1. UNOS Region 5 Meeting March 18, 2015
DMG Web Portal Update
UNOS Region 5 Meeting March 18, 2015
Darren Malinoski, MD
Mitch Sally, MD
Megan Crutchfield, MPH

2. INTRODUCTION Shortage of organs available for transplantation
Efforts needed to increase number and quality of organs from donors after neurologic determination of death (DNDDs)

3. INTRODUCTION Donor Management Goals (DMGs)
Checklist of critical care endpoints
Standardize care of potential organ donors
Normal cardiovascular, respiratory, endocrine, renal, and acid-base parameters

4. INTRODUCTION

5. DMG Web Portal Update SCD DCD ECD Total Number of Donors n=2,714 66%
66%
DCD
n=553  
14%
ECD
n=827
20%
From March 15, 2012 to March 11, 2015

6. DMG Web Portal Update Number of Donors by Region and OPO n=351 9%
 Region 4 (n=351) (since January 2014)
Life Gift of Texas (TXGC) 
n=351 9%
 Region 5 (n=3,644)
Donor Network of Arizona (AZOB) 
n=409
10%
California Transplant Donor Network (CADN) 
n=891
22%
Golden State Donor Services (CAGS) 
n=180 4%
One Legacy (CAOP) 
n=1234
30%
Lifesharing (CASD) 
n=293 7%
New Mexico Donor Services (NMOP) 
n=118 3%
Nevada Donor Network (NVLV) 
n=245 6%
Intermountain Donor Services (UTOP) 
n=274
 Region 6 (n=99) (since November 2013)
Pacific Northwest Transplant Bank (ORUO) 
n=99 2%

7. Organs Transplanted per Donor (OTPD)
DMG Web Portal Update
Organs Transplanted per Donor (OTPD)
OTPD Overall  
SCD  
DCD  
ECD  
Mean + SD

8. Individual Organs Transplanted by Donor Type
DMG Web Portal Update
Individual Organs Transplanted by Donor Type
Heart
Left Lung
Right Lung
Left Kidney
Right Kidney
Liver
Pancreas
Intestines
All Donors (n=4094)
1380, (34%)
914,
(22%)
891
3248 (79%)
3177 (78%)
2870 (70%)
433
(11%) 32
(<1%)
SCD (n=2714)
(51%) 
792 (29%)
769 (28%)
2339 (86%)
2302 (85%)
2147 (79%)
427 (16%)
(1%)
DCD (n=553) 8
469 (85%)
451 (82%)
138 (25%) 6
ECD (n=827) 42
(5%)
114
(14%)
114 (14%)
440 (53%)
425
(51%)
585
(71%)

9. Number of Donors That Met the DMG Bundle
DMG Web Portal Update
Number of Donors That Met the DMG Bundle
Referral
Authorization
12-18 Hours
Prior to OR 
All DNDDs
(n=3541)
588 (17%)
804 (23%)
1657 (47%)
2279 (64%)
SCD
(n=2714)
444 (16%)
641 (24%)
1371 (51%)
1863 (69%)
ECD
(n=827)
144 (17%)
163 (20%)
286 (35%)
416 (50%)

10. Percent DMGs Met at Each Time Point
DMG Web Portal Update
Percent DMGs Met at Each Time Point
Referral
Authorization
12-18 Hours
Prior to OR
MAP ( mmHg)
84%
91%
CVP (4-12mmHg)
10%
28%
49%
50%
EF (>50%)
15%
43%
62%
pH ( )
65%
78%
87%
90%
PF Ratio (>300)
39%
46%
56%
Sodium (<155)
92%
71%
79%
86%
Glucose (<180 mg/dL)
55%
76%
68%
81%
Urine (0.5 cc/kg/h over 4 hours)
83%
Pressors (<1 and low dose)
75%
66%

11. DMG Web Portal Update Met DMG Bundle 15% 26% 59% 68% 21% 27% 56% 79%
Referral
Authorization
12-18 Hours
Prior to the OR
OPO 1
15%
26%
59%
68%
OPO 2
21%
27%
56%
79%
OPO 3
13%
31%
55%
58%
OPO 4
24%
29%
57%
OPO 5
20%
25%
46%
OPO 6
22%
42%
OPO 7
16%
32%
OPO 8
37%
OPO 9
11%
17%
61%
OPO 10
18%
66%
Average
19%
53%
64%

