**3.2. Legislation means**

In the same time, the number of older cadaver donors doubled between 1990 and 2000

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

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

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

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

especially due to a 10 fold increase in donors older than 60 years.

154 Current Issues and Future Direction in Kidney Transplantation

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

only half of them agree to donate.

by living donation.

right information.

effort to save them [75].

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

"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 increased slightly but then reached a new plateau.

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 presumed consent law with only 7% supporting this approach.

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 wishes.

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.

#### **3.3. Expanding donation criteria**

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 potential to increase the potential donor pool comprises non-hard beating cadaver kidneys and kidneys from older donor.

*3.3.1. Older donors*

*3.3.2. Hypertension*

as pilot projects.

complications can be recognized.

Already, older donors are a major source of cadaveric donation. Some doctors found out an inferior outcome from transplants from cadaveric donors over 55 years of age. Not only did a higher percentage of recipients of such kidneys required dialysis but one year serum creatinine level was higher than that from recipient of transplants from cadaveric donors aged 5 to 55 years and the estimated halve life of the kidney was 5.8 +/- 0.3 years compared to 11+/- 0.3 years. Other analysis have found similar results but suggests that the adverse effects of the

Policies and Methods to Enhance the Donation Rates

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

157

Recipients of kidneys from donors with hypertension were more likely to have anuria and to require dialysis immediately after transplantation. Their serum creatinine level was significant higher at one year than that of recipients of kidneys from donors who were not hypertensive and the predictive graft survival was shorter (halve life of 7.7 +/- 0.5 years versus 10.7 +/- 0.3 years). Graft survival was better with 1 to 5 years of hypertension compared to 6 or more years of hypertension. The difference in serum creatinine and predicted graft survival between kidneys from diabetic and non-diabetic donors was of borderline statistical significance. Serum creatinine at one year was 1.8 +/- 0.8 mg/dL in recipient of kidneys from diabetic donors compared with 1.6 +/- 0.8 mg/dL in recipients of kidney from non-diabetic donors. Predicted

In developing new strategies for increasing kidney available for transplantation we would do well to remember that from its beginning organ transplantation has relied on public good will and support. When public opposition exists, we sometimes avoid using approaches that we find ethically acceptable. Because we really don't know what ideas or practices will strengthen public support for all organ donation the introduction of new practices should be undertaken

The public already accept living donors who were not considered 50 years ago such unrelated living donors and spouses, which are now widely excepted. Once we accept the donors autonomy and remind ourselves that the risk to the donor is not related to his relationship to the recipient, we will be able to accept the wide arrange and greater number of emotionally related donors. We need to understand that the altruistic donor, although unusual, is not pathologic. The altruistic donor can be considered an emotionally related donor who is emotionally related to all mankind. Thus, this approach to this type of donor is not to keep a registry of willing donors and their HLA types. The altruistic donor is not waiting for the right HLA type but for the right story. The acceptance of donor autonomy would allow for accepting donors with increased risk, but will require careful follow-up thus an increased risk of

donor ages affect only certain subgroups particularly black recipients.

halve life in this graft was 8.4 +/- 1.5 years compared with 10.1 +/- 0.3 years.

**3.4. Strategies for increasing organ donation**


**Table 5.** Expanded criteria for cadaveric donors

Non heart beating donors where widely used before the definition of brain death was accepted. They remain the major source of cadaver donors in countries such as Japan and Mexico, where brain death was recognized officially only recently and where social acceptance it is still limited [82]. Non heart beating donors yield about 5% of all cadaveric kidneys transplanted in USA. Use of non-heart beating cadaver donor kidneys has increased in last years. The one year survival of graft from non-heart beating donors was 83% and for brain death donors was 86%. Early function was not as good: 48% of recipient of non-heart beating donor kidneys required dialysis in the first week after transplantation compared to 22% of the recipients of kidneys from brain death donors. Primary non-function was slightly increased also (4% versus 1%). The serum creatinine level at discharge from hospital was higher in the first group. At one year follow-up, the serum creatinine levels for the two groups was, in fact, similar (1.9 mg/dL versus 1.8 mg/dL). When traumatic death were analyzed separately, the one year survival of non heart beating donors kidneys was 89% compared with 70% one year survival for non-traumatic death. Not all programs have found the same results from non-heart beating donors, but the finding of more frequent delayed function and need for dialysis has been universal. The potential for increasing the donor supply from non-heart beating donors has been estimated to be as high as 40% [83].
