Substantial increase in cadaveric organ donors in hospitals implementing the donor action program in Finland

The results of solid organ transplantation have improved during the last decade. Five-year patient survivals over 80% and graft survivals over 70% are common in many transplant centers. Also, quality-of-life assessments show that not only adults but even small children have a good quality of life after successful organ transplantation. Furthermore, transplantation programs have proved to be cost-effective. However, the organ shortage is a worldwide problem, which has in many countries led to prolonged waiting times, deaths on the waiting list, increased living related donations, acceptance of lower-quality organs, and in some instances even commercialization of the organ supply. Thus, it is extremely important to find strategies that increase the number of cadaveric organs for donation. In Finland organ transplantation is concentrated in one center with about 250 transplantations of different organs performed annually. The number of patients needing a new cadaveric organ is steadily increasing, but the number of donors has remained the same during the last decade. To improve cadaveric organ procurement the Donor Action (DA) program, which consists of a Hospital Attitude Survey and a medical records review performed by the donor hospital, has proved to increase the number of cadaveric donors. We introduced the DA program in Finland in 2000. Here in we report the results of this program in terms of its impact on the availability of cadaveric donors.     

Issues affecting liver transplantation

The process of liver transplantation is a complex intermixture of patient disease, timing of transplantation, and quality of organ eventually received. Because of the shortage of cadaveric organs, efforts to expand the pool of donors have led to the use of organs from donors of marginal quality. Recent data suggest that aggressive management of all brain-dead donors, but especially marginal donors, improves the likelihood that their organs will be acceptable and function adequately. Pulmonary pathology, especially portopulmonary hypertension, is especially problematic during the perioperative period. Recent recommendations are discussed. The timing/waiting time of liver transplantation has been a contentious issue from the beginning. While most would like to transplant patients who are sufficiently sick but not too sick for a successful result, past scoring systems have often allowed time on the waiting list to trump acuity of patient disease. The recently adopted model for endstage liver disease and pediatric endstage liver disease systems have dramatically changed the way recipients are listed and medically followed, and when they receive an organ. Each of these areas directly and indirectly affects perioperative care.     

Lung transplantation: present international status and basic approach

Lung transplantation has been established as an optional treatment for irreversible diffuse lung disease. To date, more than 8,000 patients have undergone lung transplantation, while heart-lung transplantation is confined to a very limited number of cases due to the severe shortage of donors. There are various problems in clinical lung transplantation, including limited preservation time, post-transplantation edema, acute and chronic rejection, and a shortage of donor organs. Several solutions to these problems have been found in recent experimental studies. For example, potential therapies for posttransplantation edema have been proposed, and the possibility of long-term preservation has been suggested. Research on xenotransplantation and cadaveric lung transplantation is ongoing, and this may result in options to solve the problem of the shortage of donor organs. In particular, we believe that cadaveric lung transplantation has the potential to become a clinically useful therapy in the near future.     

Anaesthesia for lobar lung transplantation from living donors

The shortage of cadaveric organs for transplantation has led to the increasing use of organs from living donors. Transplantation offers an increased length and quality of life for patients with end stage lung disease, although up to 30% of patients die before a cadaveric organ becomes available. This article summarizes the experience of lung transplantation from living donors at one United Kingdom centre. Donor and recipient selection will be outlined, and the perioperative management of both discussed. The ethical considerations of the use of lung tissue from living donors are also considered at length and common complications discussed.     

Current status of organ transplantation in Japan

To overcome severe donor shortage, Japanese doctors over the years have developed innovative strategies to maximize organs transplanted per brain death donor and expanded the donor pool using living donors. They also used living and marginal organs and drastically improved living donor lung, liver, pancreas and kidney transplantations. Moreover, they initiated ABO blood type incompatible liver transplantation advancements and succeeded in overcoming the blood type barrier in kidney and liver transplantations. Similar efforts are underway for pancreas transplantation. Furthermore, Japanese doctors have developed a nonaggressive step to achieve immunosuppression following organ transplantation by carefully monitoring donor-specific hyporesponsiveness and infectious immunostatus. However, the institution of amendments to allocation systems and the intensification of efforts to decrease living donor morbidity and to increase the number of brain death donors have remained important issues needing attention. Overall, the strategies Japan has adopted to overcome donor shortage can provide useful insights on how to increase organ transplantations.     

