Non-heart-beating donation in Spain

Purpose  

The aim of our study was to describe our protocol of non-heart-beating-donor (NHBD) lung transplantation and discuss data regarding the situation of NHBD and lung transplantation in Spain.     

Non-heart-beating donation: ten evidence-based ethical recommendations

The renewed interest in non-heart-beating donation (NHBD) in the past decade has resulted in renewed examination of the concept and meaning of death; of the nature of consent; of the propriety of interventions for the benefit of the recipient and not the donor; of potential conflicts of interest; and of defining futility. There is recognition of the need to maintain public trust. Recent experience indicates that NHBD could make a significant contribution to total renal transplant numbers. While there is graft dysfunction in the short term, the long-term results are comparable to those of transplants from heart-beating kidney donors, and in one series, even to living donors. The University of Zurich's experience indicates that waiting 10 minutes after asystole and not using in situ cooling do not adversely affect long-term outcomes. NHBD under ideal conditions could be extended to other organs such as the liver and pancreas. Ethical concerns are not insurmountable and can be minimized if cooling procedures and the use of drugs, such as heparin and phentolamine, is minimized, and if a period of 10 minutes is allowed to elapse after asystole before death is declared. We make a series of evidence-based recommendations for protocol development.     

Non-heart-beating donation: current state of the art

The use of non-heart-beating donors (NHBD) helps us to deal with the problem of the organ shortage. In addition to difficulties with legal and ethical acceptability, there are concerns regarding medical safety, which prevent the widespread use of these donors. To make optimum use of this potential organ supply, the ischemic injury that occurs after a period of warm ischemia needs to be reversed. To minimize the warm ischemia time, once the subject is declared dead, most centers commence in situ cold perfusion via a femoral access or a rapid aortic cannulation. This usually occurs within minutes of arriving at the emergency department, before the next of kin have been notified of the patient's death. The European experience of kidney transplantation from NHBD shows promising results. The long-term outcomes are similar to HBD kidneys notwithstanding a higher rate of delayed graft function, which seems not to affect the long-term survival of these kidneys. In summary, NHBD may have an important impact on the large discrepancy that exists between the organ supply and the demand. Current data suggest that the results may be further improved by better patient selection and retrieval team organization.     

Non-heart-beating donors: One response to the organ shortage

The use of organs from NHBDs is beginning to gain acceptance as a method to help alleviate the current organ shortage. This is shown by the number of OPOs that now have protocols for retrieving organs from NHBDs. In a controlled setting, NHBDs can be expected to yield kidneys and, in preliminary studies, extrarenal organs that function similarly to those retrieved from HBDs. The best method of renal preservation after retrieval from NHBDs appears to be machine perfusion—as a result of which, rates of delayed graft function can be reduced significantly. Experimental work may help further limit the damaging effects of warm ischemia.

Although controlled NHBDs could have a significant impact on extrarenal transplantation, the impact on renal transplantation will be much smaller. For this reason, in the absence of HBDs, kidneys from uncontrolled NHBDs could have the most significant impact on decreasing the disparity between donors and potential renal recipients. However, protocols involving uncontrolled NHBDs are logistically more complex and must limit warm ischemia while, at the same time, satisfying issues of consent for any procedure performed in preparation for organ donation.

Because a large number of healthcare professionals are involved with potential NHBDs, discussions with them and with on-site ethics committees are extremely important. Although the use of NHBDs has a historical precedent, many are unaware that this concept is not new. Therefore, education of these same healthcare professionals is essential. Likewise, the transplant institution by way of medical boards or IRBs should approve protocols that involve the use of NHBDs. Active discussions regarding NHBDs should help allay any fears of impropriety and should help to maintain public trust. If our approach to NHBDs is scientifically sound, ethically based, and expertly applied, the use of NHBDs can be expected to have a major impact on organ donation. Despite this resurgence of interest in NHBDs, we must not lose sight of the fact that we can and must do more to realize the full potential of HBDs.     

