Only Time Will Tell: The Future of Donation After Circulatory Death

The rapid rise of transplantation over the past 60 years has been marked by a number of critical milestones. Donation after circulatory death (DCD) has played an important role in the development of this young field. Although early observations by Dr. Tom Starzl touched on the importance of warm ischemic time, new and exciting data may be changing our views of ischemia. Indeed, as we learn more about the importance of time-to-death for DCD donors after circulatory death, the hemodynamic changes experienced by DCD donors, and the other physiologic perturbations surrounding all forms of death, we are beginning to drill down to the factors that drive recipient outcomes after deceased donor transplant. As far as the future? Only time will tell.

[An interest group in the Haina Hospital against the anatomic dissection. Actors and their protest readiness against organizational expectations]

Between 1839 and 1853 several petitions have been addressed by inmates of the Haina hospital (Hesse, Germany) in order to save them from being transferred to the Anatomical Institute of the University of Marburg for post mortem dissection. In 1855, exemptions were granted in certain cases. Initially, the petitioners' strategies of argumentation and procedure have been analysed; then--referring to the application being sent in December 1847 and signed by 30 persons--the focus goes to the formation of this group and their opportunities for action. As a result it can be stated that inmates being physically ill or impaired or with impeded visual sensory perception tried to withstand unsuitable restrictions of their liberty of action as well as their personal rights induced by the routines of every-day hospital life. Guiltless for depending on public assistance they were not willing to accept unjustified curtailing of their personal and moral integrity. The attempts of being saved from anatomical dissection are part of the inmates' self-assertion.

Conscripting Organs: "Routine Salvaging" or Bequest? The Historical Debate in Britain, 1961-75

The period 1961-76 was one of marked contestation in Britain about how organs should be obtained from recently deceased people's bodies to transplant into ailing strangers. Most were being removed from hospital patients' corpses without these people's prior consent, under a law that enabled hospital authorities to so authorize the use of a body with one caveat: enquiries should first be made to learn whether the dead person had in life objected to this or whether a family member did. Transplant surgeons argued that this requirement severely hampered their enterprise. They pushed for the 1961 Human Tissue Act to be overturned, to enable them to presume that all patients in British hospitals had consented to their organs being removed when they died, with no requirement that relatives' views be sought first. As a contemporary ethicist noted, this savored more of "conscription than of voluntary service" in the cause.(1) The following essay, based on an examination of archival sources, reveals the historical complexity of arguments that continue to be made in favor of presumed consent to organ "donation," analyzing how early attempts to change the law in that direction failed while revealing the presence of different interests and values in this contest over corpses.

Organ transplantation in Tunisia

Kidney transplants were first performed in Tunisia in 1986, and transplants soon extended to other organs including the heart, liver, and pancreas. Live-related donor and deceased-donor kidney transplants were both began in the summer of 1986. An organ procurement and transplant law was passed in March 1991, and the National Centre for Advancement of Organ Transplantation was created in 1995. The number of transplantation units has increased to 7 throughout the country, and the yearly transplant number has progressively increased to 139 in 2010, including 20% from deceased kidney donors. Despite these gains, the need continues to grow. Heart transplants began in January 1993, and Tunisia and Jordan are currently the only Arab countries where it is practiced. However, only 16 patients have received a heart transplant as of 2004, and the number of recipients has decreased in the past 10 years. Liver transplants are rare in other Arab countries, but began in Tunisia in January 1998. Over 10 years, 38 patients benefited from this procedure. After a few years of stagnation, the number of liver transplants is increasing. While all types of transplantation are needed, kidney transplantation is a priority in Tunisia. The target is to perform 400 transplants annually, which would require a long-term strategy to provide full financial coverage using the National Health Insurance Funds in both the public and private sectors.

The donor-conceived child's "Right to Personal Identity": the public debate on donor anonymity in the United Kingdom

On 1 April 2005, with the implementation of the Human Fertilisation and Embryology Authority (Disclosure of Donor Information) Regulations 2004, United Kingdom law was changed to allow children born through gamete donation to access details identifying the donor. Drawing on trends in adoption law, the decision to abolish donor anonymity was strongly influenced by a discourse that asserted the ‘child's right to personal identity’. Through examination of the donor anonymity debate in the public realm, while adopting a social constructionist approach, this article discusses how donor anonymity has been defined as a social problem that requires a regulative response. It focuses on the child's ‘right to personal identity’ claims, and discusses the genetic essentialism behind these claims. By basing its assumptions on an adoption analogy, United Kingdom law ascribes a social meaning to the genetic relatedness between gamete donors and the offspring.

Changing donor source pattern for kidney transplantation over 40 years: a single-center experience

BACKGROUND/AIMS

Kidney transplantations at our center rely mainly on living donors. The purpose of this study was to suggest future donor supply directions by reviewing changing trends in donor type.

METHODS

During the past 40 years, 1,690 kidney transplantations were performed at our center. We divided the follow-up period into four decades and the donor population into three groups: living related, living unrelated, and deceased. We analyzed changing trends in donors from each group for each decade. Patients receiving overseas transplantation were also included.

RESULTS

The proportion of living related donors decreased from 84% (54/64) in the 1970s to 61% (281/458) in the 2000s. Living unrelated donors showed a sustained proportion of around 20% after 1990. However, among living unrelated donors, the proportion of spouse donors increased from 4.6% (17/369) in the 1980s to 8.5% (39/458) in the 2000s. Transplants from deceased donors were only 3.3% (12/369) in the 1980s. However the proportion of deceased donors increased gradually, reaching 13.2% (105/799) in the 1990s and 19.9% (91/458) after 2000. Overseas transplantations increased after 2000 and reached 20% of all cases treated in our center during the 2000s. Such transplantations peaked in 2006 and decreased markedly thereafter.

