Correspondence
Organs for Transplantation
N Engl J Med 2000; 343:1730-1732December 7, 2000
- Article
To the Editor:
In the August 10 issue, two articles1,2 and an editorial3 were devoted to strategies to increase the number of organs for transplantation, including the nondirected donation of kidneys by living donors. Gridelli and Remuzzi1 failed to mention the most important factor in the procurement of organs: the system to procure organs from cadaveric donors.
The rate of procurement of organs from cadaveric donors has stagnated in all countries except Spain. In 1999 in Spain, the number of cadaveric organ donors was 33.5 per million population, as compared with 21 per million in the United States and 14 per million in the European Union.
Although the Spanish Transplantation Act of 1979 promotes the principle of “presumed consent” to donation (by which persons are presumed to have agreed to the use of their organs after death unless they have expressly forbidden it), this principle has never been applied.4 In Spain, the express written and signed authorization of the family of the potential donor has always been required in all hospitals before organs are removed.
In Spain, procurement of organs for transplantation is a service of the hospital itself that is controlled and carried out by the physicians and nurses.5,6 We believe that such a system is the only one that can guarantee adequate control and implementation of all phases of procurement.
6 ReferencesAntonio López-Navidad, M.D., Ph.D.
Francisco Caballero, M.D.
Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain1
Gridelli B ,Remuzzi G . Strategies for making more organs available for transplantation. N Engl J Med 2000;343:404-410
Full Text | Web of Science | Medline2
Matas AJ ,Garvey CA ,Jacobs CL ,Kahn JP . Nondirected donation of kidneys from living donors. N Engl J Med 2000;343:433-436
Full Text | Web of Science | Medline3
Levinsky NG . Organ donation by unrelated donors. N Engl J Med 2000;343:430-432
Full Text | Web of Science | Medline4
Caballero F ,Lopez-Navidad A ,Leal J ,Garcia-Sousa S ,Soriano JA ,Domingo P . The cultural level of cadaveric potential organ donor relatives determines the rate of consent for donation. Transplant Proc 1999;31:2601-2601
CrossRef | Web of Science | Medline5
Lopez-Navidad A ,Domingo P ,Viedma MA . Professional characteristics of the transplant coordinator. Transplant Proc 1997;29:1607-1613
CrossRef | Web of Science | Medline6
Lopez-Navidad A ,Caballero F ,Domingo P ,Esperalba J ,Viedma MA . Hospital professionalization of the organ procurement process maximizes the retrieval potential. Transplant Proc 1999;31:1039-1039
CrossRef | Web of Science | Medline
To the Editor:
Matas et al. have clearly described a method for the nondirected donation of kidneys by living donors. We have been involved in two such cases, and the results have been highly gratifying for the donors, recipients, and the nurse coordinators who performed the arduous logistic task of arranging the transplantations. Our data show that the availability of laparoscopic nephrectomy increased the likelihood of identifying a living donor by 50 percent.1 However, after using it successfully in 530 cases our enthusiasm for laparoscopic nephrectomy does not necessarily extend to its application to altruistic nondirected donations. The inquiries we have received regarding such donations have given us reason to be circumspect. Excluding the innumerable persons who have requested financial compensation, some persons have made unacceptable restrictions regarding the race, sex, or ethnicity of the recipient, and others have had mild depression. Realistically, the small number of organs that could be derived from nondirected donations by living unrelated donors is unlikely to have a great impact on the number of transplants available in the United States.
1 ReferencesStephen T. Bartlett, M.D.
David Oldach, M.D.
University of Maryland School of Medicine, Baltimore, MD 21201Stephen C. Schimpff, M.D.
University of Maryland Medical Center, Baltimore, MD 212011
Schweitzer EJ ,Wilson J ,Jacobs S , et al. Increased rates of donation with laparoscopic donor nephrectomy. Ann Surg 2000;232:392-400
CrossRef | Web of Science | Medline
To the Editor:
With regard to nondirected donation, we use both subjective and objective factors in allocating organs (liver or kidney) to a particular recipient: the size of the potential recipient, the time he or she has spent waiting for a transplant, factors related to his or her medical condition (tolerance of dialysis, severity of complications from end-stage liver disease, and presence or absence of hepatoma), plasma renin activity, and the likelihood of a favorable outcome. Unfortunately, HLA matching can only be done after the donor has been assigned to a recipient, since reimbursement by insurance companies is necessary for this test. Therefore, it is not a factor in our allocation scheme for those who make nondirected kidney donations.
