Attitudes of black South Africans concerning organ donation

Race, Kidney Transplants, Immunosuppression Research, and White Supremacy under Apartheid, 1960-80

This paper uses the history of kidney transplantation in South Africa as a lens through which to write a racialized, micro history that illustrates the politics of medical discoveries and medical research at one of South Africa's most prestigious medical research universities, the University of the Witwatersrand (Wits) in Johannesburg. Between 1966 and the 1980s, the Wits team became the most advanced and prolific kidney transplant unit in the country. Yet the racist, oppressive Apartheid system fundamentally shaped these developments. Transplantation, as this paper shows, became an elite medical procedure, performed by a select group of white doctors on mostly white patients. For these doctors, transplantation showed their medical prowess and displayed the technical advancements they were able to make in research and clinical practice as they strove to position South Africa as a significant international player in medical research, despite academic boycotts and increasing sanctions. Transplantation became a symbol of white supremacy in a country where the black majority were excluded from anything but the most basic health care.

Doação de órgãos e tecidos: relação com o corpo em nossa sociedade

Este estudo, de revisão bibliográfica, objetivou tecer considerações teóricas sobre doação de órgãos e tecidos e sua relação com o corpo em nossa sociedade. O aumento da taxa de doação depende de um olhar ampliado além das questões técnicas do processo de doação de órgãos e tecidos. Vários países, com larga experiência temporal e, que trabalham sistematicamente nesse processo, incorporaram a abordagem social e a perspectiva ética, baseadas no voluntarismo das famílias e no respeito ao direito de autonomia dos potenciais doadores. O acompanhamento do corpo, pós-doação, solicitado pelas famílias, representa o início do luto pela morte de um parente, parte da prática de ritual fúnebre cultuada em nossa sociedade. As ações que asseguram uma sequência ético-legal, definida na legislação dos transplantes, pressupõem compromisso com a qualidade e segurança do processo de doação de órgãos e tecidos, que deve ser rigorosamente perseguida pelos profissionais que trabalham na área. Espera-se, assim, que essas atitudes construam uma cultura positiva sobre a doação no país, contribuindo, a longo prazo, para o aumento nas taxas de doação.

Pediatric renal transplantation in a South African teaching hospital: a 20-year perspective

INTRODUCTION

Renal transplantation is established as the standard of care for end-stage renal failure (ESRF) in the developed world. In emerging nations, the appropriateness of such costly interventions has been questioned. We undertook an analysis of all renal transplants undertaken under the care of the pediatric nephrology service at the Johannesburg Hospital, South Africa, in order to establish the outcomes of a transplantation service in a resource-constrained environment in a developing country.

METHODS

This was a retrospective review of renal transplantation undertaken at a single teaching hospital in Johannesburg, part of the University of the Witwatersrand. Two hundred and eighty-two transplants were performed between 1984 and 2003. Demographic characteristics of the transplanted population, diagnosis, morbidity, graft survival, and mortality were recorded.

RESULTS

Overall 1-, 5-, and 10-yr graft survival was 82, 44, and 23%. Overall 1-, 5-, and 10-yr patient survival was 97, 84, and 68%. The median graft survival for all transplantation episodes was 4.38 yr; 70% of patients survive 10 yr and 54% survive 20 yr or more. Although early graft survival was good, there was a more rapid rate of graft loss than when compared to results from developed centers with much poorer results at 5 and 10 yr. Causes of ESRF show marked variation between the races, and black patients have significantly worse outcomes than others. Compared with white patients, black recipients received fewer living donor kidneys (26 vs. 10%, p = 0.0019), a greater proportion of totally mismatched organs (56 vs. 36%, p = 0.015), less pre-emptive transplantation (7 vs. 35%, p = 0.0001) and experienced a higher rate of primary non-function (13 vs. 3%, p = 0.004). Surgical complications of transplantation occurred in 9% of recipients, but rarely led to graft loss.

CONCLUSION

Pediatric renal transplantation in Johannesburg can be accomplished with low complication rates, but medium and long-term graft survival is poor when compared with contemporary results achieved in developed countries. The difficulties of undertaking such complex, multidisciplinary interventions in a developing nation are daunting, but we believe that renal transplantation should still be the treatment of choice for all children with ESRF. The poorer outcomes in black recipients can be addressed by increasing education in our communities and expanding the pool of appropriate donors. Better institutional support would allow for improved long-term patient care.

Impact of culture and policy on organ donation: a comparison between two urban trauma centers in developed nations

BACKGROUND

The similarities and differences in organ donation policies, consent rates, and number of organs transplanted from patients declared "brain dead" after traumatic injury in different countries has not been previously reported.

METHODS

An international trauma survey questionnaire was developed. Analysis of two responding centers with regard to organ donation practices between urban, free-standing adult trauma hospitals is presented: the R Adams Cowley Shock Trauma Center (STC) in Baltimore, Maryland, and the Lorenz Böhler Hospital (LBH) in Vienna, Austria.

RESULTS

Hospital admissions resulting from traumatic brain injury (TBI) account for a significantly greater number of admissions at the STC than at the LBH (761 vs. 276), and the STC has a higher number of patients admitted with severe TBI (Glasgow Coma Scale score < 8). Of 39 medically suitable brain-dead patients at the STC, 18 went to organ donation. At the LBH, 16 patients were declared brain-dead, 7 were considered to be medically suitable, and all 7 went to donation. A "presumed consent" organ donation policy in Austria resulted in 100% of medically suitable patients going to donation at the LBH. With a volunteer donation policy at the STC, 46% of patients went to donation. Of those families who refused donation at the STC, 9 of 16 eligible African Americans (56%), 10 of 21 eligible Caucasians (48%), 1 Hispanic, and 1 Native American Indian family declined donation.

CONCLUSION

"Presumed" organ donation in Austria led to 4 organs transplanted per trauma brain-death at the LBH, as compared with 3.8 organs per brain-death at the STC. The greater number of patients with severe TBI at the STC accounts for a similar organ donation rate compared with the LBH, despite the fact that the consent at the STC is voluntary and at the LBH is "presumed." A higher organ donation rate in the United States would result in a greater number of organ transplants from patients who die after traumatic injury and a resultant increase in potential lives saved. There does not appear to be a significant difference in ethnicity between families who accept and those who refuse organ donation after traumatic brain death declaration at the STC.