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Organ donation and allotransplantation

Jozef Virčík 003435Lisbon 2013

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Last year, 60 people made history by participating in the longest chain of organ transplants to date, newspapers reported this week. Coordinated by 17 hospitals in 11 U.S. states, the lifesaving string of operations unfurled in August when a California man gave a kidney to an anonymous recipient. In return, that patient’s niece—a willing donor though not a match for her relative—offered a kidney to another individual on a transplant waiting list. The domino effect continued over four months as 30 Americans received kidneys thanks to donations by friends or family members to compatible strangers.

Introduction

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800 B.C. – Indians (repairing wounds by skin transplantation)

16th Century - Gasparo Tagliacozzi (repairing nose – skin transplantation, observed immune reaction)

Early 1900s – xenotransplantation of kidneys (only few days of living)

1905 – Eduard Zirm corneal transplantation (restoring sight)

History

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1912 - Alexis Carrell – kidney transplantation on dogs, connecting blood vessels, Nobel Prize

1936 - Yu Yu Voronoy – human kidney transplantation from dead donor – patient died in few days because of rejection of organ

1954 – Boston’s Peter Bent Brigham Hospital -After years of trying first succesful kidney transplantation between relatives – doctor received Nobel Prize, patient lived 8 more years.

History

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1960 - Peter Medawar – Nobel Prize for discovery of acquired immune tolerance (beginning of anti-rejection drugs)

1960s – first lung, pancreas, liver transplants.

1967 – first heart transplantation (patient lived 18 days, died on pneumonia)

1984 – U.S. Congress passed the National Organ Transplant Act – central registry for organ matching, outlawing sell of organs

History

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2005 – Baltimore Hospital – pioneered ´domino chain´ - Willing donors who are genetically incompatible with their chosen recipients are matched with strangers; in return, their loved ones receive organs from other donors in the pool.

2010 – Spain – first full face transplantation

History

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Xenotransplantation Allotransplantation

◦ Cadevaric donor transplantation◦ Living donor transplantation

Autotransplantation

Types of Transplantation

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1 donor (cadaveric) can save up to 8 human lives

1 donor can provide organs/tissue (corneas, blood vessels, heart valves, skin, tendons, bones) for 50 people

Facts about donation

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Waiting list – more than 118,000 people Transplants performed – 28,000 Every 10 minutes another name is added 19 candidates on waiting list die every day 6935 die per year (13 Jumbo Jets – Boeing

747)

Statistics – U.S. (2012)

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Waiting list – more than 7600 people Total organ transplants – 3962

◦ Deceased donors transplants– 2915 (74 %)◦ (1088 deceased donors)◦ Living donors transplants – 1047 (26 %)

Statistics – UK (2011)

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Donor must live on (Case of father and 2 sons)

Are only subsidiary to cadaveric donor t. Prohibition of selling organs

◦ UK – Human Tissue Act (2004) Major goal of living donor liver transplants–

decrease waiting-list mortality Risk and benefit proportion Love of humanity

Living donor tranplantation

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Advantages◦ Decrease waiting-list morality◦ Better timing for procedure (previous treatment

can be finished)◦ Lower imune reaction and lower rejection rate (in

case of relatives)

Living donor transplantation

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Comparison of UK cadaveric transplantation (UKC), UK living donor transplantation (UKLD), US cadaveric transplantation (USC) and US living donation (USLD) for the last 10 years

[www.uktransplant.org.uk 2004, www.unos.org 2004].

Scoble J E , and Burnapp L Nephrol. Dial. Transplant. 2005;20:1034-1037

© The Author [2005]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oupjournals.org

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Disadvantages◦ Huge pressure on prospective donors◦ Exploitation of donors◦ Insufficient knowledge and informedness of

donors and their families about this possibility◦ Risk of nephrectomy (kidney disease)◦ Donor lives with one kidney◦ Only subsidiary position (5% of all

transplantations)

Living donor transplantation

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An organ or tissue donation from donor who has already died.

Cadaveric Transplantation

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WHEN IS THE PERSON CONSIDERED DEAD? Traditional definition of death: the act of

dying; the end of life; the total and permanent cessation of all the vital functions of an organism.

