Organ transplantation laws in Asian countries: a comparative study

Legal tools are a necessity in organ procurement to allow transplant surgeons to remove organs from potential sources. In some countries the organ transplantation law may not only increase the organ retrieval rate, but may also decrease the number of transplantations. Reassessing the impact of organ transplantation laws on the application of transplant technology is therefore an emerging issue. This article discusses organ transplantation laws in eight Asian countries: Japan, Korea, India, Iran, Philippines, Saudi Arabia, Singapore, and Turkey. The organ transplantation laws of each of these countries were compared in terms of how they address the issues of definition of death; donor consent; the role of family and surrogate decision making; age limitation for organ donation; organ trade and donor compensation; and the organ procurement model.     

The role of magnesium in the endothelial dysfunction caused by global ischemia followed by reperfusion: in vitro study of canine coronary arteries

Objective—To study the role of magnesium in the endothelial dysfunction of canine coronary arteries caused by cardiopulmonary bypass (CPB) global ischemia followed by reperfusion.

Design—Segments of canine coronary arteries were suspended in organ chambers to measure isometric contraction by prostaglandin F _2α , and relaxed by acetylcholine (ACh), sodium fluoride (NaF), calcium ionophore (A ₂₃₁₈₇ ) and sodium nitroprusside (SNP) in crescent concentrations. The investigation protocol had groups with six dogs: CONTROL group (without CPB), CPB group (105?min of CPB without aortic cross‐clamping), ISCH group (45?min of CPB with aortic cross‐clamping), ISCH/REP group (45?min of aortic cross‐clamping followed by 60?min of reperfusion). The coronary relaxations were evaluated with (phase I), without (phase II) and restored magnesium (phase III) to the organ bath.

Results—The presence of magnesium in the organ bath was associated with the greater relaxation in response to agonists of the nitric oxide production. The removal of magnesium from the organ bath was associated with the reduction in the intensity of vessel relaxation. The magnesium restoration to the organ bath was associated with the additional reduction in the intensity of relaxation with the exception of NaF that allowed re‐acquisition of the relaxation observed in the presence of magnesium.

Conclusion—This in vitro study demonstrates that magnesium ion favorably influences the nitric oxide production by the coronary endothelium, attenuating the endothelial dysfunction caused by global ischemia followed by reperfusion.     

Current Trends in Superficial Venous Surgery

In trying to overcome the growing gap between demand and offer of organs for transplantation, solutions are usually searched for by comparing successful and unsuccessful models in different countries. In particular, one element in the more successful countries such as for instance presumed consent, or one element in the less successful countries such as for instance refusal by relatives, are seen as possible reasons for these differences. This article tackles the problem of organ donor shortage through a new multi-level approach. Organ donation can indeed be analyzed on three different levels: the macro-level, the meso-level and the micro-level. The macro-level refers to the governmental structure where legislation, policies and funding are three essential elements necessary to make donation possible. The meso-level refers to the health care organization and the professionals who surround the process of organ donation and transplantation. Facilitating this process through standardized protocols and improving detection of organ donors are the two major elements. The micro-level refers to the individual believes and personal attitudes towards organ donation. This new multi-level approach gives a thorough and complete analysis of problems and allows to propose potential solutions to try to overcome the chronic organ shortage.     

Preliminary Marked Increase in the National Organ Donation Rate in Israel Following Implementation of a New Organ Transplantation Law

Israel's organ donation rate has always been among the lowest in Western countries. In 2008 two new laws relevant to organ transplantation were introduced. The Brain‐Respiratory Death Law defines the precise circumstances and mechanisms to determine brain death. The Organ Transplantation Law bans reimbursing transplant tourism involving organ trade, grants prioritization in organ allocation to candidates who are registered donors and removes disincentives for living donation by providing modest insurance reimbursement and social supportive services. The preliminary impact of the gradual introduction and implementation of these laws has been witnessed in 2011. Compared to previous years, in 2011 there was a significant increase in the number of deceased organ donors directly related to an increase in organ donation rate (from 7.8 to 11.4 donors per million population), in parallel to a significant increase in the number of new registered donors. In addition the number of kidney transplantations from living donors significantly increased in parallel to a significant decrease in the number of kidney transplantations performed abroad (from 155 in 2006 to 35 in 2011). The new laws have significantly increased both deceased and living organ donation while sharply decreasing transplant tourism.     

