Doctors Discard Viable Organs as Patients Die on Waiting Lists

How to Save a Life

If someone is suffering from kidney failure, one available option is dialysis. While it may sometimes be the treatment recommended to such failed organs, it can become expensive over time, and may not be the decisive solution they were expecting.

An alternative option is to get a kidney transplant, with successful operations resulting in the extension of a patient’s life. Unfortunately, kidneys are in short supply, as the most in-demand organ: according to OrganDonor, nearly 116,000 people are on the national transplant waiting list as of August 2017, 82.9 percent of which are waiting for a kidney organ.

The main reason for the kidney shortage lies in the fact that nearly one out of five kidneys recovered are actually discarded, and in recent years, the number of discarded organs has only increased. New research suggests this probably shouldn’t be as big of a problem as it is, and many of the discarded kidneys could actually be used by patients desperate for one.

Led by Dr. Sumit Mohan, MD, and Dr. S. Ali Husain, MD, from the Columbia University Medical Center, the study analyzed information gathered between 2000-2015 on the deceased who had both kidneys recovered, but with only one transplanted.

“It is obviously impossible to tell with certainty what would have happened to any discarded kidney if it had been used instead,” explained Dr. Sumit Mohan. “As a result, it has been difficult to categorize these discards as ‘appropriate’ or ‘inappropriate.’”

Mohan continued, adding, “We therefore aimed to identify kidney donors from whom one kidney was used but the partner kidney in the pair was discarded. By doing so, we could control for donor characteristics to better understand the reasons for discard, and whether concerns about using certain kidneys were justified.”

Wasted Organs

The team analyzed information on 88,209 donors — amounting to 176,418 kidneys — and discovered the reason to discard certain kidneys was due to “unappealing” traits. However, the partner kidneys used for transplants contained some, if not all, of the same traits, and performed well in spite of that. Based on Mohan’s prior explanation, it’s possible that thousands of usable kidneys were mistakenly discarded, causing leaving many to die without a whisper of hope, according to Dr. Husain and the rest of the team:

“We therefore concluded that many of these discarded kidneys were in fact quite usable, and that systems-level changes are needed to encourage better utilization of this valuable but scarce resource,” said Dr. Husain.

According to Kidney.org, 4,761 patients died while waiting for a transplant in 2014, with another 3,668 eventually becoming too sick to receive a transplant.

In a separate paper, Matthew Kadatz, MD and John Gill, MD from the University of British Columbia noted how Mohan and Husain’s research makes a strong argument to address the policies in place that allow so many organs to go unused.

“The current discard of kidneys would be hard to explain to the families of deceased donors and is a disservice to the thousands of older age and diabetic wait-listed patients who would benefit from transplantation with these higher risk kidneys and who have consented to receive them,” the pair wrote.

Only time will tell if this work ensures that every healthy kidney is fully utilized. Such a change wouldn’t completely eliminate the demand for kidneys, but it would certainly go a long way to save thousands of lives. Especially the lives of those who have been waiting multiple years for a chance to return to a normal life.

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Artificial Organs: We’re Entering an Era Where Transplants Are Obsolete

No More Heart Transplants

Around the world, lists of patients in need of an organ transplant are often longer than the lists of those willing (and able) to donate — in part because some of the most in-demand organs for transplant can only be donated after a person has died. By way of example, recent data from the British Heart Foundation (BHF) showed that the number of patients waiting for a heart transplant in the United Kingdom has grown by 162 percent in the last ten years.

Now, 50 years after the first successful heart transplant, experts believe we may be nearing an era where organ transplantation will no longer be necessary. “I think within ten years we won’t see any more heart transplants, except for people with congenital heart damage, where only a new heart will do,” Stephen Westaby, from the John Radcliffe Hospital in Oxford, told The Telegraph.

Westaby didn’t want to seem ungrateful for all the human lives saved by organ transplants, of course. On the contrary, he said that he’s a “great supporter of cardiac transplantation.” However, recent technological developments in medicine may well offer alternatives that could save more time, money, and lives.

