strategies in transplantation
TRANSCRIPT
STRATEGIES IN RENAL
TRANSPLANTATION:
The Philippines in Focus
Ma. Nisan T. Manauis, RN, MAN, CRNC
Founding President, Phil. Society of Transplant Nurses
International Society for Organ
Donation and Procurement (ISODP)
STRUGGLES OF A DECEASED
DONOR PROGRAM IN A
DEVELOPING COUNTRY :
PHILIPPINES
Manauis, MNT; Pilar, KAM; Lesaca, RJ; Danguilan, RA; Ona, ET
National Kidney and Transplant Institute
Manila, PHILIPPINES
Philippine Renal Disease Registry; 2008
Number of Transplants according to
Donor Source 2002 - 2008
The Philippine Health Status
Population (2007) 88.6M
10 LEADING CAUSES OF MORTALITY
(Department of Health, 2005)
1. Diseases of the Heart
2. Diseases of the Vascular System
3. Malignant Neoplasm
4. Pneumonia
5. Accidents
6. Tuberculosis, all forms
7. Chronic Lower Respiratory Diseases
8. Diabetes Mellitus
9. Conditions originating in peri-natal
period
10. Nephritis, Nephrotic Syndrome &
Nephrosis
National Bureau of Investigation REPORT, 2000
• 5 Trauma deaths/day in Metro Manila alone
• 1825 potential donors per year
• 3650 potential kidneys for transplant
Struggles of a Deceased Donor Program in
the Philippines
• Objective
▫ To describe the difficulties and struggles in developing and maintaining the Deceased Donor Program in the Philippines and to present the outcome from 2002-2008.
• Methodology
▫ Descriptive study
▫ Review of data from the National Organ Procurement Organization
Number of Deceased Donor Referrals
2002 - 2008 ONLY 62 / 1825 (3%) OF POTENTIAL DONORS ARE REFERRED ANNUALLY
Sources of Deceased Donor Referrals
2002-2008 NUMBER OF
REFERRALS (%)
TYPE OF HOSPITAL
GOVERNMENT 278 (64)
PRIVATE 156 (36)
HOSPITAL AREA
E.R. 346 (89)
ICU 48 (11)
Causes of Deceased Donor Death
2002 - 2008
NUMBER OF CASES (%)
TRAUMA 380 (88)
MEDICAL 54 (12)
CVA 40 (9)
CEREBRAL ANOXIA 6 (1)
PRIMARY BRAIN TUMOR
8 (2)
Consent Challenges
2002 - 2008 NUMBER (%)
PRODUCTIVE CONSENT 191 (44)
UNPRODUCTIVE CONSENT
241 (56)
DELAYED CONSENT 61 (14)
REFUSED 65 (15)
NOT APPROACHED 115 (27)
Reasons for Low Consent Rate • Low level of awareness of Deceased
Organ Donation (98%) • TCs are inappropriately accused of
hastening donor’s death • TCs are reported to the police as trying
to steal organs
• Inability to understand the concept of brain death
• Death was understood as cessation of heartbeat
Medical Professional Challenges
• Refusal of Attending Physicians to sign the Death Certificate form
• Hospital Administrators of private hospitals are not supportive of Deceased Organ Donation and refuse to allow organ retrievals in their facility
Logistical Challenges
• Poor laboratory facilities in referring hospitals
• Inadequate medical supplies for resuscitative measures
• No prioritization in booking commercial flights for the retrieval team and limited available flights
Logistical Challenges
• Organs not allowed to be hand carried, but are checked in as regular luggage
• Lack of knowledge on Deceased Organ Donation by airport security in transporting organs
Number of Organs Retrieved
2002 - 2008
AN AVERAGE OF ONLY 20 KIDNEYS OR 10 DONORS PER YEAR
Number of Kidneys Retrieved vs
Wasted Kidneys 2002 - 2008
CONCLUSION
• Philippine Deceased Donor Program is still in its infancy despite the existence of an organ procurement organization for almost 3 decades and an Organ Donation Law since 1991
• Low level of awareness of the deceased donor program amongst the general public, airport personnel and government employees
CONCLUSION
• There is an urgent need to intensify the educational advocacy campaign on organ donation in both the private and public sectors to improve the deceased donor program
• The medical community likewise needs support in donor management and evaluation to improve the acceptance of organs from deceased donors to avoid wastage of kidneys.
