Organ transplant

Organ transplant is the moving of an organ from one body to another (or from a donor site on the patient's own body), for the purpose of replacing the recipient's damaged or failing organ with a working one from the donor site. Organ donors can be living or deceased (previously referred to as cadaveric). The emerging field of Regenerative medicine may soon^[when?] allow organs to be re-grown from the patient's own cells (stem cells, or cells extracted from the failing organs.)

Organs that can be transplanted are the heart, kidneys, liver, lungs, pancreas, intestine, and skin. Tissues include bones, tendons, cornea, heart valves, veins, and arms. Worldwide, the kidneys are the most commonly transplanted organs.

Transplantation medicine is one of the most challenging and complex areas of modern medicine. Some of the key areas for medical management are the problems of transplant rejection, during which the body has an immune response to the transplanted organ, possibly leading to transplant failure and the need to immediately remove the organ from the recipient. When possible, transplant rejection can be reduced through serotyping to determine the most appropriate donor-recipient match and through the use of immunosuppressant drugs.^[1]

In most countries there is a shortage of suitable organs for transplantation. Countries often have formal systems in place to manage the allocation and reduce the risk of rejection. Some countries are associated within international organisations like Eurotransplant in order to increase the supply of appropriate donor organs and the organ recipients.

Transplantation also raises a number of bioethical issues, including the definition of death, when and how consent should be given for an organ to be transplanted and payment for organs for transplantation.

Contents 1 United States 2 United Kingdom 3 Types of transplants 3.1 Autograft 3.2 Allograft 3.2.1 Isograft 3.3 Xenograft and xenotransplantation 3.4 Split transplants 3.5 Domino transplants 4 Major organs and tissues transplanted 4.1 Thoracic organs 4.2 Abdominal organs 4.3 Tissues, cells, fluids 5 History 5.1 Timeline of successful transplants 6 Types of donor 6.1 Living or deceased 7 Reasons for donation and ethical issues 7.1 Living related donors 7.1.1 Paired-exchange 7.2 Good Samaritan 7.3 Compensated donation 7.4 Forced donation 7.5 Allocation of donated organs 8 Organ transplantation in different countries 8.1 Demographics 8.2 Comparative costs 8.3 Safety 8.4 Organ transplant laws 8.5 Ethical concerns 9 See also 10 References 11 Sources and bibliography 12 External links

United States

Acceptable organ donors can range in age from newborn to 65 years plus. People who are 65 years of age or older may be acceptable donors, particularly of corneas, skin, bone, for total body donation. An estimated 10,000 to 14,000 people who die each year meet the criteria for an organ donation, but less than half of that number becomes actual organ donors. Donor organs are matched to waiting recipients by a national computer registry, called the National Organ Procurement and Transplatation Network (OPTN). This computer registry is operated by an organization known as the United Network for Organ Sharing (UNOS), which is located in Richmond, Virginia. Currently there are 58 organ procurement organizations (OPOs) across the country, which provide organ procurement services to some 261 transplant centers. All hospitals are required by law to have a "Required Referral" system in place. Under this system, the hospital must notify the local Organ Procurement Organization (OPO) of all patient deaths. If the OPO determines that organ and/or tissue donation is appropriate in a particular case, they will have a representative contact the deceased patient's family to offer them the option of donating their loved one's organs and tissues. By signing a Uniform Donor Card, an individual indicates his or her wish to be a donor. However, at the time of death, the person's next-of-kin will still be asked to sign a consent form for donation. It is important for people who wish to be organ and tissue donors to tell their family about this decision so that their wishes will be honored at the time of death. It is estimated that about 35 percent of potential donors never become donors because family members refuse to give consent.^[2]

United Kingdom

In the UK the number of people needing organ transplants is significantly greater than the number of organs available. To ensure that the patients awaiting transplants are treated fairly, there is a UK-wide organ allocation system run by a body called NHS Blood and Transplant (NHSBT), which is part of the UK’s National Health Service.[8]

All patients who are waiting for transplants are registered on the UK Transplant National Transplant Database.

Allocation is carried out on the patient's need and the importance of achieving the closest possible match between donor and recipient. The rules for allocating organs are determined by the medical profession in consultation with other health professionals, the Department of Health and the specialist advisory groups of NHSBT.

The blood group, age and size of the donor and recipient are all taken into account to ensure the best possible match for each patient. For kidney transplant patients, tissue type match is also a consideration. NHSBT to identify the best matched patient, or alternatively, the transplant unit to which the organ is to be offered.

Types of transplants

Autograft

Transplant of tissue to the same person. Sometimes this is done with surplus tissue, or tissue that can regenerate, or tissues more desperately needed elsewhere (examples include skin grafts, vein extraction for CABG, etc.) Sometimes an autograft is done to remove the tissue and then treat it or the person, before returning it (examples include stem cell autograft and storing blood in advance of surgery).

