Review of Organ Donation in Hong Kong:

Original Article Review of Organ Donation in Hong Kong: 1996 29 Yuen-Fan Tong, 1 Jenny Koo, 2 Beatrice Cheng 3 Background: A retrospective review of the data entries from the Organ Procurement System of the Hong Kong Hospital Authority from January 1996 to December 29, a 14-year period, was done. The characteristics of donors and organ utilization patterns among deceased donors in Hong Kong were analyzed. Methods: A total of 1,183 organs were recovered during the study period, including 749 kidneys (63.3%), 38 livers (26.%), 94 hearts (7.9%) and 32 lungs (2.7%) from 438 deceased organ donors; 59.4% of the donors were male. The median age of the donors increased from 38.8 years in 1996 to 5.2 in 29. The two major causes of death amongst these donors were cerebrovascular accidents (n = 3, 68.5%) and head trauma (n = 93, 21.2%). There was a fourfold increase in expanded-criteria donors from 1% in 1996 to 4.5% of the total donor pool in 28. Results: Four factors family decision, donor characteristics, donor medical background and donor management were identified as contributory factors to the success of organ recovery. Outcome of donation is referred to as organs recovered per donor (ORPD). The yearly trend of ORPD ranged from 2.41 to 3., and the mean ORPD was 2.7 over the past 14 years. At least three organs were utilized from 263 (6%) donors. Organ yield was found to depend significantly on cause of death (cerebrovascular accident yield, 2.59 organs/donor; head trauma yield, 3.18 organs/donor) and donor age. The younger donors tended to be multiple organ donors. Donors at the extreme ages of below 5 and above 7 tended to be single-organ donors. Conclusion: We found that 68 (51.4%) organs came from 22 (5.2%) donors cared for in intensive care units, and 39 (26.1%) organs came from 19 (24.9%) donors cared for in neurosurgical units. The work of critical care personnel in caring for potential donors before confirmation of brain death and the subsequent maintenance of the donors is therefore essential. In the majority of donors (n = 281, 64.2%), the time period from intubation to confirmation of brain death was within 48 hours. The number of donors decreased markedly when time between intubation and brain death was longer than 72 hours. Timely and accurate declaration of brain death can promote smoother transition from patient care to donor management and a better outcome. Therefore, collaborative and effective donor management is vital to optimize organ utilization from every consensual donor. [Hong Kong J Nephrol 21;12(2):62 73] Key words: brain death, Hong Kong, organ donation, organs recovered per donor, transplantation 1 Transplant Coordination Service, Prince of Wales Hospital, 2 Transplant Coordination Service, Queen Mary Hospital, and 3 Advisor, Hospital Authority Transplant Services, Hong Kong SAR. Correspondence to: Ms. Yuen-Fan Tong, Transplant Coordinator, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR. Fax: (+ 852) 2636-9222; E-mail: tongyf@ha.org.hk 62 Hong Kong J Nephrol October 21 Vol 12 No 2

Organ donation in Hong Kong: 1996 29 INTRODUCTION Transplantation is available to all Hong Kong citizens in Hong Kong Hospital Authority hospitals. The first deceased kidney transplantation was performed in 1969. The Transplant Coordination Center of Hong Kong was first set up in Queen Mary Hospital in 1988 [1]. It was run by two nursing officers, providing territory-wide service. In 1991, the first deceased liver transplantation was performed, which was an important transplant milestone in Hong Kong. The service began to expand and by 1994, the number of transplant coordinators had increased to four, based in four renal transplant hospitals [2,3]. Currently, there are seven transplant coordinators who cover the entire territory of Hong Kong, which had a population of 7.1 million in 29. Like in other parts of the world, the shortage of organs for transplantation is a real challenge in Hong Kong [4]. Although the donation rate for deceased organs had increased from 4.3 donors per million population in 26 to 7.5 in 29, and is a comparatively high number amongst Asian countries (Figure 1), it is low when compared to Western countries like the U.S., U.K. and Spain [5]. In Hong Kong, many patients die while waiting for solid organ transplantation. As of the end of 29, the number of patients waiting for kidney, liver, heart and double-lung transplants stood at 1,62, 1, 1 and 8, respectively [6]. To meet the demand for organ transplantations, this study 4 35 Donors per million population 3 25 2 15 1 5 Spain United States United Kingdom Australia Hong Kong Singapore Malaysia Japan Country/region Figure 1. International organ donation rates in 29. Hong Kong J Nephrol October 21 Vol 12 No 2 63