RESUSCITATING THE
DECEASED DONOR
PROGRAM
Manauis, MNT; Suguitan,MG; Lesaca, JRJ; Danguilan, RA, Ona, ET
NATIONAL KIDNEY AND TRANSPLANT INSTITUTE Quezon City, PHILIPPINES
HUM
AN
OR
GA
N PRESERVATION
EF
FO
R
T
N K T I
Human Organ Preservation Effort
• Service ▫ Acts as National Organ
Procurement Organization
National Kidney and Transplant Institute’s Organ procurement arm
Established in 1983
Philippine Donor Source
• Despite 18 years of existence, the Deceased Donor Program’s potential to save lives has not been fully maximized.
Philippine Renal Disease Registry; 2008
Objectives
• Review the problems in organ procurement of the Deceased Donor Program
• Identify and implement effective strategies to improve organ yield
Methodology
• In June 2001, a system review of the Deceased Donor Program was done using performance reports as guide to determine system flaws.
• Alternative solutions were drawn October 2001.
• Solutions were implemented 2002-2004.
• Institutionalization was done January 2005.
• Frequencies and percentages were used to measure outputs annually from 2002-2008.
Problems Identified
• Low referral and consent rates
• Delayed response time to referrals
• Poor Donor Management
• Inadequate logistics
• Prolonged laboratory screening and ischemia time
Alternative Solutions
• Low referral / consent rates
▫ Intensified Hospital Development activities
▫ Intensified Community Outreach activities
▫ Designated Hotline for referrals
▫ Designated Donor Coordinators for network hospitals
• Delayed Response Time to Referrals ▫ Revised flow chart of
the donation process
▫ Acquisition of mobile phones for each TC
▫ Direct referrals to TCs
▫ Trained TCs to evaluate and screen potential deceased donors
Alternative Solutions
• Poor Donor Management
▫ Improved Donor Management protocols
▫ Empowered networks for timely referrals
▫ Trained TCs on donor management
▫ Provided pocket sized donor management guides and checklists
• Inadequate logistics
▫ Provided stocks dedicated to donor management
▫ TCs facilitated donor screening procedures and assumed costs
▫ Financial management of organ donation activities
▫ Regular audit of processes
Alternative Solutions
• Prolonged Laboratory Screening Time ▫ Set turnaround times for
screening procedures
▫ Direct access to laboratory results of potential donors
▫ Immunology staff on call for screening procedures
• Prolonged Ischemia Time ▫ Improved donor
management for closer retrieval time to transplant
▫ Designated Placement Coordinator to facilitate organ placement
▫ Improved Enlistment process
▫ Prioritization in OR time for deceased donor organ transplant
Outcome Parameters
2002 2008 ORGAN PROCUREMENT PROCESS
REFERRAL 32 112
CONSENT 20 42
RESPONSE TIME TO REFERRAL
4hrs 1hr
LABORATORY SCREENING 5hrs 2.5hrs
ISCHEMIA TIME 33hrs 16hrs
LOGISTIC AL SUPPORT
REVOLVING FUND None $1,000
ADVOCACY PROGRAMS
NETWORK HOSPITALS 10 28
COMMUNITY OUTREACH 6 15
Results
Conclusion • An improvement in response time to donor
referrals, reduction in time to get results from laboratory screening, improved donor management, shortening of cold ischemia time and improved logistical support led to an increase in deceased organ donor yield
• Constant audit of processes and strategic planning are vital to enhancing the potentials of the Deceased Donor Program.
