Changes in the organ procurement system in South Korea: effects on brain-dead donor numbers

Global legislation regulating the donation, procurement and distribution processes of organs and tissues from deceased donors for transplants: A scoping review

Introduction

Organ transplantation is one of the most successful advances in modern medicine. However, a legal system is necessary for its practice to be free from ethical flaws and to respect donors, recipients, and family members.

Objective

To map the global legislation regulating the donation, capture and distribution processes of organs and tissues from deceased donors for transplants.

Method

A scoping review according to the Joanna Briggs Institute was conducted in the following databases: Medline, CINAHL, Virtual Health Library, SCOPUS, Web of Science, Science Direct, and EMBASE, as well as gray literature, and reported according to the PRISMA extension for scoping reviews.

Results

We identified 3302 records, of which 77 were analyzed which enabled mapping the type of consent adopted and the existence of current legislation for harvesting organs and tissues after circulatory and brain death.

Conclusion

Opt-out consent predominates in Europe, and there is harvesting after brain and circulatory death. Opt-out predominates in the Americas, while Opt-in and harvesting of organs and tissues after brain death predominate in Asia and Oceania. The procurement of organs and tissues from deceased donors is practically non-existent in Africa.

International pediatric transplant association (IPTA) guidance on developing and/or expanding pediatric solid organ transplantation programs in low- and middle-income countries

Pediatric solid organ transplantation (SOT) is a preferred treatment for medically suitable children with end-stage organ failure. Still, many of them have no access to transplantation owing to socioeconomic constraints or lack of transplant facilities in low- and middle-income countries (LMIC). Establishing pediatric SOT programs in LMIC offers children the opportunities to receive transplant care in more familiar home environments as well as help curtail transplant tourism and improve transplant outcomes as pediatric transplantation would be performed ethically and legally. The International Pediatric Transplant Association (IPTA) is a professional organization aiming to promote safe, ethical, and high-quality pediatric transplantation worldwide. This society paper describes major obstacles to pediatric SOT in LMIC and provides guidance on developing and/or expanding pediatric SOT programs in such countries. We also summarize available resources from the IPTA Outreach Program to help establish and support pediatric SOT programs in LMIC.

Defining Quality Criteria for Success in Organ Donation Programs: A Scoping Review

Background

Well-established performance measures for organ donation programs do not fully address the complexity and multifactorial nature of organ donation programs such as the influence of relationships and organizational attributes.

Objective

To synthesize the current evidence on key organizational attributes and processes of international organ donation programs associated with successful outcomes and to generate a framework to categorize those attributes.

Design

Scoping Review using a mixed methods approach for data extraction.

Setting

Databases included PubMed, CINAHL, Embase, LILACS, ABI Business ProQuest, Business Source Premier, and gray literature (organ donation association websites, Google Scholar-first 8 pages), and searches for gray literature were performed, and relevant websites were perused.

Sample

Organ donation programs or processes.

Methods

We systematically searched the literature to identify any research design, including text and opinion papers and unpublished material (research data, reports, institutional protocols, government documents, etc). Searches were completed on January 2018, updated it in May 2019, and lastly in March 2020. Title, abstracts, and full texts were screened independently by 2 reviewers with disagreements resolved by a third. Data extraction followed a mixed method approach in which we extracted specific details about study characteristics such as type of research, year of publication, origin/country of study, type of journal published, and key findings. Studies included considered definitions and descriptions of success in organ donation programs in any country by considering studies that described (1) attributes associated with success or effectiveness, (2) organ donation processes, (3) quality improvement initiatives, (4) definitions of organ donation program effectiveness, (5) evidence-based practices in organ donation, and (6) improvements or success in such programs. We tabulated the type and frequency of the presence or absence of reported improvement quality indicators and used a qualitative thematic analysis approach to synthesize results.

Results

A total of 84 articles were included. Quantitative analysis identified that most of the included articles originated from the United States (n = 32, 38%), used quantitative approaches (n = 46, 55%), and were published in transplant journals (n = 34, 40.5%). Qualitative analysis revealed 16 categories that were described as positively influencing success/effectiveness of organ donation programs. Our thematic analysis identified 16 attributes across the 84 articles, which were grouped into 3 categories influencing organ donation programs' success: context (n = 39, 46%), process (n = 48, 57%), and structural (n = 59, 70%).

