Not all donors are utilized for transplantation

Particularly older donors and donors with comorbidities are more frequently unutilized. The study also demonstrates once again that organs from potential donors after brain death (DBD) are utilized more often than those from potential donors after circulatory death (DCD).

Background and objective

Hospitals and transplant centers have long noted that registered donors seem less likely to be transplanted. This study investigated whether this increase is objectively demonstrable and which factors contribute to it.

• Design: This is a retrospective analysis of all registered deceased donors in the Netherlands between January 1, 2018, and December 31, 2023 (n=2,235)
• Definitions: A utilized donor is someone from whom at least one organ was transplanted. In unutilized donors, no organs were transplanted.

What were the results?

The number of registered donors increased by 14% between 2018 and 2023: from 359 in 2018 to 410 in 2023. A total of 2,235 potential donors were registered for organ donation.

In 1,618 donors (72.4%), at least one organ was transplanted. 617 donors (27.6%) were not utilized.

Notable trends

• The number of utilized donors increased modestly: from 276 in 2018 to 285 in 2023 (+3%).
• The number of non-utilized donors increased significantly: from 83 in 2018 to 125 in 2023 (+51%).

Most common reasons why donors were not utilized:

• An agonal phase lasting longer than 2 hours in DCD donors (45%).
• An unacceptable medical history upon screening (22%).

Differences between DBD and DCD donors

• Among DBD donors, 13% ultimately were not utilized after referral, compared to 35% for DCD donors.
• Among DCD donors older than 75 years, as many as 50% were not utilized.

Donor characteristics

Looking at all donors (both DBD and DCD) who were not utilized in this study:

• They are older on average than the donors that were used.
• They more frequently have comorbidities such as hypertension or diabetes.

This confirms the hypothesis that these are more frequently so-called Extended Criteria Donors (ECD donors). These are organs from donors who were previously deemed unsuitable.

It must be noted, however, that this study does not allow us to exclude any group of potential donors from donation. Even though organs from older donors are rejected more often, this group still yields many successful transplants.

Why is this study important for the organ donation chain?

The aging of the donor population continues to increase. The chain must continue to invest in technology, such as machine perfusion. Strategic choices are also needed regarding when the limits have been reached for utilizing ECD donors (Extended Criteria Donors).

This study provides the organ donation chain with valuable insights to increase the effectiveness, efficiency, and societal impact within the organ donation chain. This enables us to continue working in a socially responsible, targeted, and sustainable manner.

Due to broader criteria for donor acceptance (including older donors and donors with comorbidities), the number of transplants increases. At the same time, the percentage of unused donors increases. Procedures that do not lead to transplantation also require intensive effort from the ICU team, OR capacity, and the deployment of perfusion equipment. Furthermore, it impacts surviving relatives if a donation ultimately does not go ahead.

Who collaborated?

The data analysis is based on national donation data from the NTS. The researchers are affiliated with various centers:

• The transplant center and the surgery department of the LUMC (Chotkan, Alwayn, Braat)
• The intensive care unit of the Medical Center Leeuwarden (Kuiper).
• NTS (Chotkan, Heemskerk, Jansen).