**3. Cadaveric donation**

transplantation to correct the coagulation. A key point is the administration of IVIG immedi‐ ately after each plasmapheresis. The plasmapheresis is continued in the first two weeks after transplantation if ABO antibody titer was over 256 before Rituximab, if there is an increase of ABO antibody more than three times after transplantation, and if the serum creatinine increases more than 15% in two weeks after transplantation. The immunosuppression includes Tacrolimus, mycophenolate mofetil and steroids. In the first three weeks, the patient is at high risk of developing hyperacute humoral rejection, thus a graft biopsy is warranted whenever

The use of specific immunoadsorbtion instead of plasmapheresis is not only less aggressive but also more effective since it allows more than two plasma exchange equivalent per one

Even if renal transplantation agains ABO blood group is expensive and, due to the increased immunosuppression, increases the infectious and malignancy risk, graft function at five years

World Health Organization condemned the sales of organs since 1989. Sales of organs and tissues has been made illegal in the majority civilized states of the world. The difference between altruistic donation of a kidney and selling off a kidney is viewed as similar to the difference between marriage and prostitution. The first is a sacrament, the second a sin.

Reimbursement for expenses related to the donation process, such as for traveling and lodging is not prohibited, although a formal mechanism to make such reimbursements is not available everywhere, a factor that could act as a decentive to donation for some potential donors.

Iran is currently the only country in which payed donation is officially sanctioned, almost all the donors are pour and uneducated and follow-up studies have shown that their lives are not

Despite the legal constraints on organ sales, commercial kidney transplantation is a common phenomena in many parts of the world, and in some cases has been linked to criminal activity. The donors are typical pour or under great financial stress, the recipients are often wealthy or

**•** The donor's choice is not voluntary because he is compelled by circumstances of poverty to donate a kidney. Poverty-stricken donors choose what they see as the best of a group of bed options. Compared to some other possibilities such working under unsafe conditions, kidney donation might carry less risk to the donor than other choices and at the same time

**•** Paid donors are usually pour and uneducated, so making them understand the risks is all

come from other wealthier countries, and middleman or brokers are often involved.

the serum creatinine increase over 15% in two weeks [69].

152 Current Issues and Future Direction in Kidney Transplantation

**2.9. Commercial renal transplantation**

Arguments against payed donation shows:

might accomplish more good for society and for the donor.

is slightly similar to transplantation of ABO compatible grafts [68].

session [70].

improved.

but impossible.

The modest increase in cadaveric renal transplant in USA has been achieved in principally by extending use of older and younger donors [71]. Fortunately, the death from motor vehicle accidents has decreased over the passed 20 years mainly due to laws meant to increase the safety on the road: the seat belt laws, passive restraints, child safety seats, and stricter drunk driving laws. The greatest number of lives saved by improved highway safety has been specially at the 15 to 40 years old age group. On the other hand, another concern is related to the estimation that 10% of potential donors might be ineligible because of HIV infection [72]. In the same time, the number of older cadaver donors doubled between 1990 and 2000 especially due to a 10 fold increase in donors older than 60 years.

**3.2. Legislation means**

wishes.

**3.3. Expanding donation criteria**

An array of various laws have been passed to maximize the number of cadaveric donor transplants. In USA, the Uniform Anatomical Gift Act, have been passed for over 30 years by american Congress and authorize individuals to give their organs and specified who could give consent if the donor were unable to do so [76]. By now, many states have such a law in

Policies and Methods to Enhance the Donation Rates

http://dx.doi.org/10.5772/55245

155

"Routine inquiry" is active in many hospitals in Europe and USA. Majority of the hospitals who are doing or not transplantation, have routine inquiry policies which qualifies for social reimbursement. Hospitals are required to notify families of potential donors about the possibility of donation and to notify organ procurement agency approved by health care finance administration. In the first years after the passage of required request laws, donation

