STRATEGIES IN RENAL TRANSPLANTATION: The Philippines in Focus Ma. Nisan T. Manauis, RN, MAN, CRNC Founding President, Phil. Society of Transplant Nurses
International Society for Organ Donation and Procurement (ISODP)
STRUGGLES OF A DECEASED STRUGGLES DONOR PROGRAM PROGRAM IN IN A DEVELOPING COUNTRY : PHILIPPINES
Manauis, MNT; Pilar, KAM; Lesaca, RJ; Danguilan, RA; Ona, ET National Kidney and Transplant Institute
Number of Transplants Transplants accord according ing to Donor Source 2002 - 2008
The Philippine Health Status Population (2007) 88.6M 10 LEADING CAUSES OF MORT MORTALITY ALITY (Department of Health, 2005)
1. 2. 3. 4. 5. 6. 7. 8. 9.
Dise Diseas ases es of the the Hea Heart rt Diseas Diseases es of the the Vascula ascularr Syst System em Mali Malign gnan antt Neop Neopla lasm sm Pneumonia Accidents Tuber ubercu culo losi sis, s, all all form formss Chron Chronic ic Lower Lower Respir Respirato atory ry Diseas Diseases es Diabet abetes es Mel Melli litu tuss Condi Conditio tions ns origin originati ating ng in peri peri-na -natal tal period 10. Nephriti Nephritis, s, Nephrotic Nephrotic Syndrome Syndrome & Nephrosis
National Bureau of Investigation REPORT, 2000 • 5 Trauma deaths/day in Metro Manila alone • 1825 potential donors per year • 3650 potential kidneys for transplant
Struggles of a Deceased Donor Program in the Philippines • Objective ▫ To describe the difficulties and struggles in developing and maintaining the Deceased Donor Program in the Philippines and to present the outcome from 2002-20 2002-2008. 08. • Methodology ▫ Descriptive study ▫ Review of data from the National Organ Procurement Organization
Number of Deceased Donor Referrals 2002 - 2008 ONLY ONL Y 62 / 1825 (3%) ( 3%) OF POTENTIAL PO TENTIAL DONORS ARE REFERRED REFER RED ANNUALLY ANNUALLY
Sources of Deceased Donor Referrals 2002-2008 NUMBER OF REFERRALS (%) TYPE OF HOSPITAL GOVERNMENT GOVERNMENT
278 (64)
PRIVATE
156 (36)
HOSPITAL AREA E.R.
346 (89)
ICU
48 (11)
Causes of Deceased Donor Death 2002 - 2008 NUMBER OF CASES (%) TRAUMA
380 (88)
MEDICAL
54 (12) CVA
40 (9)
CEREBRAL ANOXIA
6 (1)
PRIMARY BRAIN TUMOR
8 (2)
Consent Challenges 2002 - 2008
NUMBER (%)
PRODUCTIVE CONSENT
191 (44)
UNPRODUCTIVE CONSENT
241 (56)
DELAYED CONSENT
61 (14)
REFUSED
65 (15)
NOT APPROACHED
115 (27)
Reasons for Low Consent Rate • Low level of awareness of Deceased Organ Donation (98%) TCs are inappropriately accused of hastening donor’s death TCs are reported to the police as trying to steal organs •
•
• Inability to understand the concept of brain death •
Death was understood as cessation of heartbeat
Medical Professional Professional Challenges • Refusal of Attending Physicians to sign the Death Certificate form • Hospital Administrators of private hospitals are not supportive of Deceased Organ Donation and refuse to allow organ retrievals in their facility
Logistical Challenges • Poor laboratory facilities in referring hospitals • Inadequate medical supplies for resuscitative measures • No prioritization in booking commercial flights for the retrieval team and limited available flights
Logistical Challenges • Organs not allowed to be hand carried, but are checked in as regular luggage • Lack of knowledge on Deceased Organ Donation by airport security in transporting organs
Number of Organs Retrieved 2002 - 2008 AN AVERAGE AVERAGE OF O F ONLY ONLY 20 KIDNEYS KIDNEY S OR 10 DONORS DONO RS PER YEAR
Number of Kidneys Retrieved vs Wasted Kidneys 2002 - 2008
CONCLUSION • Philippine Deceased Donor Program is still in its infancy despite the existence of an organ procurement organization organization for almost 3 decades and an Organ Donation Law since 1991 • Low level of awareness of the deceased donor program amongst the general public, airport personnel and government employees
CONCLUSION • There is an urgent need to intensify the educational advocacy campaign on organ donation in both the private and public sectors to improve the deceased donor program • The medical community likewise needs support in donor management and evaluation to improve i mprove the acceptance of organs from deceased donors to avoid wastage of kidneys.