12. OTPD when bundle met v. not met
DMG Web Portal Update
OTPD when bundle met v. not met
Referral
Authorization
12-18 Hours
Prior to OR
Met
Not Met
All
DNDDs
3.44
3.12
3.64
3.04
3.77
2.71
3.75
2.35
SCD (n=2714)
4.09
3.69
4.28
3.60
4.23
3.28
4.16
2.87
ECD (n=827)
2.36
2.02
2.34
2.39
1.92
2.44
1.72

13. Lactate Levels as Predictors of Organ Transplantation Rates after Neurologic Determination of Death
UNOS Region 5 Meeting
March 18, 2015
Mitchell Sally, MD
Darren Malinoski, MD, FACS
VA Portland Healthcare System
Oregon Health & Science University
Portland, OR

14. As you have seen, and as I hope to convey here, meeting the DMG bundle is a/w more OTPD and superior graft function in those transplanted organs. Here are examples of three of our recent publications, the first two, in JOT and CCM, that focus on OTPD, and the third, which looks at the DMGs effect on DGF and kidney function. Our group has also looked at predictors of liver graft function with DMG influence.

15. And I personally have been involved in improvements in DMGs, looking at one particular component of the bundle, the glucose. About two years ago, we were able to show that a glucose level of < 180 in DNDDs was independently associated with 4 or more OTPD, and we recommended raising the DMG glucose threshold from 150 to 180, which is consistent with current critical care recommendations in the ICU.

16. LACTATE Peripheral biomarker
Common use in trauma, burns, critical illness, and sepsis to guide resuscitation
SvO2, ScvO2
CVP
UOP BP
Well, if you’ll indulge me, I’d like to discuss another potential addition and change to the DMG bundle, one that we feel will result in improved organ outcomes. Lactate is a …. And it is commonly used in multiple disease states to guide resuscitation. Other markers of resuscitation include the biomarkers SvO2 and ScvO2, and the clinical parameters such as BP, CVP and UOP.

17. LACTATE End product of anaerobic metabolism (glycolysis)
Usually in skeletal muscle, bowel, brain and RBC
Taken up and converted to glucose (gluconeogenesis) by liver
Marker for adequacy of resuscitation
Normal levels: < 2 mmol/L
Lactate is…
Curr Opin Crit Care, 2012 Jun; 18 (3):

18. GUIDING RESUSCITATION
Living Patient
DNDD
Urine output
Normal BP
Normal CVP
ScvO2
Lactate
Diabetes insipidus
Vasopressor use
Multiple organ issues
No brain oxygen extraction
Unaffected by exterior pressures
DNDDs bring with them a host of complicated physiologic processes, and though they may appear to be “normal” or stable, there may be many issues underlying the actual physiology. In living patients, there may often be normal (or even high) UOP, BP, CVP, and even normal ScvO2. However, there are multiple underlying issues that may contribute to the management of the organ donor. With urine output, a DNDD may be given a diuretic, or may have the condition of diabetes insipidus, common in neurologic death, and which results in high volume urine output. Normal BP may be masked by high or multiple vasopressor use. A CVP within range for the DMGs (4-12) may not tell the entire story, for example if great volumes of fluid are needed to maintain CVP, the likelihood of using the lungs diminishes. ScvO2, a commonly used biomarker in living patients. May misrepresent oxygen utilization, as the brain, which normally extracts a significant portion of the blood oxygen, is unable to do so after neurologic injury and death.
In contrast, lactate is unaffected by many of these confounding variables, and may represent the most true status of acid base physiology.

19. LACTATE Not currently part of the DMG Bundle
Recorded only sporadically
Utility in guiding donor management has not been examined
We would like to propose that lactate be considered to be added to the current DMG bundle, and have a bit of data to support this notion.