Y.F. Tong, et al aimed to review the current status of organ donations and the characteristics of deceased organ donors to look into possible future ways to increase the number of transplantations in Hong Kong. METHODS This was a retrospective review of data on solid organ donations from deceased donors from the centralized computerized organ donation registry (the Organ Procurement System) of the Hong Kong Hospital Authority. Entries from the 14-year period from January 1996 to December 29 were analyzed. Definitions A donor was defined as a deceased person from whom at least one solid organ was recovered and transplanted in Hong Kong. Organ counts were based on the number of organs recovered to a maximum of six (2 kidneys, 2 lungs, heart and liver). The outcome measure of donation used was organs recovered per donor (ORPD). A donor can maximally donate six organs to save the lives of six patients with end-stage organ failure [7]. A standard-criteria donor is one who suffered from brain death but is not an expanded-criteria donor (ECD) or a donation after cardiac death (DCD) donor [7]. Brain death is established by the documentation of irreversible coma and irreversible loss of brain stem reflex responses and respiratory center function, or by the demonstration of the cessation of intracranial blood flow [8]. An ECD is defined as a donor aged 6 years or aged 5 59 years plus two of the following three conditions: cerebrovascular accident as the cause of death; history of hypertension; last serum creatinine level > 1.5 mg/dl [7]. DCD is defined as organ recovery from a donor whose heart has irreversibly stopped beating (referred to as a non-heart-beating donor in some literature) [7]. RESULTS Donor characteristics Sex and age Among the 438 donors, 26 (59.4%) were male and 178 (4.6%) were female. The age of the donors ranged from 3.9 years to 76 years (mean, 45.7 years; median, 48.5 years). The median age of the donors increased from 38.8 years in 1996 to 5.2 in 29. In 29, 1.9% of donors were < 12 years old, 81.1% of donors were 12 6 years old and 17.% of donors were > 6 years of age. Causes of donor death As in other parts of the world [9 14], cerebrovascular accidents and head trauma were the two major causes of death amongst donors in Hong Kong, accounting for 68.5% (n = 3) and 21.2% (n = 93) of donor deaths, respectively. The other causes of death were hypoxia 45 4 35 Cerebrovascular accident Head trauma Hypoxia Brain tumor 3 25 2 15 1 5 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 Figure 2. Causes of death of successful organ donors. 64 Hong Kong J Nephrol October 21 Vol 12 No 2