RESUSC RESU SCIT ITA ATI TING NG TH THE E DECEASED DONOR PROGRAM
Manauis, MNT; Suguitan,MG; Lesaca, JRJ; Danguilan, RA, Ona, ET
NATIONAL KIDNEY AND TRANSPLANT INSTITUTE Quezon City, PHILIPPINES
Human Organ Preservation Effort
National Kidney and Transplant Institute’s Organ procurement arm Established in 1983
• Service ▫ Acts as National Organ Procurement Organization
Philippine Donor Source • Despite 18 years of existence, the Deceased Donor Program’s potential to save lives has not been fully maximized.
Objectives • Review the problems in organ procurement of the Deceased Donor Program • Identify and implement effective strategies to improve organ yield
Methodology • In June 2001, a system review of the Deceased Donor Program was done using performance reports as guide to determine system flaws. • Alternative solutions were drawn October 2001. • Solutions were implemented 2002-2004. • Institutionalization was done January 2005. • Frequencies and percentages were used to measure outputs annually from 2002-2008.
Problems Identified • • • • •
Low referral and consent rates Delayed response time to referrals Poor Donor Management Inadequate logistics Prolonged laboratory laboratory screening and ischemia time
Alternative Solutions • Low referral / consent rates ▫ ▫ ▫ ▫
Intensified Hospital Development activities Intensified Community Outreach activities Designated Hotline for referrals Designated Donor Coordinators for network hospitals
• Delayed Response Time to Referrals ▫ ▫ ▫ ▫
Revised flow chart of the donation process Acquisition of mobile phones for each TC Direct referrals to TCs Trained TCs to evaluate and screen potential deceased donors
Alternative Solutions • Poor Donor Management ▫ Improved Donor Management protocols ▫ Empowered networks for timely referrals ▫ Trained TCs on donor management ▫ Provided pocket sized donor management guides and checklists
• Inadequate logistics ▫ Provided stocks dedicated to donor management ▫ TCs facilitated donor screening procedures and assumed costs ▫ Financial management of organ donation activities ▫ Regular audit of processes
Alternative Solutions • Prolonged Laboratory Screening Time ▫ Set turnaround times for screening procedures ▫ Direct access to laboratory results of potential donors ▫ Immunology staff on call for screening procedures
• Prolonged Ischemia Time ▫ Improved donor management for closer retrieval time to transplant ▫ Designated Placement Coordinator to facilitate organ placement ▫ Improved Enlistment process ▫ Prioritization in OR time for deceased donor organ transplant
Outcome Parameters 2002
2008
REFERRAL
32
112
CONSENT
20
42
RESPONSE TIME TO REFERRAL
4hrs
1hr
LABORATORY SCREENING
5hrs
2.5hrs
33hrs
16hrs
None
$1,000
10
28
ORGAN PROCUREMENT PROCESS
ISCHEMIA TIME LOGISTIC AL SUPPORT REVOLVING FUND ADVOCACY PROGRAMS NETWORK HOSPITALS
Results
Conclusion
• An improvement in response time to donor referrals, reduction in time to get results from laboratory laboratory screening, improved donor management, management, shortening of cold ischemia time and improved logistical support led to an increase in deceased organ donor yield • Constant audit of processes and strategic planning are vital to enhancing the potentials of the Deceased Donor Program.
