New Organ Transplant Policies in Japan, Including the Family-Oriented Priority Donation Clause

Introducing Incentives and Reducing Disincentives in Enhancing Deceased Organ Donation and Transplantation

Despite the effectiveness of solid organ transplantation, progress to close the gap between donor organs and demand remains slow. An organ shortage increases the waiting time for transplant and involves significant costs including patient morbidity and mortality. Against the background of a low deceased organ donation rate, this article discusses the option of introducing incentives and removing disincentives to deceased organ donation. Perspectives from ethics, general public opinion, and the health care profession are examined to ensure a comprehensive appraisal and illustrate different facets of opinion on this complex area. Special cultural and psychosocial considerations in Asia, including the family based consent model, are discussed.

The Role of the Family in Deceased Organ Procurement: A Guide for Clinicians and Policymakers

Families play an essential role in deceased organ procurement. As the person cannot directly communicate his or her wishes regarding donation, the family is often the only source of information regarding consent or refusal. We provide a systematic description and analysis of the different roles the family can play, and actions the family can take, in the organ procurement process across different jurisdictions and consent systems. First, families can inform or update healthcare professionals about a person's donation wishes. Second, families can authorize organ procurement in the absence of deceased's preferences and the default is not to remove organs, and oppose donation where there is no evidence of preference but the default is to presume consent; in both cases, the decision could be based on their own wishes or what they think the deceased would have wanted. Finally, families can overrule the known wishes of the deceased, which can mean preventing donation, or permitting donation when the deceased refused it. We propose a schema of 4 levels on which to map these possible family roles: no role, witness, surrogate, and full decisional authority. We conclude by mapping different jurisdictions onto this schema to provide a more comprehensive understanding of the consent system for organ donation and some important nuances about the role of families. This classificatory model aims to account for the majority of the world's consent systems. It provides conceptual and methodological guidance that can be useful to researchers, professionals, and policymakers involved in organ procurement.

Banking on Living Kidney Donors-A New Way to Facilitate Donation without Compromising on Ethical Values

Public surveys conducted in many countries report widespread willingness of individuals to donate a kidney while alive to a family member or close friend, yet thousands suffer and many die each year while waiting for a kidney transplant. Advocates of financial incentive programs or "regulated markets" in kidneys present the problem of the kidney shortage as one of insufficient public motivation to donate, arguing that incentives will increase the number of donors. Others believe the solutions lie-at least in part-in facilitating so-called "altruistic donation;" harnessing the willingness of relatives and friends to donate by addressing the many barriers which serve as disincentives to living donation. Strategies designed to minimize financial barriers to donation and the use of paired kidney exchange programs are increasingly enabling donation, and now, an innovative program designed to address what has been termed "chronologically incompatible donation" is being piloted at the University of California, Los Angeles, and elsewhere in the United States. In this program, a person whose kidney is not currently required for transplantation in a specific recipient may instead donate to the paired exchange program; in return, a commitment is made to the specified recipient that priority access for a living-donor transplant in a paired exchange program will be offered when or if the need arises in the future. We address here potential ethical concerns related to this form of organ "banking" from living donors, and argue that it offers significant benefits without undermining the well-established ethical principles and values currently underpinning living donation programs.

Simulation-based training for determination of brain death by pediatric healthcare providers

Background

Low competency for determination of brain death (BD) and unfamiliarity with Japanese BD (JBD) criteria among pediatricians were highlighted in previous nationwide studies. Because the JBD criteria were amended in 2010 to allow organ donation from pediatric brain-dead donors, we created a 2-day training course to assess knowledge and improve skill in the determination and diagnosis of pediatric BD.

Methods

The course consisted of two modules: a multistation round session and a group discussion session, and was bookended by a before and after 20-question test. In the multistation round session, participants rotated between stations staffed by expert faculty members. For hands-on skill development, we used the Sim Junior 3G™ simulation mannequin (Laerdal Medical, Wappingers Falls, NY, USA) for structured simulations. In the group discussion session, we implemented simulation-based role playing to practice decision making in prepared scenarios of complicated clinical situations. We investigated the participants’ impressions of the course by self-scoring and questionnaires.

Results

Of 147 pediatric healthcare providers from multiple specialties who participated in this course, 145 completed the entire process. The course was evaluated in three aspects with self-scoring and questionnaires: (1) value (4.58 ± 0.64; range 1–5); (2) time schedule (2.40 ± 0.61; range 1–3); and (3) difficulty (2.89 ± 0.43; range 1–5). Finally, participants scored the entire course program (9.64 ± 1.69; range 1–11). Various positive feedbacks were obtained from a total of 93 participants. Post-test scores (83.6 %) were significantly higher than pre-test scores (62.9 %).