Coordinating organ transplantation in Turkey: effects of the National Coordination Center

In January 2001, the National Coordination Center, which brought tissue and organ procurement and transplantation under the Turkish Health Ministry, was established in Turkey. The main aims of this organization are to expand cadaveric donation and increase the number of transplantable organs supplied by cadaveric donors. We compared the proportions of cadaveric organ transplantations that were performed in Turkey before and after the national coordination system was established. Of all the cadaveric transplantations completed to date, 91.6% of kidney and 71.5% of liver procedures were done before implementation of the new system, and 8.4% and 28.5%, respectively, were performed after the system was established. The data show that the frequency of cadaveric donation has increased, as well as the number of cadaveric organ transplantations performed annually. The new national transplantation coordination system is making a good start at increasing cadaveric transplantation in Turkey. This system will hopefully lead to a larger organ pool and shorter waiting lists in future.     

Advances in organ preservation for transplantation

Organ transplantation provides the best available therapy for a myriad of medical conditions, including end‐stage renal disease, hepatic failure and type I diabetes mellitus. The current clinical reality is, however, that there is a significant shortage of organs available for transplantation with respect to the number of patients on organ waiting lists. As such, methods to increase organ supply have been instituted, including improved donor management, organ procurement and preservation strategies, living organ donation, transplantation education and the increased utilization of donation after circulatory death and expanded criteria donors. In particular, especially over the last decade, we have witnessed a significant change in the way donor organs are preserved, away from static cold storage methods to more dynamic techniques centred on machine perfusion (MP). This review highlights the current state and future of organ preservation for transplantation, focusing on both abdominal and thoracic organs. In particular, we focus on MP preservation of renal, hepatic, pancreatic, cardiac and lung allografts, also noting relevant advances in Australasia. MP of organs after procurement holds considerable promise, and has the potential to significantly improve graft viability and function post‐transplantation, especially in donors in whom acceptance criteria have been expanded.     

Evaluation of living liver donors

As a result of the cadaveric organ shortage, the number of centers performing living donor liver transplantation has increased. Living donor liver transplantation provides immediate organ availability and avoids the risk of life-threatening complications that occur with long waiting times for cadaveric organs; however, it puts a healthy person at risk for little personal gain. A standardized approach to donor evaluation ensures safety to potential donors. Careful medical (physical examination as well as laboratory and radiological evaluation) and psychological evaluation is imperative to reduce donor complications and ensure good outcomes in recipients. A social worker and psychiatrist assess for mental competency, provide emotional support, and can serve as independent donor advocates. Informed understanding and consent are crucial aspects of the evaluation and include ensuring that the donor understands all potential complications and is free of coercion. Safety of the donor must be the highest priority.     

Organ preservation

Organ preservation is currently performed by simple cold storage or continuous hypothermic perfusion. Cold storage using University of Wisconsin (UW) solution greatly prolongs the successful preservation period for abdominal organs such as the kidney, liver, and pancreas. Thoracic organs (heart, lung), however, can be preserved for only several hours even with UW solution. As a result of improvements in organ transplantation, the number of patients on waiting lists has grown rapidly. Unfortunately, many patients die while waiting for donor organs, and expansion of the donor pool is mandatory. Possible solutions to the shortage of donor organs include the use of marginal donors and non-heart-beating donors. For this purpose, more sophisticated methods of organ preservation are needed, and therefore extensive investigations using current technologies including gene transfer should be performed. Every effort should be made to accommodate the preferences of donors.     

Domino liver transplant: influence on the number of donors and transplant coordination

The shortage of organs forces coordinators to seek new forms of generating organs for transplantation of the increasing numbers of patients on waiting lists. A recent technique called sequential transplant or domino liver transplant (DLT) allows the transplantation of a patient with chronic liver disease by implantation of a full-size liver derived from a patient with familial amyloidosis polyneuropathy (FAP) who receives a cadaveric graft. Therefore, it is possible to transplant two patients with only one cadaveric liver. The present report illustrates the use of this technique for the first time in our country, thereby increasing the number of hepatic transplants by 25%.     

Finding a place for public preferences in liver allocation decisions

Over the last decade there have been major advances in all aspects of liver transplantation with the consequence that the number of patients who could benefit from the procedure is increasing. As a result, the number of patients listed for liver transplantation is growing while the donor pool is remaining constant or even falling. The effect of this donor shortage is seen clearly both in Europe and in North America. For example, in North America data from UNOS shows that between 1988 and 1997 the number of cadaveric donor liver transplants rose from 1,713 to 4,100. The number of patients waiting for transplant rose over the same time from 616 to 9,647. This shortage of organs has tragic consequences. Although the proportion of patients dying on the waiting list is falling, the number of patients dying on the liver transplant waiting list increased from 196 to 1,129 over this same period of time.     

