ORGAN DONATION AND
ALLOTRANSPLANTATION
Ana Montesinos Mayoral
INTRODUCTION
• Transplantation is the transfer of cells, tissues or
organs alive, from a person to another, or for a part
of the body to another part of it, with the purpose of
restoring a lost function
• Organs or tissues for donation:
–
–
–
–
Heart, kidneys, liver, lungs…
Pancreas, intestine
Bones, cornea, skin, heartvalves
Nerves , veins
HISTORY
• 300 B.C. Indians (repairing wounds
by skin transplantation)
• The first transplant assumed as such
is immortalized in a painting of Fra
Angelico, of 1438-1440, where we
can see the saint Cosme and the
Saint Damian transplantating an
Ethiopian's leg
• 16 th century: Gasparo Tagliacozzi
(repairing nose-skin transplantation)observed immune reaction
HISTORY
19 th century
20 th century (1/2)
• 1818: First human to
• 1905: Eduard Zirmhuman blood
corneal transplant
transfusion
(restoring sight)
• 1878: First successful
• 1912: kidney
human to human bone
transplantation on dogs,
transplant
connecting blood vessels
(Nobel prize)
• 1896: First bone marrow
transplant
• 1936: Yu Yu WronoyHuman kidney
transplantation from dead
donor (the pacient died in
few days)
HISTORY
20 th century (2/2)
• 1954: Joseph E. Murray- Brigham and Women’s Hospital (Boston,
USA)- The first successful kidney transplant (from a twin to the other
twin) The pacient lived 8 years
• 1960: Peter Medawar- Nobel Prize for discovering of acquired
immune tolerance (Beginning of anti-rejection drugs)
• 1960´s: First lung, pancreas, liver transplant
• 1967: Christiaan Barnard-SouthAfrica-First heart transplantation. The
pacient lived 18 days, died on pneumonia.
HISTORY
• In Portugal, the first transplant was made by
Linhares Furtado, in Coimbra, on 20 th July 1969
(kidney transplant)
• 2005: Baltimore Hospital- pioneered “domino
chain”- It is initiated when an altruistic donor
donates an organ to a patient who has a willing
but incompatible donor. This incompatible donor
then "pays it forward" and passes on the
generosity to another recipient who also had a
willing but incompatible donor.
“DOMINO CHAIN”
HISTORY
• 2010: SPAIN- First full face transplantation
(Hospital Universitario Valle de Hebrón,
Barcelona)
https://www.youtube.com/watch?v=o8ndC4KF7YY
TYPES OF TRANSPLANTATION
• Allotransplantation: Is the transplantation of cells, tissues or
organs to a recipient from a genetically non-identical donor
on the same species.
– Living donor transplantation
– Cadaveric donor transplantation
– Foetal tissue transplantation
• Autotransplantation: Is the transplantation of organs, tissues
or proteins from one part o the body to another in the same
individual.
• Xenotransplantation: Is the transplantation of living cells,
tissue or organs from one specie to another (Ex: pigshumans)
• Isograft: Is a graft of tissue between two individuals who are
genetically identical (Ex: Monozygotic twins)
LIVING DONOR TRANSPLANTATION
• The selection process of a living donor varies significantly
depending on the organ to transplant . In general , the donor
should be a healthy individual , mentally able to assert their
donation without pressures of emotional or socio- economic
order.
• In the case of kidney or liver donation in Portugal are accepted
as donors , relatives, spouses , friends or anyone else ,
regardless of whether any blood relationship (Lei nº 22/2007,
de 29 de Junho)
• Before being accepted as a donor , the individual has to pass
several physical, laboratory , radiological tests , in order to
detect any factors that could make the donation any riskier. If
one of these factors is detected , the individual will be rejected
as a donor .
LIVING DONOR TRANPLANTATION
ADVANTAGES
– Decrease waiting-list
– Better timing for procedure
(previous treatment can be
finished)
– Lower immune reaction and
lower rejection rate (in case
of relatives)
DISADVANTAGES
– Huge pressure on prospective
donors
– Exploitation of donors
– Insufficient knowledge and
informedness of donors and
their families about this
possibility
– Risk of nephrectomy (kidney
disease)
– Donor lives with one kidney
LIVING DONOR TRANSPLANTATION
CADAVERIC DONOR
TRANSPLANTATION
• Concept: An organ or tissue donation from a
donor who has already died.
• In Portugal, the causes of death are still mainly of
medical origin (71% in 2009 vs 74% in 2010)
• Hemmorrhagic stroke is the cause of death in
50% (n=161) of the donors, followed by other
traumas.
• The causes less frequiently pointed are Tumor
and Work Accident.
FETAL TISSUE TRANSPLANTATION
• It´s the implant of tissue from an aborted
fetus to a patient for treatment of disease.
• Human fetal transplantation is still experimental.
• Using fetal tissue for transplantation: Fetal tissue
transplantation may be able to overcome the
failures of traditional medical and surgical
therapy to ameliorate several diseases, most
notably Parkinson´s disease and insulindependent diabetes mellitus.
FETAL TISSUE TRANSPLANTATION
• ETHICAL ISSUES
- Are fetal rights violated by the use of fetal
tissue?
- Is there a moral danger that the potencial of
fetal tissue donation will encourage elective
abortions?
- What criteria should be used to select fetal
tissue transplant?...
CADAVERIC DONOR
TRANSPLANTATION
FUNDAMENTAL QUESTION
WHEN IS THE
PERSON
CONSIDERED DEAD?
WHEN IS THE PERSON CONSIDERED
DEAD?
