Organ Transplants Involving Overdose-Death Donors Increasing

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The number of transplants in the United States involving organs from individuals who died from a drug overdose rose from 149 in 2000 to 3533 in 2016.
The number of transplants in the United States involving organs from individuals who died from a drug overdose rose from 149 in 2000 to 3533 in 2016.

Transplantation of organs from individuals who died from a drug overdose have increased dramatically “in parallel with the opioid epidemic in the United States,” researchers concluded in a new report.

Recipients of overdose-death donor (ODD) organs have patient and graft survival rates similar to those of recipients of organs from donors who died from trauma or medical causes.

“Although this is not an ideal or sustainable solution to the organ shortage, use of ODD organs should be optimized,” Christine M. Durand, MD, of Johns Hopkins University School of Medicine in Baltimore, and colleagues wrote in a paper published in Annals of Internal Medicine.

In a study of organ transplants performed from January 1, 2000 to September 1, 2017, Dr Durand and her colleagues found that the number of transplants involving ODD organs increased from 149 in 2000 to 3533 in 2016. ODDs accounted for 13.4% of donors in 2017, up from 1.1% in 2000. The number of overdose deaths increased from 17,415 in 2000 to 63,632 in 2016.

The study included 138,565 deceased donors and 337,934 transplant recipients identified using the Scientific Registry of Transplant Recipients. The authors identified 7313 ODDs and 19,897 ODD transplants during the study period. The transplants included 10,347 kidneys, 5707 livers, 2471 hears, and 1372 lungs. ODDs were more likely to be white, aged 21 to 40 years, and infected with hepatitis C virus (HCV). A higher proportion of ODDs compared with TDDs and MDDs were HCV-positive (18.3% vs 3.2% and 4.1%, respectively).

The standardized 5-year patient and death-censored graft survival rates for ODD organ recipients were similar to those of trauma-death donor (TDD) and medical-death donor (MDD) organ recipients. Among kidney transplant patients, the standardized 5-year patient survival rates were 83.1%, 86.2%, and 81% for recipients of ODD, TDD, and MDD organs, respectively; the standardized 5-year death-censored graft survival rates were 87.1%, 86.9%, and 82.2%, respectively.

Dr Durand's group identified 1665 kidneys, 501 livers, 117 hearts, and 23 lungs that were recovered from ODDs, but subsequently discarded. The discard rate for ODD organs was higher than that of TDD organs and, except for lungs, lower than that of MDD organs. The kidney discard rate was significantly higher for ODDs (20%) than TDDs (14.9%), and the investigators stated that this is likely attributable to designation of ODDs as increased-infectious risk donors (IRDs) and the higher prevalence of HCV infection among ODDs. After standardization by HCV and IRD status, the kidney discard rates did not differ significantly (16.5% vs 16.1%). IRDs are individuals whose behavior increases the risk for HIV, hepatitis B virus, or HCV infection. The prevalence of HCV infection rose from 7.8% in 2000 to 30% in 2017, according to the investigators.

With viral nucleic acid and antibody testing, the authors stated, the true risk for a window-period infection for IRD organ recipients is extremely low. Additionally, they pointed out that transplant candidates who accept IRD kidneys have better survival than those who wait for another organ. Their findings of an increased discard rate associated with IRD designation are consistent with prior studies “and suggest that the organs might be unnecessarily discarded in the context of an organ shortage,” they wrote.

In an editorial commenting on the report by Dr Durand and colleagues, Camille Nelson Kotton, MD, Clinical Director, Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Boston, stated: “Early discussions with recipients and families that include data such as those in this article, with significant weight given to the risk associated with declining organs from IRDs and ODDs, can better frame future organ offers. The transplant community should understand these new data and forge ahead toward better transplant outcomes for more recipients.”

Reference

Durand CM, Bowring MG, Thomas AG, et al. The drug overdose epidemic and deceased-donor transplantation in the United States. Ann Intern Med. 2018.

Kotton CN. Every cloud has a silver lining: Overdose-death donors in organ transplantation. Ann Intern Med. 2018

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