Living Donor Organ Transplantation Research Articles

Ethical challenges in organ transplants for refugees in a healthcare system.

Several ethical issues are associated with providing living organ transplantation services, and there is limited information on these issues faced by the teams providing service to refugees or asylum seekers. To determine the challenges healthcare professionals face in organ transplant centers providing services to Syrians under temporary protection status and discern whether these difficulties align with ethical issues in living organ transplantation. This study employed a qualitative design and conducted individual semi-structured, in-depth interviews with 18 transplant team members in Istanbul between September and November 2022. Data analysis was based on Braun and Clarke's thematic analysis. The participants comprised 18 healthcare professionals, including 6 physicians and 12 nurses working in organ transplant teams in Istanbul. The University's Ethics Committee provided approval. Participants were informed regarding confidentiality and signed an informed consent form. Three themes emerged from the data on ethical issues faced by organ transplantation services to Syrians: (a) beneficence or double equipoise, (b) autonomy, and (c) justice. Transplant teams experience problems related to preserving double equipoise in the provision of living donor organ transplantation because of language barriers, poor socioeconomic conditions, and cultural factors, which increases transplant teams' individual and indirect social burden. Although problems arise from the language barrier when obtaining informed consent in the autonomy theme, institutional and national policies in preventing donor abuse have a comforting effect. Health workers had the least problems with the justice theme, wherein national health policies are determined. Fewer issues related to autonomy and justice were reported in providing organ transplantation services to Syrians, with the most intense reported issues being maintaining double equipoise. The results revealed the need to develop institutional, national, and international policies with individual solutions to prevent difficulties healthcare professionals face in this process.

Evaluation of Methods to Obtain Peripheral Blood Mononuclear Cells From Deceased Donors for Tolerance-Induction Protocols.

Regulatory cell therapies have shown promise in tolerance-induction protocols in living donor organ transplantation. These protocols should be pursued in deceased donor transplantation. Donor peripheral mononuclear cells (PBMCs) are an optimal source of donor antigens for the induction of donor-specific regulatory cells. During the development of a regulatory cell tolerance-induction protocol with organs from deceased donors, we compared 3 methods of obtaining PBMCs from deceased donors focusing on cell yield, viability, and contamination of unwanted cell types. PBMC procurement methods: 1. During organ procurement at the time of cold perfusion, blood was collected from the vena cava and placed into a 10-liter blood collection bag, and thereafter transported to Karolinska University Hospital, where leukapheresis was performed (BCL). 2. Blood was collected via the vena cava into blood donation bags before cold perfusion. The bags underwent buffy coat separation and thereafter automated leukocyte isolation system (BCS). 3. To collect PBMCs, leukapheresis was performed via a central dialysis catheter on deceased donors in the intensive care unit (ICU) prior to the organ procurement procedure (LEU).All 3 methods to obtain PBMC from deceased donors were safe and did not affect the procurement of organs. BCL contained around 50% of NK cells in lymphocytes population. LEU had a highest yield of donor PBMC among 3 groups. LEU had the lower amount of granulocyte contamination, compared to BCS and BCL. Based on these results, we choose LEU as the preferred method to obtain donor PBMC in the development of our tolerance-induction protocol.

Paired Exchange Liver Transplantation Using an Altruistic Living Donor: First Case in Saudi Arabia—A Case Report

Paired exchange (PE) living donor organ transplantation is an innovation designed to expand the pool of organs available for transplantation. In PE liver transplantation, the donor organs are exchanged between the 2 pairs to overcome blood group incompatibility or volume mismatch. There are ethical and logistic issues surrounding PE. This is the first report of PE liver transplantation in Saudi Arabia using an altruistic donor (AD). The AD may facilitate the exchange because there is no reciprocal expectation of transplantation from the AD. Paired exchange may increase only a small number of donated liver allografts. This may be the only solution for some families and in some countries.

