The first human transplant was a cornea harvested from a cadaver in 1905.

Blood transfusion became established in 1918 and the first successful human kidney transplant was in 1954. The first heart transplant took place in 1967.

In the UK between 1 April 2010 and 31 March 2011:¹

• 3,740 organ transplants were carried out through 2,055 donors.
• 1,008 lives were saved in the UK through a heart, lung, liver or combined heart/lungs, liver/kidney, liver/pancreas or heart/kidney transplant.
• 2,732 patients' lives were improved by a kidney or pancreas transplant, of whom 156 had a combined kidney/pancreas transplant.
• 3,564 people had their sight restored through a corneal transplant.
• 567 non-heartbeating donor kidney transplants took place, accounting for one fifth of all kidney transplants
• Nearly 675,000 more people added their names to the NHS Organ Donor Register, bringing the total to 17,751,795.

What can be donated?

Kidneys, heart, liver, lungs, pancreas, small bowel, corneas, heart valves and bone can all be transplanted. Skin can be used to treat patients with severe burns.

National Institute for Health and Clinical Excellence (NICE) guidance²

NICE guidelines were published in 2011 suggesting improvements in donor identification and consent rates for deceased organ donation. The guidelines acknowledge the complexities involved in obtaining consent from patients around the time of death.They also highlight the obligations which consultant staff have when considering organ donation as part of end of life care.

Consent is an important issue. Informed decisions about end of life care, including organ donation, should be made by patients with capacity after discussion with their healthcare providers; in many cases parents, guardians and families should also be involved unless this is against the patient's express wishes.

If the donor is under 16, the 'Seeking consent: working with children' guidelines should be followed.

If potential donors lack capacity, the Department of Health's guidelines on consent³ and the code of practice accompanying the Mental Capacity Act should be followed.⁴ The Welsh government's advice on consent should be followed in Wales.⁵

Identifying donors: potential donors should be identified as early as possible, based on the following criteria:.

• The patient is receiving end of life care, has had a catastrophic brain injury, there is absence of one or more cranial nerve reflexes and a Glasgow Coma Scale (GCS) score of 4 or less that is not explained by sedation.
• It is expected that withdrawal of life-sustaining treatment would result in circulatory death.

Once these criteria are met, the healthcare team should initiate discussions with the specialist nurse for organ donation.

Assessing best interests: for patients who lack capacity, an assessment will need to be made as to whether organ donation would be in the patient's best interest. Life-maintaining and sustaining treatments should be continued and the patient should be kept clinically stable whilst their wishes and clinical potential are explored, aided by clinical and legal specialist advice.

When assessing best interests, consider:

• What is known about the patient's views, especially if an advance statement or registration on the NHS Organ Donor Register has been made or the patient has expressed views to family members or friends.
• The beliefs or values likely to influence the patient if they had capacity to make the decision.
• Any other factors likely to influence the patient if they had capacity.
• The views of family, friends and anyone else involved in the provision of care.
• Anyone identified by the patient to be consulted about such decisions.

• Potential for donation.
• The NHS Organ Donor Register/Lasting Powers of Attorney for health and welfare/advance statements.
• Coronial, legal, safeguarding issues.
• Clinical history.
• Identity of key family members.
• Need for family support - faith/advocate/translator.

The discussion with those close to the patient should be conducted in a sensitive, patient and caring manner, at a mutually convenient time. They should already be aware that death has occurred or is impending. The issue should be approached in a positive way and negative comments or apologies should be avoided (e.g. 'I am sorry to have to broach this subject with you').

Discussion should include:

• The likely wishes of the patient if they had been able to express them.
• An assurance that the standard of care will not change irrespective of the decision.
• What criteria will be used to determine when death has occurred.
• What likely interventions to expect between consent being given and the organ(s) being retrieved.
• Coronial and legislative issues.
• Consent documentation.
• The fact that donation may not occur despite consent being given.

The Organ Donation Taskforce was set up by the UK government in 2006. One key area for debate is how to make organ donation usual rather than unusual. The Spanish model has demonstrated the importance of a clinical champion in each hospital, responsible for ensuring that all opportunities for donation are taken.⁶ There is a potential for an 'opt-out system' where all individuals are deemed to have given consent for organ donation unless they register otherwise.⁷ There has been some opposition to this.⁸

Living donation

The shortage of organs has led to an increasing number of organ donations by living people. The most common organ donated by a living person is a kidney.

