A European perspective on organ procurement: breaking down the barriers to organ donation.

A worldwide shortage of donor organs has led to the development of national and international systems for organ procurement and allocation. Such systems promote organ donation and ensure fair distribution of available donor organs through a combination of legislation, organ exchange organizations (OEOs), transplant coordinators, publicity campaigns, donor cards, and professional training programs. The development of national and international OEOs is central to this process because they maintain waiting lists and allocate organs in the most appropriate way. Most countries also employ transplant coordinators whose role involves promoting links between transplant centers and intensive care units, establishing protocols for organ donation, and helping hospital staff deal with the sensitive issues involved in organ donation. Educational initiatives, such as the European Donor Hospital Education Programme developed by Eurotransplant is now used in over 30 countries worldwide. The program aims to improve professionals' understanding of the legal and ethical issues involved in transplantation, to help them communicate effectively and sympathetically with bereaved families, and to increase organ donation rates. Other initiatives include programs such as the Donor Action Programme, which was set up by professional organizations in the US and Europe aiming to help hospitals establish tailor-made organ procurement policies to ensure that all potential donors can be identified and reported and the needs of unfortunate families can be met in a caring and sensitive manner.     

The System of Transplant Coordinators in Poland: Poltransplant Activity

BackgroundOne of the important tasks of a modern hospital, in addition to treatment, prevention, and education, is the activity in the field of donating organs from deceased and living donors. In July 2010, the Polish Transplantation Coordination Center Poltransplant (the national transplantation organization and the authority responsible for organ donation and transplantation), thanks to the funds of the Ministry of Health, under the National Program for the Development of Transplant Medicine, initiated the project of building a network of coordinators by employing hospital transplantation coordinators in selected hospitals, where it is possible to identify potential deceased donors, perform the brain death diagnostic procedure, and where the conditions are met and it is possible to collect organs (they have an intensive care unit and operating theater in their structures). In Poland, these conditions are met by 388 hospitals with a donation potential.AimThe aim of the work is to present the functioning of the system of transplant coordinators in Poland.ResultsThe work presents the system of employment and tasks of transplant coordinators at various levels: hospital coordinators for donating organs from deceased donors, living donation and transplant coordinators, coordinators of hematopoietic cell collection and transplantation, central coordinators of Poltransplant, and organ procurement and transplant coordinators associated with transplant centers.     

Financial aspects of organ procurement from deceased donors in the USA—Relevance to xenotransplantation

When clinical xenotransplantation is introduced, the costs associated with acquisition of a genetically engineered pig organ are as yet unknown. How will these costs compare with those currently associated with the acquisition of deceased human organs? An understanding of the financial aspects of deceased organ and tissue procurement in the USA is therefore worthwhile. We have therefore attempted to review certain economic aspects of non‐profit and for‐profit organizations that provide cadaveric organs and/or tissues for purposes of transplantation into patients with end‐stage organ failure, cellular deficiencies, or in need of reconstructive procedures. We briefly consider the laws, organizations, and business practices that govern the acquisition, processing, and/or distribution of cadaveric organs and tissues, and the economic implications of industry practices. In particular, we explore and highlight what we perceive as a lack of transparency and oversight with regard to financial practices, and we question whether donor families would be entirely happy with the business environment that has developed from their altruistic donations. Until xenotransplantation becomes established clinically, which will negate the need for any system of organ procurement and allocation, we suggest that those involved in organ and cell transplantation, as well as those who participate in reconstructive surgery, should take responsibility to ensure that the financial practices associated with procurement are transparent, and overseen/regulated by a responsible authority. We suggest the major transplant societies should take a lead in this respect. The ability to acquire a genetically engineered pig organ whenever required through a simple commercial transaction (as in the acquisition of a life‐saving drug) will be greatly to the patient's benefit.     

Transplant coordination activities in the Başkent University Hospital Network

Our transplantation center adopted a new model of operation, with 3 affiliated centers of the Ba?kent University. The aim of this system is to standardize procedures related to organ procurement and transplantation, to increase organ donation, and to improve the quality of services. The transplant team is composed of a transplant coordinator, and transplant clinicians and surgeons. The transplant coordinator works independently, and promotes organ donation and procurement, organizes interviews with donor families, and is in contact with national and international organ-sharing organizations. The organs and tissues are transplanted in the Ankara hospital of the network if the cadaver organ source is one of the Ba?kent University hospitals. If no appropriate recipient is available, the organs and tissues are offered to the National Coordination Center for other transplantation centers. To implement this system most efficiently and effectively, periodic situation analyses were made.     

