Organ Donation and Transplantation in System Progress Report – 2017 Update and Transplantation in Canada System Progress Report – 2017 Update

The people portrayed in the images are donors, recipients, staff or partners and to them we offer our special thanks.

Front Cover: Heather: Living liver donor Everad: Heart recipient (and Canadian Blood Services’ employee)

© Canadian Blood Services, 2018. All rights reserved. Extracts from this report may be reviewed, reproduced or translated for educational purposes, research or private study, but not for sale or for use in conjunction with commercial purposes. Any use of this information should be accompanied by an acknowledgement of Canadian Blood Services as the source. Any other use of this publication is strictly prohibited without prior permission from Canadian Blood Services.

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This report is accessible online at https://professionaleducation.blood.ca/en/organs-and-tissues/transplantation/reports

Organ Donation and Transplantation in Canada - System Progress Report 2017 Update 2 Dr Graham Sher CEO Canadian Blood Services

Together, we are Canada’s biological lifeline. This, our newly efforts to improve transplant opportunities for Canadians in need. adopted mission statement, rings especially true when we A significant milestone for national collaboration was achieved consider the remarkable collaborative effort that underpins the earlier this year when we marked the 1,000th kidney transplant organ and tissue donation and transplantation (OTDT) system in made possible through interprovincial organ sharing. Some of Canada. On behalf of that collaborative network, I am pleased to the patients who received these kidneys had been on dialysis for introduce this 2017 update on system progress. decades while waiting for a suitable organ. Without this national approach to increasing the potential donor pool, these 1,000 The results reflected within this report represent the individual transplants would not have occurred. and collective work of both the provincial programs and the national efforts led by Canadian Blood Services. Most Although Canada’s performance in terms of deceased organ importantly, through this report we sincerely acknowledge the donation and transplantation is encouraging, living donation rates generosity of the 1,335 organ donors and 4,969 tissue donors nationally (and internationally) have declined slightly. For every and their families who gave so selflessly in 2017. We also patient in Canada who receives a lifesaving organ transplant, recognize the heartfelt appreciation of the recipients whose there are two on a waitlist. In 2017, a total of 242 Canadians died lives were saved or changed through the act of donation. while waiting for a suitable transplant opportunity. As such, there is much work yet to be done. In recent years, Canada has shown sustained improvement in deceased organ donation, with a remarkable increase of 51 per Given our experience as the national coordinating body for cent since 2008. The 2017 data show Canada nearing 22 OTDT in Canada and our knowledge of the components required donors per million population, a rate that puts our nation on par for success, we believe that national priorities in this realm with Australia and the United Kingdom — a significant must focus on strategies that will advance interprovincial organ achievement. Although this increase in the overall number of sharing, improve living donation rates, assist jurisdictions as they deceased donors is an important metric, equally notable is the implement leading practices, and enhance system performance degree to which the system utilizes each donor’s gift. Canada’s measurements and accountability mechanisms. organ utilization rate is world class, with an average of three organs from every deceased donor being transplanted. This rate As a nation, we have the recipe for system improvement: when is better than those of Australia, Spain, the United States and the key elements are implemented, marked improvement is the United Kingdom. Utilizing as many donated organs as achieved. By working together to ensure these key elements possible and facilitating the best transplant to improve recipients’ are in place, we will continue to save lives. quality of life are of utmost importance.

Canada’s OTDT system has demonstrated that patients with the greatest need and those whose clinical profiles are most difficult to match benefit when organs are shared across provincial boundaries. By maintaining the National Organ Waitlist and the country’s interprovincial organ sharing registries (the Kidney Dr. Graham D. Sher Paired Donation and Highly Sensitized Patient registries), CEO, Canadian Blood Services Canadian Blood Services coordinates national collaborative

3 Organ Donation and Transplantation in Canada System Progress Report – 2017 Update

Overview of 2017 national performance results

RATES PER MILLION POPULATION 601 NDD 802 DECEASED 4,333 201 DCD DONORS Transplants 81.2 4% Patients on Canada’s 2,979 Organ Transplant Waitlists at Year-End Transplants, Deceased Donation 21.8 5% including 61 LIVER multi-organ 533 transplants LIVING Living Donation 14.5 3% 242 472 KIDNEY DONORS Change Patients Died from 2016 while on Waitlists

