An Organ for My Child: Public Appeals for Limited Resources.

The case of Jamie Fiske and subsequent public appeals for particular children by President Ronald Reagan represent classic cases in pediatric bioethics in which parents or others publicly appealed for a donor organ for a particular child. These raise questions about the appropriate boundaries for public appeals for a limited resource for a particular child and how the press and medical community should respond to such appeals. Public appeals by parents to advocate for their child to receive a limited resource above others promote rationing by morally irrelevant factors and shift the public focus from the national shortage of organs for transplant to the needs of a particular child. Yet these appeals are understandable and will likely continue. Recognizing this, we consider appropriate responses by the media, transplant community, hospitals, and individual clinicians.

Responsible use of organoids in precision medicine: the need for active participant involvement.

Organoids are three-dimensional multicellular structures grown in vitro from stem cells and which recapitulate some organ function. They are derivatives of living tissue that can be stored in biobanks for a multitude of research purposes. Biobank research on organoids derived from patients is highly promising for precision medicine, which aims to target treatment to individual patients. The dominant approach for protecting the interests of biobank participants emphasizes broad consent in combination with privacy protection and ex ante (predictive) ethics review. In this paradigm, participants are positioned as passive donors; however, organoid biobanking for precision medicine purposes raises challenges that we believe cannot be adequately addressed without more ongoing involvement of patient-participants. In this Spotlight, we argue why a shift from passive donation towards more active involvement is particularly crucial for biobank research on organoids aimed at precision medicine, and suggest some approaches appropriate to this context.

Deceased Donor-initiated Chains: First Report of a Successful Deliberate Case and Its Ethical Implications.

BACKGROUND: It has been suggested that deceased donor kidneys could be used to initiate chains of living donor kidney paired donation, but the potential gains of this practice need to be quantified and the ethical implications must be addressed before it can be implemented. METHODS: The gain of implementing deceased donor-initiated chains was measured with an algorithm, using retrospective data on the pool of incompatible donor/recipient pairs, at a single center. The allocation rules for chain-ending kidneys and the characteristics and quality of the chain-initiating kidney are described. RESULTS: The benefit quantification process showed that, with a pool of 69 kidneys from deceased donors and 16 pairs enrolled in the kidney paired donation program, it was possible to transplant 8 of 16 recipients (50%) over a period of 3 years. After obtaining the approval of the Veneto Regional Authority's Bioethical Committee and the revision of the Italian National Transplant Center's allocation policies, the first successful case was completed. For the recipient (male, aged 53 y), who entered the program for a chain-initiating kidney with a Kidney Donor Risk Index of 0.61 and a Kidney Donor Profile Index of 3%, the waiting time was 4 days. His willing donor (female, aged 53 y) with a Living Kidney Donor Profile Index of 2, donated 2 days later to a chain-ending recipient (male, aged 47 y) who had been on dialysis for 5 years. CONCLUSIONS: This is the first report of a successfully completed, deliberate deceased donor-initiated chain, which was made possible after a thorough assessment of the ethical issues and the impact of allocation policies. This article includes a preliminary efficacy assessment and describes the development of a dedicated algorithm.

Complete Chain of the First Global Kidney Exchange Transplant and 3-yr Follow-up.

BACKGROUND: Global Kidney Exchange (GKE) offers an opportunity to expand living renal transplantation internationally to patients without financial means. These international pairs are entered into a US kidney exchange program that provides long-term financial support in an effort to identify opportunities for suitable exchanges for both these international pairs and US citizens. OBJECTIVE: While the promise of GKE is significant, it has been met with ethical criticism since its inception in 2015. This paper aims to demonstrate the selection process and provide >3 yr of follow-up on the first GKE donor and recipient from the Philippines. DESIGN, SETTING, AND PARTICIPANTS: The first GKE transplant occurred with a young Filipino husband and wife who were immunologically compatible, but lacked the financial means to continue hemodialysis or undergo a kidney transplant in their home country. The pair was enrolled in the Alliance for Paired Donation matching system, several alternative kidney exchanges were identified, and the pair subsequently underwent renal transplantation and donation in the USA financed by philanthropy. The resulting nonsimultaneous extended altruistic chain provided transplantation for the Filipino husband and 11 US patients. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The Filipino donor and recipient were followed by transplant professionals in both the Philippines and the USA. Follow-up data were maintained as required by the Organ Procurement and Transplantation Network in the USA. RESULTS AND LIMITATIONS: The Filipino donor has normal blood pressure and renal function, and the Filipino recipient is doing well 3.5 yr after their donation and transplantation. CONCLUSIONS: While criticisms of GKE highlight concerns for possible exploitation of financially disadvantaged groups, these results demonstrate that these concerns did not come to fruition, and the outcome experienced by the GKE donor and recipient (and other US participants) was successful. PATIENT SUMMARY: The first Filipino Global Kidney Exchange (GKE) donor-recipient pair continues to be followed by both US and Filipino transplant centers. Both are in good health, support the GKE program, and advocate for its expansion.