All about the New Timeline in Organ Transplantation

Abstract Transplantation of Human Organs and Tissues (THOT) Act was enacted in 1994 by the Parliament of India to provide regulation of removal, storage and THOT for therapeutic purposes and for the prevention of commercial dealings in human organs and tissues. Under Section 9 of the 1994 Act, there is a mandate for the formation of Authorisation Committee, whose primary responsibility is to oversee and approve organ transplant procedures involving donors and recipients who are not near relatives. Although this approval is crucial and plays a critical role in the transplantation process to prevent illegal practices, the timeframe within which the Authorisation Committee should conduct interviews and make decisions is not prescribed in the Act. This has been causing significant delays in the transplant process and there have even been some cases where the recipients have in fact passed away, awaiting the decision of the Authorisation Committee. The Honourable High Court of Delhi has recently made a significant judgement and fixed the timeline for living donor organ transplantation on considering the petition filed by a patient and his donor for an order directing the Authorisation Committee to grant approval for kidney transplantation. This literature covers the analysis of the aforesaid judgement, an overview of the THO Act 1994 and the THO Rules 2014, the new timelines to be followed in the transplantation of organs and its implications.

Organ transplantation in Nepal: Ethical, legal, and practical issues.

In Nepal, live donor organ transplantation is only 14 years old with the first successful kidney transplant made in 2008 and a successful liver and bone marrow transplant made in 2016. However, transplantation of cadaveric cornea dates back to 1998. There are still no cases of animal-to-human organ transplantation in Nepal. There are stringent laws to regulate human body organ transplantation in Nepal which are amended from time to time. However, there is a racket of human traffickers who lure rural people from this low-income country into the illegal organ trade. Furthermore, there is a substantial lack of awareness of organ donation among the general public. This article focuses on the stipulations of ethical, legal, and practical issues of obtaining organs procured from living and brain-dead donors that support the process of transplantation in Nepal. In addition, the article also explores the legal and practical issues of organ trafficking and organ donation awareness in Nepal on the basis of factual data and findings from other studies.

245.2: Evaluation of Methods to Obtain Peripheral Blood Mononuclear Cells From Deceased Donors Adjacent to Organ Procurement for Tolerance-Induction Protocols

Regulatory cell therapies have shown promise in tolerance-induction protocols in living donor organ transplantation. These protocols should be pursed in deceased-donor transplantation. Donor peripheral mononuclear cells (PBMCs) are an optimal source of donor antigens for the induction of donor-specific regulatory cells that are more effective than antigen non-specific regulatory cells. During the development of a regulatory cell tolerance induction protocol with organs from deceased donors, we compared three methods of obtaining PBMCs from deceased donors focusing on: cell yield, viability, and contamination of unwanted cell types. PBMC procurement methods: During organ procurement at the time of cold perfusion, blood was collected from the vena cava and placed into a 10-liter blood collection bag, and thereafter transported to Karolinska University Hospital, where leukapheresis was performed (BCL) n=7. Blood was collected via the vena cava into blood donation bags before cold perfusion. The bags underwent buffy coat separation and thereafter automated leukocyte isolation using SEPAX (BCS) n=2.To collect PBMCs, leukapheresis was performed via a central dialysis catheter on deceased donors in the ICU prior to the organ procurement procedure (LEU) n=9. Our results show that all methods were safe in relation to the intended organ procurement procedure. LEU is a feasible method to obtain PBMC from deceased donors. LEU tend to have higher yield of donor PBMC/kg compared to BCS and BCL and acceptable level of granulocyte contamination compared to BCS. Further investigations including the quality of the cell products that was manufactured with PBMCs from these methods will be needed to determine which approach is the most suitable for tolerance induction protocols.

A liver for a kidney: Ethics of trans-organ paired exchange.

Living donation provides important access to organ transplantation, which is the optimal therapy for patients with end-stage liver or kidney failure. Paired exchanges have facilitated thousands of kidney transplants and enable transplantation when the donor and recipient are incompatible. However, frequently willing and otherwise healthy donors have contraindications to the donation of the organ that their recipient needs. Trans-organ paired exchanges would enable a donor associated with a kidney recipient to donate a lobe of liver and a donor associated with a liver recipient to donate a kidney. This article explores some of the ethical concerns that trans-organ exchange might encounter including unbalanced donor risks, the validity of informed consent, and effects on deceased organ donation.

From blood donation to kidney sales: the gift relationship and transplant commercialism.