Donors and transplants per million population (pmp) in Canada, 2008-2017 81.2 90 78.2 80 71.4 67.2 64.3 66.3 70 62.4 62.2 62.2 62.1 60 50 40 30 20 10 16.4 14.5 15.3 14.5 16.4 13.7 15.2 15.0 15.5 15.6 16.6 15.7 15.6 16.6 15.7 18.1 15.0 20.9 14.5 21.8 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Living donors PMP Deceased donors PMP Transplants PMP

Patients on transplant waitlist by province, Transplants by organ, 2017 as of December 31, 2017 count (pmp) Transplants involving other organ types Pancreas 31 (e.g. islet transplants) not included CANADA 4,333 Kidney-Pancreas 45 (118 PMP) 638 627 Heart 215 (131 pmp) (144 pmp) 361 (270 pmp) Lung 348 786 (94 pmp) Liver 585

97 1,527 297 (83 pmp) (108 pmp) (124 pmp) Kidney 1, 726

4 Deceased donation performance Canada continues to show sustained improvement in deceased donation. This important achievement involves the collective effort of the provincial Organ Donation Organizations, intensive care units, transplant programs, HLA laboratories, and researchers, including Canadian Institute of Health Research (CIHR) and Deceased donor rate by donor type, Canadian Donation and Transplant Research Program (CDTRP). 2008 – 2017 (donors per million population (dpmp))

21.8 Deceased +51% 20.9 Since Donor Utilization 20.0 2008 16.4 3.0 15.0 Organ transplants per donor in 2017 10.0 dpmp 5.5 5.0 While an increase in the overall number of deceased donors is an important metric, equally important is the degree to which the system utilizes each donor’s gift. A single donor has the potential 0.0 to provide as many as eight organs for transplant. 2011 2011 2008 2009 2010 2012 2013 2015 2016 2017 2014

The deceased donor utilization rate in Canada, as measured by Total NDD DCD the number of organ transplants per deceased donor, exceeds that of other nations such as Australia, Spain, the United Canada’s national deceased donation rate has increased by Kingdom, and the United States. 51 per cent since 2008, from 14.4 to 21.8 dpmp in 2017. The deceased donation rate in 2017 exceeded the rate in 2016 (20.9) Donation after circulatory death - a key contributor to system improvement by five per cent. Improving Canada’s deceased donation rate will require a continued focus on implementation and evaluation of donation Deceased donation by donor type, 2008 – 2017 after circulatory determination of death (DCD) programs. In 2017, 25 per cent of all deceased donor organ transplants were 1000 realized through donation after circulatory death. 800 DCD accounts for the largest increase in deceased donation 201 174 over time and, next to ensuring consistent donor identification 600 43 136 42 46 64 and referral, constitutes the greatest opportunity to continue 67 86 121 to increase donation potential. Nine provincial organ donation 400 organizations have implemented donation after circulatory death programs within their jurisdiction, in addition to their neurological 200 determination of death (NDD) programs. 439 444 420 448 455 489 470 513 584 601 0 2011 2011 2008 2009 2010 2012 2013 2015 2016 2017 2014 601 802 201 NDD DCD NDD Deceased DCD Donors Donors Donors 1in 4 Of the total transplants in 2017 in Canada, 802, or 82% were DONATIONS ARE MADE from deceased donors, and 18% were from living donors. THROUGH DCD

5 Key Elements of a High Performing Deceased Donation System

Opportunity for improvement Through experience gained provincially, nationally and internationally it is now known and generally accepted that fundamental key components to a high performing deceased donation system exist, and when implemented, lead to improved performance. Although more research is needed to inform the relative impact of each of these on performance, generally foundational elements include: adequate resources and infrastructure, availability of highly trained front-line specialists, practice guidelines and professional education, availability of performance data to inform improvement, adequate legislation, and the presence of appropriate accountability tools and structures. A general description of each is provided below.

Accountability tools and structure There are many ways in which to ensure and/or demonstrate accountability, within the OTDT system in Canada. Examples of tools and structures that have been implemented to varying degrees include: implementation of death audits to identify if a donation opportunity was lost, use of potential donor Accountability6 referral criteria checklists, integrating best practices into accreditation guidelines, and the development tools and reporting of hospital performance using benchmarks and scorecards.

Legislation A fundamental aspect of an interprovincial donation and transplantation system is ensuring appropriate legislation is in place that optimizes donation and transplantation, including provisions for mandatory referral to the ODO, sharing of donor and recipient personal information for purposes of facilitating 5 organ donation and transplantation and mandatory outcome data reporting for system performance Legislation measurement. Presumed consent or opt-out legislation is also often debated in terms of relative impact on system performance, however it is generally accepted that these other legislative elements are fundamental, as is the case in other national systems.