International challenges of self-sufficiency in blood products.

To face known and emerging threats to public health, all countries have to overcome the challenges of providing sufficient supplies of blood and blood products of the highest quality and safety. Unfortunately, self-sufficiency is not yet a reality in many countries. In 2011, experts from WHO addressed the urgent need to establish strategies and mechanisms for achieving this goal. A summary of these recommendations is further discussed.

They can't have my embryo: the ethics of conditional embryo donation.

There are substantial numbers of frozen embryos in storage that will not be used by those who produced them for their own fertility treatment. One option for such embryos is to donate them to others to use in their fertility treatment. There has been considerable debate about how this process should be organized. In the US, there are embryo adoption programmes that mediate between those relinquishing embryos and potential recipients. This is a form of conditional embryo donation, where the relinquishing couple can choose the recipient of their embryo. This article examines the ethical debate over conditional embryo donation for family building and explores the question of whether those who have unused frozen embryos should be able to determine who receives their embryos. The main objections to conditional embryo donation are examined: first, the embryo is not a person and therefore such concern over the placement of an embryo is unwarranted; secondly, potential donors might impose morally problematic conditions on who should receive their embryo; and thirdly, there are practical difficulties regarding organizational arrangements and the associated costs involved. It will be concluded that these objections can be countered and that if people wish to donate and receive embryos in this way there is no ethical objection to them doing so.

Actitud hacia la donación de vivo relacionada entre los candidatos a trasplante hepático en lista de espera / No disponible

Objetivo: analizar la actitud hacia la donación de vivo de los pacientes en lista de espera para trasplante hepático. Diseño y pacientes: seleccionados los pacientes incluidos en lista de espera para trasplante hepático (2003-2005) (n = 164). La actitud hacia la donación de vivo se valora mediante un cuestionario validado. La cumplimentación fue mediante entrevista por un profesional sanitario independiente de la Unidad de Trasplantes. Resultados: el grado de cumplimentación: 97% (n = 159). El 87% (n =138) de los pacientes indican que donarían en vida un órgano si un familiar o amigo íntimo lo necesitase. Sin embargo, solo el 39% (n = 61) aceptaría una donación hepática de vivo relacionada, prefiriendo esperar en Lista de Espera el 50% (n = 80). El 90% asume que existe algún riesgo en la donación hepática de vivo. Sin embargo, no se asocia con la aceptación de la donación de vivo relacionada (p = 0,170). De las diferentes variables analizadas, solo se relaciona con la actitud hacia la aceptación de la donación de vivo el conocer la actitud de su familia para donarles un órgano (p = 0,027). Conclusiones: los pacientes en lista de espera para trasplante hepático tienen una actitud favorable hacia la donación de vivo hepática. Un núcleo familiar propicio hacia la donación de vivo favorece la aceptación de dicha donación, por ello, es fundamental hacer un sondeo familiar entre los pacientes para detectar aquellos casos en los que se puede solicitar con éxito dicha donación de vivo(AU)

Objective: to analyze attitude of patients on the liver transplant waiting list toward living donation (LD). Design and patients: patients on the transplant waiting list —2003-2005 (n = 164)— were selected. Attitude was evaluated using a validated questionnaire, completed by an independent healthcare professional. Results: the questionnaire completion rate was 97% (n = 159). A total of 87% (n = 138) of patients stated that they would donate an organ while alive if a family member needed one. Howev er, only 39% (n = 61) would be prepared to receive a liver donation from a living relative and 50% would prefer to wait on the list (n = 80). 90% accepted that living liver donation involves a certain amount of risk. This assumption was not associated with a willingness to accept related LD (p = 0.170). A willingness to accept LD was related to patient’s knowledge of his or her family’s attitude toward donating an organ to the patient (p = 0.027). Conclusions: patients had a favorable attitude toward living liv er donation. When there was a family base that is in favor of LD then this encouraged acceptance, and therefore, it is essential to carry out family screening of patients to detect those cases in which this type of LD can be successfully requested(AU)