Do we need living unrelated organ donation in Brazil?

The remarkable success achieved by organ transplantation has also engendered the major problem of organ shortage. As a consequence, the use of living unrelated donors (LURD) has been proposed as an ethically justifiable alternative for developed nations to minimize their waiting lists for organ transplantation (OTx). This change in attitude has caused an ethical dilemma for developing countries like Brazil, which is struggling to increase the cadaver donor pool. Due to a huge socioeconomic gap of values and needs among nations, the incentive to use LURD in developed countries may not only produce a disincentive to cadaver organ donation but also stimulate organ trade in developing countries. In this paper we aimed to show that in Brazil, we do not need to use LURD because we have not optimized our cadaver donor pool. The exploitation of LURD might be a good option for developed countries, but it is not useful for developing countries. The Transplantation Society urgently needs to solve and clarify this problem by establishing basic ethical and justice principles that can serve as a guide for every country, throughout the entire process required, to achieve an adequate pool of cadaver donors.     

Ethics of paid organ donation

As the waiting list of patients requiring organ transplantation grows, there is a subtle but noticeable shift in society towards accepting organs as a commodity which can be paid for. Although nowhere is the organ trade legal, the commerce of organs goes on in different parts of the world, especially in developing countries such as India. This is largely due to societal and governmental failure to implement the existing ”transplant laws”. It is high time the medical profession ceased being an accomplice to this unscrupulous trade, which exploits the poor, deters altruism retarding the living-related and cadaver transplant programs, commercializes the human body and jeopardizes human dignity. Received: 25 October 2001 / Revised: 24 January 2002 / Accepted: 24 January 2002     

A plea for uniform European definitions for organ donor potential and family refusal rates

Conversion of potential organ donors to actual donors is negatively influenced by family refusals. Refusal rates differ strongly among countries. Is it possible to compare refusal rates in order to be able to learn from countries with the best practices? We searched in the literature for reviews of donor potential and refusal rates for organ donation in intensive care units. We found 14 articles pertinent to this study. There is an enormous diversity among the performed studies. The definitions of potential organ donors and family refusal differed substantially. We tried to re‐calculate the refusal rates. This method failed because of the influence caused by the registered will on donation in the Donor Register. We therefore calculated the total refusal rate. This strategy was also less satisfactory considering possible influence of the legal consent system on the approach of family. Because of lack of uniform definitions, we can conclude that the refusal rates for organ donation can not be used for a sound comparison among countries. To be able to learn from well‐performing countries, it is necessary to establish uniform definitions regarding organ donation and registration of all intensive care deaths.     

我国心死亡器官捐献中存在的问题及对策我国心死亡器官捐献中存在的问题及对策

供器官短缺是全球器官移植面临的最大问题之一。我国器官捐献率明显低于欧美等发达国家,心死亡器官捐献（DCD）是现阶段解决器官短缺的关键性措施。我国DCD工作刚开始,涉及到一系列伦理、法律、人权等社会问题。为避免出现器官买卖现象,保障器官捐献工作的有序开展,必须加强器官捐献工作的规范管理,用法律来规范器官捐献的社会行为,用行政手段建立具有中国特色的器官捐献协调系统,用严谨的科学态度制定器官分配的规则和合理的捐献救助标准,以保证DCD工作的健康、可持续发展。     

Assessment of the Safety of Aquatic Animal Commodities for International Trade: The OIE Aquatic Animal Health Code

Trading of aquatic animals and aquatic animal products has become increasingly globalized during the last couple of decades. This commodity trade has increased the risk for the spread of aquatic animal pathogens. The World Organisation for Animal Health (OIE) is recognized as the international standard‐setting organization for measures relating to international trade in animals and animal products. In this role, OIE has developed the Aquatic Animal Health Code, which provides health measures to be used by competent authorities of importing and exporting countries to avoid the transfer of agents pathogenic for animals or humans, whilst avoiding unjustified sanitary barriers. An OIE ad hoc group developed criteria for assessing the safety of aquatic animals or aquatic animal products for any purpose from a country, zone or compartment not declared free from a given disease ‘X’. The criteria were based on the absence of the pathogenic agent in the traded commodity or inactivation of the pathogenic agent by the commercial processing used to produce the commodity. The group also developed criteria to assess the safety of aquatic animals or aquatic animal products for retail trade for human consumption from potentially infected areas. Such commodities were assessed considering the form and presentation of the product, the expected volume of waste tissues generated by the consumer and the likely presence of viable pathogenic agent in the waste. The ad hoc group applied the criteria to commodities listed in the individual disease chapters of the Aquatic Animal Health Code (2008 edition). Revised lists of commodities for which no additional measures should be required by the importing countries regardless of the status for disease X of the exporting country were developed and adopted by the OIE World Assembly of Delegates in May 2011. The rationale of the criteria and their application will be explained and demonstrated using examples.     

