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Legacy of Life: Organ and Tissue Donation

Course Material Valid Through January 2016

This course exceeds New Jersey mandatory requirement regarding professional nurse training relative to organ, tissue donation and recovery.

About the Author/Editor

Diana Harland, BS, CCRC, received her degree in microbiology from the University of Texas at El Paso. She worked in preclinical research in retrovirology while in undergraduate school and again after graduation at the Texas Biomedical Research Institute (formerly Southwest Foundation for Biomedical Research) in San Antonio, Texas. While at the Southwest Foundation, she worked in the Department of Virology and Immunology at biosafety level 3-4 (BSL-3/BSL-4). She has extensive training in NIH, OSHA, and CDC guidelines for sterility and asepsis in tissue culture and retrovirology. She holds a certificate in bioterrorism from Tulane University School of Public Health and Tropical Medicine and the University of Alabama at Birmingham School of Public Health. She is a member of the Austin Disaster Relief Network (infrastructure for the city of Austin, Texas, disaster response) and the Association for Clinical Research Professionals.

Editing done by Cheryl Duksta, RN, ADN, M.Ed., a critical care nurse in an intermediate care unit in Austin, Texas. Cheryl is an active member of the American Association of Critical-Care Nurses (AACN) Greater Austin chapter. A master's prepared teacher and former public school teacher, she frequently serves as a continuing education facilitator. She has 15 years of experience in education and medical publishing, including writer and editor at the National Center of Continuing Education.

Purpose and Goals

The purpose and goals of this course are to educate healthcare workers in the fundamental aspects of organ and tissue donation.

Instructional Objectives

1. Define organ donation.
2. List the organs and tissues that are eligible for donation.
3. Identify the various agencies and facilities involved in organ transplantation.
4. Outline the transplantation process.
5. Explain the process for screening for infection.
6. Summarize the body's tissue rejection process.
7. Discuss the role of the transplant coordinator in organ/tissue donation.
8. Review the ethical considerations related to organ/tissue donation.

Introduction

Organ and tissue donation has come a long way since its beginnings in the late 1800s when skin was first transplanted. Today, major organs, such as hearts, lungs, and kidneys; corneas; and tissues such as heart valves are transplanted. In some cases, multiple organs are transplanted into one recipient. Each year, more than 25,000 organ donations and almost 1 million tissue and corneal transplants take place in the United States.

Simply defined, organ donation is the act of providing one or more organs or body tissues as a gift for transplantation into another person to be used in place of a diseased or nonfunctioning organ or body tissue. Donated organs include liver, kidney, kidney/pancreas, pancreas, heart, lung, heart/lung, and intestine. Tissue donations include bone, tendons, cartilage, ligaments, skin, corneas, and heart valves. Organs and tissues can be donated from deceased persons or from living persons.

The need for organs far exceeds the availability of organs that are donated. Currently, there are more than 116,500 candidates waiting for an organ donation. Statistics from the U.S. Department of Health and Human Services show that each day around 79 people receive a transplanted organ, but at the same time an average of 18 people per day die while waiting for a needed organ. The demand for kidneys is especially high due to medical advances in dialysis.

A single person can save eight lives with vital organs and enhance the lives of many others with donated tissues. In all, one person can affect up to 50 lives. Organs can be placed with a needy candidate locally, regionally, or nationally.

Agencies and Facilities Involved in the Organ Transplant Process

The complexity of the entire transplant process is a focus of several different agencies:

