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INTRODUCTION

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Solid organ transplantation remains the only lifesaving option for an increasing number of patients. Transplantation is now the treatment of choice for end-stage kidney, liver, pancreas, heart, lung, and intestine failure patients who have no contraindications to transplantation. In addition, there is an increasing demand for bone, skin, and other tissues from brain dead donors used in the treatment of other disease processes. However, the number of people requiring organ transplants is simply higher than the number of organs available. Newer approaches such as xenotransplantation and bioengineering are still in experimental stages,1 and despite advances in living-related solid organ transplantation the majority of transplant recipients remain dependent on cadaveric organ donors. With improved supportive care for patients with advanced organ failure and expanded indications for transplantation the gap between demand and supply of organs is continually increasing (Fig. 50-1). Every 10 minutes, someone is added to the national transplant waiting list and on average, 21 people die each day while waiting for a transplant [http://optn.transplant.hrsa.gov]. Currently in the United States, there are 123,337 patients active on the waiting list. In the year 2014, a total of 29,533 solid organ transplants were performed from 14,412 donors, of whom 8594 were deceased donors and 5818 were living donors. One promising strategy to decrease the gap between the organ donation need and supply is to increase the available donor pool. It is estimated that the actual number of donors in the United States represents about one-third of the potential number of donors, and there certainly is room for improvement.2

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FIGURE 50-1

Total number patients on transplant waiting list in the United States and number of deceased donors and transplants from deceased donors from 2003 to 2013. (Organ Procurement and Transplantation Network. http://optn.transplant.hrsa.gov. Accessed March 2015.)

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Traumatic brain injury is the second most common cause of death leading to cadaveric solid organ donation closely following cerebrovascular accidents/stroke (Fig. 50-2). Clinicians caring for severely injured patients play a key role in the initiation and implementation of the organ donation process. Early recognition of potential organ donors is critical to maximizing the available pool of donor organs and the number of transplantable organs per donor. It is essential for those caring for potential organ donors to be knowledgeable about the criteria and process for declaring brain death and the physiologic effects of brain death. Familiarity with local organ procurement organizations (OPOs) is important because of the vital role they play in counseling the families of potential organ donors and coordinating the transplant process. Lastly, following the declaration of brain death, treatment priorities aimed at minimizing brain injury require adjustment. Physiologic support is then directed at maintaining perfusion of potentially transplantable organs assumes priority, and timely initiation of this support is crucial to increasing the probability of successful transplantation.

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