Organ Donation and Utilization in the United States: 1998–2007

Organ transplantation remains the only life-saving therapy for many patients with organ failure. Despite the work of the Organ Donation and Transplant Collaboratives, and the marked increases in deceased donors early in the effort, deceased donors only rose by 67 from 2006 and the number of living donors declined during the same time period. There continues to be increases in the use of organs from donors after cardiac death (DCD) and expanded criteria donors (ECD). This year has seen a major change in the way organs are offered with increased patient safety measures in those organ offers made by OPOs using DonorNet^©. Unfortunately, the goals of 75% conversion rates, 3.75 organs transplanted per donor, 10% of all donors from DCD sources and 20% growth of transplant center volume have yet to be reached across all donation service areas (DSAs) and transplant centers; however, there are DSAs that have not only met, but exceeded, these goals. Changes in organ preservation techniques took place this year, partly due to expanding organ acceptance criteria and increasing numbers of ECDs and DCDs. Finally, the national transplant environment has changed in response to increased regulatory oversight and new requirements for donation and transplant provider organizations.     

A 16-fold increase in organ donation in a Hispanic population

Organ transplantation as a substitute for diseased organs in end-stage organ failure has led to a worldwide increase in this treatment modality, but donation has not kept pace with the demand, despite scientific, social, and government efforts. For many years, Hispanic donation in Puerto Rico was meager and lagged behind major centers in North America and Europe. Studies signaled mostly cultural factors in this limited donation. We report a 16-fold increase in organ donation with the development of a formal procurement organization tailored to a local culture. METHODS: The 30-year, 1400-transplant experience of the Puerto Rico Transplant Center was divided in three periods: 1977 through 1893, the latter signaling the approval of a transplant law; 1984 through 1995, signaling the commencement of a formal organ procurement organization; and 1996 through 2006. The subset of 2001 to 2006 was used in an additional calculation against 1984 to 1995. RESULTS: The comparison of the mean deceased donors from 1984 to 1995 with 1998 to 2006 shows a 12-fold increase; and the last 6 years versus 1984 to 1995, a 16.8-fold increase. CONCLUSION: Cultural and educational obstacles in a given country may be overridden by aggressive administrative and educational approaches and strategic planning tailored to local realities, with improvement in organ transplantation.     

Bold policy changes are needed to meet the need for organ transplantation in India

Twenty-five years after India passed legislation to legalize brain death, deceased donor transplantation remains underdeveloped while the country has established formidable capacity for living donor transplantation. Because of a large number of potential deceased donors, there is hope that deceased donation could help meet India's enormous need for organ transplantation. However, significant policy and practical barriers limit progress. The vast majority of potential deceased donors are poor motor vehicle accident victims who present for care in hospitals without the necessary infrastructure or expertise to support deceased donation. In contrast, transplant infrastructure and expertise are concentrated in private hospitals and are only accessible to those with the ability to pay. Given these realities, the potential of deceased donor transplantation can only be recognized if Indians who are likely to donate organs are also provided access to transplantation. In this viewpoint, we review the current status of organ transplantation in India and propose new policies to establish a national organization to oversee deceased donor services in all states, to fund resources needed to support deceased donation, to leverage the existing living donor infrastructure to advance deceased donor transplantation, and call for establishment of government policy on funding for posttransplant care and immunosuppression.     

Thirteen years of the Thai red cross organ donation centre

The Thai Red Cross Organ Donation Centre was founded more than 13 years ago. Its primary roles are to promote organ donation, recipient registration, organ allocation and coordination of procurement. METHOD: This was a retrospective analysis of data from the Thai Red Cross Organ Donation Centre from February 1, 1994, to October 31, 2007. RESULTS: There were 450,069 people registered as potential donors. Over the past 6 years, the average new registration was 35,000 people per year. There were 791 deceased organ donors, yielding 1786 organs and 1062 tissues for transplantation. They comprised 1414 kidneys, 242 livers, 125 thoracic organs, 4 liver-kidneys, 1 pancreas-kidneys, 652 corneas, 370 heart valves, 36 bones, 3 blood vessels, and 1 skin. In the early period, each donor provided about three organs/tissues for transplantation. Now, each organ donor can provide 3.6 organs/tissues for transplantation. DISCUSSION: At present, the Thai Red Cross Organ Donation Centre is also authorized by The Medical Council of Thailand to oversee transplant practices in the country. There is a tendency for an increase in organ and tissue donations, although the numbers of waiting list patients is out of proportion to those of actual donors. CONCLUSION: Over the 13-year period of the Thai Red Cross Organ Donation Centre, there were 791 deceased organ donors who provided 2809 organ/tissues for transplantation.     

