The shortage of organs for transplantation. Where do we go from here?

Alloantigen-specific CD4(+) regulatory T cells induced in vivo by ultraviolet irradiation after alloantigen immunization require interleukin-10 for their induction and activation, and flexibly mediate bystander immunosuppression of allograft rejection

Ultraviolet (UV) irradiation prior to antigen immunization is employed to induce antigen-specific regulatory T cells (Tregs). UV-induced Tregs demonstrate unique bystander suppression, although antigen-specific activation is required initially. We previously reported the phenotype of alloantigen-specific transferable Tregs induced by UV-B irradiation after immunization was the same as T regulatory type 1-like CD4(+) T cells, with antigen-specific interleukin (IL)-10 production. Here, by using semi-allogeneic transplantation models in vivo, we investigated the role of IL-10 in the induction and activation of these Tregs, and the possibility of bystander suppression of third-party allograft rejection. Naïve mice (H-2(b)) were immunized with alloantigen (H-2(b/d)), and received UV-B irradiation (40 kJ/m(2)) 1 week later. Four weeks afterwards, splenic CD4(+) T cells were purified from the UV-irradiated immunized mice, and were transferred into naïve mice (H-2(b)). Allografts expressing the same alloantigen as T-cell donors were immunized against (H-2(b/d)) or an irrelevant alloantigen (H-2(b/k)) were transplanted to CD4(+) T-cell-transferred mice, and an alloantigen-specific prolongation of allograft survival observed. Experiments where IL-10 was neutralized by monoclonal antibody in the induction or effector phase revealed that IL-10 is critical, not only for induction but also for immunosuppressive function of CD4(+) Tregs induced by UV irradiation after alloantigen immunization. Third-party allografts (H-2(d/k)) were transplanted to CD4(+) T-cell-transferred mice, and graft survival was also prolonged. Even a graft only partially compatible with immunized alloantigen worked well in vivo to activate CD4(+) Tregs induced by UV irradiation after alloantigen immunization, which resulted in the bystander suppression of third-party allograft rejection.

Outcomes of adult liver re-transplant patients in the model for end-stage liver disease era: is it time to reconsider its indications?

OBJECTIVE

To better understand the outcomes and utility of liver re-transplantation in non-hepatitis C patients, we sought to identify predictors that impact post-transplant patient and graft survival comparing primary liver transplant patients to those receiving subsequent allografts.

METHODS

We conducted a retrospective cohort analysis using the United Network for Organ Sharing database from February 2002 through December 2012, including non-hepatitis C infected adults (18 yr and older) who underwent primary and repeat liver transplantation. Patient and graft survival were compared between the two groups using the Kaplan-Meier estimator. Cox proportional hazards models were constructed to evaluate variables associated with both patient and graft survival.

RESULTS

We identified 33 176 primary transplant recipients and 2710 re-transplants. Re-transplantation patients were more likely to be on dialysis prior to transplant (18% vs. 10%), hospitalized (26% vs. 16%), in the intensive care unit (ICU) (34% vs. 13%), on a ventilator (17% vs. 3%), and had higher model for end-stage liver disease (MELD) score (27 vs. 21). Re-transplants also received livers with a lower donor risk index (DRI) (1.57 vs. 1.64). We estimated an adjusted hazard ratio (HR) of 1.7 for patient survival (95% CI: 1.56-1.84) and 1.61 (95% CI: 1.5-1.73) for graft survival.

CONCLUSIONS

Liver re-transplantation in non-hepatitis C patients, although life saving, has significantly inferior patient and graft survival compared to primary liver transplantation. Higher quality grafts are used inefficiently in a sicker patient population, suggesting that a more optimal strategy may include restricting their use to patients who obtain a longer term benefit.

National Association of Medical Examiners position paper on the medical examiner release of organs and tissues for transplantation

The medical examiner community plays a key role in the organ and tissue procurement process for transplantation. Since many, if not most, potential organ or tissue donors fall under medicolegal jurisdiction, the medical examiner bears responsibility to authorize or deny the procurement of organs or tissues on a case-by-case basis. This responsibility engenders a basic dichotomy for the medical examiner's decision-making process. In cases falling under his/her jurisdiction, the medical examiner must balance the medicolegal responsibility centered on the decedent with the societal responsibility to respect the wishes of the decedent and/or next of kin to help living patients. Much has been written on this complex issue in both the forensic pathology and the transplantation literature. Several studies and surveys of medical examiner practices, as well as suggested protocols for handling certain types of cases, are available for reference when concerns arise that procurement may potentially hinder medicolegal death investigation. It is the position of the National Association of Medical Examiners (NAME) that the procurement of organs and/or tissues for transplantation can be accomplished in virtually all cases, without detriment to evidence collection, postmortem examination, determination of cause and manner of death, or the conducting of criminal or civil legal proceedings. The purpose of this position paper is to review the available data, the arguments for and against medical examiner release, and to encourage the release of organs and tissues in all but the rarest of circumstances.