Conclusion • There has been a steady increase in the numbers of KT from deceased donors through 2008, but remains at <10% of all transplants
34
A GOVERNMENT REGUL REGULA ATED PROGRAM FOR LIVING NONRELATED KIDNEY DONATION IN THE PHILIPPINES
N Manauis, K Pilar, R Lesaca, R Danguilan, R Uriarte, E Ona
National Kidney and Transplant Institute Quezon City, PHILIPPINES October 2009
NATIONAL NA TIONAL KIDNEY AND TRANSPLA TRANSPLANT NT INSTITU INSTITUTE TE
• Largest tertiary referral center for kidney diseases and transplantation in the Philippines • Performed 368/679 (54%) kidney transplants in 2008
PREVALENCE PREVALE NCE OF DIA DIAL LYSI YSIS S PATIEN TIENTS, TS, NEW PATIENTS STARTING DIALYSIS and NEW KIDNEY TRANSPLANT PATIENTS
PHILIPPINE RENAL DISEASE REGISTRY REGISTRY
DONOR SOURCE OF FILIPINO KIDNEY TRANSPLANTS Number of Transplants Transplants
(67%)
(28%)
(5%) PHILIPPINE RENAL DISEASE REGISTRY REGISTRY
Department of Health issued Administrative Order No. 124 in June, 2002
“A National Policy on Kidney Transplantation from Living Non-Related Donors”
OBJECTIVES • Describe the regulations set-up by the Department of Health to safeguard the LNRD from exploitation and abuse • Look at the medical and economic outcome of LNRDs enrolled under this program at the National Kidney and Transplant Institute
SALIENT POINTS • Creation of the National Transplant Ethics Committee • Establish Hospital Transplant Ethics Committee in every transplant facility to evaluate all LNRDs • Prohibition of organ sale • Accreditation of transplant facilities
SALIENT POINTS cont • Creation of a National Kidney Transplant Candidate Waiting List and LNRD Registry •
•
•
Centralized allocation of kidneys from LNRDs Creation of a Donor Monitoring Unit in each transplant facility 10% cap on allocation to foreigners
SALIENT POINTS cont •
Providing donors the following•
Medical follow-up for 10 years
•
“Gifts of gratitude” •
Reimbursement of lost income during the donation process, operation and recovery
•
Health and Life insurance
•
Educational plan
•
Employment opportunities or livelihood training
Amended Administrative Order Orde r, March 2008 •
•
Created Philippine Board of Organ Donation and Transplantation Established the Philippine Network of Organ Donation and Transplantation ransplantati on (PHILNETDAT) (PHILNETDAT) •
•
National agency charged to oversee all aspects related to organ donation and transplantation
Strict enforcement of regulations with sanctions to all hospitals with accredited transplant programs and its health practitioners
DEPT OF HEALTH HEALTH
PHIL. BOARD OF ORGAN DONATION DONATION AND A ND TRANSPLANTATION
PHILNETDAT
NATL TRANSPLANT ETHICS COM
RESULTS • 2004 -2007 • DEMOGRAPHICS ▫ 80% Males ▫ Age 21- 40 years (68%) ▫ Single 55%
RESUL RESU LTS cont NUMBER (%) NUMBER OF DONORS EVALUATED
1266
ACCEPTED
278 (22)
REJECTED
988 (78) RETRACTED CONSENT
605 (61)
SALE
120 (12)
MEDICALLY UNSUITABLE
173 (17)
ETHICS DISAPPROVED
90 (9)
RESULTS cont • 163 donors transplanted since 2007 • 78% complied with medical follow-up schedule • Trace proteinuria in 3 donors, but resolved after 6 months • Hypertension in 1 donor at 4-years post donation
MEAN SERUM CREATININE POST-DONATION N=127/163
TIME POST-DONATION POST-DONATION
EMPLOYMENT PRE-DONA EMPLOYMENT PRE-DONATION TION AND 6 MONTHS POST- DONATION POST-DONATION N=161 NUMBER (%)
EMPLOYMENT STATUS
PRE-DONATION N=163 NUMBER (%)
UNEMPLOYED
21 (13)
9 (6)
BLUE COLLAR
136 (83)
5 (3)
WHITE COLLAR
2 (1)
3 (2)
SMALL SCALE ENTREPRENEUR
4 (2)
144 (89)
AVERAGE DAILY INCOME (USD$)
$ 5.40
$ 18.00
CONCLUSIONS • Majority of LNRDs were male, single, age 21-40 • At 4 years follow up ▫ Improved socio-economic status ▫ Normal renal function
• A government regulated LNRD Program can provide equitable donor allocation that can safeguard donors’ rights, avoid donor exploitation and organ sale
CONCLUSIONS • A regulated program is a viable option to the organ donor shortage • Long-term follow-up is needed to determine if the economic improvement of donors is maintained
New Issuances • AO 2010-0018 ▫ No more transplants from LNRD ▫ Main donor sources
LRD DDP
DOH, Philippines
The Challenge • DM and HTN are leading causes of ESRD. How can a patient get transplanted when he could not get a donor from his own family? ▫ When a family family member member is eligible eligible but doesn’ doesn’tt want want to donate, shall he be coerced into donating as that is the only recourse?
• Nearing its 3rd decade of existence, the DDP has only provided <10% of the total transplants in the Philippines. How long will the patients with above condition wait to get transplanted? transplanted? Will
- JACK KEROUAC
