10
Injury, 11,10-12
Printed in Greet Britain
Experience with 1000 potential cadaveric renal donors A. D. B a r n e s Renal Unit. QueenElizabeth Hospital, Birmingham
INTRODUCTION ALTHOUGH occasionally trauma surgeons may be involved in the treatment of acute renal failure, they rarely treat patients with chronic renal failure. In recent years, however, they are being called upon to perform a vital role for patients with chronic renal failure. Cadaveric renal transplantation began in the West Midlands ten years ago, and in the first nine years we were asked to consider 1000 offers of cadaveric donor kidneys. This paper reviews the offers and discusses the reasons for failure to obtain more kidneys. The analysis also highlights the areas from which more kidneys could be obtained to make up the difference, so that all patients requiring transplants could get them. The transplant unit at the Queen Elizabeth Hospital serves a population of 5-5 million between Burton and Hereford, Coventry and Stoke, with the Birmingham conurbation placed centrally. There are five haemodialysis centres in the region, four of which supervise patients on home dialysis. It has always been our policy to answer all calls offering potential donors at the transplant unit and for the kidneys to be removed by a member of the transplant team. Surgeons in the regional hospitals, who have been specially trained, have occasionally removed kidneys for us. After removal, the kidneys are transported to a recipient determined by tissue type matching on the advice of UK Transplant in Bristol. Out of the 1000 offers, 544 were of potential cadavers from hospitals within the West Midlands. The other 456 were offers of kidneys from UK Transplant or one of the other
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NUMBER OF DONORS OFFERED 1968- 1911 O
" DIALYSIS UNITS
Fig. I. West Midlands Region with Burton, Rugby, Hereford and Stoke in the NE, SE, SW and NW corners respectively and Birmingham in the centre. The numbers within the circles are the number of offers and the numbers below the circles the population of the towns. European organ exchange centres (Paris, Leiden, Aarhus). The distribution of offers from the various towns and hospitals of the West Midlands is shown in Fig. 1. A total of 321 of the offers came from hospitals in the Birmingham
Barnes: Renal Donors
Nos. 200,
11 I00
U. K . T .
80
/"x,
150,
.
Steast cancer (848)
6O
%
Renalcractcancer(l$$) F~rst cadaverJc transplant (249)
4O
Gastromte~tinal tract Cancer (289)
100,
Lung cancer (225)
20
Years
68 69 70 71 72 73 74 75 76 77 78 YEARS
Fig. 2. The number of cadaver donor offers (crossed line) related to the number of transplants performed (dotted line) in the Birmingham Transplant Unit.
Area Health Authority (T), which serves a population of 1"5 million. The remainder (233) came from the other West Midland Regional Health Authority hospitals, which serve a population of 4 million. There is some central reference of patients with head injury to the Birmingham Accident Hospital and subarachnoid haemorrhage to the Smethwick Centre for Neurosurgery, but the discrepancy of donor offers between Birmingham hospitals and regional hospitals is not explained by these references. The proportion of head injury donors has been 40 per cent and subarachnoid haemorrhage donors 40 per cent. The remainder have been of patients dying from primary cerebral tumours, cardiac disease, drug overdose and hypoxic cerebral damage. When fruitful offers alone are considered, head injuries and subarachnoid haemorrhage each total 45 per cent and patients with other diagnoses provide about l 0 per cent. DONOR PATTERN
Let us now consider the donor pattern from individual hospitals. One city general hospital with a major trauma unit and noted for accepting medical emergencies has offered 57 potential donors. Of these, 23 were declined or did not materialize for medical reasons; the patient may have died from systemic sepsis, died with deteriorating renal function or may have recovered. Ten patients' relatives refused consent for nephrectomy, where there were no other contraindications. Twenty-four cadavers were operated upon to yield 41 kidneys which were
Fig. 3. A comparison of the survival of first cadaveric renal transplants and the survival of patients from breast, renal tract, lung and gastrointestinal cancer treated surgically with intent to cure. The cancer figures are in the 15-55 age group from the Birmingham and West Midlands Regional Cancer Registry.
