ORGAN DONATION AND ALLOTRANSPLANTATION

Ana Montesinos Mayoral

INTRODUCTION

• Transplantation is the transfer of cells, tissues or organs alive, from a person to another, or for a part of the body to another part of it, with the purpose of restoring a lost function

• Organs or tissues for donation:– Heart, kidneys, liver, lungs…– Pancreas, intestine– Bones, cornea, skin, heartvalves– Nerves , veins

HISTORY• 300 B.C. Indians (repairing wounds

by skin transplantation)

• The first transplant assumed as such is immortalized in a painting of Fra Angelico, of 1438-1440, where we can see the saint Cosme and the Saint Damian transplantating an Ethiopian's leg

• 16 th century: Gasparo Tagliacozzi (repairing nose-skin transplantation)- observed immune reaction

HISTORY19 th century

• 1818: First human to human blood transfusion

• 1878: First successful human to human bone transplant

• 1896: First bone marrow transplant

20 th century (1/2)• 1905: Eduard Zirm- corneal

transplant (restoring sight)• 1912: kidney

transplantation on dogs, connecting blood vessels (Nobel prize)

• 1936: Yu Yu Wronoy- Human kidney transplantation from dead donor (the pacient died in few days)

HISTORY20 th century (2/2)

• 1954: Joseph E. Murray- Brigham and Women’s Hospital (Boston, USA)- The first successful kidney transplant (from a twin to the other twin) The pacient lived 8 years

• 1960: Peter Medawar- Nobel Prize for discovering of acquired immune tolerance (Beginning of anti-rejection drugs)

• 1960´s: First lung, pancreas, liver transplant

• 1967: Christiaan Barnard-SouthAfrica-First heart transplantation. The pacient lived 18 days, died on pneumonia.

HISTORY

• In Portugal, the first transplant was made by Linhares Furtado, in Coimbra, on 20 th July 1969 (kidney transplant)

• 2005: Baltimore Hospital- pioneered “domino chain”- It is initiated when an altruistic donor donates an organ to a patient who has a willing but incompatible donor. This incompatible donor then "pays it forward" and passes on the generosity to another recipient who also had a willing but incompatible donor.

“DOMINO CHAIN”

HISTORY

• 2010: SPAIN- First full face transplantation (Hospital Universitario Valle de Hebrón, Barcelona)

https://www.youtube.com/watch?v=o8ndC4KF7YY

TYPES OF TRANSPLANTATION

• Allotransplantation: Is the transplantation of cells, tissues or organs to a recipient from a genetically non-identical donor on the same species.– Living donor transplantation– Cadaveric donor transplantation– Foetal tissue transplantation

• Autotransplantation: Is the transplantation of organs, tissues or proteins from one part o the body to another in the same individual.

• Xenotransplantation: Is the transplantation of living cells, tissue or organs from one specie to another (Ex: pigs-humans)

• Isograft: Is a graft of tissue between two individuals who are genetically identical (Ex: Monozygotic twins)

LIVING DONOR TRANSPLANTATION• The selection process of a living donor varies significantly

depending on the organ to transplant . In general , the donor should be a healthy individual , mentally able to assert their donation without pressures of emotional or socio- economic order.

• In the case of kidney or liver donation in Portugal are accepted as donors , relatives, spouses , friends or anyone else , regardless of whether any blood relationship (Lei nº 22/2007, de 29 de Junho)

• Before being accepted as a donor , the individual has to pass several physical, laboratory , radiological tests , in order to detect any factors that could make the donation any riskier. If one of these factors is detected , the individual will be rejected as a donor .

LIVING DONOR TRANPLANTATION

ADVANTAGES

– Decrease waiting-list – Better timing for

procedure (previous treatment can be finished)

– Lower immune reaction and lower rejection rate (in case of relatives)

DISADVANTAGES

– Huge pressure on prospective donors

– Exploitation of donors– Insufficient knowledge and

informedness of donors and their families about this possibility

– Risk of nephrectomy (kidney disease)

– Donor lives with one kidney

LIVING DONOR TRANSPLANTATION

CADAVERIC DONOR TRANSPLANTATION

• Concept: An organ or tissue donation from a donor who has already died.

• In Portugal, the causes of death are still mainly of medical origin (71% in 2009 vs 74% in 2010)

• Hemmorrhagic stroke is the cause of death in 50% (n=161) of the donors, followed by other traumas.

• The causes less frequiently pointed are Tumor and Work Accident.

FETAL TISSUE TRANSPLANTATION

• It´s the implant of tissue from an aborted fetus to a patient for treatment of disease.

• Human fetal transplantation is still experimental. • Using fetal tissue for transplantation: Fetal

tissue transplantation may be able to overcome the failures of traditional medical and surgical therapy to ameliorate several diseases, most notably Parkinson´s disease and insulin-dependent diabetes mellitus.

FETAL TISSUE TRANSPLANTATION

• ETHICAL ISSUES- Are fetal rights violated by the use of fetal

tissue?- Is there a moral danger that the potencial of

fetal tissue donation will encourage elective abortions?

- What criteria should be used to select fetal tissue transplant?...

CADAVERIC DONOR TRANSPLANTATION

FUNDAMENTAL QUESTION

WHEN IS THE PERSON CONSIDERED DEAD?

WHEN IS THE PERSON CONSIDERED DEAD?

