The organ procurement problem: many causes, no easy solutions

Participants at the Second International Symposium on Organ Procurement, held in 1985 in Detroit, addressed one of the principal problems of organ transplantation: the shortage of suitable donor organs. Several factors were identified as contributing to the shortage--failure to make provision before death for donation, refusal of requests for donation by families of suitable donors, failure of hospital personnel to request donation, inability to match available organs with recipients, and improper organ allocation. The participants rejected adopting a presumed consent policy and advocated laws now being enacted in several states requiring hospital personnel routinely to request donation from family members of suitable brain dead patients.     

Potential for organ donation in Victoria: an audit of hospital deaths

OBJECTIVE: To determine the potential for organ donation in 12 Victorian hospitals. DESIGN AND SETTING: Prospective audit of all deaths in 12 major public hospitals in the state of Victoria between January 2002 and October 2004. MAIN OUTCOME MEASURES: Number of organ donors and potential organ donors (patients with brain death or likely to progress to brain death within 24 hours if supportive treatment continued), requests for organ donation and consents. Unrealised potential donors (organ donation not requested) were categorised by an independent panel of intensivists as category A (brain death formally diagnosed); B (brain death not formally diagnosed but criteria likely to be fulfilled); and C (potential to progress to brain death within 24 hours). RESULTS: There were 17,230 deaths, 280 potential organ donors and 220 requests for organ donation. The 60 unrealised potential organ donors were classified as category A (3), B (17) and C (40). Consent rate was 53% to 65%, depending on the definition of potential donor (categories A, B and C or category A only). Consent rate was lower when discussions about organ donation were held by trainees or registrars (21%) than when specialists were present (57%) (P = 0.004). A maximum practically achievable organ donation rate for Victoria was estimated to be 15 to 17 donors per million population (current rate, 9 per million population). CONCLUSIONS: The potential for organ donation in Victoria is limited by a small organ donor pool. There is potential to increase the number of organ donors by increasing the consent rate (lower than expected from public surveys), the identification of potential organ donors (particularly those likely to progress to brain death if supportive treatment is continued), and requests for organ donation.     

Non-heart-beating organ donors as a source of kidneys for transplantation: a chart review

BACKGROUND: Organ transplantation is the treatment of choice for patients with end-stage organ failure, but the supply of organs has not increased to meet demand. This study was undertaken to determine the potential for kidney donation from patients with irremediable brain injuries who do not meet the criteria for brain death and who experience cardiopulmonary arrest after withdrawal of ventilatory support (controlled non-heart-beating organ donors). METHODS: The charts of 209 patients who died during 1995 in the Emergency Department and the intensive care unit at the Foothills Hospital in Calgary were reviewed. The records of patients who met the criteria for controlled non-heart-beating organ donation were studied in detail. The main outcome measure was the time from discontinuation of ventilation until cardiopulmonary arrest. RESULTS: Seventeen potential controlled non-heart-beating organ donors were identified. Their mean age was 62 (standard deviation 19) years. Twelve of the patients (71%) had had a cerebrovascular accident, and more than half (10 [59%]) did not meet the criteria for brain death because one or more brain stem reflexes were present. At the time of withdrawal of ventilatory support, the mean serum creatinine level was 71 (29) mumol/L, mean urine output was 214 (178) mL/h, and 9 (53%) patients were receiving inotropic agents. The mean time from withdrawal of ventilatory support to cardiac arrest was 2.3 (5.0) hours; 13 of the 17 patients died within 1 hour, and all but one died within 6 hours. For the year for which charts were reviewed, 33 potential conventional donors (people whose hearts were beating) were identified, of whom 21 (64%) became donors. On the assumption that 40% of the potential controlled non-heart-beating donors would not in fact have been donors (25% because of family refusal and 15% because of nonviability of the organs), there might have been 10 additional donors, which would have increased the supply of cadaveric kidneys for transplantation by 48%. INTERPRETATION: A significant number of viable kidneys could be retrieved and transplanted if eligibility for kidney donation was extended to include controlled non-heart-beating organ donors.     