Allograft

An allograft is a transplant of an organ or tissue between two genetically non-identical members of the same species. Most human tissue and organ transplants are allografts. Due to the genetic difference between the organ and the recipient, the recipient's immune system will identify the organ as foreign and attempt to destroy it, causing transplant rejection. To prevent this, the organ recipient must take immunosuppressants. This dramatically affects the entire immune system, making the body vulnerable to pathogens.

Isograft

A subset of allografts in which organs or tissues are transplanted from a donor to a genetically identical recipient (such as an identical twin). Isografts are differentiated from other types of transplants because while they are anatomically identical to allografts, they don't trigger an immune response.

Xenograft and xenotransplantation

A transplant of organs or tissue from one species to another. An example are porcine heart valve transplants, which are quite common and successful. Another example is attempted piscine-primate (fish to non-human primate) transplant of islet (i.e. pancreatic or insular tissue) tissue. The latter research study was intended to pave the way for potential human use, if successful. However, xenotransplantion is often an extremely dangerous type of transplant because of the increased risk of non-compatibility, rejection, and disease carried in the tissue.

Split transplants

Sometimes a deceased-donor organ, usually a liver, may be divided between two recipients, especially an adult and a child. This is not usually a preferred option because the transplantation of a whole organ is more successful.

Domino transplants

This operation is usually performed on patients with cystic fibrosis because both lungs need to be replaced and it is a technically easier operation to replace the heart and lungs at the same time. As the recipient's native heart is usually healthy, it can be transplanted into someone else needing a heart transplant. That term is also used for a special form of liver transplant in which the recipient suffers from familial amyloidotic polyneuropathy, a disease where the liver slowly produces a protein that damages other organs. This patient's liver can be transplanted into an older patient who is likely to die from other causes before a problem arises.^[3]

This term also refers to a series of living donor transplants in which one donor donates to the highest recipient on the waiting list and the transplant center utilizes that donation to facilitate multiple transplants. These other transplants are otherwise impossible due to blood-type or antibody barriers to transplantation. The "Good Samaritan" kidney is transplanted into one of the other recipients, whose donor in turn donates his or her kidney to an unrelated recipient. Depending on the patients on the waiting list, this has sometimes been repeated for up to six pairs, with the final donor donating to the patient at the top of the list. This method allows all organ recipients to get a transplant even if their living donor is not a match to them. This further benefits patients below any of these recipients on waiting lists, as they move closer to the top of the list for a deceased-donor organ. Johns Hopkins Medical Center in Baltimore and Northwestern University's Northwestern Memorial Hospital have received significant attention for pioneering transplants of this kind. ^[4][5]

Major organs and tissues transplanted

Thoracic organs

• Heart (Deceased-donor only)
• Lung (Deceased-donor and Living-Donor)
• Heart/Lung (Deceased-donor and Domino transplant)

Abdominal organs

• Kidney (Deceased-donor and Living-Donor)
• Liver (Deceased-donor and Living-Donor)
• Pancreas (Deceased-donor only)
• Intestine (Deceased-donor and Living-Donor)
• Stomach (Deceased-donor only)
• Testis

Tissues, cells, fluids

• Hand (Deceased-donor only)^[6]
• Cornea (Deceased-donor only)^[7]
• Skin including Face replant (autograft) and Face transplant (extremely rare)
• Islets of Langerhans (Pancreas Islet Cells) (Deceased-donor and Living-Donor)
• Bone marrow/Adult stem cell (Living-Donor and Autograft)
• Blood transfusion/Blood Parts Transfusion (Living-Donor and Autograft)
• Blood vessels (Autograft and Deceased-Donor)
• Heart valve (Deceased-Donor, Living-Donor and Xenograft[Porcine/bovine])
• Bone (Deceased-Donor and Living-Donor)

History

Successful human allotransplants have a relatively long history; the operative skills were present long before the necessities for post-operative survival were discovered. Rejection and the side effects of preventing rejection (especially infection and nephropathy) were, are, and may always be the key problem.

Several apocryphal accounts of transplants exist well prior to the scientific understanding and advancements that would be necessary for them to have actually occurred. The Chinese physician Pien Chi'ao reportedly exchanged hearts between a man of strong spirit but weak will with one of a man of weak spirit but strong will in an attempt to achieve balance in each man. Roman Catholic accounts report the third-century saints Damian and Cosmas as replacing the gangrenous leg of the Roman deacon Justinian with the leg of a recently deceased Ethiopian. Most accounts have the saints performing the transplant in the fourth century, decades after their deaths; some accounts have them only instructing living surgeons who performed the procedure.

The more likely accounts of early transplants deal with skin transplantation. The first reasonable account is of the Indian surgeon Sushruta in the second century BC, who used autografted skin transplantation in nose reconstruction rhinoplasty. Success or failure of these procedures is not well documented. Centuries later, the Italian surgeon Gasparo Tagliacozzi performed successful skin autografts; he also failed consistently with allografts, offering the first suggestion of rejection centuries before that mechanism could possibly be understood. He attributed it to the "force and power of individuality" in his 1596 work De Curtorum Chirurgia per Insitionem.