transplanted, 30 in Birmingham and Ii elsewhere. Twenty of the donors had sustained head injuries, 2 had sustained subarachnoid haemorrhages and there were 2 cardiac deaths. The Queen Elizabeth Hospital, which houses the transplant unit, provided 54 offers, although it does not treat trauma cases. Eighteen donors were operated on to yield 32 transplants. The majority of the donors used were dying of subarachnoid haemorrhage and the majority of those not used died from cardiac causes. Twenty-nine of the 54 offers were of donors in the intensive care unit and they yielded 20 kidneys. The other 25 were from patients in the wards, all before 1971, and yielded 12 transplants. This pattern of offer within a hospital is typical, so that nowadays virtually all donor offers come from intensive care units. During the 18-month period 1968-69 we had 54 donor offers of whom 25 per cent were on ventilators. In the first six months of 1977 there were 57 offers, 65 per cent on ventilators. During 1977 85 per cent of the patients on ventilators came to nephrectomy, compared with only 20 per cent of those not on ventilators. Only 5 per cent of the relatives of potential donors on ventilators refused consent, whereas 25 per cent of those not on ventilators refused. The rate of donor offers and the rate of transplantation is shown in Fig. 2. The large increase in the number of offers between 1971 and 1972 was due to the start of UK Transplant in Bristol. The fall between 1976 and 1977 is due to a more selective approach among referring doctors and a realization that only excellently matched kidneys are worth transporting between regions.
12
Injury: the British Journal of Accident Surgery Vol. 1 1/No. 1
TableL Example of renal donor patterns in three hospitals
Hospita/
Population (x 1 0 3 )
A
50
B
C
47
250
Diagnosis
Offers
Kidneys used
Head injury Subarachnoid haemorrhage Other
4
0
10 1
t2 0
Total
15
12
Head injury Subarachnoid haemorrhage Other Total
4
4
0 1 5
0 2 6
Head injury Subarachnoid haemorrhage Other Total
11
11
1 4 16
1 3 15
N E E D FOR K I D N E Y S
Although the rate of transplantation is slowly rising each year, nowhere is the need being met. Between two and three times as many patients require transplants as receive them. Let us consider how we can get them. Take, for example, two towns each with a population of about 50 000. Hospital A (Table I) made 15 offers resulting in 12 transplantable kidneys. Hospital B made 5 offers providing 6 kidneys. In hospital A all the fruitful donors died of subarachnoid haemorrhage whereas in hospital B almost all died of head injury. As both hospitals cover the majority of needs for their areas the differences are most likely due to differences in attitude of the doctors concerned. It is most unlikely that one hospital is so brilliantly successful with one condition and disastrously bad with the other. Another difference suggesting a major medical element in the shortage of kidneys is the comparison of hospital A with hospital C, which serves a population five times as large and has a neurosurgical unit. These two have made the same number of offers in the period while the difference in diagnosis is again seen. It is often asked whether a cadaveric renal transplant is worthwhile and what are the long term results. There are many factors affecting
the results of transplantation. The results of 247 first cadaveric renal transplants from Birmingham are compared with the results of radical surgery with intent to cure some of the common malignancies in patients in the 15-55 age group (Fig. 3). The kidney transplant survival curve does not equate to a patient survival curve. With adequate facilities for dialysis and retransplantation patient survival is much greater. At present, patients with failing transplants are in competition for further treatment with new patients in terminal renal failure. How then can a trauma surgeon play his part? It is by contacting the local transplant team every time he has a patient with a severe head injury who is unlikely to recover. When brain death has been diagnosed the fact that some good may come out of the tragedy may help the bereaved relatives. The offer of the potential donor does create extra work for the medical and nursing staff of the donor hospital and for this the transplant team and their patients can only say 'thank you'. The recent DHSS letter on the interpretation of the Human Tissue Act 1961, the combined Royal Colleges' document on the certification of brain death and your help should enable our patients to get the good quality kidneys they need.
Requests for reprints shouldbe addressed to: Mr A. D. Barnes, Director, Renal Unit, Queen Elizabeth Hospital, Birmingham.