In The Gift Relationship, Richard Titmuss argued that the practice of altruistic blood donation fosters social solidarity while markets in blood erode it. This paper considers the implications of this line of argument for the organ market debate. I defend Titmuss' arguments against a number of criticisms and respond to claims that Titmuss' work is not relevant to the context of live donor organ transplantation. I conclude that Titmuss' arguments are more resilient than many advocates of organ markets suggest, and more relevant to the debate than is commonly appreciated.

Psychiatric Assessment of Transgender Adults for Sex Reassignment Surgery

While pre-surgical assessments by an internist are relatively common, those by psychiatrists are much more rare. With the exception of bariatric surgery and live donor organ transplantation, sex reassignment surgery (SRS) is the only category of surgeries for which a mental health assessment is routinely done as part of the standard of care. This presentation will outline the assessment process as performed at the Gender Identity Clinic at the Centre for Addiction and Mental Health in Toronto, Canada, which sees and approves individuals in the Canadian province of Ontario seeking to have sex reassignment surgery through the provincial health care insurance plan. There are three main tasks of the assessment, diagnosis / differential diagnosis, eligibility assessment, and readiness assessment. Diagnosis, while controversial among some in the transgender community, is generally required by most medical professionals and insurance plans that might cover surgical transition procedures. In Ontario diagnosis is a regulated professional activity and can only be done formally by physicians and clinical psychologists. Eligibility relates to certain specific requirements broadly applied to those seeking surgery that are outlined in international standards of care. For genital surgery, this includes one year of living a full time, continuous gender role experience (GRE) in the chosen gender role. Readiness is the part of the assessment that most resembles a general psychiatric assessment, in which a full biopsychosocial formulation of the client's current status leads to recommendations for improving readiness for SRS.

Quality of Life and Psychology After Living-related Kidney Transplantation From Donors and Recipients in China

BackgroundThe state of organ transplantation in general in China is experiencing transition; however, living-donor organ transplantation has gained more attention recently. We have found that because traditional Chinese ideas, few Chinese transplantation surgeons have the quality of life (QOL) and mental health of living transplantation donors and recipients as their focus in care giving. Physicians outside of China typically have a different view. This study investigated QOL and psychology characteristics in Chinese living-related kidney donors and recipients after transplantation. MethodsDemographics, socioeconomics, transplantation processes, QOL scores, and psychosocial outcomes of 169 pairs of living-related kidney donors and recipients were analyzed using a self-made socio-demographic questionnaire, the short-form 36 health survey, and the Zung self-rating anxiety and depression scales. ResultsThe majority of both donors (81.8%, 90/110) and recipients (83.1%, 103/124) were at secondary school or lesser education levels. Eighty-five and five tenths percent (94/110) of donors and 54.8% (68/124) of recipients were of moderate or low incomes. In addition, the donors were predominantly female (61.8%, 68/110), 6 of whom (5.5%, 6/110) stated that their transplantation had a negative impact on marriage due to kidney donation. The evaluation of the donors' QOL was not significantly different from that of the Chinese norm. The recipients' QOL was obviously improved comparing with the hemodialysis patients. There was no anxiety and depression among donors, but slightly anxious (1.6%, 2/124) and depressive (5.6%, 7/124) symptoms were found among recipients. ConclusionLiving-related kidney transplantation did not adversely affect the lives and psychological aspects of donors and significantly improved the QOL of recipients. Screening donors strictly, perfecting the medical care system, intensifying follow-up and social supports, and providing necessary healthy and psychological counseling should be fundamental prerequisites.

Ethical Issues Regarding Related and Nonrelated Living Organ Donors

The ethics of the clinical practice of transplanting human organs for end-stage organ disease is a fascinating topic. Who is the "owner" of the transplantable organs of a deceased, brain-dead patient? Who should have a right to receive these organs? Who set the boundaries between a living donor's autonomy and a "paternalistic" doctor? What constitutes a proper consent? These questions are only some of the ethical issues that have been discussed in the last 60 years. All of these ethical issues are intensified by the fact that supply of human organs does not match demand, and that, as a consequence, living-donor organ transplantation is widely utilized. The aim of this article is not to be exhaustive but to present the general ethical principles of beneficence, nonmaleficence, and justice as applied to organ transplantation. Moreover, the topic of reimbursement for organ donation is also discussed.

