Personnel in cadaveric organ transplant-related hospital units faced with living liver donation: an attitudinal study in a Spanish hospital with a cadaveric and living liver transplant programme.

INTRODUCTION: The attitude of health-care personnel is fundamental for the procurement of transplant organs, especially in those services that are related to transplantation. The objective of this study is to find out the attitude towards living liver donation among personnel who work in transplant-related services in a hospital with a cadaveric and living organ transplant programme. MATERIALS AND METHODS: A random sample was taken and stratified by type of service and job category (N=330), in services related to transplantation (procurement units, transplant units and follow-up units). Attitude was evaluated using a validated psychosocial questionnaire. Control group: a random sample of personnel in clinical services that do not have any direct contact with solid organ transplantation. Student's t-test and the chi(2) test complemented by a logistical regression analysis were applied in the statistical analysis. RESULTS: The questionnaire completion rate was 94% (N=309). Only 10% (N=31) of respondents are in favour of living liver donation if it is unrelated, but another 67% (N=207) are in favour if donation were for a relative. Of the rest, 11% (N=33) do not agree with living liver donation and the remaining 12% (N=38) are undecided. In the control group, attitude towards living liver donation is favourable in 82% (N=344) (P=0.0908). An analysis of the variables that influence attitude shows that the following factors are significantly related: (1) age (P=0.037); (2) a respondent's belief that he or she may need a transplant in the future (P=0.013); and (3) if it were necessary, a willingness to receive a donated living liver organ (P=0.000). Of the variables that have the most influence on attitude towards living liver donation in the bivariate analysis, there are two variables that are statistically significant in the multivariate analysis: (1) age and (2) willingness to accept a donated living liver organ from a relative if it were needed (OR=14.19). There is also a close relationship between attitude towards living liver donation and attitude towards living kidney donation (P=0.000) CONCLUSIONS: There is a favourable attitude towards living liver donation among personnel in units related to the transplantation and donation process, although it is less favourable than expected. Therefore, it will be necessary to increase this level of acceptance and to improve information about the matter if we want to encourage living liver donation. The youngest workers in these units are those who are most in favour, which leads us to believe that there is a hopeful future for this type of liver donation that is so necessary given the cadaveric organ deficit.     

Organ trafficking: Scope and ethical dilemma

The Israeli experience discloses the relationship between the traditional altruistic basis of organ donation and the new alternatives based on a utilitarian conception of unrelated compensated donation. Although organ trafficking in Israel was dramatically intensified, cadaveric and living-related donations decreased. Reforms in living donations, such as evaluation committees for unrelated directed donors, were insignificant in terms of meeting the demand of patients and reducing the volume of trafficking. It is our contention that battling organ trafficking should provide patients with a realistic alternative for kidney donations. Our model of regulated nondirect paid donations is planned to legalize significant compensation for the unrelated donors drawing individuals from falling into the trap of organ traders. This program, together with uncompromised penalties, would hopefully eradicate organ trafficking.     

The net transfer of transplant organs across race, sex, age, and income

PURPOSE: To determine how sociodemographic characteristics influence both access to transplantation and organ donation. METHODS: For all transplants in the United States from 1996 to 2001, donor-recipient pairs were categorized as white-white, white-black, black-white, or black-black. The difference in the percentage of white-black versus black-white pairs was calculated as a measure of the net transfer of organs from one racial group to another. A similar approach was used to examine the net transfer of organs across other sociodemographic categories. RESULTS: Among cadaveric renal transplants, 66% of donor-recipient pairs were white-white, 23% were white-black, 5% were black-white, and 6% were black-black. Thus, there was an 18% net transfer of organs from white donors to black recipients (23% minus 5%). Among living donor transplants involving spouses, there was a 36% net transfer from wives to husbands. Among all cadaveric transplants, there was a 36% to 68% net transfer from younger donors to older recipients. Among cadaveric nonrenal transplants, there was a 7% to 18% net transfer from lower-income donors to higher-income recipients. CONCLUSION: The sociodemographic characteristics of persons who donate organs and those who benefit from organ transplantation differ markedly. Efforts to improve access and increase donation should address these differences.     

