Immunology in medical practice. XXX. Organ transplantation: indications and results

During the past 30 years, solid organ transplantation has developed into a routine medical procedure. Currently, one-year transplant survival rates for kidney, heart, liver and pancreas are between 80 and 90%; for most organs, the long-term results are fair with 5-year survival rates of 60%. Inclusion criteria for potential recipients have become less stringent. These days, potential recipients are rarely excluded on the basis of their calendar age alone. The development of more and stronger immunosuppressive drugs has facilitated transplantation across wider immunological differences between donor and recipient with good results. While the number of patients on the waiting lists for organ transplantation increased, the number of organs offered for donation decreased. This has resulted in waiting times of several years for most organ transplantations. While the short-term outcome has improved significantly over the past decades, the long-term outcome has not. Most renal transplants, for example, are lost due to chronic rejection. The challenge for the future will be to improve the long-term outcome of organ transplantation and to decrease the morbidity associated with chronic immunosuppressive therapy.     

Welsh 2013 deemed consent legislation falls short of expectations

Wales, in 2013, was the first country in the United Kingdom to pass legislation introducing presumed (or deemed) consent for organ donation, and remains the only one. It was introduced in an attempt to increase the number of life-saving transplants taking place in the UK, in a move that policy makers hoped would mirror Spain’s success. More recently, pressure has been mounting for England to follow suit, with a public consultation currently in progress. However, the Welsh system has been far from a success, raising the question of why campaigners are so adamant that it should be replicated. Before the Welsh Government introduced the Human Transplantation (Wales) Act there had been no strong evidence to suggest it would make a difference, with countries boasting both high organ donation rates and presumed consent legislation demonstrating no clear causal relationship between the two facts. In addition, a recent report evaluating the Act has highlighted its failure to improve donation rates, and has even presented some potentially concerning statistics that may suggest a negative impact. This paper first considers presumed consent in other countries – Spain and Brazil – before illustrating the underwhelming progression of Wales’ new system and the need to look to other options.     

Liver transplantation from a living donor

Recently the first three liver transplantations from living donors were performed in The Netherlands. The motivations to proceed with this new procedure were threefold; the existing shortage of post-mortem organ donors, the successful transplants reported in the literature and the supposedly better organ quality and favourable-logistics of the procedure. This new procedure is in line with a recent advisory report on organ donation from the National Health Council of The Netherlands. As long as there is a shortage of post-mortem donors, living donation is a necessary treatment for patients with otherwise fatal liver insufficiency. However this should not keep public and governmental organisations from its continuing efforts to promote post-mortem donation. These should also include a discussion regarding changes to the organ donation law.     

Religious attitudes towards living kidney donation among Dutch renal patients

Terminal kidney patients are faced with lower quality of life, restricted diets and higher morbidity and mortality rates while waiting for deceased donor kidney transplantation. Fortunately, living kidney donation has proven to be a better treatment alternative (e.g. in terms of waiting time and graft survival rates). We observed an inequality in the number of living kidney transplantations performed between the non-European and the European patients in our center. Such inequality has been also observed elsewhere in this field and it has been suggested that this inequality relates to, among other things, attitude differences towards donation based on religious beliefs. In this qualitative research we investigated whether religion might indeed (partly) be the explanation of the inequalities in living donor kidney transplants (LDKT) among non-European patients. Fifty patients participated in focus group discussions and in-depth interviews. The interviews were conducted following the focus group method and analyzed in line with Grounded Theory. The qualitative data analyses were performed in Atlas.ti. We found that religion is not perceived as an obstacle to living donation and that religion actually promotes helping and saving the life of a person. Issues such as integrity of the body were not seen as barriers to LDKT. We observed also that there are still uncertainties and a lack of awareness about the position of religion regarding living organ donation within communities, confusion due to varying interpretations of Holy Scriptures and misconceptions regarding the process of donation. Faith leaders play an important educational role and their opinion is influential. This study has identified modifiable factors which may contribute to the ethnic disparity in our living donation program. We argue that we need to strive for more clarity and awareness regarding the stance of religion on the issue of living donation in the local community. Faith leaders could be key figures in increasing awareness and alleviating uncertainty regarding living donation and transplantation.     

