Never Too Old to Donate?

Updated 3/2017-- all links removed as many no longer active.

I happened to see this press release from American Society of Nephrology via Eurekalert regarding an article in an upcoming issue of the Clinical Journal of the American Society Nephrology (CJASN) advocating the safety of kidney donation in individuals over 70 years old.  The press release does note that kidneys from these elderly donors do not last as long as those from younger living donors.

Currently, as noted on the University of Maryland Medical Center website:

Donors need to be between the ages of 18 and early 70s and can include parents, children, siblings, other relatives, and friends. An ideal donor should have a genuine interest in donating and a compatible blood type with the recipient.

Donors should be in good general health. Donors do not need to be genetically related. Typically, someone who has cancer, diabetes, kidney disease, heart disease, liver disease, sickle cell disease, HIV or hepatitis will not qualify to be a donor. However, these diseases are not all absolute contraindications to donation. Every donor will be considered on an individual basis.

Many individuals over 70 years of age are ineligible simply due to chronic illnesses.   This recent article (full reference below) is a result of a study done by John Hopkins University School of Medicine. 

Jonathan Berger, MD, Dorry Segev, MD, PhD , and their colleagues studied 219 healthy adults over the age of 70 years who donated kidneys and compared them with healthy elderly individuals who were not organ donors.  The surgeries were done at 80 of the 279 transplant centers in the United States.

The researchers found that among recipients of older live donor allografts, graft loss was significantly higher than matched 50-to 59-year-old live donor allografts (subhazard ratio [SHR] 1.62, 95% confidence interval [CI] 1.16 to 2.28, P = 0.005) but similar to matched nonextended criteria 50-to 59-year-old deceased donor allografts (SHR 1.19, 95% CI 0.87 to 1.63, P = 0.3).

Mortality among living kidney donors aged ≥70 was no higher than healthy matched controls drawn from the NHANES-III cohort.

I don’t have full access to the article (only the abstract).  I wonder how old the oldest donor was (ie 72? or 82?).  I wonder if the risk is different for the 70-75 age group vs the 75-80 age group.

Living Donors Online: FAQ (kidney donation)

REFERENCE

Living Kidney Donors Ages 70 and Older: Recipient and Donor; Jonathan C. Berger, Abimereki D. Muzaale, Nathan James, Mohammed Hoque, Jacqueline M. Garonzik Wang, Robert A. Montgomery, Allan B. Massie, Erin C. Hall, and Dorry L. Segev;  Outcomes CJASN October 27, 2011 CJN.04160511; published ahead of print October 27, 2011, doi:10.2215/CJN.04160511 (full article is not open access)

CDC Recommends New Guidelines for Organ Transplantation

Updated 3/2017-- all links removed (except to my own posts) removed as many no longer active. 

There have been several cases of HIV or hepatitis transmitted via solid organ transplantation.  The CDC is recommending new guidelines which would replace the 1994 Public Health Service (PHS) Guidelines for Preventing Transmission of HIV through Transplantation of Human Tissue and Organs.  The draft guidelines is 159 pages long.  The most significant changes involve:

● expanding the guideline to include hepatitis B virus (HBV) and hepatitis C virus (HCV), in addition to human immunodeficiency virus (HIV);
● utilizing factors known to be associated with increased likelihood of HIV, HBV or HCV to identify potential donors at increased risk for transmitting infection;
● distinguishing between expected and unexpected transmission of HBV and HCV in goals for prevention; and
● limiting the focus to solid organ transplants and vessel conduits recovered for organ transplant purposes.

I am a strong proponent of organ donation, but anything we can do to improve the safety for all involved is a good thing to me.  


REFERENCES
CDC: Protect Organ Transplant Patients from Unintended Disease Transmission; September 21st, 2011;  Matthew J. Kuehnert, MD,
Director, Office of Blood, Organ, and Other Tissue Safety

Draft 2011 Public Health Service (PHS) Guideline for Reducing Transmission of HIV, HBV, and HCV through Solid Organ Transplantation (www.regulations.gov, docket CDC-2011-0011-000)

When Does Death Start?