Liver transplantation: Issues for the next 20 years

The growing numbers of potential transplant recipients on waiting lists is increasingly disproportionate to the supply of cadaveric donor organs. The hope for the next 20 years is that supply will satisfy demand. This requires both a reduction in indications for the procedure and an increase in the transplants performed. A multi-pronged approach is needed to increase cadaveric organ donation, generating enthusiasm for donation among both the general public and hospital staff. Accurate assessment of marginal grafts with stringent criteria known to predict graft function will diminish wastage of organs. Methods of rehabilitating marginal grafts during extracorporeal perfusion will increase organ availability. Supply of non-heart beating donors can be greatly expanded and protocols developed with ethical consent to optimize their initial function despite warm ischemia. Splitting livers that fulfill selection criteria, thus providing for two recipients, should be universally applied with acceptable incentives to those units who do not directly benefit. A proportion of recipients, though not those transplanted for autoimmune disease, will be spared the side-effects of immunosuppression thanks to immune tolerance. Protocols for close monitoring of those patients for rejection during treatment withdrawal must be carefully observed. In addition to gene therapy, it is highly likely that hepatocyte transplantation will replace orthotopic grafting in patients without cirrhosis, especially for inherited metabolic diseases. It is much more difficult to envisage that heterologous stem cell transplantation or xenotransplantation will have clinical impact in the next 20 years, although research in those areas has obvious long-term potential.     

Liver transplantation in the UK

Introduction:This paper provides a review of the practiceof liver transplantation with the main emphasis on UKpractice and indications for transplantation.Referral and Assessment:This section reviews theprocess of referral and assessment of patients with liverdisease with reference to UK practice.Donor Organs:The practice of brainstem death andcadaveric organ donation is peculiar to individualcountries and rates of donation and potential areas ofimprovement are addressed.Operative Technique:The technical innovations that haveled to liver transplantation becoming a semi-electiveprocedure are reviewed.Specific emphasis is made to therole of liver reduction and splitting and living related livertransplantation and how this impacts on UK practice arereviewed.The complications of liver transplantation arealso reviewed with reference to our own unit.Immunosuppression:The evolution ofimmunosuppression and its impact on liver transplantationare reviewed with some reference to future protocols.Retransplantation:The role of retransplantation isreviewed.Outcome and Survival:The results of liver transplantationare reviewed with specific emphasis on our ownexperience.Future:The future of liver transplantation is addressed.     

Insulin independence after living-donor distal pancreatectomy and islet allotransplantation

Rising demand for islet transplantation will lead to severe donor shortage in the near future, especially in countries where cadaveric organ donation is scarce. We undertook a successful transplantation of living-donor islets for unstable diabetes. The recipient was a 27-year-old woman who had had brittle, insulin-dependent diabetes mellitus for 12 years. The donor, who was a healthy 56-year-old woman and mother of the recipient, underwent a distal pancreatectomy. After isolation, 408 114 islet equivalents were transplanted immediately. The transplants functioned immediately and the recipient became insulin-independent 22 days after the operation. The donor had no complications and both women showed healthy glucose tolerance. Transplantation of living-donor islets from the distal pancreas can be sufficient to reverse brittle diabetes.     

A pilot iron substitution programme in female blood donors with iron deficiency without anaemia