Limitations

Consistent with scoping review methodology, the methodological quality of included studies was not assessed.

Conclusions

This scoping review identified a number of factors that led to successful outcomes. However, those factors were rarely studied in combination representing a gap in the literature. Therefore, we suggest the development and reporting of primary research investigating and measuring those attributes associated with the performance of organ donation programs holistically.

Trial Registration

Not applicable.

Expanding Indications for Liver Transplant: Tumor and Patient Factors

During the past few decades, liver transplant has developed from a high-mortality procedure to an almost routine procedure with good survival outcomes. The development of living donor liver transplant has increased the availability of liver grafts, and the scope of indications for liver transplant has been expanding ever since. The aim of this review is to provide an overview of such an expansion of scope. Various criteria have been proposed to expand the eligibility of patients with hepatocellular carcinoma exceeding the Milan criteria for liver transplant. Furthermore, liver transplant is increasingly performed as a treatment modality for cholangiocarcinoma, neuroendocrine liver metastasis and colorectal liver metastasis. The number of elderly patients receiving liver transplant is on the rise. Combined organ transplantation has also been adopted to treat patients with multiple organ failure. Going forward, further development of preoperative noninvasive predictors in tumor, patient and even donor factors is needed to identify patients at risk of poor outcomes and hence optimize patient management.

Family discussions and demographic factors influence adolescent's knowledge and attitude towards organ donation after brain death: a questionnaire study

Background

Knowledge and attitude towards organ donation are critical factors influencing organ donation rate. We aimed to assess the knowledge and attitude towards organ donation in adolescents in Austria and Switzerland.

Methods

A paper-based survey was performed in two secondary schools (age range 11–20 years) in Austria and Switzerland. 354/400 surveys were sufficiently answered and analyzed.

Results

Our study found that knowledge on organ donation is scarce in adolescents. Less than 60% of those surveyed thinks that a person is dead when declared brain dead. 84.6% would authorize organ donation after brain death for themselves, but only 69% would authorize organ donation after brain death for a close relative. 93.7% would accept a donor organ if they needed one. Family discussions, rather than school discussions, influenced knowledge on organ donation, the percentage of respondents who have a firm opinion on organ donation and the rate of declaration of this opinion. Age, gender, nationality and religion also influenced knowledge and attitude towards organ donation. Nearly one third of adolescents are of the opinion that selling non-vital organs should be legalized.

Conclusion

Since having had family discussions, a potentially modifiable factor, was positively associated with knowledge and attitude towards organ donation, we postulate that educational programs stimulating family discussions on organ donation may be a promising strategy to increase knowledge.

Prognosis of Patients Following Liver Transplant From Deceased and Living Donors

OBJECTIVES

Liver transplant is the only treatment option for patients with end-stage liver disease.

MATERIALS AND METHODS

Liver transplant procedures performed from June 2013 to March 2017 were evaluated. We evaluated the postoperative period in recipients of livers from deceased and living donors.

RESULTS

Of 31 liver transplant procedures in 30 recipients, 12 were from deceased and 19 from living donors. The final analysis included 24 liver transplants (11 males, 13 females), with 10 from deceased and 14 from living donors. No deaths or life-threatening and debilitating complications were shown in liver donors. All living-donor liver transplants were performed utilizing the right lobe, the volume of which was calculated using contrast-enhanced computed tomography. Most living-donor liver recipients had viral hepatitis, whereas most deceased-donor liver recipients had autoimmune liver disease. Median age of recipients of deceased donations was 39.3 years (median admission duration of 28.1 days), and median age of recipients of donations from living donors was 45.4 years (median admission duration of 36.4 days). All patients were started on an immunosuppression protocol, which included basiliximab on days 0 and 4, tacrolimus, mycophenolate, and prednisolone. Of 24 recipients, 5 were taking prednisolone 10 mg/day or less at discharge.

