Update on the ethical, legal and technical challenges of translating xenotransplantation

This manuscript reports on a landmark symposium on the ethical, legal and technical challenges of xenotransplantation in the UK. King's College London, with endorsement from the British Transplantation Society (BTS), and the European Society of Organ Transplantation (ESOT), brought together a group of experts in xenotransplantation science, ethics and law to discuss the ethical, regulatory and technical challenges surrounding translating xenotransplantation into the clinical setting. The symposium was the first of its kind in the UK for 20 years. This paper summarises the content of the expert lectures showcasing the progress which has been made in xenotransplantation including-the history of xenotransplantation, advances in gene edited animals and progress towards clinical xenotransplantation. We then set out the ethical and legal issues still to be resolved. Finally, we report the themes of the roundtable discussion highlighting areas of consensus and controversy. While the detail of the legal discussion was directed towards the UK, the principles and summary reported here are intended to be applicable to any jurisdiction seeking to implement clinical xenotransplantation.

[Transculturation and validation of a Questionnaire Factors Influencing Organ Donation]

Background

There are validated questionnaires in Spanish that evaluate the factors that influence organ donation, but they are not designed for the open population or do not delve into various aspects such as the one proposed.

Objective

Validate an instrument to evaluate the factors that influence organ donation in Mexico.

Material and methods

Phase 1: Development of the instrument. Translation into Spanish of the questionnaire "Factors Inffluencing Organ Donation in Qatar", adapted by experts in donation and clinimetry. Simultaneously, the definitive version of the questionnaire "Factors that Influence Organ Donation" (FIDO) and the questionnaire "International Donor Collaborative Project" were applied to patients, relatives and staff of a tertiary hospital in Puebla, Mexico. Mind a week after 200 respondents. Cronbach's Alpha (AC) (internal consistency), Intraclass Correlation Coefficient (ICC) (external consistency), and Phi (Phi) and Chi square Coefficient (concurrent validity in intention to donate) were obtained.

Results

AC and ICC by domain: Knowledge 0.625 and 0.372; Attitudes 0.776 and 0.761; Beliefs 0.649 and 0.633; Intentions 0.126 and 0.123; Phi: 0.976, Chi square: 2.358 (p = 0.125).

Conclusions

The FIDO questionnaire is valid and consistent to assess knowledge, attitudes, beliefs and intentions in organ donation in the general Mexican population.

Who should provide the uterus? The ethics of live donor recruitment for uterus transplantation

Uterus transplantation (UTx) is an experimental surgery likely to face the issue of organ shortage. In my article, I explore how this issue might be addressed by changing the prevailing practices around live uterus donor recruitment. Currently, women with children - often the mothers of recipients - tend to be overrepresented as donors. Yet, other potentially eligible groups who may have an interest in providing their uterus - such as transgender men, or cisgender women who do not wish to gestate or to have children - tend to be excluded as potential donors. Moving forward, I recommend that donor inclusion criteria for UTx be broadened to be more inclusive of these latter groups.

[Educational intervention on organ and tissue donation at UMAE No. 34]

Background

The lack of information associated with donation is devastating for those patients in need of a transplant and requires a solution based on changing social perception through educational interventions.

Objective

Determine the level of knowledge of the general population after an educational intervention about organ and tissue donation at the Hospital de Cardiología UMAE No. 34.

Methods

Educational intervention study with measurement before and after, prospective. Instrument validated using the Kuder-Richardson formula with a reliability coefficient of 0.74. The study population was made up of the general population in the waiting rooms at UMAE No. 34, only the associations with values of p < 0.05 were considered statistically significant.

Results

266 evaluation instruments were applied to 133 participants. The educational intervention contributed to an increase in the level of knowledge (p = 0.0001). The level of knowledge after the intervention was higher in the younger participants (p = 0.013) and in those with a university studies (p = 0.0001). The relation between age and the level of subsequent knowledge showed favorable significance in the intention to donate in younger participants with high subsequent knowledge (p = 0.046).

Conclusions

An educational intervention on donation of organs and tissues for transplant purposes is an effective strategy to increase and reinforce the knowledge of the general population.

