Study Raises Thorny Issue for Kidney Transplants

WEDNESDAY, July 24, 2002 (HealthDayNews) -- A kidney transplant using an organ from a donor declared dead by a somewhat controversial criterion works well, a new study says, but the finding leaves the core issue in the conflict untouched.

The definition of death is of intense interest to the 50,000 living Americans on the waiting list for kidney transplants. Fewer than 9,000 of them will receive a kidney this year, and at least seven potential recipients die every day because organs are not available.

The criterion generally used for removing organs is a complete stoppage of brain activity. However, death can also be defined as a complete cessation of heartbeat, even though some brain activity continues. The controversy about these donors without a heartbeat arises from fears that some doctors may prematurely declare a person dead to obtain kidneys and other organs for transplantation.

Physicians at the University Hospital Zurich report in tomorrow's issue of The New England Journal of Medicine that 122 transplants of kidneys from donors without a heartbeat were as successful over a decade as those from donors with a heartbeat but no brain activity.

"The results are exactly the same as for brain-dead donors," says Pierre-Alain Clavien, chairman of visceral surgery and transplantation at the Zurich hospital and lead author of the report.

The only difference was measured in the minutes after the kidney was transplanted. About half the time, kidneys from donors without a heartbeat did not start functioning as quickly as those from brain-dead donors. However, the 10-year success rate was 78.7 percent for organs from donors without a heartbeat and 76.7 percent for organs from brain-dead donors.

Taking those results to heart could mean fewer deaths for people on the waiting list, says J. Michael Cecka, director of the clinical research immunogenetics center at the University of California at Los Angeles, who has long argued for the absence-of-heartbeat criterion.

While there is no rule against using that criterion, only about 300 of the 6,000 or so kidneys transplanted in the United States each year come from donors without a heartbeat, Cecka says. "Even if we use conservative estimates, we could have 10 percent more kidneys a year using them," he adds.

In Europe, absence-of-heartbeat donation was approved at a conference in 1995, which set a standard for declaration of death in terms of the length of time after the heart stops beating, Clavien says. "At first we waited five minutes," he says. "Now we are waiting 10 minutes."

However, he acknowledges that dealing with relatives of the potential donor is "always tricky. You have to be very professional when you talk to the loved one of someone who dies."

"The problem is the public perception of what happens when the heart stops," Cecka says. "You keep seeing pictures of people being resuscitated after apparently being dead, and so the issue is when a person whose heart stops beating is irretrievably dead."

Once death occurs, quick action to remove and preserve the organs is necessary, he says, because damage begins as blood flow stops. "But even with the 10-minute wait, you have a high rate of organ recovery," Cecka says.

He does see a possible increase in use of absence-of-heartbeat kidney donations.

"Today, with the shortage of donors, it is necessary that we look at all possibilities," Cecka says. "Today, a lot of people who procure organs around the country are beginning to develop educational programs and procedures. But it will be a highly individual educational effort, with different hospitals varying in their approach."

This is not an issue for transplant surgeons, Cecka says, because "we clearly make a separation between the people who do transplants and those who find donors." Cardiologists will play "a key role" in the issue, he says, because "they need to establish the criteria for heart death."

What To Do

Donors are always needed. You can get information on organ donation from the National Kidney Foundation or the United Network for Organ Sharing.