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

H/T to @ctsinclair and @doclake  for the link to this December 16th NY Times article.  If you haven’t read it, it is worth the time, especially if you have any interest in this topic.

When does death start? from NYT http://bit.ly/8xGXjL

The article, "When does death start?",  was written by Darshak Sanghavi, the chief of pediatric cardiology at the University of Massachusetts Medical School, is Slate’s health care columnist and the author of “A Map of the Child: A Pediatrician’s Tour of the Body.”

The article uses the story of Amanda to discuss “brain death” and “death after cardiac arrest”  in conjunction with organ procurement.   No organs can be procured until a person has been declared dead (the so-called dead-donor rule). 

The question of “when does death start?” comes from the 5 minute of no heart activity after cardiac arrest.

In procuring organs from patients like Amanda, doctors have created a new class of potential organ donors who are not dead but dying. By arbitrarily drawing a line between death and life — five minutes after the heart stops — they have raised difficult ethical questions. Are they merely acknowledging death or hastening it in their zeal to save others’ lives?

The article takes the reader through the history of transplantation and the need to define “when death starts.”

Henry Beecher, a Harvard anesthesiologist and medical ethicist, convened a 13-member committee to write a definition of “irreversible coma,” or brain death, for The Journal of the American Medical Association.

President Jimmy Carter asked a blue-ribbon commission to examine the issue. The commission culminated in the Uniform Determination of Death Act in 1981, which defined death as “irreversible cessation of all functions of the entire brain, including the brainstem.”

The 1981 Uniform Determination of Death Act also defines death as the “irreversible cessation of circulatory and respiratory functions,” which left an opening for another source of donors.

In 1987, the nation’s pediatrics authorities tried to standardize the diagnosis, listing 14 different criteria to confirm brain death, like the absence of reflexes, and requiring, under certain conditions, additional X-rays and tests for brain-wave activity.

In 1997, the federal government asked the Institute of Medicine, an independent advisory body, to gather experts to determine how a dying donor might be treated. The experts ended up endorsing the procedure for donation after cardiac death, in which death occurs through a process of withdrawing life support and allowing the heart to develop “irreversible cessation.”

In 2004, pediatric cardiologist Mark Boucek at Denver Children’s Hospital, financed by a federal grant,  wrote a far more aggressive D.C.D. protocol that would save the heart, which was adopted after going through the hospital’s review process. His version …..most controversially, rejected the five-minute rule imposed by the Institute of Medicine and initially picked three minutes instead.

David Campbell, the pediatric cardiac surgeon at Denver who procured the first heart using the (Boucek) protocol, realized that even three minutes was too long. ….. In reviewing the medical literature, Boucek found the longest recorded time that a heart had ever stopped and then spontaneously restarted without medical intervention was 65 seconds.

The article goes on to discuss the current needs for organ donation.  It is estimated that at least 18 people on the transplantation list die each day before the needed organ becomes available.  This need makes the need for an answer to the question of “when does death start?’ extremely important.  The answer could increase the availability of viable organs.

The Institute of Medicine created a new class of potential organ donors: living patients with little hope of recovery who could be declared dead soon after life-support removal. Within a decade, the number of such donors increased tenfold; they now account for 8 percent of organ transplants nationwide, up to 20 percent in certain areas. Still, many hospitals were slow to adopt the practice.

April is National Donor Month

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I was reminded that April is National Donor Month by a post over at Donorcycle.  I am a strong organ donation advocate.  My driver’s license is signed.  My family has been informed of my wishes. 

It is a point of a contention in my family, hopefully a small one that will be resolved (or never come up for real).  My niece, K, who is in nursing school has signed her driver’s license to be an organ donor.  Her mother, my sister, J, will not give her permission if asked – not readily anyway.  “I don’t want my baby cut up.”  That is her reason. 

My niece, K, is a giving soul.  Her wishes should be honored.  She should be allowed to make that last gift if the time ever arises.

