How organs are selected for transplant

There's been a lot of controversy over the British soldier who died after receiving cancerous lungs from a donor who was a heavy smoker. This report discusses why organs from smokers have been accepted for transplant and will continue to be accepted for transplant, mainly because of the shortage of donors.

Surgeons "aren't in a position in to turn down organs because they're not absolutely perfect."

By Mark Tutton for CNN

LONDON, England (CNN) -- News that a British soldier died after he received the cancerous lungs of a heavy smoker has sparked intense debate as to whether organs from people with unhealthy lifestyles should be used in transplants.

Corporal Matthew Millington, 31, died in 2008, less than a year after receiving a transplant at Papworth Hospital in Cambridgeshire, England.

However a transplant surgeon has told CNN that smokers organs will continue to be used as long as medical services face a severe shortage of organs.

Chris Watson, vice president of the British Transplantation Society, told CNN that 49 percent of last year's lung donors in the UK were smokers.

"We're not in the luxurious position in transplantation to turn down organs because they're not absolutely perfect -- there are very few perfect organs," he said.

What should be done to encourage organ donation?

"In the case of Corporal Millington the donor had a chest X-ray, broncoscopy and a careful inspection of the lungs once they were removed," he said.

"When they found the tumor in Corporal Millington it was seven millimeters across and it was likely to have been two or three millimeters when it was transplanted. To find something that small you'd need to chop the lungs up into fine pieces, and then you can't transplant."

The UK National Health Service National Reporting and Learning Service (NRLS) recently released an alert saying it had found 11 reported incidents "relating to the condition of an organ for transplant or other errors."

One incident reported to the NRLS read: "Kidney arrived completely surrounded by fat and muscle -- nothing was recognizable. After dissection, a fatty tumor appeared on the upper pole, decision was taken to transplant anyway.

"After unclamping, there was a massive bleed from the tumor leading to urgent transplantectomy -- kidney sent to the path lab -- renal cell carcinoma... not fit for purpose."

Watson told CNN that organs are thoroughly tested for suitability before they are transplanted.

He said that once a patient has been diagnosed as brain dead and donation is a possibility, a donor coordinator will approach their family to learn more about the patient's history.

Medics ask about the donor's medical history and lifestyle. They also take a blood test and may contact the donor's doctor for more information.

But Watson stresses that medics only have a few hours between diagnosis of brain death and organ removal.

When the organs are removed the donor's body is examined for evidence of infection, cancer, or anything else that might affect decision to use an organ.

In the case of lung transplants, the donor will have a chest x-ray and broncoscopy, where an endoscope is used to examine lungs from the inside.

"The main thing is how well lungs work," Watson told CNN.

"We would check blood gases, taking a blood sample and seeing how much oxygen is dissolved in the blood to see how well lungs are working.

"If they work well and there's no evidence of any problems then we would use them, regardless of if they came from a smoker."

Watson says a biopsy is carried out on donated livers to check for any damage. He says fatty livers are common, not because the donor is overweight, but as a result of the donor having been starved in intensive care.

Different organs have different tolerances to being without a blood supply. Watson says a heart doesn't respond well to being out of the body for more than three or four hours. Livers can remain viable for around 12 hours and kidneys for about 24 hours.

Those time constraints mean medics have to make quick judgments about the suitability of donated organs, even if it that means using imperfect organs.

"We're happy to use the organs available knowing they're not ideal and we'll make the best use of them and keep them functioning as well as we can," said Watson.

"The alternative for recipients is to die, so there's really not much choice for them."

