Organ Donation and Allocation
Section 2: Organ Donation and Allocation
What organs can be donated?
Deceased Organ Donation:
- Two Kidneys
- Two Lungs
Hand and face transplant is known as vascular composite allograft (VCA). These are surgeries composed of grafting many kinds of tissue: bones, muscles, nerves, skin, and blood vessels. As of January 2018, less than 200 VCA organ transplants had been performed around the world. Visit the organdonor.gov website to learn more about VCA transplants.
Living Organ Donation:
- One Kidney
- One Lung
- Portion of intestine
- Portion of a liver
- Portion of a pancreas
Tissue Donation: can dramatically improve the quality of life for the people who receive them
- Heart valves can help children born with defects or adults with damaged heart valves.
- Skin can be used for those with serious burns and help to stop serious infection.
- Bone is important in artificial joint replacements or those with illness or injury to bone.
- Tendons can be used to help rebuild damaged joints.
- Cornea can help to restore sight in those with scarred or diseased corneas.
- Middle ear
Tissue donation must be initiated within 24 hours of death. However, once processed, it can be stored for an extended period of time.
How is death declared for deceased donors?
Before evaluation and allocation of organs for donation, brain death of an individual must be declared. Brain death is diagnosed as an irreversible loss of blood flow to the brain, causing the whole brain to die.
Note: Federal law prohibits the patient’s physician and the physician who determines the patient’s death from taking any part in the transplantation process.
Certain conditions that mimic brain death, but are reversible and a doctor may be on the look- out for, include, but are not limited to:
- Severe imbalance of electrolyte, acid-base, and endocrine function.
- Drug intoxication and poisoning.
- Use of sedatives or neuromuscular blockades.
- Hypotension (low blood pressure).
- Hypothermia (extremely low body temperature).
A physician will conduct the neurological testing numerous times to confirm the diagnosis of brain death.
What is the authorization and evaluation process of deceased donor allocation?
When a patient is close to being declared as brain dead or has been declared brain dead, the local organ procurement organization is notified. At that point in time, the OPO checks the DMV to make sure the donor has made an anatomical gift. In the event the individual has not indicated their wishes, a trained member of the OPO contacts a family member, usually the next of kin, to make the decision of whether or not to donate the organs.
What does it mean to be a high risk donor?
A high-risk donor is a donor that has a possible history of HIV or hepatitis including:
- History of being incarcerated.
- History of intravenous (IV) drug use.
- Multiple past sexual partners.
What factors are considered in respect to donor quality with deceased donors?
Assessment of donor quality is based on many factors, some which include:
- Donor age
- Size and body mass index (BMI)
- General medical history
- Organ specific history
- Smoking history
- Malignancy and infection
- High risk behaviors, including substance abuse, multiple sexual partners, incarceration
- Cause of death
- Length of hospital stay
- Pulmonary (lung) function
- Hepatic (liver) function
- Urine output
- Glucose level
- Acid-base balance
What donor factors are associated with organ dysfunction post-transplant?
Factors associated with increased risk of organ dysfunction and poor outcome post-transplant:
- Increasing age.
- High body mass index (BMI).
- History of co-morbidities.
- Prolonged ischemic time.
- Hemodynamic instability (lack of adequate blood flow throughout the body).
What is the organ allocation procedure of deceased donor transplant?
When the OPO determines that an individual is medically suitable to be a donor, and authorization for the donation is confirmed, the OPO enters the donor’s information into the national organ allocation program called DonorNet. This system creates a set of rank lists to identify potential candidates. The OPO offers the available organs to the transplant center or centers of the listed recipients. The transplant center then has one hour to accept or express interest in the offer.
Factors taken into consideration when matching organs include:
- Blood type (ABO exact match)
- Body size
- Severity of patient’s medical condition
- Distance between the donor’s hospital and the patient’s hospital
- The patient’s waiting time
- Whether the patient is available (for example, whether the patient can be contacted and has no current infection or other temporary reason that transplant cannot take place)
What factors are considered for matching an intestine to a recipient?
Specifically, for intestinal transplant surgeons consider:
- ABO blood types must be an exact match due to the possibility of graft vs. host (GVHD) and the intense immune response of the intestinal tract.
- Size of the organ, due to the fact the abdominal cavity often shrinks with intestinal resection or short bowel syndrome.
- Cytomegalovirus (CMV) and Epstein-Barr (EBV) viral status, patients who have never been exposed to CMV or EBV before are usually matched with donors who are similarly CMV-negative or EBV-negative, respectively.
- Note: This is not absolute since post-transplant prophylactic medications are available. Mismatched donor-recipients are transplanted and patients post-transplant may just require treatment for CMV and/or EBV infection.
