Organ Transplantation

Transplantation (grafting) is the replacement of a failing organ or tissue by a functioning one. Transplantation was a dream in antiquity. The Hindu deity Ganesha had his head replaced by an elephant's head soon after birth (Rig-Veda, 1500 B.C.). In the Christian tradition Saints Cosmas and Damian (fl. 3rd century A.D.) are famous for replacing the diseased leg of a true believer with the leg of a dark-skinned Moor, thereby becoming the patron saints of physicians and surgeons.

Transplantation may be from the same person (autologous), from the same species (homologous—the allograft can come from a genetically identical twin, genetically close parent or sibling, living unrelated person, or cadaver) or from a different species (xenotransplant).

Human tissues carry highly specific antigens, which cause the immune system to react to "foreign" materials. An antigen is a substance that when introduced into an organism evokes the production of substances—antibodies—that destroy or neutralize the antigen. Grafts of a person's own tissue (such as skin grafts) are therefore well tolerated. Homologous grafts are plagued by attempted rejection by the recipient human. The biological acceptability of the graft is measured by tissue typing of the donor and recipient using the human leucocyte antigen, or HLA, panels. The closer the match between the donor and the recipient, the greater the chance of graft acceptance and function. Xenotransplantation is as yet entirely experimental because of tissue rejection and the possibility of transmitting animal diseases to the human recipient.

Organ transplantation has two sets of problems. The first relate to the recipient: the magnitude of the procedure and the intricacies of the surgical technique, the avoidance of rejection (acute or chronic) of the grafted tissue because of antigens in the tissue, and temporary and long-term suppression of the recipient's immune processes, with resulting infections and cancers. The second set of problems relates to the graft itself: the source of the graft and its collection, preservation, and transport to the recipient. Associated problems are ethical and economic, including the expense of the procedure and the cost of long-term monitoring and support of the patient.

Many of the technical problems associated with transplantation are gradually being overcome, and solutions are being constantly improved. Obtaining donor organs and distributing them equitably remain critical problems.

Transplantation is well established for skin, teeth, bone, blood, bone marrow, cornea, heart, kidney, liver, and to a lesser extent for the lung, pancreas, and intestines. On occasion two transplants are combined, such as heart and lungor pancreas and kidney.

Grafting an individual's own skin was well known to the ancient Hindus and has been widely used in the Western world since the middle of the nineteenth century. Skin grafting is a major resource in treating large wounds and burns. Artificially grown skin analogues and frozen pigskin can temporarily meet massive immediate needs.

Blood transfusion was attempted in the seventeenth century in France and England but was abandoned because of adverse reactions, including death. The identification of blood types in the early twentieth century and the discovery of methods of separating and preserving blood and its components have made transfusion a common and effective therapy. An important side effect of World War II and later conflicts has been improvement in all aspects of blood transfusion—collection, preservation, and delivery. The recognition of HLA types was based largely on the practices of blood transfusion and skin grafting. Transplantation of bone marrow and stem cells (precursors from which blood cells develop) is used to treat patients with malignancies of the blood and lymphatic system, such as the leukemia and lymphoma. Donor cells may be from the patient or from antigenmatched donor(s). Usually the patient's bone marrow (with the stem cells) is totally destroyed by chemotherapy, sometimes with whole body irradiation afterward. Donor cells are then introduced into the body, with the expectation that they will take over the production of new blood cells.

The commonest organ transplanted is the kidney. The first successful kidney transplant was done in 1954 in the United States between identical twins; before immunosuppressive procedures were developed, twins were the most successful donors. Transplantation between twins evokes the least immune reactions as the HLA types of twins are identical or nearly so. In 2001, about 14,000 kidney transplants were performed in the United States, 63 percent using kidneys obtained from cadavers. Patient survival using cadaveric donor kidneys is more than 90 percent at 1 year after surgery, and 60 to 90 percent at 5 years. For living donor kidneys, survival is above 98 percent at 1 year and 71 to 98 percent at 5 years. Corneal transplants have a high rate of success because the cornea does not have blood vessels and hence is not highly antigenic. Cadaver corneas can be successfully preserved and stored in eye banks for delivery as needed. More than 30,000 corneas are grafted each year in the United States.

More than 5,000 liver transplantations were done in the United States in 2001. Some of these transplants were portions of livers from living donors. In living adult liver donors, significant surgical complications and even a few deaths have raised some questions about the procedure. Though this is a controversial procedure, the great demand for donor livers will certainly keep this practice going. The heart is the fourth most common organ replaced. The first heart transplantation was done in South Africa in 1967; the high risk made it very controversial at the time. In 2000, almost 2,200 heart transplants were performed in the United States. Graft rejection remains a problem, and immunosuppresion (with its attendant dangers) has to be continued lifelong. If patients do not have other significant diseases, they return to near-normal functioning. More than 80 percent of patients function satisfactorily 1 year after surgery, and 60 to 70 percent at 5 years. At any given time, thousands of patients are waiting for donated organs. With progressive technical improvement in keeping seriously ill patients alive and making transplantation less risky, the need for organs continues to rise. Bioengineering is the application of engineering principles to biology—this includes the artificial production of cells and organs, or that of equipment that can perform functions of organs such as the kidneys or the heart. Bioengineered cells and tissues are a promising field in transplantation. Bioengineered skin is widely used for short-term coverage. Bioengineered corneas appear to be promising. Primitive heart-muscle cells (myoblasts) are being transplanted into diseased hearts, chondrocytes or cartilage cells are being cultured for use in degenerated joints, and there is considerable interest in xenografts.