Donación tras la muerte cardíaca. Parada cardíaca en el mantenimiento del donante en muerte encefálica / Donation after cardiac death: Cardiac arrest during donor maintenance after brain death

La muerte encefálica comporta el cese completo e irreversible de las funciones de ambos hemisferios cerebrales y del tronco encefálico. Esto conlleva trastornos fisiopatológicos muy graves que hacen que el mantenimiento del donante sea complejo y el riesgo de deterioro orgánico aumente de forma muy rápida. El corazón es uno de los órganos diana en este proceso evolutivo de fracaso multiorgánico. Sobre él actúan el propio aturdimiento miocárdico producido por la tormenta catecolamínica y posteriormente la liberación de multitud de mediadores proinflamatorios, radicales oxígeno libres y el desequilibrio hidroelectrolítico secundario a la diabetes insípida e hipotermia. La parada cardíaca en el mantenimiento del donante en muerte encefálica es una situación aún relativamente frecuente. La carencia de órganos para el trasplante ha llevado a desarrollar programas de donación con criterios expandidos, entre los que se incluye la donación tras la muerte cardíaca o donación a corazón parado (AU)

Brain death implies the complete cessation of activity in both cerebral hemispheres and in the brainstem; this leads to severe physiopathological disorders that make donor maintenance complex and involve the concomitant risk of rapid organ deterioration. The heart is one of the target organs in this process of multiple organ failure. Myocardial stunning occurs due to a «catecholamine storm» and subsequent release of many proinflammatory mediators, free oxygen radicals, and electrolyte imbalance secondary to insipid diabetes and hypothermia. Cardiac arrest during the maintenance of a donor after brain death is relatively frequent. The shortage of organs for transplantation has led to the broadening of the criteria for organ donation to include donation after cardiac death or non heart beating donation, among others (AU)

Doação de órgãos e tecidos no Brasil: podemos evoluir? / Donación de órganos y de tejidos en el Brasil: ¿podemos desarrollarnos? / Organ and tissues donation in Brazil: can we evolve?

Desde 1997, quando da aprovação da chamada Lei dos transplantes, até os dias de hoje, tivemos várias oportunidades de esclarecimentos àpopulação acerca da doação de órgãos e tecidos no Brasil. Adicionalmente, também tivemos um importante avanço nessa área, possibilitando aos profissionais mudanças e melhorias em suas práticas assistenciais. Mas ainda buscamos não somente entender o significado da doação, em constante mudança, frente aos valores morais que também se alteram, mas, sobretudo, buscar constantemente aprimorar nossos processos assistenciais, por meio das melhores evidências. Assim, este estudo faz uma revisão de literatura e discussão, sobre o tema doação de órgãos e tecidos. Observou-se que as evidências constroem um cenário internacional, em que a lei do consentimento presumido é associada ao aumento das taxas de doação de órgãos, e que o acompanhamento das famílias durante e após a doação tem sido uma importante recomendação de especialistas. A evolução das taxas de doação também está ligada, indiretamente, às propostas de capacitações, produção científica, eventos, parcerias público-privadas, desenvolvimento de um sistema de qualidade, contribuição social para as adequações legais, entre outros.Palavras-chave: Consentimento presumido. Doação dirigida de tecido-tendências. Família.

Since 1997, when Transplants Act was approved, until the present, we had some opportunities for explaining to the population legislation on organ and tissue donation in Brazil. Additionally, we also had an important advance in this area, making possible that professionals change and improve care practices. But still we search not only to understand the meaning of donation, in a constant change, before moral values that also change, but, over all we search constantly to improve our assistance processes by means of the best evidences. Thus, this study is a literature survey on and a discussionabout organ and tissue donation. We found evidences that point to a worldwide trend, where the law of presumed consent is associated to the increase of organ donation rates and that giving assistance to families during and after the donation has been an important recommendation of specialists. The evolution of donation rates is also indirectly linked to proposals of qualifications, scientific production, events, public-private partnerships, development of a quality system, social contribution for the legal adequacies, among others. Keywords: Presumed consent. Directed tissue donation-trends. Family.