“I think the combination of heart pumps and stem cells has the potential to be a good alternative which could help far more people,” Westaby told The Telegraph.

An Era of Artificial Organs

Foremost among these medical advances, and one that while controversial has continued to demonstrate potential, is the use of stem cells. Granted, applications for stem cells are somewhat limited, though that’s down more to ethical considerations more than scientific limitations. Still, the studies that have been done with stem cells have proven that it is possible to grow organs in a lab, which could then be implanted.

Science has also made it possible to produce artificial organs using another technological marvel, 3D printing. When applied to medicine, the technique is referred to as 3D bioprinting — and the achievements in the emerging technique have already been quite remarkable.

Thus far, scientists have successfully 3D-bioprinted several organs, including  a thyroid gland, a tibia replacement that’s already been implanted into a patient, as well as a patch of heart cells that actually beat. All of these organs were made possible by refinements to the type of bioink; one of many improvements to the process we can expect to see in the years to come, as there’s now an institution dedicated to advancing 3D bioprinting techniques.

Other technologies that are making it possible to produce synthetic organs include a method for growing bioartificial kidneys, the result of a study in 2016.

For his part, Westaby is involved in several projects working to continue improving the process: one uses stem cells to reverse the scarring of heart tissue, which could improve the quality of life for patients undergoing coronary bypass. Westaby is also working on developing better hardware for these types of surgical procedures, including inexpensive titanium mechanical heart pumps.

Together with 3D bioprinting such innovations could well become the answer to donor shortages. The future of regenerative medicine is synthetic organs that could easily, affordably, and reliably be printed for patients on demand.

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A Breakthrough Initiative Has Been Announced to Manufacture Human Organs

Heart of a Pig

United Therapeutics is set to take a big step forward in its plans to pursue advances in the field of organ transplantation thanks to a new partnership with the University of Maryland. The company has announced a $ 24 million research partnership that will help the school establish a center specializing in cardiac xenotransplantation research, the first of its kind in the US.

Xenotransplantation refers to the cutting-edge practice of transplanting organs between different species. Organ shortages are already a very real concern, and they could grow more pronounced in the future. If we’re able to genetically modify organs from animals, we might be able to better satisfy demand.

The center, which will be constructed in Baltimore, is set to focus on cardiac xenotransplantation. United Therapeutics is also collaborating with the University of Alabama on research pertaining to kidneys, and Columbia-Presbytarian on lung transplants.

“Xenotransplantation offers hope to thousands of patients who are currently waiting for heart transplants and most of them die waiting for the human organs,” wrote Muhammad Mansoor Mohiuddin, director of xenoheart transplantation in the Department of Surgery at the University of Maryland School of Medicine, in email correspondence with Futurism. “Xenotransplantation will provide an alternative to the current available treatment options for end stage organ failure.”

The partnership will focus on transplanting pig hearts into human bodies. This concept has been the subject of various studies, including a recent project that was centered around cloned pigs, and a Chinese effort that expects to carry out a successful transplant within the next two years.

“This grant thrusts our Transplant Division into an elite group of centers doing cutting-edge xenotransplantation research,” said University of Maryland’s chair of the Department of Surgery, Dr. Stephen Bartlett, in a press release. “We now can look forward to exponentially expanding our department’s current and new xeno initiatives, creating an even greater impact in accelerating our trajectory of discovery and innovation in medicine.”

Xenotransplantation Allows for More Organ Donors

Mohiuddin stressed that both the University of Maryland and United Therapeutics are eager to make this procedure a “clinical reality.” This isn’t a research project intended to push the limits of what might be feasible; it’s an effort to establish how cardiac xenotransplantation might be used in a practical context.

To that end, researchers will address some of the most pressing issues that are stopping people in need of organ transplants from being helped. Mohiuddin describes the human immune system’s rejection of animal organs as being a “major barrier” that has prevented the success of this method in the past. However, genetic modification is offering up ways to counteract these issues.

Xenotransplantation
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“Due to our ability to genetically modify the pigs to make their organs less immunogenic to humans, and the development of novel immunosuppressive drugs, we are able to prevent or delay rejection,” explained Mohiuddin. Genetic engineering also makes it possible to remove any viruses that might infect humans after the organ has been transplanted.