LIVE DONOR KIDNEY TRANSPLANTATION AND THE PLACE OF CHAPLAINCY IN THE DONOR ADVOCACY TEAM

These two pieces (one from a transplant co-ordinator and one from a chaplain) outline some of the ethical and pastoral issues raised in the increasing field of live donor organ transplantation. These include autonomy, ‘first do no harm’ and the support of families facing these decisions. The articles are based on the work of two members of staff in the Royal Infirmary of Edinburgh.

The effectiveness of transplant legislation, procedures and management: Cross-country evidence

This article investigates the impact of legal determinants of cadaveric and living donor organ transplantation rates using panel data on legislative, procedural and managerial aspects of organ transplantation and procurement, government health expenditures, enrollment rates, religious beliefs, legal systems and civil rights and liberties for 62 countries over a 2-year period. Under living donor organ transplantation, we found that guaranteeing traceability of organs by law or performing psychiatric evaluation to living donors has a sizeable, negative impact on living transplant rates once the remaining determinants of living transplantation have been controlled for. Under cadaveric transplantation, our findings do not suggest an unequivocal and positive association between presumed consent, donor registries and cadaveric transplant rates. However, legally requiring family consent or maintaining written procurement standards for deceased donors has a sizeable, negative impact on cadaveric transplant rates. The latter finding suggests that informing families rather than asking for consent may be an effective strategy to raise procurement rates while respecting patient autonomy. Finally, we confirm that predominantly non-Christian countries have significantly higher living but lower cadaveric transplant rates.

Cytokine concentrations and regulatory T cells in living donor and deceased donor liver transplant recipients

Outcomes of pediatric liver transplantation have constantly improved in the last decade. Living-related liver transplantation does not seem to improve long-term outcomes following liver transplantation, but few studies have evaluated immunological parameters of the alloimmune response after living vs. deceased donor organ transplantation. We analyzed numbers of regulatory T cells, lymphocyte subsets, and serum cytokine concentrations in 12 pediatric recipients of living-related liver transplants and in 28 pediatric recipients of deceased donor organs during their annual follow-ups. Transplant recipients who underwent living donor organ transplantation had significantly higher numbers of regulatory T cells and IL-4 serum concentrations than recipients of deceased donor organs; both of these factors are associated with beneficial outcomes and transplantation tolerance. Living-related liver transplantation may have potentially beneficial immunological aspects, although long-term outcomes do not seem to be better in recipients of living donor organs than in recipients of deceased donor organs. Further studies are needed to compare immunological aspects of the two transplant procedures.

Immunological Monitoring for the Detection of Allograft Rejection after Pediatric Liver Transplantation

Introduction: Individualization of immunosuppressive medications is an important objective in transplantation medicine, but reliable biomarkers to identify tolerant patients among pediatric liver transplant recipients receiving immunosuppressive medications are still not established. We evaluate the potential of regulatory t cells, lymphocyte subsets and cytokine concentrations as potential biomarkers to individualize immunosuppressive medications. Methods: Lymphocyte subsets, regulatory T cells and serum cytokine concentrations were measured in 60 pediatric liver transplant recipients with acute and chronic rejection or normal graft function, and in 11 non-transplanted patients. We also compared these parameters in 12 pediatric living related liver transplant recipients and in 28 children following transplantation with a deceased donor organ presenting with good graft function. Results: Transplant recipients presenting with acute rejection had significantly lower numbers of CD4+ T-cells and increased CD8+ T-cell counts. Regulatory T cell numbers did not differ between children with rejection and patients with good graft function. Children with rejection showed increased concentrations of IL-2 and IFN-γ compared to asymptomatic patients, and high concentrations of IL-4 and TGF-β were detected in transplant recipients with good graft function. Transplant recipients who underwent living donor organ transplantation displayed significantly higher numbers of regulatory T-cell numbers and IL-4 serum concentrations compared to deceased donor organ recipients, both factors associated with beneficial outcome and transplantation tolerance. Conclusion: Cross-sectional parameters of peripheral regulatory T cells in pediatric liver transplant recipients do not seem to be valuable biomarkers for individualizing immunosuppressive therapy. Lymphocyte subpopulations, IL-2, IFN-γ, IL-4 and TGF-β serum concentrations may be potential marker for identification of rejection-prone children following liver transplantation. Living related liver transplantation may imply potentially beneficial immunological aspects.

