Organ Donor Potential Increases Despite Rising Numbers of Decompressive Craniectomies

Background

The number of organ donations in Germany fell by 28%, from 1296 to 932, in the period from 2010 to 2019 (1). By analyzing all German hospital cases, we have previously shown that this is due to a deficiency in the recognition and reporting of potential organ donors (2). In addition, our study suggested that the organ donation potential in Germany has increased in recent years. However, several studies have shown that patients with severe brain damage benefit from a decompressive craniectomy (for example, see [3]). It is therefore conceivable that the decompressive craniectomy procedure has been increasingly performed in patients with severe brain damage in recent years. As a result, fewer patients would have suffered an irreversible loss of brain function, as they were either saved by this measure or died from another complication. Therefore, in contrast to what we previously claimed (2), these patients would not have been considered as organ donors. In turn, the detection and reporting deficiencies are also likely to have been overestimated.

Methods

To examine the relationship between the number of craniectomies performed and the organ donor potential, we examined the hospital billing data for all inpatient treatment cases from 2010 to 2016 across Germany (n = 131 236 558). Potential organ donors were detected in a four-step process with the aid of 707 different ICD codes: all cases of death of the respective year were identified (1^st step); of these, the cases with patients for whom the main or secondary diagnoses indicated primary or secondary brain damage were selected (2^nd step), Next, all cases in which organ donation was contraindicated were excluded (3^rd step). As an irreversible loss of brain function is defined by a failure of spontaneous breathing (among other things), the fourth step excluded cases with patients for whom invasive ventilation was not used before death. This analysis algorithm was developed by the German Organ Transplantation Foundation (Deutsche Stiftung Organtransplantation; DSO) and evaluated in several studies (2). In a further, additional 5^th step, the OPS code 5–01 (of the German procedure classification code) was used to determine the proportion of possible organ donors who received decompressive craniectomy. Hospital performance data was analyzed by the data service of the German Federal Statistical Office. At the time this study was submitted to this journal, the hospital billing data was available up to 2016. The analysis algorithm used is shown in Figure 1.

Figure 1

Presentation of the applied analysis algorithm

Results

The number of potential organ donors in Germany increased by 17.3% from 2010 to 2016, from 23 937 to 28 087 (Figure 2). First, this increase can be explained by an increase in cases of death from primary or secondary brain damage. The number of these cases rose by 5.2%, from 65 080 cases in 2010 to 68 445 cases in 2016. Second, a larger proportion of patients with brain damage but with no contraindication for donation received invasive ventilation. This proportion increased from 40.8% to 46.3% (relative increase 13.5%). The number of decompressive craniectomies performed on the identified potential organ donors increased by 17.4%, from 2060 to 2419 (Figure 2). Accordingly, the proportion of potential organ donors in whom a craniectomy was performed remained constant over the period under review, at 8.6% in 2010 as well as in 2016 (Figure 2).

Figure 2

Number of potential organ donors and decompressive craniectomies performed in Germany

Discussion

The data collected here suggest that the organ donation potential in Germany has not decreased due to an increase in the number of craniectomies performed. Indeed, while the number of craniectomies increased during this period, there was a parallel increase in the number of potential organ donors. As such, this development is not due to a changed neurosurgical procedure but rather to an increase in the number of cases. This analysis therefore suggests that the organ donation potential increased during the period under review, despite rising numbers of decompressive craniectomies.

This finding again illustrates where the core problem of the German organ donation system lies: despite a high number of potential organ donors and consistently high levels of acceptance of organ donation in the population for years (4), the organ donation rate in Germany remains very low due to a deficiency in the recognition and reporting of potential organ donors. To improve this deficiency, the German law for Amelioration of Cooperation and Structure of Organ Donation (Stärkung der Zusammenarbeit und der Strukturen bei der Organspende; GZSO) came into force on 1 April 2019. Changes since then include that the reporting and implementation of organ donations have been significantly better compensated, and that transplant coordinators have to be released for their tasks, among other things. While the organ donation rate has not yet increased significantly, a central element of the GZSO is not yet in effect. Namely, according to the law, every hospital licensed for organ removal must now report its organ donation potential annually and be accountable for why potential organ donors were not reported. The DSO will obtain these data for the first time on 30 June 2020 and will publish them thereafter (5). As the same general conditions apply to all removal hospitals, the internal processes in hospitals that do not realize their organ donation potential must be evaluated. It is to be hoped that this process will lead to an increased number of organ donations in Germany in the future, such that it reaches an international level.

Kevin Schulte, Grit Esser, Christoph Borzikowsky, Benedikt Kolbrink, Ulrich Kunzendorf, Thorsten Feldkamp

Clinic for Nephrology and Hypertension, University Hospital of Schleswig-Holstein, Christian-Albrecht University of Kiel, Germany (Schulte, Esser, Kolbrink, Kunzendorf, Feldkamp), [e-mail]

Department of Medical Informatics and Statistic, Christian-Albrechts-Universität of Kiel, Germany (Borzikowsky)

Conflict of interest statement
Prof. Feldkamp has served as a paid consultant for Bristol-Myers-Squibb (BMS), Roche, Novartis, Fresenius, Chiesi, Teva, Neovii, and Sanofi and has received royalties from Novartis. He has received reimbursement of meeting participation fees and travel expenses as well as payment for lectures from Sanofi, BMS, Astellas, Chiesi, and Novartis. He has received reimbursement of meeting participation fees and travel expenses from Biotest and payment for lectures from Fresenius, Roche, and Hexal. He has received study support (third-party funds) for carrying out commissioned studies from Chiesi, BMS, Astellas, Novartis, Hexal, and Teva.

The remaining authors declare that no conflict of interest exists.

Manuscript received on 20 March 2020, revised version accepted on 7 May 2020.

Translated from the original German by Veronica A. Raker, PhD

Cite this as:
Schulte K, Esser G, Borzikowsky C, Kolbrink B, Kunzendorf U, Feldkamp T:
Organ donor potential increases despite rising numbers of decompressive craniectomies. Dtsch Arztebl Int 2020; 117: 542–3. DOI: 10.3238/arztebl.2020.0542

References

1. Deutsche Stiftung Organtransplantation: Organspende und Transplantation in Deutschland. Jahresbericht 2019. Frankfurt/Main: Deutsche Stiftung Organtransplantation 2020.

2. Schulte K, Borzikowsky C, Rahmel A, et al.: Decline in organ donation in Germany—a nationwide secondary analysis of all inpatient cases. Dtsch Arztebl Int 2018; 115: 463–8

3. Vahedi K, Vicaut E, Mateo J, et al.: Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL trial). Stroke 2007; 38: 2506–17

4. Bundeszentrale für gesundheitliche Aufklärung (BZgA): BZgA Repräsentativbefragung. www.organspende-info.de/infothek/studien (last accessed on 18 March 2020).

5. Deutsche Stiftung Organtransplantation: Vereinbarung zur Tätigkeit und Finanzierung von Transplantationsbeauftragten. www.dso.de/SiteCollectionDocuments/KH_Vereinbarung_Finanzierung_Transplantationsbeauftragte_11.11.2019.pdf (last accessed on 18 March 2020).