Organ donation in Hong Kong: 1996 29 (9.6%, n = 42) and primary brain tumor (.7%, n = 3). There was a clear increasing trend of cerebrovascular accidents being a cause of death, from 19 donors in 1996 to 43 donors in 29 (Figure 2). Trends in deceased organ donation Due to the scarcity of suitable organ donors, there is a worldwide trend to relax donor acceptance criteria so that marginal donors can be accepted. In Hong Kong, more organs were recovered from older donors in recent years. This indicates the usage of ECDs as well as the aging population. An increasing median age of deceased donors has also been observed in Western countries [9 13]. There was also an observed increase in the prevalence of known medical diseases amongst donors. Over the whole period from January 1996 to December 29, 2 (4.6%) donors had diabetes while 19 (24.9%) had hypertension. In 1996, no donor had hypertension. The prevalence of hypertension amongst donors was 27.% and 37.7% in 28 and 29, respectively (Figure 3). This change reflects the fact that in Hong Kong, as in other countries, donor selection criteria have been relaxed as we attempt to increase the donor pool by using ECDs [15 17]. There was increasing acceptance of ECDs from 3 in 1996 to 15 in 28 and 15 in 29 (Figure 4). In terms of ECDs as a percentage of the total donor pool, there was a fourfold increase from 1% in 1996 to 4.5% in 28. Serologic status for hepatitis virus In Hong Kong, all patients on solid organ transplant waiting lists have their hepatitis B virus (HBV) and hepatitis C virus (HCV) antibody status recorded on the registries. For kidney allocation, with the exception of zero subgroup mismatch, HBV/HCV-negative kidneys would go to HBV/HCV-negative recipients, and HBV/HCVpositive kidneys would only go to HBV/HCV-positive recipients. In life-saving situations such as liver and heart transplantation, HBV/HCV-positive organs might go to HBV/HCV-negative recipients, together with antiviral prophylaxis, if informed consent has been obtained. There were only six HCV-positive donors (1.4%) in the past 14 years in Hong Kong. The prevalence of HCV positivity in the general population is low. It has been estimated by the World Health Organization that 3% of the world s population is infected with HCV [18]. There were 38 HBV-positive donors in the past 14 years in Hong Kong, accounting for 8.7% of the total. In kidney transplantation, 38 HBV-positive and 5 HCV-positive grafts were transplanted into recipients who had positive serology. Two HBV-positive heart grafts were transplanted into two HBV-negative recipients and one HCV-positive liver graft was transplanted into one HCVnegative recipient as life-saving procedures with prior informed consent from the recipients. Serologic status for ABO blood group The ABO blood group distribution of deceased donors was as follows: group O, 41.8%; group A, 26.5%; group B, 26.5%; and group AB, 5.3%. This distribution is very similar to that of Hong Kong blood donors. According to data from the Hong Kong Red Cross Blood Transfusion Services, the ABO blood group distribution amongst blood donors in 29 was as follows: group O, 41.5%; group A, 26.1%; group B, 25.3%; and group AB, 6.4% [19]. 4 35 With hypertension history No hypertension history Unknown 3 25 2 15 1 5 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 Figure 3. Prevalence of hypertension among donors. Hong Kong J Nephrol October 21 Vol 12 No 2 65

Y.F. Tong, et al 4 35 ECD DCD SCD 38 3 25 2 15 1 5 3 27 25 24 23 22 22 22 2 19 16 16 15 15 14 13 11 1 8 8 8 7 6 5 4 4 3 2 1 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 Figure 4. Number of donors by donor type and year. Donors were divided into three mutually exclusive categories. All those who met the criteria for expanded-criteria donors (ECDs) for kidneys were classified as an ECD regardless of whether or not the kidneys were allocated under the ECD system. Non-ECDs were classified as either donation after cardiac death (DCD) donors or standard-criteria donors (SCD). Donors who qualified as both an ECD and DCD donor were classified as an ECD. Table 1. Summary of organ recovery from 438 deceased donors, 1996 29 Kidney Liver Heart Lung Deceased donors 39 38 94 16 Deceased organs donated 749 38 94 32 Age range (yr) 5. 72.4 3.9 76. 7.3 61.7 12.8 57.2 Mean age (yr) 45.2 44.9 4.6 34. Sex, n (%) Male 227 (58.2) 184 (59.7) 58 (61.7) 9 (56.3) Female 163 (41.8) 124 (4.3) 36 (38.3) 7 (43.7) Serology, n (%) HBV positive 38 (9.7) 2 (2.1) Anti-HCV positive 5 (13.2) 1 (3.3) Blood group, n (%) A 16 (27.2) 78 (25.3) 17 (18.1) 3 (18.7) B 15 (26.9) 8 (25.9) 18 (19.1) 1 (6.3) O 157 (4.2) 134 (43.5) 58 (61.7) 12 (75) AB 22 (5.6) 16 (5.2) 1 (1.1) Clinical presentation, n (%) Oliguria 125 (32.1) 98 (31.8) 2 (21.3) 3 (18.8) Serum creatinine (< 15 μmol/l) 368 (94.4) 272 (88.3) 87 (92.6) 16 (1) Donor management Median time from intubation to brain death (hr) 62.1 61.4 6.9 3.8 Organ utilization A total of 1,183 organs were recovered during the study period from the 438 deceased organ donors, and included 749 kidneys (63.3%), 38 livers (26.%), 94 hearts (7.9%) and 32 lungs (2.7%). Amongst the donors, 39 were kidney donors, 38 were liver donors, 94 were heart donors, and 16 were lung donors. Table 1 shows a summary of organ recovery from the donors. 66 Hong Kong J Nephrol October 21 Vol 12 No 2

