A Smartphone App for Increasing Live Organ Donation

The incidence of live donor transplantation has declined over the past decade, and waitlisted candidates report substantial barriers to identifying a live donor. Since asking someone to donate feels awkward and unfamiliar, candidates are hesitant to ask directly and may be more comfortable with a passive approach. In collaboration with Facebook leadership (Facebook Inc., Menlo Park, CA), we developed a mobile application—an app—that enables waitlisted candidates to create a Facebook post about their experience with organ failure and their need for a live donor. We conducted a single‐center prospective cohort study of 54 adult kidney‐only and liver‐only waitlisted candidates using the Facebook app. Cox proportional hazards models were used to describe donor referral on behalf of candidates using the app compared with matched controls. The majority of candidates who used the app reported it to be “good” or “excellent” with regard to the installation process (82.9%), readability (88.6%), simplicity (70.6%), clarity (87.5%) and the information provided (85.3%). Compared with controls, candidates using the Facebook app were _2.436.61_17.98 times more likely to have a donor come forward on their behalf (p < 0.001). The Facebook app is an easy‐to‐use instrument that enables waitlisted candidates to passively communicate with their social network about their need for a live donor.     

Optimizing Cadaveric Organ Procurement: the Catalan and Spanish Experience

The need to face the increasing gap between the supply and the demand of transplants has led to the development of a permanent network of trained medical staff responsible for the organ donation and removal process in all centers accredited for that process. In Spain, this activity received a specific budget, like any other medical activity in hospitals, and the responsible staff became accountable for performance. This system dramatically increased the number of potential donors referred, not only young donors with trauma, but also elderly donors dying from stroke. The effect was that the donation rate increased by more than 100% in 10 years (from 14 to 34 donors per million population). Consequently, so did all the transplant figures. In some areas, such as Catalonia, it has been demonstrated that sustained kidney transplant activity of over 60 procedures per million population can maintain or slightly decrease the waiting list, despite increasing incidence and prevalence of end-stage renal failure. Quality monitoring of the donation and retrieval process shows that there are still opportunities for improvement if all potential donors are referred and all technical problems are overcome. Living donation and nonheart beating organ retrieval should also be promoted.     

Risk Appreciation for Living Kidney Donors: Another New Subspecialty?

Quantitative estimates of the risk of end stage renal disease (ESRD) for living donors would seem essential to defensible donor selection practices, as the 'safe/unsafe' model for donor selection is not viable. All kidney donors take risk, and four fundamental, qualitative criteria should instead be used to decide when donor rejection is justified. These criteria are lack of donor education about transplantation, donor irrationality, lack of free and voluntary donation, and/or that donor acceptance would unavoidably threaten the public trust or the integrity of the center's selection procedures. Such a data-based selection policy, with explicit documentation of unbiased and comprehensive donor education, will help neutralize the center's self interest in a more defensible way than by rejecting 'complicated' kidney donors out of hand, and in a more practical way than by the creation of center-independent donor counselors or waiting for donor registries to come to fruition. Living kidney donors with isolated medical abnormalities comprise a sizable subset of at risk donors for whom center acceptance practices vary markedly. This population provides a paradigm opportunity for quantitative risk estimation and counseling.     

Estimating the risks of acquiring a kidney abroad: a meta-analysis of complications following participation in transplant tourism

A meta-analysis of odds ratios comparing the risks of participating in transplant tourism by acquiring a kidney abroad to the risks associated with domestic kidney transplant was undertaken. Comparison across 12 medical outcomes indicates transplant tourists are significantly more likely to contract cytomegalovirus, hepatitis B, HIV, post-transplantation diabetes mellitus, and wound infection than those receiving domestic kidney transplant. Results also indicate that domestic kidney transplant recipients experience significantly higher one-yr patient- and graft-survival rates. Analyses are supplemented by independent comparisons of outcomes and provide practitioners with weighted estimates of the proportion of transplant recipients experiencing 15 medical outcomes. Practitioners are encouraged to caution patients of the medical risks associated with transplant tourism. Despite the illegal and unethical nature of transplant tourism, additional efforts are indicated to eliminate the organ trade and to educate wait-listed patients about the risks of transplant tourism.     

Organ donation and utilization in the USA

The processes leading to donor identification, consent, organ procurement, and allocation continue to dominate debates and efforts in the field of transplantation. A considerable shortage of donors remains while the number of patients needing organ transplantation increases.
This article reviews the main trends in organ donation practices and procurement patterns from both deceased and living sources in the USA. Although there have been increases in living donation in recent years, 2002 witnessed a much more modest growth of 1%. Absolute declines in living liver and lung donation were also noted in 2002.
In 2002, the number of deceased donors increased by only 1.6% (101 donors). Increased donation from deceased donors provides more organs for transplantation than a comparable increase in living donation, because on average 3.6 organs are recovered from each deceased donor. The total number of organs recovered from deceased donors increased by 2.1% (462 organs). Poor organ quality continued to be the major reason given for nonrecovery of consented organs from deceased donors.
The kidney is the organ most likely to be discarded after recovery. Over the past decade the discard rate of recovered kidneys has increased from 6% to 11%. Many of these are expanded criteria donor kidneys.     