CONCLUSIONS

Most of our liver transplant procedures were living-donor liver transplants (61.3%). Most patients who received living donations had viral hepatitis, with all cases related to autoimmune liver disease receiving deceased donations. This may be related to the possibility of antiviral therapy controlling all stages of liver disease versus no chance of controlling autoimmune liver disease. Living-donor liver transplant recipients required more time to recover to reach initial liver volume; 20.8% of recipients were discharged with prednisolone of 10 mg/day or less. Our results suggest a need for further development of nonsteroidal immunosuppression strategies to minimize infections and steroid-related adverse effects.

Fighting Mortality in the Waiting List: Liver Transplantation in North America, Europe, and Asia

Liver disease is a major cause of mortality worldwide. Liver transplantation (LT) is the most effective treatment for end stage liver disease. Available resources and social circumstances have led to different ways of implementing LT around the world. The experience with pediatric LT corroborates the hypothesis that a combination of surgical strategies can be beneficial. The goal of this manuscript is to describe the strategies used by LT centers in North America, Europe and Asia and how these strategies can be applied to reduce waitlist mortality and increase access to LT.

Features and ethical considerations associated with living kidney and liver transplantations in South Korea

When the Organ Transplantation Act came into effect in 2000 in South Korea, living organ donations were legalized and the Korean Network for Organ Sharing (KONOS) had a duty to approve the application of donation. The number of living organ donors has increased and the waiting time of recipients has been steady or decreased. The Organ Transplantation Act mainly focuses on the informed consent process of donations, so unrelated directed donations are permitted unless there is a suspicion of organ trafficking. But the annual reports show that directed donations of unrelated and related donors may have an ethical concern about organ sales. The donations of family members show another ethical concern. The numbers of ABO-incompatible transplantations have steadily increased since 2008, and lineal descendants, including minors, comprised 61% of living liver donors in 2012. Addressing the unethical practices without inhibiting living organ donations is the current task in South Korea. Private agencies have actively operated the living organ donations programs. The web-based computerized organ exchange program has been cooperatively run by hospital-based organizations. The strict legal regulations that could decrease living organ donations are hard to adopt. In the current situation, the functions of the official system need to be more developed. A national organ exchange program run by KONOS could be an option which could reduce ABO-incompatible transplantations and relieve the ethical concern of organ sales in unrelated directed donations.

The current status and future perspectives of organ donation in Japan: learning from the systems in other countries

The revised Organ Transplant Law came into effect in Japan in July 2010. The law allows for organ procurement from brain-dead individuals, including children, with family consent from subjects who had not previously rejected organ donation. Nevertheless, the number of cadaveric organ donations has not increased as expected. The Spanish Model is widely known as the most successful system in the field of organ donation. The system includes an earlier referral of possible donors to the transplant coordination teams, a new family-based approach and care methods, and the development of additional training courses aimed at specific groups of professionals, which are supported by their corresponding societies. South Korea, a country which neighbors Japan, has recently succeeded in increasing the rates of organ donation by introducing several systems, such as incentive programs, an organ procurement organization, a donor registry, and a system to facilitate potential donor referral. In this review, we present the current status of organ donation in Japan and also explore various factors that may help to improve the country's low donation rate based on the experiences of other developed countries.

Why does living donor liver transplantation flourish in Asia?

The success of liver transplantation worldwide has brought increased demand for the liver graft. Western and Asian countries have coped differently with the problems of the shortages in organ donation. In the West, efforts have focused on promoting deceased donor organ donation, whereas in Asia the focus has been on living donor liver transplantation (LDLT), as this procedure is more acceptable in most Asian cultures. LDLT, which was initially devised for paediatric liver transplant patients, has evolved from using a left lobe graft to a right lobe graft for an adult recipient. To widen the donor pool, dual grafts for a single recipient have been used in LDLT, and donors with hepatitis B core antibody positivity have been accepted, as well as ABO incompatible donors and recipients. The great advances in the field of LDLT have been dictated by the needs and the norms of Asian society. In this Perspectives article, we outline the reasons why LDLT flourishes in Asia.