Data and system performance improvement To ensure quality care, performance must be monitored, measured and reviewed systematically. Foundational to improvement is defining metrics at the hospital, provincial and national level System performance4 and working towards achieving performance targets. Opportunities exist to continue to build on data and quality performance data that is currently collected and available to continue to improve outcomes improvement for patients.

Leading practices and professional education Donation and transplantation are low frequency, high impact events. Development and implementation of leading practices and clinical practice guidelines is essential to guide current practice and aid in the 3 management of complexities of the donation and transplantation process. Special attention must be Leading practices applied to ensure staff leading these processes at the bedside are highly-trained. Public education and professional and awareness is another important driver of change but must be supported by knowledgeable education health professionals.

Specialization An essential aspect of a high-performing donation system is the availability of highly trained specialized staff such as donation coordinators and donation physicians. These specialists are required to coordinate progression along the donation pathway, implement best practices, support Specialization2 donor care, improve quality, and provide education. Donation specialist models have been implemented in many provinces to differing degrees. Implementation & Alignment Adequate front-line resources and infrastructure Adequate resources and infrastructure are necessary to ensure that the clinical donation process is supported at every step in the pathway from donor identification and referral through to transplant and 1 post-transplant care. For example, without adequate hospital capacity, support for donor assessment Adequate resources and and management, and availability of surgical retrieval and transplant teams, organ donation and infrastructure transplantation may not proceed.

6 Performance among provinces varies The degree to which provincial variability in performance affects variability in national performance trends is an important consideration. In 2012, a deceased donation target of 22 dpmp was proposed with input from donation and transplantation experts in Canada, and in 2017 national donation rates are approaching that target at 21.8 dpmp.

Deceased donor rate by province, 2015 – 2017 (dpmp) Canada Target: 22 dpmp 30 2017: 21.8 dpmp

25

20

15

10

5 8.8 20.1 20.3 24.9 12.4 16.1 18.5 12.2 14.6 13.1 12.1 14.9 19.4 25.2 24.4 20.8 20.4 21.7 10.6 17.2 14.5 21.2 21.1 16.8 15.2 13.2 13.2 0 BC AB SK MB ON QC NB NS NL 2015 2016 2017

Factors contributing to higher donation rates The table below highlights some of the key factors that contribute to a high performing deceased donation program and how each province is progressing in terms of implementation of these practices. The elements included do not constitute a complete list of all contributory factors and should not be interpreted as a comprehensive assessment of provincial performance.

BC AB SK MB ON QC NB NS NL Mandatory Referral • • • ••• •* • • Donation Physicians (Number of Donation Physicians) (8)• (2)• (4)• (6)• (61)• (12)• (2)• (1)• (1)• NDD Leading Practices • • • • • • • • •

DCD Programs (% DCD donors) (26%)• (20%)• (0%)• (15%)• (31%)• (18%)• (0%)• (56%)• (0%)• Donor Management LP • • • • • • • • •

Deceased Donors (dpmp) 24.9 18.5 14.6 14.9 24.4 21.7 14.5 16.8 13.2 (Number of Donors) (121) (81) (17) (20) (347) (182) (11) (16) (7) % change in dpmp, 2016-2017 ꜛ23% ꜛ15% ꜛ20% ꜛ24% ꜜ3% ꜛ6% ꜜ16% ꜜ21% 0% • Implementation complete or near completion • Implementation in progress • Implementation not started * Mandatory referral in NB has been implemented for tissue donation only

7 Living donation performance Living donation offers advantages to recipients relative to deceased donation, including better long-term health outcomes.

Canada’s living donation rate in 2017 was 14.5 dpmp, which is While opportunities for deceased down three per cent from 15.0 dpmp in 2016. This rate — which % donation are limited and is primarily made up of kidney donors, but does include liver and unpredictable (only about one to lung donors — has decreased by 11 per cent since 2008. Similar 11 two per cent of in hospital deaths DECREASE declines in living donation rates in recent years have been seen in IN LIVING are eligible for donation), living other countries as well, including Spain and the United Kingdom. DONATION donation is a controlled process SINCE 2008 which has significant potential Transplant rate from living donors in Canada, for growth and impact on kidney 2008 – 2017 (dpmp) transplantation rates.