Improving transplantation programs and patient care

Organ transplantation is the preferred mode of replacement therapy. Currently acceptable 5-year posttransplantation survival rates are 85% for renal grafts, 70% for liver, and 65% for heart. Organ donation, however, remains a significant factor in organ transplantation, as humans are the only possible donors and the numbers of patients on waiting lists remain high. Several factors affect organ transplantation in countries in the Middle East Society for Organ Transplantation (MESOT) region, including inadequate preventive medicine, differing health infrastructures, poor awareness within the medical community and lay public regarding the importance of organ donation and transplantation, a high level of ethnicity, and poor government support of organ transplantation. Moreover, there is lack of team spirit among transplant physicians, a lack of coordination between groups that manage organ procurement and the transplant centers, and a lack of effective health insurance coverage for many persons. Three models of organ donation and transplantation exist in the MESOT region-the Saudi, Iranian, and Pakistani models. Living-organ donation, the most widely practiced form of donation in countries in the MESOT region, includes kidney and partial liver. Cadaveric organ donation has significant potential in the MESOT region. However, numerous obstacles must be overcome in MESOT countries. Resolution of these obstacles will require continuous work on many fronts. Experiences from all sources must be incorporated into new and improved models that can overcome current inadequacies. Solutions will require continued focus within the medical community, steady support from the lay public and religious institutions, as well as governmental assistance.

Efficacy of an educational programme for secondary school students on opinions on renal transplantation and organ donation: a randomized controlled trial

CONTEXT

Organ shortage for transplantation is a crucial problem; educational interventions may increase donations and decrease opposition.

OBJECTIVE

To test the efficacy of an educational programme on opinions on organ transplantation and kidney donation.

DESIGN AND PARTICIPANTS

Cluster Randomized Controlled Trial: eight intervention and eight control schools were randomly selected from the 33 public schools that agreed to participate. Targets: students in the last 2 years of secondary school (17-18 years); seven schools per group completed the study. EDUCATIONAL PROGRAMME:

INTERVENTION

first questionnaire (anonymous); 2 h lesson in each class; 2 h general session with patients and experts; second questionnaire.

CONTROL

questionnaires.

MAIN OUTCOME MEASURES

Differences between questionnaires (comparative analysis); interest; satisfaction with the programme; (cross-sectional analysis).

RESULTS

1776 first, 1467 second questionnaires were retrieved. Living kidney donation: at baseline 78.8% of students would donate a kidney to a relative/friend in need. The answers were unaffected by type of school but depended on sex (females more prone to donate, P<0.001); the answers did not change after the lessons. Cadaveric kidney donation: baseline opinions were mixed (intervention schools: 31.5% yes, 33.7% no, 34.8% uncertain), depending on type of school (classical-scientific high schools more positive than technical institutes, P<0.001), sex (males more prone to donate, P<0.001). Answers on living and cadaveric donation were correlated (P<0.001). The educational intervention increased favourable (31.5 to 42.9%) and uncertain (34.8 to 41.1%) opinions and decreased negative ones (33.7 to 16%) (P<0.001).

CONCLUSIONS

Educational interventions are effective in increasing interest and improving opinions about cadaveric organ donation.

Ethics seminars: the ethical debate on practicing procedures on the newly dead

Emergency medicine and its academic teaching programs face an ethical dilemma surrounding the question of practicing procedures on the newly dead. For many years, procedures have been practiced on the newly dead, but few institutions have had policies addressing the practice. This article considers the ethical arguments both for and against practicing procedures on the newly dead without consent, reviews the empirical studies on the subject, and presents the positions of other professional societies, before concluding with the position of the Society for Academic Emergency Medicine (SAEM). SAEM strongly encourages all emergency medicine training programs to develop a policy and make that policy available to the institution, educators, trainees, and the public. The practice should not occur behind closed doors or on an ad hoc basis without clearly articulated guidelines. With improvements in technology, including patient simulation and virtual reality, the need for the practice may decrease, but there is no current evidence that is compelling regarding the best methods of teaching procedural skills. Given the importance of protecting trust in the profession of medicine and the existing evidence that the public would expect that consent be obtained, SAEM recommends that families be asked for consent prior to practicing procedures on the newly dead.