Liver transplantation with grafts obtained after cardiac death-current advances in mastering the challenge

The scarcity of donor livers has increased the interest in donation after cardiac death(DCD) as an additional pool to expand the availability of organs. However, the initial results of liver transplantation with DCD grafts have been suboptimal due to an increased rate of complications, as well as decreased graft survival. These challenges have led to many developments in DCD donation outcome, as well as basic and translational research. In this article we review the unique characteristics of DCD donors, nuances of DCD organ procurement, the effect of prolonged warm and cold ischemia times, and discuss major studies that compared DCD to donation after brain death liver transplantation, in terms of outcomes and complications. We also review the different methods of donor treatment that has been applied to ameliorate DCD organ outcome, and we discuss the role of machine perfusion techniques in organ reconditioning. We discuss the two major perfusionmodels, namely, hypothermic machine perfusion and normothermic machine perfusion; we compare both methods, and delineate their major differences.     

The impact of presumed consent legislation on cadaveric organ donation: a cross-country study

In the U.S., Great Britain and in many other countries, the gap between the demand and the supply of human organs for transplantation is on the rise, despite the efforts of governments and health agencies to promote donor registration. In some countries of continental Europe, however, cadaveric organ procurement is based on the principle of presumed consent. Under presumed consent legislation, a deceased individual is classified as a potential donor in absence of explicit opposition to donation before death. This article analyzes the impact of presumed consent laws on donation rates. For this purpose, we construct a dataset on organ donation rates and potential factors affecting organ donation for 22 countries over a 10-year period. We find that while differences in other determinants of organ donation explain much of the variation in donation rates, after controlling for those determinants presumed consent legislation has a positive and sizeable effect on organ donation rates. We use the panel structure of our dataset to test and reject the hypothesis that unmeasured determinants of organ donation rates confound our empirical results.     

A Culturally Competent Approach to Exploring Barriers in Organ Donation Consent Among Haitian Immigrants: Formative Focus Group Findings and Implications

African Americans consent to donation less often than whites, have fears and misconceptions about donation specific to their cultures, and wait longer to receive transplants when the need is identified. However, there is less detailed empirical data on the transplant needs and barriers for Haitian immigrants. This paper describes focus group results designed to identify culturally grounded beliefs, attitudes, and barriers to organ donation. Results were used to design and implement the “Bay Lavi” (Give Life) campaign designed to raise awareness and increase organ donation consent among Haitian Immigrants.     

Gender imbalance in living organ donation

Living organ donation has developed into an important therapeutic option in transplantation medicine. However, there are some medico-ethical problems that come along with the increasing reliance on this organ source. One of these concerns is based on the observation that many more women than men function as living organ donors. Whereas discrimination and differential access have been extensively discussed in the context of cadaveric transplantation and other areas of health care, the issue of gender imbalance in living organ donation has received less attention. This paper presents relevant data from the Eurotransplant and UNOS transplantation systems and discusses possible explanations for the documented gender discrepancies. The conclusion calls for are view of existing practice guidelines in order to secure effective protection of particularly vulnerable potential donors and an equitable donor-recipient-ratio in living organ donation. This revised version was published online in July 2006 with corrections to the Cover Date.     

Organ transplantation and tissue donation: a theological look

The author's position is that the work of organ donation and transplantation and tissue donation over the past forty-five years is in need of theological reflection. Some profound events and processes are involved in transplantation as the human family engages in a quest for wholeness. Different religious traditions-Jewish, Catholic, Eastern Orthodox, and Protestant-view the use of organs for transplantation differently. General attribution theory is adapted as a perspective on organ transplantation.     