In 2016, Mohiuddin led a groundbreaking trial where immunosuppressive drugs were used alongside immunomodulatory antibodies to allow a baboon to support a heart inside its abdomen (with the original heart intact) for a record-breaking 945 days. Now, the challenge is how to build upon those techniques to transplant animal hearts into human patients that can endure for an even greater period of time.

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Black Market Bodies: How Legalizing the Sale of Human Organs Could Save Lives

Trafficking in Body Parts

When a failing heart, liver, or other vital organ proves resistant to all available forms of treatment, a dying patient’s only shot at survival may be an organ transplant. Unfortunately, there aren’t enough donor organs to save all the patients who need one. Feeling desperate with precious time running out, some patients may attempt to purchase an organ illegally. In fact, thousands of sales or purchases of black market organs take place every year, according to the World Health Organization.

In the 1980s, Iran had both a shortage of legally donated kidneys and subpar dialysis equipment to treat the growing segment of the population with end-stage renal disease (ESRD). It did have highly trained surgeons capable of performing organ transplants, though. So in 1988, the nation decided on a bold (and somewhat controversial) new strategy to eliminate the dangers that come with procuring or receiving an organ illegally: they made it legal for a living person to sell their kidney.

Nearly three decades later, Iran is one of the few nations without an organ shortage every Iranian who needs a kidney can receive one. Should other nations follow suit?

In 2014, 4,761 Americans died waiting for a kidney transplant.

In 2016, legally donated organs met less than 10 percent of global need, according to a report from ONT-WHO Global Observatory on Donation and Transplantation, the world’s most comprehensive source on transplant-related data. In 2014, 4,761 Americans died waiting for a kidney transplant, and another 3,668 dropped off the list because they became too sick to receive one, notes the National Kidney Foundation (NKF), an organization dedicated to the awareness, prevention, and treatment of kidney disease.

Given this substantial need, perhaps it’s not a surprise that people turn to the black market to save their lives. While exact figures are hard to come by (the black market doesn’t exactly have any official ways to track it), the illegal trade of all organs generates between US$ 840 million and $ 1.7 billion annually and accounts for an estimated 10 percent of transplanted organs, according to a 2017 report from Global Financial Integrity (GFI), a non-profit research and advisory organization focused on illicit financial flows.

Kidneys are the most-frequently sold organs for a fairly simple reason: humans have two and can live a healthy life with just one. Selling kidneys, then, might seem like a simple matter of supply and demand — the demand for kidneys is high, so willing donors should, in theory, be able to negotiate their price from a position of strength.

However, the population supplying the organs is nothing like the people receiving them. GFI researchers found that kidney buyers are usually middle- to high-income individuals from developed countries, while kidney sellers are typically from the world’s most vulnerable populations. For poor and uneducated citizens of developing countries, selling a kidney may seem like the only way to escape poverty or settle a debt.

Recipients may pay upwards of $ 200,000 for a kidney, but the donor may receive as little as $ 5,000 of that (a broker pockets the rest), according to the WHO. Some donors aren’t paid at all, and because the sale is illegal, they have little recourse to obtain the money they are owed.

Even worse, inadequately trained surgeons may perform the surgeries under unhygienic conditions. Donors may be left with dangerous, painful complications that could force them to miss work or require expensive follow-up care, leaving the donor in a more financially precarious situation than prior to selling his or her organ.

A Market Unlike Any Other

By legalizing the sale of kidneys from living donors, Iran has been able to avoid these pitfalls of a black market, and today, about 55 percent of all kidneys donated in the nation are from living donors, according to government statistics obtained by the Associated Press. For comparison, only about 38 percent of kidney donations in the U.S. are from living donors. The rest come from deceased donors, and those organs aren’t as likely to keep recipients healthy in the long term.