Protection behaviour: a phenomenon affecting organ and tissue donation in the 21st century?

UK statistics show that whilst waiting lists for transplantation surgery continue to increase, donor numbers are static. This paper describes the hermeneutic phase of a mixed method study and puts forward the concept of protection behaviour as one explanation for nurses' reticence to discuss post-mortem donation wishes with patients' relatives. The desire to protect appears to influence attitudes, confidence levels and perceived ability to become involved in donor identification and donation discussion, consequently affecting the availability of transplantable organs and tissue. By understanding more fully why protective behaviours are employed, it increases the likelihood of a solution being found.

Presentation and outcomes for organ donation in patients with cerebral gunshot wounds

This study was undertaken to examine the presentation and outcomes relative to solid organ donation in patients with fatal cerebral gunshot wounds at a level I trauma center over a 7-year period. A retrospective chart review of patients with such wounds over the years 1993-99 was completed. Eighty (80) patients were considered potential solid organ donors. Of these, 28 (35%) became organ donors, yielding 97 transplantable organs. Ninety-six percent presented with a GCS of less than 6. Mean SBP on presentation was 130, ranging from 48 to 225. Median time from presentation to death was 18 hours. Intravenous fluids given over the first 6 hours averaged 4.3 liters. Pressors were required in 68% of cases, blood products in 34%. Consent rate for donation was 32% when requested by a physician and 59% when requested by an organ procurement organization (OPO) co-ordinator. No request was made in 15 cases. Patients with fatal cerebral gunshot wounds, but with solid organ donor potential, have a characteristic presentation. Those with hemodynamic stability and those whose hypotension responds promptly to treatment can be expected to have a donor potential despite their devastating brain injury. Minimal time and resources are required to support such patients. Additional organs may have been obtained if the request for donation was consistently separated from the families' notification of brain death, and if the request was initiated by an OPO coordinator rather than a physician. Further, all patients admitted with cerebral gunshot wounds and poor neurologic function should have local OPO referral, potential survival notwithstanding.

The effect of state legislation on eye donation

PURPOSE

Pennsylvania Act 102 implemented in March 1995 required all acute care hospitals in Pennsylvania to routinely refer all deaths to the Organ Procurement Organization for determination of suitability for organ/tissue donation. This study analyzed the effect of the law on eye donation.

METHODS

Retrospective analysis of the total number of referrals and the actual number of eye donations from 62 hospitals in Pennsylvania to the Lions Eye Bank of Delaware Valley was performed for the years 1993 to 1998. Information gathered included donor's age, gender, race, cause of death, referring institution, and result of referral.

RESULTS

From 1993 to 1998, the total numbers of referrals were 988, 1,647, 8,101, 21,123, 21,783, and 22,987, and the numbers of donors were 570, 574, 660, 644, 594, and 568, respectively. The increase in the number of donors after implementation of the law was not commensurate with the number of referrals. This was caused by a disproportionate increase in the number of referrals older than 70 years of age (from a mean of 33% to 52%), which exceeded the donor age limit of 69 years, and also to a lower family consent rate (from a mean of 48% to 24%).

CONCLUSIONS

Well-designed state legislation with proper implementation greatly increased hospital referrals for eye donation. However, there was only a small increase in the number of eye donors because many of the referrals were beyond the acceptable upper age limit for eye donation. A small increase in the donor age limit would increase the number of eye donations without having to expand the potential donor pool. Education of the public may help to improve the family consent rate.

Improving organ retrieval rates: various proposals and their ethical validity

The current global shortage of organs has prompted a series of proposals for improving organ retrieval rates. They include preferred recipient status for registered organ donors, payment for organs, presumed consent and required response. This paper examines the tenability of these proposals and points out their shortcomings. Taking the Canadian situation as an example, it argues further that the shortage is exacerbated by unethical and essentially illegal retrieval protocols that flout the law of informed consent. It is suggested that before any redrafting of laws and regulations is undertaken, these protocols should be revised.