Transplanting kidneys from donors with prior hepatitis B infection: one response to the organ shortage

While the number of cadaveric organ donors remains relatively stable, the number of patients awaiting transplantation continues to increase, creating a shortage of donor organs. To address this imbalance, there is interest in transplanting organs formerly considered marginal or undesirable. Thus, more organs are currently transplanted from living donors, older donors, hemodynamically unstable donors, non-heart-beating donors and donors with markers of prior hepatitis B virus (HBV) infection. A large number (up to 93.8%) of liver transplant seronegative recipients from anti-HBc antibody positive donors have acquired HBsAg after liver transplantation in the absence of immunoprophylaxis. Based on experience in liver transplantation programs, transmission of HBV from donors without HBsAg but with antibody to HBV core antigen (anti-HBc), although conventionally defined as evidence of resolved infection, can have adverse consequences on both graft and recipient. On the contrary, HBV appears to be in-frequently transmitted from HBsAg negative/anti-HBcAb positive kidney donors: the incidence of de novo HBsAg seropositivity after renal transplantation ranges between 0 and 5.2%. A significantly higher incidence of anti-HBc antibody seroconversion (without developing HBsAg) after renal transplantation with anti-HBc antibody positive donors was seen. However, anti-HBc antibody positive renal allografts should be considered, especially for recipients who have been successfully immunized with HBV vaccine. Prospective long-term studies are in progress to assess the risk of de novo HBV infection (HBsAg seroconversion) in renal transplant recipients who have not been successfully immunized with vaccine against HBV.     

Changing patterns in organ donation in Eurotransplant, 1990–1994

Organ transplantation has become the treatment of choice for patients with end-stage organ failure and has led to progressive increases in the size of waiting lists over the past decade. Unfortunately, from 1990 to 1994, the number of organ donors remained stable while the number of organs transplanted from these donors increased by only 10%. In view of the severity of the current organ shortage, elderly individuals are increasingly being accepted as organ donors. The graft survival rate with kidneys from donors older than 55 years is 5% lower than that with kidneys from younger donors at 1 year and 9% lower at 3 years post-transplantation. Graft survival is also significantly lower with organs from donors who die from cerebrovascular accidents than it is with organs from donors whose cause of death is cerebral trauma. The number of patients waiting for a nonrenal donor organ has increased rapidly in the past 5 years, and an increasing number of donor kidneys are now being provided by multiorgan donors. The favorable graft survival rate with multiorgan donor kidneys, which is significantly better than that obtained with single organ donor kidneys, confirms their suitability for renal transplantation.     

Changing patterns in organ donation in Eurotransplant, 1990–1994

Abstract Organ transplantation has become the treatment of choice for patients with end-stage organ failure and has led to progressive increases in the size of waiting lists over the past decade. Unfortunately, from 1990 to 1994, the number of organ donors remained stable while the number of organs transplanted from these donors increased by only 10 %. In view of the severity of the current organ shortage, elderly individuals are increasingly being accepted as organ donors. The graft survival rate with kidneys from donors older than 55 years is 5 % lower than that with kidneys from younger donors at 1 year and 9 % lower at 3 years post-transplantation. Graft survival is also significantly lower with organs from donors who die from cerebrovascular accidents than it is with organs from donors whose cause of death is cerebral trauma. The number of patients waiting for a nonrenal donor organ has increased rapidly in the past 5 years, and an increasing number of donor kidneys are now being provided by multior-gan donors. The favorable graft survival rate with multiorgan donor kidneys, which is significantly better than that obtained with single organ donor kidneys, confirms their suitability for renal transplantation.     

Rewarded gift for living renal donors

Although the waiting list for renal transplantation is growing from year to year, the participation of unrelated living donors in kidney transplantation remains controversial. Patients want to be transplanted as soon as possible, not years later. Nevertheless, cadaveric organ donation has not been able to meet the requirements for all patients in need. With a continuous shortage of organs, the use of living unrelated donors is likely to decrease patient suffering and waiting list mortality. The excellent short- and long-term results of living unrelated transplantation have stimulated physicians toward a wider use of this donor pool. Therefore, transplants from living donors, whether related or unrelated, may be proposed as a therapeutic option for end-stage renal disease patients. In this article we explain the necessity of compensating altruistic living donors as an incentive. It is concluded that living unrelated renal transplantation programs should be legalized and controlled by international and national transplant societies to prevent illegal trade and to provide better care for donors.     