A criminological perspective: why prohibition of organ trade is not effective and how the Declaration of Istanbul can move forward

The Declaration of Istanbul is the first document that has been established by the international transplant community that defines and prohibits transplant commercialism and organ trafficking. Its Custodian Group has successfully led various countries to implement legislation against trafficking and commercialism. The question arises, however, whether efforts to prohibit organ trade are realistic and effective. The Declaration differentiates trafficking from commercialism, yet it does not mention how both acts should be approached by policy. Policies that address transplant commercialism work differently from policies that tackle organ trafficking. There is considerable room for improvement in the current prohibitive approach to commercialism and organ trafficking. The Custodian Group and World Health Organization (WHO) should address commercialism by encouraging the expansion of living donation in the same manner as they encourage deceased donation. Furthermore, the Custodian Group and the WHO can improve their strategy to combat organ trafficking by raising awareness for enforcement. To achieve a consistent and effective prohibition of trafficking, legislation and law enforcement must go hand in hand. Ideally, this can best be achieved by close collaboration between the medical field and (international) criminal justice agencies.     

Screening for Zika virus in deceased organ donors in Florida

Zika virus (ZIKV) cases have been detected across the United States (US) and locally acquired cases have been reported in Florida. Currently, there are no ZIKV screening guidelines and no data on the incidence among organ donors in the US. This retrospective study was conducted at Jackson Memorial‐Miami Transplant Institute. Positive ZIKV tests in local deceased organ donors were investigated from 6/2016 to 1/2017. We evaluated demographics and risk factors for ZIKV infection among organ donors and transplant outcomes among recipients of donors with positive ZIKV testing. One hundred forty‐two donors were analyzed. Ten percent had traveled to ZIKV‐endemic countries and 19% had outdoor occupations. Only 3% had positive ZIKV IGG. None had a positive ZIKV IGM or PCR. ZIKV‐positive donors were more likely to have traveled to ZIKV‐endemic countries (50% vs. 9%, P = .05). The kidneys from a ZIKV‐positive donor were transplanted in our hospital with no 6‐month rejection, graft failure, or death in the recipients. Our study demonstrated a low prevalence of ZIKV among deceased donors in our community. Despite local ZIKV transmission, ZIKV was more common in donors who traveled to ZIKV‐endemic countries. This cohort demonstrated excellent outcomes in recipients of ZIKV IGG‐positive donors. However, larger studies are needed.     

Chronic Kidney Disease, Transplantation Practices and Transplantation Law in Pakistan: Opportunity for a Global Meditation

The majority of countries have enacted edicts to regulate organ transplantation due to mounting recognition of its intricacies and increasing level of global disquiet. Frail national economy and status of health care infrastructure restricts access of the local population to both dialysis and transplantation in Pakistan. There is a surge in kidney transplantation activities, however. I have reported the enormity of organ crime in Pakistan. The number of commercial renal transplants range from 3000 to 4500. Foreign nationals share the marketplace. There are current attempts from the government to stop organ trade by strictly enforcing a recently sanctioned law on organ transplantation. Scarcity of comprehensive reliable data has hampered plausible assessments and indispensable modifications to facilitate designs for the future health care. Alternatives to organ transplantation will augment the choice of treatment modalities for a proliferating end-stage renal disease (ESRD) population. The whole array of existing therapeutic modalities for ESRD has to be utilized. Promoting a fresh culture of organ donation by strengthening of the family institution may be another objective.     

