Changes in the clinical features and demographics of donors after brain death, before and after the establishment of a regional trauma center: 20 years of experience at a single center in Korea
Article information
Abstract
Purpose
Organ transplantation is considered the definitive treatment for end-stage organ disease. However, the scarcity of donor organs compared to the number of patients awaiting transplants is a major barrier. This study aimed to assess the impact of a regional trauma center on organ procurement and to provide a basis for future collaboration between regional trauma centers and transplant centers.
Methods
This retrospective study analyzed organ donors after brain death over a 20-year period from January 1, 2003, to December 31, 2022. It compared patients before and after the establishment of the regional trauma center, as well as trauma and nontrauma patients. The study investigated general patient characteristics and the number and types of donated organs.
Results
The average age of patients significantly increased from 37.75 years before the trauma center was established to 46.72 years after (t=–4.32, P<0.001). The organ acquisition rate significantly increased from 3.03 before to 3.47 after (t=–2.96, P=0.003). Suicide (t=6.52, P=0.011) and cardiopulmonary resuscitation cases were more common among nontrauma patients than among trauma patients (t=8.34, P=0.004). However, the organ acquisition rate was significantly higher among trauma patients than among nontrauma patients (3.53 vs. 3.21; t=2.04, P=0.004).
Conclusions
This study identified changes in the characteristics and donor organs of patients diagnosed with brain death after the establishment of a regional trauma center. Given the increase in the proportion of trauma patients and the rate of organ acquisition per capita post-establishment, efforts should be made to encourage organ donation from patients diagnosed with brain death through close collaboration between regional trauma centers and organ transplant centers.
INTRODUCTION
Background
Organ transplantation is the definitive treatment for end-stage organ disease; however, a significant challenge is the shortage of donor organs relative to the number of patients on the waiting list [1,2]. Since 1979, organ transplantation has been actively performed in Korea, with the number of successful transplants increasing from 849 in 2010 to 1,440 in 2014, and reaching 1,502 in 2018. To address this issue, the Korean government has introduced various support measures aimed at boosting the rates of organ donation and transplantation [3].
Changes in social perceptions of organ donation, the use of marginal donors, comprehensive evaluations of all patients with potential brain death, and advancements in donor management techniques and medicine have significantly enhanced organ procurement [4,5]. Organ donors are generally categorized into two groups: brain-dead donors and post-cardiovascular death donors. Recently, there has been a notable increase in the proportion of post-cardiovascular death donors [6]. However, in Korea, organ donation from patients who have suffered cardiovascular death is not yet possible, and brain-dead donors remain the sole source of organs [7]. Among organ donors, trauma-related cases account for 21.3% to 28.7% of brain deaths, ranking trauma as the third most common cause of brain death in these donors [1].
In Korea, trauma is the fourth leading cause of death, especially among individuals under 40 years, following cancer, circulatory diseases, and respiratory diseases [8]. Studies and data from the Korean Network for Organ Sharing (KONOS) indicate that from 2015 to 2020, traumatic brain injuries increasingly contributed to brain death among organ donors. Since 2021, however, the incidence of traumatic brain injuries has declined, whereas hypoxic brain injuries, resulting from oxygen deprivation, have become more prevalent [1,9].
The rate of organ donation among trauma patients varies widely, from 14.0% to 75.2% [10]. Organ donations following traumatic brain death yield a higher number of organs and kidneys of better quality compared to donations after nontraumatic brain death [11].
Gachon University Gil Medical Center, a tertiary hospital situated in Incheon, Korea, receives between 20 and 25 brain-dead donors each year and was ranked third in Korea in 2019. The hospital established a level I regional trauma center in 2014 and annually treats 3,000 to 3,500 trauma patients, of which 600 to 700 are severe cases.
Objectives
The objective of this study was to assess the impact of establishing a regional trauma center on organ procurement by analyzing the clinical characteristics and demographic variables of brain-dead organ donors before and after the center's establishment. This analysis aims to lay a foundation for future collaboration between regional trauma centers and organ transplant centers.