“You Have the Power to Save Lives – Sign Your Donor Card & Tell Your Loved Ones of Your Decision”

Register to be a donor in Ontario or Download Donor Cards from Trillium Gift of Life Network. NEW for Ontario: recycleMe.org - Learn The Ins & Outs Of Organ And Tissue Donation. Register Today! For other Canadian provinces click here

In the United States, be sure to find out how to register in your state at ShareYourLife.org or Download Donor Cards from OrganDonor.Gov

In Great Britain, register at NHS Organ Donor Register

In Australia, register at Australian Organ Donor Register

Your generosity can save up to eight lives with heart, kidneys, liver, lungs, pancreas and small intestine transplants. One tissue donor can help up to 100 other people by donating skin, corneas, bone, tendon, ligaments and heart valves

Has your life been saved by an organ transplant? "Pay it forward" and help spread the word about the need for organ donation - In the U.S. another person is added to the national transplant waiting list every 11 minutes and 18 people die each day waiting for an organ or tissue transplant.

The Big Question: Should organs donated for transplant always come from healthy people?

This follow-up to previous posts about infected organs somehow getting through the screening process and actually being transplanted will hopefully add to the cry for more stringent controls that will prevent an unsuspecting recipient being infected with a deadly disease such as cancer.

By Jeremy Laurance The Independent

Why are we asking this now?

Matthew Millington died from lung cancer less than a year after undergoing a lung transplant. He was 31. The donor was a heavy smoker. The case, details of which emerged yesterday, has raised concerns about the screening of donors for transplants. Mr Millington, who was from near Stoke-on-Trent, was diagnosed in 2006 with an unspecified "serious lung condition" and told that without a transplant he had two years to live. He got his transplant in April 2007 and died 10 months later. An inquest into the Iraq war veteran's death concluded that he died of "complications of transplant surgery".

Why did he receive the lungs of a smoker?

Because there is a national shortage of organs for transplant and a reluctance by patients and transplant surgeons to reject any offered unless there are compelling reasons why they should be refused. Not every person who smokes develops lung cancer but everyone on the list for a lung transplant will die without the transplant. It is a balance of risk and benefit. In a statement, a spokesman for Papworth Hospital, Huntingdon, where the transplant was carried out, said: "Using lungs from donors who have smoked in the past is not unusual. During 2008/09 there were 146 lung transplants carried out in the UK. During the same period 84 people died on the waiting list. If we had a policy that said we did not use the lungs of those who had smoked, then the number of lung transplants carried out would have been significantly lower."

Are organs checked for cancer before they are transplanted?

Yes. All donor organs are supposed to be screened rigorously before transplant to check for tumours, injury and signs of damage. If cancer is present in the organ, or develops after transplant, its growth is likely to be accelerated by the use of immuno-suppressant drugs, necessary to prevent rejection of the organ. By suppressing the immune system, the drugs also remove the body's natural defences against the cancer.

What went wrong in this case?

It is unclear. Papworth Hospital said that early screening checks did not detect any sign of cancer in the lungs. But the speed with which the tumour appeared and led to Mr Millington's death is disturbing. He underwent the transplant in April 2007, the cancer was detected six months later and he died in February 2008. His wife, Siobhan, said that when he woke from the surgery his lungs felt like "two deflated balloons." Later, after the cancer had been discovered, he said to her: "They've given me a dud pair of lungs. Get me another." Papworth said it was an "extremely rare case".

Have other patients received diseased or infected organs?

Yes. A kidney sent for transplant was found to be in a poor state but was transplanted anyway. Later the patient haemorrhaged and the organ had to be removed. Further checks revealed the presence of a tumour. The National Patient Safety Agency (NPSA) said it had received 11 reports in which organs had been found to be unsuitable by the surgeons about to transplant them because they were infected with hepatitis or variant CJD, or there was a tumour present or there was damage as a result of trauma. Dr Kevin Cleary, medical director at the NPSA, said: "Although these numbers are small, the NPSA believes this was a significant issue for a number of NHS organisations. We shared our data with the NHS Blood and Transplant Service which is now establishing more robust systems for retrieving organs and enhancing quality."

Are any health checks made on donors?