The Latin American population in Spain and organ donation. Attitude toward deceased organ donation and organ donation rates

The Latin American (LA) population has similarities with the Spanish population which makes its integration into Spanish society easier. Objective: to analyze the attitude toward organ donation among Latin American citizens residing in Spain, to determine the psychosocial variables which affect this attitude, and to examine the correlation between donation rates of LA citizens in Spain and in their countries of origin. A random sample of LA residents in Spain was taken and stratified according to the respondent's nationality (n = 1.314), in the year 2010. Attitude was assessed using a validated questionnaire (PCID‐DTO Dr Rios). The survey was self‐administered and completed anonymously. Statistical analysis: Student's t‐test, the χ² test, and logistic regression analysis. There was a 94% completion rate (n = 1.237). Attitude toward donation was favorable in 60% of cases (n = 745), 12% (n = 145) were against, and 28% (n = 347) were undecided. The following variables were associated with attitude toward donation: sex (P = 0.038), level of formal education (P < 0.001), country of origin (P = 0.002), attitude toward the donation of a family member's organs (P < 0.001), having discussed donation with the family (P < 0.001), carrying out prosocial activities (P = 0.025), attitude toward cremation of the body (P < 0.001), attitude toward burial of the body (P < 0.001), attitude toward having an autopsy carried out (P < 0.001), previous experience of the organ donation and transplantation process (P < 0.001), fear of mutilation after donation (P < 0.001), knowledge that the Church has a positive attitude toward organ donation and transplantation (P < 0.001), knowledge of one's partner's attitude toward organ donation (P < 0.001), and a belief that one might need a transplant in the future (P < 0.001). The donation rates in this population group in Spain are higher than those recorded in their countries of origin (55.76 vs. <10 pmp; P < 0.001). The attitude toward organ donation among LA citizens residing in Spain is slightly worse than that reported in the native Spanish population and is determined by many psychosocial factors. The donation rates of LA citizens in Spain are higher than those in their countries of origin.     

Consent for organ donation

Improving the consent rate for solid organ donation from deceased donors is a key component of strategies in the UK and other countries to increase the availability of organs for transplantation. In the UK, the law is currently clear on what forms consent may take, with the views of the individual expressed previously in life taking priority. Such views may have been expressed prospectively, via membership of the Organ Donor Register or by talking to family members. The factors determining such actions include both positive altruistic motives and negative psychological responses. Studies have examined why some families of potential donors refuse consent, while others have demonstrated a key set of 'modifiable' factors relating to the family approach. These include ensuring the right timing of a request in an appropriate setting, providing emotional support, and imparting specific information, particularly concerning the nature of brain death. If these are optimized and the right personnel with adequate training are involved in a planned process, then consent rates may be improved as reported in other countries with organized donation systems.     

人类器官移植供体来源的发展历程

移植器官来源模式是科学技术发展和人文精神升华完美结合的产物.移植器官来源经历了异种动物、死刑遗体、亲属活体、脑死亡供体、亲属活体+非亲属活体、心死亡供体、多种来源这7个不同的历史阶段.异种移植离临床应用遥远;死刑来源倍受批评;活体移植伤害健康人.器官捐献移植发展史证明,公民逝世后器官捐献值得大力推广.以美国全脑死亡器官捐献和英国脑干死亡器官捐献为代表的美-欧模式,均为生前自愿同意,且绝对无偿.公民认为任何形式的补偿都会改变捐献行为本来的性质.心死亡器官捐献是脑死亡器官捐献的补充,适用于既不符合脑死亡标准又无法救治,同时家属又有强烈捐献意愿者.     

Trends in organ donation

Presumed consent legislation produces more donors and in particular more organs per donor. In cadaveric donation, the number of elderly donors is increasing, so the quality of organs available is getting poorer. There will be no substantial rise in transplantation unless there is a major breakthrough in the current programs. There will be an increase in the proportion of living (un)related donors and debate about ethics of transplantation. Adverse publicity and debate may affect cadaveric donation and refusal rates.     

The organ donation conundrum

A discrepancy exists between the demand for and the availability of solid organs for transplant. Barriers to organ donation can be encountered at 2 key points: (1) when trying to increase the number of people willing to become organ donors and registering their intent and (2) at the time of organ procurement. Several predictors of individual willingness to register as an organ donor are discussed, along with issues surrounding families' refusal of consent or failures in the hospital system to identify potential donors. Several countries have adopted presumed-consent policies and have seen a subsequent increase in donation rates. Research is needed to explore the effectiveness of approaches to overcome the barriers to individual registration and family consent, particularly in countries where presumed consent has not been and is not likely to be adopted.