Organ Transplantation and Tissue Donation:

The author's position is that the work of organ donation and transplantation and tissue donation over the past forty-five years is in need of theological reflection. Some profound events and processes are involved in transplantation as the human family engages in a quest for wholeness. Different religous traditions-Jewish, Catholic, Eastern Orthodox, and Protestant-view the use of organs for transplantation differently. General atrribution theory is adapted as a perspective on organ transplantation.     

Knowledge, Beliefs, and Behaviors Regarding Organ and Tissue Donation in Selected Tribal College Communities

American Indians and Alaska Natives (AI/ANs) suffer a disproportionate burden of diabetes and kidney failure. For those with chronic kidney disease, transplantation may be the most effective treatment option. However, low rates of organ donation and transplantation are reported for AI/ANs, who face significant barriers in accessing the transplant waiting list. They are also less likely than Whites to consent to become organ donors. We partnered with five tribal colleges and universities to conduct focus groups to assess knowledge, cultural beliefs, and behaviors related to organ donation and transplantation among AI/AN college students. Focus group data were used to develop a culturally targeted media campaign and outreach strategy aimed at increasing rates of consent to donate organs. Community knowledge typically drew from direct family experience with chronic illness. Study findings confirmed that attitudes about organ donation were influenced by cultural beliefs. Nevertheless, many participants supported organ donation even when it conflicted with cultural and spiritual beliefs about keeping the body intact for burial. Participants also expressed mistrust of the local health care system, suggesting that trust issues might interfere with health messaging on this topic. This is the first study to examine sociocultural beliefs about organ donation among AI/AN college students. Through focus group findings, study staff were better positioned to develop culturally relevant outreach materials. Rising rates of chronic illness among AI/ANs ensure that organ donation and transplantation will be a long-term feature of the health landscape in AI/AN communities. Targeted health messaging must be part of the strategy to reduce donor shortages.     

Exploring the relationship of hospital and market characteristics and organ donation in U.S. hospitals

Unmet demand for organ transplantation is, in part, a result of low rates of organ donation. While the transplant community works diligently to improve rates of organ donation, patients on waiting lists for transplantation continue to die. This article reviews factors that are associated with rates of organ donation at U.S. hospitals. We analyzed two years of data on the numbers of actual and potential donors at U.S. hospitals to discern whether hospital or market attributes are directly related to a hospital's rate of securing organ donations. We found that certain hospital characteristics are related to higher donation rates. Further research and a deeper understanding of organizational and environmental influences on the complex nature of securing organ donations are needed to help alleviate transplantation waiting lists.     

'New pathways to organ donation'; a recommendation of the Dutch Health Council

Despite recent efforts at improvement, the current status of postmortem organ donation in the Netherlands is a reason for serious concern. The waiting lists for all organ transplantations are increasing in length. The Dutch Health Council was asked by the Minister of Health to report on any available alternative sources of donor organs, focusing especially on donation from living donors and postmortem donors in whom the heart is no longer beating. Kidney donation by living relatives is a well-known procedure that has been performed since 1950. Since HLA-matching is now less important due to new immunosuppressive regimens, transplants from unrelated living volunteers are also possible with good results. Live donation from emotionally involved persons should be encouraged. In case of ABO incompatibility, donors could be exchanged via the organ exchange institution. Live donation of liver segments by an adult to benefit a child recipient is justified. In case of an adult recipient this should be performed only under exceptional circumstances. Live donation of lung lobes and segments of intestine is still in a developmental phase. Postmortem donation of kidneys and livers from donors in whom the heart is no longer beating should also be encouraged. Donation of the lungs and pancreas from these donors is still an experimental procedure.     

Zum Stand der Lebendorganspende

In the Federal Republic of Germany the number of living organ donations is increasing. In 2001, 382 (16, 3%) kidney transplantations and 95 (12,5%) liver transplantations have been carried out by using organs or tissue of living donors. Graft survival in kidney transplantation is 91% for living related donation and 89% for living unrelated donation compared to 75% for cadaveric donation after a five year follow-up period. Detailed medical examinations of the donor and the recipient are an absolute prerequisite for organ donation. In Germany, living donation must be performed according to the criteria given in the Transplantation Act.     