Ethical Evaluation of Risks Related to Living Donor Transplantation Programs

The shortage of available cadaveric organs for transplantation and the growing demand has incresed live donation. To increase the number of transplantations from living donors, programs have been implemented to coordinate donations in direct or indirect form (cross-over, paired, and domino chain). Living donors with complex medical conditions are accepted by several transplantation programs. In this way, the number of transplants from living has exceeded that from cadaver donors in several European countries. No mortality has been reported in the case of lung, pancreas, or intestinal Living donations, but the perioperative complications range from 15% to 30% for pancreas and lung donors. In living kidney donors, the perioperative mortality is 3 per 10,000. Their frequency of end-stage renal disease does not exceed the United States rate for the general population. However, long-term follow-up studies of living donors for kidney transplantations have several limitations. The frequency of complications in live donor liver transplantation is 40%, of these, 48% are possibly life-threatening according to the Clavien classification. Residual disability, liver failure, or death has occurred in 1% of cases. The changes in live donor acceptance criteria raise ethical issues, in particular, the physician's role in evaluating and accepting the risks taken by the living donor. Some workers argue to set aside medical paternalism on behalf of the principle of donor autonomy. In this way the medical rule “primum non nocere” is overcome. Transplantation centers should reason beyond the shortage of organs and think in terms of the care for both donor and recipient.     

Impact of organ shortage on the transplantation program]

The purpose of the study was to evaluate the consequences of a recent progressive shortage of donor organs on our different transplant programs. Although the waiting time before transplantation remained in general relatively short (4.6 [mean], 0-3, 0-10 months for renal, liver and heart transplantation, respectively), patients started to accumulate on our waiting list during the last year (1990) of the study (kidney transplantation). Furthermore some patients clearly deteriorated, other died awaiting transplantation (18% and 15% of the patients listed for liver and heart transplantation, respectively). In emergency, organs were provided most often by neighbouring foreign centers. Given these facts adhesion to supranational donor networks should be considered.     

Ethical guidelines for the evaluation of living organ donors.

Transplantation is an effective, life-prolonging treatment for organ failure. Demand has steadily increased over the past decade, creating a shortage in the supply of organs. In addition, the number of deceased organ donors has reached a plateau. Living-donor transplantation is increasingly an option, influenced by favourable clinical outcomes and increased waiting times at most transplant centres across North America. Living-donor kidney transplants have exceeded deceased-donor transplant rates at some centres. Organ donations from living donors have challenged transplant programs to develop a framework for determining donor acceptability. After a multidisciplinary consensus-building process of discussion and debate, the Multi-Organ Transplant Program of the University Health Network in Toronto has developed ethical guidelines for these procedures. These proposed guidelines address ethical concerns related to selection criteria and procedures, voluntariness, informed consent and disclosure of risks and benefits to both donor and recipient.     

Non-heart-beating donors

The widespread application of lung transplantation is limited by the shortage of suitable donor organs resulting in longer waiting times for listed patients with a substantial risk of dying before transplantation. To overcome this critical organ shortage, some transplant programs have now begun to explore the use of lungs from circulation-arrested donors, so called non-heart-beating donors (NHBDs). This review outlines the different categories of NHBDs, the relevant published experimental data that support the use of lungs coming from these donors and the clinical experience worldwide so far. Techniques for NHBD lung preservation and pretransplant functional assessment are reviewed. Ethical issues involved in transplanting lungs from asystolic donors are discussed.     

A decade of continuous improvement in cadaveric organ donation: the Spanish model

BACKGROUND: There is an ever-increasing demand for cadaveric solid organs for transplantation all over the world. Partial strategies in many countries have resulted in small or transient increases in organ donation or even no improvement at all. In the early nineties, Spain started an original integrated approach designed to improve cadaveric organ donation. METHODS: In 1989 an official agency, the National Transplant Organization (ONT), and a national network of specially trained, dedicated and strongly motivated hospital physicians in charge of the whole process of organ donation, was created. The network now covers 139 hospitals. RESULTS: Cadaveric organ donors grew from 550 in 1989 to 1334 in 1999, a 142% increase, Cadaveric kidney transplants from 1021 to 2005 (96% increase), and total solid organs transplanted from 1302 to 3330 in ten years (156%). The rates of cadaveric organ donation per million inhabitants (33.6), kidney and liver transplantation (50.6 and 24.2) are the highest in the world. CONCLUSIONS: Spain is the only example in the world of continuous improvement in cadaveric organ donation registered in a large country over a ten-year period. Organ shortage is not due to a lack of potential donors, but rather to a failure to turn many potential into actual donors. A proactive donor detection program performed by well trained transplant coordinators, the introduction of systematic death audits in hospitals and the combination of a positive social atmosphere with adequate economic reimbursement for the hospitals have accounted for this success. This model can be partially or totally translated to other countries if basic conditions are satisfied.