Organ Donation

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.

At March 31st, 2007, 7234 patients were listed as actively waiting for a transplant.¹ Most are waiting for a kidney. Around 3000 transplants are carried out each year.
In the UK between 1 April 2006 and 31 March 2007:

• Organs from 1495 people who died were used in 3086 transplants.
• 949 lives were saved in the UK through a heart, lung, liver or combined heart/lungs, liver/kidney, liver/pancreas or heart/kidney transplant.
• 164 people received a pancreas or combined kidney/pancreas transplant.
• 2402 people had their sight restored through a cornea transplant.

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.

Several studies have shown that over 70% of the population is positive to donate their organs after their death.² Despite this it is not unusual for organ donation to be not performed. The most important factor in increasing donation is early identification of a potential subject. Early identification and optimal medical care occur more frequently when there is a good, positive attitude of the ICU staff toward the process.

The Organ Donation taskforce set up by the UK government in 2006, says an extra 1,200 transplants could be done each year, (which it says could save the NHS more than £500m over 10 years) if its recommendations are realised.³ 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. 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.
There has been some opposition to this.

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.
Living donor kidney transplants are increasing; 461 in 2003-2004 to 690 in 2006-2007, and now represent more than one in four of all kidney transplants.
Most living donor kidney transplants are between close family members because they usually provide the best match. This limits the numbers to 500 a year in the UK. Under the new 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.⁴

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 transplanted⁵ and it is also possible to donate a segment of a lung⁶ and, in a very small number of cases, part of the small bowel.

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-heart beating donors as well as conventional brain dead donors.⁷ However 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. The opposite situation pertains in younger patients.⁸

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.⁹ 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.¹⁰

This is the confidential, computerised database which holds the wishes of more than 12 million 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.
On 31 March 2007 14,201,229 people had promised to help after death by adding their names to this register.

How to become a donor

You can become a donor via the referenced website or by calling the NHS Organ Donor Line: 0845 60 60 400.¹¹ The lines are open 24 hours, 365 days a year. The calls are charged at the contracted rate for local calls.
Donor cards are available at some surgeries and hospital departments, which can be carried.

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.¹² 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. 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 enables donor organs to be offered to other EU countries.

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 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.

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 2004.¹³ 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.