Winning hearts and minds: using psychology to promote voluntary organ donation

Recent psychological research concerning determinants of and barriers to organ donation is reviewed with the intention of ascertaining acceptable and potentially effective ways of improving organ retrieval. On the basis of this review, five recommendations are made. (1) Individuals' donation wishes, where explicit, should be decisive. (2) Next of kin should witness donor decisions. (3) Mandated choice should replace voluntary 'opting-in'. (4) Initial donation choices should be repeatedly re-evaluated. (5) Those involved in organ procurement should distance themselves from model of bodies as machines or gardens and embrace models where bodies are viewed as sacred extensions of self. In combination, these recommendations are argued to be preferable in several ways to opt-out/presumed consent procurement options.

The transplant experience of liver recipients: ethical issues and practice implications

The transplant experience of 20 liver organ transplant recipients was investigated in a longitudinal study. Five primary themes were identified from analysis of recipients' interviews including concerns about: (1) quality of life, (2) quality of health care, (3) economic factors, (4) social support factors, and (5) psychological factors. These findings are analyzed within the current context of social work in health care characterized by three interactive trends: advances in medical technology, changing health care economics, and a shift in the locus of health care delivery from institutions to the community. All five themes reflect the impact of these trends and give rise to ethical issues with practice implications.

Ethical analysis of organ recovery denials by medical examiners, coroners, and justices of the peace

CONTEXT

Despite its pivotal nature, until the early 1990s the role of medical examiners, coroners, and justices of the peace was largely ignored in discussions of the critical shortage of organs for transplantation in the United States. These officials have the right to determine, from a medico-legal perspective, whether a deceased person can be an organ donor. Thus, they play an important role in the donation process. Using a principles-based ethical framework, this article examines the problem of nonrecovery of life-saving organs for transplantation in the United States because a medical examiner or other official denies recovery.

OBJECTIVE

The goals of organ donation and the collection of forensic evidence are not mutually exclusive. An analysis of the ethical principles and obligations of beneficence, respect for autonomy, and justice reveals that medical examiners and other officials could probably, after appropriate review, release all cases under their jurisdiction for organ donation.

CONCLUSION

Medical examiners, coroners, and justices of the peace could assume a leadership role, working together on public policy with medical, social, and legal groups, spearheading efforts to stop the loss of organs due to official denials, up to and including state and federal regulation and legislation. Beyond their professional obligations, as agents of a social institution, medical examiners and other officials have the more general ethical responsibility of promoting the public health and welfare and of reinforcing societal consensus that transplantation is a social good which should be optimized through formal and informal activities.

Some politico-economic aspects of organ shortage in transplantation medicine

Transplantation of solid organs has become a widely performed and accepted procedure. This type of high-performance medicine has led to vigorous debates on ethical and economic issues and most of this discussion can be seen as an example of the different opinions about highly individualised and technologised approaches in health care. The paper focuses on the rising gap in the demand for suitable organs for transplantation and the levelling off, or even fall, in the supply of these organs. Despite the rather demanding requirements for organ donation, there appear to be a sufficient number of deaths under suitable circumstances to satisfy the annual demand of transplantable organs--if the collection rates are adequate. It has been shown that there are great differences in the rate of organ procurement efficiency within different regions. The question then is how to set appropriate incentives to obtain organs in sufficient quantities from eligible donors to meet the demand. This paper discusses the different medical and societal approaches as well as the economic proposals to overcome the organ shortage. The theory of Public Choice is used to develop a specific policy that can be applied to organ procurement efforts. This is a different approach, whereby political and economic considerations of ethical dilemmas focus on setting appropriate and widely accepted frameworks and rules, in which individuals may then decide about their behaviour. In an appendix, the economic consequences of transplantation medicine are discussed if more organs were to be made available and the impacts of relaxing the simplifying assumptions on effectiveness of organ replacement therapy and on the allocation system are considered. Ultimately, artificial organs or genetically transformed animal organs may be used but it is highly likely that a vigorous debate on the ethics and especially financial implications of these interventions will take place beforehand.

Nonprocurement of transplantable organs in a tertiary care hospital: a focus on sociological causes

BACKGROUND

The purpose of this study was to investigate prospectively the medical and organizational causes of nonprocurement of transplantable organs and to provide explicit information on the determining factors of family response to donation request.

METHODS

Medical causes investigated were age, human immunodeficiency virus, human T-cell lymphoma virus and hepatitis C virus status, documented malignancy, and chronic cardiac or renal failure. Organizational aspects investigated were cause and place of death and number of referrals. Sociological aspects were investigated by semidirective interviews with the families of the deceased.

