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Organ and Tissue Donation

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Author:    Raymond M. Lengel (ARNP)

Purpose/Goals

This course will provide instruction in the clinical aspects of organ and tissue donation and recovery.

Objectives

  • List five organs and tissues that may be donated
  • Discuss the role of the organ procurement organization
  • Explain the organ and tissue donation and recovery process
  • Identify three strategies to prevent and treat organ/tissue rejection

Organ donation has the potential to save 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. One state legislature felt so strongly about encouraging organ donation, that professional nurses are required to complete continuing education in organ procurement. New Jersey Board of Nursing Laws 45:11-26.1:

  1. Numbered List Course Objectives
    1. Include instruction in organ and tissue donation and recovery designed to address clinical aspects of the donation and recovery process.
    2. Completion of organ and tissue donation and recovery instruction as provided in subsection a. of this section shall be required as a condition of receiving a degree or diploma, as applicable, in professional nursing from a nursing program in this State.
    3. A nursing program which includes instruction in organ and tissue donation and recovery as provided in subsection a. of this section in its curricula shall offer such training for continuing education credit.
    4. (1) A licensed professional nurse licensed to practice nursing in this State prior to the effective date of this act, who was not required to receive and did not receive instruction in organ and tissue donation and recovery as part of his nursing program curriculum, shall be required, as a condition of relicensure, to document completion of such training to the satisfaction of the board no later than three years after the effective date of this act. The training may be completed through an on-line, one credit hour course developed by or for the organ procurement organizations and approved by the board.

      (2) The board may waive the requirement in this subsection if an applicant for relicensure demonstrates to the satisfaction of the board that the applicant has attained the substantial equivalent of this requirement through completion of a similar course in his postsecondary education which meets criteria established by regulation of the board.

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. The first liver transplant was done in 1967 and the first heart and lung transplant was done in 1981.

Every individual has the right to become an organ donor. Individuals who are under 18 years old 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.

As of May 14, 2013, there were 118,100 people on the waiting list for a transplant. On average 79 people receive an organ transplant every day and 18 die every day waiting for a transplant. One person may save eight lives through donation of vital organs. In addition, one person can affect the lives of up to 50 people with the donation of organs and tissues (2). Healthcare professionals are in a position to assist patients and families in making organ donation decisions.

To Donate or Not to Donate

Many people want to be organ donors, but many do not want to be organ donors. Reasons that one would choose to donate their organs include:

  • the desire to help another or save someone's life,
  • the desire to help a loved one,
  • or to improve one's sense of worth.

When families make a decision to donate a loved one's organs they may feel as though their loved one is helping another or even feel as though their loved one is living on through others.

Reasons that individuals or families of individuals would not want to donate organs or tissues include:

  • The fear that future or present medical care will be limited in order to get the organs from the individual who has agreed to donate
  • The fear of the procedure to harvest the organs
  • Fear of pain (deceased donor's are brain dead and feel no pain)
  • Cost concerns (there is no direct cost to the family who donates)
  • Religious concerns most religions do not discourage organ/tissue donation (if there is concern encourage the potential donor/family to talk to a clergy member)

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 talked to in a sensitive way and improve the chances of donation.

Organs that may be Donated

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 (3).

Case 1 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 decides to officially 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 day he works five, eight hour shifts.

He finally receives his kidney transplant after four years on the transplant list.

Organ Transplant Process

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).

Table 1: Disease States that may Lead to Organ Failure
OrganSelected diseases that may lead to organ failure
HeartHeart failure, cardiomyopathy, coronary heart disease
KidneyPolycystic kidney disease, end-stage renal disease due to hypertension or diabetes
LiverHepatitis, acute liver failure due to medications, hemochromatosis, nonalcoholic steatohepatitis
LungChronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis, cystic fibrosis
IntestineShort 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 get 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. It is available at HRSA.Gov.

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).

Table 2: Selected Responsibilities of the United Network for Organ Sharing
  • Maintain the organ transplant data base
  • Provide assistance to patients and families in the process of organ transplantation
  • Educate the public and health care professionals
  • Manage the waiting list
  • Develop policies and procedures
  • Monitors organ matches
  • Operate the OPTN

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 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 (4). For the donor, it does not cost anything for the patient's family or the patient's estate after the patient dies.