Conclusion

This simulation-based course represents an effective method to train pediatric healthcare providers in determining BD in Japan and may improve baseline knowledge of BD among participants.

Interim report of the Japanese original donor evaluation and management system: the medical consultant system

PURPOSE

Lung transplantation (LTx) is an established therapy for end-stage lung failure. However, in Japan, the donor organ shortage is extremely severe compared with other developed countries, because of the strict Japanese Organ Transplantation Law. To maximize LTx opportunities in Japan, we have established a special donor evaluation and management system termed the medical consultant (MC) system.

METHODS

Data from 171 lung donor candidates registered in Japan from May 1998 to May 2012 were obtained and investigated in a retrospective manner. The candidates were separated into the non-MC-intervened and MC-intervened groups, and then data regarding the PaO2/FiO2 ratio, donation rate and organ survival rate were analyzed and compared between the groups.

RESULTS

The PaO2/FiO2 ratio of the MC-intervened group was ameliorated from the time of first brain death diagnosis to organ harvest. Although the base condition of the MC-intervened group was significantly worse than that of the non-MC-intervened group, the donation rates showed no significant difference (0.64 and 0.66, respectively; p = 0.89). There was a difference in the organ survival rate between the non-MC and MC-intervened groups (5-year survival rates of 67.2 and 88.3 %, respectively; p = 0.16).

CONCLUSION

The MC system used for organ donor evaluation and management in Japan has achieved acceptable interim results.

Knowledge of the Brain Death Concept by Personnel in Spanish and Latin-American Healthcare Centers

Background

The knowledge and acceptance of the concept of brain death (BD) among health care personnel is fundamental.

Objective

To analyze the level of understanding of the BD concept among personnel in Spanish and Latin American healthcare centers and to determine the factors affecting this attitude.

Material and methods

Data from 12 hospitals and 32 primary care centers in 4 countries within the International Collaborative Donor Project were selected (Spain, Mexico, Cuba and Costa Rica (n = 4378)).

Results

62% of the personnel (n = 2714) understood BD and believed that this was the death of an individual. Of the rest, 30% (n = 1 333) did not understand it and the remaining 8% (n = 331) believed it did not mean the death of a patient. 83% (n = 931) of physicians understood BD, compared to 75% (n = 895) of nurses, 55% (n = 299) of healthcare assistants, 53% (n = 108) of non-healthcare university-educated personnel and 36% (n = 481) of those without a university education (p<0.001). 68% (n = 1084) of Mexicans understood BD compared to 66% (n = 134) of Cubans, 58% (n = 1411) of Spaniards, and 52% (n = 85) (p<0.001) of Costa Ricans. There were significant relationships between knowledge of the concept and the following: type of healthcare center (p<0.001), clinical service (p<0.001), having spoken about organ donation within the family (p<0.001) and one's partner's attitude to the subject (p<0.001). A direct relationship has been found between understanding the concept and attitude toward deceased donation (p<0.001).

Conclusions

The understanding of BD by personnel from healthcare centers was not as good as expected. There were marked differences depending on job category.

The difference in the attitude of Chinese and Japanese college students regarding deceased organ donation

BACKGROUND

Under the influence of traditional oriental culture, the lack of organ donation is especially serious in China and Japan. The aim of this study was to compare Chinese and Japanese college students' attitudes and analyze contributing factors toward deceased donation.

METHODS

An anonymous, self-administered questionnaire comprising 15 questions was distributed to approximately 400 college students at Liaoning University, China, and Kyushu University, Japan. Statistical analysis used SPSS software.

RESULTS

Japanese students' attitude towards deceased organ donation was more favorable than that of Chinese students (43.6% versus 35.9%, P = .001). Several factors contributed to positive responses by students from both countries: family perspective on organ donation and transplantation; decision to donate to family members; prior blood donation; living liver or kidney donation; possibility of needing a transplant; and willingness to receive a deceased or a living donor organ.

CONCLUSIONS

More efforts must emphasize awareness and up-to-date knowledge regarding organ donation among citizens and should be undertaken by the Chinese and Japanese governments.

