We Have an Obligation to Provide Organs for Transplantation After We Die

The rhetoric of providing organs for transplantation is similar to that of a charity with terms such as 'donate life' and 'gift of life' frequently being used. It is argued that providing organs from deceased individuals should be and is a moral obligation or moral duty. We place high value on the lives of others, even if we do not know them (such as people on the transplant waiting list). And because permitting organ removal after death poses no risks, discomfort, costs or inconvenience, it is an obligation of easy rescue. The transplant community should begin to frame the discussion in these terms.     

《移植器官质量与安全指南（第6版）》解读——供者及器官的评估和选择标准

器官移植是治疗终末期器官衰竭最有效的手段。随着供者来源性疾病传播风险的增加,移植器官的质量、安全和选择标准越来越重要。欧盟的《移植器官质量与安全指南（第6版）》第7章,在供者和器官质量评估、选择标准和流程方面,提出了基本要求,值得临床学习和实践。     

A Consolidated Biovigilance System for Blood,Tissue and Organs: One Size Does Not Fit All

Biovigilance systems to assess and analyze risks for disease transmission through the transfer of organs, tissue, cells and blood between people is part of administrative oversight and has impact upon clinical practice and policy. In 2009, a formal recommendation by the Public Health Service requested that Health and Human Services fund and support efforts to consolidate national biovigilance efforts. There are differences in the biovigilance issues involved in organ and tissue donation/transplantation. If disease avoidance is made the dominant principle guiding organ donor testing, an unintended consequence may be an increase in deaths on the waiting list. We propose that overall benefit for the organ transplant recipient, tempered by patient informed awareness of limited organ availability and assessment processes, should be the guiding principle of such a system.     

Artificial Organs: Thoughts & Progress

Within recent years we have significantly broadened the indication for the treatment of acute renal failure in intensive care patients, even in the presence of multiple organ failure. This was made possible by: 1. safe heparinization of the extracorporeal circulation while avoiding bleeding tendencies 2. hemofiltration of patients threatened by pulmonary complications early during renal failure and 3. the simultaneous use of various special intensive care measures. By this approach we have succeeded in a number of cases to break the chain of complications leading to multiple organ failure and death.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Factors predictive of signed consent for posthumous organ donation

CONTEXT: The shortage of organs for transplantation has led public health authorities to invest significant efforts in the promotion of organ donation. OBJECTIVE: To identify factors predictive of signed consent for posthumous organ donation by using the theory of planned behavior. PARTICIPANTS AND DESIGN: A random sample of 602 adults completed a questionnaire at baseline, and behavior was self-reported 15 months later. RESULTS: Logistic regression indicated that intention, perceived behavioral control, moral norm, and past behavior were factors predictive of consent for posthumous organ donation. Participants' perceived behavioral control, past behavior, and moral norm were also predictive of intention to sign, but attitude and perceived barriers were 2 additional determinants. Finally, anticipated regret and knowledge of persons who had made an organ donation were 2 moderators of the intention-behavior relationship. CONCLUSION: Overall, the results showed that intention is an important determinant of signing the organ donor's consent sticker and also highlighted that moral consideration and perceived difficulties could be 2 potential avenues for designing interventions.     

Reasons Why Organs From Deceased Donors Were Not Accepted for Transplantation

IntroductionThe rate of organ donations from deceased donors in Turkey is among the lowest in the world. We analyzed the reasons why some potential donors whose families had given consent did not become actual solid organ donors.MethodsWe retrospectively reviewed the organ donation, retrieval, and transplantation registries of 102 potential donors from the Ministry of Health Organ and Tissue Transplant Coordination Centre of Istanbul Region from the year 2015.ResultsCardiac arrest occurred in 8 of the potential donors while waiting for organ procurement or during surgery. The organ specific suitability ratio was 83% for kidneys, 82% for livers, 72% for hearts, and 75% for lungs. Of these suitable organs, the transplantation rates were as follows: kidneys 88%, livers 70%, hearts 30%, and lungs 13%. Medical reasons (donor unsuitable) (14%–24%) and poor organ function (2%–24%) were the reasons most organs were not accepted for transplant. These reasons included diabetes insipidus, electrolyte imbalance caused by neuro-humoral changes, inotrope/vasopressor requirement for hemodynamic instability, hypoperfusion, and myocardial dysfunction after brain death.ConclusionThe mismatch between organ donation and demand is a major problem worldwide. In addition to low organ donation rates, late diagnosis of potential donors or inappropriate management of the pathophysiological consequences of brain death reduce the number of transplantable organs even more in our country. In order to overcome these setbacks, we need education programs to improve quality and decrease donor losses in an intensive care unit goal-directed protocol for the management of potential donors.     