CONCLUSIONS

The proportion of each donor type has continuously changed, and the changes were associated with changes in the social structure and system. We expect that this study could be an important reference for other countries to estimate future changes of donor type.

The concept of brain death did not evolve to benefit organ transplants

Although it is commonly believed that the concept of brain death (BD) was developed to benefit organ transplants, it evolved independently. Transplantation owed its development to advances in surgery and immunosuppressive treatment; BD owed its origin to the development of intensive care. The first autotransplant was achieved in the early 1900s, when studies of increased intracranial pressure causing respiratory arrest with preserved heartbeat were reported. Between 1902 and 1950, the BD concept was supported by the discovery of EEG, Crile's definition of death, the use of EEG to demonstrate abolition of brain potentials after ischaemia, and Crafoord's statement that death was due to cessation of blood flow. Transplantation saw the first xenotransplant in humans and the first unsuccessful kidney transplant from a cadaver. In the 1950s, circulatory arrest in coma was identified by angiography, and the death of the nervous system and coma dépassé were described. Murray performed the first successful kidney transplant. In the 1960s, the BD concept and organ transplants were instantly linked when the first kidney transplant using a brain-dead donor was performed; Schwab proposed to use EEG in BD; the Harvard Committee report and the Sydney Declaration appeared; the first successful kidney, lung and pancreas transplants using cadaveric (not brain-dead) donors were achieved; Barnard performed the first human heart transplant. This historical review demonstrates that the BD concept and organ transplantation arose separately and advanced in parallel, and only began to progress together in the late 1960s. Therefore, the BD concept did not evolve to benefit transplantation.

TheUniform Anatomical Gift Act and organ donation in the United States

The Uniform Anatomical Gift Act (UAGA) and its periodic revisions provide a template for the creation and amendment of legislation to adjust public policy and align it with developments in medical practice. It is also a model for statutory response to societal change as well as changes in regulatory and judicial precedents. Conversely, the history of the UAGA shows the limits of legislation to achieve certain social goals.

Intellectual property and biotechnology: the U.S. internal experience--Part I

In the development of biotechnology in the United States, many questions were raised about the appropriateness of applying to this area a traditional robust system of intellectual property rights. Despite these hesitations, the U.S. rejected suggested modifications. This was a mistake, and there is a need to develop a modified system that promotes more of the relevant ethical values.

The first organ transplant from a brain-dead donor

In 1968, publication of the Harvard committee's report concerning "irreversible coma" established a paradigm for defining death by neurologic criteria (brain death [BD]). Five years earlier, Dr. Guy Alexandre, a Belgian surgeon, had not only adopted closely similar diagnostic criteria for BD but also applied those criteria in performing the first organ transplant from a brain-dead donor--a procedure many of his colleagues considered ethically unacceptable. To put those events into present-day perspective, the author reviewed the proceedings of a Ciba Symposium held in London in 1966 at which Alexandre introduced his pioneering view, obtaining information and documents from Alexandre and others who attended that meeting. Comparing Alexandre's approach with the Harvard report and later advances helps in understanding how both defining death by brain criteria and transplanting organs from a brain-dead donor have become morally tolerable today.

Milestones in the development of pediatric hematopoietic stem cell transplantation--50 years of progress

In the 1950s, the first infusions of hematopoietic stem cells were given as a form of treatment for childhood leukemia. This heralded the beginning of a field that has expanded to include the treatment of immune deficiencies, a variety of leukemias and solid tumors, and then genetic diseases. A number of milestones are highlighted, particularly in regard to the use of alternative sources of hematopoietic stem cells such as unrelated donors, peripheral blood stem cells and umbilical cord stem cells. In addition, newer techniques of using non-myeloablative preparative regimens helped to reduce the toxicity and long-term consequences of hematopoietic stem cell transplant. Many diseases now benefit from the replacement of the marrow stem cells and the provision of a new immune system and improved immune surveillance.

Ancient myth, modern reality: a brief history of transplantation

From trephination to modern surgical procedures, transplantation is an exciting technology that has evolved over centuries. This article reviews the historical incidences of organ and tissue transplantation among humans and reflects on accomplishments made in general surgery that assisted transplant technology. Following a brief historical overview, the article focuses on modern transplanting issues including: development of immunosuppressive therapy, organ availability, qualifications for donors and recipients, organ procurement, and new transplant technology.

Renal transplantation: a quarter century of achievement

Renal transplantation has become the treatment of choice for most types of end-stage renal failure. Immunosuppressive drug therapy has improved enormously over the past 25 years, and the advent of potent new drugs in addition to cyclosporine make multiple drug therapy for immunosuppression the direction of the immediate future. Monoclonal antibodies have so far had a limited role in immunosuppression, but are likely to prove of value in protocols aimed at inducing specific unresponsiveness to a renal allograft. This remains the goal of transplantation biology, because the long-term complications of all current nonspecific immunosuppressive protocols are formidable. In addition, the shortage of cadaver kidneys for transplantation has led to an increasing use of living related and unrelated donors, and stimulated a major research activity in xenotransplantation in an attempt to bring it to the clinic in the not too distant future.

Eye bank's success due to vision of its founders

In 1955, the Eye Bank of Canada introduced Canadians to the idea of postmortem tissue donation. The long-time administrator of the bank's Ontario Division, Anne Wolf, recalls the organization's early days and how the management of donated corneas became a family affair.

The first lung transplantation

The first lung transplantation in a human occurred at the University of Mississippi Medical Center on June 11, 1963. I was privileged to participate in this historic event, and I am pleased to share my thoughts with the readership of The Annals of Thoracic Surgery.