Organ donation in Hong Kong: 1996 29 The majority (84.9%, n = 372) of solid organ donors had in fact donated two or more organs for transplantation. The number of organs donated by each donor ranged from two to six. Figure 5 shows the ORPD; 4% of donors donated three organs and 24.9% donated two organs. The yearly trend of ORPD ranged from 2.41 to 3. (mean ORPD, 2.7; Figure 6). Factors affecting success of organ recovery Four factors family decision, donor characteristics, donor medical background and donor management were identified to affect the success of organ recovery. Four, 73 (16.7%) Five, 8 (1.8%) Three, 175 (4.%) Six, 7 (1.6%) Two, 19 (24.9%) Single, 66 (15.1%) Figure 5. Organs recovered per donor among 438 donors, 1996 29. Family decision In the 14-year study period, transplant coordinators received a total of 2,127 referrals. Of these, 1,16 (52.%) were subsequently confirmed as brain deaths and 1,99 (51.7%) families were approached for consent. The average consent rate was 44.8% amongst those approached. Families consent is crucial to successful organ donation. However, donor families were not usually the initiating party. Instead, 9% of referrals were initiated by hospital staff or transplant coordinators. Only 32 (7.3%) of the successful donations were initiated by family members (Figure 7). Twenty-one (4.8%) of the actual organ donors had registered their intention to be a donor, either in the form of an organ donation card that was found, or as an entry in the organ donation registry. In 29, in terms of an expressed wish by the deceased organ donor to donate their organs, only 2 (3.8%) of the 53 organ donors had donor cards (Figure 8). This figure is lower than some other countries. In Australia in 29, out of the 256 donors, 74 (28.9%) had registered their intention in the Australian Organ Donor Registry [9]. When our transplant coordinators approach potential donor families, the option of donating all useful organs/ tissues is offered. However, the ultimate decision rests with the family, who can consent to donate a specific number or types of organ/tissue. Sixty-six (15.1%) of our donors were single-organ donors: 44 were liver donors, 1 was a heart donor, and 21 were single kidney donors. Of the 21 single kidney donors, 14 (66.7%) were as a result of the family s decision, while 7 (33.3%) were 6 2.92 3. 2.71 2.82 2.97 2.83 2.76 2.68 2.72 3. 5 2.43 2.48 2.41 2.5 2.5 2.5 4 ORPD Donors 2. 3 1.5 ORPD 2 1. 1.5 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29. Figure 6. Successful organ donors and organs recovered per donor (ORPD). Hong Kong J Nephrol October 21 Vol 12 No 2 67

Y.F. Tong, et al as a result of medical contraindications. According to the experience of our transplant coordinators, families who choose to donate only a single kidney are willing to help others but, at the same time, they cannot let go of the traditional concept of the importance of keeping the body intact. Donor characteristics Donor characteristics, such as age and cause of death, also contributed to donation outcome. Figure 9 shows a close relationship between donor age and the outcome of donation. Donors of extreme ages (< 5 and > 7 years) were usually single-organ donors. Generally, multiorgan donors were younger than single-organ donors. Very young donors were rare; we only had three donors who were younger than 5 years of age. The younger donors tended to be multiorgan donors. The average number of organs donated per donor increased from the age group Donor card signed, 21 (4.8%) Family initiated to donate, 32 (7.3%) No expression on donation, 385 (87.9%) Figure 7. Expression of intent to donate by donors and donor families, 1996 29. of 5 11 years, peaked at 2 29 years, and then dropped with increasing age (Figure 1). With regard to donor cause of death, a mean of 3.18 organs were recovered per donor among donors who died of head trauma, 2.59 organs per donor were recovered from those who died of cerebrovascular accident, and 2.34 organs per donor were recovered from those who died of cerebral hypoxia. These findings are similar to those of other studies [9 11,13]. Donor medical background Selck et al [11] reported that organ yield was found to depend significantly on donor medical history such as hypertension, diabetes and renal function. In our study, 25 (37.9%) of the 66 single-organ donors had known hypertension, while 85 (22.8%) of the 372 multiorgan donors had known hypertension (Table 2). The prevalence of known hypertension among single-organ donors was comparatively higher than among multiorgan donors, which implies that the presence of known hypertension affects donation outcome. For known diabetes and cardiac arrest, we found no differences in donation outcome. Compared with single-organ donors, multiorgan donors tended to have better renal function in terms of lower serum creatinine level and less oliguria. The last creatinine level measured was found to be an important factor in determining the number of organs recovered. Figure 11 shows that ORPD significantly depended on donors renal function. When serum creatinine was > 15 μmol/l, there was a dramatic decrease in the number of donors and organs recovered. 6 Organ donor Donor card signed in organ donor 5 4 3 2 1 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 Figure 8. Expression of wish to donate by deceased donors. 68 Hong Kong J Nephrol October 21 Vol 12 No 2