• United Network for Organ Sharing (UNOS). This agency is a private, nonprofit organization that manages the U.S. transplant system under contract with the federal government. In 1984, the National Organ Transplant Act was enacted, which called for an Organ Procurement and Transplantation Network (OPTN) that would link all of the professionals involved with organ donation and transplantation. In 1986, UNOS was awarded the contract to operate the OPTN and has been the only organization to ever operate it. Today, UNOS provides the following services:
  • Management of the national transplant waiting list to match donors and recipients on a 24/7, 365-day basis
  • Maintenance of the database containing all organ transplant data for all transplants occurring in the United States
  • Development of policies that give every patient a fair chance of receiving a needed organ
  • Monitoring of organ matches to ensure organ allocation policies are followed
  • Assistance to patients, family, and friends
  • Education for transplant professionals regarding their roles in the transplantation process
  • Education of the public regarding the importance of organ donation
• Organ Procurement and Transplantation Network (OPTN). This network is a nonprofit, private-sector entity whose members include all U.S. transplant centers, all organ procurement organizations, all histocompatibility laboratories, medical and scientific organizations, and members of the general public. The OPTN is governed by a Board of Directors and is operated by UNOS.
• Organ procurement organizations (OPOs). There are currently 58 OPOs in the United States. They are nonprofit organizations that must be certified by the Centers for Medicare and Medicaid Services and must abide by their regulations. They must also be members of the OPTN and the Association of Organ Procurement Organizations. These OPOs have two main functions:
  • Increasing the number of registered donors. This may be done through a variety of community outreach activities.
  • Coordinating the donation process when actual donors become available. This involves evaluation of the potential donor, checking the deceased's state donor registry, discussing donation with family and offering bereavement support, contacting the OPTN and running a match list, and arranging for surgical recovery and transport of donated organs.
• Transplant centers. Numbering more than 250 across the United States, transplant centers are entities within hospital facilities that operate organ transplant programs. They must be members of the OPTN and must meet strict professional standards.
• Histocompatibility laboratories. As members of the OPTN, these labs are certified to perform human leukocyte antigen (HLA) typing to determine the compatibility between a donor's organ or tissue and that of a recipient. Histocompatibility antigens are genetically determined antigens found on the cell membranes of the cells of most tissues. These antigens are responsible for the processes of tissue rejection when organs or tissues from a different individual are grafted to a host recipient.
• Medical and scientific organizations. Also members of the OPTN, medical and scientific organizations include such agencies as the Eye Bank Association of America and the American Society of Transplant Surgeons.
• Local hospitals. Almost all donor organs are from donors who died in a hospital. Staff members from local hospitals are instrumental in making a patient's wishes for organ donation possible.

The Transplantation Process

The transplant evaluation process is complex. A patient who becomes a candidate for an organ transplant is referred by his or her physician to a transplant center. The transplant center conducts various tests to assess both the physical and mental health of the patient as well as the patient's social support structure. If the patient is accepted as a candidate, the patient's name and all appropriate information is added to the national waiting list for organ transplantation. All patient data are kept current during this waiting period.

Deceased Donors

When an organ from a deceased donor becomes available, a transplant coordinator from an OPO enters the information regarding the donor into the national database maintained by the OPTN. Patients on the waiting list are then matched against the donor organ, and a computer-generated list of potential recipients is created. The candidates are ranked in an order that is determined by OPTN organ allocation policies, acceptance criteria of the transplant center, and local variances that are OPTN-approved variations of national allocation policies. Factors that affect how a candidate is ranked include tissue match, blood type, immune status, body size, height, weight, the length of time the candidate has been on the waiting list, the medical urgency of the patient's condition, and the distance between the candidate's hospital and the donor's hospital.

The donated organ is offered to the transplant center of the first person on the generated list for evaluation. Candidates must be immediately available and willing to accept the donated organ. They must be healthy enough for major surgery, and they must be able to pass any compatibility tests necessary between candidate and donor organ to ensure that the organ will not be rejected by the candidate's immune system. The decision to accept an organ is made by the candidate's transplant team. The transplant team has 1 hour to make a decision; if the team does not make a decision within that time the organ is offered to the transplant center of the next person on the list. This process continues until a candidate who meets all necessary criteria is found.

If all testing is successful, and the organ is accepted, a transplant team recovers the organ from the donor. The organ is then transported to the recipient's transplant center. Immediate surgery is scheduled for the recipient, and the organ is transplanted by the candidate's transplant surgeons. The recipient then begins the recovery period and must take immunosuppressant medications to prevent rejection of the organ.

Living Donors

A living donor is a healthy person who volunteers to donate a whole organ (usually a kidney) or an organ segment (liver, lung, pancreas, or intestine) to a transplant recipient. Persons who have a history of high blood pressure, diabetes, cancer, hepatitis, or HIV cannot become living donors. A transplant center makes the decision to accept a person as a living donor. For living donors, the multidisciplinary transplant team consist of a living donor coordinator, a physician specializing in the organ to be donated (e.g., a nephrologist), a transplant surgeon, a psychiatrist, a social worker, and a nutritionist.