20 Living donor rates by province, 2015 – 2017 (dpmp) 14.5 with % change from 2016 to 2017 15 % change in 30% total living 1% 0% 12.9 donor rates 10 -1% -4% 30 -17%

24.7 -55% 5 1.7 23.7 25 20.3 20.0 19.8 19.8 19.0 18.5 18.4 18.3

0 20 16.5

15 11.6 2011 2011 2008 2009 2010 2012 2013 2015 2016 2017 2014 8.0 7.5 7.0 6.9 6.7 6.7 Total Kidney Liver 10 6.4 3.3 5 2.6 In 2017, the Kidney Paired Donation (KPD) registry operated 0 by Canadian Blood Services had its most successful year since BC AB SK MB ON QC ATL inception and contributes to the national total of transplants made possible from living donors. Without this contribution, the decline 2015 (Liver) 2016 (Liver) 2017 (Liver) in Canada’s living donation rate over time would have been more 2015 (Kidney) 2016 (Kidney) 2017 (Kidney) significant. In 2017 there were a total 533 transplants from living donors (see figure below), a two per cent decrease from 2016. Although living lung donation does exist, it is very rare and has seen a decrease in activity in recent years. In the past 10 years Number of transplants from living donors there have been only two living lung transplants nationally and none in the past four years. in Canada, 2008 – 2017

600 70 64 78 89 82 73 61 500 67 64 61 64 85 50 70 77 83 86 400 44

300 The KPD Registry has 474 435 437 430 200 389 421 387 411 389 386 facilitated an average of three transplants every two weeks 100 since 2010. These transplants would not have occurred without national collaboration and 0 interprovincial organ sharing. 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Kidney (non-KPD Registry) Kidney (KPD Registry) Liver

8 100 Transplant ratesinCanadabyorgantype,2008–2017(tpmp) Transplants inCanadabydonortype,2008–2017 1,000 1,500 2,000 2,500 3,000 re-transplants isminimizedorprevented. that improvepatientoutcomessoinstancesofgraftrejectionandtheneedfor A necessaryfocusofcurrentandfutureworkwillcontinuetooninitiatives patient outcomeswiththeultimategoalof“onetransplantforlife”. should becelebrated,equallyifnotmoreimportantismonitoringandreportingon for afirsttransplant. Therefore,whileanincrease inthenumberoftransplants these patientsarere-listedfortransplantandaddtothenumberofwaiting out-lived thelifeoftheirgraft. This trendisagrowingchallengetothesystemas includes “re-transplants”(secondorthirdtransplants)forpatientswhohave It isimportanttonotethattheoverallnumberoftransplantsinCanadaalso in 2017.Kidneytransplantsaccountforthemajorityofthisrate. continued toclimb,reaching71.4tpmpin2015,78.22016and81.2 67 transplantspermillionpopulation(tpmp).Inthelastthreeyearsratehas In theperiod2008to2014,Canada’s transplantraterangedbetween62and waitlists isimperativetoincreasingsystemperformanceandimprovingoutcomes. Maximizing donorpotentialandensuringequitableaccessforpatientsonCanada’s of whomwillneverreceiveoneduetothelimitednumberdonatedorgans. Over 4,000Canadiansarewaitingfororgantransplantsatanygiventime,many Transplantation performance 20 40 60 80 500 0 0 2076 2008 2008 1530 546 2093 2009 1577 516 2009 2010 2116 1559 Transplants fromdeceaseddonors Transplants fromlivingdonors 557 2131 2011 1609

2010 522 2235 2012 Kidney 1698 537 2363 2013

2011 1778 585 2014 2358

Liver 1805 553 2518 2015 2012 1955 563 2835 2016 Heart 2291

545 2013 2979 2017 2446 533 Lung 2014 OTHER MULTI/ December 31,2017 transplants asof Patients waitingfor WAITLIST IN2017 PATIENTS DIEDON THE 242 3,253 Kidney 28 Heart 146 Total 2015 Pancreas Kidney-Pancreas Liver 430 42* 4,333 WAITING CANADIANS 112 2016 patients (63) * Doesnotincludesislet Small Bowel