Organ donation in Hong Kong: 1996 29 1 9 8 7 Percentage 6 5 4 3 2 1 Six Five Four Three Two Single < 5 5 11 12 19 3 2 29 3 39 1 4 49 2 5 59 1 6 69 7 1 2 2 3 1 3 17 9 25 16 2 3 12 16 18 39 59 24 4 1 7 4 1 34 32 21 3 1 2 8 19 19 8 6 Age group (yr) Figure 9. Number of organs recovered by age group, 1996 29. 14 12 1 3. 3.19 3.32 2.79 2.66 2.65 2.36 3.5 3. 2.5 8 6 Organs per donor Donors 1.8 2. 1.5 Organs per donor 4 1. 1. 2.5 < 5 5 11 12 19 2 29 3 39 Age (yr) 4 49 5 59 6 69 7. Figure 1. Number of organs recovered per donor by age group, 1996 29. Hong Kong J Nephrol October 21 Vol 12 No 2 69

Y.F. Tong, et al Donor management Good donor management is a very important contributing factor to the successful recovery of organs in the donation process. Most of our organ donors were cared for in critical care units. A total of 68 (51.4%) organs came from 22 (5.2%) donors cared for in intensive care units, and 39 organs (26.1%) came from 19 donors (24.9%) cared for in neurosurgical units (Figure 12). ORPD was higher among donors from neurosurgical and intensive care units compared to donors not cared for in such units. Donor management involves identification, evaluation, seeking the family s consent, and donor maintenance and organ recovery. The time may span 24 72 hours or even longer [19,2]. The median time from ventilation Table 2. Comparison between single-organ donors and multiorgan donors* Single-organ Multiorgan donors donors (n = 66) (n = 372) Medical history Known hypertension 25 (37.9) 85 (22.8) Known diabetes mellitus 2 (3.) 18 (4.8) History of cardiac arrest 1 (15.2) 6 (16.1) Clinical presentation Oliguria 27 (42.2) 117 (31.5) Serum creatinine > 15 μmol/l 25 (37.9) 23 (6.2) *Data presented as n (%). to brain death in 28 was 36.9 hours in Australia and 25.6 hours in New Zealand [9]. In our study, in the majority of donors (n = 281, 64.2%), the time from intubation to confirmation of brain death was within 48 hours. The number of donors decreased markedly when time between intubation and brain death was more than 72 hours (Figure 13). In seven (1.6%) donors who donated six organs, the time interval between intubation and brain death was within 72 hours. Prolonged ventilation seemed to adversely affect the outcome of donation in terms of the number of organs recovered. Several studies have stressed that timely and accurate declaration of brain death can promote a smoother transition from patient care to donor management and, hence, a better donation outcome [2 22]. A summary of time from intubation to brain death by organ type is shown in Table 1. The median time from intubation to brain death for kidney, liver and heart donors was less than 72 hours, but was much shorter, at 3.8 hours, for lung donors. DISCUSSION Organ shortage is a worldwide problem and Hong Kong is no exception. Hong Kong has adopted an opt-in system for organ donation. In 28, the Department of Health set up the Centralised Organ Donation Register, which allows Hong Kong people to conveniently and voluntarily register their wish to donate their organs after death [23]. Up to 29, approximately 45, individuals in 25 2 2.86 2.82 2.74 Organs per donor Donors 3.5 3. 2.39 2.5 15 1 1.69 1. 2. 1.5 1. Organs per donor 5.5 < 5 5 99 1 149 15 199 2 299 Creatinine (μmol/l) 3. Figure 11. Number of organs recovered per donor by last creatinine level measured, 1996 29. 7 Hong Kong J Nephrol October 21 Vol 12 No 2

