Kidney exchange in Turkey, and the state of Turkish transplantation

Here are two articles from the June issue of Transplantation Proceedings

First International Paired Exchange Kidney Transplantations of Turkey    

M. Tuncer

, S. Tekin

, Y. Yuksel

, L. Yücetin

, L. Dosemeci

, A. Sengul

 and A. Demirbaş

Transplantation Proceedings, 2015-06-01, Volume 47, Issue 5, Pages 1294-1295, Copyright © 2015 Elsevier Inc.

Abstract

Objective

We estimated that many patients on the waiting list for kidney transplantation in Turkey have immunologicaly incompatible suitable living donors. Paired exchange kidney transplantation (PETx) is superior to desensitization for patients with incompatible donors. Recently we decided to begin an international PETx program.

Methods

We report three international living related paired kidney transplantations which occurred between May 14,2013, and March 7, 2014. The international donor and recipient operations were performed at Medical Park Hospital, Antalya, Turkey. All pairs were living related and written proofs were obtained according to Turkish laws. As with the donor procedures, the transplantation procedures were performed at the same time.

Results

The uniqueness of these transplantations was that they are the first international exchange kidney transplantations between Turkey and Kirghizia. Currently all recipients are alive with wel-functioning grafts.

Conclusion

In our institute, a 5% increase was obtained in living-related kidney transplantations by the help of PETx on a national basis. We believe that international PETx may also have the potential to expand the donor pool.

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State of Turkish Transplantation    

• Sukru H. Emre Prof.
•  and Ulug Eldegez Prof.

Transplantation Proceedings, 2015-06-01, Volume 47, Issue 5, Pages 1243-1243, Copyright © 2015 Elsevier Inc.

The 10th Congress of the Turkish Transplantation Centers Coordination Association (TTCCA) was held on October 15–18, 2014 in the ancient city of Bodrum, Turkey (formerly Halicarnassus), where one of the Seven Wonders of the Ancient World, “Mausoleum at Halicarnassus,” resides.

This congress also marked the 20th anniversary of the TTCCA. Since its inaugural meeting, TTCCA's congresses have hosted international leaders in the fields of transplantation in transplant immunology, hepatology, nephrology, surgery, radiology, infectious disease, intensive care, nursing, and other related disciplines. Throughout the years, these congresses have served as a great training ground for young Turkish physicians, surgeons, and scientists to meet with world experts and discuss cases. These congresses have also helped Turkish physicians develop international networks so that they may visit transplant centers around the world.

Twenty years ago, TTCCA was established by two pioneers of Turkish transplant surgery: Professors Tuncer Karpuzoglu and Ulug Eldegez. These men were the ones who approached the young transplant surgeons, physicians, immunologists, and nurses to welcome them, encourage them, guide them and point them in the right direction. TTCCA has had bi-annual national meetings since its inception. These meetings have brought almost all transplantation centers in Turkey together under the TTCCA and initiated a nationwide deceased organ distribution system for kidney, liver, and heart transplantations. This effort was sponsored by a grant provided by Novartis. This was the first attempt in Turkey to institute the equal, fair sharing of organs procurred from deceased organ donors. After almost 10 years of serving in this capacity, TTCCA partnered with the Ministry of Health of Turkey (MoH) to achieve the current organ allocation system. During the development of the new organization under the auspices of the MoH, TTCCA leadership and many members have played crucial roles by serving on many committees of this national organization.

As a result of these efforts ignited by TTCCA, solid organ transplantation in Turkey has became a routine procedure with reasonably good outcomes.

Despite these achievements, there are many areas that the transplantation society and MoH can work on:

• 1. 
  Based on the 2014 statistics, approximately 80% of kidney and liver transplants were done with living donors and only 20% of organs were from deceased donors. In living donor liver transplantation, Turkey is the one of the leading countries in the world together with South Korea. These ratios are the opposite to the ratios of Europe and the US where most of donations are from deceased donors. Therefore, there is an ample opportunity to increase deceased organ donation in Turkey. This effort requires continuous education of the public on organ donation.
• 2. 
  It is imperative to establish a Turkish Transplantation Network similar to UNOS. Besides what has been achieved, this organization should be in charge of increasing the number of deceased donors, more detailed organ specific data from transplant centers, auditing, controlling the quality of transplant centers in terms of policies, processes, quality and accreditation of medical and surgical staff involved in transplant centers, education, and monitoring transplant related disease transmission.

TTCCA and MoH have been working with The Transplantation Society (TTS), World Health Organization (WHO), EuroTrans and the Declaration of Istanbul on Organ Trafficking and Transplantation Tourism leadership to honor the concept of the “gift of life,” prevent organ trafficking and increase the number of deceased donors for transplantation. I hope that these commendable efforts would be honored by TTS by allowing the 2020 World Congress to be held in Istanbul, Turkey.

