This course will provide an overview of the clinical aspects of organ and tissue donation and recovery.
Organ donation is the process of taking healthy organs and tissues from one person and transplanting them into another person.1 The majority of organs and tissues are taken from deceased donors, but occasionally they are taken when the donor is alive. The first successful organ transplant was a kidney donated by a man to his identical twin in Boston, Massachusetts in 1954. The first simultaneous kidney/pancreas transplant was done in 1966. In 1967, the first liver transplant was performed, and in 1981, the first heart and lung transplant were done.2 Between January 1, 1988 and December 31, 2018, over 750,000 organ transplants have been performed.3
Every individual has the right to become an organ donor. Individuals who are under 18 years of age need to have permission from a parent or guardian if they want to be a donor. Organs are donated by a deceased person who gave permission prior to death; the family of a deceased patient may offer their loved one’s organs or tissues, or a living person may act as a living donor.
Organ donation has the potential to save the lives of individuals with end-stage organ failure. In addition, organ and tissue transplants have the potential to restore health and function to many individuals.
As of February 9, 2019, there are 113,847 people in need of a lifesaving transplant. In 2018, 36,528 transplants were performed. Every day, 20 people die waiting for a transplant. One person may save eight lives through the donation of vital organs. In addition, one person can affect the lives of up to 50 people with the donation of organs and tissues.3
Organ donation is a very personal and difficult decision for many to make. Reasons that one may choose to donate their organs include the desire to help others or save someone’s life, the desire to help a loved one, or to improve one’s sense of worth. When families decide to donate a loved one’s organs, they may feel as though their loved one is helping others or as though their loved one is living on through others.
Reasons individuals or families of individuals would not want to donate organs or tissues include:
Lastly, the fear of the health care provider not wanting to interfere with a grieving family after their loved one has died or has been declared brain dead is another barrier to organ donation. Bringing in an organ procurement organization will help assure that the family of a loved one is approached in a sensitive way so as to improve the chances of donation.
Organs that may be donated include the heart, heart valves, kidneys, liver, lungs, pancreas, intestines, eyes/cornea, skin, some veins, bone and bone marrow. Deceased donors can offer the heart, heart valves, kidneys, liver, lungs, pancreas, intestines, cornea, skin, bone and veins. Living donors may give a kidney, part of the liver, lung or intestine.4 The vast majority of transplant performed involve the kidneys.
Lack of Available Kidneys Lead to Long Wait Times for Transplant
John T. is a 35-year-old white male who has been treated for hypertension for three years with lisinopril. He is married and is the sole provider for his wife and four children. Upon a routine annual checkup, he is noted to have an elevated creatinine and potassium level. He is admitted to the hospital, and further evaluation shows that he has polycystic kidney disease. He is stabilized in the hospital but is told he will eventually need a kidney transplant or spend the rest of his life on dialysis.
Over the next two years, his kidney function slowly deteriorates to a point where his nephrologist officially decides to place him on the kidney transplant list. He undergoes fistula placement for impending dialysis and starts dialysis nine months later.
Because he needs to keep working to support his family, John does overnight dialysis three days a week where he goes to a center to receive dialysis while he sleeps. During the week, he works six 8-hour day shifts. He finally receives his kidney transplant after four years on the transplant list.
Organ transplantation is when a donated organ is surgically transferred to another person. Organ transplant typically occurs due to end-stage organ failure which may occur due to multiple disease states (see table 1).
|Organ||Selected diseases that may lead to organ failure|
|Heart||Heart failure, cardiomyopathy, coronary heart disease|
|Kidney||Polycystic kidney disease, end-stage renal disease due to hypertension or diabetes|
|Liver||Hepatitis, acute liver failure due to medications, hemochromatosis, nonalcoholic steatohepatitis|
|Lung||Chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis, cystic fibrosis|
|Intestine||Short gut syndrome|
When it is determined by the physician that a transplant is necessary, a referral is made to a transplant program. The patient should be encouraged to obtain a copy of Partnering with Your Transplant Team, which is a free handbook from the U.S. Department of Health. It provides the patient and family with information about the process including an overview of the transplant process and how the patient can best navigate the system.5
After a transplant is decided on, an organ procurement organization (OPO) helps. The OPO has two major roles. It works to coordinate the donation process when an organ becomes available and works to increase the number of registered donors. There are 58 OPOs in the United States and two in New Jersey. The OPO is a critical component to the donation process and has personnel available at all times to help in the process.