Since 1968 a Uniform Anatomical Gift Act allows adults to donate their organs for transplantation after death. In every state, some form of donor card is associated with driver's licenses, and health care providers in most states are required to ask permission for postmortem organ procurement. (In some European countries consent for organ donation is presumed.) The United Network for Organ Sharing (UNOS) was established in 1977 to coordinate the distribution of kidneys and later other organs nationally and to maintain a registry of persons awaiting transplant. The UNOS generally prefers that donated organ(s) be used in the local community. All transplant centers are required to join the network and abide by its rules. By May 2002, UNOS membership included 255 Transplant Centers, 156 Histocompatibility Laboratories, and 59 Operating Organ Procurement Organizations. With all these efforts, the shortage of organs persists.

Bibliography

Cooper, David K. C., and Robert P. Lanza. Xeno: The Promise of Transplanting Animal Organs into Humans. Oxford and New York: Oxford University Press, 2000.

Fox, Renée C., and Judith P. Swazey, with the assistance of Judith C. Watkins. Spare Parts: Organ Replacement in American Society. New York: Oxford University Press, 1992.

Lock, Margaret M. Twice Dead: Organ Transplants and the Reinvention of Death. Berkeley: University of California Press, 2002.

Munson, Ronald. Raising the Dead: Organ Transplants, Ethics, and Society. Oxford and New York: Oxford University Press, 2002.

Murray, Joseph E. Surgery of the Soul: Reflections on a Curious Career. Canton, Mass.: Science History Publications, 2001.

Parr, Elizabeth, and Janet Mize. Coping With an Organ Transplant: A Practical Guide to Understanding, Preparing For, and Living With an Organ Transplant. New York: Avery, 2001.

United States Congress, House Committee on Commerce. Organ and Bone Marrow Transplant Program Reauthorization Act of 1995: Report (to Accompany S. 1324). Washington, D.C.: U.S. General Printing Office, 1996.

United States Congress, House Committee on Commerce, Subcommittee on Health and the Environment. Organ Procurement and Transplantation Network Amendments of 1999: Report Together with Dissenting Views (to Accompany H.R. 2418). Washington, D.C.: U.S. General Printing Office, 1999.

United States Congress, House Committee on Government Reform and Oversight, Subcommittee on Human Resources. Oversight of the National Organ Procurement and Transplantation Network: Hearing Before the Subcommittee on Human Resources of the Committee on Government Reform and Oversight. 105th Cong., 2nd sess., 8 April 1998. Washington, D.C.: General Printing Office, 1998.

Youngner, Stuart J., Renée C. Fox, and Laurence J. O'Connell, eds. Organ Transplantation: Meanings and Realities. Madison: University of Wisconsin Press, 1996.

Internet Sources
For current national statistical data, see the Web sites of the Scientific Registry of Transplant Recipients, http://ustransplant.org/annual.html, and the United Network for Organ Sharing, http://www.unos.org/frame_default.asp.

For general information for patients, updated regularly, see http://www.nlm.nih.gov/medlineplus.

View more Law & Legal Issues videos

The transfer of organs such as the kidneys, heart, or liver from one body to another.

The transplantation of human organs has become a common medical procedure. Typical organs transplanted include the kidneys, heart, liver, pancreas, cornea, skin, bones, and lungs. The organ most frequently transplanted is the cornea, followed by the kidney.

The first human organ transplants were performed in the early 1960s, when it became possible to use special tissue-matching techniques and immunosuppressive drugs that reduced the chance that a transplanted organ would be rejected by the host body. By the early 1980s, the new immunosuppressive drug cyclosporine led to great advances in the success rate of organ transplants.

Organ Shortages

As organ transplants have become increasingly successful, the most significant problem related to them has become the shortage of available organs. A large gap separates the high demand for organs and their scarce supply. Experts estimated that by the late 1980s, three people were on transplant waiting lists for every available organ. Given the grossly inadequate supply of organs, many vexing ethical, legal, and political issues surround the question of what is the best way to harvest or procure organs.

A number of laws have sought to address the problem of organ procurement. The Uniform Anatomical Gift Act (8A U.L.A. 15-16 [1983]), drafted in 1968 and adopted in all fifty states, allows any competent adult to state in writing, including by signing a donor card or checking off an item on a driver's license application, whether he wishes to allow or forbid the use of her or his organs after death. The act also permits next of kin to authorize donation. Such a program, termed encouraged voluntarism, relies on the free and autonomous choice of the individual or surviving family as the basis for organ donation.