Injury, 11,10-12
Printed in Greet Britain
Experience with 1000 potential cadaveric renal donors A. D. B a r n e s Renal Unit. QueenElizabeth Hospital, Birmingham
INTRODUCTION ALTHOUGH occasionally trauma surgeons may be involved in the treatment of acute renal failure, they rarely treat patients with chronic renal failure. In recent years, however, they are being called upon to perform a vital role for patients with chronic renal failure. Cadaveric renal transplantation began in the West Midlands ten years ago, and in the first nine years we were asked to consider 1000 offers of cadaveric donor kidneys. This paper reviews the offers and discusses the reasons for failure to obtain more kidneys. The analysis also highlights the areas from which more kidneys could be obtained to make up the difference, so that all patients requiring transplants could get them. The transplant unit at the Queen Elizabeth Hospital serves a population of 5-5 million between Burton and Hereford, Coventry and Stoke, with the Birmingham conurbation placed centrally. There are five haemodialysis centres in the region, four of which supervise patients on home dialysis. It has always been our policy to answer all calls offering potential donors at the transplant unit and for the kidneys to be removed by a member of the transplant team. Surgeons in the regional hospitals, who have been specially trained, have occasionally removed kidneys for us. After removal, the kidneys are transported to a recipient determined by tissue type matching on the advice of UK Transplant in Bristol. Out of the 1000 offers, 544 were of potential cadavers from hospitals within the West Midlands. The other 456 were offers of kidneys from UK Transplant or one of the other
@ 265
Q
@
50
55
© 56
© © ©
©
I06
61
~7
® Q33,©
lR
80
60
47
NUMBER OF DONORS OFFERED 1968- 1911 O
" DIALYSIS UNITS
Fig. I. West Midlands Region with Burton, Rugby, Hereford and Stoke in the NE, SE, SW and NW corners respectively and Birmingham in the centre. The numbers within the circles are the number of offers and the numbers below the circles the population of the towns. European organ exchange centres (Paris, Leiden, Aarhus). The distribution of offers from the various towns and hospitals of the West Midlands is shown in Fig. 1. A total of 321 of the offers came from hospitals in the Birmingham
Barnes: Renal Donors
Nos. 200,
11 I00
U. K . T .
80
/"x,
150,
.
Steast cancer (848)
6O
%
Renalcractcancer(l$$) F~rst cadaverJc transplant (249)
4O
Gastromte~tinal tract Cancer (289)
100,
Lung cancer (225)
20
Years
68 69 70 71 72 73 74 75 76 77 78 YEARS
Fig. 2. The number of cadaver donor offers (crossed line) related to the number of transplants performed (dotted line) in the Birmingham Transplant Unit.
Area Health Authority (T), which serves a population of 1"5 million. The remainder (233) came from the other West Midland Regional Health Authority hospitals, which serve a population of 4 million. There is some central reference of patients with head injury to the Birmingham Accident Hospital and subarachnoid haemorrhage to the Smethwick Centre for Neurosurgery, but the discrepancy of donor offers between Birmingham hospitals and regional hospitals is not explained by these references. The proportion of head injury donors has been 40 per cent and subarachnoid haemorrhage donors 40 per cent. The remainder have been of patients dying from primary cerebral tumours, cardiac disease, drug overdose and hypoxic cerebral damage. When fruitful offers alone are considered, head injuries and subarachnoid haemorrhage each total 45 per cent and patients with other diagnoses provide about l 0 per cent. DONOR PATTERN
Let us now consider the donor pattern from individual hospitals. One city general hospital with a major trauma unit and noted for accepting medical emergencies has offered 57 potential donors. Of these, 23 were declined or did not materialize for medical reasons; the patient may have died from systemic sepsis, died with deteriorating renal function or may have recovered. Ten patients' relatives refused consent for nephrectomy, where there were no other contraindications. Twenty-four cadavers were operated upon to yield 41 kidneys which were
Fig. 3. A comparison of the survival of first cadaveric renal transplants and the survival of patients from breast, renal tract, lung and gastrointestinal cancer treated surgically with intent to cure. The cancer figures are in the 15-55 age group from the Birmingham and West Midlands Regional Cancer Registry.