'Brain death' and organ retrieval. A cross-sectional survey of knowledge and concepts among health professionals

A sample of 195 physicians and nurses likely to be involved in organ procurement for transplantation was interviewed about knowledge, personal concepts, and attitudes concerning "brain death" and organ donation. Only 68 respondents (35%) correctly identified the legal and medical criteria for determining death. Personal concepts of death varied widely. Most respondents (58%) did not use a coherent concept of death consistently; others (19%) had a concept of death that was logically consistent with changing the whole-brain standard to classify anencephalics and patients in a persistent vegetative state as dead. The findings demonstrate confusion about correct criteria for determining death and differences in concepts of death that might prove troublesome to the transplantation enterprise. We conclude that health professionals should do more to resolve the clinical and conceptual issues in the definition and determination of death before policies concerning organ retrieval are changed.     

Does it matter that organ donors are not dead? Ethical and policy implications

The "standard position" on organ donation is that the donor must be dead in order for vital organs to be removed, a position with which we agree. Recently, Robert Truog and Walter Robinson have argued that (1) brain death is not death, and (2) even though "brain dead" patients are not dead, it is morally acceptable to remove vital organs from those patients. We accept and defend their claim that brain death is not death, and we argue against both the US "whole brain" criterion and the UK "brain stem" criterion. Then we answer their arguments in favour of removing vital organs from "brain dead" and other classes of comatose patients. We dispute their claim that the removal of vital organs is morally equivalent to "letting nature take its course", arguing that, unlike "allowing to die", it is the removal of vital organs that kills the patient, not his or her disease or injury. Then, we argue that removing vital organs from living patients is immoral and contrary to the nature of medical practice. Finally, we offer practical suggestions for changing public policy on organ transplantation.     

公民死亡器官捐献潜在供体转运通道建立及供体重症监护室器官维护

目的 探讨适合临床的公民死亡器官捐献(DCD)潜在供体转运通道及供体重症监护室供体维护机制.方法 首都医科大学附属北京佑安医院自2012年1月开通转运通道,至2016年6月,器官获取组织(Organ Procurement Organization,OPO)共接到DCD相关信息152例,评估152例.临床判定为潜在捐献者合格84例,访谈84例,41例潜在供体家属同意捐献.建立DCD潜在供体转运通道,一般流程下直接转运潜在供体入供体重症监护室(DI-CU),并立即进行各重要器官的评估及维护.当潜在供体在转运过程中出现生命体征的恶化,紧急情况下启动应急流程.评价潜在供者进入DICU时和捐献前各项实验室检查指标的变化.结果 自2012年首都医科大学附属北京佑安医院共接收潜在供体41例,其中男29例,女12例;年龄(35.17±19.51)岁.1例(2.4％)转运过程中出现呼吸心跳停止,3例(7.3％)因家属意愿改变而中止捐献,37例(90.2％)顺利完成器官捐献.按中国心脏死亡器官捐献分类标准进行分类,此37例中国际标准化脑死亡供体28例(75.7％),国际标准化心脏死亡供体3例(8.1％),国际标准化心脑死亡供体6例(16.2％).其中31例供体捐献器官用于移植,6例供体的器官捐献后因损伤超出标准被弃用.潜在供体入DICU时和捐献前各项化验指标变化,AST、T-BIL、D-BIL、BUN的差异有统计学意义(P＜0.05).结论 建立适合临床工作的公民死亡器官捐献潜在供体转运通道及供体重症监护室以维护器官功能、提高捐献成功率非常重要,保证了供体器官的数量及质量.     

脑死亡无偿器官捐献肝脏移植2例报道

目的总结并探讨脑死亡无偿器官捐献肝脏移植在我国临床实施的可行性.方法昆明市第一人民医院于2011年12月至2012年1月期间共完成2例脑死亡无偿器官捐献工作.2例供体确诊为脑死亡,应用机械通气、血管活性药物等治疗维持供体器官灌注.受体1男性,术前诊断乙肝后性肝硬化,肝功能失代偿,child-pugh C级,MELD评分29分;受体2男性,术前诊断乙肝后性肝硬化,原发性肝癌,child-pugh C级,MELD评分26分.结果 2例脑死亡供体均顺利无偿捐献肝脏,2例受体均顺利接受肝脏移植手术并康复出院,目前随访移植肝功能良好.结论脑死亡无偿器官捐献肝脏移植的临床实施顺利,可以在我国逐渐推广实行,对缓解我国目前器官短缺状况起到相当重要的作用.     