What factors are considered for matching a liver to a recipient?
Individuals that require a liver transplant are assigned a MELD (Model for End Stage Liver Disease) or PELD (Pediatric End Stage Liver Disease) score that indicates how urgently they need an organ.
A donor liver is offered first to the candidate who matches on the above common elements (ABO blood type, body size, distance from the donor hospital) and has the highest MELD or PELD score (indicating the most need).
What is the organ recovery process of deceased donor transplant?
The OPO is then responsible for coordinating the recovery of the donated organs, including making arrangements with the donor hospital for access to the operating room, necessary staff, packaging, and arranging transport of organs to the intended destinations. The organs are transplanted to the matched recipients.
What is the funeral process after deceased donor donation?
After donation, the donor is taken to a funeral home, and the OPO works with the funeral director to honor the donor and donor family’s funeral wishes. An open casket funeral is possible after organ donation.
How does the OPO follow-up with the donor family after deceased donor organ donation?
A few weeks later, the OPO sends a letter to the donor’s family, letting them know which organs were transplanted while keeping the names of the recipients confidential. Most OPOs continue to provide support to donor families, such as bereavement counseling and later, memorial events.
Section 1: Transplant Policy
The National Organ and Transplant Act (NOTA) of 1984
This act established the basic institutional framework for organ recovery distribution and use in the United States. NOTA prohibited the sale of organs as well as created a network of organ procurement organizations (OPOs). The OPOs are required to be a part of the Organ Procurement Transplantation Network (OPTN), which is the entity created on the national level for coordination of the OPOs. The first OPTN contract was awarded to the United Network for Organ Sharing (UNOS) in 1986 and they have held the contract ever since.
What is the function of Organ Procurement Organizations (OPOs)?
- Each OPO is responsible for a defined geographic area known as a donation service area (DSA)- the United States is divided into 58 DSAs, so there are 58 OPOs.
- The OPOs are designated by the federal government to promote organ donation, identify potential donors, and recover and distribute recovered organs for transplantation into patients who require them.
- New allocation policies for liver and intestine as of February, 2020 has changed organ distribution based on DSAs to acuity circles. Find out more information here.
What is the function of the United Network for Organ Sharing (UNOS)?
- Manages the national transplant waiting list, matching donors to recipients.
- Maintains the database that contains all organ transplant data that occurs in the US (Organ Procurement and Transplantation Network).
- Monitors every organ match to ensure organ allocation policies are followed.
The OPTN (which in the United States is contracted as UNOS) works hard to make sure that everyone who needs an organ will have an equal chance of getting a transplant. A patient’s chance to receive an organ is not affected by age, gender, ethnicity, religion, lifestyle, financial status, or social status. Many groups work together to make transplant possible, each group has a different job, and all members are involved in helping to make OPTN policies.
Who belongs to the OPTN?
Family members of transplant candidates and recipients
Family members of organ donors
Living organ donors
Nurses, social workers, surgeons, physicians and lab technicians who specialize in transplantation
Members of the general public who have an active interest and involvement in donation/transplantation
Organ procurement organizations
OPTN members work to make policies as fair as possible and the involvement of all members of the transplant community help to do this.
What is the Organ Donation Breakthrough Collaborative (ODBC)?
This was an initiative started by the Secretary of Health and Human Services in 2003 with the aim to dramatically increase the availability of transplantable organs and provide best practices for organ recovery and placement. The collaborative worked to create systems to allow accurate and timely donor referral, screening, consent, organ recovery, and placement. The ODBC was institutionalized into the Donation and Transplantation Community of Practice (DTCP) and is coordinated by the Organ Donation and Transplant Alliance formed in 2006 to continue the efforts.
What is the Arbor Research Collaborative for Health?
This is a nonprofit research organization established for the purpose of conducting major studies in epidemiology and public health. It is important to transplant because it is in charge of administering the Scientific Registry of Transplant Recipients (SRTR)- a national database of transplant statistics. The registry was founded in 1987, and exists to support ongoing evaluation of scientific and clinical status of solid organ transplant, including kidney, heart, liver, lung, intestine, and pancreas.
Learn more about SRTR here.
Section 3: Additional Resources
Video: Organ Donation
Organ Donation Video: Created by UNOS explains the basics of the organ donation process.
Website: Association of Organ Procurement Organizations (AOPO)
Association of Organ Procurement Organizations (AOPO): Learn more about Organ Procurement Organizations and how they function.
Useful Information: History of UNOS
History of UNOS: Learn more about the United Network for Organ Sharing (UNOS).