The first successful corneal allograft transplant was performed in 1837 in a gazelle model; the first successful human corneal transplant, a keratoplastic operation, was performed by Eduard Zirm in Olomouc, Czech Republic, in 1905. Pioneering work in the surgical technique of transplantation was made in the early 1900s by the French surgeon Alexis Carrel, with Charles Guthrie, with the transplantation of arteries or veins. Their skillful anastomosis operations, the new suturing techniques, laid the groundwork for later transplant surgery and won Carrel the 1912 Nobel Prize in Physiology or Medicine. From 1902 Carrel performed transplant experiments on dogs. Surgically successful in moving kidneys, hearts and spleens, he was one of the first to identify the problem of rejection, which remained insurmountable for decades.

Major steps in skin transplantation occurred during World War I, notably in the work of Harold Gillies at Aldershot. Among his advances was the tubed pedicle graft, maintaining a flesh connection from the donor site until the graft established its own blood flow. Gillies' assistant, Archibald McIndoe, carried on the work into World War II as reconstructive surgery. In 1962 the first successful replantation surgery was performed - re-attaching a severed limb and restoring (limited) function and feeling.

Transplant of a single gonad (testis) from a living donor was carried out in early July 1926 in Zaječar, Serbia, by a Russian emigré surgeon Dr. Peter Vasil'evič Kolesnikov. The donor was a convicted murderer, one Ilija Krajan, whose death sentence was commuted to 20 years imprisonment and he was led to believe that it was done because he had donated his testis to an elderly medical doctor. Both the donor and the receiver survived, but charges were brought in a court of law by the public prosecutor against Dr. Kolesnikov, not for performing the operation, but for lying to the donor. (v. Timočki medicinski glasnik, Vol.29 (2004) #2, p.115-117 ISSN 0350-2899 article in Serbian)

The first attempted human deceased-donor transplant was performed by the Ukrainian surgeon Yu Yu Voronoy in the 1930s; rejection resulted in failure. Joseph Murray performed the first successful transplant, a kidney transplant between identical twins, in 1954, successful because no immunosuppression was necessary in genetically identical twins.

In the late 1940s Peter Medawar, working for the National Institute for Medical Research, improved the understanding of rejection. Identifying the immune reactions in 1951 Medawar suggested that immunosuppressive drugs could be used. Cortisone had been recently discovered and the more effective azathioprine was identified in 1959, but it was not until the discovery of cyclosporine in 1970 that transplant surgery found a sufficiently powerful immunosuppressive.

Dr. Murray's success with the kidney led to attempts with other organs. There was a successful deceased-donor lung transplant into a lung cancer sufferer in June 1963 by James Hardy in Jackson, Mississippi. The patient survived for eighteen days before dying of kidney failure. Thomas Starzl of Denver attempted a liver transplant in the same year, but was not successful until 1967.

The heart was a major prize for transplant surgeons. But, as well as rejection issues the heart deteriorates within minutes of death so any operation would have to be performed at great speed. The development of the heart-lung machine was also needed. Lung pioneer James Hardy attempted a human heart transplant in 1964, but a premature failure of the recipient's heart caught Hardy with no human donor, he used a chimpanzee heart which failed very quickly. The first success was achieved December 3, 1967 by Christiaan Barnard in Cape Town, South Africa. Louis Washkansky, the recipient, survived for eighteen days amid what many saw as a distasteful publicity circus. The media interest prompted a spate of heart transplants. Over a hundred were performed in 1968-69, but almost all the patients died within sixty days. Barnard's second patient, Philip Blaiberg, lived for 19 months.

It was the advent of cyclosporine that altered transplants from research surgery to life-saving treatment. In 1968 surgical pioneer Denton Cooley performed seventeen transplants including the first heart-lung transplant. Fourteen of his patients were dead within six months. By 1984 two-thirds of all heart transplant patients survived for five years or more. With organ transplants becoming commonplace, limited only by donors, surgeons moved onto more risky fields, multiple organ transplants on humans and whole-body transplant research on animals. On March 9, 1981 the first successful heart-lung transplant took place at Stanford University Hospital. The head surgeon, Bruce Reitz, credited the patient's recovery to cyclosporine-A.

As the rising success rate of transplants and modern immunosuppression make transplants more common, the need for more organs has become critical. Advances in living-related donor transplants have made that increasingly common. Additionally, there is substantive research into xenotransplantation or transgenic organs; although these forms of transplant are not yet being used in humans, clinical trials involving the use of specific cell types have been conducted with promising results, such as using porcine islets of Langerhans to treat type one diabetes. However, there are still many problems that would need to be solved before they would be feasible options in patients requiring transplants.