Unlike Matas et al., we allow donor bias to influence the selection of the recipient. Honoring a donor's preference that the organ go to a child or a member of a specific ethnic or racial group and not a recipient who has been a substance abuser does not seen unreasonable, considering the sacrifice. This policy is different from that governing organs from cadaveric donors and reflects the extremely personal nature of donation of an organ by a living donor.
We have successfully transplanted the right lobe of the liver from an adult and one kidney received as nondirected donations from living donors, with subsequent good graft function and without major complications. Like Matas et al., we have not allowed contact between donors and recipients before the operation but have allowed it after the recovery period.
Rick Selby, M.D.
Yuri Genyk, M.D.
Nicolas Jabbour, M.D.
University of Southern California Medical Center, Los Angeles, CA 90033To the Editor:
Gridelli and Remuzzi only briefly mention the use of kidneys from donors whose hearts have stopped beating, although this practice is extremely important from a quantitative point of view. A survey of 11 Dutch hospitals indicated that the number of kidneys that can be retrieved from donors whose hearts have stopped beating is several times as large as the number of kidneys currently obtained from donors whose hearts have not stopped beating.1 However, because such kidneys are assumed to be of suboptimal quality, they are accepted for transplantation by only a minority of the renal-transplantation centers in Europe. Nevertheless, several studies have demonstrated that patient survival and graft survival after the transplantation of kidneys from donors whose hearts have stopped beating are similar to the results obtained with kidneys from donors whose hearts have not stopped beating.2,3 In view of the long waiting list for renal transplantation, we believe that these results — as well as our own favorable experience — strongly support the more widespread use of kidneys from donors whose hearts have stopped beating. In our program, such kidneys have represented more than 25 percent of kidneys from cadaveric donors during the past two years.
3 ReferencesLukas B. Hilbrands, M.D.
Willem Hordijk
J. Adam van der Vliet, M.D.
University Medical Center, 6500 HB Nijmegen, the Netherlands1
Kranenburg J, Willems L, Sieber-Rasch MH, Geertsma A, Ploeg RJ, eds. Het Don Quichot onderzoek: donortekort of donatietekort? Amsterdam: Spring Communication BV, 1998.
2
Wijnen RM ,Booster MH ,Stubenitsky BM ,de Boer J ,Heineman E ,Kootstra G . Outcome of transplantation of non-heart-beating donor kidneys. Lancet 1995;345:1067-1070
CrossRef | Web of Science | Medline3
Cho YW ,Terasaki PI ,Cecka JM ,Gjertson DW . Transplantation of kidneys from donors whose hearts have stopped beating. N Engl J Med 1998;338:221-225
Full Text | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: Hilbrands et al. mention the use of kidneys from donors whose hearts have stopped beating as a means to expand donor pools. Studies have shown that graft survival is similar for kidneys obtained from donors whose hearts have stopped beating and those obtained from donors whose hearts have not stopped beating.1 Moreover, one kidney-procurement program that included organs from donors whose hearts have stopped beating increased its cadaveric kidneys by 40 percent.2 In many transplantation centers, however, interest in kidneys from such donors is limited because of the risk of delayed graft function after transplantation.3 A controlled study is required to compare the incidence of delayed graft function after dual and single transplantation of kidneys from donors whose hearts have stopped beating. Can the greater nephron mass supplied by two marginal kidneys obviate the loss of viable nephrons resulting from ischemia before transplantation?
We agree with López-Navidad and Caballero that the key to increasing the availability and rate of donation of cadaveric organs is a procurement system such as that in Spain. Policies for organ procurement and legal issues were beyond the scope of our review. Spain, the country with the highest procurement rate, does not enforce its presumed-consent legislation and relies instead on an informed-consent policy. In France, Italy, and Greece, which also have presumed-consent laws, fewer organs are transplanted. As shown by López-Navidad and Caballero, the best way to identify potential donors and monitor donation rates is to establish in every acute care hospital a monitoring system that is overseen by specially trained doctors and nurses.4 We believe that the procurement system in Spain should be extended to other nations in the European Union. The current donation rates range from 33.5 per million population per year in Spain to 5.7 per million population per year in Greece.5 New laws or different procurement methods are not required and may be detrimental. The system in Spain is well established, and the organ-donation rate is approaching the maximum that is potentially achievable.6
6 ReferencesGiuseppe Remuzzi, M.D.
Bruno Gridelli, M.D.
