Donation to Transplantation — How it Works
It is only fitting that on the eve of the fourth anniversary of my heart transplant that blog 100 on this site addresses the donation/transplantation process. My undying thanks to my donor, his family and my caregiver wife for giving me these extra years. Bob Aronson
Joel Newman is the Assistant Director of Communications for the United Network for Organ Sharing (UNOS). UNOS coordinates all organ transplants in the United states and is located in Richmond, Virginia. In response to my request for a guest blog on how the donation/transplantation system works, Joel wrote the following. Our sincere thanks to him and all the dedicated people at UNOS for their life saving work and for allowing us to use them as a resource.
How It Works
By Joel Newman, UNOS
Since the first successful organ transplant in 1954, more than 500,000 transplants have been performed in the United States. About 250,000 transplant recipients are alive today, and most enjoy a greatly enhanced quality of life as a result of this life-giving therapy.
Under federal contract, UNOS (United Network for Organ Sharing) maintains an extensive national transplant network to assist medical professionals in the recovery and allocation of donated organs. This network is called the Organ Procurement and Transplantation Network (OPTN).
This is a brief overview of the processes involved in listing transplant candidates, organ donation and organ allocation. We at UNOS are glad to address more specific questions.
Transplant Evaluation and Listing
To be considered for a transplant, a person approaching end-stage organ failure must be evaluated at one of roughly 250 transplant hospitals nationwide. A transplant program’s medical team will address issues such as:
- Will a transplant effectively treat his or her disease?
- Does this person have other medical conditions that would complicate his or her care?
- Can this person participate in his or her own care by taking medications on time, following medical advice, keeping appointments, etc.? Does he or she have family or caregiver support to assist if needed?
- Does this person qualify for insurance for transplant costs? If not, can he or she raise funds to defray expenses?
The transplant team makes individual decisions according to its medical judgment. If the program agrees to accept the person as a transplant candidate, it will submit a set of basic data to the OPTN. The OPTN maintains a highly secure, continuously operated computer database to compare medical and logistical information about transplant candidates at hospitals with that of available organs from deceased donors.
An issue sometimes raised is whether a person’s past history of substance abuse, non-compliance with medical care or other self-destructive behavior may count against the possibility of listing. While this remains a medical judgment of the transplant team, their emphasis is not on past behavior but current and likely future status. If the team is reasonably assured that the person has ended harmful behavior and is not likely to resume that behavior once transplanted, they would be more likely to list the person as a transplant candidate. UNOS is not involved in any program’s decision to list a transplant candidate or remove a candidate once listed.
Organ Donation and Recovery
Organ transplantation depends entirely upon the generosity of one human being to help others through the gift of organ donation. While this gift may involve a living donor, we will focus here on donation from those who have recently died in a hospital and who meet criteria for donation.
An organ procurement organization (often called an OPO) is responsible for several key functions in the donation process, including:
- identifying potential donors
- documenting donation consent
- collecting key medical history and lab test results to assess organ function and risk of any diseases that might be transmitted to recipients
- entering donor information and organs available for matching into the OPTN database
- assuming a transplant center accepts the organ offer, arranging for logistics of organ recovery, preservation and transportation
Most deceased organ donors in the U.S. encounter brain death (a complete and irreversible loss of brain function, determined by physicians not involved in the donation process). For such potential donors, respiration and circulation can be maintained artificially for some time (commonly 24 to 48 hours) after brain death has been pronounced.
In other instances, donation may be possible for some people who die in a hospital setting from cardiorespiratory failure. The person’s treating medical team (in no way involved with organ donation) must conclude that he or she cannot survive but will die of cardiac failure instead of brain death. The next of kin must agree that death is imminent and that they will agree to end supportive care. Only then, if the individual meets other criteria for donation, would donation be considered.
Surgeons with specific training and experience remove the organs to be transplanted. Each organ is packaged in sterile conditions and carefully labeled with a unique identification number to be matched with the recipient when it arrives at the transplant hospital. The organ cannot be frozen, as this would cause permanent damage to the blood vessels supplying it. It is preserved in a series of sterile containers that are then surrounded by a solution of wet ice.