METHODS
Ethics statement
This study was approved by the Institutional Review Board of Gil Medical Center (No. GDIRB2023-333). The secondary data analysis study utilized electronic medical records and was conducted with a waiver of consent for the participants. The requirement for informed consent was waived due to the retrospective nature of the study.
Study design
This retrospective study aimed to identify differences in the clinical characteristics and demographic variables of patients who underwent organ transplantation following brain death, comparing periods before and after the establishment of a regional trauma center. The analysis utilized data from electronic medical records.
Description of participants
The study participants consisted of patients who underwent organ donation following brain death at our medical center over a 20-year period, from January 1, 2003, to December 31, 2022. These participants were categorized into two groups based on the timeline of the regional trauma center's establishment: the period before its establishment (January 2003 to December 2013) and the period after (January 2014 to December 2022). Demographic variables analyzed included age, sex, marital status, trauma status, and suicide status. Clinical characteristics encompassed cardiopulmonary resuscitation prior to organ donation, the cause of brain death, the use of inotropes and vasopressors, the duration of stay in the intensive care unit, and the type and number of organs donated.
Statistical analysis
The data were collected using IBM SPSS ver. 22.0 (IBM Corp). The clinical characteristics and demographic variables of the participants were analyzed through frequency analysis and descriptive statistics. Differences in clinical characteristics and donor organs between the two groups were assessed using the independent t-test and chi-square test. A P-value of <0.05 was considered statistically significant.
RESULTS
Demographic differences among participants before and after the establishment of the regional trauma center
Participants’ age significantly increased from 37.75 to 46.72 years after the establishment of the trauma center (t=–4.32, P<0.001). The proportion of suicide cases among participants rose from 11.5% to 21.3% after the trauma center was established; however, this increase was not statistically significant, nor was there a significant difference in the proportion of trauma patients. There were slight increases in the rates of patients receiving cardiopulmonary resuscitation and those suffering from head trauma, along with a decrease in the proportion of patients with cerebral aneurysms; however, these changes were not statistically significant. A significant decrease in the use of inotropes (t=56.83, P<0.001) and a significant increase in the use of vasopressors (t=28.55, P<0.001) were also observed (Table 1).
Comparison of demographic characteristics before and after the establishment of a trauma center
Differences in donor organs before and after the establishment of the regional trauma center
The acquisition rate significantly increased from 3.03 to 3.47 after the center was established (t=–2.96, P=0.003). Heart donations significantly increased from 21.8% to 45.3% (t=12.16, P<0.001), and lung donations from 0% to 28.0% (t=26.77, P<0.001). No significant differences were observed in kidney or liver donations between pre- and post-trauma center establishment. However, pancreas donations decreased overall, with a significant decrease in pancreas-kidney combined transplants (t=8.08, P=0.004) (Table 2).
Comparison of donated organs before and after the establishment of a trauma center
Demographic differences between trauma and nontrauma patients
Men were significantly more prevalent among trauma patients than among nontrauma patients (82.1% vs. 67.3%; t=5.56, P=0.018), while suicide cases were significantly more frequent among nontrauma patients (9.0% vs. 22.7%; t=6.52, P=0.011). Cardiopulmonary resuscitation was performed significantly more often in nontrauma patients than in trauma patients (26.9% vs. 46.7%; t=8.34, P=0.004). However, no significant differences were observed in the use of inotropes and vasopressors between the two groups (Table 3).
Comparison of demographic characteristics between trauma and nontrauma patients
Differences in donor organs between trauma and nontrauma patients
The acquisition rate was significantly higher for trauma patients than for nontrauma patients (3.53 vs. 3.21; t=2.04, P=0.004). Heart and lung donations were marginally higher among trauma patients than nontrauma patients; however, the difference was not significant. Kidney, liver, and pancreas donations did not significantly differ between trauma and nontrauma patients (Table 4).
Comparison of donated organs between trauma and nontrauma patients
DISCUSSION
Despite efforts by the KONOS, medical institutions, and medical staff, organ donation in Korea has not kept pace with the increasing number of patients awaiting transplants [1,12]. While living donors constitute the majority of organ donations in Korea, and their numbers have risen over the years, the number of brain death donors has remained relatively unchanged [1].