Lung 258 1 2017 9 Transplantation performance by organ type and by province Number of transplants from living and deceased donors are provided by province and nationally by organ type. For comparison, rates from the top five international Awareness and approval of performers have also been included as referenced in the organ and tissue donation 2017 IRODaT Newsletter* in Canada Kidney transplants from deceased donors by Trust in the system province, 2017 (tpmp) There has been a significant increase in the proportion of Canadians who trust that the organ and tissue donation system in 70 Canada is administered in the best interest of the public (76%, up 60 from 71% in March 2015) and who trust Canadian Blood Services Top international performer range 50 to do what is best for the system in Canada (76%, up from 72%). 40 30 20 % 10 76 of Canadians trust that the organ 0 and tissue donation system in Can BC AB SK MB ON QC ATL Canada is administered in the best interest of the public Kidney transplants from living donors by province, 2017 (tpmp) Awareness and Approval of Organ and Tissue 40 Donation in Canada Approval for organ and tissue donation in Canada has remained 30 Top international performer range stable at 89%. Those who are more likely to disapprove include those who also disapprove of living organ donation, those who 20 have decided not to donate their organs/tissues at the time of their death and those who are undecided whether they would 10 accept an organ or tissue transplant if they needed one. Fewer than half (47%) of Canadians indicate they have seen, 0 read or heard ‘a lot’ or ‘something’ about the topic of organ and Can BC AB SK MB ON QC ATL tissue donation over the last few years, a decline since last surveyed in 2015 when it was 54%.

Heart, Lung, and Liver transplants, 2017 (tpmp)

30 25 20 Top international performer range 15 47% 89% 10 5

0 of Canadians have of Canadians approve Heart Lung Liver recently heard some or of organ and tissue a lot about organ and donation after death tissue donation

Trust and awareness results are from the “Organs and Tissues General Public Opinion Survey” conducted by IPSOS on behalf of Canadian Blood Services every two years. * Source: http://www.irodat.org/img/database/pdf/NEWSLETTER2018_June.pdf

10 International donation rates The deceased donation rate in Canada continues to increase, and is on par with Australia and the United Kingdom, despite Canada adopting a more conservative definition in tracking donation performance than is typically used by the international community. International living donor rates, The deceased donation results in Canada report “utilized” donors, 2008–2017 (dpmp) a metric that requires at least one organ from a donor to have been 25 transplanted into a recipient. The donors per million population metric in most other countries counts a donor if an incision has been made 20 19.2 for the purposes of organ recovery, regardless of whether or not 15 15.6 an organ has been transplanted. These are called “actual” donors. 14.5 Annual reports on organ donation and transplantation activity issued 11.1 by the National Health Service in the United Kingdom (2012–2015) 10 estimate differences of between four to eight per cent when 7.5 5 comparing actual donors and utilized donors. Unless otherwise stated in the title, the figures below represent 0 actual donor rates for non-Canadian countries. 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Spain United States Australia United Kingdom Canada International deceased donor rates, 2008-2017 (dpmp) Living donation rates in the United States and Australia have 50 remained relatively stable over the past five years. Conversely, 46.9 45 the living donation rates in Canada, the United Kingdom, and 40 Spain have been declining over the last three or four years, 35 32.0 with Canada’s rate decreasing from 16.6 in 2013 to 14.5 30 in 2017. Similarly, the rates for both Spain and the United UK: 23.1 25 Kingdom dropped by two dpmp over the past three years. 20 21.8 Aus: 20.7 15 Combined living and deceased donor rates, 10 5 2008–2017 (dpmp) 0 60 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 54.4 Spain United States Australia 50 51.2

United Kingdom Canada 40 38.7 36.3 The organ donation rate for donation after circulatory determination 30 31.8 of death (DCD) in Canada is similar to rates in Australia and the United States. The top performer is Spain is at 10.5 utilized 20 dpmp. Canada is currently sixth internationally in terms of DCD 10 performance. 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 DCD utilized donors per million population, Spain United States Australia 2017 United Kingdom Canada Canada Why these Australia Living and deceased utilized donation rates, benchmarks: Spain United States 2017 (dpmp) is considered to be an United Kingdom international leader in Spain United States 19.2 29.9 49.1 deceased donation. The United Kingdom 15.6 21.3 36.9 U.S., U.K. and Australia dpmp represent countries that 10.5 Spain 7.5 41.1 48.6 most align with Canada Australia 11.1 19.6 30.7 either politically, socially, 8.2 5.0 Canada 14.5 21.8 36.3 legislatively and /or geographically. 5.7 5.5 Living Donation Deceased Donation

11 Eye and tissue performance

Eye and tissue donation

Ensuring availability of tissue grafts is an important aspect of the donation and transplantation system in Canada. Tissue grafts are used for purposes such as to restore sight, repair sports or trauma injuries, to treat severe burns, and to replace damaged heart valves.