A 10-year analysis of organ donation after cardiac death in the United States

BACKGROUND: The greatest challenge facing transplantation today is how to increase the number of organ donors. Patients with severe brain injury who are not brain-dead can donate organs after they are removed from a ventilator and allowed to die, termed donation after cardiac death (DCD). METHODS: We analyzed the database of all organs recovered from deceased donors in the United States from 1994 through 2003 to determine DCD trends in the United States. The database was obtained from the United Network for Organ Sharing (UNOS). RESULTS: There were 57,681 deceased donors reported from 1994 through 2003. Of these, 1,177 were donors without a heartbeat (DWHB), 55,206 were brain dead donors, and 1,298 were unspecified donors. At least one organ was transplanted from 1010 of the 1177 DWHB. Organ procurement organizations (OPOs) reported 0-212 DWHB accounting for up to 12.3 percent of deceased donors. There was a steady annual increase in the number of DWHB, but in 2003 there were still 19 of 59 OPOs that recovered no DWHB. A total of 2,231 organs were transplanted from the 1,177 DWHB donors, and another 665 organs were recovered for transplantation but not transplanted. The transplanted organs included 1,779 kidneys, 395 livers, 54 pancreata, 2 lungs, and 1 heart. Organs from DWHB can be successfully transplanted. CONCLUSIONS: Wider use of DWHB has the potential to greatly increase the number of organ transplants performed each year in the United States.     

International practices of organ donation

Organ donation and transplant rates vary widely across the globe, but there remains an almost universal shortage of deceased donors. The unmet need for transplants has resulted in many systematic approaches to increase donor rates, but there have also been practices that have crossed the boundaries of legal and ethical acceptability. Recent years have seen intense interest from international political organizations, led by the World Health Organization, and professional bodies, led by The Transplantation Society. Their efforts have focused on the development of a series of legal and ethical frameworks, designed to encourage all countries to eradicate unacceptable practices while introducing programmes that strive to achieve national or regional self-sufficiency in meeting the need for organ transplants. These programmes should seek to reduce both the need for transplantation and also develop deceased donation to its maximum potential. Living donation remains the mainstay of transplantation in many parts of the world, and many of the controversial--and unacceptable--areas of practice are found in the exploitation of living donors. However, until lessons are learnt, and applied, from countries with highly developed deceased donor programmes, these abuses of human rights will be difficult to eradicate. A clear international framework is now in place to achieve this.     

Development of organ transplantation in Quebec from 1985 to January 1990]

In Québec, the first organ transplantations have been realized in 1958. Several kidney transplant programs started at that time. Cardiac, liver, pancreas and lungs programs followed and reached a full development in the eighties when Cyclosporin became available. Today, there are 4 university transplant programs in Québec (McGill, Montréal, Laval and Sherbrooke) with a total of 7 kidney, 4 liver, 4 heart, 2 pancreas and 2 lungs centers. More than 2,900 transplantations have been realized. Since 1970, organ procurement and distribution is organized by a central agency called Québec-Transplant (previously Métro-transplantation). Organ donation is done on a voluntary basis as every where in North America. More than 90% of the organs comes from cadaveric donors and more than 90% of the relatives accept organ donation. 50% of the donors have deceased from head trauma and 50% from cerebral hemorrhage. In 1989, multi-organ harvesting has been realized in 64% of the donors. Despite efforts and progresses, the number of patients awaiting an organ transplant is steadily growing and outlast the number of available organs. It is hoped that maximal utilisation of the donors and growing exchanges at a national and international level will help to solve this crucial problem.     

Role of patient-support groups in the Thailand transplant program

Thailand started kidney transplantation in 1972 when vascular and nonvascular transplant programs were first established. Presently, we have 27 kidney, 6 liver, and 6 intrathoracic private or governmental transplantation centers, all approved and members of the Organ Donation Centres Thai Red Cross Society (ODC). They also provide organ procurement teams to the ODC. The Thai Medical Council has issued and supervised the criterion of brain death and ethical rules of transplantation to all practicing physicians since 1989. All recipients must register at these selected transplantation centers and at the ODC. When the potential donor arrives from any hospital in Thailand, the donor hospital notifies the ODC and organ procurement teams are sent out to harvest organs and transfer them to the recipient transplantation centers. The ODC computerizes and shares organs according to ABO, HLA typing, and crossmatching results. After transplantation all patients register with the Thai Transplantation Society (TTS) and the ODC. The TTS, the Thai Transplant Coordinator Society, and the ODC are responsible for the education of surgeons, physicians, nurses, patients, the public, and mass media to improve our transplant program. Bone marrow transplantation has separate regulations. Pooled, nonrelated bone marrow donors are registered at the blood-bank of the Thai Red Cross Society to provide donors for bone marrow transplantation. Financially, government support recipients only if they are state enterprise workers or civil servants. Public fund support through the ODC for organ procurement and the Kidney Foundation of Thailand is available for kidney transplantation. The ODC and the transplantation centers are the main patient-support groups for transplant programs in Thailand.     