Recently, researchers have been looking into steroid-free immunosuppression. This type of immunosuppression is being pioneered on a large scale at Northwestern University in Evanston, Illinois and other smaller institutions, while steroid minimization is being employed at the University of Wisconsin–Madison and other smaller institutions. This would avoid the side-effects of steroids. While short-term outcomes appear promising, long-term outcomes are still unknown.

In addition, calcineurin-Inhibitor-Free Immunosuppression is currently undergoing extensive trialing, the result of which would be to allow sufficient immunosuppression, without the nephrotoxicity associated with standard regimens that include calcineurin inhibitors. Positive results have yet to be demonstrated in any trial.

An FDA approved immune function test from Cylex has shown effectiveness in minimizing the risk of infection and rejection in post-transplant patients^[8] by enabling doctors to tailor immunosuppressant drug regimens. By keeping a patient's immune function within a certain window, doctors can adjust drug levels to prevent organ rejection while avoiding infection. Such information could help physicians reduce the use of immunosuppressive drugs, lowering drug therapy expenses while reducing the morbidity associated with liver biopsies, improve the daily life of transplant patients, and could prolong the life of the transplanted organ. There is minimal evidence that this monitoring can be used with clinical benefit to patients.

Many other new drugs are under development for transplantation.^[9]

The emerging field of Regenerative medicine promises to solve the problem of organ transplant rejection by regrowing organs in the lab, using the patients' own cells (stem cells, or healthy cells extracted from the donor site.)

At the Wake Forest Institute for Regenerative Medicine, in North Carolina, Dr. Anthony Atala and his colleagues have successfully extracted muscle and bladder cells from several patients' bodies, cultivated these cells in petri dishes, and then layered the cells in three-dimensional molds that resembled the shapes of the bladders. Within weeks, the cells in the molds began functioning as regular bladders which were then implanted back into the patients' bodies. ^[10] The team is currently working on re-growing over 22 other different organs including the Liver, Heart, Kidneys and Testicles. ^[11]

In June 2008, at the Hospital Clínic (Barcelona Metro), Professor Paolo Macchiarini and his team, of the University of Barcelona, performed the first tissue engineered trachea (wind pipe) transplantation. Adult stem cells were extracted from the patient's bone marrow, grown into a large population, and matured into cartilage cells, or chondrocytes, using an adaptive method originally devised for treating osteoarthritis. The team then seeded the newly grown chondrocytes, as well as epithileal cells, into a decellularised (free of donor cells) tracheal segment that was donated from a 51 year old transplant donor who had died of cerebral hemorrhage. After four days of seeding, the the graft was used to replace the patient's left main bronchus. After one month, a biopsy elicited local bleeding, indicating that the blood vessels had already grown back successfully.^[12][13]

Timeline of successful transplants

• 1905: First successful cornea transplant by Eduard Zirm^[14]
• 1954: First successful kidney transplant by Joseph Murray (Boston, U.S.A.)
• 1966: First successful pancreas transplant by Richard Lillehei and William Kelly (Minnesota, U.S.A.)
• 1967: First successful liver transplant by Thomas Starzl (Denver, U.S.A.)
• 1967: First successful heart transplant by Christiaan Barnard (Cape Town, South Africa)
• 1981: First successful heart/lung transplant by Bruce Reitz (Stanford, U.S.A.)
• 1983: First successful lung lobe transplant by Joel Cooper (Toronto, Canada)
• 1986: First successful double-lung transplant (Ann Harrison) by Joel Cooper (Toronto, Canada)
• 1987: First successful whole lung transplant by Joel Cooper (St. Louis, U.S.A.)
• 1995: First successful laparoscopic live-donor nephrectomy by Lloyd Ratner and Louis Kavoussi (Baltimore, U.S.A.)
• 1998: First successful live-donor partial pancreas transplant by David Sutherland (Minnesota, U.S.A.)
• 1998: First successful hand transplant (France)
• 1999: First successful Tissue Engineered Bladder transplanted by Anthony Atala (Boston Children's Hospital, U.S.A.)^[15]
• 2005: First successful partial face transplant (France)
• 2006: First jaw transplant to combine donor jaw with bone marrow from the patient, by Eric M. Genden (Mount Sinai Hospital, New York)^[16]
• 2008: First successful complete full double arm transplant by Edgar Biemer, Christoph Höhnke and Manfred Stangl (Technical University of Munich, Germany)^{[citation needed]}
• 2008: First baby born from transplanted ovary.^[17]
• 2008: First transplant of a human windpipe using a patient’s own stem cells, by Paolo Macchiarini (Barcelona, Spain)^[18]

Types of donor

Living or deceased

In living donors, the donor remains alive and donates a renewable tissue, cell, or fluid (e.g. blood, skin); or donates an organ or part of an organ in which the remaining organ can regenerate or take on the workload of the rest of the organ (primarily single kidney donation, partial donation of liver, small bowel). Regenerative medicine may one day allow for laboratory-grown organs, using patient's own cells (stem cells, or healthy cells extracted from the failing organs.)

