**3. Expanding donors**

Pilot programs are proposed to evaluate the potential effects of financial incentives for organ donation instead of rejecting this proposal on the basis of theoretical disadvantages not yet tested [36]. This means that it is time to use incentives to reward people who are willing to

Those who support the establishment of economic incentives consider that our current transplant system is inadequate for the task of increasing the volume of organs necessary to save

On the other hand, opposed to financial incentives base their objections on the argument that

It is pointed out that there would be a decrease in respect for life and the sanctity of the human body, and a loss of the personal relationship that currently exists in the donation process [38].

Great concern has also been expressed regarding a potential phenomenon of rich versus poor. Ironically, this type of incentive would be mainly aimed at racial communities of significant

Economic necessity should not be linked in a coercive way to consent to obtain organs. This money would be better spent more on education for medical communities regarding the need for organ donation through the current system to make the society understand the fundamen-

Beyond that the proposed incentives can be negative for potential donors, it has been argued that the financial gain of the family of the donor has not resolved at all the economic problem

On the other hand, the relative failure of the medical community to participate in the donation process will not be improved by the incentives directed to the potential donor [40].

In the discussion of the problem of acceptance of economic incentives for organ donation, it is convenient to mention the Iranian program of transplants. In this country, a system for payment of organ donation coordinated by the government has been implemented with significant results. Actually, a candidate for transplantation in Iran can get a kidney from a cadaver,

However, in contrast to most countries, 76% of kidneys come from strangers; only 12% of

This significant difference makes it necessary to consider the obvious poverty-donation relationship, which notwithstanding any image of responsibility on the part of the state, does not excuse an unavoidable presumption of social injustice, ethically not compatible with the basic

Those who oppose the financial incentives for organ donation predict the possible loss of control of this process by the government bureaucracy and the "organ traffickers" with a

Until it is available through universally accepted surveys as accurate and representative, the

feasibility and effect of financial incentives for organ donation remain questionable.

tremendous increase in the cost of administrative requirements [39].

save the life of a stranger through donation.

poverty [39].

lives. Altruism is not enough, incentive pilot trials are needed [37].

tal benefit for its future of donation and organ transplantation.

motivating the acceptance of economic incentive to donation.

living relative, or a living stranger.

kidneys are from deceased donors.

principles of ethics in organ transplants.

the altruistic system has not been correctly promoted.

56 Organ Donation and Transplantation - Current Status and Future Challenges

One important factor in the number of transplantations, currently performed, is the growing acceptance of marginal grafts, which are defined as organs at increased risk for poor function or failure that may subject the recipient to greater risks of morbidity or mortality [41].

The persistent "organ shortage" remains with an increase of 8% organ transplants per year. The annual growth of patients on the waiting list is 22% and its mortality is 18%.

This reality has conditioned a modification of the classic acceptance criteria for an organ donor. Currently, donors regarded as "expanded criteria donors" with potentially suboptimal organs have been included.

Simultaneously, the number of cadaveric organ donors has remained relatively static, with only a 4% increase per year. Most of this incrementally small increase has been through the use of "expanded" donors, reflected by the fact that the uses of donors older than 50 years old increased by 24% per year while those younger than 50 years increased by only 1.5% per year [42].

As it was mentioned, to increase the potential donor supply, the implementation of presumed consent and financial incentives for donation have been proposed, nevertheless public attitude toward presumed consent would probably not be acceptable. On the other hand, there has been resistance to financial incentives to the donor family because of the perceived danger of this escalating to the selling of organs as currently taking place in Southeast Asia and India [42].

Efforts to expand the donor pool are therefore limited to expand the criteria for the use of "suboptimal" organs.

Mainly, suboptimal donors are considered when donors are less than 5 years old or older than 65, donors with moderate decrease in renal function, donors with antibodies positive against hepatitis C, donors with type 2 diabetes or with moderate arterial hypertension and particularly the use of donors with cardio-circulatory death [42].

Essential characteristics of these suboptimal donors:

*Older donors*: the general refusal to use kidneys from older donors is due to the normal structural changes in the aging kidney.

However, these changes may not occur in all donors. For this reason, it has been considered that the older donor should be evaluated individually for its renal function at the time of death. Renal biopsy can be used in donors older than 50 years or with a history of significant hypertension. An organ that presents a glomerular sclerosis less than 20% and with mild interstitial fibrosis is acceptable to be implanted.

It is important in these cases to implement the system called Old to Old, it does means, old donors kidneys for old donor receptors.

It is very important in these kidneys the evaluation of the cold ischemia time (CIT). Kidneys with CIT of more than 48 h have a graft survival of 38% compared to kidneys with CIT less than 48 h, which had a very acceptable graft survival of 76% at 1 year.