Live donor kidney transplants are increasing. 1,045 live donor kidney transplants took place for the year ending March 2011, accounting for more than a third of all kidney transplants.¹

Most living donor kidney transplants are between close family members because they usually provide the best match. Under rules which came into force throughout the UK on 1 September 2006, 'altruistic' donations - those from living people who simply want to donate a kidney but not to any particular person - have been permitted.⁹

Altruistic donors will have to have a psychiatric assessment in addition to the usual medical and surgical preparation. Patients with a friend or relative prepared to donate a kidney, but whose tissue is found to be incompatible, will be able to be paired with another couple in the same situation. If the donor in each couple is a match for the patient in the other, the transplant could go ahead. For a pooled donation, there would be a chain of several pairs.

Part of a liver can be transplanted¹⁰ and it is also possible to donate a segment of a lung¹¹ and, in a very small number of cases, part of the small bowel.

Non-heartbeating donors

Kidneys transplanted from living donors were thought to have a better chance of long-term survival than those transplanted from people who have died. In an effort to increase numbers of organs for donation, several centres are now retrieving organs from non-heartbeating donors as well as conventional brain-dead donors.¹² Some research suggests that an elderly recipient (with an imminent live donor transplant) should never be offered a cadaveric donor because of increased risk of graft failure.¹³ However, this has been disputed.¹⁴ In younger patients, cadaveric kidneys are to be preferred.¹³

These organs come from patients who have a cardiac arrest and cannot be resuscitated, whose kidneys are flushed with a cold preserving solution so that the kidneys can then be removed before irreversible damage occurs. With careful selection of donors and appropriate infrastructure, these kidneys have been shown to perform as well as kidneys from brain-dead donors.¹⁵ The background to the changes includes evidence of variation in access to kidneys and recent improvements in immunosuppression. Probably because of more potent immunosuppressant drugs, tissue type matching has a much smaller effect on the long-term outcome of kidney transplantation.¹⁶

The NHS Organ Donor Register

This is the confidential, computerised database which holds the wishes of people who have decided that, after their death, they want to donate organs. The register is used after a person has died, to help establish whether they wanted to donate and, if so, which organs.

How to become a donor

You can become a donor via the referenced website or by calling the NHS Organ Donor Line: 0300 123 23 23.¹⁷ The lines are open 24 hours, 365 days a year. The calls are charged at the contracted rate for local calls. The register can also be joined by texting SAVE to 84118.

Other opportunities to register are when:

• Registering for a driving licence.
• Applying for a Boots Advantage card.
• Registering at a GP surgery.
• Registering for a European Health Insurance Card (EHIC).

Donor cards, which can be carried, are available at some surgeries and hospital departments.

Organ allocation

The shortage of organs has highlighted inequities in access to deceased donor kidneys and, after prolonged controversy, the national kidney allocation scheme administered by UK Transplant changed from April 2006. The main changes, campaigned for by representatives of patients and professional groups, are thought to represent a fairer deal for patients in that they take more account of waiting time and less of tissue type matching.¹⁸ The scheme continues to take into account many factors relating to the donated kidney and potential recipients, using complex computerised simulations designed to balance equity of access and utility of transplanted kidneys.¹⁹ When an organ becomes available anywhere in the country, the duty office at UK Transplant is notified immediately.

Staff identify whether there are any urgent cases, with blood group or age compatibility, in any of the transplant centres. Sometimes there are no suitable patients anywhere in the UK but a reciprocal arrangement with the European Union (EU) enables donor organs to be offered to other EU countries.

Priority

Organs donated from children generally go to child patients to ensure the best match in size but, when there are no suitable child recipients, organs from young people are given to adults.

All kidneys from deceased heartbeating donors are allocated according to a national system. This is based on five tiers:

• Complete matches for children - difficult to match patients.
• Complete matches for children - others.
• Complete matches for adults - difficult to match patients.
• Complete matches for adults - others and well-matched children.
• All other eligible patients (adults and children).