Only limited ones. Blood is taken and tested for transmissible diseases such hepatitis, variant CJD and HIV. But there are only two conditions where donation is ruled out completely – HIV and variant CJD. Other conditions may rule out the transplant of certain organs but not of others. The decision as to whether some or all of a person's organs are suitable for transplant is made on an individual basis by a doctor, taking account of their medical history. Even people who have been turned down as blood donors may be accepted as organ donors, if for example they were turned down for specific reasons, such as having had a blood transfusion or hepatitis in the past.

So the NHS is desperate for organ donations?

Yes. There is already a critical shortage of organs and it is getting worse. The number of people needing transplants is rising every year, because of the ageing of the population and advances in medical care, but the number of donors is not. Fewer than half of those on the waiting list will get a transplant this year and around 450 will die as a result, according to UK Transplant. People worried about receiving, say, organs from a smoker should ask themselves the question: would you prefer to pass up the offer or take the chance?

Has organ transplantation been a success?

Yes. The first successful major organ transplant – of a kidney – was carried out in 1954. Today, kidney transplants are established as routine. Heart, lung and liver transplants came later and have also grown rapidly. Last year in the UK 977 lives were saved through heart, lung and liver transplants. A further 2,536 received a kidney transplant. In total, last year (2008-09) there were 3,513 organ transplants carried out – but there were still 7,877 patients on the waiting list at 31 March. The biggest constraint is the shortage of organs suitable for transplant.

Could the number of organs for transplant be increased?

The Government launched a £4.5m advertising campaign in March to boost the number of people on the Organ Donor register to 25 million – half the adult population – over the next five years. Membership is voluntary and people signing up agree to give their organs in the event of their death. In practice, however, organs are only taken with the consent of relatives, which is not always granted. Gordon Brown spoke last year of the "aching gap" between the supply of organs and the demand for them and the need to close it. More transplant co-ordinators have been hired. They talk to relatives at the time of a death, a process which experience from other countries, especially Spain, has shown can increase donations.

Are there any other ways of boosting donation?

Some people say an "opt-out" system would be better than our current "opt-in" system. An opt-out system would require people to sign a register if they did not want their organs used after their death. There would then be a presumption that everyone who had not signed the register was prepared to donate their organs. However, a taskforce appointed by the Government to examine the issue rejected the opt-out system last year. They said it could undermine the "vital relationship of trust" between doctors and patients.

Can it be right to transplant organs from a heavy smoker?

Yes

*There is a critical shortage of organs and fewer than half of those waiting will get one

*Patients awaiting lung transplants will die if they do not get one within a reasonable time

*Not all smokers develop lung cancer, and the decision whether to use their lungs is made by a specialist

No

*Patients awaiting a transplant do not expect to receive a diseased or damaged organ

*Transplanting organs from a person with a lifestyle known to damage their health is too risky

*Donors are already screened for diseases such as HIV and variant CJD and should be screened for smoking too.

“You Have the Power to Save Lives – Sign Your Donor Card & Tell Your Loved Ones of Your Decision”

Register to be a donor in Ontario or Download Donor Cards from Trillium Gift of Life Network. NEW for Ontario: recycleMe.org - Learn The Ins & Outs Of Organ And Tissue Donation. Register Today! For other Canadian provinces click here

In the United States, be sure to find out how to register in your state at ShareYourLife.org or Download Donor Cards from OrganDonor.Gov

In Great Britain, register at NHS Organ Donor Register

In Australia, register at Australian Organ Donor Register

Your generosity can save up to eight lives with heart, kidneys, liver, lungs, pancreas and small intestine transplants. One tissue donor can help up to 100 other people by donating skin, corneas, bone, tendon, ligaments and heart valves

Has your life been saved by an organ transplant? "Pay it forward" and help spread the word about the need for organ donation - In the U.S. another person is added to the national transplant waiting list every 11 minutes and 18 people die each day waiting for an organ or tissue transplant.

Alert in UK over donor organs riddled with cancer, mad cow disease and hepatitis

Donor organs for transplant have been found to be infected with deadly diseases, carry cancerous tumours and have been too damaged to use, an alert to the health service has warned.

By Rebecca Smith, Medical Editor Telegraph.co.uk.