Nefrotoxic injury with medication or rejection may also limit the long-term final result of these organs [43].

*The hypertensive and diabetic donor*: patients who received cadaveric kidneys from donors with a history of either diabetes or hypertension ("non-ideal") were compared with recipients of "ideal" organs. Although the overall graft survival of the non-ideal organs was somewhat less (69% versus 74%), these differences were not significant. Again, these kidneys should be evaluated on an individual basis by biopsy and donor history [42].

crisis. Education and information will increase the value of altruism by protecting the population

The Society, the Barriers to Organ Donation and Alternatives for a Change

http://dx.doi.org/10.5772/intechopen.73756

59

Organ donation and transplantation education at all levels of society have been a matter of interest for decades. Nevertheless, the results observed to date must be considered inadequate because organ donation and procurement have not improved worldwide. With regard to medical education on transplantation, multiple polls show a severe lack of knowledge [3–7].

When searching for new alternatives to modify ancestral prejudices and barriers inhibiting the use of the body after life, priority should be given to youth education starting with chil-

The rationale of this proposal is that young people, particularly children, are free of prejudices, and are able to easily learn new ideas, sometimes much more easily than adults. Modern psychology suggests that childhood is the best developmental stage to start prevention programs against harmful prejudices. In addition, new notions learned by children at schools can be a

The central task of education is to implement facilities to learn; it should produce learning people. The truly human society is a learning society, where grandparents, parents and chil-

At present, young people have not been sufficiently informed of their future organ transplant

No one has yet realized the wealth of sympathy, the kindness and generosity hidden in the soul of a child. The effort of every true education should be to unlock that treasure [52].

Organ and tissue donation can also involve children. Because of its sensitivity, this topic requires careful decision-making. Children have the ability to carefully reflect on this subject

Shoenberg consider that teaching young people about organ transplantation is not particularly difficult. He considered that helping young people understand the problem of transplant increases the possibility that they clearly understand its importance. Probably young people in response to this teaching will discuss this issue with their families or with their peers, thus multiplying the educational effect. Intense and persistent educational efforts focused specifically on young people are relatively rare. Consequently, this leading educator not related to medicine, suggested that "the transplant community has to offer strong stimuli that induce

Undoubtedly, the insufficient results of people's education, without significant changes over the decades, indicate the need to review the current methodology of teaching society about

The introduction to the permanent curricula of study, in the different levels of education; structured by a commission of experts, that will analyze the insufficient achievements

this severe crisis, consequently of their current behavior toward organ donation.

from exploitation, increasing the meaning and value of organ donation [48, 49].

way to offer clear and unprejudiced knowledge to their families [50, 51].

needs and their potential role in the development of educational programs.

and enjoy participating in family discussions about it [53].

professors in various places to assume such a task" [54].

obtained with the current education methodology.

dren in schools.

dren are students together.

*The donor with hepatitis C*: the use of the hepatitis C (HCV) + donor organ has been controversial and was a subject of debate. Nevertheless, today advances in the treatment of hepatitis C have change acceptance criteria for these donors.

Prevalence of HCV positivity in organ donors has been reported to be between 2 and 6% with contradictory data with respect to the risk of transmission of HCV from positive organ donors [44].

*Non-heart beating donors (NHBD)*: the use of NHBD has been increasing all over in recent years. In controlled and uncontrolled trials, delayed graft function is 60–80% of cases. Nevertheless, no matter this consequence of longer periods of warm ischemia, long-term results and graft survival rates are excellent [45].

Until other options such as xenotransplantation or tissue engineering become realistic, the challenge for the millennium will be to identify which donor organs previously considered suboptimal can be safely used to expand the organ donor pool.

*Paired kidney donation*: increased living donation (LD) rates are determined by less invasive approaches to donor nephrectomy and by the excellent long-term results.

In recent years, a number of strategies have been introduced to expand living donation programs beyond the classical direct donation, to overcome immunological barriers of blood group or HLA sensitization of recipients.

New strategies in LD include paired kidney exchange. In order to overcome the sometimes difficult barriers of incompatibility in blood groups or the hyper immunized receptor, the pair kidney donation technique has been a significant advance.

The procedure consists of combining the pair of incompatible donor recipients with each compatible member of different pair. Other alternative programs are: altruistic donation, altruistic donor chains and list exchange programs, and desensitization of hyper immunized patients and transplantation across the blood-type barrier [46].

The transplant community is challenged to address the ongoing crisis in organ transplant access. A discarded organ may be a missed opportunity to save a life. While careful judgment and prospective monitoring is crucial, a blanket "no" to these organs will help neither you nor your patients [47].