Specifically, the OPO will evaluate the potential donor, contact the Organ Procurement and Transplantation Network (OPTN), run a match list, work with family members and arrange for the transport and recovery of donated organs. All OPOs are certified by the Centers for Medicare and Medicaid Services and must be members of the OPTN.
In addition to the OPO, there are multiple organizations involved in the transplant process. These include the transplant hospital, the OPTN and the United Network for Organ Sharing (UNOS).
Every transplant hospital in America is an OPTN member and must have a transplant surgeon and a physician with training/experience in the type of organ that is transplanted.
The OPTN is a unified transplant network created in 1984. The network is non-profit, operated privately, and under federal contract. The organization works to increase the supply of donated organs and increase the effectiveness and efficacy of organ donation.
UNOS manages the transplant system in the United States. It is a non-profit, private organization and has multiple responsibilities (see Table 2).
After the patient has selected a transplant program, an evaluation is set up to determine if the patient is a candidate and to provide help with finances. The transplant coordinator works with the recipient and is involved in the testing, evaluation and getting the patient on the national waiting list. If the transplant team determines that the patient is a candidate they are listed on the OPTN national list of all individuals awaiting a transplant.
Patients need to have an understanding of the financial commitment to the transplant process. It is important to work with the insurance company to help the patient understand the personal cost for the donor. In 2008, the average cost of a transplant of one kidney was 259,000 dollars, and a heart-lung transplant was 1,200,000 dollars.6 Regarding the donor, it does not cost the patient’s family or estate anything postmortem.
Once on the national list, wait times are variable and patients need to be educated about average wait times for their organ. The longest wait time is for kidney transplantation, averaging 3-5 years.6
Patients should be encouraged to take care of themselves while they wait for a transplant. They should be instructed to maintain their doctor appointments, take all medications, exercise (as appropriate), eat healthily, and do not smoke, drink alcohol or do illegal drugs. Patients must always be prepared with adequate transportation in case they are notified that an organ is available.
Deciding on organ donation is a difficult situation for loved ones. The family has just lost a loved one and is then faced with the decision regarding organ donation. The way in which the health care team approaches this process will greatly affect the chance of donation. It is important to have an individual experienced in the process of handling organ donation to work with the family. This commonly includes a member of the OPO. Collaboration with other health care members often occurs in the process and may include clergy, social workers, physicians, nurses or others.
No mention of organ donation is brought up until the family is aware of the patient’s condition. The decision to donate organs and tissues should occur after a discussion regarding withdrawal of life support has taken place.7 If the family is approached about organ donation when they have not been made aware of the grim prognosis, the outcome will likely be poor as distrust or distress may occur.
The health care team needs to reach out to the grieving family in a sensitive manner. When talking to a grieving family member or loved one, it is important to find a quiet private room to discuss issues. Utilize clergy, if necessary, to help with the grief.
Throughout the process it is important to keep the family updated regarding the condition of the patient. If the family needs a break, provide it. The family will need time to let information about the pending death of their loved one and organ donation sink in, but it is important for staff to remain by for support.
The hospital makes the local organ procurement organization (OPO) aware of every patient that is near death or who has recently died. If the patient is determined to be a potential donor, an OPO member will visit the hospital. The OPO is exempt from the Health Insurance Portability and Accountability Act (HIPAA).
The health care provider who declares death after life support is withdrawn cannot be associated with the transplant process.8 Upon hearing that an organ is available, the transplant coordinator enters the information into the national database. The computer will match the available organ to donors, and a list of possible recipients is generated.
The potential recipients are ranked. The organ is then offered to the first person on the list. Assuming that the candidate is a match, immediately available, in a state of health that allows him/her to have major surgery and the transplant team accepts the organ within one hour, the organ goes to that candidate. If these criteria are not meet the organ goes to the next person on the list.
In 2006, UNOS launched an online system called DonorNet. This uses numerous algorithms to match organs from a recently deceased patient to those on the waiting list. Factors included are blood type, body size, the distance the organs would have to travel, and organ survival during travel.9 The use of this system is ensuring a quick turnaround time for organ matches and consideration of various criteria.