Priority in Organ Allocation to Previously Registered Donors: Public Perceptions of the Fairness and Effectiveness of Priority Systems

A priority system is one in which previously registered donors receive a preference in the allocation of organs for transplant ahead of those who have not registered. Supporters justify these systems on the basis that they are fair and will encourage donor registration. This article reviews existing studies of public reactions to priority systems, as well as studies of the extent to which the moral principle of reciprocity affects decision making in organ donation. The role of reciprocity in the public discourse surrounding the enactment of priority systems in Singapore and Israel is described. One factor that seems to have been relevant in these countries is the existence of a religious minority that is perceived as willing to take an organ but not to donate one. Although this perception may have fueled a resentment of perceived “free-riders,” concerns were raised about the social divisiveness of priority systems. In sum, people appear to be sensitive to the principle of reciprocity in the context of organ donation, but this sensitivity does not always translate into support for priority systems. Further research into whether public messaging about organ donation could be modified to encourage registration by appeal to the golden rule would be worthwhile.

Characteristics of progressive multifocal leukoencephalopathy clarified through internet-assisted laboratory surveillance in Japan

Background

Progressive multifocal leukoencephalopathy (PML), a rare but fatal demyelinating disease caused by JC virus (JCV), occurs mainly in immunocompromised patients. As PML develops in individuals with various underlying disorders sporadically and infrequently, a nationwide survey of PML is difficult. This study was conducted to elucidate the characteristics of PML in Japan through an internet-assisted laboratory surveillance program.

Methods

A diagnostic support system for PML was established using a real-time PCR assay of JCV DNA in cerebrospinal fluid (CSF), and requests for testing were received from clinicians via specialized websites. Medical histories of patients were collected through standardized questionnaires, and a database of CSF JCV loads and clinical information was created and analyzed.

Results

For 4 years from April 2007 to March 2011, CSF specimens from 419 patients were tested. Forty-eight individuals were found positive for JCV DNA in their CSF and were diagnosed with PML. PML primarily occurred not only in HIV-positive patients (33.3%) but also in patients with hematologic disorders after receiving stem cell transplantation, chemotherapy, and/or immunosuppressive treatment (39.6%). The frequencies of PML cases among the subjects in these two categories were 20.3% and 23.5%, respectively. Although no significant features were observed with respect to CSF JCV loads in PML patients with an HIV infection or hematologic disorder, males were predominant in both groups (100% and 89.5%, respectively). The proportion of PML cases with autoimmune disorders (6.3%) or solid-organ transplants (2.1%) was smaller than those with HIV infection or hematologic disorders, probably due to the limited availability of therapeutic monoclonal antibodies and transplantation from brain dead donors.

Conclusions

The results suggest that the internet-assisted laboratory surveillance program might be a useful strategy for collecting precise real-time information on PML on a national level. The current database provides important background information for the diagnosis and treatment of patients with risk factors for PML.

Liver transplantation in an African setting

Liver disease in children in the developing world is a frequent occurrence, which is generally inadequately managed because of lack of resources. However, increasingly, there has been a demand for liver transplantation, where primary medical or surgical therapies have failed. The expertise and infrastructure required for a successful outcome are no different from those in more developed countries; if anything, the challenges are greater. Lack of deceased donors because of cultural and religious factors has driven the use of living donors. Short-term survival has generally been good, but long-term outcomes have rarely been reported. In this article, we review the experience of 2 centers at opposite ends of the continent and share our experience of slightly different settings and show that success can be achieved even in resource-reduced environments.

Cost-effectiveness achieved through changing the composition of renal replacement therapy in Japan

OBJECTIVE

The cost-effectiveness of renal replacement therapy (RRT) is affected by the composition of treatment. This study aimed to estimate the costs and outcomes associated with changing the composition of RRT modality over time.

METHODS

By using clinical and cost data from a systematic review, a Markov model was developed to assess the costs and benefits of the four main treatments available for RRT in Japan. The model included direct health service costs and quality-adjusted life years (QALY). Sensitivity analyses were performed to assess the robustness of the results.

RESULTS

Over the 15-year period of the model, the current composition of RRT (i.e., the base composition of RRT) was $84,008/QALY. The most cost-effective treatment was when the likelihood of a living donor transplant was increased by 2.4-times ($70,581/QALY). Compared with the base composition of RRT, dominant treatments with respect to cost-effectiveness were when the likelihood of a deceased donor transplant was increased by 22-times and when the likelihood of a pre-emptive living donor transplant was increased by 2.4-times. Little difference was found between these two treatments. One-way sensitivity analysis did not change the cost effectiveness except for costs of chronic hemodialysis and a living donor transplant in subsequent years.

LIMITATIONS

It is difficult to increase the rate of transplant overall in the shorter term nationally and internationally.

CONCLUSIONS

Appropriate distribution of all transplant options and hemodialysis is necessary to achieve the most cost-effective solution.