Organ procurement

After organ procurement the organs are often rushed to the site of the recipient for transplantation or preserved for later study. The faster the organ is transplanted into the recipient, the better the outcome. While the organ is being transported, it is either stored in an icy cold solution to help preserve it or it is connected to a miniature organ perfusion system which pumps an icy solution (sometimes enriched with potassium) through the organ.[4][9][10][11] This time during transport is called the "cold ischemia time". Heart and lungs should have less than 6 hours between organ procurement and transplantation.[12] For liver transplants, the cold ischemia time can be up to 24 hours,[12] although typically surgeons aim for a much shorter period of time. For kidney transplants, as the cold ischemia time increases, the risk of delayed function of the kidney increases.[4] Sometimes, the kidney function is delayed enough that the recipient requires temporary dialysis until the transplanted kidney begins to function.

In recent years novel methods of organ preservation have emerged that may be able to improve the quality of donated organs or assess their viability. In the case of DCD, the first technique established for organ procurement was super-rapid recovery.[13] The most widely used technique involves machine perfusion of the organ at either hypothermic (4-10 °C) or normothermic (37 °C) temperatures. Hypothermic perfusion of kidneys is a relatively widespread practice. For the heart normothermic preservation has been used in which the heart is provided with warm oxygenated blood and so continues to beat ex-vivo during its preservation. This technique has also been applied to lungs and led to the emergence of donor lung reconditioning centres in North America. For the liver, hypothermic and normothermic techniques are being used with evidence to suggest that both may be beneficial.[14]

In 2005, China admitted to using the organs of executed prisoners for transplant.[18] Due to religious tradition of many Chinese people who value leaving the body whole after death, the availability of organs for transplant is much more limited. Almost all the organs transplanted from deceased donors came from executed prisoners.[18] Since then, China has repeatedly been found to have a rampant black market for organs for transplant, including continued use of organs from executed prisoners without their consent and targeting young army conscripts for their organs.[19] In 2014, China promised that by January 1, 2015, only voluntary organ donors would be accepted.[20] China has worked to increase the number of voluntary organ donors as well as to convince the international community that they have changed their organ procurement practices after many prior failed attempts to do so.[21] According to the former vice-minister of health, Dr. Huang Jiefu, the number of voluntary organ transplants increased by 50% from 2015 to 2016.[21] Many of the organs harvested are sold to overseas buyers who fly to China for the transplantation procedure. It is possible to schedule these surgeries in advance which is not possible in systems which rely on voluntary organ donation.[22] Muslim customers from the Middle East reportedly request Halal organs, those which come from a Muslim person.[23]

Organ procurement is tightly regulated by United Network for Organ Sharing (UNOS). In the United States, there are a total of 58 Organ Procurement Organizations (OPOs) that are responsible for evaluating the candidacy of deceased donors for organ donation as well as coordinating the procurement of the organs.[4] Each OPO is responsible for a particular geographic region and is under the regulation of the Organ Procurement and Transplantation Network.

The United States is divided into 11 geographic regions by the Organ Procurement and Transplantation Network.[25] Between these regions, there are significant differences in wait time for patients on the organ transplant list. This is of particular concern for liver transplant patients because transplantation is the only cure to end-stage liver disease and without a transplant, these patients will die.[26] One example that brought this disparity to light was in 2009, when Steve Jobs traveled from California, where wait times are known to be very long, to Tennessee, where wait times are much shorter, to increase his chances of getting a liver transplant.[25] In 2009, when Jobs received his liver transplant, the average wait time for liver transplantation in the United States for a patient with a MELD score of 38 (a metric of severity of liver disease) was about 1 year. In some regions, the wait time was as short as 4 months, while in others, it was more than 3 years.[27] This variation for a patient with the same illness severity has caused significant controversy over how organs are distributed.

The HOPE (HIV Organ Policy Equity) Act allows for clinical research on organ transplantation from HIV+ donors to HIV+ recipients. The Act was passed by Congress in 2013 and officially changed OPTN policy to allow for its implementation in November, 2015.[28] Prior to the HOPE Act, it was banned to acquire organs from any potential donor who was known to have, or even suspected to have, HIV.[29] According to UNOS, in the first year of implementation, 19 organs were transplanted under the HOPE Act.[30] Thirteen of those organs transplanted were kidneys and 6 were livers.[30]