Characteristics of Foot‐and‐Mouth Disease Viral Strains Circulating at the Wildlife/livestock Interface of the Great Limpopo Transfrontier Conservation Area

Foot‐and‐mouth disease (FMD) inflicts severe economic losses within infected countries and is arguably the most important trade‐restricting livestock disease in the world. In southern Africa, infected African buffaloes (Syncerus caffer) are the major reservoir of the South African Territories (SAT) types of the virus. With the progressive expansion of transfrontier conservation areas (TFCAs), the risk of FMD outbreaks is expected to increase due to a higher probability of buffalo/livestock contacts. To investigate the dynamics of FMD within and around the Great Limpopo TFCA (GLTFCA), 5 herds of buffaloes were sampled in June 2010 to characterize circulating viruses in South Africa and Zimbabwe. Three SAT‐2 and three SAT‐3 viral strains were isolated in both countries, including one that was genetically linked with a recent SAT‐2 outbreak in Mozambique in 2011. In addition, two groups of unvaccinated cattle (n = 192) were serologically monitored for 1 year at the wildlife/livestock interface of Gonarezhou National Park (GNP) in Zimbabwe between April 2009 and January 2010, using the liquid‐phase blocking ELISA (LPBE) and a test for antibodies directed against non‐structural proteins (NSP). Neither clinical signs nor vaccination of cattle were reported during the study, yet a high proportion of the monitored cattle showed antibody responses against SAT‐3 and SAT‐1. Antibodies against NSP were also detected in 10% of the monitored cattle. The results of this study suggest that cattle grazing in areas adjacent to the GLTFCA can be infected by buffalo or other infected livestock and that cattle trade movements can act as efficient disseminators of FMD viruses to areas several hundred kilometres from the virus source. Current methods of surveillance of FMD at the GLTFCA interface seem insufficient to control for FMD emergence and dissemination and require urgent reassessment and regional coordination.     

Coverage of the organ donation process on Grey’s Anatomy: the story of Denny Duquette

Abstract: This investigation examined the impact of Grey’s Anatomy viewing on a host of organ donation‐related variables: organ donation beliefs and attitudes and a willingness to discuss organ donation with family. Following exposure to a storyline in which two myths were presented: (i) the rich and famous can buy their way to the top of organ waiting lists (purchase myth) and (ii) friends and family of medical professionals receive organ transplants quicker than other individuals (relationship myth), results revealed that loyal viewers of Grey’s Anatomy are less likely to believe the purchase myth compared to non‐viewers. No difference emerged between these two groups with respect to the relationship myth. Additionally, loyal viewers were more likely to talk about their willingness to donate organs than non‐viewers. Results are discussed with an emphasis on how Grey’s Anatomy portrayals can impact perceptions and action tendencies related to organ donation.     

When politics meets science: What impact might Brexit have on organ donation and transplantation in the United Kingdom?

Brexit may lead to major political, societal, and financial changes—this has significant implications for a tax revenue funded healthcare system such as the United Kingdom's (UK) National Health Service. The complex relationship between European Union (EU) legislation and clinical practice of organ donation and transplantation is poorly understood. However, it is unclear what impact Brexit may have on organ donation and transplantation in the UK and EU. This work aims to describe the current legislative interactions affecting organ donation and transplantation regulation and governance within the UK and EU. We consider the potential impact of Brexit on the practical aspects of transplantation such organ‐sharing networks, logistics, and the provision of health care for transplant patients when traveling to the EU from the UK and vice versa, as well as personnel, and research. Successful organ donation and transplantation practices rely on close collaboration and co‐operation across Europe and throughout the United Kingdom. The continuation of such relationships, despite the proposed legislative change, will remain a vital and necessary component for the ongoing success of transplantation programs.     

Care for commercial living donors: the experience of an NGO’s outreach in Egypt

Follow‐up care for living organ donors is inadequate in countries with advanced transplantation systems based on altruistic donation. In cases where financial incentives drive an organ donation, care for the live ‘donor’ is largely absent. Care must be provided not only to living altruistic organ donors but especially to victims of organ trafficking who are often not suitable candidates for a donation and subject to poor surgical practices and conditions. Such follow‐up is essential not only as a basic right, but also as an important reconciliatory step to regain public trust in transplants where they have been characterized by commercialism. Yet, the question, who will provide care for the commercial living donor? persists. In the absence of public or private commitments to this care, the Coalition for Organ‐Failure Solutions (COFS) conducts outreach programmes that include identifying victims of organ trafficking, assessing their consequences and arranging support services. This paper presents studies on consequences for commercial living donors (CLDs), describes the case of organ trafficking and COFS’ care provision in Egypt and discusses why follow‐up care for CLDs is not an appropriate ingredient for advancing regulation proposals but should be considered an essential component of the movement to end organ trafficking.     