Ethical analysis of the first porcine cardiac xenotransplantation

In this article, we provide an ethical analysis of the first porcine cardiac xenotransplant, performed in Maryland, USA in early 2022. David Bennett was offered the experimental procedure after he was deemed ineligible for human heart transplantation and mechanical circulatory support, based on a history of non-compliance. It was reported that Mr Bennett's previous instances of non-compliance were for medically non-life-threatening conditions years earlier, where the risks of non-compliance were not as high. We argue that, in Mr Bennett's case, a history of non-compliance in a different context, should not necessarily rule him ineligible for a potentially life-saving treatment now. Furthermore, using previous non-compliance to exclude individuals from donor organs may have the unintended effect of placing the burden of testing xenotransplantation on those who are already disadvantaged. We then argue that it is not enough to rely on patient consent to ethically justify xenotransplantation research. Taking a broad ethical perspective is crucial when mapping a clinical pathway for xenotransplantation.

OPTN/SRTR 2020 Annual Data Report: Living Donor Collective

The first successful solid organ transplant was a living donor kidney transplant in 1954. Since then, living donation has been an important source of organs for kidney and liver transplants in the United States. Unfortunately, the demand for organs has not kept pace with the supply, and unlike deceased donor transplant, there has been little growth in the number of living donor transplants over the past decade. To better understand possible barriers to living donation and long-term risks attributable to donation, the Health Resources and Services Administration (HRSA) directed the Scientific Registry of Transplant Recipients (SRTR) to establish a national registry of all living donor candidates and donors evaluated at US transplant programs to acquire lifetime follow-up information. Other goals include understanding the factors associated with candidate approval and variation in approval practices across centers. A pilot program was conducted from June 2018 through September 2020 to inform baseline data collection and registration processes. In September 2020, the registry began recruiting additional sites evaluating candidates for living donation. Here, we describe candidates registered at participating living donor kidney and liver programs, from June 2018 through the end of 2020. Not all programs submitted data throughout the whole period. Data for kidney and liver living donor candidates are presented separately.

Analysis of Factors Affecting Emergency Physicians' Attitudes toward Deceased Organ & Tissue Donation

BACKGROUND

This study aimed to investigate differences in knowledge, and attitudes toward deceased organ and tissue donation of emergency physicians. Additionally, we analyzed factors affecting the attitudes toward deceased organ and tissue donation.

METHODS

We conducted a survey of specialists and residents registered with the Korean Society of Emergency Medicine in December 2020. The respondents' sex, age, position, personal registration for organ donation, experience of soliciting organ donation, participation in related education, knowledge, and attitude about brain death organ donation, and attitude toward stopping life-sustaining treatments were investigated. According to the characteristics of the respondents (specialists or residents, experience and education on organ and tissue donation), their knowledge and attitude toward deceased organ donation were compared. Stepwise hierarchical multiple regression analysis was used to investigate the factors affecting the attitudes toward deceased organ and tissue donation.

RESULTS

Of the total 428 respondents, there were 292 emergency medicine specialists and 136 medical residents. Specialists and those who registered or wished to donate organs had higher knowledge and attitude scores regarding deceased organ and tissue donation. Those who had experience recommending organ and tissue donation more than 6 times had higher knowledge scores on deceased organ and tissue donation and higher overall scores in attitude. Those who received education from the Korean Organ Donation Agency had higher knowledge scores. Specialists, and those who wished to donate or had registered as organ donors and had a higher life-sustaining treatment attitude score and knowledge about deceased organ and tissue donation, had more positive attitudes toward deceased organ and tissue donation.

CONCLUSION

For more potential deceased organ and tissue donors to be referred for donation, there should be continuous education for emergency physicians on brain-dead organ and tissue donation-related knowledge and procedures. In addition, institutional or systematic improvements that can lead to organ donation when deciding on the withdrawal of life-sustaining treatment should be considered.

[Donation in the Cardiology Hospital No. 34]

BACKGROUND

Chronic degenerative diseases have become a challenge for the Mexican health system. Faced with this problem, health institutions have focused on the therapeutic potential of organ and tissue donation and transplantation.

OBJECTIVE

To analyze the experience of the donation program and to identify areas of opportunity at the Hospital de Cardiología No. 34 (Hospital of Cardiology Number 34), in Monterrey, Nuevo León, Mexico.

MATERIAL AND METHODS

Observational, cross-sectional, and retrospective study. The study population was made up by deaths and successful interviews. Only groupings with values of p < 0.05 were considered statistically significant.