Donors can be deceased or living. Deceased donors have to be declared brain dead, which happens when the brain is completely and irreversibly non-functional and is caused by insufficient blood/oxygen supply, causing the brain cells to die.3
When an individual dies, the OPO determines if the patient is suitable to donate. Donors are often victims of injuries (brain trauma), have catastrophic strokes, or suffer an aneurysm. Some conditions rule out donation, such as human immunodeficiency virus (HIV), other infectious diseases, many active cancers, or organs that are damaged by trauma or lack of perfusion.
A living donor will give an organ or part of an organ. Organs given may include a kidney or possibly a part of the liver, pancreas, lung or intestine. Living donors cannot have HIV, hepatitis, an array of other infections, cancer, uncontrolled high blood pressure, or diabetes.
All deceased donors are screened for HIV at the time of brain death. Living donors are screened sometime before the transplant. Because there is a chance that the donor may have contracted HIV in the interim, repeat testing must occur as close to the date of transplant as possible, but no longer than 7 days prior.8 Living donors should be educated to avoid behaviors that are associated with an increased risk of acquiring HIV infection before transplant surgery.
Recent statistics show that over 138 million adults have registered to be organ donors as of 2017.10 The process to register is relatively simple and only takes a few minutes to complete.
Techniques people can use to make their wishes known include using advanced directives, a living will, a donor card, communicating the desire to donate on their driver’s license, or signing up online at the state donor registry. One can register through their state online here. As of 2016, iPhone users are now able to register to be an organ donor via the Health app, which is then sent directly to the National Donate Life Registry.11
In addition, individuals should let their family know they want to become an organ donor. This should be done both verbally and in the form of advanced directives/living will. If an individual is in a traumatic accident, the family will be consulted before the organs are harvested for donation. If the family is unsure of the patient’s wishes, the decision may be more difficult. Having these open and honest discussions often helps the family accept the donor’s decision and provides a better understanding of their wishes.
There are continued postop measures aimed at ensuring the transplant is successful. The transplant recipient must still take medications, have follow-up appointments, and live a healthy lifestyle. One of the biggest tasks is to take anti-rejection medication, with the goal of preventing the body from rejecting the transplanted organ. Finding the right dose after surgery often takes some time as transplant surgeons may have to adjust dosages or even change medications frequently.
A group of genes called the major histocompatibility complex (also known as the human leukocyte antigen [HLA] system) helps determine if grafted organs or tissues will be accepted or rejected. The HLA antigens are expressed on the lymphocyte surface and vary from person to person. When deciding if an organ will be rejected or accepted it is critical to get the HLA antigens to match as close as possible between the donor and recipient. In addition, donor and recipient are matched for ABO blood type. There are also minor histocompatibility genes that are involved in the rejection or acceptance of organs/tissues.
For the transplant to stay viable, the body’s desire to reject the organ must be countered. This is partially done by tissue typing, which is a blood test that measures antigens. Tissue typing assures that the donated tissue is as similar to the recipient’s tissue as possible. Each cell in the body has a double set of six major tissue antigens in as many as twenty different varieties. One in 100,000 people has identical transplant antigens.12
In bone marrow transplants, the transplanted marrow cells can develop into functioning B and T cells. Therefore, in bone marrow transplants a close match is critically important. The body may not only reject the transplanted marrow, but the bone marrow may create T cells that destroy the recipient’s tissue.
Graft-versus-host disease (GVHD) happens when immune cells transplanted from a non-identical donor (the graft) identify the transplant recipient (the host) as foreign. At this point, an immune reaction leads to disease in the transplant recipient. The pathogenesis of GVHD is a complex, multistep process but is primarily a T cell-mediated process.
Symptoms of acute and chronic GVHD most commonly involve the skin, liver, and gastrointestinal tract. It is sometimes clinically (based on signs and symptoms) challenging to diagnose and may require histological confirmation. The severity of GVHD is determined by grading from I (mild) to IV (life-threatening).
Acute GVHD occurs within three months of transplantation, and chronic GVHD occurs after three months. Acute GVHD is diagnosed clinically and may present with abdominal cramping, pain at the site of the organ, nausea, vomiting, dry eyes, diarrhea, a maculopapular rash and/or elevated serum bilirubin level. Kidney rejection may be suggested by a reduced urine output; liver rejection by bleeding and/or jaundice; and heart/lung rejection with shortness of breath.