It has been my pleasure to live through these amazing improvements in Turkish Transplantation along the last 20 years.

Taiwan moves to criminalize transplant tourism to China

Taiwan Shuts Down Organ Transplant Tourism, By Jenny Li, Epoch Times |

"Taiwan’s Parliament has made amendments to its organ transplantation law that would have the effect of criminalizing the transplantation of organs from executed prisoners in China, part of a global trend to halt thetrafficking of human organs in China.

In a June 12 session in Taiwan’s Legislative Yuan, a number of important amendments to the Human Organ Transplant Ordinance were read and passed as law.

Under the updated legislation, patients who travel abroad to receive an organ acquired by illegal means can be sentenced up to five years in jail and face fines from $NT300,000 (about $9,700) up to $NT15,000,000 (about $484,000).

The new amendments place some of the responsibility of regulation on doctors and hospitals. Doctors must file a report for any patient who receives a transplant overseas and carries out follow-up treatment in the country. Both doctors and hospitals are subjected to fines of up to $NT150,000 (about $4,840) if they fail to submit reports. Medical institutions and staff will incur criminal charges for filing false reports."

Maine hospital goes through with kidney donation despite donor raising funds online

Long story short: woman in need of kidney posts a sign on a car, seen by a stranger who agrees to donate and is compatible. Then he uses social media to raise some money to pay his expenses, and raises more than he anticipated. Hospital delays surgery, worrying that maybe he's breaking the law against getting "valuable consideration" for his donation, but eventually goes ahead. Both donor and recipientt are doing well.

Maine man sees plea on car window, to donate kidney to stranger
Maine donor says kidney transplant OK'd for next week
"Joshua Dall-Leighton of Windham said the surgery will take place June 16 at Maine Medical Center in Portland. Hospital spokeswoman Matt Paul confirmed on Monday that the living kidney donation is scheduled for that day.
 
"Dall-Leighton responded to the plea for a donor on South Portland resident Christine Royles' car. But the surgery was delayed by medical and legal hurdles, including crowdsourced donations to Dall-Leighton aimed at defraying his expenses. Paul said those concerns have been addressed.
...
"Hospital officials said in April they needed time to determine if the donation violated the National Organ Transplant Act, which forbids potential donors from profiting from a donation. A crowdfunding website set up for the donation has raised more than $49,000. Royles also organized fundraisers to pay bills and reimburse Dall-Leighton's time away from work.
 
"Paul said an external legal review confirmed that the transplant "will comply with federal laws that are designed to regulate organ transplants and protect living donors."
    ******************

From Bill of Health: Fundraising and the Delayed Kidney Transplantation: A Loophole in the Ban against Commercialization?
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And here's the happy ending
Car-window wish for kidney rewarded: Maine woman receives lifesaving transplant--Both patient and donor are reported to be doing well after surgery, capping an unusual story of strangers and sacrifice.

"Josh Dall-Leighton, 30, a corrections officer at the Southern Maine Re-entry Center in Alfred, saw the sign on Royles’ car last fall and immediately contacted her.

“He saw that sign and said, ‘I need to do this,’ ” his wife said.

Royles, whose kidney failure was caused by an autoimmune disease, was placed on a waiting list of more than 100,000 in need of kidney transplants in 2014, but decided to try to find a donor on her own.

The surgery was almost derailed after a GoFundMe effort raised nearly $50,000 for the couple. The account was set up by a friend of Josh Dall-Leighton with a goal of raising $6,000 to cover expenses for the six weeks he was expected to take off work to recover from the surgery.

But after a story about the transplant was published in the Press Herald and was widely picked up by other media outlets, the donations far exceeded the original goal.

Maine Medical Center put the potential transplant on hold until lawyers could sort out legal and ethical issues regarding the large sum of money. Federal and international laws prohibit the sale of organs, but hospital officials have said it was clear that there was no intent to profit from donating the organ.

Last week the hospital announced that the donation was not a legal impediment, and the surgery would go forward.

“If we didn’t have as strong a voice about this as we did, I don’t believe we would be here right now,” Ashley Dall-Leighton said.

She has said they are considering donating the money to a kidney foundation and the neonatal intensive care unit at Maine Med, where their twins were patients when they were born. They wanted to wait until after the surgery and recovery period to have a true accounting of their expenses – as opposed to an estimate – before determining how much and where to donate, she said."

Liver transplant waiting times and MELD scores around the country (and a calculator you can use)

Here's a story in the Wisconsin State Journal: Access to liver transplants unequal in Wisconsin, nation . (Link to a liver calculator at bottom, by transplant center, etc.)