RESULTS

A global of 1947 deaths were registered and a total of 210 interviews were carried out; 83 (39.5%) family members accepted to donate and 127 (60.5%) refused to donate. Only 3 associations between variables had significant statistical value. The year was an important determinant in the increase in effective donations (p = 0.010), and so was the month of the year (p = 0.037), obtaining more positive interviews in the second half of the year; finally, the shift also contributed to the family response (p = 0.012), with the morning shift being the best shift to conduct a successful family interview.

CONCLUSIONS

It is imperative to conduct studies that analyze and describe the experience of donation programs to promote and encourage the value of donation.

The Association of Time to Organ Procurement on Short- and Long-Term Outcomes in Kidney Transplantation

BACKGROUND AND OBJECTIVES

Transplant centers in Europe aim to minimize the time from brain death to organ procurement (procurement delay), but evidence to justify this is scarce. In the United States, procurement times are significantly longer. Our objective was to analyze how procurement delay associates with kidney allograft outcomes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Kidney transplantations from brain-dead donors were retrospectively analyzed from the Finnish Kidney Transplant Registry and the Scientific Registry of Transplant Recipients in the United States. Multivariable models were adjusted with donor and recipient characteristics, and the relationship between procurement delay and outcomes was modeled with cubic spline functions.

RESULTS

In total, 2388 and 101,474 kidney transplantations in Finland and the United States were included, respectively. The median procurement delay was 9.8 hours (interquartile range, 7.8-12.4) in Finland and 34.8 hours (interquartile range, 26.3-46.3) in the United States. A nonlinear association was observed between procurement delay and the risk of delayed graft function, with highest risk seen in short and very long procurement delays. In multivariable models, the lowest risk of delayed graft function was associated with procurement delay between 20 and 50 hours. In multivariable models, longer procurement delay was linearly associated with lower risk of graft loss (hazard ratio, 0.90/1 h longer; 95% confidence interval, 0.88 to 0.92; P<0.001). Acute rejection rates, for which data were only available from Finland, were not associated with procurement delay.

CONCLUSIONS

Longer procurement delay was associated with noninferior or even better kidney allograft outcomes.

[Management of Organ Donation During the COVID-19 Pandemic]

N/a.

Controlled Donation After Circulatory Determination of Death: A Scoping Review of Ethical Issues, Key Concepts, and Arguments

Controlled donation after circulatory determination of death (cDCDD) is an important strategy for increasing the pool of eligible organ donors.

[Standard versus extended criteria graft procurement. Experience at the Hospital de Especialidades La Raza]

BACKGROUND

In Mexico, there are 23 158 patients waiting for an organ or tissue transplant. The increasing demand of grafts justifies the use of expanded criteria donors; however, not even all standard grafts have been procured.

OBJECTIVE

To identify the associated factors to the decision of not procuring grafts from brain death donors whose donation was consented.

METHOD

Retrospective cohort, univariate and multivariate analysis. 35 donation files with brain death were included from 2014 to 2019. Groups in which the heart wasn't procured versus those in which it was procured were compared; same comparisons were made for liver, kidney, skin, bone tissue and corneas.

RESULTS

20 women (57.1%), 15 men (42.9%) average age of 43.8 ± 16.4 years. High-dose of inotropic or norepinephrine use increased the probability of cardiac procurement (odds ratio [OR] 0.57; 95% confidence interval [95% CI]: 0.0-0.5). It was not detected a sensitive and specific variable for decision making at liver procurement. Implementation of two or more diagnostic methods for BD were associated with kidney loss (OR: 10; 95% CI: 1.2-78.1). Organs and tissues met standard criteria; however, 76 (41.5%) were not procured.

CONCLUSIONS

Non-procurement associated factors were different from the standard donor established criteria. It is necessary to follow clear procurement criteria, in order to reduce viable grafts loss.

Can Behavioral Research Improve Transplant Decision-Making? A Mock Offer Study on the Role of Kidney Procurement Biopsies

Background

The use of procurement biopsies for assessing kidney quality has been implicated as a driver of the nearly 20% kidney discard rate in the United States. Yet in some contexts, biopsies may boost clinical confidence, enabling acceptance of kidneys that would otherwise be discarded. We leveraged a novel organ offer simulation platform to conduct a controlled experiment isolating biopsy effects on offer acceptance decisions.