Financial Neutrality for Living Organ Donors: Reasoning,Rationale, Definitions,and Implementation Strategies

In the United States, live organ donation can be a costly and burdensome undertaking for donors. While most donation‐related medical expenses are covered, many donors still face lost wages, travel expenses, incidentals, and potential for future insurability problems. Despite widespread consensus that live donors (LD) should not be responsible for the costs associated with donation, little has changed to alleviate financial burdens for LDs in the last decade. To achieve this goal, the transplant community must actively pursue strategies and policies to eliminate unreimbursed out‐of‐pocket costs to LDs. Costs should be more appropriately distributed across all stakeholders; this will also make live donation possible for people who, in the current system, cannot afford to proceed. We propose the goal of LD “financial neutrality,” offer an operational definition to include the coverage/reimbursement of all medical, travel, and lodging costs, along with lost wages, related to the act of donating an organ, and guidance for consideration of medical care coverage, and wage and other expense reimbursement. The intent of this report is to provide a foundation to inform discussion within the transplant community and to advance initiatives for policy and resource allocation.     

The beauty of the gift: the wonder of living organ donation

In a recent opinion piece, Nancy Scheper-Hughes provides a sweeping indictment of living organ donation, even in cases where the gift is directed to a close family member. She describes the process with caustic powerful phrases such as "sacrificial violence" and a "call to 'self-sacrifice.'" She concludes that living organ donation "should be consigned to a back seat as an exceptional back-up to deceased donation." But her conclusions are based on anecdotes and data that are not representative of donor practice and motivation in the United States and other developed countries. At reputable transplant centers great care is taken to identify genuine volunteers and to protect their interests. Under these circumstances living organ donation remains a generally safe and beneficial procedure for the donor as well as the recipient, and a wonderful example of the goodness of people.     

Organ donation and utilization in the United States, 2004

This article discusses issues directly related to the organ donation process, including donor consent, donor medical suitability, non-recovery of organs, organs recovered but not transplanted, expanded criteria donors (ECD), and donation after cardiac death (DCD). The findings and topics covered have important implications for how to evaluate and share best practices of organ donation as implemented by organ procurement organizations (OPOs) and major donor hospitals in the same donation service areas (DSAs). In 2002 and 2003, US hospitals referred more than one million deaths or imminent deaths to the OPOs of their DSA. Referrals increased by nearly 10% from 2002 to 2003 (1,022,280 to 1,121,392). Donor consents have increased by about 5% and the number of total deceased donors has risen from 6,187 to 6,455. Since multiple organs are recovered from most donors, this increase allowed more than 500 additional wait-listed candidates to receive an organ transplant than in the prior year. Non-traditional donor sources have experienced a large rate of increase; in 2003 the number of ECD kidney donors increased by 8% and the number of DCD donors increased by 43% , from 189 donors in year 2002 to 271 donors in 2003.     

Thoracic Organ Transplantation in the United States, 1995–2004

This article reviews trends in thoracic organ transplantation based on OPTN/SRTR data from 1995 to 2004. The number of active waiting list patients for heart transplants continues to decline, primarily because there are fewer patients with coronary artery disease listed for transplantation. Waiting times for heart transplantation have decreased, and waiting list deaths also have declined, from 259 per 1000 patient-years at risk in 1995 to 156 in 2004. Fewer heart transplants were performed in 2004 than in 1995, but adjusted patient survival increased to 88% at 1 year and 73% at 5 years. Emphysema, idiopathic pulmonary fibrosis and cystic fibrosis were the most common indications among lung transplant recipients in 2004. Waiting time for lung transplantation decreased between 1999 and 2004. Waiting list mortality decreased to 134 per 1000 patient-years at risk in 2004. One-year survival following transplantation has improved significantly in the past decade. The number of combined heart-lung transplants performed in the United States remains low, with only 39 performed in 2004. Overall unadjusted survival, at 58% at 1 year and 40% at 5 years, is lower among heart-lung recipients than among either heart or lung recipients alone.     

Evaluation and selection of potential live kidney donors

PURPOSE: Renal transplantation is an optimal therapy for patients with end stage kidney disease. A thorough evaluation of potential donors is necessary to provide the best functional outcome for recipients and ensure no or minimal morbidity for donors. MATERIALS AND METHODS: Between 1992 and 2001, 1661 ABO compatible potential living donors were evaluated clinically as well as by laboratory and imaging studies. RESULTS: Of 1661 potential donors 814 (49%) were excluded. The reasons for elimination were general medical reasons in 34.4% of cases, nephrological disorders in 25.6%, urological diseases in 11.7% and immunological causes in 16.2%. Exclusion on an ethical basis accounted for 12.2% of cases. CONCLUSIONS: Although kidneys from living donors provide the best functional outcome, 50% of potential candidates must be excluded.     