The length of time a donated organ can be kept alive outside the human body is brief. In this small time interval the organ must be recovered from the donor and transported to the transplant hospital to be given to the recipient. Following are transplant time intervals for specific organs:

• Heart: 4–6 hours
• Lung: 4–6 hours
• Combined heart/lung: 4–6 hours
• Liver: 12–24 hours
• Kidney: 48–72 hours

In the case of kidney donation when a donor and candidate do not match, paired exchange donation may be a possibility. In this process, two or more pairs of kidney donors trade recipients so that each recipient receives a compatible kidney. Another option for nonmatching kidney transplant is blood type incompatibility donation. This option allows recipients to receive a kidney from a donor with an incompatible blood type. During the transplant, the surgeon also removes the spleen of the recipient. Afterward, recipients must receive specialized treatment to prevent rejection of the organ.

Screening for Infection

Routine screening of organ donors for HIV began in 1985. Although reports of donor-derived HIV infection are rare, they are still an important cause for public health concern. Assessment of infectious risk of donor organs and tissues is challenging and is limited by current screening and lab testing methods. Deceased organ donors are screened for HIV infection at the time of cardiac or brain death. In comparison, living donors undergo a more complicated process, and a significant amount of time between initial evaluation and actual transplant surgery may be needed to complete the process. During this time, donors may become infected with HIV. For example, despite careful screening, a donor became HIV positive during this interim time, and the kidney he donated was transplanted in a recipient who later became HIV positive due to the transplantation.

To reduce the chance of infection from a donor during the interim time period, repeat testing must occur as close as possible to the date of transplantation using both serologic and nucleic acid testing (NAT) before an organ is recovered to rule out a recently acquired HIV infection. NAT has reduced the window period (time between infection and the ability to detect the presence of HIV in the blood) to 8–10 days. Living donors should be educated in the risk factors and modes of HIV transmission. Organ recipients must be counseled about the potential risks involved in organ transplantation. Table 1 lists the CDC recommendations for prevention and screening of HIV in the organ donation process.

The CDC has also documented the transmission of West Nile virus, Chagas disease, and amebic encephalitis through organ donation.

Organ and Tissue Rejection

In the 1940s, researchers discovered a set of genes that determined whether there was acceptance or rejection of grafted tissues. This group of genes was named the major histocompatibility complex (MHC). In humans, the MHC is called the human leukocyte antigen (HLA) system and is responsible for enabling the body to distinguish the presence of "self" from "foreign" at the molecular level. The HLA antigens expressed on the surface of lymphocytes are different for each individual, though they are alike in identical twins. It is important to match the tissues of the donor and recipient with respect to HLA typing as much as possible to minimize rejection. The greater the number of identical HLA antigens, the greater the probability that a transplant will be successful. Donors and recipients are matched for ABO (blood) typing as well. In addition to the MHC, other more minor genes are involved in rejection. These minor histocompatibility genes can still trigger rejection even when the donor and recipient are well matched.

Graft rejection and the immune response is a function of the body's white blood cells. The body's humoral immunity occurs when B lymphocytes develop into antibody-producing cells, and these antibodies activate enzymes known as the complement system. The body's cellular immunity occurs when T lymphocytes develop into either T-helper cells or cytotoxic T cells, or killer T cells. Graft rejection occurs when T lymphocytes of the recipient recognize specific HLA antigens on the cells of the graft as "foreign." In a complex pathway, T-helper cells induce cytotoxic T cells to attack and destroy the cells of the foreign graft.

After transplantation, the primary goal of the transplant team is to suppress the patient's immune system without putting the patient in jeopardy for increased risk of infectious disease. By suppressing the immune system the newly transplanted graft can heal and survive as a properly functioning organ or tissue. Immunosuppressive drugs such as cyclosporine and methotrexate have greatly enabled patients to survive rejection.

Two types of rejection may occur after transplantation. Acute rejection occurs within a year of transplantation. Chronic rejection occurs over time as the organ slowly loses its ability to function. Symptoms of organ rejection vary depending on the organ. Common symptoms may include pain at the location of the organ, fever, edema, malaise, flulike symptoms, fatigue, decreased urine (kidney transplant), dyspnea (heart, lung transplant), and jaundice and bleeding (liver transplant). Routine biopsies may show organ rejection even before symptoms develop.