Factors influencing refusal by relatives of brain-dead patients to give consent for organ donation: experience at a transplant centre

To analyse the reasons for family refusal for donating the organs of their deceased relatives, 33 families were approached and interviewed as a part of the consent process. Thirty of these refused and their reasons for refusal were documented. In 83%, the principle reason for refusal to give consent was the non-acceptance of brain death. Superstitions relating to being reborn with a missing organ (that had been donated) in 40% or that tampering with the body would not free their dead relatives from the cycle of life-death-rebirth in 26% were next most frequently voiced. A delay in funeral (23%), lack of consensus within family members (17%), fear of social criticism (10%), dissatisfaction with the hospital staff (10%) and being unaware of their deceased relatives' wishes (6%) were the other reasons cited.     

Optimal management of brain-dead organ donor

Maintaining a brain stem–dead (BSD) donor is specialized science. It is a daunting task as they are fragile patients who need to be handled with utmost care owing to extreme haemodynamically instability and need the best of monitoring for maintenance of organs. To ensure a successful transplant, a BSD donor first needs to be identified on time. This requires scrupulous monitoring of neurologically compromised patients who tend to be the most frequent organ donors. Once the donor is identified, an all-out effort should be made to legally obtain consent for the donation. This may require numerous sessions of counselling of the relatives. It needs to be performed tactfully, displaying the best of intentions. It is important to understand the physiology of a brain-dead individual. A cascade of changes occurs in BSD donor which result in a catastrophic plummeting of the clinical condition of the donor. All organ systems are involved in this clinical chaos, and best possible clinical support of all organ systems should be available and extended to the donor. Organ support includes cardiovascular, pulmonary, temperature, glycaemic, metabolic and hormonal. This article has been written as a follow-up article of previously published article on identifying an organ donor. It intends to give the reader a concept of what the BSD donor undergoes after brain death and as to how to maintain and preserve various organs for donation for successful transplantation of maximum organs.     

Factors influencing families' consent for donation of solid organs for transplantation.

CONTEXT: Transplantation has become the therapy of choice for patients with organ failure. However, the low rate of consent by families of donor-eligible patients is a major limiting factor in the success of organ transplantation. OBJECTIVE: To explore factors associated with the decision to donate among families of potential solid organ donors. DESIGN AND SETTING: Data collection via chart reviews, telephone interviews with health care practitioners (HCPs) or organ procurement organization (OPO) staff, and face-to-face interviews with family for all donor-eligible deaths at 9 trauma hospitals in southwestern Pennsylvania and northeastern Ohio from 1994 to 1999. PARTICIPANTS: Family members, HCPs, and OPO staff involved in the donation decision for 420 donor-eligible patients. MAIN OUTCOME MEASURE: Factors associated with family decision to donate or not donate organs for transplantation. RESULTS: A total of 238 of the 420 cases led to organ donation; 182 did not. Univariate analysis revealed numerous factors associated with the donation decision. Multivariable analysis of associated variables revealed that family and patient sociodemographics (ethnicity, patient's age and cause of death) and prior knowledge of the patients' wishes were significantly associated with willingness to donate (adjusted odds ratio [OR], 7.68; 95% confidence interval [CI], 6.55-9.01). Families who discussed more topics and had more conversations about organ donation were more likely to donate (adjusted OR, 5.22; 95% CI, 4.32-6.30), as were families with more contact with OPO staff (adjusted OR, 3.08; 95% CI, 2.63-3.60) and those who experienced an optimal request pattern (adjusted OR, 2.96; 95% CI, 2.58-3.40). Socioemotional and communication variables acted as intervening variables. CONCLUSIONS: Public education is needed to modify attitudes about organ donation prior to a donation opportunity. Specific steps can be taken by HCPs and OPO staff to maximize the opportunity to persuade families to donate their relatives' organs.     

Brain death--an opposing viewpoint.

Recent and proposed legislation to establish "brain-related" criteria of death has uniformly confounded irreversible cessation of total brain function with the death of the human person. Much of the confusion comes from widespread misunderstanding of how the word "death" is used and what it means. Cessation of total brain function, whether irreversible or not, is not necessarily linked to total destruction of the brain or to the death of the person. Further, to take vital organs or to otherwise treat people as though they were dead already on the basis of these recent criteria is morally unacceptable to most Orthodox Jews and Christians.     