Background and objectives Blood donation can contribute to iron deficiency. The possibly resulting anaemia importantly affects donor return rate. The determination of serum ferritin levels revealed iron deficiency in many non‐anaemic premenopausal female blood donors at our Institution. We started an iron substitution programme targeting this donor group to prevent anaemia and enhance donor retain. Materials and methods Women aged ≤50 with haemoglobin levels adequate for donation and serum ferritin ≤10 ng/ml were offered iron supplementation. Substitution lasted 16 weeks and the donation interval was extended. History collection including iron deficiency–related symptoms, whole blood count and serum ferritin determination was performed at baseline and after 2 and 6 months. Data were recorded prospectively and compared with those of 108 female controls with iron deficiency not receiving iron substitution (retrospective data). Results Of the 116 participating subjects, 60% completed the programme. Significant results were serum ferritin increase (from a mean value of 7·12 to 25·2 ng/ml), resolution of prostration, fatigue, sleep disturbances, tension in the neck, hair loss and nail breakage. No case of anaemia occurred. Sixty per cent of the women completed the programme and donated blood again. Conclusions Targeted iron substitution prevents the development of anaemia and enhances donation return in premenopausal female blood donors with iron deficiency.     

Surgical advances in liver transplantation. Living related and split donors

Surgical innovations to expand an exceedingly small cadaveric liver pool have paved the way for the more complex procedure of adult-to-adult living donation. Although reduced-size liver transplant (RSLT) has provided children and small adults with much needed small size grafts, discarding a part of the liver can no longer be justified in the current era of severe organ shortage. Split liver transplantation may eliminate the need for RSLT and may replace adult-to-adult pediatric donation except in urgent situations. Adult-to-adult living donation is a formidable undertaking that tremendously impacts adult recipients. Adult-to-adult living donation should be approached cautiously to ensure the safety of living donors. Expansion of adult living donation can only be achieved when ethical issues of donation are resolved and long-term donor safety is established.     

Debate on live related liver transplant: Pro

Abstract   Live donor liver transplantation (LDLT) in adults is life saving for patients with fulminant hepatic failure, acute on chronic liver failure and end-stage cirrhosis, particularly in Asia where cadaveric organ donation is scarce. Without this modality, 50% of adult patients waiting for deceased donor liver grafts and 95% of patients with fulminant hepatic failure died. With right lobe LDLT, the overall survival rate of patients with fulminant hepatic failure increases from 5–50% and the transplant rate of patients waiting for deceased donor grafts increased from 13–42%.     

Understanding organ donation in the collaborative era: a qualitative study of staff and family experiences

Background:  Despite the success of the Breakthrough Collaborative Methodology (BCM) in increasing organ donation rates there has been little published evidence on the effect of the BCM on the wider attitudes and experiences of those involved in organ donation. This study sought to identify whether the National Organ Donation Collaborative in Australia had any additional influence on improving the experiences of staff and family members in the organ donation process.
Methods:  In-depth qualitative interviews with 17 family members from 13 families who had agreed to the organ donation of a deceased relative and 25 nurses and intensive care specialists at the Alfred Hospital, Melbourne, Victoria were carried out.
Results:  The key factor in family members' decision to donate was prior knowledge of the deceased's donation wish. Although most family members did not regret their decision to donate, many were deeply dissatistified and, at times, confused by the technical and administrative nature of the donation process. Most staff members commented that the key community message about donation should be to encourage people to discuss donation rather than urging people to sign donor registers.
Conclusion:  This study identified valuable insights into the processes by which family members and intensive care unit staff deal with the actual processes of donation. Findings suggest that the process for families is far more complex than a simple agreement or refusal to donate. This study suggests that we should not assume that 'rates' of donation in Australia would increase merely through administrative programmes or marketing campaigns.     

Ethical issues in living donor liver transplantation

The cadaveric organ shortage and the high mortality rate while patients wait for an organ have driven the medical community to develop alternative strategies for treating patients with end-stage liver disease. Adult living donor liver transplantation (ALDT) has evolved in response to the cadaveric organ shortage. Although there are benefits for recipients of ALDT, donors may incur substantial risk, including death. In contrast to pediatric living donation, in which the left lateral segment of the liver is resected from a donor, ALDT generally requires right hepatectomy, which is associated with greater morbidity and mortality. Because ALDT places a healthy individual at risk for substantial morbidity and mortality, debate over the ethics of this procedure is ongoing. Two donor deaths have occurred in the United States, adding to the concern over donor safety. Despite the risks associated with ALDT, many individuals elect to proceed with living donation with the hope of improving the life of a relative or friend. When considering whether we as a society should support and encourage ALDT, we should examine the perspective of the donor, recipient, and medical community as well. The medical community has an obligation to study carefully the risks and outcomes associated with ALDT so that we can deliver the highest quality of care that is not at the expense of healthy individuals.     

