美国器官捐献和移植立法主要事件

1968年哈佛大学提出“脑死亡定义”1968年《人体器官捐献法》对以移植为目的的器官和组织捐献进行了法律规范 1971年修订《人体器官捐献法》，赋予器官捐献卡片法律效力     

Current techniques of organ procurement and organ conservation

Since organ transplantation became a standard procedure in medicine, some interdisciplinary discussion has evolved around the availability of organs for transplantation. The shortage of available donors leads to numerous deaths on waiting lists where heart, lung and liver disease is concerned. Patients on dialysis spend years waiting for a suitable cadaveric graft. The shortage of organs has widened not only the selection criteria for cadaveric donors and the optimization of procurement but also has led to the increased acceptance of relatives and friends as living donors for kidneys, parts of the liver and maybe in the future of the lung. It has to be decided in which direction one wants to influence the discussion about the retrieval of an adequate number of organs for our waiting patients.     

Extended criteria for organ acceptance. Strategies for achieving organ safety and for increasing organ pool

The terms extended donor or expanded donor mean changes in donor acceptability criteria. In almost all cases, the negative connotations of these terms cannot be justified. Factors considered to affect donor or organ acceptability have changed with time, after showing that they did not negatively affect graft or patient survival per se or when the adequate measures had been adopted. There is no age limit to be an organ donor. Kidney and liver transplantation from donors older than 65 years can have excellent graft and patient actuarial survival and graft function. Using these donors can be from an epidemiological point of view the most important factor to esablish the final number of cadaveric liver and kidney transplantations. Organs with broad structural parenchyma lesion with preserved functional reserve and organs with reversible functional impairment can be safely transplanted. Bacterial and fungal donor infection with the adequate antibiotic treatment of donor and/or recipient prevents infection in the latter. The organs, including the liver, from donors with infection by the hepatitis B and C viruses can be safely transplanted to recipients with infection by the same viruses, respectively. Poisoned donors and non-heart-beating donors, grafts from transplant recipients, reuse of grafts, domino transplant and splitting of one liver for two recipients can be an important and safe source of organs for transplantation.     

Thoracic organ transplantation

This article presents an overview of factors associated with thoracic transplantation outcomes over the past decade and provides valuable information regarding the heart, lung, and heart-lung waiting lists and thoracic organ transplant recipients. Waiting list and post-transplant information is used to assess the importance of patient demographics, risk factors, and primary cardiopulmonary disease on outcomes.
The time that the typical listed patient has been waiting for a heart, lung, or heart-lung transplant has markedly increased over the past decade, while the number of transplants performed has declined slightly and survival after transplant has plateaued. Waiting list mortality, however, appears to be declining for each organ and for most diseases and high-severity subgroups, perhaps in response to recent changes in organ allocation algorithms. Based on perceived inequity in organ access and in response to a mandate from Health Resources and Services Administration, the lung transplant community is developing a lung allocation system designed to minimize deaths on the waiting list while maximizing the benefit of transplant by incorporating post-transplant survival and quality of life into the algorithm. Areas where improved data collection could inform evolving organ allocation and candidate selection policies are emphasized.     

Intrathoracic organ transplantation

Thoracic organ transplantation improves survival and quality of life in patients with severe and refractory end-stage heart or respiratory failure. Since the first human-to-human heart transplant in 1967 there have been huge developments in organ preservation, perioperative management and immunosuppression regimes; and outcomes have improved accordingly. As the population ages and medical therapies improve, the number of patients who survive long enough to be considered for transplantation is increasing. At the same time, the number of donor organs available is static, even decreasing in some countries (including the UK), and the average age of donors is increasing. The lack of organs suitable for transplantation is a significant cause for concern and makes it imperative that all available donor organs are optimized. In this article we will summarize the principles of heart and lung transplantation, with emphasis on patient selection and donor and recipient management, as outlined in the Intercollegiate Surgical Curriculum Programme (ISCP) cardiothoracic surgery syllabus.     

Pediatric organ transplantation

Since we started our pediatric kidney transplant program in 1970, we advocate children's transplantation to be performed in pediatric surgery units. Recent progress in immuno-suppression with ciclosporine and in operative procedures lead us to extend the program to liver transplantations in 1986, then to heart and lung transplantations in 1988. The Pediatric Transplant Unit was designed to assume the pre-operative evaluation of the recipients and the post-operative course of transplanted patients, closely connected to all specialists dealing with medical and surgical diseases of children. 29 patients were transplanted (kidney: 8, liver: 14, heart: 1, lungs: 6) with a 83% overall survival rate. The goal of this paper is not to discuss and compare indications or results with others series. Through our experience of pediatric organ transplantation, we shall try to point out the main advantages of a Pediatric Transplantation Unit: it optimizes the management of the rare pediatric donnors, and allows better skill and efficiency of the numerous specialities concerned by organ transplantation, such as intensive care, infectiology, immunology, radiology... The common medical and para-medical staff, common operative theater, and common use of equipment in the same department for transplantation of different organs is also an important matter to be considered now in term of cost-effectiveness.     