Challenges and Clinical Decision‐Making in HIV‐to‐HIV Transplantation: Insights From the HIV Literature

Life expectancy among HIV‐infected (HIV+) individuals has improved dramatically with effective antiretroviral therapy. Consequently, chronic diseases such as end‐stage liver and kidney disease are growing causes of morbidity and mortality. HIV+ individuals can have excellent outcomes after solid organ transplantation, and the need for transplantation in this population is increasing. However, there is a significant organ shortage, and HIV+ individuals experience higher mortality rates on transplant waitlists. In South Africa, the use of organs from HIV+ deceased donors (HIVDD) has been successful, but until recently federal law prohibited this practice in the United States. With the recognition that organs from HIVDD could fill a critical need, the HIV Organ Policy Equity (HOPE) Act was passed in November 2013, reversing the federal ban on the use of HIV+ donors for HIV+ recipients. In translating this policy into practice, the biologic risks of using HIV+ donors need to be carefully considered. In this mini‐review, we explore relevant aspects of HIV virology, antiretroviral treatment, drug resistance, opportunistic infections and HIV‐related organ dysfunction that are critical to a transplant team considering HIV‐to‐HIV transplantation.     

Innovation in organ transplantation: A meeting report

This workshop targeted opportunities to stimulate transformative innovation in organ transplantation. Participants reached consensus regarding the following: (1) Mechanisms are needed to improve the coordination of policy and oversight activities, given overlapping responsibilities for transplantation and clinical investigation among federal agencies. Innovative clinical trials span traditional administrative boundaries and include stakeholders with diverse interests. Participants identified the need for a governmental interagency working group to coordinate nationwide transplant‐related activities. (2) Improvements are required in clinical metrics for transplantation, with alignment of performance goals across transplantation organizations and any development of data requirements being consistent with those goals. Database coordination among clinical centers, organ procurement organizations, regulatory agencies, and payers would facilitate research and better inform policy. New data requirements should provide actionable insights into clinical performance. (3) Innovative research seen as potentially adversely affecting Program‐Specific Reports may reduce centers’ participation. Cutting‐edge research requires mitigation of risk‐aversive behaviors created by reporting of clinical outcomes data. Participants proposed a new review process in advance of implementation of clinical trials to guide “carve‐outs” of transplant center outcomes data from Program‐Specific Reports. Clinical transplantation will be advanced by the development of a shared and comprehensive research agenda to facilitate coordination of research and policy.     

Aspects of Present and Future Data Presentation in Scandiatransplant

Scandiatransplant is the Nordic organ exchange organization having existed for almost 40 years. With close collaboration between transplant centers in the Nordic countries, it has been valuable to ensure the optimal usage of available organs. The heart is the most often exchanged organ within the collaboration. It has been decided to create a priority for hyperimmunized kidney patients for compulsory exchange of organs from deceased donors.The age of the deceased organ donors has changed from younger to older donors. The evaluation of deceased kidney transplantations and deceased liver transplantations from 1995 to 2007 is shown for 4 countries. Iceland by itself is performing living donor kidney transplantations with great intensity. Scandiatransplant will make efforts to present more data than just transplantation to yield a more complete picture of organ transplantation.     

Variation in Organ Quality between Liver Transplant Centers

A wide spectrum of quality exists among deceased donor organs available for liver transplantation. It is unknown whether some transplant centers systematically use more low quality organs, and what factors might influence these decisions. We used hierarchical regression to measure variation in donor risk index (DRI) in the United States by region, organ procurement organization (OPO) and transplant center. The sample included all adults who underwent deceased donor liver transplantation between January 12, 2005 and February 1, 2009 (n = 23 810). Despite adjusting for the geographic region and OPO, transplant centers’ mean DRI ranged from 1.27 to 1.74, and could not be explained by differences in patient populations such as disease severity. Larger volume centers and those having competing centers within their OPO were more likely to use higher risk organs, particularly among recipients with lower model for end‐stage liver disease (MELD) scores. Centers using higher risk organs had equivalent waiting list mortality rates, but tended to have higher post‐transplant mortality (hazard ratio 1.10 per 0.1 increase in mean DRI). In conclusion, the quality of deceased donor organ patients receive is variable and depends in part on the characteristics of the transplant center they visit.     

