Changing patterns in organ donation in Eurotransplant, 1990–1994

Organ transplantation has become the treatment of choice for patients with end-stage organ failure and has led to progressive increases in the size of waiting lists over the past decade. Unfortunately, from 1990 to 1994, the number of organ donors remained stable while the number of organs transplanted from these donors increased by only 10%. In view of the severity of the current organ shortage, elderly individuals are increasingly being accepted as organ donors. The graft survival rate with kidneys from donors older than 55 years is 5% lower than that with kidneys from younger donors at 1 year and 9% lower at 3 years post-transplantation. Graft survival is also significantly lower with organs from donors who die from cerebrovascular accidents than it is with organs from donors whose cause of death is cerebral trauma. The number of patients waiting for a nonrenal donor organ has increased rapidly in the past 5 years, and an increasing number of donor kidneys are now being provided by multiorgan donors. The favorable graft survival rate with multiorgan donor kidneys, which is significantly better than that obtained with single organ donor kidneys, confirms their suitability for renal transplantation.     

Changing patterns in organ donation in Eurotransplant, 1990–1994

Abstract Organ transplantation has become the treatment of choice for patients with end-stage organ failure and has led to progressive increases in the size of waiting lists over the past decade. Unfortunately, from 1990 to 1994, the number of organ donors remained stable while the number of organs transplanted from these donors increased by only 10 %. In view of the severity of the current organ shortage, elderly individuals are increasingly being accepted as organ donors. The graft survival rate with kidneys from donors older than 55 years is 5 % lower than that with kidneys from younger donors at 1 year and 9 % lower at 3 years post-transplantation. Graft survival is also significantly lower with organs from donors who die from cerebrovascular accidents than it is with organs from donors whose cause of death is cerebral trauma. The number of patients waiting for a nonrenal donor organ has increased rapidly in the past 5 years, and an increasing number of donor kidneys are now being provided by multior-gan donors. The favorable graft survival rate with multiorgan donor kidneys, which is significantly better than that obtained with single organ donor kidneys, confirms their suitability for renal transplantation.     

The marginal liver donor – an update

The number of patients awaiting liver transplantation keeps steadily rising with no corresponding rise in suitable grafts for transplantation. There also is an increasing trend of patients dying or being taken off waiting lists because of deterioration while waiting for a transplant. Over the preceding years the use of marginal grafts in liver transplantation has been driven by the critical shortage of donor organs and by emerging data that their use has resulted in a favourable outcome. This review revisits the factors defining marginality of a graft, and the issues faced by transplant units in making the decision to use such a graft. It also looks at the innovations in transplantation geared towards increasing the donor pool and the resulting issues of matching marginal grafts to suitable recipients.     

The marginal liver donor--an update.

The number of patients awaiting liver transplantation keeps steadily rising with no corresponding rise in suitable grafts for transplantation. There also is an increasing trend of patients dying or being taken off waiting lists because of deterioration while waiting for a transplant. Over the preceding years the use of marginal grafts in liver transplantation has been driven by the critical shortage of donor organs and by emerging data that their use has resulted in a favourable outcome. This review revisits the factors defining marginality of a graft, and the issues faced by transplant units in making the decision to use such a graft. It also looks at the innovations in transplantation geared towards increasing the donor pool and the resulting issues of matching marginal grafts to suitable recipients.     

Liver transplantation from non-heart-beating donors: current status and future prospects.

Liver transplantation is the treatment of choice for many patients with acute and chronic liver failure, but its application is limited by a shortage of donor organs. Donor organ shortage is the principal cause of increasing waiting lists, and a number of patients die while awaiting transplantation. Non-heart-beating donor (NHBD) livers are a potential means of expanding the donor pool. This is not a new concept. Prior to the recognition of brainstem death, organs were retrieved from deceased donors only after cardiac arrest. Given the preservation techniques available at that time, this restricted the use of extrarenal organs for transplantation. In conclusion, after establishment of brain death criteria, deceased donor organs were almost exclusively from heart-beating donors (HBDs). To increase organ availability, there is now a resurgence of interest in NHBD liver transplantation. This review explores the basis for this and considers some of the published results.     

Organ preservation

Organ preservation is currently performed by simple cold storage or continuous hypothermic perfusion. Cold storage using University of Wisconsin (UW) solution greatly prolongs the successful preservation period for abdominal organs such as the kidney, liver, and pancreas. Thoracic organs (heart, lung), however, can be preserved for only several hours even with UW solution. As a result of improvements in organ transplantation, the number of patients on waiting lists has grown rapidly. Unfortunately, many patients die while waiting for donor organs, and expansion of the donor pool is mandatory. Possible solutions to the shortage of donor organs include the use of marginal donors and non-heart-beating donors. For this purpose, more sophisticated methods of organ preservation are needed, and therefore extensive investigations using current technologies including gene transfer should be performed. Every effort should be made to accommodate the preferences of donors.     