After an allogenic stem cell or bone marrow transplant, T lymphocytes in the graft may view the host tissue as foreign and produce an attack on the recipient. Known as graft-versus-host disease (GVHD), this potentially life-threatening condition can be acute or chronic. Acute GVHD usually becomes apparent in the first 3 months after a transplant. Symptoms include diarrhea, abdominal pain and cramping, dryness and irritation of the eyes, skin rash, erythema, itching, and jaundice. Chronic GVHD occurs more than 3 months after transplant and can be a lifelong condition. Symptoms include chronic pain, muscle weakness, fatigue, dyspnea, dry mouth, skin rash and skin changes such as thickening or tightening, weight loss, and vaginal dryness.

Cost of Organ Donation

Organ donation is free of charge to the donor or family of the donor; costs for organ removal and transplantation are charged to the transplant recipient. Financial coordinators and social workers are available to help recipients with planning for the various transplant costs. The cost of a kidney transplant can reach $260,000; a liver transplant can cost $570,000; a heart transplant can cost as much as $997,000; and an intestinal transplant, the most costly transplant type, can exceed $1 million.

Under the National Organ and Transplant Act of 1984 it is illegal for a living donor to be paid for donating an organ; however, living donors can be reimbursed for certain expenses involved in the donation process.

The Role of the Healthcare Worker in Transplantation

There are many roles for healthcare workers in transplantation. In addition to physicians, organ procurement coordinators, transplant coordinators, staff nurses, clinical nurse specialists, and charge nurses all have different roles in the coordination of organ and tissue donations.

The transplant coordinator, for example, may work with the living donor or the transplant recipient. Donors and recipients have separate transplant coordinators, allowing the two parties to make decisions that are right for them, with the transplant coordinator acting as an advocate. After a patient is referred for a transplant, the transplant coordinator participates in the testing, evaluations, and listing of the patient on the national waiting list. When an organ is located, the transplant coordinator's tasks may include ordering lab tests for organ matching, preparing living donors for transplant procedures, assisting during surgery, and providing postoperative care of the recipient after surgery.

Discussing Donation With Potential Organ Donors

The way in which donation is discussed with a patient and family members can be the most important factor in determining whether a choice is made to donate organs or tissue. Healthcare professionals must take into account the distress, grief, and complex feelings of a family who are coping with the loss of a loved one. Under federal regulations, anyone approaching a family about organ donation must be trained in this process. Such persons are known as designated requestors, and are often staff members of an OPO. Members of the patient's healthcare team assist requestors since they are familiar to and trusted by the family. It is important to note that OPO members are exempt from the Health Insurance Portability and Accountability Act (HIPAA) because they need a basic understanding of the patient's health conditions to determine if the patient is a candidate for organ donation.

Before a conversation about organ donation can take place the patient's family must be able to express what is happening to their loved one. When a patient is facing imminent death, a member of the hospital should notify the OPO. The nurse directly caring for the patient is the most likely person to identify the potential donor and begin the notification process. The OPO representative is then informed about the patient's medical condition and prognosis and meet with the family to discuss donation.

Timing the conversation regarding donation is critical. Family and loved ones must not still believe that the patient will recover. The setting in which conversations are carried out is also important; they must be private and quiet. Participants in the conversation may include the patient's family, healthcare staff, a member of the clergy, and the OPO representative. Families that are treated in a respectful manner and are allowed to express their emotions and grief are most likely to respond in a positive manner. When families feel that they are doing what is best and are carrying out the wishes of their loved one, their grief can be turned to something positive: knowing that their loved one has saved or enhanced the lives of others.

Ethical Considerations in Transplantation

Organ and tissue donation brings up ethical considerations for patients as well as healthcare workers. The dead donor rule is an ethical norm that states that a person must be declared legally dead before any vital organs are removed, which implies that an organ that is harvested must not cause the death of the donor. Ethical and legal issues revolve around the question "When is a person actually dead?" A person is said to be dead when the complete electrical activity of the brain ceases and this becomes truly irreversible (brain death), or when the heart quits beating and this becomes truly irreversible (cardiac death). Over the years, great debate has occurred among the medical, scientific, religious, and lay communities concerning the criteria for determining who can be considered legally dead and when one can be considered legally dead. This multifaceted ethical, moral, and religious dilemma has long existed and will likely continue to be discussed.