The Current Status of Organ Donation and Transplantation in Poland. Poltransplant Activity

BackgroundThis article summarizes comprehensive information about the current status of organ donation and transplantation in Poland.Material and MethodsReported statistical data of solid organs and vascularized composite allograft donation and transplantation from both deceased and living donors in Poland in 2015-2020 (presented in tables according to selected variables) are based on the national transplant registries, gathering information on donation and transplantation activity in medical centers involved in donation and transplantation programs in Poland.ResultsIn 2020 during the COVID-19 pandemic, 529 potential deceased donors were referred to the Polish Transplant Coordinating Centre Poltransplant; 1310 solid organs from 393 actual deceased donors (10.2 per million population) were procured, mostly kidneys (758), livers (285), and hearts (157). Eighty percent were multiorgan retrievals (314). In 2020, 1231 organs procured from deceased donors and 59 organs from living donors were transplanted to 1236 recipients.ConclusionThis overview indicates that donation and transplantation activity from deceased donors in Poland decreased about 20% in 2020 compared with 2019, which is comparable with worldwide rates. As the unprecedented pandemic situation affected donation and transplantation procedures, there are measures that must to be taken to return to prepandemic donation and transplantation rates in both deceased and living transplant programs and then continue to improve in the years to come.     

Call to Develop a Standard Acquisition Charge Model for Kidney Paired Donation

We propose a Medicare Demonstration Project to develop a standard acquisition charge for kidney paired donation. A new payment strategy is required because Medicare and commercial insurance companies may not directly pay living donor costs intended to lead to transplantation of a beneficiary of a different insurance provider. Until the 1970s, when organ procurement organizations were empowered to serve as financial intermediaries to pay the upfront recovery expenses for deceased donor kidneys before knowing the identity of the recipient, there existed similar limitations in the recovery and placement of deceased donor organs. Analogous to the recovery of deceased donor kidneys, kidney paired donation requires the evaluation of living donors before identifying their recipient. Tissue typing, crossmatching and transportation of living donors or their kidneys represent additional financial barriers. Finally, the administrative expenses of the organizations that identify and coordinate kidney paired donation transplantation require reimbursement akin to that necessary for organ procurement organizations. To expand access to kidney paired donation for more patients, we propose a model to reimburse paired donation expenses analogous to the proven strategy used for over 30 years to pay for deceased donor solid organ transplantation in America.     

Development of a successful non-heart-beating organ donation program

To help alleviate the organ shortage, transplant centers are using organs from expanded-criteria donors, who were considered unsuitable just a few years ago, such as non-heart-beating donors. In 1998, we made a concerted effort to increase the number of non-heart-beating donors recovered by our organ procurement organization. In this paper, we discuss the steps in establishing this program, including transplant center support, estimating the number of potential non-heart-beating donors, organ procurement support, protocol development, hospital development, education, putting the protocol into practice, follow-up, and effect of the program on organ procurement. With the establishment of this program, the number of non-heart-beating donors increased from 2% to 5% per year to over 10% for the past 2 years. From these donors, 61 of 82 recovered kidneys were transplanted into 58 patients, and 18 of 20 recovered livers were transplanted. A non-heart-beating donor program can significantly add to the number of organ transplants and successful transplantations.     

Research to practice: a national consensus conference

PURPOSE: To gain consensus on aspects of the process of gaining consent for organ donation that should be mainstream daily practice. METHODS: A 3-day consensus conference of transplant professionals that provided a forum for research and innovative ideas about gaining consent for organ donation. Four work groups were assembled to address issues of gaining consent from organ and tissue donors: (1) demystifying first-person consent (donor authorization): is it a matter of law?, (2) recovery coordinators: getting from green to great, (3) maximizing the process: old views and new, and (4) donor family support: mother or smother? RESULTS: Participants reached a consensus about major consent-related practices, identified areas of practice variance, and defined topics in need of further research. CONCLUSIONS: The conference participants agreed that (1) the primary role of the organ procurement organization is to recover organs for transplantation from deceased donors and to facilitate distribution of those organs to the appropriate recipients; (2) early referral of potential donors from the hospital to the organ procurement organization is desirable; (3) a score less than 5 on the Glasgow Coma Scale should initiate end-of-life discussions with family members; a procurement coordinator from the organ procurement organization who is physically housed within the hospital is the most successful model for accommodating early referral of potential donors and optimizing family support practices; and (3) a decedent's right to donate should take precedence in the donation process and such designation by the donor before death is irrevocable and does not require the consent or concurrence of any person after the donor's death.