Ospedali Riuniti di Bergamo, 24125 Bergamo, Italy1
Cho YW ,Terasaki PI ,Cecka JL ,Gjertson DW . Transplantation of kidneys from donors whose hearts have stopped beating. N Engl J Med 1998;338:221-225
Full Text | Web of Science | Medline2
Kootstra G . The asystolic, or non-heartbeating, donor. Transplantation 1997;63:917-921
CrossRef | Web of Science | Medline3
Schweizer RT ,Sutphin BA ,Bartus SA . In situ cadaver kidney perfusion: experimental and clinical studies. Transplantation 1981;32:482-484
CrossRef | Web of Science | Medline4
Lopez-Navidad A ,Caballero F ,Domingo P ,Esperalba J ,Viedma MA . Hospital professionalization of the organ procurement process maximizes the retrieval potential. Transplant Proc 1999;31:1039-1039
CrossRef | Web of Science | Medline5
Matesanz R ,Miranda B . International figures on organ donation and transplantation: 1998. Transplant Newsletter 1999;4:1-236
Gortmaker SL ,Beasley CL ,Brigham LE , et al. Organ donor potential and performance: size and nature of the organ donor shortfall. Crit Care Med 1996;24:432-439
CrossRef | Web of Science | Medline
Author/Editor Response
López-Navidad and Caballero suggest that promoting living organ donation is “not justified unless adequate measures are first adopted to increase procurement from cadaveric donors.” Our view is that efforts to increase the number of cadaveric and live donors ought to be used together to close the gap between the numbers of patients waiting for transplants and the supply of solid organs.
Bartlett et al. use their experience with the questionable motives of prospective nondirected donors to argue for circumspection on the part of transplantation programs. We agree. Transplantation centers must have very clear policies and practices regarding the criteria of and process for donation and the way in which donated organs are allocated. They conclude that the probably small numbers of nondirected donations will have a limited impact on the number of transplantations in the United States. Our experience is that establishing a program for nondirected donation of organs from living donors creates a new method of donation without requiring substantial additional resources. Even if few new donors come forward, every additional organ added to the supply means that one more person will receive a transplant and one fewer person will remain on the transplantation waiting list.
The experience of Selby et al. with donor testing differs from our own. One approach is simply to delay charges for donor evaluation until a recipient is selected. The more challenging issue is how to pay for donor evaluations that end up ruling out prospective donors. In our system, those costs are spread among all recipients in the form of slightly higher recipient charges. In a direct-payment system, the institution might have to absorb the evaluation costs of donors who are rejected. Selby et al. also claim that because of the parallel to living related donation, nondirected donors should be permitted to express their personal preferences for the recipient of their organ. Our policy group spent many hours discussing whether to accept conditional donations. We concluded that the only acceptable donations would be those made to the pool of waiting recipients. As the definition of emotional relationship has been extended to include casual friends and the like, there is ample opportunity for potential donors to seek out particular types of recipients if they so desire. We believe, however, that it is unethical for transplantation programs to endorse the inherent unfairness and unacceptable discrimination at work in conditional donations that limit recipients based on such factors as race, sex, age, and sexual orientation. Fairness in allocation has always been a hallmark of the organ-allocation system in the United States. Any practices that undermine either the perception or the reality of a fair process could easily ripple throughout the system.
Jeffrey Kahn, Ph.D., M.P.H.
Arthur Matas, M.D.
University of Minnesota, Minneapolis, MN 55455- Citing Articles (3)
Citing Articles
1
Constantino Fondevila, Rafik M. Ghobrial. 2005. Donor Selection and Management. , 515-528.
CrossRef2
Antonio Lopez-Navidad, Francisco Caballero. (2003) Extended criteria for organ acceptance. Strategies for achieving organ safety and for increasing organ pool. Clinical Transplantation 17:4, 308-324
CrossRef3
Antonio Lopez-Navidad. (2002) Persistent and complete intracranial circulatory arrest is sufficient by itself to confirm brain death. Transplantation 74:2, 284
CrossRef