transplanted, 30 in Birmingham and Ii elsewhere. Twenty of the donors had sustained head injuries, 2 had sustained subarachnoid haemorrhages and there were 2 cardiac deaths. The Queen Elizabeth Hospital, which houses the transplant unit, provided 54 offers, although it does not treat trauma cases. Eighteen donors were operated on to yield 32 transplants. The majority of the donors used were dying of subarachnoid haemorrhage and the majority of those not used died from cardiac causes. Twenty-nine of the 54 offers were of donors in the intensive care unit and they yielded 20 kidneys. The other 25 were from patients in the wards, all before 1971, and yielded 12 transplants. This pattern of offer within a hospital is typical, so that nowadays virtually all donor offers come from intensive care units. During the 18-month period 1968-69 we had 54 donor offers of whom 25 per cent were on ventilators. In the first six months of 1977 there were 57 offers, 65 per cent on ventilators. During 1977 85 per cent of the patients on ventilators came to nephrectomy, compared with only 20 per cent of those not on ventilators. Only 5 per cent of the relatives of potential donors on ventilators refused consent, whereas 25 per cent of those not on ventilators refused. The rate of donor offers and the rate of transplantation is shown in Fig. 2. The large increase in the number of offers between 1971 and 1972 was due to the start of UK Transplant in Bristol. The fall between 1976 and 1977 is due to a more selective approach among referring doctors and a realization that only excellently matched kidneys are worth transporting between regions.
12
Injury: the British Journal of Accident Surgery Vol. 1 1/No. 1
TableL Example of renal donor patterns in three hospitals
Hospita/
Population (x 1 0 3 )
A
50
B
C
47
250
Diagnosis
Offers
Kidneys used
Head injury Subarachnoid haemorrhage Other
4
0
10 1
t2 0
Total
15
12
Head injury Subarachnoid haemorrhage Other Total
4
4
0 1 5
0 2 6
Head injury Subarachnoid haemorrhage Other Total
11
11
1 4 16
1 3 15
N E E D FOR K I D N E Y S
Although the rate of transplantation is slowly rising each year, nowhere is the need being met. Between two and three times as many patients require transplants as receive them. Let us consider how we can get them. Take, for example, two towns each with a population of about 50 000. Hospital A (Table I) made 15 offers resulting in 12 transplantable kidneys. Hospital B made 5 offers providing 6 kidneys. In hospital A all the fruitful donors died of subarachnoid haemorrhage whereas in hospital B almost all died of head injury. As both hospitals cover the majority of needs for their areas the differences are most likely due to differences in attitude of the doctors concerned. It is most unlikely that one hospital is so brilliantly successful with one condition and disastrously bad with the other. Another difference suggesting a major medical element in the shortage of kidneys is the comparison of hospital A with hospital C, which serves a population five times as large and has a neurosurgical unit. These two have made the same number of offers in the period while the difference in diagnosis is again seen. It is often asked whether a cadaveric renal transplant is worthwhile and what are the long term results. There are many factors affecting
the results of transplantation. The results of 247 first cadaveric renal transplants from Birmingham are compared with the results of radical surgery with intent to cure some of the common malignancies in patients in the 15-55 age group (Fig. 3). The kidney transplant survival curve does not equate to a patient survival curve. With adequate facilities for dialysis and retransplantation patient survival is much greater. At present, patients with failing transplants are in competition for further treatment with new patients in terminal renal failure. How then can a trauma surgeon play his part? It is by contacting the local transplant team every time he has a patient with a severe head injury who is unlikely to recover. When brain death has been diagnosed the fact that some good may come out of the tragedy may help the bereaved relatives. The offer of the potential donor does create extra work for the medical and nursing staff of the donor hospital and for this the transplant team and their patients can only say 'thank you'. The recent DHSS letter on the interpretation of the Human Tissue Act 1961, the combined Royal Colleges' document on the certification of brain death and your help should enable our patients to get the good quality kidneys they need.
Requests for reprints shouldbe addressed to: Mr A. D. Barnes, Director, Renal Unit, Queen Elizabeth Hospital, Birmingham.