Desde 1997, cuando se aprobó la Ley de los Trasplantes, hasta el presente, tuvimos algunas oportunidades como para explicar a la población la legislación sobre la donación de órganos y tejidos en Brasil. Además, también tuvimos un avance importante en esta área, haciendo posible que losprofesionales cambian y mejoren las prácticas del cuidado. Pero todavía buscamos no sólo entender el significado de la donación, en cambio constante, delante valores morales que también cambian, pero, sobretodo, la búsqueda constante de mejoría de nuestros procesos de ayuda de promedio las mejores evidencias. Así, este estudio es una encuesta sobre la literatura especializada y una discusión sobre la donación de órganos y tejidos. Encontramos evidencias que demuestran una tendencia mundial, donde la ley del consentimiento presumido se asocia al incremento de las tajas de donación de órganos y que la asistencia a las familias durante y después la donación ha sido una recomendación importante de especialistas. La evolución de las tajas de donación también se liga indirectamente a las propuestas de calificaciones, producción científica, eventos, aparcerías público-privadas, desarrollo de un sistema de calidad, contribución social para las adecuaciones legales, entre otros.

Twenty-first century brain banking: at the crossroads.

Brain banks form an increasingly important resource for research. In view of declining autopsy rates, brain banks are also gaining importance for medical diagnostics, quality control and teaching. In the case of neurodegenerative diseases, brain banks have become drivers of discovery and are yielding invaluable taxonomic references for neuropathologists. This article provides comments on two recent landmark papers in the field (Bell JE et al. Acta Neuropathol 2008. doi:10.1007/s00401-008-0358-8; Vonsattel JP et al. Acta Neuropathol 2008. doi:10.1007/s00401-007-0311-9). Professionalisation of brain banking standards, ethical principles safeguarding the running of a brain bank and a proposed code of conduct for brain bank staff are outlined and discussed. Special emphasis is placed on the need to enable sustainability of the human brain tissue resource in the face of increased financial pressures on medical institutions and raised public expectations towards ethical human brain banking in a globalised economic environment. It is proposed that brain banks undergo rigorous international audit as a prerequisite for their registration with the relevant national neuropathological society. This promises to be an important safeguard so that proper standards can be assured when tissue is handed out to commercial companies. Honesty, accountability and complete transparency are mandatory to allow long-lasting success of the brain banking operation by guaranteeing that the best possible use is made of the tissue. Preferred access by private tissue users must be avoided and money must never be allowed to buy access to a brain bank. Since brain banks operate internationally, any mistake made may be felt around the globe and could endanger the public's willingness to donate brains for research. The much-needed increase in the number of control brain donations will only be achievable if broad-based support from the general public can be won and maintained.

Actitud hacia el xenotrasplante en los servicios quirúrgicos en un hospital con un programa preclínico de xenotrasplante hepático / Attitude to xenotransplantation in surgical departments in a hospital with a preclinical liver xenotransplant program

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Cord blood transplantation for adults.

Allogeneic haematopoietic stem cell transplant has become an import tool for the treatment of high risk and advanced haematological diseases. However, allogeneic transplantation has been limited by the availability of suitable related and unrelated donors. The positive results with umbilical cord blood as an alternative source of haematopoietic stem cells for transplantation in the paediatric setting encouraged studies in adult patients. In adults, however, the progress of cord blood transplantation has been slower, in part limited by the limitation of cell dose. We review here the current state of the art on cord blood transplantation for adults, and discuss some of the newer strategies being pursued in order to improve its safety and efficacy.

[Ten years of laparoscopic living kidney donation. From an extravagant to a routine procedure]. / 10 Jahre laparoskopische Lebendnierenspende. Von Rarität zu Routine.

Ten years ago the first laparoscopic living donor nephrectomy (LDN) was performed. Today, LDN is a routine operation in many US-American transplantation centers and an increasing number of centers in Europe are practicing LDN. In this article the different aspects of LDN for donor, kidney, recipient and operating surgeon are evaluated. We performed a literature research concerning LDN and the different aspects. Our own experience, as the largest LDN center in Germany, is part of the evaluation. Laparoscopic extraction of a kidney from a living donor is as safe for the donor as the open approach. At the same time, LDN offers multiple advantages like reduced pain and shorter convalescence. For the donated kidney and the recipient no disadvantages occur from the laparoscopic technique, as long as special intra- and perioperative demands are met. For the operating surgeon multiple developments have expanded the technical armentarium. LDN is safe for donor, recipient and kidney. Central issue of an optimal LDN is sufficient experience with laparoscopic urological techniques.