Bioartificial Organs

Bioartificial organs combine the physical aspects of implantable prostheses with the biological advantages of organ transplantation. Enclosing live cells in a permselective, synthetic envelope avoids rejection by an immunoincompatible host while the geometric limitation of the closed polymer capsule prevents overgrowth of the transplanted material. As a tenet bioartificial organs widen the range of therapeutics based on the biological activity of cell transplants and open an alternative path to gene therapy.     

Intelligent Freeform Manufacturing of Complex Organs

Different from the existing tissue engineering strategies, rapid prototyping (RP) techniques aim to automatically produce complex organs directly from computer‐aided design freeform models with high resolution and sophistication. Analogous to building a nuclear power plant, cell biology (especially, renewable stem cells), implantable biomaterials, tissue engineering, and single/double/four nozzle RP techniques currently enable researchers in the field to realize a part of the task of complex organ manufacturing. To achieve this multifaceted undertaking, a multi‐nozzle rapid prototyping system which can simultaneously integrate an anti‐suture vascular system, multiple cell types, and a cocktail of growth factors in a construct should be developed. This article reviews the pros and cons of the existing cell‐laden RP techniques for complex organ manufacturing. It is hoped that with the comprehensive multidisciplinary efforts, the implants can virtually replace the functions of a solid internal organ, such as the liver, heart, and kidney.     

Increased Transplanted Organs from the Use of a Standardized Donor Management Protocol

The organ shortage has resulted in increasing recipient waiting lists and waiting-list deaths. The increased use of expanded donors has been associated with increased discarding of procured organs because of poor organ function. A structured donor management algorithm or critical pathway was tested to determine its effect on the donor management and procurement process. A pilot study examined donors from 88 critical care units in 10 organ procurement organizations managed under the critical pathway and compared them to retrospective data collected at those same pilot sites. The total number of organs both procured and transplanted per 100 donors was significantly greater (p <0.01) in the critical pathway group when compared to the control group. There was no significant difference in 1-year graft survival for any of the organs recovered, and no significant difference in the rate of delayed graft function in the kidneys transplanted. Use of a structured donor management algorithm results in significant increases in organs procured and organs transplanted without any reduction in the quality of the organs being transplanted.     

Prospective psychosocial evaluation of related kidney donors: Indian perspective

With increasing acceptance of living organ transplantation and growing numbers of organ donors, it becomes important to look for any adverse outcomes in this population. Prospective psychosocial evaluation of living related donors and assessment of the outcome of donation process was done. We also tried to identify any risk factors associated with any adverse event. Between January 2003 and December 2003, 75 consecutive donors (mean age 42.8 +/- 11.6 years; M:F 54:21) were interviewed preoperatively and at 3 months postoperatively based on a 57-item questionnaire. Objective assessment of anxiety, depression, and social support was done with "modified Beck's depression inventory," "Speilberg's state and trait anxiety," and "social support" questionnaires. The majority (85.3%) of donors had volunteered for donation. There were no major depressive or anxiety disorders following donation. Though 21.3% donors perceived some negative impact on their health, none regretted the decision to donate and most (96%) would encourage organ donation. Prolonged donor hospitalization, persistent pain, poor recipient reciprocation, or recipient death were associated with a poor psychosocial outcome.     

