Expanded Criteria Donors

Young Hoon Kim; Mi Ri Lee

doi:10.4285/jkstn.2010.24.3.159

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Kim and Lee: Expanded Criteria Donors

Review Article

J Korean Soc Transplant 2010;24(3):159-164.

Published online: 10 September 2010

DOI: https://doi.org/10.4285/jkstn.2010.24.3.159

Expanded Criteria Donors

Young Hoon Kim, M.D., Mi Ri Lee, M.D.

¹Department of Surgery, Dong-A University College of Medicine, Busan, Korea

책임저자：김영훈, 부산시 서구 동대신동 3가 1번지동아대학교 의과대학 외과학교실, 602-715 Tel: 051-240-5140, Fax: 051-247-9316 E-mail: yhkim1@dau.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Due to an impressive reduction in traffic mortalities in recent years, stroke has replaced trauma as the main cause of brain death, and the mean age of donors has increased gradually. As an immediate consequence, donations are growing increasingly more complex and less effective in terms of the number of recipients transplanted, particularly with organs affected negatively by age. The huge regional variability in donation activity observed suggests that there is room for improvement. Generally, liver transplantation extended criteria donors (ECD) are divided by donor-specific characteristics: age ＞65 years, steatosis ＞30% of graft volume, long interval between brain death and procurement or graft infected by hepatitis B or C, cold ischemia ＞12 hours, living donor grafts, split liver grafts, and liver grafts from donors after cardiac death. Deceased donor kidneys are classified as ECD if they meet either of the following conditions: (1) Donor age more than or equal to 60-years or (2) donor age 50 to 59 years, with at least two of the following criteria: serum creatinine more than 1.5 mg/dL, death due to cerebrovascular accident, or history of hypertension. No guidelines exist for allocating an ECD organ. Accurate assessment of the relative risk of graft failure associated with various combinations of donor characteristics is an essential prerequisite for counseling patients, making the decision to accept a transplant offer, evaluating programs, and developing allocation policy.

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Keywords: Expanded criteria donor, Donor age, Allocation

References

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Fig. 1.

National Organ Retrieval Imaging System (NORIS) providing online access to the retrieval images. (A) The color and (B) sharp edges of the harvested liver graft suggests minimal steatosis, while additional information like size of the hepatic artery (C) and relevant vascular anatomy (D) may prove vital information when implanting center is located geographically distant to the harvesting/splitting centers (www.nons.org.uk). Adopted/Reprinted from reference [5].

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Fig. 2.

Proposed algorithm for expanded criteria donor (ECD) kidney transplant acceptance. Patients undergoing retransplantation or primary transplant candidates younger than 40 years should not be listed for an ECD kidney transplant. Primary transplant recipients 40 years or older might be listed for an ECD kidney transplant if they have diabetes or are listing in a program with more than 4 years of median waiting time for a standard donor (This algorithm represents only the author's interpretation of the data). Abbreviation: ESRD, end-stage renal disease. Adopted/Reprinted from reference [21].

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Table 1.

Maastricht Workshop categories that define the type of DCD donor

I	Dead on arrival
II	Unsuccessful resuscitation
III	Awaiting cardiac arrest/cessation of futile treatment
IV	Cardiac arrest in brain dead donor

Abbreviation: DCD, donation after cardiac death.

Adopted from Table 1 of reference [4].

Table 2.

Selection criteria for non-heart-beating donor transplantation

Donor factor	Selection criteria
Donor age	＜40 years
Intensive care unit stay	＜5 days
Warm ischemia ^a	＜15 minutes
Cold ischemia	＜10 hours
Steatosis	Absent or minimal

^a : Warm ischemia is defined by a mean arterial pressure ＜50 mm Hg and/or oxygen saturation ＜70 mm Hg. Adopted/Reprinted from reference [9].

Table 3.

Donor factors associated with liver graft failure

Donor factor	Risk ratio	P value
Age
＜40	1.00	0.0002
40∼49	1.17	＜0.0001
50∼59	1.32	＜0.0001
60∼69	1.53	＜0.0001
＞70	1.65	＜0.0001
African American (versus white)	1.19	＜0.0001
Donor height (by 10-cm decrease)	1.07	＜0.0001
Cause of death, cerebrovascular accident	1.16	＜0.0001
Cause of death, other ^a	1.20	0.018
Non-heart-beating	1.51	0.0006
Partial/split	1.52	＜0.0001

^a : The cause of death was not trauma, stroke, or anoxia. Adopted/Reprinted from reference [9].

Table 4.

Allocation policies of extended criteria donors for low-risk or high-risk recipients: arguments

Policy	Arguments
Extended criteria graft to the healthiest recipients	Pro: The recipient can tolerate a difficult post-operative course. Con: The recipient can wait for a better graft.
Extended criteria graft to the sickest recipients	Pro: The recipient will die if he does not receive a donor rapidly. No synergistically adverse interactions of the donor risk index and Model for End-Stage Liver Disease score have been identified.
	Con: The recipient is unlikely to endure the difficult postoperative course.

Adopted/Reprinted from reference [21].

Table 5.

Kidney transplants by donor type in the United States

Donor type	1996	1999	2002	2005
All deceased donors	7,729 (100)	8,042 (100)	8,538 (100)	9,914 (100)
Standard criteria donors	6,558 (84.8)	6,680 (83.1)	7,018 (82.2)	7,554 (76.2)
Expanded criteria donors	1,076 (13.9)	1,218 (15.1)	1,230 (14.4)	1,609 (16.2)
Donation after cardiac death, non-expanded criteria donor	82 (1.1)	127 (1.6)	264 (3.1)	677 (6.8)
Donation after cardiac death, expanded criteria donor	13 (0.2)	17 (0.2)	26 (0.3)	74 (0.7)

Values expressed as number (percent).

Data from 2006 Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients Report.

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