Deceased (formerly cadaveric) are donors who have been declared brain-dead and whose organs are kept viable by ventilators or other mechanical mechanisms until they can be excised for transplantation. Apart from brain-stem dead donors, who have formed the majority of deceased donors for the last twenty years, there is increasing use of Donation after Cardiac Death - DCD- Donors (formerly non-heart beating donors) to increase the potential pool of donors as demand for transplants continues to grow.^{[citation needed]} These organs have inferior outcomes to organs from a brain-dead donor; however given the scarcity of suitable organs and the number of people who die waiting, any potentially suitable organ must be considered.^{[citation needed]}

Reasons for donation and ethical issues

Living related donors

Living related donors donate to family members or friends in whom they have an emotional investment. The risk of surgery is offset by the psychological benefit of not losing someone related to them, or not seeing them suffer the ill effects of waiting on a list.

Paired-exchange

A "paired-exchange" is a technique of matching willing living donors to compatible recipients using serotyping. For example a spouse may be more than willing to donate a kidney to their partner but cannot since there is not a biological match. The willing spouse's kidney is donated to a matching recipient who also has an incompatible but willing spouse. The second donor must match the first recipient to complete the pair exchange. Typically the surgeries are scheduled simultaneously in case one of the donors decides to back out and the couples are kept anonymous from each other until after the transplant.

Paired exchange programs were popularized in the New England Journal of Medicine article "Ethics of a paired-kidney-exchange program" in 1997 by L.F. Ross[9]. It was also proposed by Felix T. Rapport[10] in 1986 as part of his initial proposals for live-donor transplants "The case for a living emotionally related international kidney donor exchange registry" in Transplant Proceedings[11]. A paired exchange is the simplest case of a much larger exchange registry program where willing donors are matched with any number of compatible recipients[12]. Transplant exchange programs have been suggested as early as 1970: "A cooperative kidney typing and exchange program."[13].

The first pair exchange transplant in the U.S. was in 2001 at Johns Hopkins Hospital[14]. The first complex multihospital kidney exchange involving 12 patients was performed in February 2009 by The Johns Hopkins Hospital, Barnes-Jewish Hospital in St. Louis and Integris Baptist Medical Center in Oklahoma City.^[19] Another 12-patient multihospital kidney exchange was performed four weeks later by Saint Barnabas Medical Center in Livingston, New Jersey, Newark Beth Israel Medical Center and New York-Presbyterian Hospital.^[20] Surgical teams led by Johns Hopkins continue to pioneer in this field by having more complex chain of exchange such as eight-way multihospital kidney exchange.^[21]

Paired-donor exchange, led by work in the New England Program for Kidney Exchange as well as at Johns Hopkins University and the Ohio OPOs may more efficiently allocate organs and lead to more transplants.

Good Samaritan

"Good Samaritan" or "altruistic" donation is giving a donation to someone not well-known to the donor. Some people choose to do this out of a need to donate. Some donate to the next person on the list; others use some method of choosing a recipient based on criteria important to them. Web sites are being developed that facilitate such donation. It has been featured in recent television journalism that over half of the members of the Jesus Christians, an Australian religious group, have donated kidneys in such a fashion.^[22]

Compensated donation

In compensated donation, donors get money or other compensation in exchange for their organs. This practice is common in some parts of the world, whether legal or not, and is one of the many factors driving medical tourism.^[23]

In the United States, The National Organ Transplant Act of 1984 made organ sales illegal. In the United Kingdom, the Human Tissue Act 1961 made organ sales illegal.

In 2007, two major European conferences recommended against the sale of organs^[24].

Recent development of web sites and personal advertisements for organs among listed candidates has raised the stakes when it comes to the selling of organs, and have also sparked significant ethical debates over directed donation, "good-Samaritan" donation, and the current U.S. organ allocation policy. Bioethicist Jacob M. Appel has argued that organ solicitation on billboards and the internet may actually increase the overall supply of organs.^[25]

Two books, Kidney for Sale By Owner by Mark Cherry (Georgetown University Press, 2005); and Stakes and Kidneys: Why markets in human body parts are morally imperative by James Stacey Taylor: (Ashgate Press, 2005); advocate using markets to increase the supply of organs available for transplantation. In a 2004 journal article Economist Alex Tabarrok argues that allowing organ sales, and elimination of organ donor lists will increase supply, lower costs and diminish social anxiety towards organ markets.^[26]

In 2006, Iran became the only country to legally allow individuals to sell their kidneys, and the market price is of the order of US$2,000 to US$4,000. The Economist[15] and the Ayn Rand Institute[16] approved and advocated a legal market elsewhere. They argued that if 0.06% of Americans between 19 and 65 were to sell one kidney, the national waiting list would disappear (which, the Economist wrote, happened in Iran). The Economist argued that donating kidneys is no more risky than surrogate motherhood, which can be done legally for pay in most countries.

