**2. Living and deceased donations**

The demand for transplants continues to increase with the increasing aging population and prevalence of renal failure. Thousands of patients on the wait list die annually, and the wait for an organ transplant has significantly increased due to the wide gap between organ supply and demand. Transplantation has become a consolidated therapy to extend or improve quality of life, an activity that constitutes less than 10% of the global transplant needs [1].

The medical safety associated with living kidney donations is an ongoing issue. The premise of living donations of the kidneys is that the removal of one does not impair survival or long-term kidney function of the donors. Data have shown that live kidney donations are safe in northern European populations who underwent nephrectomy [2–5]. Nevertheless, Ellison et al. [6] identified 56 live kidney donors in the OPTN database who were subsequently listed for a kidney transplant. The rate of ESRD in donors (0.04%) is comparable to the rate in the general US population (0.03%). In a meta-analysis evaluating reduced renal mass in humans, Kasiske et al. [7] demonstrated that living donations were free of progressive renal dysfunction or an increased incidence of proteinuria. The data indicated little long-term medical risks in healthy donors after unilateral nephrectomy. However, it is recommended that before the donation, the donor receives a complete medical and psychosocial evaluation, provides informed consent, and is capable of understanding the information presented to ensure a

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Although living and deceased donations are important sources of organs for transplantation, a proportion of organs from deceased donors worldwide are not being used due to a lack of information, education, and social system. The use of organs from deceased donors could be significantly increased with the implementation of public education and social systems. Unlike the practical problems observed in living donors, the ethical issues associated with deceased organ donations occur post mortem and can be solved by social agreement and systemic supplementation. In addition to the efforts to increase living donation, a social infrastructure, including education and the creation of laws, should be established to promote

Most of the progresses made in modern transplantation were to overcome the organ shortage (**Figure 1**). Medical and surgical progresses include ABO-incompatible transplantation, en bloc transplantation, and using expanded criteria for donors. On a social level, progress includes the legalization of donations after circulatory death, an opt-out system, and donor action program. The establishment of these systems is needed to promote deceased

voluntary decision.

deceased donations.

**Figure 1.** Measures used to overcome organ shortage.

Living and deceased donations are two sources for organ transplantation. Each organ donation has its advantages and disadvantages. The advantages and disadvantages for kidney transplantation from living and deceased donations are listed in **Table 1**.

There are also ethical issues associated with each donation. In living donations, it is the safety of the healthy individual undergoing the surgical removal of an organ. This is associated with long-term consequences and affects donors' quality of life. Another important ethical concern is the motivation of the donor. The decision to donate is a psychologically complicated one. Living donors can be impacted by a feeling of moral obligation, not just pure altruism. In addition, there are issues surrounding the commercialization of organ donation and donor rewards. Deceased donations also have important ethical issues. In particular, who should be the one to decide on the donation in the absence of a declared opinion. Does the family have the right to decide? Deceased donations can also result from moral obligation. Financial and non-financial incentives for the families can also affect deceased donations.


**Table 1.** Living versus deceased kidney donation.

The medical safety associated with living kidney donations is an ongoing issue. The premise of living donations of the kidneys is that the removal of one does not impair survival or long-term kidney function of the donors. Data have shown that live kidney donations are safe in northern European populations who underwent nephrectomy [2–5]. Nevertheless, Ellison et al. [6] identified 56 live kidney donors in the OPTN database who were subsequently listed for a kidney transplant. The rate of ESRD in donors (0.04%) is comparable to the rate in the general US population (0.03%). In a meta-analysis evaluating reduced renal mass in humans, Kasiske et al. [7] demonstrated that living donations were free of progressive renal dysfunction or an increased incidence of proteinuria. The data indicated little long-term medical risks in healthy donors after unilateral nephrectomy. However, it is recommended that before the donation, the donor receives a complete medical and psychosocial evaluation, provides informed consent, and is capable of understanding the information presented to ensure a voluntary decision.

Although living and deceased donations are important sources of organs for transplantation, a proportion of organs from deceased donors worldwide are not being used due to a lack of information, education, and social system. The use of organs from deceased donors could be significantly increased with the implementation of public education and social systems. Unlike the practical problems observed in living donors, the ethical issues associated with deceased organ donations occur post mortem and can be solved by social agreement and systemic supplementation. In addition to the efforts to increase living donation, a social infrastructure, including education and the creation of laws, should be established to promote deceased donations.

