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The Problems of Organ Donor Shortage

  • Susan Galandiuk
    Correspondence
    Address reprint requests and correspondence to Susan Galandiuk, MD, Professor of Surgery and Program Director, Section of Colon and Rectal Surgery, Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40292
    Affiliations
    Section of Colon and Rectal Surgery, Department of Surgery, University of Louisville School of Medicine, Louisville, Ky

    Section of Colon and Rectal Surgery, Department of Surgery, University of Louisville School of Medicine, Louisville, Ky
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  • Sylvester Sterioff
    Affiliations
    Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minn
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      In this issue of the Mayo Clinic Proceedings, Cascalho and Platt
      • Cascalho M
      • Platt JL
      New technologies for organ replacement and augmentation.
      describe an improvisational approach of combining different transplantation technologies to help bridge the gap formed by the ongoing shortage of donor organs for transplantation into humans. The Proceedings reader may wonder, “What can I possibly learn from reading this article?” The answer is multifactorial. Organ transplantation is one of the most cost-effective and efficacious therapies for chronic end-stage disease in many organs. Other factors are important to general health care providers as well.
      The current system for procuring and distributing organs to patients in need has failed despite pertinacious efforts to keep up with demand. Transplant physicians and surgeons have compounded the problem by expanding the criteria for transplantation beyond the original restrictions on age, comorbidities, and systemic disease. Despite organs being transplanted into increasingly older and sicker patients, organ transplantation has been remarkably successful.
      In the United States and Europe, only about 5% of needed organs are donated despite the long-established practice of “decoupling” the pronouncement of death of a patient from the subsequent request for organ donation.
      • Gortmaker SL
      • Beasley CL
      • Sheehy E
      • et al.
      Improving the request process to increase family consent for organ donation.
      • Roth BJ
      • Sher L
      • Murray JA
      • et al.
      Cadaveric organ donor recruitment at Los Angeles County Hospital: improvement after formation of a structured clinical, educational and administrative service.
      • Siminoff LA
      • Gordon N
      • Hewlett J
      • Arnold RM
      Factors influencing families' consent for donation of solid organs for transplantation.
      Nonphysician organ-donation facilitators have a much more favorable rate of obtaining consent for organ donation than do physicians,
      • Roth BJ
      • Sher L
      • Murray JA
      • et al.
      Cadaveric organ donor recruitment at Los Angeles County Hospital: improvement after formation of a structured clinical, educational and administrative service.
      in part because the pronouncement of death or likely death is separated from the request for organ donation. The need for engaging nonphysicians in the requesting process is further dictated by the fact that most physicians have never asked a family for an organ donation, even though they may refer patients with organ failure to transplant centers.
      The vast majority of American hospitals have extremely low rates of organ donation, a problem compounded by not having advocates on their staff.
      • Beasley CL
      • Capossela CL
      • Brigham LE
      • Gunderson S
      • Weber P
      • Gortmaker SL
      The impact of a comprehensive, hospital-focused intervention to increase organ donation.
      Former Secretary of the US Department of Health and Human Services Tommy G. Thompson has proposed novel Medicare incentives that would reward hospitals with exemplary organ donor procurement rates. Such incentives would benefit urban hospitals, often serving indigent populations and/or representing major teaching institutions, which currently contribute a disproportionate number of organs for transplantation.
      Extending the criteria for organ and tissue donation for deceased donors, including donation after cardiac death and from older donors, has provided small incremental improvements in organ donation rates. However, living related donation has been the single reason for the increased number of kidney transplants in the United States in the past 10 years.
      • Roth BJ
      • Sher L
      • Murray JA
      • et al.
      Cadaveric organ donor recruitment at Los Angeles County Hospital: improvement after formation of a structured clinical, educational and administrative service.
      OPTN: The Organ Procurement and Transplantation Network.
      To a lesser extent, living donors have increased the number of liver transplants as well.
      • Amersi F
      • Farmer DG
      • Busuttil RW
      Fifteen-year experience with adult and pediatric liver transplantation at the University of California, Los Angeles.
      Living donors for lung