Doctors reported one instance where a kidney arrived for transplant in a poor state but the operation was carried out anyway only for a 'massive bleed' to occur from he organ meaning it had to be removed again. It was sent for testing and found to contain a cancerous tumour.

The incident prompted a search of the National Patient Safety Agency database which uncovered 11 similar reports of faulty organs.

An alert sent to the health service said other examples included `fatty’ organs, which can be caused by the donor patient being obese and fatty liver can also be caused by alcoholism and may lead to cirrhosis; the donor patient found to be infected with vCJD – the human form of mad cow disease and hepatitis B; and cuts and damage to an organ during the retrieval operation.

The report said there were also incidents relating to mismatching of tissue typing and patient identification errors.

It is not known if the transplant operations went ahead in all cases or if the recipients suffered any adverse effects.

The quality of transplant organs has been called into question before when it emerged that donations were being accepted from drug addicts due to the critical shortage.

There are around 10,000 people on the waiting list for an organ transplant and around 1,000 die each year waiting for a match.

The waiting list grows by around eight per cent each year and advances in intensive care medicine and surgery mean more patients who would become donors are surviving their injuries.

Representatives from the National Patient Safety Agency called an urgent meeting with NHS Blood and Transplant, the special trust which oversees transplants, after the incidents came to light.

The report added: "There was encouraging news on very recent changes where, for the first time, there will be a robust, secure and funded national system for organ retrieval, staffed by well-trained surgeons and other healthcare professionals.

"NHS Blood and Transplant is setting up a system for monitoring the quality of organs and this will be supplemented by a photographic assessment of livers that is currently being evaluated.

"While these changes address many of our concerns, NHS Blood and Transplant strongly encourages staff to continue reporting all adverse events and any concerns about preventable harm to donated organs."

The National Patient Safety Agency database contains 3.5 million incident reports from England and Wales made by NHS staff since 2001 which can be analysed for patterns.

Keith Rigg, president of the British Transplant Society, said there has been a shift in donors with fewer young people dying of head injuries and more older people dying of brain haemorrhages which meant organs tended to be older.

But he added that all potential organs are inspected before the recipient is anaesthetised.

Mr Rigg, who is a transplant surgeon in Nottingham, added: "People are aware that quality and safety is an important issue and the cases highlighted here are a very small minority. Surgeons are careful about what they transplant and do not take unnecessary risks."

A Department of Health spokesman said: "We are committed to supporting new initiatives to optimise the number and quality of donor organs.

"Following the Organ Donation Taskforce recommendations, NHS Blood and Transplant are investing in the development a new national system for organ retrieval with a UK-wide network of highly trained organ retrieval teams, working to ensure high quality organ removal.

"This will be complemented by a new digital imaging service that allows surgeons to inspect livers online before accepting them.”

In a separate case, it was disclosed yesterday that an Iraq war veteran died after a transplant in which he was given a pair of cancerous lungs donated by a smoker.

“You Have the Power to Save Lives – Sign Your Donor Card & Tell Your Loved Ones of Your Decision”

Register to be a donor in Ontario or Download Donor Cards from Trillium Gift of Life Network. NEW for Ontario: recycleMe.org - Learn The Ins & Outs Of Organ And Tissue Donation. Register Today! For other Canadian provinces click here

In the United States, be sure to find out how to register in your state at ShareYourLife.org or Download Donor Cards from OrganDonor.Gov

In Great Britain, register at NHS Organ Donor Register

In Australia, register at Australian Organ Donor Register

Your generosity can save up to eight lives with heart, kidneys, liver, lungs, pancreas and small intestine transplants. One tissue donor can help up to 100 other people by donating skin, corneas, bone, tendon, ligaments and heart valves

Has your life been saved by an organ transplant? "Pay it forward" and help spread the word about the need for organ donation - In the U.S. another person is added to the national transplant waiting list every 11 minutes and 18 people die each day waiting for an organ or tissue transplant.