I need to find a way to reassure my sister that we don’t “butcher” the body when donor organs are harvested.  I need to get her to read Dr Cris’ blog post “Organ Donation from the Inside”

Transplant surgeons care about donors. Staff respect them, and the decision they have made. Their job in this case is to implement the wishes of the donor and not waste their sacrifice. …... I have assisted at an organ retrieval for transplant, and that is why I am on the Organ Donor Register

Another of my sisters recently was widowed when her husband died of heart failure.  He had had many heart attacks over the last several years.  In the end, he was told he needed a heart transplant.  He didn’t live long enough, but I use this to show that the need it there.  The need is great.  If we would be receivers of the organs, then we need to be givers when able.

Organ Donation (October 22, 2008)

OrganDonor.gov

Organ Donation

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active and it was easier than checking each one.

Last week my friend and fellow blogger Vijay (Scan Man) asked me for information regarding organ donation in the United States.  He was preparing a talk for a local Rotary Club to try to increase organ donation in his country.  My Oct 13th issue of the AMA News arrived a couple of days later and had an article on the same issue here – trying to increase the number of organ donations in our own country.  The article is “Other Nations, Other Answers”.  I think it is a free, open link, but in case it doesn’t here are the highlights.

The highlights:

• In late September, 99,728 people were on the United Network for Organ Sharing waiting list.
• One waiting patient dies every 73 minutes.  Three in four waiting patients need kidneys.
• Iran has the world’s only legal, regulated system of kidney donor compensation.  They claim to have nearly eliminated their country’s waiting list.
• Iran implemented its unique kidney donor compensation system in 1988, and by 1999, the wait for kidneys was eliminated, according to a study in the Nov. 1, 2006, Clinical Journal of the American Society of Nephrology. By the end of 2005, nearly 20,000 kidney transplants had been performed in Iran, with more than three-quarters of the supplied kidneys coming from unrelated living donors who were paid.
• Iran's regulated, legal system of compensating living kidney donors aims to eliminate black market organ brokers and transplant tourists, encourage cadaveric organ donation, and give both rich and poor a chance to get a kidney. Once a potential kidney recipient -- who must be an Iranian citizen -- is identified, a screening process occurs. (reference article below explains the system)
• Spain, by law, presumes organ donation after death unless the individual said otherwise while alive.  Their cadaveric organ procurement rate is 35% higher than ours. If the U.S. could do what Spain does with its presumed-consent law, the U.S. would net nearly 14,000 more organs a year.
• Extreme poverty, endemic corruption and a growing demand for transplants, especially of kidneys, have allowed black market trafficking to flourish in countries such as the India, Philippines, Pakistan and South Africa. This unregulated trade is universally condemned, as there is no assurance that donors are treated well or that recipients get healthy, matching organs.
• On the black market, donors are often paid as little as $1,000 for kidneys, which sell for nearly $40,000.
• The American Medical Association is examining solutions to the organ shortage. The AMA favors studying presumed consent as well as compensation for families of cadaveric organ donors. The Association will lobby Congress to change the 1984 National Organ Transplant Act, which bans "valuable consideration" in exchange for donation, to allow for ethically designed trials of financial incentives.

This referenced article gives the Iran system.  Organ Sales and Moral Travails: Lessons from the Living Kidney Vendor Program in Iran, Policy Analysis No. 614, Cato Institute, March 20;  Benjamin E. Hippen, MD

Other References
"A Gift of Life Deserves Compensation: How to Increase Living Kidney Donation with Realistic Incentives," Cato Institute, Nov. 7, 2007
Do Presumed Consent Laws Raise Organ Procurement Rates?" DePaul Law Review, Winter 2005-06, in pdf
AMA meeting: Delegates seek to change law on organ donor incentives July 7
Economists' study says paying for organs would cut wait lists Jan. 28
Campaign targets TV's skewed view of organ donation Sept. 3, 2007
Prisoner organ donation proposal worrisome April 9, 2007
Kidney transplant turns doctor into activist July 17, 2006

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I am an advocate of organ donation.  My driver’s license is states that I wish to be an organ donor.  I would have no problems with doing as Spain does and making everyone a “presumed” donor.  I applaud the AMA for pushing for ethically designed trials of financial incentives.