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CLINICAL AND TRANSLATIONAL RESEARCH

Is the Increase in DCD Organ Donors in the UnitedKingdom Contributing to a Decline in DBD Donors?

Dominic M. Summers,1,3 Claire Counter,2 Rachel J. Johnson,2 Paul G. Murphy,2 James M. Neuberger,2

and J. Andrew Bradley1

Introduction. Organ donation after brain death (DBD) has declined in the United Kingdom, whereas donation aftercardiac death (DCD) has increased markedly. We sought to understand the reasons for the decline in DBD anddetermine whether the increase in DCD was a major factor.Methods. The UK Transplant Registry was analyzed to determine trends in organ donation. Data from the PotentialDonor Audit, an audit of all patients younger than 76 years who died in noncardiothoracic UK intensive care units, wasanalyzed to identify trends in clinical demographics and management and to determine whether potential donors(DBD and DCD) were identified and appropriate steps were taken to enable organ donation.Results. There were 7589 (12.8 per million of population [pmp]) deceased organ donors in the United Kingdom from1999 to 2009. The total number of deceased donors increased by 16% (to 14.9 pmp), but DBD donors decreased from744 to 612, and the overall increase in donors was due to an 8-fold increase in DCD donors (33 in 1999 to 2000, 288 in2008 to 2009). Analysis of the Potential Donor Audit over the 5-year period 2004 to 2005 to 2008 to 2009 showed thatthe number of patients dying in intensive care units who were possibly brain stem dead (comatose, apparently apnoeicwith unresponsive pupils) decreased from 1929 in 2004 to 2005 to 1495 in 2008 to 2009 (22.5% reduction). Theproportion of potential DBD donors who became donors increased from 45% to 51%.Conclusion. There is no evidence that the increase in DCD donors has contributed directly to the decline in DBD,which reflects a decrease in the number of patients with brain death.

Keywords: Organ donation, Donation after cardiac death, Donation after brain death, Donor trends.

(Transplantation 2010;90: 15061510)

Organ donation after cardiac death (DCD) is increasingmarkedly in the United Kingdom, United States, andsome parts of Europe, and controlled DCD donors now rep-resent around one third of all deceased donors in the UnitedKingdom (13). The outcome after transplantation with or-gans from DCD donors is generally good, and such donorsundoubtedly represent an important addition to the organdonor pool (4 7). However, recovery of organs from DCDdonors is particularly demanding in terms of logistics and

resources, particularly because not all potential DCD donorsproceed to organ donation and for those who do, the timingof donation is both variable and unpredictable (8, 9). More-over, DCD donors provide fewer transplantable organs perdonor than donors with brain death (donation after braindeath [DBD]) (10). DCD donors are not currently used toprovide hearts for transplantation, and there are concernsthat in some cases, other organs from DCD donors may be atrisk of additional complications (5, 6).

Although there has been an increase in the number ofDCD donors in the United Kingdom, the number of DBDdonors has gradually decreased, and there is concern, basedmainly on anecdotal evidence, that many donors who mightpreviously have become DBD donors are proceeding insteadto DCD. The suggestion that the availability of DCD mayhave an adverse impact on DBD is consistent with data fromThe Netherlands where the successful introduction of alarge program of DCD has corresponded with a decrease inDBD (1).

We have sought to clarify the likely extent to which thegradual decline in DBD within the United Kingdom over thepast decade may be attributed to the increase in DCD. Inaddition to national data on deceased donor demographics,we have analyzed information arising from the UK audit of alldeaths in intensive care units (ICUs) to identify potential de-ceased donors.

This work was supported by a Ph.D. grant from National Health ServiceBlood and Transplant (D.M.S.) and Cambridge National Institute forHealth Research Biomedical Research Centre (J.A.B. and D.M.S.).

The authors declare no conflict of interest.1 Department of Surgery, University of Cambridge, Addenbrookes Hospital,

Cambridge, United Kingdom.2 Organ Donation and Transplantation, NHS Blood and Transplant, Bristol,

United Kingdom.3 Address correspondence to: Dominic M. Summers, M.B., B.Chir., Depart-

ment of Surgery, Box 202, Addenbrookes Hospital, Hills Road, Cam-bridge CB2 0QQ, United Kingdom.

