Organ Transplants - Downward Trend?

The lines on the graph track the total number of organ transplants completed annually (starting in 1988) for the 4 most active categories. The source of the data is the Organ Procurement and Transplantation Network (OPTN), the agency under contract with the U.S. government to maintain the national patient waiting list.

It is interesting to note the interruption in 2006 of the steady upward trend in all categories. All categories, except for heart, are on the decline. What happened??

Well, it seems that in the 2006 timeframe, "an endorsement of DCD (donation after cardiac death) by the Institute of Medicine followed by timely federal mandates issued by the Department of Health and Human Services and the Health Resources and Services Administration have bolstered the number of DCD transplants. Consequently, DCD has risen more than 10-fold over the past decade currently comprising >10% of all deceased donors. In contrast, donation after brain death (DBD) has reached a plateau and more recently has declined since 2006". See the entire American Journal of Transplantation article at the link provided below.

The answer to my question is somewhere in the detail of this article but I can't fully understand it. Why are fewer transplants being performed in spite of stable organ donation rates? Perhaps someone with better analytical skills than mine can shed some light on this worrisome trend.

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  • Ok Lawrence, here is a recent article that substantiates your reasoning (on brain death trends) even further.

    A new study published in the Canadian Medical Association Journal shows that the number of patients being declared "brain dead" has decreased over the past 10 years, but this has serious implications for organ donations and transplants.



  • Debbie, you are correct. From the Gift of Life website:

    "Local patients also get special attention, when an organ donation happens in their community. The country is divided into 11 geographic regions, each served by an organ procurement organization (OPO) like Gift of Life Donor Program. With the exception of perfectly-matched kidneys and the most urgent liver patients, first priority goes to patients at transplant hospitals located in the region served by the OPO. Next in priority are patients in areas served by nearby OPOs. Finally, only if no patients in these communities can use the organ, it is offered to patients elsewhere in the U.S. The use of a local donor has several medical benefits to the potential recipient: The less time that elapses during the transplant process, the more chance of success the transplant has. It has also been shown that people are more likely to consent to donation if they know that someone in their own community could benefit."

    Here is a chart which breaks down the percentage that local (regional) transplant candidates benefit from local organ donors. The average percent transplants vs. available organs nationwide is 24%.


  • There are a few transplant centers that have too many people on their lists and keep taking more patients. It would be impossible for them to transplant all these patients so a large percentage will die while waiting. Please be sure to check this before you sign up somewhere. I had several friends who died while waiting due to the long line ahead of them. They were definitely ready to be transplanted as they had the same numbers I did. Make sure your hospital can accommodate you.

  • Excellent analysis, Bob and Lawrence. I think your combined theories make a lot of sense and probably represent the best explanation for the recent downward trend in overall number of transplants. The financial realities you both touch on are troubling because I believe that the current technology is only a temporary but a necessary stepping stone to future, more economical treatment for end stage organ failure (e.g. stem cell technology). In other words, the cost of our care and treatment as transplant patients should be viewed by the public as valuable R & D that will have a huge return on investment in future years.

    More later ...
  • Bob, I wrote the following before reading your information. You have an inside view of the situation and thank you for sharing.

    Mark…since I have minimal knowledge of medicine, I wondered if there was a business and numerical explanation for your question.

    My understanding is that donor registration is separate from the actual number of donors each year. Also, since more than 50% of organ donors have been in the DBD category, then an increase in DCD – if the number of donors was constant - could reduce the number of available organs because of the numerical increase in DCD’s.

    If the DCD’s have increased by 800 per year, and if DCD produces up to one less organ than DBD, then there would be up to 800 less organs available. 

    As Susie said yesterday in “Insurance Coverage Issue,” the cost health care is now up to 18.7% of our GNP. A portion of this could be attributed to today’s more aggressive neurological management.

    In the Massachusetts General Hospital example in the article you posted, their reference listed the cause of death in three time periods – 1998-2001, 2002-2005, and 2006-2008. 

    Cardiovascular/CVA was: 57.1%, 69.2%, and 74%.

    Trauma was: 33.3%, 28.8%, and 12%.

    Those numbers show a significant swing, and there is other documentation that shows a similar trend.

    For this reason, the initial comment suggested that “Perhaps the 2006 DCD protocols even have helped the situation, since it’s easier to bypass the DBD requirements for a NDD (Neurological Determination of Death Declaration).”

    And, for all we know, in the case of kidneys, there are significantly more ECD donors than before. Not only are less organs harvested with ECD, but the lifetime of an ECD kidney is slightly more than 50% of someone younger than 50.

    Even if the donor registrations have held steady, our society continues to live longer, and perhaps this equals fewer usable donor organs. As it is, less than 1 in a 1,000 deaths result in organ donation.

    Here is what one regional site said:

    DCD rationale

    • Growing disparity between supply and demand

    • Appropriate patients / families who wish to donate

       –not candidates for NDD

       –good candidates for DCD

    • Significant source of organs: 10-34%

    • Experience

       –pre NDD

       –other jurisdictions

    DCD Who are the candidates?

    • Family and physician elect to withdraw support

    • Patients with severe neurological injury

       –Intracranial hemorrhage, stroke, anoxia, trauma

    • Patients without neurological injury

       –Degenerative neuromuscular diseases

       –End-stage cardiopulmonary diseases

       –High spinal cord injury

    • Do not meet the criteria for brain death

    • No chance for survival off the ventilator

    You ask a good question about the downward trend in organ transplants, and I look forward to hearing what information you uncover.   

  • Well, my personal observation is that the census at the tufts transplant center in Boston is down substantially and they no longer have resident Fellows on stuff at the clinic. Rather they have PA's conducting patient assessments and review prior to the nephrologist's exam. In addition, people have lost health plans during the economic downturn and even though the clam is unemployment rates are down, job growth has been in the part time employment sector providing little to no benefits.

    Also, I do know with certainty that one of the major national insurance companies is seriously considering dropping donor medical expense coverage in the future. This is sourced from an executive within the insurance company's senior leadership level and is factual. And let's not forget forget the new cost benefit criteria that will soon be applied to medical coverage and procedure approval with age and outcome criteria being a driving factor as to who or when a transplant will be approved...... I am not talking about "death panels" but the new philosophy of cost shifting from late life medical expenses to patients within earlier life stages. The analysis reports the lion share of medical expenses are incurred by patients within late life demographics.....and you can be certain transplantation availability is going to be negatively affected.
  • Lawrence, thanks for the input. Each of your points are valid but taken together, they don't appear to explain the interruption in the upward trendline. Why would DCD protocols be preferable if "DBD (brain) deaths provide more usable organs"? It just doesn't make sense given the fact that donor registration has held steady and more transplant facilities are coming on line every year. Dramatic improvements have been made in reducing the surgical invasiveness to living kidney and liver donors, yet those numbers are declining as well. I'm going to research this further as time permits :)

  • Mark…you post a complex question, and as you say, the article only provides some conditional answers.

    I wonder if a plateau of organs available for transplantation reflects that there are significantly fewer trauma deaths, and that people are being kept alive longer – which results in poorer donor organ quality. DBD (brain) deaths provide more usable organs than DCD (cardiac) deaths.

    Perhaps the 2006 DCD protocols even have helped the situation, since it’s easier to bypass the DBD requirements for a NDD (Neurological Determination of Death Declaration). There seems to be more ECD donors (age 60+). Could that be the result of people living longer or fewer younger donors?

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