Current status and perspectives in split liver transplantation

Growing experience with the liver splitting technique and favorable results equivalent to those of whole liver transplant have led to wider application of split liver transplantation(SLT) for adult and pediatric recipients in the last decade. Conversely, SLT for two adult recipients remains a challenging surgical procedure and outcomes have yet to improve. Differences in organ shortages together with religious and ethical issues related to cadaveric organ donation have had an impact on the worldwide distribution of SLT. Despite technical refinements and a better understanding of the complex liver anatomy, SLT remains a technically and logistically demanding surgical procedure. This article reviews the surgical and clinical advances in this field of liver transplantation focusing on the role of SLT and the issues that may lead a further expansion of this complex surgical procedure.     

The general public new views on deceased organ donation in China

Background:The organ donation in China has developed rapidly since fully launched donations after citizens death in 2015. This study was conducted to evaluate how the Chinese general public views changed on deceased organ donation, and to improve the donation process.Methods:A total of 110 eligible studies, including 103, 410 individuals, were selected to analyze through searching PubMed, CBMdisc, CQVIP, CNKI, and Wanfang Data from Jan 1, 1990 to May 31, 2019. The pooled proportions (and 95% CIs) of cognition, attitudes and willingness related to organ donation were calculated using the Freeman–Tukey double arcsine transformation.Results:The pooled proportions of knowing about organ donation and willing to donate increased from 84.6% (73.0–93.4) and 32.4% (23.9–41.6) before 2015, to 86.4% (74.5–95.1) and 39.9% (32.8–47.2) after 2015, respectively. The willingness to posthumous organ donation for cornea, heart, kidney, and liver had a significant improvement. Especially, the proportion of willingness to donate cornea increased to 56.0% (43.3–68.3) after 2015, from 39.2% (31.2–47.4) before 2015. However, although 69.7% (62.7–76.4) of participants approved the deceased organ donation, only 35.6% (29.7–41.8) and 43.9% (37.2–50.8) were willing to donate their own and relatives organs postmortem, respectively. The leading reasons for refraining from donating organs postmortem were distrusting the medical professionals (49.8%, 35.2–64.4) and traditional Chinese values (40.6%, 32.4–49.0). Popularizing knowledge about organ donation (61.5%, 45.7–76.1), humanitarian aid (57.1%, 48.8–65.3), and priority of using donated organs for relatives (53.1%, 30.8–74.7) were the applauded strategies to improve the willingness to posthumous organ donation.Conclusions:The willingness toward posthumous organ donation has a significant improvement among Chinese general public since 2015, however, several important measures still need to be taken to promote the favorable attitudes and willingness toward organ donation.     

Ethical considerations in living organ donation and a new approach. An Advance-Directive Organ Registry.

Living organ donation should be recognized as an ethical compromise to the principle of nonmaleficence (doing no harm), given the risks healthy donors are allowed to assume. Living organ donation should be reserved for situations in which there is no acceptable alternative. Increasing the availability of cadaveric organs is most desirable, since it would decrease (although probably not eliminate) the need for living organ transplantation and would provide organs (ie, hearts) that could not otherwise be obtained. We propose the development of an incentive-based Advance-Directive Organ Registry, in which all adults are encouraged to register their advance directive regarding organ donations. Those individuals agreeing to permit usable organs to be taken at the time of death would receive priority for organs generated by the program, should a transplant become necessary when there is a shortage of organs. The proposed Advance-Directive Organ Registry is firmly founded on the principles of autonomy, beneficence, and justice.     