The acceptability of pig organ xenografts to patients awaiting a transplant

Abstract: As the waiting lists for allotransplants of heart, kidney, and liver continue to grow, alternative sources of organs for transplantation are being sought: xenografts from pigs to humans could be a solution. However, is this solution acceptable to patients? To answer this question, we sought opinions, using a questionnaire, from 277 patients on a waiting list for a cadaver transplant for either a kidney (207), heart, or heart/lung transplant (70); there was a 65% (188) response rate. Approximately 75% of respondents had heard of xenografting; 50% would accept a xenograft for themselves and 43% for a relative; and 10% found a xenograft to be unacceptable and 40% were unsure and wanted more information. The most acceptable donor animal was the pig (27%), but 24% would accept organs from any animal; 68% had no objection to breeding animals as a source of organs and considered that the most appropriate use of animal tissue to be when no human organs were available. Thus, a minimum of 50% and a maximum of 90% of patients awaiting an allograft would accept a xenograft, although most would prefer a human rather than an animal donor.     

Lobar Lung Transplantation From Deceased Donors: A Valid Option for Small-Sized Patients With Cystic Fibrosis

BackgroundSmall-sized patients with cystic fibrosis usually face long waiting times for a suitable lung donor. Reduced-size lung transplantation (LTx) was promoted to shorten waiting times. We compared donor and recipient characteristics and outcome in lobar ([L]) versus full-size ([FS]) lung recipients.MethodsBetween July 1, 1991, and February 28, 2011, 535 isolated LTx were performed, including 74 in cystic fibrosis patients (8 L, 66 FS). Patients were followed up until September 2012.Results[L] recipients were younger, smaller, and lighter. Sex, waiting times, and donor data (age, sex, height, weight, PaO₂/FiO₂, and ventilation time) were comparable. Cardiopulmonary bypass was used more often in [L]; cold ischemia was comparable for first lung but longer in [L] for second lung; implantation times were comparable. In-hospital mortality rate was 0% in [L] versus 3% in [FS]. Both intensive care unit and hospital stay were longer in [L]. Grade 3 primary graft dysfunction was more pronounced in [L] at T0 and at T48. FEV₁ increased significantly in both groups from preoperative value. Bronchiolitis obliterans syndrome was absent in [L] and diagnosed in 18 patients in [FS], accounting for 6 of 15 late deaths. All [L] are still alive. No differences in survival were found between the groups.ConclusionsAlthough hindered by a higher incidence of primary graft dysfunction, L-LTx is a viable option with excellent survival and pulmonary function comparable to FS-LTx.     

A Novel Experience in Living Donor Renal Transplantation: Voluntary Exchange Kidney Transplantation

Organ supply is an important problem worldwide with an ever-increasing number of patients on the waiting lists. Various strategies are implemented in the centers to increase the number of transplantations. Paired kidney exchange or nondirected organ donation to an exchange list is being performed for a while. However, the number of renal transplantations has failed to achieve the targeted levels. The present study aimed to provide information regarding 1-year outcomes of voluntary exchange kidney transplantation, which is performed in our center, and to raise awareness about the method. Compatible donor–recipient pairs and ABO-mismatched donor–recipient pairs were invited to participate in the model of voluntary exchange kidney transplantation. Of 42 donor–recipient pairs fulfilling the criteria, 22 (52.4%) accepted to participate in the model. In 4 of these 22 donor–recipient pairs, patients received a kidney transplant from their own donor due to the lack of another suitable donor on the waiting list. Thus, the remaining 18 donor–recipient pairs were included in the model of voluntary exchange kidney transplantation. Sixteen two-way, 1 three-way, and 1 four-way exchange kidney transplantations were performed. Thus, this provided 21 more patients an opportunity to have a renal transplant. Accordingly, the number of living donor transplantations performed in our center increased by 6.1% using this method. We anticipate that the number of patients on the waiting lists for transplantation would be decreased by the widespread use of voluntary exchange kidney transplantation.     

Impact of organ shortage on the transplantation program]

The purpose of the study was to evaluate the consequences of a recent progressive shortage of donor organs on our different transplant programs. Although the waiting time before transplantation remained in general relatively short (4.6 [mean], 0-3, 0-10 months for renal, liver and heart transplantation, respectively), patients started to accumulate on our waiting list during the last year (1990) of the study (kidney transplantation). Furthermore some patients clearly deteriorated, other died awaiting transplantation (18% and 15% of the patients listed for liver and heart transplantation, respectively). In emergency, organs were provided most often by neighbouring foreign centers. Given these facts adhesion to supranational donor networks should be considered.     