Lifetime risk of end‐stage kidney disease in living donors for paediatric kidney transplant recipients in Australia and New Zealand – a retrospective study

Living kidney donors (LKD) for paediatric kidney transplant recipients (KTR) have a heightened motivation to donate for emotional reasons and the clear health benefits to the KTR. We hypothesized that the cohort of LKD for paediatric KTR (LKD‐P) includes motivated young parents with a higher lifetime end‐stage kidney disease (ESKD) risk compared to adult KTR (LKD‐A). Data from the Australia and New Zealand Dialysis and Transplant LKD Registry (2004–2015) was analysed to compare baseline characteristics and predonation ESKD risk in LKD‐P (n = 315) versus LKD‐A (n = 3448). LKD‐P were younger (median age 42 vs. 50 years; P < 0.001) and had a marginally higher lifetime ESKD risk (median 0.44% vs. 0.40%; P < 0.01), with a similar proportion of LKD exceeding 1% risk threshold (5.4% vs. 5.6%; P = NS). Compared to grandparents as LKD‐P, parents (median age 41 vs. 59 years; P < 0.001) had a higher lifetime ESKD (0.44% vs. 0.25%; P < 0.001). Although unique benefits to paediatric KTR justify the minor increase in lifetime ESKD risk in young parents, carefully selected grandparents are an alternative LKD‐P option, allowing parents to donate for subsequent transplants.     

On Patients Who Purchase Organ Transplants Abroad

The international transplant community portrays organ trade as a growing and serious crime involving large numbers of traveling patients who purchase organs. We present a systematic review about the published number of patients who purchased organs. With this information, we discuss whether the scientific literature reflects a substantial practice of organ purchase. Between 2000 and 2015, 86 studies were published. Seventy‐six of these presented patients who traveled and 42 stated that the transplants were commercial. Only 11 studies reported that patients paid, and eight described to what or whom patients paid. In total, during a period of 42 years, 6002 patients have been reported to travel for transplantation. Of these, only 1238 were reported to have paid for their transplants. An additional unknown number of patients paid for their transplants in their native countries. We conclude that the scientific literature does not reflect a large number of patients buying organs. Organ purchases were more often assumed than determined. A reporting code for transplant professionals to report organ trafficking networks is a potential strategy to collect and quantify cases.     

The ELPAT living organ donor Psychosocial Assessment Tool (EPAT): from ‘what’ to ‘how’ of psychosocial screening – a pilot study

Thorough psychosocial screening of donor candidates is required in order to minimize potential negative consequences and to strive for optimal safety within living donation programmes. We aimed to develop an evidence‐based tool to standardize the psychosocial screening process. Key concepts of psychosocial screening 1 were used to structure our tool: motivation and decision‐making, personal resources, psychopathology, social resources, ethical and legal factors and information and risk processing. We (i) discussed how each item per concept could be measured, (ii) reviewed and rated available validated tools, (iii) where necessary developed new items, (iv) assessed content validity and (v) pilot‐tested the new items. The resulting ELPAT living organ donor Psychosocial Assessment Tool (EPAT) consists of a selection of validated questionnaires (28 items in total), a semi‐structured interview (43 questions) and a Red Flag Checklist. We outline optimal procedures and conditions for implementing this tool. The EPAT and user manual are available from the authors. Use of this tool will standardize the psychosocial screening procedure ensuring that no psychosocial issues are overlooked and ensure that comparable selection criteria are used and facilitate generation of comparable psychosocial data on living donor candidates.     

Time to Cardiac Death After Withdrawal of Life-Sustaining Treatment in Potential Organ Donors

Organ donation after cardiac death (DCD) is increasing markedly, allowing more patients to benefit from transplantation. The time to cardiac death following withdrawal of life-supporting treatment varies widely and is an important determinant of whether organ donation occurs. A prospective multicenter study of potential DCD donors was undertaken to evaluate the time to death and identify associated factors. One hundred and ninety-one potential adult DCD donors at nine UK centers were studied. Treatment withdrawal comprised stopping ventilator support and inotropes. Demographics and physiological variables at the time of death were recorded. Following treatment withdrawal, all potential donors died, with median time to death of 36 min (range 5 min to 3.3 days). Eighty-three potential donors (43.5%) remained alive 1 h after treatment withdrawal, and 69 (36.1%) and 54 (28.3%) at 2 and 4 h, respectively. Univariate analysis revealed that age, cause of death, ventilation mode, inotrope use, systolic blood pressure, FiO₂ and arterial pH at treatment withdrawal were all associated with time to death. Multivariable analysis showed that younger age, higher FiO₂ and mode of ventilation were independently associated with shorter time to death. This information may aid planning and resourcing of DCD organ recovery and help maximize DCD donor numbers.