Working Paper of Public Health Volume 2012 - Azienda Ospedaliera ...

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Azienda Ospedaliera Nazionale“SS. Antonio e Biagio e Cesare Arrigo”Working Paper of Public Healthnr. 3/2012transplantation rates could be higher still except that there is a serious constraint: theorgan donation shortage. The supply of organs is smaller than required to keep up withthe demand. Due to this gap, the waiting list for a transplant has increased in mostcountries around the world. Several factors may have caused increase in the demand fororgan transplantation. First, many improvements have been made on immunosuppressivedrugs, especially after the use of cyclosporine in the 1980’s, which have tremendouslyimproved graft survival in all types of transplantation. Second, there has been an increasein the number of surgeons and physicians with specialized knowledge, improvingmedical awareness of techniques about transplantation. Third, incidence and prevalenceof diseases have increased around the world, particularly ESRD 11 . Finally, the graft is setat zero price, as the law in most countries does not permit paying for organs 12 , whichmeans an infinite demand from an economic point of view.Another point to highlight is the nature of the supply side of organ transplantation. For anorgan to be removed, several requirements need to be met. First, the potential donor musthave healthy and well-functioning organs and be free of infection and cancer. Second, inmost of the cases the cadaveric donation comes from a donor that is declared brain dead,i.e. the donor had suffered complete and irreversible loss of all brain functions. To bedeclared brain dead, more than one physician carries out a full range of tests, and at leastone of them must be not related to the transplantation proceedings. After that, the hospitalmust then communicate the organ procurement to find the recipient that best matcheswith the available organ. Third, the consent for donation needs to be obtained, whichoften comes from the donor’s family. Finally, if consent is given, the organ from thedonor must be removed and allocated to the recipient.The above process typically breaks down at one or more stages, resulting in a failure tocollect the organs. Brain death may not be confirmed given the absence of staff or11 The ESRD prevalence rate has increased drastically, particularly in North America. In the USA, it wasreported an increasing of 70% in the number of people on chronic maintenance dialyse from 1991 (573 permillion population -pmp) to 2000 (977 pmp) (Renal Network, 2006). In Europe, this rate was 1360 pmp in1991 and 1393 in 2001 (USRDS, 2006). The lowest prevalence rate of replacement therapy was reportedin Latin America, which increased from 119 pmp in 1991 to 352 pmp, a huge increase of 295% over tenyears. It is not just the prevalence rate of ESRD patients that is increasing, but also the incidence rate. Itmeans that more people are diagnosed as having ESRD, aggravating even more the problem.12 Just in Iran and the Philippines organ sales are legal.5
Azienda Ospedaliera Nazionale“SS. Antonio e Biagio e Cesare Arrigo”Working Paper of Public Healthnr. 3/2012hospital’s infrastructure 13 , the hospital may not communicate fast enough that there is anorgan available, the request for consent may not be made in a competent way, and theorgan procurement may not be efficient in the logistics of matching the donor to therecipient. Because of these problems, it has been estimated that only about 1% of alldeaths in the USA occur under circumstances that would allow the organs of the deceasedto be used in transplantation (Kaserman and Barnett, 2002).Because of the inadequate organ supply, the organ shortage is increasing worldwide, witha few exceptions such as Spain. In Brazil, the organ shortage rose 54% from 2001 to2005. In the UK, it increased 43% in 8 years (1998-2005). In the same period, the USAreported an increase of 56% in organ shortage. Consequently, the length of waiting timesis increasing, causing further suffering to patients and considerable expense to keep themalive, as well as deterioration of the patients’ health throughout the time, which can causethem to be too debilitated to undergo the transplant operation.Living donors are another option for reducing the gap between demand and supply oforgans. However, it is still seen as a controversial issue in the medical community. Eitherrelated donors (parental) or unrelated donors (altruist) are considered with suspicion by arepresentative number of transplant centres, since the donation could be influenced byfamily pressure and psychiatric disorder, respectively (Hou, 2000). Another concernabout using a living donor is that someone can offer some kind of monetary benefit for apotential donor, especially for poor and less educated people who have a weak bargainingpower, to donate a kidney (Anbarci and Caglayan, 2005). Based on this, some specialistsbelieve that the priority should be placed on cadaveric donor.3. Data and Methods3.1 Data: Source and Description13 Faults in the detection process of brain death are the main reason for losing potential donors (Matesanz,2001). The main recommendations to improve that problem are: i) increase the number of intensive carebeds, especially in neurosurgical units; and ii) increase the number of nurses and physicians available(Cameron and Forsythe, 2001).6
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