Social Adaptability Index predicts access to kidney transplantation

Identifying the group of subjects prone to disparities in access to kidney transplantation is important for developing potential interventions. Data from the United States Renal Data System (January 1, 1990-September 1, 2007; n = 3407) were used to study association between the Social Adaptability Index (SAI; based upon employment, marital status, education, income, and substance abuse) and outcomes (time to being placed on the waiting list and time to being transplanted once listed). Patients were 56.9 ± 16.1 yr old, 54.2% men, 64.2% white, and 50.4% had diabetes. SAI was higher in whites (7.4 ± 2.4) than African Americans (6.5 ± 2.6) [ANOVA, p < 0.001] and greater in men (7.4 ± 2.4) than in women (6.7 ± 2.5) [T-test, p < 0.001]. In multivariate model, greater SAI (range 0-12) was associated with increased likelihood of being placed on the waiting list (hazard ratio [HR] 1.19 [95% CI 1.15-1.23] per each point of increase in SAI, p < 0.001) and greater likelihood of receiving a transplant once listed (HR of 1.06 [95% CI 1.03-1.09] per point of increase in SAI, p < 0.001). Similar trends were observed in most of the subgroups (based upon race, sex, diabetic status, age, comorbidities, and donor type). SAI is associated with access to renal transplantation in patients with end-stage renal disease; it may be used to indentify individuals at risk of healthcare disparities.     

Renal Transplantation: Progress and Prospects

Abstract: Despite encouraging and improving results, organ transplantation is still hampered by a shortage of organs, chronic transplant loss, and a changed patient population. Liberal inclusion criteria for dialysis and/or renal transplantation and the increasing unwillingness to donate organs in some countries has led to a growing imbalance between the numbers of transplantations performed and patients on waiting lists. Until now, poorly understood chronic transplant dysfunction is responsible for a still unchanged graft loss of approximately 5% per year. The patient population has changed to include more multimorbidity and an increasing number of risk factors (age, diabetes mellitus, former [failed] transplantations, or preexisting cardiovascular diseases). The recommendation for or against dialysis or transplantation has become increasingly difficult for the responsible physician. Newly developed immunosuppressant drugs, an increasing consideration regarding living organ donation, or xenotransplantation in the future may solve this dilemma. New reflections and considerations about the ethical background of transplantation medicine are necessary.     

Governed financial incentives as an alternative to altruistic organ donation

In 1984, an offensive proposal for kidney sales by a US physician led the National Organ Transplant Act to become a law in the United States. Similar legislation passed in many other countries. An ethical consensus developed around the world that there should be no monetary compensation for transplantable organs, either from living or deceased persons. Unfortunately, the altruistic supply of organs has been much less than adequate, and thousands of patients die each year waiting for organ transplantation. As the altruistic system of organ donation has met with failure, some from the transplant community believe that altruism alone is not enough to satisfy the needs of the thousands of patients on organ transplant waiting lists, and providing some financial incentives or social benefits to organ sources is necessary to increase the number of cadaveric or living organ donations. In this article, the many controversies surrounding altruistic and compensated organ donation systems are discussed. The Iran model for renal transplantation, a compensated and well-regulated living-unrelated donor renal transplantation program that has successfully eliminated a renal transplant waiting list in Iran, is briefly reviewed.     

Living-donor liver transplantation in adults

End-stage liver disease is being treated by liver transplantation. Despite legislative and social efforts, the number of cadaveric organs suitable for liver transplantation has not grown to match the increasing demand. The insufficient number of grafts results in high mortality for patients on the waiting list and prolonged waiting times with increasing morbidity. Following the success of living related-donor segmental liver transplantation in children, an amended concept has been applied to the adult patients. The early experience with this technique, the process concerning the selection of the donor for the recipient, the risks of the donor, and the future evolution of living related-donor liver transplantation are the topics of this article. Received: 15 October 1999 Accepted: 20 October 1999     

Impact of adult-to-adult living donor liver transplantation on access to transplantation and patients' survival: an 8-year single-center experience.

While the number of candidates for liver transplantation has increased in the recent years, the pool of cadaveric donor organs has remained constant and the waiting time progressively increases. These facts led us to start a program of adult-to-adult living-donor liver transplantation in 1998. The aim of this study was to compare the outcome of all patients put on the waiting list since 1998. Between January 1, 1998, and January 1, 2005, 505 patients were put on the waiting list in our center, and living donor liver transplantation was considered in 57 cases (11.3%). At the time of evaluation (April 1, 2006), liver transplantation was performed in 377 patients (46 living donor liver transplantations), and 89 patients died on waiting list. On an intention-to-treat basis, the 1-year survival rate from the time of listing was 87.5% in the "living donor" group vs. 76.2% in the "cadaveric donor" group (P < 0.05), whereas the 1-year survival after liver transplantation was similar (92.3% vs. 86.9%). Our living donor liver transplantation program was able to improve the access to liver transplantation by reducing waiting time and the number of deaths on waiting list, despite the fact that these patients were more critically ill (liver failure and/or liver cancer).     