20. Lactate Levels Present at Each Time Point
DMG Web Portal Update
Lactate Levels Present at Each Time Point
Referral
Authorization
12-18 Hours
Prior to OR
TXGC (n=295)
n=19 (6%)
n=14 (5%)
n=10 (3%)
n=7 (2%)
AZOB (n=312)
n=32 (10%)
n=27 (9%)
n=15 (5%)
CADN (n=828) 
n=168 (20%)
n=253 (31%)
n=363 (44%)
n=351 (42%)
CAGS (n=156)
n=75 (48%)
n=71 (45%)
n=86 (55%)
n=65 (42%)
CAOP (n=1105)
n=283 (26%)
n=708 (64%)
n=1007 (91%)
n=996 (90%)
CASD (n=227) 
n=30 (13%)
n=27 (12%)
n=29 (13%)
n=25 (11%)
NMOP (n=118) 
n=38 (36%)
n=14 (13%)
n=9 (8%)
n=8 (7%)
NVLV (n=244) 
n=12 (5%)
n=4 (2%)
n=6 (2%)
UTOP (n=209) 
n=101 (48%)
n=134 (64%)
n=110 (53%)
n=103 (49%)
ORUO (n=68)  
n=13 (19%)
n=9 (13%)
n=5 (7%)
n=3 (4%)
TOTAL (n=3562)
n=771 (22%)
n=1261 (35%)
n=1640 (46%)
n=1571 (44%)
A recent pull of data from the web portal supports the idea of lactate being inconsistently recorded, as it is not currently part of the DMG bundle. We can see that these levels are recorded or taken ranging from anywhere from 2 to 90 per cent of the opportunities. Overall, lactate levels appear to be recorded approximately 40% of the time. You will note that these numbers are slightly different than the data the I am going to present, which represent different timing of data downloads from the web portal.

21. OBJECTIVES/HYPOTHESIS
To determine the association between blood lactate levels and organ transplantation rates.
We hypothesized that normal lactate levels would be associated with more OTPD.

22. METHODS Prospective, observational study Three standard time points:
All DNDDs
10 OPOs, UNOS Regions 4, 5, and 6
March August 2014
Three standard time points:
Authorization for donation
12-18 hours after authorization
Prior to organ recovery
This was a prospective….
The three standard time points that we chose to examine began with authorization for donation… We chose these three time points for two reasons: the first, simply because of the variability and infrequency of recording at referal for donation but perhaps more importantly, because these three time points are truly when donor management occurs.

23. METHODS Primary outcome: achieving ≥ 4 OTPD
Secondary outcomes: individual organ transplantation rates

24. RESULTS 1351 donors 3.4 ± 1.8 OTPD 45% ≥ 4 OTPD
Lactate values recorded:
831/1351 (61.5%) at Authorization
1090/1351 (80.7%) at Hours
1045/1351 (77.4%) Prior to recovery

25. RESULTS – LACTATE Mean lactate levels (mmol/L):
overall
at Authorization
at Hours
Prior to organ recovery
2,008/2,966 (67.7%) levels were < 2 mmol/L.

26. # Lactates < 2 mmol/L (n=579)
RESULTS – UNIVARIATE
Continuous
OTPD < 4
OTPD > 4 p
Overall Mean
3.11
2.88
< 0.01
Authorization Mean
3.01
2.45
12-18 Hrs Mean
2.96
2.58
Terminal Mean
2.78
2.08
Categorical
Authorization Lactate < 2 mmmol/L
60.3%
70.1%
12-18 Hours Lactate < 2 mmol/L
54.3%
66.5%
OR Lactate < 2 mmol/L
71.8%
85.0%
# Lactates < 2 mmol/L (n=579)
1 measurement (n=116)
18.2%
17.3%
0.76
2 measurements (n=147)
20.5%
24.6%
0.22
3 measurements (n=316)
44.3%
52.7%
0.03

27. RESULTS - MULTIVARIABLE
Continuous OR
95% CI p
Overall Mean
0.92
0.02
Authorization Mean
0.90
0.01
12-18 Hrs Mean
0.94
0.06
Terminal Mean
0.88
Categorical
Authorization Lactate < 2 mmmol/L
1.37
0.14
12-18 Hours Lactate < 2 mmol/L
1.33
0.11
OR Lactate < 2 mmol/L
1.93
<0.01
# Lactates < 2 mmol/L (n=579)
1 measurement (n=116)
1.35
0.79–2.32
0.27
2 measurements (n=147)
1.14
0.71–1.85
0.58
3 measurements (n=316)
1.22
0.35
*Results controlled for with known predictors of > 4 OTPD: age, weight, BMI, terminal creatinine, donor management bundle met at all 3 time points, standard criteria status, gender, thyroid hormone administration, and CDC high risk status.

28. RESULTS – INDIVIDUAL ORGANS
Lower mean lactate levels found in DNDDs whose organs were utilized:
Used
Not Used p
Hearts
< 0.01
Lungs
Livers

29. CONCLUSIONS
Lactate measurements are inconsistently drawn in DNDDs during donor management
Lower mean lactate levels remained independent predictors of ≥ 4 OTPD
Terminal lactate < 2 mmol/L: independently associated with > 4 OTPD
Inclusion of a lactate level < 2 mmol/L into existing DMG Bundles should be considered

30. QUESTIONS