Another way to approach organ donation, especially in European countries is that of presumed consent. Unless the potential donor has previously expressed a wish not to donate, he is presumed to have agreed to donate. The role of the family is to confirm that the deceased has not expressed an unwillingness to be a donor. The application of the law is variable and approximatively one half of the nations continues to depend on family consent in practice. The effect of donation have been variable; the refusal rate in Austria and Belgium, where the law is strictly applied dropped under 10%. In USA, public opinion shows little support for

An alternative to presumed consent has been proposed in the USA which is mandated choice [77]. When getting or renewing a driving license, a person would have to decide whether to become a potential donor, and the person's choice would take precedence over the family's

Another law which is active in some states in USA and some countries in Europe, is to provide a compensation for the donor's family. The fund for such thing is obtained by voluntary donations. One thing which is important here that the law makes the distinction between purchasing organs and bestowing a gift to the family in appreciation of its generosity.

When efforts that increase the consent rate for cadaver donors, another approach expanding the criteria for an acceptable cadaver donors, also has attempted to increase the number of kidneys available for transplantation. Less than 25% of the increase in cadaveric donors has come from traditional pool age 16 to 50 year age donors. The criteria have been expanded further in some instances by use of donors with encephalitis and core antibody positivity for hepatitis B [78]. Recent data have confirmed that safety of even using kidney from infected donors with blood cultures with pseudomonas and candida, provide appropriate antibiotic treatment is given [79]. There are studies which determined that bacteriemia accounted for 30% of medically unsuitable kidneys in brain death potential donor. There are also transplan‐ tation of horse shoe kidney [80] or kidneys from non renal organ transplant recipient which have to be mentioned. From any point you are going to look at this problem, the greatest

place and many of them use the driver license as a donor card.

presumed consent law with only 7% supporting this approach.

increased slightly but then reached a new plateau.

The percentage of donors dying in motor vehicle accidents decreased from 34.4% to 24.00% while the percentage of donors dying from stroke increased from 27% to 42% [71]. Despite the decrease in motor vehicle accidents, enough deaths still occur under circumstances that allow transplantation and could reduce the gap between the need for and the supply of kidneys in all civilized states in the world. The failure to make use of these organs has been attributed to the failure of the intensive care unit staff to recognize potential donors as well as the high refusal rate by families of potential cadaveric donors. Multiple new mechanisms for preventing potential donor from being missed in ICU appear to have been successful. Hospital staff are recognizing over two thirds of potential donors, are asking their families about donation but only half of them agree to donate.

Much attention has been focused on disparity among different ethnic groups as organ donors. A study of 1772 requested donation in come important cities from USA reported a family refusal rate of 17% in whites, 43% in Hispanics, and 45% in blacks [73], but the situation has changed in last period due to intensive efforts done to encourage minority families to donate. As a consequence the rate of cadaver kidney donation became similar for whites, blacks and Hispanics but remained low for Asians. Estimate of the overall refusal rate in the USA is between 38% to 50%. The refusal to donate lead to a 4755 kidneys lost for donation but the true potential in higher since we can't determine the real number of potential donors. This number would have enclosed 81% of the gap between the yearly increase in need and the available kidneys. Even so, the shortage of kidneys can not be closed by eligible donors lost by families refusal to donate and the difference would have to be provided by new cadaveric sources and by living donation.

#### **3.1. Disparity among attitudes regarding cadaver donation**

Even it might be only a believing, there is a dichotomy between the public and the medical community regarding cadaveric organ donation. The medical community is preferring cadaver organ donation since there are less concerns on the quality and risks associated with the donor's organs. Physicians don't share the cultural and religious believes of families opposed to organ donation. The doctors are relieved of concerns regarding doing harm to the donor because they often see the main problem as one that may be corrected by education and right information.

Even though over 90% of the public supports allowing living donation [74], many people do have reservations about cadaveric organ donation due to cultural and religious beliefs or beliefs that the dead can still suffer. The concept of brain death remains only a concept when it is about a loved one who has died unexpectedly. Families also express concern that the deceased's own wishes cannot be known or carried out. People might fear that being identified ahead of time as an organ donor would lead the medical team to make less than the maximal effort to save them [75].