Knowledge and Attitude of Iranian Medical University Students about Organ Donation and Transplantation: A Cross-Sectional Study

BackgroundMedical professionals'' knowledge of and attitudes toward organ donation and transplantation have positive impact on donation rates. The aim of this study was to determine the knowledge and attitude of medical university students in Iran about organ donation and transplantation.MethodsThis cross-sectional study was carried out on 1078 undergraduate students in Golestan University of Medical Sciences, Gorgan, Iran, from January to June 2019. All eligible students were recruited using convenient sampling. Data were gathered using knowledge and attitude toward organ donation and transplantation questionnaire. The higher scores of both subscales, the knowledge subscale (range from 0 to 13) and the attitude subscale (range from 13 to 65), indicate the better knowledge and attitude toward organ donation and transplantation.ResultsThe mean age of students was 22.24±5.16 years. Finding showed that the mean score of students'' knowledge and attitude toward organ donation and organ transplantation were 8.48±1.71 and 48.55±8.11 respectively. Also, the mean score of students'' knowledges in females (P<0.001), married (P=0.001) and who had organ donation card (P<0.001) was significantly higher. Nearly all of the students had heard about organ donation (98.3%) and organ transplantation (98.4%). Majority of them pointed that their source of information about organ donation and transplantation was television (TV) program (47.1%). Most of the students (73.8%) reported that they agree to donate their organs but most of them (67.5%) did not know how to obtain organ donation card and only 9.6% of them had the organ donor card as a volunteer donor.ConclusionAccording to finding, despite the awareness and favorable attitude about organ donation and transplantation among medical students, the number of registered donors was low. In addition to promoting college students'' awareness about organ donation for increasing registered donors, it is needed to aware and pursue lay people through social media.     

A case study in planning for public health education: the organ and tissue donation experience.

The chasm between the supply and demand of donated organs and tissues continues to grow despite widespread public awareness of transplantation and numerous efforts to educate the public about organ donation. It is fast becoming a significant public health problem in this country. The need for more effective public education is well documented in the literature on transplantation and is a primary objective of organizations in the transplant field. In response to this need, the Division of Organ Transplantation in the Health Resources and Services Administration of the Public Health Service initiated a project to examine the nature and scope of donation education initiatives throughout the country, to identify shortcomings, and to suggest ways the Federal Government could contribute to the effectiveness of public education in organ and tissue donation. The project resulted in the development of a protocol that also is applicable to other health education programs. Its major steps consisted of assessing the status of donation-related public education in the United States, identifying existing needs in donation education by applying principles learned from other public health education programs, and identifying roles that could be assumed to help strengthen the American public''s commitment to organ and tissue donation. These roles, which could be adopted by an transplant-related organization, were as broker of knowledge, producer of educational strategies, energizer through communications research, and catalyst by bringing together other groups. This approach to needs assessment and planning may provide useful insights both for those concerned with transplants and for professionals conducting education campaigns related to other public health issues.     

Der Organspendeprozess und Ansatzmöglichkeiten zur Erhöhung der Spenderate

For a number of life-threatening diseases, organ transplantation remains the only therapeutic option. Today, the crucial issue is shortage of available organs for transplantation rather than technical problems, peri-operative mortality or allograft rejection. While surveys among the general public have consistently shown strong support for transplantation medicine and a high willingness to donate, the donation rate in Germany remains low and has decreased over the past years. In this paper, we discuss different factors that may influence donation rate and examine their potential of helping to increase organ donation. These factors – in order of the time course of the organ donation process – include: donor detection, referral, assessment of medical contra-indications, decision, maintenance, ex-/transplantation. We discuss factors of organizational, psychological and medical nature that may influence the number of organ donations in each of these phases and review available empirical data. Based on this analysis, we propose a heuristic six-step model of the organ donation process. Subsequently, we outline a possible “orchestra” of coordinated strategies that simultaneously act on different stages of the model and may thus help to increase the organ donation rate.     