In Pakistan, 40 percent to 50 percent of the residents of some villages have only one kidney because they have sold the other for a transplant into a wealthy person, probably from another country, said Dr. Farhat Moazam of Pakistan, at a World Health Organization conference. Pakistani donors are offered $2,500 for a kidney but receive only about half of that because middlemen take so much^[27]. In Chennai, southern India, poor fishermen and their families sold kidneys after their livelihoods were destroyed by the Indian Ocean tsunami in December 26, 2004. About 100 people, mostly women, sold their kidneys for 40,000-60,000 rupees ($900-$1,350)^[28]. Thilakavathy Agatheesh, 30, who sold a kidney in May 2005 for 40,000 rupees said, "I used to earn some money selling fish but now the post-surgery stomach cramps prevent me from going to work." Most kidney sellers say that selling their kidney was a mistake^[29].

Forced donation

There have been various accusations that certain authorities are harvesting organs from those the authorities deem undesirable, such as prison populations. The World Medical Association stated that individuals in detention are not in the position to give free consent to donate their organs ^[30]. Illegal dissection of corpses is a form of body-snatching and may have taken place to obtain allografts. [17]

According to the Chinese Deputy Minister of Health, Huang Jiefu, ^[31] approximately 95% of all organs used for transplantation are from executed prisoners. The lack of public organ donation program in China is used as a justification for this practice. However reports in Chinese media raised concerns if executed criminals are the only source for organs used in transplants.

In October 2007, bowing to international pressure, the Chinese Medical Association agreed on a moratorium of commercial organ harvesting from condemned prisoners, but did not specify a deadline. China agreed to restrict transplantations from donors to their immediate relatives.^[32][33]

People in other parts of the world are responding to this availability of organs, and a number of individuals (including US and Japanese citizens) have elected to travel to China or India as medical tourists to receive organ transplants which may have been sourced in what might be considered elsewhere to be unethical ways (see later). [18] [19] [20].

Allocation of donated organs

The overwhelming majority of deceased-donor organs in the United States are allocated by federal contract to the Organ Procurement and Transplantation Network (OPTN), held since it was created by the Organ Transplant Act of 1984 by the United Network for Organ Sharing or UNOS. UNOS does not handle donor cornea tissue. Corneal donor tissue is usually handled by various eye banks. This allocates organs based on the method considered most fair by the scientific leadership in the field. For kidneys, for instance, that is by waiting time; for livers, it is by MELD (Model of End-Stage Liver Disease), an empirical score based on lab values indicative of the sickness of the patient from liver disease. Experiencing somewhat increased popularity, but still very rare, is directed or targeted donation, in which the family of a deceased donor (often honoring the wishes of the deceased) requests an organ be given to a specific person. If medically suitable, the allocation system is subverted, and the organ is given to that person. In the United States, there are various lengths of waiting due to the different availabilities of organs in different UNOS regions. In other countries such as the UK, only medical factors and the position on the waiting list can affect who receives the organ. If this is not the desired person, it is noted that this puts them higher on the list.

One of the more publicized cases of this type was the 1994 Chester and Patti Szuber transplant. This was the first time that a parent had received a heart donated by one of their own children. Although the decision to accept the heart from their recently killed child was not an easy decision, the Szuber family agreed that giving Patti’s heart to her father would have been something that she would have wanted.^[34]

Access to organ transplantation is one reason for the growth of medical tourism.

Organ transplantation in different countries

Demographics

Despite efforts of international transplantation societies, it is not possible to access an accurate source on the number, rates and outcomes of all forms of transplantation globally; the best that we can achieve is estimations. This is not a sound basis for the future and thus one of the crucial strategies for the Global Alliance in Transplantation is to foster the collection and analysis of global data.

Transplantation of organs in different continents/regions year/ 2000

	Kidney (pmp*)	Liver (pmp)	Heart (pmp)
USA	52	19	8
Europe	27	10	4
Turkey	11	3.5	1
Asia	3	0.3	0.03
Latin America	13	1.6	0.5

• All numbers per million population

Source: [21],[22]

According to the Council of Europe, Spain through the Spanish Transplant Organization led by Dr Rafael Matesanz shows the highest worldwide rate of 35.1.^[35][36] donors per million population in 2005 and 33.8^[37] in 2006.

In addition to the citizens waiting for organ transplants in the US and other developed nations, there are long waiting lists in the rest of the world. More than 2 million people need organ transplants in China, 50,000 waiting in Latin America (90% of which are waiting for kidneys), as well as thousands more in the less documented continent of Africa. Donor bases vary in developing nations.