"Access to liver transplants varies in Wisconsin and around the country, with relatively healthy patients getting organs in some places while sicker patients elsewhere deteriorate or die on the waiting list.

"The geographic disparities persist even after a policy two years ago required broader access to patients most in need.

"Policymakers are proposing a more radical change: Dividing the country into four or eight districts for liver sharing instead of the 11 regions and 58 local areas used today.

"Populous states welcome the idea. It would direct livers to “patients in most urgent need, drastically reduce existing geographic disparities in access and, most importantly, save lives,” members of Congress from California, New York and other states wrote to federal officials after the proposal was released last year.

"But congressional representatives mostly from the Midwest and South said the proposal would disadvantage more rural parts of the country. “Areas with high organ donation rates would be disproportionately affected,” they wrote.
...
 "Nationwide, more than 15,000 people await livers, nearly 13,000 of them in active status, meaning they could receive an organ today. About 6,700 people got liver transplants last year.

"Roughly 1,500 people die waiting for livers each year, according to the United Network for Organ Sharing, or UNOS, which runs the transplant system.

"Patients are ranked by medical urgency scores called Model for End-Stage Liver Disease, or MELD. The scores, based on three lab tests, range from 6 for least ill to 40 for gravely ill.

"The sickest patients go to the top of their local waiting lists. But where they rank depends on where they live, as demand for and supply of livers varies around the country.

"Patients getting livers in much of Indiana, Iowa, South Carolina and Tennessee typically have MELD scores of 25 or lower. In parts of California, Massachusetts and New York, the median MELD score at the time of transplant is 33 or higher.

"In Madison’s local area, the median MELD is 28.5. In Milwaukee, it’s 34. In Chicago, it’s 30.

"When the late Apple founder Steve Jobs flew from California to Tennessee for a liver transplant in 2009, he brought attention to one way patients can circumvent the system — by going to places with lower MELD scores and shorter wait times.

"To assist the vast majority of patients who don’t have private jets, Sridhar Tayur launched OrganJet in 2011. The Weston, Massachusetts, company can help people waiting for kidneys or livers get to hospitals in other states in time for transplants, said Tayur, an operations management professor at Carnegie Mellon University in Pittsburgh.

"The cost: $17,000 to $24,000 per flight. So far, about 35 people have signed up for the service but nobody has used it, Tayur said.

He’s trying to get insurance companies to cover the fee. “That would really increase demand,” he said.
...
"Opponents of broader sharing also say more time is needed to gauge the impact of a 2013 policy requiring partial sharing of livers.

The policy, called Share 35, gives livers to patients with MELD scores of 35 or higher throughout each region before local patients with lower scores get them.

A Milwaukee patient with a MELD of 36 gets priority for a Madison donor’s liver over a Madison patient with a MELD of 28, for example. Previously, the Madison patient would have received the liver.

What most irks Madison doctors is something called MELD exception points. Extra points can be given to patients with conditions such as liver cancer, who otherwise have low MELD scores.

Use of exception points varies, with some studies showing more liberal use on the coasts.

“People have gamed the system to have livers sent their way,” said Dr. Tony D’Alessandro, a transplant surgeon at UW Hospital.

Dr. Peter Stock, a transplant director at the University of California, San Francisco, said exception points “are only given if they’re truly, truly needed.”

UNOS is looking at creating a national board to review MELD exceptions, which would replace regional boards used today."
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You can get information about different transplant centers around the country, for patients of different ages, blood types and MELD scores using a calculator from the Scientific Registry of Transplant Recipients (SRTR)
 Liver Transplant Waiting List Outcomes Tool Beta

Everything for Sale? The Ethics and Economics of Compensation for Body Parts (Video of the panel discussion)

Here's the video of the panel discussion I participated in at Johns Hopkins on May 7, Everything for Sale? The Ethics and Economics of Compensation for Body Parts: the panelists were James Childress, Michele Goodwin, Alvin Roth and Debra Satz

The video, including introductions before and questions after, is an hour and 20 minutes. The introduction by Mario Macis starts around minute 6:40, and includes audience voting on questions of whether they would be in favor of regulated markets for kidneys, for hearts, for blood, for human eggs and sperm, and for breast milk. The panel discussion, moderated by Jeff Kahn, starts at minute 14, with each of the panelists, in alphabetical order, giving an 8 minute opening statement. (Mine begins at 33:20, and ends at 41:41, pretty close to the 8 minute guideline:) .)

The difficulties of deceased donation by the terminally ill

Two transplant surgeons, Joshua Mezrich and Joseph Scalea at the University of Wisconsin, write in The Atlantic about a terminally ill patient who wished to be an organ donor.

As They Lay Dying--Two doctors say it’s far too hard for terminal patients to donate their organs.