Methods

Between November 26 and December 14, 2018, 41 kidney transplant surgeons and 27 transplant nephrologists each received the same 20 hypothetical kidney offers using a crossover design with weekend "washout" periods. Mini-study 1 included four, low serum creatinine (<1.5 mg/dl) donor offers with arguably "poor" biopsy findings that were based on real offers that were accepted with successful 3-year recipient outcome. For each of the four offers, two experimental variants-no biopsy and "good" biopsy-were also sent. Mini-study 2 included four AKI offers with no biopsy, each having an offer variant with "good" biopsy findings.

Results

Among low serum creatinine donor offers, we found approximately threefold higher odds of acceptance when arguably poor biopsy findings were hidden or replaced with good biopsy findings. Among AKI donor offers, we found nearly fourfold higher odds of acceptance with good biopsy findings compared with no biopsy. Biopsy information had profound but variable effects on decision making: more participants appeared to have been influenced by biopsies to rule out, versus rule in, transplantable kidneys.

Conclusions

The current use of biopsies in the United States appears skewed toward inducing kidney discard. Several areas for improvement, including reducing variation in offer acceptance decisions and more accurate interpretation of findings, have the potential to make better use of scarce, donated organs. Offer simulation studies are a viable research tool for understanding decision making and identifying ways to improve the transplant system.

HLA-DQ Mismatching and Kidney Transplant Outcomes

BACKGROUND AND OBJECTIVES

Recent evidence suggests that HLA epitope-mismatching at HLA-DQ loci is associated with the development of anti-DQ donor-specific antibodies and adverse graft outcomes. However, the clinical significance of broad antigen HLA-DQ mismatching for graft outcomes is not well examined.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using the United Network Organ Sharing/the Organ Procurement and Transplantation Network (UNOS/OPTN) data, patients with primary kidney transplants performed between 2005 and 2014 were included. Patients were classified as having either zero HLA-DQ mismatches, or one or two HLA-DQ mismatches. Primary outcomes were death-censored graft survival and incidence of acute rejection.

RESULTS

A total of 93,782 patients were included. Of these, 22,730 (24%) and 71,052 (76%) received zero and one or two HLA-DQ mismatched kidneys, respectively. After adjusting for variables including HLA-ABDR, HLA-DQ mismatching was associated with a higher risk of graft loss in living kidney donor recipients with an adjusted hazard ratio (HR) of 1.18 (95% confidence interval [95% CI], 1.07 to 1.30; P<0.01), but not in deceased kidney donor recipients (HR, 1.05; 95% CI, 0.98 to 1.12; P=0.18) (P value for interaction <0.01). When taking cold ischemic time into account, HLA-DQ mismatching was associated with a higher risk of graft loss in deceased kidney donor recipients with cold ischemic time ≤17 hours (HR, 1.12; 95% CI, 1.02 to 1.27; P=0.002), but not in deceased kidney donor recipients with cold ischemic time >17 hours (HR, 0.97; 95% CI, 0.88 to 1.06; P=0.49) (P value for interaction <0.01). Recipients with one or two HLA-DQ mismatched kidneys had a higher incidence of acute rejection at 1 year, with adjusted odds ratios of 1.13 (95% CI, 1.03 to 1.23; P<0.01) in deceased donor and 1.14 (95% CI, 1.03 to 1.27; P=0.02) in living donor kidney transplant recipients. Specific donor-DQ mismatches seemed to be associated with the risk of acute rejection and graft failure, whereas others did not.

CONCLUSIONS

HLA-DQ mismatching is associated with lower graft survival independent of HLA-ABDR in living donor kidney transplants and deceased donor kidney transplants with cold ischemia time ≤17 hours, and a higher 1-year risk of acute rejection in living and deceased donor kidney transplants.

Kidney Allocation: New Contributions to an Ongoing Challenge

N/A.

Early Experience with the New Kidney Allocation System: A Perspective from UNOS

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_11_21_CJASNPodcast_18_1_v.mp3.

