Predictors of brain death and barriers to organ donation in north African intensive care units: a multicenter prospective study on severe coma patients

Organ donation from brain-dead patients is a major advancement in transplantation medicine. However, challenges remain in identifying and managing potential donors. In Tunisia, low donation rates reflect both medical limitations and significant sociocultural barriers, with limited national data addressing these factors. This study aimed to describe the epidemiological, clinical, and paraclinical profiles of patients with severe coma in Tunisian intensive care units (ICUs), and to identify factors associated with progression to brain death (BD) and subsequent organ donation outcomes. A pilot prospective multicenter study was conducted over one year (November 2022 - October 2023) in three Tunisian university hospitals: Sahloul and Farhat Hached (Sousse), and Mohamed Taher Maamouri (Nabeul). All ICU patients with severe coma (i.e.; Glasgow coma scale≤8) requiring invasive mechanical ventilation were included. Patients were followed until BD confirmation or ICU discharge. The transplant coordination team approached families of confirmed BD patients for donation consent. Among 104 patients (mean age: 47years; 76% male), 26 (25%) progressed to BD, mainly due to haemorrhagic stroke (57.7%) and traumatic brain injury (30.8%). BD was significantly associated with male sex (odds ratio (OR)=2.63; <i>p</i>=0.047), comorbidities such as arterial hypertension and/or diabetes mellitus (OR=2.63; <i>p</i>=0.041), traumatic causes (5.76; <i>p</i><0.001), haemorrhagic stroke (OR=13.83; <i>p</i><0.001), and prolonged ICU stay defined as a stay exceeding 14days (OR=12.54; <i>p</i>=0.014). Of the 17 confirmed BD cases, families of 12 were approached, with consent obtained in five (41.6%). Refusals (58.3%) were mainly due to concerns about body integrity, religious beliefs, and family influence. Improved donor management, family communication, and public awareness are crucial to increasing donation rates. <b>Registration</b>. This study protocol was registered on ClinicalTrials.gov (Identifier: <b>NCT06948669</b>).