Not much sets the world of transplant medicine abuzz. But in the early 2000s, a creative idea in Missouri got everyone in the field talking.
For the first time, organ donors who were declared brain-dead were moved out of the hospital and into an independent, freestanding center to have their organs removed. With these patients out of the precious and limited ICU beds, the hospital could devote its time and resources to living patients. At the freestanding center, staff could focus on getting organs into the best shape possible before the grafts made their way to people on the transplant waitlist.
“When we started, we had no idea how it was going to take off,” said Gary Marklin, chief medical and research officer at Mid-America Transplant in St. Louis. Mid-America is an organ procurement organization, one of 56 nonprofits across the country that manages the flow of donated organs.
It turned out to be a popular idea. Today, up to 30 of these donor care units or “recovery centers” are open across the country. Nearly half of organ procurement organizations operate one. No official list exists, because the centers aren’t regulated the same way as hospitals or transplant centers. But experts count about 11 independent units. They have small ICUs, fully stocked operating rooms, and a staff of medical personnel. Another 15 to 19 are based in hospitals, but devoted to only brain-dead organ donors.
The widely adopted idea — that it’s more efficient to concentrate supplies and expertise on organ donors at a separate clinic — seems to be proving out in some ways. Studies report more organs make it to transplant when a donor is moved out of the hospital ICU and into a separate recovery center. But questions remain about whether that translates into better outcomes for transplant recipients.
Only about 20% of organ donors produce lungs healthy enough to be transplanted. In 2022, there were 2,743 lung transplants performed in the U.S. and 3,161 candidates added to the list.
A new study of 11,000 organ donors between 2017 and 2022 found a slight disparity in outcomes between patients moved into hospital-based donor care units versus those who went out into independent centers.
Lung transplants fared better — the grafts survived four months longer, on average — when they had come from hospital-based donor care units, as opposed to freestanding centers. The result, published in JAMA Network Open on Tuesday, “was unexpected,” said lead author Emily Vail. It’s not clear to the researchers why lung grafts lasted longer when they came from hospital-based units.
They theorize that different donor management or selection could be to blame. Independent donor care units may be accepting patients who have a greater number of underlying conditions or lungs with more injuries, for example. Certain characteristics aren’t captured in the data, said Vail, who is an assistant professor of anesthesiology and critical care at the University of Pennsylvania Perelman School of Medicine. It’s also possible that existing relationships between transplant programs and donor centers mean organs of higher or lower quality might be accepted there.
Vail and her colleagues found that donors who went to independent care units spent less time there than donors at hospital-based ones. That could imply a more swift process at freestanding centers. “However, it may also imply that there are some lost opportunities to provide more rehabilitation and therapy,” and get better organs, she told STAT. That could mean treatment with antibiotics or other medications, or procedures to clear up any issues in the body.
Marklin, a pulmonologist and critical care physician, isn’t convinced a four-month difference will be clinically significant — that is, make a difference in patients’ lives. And while he acknowledged the study’s findings, he pointed to the paper’s retrospective design (“Things change in five years,” he said) and the chosen comparison groups. His experience as an expert on donor care units, and an author on over a dozen best-practice studies, has shown him how little consistency there is across the country.
In New Orleans, they do things differently than the team in Pittsburgh does it. Houston’s two units (a couple of blocks apart) might have distinct protocols from each other. Orlando is another story altogether. Late last year, Marklin and other investigators published a study in the New England Journal of Medicine showing IV infusions of the hormone replacement drug levothyroxine didn’t result in more hearts being transplanted. The finding went against decades of clinical practice. “I talk to people and they still haven’t stopped the T4,” he told STAT.
For that reason, Marklin said it’s not fair to lump together a bunch of independent donor units and hospital-based units. He and Vail agree on one point: More research needs to be done to establish the best ways to manage an organ donor. In the absence of any clear standards or rigorous trials of different approaches, each unit has been figuring things out on its own, and through word-of-mouth from other centers.
“We owe it to patients in the health care system to understand if this is really better for everyone,” Vail said.
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