RESULTS

A total of 105 brain-dead patients and 42 families were included. Of the 105 patients, 9 were not eligible for donation because of medical reasons; cardiac arrest occurred before organ procurement in 6 cases. Denial of consent from the coroner occurred in 7 cases. Consent was requested from the families in 82 cases, obtained in 53 cases, and denied in 29 cases. Consent to donation was associated with openness of the process, information about brain death and transplantation, previously stated will of the deceased, favorable attitude of the deceased toward the medical profession, and a generally altruistic attitude of the deceased. Denial of donation was associated with poor understanding of brain death and fear of being deprived of the deceased body.

CONCLUSIONS

Practical implications of this study include encouraging people to state their attitudes toward organ donation and improving the level of information available to the general public on the meaning of brain death and on the medical aspects of organ transplantation.

Health insurance for kidney donors: how easy is it to obtain?

Because there is a severe shortage of cadaver organs, living donors are a valuable source of kidneys for patients with end-stage renal disease. One area of concern to many potential donors is their ability to obtain health insurance after donation. To investigate this issue, we surveyed 99 health insurance organizations in the United States, including the 10 largest health maintenance organizations, asking for their views and practices regarding living kidney donors; 44% of these organizations responded. The responses were strikingly uniform and indicate that healthy kidney donors should be able to obtain and maintain health insurance at standard rates. This information should be reassuring for concerned people who are considering donating a kidney.

Marketing human organs: the autonomy paradox

The severe shortage of organs for transplantation and the continual reluctance of the public to voluntarily donate has prompted consideration of alternative strategies for organ procurement. This paper explores the development of market approaches for procuring human organs for transplantation and considers the social and moral implications of organ donation as both a "gift of life" and a "commodity exchange." The problematic and paradoxical articulation of individual autonomy in relation to property rights and marketing human body parts is addressed. We argue that beliefs about proprietorship over human body parts and the capacity to provide consent for organ donation are culturally constructed. We contend that the political and economic framework of biomedicine, in western and non-western nations, influences access to transplantation technology and shapes the form and development of specific market approaches. Finally, we suggest that marketing approaches for organ procurement are and will be negotiated within cultural parameters constrained by several factors: beliefs about the physical body and personhood, religious traditions, economic conditions, and the availability of technological resources.

Ethical issues in organ procurement: a review for intensivists

The current state of organ procurement and the ethical issues raised by the procurement process are reviewed in this article. After an examination of the legislative framework governing organ procurement, the intensivist's role in donation is discussed, including (1) donor identification, (2) asking the family to donate, and (3) obtaining consent. Recent proposals for changing the organ procurement system are analyzed, including increasing family donation or increasing the donor pool.

The identification of potential cadaveric organ donors

Most Australian transplantation programs are severely restricted in their activities by a limited availability of cadaveric donor organs. To investigate possible reasons for this problem, an audit was undertaken over three 12-month periods of all deaths in 13 hospitals in New South Wales and the Australian Capital Territory. From 7406 deaths, 271 patients were classified as having been realistic, medically suitable potential donors. Of these, only 60 (22%) became actual donors. In the other 211 patients, donation did not occur because of unsuccessful resuscitation (30%), permission refusal by relatives (34%), and failure to identify or support the potential donors (36%). If the impediments to organ donation which were identified in this study could be overcome, allowing a greater number of potential donors to become actual donors, the chronic shortage of cadaveric donor organs for transplantation could be at least partly relieved.

The present state of heart transplantation

After more than 25 years, including long periods of scepticism, heart transplantation, with the introduction of several fundamental innovations, has become a routine clinical procedure for treating life-threatening end-stage heart failure. Annually, 3000-4000 transplantations are performed worldwide. Heart transplantation has been performed successfully in patients of almost all ages, from newborn babies with untreatable heart defects to 70-year-olds. Transplant organs are explanted from deceased donors who have suffered brain death. The circulation is kept stable for several hours during which time a well-functioning heart can be excised. In Europe, as a rule, donor organs are matched to recipients by national or multinational organ-sharing organisations. 'Eurotransplant', for example, serves medical institutions in Germany, Austria, and the Benelux states. This enables 500-600 hearts to be transplanted in Germany each year. Since 1986, 650 heart transplantations have been performed at the German Heart Institute Berlin (GHIB) and more than 100 are performed per year. In recent years, heart-lung, single-, and double-lung transplantations have been added to the GHIB's surgical program, accounting for more than 40 operations since the institute's inception. Patients at the GHIB have ranged in age from 8 days to 68 years, including 48 patients under the age of 16 years. Approximately two-thirds of the patients suffered from dilated cardiomyopathy and one-third from coronary artery disease. Smaller groups of patients suffered from valvular or congenital heart disease. Patients were selected for heart transplantation when heart failure was untreatable by other means and when their life expectancy was estimated to be 6 months or less.(ABSTRACT TRUNCATED AT 250 WORDS)

Development of a central matching system for the allocation of cadaveric kidneys: a simulation of clinical effectiveness versus equity

OBJECTIVES

1) To develop a computer-based simulation to prospectively study the impacts of explicitly incorporating different equity criteria into the process of allocating kidneys to recipients, given the scarcity of this resource. 2) To assess the tradeoffs between systems that allocate kidneys based only on medical criteria, systems that allocate kidneys based only on equity criteria, and systems that consider both medical and equity criteria.

