The organ shortage and allocation issues

Non-Heartbeating Organ Donation: A Review

Organ transplantation is one of the groundbreaking achievements in medicine in the 20th century. In the early days of transplantation, organs were obtained from non-heartbeating (NHB) cadavers. With time, better options for organ sources became available (for example, living-related and “brain dead” donors), and the practice of obtaining organs from NHB cadavers fell out of favor. Improvements in the field of transplantation have led to an increased demand for organs. Various strategies have been employed recently to increase the supply, one of them being non-heartbeating organ donation (NHBOD). NHBOD can take place in controlled or uncontrolled circum-stances. Recently, national organizations have supported and proposed guidelines for NHBOD and to aid clinicians in identifying potential donors. Outcomes of organs obtained from NHB cadavers are comparable to those obtained from heartbeating donors. The practice of NHBOD is increasing and has proven that it can contribute to increasing organ availability.

Who donates their bodies to science? The combined role of gender and migration status among California whole-body donors

The number of human cadavers available for medical research and training, as well as organ transplantation, is limited. Researchers disagree about how to increase the number of whole-body bequeathals, citing a shortage of donations from the one group perceived as most likely to donate from attitudinal survey data - educated white males over 65. This focus on survey data, however, suffers from two main limitations: First, it reveals little about individuals' actual registration or donation behavior. Second, past studies' reliance on average survey measures may have concealed variation within the donor population. To address these shortcomings, we employ cluster analysis on all whole-body donors' data from the Universities of California at Davis, Irvine, Los Angeles, and San Francisco. Two donor groups emerge from the analyses: One is made of slightly younger, educated, married individuals, an overwhelming portion of whom are U.S.-born and have U.S.-born parents, while the second includes mostly older, separated women with some college education, a relatively higher share of whom are foreign-born and have foreign-born parents. Our results demonstrate the presence of additional donor groups within and beyond the group of educated and elderly white males previously assumed to be most likely to donate. More broadly, our results suggest how the intersectional nature of donors' demographics - in particular, gender and migration status - shapes the configuration of the donor pool, signaling new ways to possibly increase donations.

Remuneration of hematopoietic stem cell donors: principles and perspective of the World Marrow Donor Association

Hematopoietic stem cell transplantation is a curative procedure for life-threatening hematologic diseases. Donation of hematopoietic stem cells (HSCs) from an unrelated donor, frequently residing in another country, may be the only option for 70% of those in need of unrelated hematopoietic stem cell transplantation. To maximize the opportunity to find the best available donor, individual donor registries collaborate internationally. To provide homogeneity of practice among registries, the World Marrow Donor Association (WMDA) sets standards against which registries are accredited and provides guidance and regulations about unrelated donor safety and care. A basic tenet of the donor registries is that unrelated HSC donation is an altruistic act; nonpayment of donors is entrenched in the WMDA standards and in international practice. In the United States, the prohibition against remuneration of donors has recently been challenged. Here, we describe the reasons that the WMDA continues to believe that HSC donors should not be paid because of ethical concerns raised by remuneration, potential to damage the public will to act altruistically, the potential for coercion and exploitation of donors, increased risk to patients, harm to local transplantation programs and international stem cell exchange, and the possibility of benefiting some patients while disadvantaging others.

Personal experience with the procurement of 32 liver allografts

AIM: To introduce the American Pittsburgh’s method of rapid liver procurement under the condition of brain death and factors influencing the quality of donor liver.

METHODS: To analyze 32 cases of allograft liver procurement retrospectively and observe the clinical outcome of orthotopic liver transplantation.

RESULTS: Average age of donors was 38.24 ± 12.78 years, with a male:female ratio of 23:9. The causes of brain death included 21 cases of trauma (65.63%) and nine cases of cerebrovascular accident (28.13%). Fourteen grafts (43.75%) had hepatic arterial anomalies, seven cases only right hepatic arterial anomalies (21.88%), five cases only left hepatic arterial anomalies (15.63%) and two cases of both right and left hepatic arterial anomalies (6.25%) among them. Eight cases (57.14%) of hepatic arterial anomalies required arterial reconstruction prior to transplantation. Of the 32 grafts evaluated for early function, 27 (84.38%) functioned well, whereas three (9.38%) functioned poorly and two (6.25%) failed to function at all. Only one recipient died after transplantation and thirty-one recipients recovered. Four recipients needed retransplantation. The variables associated with less than optimal function of the graft consisted of donor age (35.6 ± 12.9 years vs 54.1 ± 4.3 years, P < 0.05), duration of donor’s stay in the intensive care unit (ICU) (3.5 ± 2.4 d vs 7.4 ± 2.1 d, P < 0.005), abnormal graft appearance (19.0% vs 100%, P < 0.05), and such recipient problems as vascular thromboses during or immediately following transplantation (89.3% vs 50.0%, P < 0.005).

