Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule by Institute of Medicine

Author:Institute of Medicine
Language: eng
Format: epub
Tags: Health and Medicine : Medical Technologies and Treatments
Publisher: NATIONAL ACADEMY PRESS
Published: 1999-12-08T00:00:00+00:00

Organ Preservation and Donor Influences

In the early days of transplantation, the optimal approach to preserve and protect the function of organs deprived of their blood flow had not been well explored. As a result, the donor and recipient had to be located very close to each other to minimize ischemic time. Methods to improve the medically acceptable ischemic time became an intense focus of research that continues. As organ preservation and technical aspects of transplantation improve, the geographic limitations for organ transport have been eased, but not totally eliminated.

The medical literature addressing the impact of cold ischemic time on outcome is expanding but is not yet sufficiently developed to state with certainty the optimal times on an organ-by-organ basis. Even the basic criteria by which viability and function are judged in laboratory-based studies are subject to scientific debate. More to the point, the number of patient and donor variables that confound the interpretation of clinical transplant results is large. Moreover, variability among transplant programs in their philosophy regarding the use of extended criteria donors and organs, as well as the role of retransplantation, significantly affects the results produced in any series.

In addition to ischemic time, several donor factors also influence graft survival. As a result of the shortage of organs for transplantation, the criteria for organ donation have been expanded to include marginal donors (i.e., extended criteria donors) for those candidates awaiting a transplant who could face death if a donor does not become available within a limited time. Donor age, health at the time of donation, and the presence of fatty change on donor liver biopsy are all representative of donor and donor organ characteristics that may influence graft survival.

The transplant team needs to have the flexibility to apply medical judgment in selecting extended criteria donors for candidate recipients with life-threatening organ failure. These decisions may relate solely to the donor source or to the recipient’s medical status, and the results of such transplantation decisions must be weighed in clinical context. As an example, approximately 50 percent of candidates for a cardiac transplant die before a donor becomes available. In this circumstance, a 10-15 percent risk of primary graft nonfunction, hypothetically, might be acceptable if the patient was medically decompensating and likely to die if no donor were available. However, the increased use of non-heartbeating donors and other extended criteria donors must be prospectively evaluated within the context of current and novel technology. The impact on total organ allocation among potential recipients must also be assessed. These analyses must be formulated in a manner that recognizes that clinical and programmatic philosophies will influence perceived differences in outcome.

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