Conclusion
• There has been a steady increase in the numbers of KT from deceased donors through 2008, but remains at <10% of all transplants
A GOVERNMENT REGULATED
PROGRAM FOR LIVING NON-
RELATED KIDNEY DONATION
IN THE PHILIPPINES
N Manauis, K Pilar, R Lesaca, R Danguilan, R Uriarte, E Ona
National Kidney and Transplant Institute Quezon City, PHILIPPINES October 2009
34
NATIONAL KIDNEY AND TRANSPLANT INSTITUTE
• Largest tertiary referral center for kidney diseases and
transplantation in the Philippines
• Performed 368/679 (54%) kidney transplants in 2008
PREVALENCE OF DIALYSIS PATIENTS,
NEW PATIENTS STARTING DIALYSIS and
NEW KIDNEY TRANSPLANT PATIENTS
PHILIPPINE RENAL DISEASE REGISTRY
DONOR SOURCE OF FILIPINO KIDNEY
TRANSPLANTS Number of Transplants
(5%)
(67%)
(28%)
PHILIPPINE RENAL DISEASE REGISTRY
Department of Health issued
Administrative Order No. 124
in June, 2002
“A National Policy on
Kidney Transplantation from
Living Non-Related Donors”
OBJECTIVES
• Describe the regulations set-up by the
Department of Health to safeguard the LNRD
from exploitation and abuse
• Look at the medical and economic outcome
of LNRDs enrolled under this program at the
National Kidney and Transplant Institute
SALIENT POINTS
• Creation of the National Transplant Ethics
Committee
• Establish Hospital Transplant Ethics
Committee in every transplant facility to
evaluate all LNRDs
• Prohibition of organ sale
• Accreditation of transplant facilities
SALIENT POINTS cont
• Creation of a National Kidney Transplant Candidate Waiting List and LNRD Registry
• Centralized allocation of kidneys from LNRDs
• Creation of a Donor Monitoring Unit in each transplant facility
• 10% cap on allocation to foreigners
SALIENT POINTS cont
• Providing donors the following-
• Medical follow-up for 10 years
• “Gifts of gratitude”
• Reimbursement of lost income during the
donation process, operation and recovery
• Health and Life insurance
• Educational plan
• Employment opportunities or livelihood training
Amended Administrative Order, March 2008
• Created Philippine Board of Organ
Donation and Transplantation
• Established the Philippine
Network of Organ Donation and
Transplantation (PHILNETDAT)
• National agency charged to
oversee all aspects related to organ
donation and transplantation
• Strict enforcement of regulations
with sanctions to all hospitals with
accredited transplant programs
and its health practitioners
DEPT OF HEALTH
PHIL. BOARD OF ORGAN
DONATION AND
TRANSPLANTATION
PHILNETDAT
NATL TRANSPLANT
ETHICS COM
RESULTS
• 2004 -2007
• DEMOGRAPHICS
▫ 80% Males
▫ Age 21- 40 years (68%)
▫ Single 55%
RESULTS cont
NUMBER (%)
NUMBER OF DONORS EVALUATED 1266
ACCEPTED 278 (22)
REJECTED 988 (78)
RETRACTED CONSENT 605 (61)
SALE 120 (12)
MEDICALLY UNSUITABLE 173 (17)
ETHICS DISAPPROVED 90 (9)
RESULTS cont
• 163 donors transplanted since 2007 • 78% complied with medical follow-up schedule • Trace proteinuria in 3 donors, but resolved
after 6 months
• Hypertension in 1 donor at 4-years post donation
MEAN SERUM CREATININE POST-DONATION
N=127/163
TIME POST-DONATION
EMPLOYMENT PRE-DONATION AND
6 MONTHS POST- DONATION
EMPLOYMENT
STATUS
PRE-DONATION
N=163
NUMBER (%)
POST-DONATION
N=161
NUMBER (%)
UNEMPLOYED 21 (13) 9 (6)
BLUE COLLAR 136 (83) 5 (3)
WHITE COLLAR 2 (1) 3 (2)
SMALL SCALE
ENTREPRENEUR 4 (2) 144 (89)
AVERAGE DAILY
INCOME (USD$) $ 5.40 $ 18.00
CONCLUSIONS
• Majority of LNRDs were male, single, age 21-40
• At 4 years follow up ▫ Improved socio-economic status ▫ Normal renal function
• A government regulated LNRD Program can provide equitable donor allocation that can safeguard donors’ rights, avoid donor exploitation and organ sale
CONCLUSIONS
• A regulated program is a viable option to
the organ donor shortage
• Long-term follow-up is needed to determine if the economic improvement of donors is maintained
New Issuances
• AO 2010-0018
▫ No more transplants from LNRD
▫ Main donor sources
LRD
DDP
DOH, Philippines
The Challenge
• DM and HTN are leading causes of ESRD. How can a patient get transplanted when he could not get a donor from his own family?
▫ When a family member is eligible but doesn’t want to donate, shall he be coerced into donating as that is the only recourse?
• Nearing its 3rd decade of existence, the DDP has only provided <10% of the total transplants in the Philippines. How long will the patients with above condition wait to get transplanted? Will they be still alive by then?
- JACK KEROUAC