Introduction
The incidence of accidents causing the occurrence of brain death in Iran is high. In this regard, the use of brain death cases’ organs for transplantation has been carried out in Iran for a long time. Several factors are influential in this field. Guilan province is the center of organ donation and transplantation in Iran. The present study aims to determine the frequency of organ donation and the related factors in patients with a low consciousness level in hospitals of Guilan province.

Methods
In this analytical cross-sectional study, the data of all patients with a Glasgow coma scale (GCS) score less than five admitted to the hospitals of Guilan province in 2021 and 2022 were examined. Information was extracted from the medical files of patients, the organ procurement unit (OPU), and the organ transplantation registry of Iran. After entering the data in SPSS software, version 21, data were analyzed using descriptive and inferential statistics.

Results
The results showed the mean age of participants was 52.06±19.9 years. There were 245 males (74.9%) and 82 females (25.1%). Most of patients were married (n=266, 81.3%). The mean BMI was 26.25±3.23. For brain death cases, the mean age was 38.26±12.9 years. The most common blood type was O+ (n=187, 57.2%) while the rarest blood type was AB- (n=8, 2.4%). Most participants had a high school diploma (33.3%), with moderate income (59.6%), and were mostly self-employed (58.7%), with no organ donation card (93.9%). 
 The most common reasons for not donating organs were the non-occurrence of brain death (30.9%) and not being suitable for organ donation (30%). Also, among 195 brain death cases, there were 27 cases (30.7%) whose relatives did not declare consent for organ donation. In 2021, there were 179 patients with a GCS below 5, which decreased to 148 in 2022. Among 48 brain-dead organ donors, 109 organs were retrieved for transplantation. The most commonly retrieved organs were kidneys (n=68, 62.4%), livers (n=36, 33%), and hearts (n=5, 4.6%). The number of organs retrieved from brain death cases in 2021 and 2022 is shown in Table 1. 



Analysis of patient records showed that 96 patients (29.4%) had diabetes, 175(53.5%) had hypertension, 11 (3.4%) had malignancies, 56(17.1%) had heart disease, 82(25.1%) had undergone surgery, and 134(59%) had a history of smoking and alcohol use. The leading causes of decreased consciousness leading to brain death were cerebrovascular events (48.3%), trauma (37.3%), and cardiovascular events (6.1%), while malignancies (4.3%) and unknown causes (0.4%) were less frequent. Among cerebrovascular events, stroke was the most common event (n=101, 30.9%), followed by spontaneous hemorrhage (n=46, 14.1%) and cerebral vascular aneurysm (n=11, 3.4%). In trauma-related events, car/motorcycle accident was the most common event (n=95, 28.1%), followed by falling (n=27, 8.3%). Among cardiovascular events, cerebral hypoxia following CPR was the most common event (n=15, 4.6%).

Conclusion
The present study demonstrated that cerebrovascular events were the most prevalent cause of brain death in Iran, accounting for nearly half of all cases. A detailed analysis revealed that among patients with low consciousness (GCS<5), a remarkably high number had brain death. While a substantial number of these brain-dead patients met the initial criteria for organ donation, our findings indicate that approximately 40-60% of cases presented with either relative or absolute contraindications that ultimately precluded donation. Absolute contraindications included active HIV infection, COVID-19, and metastatic malignancies, while relative contraindications were higher age (>65 years), uncontrolled systemic infections (particularly septicemia), significant hemodynamic instability requiring high-dose vasopressors, and various legal impediments. Notably, the study observed that nearly 30% of potential donors were excluded due to cardiovascular events. We found that family refusal is the most significant barrier to organ donation, reported in approximately 60% of eligible cases. 
We recommend implementing a multi-dimensional strategy to address these challenges: Hospital-based family education programs by trained counselors, developing nationwide public awareness campaigns to destigmatize organ donation, and creating standardized protocols for evaluating donors in critical care settings. 

Ethical Considerations

Compliance with ethical guidelines
This study was approved by the Ethics Committee of Guilan University of Medical Sciences, Rasht, Iran (Code: IR.GUMS.REC.1402.056).

Funding
This study was funded by the Multidisciplinary Center for Reconstructive Medicine, Organ Procurement and Transplantation and the Guilan University of Medical Sciences.

Authors contributions
Preparing the initial draft and acquisition, analysis, or interpretation of data: Ali Monfared, Saeid Anvari, Siamak Rimaz, Latif Panahi, Somaye Pouy and, Samaneh Ghazanfar Tehran; Study concept and design: Ali Monfared, Saeid Anvari, Siamak Rimaz and, Latif Panahi; Statistical analysis: Saman Maroufizadeh, Latif Panahi and, Somaye Pouy; Funding acquisition: Siamak Rimaz and Latif Panahi; Administrative, technical, or material support: Siamak Rimaz, Arezo Khiali, Keyvan Abdi and, Latif Panahi; Study supervision: Ali Monfared, Siamak Rimaz, Saeid Anvari, and Morteza Rahbar-Taramsari.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to thank the Multidisciplinary Center for Reconstructive Medicine, Reconstructive Organ Procurement and Transplantation, the Guilan University of Medical Sciences, the staff of Razi Hospital in Rasht, and all participants for their support and cooperation in this study.



 

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