Organ transplantation: present scenario and future strategies for transplant programme (specially cadaveric) in India: socio-administrative respects

Organ transplantation was enacted by a law "Transplantation of Human Organ Act" in 1994 but still, getting the consent from the relatives of brain dead person is a very difficult task and hence cadaveric transplant accounts for a minimum number. In India, most of the transplantations carried out are related to living donor and very few are cadaveric. The poor status of cadaver transplantation may be attributed to the moral, emotional and religious beliefs and taboos that inhibit the relatives of the deceased to come forward to donate organ(s) of a brain dead person.Non-existence of a trained transplant co-ordinator who is the backbone of any successful transplant programme is another reason for poor response in cadaver transplantation. The great task is to motivate and prepare the relatives for organ donation of their near and dear ones. Transplant co-ordinators are being prepared for motivating individuals or relatives for donation. To promote human organ transplantation government's initiative is very important. Mass media supported by the government can develop better awareness among the people. Non-government organisations (NGOs) can help in the similar ways. All hospitals are not authorised for the procedure of human organ transplantation. Other hospitals can help the process by informing the authorised hospitals about recent admission of potential donor (brainstem death). Role of transplant coordinator is crucial. He/she is the real inspiration to make agree the relatives for organ donation. Overall success of transplant programme is based on co-ordinated activity. Involvement of all agencies to motivate the person to pledge for organ donation during his/her life time is the first and the foremost requirement for successful planning and programme of organ transplantation.     

基于ROC曲线的非亲缘造血干细胞捐献志愿者筛选标准

目的：基于ROC曲线分析方法探讨非亲缘造血干细胞捐献志愿者筛选标准。方法：采用问卷调查法收集温州市2007年至2018年间共40名成功捐献造血干细胞志愿者以及166名尚未完成捐献的入库志愿者信息,构建捐献认知、捐献意愿、捐献态度及三种得分联合检验的ROC曲线。结果：综合了捐献认知、捐献意愿及捐献态度的联合筛选方法ROC曲线下面积为0.87（95%CI：0.81～0.93）,灵敏度为70.00%,特异度为90.96%,一致率为86.89%,Youden指数为0.61。结论：增强入库志愿者对非亲缘造血干细胞捐献的认知程度,提高入库志愿者的捐献意愿与态度,有利于提高志愿者的捐献可能性,降低悔捐率。     

Life or death. The issue of payment in cadaveric organ donation

In view of the increasing need for transplantable organs and the failure of awareness education and legislation to increase organ donation, Peters proposes as a policy a death benefit payment to motivate families of potential cadaveric donors. The program, which would be administered through existing organ procurement agancies, would pay $1000 to the consenting next-of-kin in any case where solid organ recovery for transplantation is completed. Peters discusses the issues of altruism and coercion, organ brokerage, benefits to the socially and economically deprived, legal aspects, and the payment process. He proposes establishing pilot programs to determine the impact of death benefit payments on organ recovery, with a national program to follow if the supply of donor organs increases.     

我国公民逝世后器官捐献移植运作流程分析

随着器官移植技术的飞速发展,我国人体器官的需求量日益增加,为了扭转目前国内器官供需比例严重失调的局面,提高大众时器官捐献的知晓率和认同感,国家先后出台了一系列关于公民逝世后器官捐献移植的法律法规,各省市也根据实际情况先后对器官捐献移植运作流程进行了探索性研究。但是,目前在国家层面,器官捐献移植仍无统一的运作流程,缺乏统一的衡量标准,严重制约了我国器官移植事业的发展、本文从器官捐献的基本概念出发,总结分析了我国公民逝世后器官捐献移植的基本组成结构。以运作流程为视角,将我国公民逝世后器官捐献移植过程划分为器官捐献流程、器官获取流程、器官分配移植流程和器官移植后的总结分析流程,并对每个流程的具体运作过程进行了详细阐述。,     

突发性儿童外伤死亡：“我们已经尽力,但您的孩子还是没能活下来”