E-mail: [email protected] authors contributed to study design, data analysis, and interpretation and

preparation of the manuscript.Received 2 August 2010.Accepted 30 September 2010.Copyright 2010 by Lippincott Williams & WilkinsISSN 0041-1337/10/9012-1506DOI: 10.1097/TP.0b013e3182007b33

1506 | www.transplantjournal.com Transplantation Volume 90, Number 12, December 27, 2010

http://www.transplantjournal.com

RESULTS

Deceased Donor TrendsThe trends in deceased organ donation in the United

Kingdom over the past decade, obtained from analysis of datafrom the UK Transplant Registry held by National HealthService Blood and Transplant, are shown in Figure 1. Figure1(A) depicts the number of deceased organ donors in theUnited Kingdom and shows that the number of DBD donorshas gradually declined over the past decade from 744 (12.3pmp) in the 12 months April 1, 1999 to March 31, 2000 to 612(10.1 pmp) in the corresponding period of 2008 to 2009. Incontrast, the number of DCD organ donors has increasedmarkedly during the same decade from 33 (0.5 pmp) in 1999to 2000 to 288 (4.8 pmp) in 2008 to 2009. The causes of donordeath are shown in Figure 1(B), and it can be seen that forboth DBD and DCD donors, stroke remains the major causeof death, accounting for 43.4% of DCD deaths and 67.4% ofDBD deaths in 2008 to 2009. There was a decline in the pro-portion of deaths attributable to trauma in DBD donors dur-ing the 10-year period from more than 22% in 1999 to 2000 to11% 2008 to 2009, whereas trauma deaths still accounted formore than 15% deaths in DCD donors in 2008 to 2009. Themean number of organs retrieved for transplantation from anindividual donor provides a helpful indicator of organ avail-ability and utilization over time according to donor type(DBD and DCD). The number of organs retrieved per donorincreased gradually for both DBD and DCD donors duringthe 10-year study period (Fig. 1C), although the mean num-

ber of organs donated per DCD donor remained less than thatper DBD donor (mean 2.7 organs/donor vs. 4.0 organs/donorrespectively in 2008 2009). All deceased donors were furthercategorized according to the American classification for ex-tended criteria kidney donors (11). During the 10-year studyperiod, the percentage of DBD donors categorized as ex-tended criteria donors remained relatively stable at approxi-mately 25%, whereas donation from extended criteria DCDdonors increased markedly from less than 5% in 1999 to 2001to 28% in 2008 to 2009, which marginally exceeded that forDBD donors (Fig. 1D).

Audit of Potential Deceased DonorsThe UK wide audit of potential deceased organ donors

was initiated in April 2003 to determine the true potential forsolid-organ donation and identify shortcomings of the de-ceased organ donation system (12). It has undergone severalrevisions since its inception, but during the study period(April 1, 2004 to March 31, 2009), it aimed to audit compre-hensively all deaths occurring in patients younger than 76years in ICU (excluding those in cardiothoracic ICU) anddetermine whether potential donors were identified andappropriate steps were taken to enable them to proceed toorgan donation. During the 5-year period (April 2004 toMarch 2009), a total of 78,338 deaths were included in theaudit (Fig. 2). The annual number of deaths reported re-mained relatively constant during the audit period (mean15,668 deaths/year).

FIGURE 1. Donor trends April 1, 1999 to March 31, 2009. (A) Total number of deceased organ donors. (B) Donor cause ofdeath for donation after cardiac death (DCD) and donation after brain death (DBD). (C) Mean number of solid organsdonated per donor. (D) Extended criteria donors.

2010 Lippincott Williams & Wilkins 1507Summers et al.

A total of 8345 (10.7%) of patients who died in ICUwere found to be potential candidates for brain stem deathtesting, on the basis that they were deeply comatose (GlasgowComa Score 3), apparently apnoeic on a mechanical ventila-tor and had unreactive pupils. During the 5-year audit period,there was a gradual decline (of 22.5%) in the number of po-tentially brain-dead patients identified from 1929 in 2004 to2005 to 1495 in 2008 to 2009 (Fig. 3A).

The majority (6323 or 75.8%) of potentially brain-deadpatients were formally tested for brain stem death, and ofthese, 6160 (97.4%) were found to fulfill the diagnostic crite-ria for brain death. It was notable that the percentage of po-tential brain-dead patients who were tested for brain stemdeath increased during the audit period from 72.1% in 2004to 2005 to 77.9% in 2008 to 2009 (Fig. 3A).

Of the 6160 patients who were confirmed brain stemdead, 39 patients (0.4%) had absolute medical contraindica-tions to organ donation (HIV or known or suspected variantCreutzfeldt-Jakob disease). For the purposes of the audit, theremaining 6121 patients were defined as the potential pool ofDBD organ donors. Approximately half (2980 or 48.5%) ofthese patients subsequently became organ donors with theremainder not progressing to organ donation, predomi-

nantly because of additional medical contraindications to do-nation or lack of consent to donation from the donor family.

The pathway for patients who died in ICU becomingDCD donors was more varied t