Evaluation of blood pressure in children

PURPOSE OF REVIEW: This review briefly highlights origins of hypertension with emphasis on the influences of gestation, birth weight, salt intake, and adiposity. We focus on the role of ambulatory blood pressure monitoring, and the assessment of comorbidity and target organ change in hypertensive children and adolescents. RECENT FINDINGS: Low birth weight, prematurity and uric acid levels are associated with hypertension early in childhood and in young adult life, not just in later adult life. Reduction of dietary salt intake leads to significant reductions in blood pressure in infants and young children. Newly applied techniques for assessment of target organ damage in children include arterial studies using retinal photography, ultrasound assessment of arterial intima-media thickness, and applanation tonometry. SUMMARY: Overweight and obesity are increasingly common, and are major determinants of high blood pressure in children, in both the developed and developing world. Initial evaluation of the hypertensive child must include carefully confirming if they are hypertensive using published reference data for blood pressure in children, and increasingly through ambulatory blood pressure monitoring. Left ventricular hypertrophy based on echocardiography remains the most widely used indirect marker of hypertensive end organ change. New techniques for assessing target organ damage are being developed.     

Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003

BACKGROUND: A widely reported ABO-mismatch accident in March of 2003 raised concerns about the reliability of the transplantation system. Because this type of failure is rare and significant, we performed a probabilistic risk assessment (PRA) of the donor-recipient matching processes for thoracic organ transplantation. METHODS: A probabilistic risk assessment was performed. RESULTS: The likelihood of accidental incompatible implantation was already low in 2003. The PRA model indicates that the likelihood of such an event was 1.38x10 per donated organ. This estimate correlates closely with the observed rate of these accidents. Based on this model, process changes put in place shortly after the accident reduced the probability to approximately 3.08x10 and changes put in place in October 2004 further reduced the probability to approximately 2.22x10 per organ donated. CONCLUSIONS: The observed and predicted likelihoods of accidental incompatible thoracic organ transplantation are comparable. These likelihoods are several orders of magnitude smaller than other hazards associated with solid organ transplantation. The PRA model indicates that changes that followed the March 2003 accident further reduced the likelihood of accidental incompatible implantation by roughly two orders of magnitude. Quantitative estimates from PRA can be used to assess risks in healthcare and to gauge the impact of system changes on these risks.     

酗酒者肝移植公正分配的争议与未来方向

酗酒者肝移植的公正分配一直是生命伦理学研究领域备受争议的主题。这些激烈的争论围绕的主题主要包括：酗酒是疾病还是道德恶；酗酒者肝脏分配的责任（医学责任、道德责任以及责任能否作为稀缺医疗资源的分配标准）；公众意见在酗酒者肝移植分配中的作用。研究发现，绝对排除酗酒者的肝移植资格在当前的争论中不被支持，而伦理上的论证更倾向于支持降低酗酒者肝移植优先权的决定。为了进一步实现我国肝脏分配的公平性，需要加强酗酒者肝移植的个例评估，严格控制酗酒者肝移植术后的酒精摄入，并且重视公众意见在国家制定器官分配指南中的重要作用。笔者就当前酗酒者肝移植公正分配的争议现状作一综述，以期为临床器官分配及国家制定肝脏分配指南提供一定参考。     

Hybrid Artificial Organs: Are They Really Necessary?

In order to reproduce completely the function of an organ, past research has considered hybrid artificial organs as the only method to achieve this goal. Various attempts have been made to use cell components, whole cells, tissue, and organ sections in conjunction with artificial organ systems. However, utilization of biological preparations or tissues is not clinically practical today. In this paper disadvantages of using natural tissue preparations are outlined. Recent progress in membrane technology such as membrane plasmapheresis, particularly on-line plasma treatment by multiple reactors, on-line plasma treatment by cryogelation, or the use of a cascade membrane scheme for the selective removal of macromolecules, will provide the tools to treat and remove macromolecules which were once considered extremely difficult to treat. The historical development of membrane plasmapheresis is described, including potential applications of this type of artificial organ for practical clinical treatment of metabolic, toxic and immunologic disease states.     