• BRAIN DEATHBrain death means that all brain and brain stem function has irreversibly ceased, while circulatory and ventilatory functions are maintained temporarily

The clinical diagnosis of brain death rests on three criteria:(a) irreversibility of the neurologic insult; (b) absence of clinical evidence of cerebral function; and most important, (c) absence of clinical evidence of brain stem function.

SYSTEM OF CONSENT

OPT-IN SYSTEMPotential donors must express their consent during the life, otherwise they do not donate their organs

OPT-OUT SYSTEMThere is presumptive consent from every person, unless the person expresses refusal to donate

(Ex: Portugal)

SYSTEM OF CONSENT

OPT-OUT SYSTEM IN PORTUGAL

• In Portugal, any national or foreign citizen who lives in the portuguese territory, is considered a donor since birth. It´s not necessary to perform any application, registration or authorization for the donation.

• Those who do not wish to donate their organs after death must register in “Registro Nacional de Não Dadores” (RENNDA)

• The Decreto-lei 244/94, de 22 de abril, rules REENDA

SYSTEM OF CONSENT

OPT-IN SYSTEM– Lower percent of population

sign the consent (90 percent of Americans agree with donation, but only 30 percent of them consented to donate their organs).

– Icky and difficult for persons to think about it.

– Need of education and publicity in media.

– Connection of the consent form with the issuance of driver’s license.

OPT-OUT SYSTEM– Much higher percentage

of cadaveric donors (more than 90 percent).

– People do not have to solve this issue, only if they are strictly against it.

– Questionable role of family.

– Poor informed society.– Missing of the consent.

STATISTICSSPAIN (2013)- Organización Nacional de

Transplantes (ONT)• 4279 transplants• 1655 donors• 35.12 donors per million people• Decreasing number of patients in waiting-list

(5513 in 2012 vs. 5418 in 2013)• Only 15.16% families said “no” to donation• 30000 bone marrow donations

STATISTICSPORTUGAL (until 2010)- Sociedade Portuguesa

de Transplantação (SPT)

STATISTICS

STATISTICS

INTERNATIONAL AND NATIONAL LAW ABOUT TRANSPLANTATION

International Law• Additional Protocol to the Convention of Human Rights

and Biomedicine concerning transplantation of organs and tissues of human origin.

Since 1st May 2006 Applies the Principles of the Convention to the field of

organ and tissue transplants, respecting its main objectives: protecting the dignity and integrity of the human being and protecting the rights and fundamental freedoms, with regard to advances in Medicine and Science.

INTERNATIONAL AND NATIONAL LAW ABOUT TRANSPLANTATION

The Principles:• Equality of access to patients in the transplant services;• Transparency of rules for allocation of organs and

tissues;• Setting safety standards;• Gratuity of donations;• Good information for all involved;• Confidentiality;• Punishments in case of violation.

INTERNATIONAL AND NATIONAL LAW ABOUT TRANSPLANTATION

National Law• Constituição da República PortuguesaPart I: Contains provisions which supervise fundamental values of bioethicsPrinciple of Equality (13º)Right to Life (24º)Right to Humane Treatment (25º)Right to Health (64º)

INTERNATIONAL AND NATIONAL LAW ABOUT TRANSPLANTATION

• Lei 12/93, de 22 de Abril Rules the harvesting and transplantation of

organs and tissues of human originIt was amended by Lei 22/2007, de 29 de

Junho and Lei 12/2009, de 26 de Março

INTERNATIONAL AND NATIONAL LAW ABOUT TRANSPLANTATION

Additional national legislation• Lei n.º 141/99 da Assembleia da

República (Criteria of brain death)• Decreto-Lei n.º 244/94 de 26 de

Setembro (National Register of No-Donors)• Portaria n.º 31/2002 de 08 de

Janeiro (Transplant Centers)

“ILEGAL ORGAN TRADE”• According to the World Health Organization (WHO),

illegal organ trade occurs when organs are removed from the body for the purpose of commercial transactions.

• Organ traffic is the third most lucrative crime in the world.

• It occurs especially in some Asian countries with a particularly permissive legislation.

• Many people travel to get a transplant, without questioning how the agency obtained the organ and without knowing that the operation hasn’t any medical guarantee, since neither the giver nor the receiver is followed later.

ETHICAL ISSUES OF TRANSPLANTATION

• Financial advantageous of transplantation – often lower costs than medical treatment of ill person

• Family acceptance of death takes a while• Habits and rites• Human body is not a property• Unity of soul and body• Biological ethic– neutral value of such procedure– Biomass

RELIGION

• Christianity – supports donation• Jehovah's Witnesses – cancelled prohibition of

transplantations in 1967, but it is not clear, how to perform it, when blood transfusion is forbidden.

• Orthodox Jewish (not reformed and liberal ones) does not allow the transplantations, which are terminating human life by human extraction.

RELIGION

• Islam– different scholars– generally organ donations are not permitted – some of the schools permit live donations– some of them also cadaveric donations, if it is not

transplantation of organ, upon which the life depend (heart, liver), because it kills the soul

– but not unconditionally, they have their own rules which must be fulfilled

RELIGION

• Buddhism– Allows, but let every single person to decide on his

own– Tibetan Buddhists believe in consciousness after

death, and such a person/body cannot be disturbed, so cadaveric transplants are not possible for them