Tissue banks exist in eight provinces, and Canadian Blood Eye and tissue banks in Canada Services in collaboration with Canadian eye and tissue Comprehensive Tissue Banks programs collects, collates, and distributes data on tissue Musculoskeletal Tissue Banks donation activity which serves to inform provincial strategies and Tissue Specific Banks policy. Eye Banks Surgical Bone Bank Consent Recovery Organization Deceased tissue donation consent rate, 2013-2017 54% 52% 53% 48% 46%

Living donation 2013 2014 2015 2016 2017 Number of living donors by year, 2013-2017

In 2017, 11 programs were able to provide data on 9,057 Amnion approaches for deceased tissue donation. A consent rate of 15 53% was identified, which is on par with the consent rates in 15 12 13 2015 and 2016. 12 9 8 9 Deceased donation 6 3 Number of deceased tissue donors by year, 0 2013-2017 2013 2014 2015 2016 2017

5000 4,383 4,510 4,473 4,418 4,518

4000 Surgical Bone 800 700 669 3000 549 600 456 3,863 3,611 3,611 3,883 3,883 2000 3,821 379 400 1000 200 772 627 590 597 657 0 0 2013 2014 2015 2016 2017 2013 2014 2015 2016 2017

Musculoskeletal/ Skin/Cardiac Ocular Only Living donors are a feature of the Canadian tissue system.

Results for Musculoskeletal/Skin/Cardiac donors include donors where ocular tissue In some hospitals, femoral heads are donated from patients was also recovered. having total hip replacements; this donated bone can be used in surgical repairs. Donation of surgical bone continues In 2017 there were 4,575 deceased tissue donors and 394 living to decrease as hospitals demand shifts to tissue donors - 86% of tissue donations were for ocular tissue more highly processed grafts. only, while 14% of tissue donations were for musculoskeletal, cardiac and/or skin tissue. In 2017 donations resulted in In some centres mothers donate their amniotic membrane which the production of 17,532 grafts which included: cornea, can be used in eye surgery and in wound healing. musculoskeletal, cardiac and skin grafts. 12 Eye and tissue performance Cornea Cornea transplants* (keratoplasty) by type of procedure, 2013-2017 There is a significant variance in the 5000 rate between provinces, ranging from 40 to 124 corneas 4000 transplanted per million population. Some jurisdictions supplement their cornea production through importation; 8% 3000 of all cornea transplants performed in Canada utilize corneas from the United States. 2000 1000 Cornea transplants (keratoplasty) by province, 0 2017 (tpmp) 2013 2014 2015 2016 2017 200 PK DSAEK DMEK ALK Unknown procedure 163 150 Canadian production and distribution of corneas is stable 123 118 104 104 103 showing no significant growth over the past five years, with 3,820 91 distributed for transplant in 2017. 100 78

Improved outcomes resulting from pre-transplant processing 40 of corneas (DSAEK and DMEK endothelial keratoplasty) is 50 continuing to increase the demand for these procedures. Within endothelial keratoplasty the demand for the highly technical 0 DMEK procedure continues its rapid growth. Can BC AB SK MB ON QC NB NS

Cardiovascular, Tendon, Skin and Musculoskeletal Canadian production and distribution of musculoskeletal (bone and tendons), cardiac and skin grafts is stable, with no significant growth over the past five years. In 2017 12,652 musculoskeletal, cardiac, tendon and skin tissue grafts were transplanted.

Total non-ocular tissue grafts transplanted from living and deceased donors, 2013-2017

Cardiovascular Tendon Skin Musculoskeletal 9000 8000 7000 6000 5000 4000 3000 2000 1000 203 168 201 170 171 1398 1781 1909 1724 1936 3261 2165 2676 2977 2784 7539 7508 7233 7660 7637 0 2013 2014 2015 2016 2017 2013 2014 2015 2016 2017 2013 2014 2015 2016 2017 2013 2014 2015 2016 2017 Cardiovascular Tendon Skin Musculoskeletal

Not represented in the graph: soft tissue, fresh osteoarticular, and other non-ocular tissue grafts from deceased donors (124 grafts were distributed in 2017)

Variance in the transplantation of tissue grafts per province is related to tissue bank activity, population, and the number and type of surgical programs. Many hospitals continue to import tissue grafts from the United States to supplement their needs.

