Organ donation Oxford Medicine Online Oxford Textbook of Clinical Nephrology (4 ed.) Edited by Neil Turner, Norbert Lameire, David J. Goldsmith, Christopher G. Winearls, Jonathan Himmelfarb, and Giuseppe Remuzzi Publisher: Oxford University Press Print Publication Date: Oct 2015 Print ISBN-13: 9780199592548 Published online: Oct 2015 DOI: 10.1093/med/ 9780199592548.001.0001 Organ donation Chapter: Organ donation Author(s): Thomas Mone DOI: 10.1093/med/9780199592548.003.0277 Essentials Kidney transplantation has been and continues to be dependent on the apparently unscientific and decidedly personal act of organ donation. In the best-performing regions of the world, 75–95% of those who are medically suitable actually become donors upon their deaths, but because of increasing rates of organ failure, even in these high-performing areas, waiting lists continue to grow. Deceased organ donation performance is highly variable even among medically developed countries, and it is especially challenged in countries with Page 1 of 33 PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford University Press, 2015. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Medicine Online for personal use (for details see Privacy Policy). Subscriber: Thomas Mone; date: 12 May 2016 Organ donation cultural, legal, ethical or religious, economic, clinical, or organizational practices that limit donation. Recognizing these challenges, the transplantation community has collaborated to identify and promulgate international best practices and to foster innovation in the management of deceased donation. The goal of this effort is to clarify the organizational structures, social change interventions, and medical practices necessary to maximize both living and deceased donation. Although donation practice differs significantly across countries, successful organ donation programmes share certain traits and practices that can be modified to fit varied medical delivery reimbursement and social systems and structures. The world’s best-performing donation programmes have focused on increasing the public’s and healthcare professionals’ trust in the donation process, ensuring equitable access to transplantation, and they have built donation organizations that borrow from the theory and practice of business and healthcare management systems. The critical processes, essential functions, job roles, and foundational principles of successful donation programmes require the use of the tools that have been shown to improve donation and increase transplantation, thereby reducing (or, ideally, ending) deaths on the waiting lists. The wider adoption of these tools by countries with fledgling or struggling organ donation would increase organ availability and its exploitation of the poor who in many countries become organ ‘vendors’ rather than donors. Current state of organ donation A country’s organ donation performance correlates roughly with its general development status and medical infrastructure. The United States, the countries of Western Europe, Australia, and Canada consistently report higher deceased donation rates than the developing world. Annual donation rates in these countries range from 8 to 32 donors per million population (DPM), with Spain and the United States reporting the highest rates (32 and 26 DPM, respectively) (Organ Procurement and Transplantation Network (OPTN), 2010; US Census, 2010; IRODAT: European Transplant Coordinators Organisation, 2011). Regions where general access to healthcare and funds to support transplant programmes are limited (e.g. Africa and the Indian subcontinent) report donation rates of 0–3 DPM. Between these two poles, are countries reporting donation rates ranging from 0 to 15 DPM where adequate to sophisticated medical systems have been established Page 2 of 33 PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford University Press, 2015. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Medicine Online for personal use (for details see Privacy Policy). Subscriber: Thomas Mone; date: 12 May 2016 Organ donation but traditional cultural, legal, or structural barriers to donation exist (e.g. Japan, Russia, and much of Latin America). Although DPM is commonly used for comparative measurement, it is a relatively crude measure of donation practices across regions, because donation is influenced by multiple factors, including death rate, in the United States, for instance, state death rates average 8.2 per million but range from a high of 14 per million in West Virginia to a low of 5 per million in Utah (US Census CDC, 2010). In addition cause of death, age, population, and availability of intensive care unit (ICU) beds can vary dramatically (Sheehy et al., 2012). Therefore, DPM should be supplemented with additional measurements, such as transplants per million population (TPM), in which world leaders include the United States (92.8), Croatia (88.9), Norway (88.3), Portugal (83.5), and, Spain (75.3) (OPTN, 2010; Nanni et al., 2011a). Ideally, donation performance should be measured by the conversion rate now used by the US OPTN, which assesses the percentage of declared brain-dead donors without contraindicating diagnoses (e.g. cancers, viral meningitis) who actually donate upon death. In the United States, where this statistic has been the standard measure of donation effectiveness since 2004, the conversion rate averages 76% (OPTN, 2011). In other countries, however, it is not routinely and consistently measured, so DPM is the only common measure. To make this statistic more reliably comparable, normalizing DPM to a mean death rate (normalized DPM) enables a more accurate assessment of donation performance by region (see Table 277.1). Page 3 of 33 PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford University Press, 2015. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Medicine Online for personal use (for details see Privacy Policy). Subscriber: Thomas Mone; date: 12 May 2016 Organ donation Table 277.1 Organ donors, donation rate (normalized by death rate), and transplantation volumes in 2010 (among countries with verifiable routine reporting of donation and transplantation data) Country 2010 Population 2010 Death Death rate Total 2010 deceased (millions) donors/ rate normalized trans- Tx/ donors million nDPM plants million pop. (Tx) Pop. (DPM) (TPM) Spain 1502 47.1 31.9 8.8 33.3 3781 80.3 United 7943 309.6 25.7 8.4 28.1 28663 92.6 States Portugal 323 10.7 30.2 10.8 25.7 893 83.5 France 1538 63 24.4 8.8 25.5 4747 75.3 Croatia 135 4.4 30.7 11.9 23.7 391 88.9 Austria 196 8.2 23.9 10.1 21.7 762 92.9 Italy 1298 60.5 21.5 9.2 21.4 3146 52.0 Norway 102 4.9 20.8 9.2 20.8 432 88.2 Australia 302 21.8 13.9 6.9 18.5 1279 58.7 Belgium 221 10.4 21.3 10.6 18.4 900 86.5 Argentina 583 40.5 14.4 7.4 17.9 1586 39.2 Canada 495 34.1 14.5 8 16.7 2114 62.0 Czech 206 10.5 19.6 10.9 16.5 573 54.6 UK 1015 62.2 16.3 9.3 16.1 3946 63.4 Finland 92 5.4 17.0 10.2 15.4 265 49.1 Page 4 of 33 PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford University Press, 2015. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Medicine Online for personal use (for details see Privacy Policy). Subscriber: Thomas Mone; date: 12 May 2016 Organ donation Brazil 1934 193.3 10.0 6.4 14.4 6422 33.2 Netherlands 227 16.6 13.7 8.9 14.1 1136 68.4 Germany 1296 81.6 15.9 10.9 13.4 5194 63.7 Israel 60 7.6 7.9 5.5 13.2 235 30.9 Denmark 73 5.5 13.3 10.2 12.0 332 60.4 Sweden 118 9.4 12.6 10.2 11.3 641 68.2 Mean 908 48.0 18.4 9.2 18.4 3183 66.3 California, 785 37.3 21.0 6.2 31.2 3222 86.4 United Statesa Donor data: European Transplant Coordinators Organisation (2011). Organs, Tissues, & Cells, 14(3). UNCS/OPTN: California, United States: >http:// optn.tranplant.hrsa.gov/latestData/viewDataReport.asp< Death Rate Data: CIA. World Fact Book >https://www.cia.gov/library/ publications/the-world-factbook/index.html< 2020 population data: >http://www.ration.online.org/onworld/< a California induced to demonstrate impact of low death return on donor availability and DPM. Ultimately, the success of organ donation in a region is judged by the status of the transplant waiting lists. Clearly, even in the most successful regions (e.g. the United States and Austria), donation is not keeping up with the need for organs. This shortfall is attributable partly to an ageing and affluent society experiencing organ failure secondary to hypertension, diabetes, and partly to advances in medical technologies such as dialysis and left ventricular assist devices, which enable patients to wait years for an organ. In fact, even if 100% of potential deceased organ donors donated, waiting lists would not disappear, not only Page 5 of 33 PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford University Press, 2015. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Medicine Online for personal use (for details see Privacy Policy). Subscriber: Thomas Mone; date: 12 May 2016 Organ donation because of the current high demand but also because over the past 20 years, any increases in the availability of organs have routinely been matched or exceeded by increases in the number of potential recipients.