Expanding the donor pool for liver transplantation

Because of the growing shortage of donor organs, physicians and organ procurement agencies are expanding the donor pool through three mechanisms. The first mechanism is to increase the number of patients (and their families) who give consent for organ donation and thus extend the number of cadaveric livers. The second mechanism is that marginal livers, previously considered unacceptable for transplantation, are now being successfully transplanted. The third way to expand the donor pool is through advances in medical practice such as living-donor liver transplantation and split-liver transplantation.     

Exploring pathways to improve indigenous organ donation

Australia has one of the worst organ donation rates in the western world. The consequence of this is that the waiting list for life-saving transplants is increasing. Australia has a highly successful transplant programme, but a limited number of organs are donated. Unfortunately, Aboriginal people are over-represented in the organ-failure patient group – particularly in end-stage renal disease. Renal transplantation has the potential to improve quantity and quality of life for Aboriginal people with renal failure. Aboriginal people have a right to be given the same opportunities as non-indigenous people to donate their organs at the end of life and improve the transplantation rates among their own people. The most effective way to improve indigenous donation rates will be through improving the knowledge of Aboriginal people about organ donation. There are cultural complexities and end-of-life rituals that make the decision to donate organs difficult, but these issues do not preclude a family from making the decision to donate organs at the end of life. We need to provide Aboriginal communities with appropriately presented information to give them a basis for making an informed decision about organ donation. Equity of access is important. Cultural competence of requestors is important. Consultation, communication and education are the way forward.     

Public awareness and acceptance of tissue and organ donation

Organ donation is a worldwide problem especially in developing countries due to lack of knowledge about brain death and organ transplantation as well as traditional values and beliefs. Limited data are available concerning public knowledge and awareness of organ donation and transplantation in Turkey. A prospective study was carried out and data (n=774) were gathered from a structured questionnaire. The results indicated that 96.6% of participants had heard of organ donation and transplantation, 91.8% approved donation, and 59.2% would consider donating organs of their own. 62.6% were unaware of the donation law. As 81.7% of participants were interested in having more information on the issue, information booklets covering brain death, donation law and the organ donation process may increase donation of organs.     

Attitudes and knowledge of nurses regarding organ procurement

The purpose of this study was to examine nurses' attitudes and knowledge regarding organ procurement. Nurses in critical care areas completed a questionnaire designed to elicit their attitudes toward and knowledge of organ donation. Differences were found between the unit in which nurses worked and the extent to which they would participate in care of a patient for organ donation. Significant relationships were found between the fact that a nurse had previously cared for donors and the degree of comfort felt in obtaining consent, extent to which the nurse would participate in care, and knowledge of organ procurement procedures. The nurses' feelings regarding donation and their degree of comfort in obtaining consent were correlated positively with higher knowledge scores. Knowledge deficits were identified in all areas. Results indicated that although most nurses were supportive of organ procurement, there were aspects with which they were uncomfortable and others in which they lacked knowledge. The study revealed the need for additional awareness and education of nurses in all areas of the organ donation process.     

The hospital's role in improving survival of patients with out-of-hospital cardiac arrest

Out-of-hospital cardiac arrest (OHCA) is a major public health problem. Unfortunately, in spite of recurring updated guidelines, survival of patients with OHCA had been unchanged for decades. Recently, new approaches to patients with OHCA during the community and prehospital phases of therapy for cardiac arrest have resulted in a dramatic improvement in survival. Further improvement in survival has resulted from hospitals designated as Cardiac Receiving Centers. These centers are committed to the treatment of post-cardiac arrest syndrome by providing 24/7 therapeutic mild hypothermia, urgent cardiac catheterization and percutaneous coronary intervention, evidence-based termination of resuscitation protocols that limit premature withdrawal of care, protocol to address organ donation, commitment of cardiocerebral resuscitation training in their community, and a commitment and proven ability of data collection to assure that instituted changes result in improved survival. This newer aspect of hospital practice is an aspect that needs to be embraced by either becoming a Cardiac Receiving Center or partnering with other hospitals that can provide this critically important service.