Transportation arrangements for deceased donor organs will differ according to the type of organ, the circumstances of the donation, and the distance between donor and recipient hospital. If they are to be used within a local area, ground transportation (ambulance or chartered vehicle) may be used. Hearts, lungs and livers, commonly used within a few hundred miles of the donor location, often travel by charter air flight along with a team from the receiving transplant center. Kidneys have the longest preservation time (commonly up to 36 hours from recovery). If they are being transported over long distances, they may travel on commercial flights and be delivered to and from the airport by a courier service.
Federal law and regulation charge the OPTN to maintain an allocation system that promotes equity and efficiency, minimizes wastage of transplantable organs, and allows individual medical judgment in evaluating and accepting organ offers.
Candidates do not have a designated “ranking” on a waiting list until the OPO enters data for a given organ offer. The characteristics of each offer may be different in terms of donor size, blood type and location, thus the rank-order of potential recipients will be unique to each offer.
The OPTN computer system generates a “match run” list. This displays which potential recipient is to be offered each organ in sequence. Using the match run results, a specialist at either the OPO or UNOS notifies the medical teams for the highest-ranked candidates and provides additional detail to help the team evaluate the organ offer. This initial notification is usually sent electronically via computer or text message, but the transplant program may request additional information by phone.
Once the transplant team for the highest-ranked patient is notified, they have one hour to review detailed information about the donor and the organ and either accept or refuse the offer. If the organ is accepted, arrangements are made for recovery and transportation. If the transplant program declines the offer, it will note a refusal reason back to UNOS. The offer process will continue either until the organ is accepted or until no one can accept it in time to arrange a successful transplant.
The OPTN matching system is programmed to reflect many factors. These include medical data known to affect the likelihood of a successful transplant and ethical principles to promote fairness and public trust in the transplant system. Public trust is especially vital, for if people perceive that the system is unfair they may choose not to support it through organ donation.
In general, OPTN organ allocation policies seek to balance two overarching principles. One is equity – ensuring that each candidate has an equivalent opportunity to be considered for organ offers according to his or her specific need. The other is medical utility – ensuring that the system is able to transplant as many people as possible and with the best possible survival.
In theory, the candidate who is first on the match run list for a given organ should be both in great need of the transplant and have a reasonable chance for long-term survival and quality of life afterward. The specific policies used to generate the computerized match run are weighted statistically to maintain a balance of equity and utility.
While the specific weight of each factor varies according to each organ type, common factors considered in the match run include:
- how well the donor and potential recipients match in terms of blood type, body size and immune system compatibility
- (for heart, lung, liver and intestinal organs) the candidate’s medical urgency, with sicker patients getting highest priority
- the relative distance between donor and recipient (local recipients are considered before more distant patients, to minimize time the organ must be preserved and provide the best chance for a successful transplant)
- if all other factors are equal, priority is given to patients younger than age 18 if the donor is younger than 35 (for kidneys) or 18 (for all other organs)
The matching system does not consider social factors that do not affect medical need or prognosis, such as a person’s wealth, celebrity status or cause of his/her organ failure.
All donation and transplantation professionals work to save and enhance as many lives as possible through the selfless gift of organ donation. We share in the hope that in the future, no one will suffer or die needlessly because an organ was not available in time.
You may comment in the space provided or email your thoughts to me at email@example.com. And – please spread the word about the immediate need for more organ donors. There is nothing you can do that is of greater importance. If you convince one person to be an organ and tissue donor you may save or positively affect over 60 lives. Some of those lives may be people you know and lovePlease view our two brand new video “Thank You From the Bottom of my Donor’s heart” on You Tube at http://www.youtube.com/watch?v=ifyRsh4qKF4 This video was produced to promote organ donation so it is free and no permission is needed for it’s use.
Another important video is “A Transplant for Nurse Lori” this brave woman has Multiple Sclerosis and needs help paying her share of the bill for a procedure that can halt the disease in its tracks and even reverse some of it. Watch the video at http://www.OrganTI.org.
Also…there is more information on this blog site about other donation/transplantation issues.
We would love to have you join our Facebook group, Organ Transplant Initiative The more members we get the greater our clout with decision makers.
Posted on August 4, 2011, in The Donation/transplantation process and tagged Education, Health, Joel Newman, life saving, OPOs, Organ, organ donation, Organ Procurement Organizations, Organ transplantation, physicians, suirgeons, transplantation, United Network for Organ Sharing, United States, UNOS. Bookmark the permalink. Leave a comment.