDR Annual Report, Renal Disease Control Program (REDCOP), National Kidney and Transplant Institute (NKTI) and National Epidemiology Center (NEC) of the Department of Health (DOH), 2012.
Outcome of Organ Donation Referral to HOPE(2009-2012)
Suguitan, MGA; Casasola, CC; Danguilan RA; Jaro JM. Outcome of Deceased Organ Donation Referral to NKTI.
437
264
104
0
50
100
150
200
250
300
350
400
450
Referrals Consented fordonation
Donor retrieval amongthose who consented
Suguitan, MGA; Casasola, CC; Danguilan RA; Jaro JM. Outcome of Deceased Organ Donation Referral to NKTI.
Outcome of Organ Donation Referral to HOPE(2009-2012)
Suguitan, MGA; Casasola, CC; Danguilan RA; Jaro JM. Outcome of Deceased Organ Donation Referral to NKTI.
437
264
104
0
50
100
150
200
250
300
350
400
450
Referrals Consented fordonation
Donor retrievalamong those who
consented
Reasons for non-retrieval:
• Medically unsuitable
• Donor expired prior to organ procurement
• Retracted consent
• Improved sensorium
• No recipient available
• Rejected by recipient’s AP− abnormal urinalysis− azotemia− hypertension− kidney stones
CHALLENGES TO DEVELOPING DECEASED ORGAN DONATION
1. Regulatory environment
2. Logistic capability
3. Health care financing
4. Public awareness and trust
Challenges to Developing Deceased Organ Donation
1. Regulatory environment
Republic Act No. 7170: Organ Donation Act of 1991
Congress of the Philippines07 January 1992
DOH Administrative OrderNo. 2010-0019
Department of Health2010
Challenges to Developing Deceased Organ Donation
2. Logistical Capability
KT centers KT living KT deceasedNCR 19 273 88Luzon 3 6 2Visayas 7 9 0Mindanao 4 1 0
Prevalent HD pxs
KT deceased Proportion
NCR 5183 88 1.7%Luzon 6288 2 0.03%Visayas 2030 0 0Mindanao 2142 0 0
Philippine Renal Disease Registry; PRDR Annual Report, Renal Disease Control Program (REDCOP), National Kidney and Transplant Institute (NKTI) and National Epidemiology Center (NEC) of the Department of Health (DOH), 2011.
Challenges to Developing Deceased Organ Donation
2. Logistical Capability
Improving access to deceased donors:
PhilNOS is currently in the process of organizing regional OPOs
Zone 1: Region I Medical Center, Dagupan Zone 2: Bicol Regional Medical Center, Naga Zone 3: Vicente Sotto Medical Center, CebuZone 4: Southern Philippines Medical Center, Davao
Regional Hospital, TagumNCR: HOPE
Challenges to Developing Deceased Organ Donation
3. Health care financing
Inability to pay for a transplant is at least as important a factor in limiting transplants as lack of donors.
Cost of a kidney transplant: ≥ P 800,000
Immunosuppression medications: ≥ P 30,000(per month)
Challenges to Developing Deceased Organ Donation
3. Health care financing
• The PhilHealth Z package became available in 2012
• P600,000 to cover hospital bills for members who fulfill the inclusion criteria
• Excludes patients who are considered “high risk”
• Currently available only at the National Kidney and Transplant Institute
Challenges to Developing Deceased Organ Donation
4.Public awareness and trust
437
264
104
0
50
100
150
200
250
300
350
400
450
Referrals Consented fordonation
Donor retrievalamong those who
consented
Reasons for consent refusal:
• Families do not believe in organ donation
• Families do not want the patient to “suffer more”
• Legal next of kin do not want to be “blamed”
• Families want the body to be “whole” when they bury it
• Legal next of kin wanted remuneration
• Religious belief of the family
• Wanted only 1 kidney to be retrieved
Suguitan, MGA; Casasola, CC; Danguilan RA; Jaro JM. Outcome of Deceased Organ Donation Referral to NKTI.
Challenges to Developing Deceased Organ Donation
4.Public awareness and trust
• Some doctors hesitant to sign death certificate with a brain dead, heart beating donor
• Air transport companies unfamiliar with procedures for transporting organs
• Unfamiliarity with concept of brain death have led to accusations of death being caused by donation
Manauis, Pilar, Lesaca, Danguilan, Ona, 2009.