• BRAIN DEATH
Brain death means that all
brain and brain stem
function has irreversibly
ceased, while circulatory
and ventilatory functions
are maintained
temporarily
The clinical diagnosis of
brain death rests on three
criteria:
(a) irreversibility of the
neurologic insult;
(b) absence of clinical
evidence of cerebral
function; and most
important,
(c) absence of clinical
evidence of brain stem
function.
SYSTEM OF CONSENT
OPT-IN SYSTEM
Potential donors must
express their consent
during the life, otherwise
they do not donate their
organs
OPT-OUT SYSTEM
There is presumptive
consent
from
every
person, unless the person
expresses
refusal
to
donate
(Ex: Portugal)
SYSTEM OF CONSENT
OPT-OUT SYSTEM IN PORTUGAL
• In Portugal, any national or foreign citizen who
lives in the portuguese territory, is considered a
donor since birth. It´s not necessary to perform
any application, registration or authorization for
the donation.
• Those who do not wish to donate their organs
after death must register in “Registro Nacional de
Não Dadores” (RENNDA)
• The Decreto-lei 244/94, de 22 de abril, rules
REENDA
SYSTEM OF CONSENT
OPT-IN SYSTEM
– Lower percent of population
sign the consent (90 percent
of Americans agree with
donation, but only 30 percent
of them consented to donate
their organs).
– Icky and difficult for persons
to think about it.
– Need of education and
publicity in media.
– Connection of the consent
form with the issuance of
driver’s license.
OPT-OUT SYSTEM
– Much higher percentage of
cadaveric donors (more than
90 percent).
– People do not have to solve
this issue, only if they are
strictly against it.
– Questionable role of family.
– Poor informed society.
– Missing of the consent.
STATISTICS
•
•
•
•
•
•
SPAIN (2013)- Organización Nacional de
Transplantes (ONT)
4279 transplants
1655 donors
35.12 donors per million people
Decreasing number of patients in waiting-list
(5513 in 2012 vs. 5418 in 2013)
Only 15.16% families said “no” to donation
30000 bone marrow donations
STATISTICS
PORTUGAL (until 2010)- Sociedade Portuguesa
de Transplantação (SPT)
STATISTICS
STATISTICS
INTERNATIONAL AND NATIONAL LAW
ABOUT TRANSPLANTATION
International Law
• Additional Protocol to the Convention of Human
Rights and Biomedicine concerning transplantation of
organs and tissues of human origin.
 Since 1st May 2006
 Applies the Principles of the Convention to the field of
organ and tissue transplants, respecting its main
objectives: protecting the dignity and integrity of the
human being and protecting the rights and
fundamental freedoms, with regard to advances in
Medicine and Science.
INTERNATIONAL AND NATIONAL LAW
ABOUT TRANSPLANTATION
The Principles:
• Equality of access to patients in the transplant
services;
• Transparency of rules for allocation of organs and
tissues;
• Setting safety standards;
• Gratuity of donations;
• Good information for all involved;
• Confidentiality;
• Punishments in case of violation.
INTERNATIONAL AND NATIONAL LAW
ABOUT TRANSPLANTATION
National Law
• Constituição da República Portuguesa
Part I: Contains provisions which supervise
fundamental values of bioethics
Principle of Equality (13º)
Right to Life (24º)
Right to Humane Treatment (25º)
Right to Health (64º)
INTERNATIONAL AND NATIONAL LAW
ABOUT TRANSPLANTATION
• Lei 12/93, de 22 de Abril
Rules the harvesting and transplantation of
organs and tissues of human origin
It was amended by Lei 22/2007, de 29 de
Junho and Lei 12/2009, de 26 de Março
INTERNATIONAL AND NATIONAL LAW
ABOUT TRANSPLANTATION
Additional national legislation
• Lei n.º 141/99 da Assembleia da
República (Criteria of brain death)
• Decreto-Lei n.º 244/94 de 26 de
Setembro (National Register of No-Donors)
• Portaria n.º 31/2002 de 08 de
Janeiro (Transplant Centers)
“ILEGAL ORGAN TRADE”
• According to the World Health Organization (WHO),
illegal organ trade occurs when organs are removed from
the body for the purpose of commercial transactions.
• Organ traffic is the third most lucrative crime in the
world.
• It occurs especially in some Asian countries with a
particularly permissive legislation.
• Many people travel to get a transplant, without
questioning how the agency obtained the organ and
without knowing that the operation hasn’t any medical
guarantee, since neither the giver nor the receiver is
followed later.
ETHICAL ISSUES OF
TRANSPLANTATION
• Financial advantageous of transplantation – often lower costs
than medical treatment of ill person
• Family acceptance of death takes a while
• Habits and rites
• Human body is not a property
• Unity of soul and body
• Biological ethic
– neutral value of such procedure
– Biomass
RELIGION
• Christianity – supports donation
• Jehovah's Witnesses – cancelled prohibition of
transplantations in 1967, but it is not clear,
how to perform it, when blood transfusion is
forbidden.
• Orthodox Jewish (not reformed and liberal
ones) does not allow the transplantations,
which are terminating human life by human
extraction.
RELIGION
• Islam
– different scholars
– generally organ donations are not permitted
– some of the schools permit live donations
– some of them also cadaveric donations, if it is not
transplantation of organ, upon which the life
depend (heart, liver), because it kills the soul
– but not unconditionally, they have their own rules
which must be fulfilled
RELIGION
• Buddhism
– Allows, but let every single person to decide on his
own
– Tibetan Buddhists believe in consciousness after
death, and such a person/body cannot be
disturbed, so cadaveric transplants are not
possible for them