Kamarainen O, Huttunen J, Lindgren A, et al. Identification of potential organ donors after aneurysmal subarachnoid hemorrhage in a population-based neurointensive care in Eastern Finland. Acta Neurochirurgica
Reviewed by: Kyle Hobbs, MD, Assistant Professor of Neurology and Neurocritical Care, Wake Forest University School of MedicineRead the article* *You will need to log in to US National Library of Medicine National Institutes of Health to read this article.
Aneurysmal SAH is a leading cause of brain death in the ICU, but the vast majority of potential organ donors do not go on to organ donation. Increased donor conversion rates (DCRs) have the potential to alleviate the chronic shortage of organs available for transplantation. This was a retrospective registry study in Finland analyzing 769 acute aneurysmal SAH patients admitted to Kupio University Hospital from 2005-2015. Of these patients, 145 died within 14 days of hospital admission (the time period considered acceptable for donation). Data for these patients was then reviewed in the National Organ Transplantation Center for actual organ donations. Potential organ donors (PODs) were identified as having imminent brain death, defined as: Known origin of catastrophic brain damage, irreversible condition, ventilated patient, GCS 3, absence of two out of six brainstem reflexes, and no exclusion by age or medical conditions on admission. Of the 145 SAH patients who died within 14 days, 62 (43 percent) died of cardiopulmonary causes, while 83 (57 percent) were identified as PODs. Sixty-nine percent of PODs had not had occlusion of the aneurysm. Eighty-two percent of PODs were Hunt and Hess grade IV or V on admission. Only 49/83 (59 percent) became actual donors. Of the 34 PODs who did not donate, 44 percent were due to refusal of consent, and 53 percent were medically unsuitable for donation.
In 2010, Finland implemented the national presumed consent (opt-out) policy. This policy applies to brain-dead patients over 18 years of age, with previous full capacity to make binding amendments to their rights. Relatives are informed of brain death, and asked whether the brain-dead patient had expressed refusal of organ donation in the case of his own brain death. The Finnish National Archive for Health Information allows all citizens to enter their opinion in an online platform accessible to healthcare providers. Near relatives do not have a legal right to veto organ donation, but strict refusals are respected in practice. In the study period prior to this (2005-2010), 11 near relatives refused organ donation, resulting in a donor conversion rate of 52 percent (29/56). After presumed consent implementation (2011-2015), only three refused organ donation (donor conversion rate of 74 percent, 20/27).
This study demonstrates the significant proportion of aneurysmal subarachnoid hemorrhage patients who are potential organ donors but do not go on to organ donation. While over half of potential organ donors were ultimately medically unsuitable for donation, 44 percent did not donate due to family refusal, suggesting that community outreach and increased awareness of organ donation could be beneficial. The implementation of presumed consent did result in a decrease from 11 refusals of donation prior to the policy, to three afterward. While these numbers are small, it does suggest that presumed consent policies could result in increase in organ donation among eligible patients. This study is limited by being retrospective, but did have the benefit of measuring pre- and post-presumed consent implementation. This was a single-center trial in a homogeneous Finnish population, so generalizability is unclear. It is suggested that donor conversion rates could also be improved by admitting all aneurysmal SAH patients to the ICU regardless of dismal prognosis, with the intent to evaluate for organ donation, although this study did not explicitly examine patients who were not admitted to this tertiary care center due to poor prognosis. #LiteratureWatch #NEWSReview #KyleHobbs