Traditionally, Muslims believe body desecration in life or death to be forbidden, and thus many reject organ transplant. ^[38] However most Muslim authorities nowadays accept the practice if another life will be saved. ^[39]

In Latin America the donor rate is 40-100 per million per year, similar to that of developed countries. However, in Uruguay, Cuba, and Chile, 90% of organ transplants came from cadaveric donors. Cadaveric donors represent 35% of donors in Saudi Arabia. There is continuous effort to increase the utilization of cadaveric donors in Asia, however the popularity of living, single kidney donors in India yields India a cadaveric donor prevalence of less than 1 pmp.

China does 10,000 transplants a year, with sources claiming up to 90% of organs are taken from executed prisoners, without signed consent, since Chinese have taboos against donating organs of deceased family members.^[40][41] Amnesty International has criticized this practice, and accused the Chinese of executing people without fair trials.^[42] Close relative donations represent only 2% of transplants^{[citation needed]}.

In Israel, there is a severe organ shortage due to religious objections by some rabbis who oppose all organ donations and others who advocate that a rabbi participate in all decision making regarding a particular donor. This shortage has resulted in one-third of all heart transplants performed on Israelis being done in the Peoples' Republic of China; others are done in Europe. Dr. Jacob Lavee, head of the heart-transplant unit, Sheba Medical Center, Tel Aviv, believes that "transplant tourism" is unethical and Israeli insurers should not pay for it.^[40] The organization HODS (Halachic Organ Donor Society) is working to increase knowledge and participation in organ donation among Jews throughout the world.^[43]

Comparative costs

One of the driving forces for illegal organ trafficking and “transplantation tourism” is the price differences for organs and transplant surgeries in different areas of the world. According to the New England Journal of Medicine, a human kidney can be purchased in Manila for $1000- $2000, but in urban Latin America a kidney may cost more than $10,000. Kidneys in South Africa have sold for as high as $20,000. Price disparities based on donor race are a driving force of attractive organ sales in South Africa, as well as in other parts of the world.

In China, a kidney transplant operation runs for around $70,000, liver for $160,000, and heart for $120,000 [23]. Although these prices are still unattainable to the poor, compared to the fees of the United States, where a kidney transplant may demand $100,000, a liver $250,000, and a heart $860,000, Chinese prices have made China a major provider of organs and transplantation surgeries to other countries.

Safety

Compensation for donors also increases the risk of introducing diseased organs to recipients because these donors often yield from poorer populations unable to receive health care regularly and organ dealers may evade disease screening processes. The majority of such deals include one major payment and no follow up care for the donor. Some cases argue that there is a possibility of 1:18 to acquire HIV from such transplants.^{[citation needed]}

In November 2007, the CDC reported the first-ever case of HIV and Hepatitis C being simultaneously transferred through an organ transplant. The donor was a 38-year-old male, considered "high-risk" by donation organizations, and his organs transmitted HIV and Hepatitis C to four organ recipients, none of whom had been told he was "high-risk." Experts say that the reason the diseases didn't show up on screening tests is probably because they were contracted within three weeks before the donor's death, so antibodies wouldn't have existed in high enough numbers to detect. The crisis has caused many to call for more sensitive screening tests, which could pick up antibodies sooner. Currently, the screens cannot pick up on the small number of antibodies produced in HIV infections within the last 90 days or Hepatitis C infections within the last 18-21 days before a donation is made.

NAT (nucleic acid testing) is now being done by many organ procurement organizations and is able to detect antibodies for HIV and Hepatitis C within seven to ten days of exposure to the virus.

Organ transplant laws

Both developing and developed countries have forged various policies to try to increase the safety and availability of organ transplants to their citizens. Brazil, France, Italy, Poland and Spain have ruled all adults potential donors with the “opting out” policy, unless they attain cards specifying not to be. Iran is the only country in the world where it is lawful for one citizen to sell an organ to another for transplantation.^{[citation needed]} However, whilst potential recipients in developing countries may mirror their more developed counterparts in desperation, potential donors in developing countries do not. The Indian government has had difficulty tracking the flourishing organ black market in their country and have yet to officially condemn it. Other countries victimized by illegal organ trade have implemented legislative reactions. Moldova has made international adoption illegal in fear of organ traffickers. China has made selling of organs illegal as of July 2006 and claims that all prisoner organ donors have filed consent. However, doctors in other countries, such as the United Kingdom, have accused China of abusing its high capital punishment rate. Despite these efforts, illegal organ trafficking continues to thrive and can be attributed to corruption in healthcare systems, which has been traced as high up as the doctors themselves in China, Ukraine, and India, and the blind eye economically strained governments and health care programs must sometimes turn to organ trafficking. Some organs are also shipped to Uganda and the Netherlands. This was a main product in the triangular trade in 1934.

