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March 1997
Procurement and allocation of Solid Organs for Transplantation
Hauptman and O'Connor NJEM 1997; 336:422
[ no abstract available ]
The demand for more solid organ donors is increasing beyond the supply. The process of organ transplantation has direct meaning to the providers of perioperative services, including anesthesia and critical care. This article reviews the current state of procurement and allocation of organs, beginning with the evolving sources of organs, trends in the characteristics of cadaveric donors, the organ allocation process and an evaluation of the performance of the present procurement and allocation process.
Sources of organs may be categorized into 4 groups:
- Cadaveric donors with intact circulation - This represents the single largest source of solid organs. Traditionally the donors have been come from traumatic injuries, usually younger patients, while there has been a growing increase in the number of donors as a result of primary central nervous system events. Decreased organs from traumatic (primarily motor vehicle) injury have not been offset by increased procurement from donors with primary central nervous system events.
- Living related donors - This category began with kidney transplantation, and now represents about 35% of the transplanted kidneys nationwide. Now, other organs from living related donors include lung segmentectomy/lobectomy, hemipancreatectomy and liver segmentectomy.
- Living unrelated donors - This amounts to a minority of noncadaveric donors.
- Asystolic cadaveric donors - This category of donors are declared dead prior to surgery. The relative potential contribution of this group of donors is unclear, but may approach 25%.
Pressures to increase the numbers of organs available for transplantation have broadened the inclusion criteria of cadaveric donors to include extended age, coexisting disease and other factors. The authors focus primarily on age as a factor in organ transplant. More importantly, they emphasize the need for healthcare personnel to be aware of the expanding criteria defining the acceptable donor, as well as the definition of brain death and the legality of that declaration, in order to optimize the chances for successful outcomes following procurement of the organs.
The authors review the proper steps in evaluating cadaveric organ donors and well as the experiences gained in obtaining consent, which continues to be the major barrier in acquiring organs.
The authors outline the process by which organs are allocated, including tables with criteria and factors considered for allocating cadaveric kidneys and other organs. Finally, the authors review the effectiveness of the existing procurement and allocation system. They acknowledge that there are no well-defined criteria in place to assess this, but with so many payors, providers, consumers, policy-makers watching this process, there is little doubt that increasing attention will be placed on suitable supply and equitable distribution of solid organs.
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