The process of buying or selling a kidney in Iran is fairly straightforward, a 2011 paper shows. A doctor writes a letter stating that a patient needs a kidney, and the patient then brings that letter to an office of the Kidney Foundation of Iran, a nonprofit organization that facilitates the nation’s kidney transplants. The organization adds the patient to a list and sorts by his or her blood type. Patients in the midst of a medical emergency and disabled soldiers are placed higher up on the list, according to the paper.

To be approved as a living donor, interested Iranians go to one of the foundation’s offices to undergo medical testing (the donor pays for the tests). If the foundation believes the kidneys are healthy enough for transplantation, they approve the donor. Next, the foundation will contact the person nearest the top of the list for that donor’s blood type, taking into consideration other factors such as the donor’s physical build — a particularly small kidney might go to a child or female patient even if they are listed below average-sized men because a closer match between the size of a donated kidney and a recipient’s original kidneys results in a better long-term outcome.

The Iranian government pays for the transplant surgery itself as well as one year of health coverage for the donor after the surgery. The recipient (or their family) pays the donor, using the foundation as an intermediary, Farshad Fatemi, a micro-economist at Sharif University of Technology and author of the 2011 paper, told Futurism. The base price is set at $ 4,600, but if the donor isn’t willing to sell their kidney for that price, they and the recipient can privately negotiate a higher amount shortly after a match is set up. In 2011, Fatemi estimated that organ recipients will sometimes pay an extra $ 530 to $ 1,060 on average.

If the donor and recipient agree on terms, both undergo tissue testing to make sure the recipient would be unlikely to reject the new kidney. If the results are favorable, the patient and donor sign an agreement and are given a list of centers and doctors that can perform the transplant. The center will hold the check from the recipient during the surgery and hand it over to the donor afterward to ensure payment is made.

A Viable Model?

While the Iranian system does speed up the process of organ donation for patients — the average wait between reaching out to the foundation and receiving a kidney is five months — Fatemi said the legal kidney market is not without its shortcomings.

One issue is that doctors often fail to follow up with donors post-surgery. It’s important to follow donors for several decades after donation to see how the process affects them, Fatemi stressed, but said doing so would be difficult, as donors often try to hide their identity to avoid the stigma associated with selling a kidney. Educating the public on the benefits of donation, paid or not, could help solve this problem, Fatemi said.

Fatemi also noted that, just like the illegal kidney market, the poorest, more vulnerable members of society are still the ones donating in Iran’s legal market, and they typically only do so because they feel they have no other option to escape poverty. “I have been to the foundation. The people who are donating are young and full of energy, but they are poor and selling a part of their body to solve what may amount to very small problems in their everyday lives,” Fatemi said.

Given the lack of follow-up, no one even knows for sure if these vulnerable citizens benefit from the sale.

Though Iran’s market may be imperfect and only stops the illegal sale of one type of organ, Fatemi believes it’s better than the alternative of having a black market. The system protects disadvantaged donors by ensuring they are paid what they are owed and taken care of medically, and it also gives recipients a second chance at life that they may not get otherwise.

“With these transplants, people can live two, three decades longer than they would without them,” said Fatemi. “During that time, they have good times with their families. They are productive members of the economy. That’s the positive side.”

For now, Iran still stands alone in allowing citizens to legally sell their kidneys, and no other nation appears on the cusp of doing so. However, that’s not to say a new legal kidney market couldn’t emerge. A 2015 study published in the journal American Economic Review concluded that U.S. citizens were more open to the idea of organ sales when presented with information on their potential benefits, so at least one barrier to creating such a market — public disapproval — could potentially be eliminated through education programs.

Still, Iran didn’t decide to legalize kidney sales until the situation was dire, so if history is any indicator, the next nation to test a system will likely be one facing a similar situation, perhaps somewhere like India where end-stage renal disease is becoming more common and the black market is thriving. Meanwhile, nations where the frequency of end-stage renal disease has stabilized over the last decade, such as the U.S., may choose to continue with the status quo until new technologies and treatments render the kidney market, both legal and illegal, obsolete.

“Every time I go to the foundation, I wish for the day when we can clone a kidney for a person,” said Fatemi. Until that happens, he said, Iran’s system is a good one.

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