METHODS

A computer-based simulation was developed that describes the flows of patients and kidneys. This model provides information at various time points about the number of patients in the system who are awaiting transplants, the number of kidneys available for transplantation, the number of transplantations performed for each matching algorithm, and the number of kidneys discarded (when applicable), as well as the means and standard deviations of the HLA-match scores, number of days from registration to transplantation, and number of days (from registration) of those who are still waiting for transplants. Five different matching algorithms were compared, ranging from determination of the allocation by a single medical criterion (i.e, HLA match) to determination by a single equity criterion (i.e., relative position in the waiting queue). The remaining algorithms represent different strategies of weighting these two considerations. Estimates regarding the main parameters of the model were derived utilizing data collected through the Multiple Organ Retrieval and Exchange Programme of Ontario, Canada.

RESULTS

The simulation was set to run for a period of ten years. A tradeoff between graft survival (or improved HLA matching) and equal treatment of patients regardless of their likelihood to benefit was found. It is clear that an algorithm that allocates kidneys based only on temporal location of patient on the waiting list is likely to be unacceptable because of the very poor average HLA-match scores that it yields. Pool size was found to be a major determinant in the attainment of optimal matching from a medical perspective.

CONCLUSIONS

1) The final choice about any allocation algorithm to be used requires that a value judgment be made, i.e., how great a reduction in HLA-match score should be traded in order to improve equity score (or vice versa). 2) A computer-based simulation model is a feasible way to prospectively test the impact of any given allocation algorithm on any given system.

The toxic patient as a potential organ donor

The use of organs from poisoned victims for the purpose of transplantation has been poorly studied; criteria for organ donation is virtually non-existent in such cases. To further elucidate these indications, a retrospective review of all organ transplantation donated by poisoned victims in Northern and Central Illinois was undertaken. From January 1988 to December 1993, 17 poisoned victims were identified as having donated organs to 41 recipients. Eleven of the donors died as a direct result of drug toxicity, whereas six donors had drug-related deaths. The cases were reviewed for toxin involved, organ preoperative function and postoperative function (up to 1 year after transplant). Kidney transplants postoperative function was rated as good if creatinine was less than 1.9, fair if creatinine was 2 to 2.9, and poor if creatinine was 3. Donor age ranged from 2 years to 54 years. Toxins involved in donation included ethanol (n = 8), cocaine (n = 5), carbon monoxide (5), barbiturates (2) and lead (1), six patients had multiple drugs. Two of the nine recipients of livers died intraoperatively, both unrelated to organ function. Thirty-two kidneys were transplanted with 28 having good 10-day postoperative function, three having fair postoperative function, and one (cocaine donor) having poor postoperative function. One kidney transplanted from a cocaine donor had a thrombosed graft 5 days postoperatively. Deaths involving toxins in general does not seem to be a contraindication to donation of liver and kidney for transplantation.

Outcome of bought living non-related donor kidneys followed up at a single centre

Between October 1985 and November 1991, 16 dialysis patients travelled to Bombay and bought kidneys from living non-related Indian donors for U.S. $7,372. One patient died peri-operatively; one contracted HIV and another hepatitis B virus infections. Six patients are presently positive for hepatitis C virus antibody compared to two cadaver graft recipients (P = 0.03); two of the six patients have chronic active hepatitis. Five-year patient and graft survival rates (75% and 43%, respectively) were similar to those of recipients of 24 cadaver grafts obtained in the United States (67% and 55%, respectively), as was graft function during the first 5 years of follow-up. Graft survival may have improved following commercial kidney transplantation in Bombay, but this practise still poses a risk of dangerous infections and exploitation of donors and recipients. The establishment of a centralized programme of anonymous "rewarded gifting" in countries that cannot eradicate rampant organ commerce may help to expunge exploitation and to ensure uniform, acceptable clinical standards and the safety of patients.