Pancreas organ transplantation

Diabetes mellitus is a very common and dreadful disease which cannot be cured by exogenous insulin substitution. Many of the patients suffer from recurrent, and sometimes rather dangerous, hypo- or hyperglycemias and, in the long term, from the well-known secondary diabetic complications. At the moment, pancreas transplantation is the only known therapy to reliably reestablish endogenous insulin secretion responsive to normal feed back controls. Within the last decade, pancreas transplantation has evolved as a clinically well-established procedure. Nevertheless, the perioperative risk after pancreas/kidney transplantation is still higher than after isolated kidney transplantation. However, the benefits of a functioning pancreas graft for the patients are enormous. Ten-year survival of type-I diabetic patients with combined pancreas/ kidney grafts is dramatically better than of those with an isolated kidney graft. Long-term function of the pancreas grafts is excellent, reaching more than 60% after 10 years. Contrary to kidney transplantation, chronic rejection does not seem to be a major problem. Blood glucose levels in the fasting state, after glucose challenge, and in the postprandial state are completely normalized. A significant peripheral hyperinsulinemia, however, is found when the pancreas graft is connected to the systemic venous circulation. Thus, portal venous drainage of the pancreas graft, which is already being performed by a few transplant centers routinely, might be the procedure of choice for the future. Beneficial effects on secondary diabetic lesions can only be expected after a rather long observation period. In addition, for all secondary diabetic complications, there is a point of no return. Nevertheless, significant improvement of diabetic polyneuropathy, diabetic nephropathy, and the disturbed microcirculation has been convincingly demonstrated. The effect on diabetic retinopathy, however, is still controversial. One of the most impressive effects for the pancreas graft recipients seems to be the enormous improvement in quality of life, which is reported unanimously by almost all patients. Thus, simultaneous pancreas/kidney transplantation can be regarded as the optimal and only causal therapy for type-I diabetic patients with end-stage renal disease.     

Increasing organ transplantation--fairly

Ten to 30 times as many people die as a result of end-organ failure than are fortunate enough to undergo transplantation. To date, efforts to increase the donor pool or establish an alternative to transplant have failed. The authors' goal was to define a revision to the transplant system that can use innate human motivators to lead to an increase in organ donation. People are motivated more by self-interest than by altruism. To increase organ donation, the incentive needs to be aligned with self-interests. Therefore, the authors propose that the priority to receive a transplant should be based on prior willingness to be a donor: to get, you have to be willing to give. This would replace the "time on list" as a key variable in determining priority and waiting time. The commitment to the system of transplant--being a willing donor--is the fairest way to prioritize recipient status. Such a system will encourage more donation as people on the donor list start to receive transplants themselves, especially when the transplant takes place quickly, before risk becomes excessive.     

Normothermic organ preservation

Although organ preservation has relied upon hypothermia throughout the history of clinical transplantation, increasing reliance on suboptimal organs has recently focused attention on novel techniques that avoid the cumulative effects of preexisting organ damage and cold preservation. Normothermic preservation provides oxygen delivery at physiologic or near-physiologic temperature and allows maintenance of normal cellular metabolism. There is increasing evidence, mainly from experimental models, that this technique reduces preservation-related organ damage and that it has potential application particularly in the transplantation of marginal donor organs. The technical challenges and logistic constraints of what is an intrinsically more complex method have prevented introduction of normothermic preservation other than very limited clinical trials. However, the potential advantages of this technique are considerable, and it is likely that the technical problems will be overcome, allowing more widespread application into clinical practice.     

The Latin American population in Spain and organ donation. Attitude toward deceased organ donation and organ donation rates

The Latin American (LA) population has similarities with the Spanish population which makes its integration into Spanish society easier. Objective: to analyze the attitude toward organ donation among Latin American citizens residing in Spain, to determine the psychosocial variables which affect this attitude, and to examine the correlation between donation rates of LA citizens in Spain and in their countries of origin. A random sample of LA residents in Spain was taken and stratified according to the respondent's nationality (n = 1.314), in the year 2010. Attitude was assessed using a validated questionnaire (PCID‐DTO Dr Rios). The survey was self‐administered and completed anonymously. Statistical analysis: Student's t‐test, the χ² test, and logistic regression analysis. There was a 94% completion rate (n = 1.237). Attitude toward donation was favorable in 60% of cases (n = 745), 12% (n = 145) were against, and 28% (n = 347) were undecided. The following variables were associated with attitude toward donation: sex (P = 0.038), level of formal education (P < 0.001), country of origin (P = 0.002), attitude toward the donation of a family member's organs (P < 0.001), having discussed donation with the family (P < 0.001), carrying out prosocial activities (P = 0.025), attitude toward cremation of the body (P < 0.001), attitude toward burial of the body (P < 0.001), attitude toward having an autopsy carried out (P < 0.001), previous experience of the organ donation and transplantation process (P < 0.001), fear of mutilation after donation (P < 0.001), knowledge that the Church has a positive attitude toward organ donation and transplantation (P < 0.001), knowledge of one's partner's attitude toward organ donation (P < 0.001), and a belief that one might need a transplant in the future (P < 0.001). The donation rates in this population group in Spain are higher than those recorded in their countries of origin (55.76 vs. <10 pmp; P < 0.001). The attitude toward organ donation among LA citizens residing in Spain is slightly worse than that reported in the native Spanish population and is determined by many psychosocial factors. The donation rates of LA citizens in Spain are higher than those in their countries of origin.     

Determination of the factors affecting organ donation: Voluntary organ donors

IntroductionIn Turkey, even if a person wishes to be an organ donor while alive, approval from the family is required after brain death. Therefore, many potential organ donations are lost as approval cannot be obtained from the family of the deceased. The aim of this study was to determine the factors affecting organ donation.MethodA total of 219 organ donation documents of Voluntary Organ Donors (VOD) were examined in a public hospital. The information examined included the age, gender, occupation, marital status, and place of birth of the donor, the number of organs donated, and the person from whom permission should be requested after brain death.ResultsOf the total organ donors, 62.6% were aged 19–25 years, 67.6% had a high level of education, 35.6% stated that permission should be sought from their father, and 69% were born in the Mediterranean region. A significant relationship was determined between age and the number of organs donated (p < 0.05).ConclusionIt can be recommended that education about organ transplantation and donation is given in regions where donor rates are low and there are groups with a high mean age, and a low education level of nurses. It could also be effective for nurses to lead organ donation campaigns to be able to increase the number of donations.