Persons deciding to become organ donors or families making the decision for their loved one to become an organ donor must ultimately do what is right for them. They should not feel swayed or pressured into doing anything they do not feel right about doing. In this manner, regardless of the debates that are ever present, donors and donor families can rest assured that they have made the correct decision.

Designating Yourself as a Donor

A single person can save 8 lives with vital organs and also enhance the lives of many others with donated tissues. In all, one person can affect up to 50 lives. Organs can be placed with a needy candidate locally, regionally, or nationally.

Sadly, many people only know about organ donation because of what little they have learned at their state department of motor vehicles. They may sign the back of their driver's license to become an organ donor and not know that if they die their families will still be consulted before a donation can take place. There is no national registry for organ donors, so it is important for anyone wanting to be an organ donor to let their relatives know this.

If a person wishes to become an organ donor, they should first ensure that their relatives know this. In 45 states, the law states that persons have the right to donate their organs upon death, and this designation overrides the decisions of any relatives. A Uniform Donor Card, available on many websites, may be issued to be carried by the potential donor. This card is a legal document that gives permission for organ donation in the event of death of the individual. A state driver's license can also designate a person as an organ donor. Potential donors should also register with their state's donor registry.

For more information about how to become an organ donor, consult the U.S. Department of Health and Human Services Web site: http://www.organdonor.gov/howhelp/index.html

For information on the ethics of organ donation, see the following publication from the Center for Bioethics: http://www.ahc.umn.edu/img/assets/26104/Organ_Transplantation.pdf

Conclusions

Posthumous organ donation can be a final and lasting way to show caring and love for one's fellow man. The donation of an organ or tissue by a living donor is another example of this selfless act of caring. Healthcare professionals have an important role to play in this life-giving process.

References and Suggested Readings

Bentley TS, Hanson SG. Milliman research report, 2011. U.S. organ and tissue transplant cost estimates and discussion. 2011. Avail at: http://www.transplantliving.org/before-the-transplant/financing-a-transplant/the-costs/.

Centers for Disease Control and Prevention. HIV transmitted from a living organ donor–New York City, 2009. MMWR 2011;60(10):297–301. Avail at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6010a1.htm?s_cid=mm6010a1_e.

Greenwald MA, Kuehnert MJ, Fishman JA. Infectious disease transmission during organ and tissue transplantation. Online report. Emerg Infect Dis. Aug 2012. Avail at: http://wwwnc.cdc.gov/eid/article/18/8/12-0277_article.htm.

National Institute of Allergy and Infectious Diseases. Immune system. Bethesda, MD; 2012. Avail at: http://www.niaid.nih.gov/topics/immunesystem/immunecells/pages/tcells.aspx

National Marrow Donor Program. Improved management of graft-versus-host disease. Minneapolis, MN; 2012. Available at: http://marrow.org/Physicians/Transplant_Advances/GVHD_Treatment.aspx

President's Council on Bioethics: Controversies in the determination of death. Personal statement of Edmund D. Pelligrino, M.D. 2009. Avail at: http://bioethics.georgetown.edu/pcbe/reports/death/pellegrino_statement.html.

United Network for Organ Sharing. Donation and transplantation. Washington, DC: UNOS; 2012. Avail at: http://www.unos.org/donation/index.php.

United Network for Organ Sharing. Talking about transplantation: What every patient needs to know. Washington, DC: UNOS; 2012.

U.S. Department of Health and Human Services. Organ Procurement and Transplantation Network. Washington, DC: HHS; 2012. Avail at: http://optn.transplant.hrsa.gov/.

U.S. Department of Health and Human Services. Organ and tissue donation and transplantation. Washington, DC: HHS; 2012. Avail at: http://www.organdonor.gov/index.html.

State of New Jersey legislation

SENATE BILL 755

This bill seeks to establish the "New Jersey Hero Act," so named to highlight the heroic act of donating one’s organs and tissues to save and enhance the lives of others. It was introduced by Senator Richard J. Codey and referred to the Senate Health Human and Senior Citizens Committee. As amended by the committee, this bill contains two major initiatives. First, the bill mandates education for healthcare professionals to dispel myths associated with organ donation, provide accurate information, and emphasize the fundamental responsibility of individuals to take appropriate action, when able, to help save another person's life.

The curriculum in each school in this State shall include instruction in organ and tissue donation and recovery designed to address clinical aspects of the donation and recovery process.

http://www.nj.gov/oag/ca/adoption/nurado_020711.htm