* Transplantation results based on distributed for transplant by programs

For the full annual Eye and Tissue Data Committee Tissue Report please visit the Canadian blood Services Professional Education Website at https://professionaleducation.blood.ca/en 13 Acknowledgements Data Sources This report acknowledges the generous gift made by organ and The Canadian data collected for this report was compiled from a tissue donors, both living and deceased, and the families of those number of sources and standardized and validated to the greatest who have donated. The report further acknowledges the hope degree possible by experts from Canadian Blood Services. and expectations of patients with end-stage organ failure and Source material was derived from figures compiled f rom the the dedication of healthcare teams and practitioners though-out Canadian Transplant Registry, and materials published by the the healthcare system who make it possible to fulfill and increase Canadian Institute for Health Information and the Canadian opportunities for organ and tissue donation and transplantation. Organ Replacement Register and the Canadian Eye and Tissue Data Committee. Canadian Blood Services’ personnel also This report was made possible through the collective effort and collected and validated data from the provincial organ input from members of Canadian Blood Services’ Organ and Tissue donation organizations. Donation and Transplantation Committees and the Canadian The international donation and transplantation data collected for this Institute for Health Information. report was compiled from a number of sources and standardized and validated to the greatest degree possible by experts from Canadian Blood Services. Source material was derived from figures compiled from the International Registry in Organ Donation and Transplantation, the and Transplantation Network in the United States, and the Organizacion Nacional de Trasplantes in Spain. In accordance with Canadian Institute of Health Information (CIHI) standards, demographic data for estimates per million population (PMP) are based on Statistics Canada Table 17-10-0086-01 Estimates of population (2011 Census and administrative data), by age group and sex for July 1st, Canada, provinces, territories, health regions (2017 boundaries) and peer groups. For the purpose of this calculation, PMP rates for are based on the combined populations of British Columbia and Yukon, PMP rates for Alberta are based on the combined populations of Alberta, Northwest Territories and Nunavut, and Atlantic population includes New Brunswick, Nova Scotia, Prince Edward Island, and Newfoundland and Labrador.

Deceased donation rates for Atlantic provinces are based on their respective populations; however, the donation program in Prince Edward Island identifies potential donors who may be transferred to New Brunswick or Nova Scotia for declaration and recovery.

14 Appendix A: Acronyms

Acronyms

Atlantic provinces (includes New Brunswick, Nova ATL Scotia, Prince Edward Island, and Newfoundland HLA Human Leukocyte Antigen and Labrador)

Canadian Donation and Transplant International Registry in Organ Donation and CDTRP Research Program IRODaT Transplantation

CIHI Canadian Institute of Health Information KPD Kidney Paired Donation [program]

CIHR Canadian Institutes of Health Research NDD Neurological Determination of Death

DALK Deep Anterior Lamellar Keratoplasty ODO Organ Donation Organization

DCD Donation after Circulatory Death ODT Organ Donation and Transplantation

DMEK Descemet’s Membrane Endothelial Keratoplasty OTDT Organ and Tissue Donation and Transplantation

DPMP Donors Per Million Population PK Penetrating Keratoplasty

Descemet’s Stripping Automated Endothelial Per Million Population DSAEK Keratoplasty PMP

EK Endothelial Keratoplasty TPMP Transplants Per Million Population

ETDC Eye and Tissue Data Committee

15 Appendix B: Definitions

Definitions of Key Terms

Donation after A diagnosis and confirmation of death based on circulatory criteria Circulatory Death (DCD)

Patients who died while waiting for a transplant Deaths on waitlist Note: This does not include patients who die immediately after being removed from a transplant waitlist.

A partial thickness corneal transplant procedure used to treat disease or injury confined Deep Anterior Lamellar to anterior layers of the cornea: the epithelium, Bowman’s layer and stroma. This Keratoplasty (ALK/DALK) procedure is most often used to treat keratoconus and corneal scarring.

The transplantation of only the Descemet’s membrane and endothelial layer of the Descemet’s Membrane Endothelial cornea. DMEK has been described as a more technically challenging surgical procedure Keratoplasty (DMEK) than DSAEK but also has been reported to provide better, post-transplant patient visual acuity, lower rejection rates and faster visual recovery

The vast majority of EK today is DSAEK where the precuts the corneal tissue, Descemet’s Stripping (Automated) or the surgeon precuts the corneal tissue in the operating room. The prepared (cut) graft Endothelial Keratoplasty (DSAEK) is comprised of the donor tissue endothelium, Descemet’s membrane and a thin, partial layer of the donor tissue’s stroma.