儿童出现突发性严重病变时,往往病情复杂,病程演变迅速,此时,临床医师必须迅速地采取相应医疗措施,同时,要关心患儿家属并与其建立互信关系,还要与同事们进行充分交流。一名18月龄的幼儿,在车祸中遭受重度颅脑损伤,被送到医院救治。入院时,损伤严重,预后不明;数小时后,即发展为     

Defining death in non-heart beating organ donors

Protocols for retrieving vital organs in consenting patients in cardiovascular arrest (non-heart beating donors, NHBD) rest on the assumptions that irreversible asystole a) identifies the instant of biological death, and b) is clinically assessable at the time when retrieval of vital organs is possible. Unfortunately both assumptions are flawed. We argue that traditional life/death definitions could be actually inadequate to represent the reality of dying under intensive support, and we suggest redefining NHBD protocols on moral, social, and anthropological criteria, admitting that irreversible (however defined) asystole can only equate a clinically determinable point of no return in the process of dying, where organ retrieval can be morally and socially accepted in previously consenting patients.     

Early experiences on living donor liver transplantation in China: multicenter report

Background Because of the lack of brain death laws in China, the proportion of cadaveric organ donation is low. Many patients with end-stage liver disease die waiting for a suitable donor. Living donor liver transplantation （LDLT） would reduce the current discrepancy between the number of patients on the transplant waiting list and the number of available organ donors. We describe the early experience of LDLT in the mainland of China based on data from five liver transplant centers. Methods Between January 2001 and October 2003, 45 patients with end-stage liver disease received LDLT at five centers in China. The indication and timing, surgical techniques and complications, nonsurgical issues including rejection, infection, and advantages of LDLT in the series were reviewed. Actuarial patient and graft survival rates were calculated by using the Kaplan-Meier product-limit estimate. Statistical analysis was completed by using SPSS 10.0. Results All LDLT recipients were cirrhotic patients, except for one man with fulminant hepatic failure. Among the 45 cases of LDLT, 35 （77.8%） were performed in one center （the First Affiliated Hospital of Nanjing Medical University）. The overall 1 and 3 year survival rate of the recipients was 93.1% and 92.0%, respectively. Of the 45 LDLT donors, there were 3 cases of biliary leakage, 2 subphrenic collections, 1 fat liquefaction around the incision and 1 biliary peritonitis after T tube removal. All donors recovered completely. Conclusions LDLT provides an excellent approach to addressing the problem of donor shortage in China even though the operation is complicated, uncompromising and difficult with respect to the safety of the donors and receptors. Despite early technical hurdles having been overcome, perfection of technique is still necessarily. At present, LDLT is a good choice for the patients with irreversible liver disease.     

The potential supply of organ donors. An assessment of the efficacy of organ procurement efforts in the United States.

OBJECTIVES--To estimate the potential supply of organ donors and to measure the efficiency of organ procurement efforts in the United States. METHODS--A geographic database has been developed consisting of multiple cause of death and sociodemographic data compiled by the National Center for Health Statistics. All deaths are evaluated as to their potential for organ donation. Two classes of potential donors are identified: class 1 estimates are restricted to causes of death involving significant head trauma only, and class 2 estimates include class 1 estimates as well as deaths in which brain death was less probable. RESULTS--Over 23,000 people are currently awaiting a kidney, heart, liver, heart-lung, pancreas, or lung transplantation. Donor supply is inadequate, and the number of donors remained unchanged at approximately 4000 annually for 1986 through 1989, with a modest 9.1% increase in 1990. Between 6900 and 10,700 potential donors are available annually (eg, 28.5 to 43.7 per million population). Depending on the class of donor considered, organ procurement efforts are between 37% and 59% efficient. Efficiency greatly varies by state and organ procurement organization. CONCLUSIONS--Many more organ donors are available than are being accessed through existing organ procurement efforts. Realistically, it may be possible to increase by 80% the number of donors available in the United States (up to 7300 annually). It is conceivable, although unlikely, that the supply of donor organs could achieve a level to meet demand.     

发展器官移植技术,保护病人和器官捐献人权益

国务院通过的《人体器官移植条例》,规定了器官捐献和移植的自愿原则、无偿原则、知情同意原则以及公平、公正、公开原则等,严格执行这些原则,既可促进器官移植技术的发展,又可保护病人及器官捐献人的权益。