CONCLUSION: During liver procurement, complete heparization, perfusion in situ with localized low temperature and standard technique procedures are the basis ensuring the quality of the graft. The hepatic arterial anomalies should be taken care of to avoid injury. The donor age, duration of donor’s staying in ICU, abnormal graft appearance and recipient problem are important factors influencing the quality of the liver graft.

Factors that identify survival after liver retransplantation for allograft failure caused by recurrent hepatitis C infection

Hepatitis C virus (HCV) is becoming the most common indication for liver retransplantation (ReLTx). This study was a retrospective review of the medical records of liver transplant patients at our institution to determine factors that would identify the best candidates for ReLTx resulting from allograft failure because of HCV recurrence. The patients were divided into 2 groups on the basis of indication for initial liver transplant. Group 1 included ReLTx patients whose initial indication for LTx was HCV. Group 2 included patients who received ReLTx who did not have a history of HCV. We defined chronic allograft dysfunction (AD) as patients with persistent jaundice (> 30 days) beginning 6 months after primary liver transplant in the absence of other reasons. HCV was the primary indication for initial orthotopic liver transplantation (OLT) in 491/1114 patients (44%) from July 1996 to February 2004. The number of patients with AD undergoing ReLTx in Groups 1 and 2 was 22 and 12, respectively. The overall patient and allograft survival at 1 year was 50% and 75% in Groups 1 and 2, respectively (P = .04). The rates of primary nonfunction and technical problems after ReLTx were not different between the groups. However, the incidence of recurrent AD was higher in Group 1 at 32% versus 17% in Group 2 (P = .04). Important factors that predicted a successful ReLTx included physical condition at the time of ReLTx (P = .002) and Child-Turcotte-Pugh score (P = .008). In conclusion, HCV is associated with an increased incidence of chronic graft destruction with a negative effect on long-term results after ReLTx. The optimum candidate for ReLTx is a patient who can maintain normal physical activity. As the allograft shortage continues, the optimal use of cadaveric livers continues to be of primary importance. The use of deceased donor livers in patients with allograft failure caused by HCV remains a highly controversial issue.

Organ and tissue procurement system: a novel intervention to increase organ donation rates in Venezuela

The limited number of organs and tissues available for transplantation in Venezuela and the need to improve outcomes for patients with life-threatening end-stage organ failure or inadequate quality of life resulted in the development and implementation of an organ and tissue procurement system by the Venezuelan National Transplant Organization. This procurement system, a 24-hour, nationwide, free phone service for detection of potential organ donors, connects callers with transplant coordinators. The on-call coordinator supervises family approach as well as maintenance, transport, and allocation of the organs and tissues. During a period of 21 months, the phone service received 1191 calls (713 requesting information to become a voluntary donor, 207 requesting information about donation and transplantation, and 271 reporting potential donors). Of the potential donors, 74% were men and 67% were aged between 11 and 40 years, and most came from hospital intensive care units, emergency departments, and trauma shock units. The main causes of death were trauma and stroke. Reasons why donation was not accomplished included early cardiorespiratory arrest and denied consent. In conclusion, establishing the procurement system resulted in an increase in the detection, referral, and maintenance of potential donors; doubling of the number of donors per million population; and an increase in the number of cadaveric transplants.

Organ and Tissue Procurement System: A Novel Intervention to Increase Organ Donation Rates in Venezuela

The limited number of organs and tissues available for transplantation in Venezuela and the need to improve outcomes for patients with life-threatening end-stage organ failure or inadequate quality of life resulted in the development and implementation of an organ and tissue procurement system by the Venezuelan National Transplant Organization. This procurement system, a 24-hour, nationwide, free phone service for detection of potential organ donors, connects callers with transplant coordinators. The on-call coordinator supervises family approach as well as maintenance, transport, and allocation of the organs and tissues. During a period of 21 months, the phone service received 1191 calls (713 requesting information to become a voluntary donor, 207 requesting information about donation and transplantation, and 271 reporting potential donors). Of the potential donors, 74% were men and 67% were aged between 11 and 40 years, and most came from hospital intensive care units, emergency departments, and trauma shock units. The main causes of death were trauma and stroke. Reasons why donation was not accomplished included early cardiorespiratory arrest and denied consent. In conclusion, establishing the procurement system resulted in an increase in the detection, referral, and maintenance of potential donors; doubling of the number of donors per million population; and an increase in the number of cadaveric transplants.