Not all donors are utilized for transplantation
Not all registered donors lead to transplants. This study shows which factors contribute to potential donors ultimately not being utilized.
Especially older donors and donors with comorbidities are more frequently not utilized. The research also shows again that organs from potential donors after brain death (DBD) are utilized more often than those from potential donors after circulatory death (DCD).
Publication
Analysis of Unused Organ Donors in the Netherlands: Older Donor Age Associated With Higher Risk of Non-Utilization
Authors: K.A. Chotkan, M.A. Kuiper, I.P.J. Alwayn, M.B.A. Heemskerk, A.E. Braat, N.E. Jansen
Transplant International, March 11, 2025
Background and objective
Hospitals and transplant centers have long signaled that registered donors seemed to be transplanted less frequently. This study investigated whether this increase is objectively demonstrable and which factors contribute to it.
- Design: It 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 the case of unutilized donors, no organs were transplanted.
What were the results?
The number of registered donors increased by 14% in the 2018–2023 period: 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 slightly: 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 during screening (22%).
Differences between DBD and DCD donors
- Among DBD donors, 13% were ultimately not utilized after registration, compared to 35% of DCD donors.
- Among DCD donors older than 75, as many as 50% were not utilized.
Donor characteristics
Looking at all donors (both DBD and DCD) that were not utilized in this study:
- They are on average older than the donors that were used.
- They more frequently have comorbidities such as hypertension or diabetes.
This confirms the hypothesis that these are more often so-called Extended Criteria Donors (ECD donors). These are organs from donors who were previously considered unsuitable.
It should 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 provides many successful transplants.
Background: why is donation less frequent in DCD donors?
For DCD donors, donation was more often cancelled due to an agonal phase lasting longer than 2 hours. The agonal phase is the period between the cessation of life-sustaining treatment (switch-off) and the patient's death. Organs are only retrieved after death.
To preserve organ quality, a maximum time limit has been set until circulatory arrest. After that, an organ is less suitable or even unsuitable for transplantation.
In addition, it is difficult to predict when death will occur; some patients do not pass away until many hours later, which is why a clear limit is necessary.
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 offers the organ donation chain valuable insights to increase effectiveness, efficiency, and social impact within the chain. This allows us to continue working in a socially responsible, targeted, and sustainable manner.
Broader criteria for donor acceptance (including older donors and donors with comorbidities) increase the number of transplants. At the same time, the percentage of unused donors is rising. Procedures that do not lead to transplantation also require intensive efforts from the ICU team, OR capacity, and the use of perfusion equipment. It also has an impact on surviving relatives if a donation turns out not to proceed.
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 department of surgery at the LUMC (Chotkan, Alwayn, Braat)
- The intensive care unit of the Medisch Centrum Leeuwarden (Kuiper).
- NTS (Chotkan, Heemskerk, Jansen).
Related research
Donation intensivist Angela Kotsopoulos developed a model to predict the time until death. The model predicts quite well which patients will die within 1 or 2 hours. However, this study also failed to identify a group of donors that you would no longer want to attempt to use.