Most of the progresses made in modern transplantation were to overcome the organ shortage (**Figure 1**). Medical and surgical progresses include ABO-incompatible transplantation, en bloc transplantation, and using expanded criteria for donors. On a social level, progress includes the legalization of donations after circulatory death, an opt-out system, and donor action program. The establishment of these systems is needed to promote deceased

**Figure 1.** Measures used to overcome organ shortage.

**2. Living and deceased donations**

4 Organ Donation and Transplantation - Current Status and Future Challenges

donations.

**Living donor kidney transplantation**

**Deceased donor kidney transplantation**

**Table 1.** Living versus deceased kidney donation.

The demand for transplants continues to increase with the increasing aging population and prevalence of renal failure. Thousands of patients on the wait list die annually, and the wait for an organ transplant has significantly increased due to the wide gap between organ supply and demand. Transplantation has become a consolidated therapy to extend or improve qual-

Living and deceased donations are two sources for organ transplantation. Each organ donation has its advantages and disadvantages. The advantages and disadvantages for kidney

There are also ethical issues associated with each donation. In living donations, it is the safety of the healthy individual undergoing the surgical removal of an organ. This is associated with long-term consequences and affects donors' quality of life. Another important ethical concern is the motivation of the donor. The decision to donate is a psychologically complicated one. Living donors can be impacted by a feeling of moral obligation, not just pure altruism. In addition, there are issues surrounding the commercialization of organ donation and donor rewards. Deceased donations also have important ethical issues. In particular, who should be the one to decide on the donation in the absence of a declared opinion. Does the family have the right to decide? Deceased donations can also result from moral obligation. Financial and non-financial incentives for the families can also affect deceased

ity of life, an activity that constitutes less than 10% of the global transplant needs [1].

transplantation from living and deceased donations are listed in **Table 1**.

Advantages Longer graft survival than deceased donation

Disadvantages Requires that the donor undergo major surgery

Disadvantages Shorter graft survival than living donation

Advantages No harm to the donor

Short cold ischemia time Planned surgery

No waiting time

Possible pre-emptive transplantation

Long-term donor safety concerns

Long cold ischemia time Long waiting time on list Requires an unplanned surgery

Possible options for patients without a living donor.

donations. However, organ donation also needs to be socially accepted, and public opinion should change before the change of social system.

**4. Practical issues with organ donation after brain death**

incorporated in end-of-life decisions.

which are listed in **Table 2**.

Death.

The clinical course of patients with severe brain injury varies depending on the degree of injury and the clinical decisions made by the primary physician. The latter are impacted by legislative and ethical frameworks, as well as patterns of end-of-life care. Organ donation is one of the options in end-of-life decision, which must be considered in every patient who may become brain dead (**Figure 3**). Organ donation counseling is an essential step that should be

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Although the consent rate for organ donation in Europe is 50–80% with approximately 85% of families being requested to donate, only 50% provide consent. Other studies have confirmed these findings [10–14]. It is important to identify potential cases of brain deaths and obtain informed consent for organ donation from the families of the patients. Because most countries have an opt-in system, voluntary consent is considered an essential factor in organ donation. Only a small portion of these brain-dead donors are being used for solid-organ transplantation, primarily because of the low percentage of families who consent to donation [15]. Several studies have evaluated the factors associated with these types [1–4, 12, 14–16],

How to ask for an organ donation correctly is another important practical issue. The physician should call an Organ Procurement Organization (OPO) coordinator before meeting with the family of a potential donor and it must be a standard practice. Including an OPO coordinator in conversation is critical to successfully counsel families. Studies have shown that the time spent with an OPO coordinator is strongly associated with a family's decision to donate organs [15]. Incomplete or inaccurate information about the donation process may limit consent. Furthermore, the early involvement of an OPO coordinator is the best way to deliver complete and accurate information to families. Discussion of common fears and misinformation about organ donation should be part of the organ donation request process during counseling. Important questions families typically have regarding organ donation focus on the process, physical impairment during organ recovery, and the way the organs are used.

**Figure 3.** Clinical pathways of potential brain-dead donor. LST, Life-Supporting Treatment; DBD, Donation after Brain