Living Organ Donors’ Stories: (Unmet) Expectations about Informed Consent, Outcomes, and Care

Living Organ Donors’ Stories: (Unmet) Expectations about Informed Consent, Outcomes, and Care Elisa J. Gordon, Symposium Editor Keywords Ethics, informed consent, kidney, liver, living donor, narrative, transplantation Living donor organ transplantation has become standard treatment for patients with end-stage kidney or end-stage liver disease. Live donors comprised approximately 5,769 (34%) and 247 (4%) of all kidney and liver transplants in 2011, respectively (OPTN/UNOS). The reasons why people donate, the perception that donating does not entail a decision per se, and the attendant fears and anxieties living donors feel about donating, have all been previously well investigated (Lennerling, Forsberg, Meyer, & Nyberg, 2004; Papachristou, Walter, Frommer, & Klapp, 2010). But much less is known about how donors experienced the overall donation process including the donor evaluation, preparation, appreciation of risks, decision-making, informed consent, post-operative, recovery processes, and the impact of donating on all aspects of their life, from their point of view. Thus, a narrative approach is essential for gaining insights into these less well known phenomena. There is good reason to remain concerned about the safety and ethical basis of living donation considering that living donors undergo serious health risks for no direct medical benefit to themselves (Ethics Committee of the Transplantation Society, 2004; Laird, 2012; Neergaard, 2011; Ratner & Sandoval, 2010; Shelton, 2011). The situation raises serious ethical questions specifically about nonmaleficence and informed consent, and more broadly about using people as a means to an end. The absence of long-term information may not undermine a willing donor’s commitment to save a loved one’s life, but is certainly cause for concern among transplant clinicians who want to be sure to disclose information that may be material for donors in order to provide adequate informed consent. In other words, the disjuncture between what transplant clinicians find important to disclose to donors and what prospective donors need to know—which follows along the lines of what Elliot Mishler referred to as the ‘voice of medicine’ versus the ‘voice of the lifeworld’(1984)—seems to complicate donors’ preparation for donation. Donors’ stories are important for addressing these concerns by identifying risks that typically do not get reported in the scientific literature—perhaps owing to a different [End Page 1] conceptualization of what should be construed as noteworthy risks—as well as by demonstrating how personal situations can enhance or detract from the experience overall. This issue of Narrative Inquiry in Bioethics (NIB) affords a unique entrée into both the often heard and unheard stories of living organ donors. A set of topical areas were presented for the authors’ consideration that relate to the donation process in general and the informed consent process more specifically: whether donors were prepared to donate; comprehended what they were told; could have understood the process better, as well as, the impact of donation on health, employment, finances, and personal relationships (Table 1). When soliciting donors’ stories, every effort was made to include a full range of experiences—both good and bad—from a variety of donors: kidney donation, liver donation, adult-to-adult and adult-to-child donation, related, unrelated, directed and anonymous (also known as ‘altruistic’ or ‘good Samaritan’ donors), paired chain exchange, and list exchange (Table 2)—in order to present a balanced perspective on live donation. Additionally, this issue includes a full breadth of stories about the donor experience, ranging from positive to mixed to negative (Table 3). While donors were given tremendous leeway in what stories they told, they were asked to focus their narratives on the lesser known dimensions of donation—the experience of it. While additional stories from liver donors would have helped to underscore common concerns among liver donors, we only received a few. Some of the donors are themselves health care professionals, active in the United Network for Organ Sharing (UNOS) or their local OPO, or have leveraged their experiences to help others by becoming a donor buddy or donor advocate. Given that we received more stories than Click for larger view View full resolution Table 1. Topical areas to address [End Page 2] Click for larger view View full resolution Table 2. Forms of Living Donation Click for larger view View...