Chronic GVHD affects many long-term survivors of transplants. It may occur after acute GVHD, or it can occur when there was no history of acute GVHD. Chronic GVHD presents clinically as a skin rash that resembles cutaneous scleroderma or lichen planus; oral ulcers; diarrhea; dysphagia; or elevated serum bilirubin. Biopsy of the involved tissue is typically required to make the diagnosis. Closely matching HLA between recipient and donor can help prevent GVHD. Advancements in technology around DNA-based tissue typing allows for more precise matching.
The patient’s immune system must be suppressed after the transplant, but not so much that the infection risk is increased. None-the-less, the risk of infection is always a concern due to the use of immunosuppressant medications. Treatment and prevention of GVHD involve the use of non-specific immunosuppressive medications such as methotrexate, corticosteroids, cyclosporine and tacrolimus.
A 28-year-old male arrives in the emergency department after he suffered a closed head injury from a motor vehicle accident. His wife and mother were in the emergency department shortly after he arrived as they were traveling in a car behind him when he was in the accident.
He was intubated by the paramedics in the field. Upon arrival in the emergency department, he is hypotensive and has an elevated heart rate. His left pupil was 8 mm and minimally reactive, and his right pupil was 5 mm and nonreactive. When turning the head to both sides, there was no eye movement. When ice water was injected in both ear canals, no movement was noted. The corneal reflex in both eyes was absent.
The computed tomography head scan showed a large subdural hematoma with a left-to-right shift. The patient was deemed not to be a surgical candidate by the neurosurgeon. He was treated medically in intensive care with hyperventilation while he was monitored to see if the injury would be somewhat reversible.
After four hours, there was no improvement in the patient clinically. The patient is continued on respiratory support.
The next morning there was no improvement clinically, and the neurologist who examined the patient recommended a brain blood flow study because he had a Glasgow Coma Scale Score of 3, no purposeful movement, with no cough or gag reflex, no spontaneous respirations and fixed and dilated pupils.
The brain flow study showed no blood flow to the brain. Based on this and the physical exam the neurologist determined that the patient was brain dead. A referral was made to the organ procurement organization.
During this process, the patient had a reduction in blood pressure to an average blood pressure of 98/56 mm Hg with an average heart rate of 103 beats per minute. The patient was noted to have a stable creatinine level, blood urea nitrogen level and liver function tests.
The organ recovery coordinator evaluated the patient and determined that the patient was a candidate for organ donation but was concerned with the clinical picture. The attending physician increased the intravenous fluids to help maintain blood pressure to reduce the risk or organ hypoperfusion.
The family was made aware that the patient was brain dead. The physician who had the conversation with the family discussed organ donation but did not push the issue because the family was very upset about losing their loved one.
The physician spoke to the transplant coordinator from the OPO and suggested that she talk to the family. The coordinator, who has special training in grief counseling, counseled the family. She worked with the family and helped them accept the fact their loved one was brain dead. After a period of time, the family was open to the option of organ donation. After working with the coordinator, the family was agreeable to donate all tissues and organs.
Although the organ donation process is often a difficult one for families, nurses should be able to provide support and education.13 This may include being knowledgeable of the process and knowing who can be contacted for specific questions. It also includes being able to determine which patients might be eligible organ donors and quickly referring them to the local organ procurement organization. The nurse must then continue caring for the organ donor and ensure the continued preservation of organs while supporting the family.14 Throughout the process of their patient becoming a possible organ donor, the nurse must maintain high ethical standards and adhere to the ANA’s Code of Ethics, including advocating for the safety of the patient and maintaining compassion and respect.15
Many people die every year needing a transplant. It is essential to understand the importance of becoming an organ donor as there is a severe shortage of organs with many individuals awaiting transplant. Nurses have key roles in helping people understand the organ and tissue donation process. Healthcare professionals need to be able to provide accurate information about organ donation including dispelling myths surrounding organ donation, encouraging people to get involved in the donation process and possibly becoming an organ donor. Lastly, nurses need to have an understanding of organ rejection and the steps required to reduce the risk of rejection.