The Lived Experience of "Being Evaluated" for Organ Donation: Focus Groups with Living Kidney Donors

BACKGROUND AND OBJECTIVES

Comprehensive evaluations are required to safeguard voluntarism and minimize harm to living kidney donors. This process is lengthy, invasive, and emotionally challenging, with up to one fifth of potential donors opting out. We aimed to describe donors' experiences of the evaluation process.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted 14 focus groups involving 123 kidney donors who completed donation from three transplant centers (Australia and Canada). Transcripts were analyzed thematically.

RESULTS

We identified six themes reflecting donors' experiences of evaluation. The themes that related to perseverance included emotional investment (prioritizing the recipient's health, desperation for a normal life, protecting eligibility, shame of disappointing others, and overcoming opposition), undeterred by low risks (medical confidence and protection, worthwhile gamble, inherent invincibility, and normalizing risks), and mental preparation (avoiding regret, resolving decisional ambivalence, and managing expectations of recovery). The challenges included underlying fears for health (processing alarming information, unsettling uncertainty, and preoperative panic), system shortfalls (self-advocacy in driving the process, stressful urgency, inconsistent framing of safety, unnerving bodily scrutiny, questioning risk information, and draining finances); and lifestyle interference (living in limbo, onerous lifestyle disruption, and valuing flexibility).

CONCLUSIONS

Previous donors described an emotional investment in donating and determination to protect their eligibility, despite having concerns for their health, financial and lifestyle disruption, and opposition from their family or community. Our findings suggest the need to prepare donors for surgery and recovery, minimize anxiety and lifestyle burdens, ensure that donors feel comfortable expressing their fears and concerns, reduce unnecessary delays, and make explicit the responsibilities of donors in their assessment process.

Survival Benefit of Transplantation with a Deceased Diabetic Donor Kidney Compared with Remaining on the Waitlist

BACKGROUND AND OBJECTIVES

Use of diabetic donor kidneys has been a necessary response to the donor organ shortage. Recipients of diabetic donor kidneys have higher mortality risk compared with recipients of nondiabetic donor kidneys. However, the survival benefit of transplantation with diabetic donor kidneys over remaining on the waitlist has not been previously evaluated.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed an observational cohort study of 437,619 kidney transplant candidates from the Organ Procurement and Transplantation Network database, including 8101 recipients of diabetic donor kidneys and 126,560 recipients of nondiabetic donor kidneys. We used time-varying Cox proportional hazards modeling to assess the mortality risk of accepting a diabetic donor kidney compared with remaining on the waitlist or receiving a nondiabetic donor kidney.

RESULTS

Among transplant recipients, median follow-up was 8.9 years and mortality rate was 35 deaths per 1000 person-years. Recipients of diabetic donor kidneys had 9% lower mortality compared with remaining on the waitlist or transplantation with a nondiabetic donor kidney (adjusted hazard ratio, 0.91; 95% confidence interval, 0.84 to 0.98). Although recipients of nondiabetic donor kidneys with a Kidney Donor Profile Index score >85% had lower mortality risk (adjusted hazard ratio, 0.86; 95% confidence interval, 0.81 to 0.91), recipients of diabetic donor kidneys with an index score >85% did not show any difference (adjusted hazard ratio, 1.09; 95% confidence interval, 0.97 to 1.22). Patients aged <40 years attained no survival benefit from transplantation with diabetic donor kidneys; diabetic patients at centers with long waitlist times attained the greatest survival benefit.

CONCLUSIONS

Diabetic donor kidneys appear associated with higher mortality risk compared with nondiabetic donor kidneys, but offer greater survival benefit compared with remaining on the waitlist for many candidates. Patients with high risk of mortality on the waitlist at centers with long wait times appear to benefit most from transplantation with diabetic donor kidneys.

A Case-Based Analysis of Whether Living Related Donors Listed for Transplant Share ESRD Causes with Their Recipients

BACKGROUND AND OBJECTIVES

Two recent studies reported increased risk of ESRD after kidney donation. In both, the majority of ESRD was seen in those donating to a relative. Confounding this observation is that, in the absence of donation, relatives of those with ESRD are at increased risk for ESRD. Understanding the pathogenesis and risk factors for postdonation ESRD is critical for both donor selection and counseling.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We hypothesized that if familial relationship was an important consideration in pathogenesis, the donor and linked recipient would share ESRD etiology. We obtained information from the Organ Procurement and Transplantation Network (OPTN) on all living kidney donors subsequently waitlisted for a kidney transplant in the United States between January 1, 1996 and November 30, 2015, to determine (1) the donor-recipient relationship and (2) whether related donor-recipient pairs had similar causes of ESRD.