Reply: Ethical perspectives on living donor organ transplantation in Asia

We thank Omar et al. for their interest in our article entitled “Ethical Perspectives on Living Donor Organ Transplantation in Asia.”1 We are aware that there is no legal compensated living donation in Sweden. With respect to their article “Compensated Living Kidney Donation: A Plea for Pragmatism,”2 to which we referred in our article, we agree that they discussed a proposed scheme of compensated kidney donation as a way of addressing the current kidney shortage because true altruism in living organ donation is usually unsuccessful. As such, we stated that some believe that a regulated market is an ethical vehicle for shortening waiting lists and decreasing illegal organ sales. However, when we added “this concept forms the basis for compensated living donation in Sweden,” we did not mean to imply that compensated living donation is actually happening in Sweden. What we wished to convey is the possibility of implementing compensated living donation in Sweden because altruism only in living kidney donation is generally an unsuccessful doctrine in increasing organ donation2 and just compensation may gain public support and increase living donation. Some European countries share this view, and this position has been voiced by other authors.3 Again, just compensation is an ethical question. Allan M. Concejero M.D.*, Chao-Long Chen M.D.*, * Chang Gung Memorial Hospital–Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan.

Elective Surgical Patients as Living Organ Donors: A Clinical and Ethical Innovation

To the Editor: One of the principal reasons for publishing our concept paper regarding elective surgical patients as living kidney donors was to encourage criticism of the proposal from experienced transplantation physicians and surgeons such as Drs. Mortier and Rogiers. In this way, we hope to improve and refine our proposal. Mortier and Rogiers are correct in observing that the proposal aims to decrease donor risk in two very different ways: individually and collectively. First, the overall surgical risk would probably decrease for an individual who needs an elective cholecystectomy and who also is motivated or inclined to become an unrelated living organ donor, either now or the future. We believe that, for such persons, the incremental risk of combining the cholecystectomy with the donor nephrectomy during the same operation and anesthesia is likely to be less than the overall risk for the same individual in having two separate surgical procedures and two different general anesthesias. The second decrease in risk is to the collective society. If enough kidneys could be obtained from willing, voluntary elective surgery patients, there would be a decreased need for surgeons to use healthy, related living donors. Using living donors in this way exposes them to risks and harms from a surgical operation that they do not need for their own health but agree to, only to benefit a third party, usually a related recipient, who needs a kidney transplant. Mortier and Rogiers criticize both of these efforts at risk reduction. At the individual level, they claim that surgical patients who might become kidney donors are susceptible to coercion and cannot make an independent decision. While we state in our paper that coercion of living unrelated donors is a critical issue, we believe the same concerns have been raised for 50 years about living-related donors, who are also thought to be susceptible to subtle and overt coercion from family members and physicians (1, 2). We continue to believe that with proper ethical safeguards, such as those implemented in our living liver transplantation program in the 1980s and 1990s (3) and described in the current paper, donor coercion can be minimized. Such proposed safeguards include the use of an independent donor advocate, separate from both the general surgeon and the transplant surgeon, as well as the requirement that any elective surgical patient interested in discussing this idea further would not be asked directly to donate but would have to make a proactive effort to obtain more information about the possibility of donating. At the societal, collective level, we recognize the concerns expressed by Mortier and Rogiers that social trust in the transplantation enterprise could be undermined by this new approach. A different outcome is possible, however. We would hope that relying on voluntarism for unrelated donors would serve as a strong positive statement of altruism and community support and could actually increase the understanding and public acceptance of living donor organ transplantation worldwide. Sincerely, Giuliano Testa, MD

Reply: Ethical perspectives on living donor organ transplantation in Asia

Live donors are a continuing source of organ grafts for solid organ transplantation in Asia. Ethical issues surrounding the development of living donor organ transplantation in Eastern countries are different from those in Western countries. Donor safety is still the paramount concern in any donor operation. Issues on organ trafficking remain societal concerns in low-income nations. Religion, cultural background, economic prerogatives, and timely legislation contribute to the social acceptance and maturation of organ donation.

Ethical perspectives on living donor organ transplantation in Asia

Live donors are a continuing source of organ grafts for solid organ transplantation in Asia. Ethical issues surrounding the development of living donor organ transplantation in Eastern countries are different from those in Western countries. Donor safety is still the paramount concern in any donor operation. Issues on organ trafficking remain societal concerns in low-income nations. Religion, cultural background, economic prerogatives, and timely legislation contribute to the social acceptance and maturation of organ donation.