Starting on May 1, 2007, doctors involved in commercial trade of organs will face fines and suspensions in China. Only a few certified hospitals will be allowed to perform organ transplants in order to curb illegal transplants. Harvesting organs without donor's consent was also deemed a crime.^[44]

On June 27, 2008, Indonesian, Sulaiman Damanik, 26, pleaded guilty in Singapore court for sale of his kidney to CK Tang's executive chair, Mr Tang Wee Sung, 55, for 150 million rupiah (S$ 22,200). The Transplant Ethics Committee must approve living donor kidney transplants. Organ trading is banned in Singapore and in many other countries to prevent the exploitation of "poor and socially disadvantaged donors who are unable to make informed choices and suffer potential medical risks." Toni, 27, the other accused, donated a kidney to an Indonesian patient in March, alleging he was the patient's adopted son, and was paid 186 million rupiah (20,200 US). Upon sentence, both would suffer each, 12 months in jail or 10,000 Singapore dollars (7,300 US) fine.^[45][46]

In an article appearing in the Econ Journal Watch, April 2004.^[47] Economist Alex Tabarrok examined the impact of direct consent laws on transplant organ availability. Tabarrok found that social pressures resisting the use of transplant organs decreased over time as the opportunity of individual decisions increased. Tabarrok concluded his study suggesting that gradual elimination of organ donation restrictions and move to a free market in organ sales will increase supply of organs and encourage broader social acceptance of organ donation as a practice.

Ethical concerns

The existence and distribution of organ transplantation procedures in developing countries, while almost always beneficial to those receiving them, raise many ethical concerns. Both the source and method of obtaining the organ to transplant are major ethical issues to consider, as well as the notion of distributive justice. The World Health Organization argues that transplantations promote health, but the notion of “transplantation tourism” has the potential to violate human rights or exploit the poor, to have unintended health consequences, and to provide unequal access to services, all of which ultimately may cause harm. Regardless of the “gift of life”, in the context of developing countries, this might be coercive. The practice of coercion could be considered exploitative of the poor population, violating basic human rights according to Articles 3 and 4 of the Universal Declaration of Human Rights. There is also a powerful opposing view, that trade in organs, if properly and effectively regulated to ensure that the seller is fully informed of all the consequences of donation, is a mutually beneficial transaction between two consenting adults, and that prohibiting it would itself be a violation of Articles 3 and 29 of the Universal Declaration of Human Rights.

Even within developed countries there is concern that enthusiasm for increasing the supply of organs may trample on respect for the right to life. The question is made even more complicated by the fact that the "irreversibility" criterion for legal death cannot be adequately defined and can easily change with changing technology ^[48].

See also

• Organ donor
• List of notable organ transplant donors and recipients
• Transplant rejection
  • Human leukocyte antigen, the major antigen for transplant rejection
• Organ donation taskforce
• Organ harvesting in China
• Organ replacement in animals
• Medical tourism
• Donald Wilford

References

Sources and bibliography

• Appel, Jacob M. and Fox, Mark D. (2005) Organ Solicitation on the Internet: Every Man for Himself? Hastings Center Report 35(3):14–15.

• Lock, M. (2002) Twice Dead: Organ Transplants and the Reinvention of Death. Berkeley, CA: University of California Press. ISBN 0-520-22605-4.
• Morris, PJ. Transplantation — A Medical Miracle of the 20th Century. N Engl J Med 2004;351:2678-80. PMID 15616201.
• Finn, R. (2000). Organ Transplants: Making the Most of Your Gift of Life. Sebastopol: O'Reilly & Associates. ISBN 1-56592-634-X.
• Hu, W (2006) A Preliminary Report of Penile Transplantation. Urology Amsterdam: Elsevier.
• Taylor, James Stacey (2005) Stakes And Kidneys: Why Markets In Human Body Parts Are Morally Imperative. Ashgate Publishing. ISBN 0754641090.
• Köchler, Hans, ed. (2001). Transplantationsmedizin und personale Identität. Medizinische, ethische, rechtliche und theologische Aspekte der Organverpflanzung. (Transplantation Medicine and Personal Identity. Medical, Ethical, Legal and Theological Aspects of Organ Transplantation / German) Frankfurt a. M. etc.: Peter Lang. ISBN 3-631-38363-0
• Cherry, Mark J. (2005). Kidney For Sale By Owner: Human Organs, Transplantation, And The Market. Georgetown University Press. ISBN 158901040X.

External links

Wikimedia Commons has media related to: Transplantation

• Organ Transplant survival rates from the Scientific Registry of Transplant Recipients
• Latest Development in Multiple Organ Transplant at Irish Medical News
• Could we clone our organs to be used in a transplant? at HowStuffWorks
• How does organ transplantation works? at HowStuffWorks
• Liver Transplant Procedure description - by Children's Hospital of Pittsburgh
• The Gift of a Lifetime - Online Educational Documentary
• Doctors Against Forced Organ Harvesting
• Revised Report into Allegations of Organ Harvesting of Falun Gong Practitioners in China
• Vladimir Demikhov transplantology, footage of a two-headed dog: a puppy's head on a full-grown pooch

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