Organ donation is also aided by brain-death statutes. These make it possible to declare as dead those who have lost whole-brain function but whose bodies are kept alive through artificial means. Such brain-dead persons become potential organ donors. In fact, most organs are obtained from accident victims.

The combination of encouraged voluntarism and brain-death statutes has not produced adequate numbers of organs. For example, a 1984 study estimated that of the 20,000 people each year who die of accidents or strokes and are medically suitable organ donors, only 3,000 served as donors. Experts have estimated that only three percent of those who serve as organ donors are actually carrying a donor card at the time they are pronounced dead.

A number of different problems contribute to this shortage of donated organs. Most people are fearful or uncomfortable with thoughts of death — particularly their own — and consequently do not contemplate organ donation. Others point out that some states have not yet enacted statutes that recognize brain death as the definition of death. Also, a general distrust of large, impersonal medical institutions keeps many people from committing to organ donation. Many people are afraid that if they carry an organ donor card, they will not receive adequate medical treatment in an emergency. Moreover, medical professionals are generally not required to present the option of organ donation to critically ill or injured patients and their families. As a result, even if a person has a donor card, it may go unnoticed.

When the system of encouraged voluntarism established by the Uniform Anatomical Gift Act failed to increase the number of available organs adequately, some individuals advocated establishing a legal market in organs. Some versions of an organ market would allow living individuals to sell one of their kidneys at a market price. More commonly, organ market advocates propose the sale of organs taken only from those who have died — that is, cadaveric organs — usually through "forward contracts" signed when the patient was living. However, the sale of organs has been barred by state and federal legislation, particularly the National Organ Transplant Act (42 U.S.C.A. § 274(e) [1985]), which states, "It shall be unlawful for any person to knowingly acquire, receive or otherwise transfer any human organ for valuable consideration for use in human transplantation if the transfer affects interstate commerce." Rather than creating an organ market, Congress has since sought to establish laws that establish "required request" protocols. These protocols would require major hospitals to ask a patient's family if it wishes to donate the patient's organs (Omnibus Reconciliation Act of 1986, Pub. L. No. 99-509, 100 Stat. 1874, 2009).

Some states have gone a step further, passing "presumed consent" laws that allow for the removal of organs unless the next of kin objects or it is known that the potential donor objected to such a procedure while alive. Some of these laws allow only the removal of corneas under such conditions; others apply only to unclaimed dead bodies. The huge demand for organs may lead to the wider passage of presumed consent laws and the creation of market incentives for organ donation.

Controversial Issues

Organ transplants generate increasingly vexing legal and ethical questions as medical technology becomes more complex. Three controversial issues surrounding the subject are conception for organ donation, donor consent, and transplants from terminally disabled infants.

In some instances, a child is conceived expressly for the purpose of using her organs for transplantation in another person, usually a blood relative. In 1990, for example, a California couple gave birth to a child they had conceived solely in hopes that the baby's bone marrow cells would save the life of their teenage daughter, who was dying of cancer. Although the legality of such conceptions has not been challenged, the practice raises ethical questions relating to who may give informed consent for the donor child and whether such a practice may be considered child abuse.

The problem of donor consent has arisen in lawsuits seeking to compel persons to donate organs to relatives. For example, in 1990, an Illinois family with a son who had leukemia brought a lawsuit seeking to compel the boy's half sister and half brother to submit to preliminary medical tests that would have established their suitability to serve as bone marrow donors. A judge, noting the objections of the mother of the half siblings, ruled that such tests would be an invasion of the potential donors' right of privacy. The Illinois Supreme Court later upheld this ruling (Curran v. Bosze, No. 70501 [Ill. filed Dec. 20, 1990]). In its opinion, the court outlined three critical factors in determining the best interests of the donating child: (1) the consenting parent must know the inherent risks and benefits of the procedure, (2) the primary caretaker of the child must be able to provide emotional support, and (3) there must be an existing, close relationship between the donor and the recipient.

The issue of organ donations made by terminally disabled infants came to national attention in 1992 when a Florida couple sought to have the organs of their anencephalic baby, Theresa Ann Campo Pearson, donated for use by other newborns. Anencephaly is a rare and always fatal gestational disorder in which the brain develops a stem, or lower brain, but not a cortex, or upper brain. Though the rest of the anencephalic infant's body is healthy, the disorder causes the child to die soon after birth. Theresa Ann's mother and father sought to have her declared brain dead, but a judge stated that under Florida statutes, a declaration of brain death may be made only if activity in all parts of the brain has ceased (Fla. Stat. ch. 382.009 [1992]). The judge noted that Theresa Ann had lower-brain activity. She died ten days after birth, without having donated her organs.

Critics of this decision have argued that because anencephaly is always fatal, the organs of children with this disorder should be used to save other children. Supporters note that if an exception were made for anencephaly, other severely disabled persons may be inappropriately targeted as a source for organs. Others argue that the life of one child, no matter how brief or unsatisfactory, cannot be taken to save another.

See: death and dying; fetal rights.