Marginal donors for patients on regular waiting lists for liver transplantation

Abstract  The use of marginal donors is well accepted by most centers for emergency situations, but there is debate on their use for patients on regular waiting lists. We report our experience of the l-year survival for patients on waiting lists ( n = 147, 1-year survival = 32 %), patients transplanted from good donors ( n = 60, l-year survival = 84 %), and patients transplanted from marginal donors (n = 15, l-year survival = 56 %). We concluded that liver transplantation from marginal donors (a) is a safe procedure (b) has a 1 -year survival that is significantly better than that on a waiting list (c) is ethically justified especially in countries with donor shortages, and (d) may allow transplantation of "special" high risk and poor long-term outcome patients.     

Advances in organ preservation for transplantation

Organ transplantation provides the best available therapy for a myriad of medical conditions, including end‐stage renal disease, hepatic failure and type I diabetes mellitus. The current clinical reality is, however, that there is a significant shortage of organs available for transplantation with respect to the number of patients on organ waiting lists. As such, methods to increase organ supply have been instituted, including improved donor management, organ procurement and preservation strategies, living organ donation, transplantation education and the increased utilization of donation after circulatory death and expanded criteria donors. In particular, especially over the last decade, we have witnessed a significant change in the way donor organs are preserved, away from static cold storage methods to more dynamic techniques centred on machine perfusion (MP). This review highlights the current state and future of organ preservation for transplantation, focusing on both abdominal and thoracic organs. In particular, we focus on MP preservation of renal, hepatic, pancreatic, cardiac and lung allografts, also noting relevant advances in Australasia. MP of organs after procurement holds considerable promise, and has the potential to significantly improve graft viability and function post‐transplantation, especially in donors in whom acceptance criteria have been expanded.     

Hyperimmunized patients awaiting cadaveric kidney graft: is there a quick desensitization possible?

On all kidney waiting lists the 10% to 20% of patients who have antibodies against more than 80% of a panel of HLA antigens (panel reactive antibody [PRA] >80%) are difficult to transplant. The best solution for these patients is to find a compatible donor, ideally a full match, who yields a negative crossmatch test (CMX). If this is not possible, desensitization treatment (high-dose) intravenous immunoglobulin (IVIG) or plasmapheresis (PP) + low-dose IVIG is possible with good results in living donor kidney transplantation mainly if the antibody titer is low. It may also be offered to patients awaiting cadaveric donors too after a long waiting time; however, when applied for several months, it has the obvious disadvantage of giving the patient the risk for long-lasting immunologic weakness without the certitude of finding a kidney. In one of our recent cases of combined liver plus kidney transplantation, a positive CMX became negative 8 hours after the liver operation; the kidney was transplanted with a good result which lasted over 3 years. This observation suggested the possibility of a quick desensitization protocol in selected patients with a large (but not strong) immunization who probably are the majority. Patients sensitized to IVIG and with low titer PRA could be given a single PP + low-dose IVIG (what can be done within the time limit of cadaveric donor kidney transplantation) with good probability of turning an initial positive CMX to negative with the possibility of performing the operation and the advantage of giving the immunosuppression only when the kidney is present.     

Prevalence of Family Refusal and Associated Factors in Declared Brain Death: A Six-Year Retrospective Study in Northern Cyprus

Kidney transplantation provides a higher quality of life, a longer life expectancy for end-stage renal disease patients, and a lower cost than other treatments. Unfortunately, organ shortage for kidney transplantation is a major obstacle for countries with long waiting lists. Approaches to solving organ shortages with laws and regulations differ between countries. The reasons for these differences are evaluated by considering many factors, such as religious beliefs, sociocultural differences, and distrust in health systems. Until another evidence-based treatment becomes available, efforts to increase dead donor transplants are the main solution to reducing waiting lists.In a retrospective study conducted in our region, we investigated the prevalence and potential correlation of deceased organ transplantation based on family refusal and other issues.     

Orthotopic heart transplantation: highlights and limitations

A little more than three decades after the successful introduction of cardiac transplantation, this revolutionary concept of advanced heart failure treatment has gained tremendous momentum and is considered the gold standard therapy in selected patients. More specific modalities of immunosuppression continue to decrease the impact of acute and chronic rejection and immunosuppression-related side effects. The success of cardiac transplantation has led to a widespread initiation of transplant programs and a run on cardiac transplantation waiting lists. The increasing gap between waiting lists and donor organ supply has stimulated research to identify those patients who benefit most from cardiac transplantation, as well as research to develop alternative therapies for advanced heart failure. Furthermore, it serves as a stimulus to address paradigmatic issues that are fundamental to modern medicine and society.