This study aimed to assess the impact of establishing a regional trauma center in Korea on brain death organ donation. It sought to identify differences in the characteristics of trauma and nontrauma patients, as well as variations in the organs transplanted. Additionally, the study aimed to provide a foundation for collaboration between regional trauma centers and organ transplant centers to promote organ donation.
In this study, the average age of patients diagnosed with brain death increased significantly following the establishment of the regional trauma center. Previous research has similarly noted a rise in donor age, which has been attributed to advancements in medical care and improvements in socioeconomic status [13,14].
In this study, there was no significant increase in the proportion of trauma patients before and after the establishment of the regional trauma center. This outcome can be attributed to the fact that the medical institution was already treating a large number of trauma patients prior to the establishment of the trauma center in 2014.
However, previous studies have reported that after the establishment of regional trauma centers, the distribution of brain-dead donors, previously concentrated in metropolitan areas, shifted significantly towards regions with these centers. By 2019, organ donations at nine regional trauma centers had increased by 75.9%, rising from an average of 39.8 cases to 70.3 cases [15].
Therefore, future multicenter studies should include other regional trauma centers, especially those that have not previously treated a high volume of trauma patients, to control for these variables. Conducting such follow-up studies would offer a comprehensive understanding of the impacts of establishing regional trauma centers from various perspectives.
The proportion of suicidal patients also increased from 11.5% to 21.3%, likely reflecting the overall rising suicide rate in Korea [8,15]. Previous studies indicate that the suicide rate per 100,000 population rose from 15.1 in 1999 to a peak of 31.7 in 2011. Despite annual fluctuations, this rate consistently remained above 20%, reaching 26.9 in 2019. Thus, the observed increase in the proportion of suicidal patients seems to mirror the escalating suicide rates in Korea [8,10].
Cerebrovascular disease has seen a slight decline, while the incidence of head trauma has risen, likely due to the increased number of severe trauma cases following the establishment of regional trauma centers. There is a growing trend in organ donations from patients who are declared brain dead due to trauma, both in Korea and internationally [10,11,16]. It is believed that regional trauma centers enhance the initial survival rates of many marginal donors by providing aggressive treatment for severe trauma cases [17]. Further research is needed to substantiate these findings. Additionally, a follow-up study that accurately determines the proportion of patients diagnosed with brain death from head trauma in regional trauma centers, and identifies the donor organs, would provide a clearer understanding of the impact of these centers.
In this study, we observed a decrease in the use of inotropics (dopamine and dobutamine) and an increase in the use of vasopressors (norepinephrine and vasopressin) following the establishment of the regional trauma center. Medications administered as a bolus during cardiopulmonary resuscitation were excluded from this analysis, which focused solely on those used in the intensive care unit. This shift in medication use is likely attributable to updated treatment guidelines that emphasize reducing the inflammatory response in brain death, enhancing oxygenation, and aggressively managing hemodynamically unstable patients to maintain stability and preserve potential organ donors [17,18]. This change is not directly related to the establishment of regional trauma centers. Furthermore, previous studies have reported that dopamine does not have beneficial effects on multi-organ donation in brain-dead patients. Research supporting the efficacy of norepinephrine and vasopressin in managing critically ill and brain-dead patients further corroborates these findings [19–21].
After the establishment of the regional trauma center, the per capita organ acquisition rate among patients diagnosed with brain death improved from 3.03 to 3.47. According to data from KONOS, the organ retrieval rate increased from 3.14 to 3.25 organs per donor before the establishment of regional trauma centers (2009–2013) to 3.24 to 3.58 organs per donor after their establishment (2014–2023) [1]. This increase is likely attributable to improved resuscitation rates for marginal donors and the impact of organ donation campaigns. However, in Japan, the retrieval rate was significantly higher, at 5.3 organs per donor, as of 2015 [22].
Therefore, Korea must not become complacent with the current upward trend. Continued efforts are needed to improve societal perceptions of organ donation and provide sustained national-level support. As part of these efforts, advancements in regional trauma centers should aim to enhance the initial resuscitation rates of marginal donors. Furthermore, active collaboration between regional trauma centers and organ transplant centers will be essential to maximize the potential for organ donation.