《移植器官质量与安全指南（第6版）》解读——生物安全性预警

随着器官捐献和移植事业的蓬勃发展,完善管理体系,确保移植器官的质量和安全也越来越重要。欧盟的《移植器官质量与安全指南(第6版)》在生物安全性预警方面提出了严重不良反应和严重不良事件的定义,以及管理和报告的流程,鼓励器官移植相关医务人员尽早发现不良反应和不良事件,并进行调查、评估和反馈。同时对移植风险警戒和监控进行了系统地阐述,值得临床学习和实践。     

Ethics regarding living-donor organ transplantation

During the last two decades, an intensive discussion has taken place in the field of medical ethics, which has lead to a reawakening of interest in the subject of living-donor organ transplantation and a re-evaluation of the moral problems related to it. In this process, traditional professional ethics have, to a large extent, been replaced by more complex modes of moral reasoning. The ethical principle of respect for the autonomy of persons has proven to be of prime importance in this field. Received: 15 October 1999 Accepted: 20 October 1999     

Congress Presidential Address: 5th WAA Congress Therapeutic Artificial Organs, 10 Years After

Abstract: In 1983, more than 10 years ago, the concept of therapeutic artificial organs was proposed by this author. Currently developments of various types of immunomod-ulation technologies are well established, and therapeutic artificial organs for the treatment of autoimmunodiseases have become a well-accepted concept. It is this author's opinion that if we utilize apheresis technologies properly we should be able to prevent the aging process of mankind. Physical youth, and perhaps mental youth, can be achieved by apheresis technologies. However, in order to maintain youth and enjoy a high quality of life, it is essential to maintain a strong will to live. In this paper a new type of an artificial organ is proposed. This antiaging artificial organ is named "Juzo," the organ for a longer life, in Japanese, by this author.     

Provider Utilization of High-Risk Donor Organs and Nucleic Acid Testing: Results of Two National Surveys

Fears of infectious transmission from CDC high-risk donors (HRDs) remain a significant disincentive, and the potential for human immunodeficiency virus/hepatitis C virus (HIV/HCV) nucleic acid testing (NAT) to allay these fears remains unstudied. We hypothesized that NAT, which narrows the window period between infection and detectability compared to the standard ELISA, might lead to increased provider willingness to use HRDs. Between January and April 2008, we performed two national surveys: one of current NAT practice among organ procurement organizations (OPOs); a second of HRD use among transplant surgeons. Surgeons who reported accepting 10% or more offers for a given HRD behavior and organ type were classified as 'high utilizers' of that subgroup. We built hierarchical models to examine associations between OPO NAT performance and provider utilization. Providers who ranked medical risks of HIV or HCV as important disincentives to HRD use had significantly lower odds of being high utilizers (HIV odds ratio 0.22, HCV odds ratio 0.41, p < 0.005). Furthermore, both HIV and HCV NAT performance were associated with significantly higher odds of being high utilizers (HIV odds ratio 1.58, HCV 2.69, p < 0.005). The demonstrated associations between OPO NAT performance and high provider utilization of HRDs should be considered in the ongoing debate about NAT in transplantation.     

Development of an objective,standardized tool for surgical assessment of deceased donor kidneys: The Cambridge Kidney Assessment Tool

Quality assessment in kidney transplantation involves inspection to identify negative markers of organ quality. However, there is a paucity of evidence guiding surgical appraisal, and currently there is no evidence to differentiate important features from those that can be safely ignored. We propose a method to standardize surgical assessment and derived a simple rule to rapidly identify kidneys suitable for transplantation. Donor and recipient data were recorded alongside clinical outcomes in a prospectively maintained database. We developed a proforma (Cambridge Kidney Assessment Tool, CKAT) and used it to assess deceased donor kidney transplants. Factors predictive of utilization were identified by multivariate and univariate logistic regression analysis of CKAT-assessment scores, and test performance was evaluated using standard 2 × 2 contingency tables. Ninety-seven kidneys were included at a single center (2013-2014), and 184 CKAT assessments were performed. A CKAT threshold of “Carrell + Perfusion >3” was highly specific (99%) and performed favorably to consultant opinion (specificity 95%). 96% of the kidneys implanted in accordance with the rule survived to 1 year (mean eGFR 45.3 mL/min/1.73 m²). To our knowledge, this is the first attempt to objectively define macroscopic features that are relevant to kidney utilization. Common language could support training in organ assessment and ultimately help address unnecessary discard of donor kidneys.