      • Dark JH
      Lung: living related transplantation.
      and pancreas
      • Zielinski A
      • Nazarewski S
      • Bogetti D
      • et al.
      Simultaneous pancreas-kidney transplant from living related donor: a single-center experience.
      transplants have been tried in isolated centers; however, the effect of this approach is minimal considering the need.
      Some high-profile publicity has focused on adverse outcomes in a few cases of living related donors
      • Grady D
      Donor's death at hospital halts some liver surgeries.
      and has negatively affected the willingness of potential donors to participate. Recently, Web and newspaper advertisements for donors have become more prevalent, an ethical concern addressed by the American Society of Transplant Surgeons (ASTS) Council on November 11, 2004.
      • United Network for Organ Sharing
      Organ donation and transplantation.
      • American Society of Transplant Surgeons
      Statement on solicitation of donor organs.
      The ASTS advocates altruistic acts and expressed opposition to solicitation of organs by recipients or their agents.
      Transplantation ethics are being discussed constantly, and the new technologies proposed by Cascalho and Platt are not immune from ethical scrutiny. Use of animals in research, animal organs for transplantation, and embryonic stem cell research are bellwether subjects, as is the recent passage of Proposition 71 in California, which supports funding for stem cell research.
      • Holden C
      California's Proposition 71 launches stem cell gold rush.
      Stem cell research may be applicable to a wide variety of diseases including Alzheimer disease, diabetes mellitus, and most end-stage diseases for which transplantation is required. In their discussion of stem cells for organ replacement, Cascalho and Platt correctly admonish us to not expect quick returns because of the need for vascularized tissue, the associated difficulties, and the multiple steps that may be needed to accomplish the goal. This is a wise comment, recognizing that all too often medicine has overpromised what can be accomplished.
      Mechanical devices as a bridge to transplantation, already used in cardiac surgery, and the potential for transplantation from animal donors are both discussed in appropriate perspective by Cascalho and Platt. Importantly, both techniques require animal-based research. Obstructionist and sometimes violent behavior by members of organizations such as People for the Ethical Treatment of Animals (PETA) has been defined as progressively illegal throughout the federal and state court systems.
      • Foundation for Biomedical Research
      Violent and illegal activity by animal activists is escalating.
      These individuals are opposed to any type of research involving animals and have impaired innovation research, especially in the field of transplantation. Organizations such as the Foundation for Biomedical Research promote public understanding and support for the humane and responsible use of animals in medical and scientific research for the cure of both human and animal disease.
      • Beasley CL
      • Capossela CL
      • Brigham LE
      • Gunderson S
      • Weber P
      • Gortmaker SL
      The impact of a comprehensive, hospital-focused intervention to increase organ donation.
      Immunologic tolerance is one of several approaches proposed by Cascalho and Platt for diminishing transplant rejection. In theory, it should be possible to condition or treat the recipient so that minimal or no immunosuppression will be needed to prevent organ rejection. Indeed, this may be one of the most innovative concepts in transplantation and could result in profound changes in clinical care. Induction of immunologic tolerance may allow patients to avoid ongoing treatment with immunosuppressive drugs, the associated cost, and the dangerous adverse effects.
      The article by Cascalho and Platt provides a broad view of many strategies that may offer legitimate promise for patients with end-stage organ disease who undergo transplantation to improve their quality of life.

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        New technologies for organ replacement and augmentation.
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      Linked Article

      • New Technologies for Organ Replacement and Augmentation
        Mayo Clinic ProceedingsVol. 80Issue 3
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          The most common causes of disability and death are diseases of the heart, lungs, liver, kidneys, and pancreas, many of which are potentially treated by organ transplantation. The effect of organ dysfunction and failure will likely grow over time, and patients will increasingly expect “safer” transplants, in particular in cases of “preemptive transplantation.” New technologies are being developed in part because of the limited availability of organs, and include transplantation with stem cells, tissue engineering, cloning, and xenotransplantation, which some researchers believe promise ready solutions.
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