In addition, the rate of heart and lung transplantation significantly increased after the regional trauma center was established. This necessitates further studies to determine whether the rise can be attributed to the center's establishment or to advancements in technology and donor availability by 2014.
The study compared trauma and nontrauma patients diagnosed with brain death, revealing a significantly higher proportion of men in the trauma group. This disparity is likely due to the greater number of men engaged in active social and economic roles, as well as those employed in fieldwork [23,24]. Among nontraumatic patients, suicides were more prevalent than in the traumatic group. These were categorized into two types based on the method used: those resulting in head trauma, such as falls and traffic accidents, and those leading to decreased brain perfusion, such as hanging [1]. In the medical institution where this research was conducted, cases of suicide involving hanging or poisoning are managed at the regional emergency medical center. Conversely, cases resulting from injury mechanisms like falls or stab wounds are treated at the regional trauma center.
Hanging and similar cases are not classified as trauma, but rather as instances of hypoxic brain injury due to reduced cerebral perfusion. Therefore, they are categorized as nontrauma cases. In the classification of causes of brain death among brain-dead donors, hanging is distinctly categorized under asphyxia or hypoxic brain injury instead of trauma [1]. Additionally, numerous previous studies have also classified hanging separately from trauma [25], and this study adhered to the same classification criteria. Future follow-up research is recommended to refine and develop more precise classification systems by further subdividing the various methods of suicide and mechanisms of injury.
Korea's suicide rate is the highest among Organization for Economic Cooperation and Development (OECD) countries, significantly contributing to the incidence of brain deaths [10]. Consequently, it is crucial to explore ethical and policy options for organ donation and the subsequent follow-up care for these patients.
Trauma patients exhibit a higher per capita organ acquisition rate (3.53 organs) compared to nontrauma patients (3.31 organs). Additionally, trauma patients tend to have a higher organ acquisition rate and procure kidneys of superior quality compared to nontrauma patients. This necessitates the development of institutional and ethical frameworks to encourage organ donation from patients who are brain-dead due to trauma [11].
Overall, organ retrieval rates have risen following the establishment of trauma centers, especially among trauma patients. This indicates that the creation of trauma centers contributes to an increase in the availability of organs for transplantation. An earlier study by Lee [15] noted that after regional trauma centers were established, brain-dead organ donation increased across various regions, moving away from a system centered in metropolitan areas. This shift toward decentralization has likely improved organ utilization by enabling transplants in a broader range of locations.
Prepared organs are sometimes discarded when recipients are in poor condition or pass away. The concentration of brain-dead donors and organ transplants in metropolitan areas also poses challenges, particularly regarding the timely transportation of prepared organs. Expanding brain-dead donor procurement and organ transplantation activities to a broad range of regions could address these shortcomings. Moreover, hospitals with regional trauma centers but without transplant centers must collaborate closely with nearby transplant centers to ensure a swift and efficient organ allocation system, thereby maximizing the number of recipients who can benefit.
Limitations
This study identified differences in the characteristics of patients diagnosed with brain death and their donor organs before and after the establishment of a regional trauma center. However, it had some limitations. Being a retrospective study conducted at a single institution, the results are not generalizable, and future multicenter prospective studies are recommended.
Conclusions
Through this study, we were able to confirm the impact of the establishment of regional trauma centers on brain dead donors and organ transplantation. Considering the increase in the proportion of trauma patients and the rise in the number of organ acquisition per donor after the establishment of regional trauma centers, efforts should be made to promote organ donation from brain dead donors through close collaboration between regional trauma centers and organ transplantation centers in the future.
Notes
Author contributions
Conceptualization: all authors; Data curation: STC, DJK, WSL; Formal analysis: MJJ, STC, GJL; Visualization: all authors; Writing–original draft: all authors; Writing–review & editing: all authors. All authors read and approved the final manuscript.
Conflicts of interest
Gil Jae Lee is the co-editor-in-chief of this journal, but was not involved in the peer reviewer selection, evaluation, or decision process of this article. The authors have no other conflicts of interest to declare.
Funding
The authors received no financial support for this study.
Data availability
Data analyzed in this study are available from the corresponding author upon reasonable request.