Scottish Donation and Transplant Group written update: April 2024

National Organ Retrieval Service (NORS) activity update

Update given by:

• Chris Johnston, Consultant Transplant Surgeon/NORS representative

Retrieval team activity and results

As detailed above, activity for the Edinburgh National Organ Retrieval Service (NORS) team has continued to increase, with 175 multiorgan retrievals last year, compared to a historical five year average of 150.

Normothermic Regional Perfusion (NRP) is a specialist technique used at the time of Donation after Circulatory Death (DCD) organ retrieval to re-establish an oxygenated blood supply to the abdominal organs shortly after asystole prior to organ retrieval. It allows for dynamic functional assessment of the liver ‘in situ’ and has been shown to dramatically improves outcomes of DCD liver, kidney and pancreas transplantation (reducing the DCD liver retransplant rate from 20% to 1%). The proportion of DCD donors remains high (at 60%); Edinburgh is again this year the busiest NRP team in the UK (76 NRP retrievals) and has maintained one of the lowest organ injury rates of all UK centres.

Recruitment challenges and service threats

Confirmation of funding for staffing of new and replacement positions in NHS Lothian has been very difficult over the last 12 months, amounting to effectively a recruitment freeze. Over 50% of all livers transplanted in Edinburgh over the last year involved NRP (a 6-fold increase in 4 years) and this has been achieved with less than a full complement of staff for the perfusion team (five rather than six members). With an average NRP retrieval call out lasting 15 hours, this has placed an unprecedented and unsustainable strain on the service. 

29 DCD donors were attended by the Edinburgh team without NRP last year and many other out-of-region donors that our team could have attended with NRP were not possible due to a lack of perfusion availability (500 out-of-region DCD liver offers per year; with conservative estimates that at least 50 would be suitable for liver transplantation after NRP). Our Band 7 perfusion team lead is about to move to a PhD fellowship with Edinburgh University; if a suitable replacement appointment cannot be made in the very near future, this may ultimately lead to suspension of the NRP service with an immediate considerable impact on liver transplantation activity.

Delays in recruitment across NHS Lothian are impacting the following domains:

• perfusion service – as detailed above, a team of six perfusion specialists is required for a full-time service, this will imminently reduce to less than four full-time equivalent posts
• consultant Transplant Surgeons – replacement of two consultant liver transplant surgeons has been delayed, placing unsustainable pressure on both the liver transplant and NRP surgeon on call rotas (more than 1 in 3 on call for surgeons contributing to both rotas)
• transplant surgical fellows – recruitment of surgical fellows has also been delayed. The transplant service has benefited from some exceptionally talented and motivated surgical fellows over the last five years. The delay in recruitment for positions due to start in August will have an immediate impact on both retrieval and transplant impact activity, placing further strain on (currently understaffed) consultant rotas

OrganOx (NMP)

The OrganOx machine allows for a liver that has already been retrieved (possibly by another UK team) to be perfused with oxygenated blood and safely preserved for 24 hours or more. This allows for a considerable increase in transplant activity by overcoming logistics (e.g. simultaneous liver or pancreas transplant) and dynamic assessment of marginal grafts (e.g. lactate clearance on serial blood tests on the machine). It also has the capacity to increase the safety of liver transplantation by removing time pressure for the recipient hepatectomy and allowing complex transplants (e.g. redo or transplants that might require veno-venous bypass) to be performed during the day.

Edinburgh introduced OrganOx into routine clinical practice in 2019 and this capability proved invaluable in overcoming many logistical challenges during the COVID pandemic.

A meeting of consultant across all specialties involved in transplantation (liver/kidney/pancreas transplant surgeons, physicians and anaesthetists) was held in Edinburgh on 5 February 2024, with unanimous agreement across all specialist groups that OrganOx is an essential capability for the transplant unit to increase provision of liver and pancreas transplantation, and to enable safe delivery of liver transplantation for complex patients. 

Unfortunately, confirmation of ongoing funding for OrganOx has not been confirmed and this has led to an effective suspension of the service (support from OrganOx for training of new team members is pending renewal of the Edinburgh contract).