Organ donation in Hong Kong: 1996 29 6 5 2.76 2.83 2.83 2.9 2.8 2.7 No. of donors and organs 4 3 2 2.39 2.57 Organs per donor Donors Organs 2.6 2.5 2.4 2.3 Organs per donor 1 2.2 Intensive care Neurosurgical Medical Pediatric Surgical 2.1 Figure 12. Number of organs recovered per donor by department, 1996 29. 12 1 8 Single Two Three Four Five Six 6 4 2 23 24 47 48 71 72 95 96 119 Time (hr) 12 143 144 167 168 Unknown Figure 13. Time from intubation to brain death in organ donors, 1996 29. Hong Kong have registered in the system [24], which is less than 1% of the population. There is clearly much room for improvement with regard to public education and encouraging individuals to take the initiative to register their wish to donate. Nevertheless, Hong Kong has experienced a rising number of donations from deceased donors. The number of successful donors rose from 3 in 1996 to 44 in 22, although there was a drastic drop to 26 in 23 when Hong Kong was hit by the SARS outbreak. The number rose slowly after 23, and reached a historical peak of 53 donors in 29. In the same year, the Hospital Authority re-emphasized organ donation and the transplantation service as a priority service. The number of transplant coordinators increased from four to seven in 29, covering seven clusters of Hospital Authority Hong Kong J Nephrol October 21 Vol 12 No 2 71

Y.F. Tong, et al hospitals. In addition, with adoption of marginal donors, the acceptance of ECDs increased from 3 in 1996 to 15 in 28 and 15 in 29. In terms of ECDs as a percentage of the total donor pool, there was a fourfold increase from 1% in 1996 to 4.5% in 28. Medical and health professionals are the most critical link in the organ procurement process [11,25,26]. One of their crucial roles in end-of-life care is in respecting the autonomy of patients and their families in the choice of organ donation, which has been shown to assist families in their grieving process. Timely referrals will not only enable transplant coordinators to evaluate the suitability of a potential donor to donate organs, but will also help families earlier in the bereavement process [27,28]. Collaborative and effective donor management is vital to optimize organ utilization from every consensual donor. The work of critical care personnel in caring for potential donors before confirmation of brain death, and subsequent maintenance of the donors, is therefore essential [22 24]. Organ donation and procurement is a very delicate and complex process, which requires the cooperation of various healthcare professionals and collaboration at every step along the caring process. Education and a positive attitude in organ procurement could help to increase the organ donation rate. Transplant coordinators and patient groups can contribute by conducting educational and thank you for your referral rounds to constantly remind medical and nursing personnel of the essentials of organ donation in end-of-life care. The hospital can be a place for turning a sad departure of a loved one into a chance for giving new life to a patient waiting for transplant. ACKNOWLEDGMENTS The authors extend their gratitude to every donor and donor family. We also thank the transplant coordinators involved in data entry and registry maintenance. Transplant coordinators: Ms. Angela Wong (Queen Elizabeth Hospital), Ms. Y.F. Tong (Prince of Wales Hospital), Ms. Monica Wong (Princess Margaret Hospital), Ms. Jenny Koo (Queen Mary Hospital), Ms. S.M. Cheung (Tuen Mun Hospital), Ms. Y.S. Lam (United Christian Hospital), Mr. C.L. Tsoi (Pamela Youde Nethersole Eastern Hospital). Ex-transplant coordinators: Ms. Shelley Ho (Queen Mary Hospital), Mr. P.C. Chan (Princess Margaret Hospital), Ms. Marie Szeto (Princess Margaret Hospital), Ms. Liza Cheung (Prince of Wales Hospital), Ms. Eliza Lau (Princess Margaret Hospital), Ms. Terry Wu (Queen Elizabeth Hospital). Information Technology Division, Hospital Authority: Mr. Johnny Lam, Mr. Nicholas Yeung, Mr. Herman Sin, Ms. Freda Chan. Advisors, Organ Pro curement System: Dr. Y.W. Ho (United Christian Hospital), Dr. K.F. Chau (Queen Elizabeth Hospital). REFERENCES 1. Ho S, Cheng B. 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