Challenges to Developing Deceased Organ Donation
4.Public awareness and trust
• It is essential that the whole health care body receives clear and scientific information, and learn the necessary skills for:
Diagnosis of brain death
Physiology and treatment of the organs of potential deceased donors
Legal and ethical aspects of donation
• Public information campaigns to be initiated by the medical community
ADVANCINGDECEASED ORGAN
DONATION
Instructional Module:
General Objective:
To increase the number of end-stage kidney disease patients undergoing kidney transplantation by increasing the rate of organ donation from deceased donors.
Specific Objectives:To provide IM residents-in-training with adequate knowledge on deceased organ donation to enable them to:
1) identify potential deceased organ donors (Module 1)2) initiate the organ donation process, and; (Module 1)3) manage deceased organ donors in (Module 2)
preparation for organ donation.
Unique Challenges
• Increase the number of organs for transplantation
• Increase access to transplantation, and renal replacement therapy
• Allocate organs equitably considering the absence of universal coverage, and the prospect of only the rich benefiting from a successful deceased organ donation program
The internist’s roles…
1. Identify a potential deceased organ donor
Who may or may not be considered candidates for deceased organ donation?
Deceased Organ Donation
“Any patient who is deemed to be brain dead or in a state of
imminent brain death may be considered a potential multiple
organ donor.”
Republic of the Philippines, Department of Health A.O. No. 2010-0019.
Republic Act No. 7170Congress of the Philippines 1992
"Death”• irreversible cessation of
circulatory and respiratory functions; or,
• irreversible cessation of all functions of the entire brain, including the brain stem
Republic Act No. 7170. Congress of the Philippines, 1992.
Brain DeathThe following steps must be undertaken before
declaring brain death:
1. Demonstrate absence of cerebral and brain stem functions.
2. Establish irreversibility of coma.
3. Exclude conditions which may confound the diagnosis of brain death.
4. Perform ancillary tests when necessary.
Philippine Neurological Association (PNA) Committee on National Policies, 07 Feb 2012.American Academy of Neurology. Practice Parameters: Determining Brain Death in Adults. US, 1994.
Intensive Care Society. Guidelines for Adult Organ and Tissue Donation. UK, 2005.Manual of Kidney Transplantation, National Kidney and Transplant Institute, 2008.
Philippine General Hospital Kidney Transplant Manual (unpublished).
Death CertificationWho may certify brain death?
• “…attending physician and another physician, preferably a neurologist or a neurosurgeon or an internist or anesthesiologist…”
- Philippine Neurological Association (PNA)
• “…two licensed medical doctors, at least one of whom is a consultant, and neither one is a member of an organ procurement organization (OPO) or the transplant team…”
- Republic of the Philippines, Department of Health A.O. No. 2010-0019
Philippine Neurological Association (PNA) Committee on National Policies, 07 Feb 2012.Republic of the Philippines, Department of Health A.O. No. 2010-0019.
Deceased Organ DonationAbsolute contraindications
• Presence of malignancy except primary non-invasive brain tumors, non-melanotic non-metastasizing skin tumors, and cancer in-situ of uterine cervix
• Presence of infection such as HIV, active and untreated tuberculosis, acute hepatitis B and C, and severe untreated systemic sepsis and viral infection
• History of cardiac arrest > 10 minutes• High risk factors for vascular disease like long-standing
and uncontrolled hypertension (BP >160/100), long-term diabetes with proteinuria
• Presence of chronic renal disease (calculated creatinine clearance of < 60 ml/min or with significant proteinuria)
• Persistent oliguric acute renal failureEuropean Best Practice Guidelines (EBPG) for Renal Transplantation (Part 1). EBPG Expert Group on Renal Transplantation.
Nephrol Dial Transplant, (2000) 15 [Suppl 7]: 39-51.Intensive Care Society. Guidelines for Adult Organ and Tissue Donation. UK, 2005
Manual of Kidney Transplantation, National Kidney and Transplant Institute, 2008Philippine General Hospital Kidney Transplant Manual (unpublished)
The internist’s roles…
2. Introduce the option of organ donation to relatives of the deceased
Consent for Organ Donation• Since the patient lacks the capacity to
consent to organ donation, seek to establish the patient's prior consent by:
– referring to an advance statement if available (i.e., driver’s license, organ donor card)
– exploring with those close to the patient whether the patient had expressed any views about organ donation.
• The patient’s prior consent to organ donation is not a prerequisite but it helps in obtaining consent from the patient’s family.
• Despite the presence of prior consent from the patient, the decision of the patient’s family must always be respected.