A Review of OIE Country Status Recovery Using Vaccinate‐to‐Live Versus Vaccinate‐to‐Die Foot‐and‐Mouth Disease Response Policies II: Waiting Periods After Emergency Vaccination in FMD Free Countries

For countries with OIE status, FMD free country where vaccination is not practised, vaccinate‐to‐live policies have a significant economic disincentive as the trade restriction waiting period is double that of vaccinate‐to‐die policies. The disposal of healthy vaccinated animals strictly for the purpose of regaining markets with debatable scientific justification is a global concern. The feasibility of aligning the waiting periods to facilitate vaccinate‐to‐live is explored. The first article of this two‐part review (Barnett et al., 2015) explored the qualities of higher potency Foot‐and‐Mouth Disease (FMD) vaccines, performance of differentiating infected from vaccinated animals (DIVA) diagnostic assays particularly in vaccinates and carriers, as well as aspects of current limitations of post‐outbreak surveillance. Here, the history behind the OIE waiting periods for FMD free status is reviewed as well as whether the risk of vaccinated animals and their subsequent products differ appreciably at 3 versus 6 months. It is concluded that alignment is feasible for vaccinate‐to‐live using higher potency FMD vaccines within the current OIE waiting period framework of 3 and 6 months blocks of time. These waiting periods reflect precedence, historical practicalities and considered expert opinion rather than a specific scientific rationale. The future lies in updated epidemiological and diagnostic technology to establish an acceptable level of statistical certainty for surveillance or target probability of freedom of FMDV (infection or circulation) not time restricted waiting periods. The OIE Terrestrial Code limits trade from a FMD free country where vaccination is not practiced to animal products and live non‐vaccinated animals. The risk of FMDV in products derived from higher potency vaccinated animals is appreciably less than for countries with infected FMD status or even from a FMD free country where vaccination is practised for which the Code has Articles with guidelines for safe trade with time restrictions of 3 months or less. All these presume that key requirements in the implementation of emergency vaccination including appropriate vaccine match, vaccine application, susceptible population coverage, etc. are addressed.     

Diagnosis and Management of Tuberculosis in Transplant Donors: A Donor‐Derived Infections Consensus Conference Report†

Mycobacterium tuberculosis is a ubiquitous organism that infects one‐third of the world's population. In previous decades, access to organ transplantation was restricted to academic medical centers in more developed, low tuberculosis (TB) incidence countries. Globalization, changing immigration patterns, and the expansion of sophisticated medical procedures to medium and high TB incidence countries have made tuberculosis an increasingly important posttransplant infectious disease. Tuberculosis is now one of the most common bacterial causes of solid‐organ transplant donor‐derived infection reported in transplant recipients in the United States. Recognition of latent or undiagnosed active TB in the potential organ donor is critical to prevent emergence of disease in the recipient posttransplant. Donor‐derived tuberculosis after transplantation is associated with significant morbidity and mortality, which can best be prevented through careful screening and targeted treatment. To address this growing challenge and provide recommendations, an expert international working group was assembled including specialists in transplant infectious diseases, transplant surgery, organ procurement and TB epidemiology, diagnostics and management. This working group reviewed the currently available data to formulate consensus recommendations for screening and management of TB in organ donors.     

Differences in Organ Donation and Transplantation in States Within the United States and in European Countries: Is There a Benefit to Opting Out?

BackgroundOrgan donation in the United States currently requires explicit consent by an “opt-in” approach. Some European countries have reported an increase in donation rates with an “opt-out” strategy. We hypothesized that regional differences in decision making affect organ donation rates in different countries and suggest no single approach will reliably increase organ donation rates.MethodsDonation and transplantation rates in European countries and states within the United States with populations of >10 million and a minimum organ donation rate of 10 donors per million were compared. 2016 International Registry in Organ Donation and Transplantation data and the 2016 Scientific Registry of Transplant Recipients annual report were used for European countries and US states, respectively. Comparisons by region and donation model were made.ResultsDeceased organ donor rates and transplants did not differ between opt-in and opt-out models. Living donation was increased in all opt-in entities. When comparing European countries, there was a trend toward higher organ donation rates in opt-out countries than in opt-in countries. Donation and transplantation rates of US states were higher than both European opt-in and opt-out countries.ConclusionThere were no differences in deceased donor organ donation when considering the donation consent model. These data do not support that an opt-out approach will increase the number of transplants in the United States.