RESULTS

We found that a significant amount of information, potentially available at the time of listing, was not reported to the OPTN. Of 441 kidney donors listed for transplant, only 169 had information allowing determination of interval from donation to listing, and only 99 (22% of the total) had information on the donor-recipient relationship and ESRD etiology. Of the 99 donors, 87 were related to their recipient. Strikingly, of the 87, only a minority (23%) of donor-recipient pairs shared ESRD etiology. Excluding hypertension, only 8% shared etiology.

CONCLUSIONS

A better understanding of ESRD in donors requires complete and detailed data collection, as well as a method to capture all ESRD end points. This study highlights the absence of critical information that is urgently needed to provide a meaningful understanding of ESRD after kidney donation. We found that of living related donors listed for transplant, where both donor and recipient cause of ESRD is recorded, only a minority share ESRD etiology with their recipient.

Human Tissue Processing and Transplantation in MESOT States: How to Promote?

Middle East, with more than 650 million inhabitants, has one the lowest mean donation rate in the world in the context of organ procurement from deceased donors with <2 per million population as actual deceased organ donation rate in 2014. Tissue processing and transplantation in this region are also restricted to a few countries among those representing Middle East Society for Organ Transplantation. Aiming to promote human tissue processing and transplantation in this region, as a life-enhancing therapeutic modality, we have to share our know-how and facilities in order so that the patients in different countries gain almost equal benefit of this vital procedure. To take different infrastructure of Middle Eastern countries into consideration and their plans to extend their activities, this intention will be come to the reality and materialized by primarily sharing the processed tissues among member states in a centralized manner and to offer processing services and banking to locally retrieved tissues.

Donor-site morbidity following minimally invasive costal cartilage harvest technique

OBJECTIVES

Autologous costal cartilage is a promising alternative for mastoid obliteration. However, donor-site morbidities of the chest wall limit the use of this graft. To address this issue, we have developed a minimally-invasive technique of harvesting costal cartilage and report donor site morbidity associated with the procedure.

METHODS

Donor site morbidities were evaluated for 151 patients who underwent costal cartilage harvest, canal wall down mastoidectomy, and mastoid obliteration. Pain and cosmetic concern were evaluated via visual analogue scale (VAS). Scars were evaluated via the modified Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). Postoperative complications were assessed during the follow-up period.

RESULTS

The mean duration of noticeable pain was 5.3 days post operation. The mean VAS score for pain was 3.0 of 10 on the first day after the operation and gradually declined. At the 6 months post operation, the mean VAS cosmetic score at the costal cartilage harvest site was 0.6 of 10. The mean VSS score was 9.5 out of 10 total, and the mean POSAS score was 23.27 out of 110 total.

CONCLUSION

The minimally-invasive chopped costal cartilage harvest technique resulted in acceptable pain, cosmetic concern, and postoperative complications for most patients. There were no major postoperative complications. Costal cartilage is an acceptable donor for mastoid obliteration in canal wall down mastoidectomy, especially in the context of the extremely low donor site morbidity of the minimally-invasive technique presented in the study.

Trends in deceased organ donation and utilization in Korea: 2000-2009

Continuous efforts have been made by the organ donation and transplantation community in Korea to increase organ donation by the deceased. The authors detailed trends of organ donation and utilization over the past 10 yr using data provided by the KONOS. The yearly number of deceased donors has grown gradually since 2003. The number and percentage of old donors (> or = 50 yr) and donors dying from intracranial hemorrhage has increased continuously. Therefore, the percentage of standard criteria donors (SCD) has been declining significantly, from 94% in 2000 to 79.2% in 2009. The number of organs transplanted per donor (OTPD) has also declined slightly since 2007, from 3.28 in 2007 to 2.95 in 2009. This decline may be attributable to increases in the number and percentage of extended criteria donors (ECD) and donors after cardiac death (DCD), since the OTPD was 2.25 for DCD, 2.5 for ECD, and 3.09 for SCD in 2009. In summary, the makeup of donors has changed significantly. There is an urgent need for establishment of an institutional framework including an independent organ procurement organization and for improvement for the National Transplant Act to increase deceased donor pool and to optimize management of ECD and DCD.