NICE Clinical Guideline: Organ Donation for Transplantation.National Institute for Health and Clinical Excellence, UK, 2011
Consent for Organ Donation
• Consent for organ donation may be obtained from the legal next-of-kin in the following order of priority:
• Legal spouse• Son or daughter of legal age• Either parent• Brother or sister of legal age• Guardian over the deceased person at the
time of death
Republic of the Philippines, Department of Health A.O. No. 2010-0019Republic Act No. 7170. Congress of the Philippines, 1992.
Consent for Organ Donation
• Securing consent for organ donation from the family of the deceased shall be the sole responsibility of theTRANSPLANT COORDINATOR.
• The Transplant Coordinator shall obtain consent for organ donation AFTER brain death certification.
Republic of the Philippines, Department of Health A.O. No. 2010-0019
Consent for Organ DonationThe Physician’s roles…
• Inform the patient’s family of the patient’s death and address any questions or concerns the family may have regarding the patient’s death
• Ask the relatives to consider the option of organ donation
• Encourage the relatives to agree to discuss the process of organ donation with a transplant coordinator
• Introduce the transplant coordinator to the patient’s family
Consent for Organ DonationFAQs…
– “Paano kayo nakasisiguro na patay na ang anak ko?”(How can you be sure that my son is really already brain dead?)
– “Kapag pumayag kami i-donate ang organs ng anak ko, gagawin niyo pa rin ba ang lahat para alagaan siya?”(If we agree to donate my son’s organs, will my son still receive the best medical care?)
– “Kanino mapupunta ang mga organs na ido-donate ng anak ko?”(Who will receive my son’s donated organs?)
– “Ano ang mangyayari sa katawan ng anak ko pagkatapos niya mag-donate ng organs?”(What will happen to my son’s body after he donates his organs?)
– “Matatagalan ba bago namin makuha ang katawan ng anak ko kung magdo-donate siya ng organs?”(Will it take long before we can get my son’s body if ever we decide to donate his organs?)
– “Meron ba kaming gagastusin kung pumayag kaming i-donate ang mga organs ng anak ko?”(Do we have to pay any additional fees if we agree to donate his organs?)
The internist’s roles…
3. Institute initial donor management
Objectives:
1. Maintain hemodynamic stability and ensure adequate organ perfusion
2. Manage fluids and electrolytes and acid-base balance
3. Work-up, diagnose, and treat infections
Donor Management
The internist’s roles…
4. Initiate the process of deceased organ donation
THE PROCESS OF DECEASED ORGAN DONATION
Yes
No
P A T I E N T
Quick Hx/PEInitial medical management Initial diagnostic tests
Notify AP / Service consultant / Senior resident
Continue appropriate management
Does the patient show signs of brain death?
Notify AP / Service consultant / Senior resident
Neurology service available?
Yes
No
Notify AP / Service consultant / Senior resident
Refer to available consultant for death
certification
Neurology service available?
Refer to Neurology for death certification
No
Continue appropriate management
Death certified?
Communicate patient’s death to patient’s family
Is the patient eligible for deceased organ donation?
Yes
Yes
No
Transplant coordinator available?
Refer to Hospital Transplant Coordinator
Consent obtained for deceased organ donation?
Refer to OPO Transplant
Coordinator
Yes
No
Notify AP / Service consultant / Senior resident
Continue appropriate management
Is the patient eligible for deceased organ donation?
Continue appropriate management
Consent obtained for deceased organ donation?
Refer to Organ Procurement Organization
YesNo
Continue donor management until time of organ procurement
ORGAN PROCUREMENT
PHILNOS
Location:
Department of Health, NCDPC-DDO, 2nd floor, Bldg 9, Manila 1003 Philippines
Phone:
+63 2 731 8234
Email:
doh.philnos@gmail.com
Website:http://podrrs.doh.gov.ph/philnos/
NKTI-HOPE
Location:Human Organ Preservation Effort (HOPE) Office4th Floor, NKTI Diagnostic BuildingNational Kidney and Transplant Institute, East Avenue, Quezon City 1100 Philippines
Phone:924-HOPE (+63 2 924 4673)981 0300 / 981 0400 loc 4410 – 4413
Email:hopetransplant@msn.comHOPE@nkti.gov.phhopetransplant@gmail.com
PSN
Location:24/F One San Miguel Ave Condominium, corner San Miguel Ave & Shaw Blvd, Pasig City, Metro Manila, 1603 Philippines
Phone:+63 2 687 1198
Telefax:+63 2 687 1187
Mobile:+63 917 823 6726
Email:secretariat@psn.phpsnmanila@gmail.com
Website:www.psn.ph
“I’m a lifeline!”http://globalnation.inquirer.net/99706/ph-breaks-record-on-donation-of-organs
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