"Two major obstacles have prevented us from helping W.B. The first concerns his desire to donate a kidney while he is still alive. In his weakened state, will he tolerate the anesthesia and surgery? Or will they hasten his death? If he survives the surgery, will he ever leave the hospital?

"As doctors, we have sworn to do no harm. And yet, every Wednesday and Thursday morning, we remove kidneys from living donors. These patients are not getting any medical benefit from donating one of their kidneys—to the contrary, they are accepting a small risk of complications, including hypertension and a slightly increased likelihood that their remaining kidney will fail. But they do experience a very real, if intangible, benefit: the experience of saving someone’s life.

"In evaluating W.B.’s request, we had to weigh carefully not only the risk to him—which W.B. clearly understood—but also the risk that a donor death after surgery would pose to our hospital. Transplant-surgery programs in the United States are scrutinized by an alphabet soup of federal and nongovernmental entities. Centers with worse-than-expected transplant outcomes can be placed on probation or shut down. A single bad outcome involving a living donor can lead to an investigation. While there are good reasons for this monitoring, it can cause surgeons to avoid complicated cases and innovation. If we were to remove one of W.B.’s kidneys, and he died one, two, or even six months after surgery, his death would be a very public black mark on our program.
...
"From the earliest days of transplantation, surgeons subscribed to an informal ethical norm known as the “dead-donor rule,” holding that organ procurement should not cause a donor’s death. In practice, this meant waiting until patients were by all measures completely dead—no heartbeat, no blood pressure, no respiration—to remove any vital organs. Unfortunately, few organs were still transplantable by this point, and those that were transplanted tended to have poor outcomes by today’s standards.

As the field burgeoned, doctors could see the potential to save ever more lives—if only more organs could be found. In 1968, in an effort to address the shortage of transplantable organs (as well as the delivery of futile care to people in irreversible comas), an ad hoc committee at Harvard Medical School suggested that patients with no identifiable brain function could be designated as “brain-dead,” thereby making them candidates for organ donation. The definition the committee came up with informed the Uniform Determination of Death Act, a model state law drafted in 1980 and subsequently enacted by most states, which holds that brain-dead patients are legally dead. Under the new state laws, doctors could remove organs from patients whose hearts were still beating without violating the dead-donor rule.

Although the dead-donor rule is ostensibly a fine standard, it doesn’t address the situation of most people who are terminally ill. Nor do the laws regarding brain death. Today, terminally ill patients’ best—in many cases, only—chance of passing on their organs is via a wrenching process known as donation after circulatory death, or DCD, whereby a patient’s doctor withdraws all life support while an organ-recovery team stands by. For organs to be successfully transplanted this way, however, the donor typically needs to die within an hour or two of being taken off life support—otherwise, decreased blood flow leaves the organs unsuitable for transplantation. Even when DCD organ donors do die in the allotted time, we tend to recover fewer organs from them than from brain-dead donors, whose bodies aren’t subjected to this drawn-out process.

Over the course of a single week while we were writing this article, three potential DCD donors at our transplant center had life support removed with the intention of donating their vital organs, but failed to die quickly enough.
...
"When the term brain death was introduced half a century ago, it was meant to provide an objective legal definition for a group of patients whom we might otherwise describe as “unrecoverable.” Of course, we also recognize as “unrecoverable” many patients who do not meet the standard for brain death. Those who have suffered devastating strokes or heart attacks, or who have sustained major head trauma, may not be brain-dead even though they have brain injuries that render them unable to survive without life support.

"A more useful ethical standard could involve the idea of “imminent death.” Once a person with a terminal disease reaches a point when only extraordinary measures will delay death; when use (or continued use) of these measures is incompatible with what he considers a reasonable quality of life; and when he therefore decides to stop aggressive care, knowing that this will, in relatively short order, mean the end of his life, we might say that death is “imminent.” If medical guidelines could be revised to let people facing imminent death donate vital organs under general anesthesia, we could provide patients and families a middle ground—a way of avoiding futile medical care, while also honoring life by preventing the deaths of other critically ill people. Moreover, healthy people could incorporate this imminent-death standard into advance directives for their end-of-life care. They could determine the conditions under which they would want care withdrawn, and whether they were willing to have it withdrawn in an operating room, under anesthesia, with subsequent removal of their organs."
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HT: Frank McCormick

American Society of Transplantation conference on Resolving the Organ Shortage

Here's an early announcement of a conference scheduled for February 2016, organized by the American Society of Transplantation, which reflects some of the intense discussion going on in the transplant community about how to alleviate the shortage of transplantable organs.

(As background, recall these three recent posts:

Friday, April 3, 2015

In defense of pilot studies for organ donor incentives

There's no consensus on incentives for kidney donation, but maybe there is on removing disincentives

Two major transplantation societies cautiously consider incentives for organ donation