Donor registries,first-person consent legislation,and the supply of deceased organ donors

In this paper, we exploit the varied timing in state adoption of organ donor registries and first-person consent (FPC) legislation to examine corresponding changes in the supply of deceased organ donors. Results indicate that the establishment of a state organ donor registry leads to an increase in donation rates of approximately 8%, while the adoption of FPC legislation has no effect on the supply of organ donors. These results reinforce the need to encourage individuals to communicate their donation preferences, either explicitly via a registry or by discussing them with family.     

On harm thresholds and living organ donation: must the living donor benefit,on balance,from his donation?

For the majority of scholars concerned with the ethics of living organ donation, inflicting moderate harms on competent volunteers in order to save the lives or increase the life chances of others is held to be justifiable provided certain conditions are met. These conditions tend to include one, or more commonly, some combination of the following: (1) The living donor provides valid consent to donation. (2) Living donation produces an overall positive balance of harm–benefit for donors and recipients which cannot be obtained in a less harmful manner. (3) Donation is not liable to cause significant and long-term morbidity to, or the death of, the donor. This paper critically examines the suggestion that these criteria are not sufficient to offer a general account of justified living organ donation in the context of competent volunteers and that key to justified living organ donation is that donors receive sufficient benefits from their donation that these outweigh the harms they suffer. However, although this view—termed here ‘The Donor Benefit Standard’—directs welcome attention to the many and complex motives which may underlie living organ donation, this paper ultimately concludes that given the threats this position poses to individual autonomy and the lives of those in need of organ transplants ‘The Donor Benefit Standard’ should ultimately be rejected.     

Why are cadaveric renal transplants so hard to find in Japan? An analysis of economic and attitudinal aspects.

In view of the fact that in Japan treatment of end-stage renal disease depends disproportionately heavily on hemodialysis and almost negligible on transplants from cadaveric donors (hemodialysis 44.4/100,000; renal transplants 0.31/100,000 per year; cadaveric renal transplants 0.11/100,000 per year (1983 data)), we analysed the cost-effectiveness of hemodialysis and renal transplantation, predicted economic gains under expected changes in variables and described attitudes of the Japanese hampering cadaveric renal transplantation. Adjusted life expectancy of transplant recipients (live and cadaveric combined) under the current technical conditions is longer than that of those on hemodialysis (18.3 vs. 14.7 years) and the cost per year for maintaining the transplant is approximately one third of hemodialysis ($12,000 vs $32,000). If the proportion of cadaveric transplant recipients would increase to the levels of the USA (hemodialysis 30.8/100,000; transplants 2.6/100,000 per year; cadaveric transplants 1.9/100,000 per year (1983 data)) along with improvement in graft survival rate, the life expectancy for transplant recipients in Japan could increase by 2 years, thus reducing the annual cost even further. The current number of patients starting hemodialysis (11,500 cases per year) coupled with their life expectancy predicts the number of patients on hemodialysis to reach equilibrium at around 174,000 in a decade (Japanese population 110 million). Based on current price, their annual cost will be about 5.3 billion dollars. Medical expenditure of this magnitude for such a small fraction of people is expected to become an increasingly strong economic incentive for cadaveric renal transplantation. A review of studies on Japanese attitudes toward cadaveric renal transplantation in both urban and rural areas shows that approximately 60% are in favor of donating their kidney after death, though with the majority of cases the donation is contingent upon agreement of their family. It was suggested that the paucity of cadaveric kidney supply stems mainly from the custom of the Japanese to make decisions by consensus. It was also reported that more than 80% of physicians supported the donation of cadaveric grafts while this rate fell to 40% in case of brain death. As the first heart transplantation was carried out in 1968 under both medically and ethically dubious circumstances, distrust toward the diagnosis of brain death appears to be still quite strong. (Not a single heart transplantation has been attempted in Japan in the past 18 years).(ABSTRACT TRUNCATED AT 400 WORDS)