Within the first two tiers, children are prioritised according to their waiting time. In the remaining tiers, patients are prioritised according to a points score, whereby organs are allocated to the patients with the highest number of points. The score for an individual patient is based on a number of factors:

• Time on the waiting list (favouring patients who have waited longest).
• Tissue match and age combined (favouring well-matched transplants for younger patients).
• The age difference between donor and patient (favouring closer age matches).
• Location of the patient relative to the donor (favouring patients who are closer in order to minimise the transportation time of the kidney).
• Three other factors relating to blood group match and rareness of the patient's tissue type.

The Human Tissue Act 2004

This legislation was introduced to regulate the removal, storage and use of human organs and tissue. The Human Tissue Act 2004 received Royal Assent on 15th November 2004.²⁰ It provides safeguards and penalties to prevent a recurrence of the distress caused by retention of tissue and organs without proper consent and the public outcry over the retention of children's organs without their parents' consent by Bristol Royal Infirmary and Alder Hey Hospital. Tissue or organs cannot be taken or kept without consent other than for a coroner to establish the cause of death.

Document references

1. Statistics: Transplants save lives, NHS Blood and Transplant
2. Organ donation, NICE Clinical Guideline (December 2011)
3. Reference guide to consent for examination or treatment, second edition, Dept of Health, 2009; Updated May 2010
4. The Mental Capacity Act 2005, Dept of Health
5. Good Practice in Consent, Welsh Assembly Government, 2008; link to document
6. Hamm D, Tizzard J; Presumed consent for organ donation. BMJ. 2008 Feb 2;336(7638):230.
7. Callender TA; Presumed consent. Incentivising organ donation. BMJ. 2010 Jun 16;340:c3152. doi: 10.1136/bmj.c3152.
8. Yadav S; Lords committee comes down against presumed consent for organ donation. BMJ. 2008 Jul 4;337:a698. doi: 10.1136/bmj.a698.
9. Dyer C; Paired kidney transplants to start in the United Kingdom. BMJ. 2006 Apr 29;332(7548):989.
10. Living-donor liver transplantation, NICE Interventional Procedure Guideline (2006)
11. Living donor lung transplantation for end-stage lung disease, NICE (2006)
12. Transplantation guidelines (various), British Transplantation Society (various dates)
13. Mandal AK, Snyder JJ, Gilbertson DT, et al; Does cadaveric donor renal transplantation ever provide better outcomes than live-donor renal transplantation? Transplantation. 2003 Feb 27;75(4):494-500. [abstract]
14. Sener A, Schweitzer EJ, Munivenkatappa R, et al; Deceased-donor renal transplantation in the geriatric population demonstrates Transplantation. 2009 May 27;87(10):1549-54. [abstract]
15. Summers DM, Johnson RJ, Allen J, et al; Analysis of factors that affect outcome after transplantation of kidneys donated Lancet. 2010 Oct 16;376(9749):1303-11. Epub 2010 Aug 18. [abstract]
16. Collins BH et al, Renal Transplantation (Urology), Medscape, Aug 2011
17. How to become a donor, UK Transplant Website
18. Geddes CC, Rodger RS; Kidneys for transplant. BMJ. 2006 May 13;332(7550):1105-6.
19. Equality of access to donor organs, NHS Blood and Transplant, 2011
20. Human Tissue Act 2004

Internet and further reading

• Hirschfield GM, Gibbs P, Griffiths WJ; Adult liver transplantation: what non-specialists need to know. BMJ. 2009 May 22;338:b1670. doi: 10.1136/bmj.b1670.
• Guidelines on Renal Transplantation, European Association of Urology (2009)
• Stock PG, Barin B, Murphy B, et al; Outcomes of kidney transplantation in HIV-infected recipients. N Engl J Med. 2010 Nov 18;363(21):2004-14. [abstract]
• Codes of practice related to: removal, storage, use and disposal of human tissue and organs, Human Tissue Authority (various dates); includes donation of organs, tissue and cells, bone marrow and peripheral blood stem cells for transplantation
• McGlade D, Rae G, McClenahan C, et al; Regional and temporal variations in organ donation across the UK (secondary BMJ Open. 2011 Jan 1;1(2):e000055. [abstract]
• British Transplant Society, Various UK endorsed guidelines, 2011