Donation rate The number of donors relative to the population

A consented eligible donor from whom at least one organ was transplanted. Donor (Organ) Note: Non-Canadian results presented may reflect a different definition.

Donor (Tissue) A consented donor from which at least one tissue was recovered.

The mean number of organs used from each donor from whom at least one organ was Donor utilization transplanted.

A corneal transplant procedure where only a patient’s compromised posterior layers Endothelial Keratoplasty of the cornea are removed and replaced by similar posterior corneal layers of a donor cornea.

Neurological Determination of Death A diagnosis and confirmation of death based on neurological criteria

Non Ocular Tissue Musculoskeletal, tendons, soft tissue, cardiac and skin tissue

Ocular Grafts Grafts produced from the eye including cornea and scleral grafts

Organs transplanted The number of individual organs transplanted.

Patients who are awaiting a transplant and (a) can receive a transplant at any time or (b) Patients waiting for transplants/ cannot receive a transplant for a medical or other reason for a short time. Results are patients on waitlist based on a snapshot of patients as of December 31 2017.

Corneal transplant with replacement of all layers of the cornea, but retaining the Penetrating Keratoplasty peripheral cornea.

A completed transplant procedure. Transplant Note: Multiple organs may be transplanted as part of the same transplant procedure.

Transplant rate The number of transplants relative to the population.

16 Appendix C: Contributing Programs Canadian Transplant Programs British Columbia Manitoba Toronto General Hospital – Institut de Cardiologie de University Health Network* Montréal BC Children’s Hospital Health Sciences Centre* Institut universitaire de St. Paul’s Hospital* Children’s Hospital of Québec cardiologie et de General Hospital* Winnipeg C.H. de l’Université de pneumologie de Québec Alberta Ontario Montréal, Hôpital Notre McGill University Health Dame* Centre, Montreal Children’s Foothills Medical Centre* Hospital for Sick Children Hospital University of Alberta Hospital* C.H. de l’Université de Kingston General Hospital* Montréal, Hôpital St.-Luc McGill University Health Stollery Children’s Hospital, London Health Sciences Centre, Royal Victoria University of Alberta C.H. universitaire de Centre* Québec - Université Hospital* Alberta Children’s Hospital * Laval* Nova Scotia Saskatchewan University of Ottawa Heart C.H. universitaire de Institute Sherbrooke* Queen Elizabeth II* St. Paul’s Hospital* IWK Grace Health St. Joseph’s Hospital* Hôpital Maisonneuve- Rosemont* *Operates a living donation program St. Michael’s Hospital* CHU Sainte-Justine Canadian Organ Procurement Organizations British Columbia Saskatchewan Québec Nova Scotia Saskatchewan Transplant Transplant Québec Legacy of Life BC Transplant Society Program New Brunswick Newfoundland Alberta Manitoba and Labrador Southern Alberta Organ New Brunswick Organ Organ Procurement and Tissue Donation Transplant Manitoba — and Tissue Program, Exchange of Newfoundland Program (SAOTDP), Gift of Life Program Horizon Health Network and Labrador (OPEN) Calgary Ontario HOPE Program, Edmonton Trillium Gift of Life Network

Canadian Eye and Tissue Banks

British Columbia Manitoba Québec Eye Bank of British Columbia Tissue Bank Manitoba Héma-Québec: Island Health Bone Bank Misericordia Eye Bank • Banque d’yeux du Québec Alberta Ontario • Banque d’yeux du Centre universitaire d’ophtalmologie Southern Alberta Tissue Trillium Gift of Life Network** manages the Program, Calgary collation and submission of data from New Brunswick Ontario eye and tissue banks including: Lions Eye Bank of Calgary, New Brunswick Organ and Tissue Calgary • Eye Bank of Canada (Ontario Division) Program Comprehensive Tissue • The Hospital for Sick Children Tissue Laboratory Nova Scotia Centre, Edmonton • Ontario Professional Fire Fighters Skin Bank Regional Tissue Bank Saskatchewan • Mount Sinai Allograft Technologies Saskatchewan Transplant • Lake Superior Centre for Regenerative Medicine Program

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