Once on the national list, wait times are variable and patients need to be educated about average wait times for their organ. According to the U.S. Department of Health and Human Services the median national wait times are (4):

  • Heart 113 days
  • Lungs 141 days
  • Intestines 159 days
  • Pancreas 260 days
  • Liver 361 days
  • Kidneys 1219 days

Patients need to be encouraged to take care of themselves while they wait for the transplant. They should be encouraged to maintain their doctor appointments; take all medications; exercise (as appropriate); eat healthy; and do not smoke, drink alcohol or do illegal drugs. Patients must always be prepared with transportation in case they are notified that an organ is available.

Agreeing to Donate

It is a difficult time for the family when having to decide to donate organs. The family has just lost a loved one and then has to make a decision to donate organs. Many thoughts are going the families' mind.

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 dealing with organ donation and the process working 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 (5). 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/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 of 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 aware of every patient that is near death or who has died. If the patient is determined to be a potential donor an OPO member will come to the hospital. The OPO is Health Insurance Portability and Accountability Act exempt.

The health care provider who declares death after life support is withdrawn cannot be associated with the transplant process (6). 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 than 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.

Who is a Candidate to Donate?

Donors can be dead or living. Deceased donors have to be declared brain dead. Brain death happens when the brain is completely and irreversibly non-functional and is caused by insufficient blood/oxygen supply which causes the brain cells to die (2).

When an individual dies the organ procurement organization 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.

All deceased donors are screened for HIV at the time of brain death. Living donors are screened sometime before the transplant and there is a chance that the donor may have contracted HIV in the interim. If possible repeat testing must occur as close to the date of transplant as possible, but no longer than 7 days (6). Living donors should be educated to avoid behaviors that are associated with increased risk of acquiring HIV infection before transplant surgery.

How to Register to be an Organ Donor

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 on the internet at the state donor registry. One can register through their website.

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 bad 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.

After the Transplant

After the transplant, the job is not over. The transplant recipient must still take medications, have follow up appointment and live a healthy lifestyle. One of the biggest tasks is to take anti-rejection medication, with the goal of preventing the body from rejected the transplanted organ. Finding the right dose after surgery often takes some time as transplant surgeons may have to frequently adjust dosages or even change medications.

Organ and Tissue Rejection

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 accepting 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 have identical transplant antigens (7).

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.

hronic GVHD affects many long-term survivors of transplants. It may 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 an 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. Advancing technology around DNA-based tissue typing allows 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 increased with the use of immunosuppressant medications. Treatment and prevention of GVHD involves the use of non-specific immunosuppressive medications such as methotrexate, corticosteroids, cyclosporine and tacrolimus.

Case Study
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 travelling in a car behind his 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 the 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.

uring 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 recover 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 the 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 love 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.

Conclusions

Many people die every year needing a transplant. It is important 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 about organ rejection and the steps required to reduce the risk of rejection.

References

1. National Institute of Health. (2013). Organ Donation. Retrieved May 1, 2013 from (Visit Source).
2. U. S. Department of Health and Human Services. (2013). The Need is Real: Data. Retrieved May 3, 2013 from (Visit Source).
3. U. S. Department of Health and Human Services. (2013). Organ Donation. Retrieved May 2, 2013 from (Visit Source) 
4. U. S. Department of Health and Human Services. (2013). Organ Donation Retrieved May 10, 2013 from (Visit Source). 
5. DuBois, J. M. (2001). Non-heart-beating organ donation: designing an ethically acceptable protocol. Health Progress. 82(1), 18-21.
6. Center for Disease Control. (2011). HIV Transmitted from a Living Organ Donor -- New York City, 2009. Morbidity and Mortality Weekly Report (MMWR). 60(10), 297-301
7. National Institute of Health. (2008). Immunology and Transplants. Retrieved May 5, 2012 from (Visit Source).
8. New Jersey Board of Nursing Laws 45:11-26.1: page 15-16.