Not very usable for organ donation

Fundamental question

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General definition - complete cessation of brain function as evidenced by absence of brain-wave activity on an electroencephalogram: sometimes used as a legal definition of death.

irreversible cessation of respiration due to irreparable brain damage, even though the heart may continue beating with the aid of a mechanical ventilator: widely considered as the criterion of death. (Collins English Dictionary 2009)

This definition arise ethical questions.

Brain Death

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UK (Code of practice)◦ Permanently lost consciousness◦ Permanently lost ability to breathe◦ Regardless of continuing life in the body and the

parts of the brain◦ Brain stem death is sufficient to produce this

state The same attitude in India and Trinidad &

Tobago

Brain Death

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The rest of the World◦ Whole brain death concept◦ Permanent cessation of all functions in all parts of

the brain. United States President’s Council on Bioethics

◦ UK concept and clinical criteria are not considered sufficient for the diagnosis of death in the USA.

Japan◦ Antipathy to the concept of brain death in the

World, only non-heart beating donations are performed legally.

Brain Death

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Mandatory organ donation Opt-in system

◦ Potential donors must express their consent during the life, otherwise they do not donate their organs.

Opt-out system◦ There is presumptive consent from every person,

unless the person expresses refusal to donate (opt-out).

Systems of consent

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USA UK Portugal

Slovakia

Opt-in system

X X

Opt-out system

X XRespect of

family’s decision

Opt-in vs. Opt-out system

Opt-in system : Germany, GreeceOpt-out system : Austria, Spain, Sweden, Belgium

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Opt-in◦ Lower percent of population sign the consent (90

percent of Americans agree with donation, but only 30 percent of them consented to donate their organs).

◦ Icky and difficult for persons to think about it.◦ Need of education and publicity in media.◦ Connection of the consent form with the issuance

of driver’s license.

Opt-in or Opt-out system?

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Opt-out◦ Much higher percentage of cadaveric donors

(more than 90 percent).◦ People do not have to solve this issue, only if they

are strictly against it.◦ Questionable role of family.◦ Poor informed society.◦ Missing of the consent.

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Integrity of person/individual Protection of donor’s interests Protection of patient (recipient)

◦ Transplantation must have good prognosis for donor◦ Protection from extortion (living donor, patient-recipient, family of

recipient)◦ Mutual anonymity of donor and recipient◦ Providing care after transplantation

Discussion about real death of person / brain death Unfair obtaining organs for transplants :

◦ murder, kidnap…◦ Market with organs + import from poor countries (India, Africa) –

exploitation Which organs we cannot transplant ?– identity of donor

(brain, gonad (genital organs) )

Ethical Issues of Transplantation

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Financial advantageous of transplantation – often lower costs than medical treatment of ill person

Family acceptance of death takes a while Habits and rites Human body is not a property Unity of soul and body Biological ethic

◦ neutral value of such procedure◦ Biomass

Ethical Issues of Transplantation

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Christianity – supports donation Jehovah's Witnesses – cancelled prohibition

of transplantations in 1967, but it is not clear, how to perform it, when blood transfusion is forbidden.

Orthodox Jewish (not reformed and liberal ones) does not allow the transplantations, which are terminating human life by human extraction.

Religion

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Islam◦ different scholars◦ generally organ donations are not permitted ◦ some of the schools permit live donations◦ some of them also cadaveric donations, if it is not

transplantation of organ, upon which the life depend (heart, liver), because it kills the soul

◦ but not unconditionally, they have their own rules which must be fulfilled

Religion

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Buddhism◦ Allows, but let every single person to decide on

his own◦ Tibetan Buddhists believe in consciousness after

death, and such a person/body cannot be disturbed, so cadaveric transplants are not possible for them

Religion

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Would you provide your organ for living donation/cadaveric donation?

Do you think that brain death is sufficient for qualification of death?

Isn’t it just a type of euthanasia? Opt-in vs. Opt-out system?

Discussion

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THANK YOU FOR YOUR ATTENTION