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Fall in number of organ donors

THE NUMBER of human organs being donated in Portugal is insufficient to meet transplant requirements.

The fall in the number of kidneys available for transplantation was particularly worrying, said the Organização Portuguesa de Transplantação (OPT).

Figures released by the OPT showed there were 19.4 donors per million inhabitants last year against 21.9 donors per million inhabitants in 2004, equating to a drop of over two per cent.

In total, 232 people donated organs in 2005, against 256 in 2004. Each person can donate up to six organs upon death, should they be healthy.

Speaking to The Resident’s Caroline Cunha, Manuel Abecassis, national co-ordinator at the OPT, attributed the decrease to various factors, including the temporary closure of the intensive care unit at Lisbon’s Hospital de São José.

“Last year, due to a fire at the hospital, the intensive care unit had to be closed for repairs and, at the same time, the opportunity was taken to modernise the unit, meaning that it was shut for several months,” he said.

A potential donor must be kept alive through mechanical ventilation, which can only be carried out in an intensive care unit.

With the Hospital de São José being home to Lisbon’s main trauma unit, it is clear that its closure, albeit temporary, would have a negative effect on the numbers of organs available for transplantation.

In addition, in the north of the country there were changes in the management of the intensive care units in two hospitals, which saw a reduction in the number of organs at both these hospitals.

Manuel Abecassis also said the reduction of organs for donation can be attributed to the decrease in the number of fatal work accidents and the fact that with regard to road accidents, more people were killed instantly or died at the scene last year, making it impossible for the organs to be saved.

But the problem is not limited to Portugal. Currently, it seems there are insufficient human organs to meet transplant requirements in Europe as a whole. The transplant waiting lists increased by seven per cent in 2005, while the number of donors registered increased by only four per cent last year.

Good co-ordination is essential

Abecassis, a bone marrow transplant specialist, explained that the window of opportunity for harvesting and transplanting organs is very small. “On average, a heart is only suitable for transplantation up to a maximum of six hours after it has been harvested, a lung for four hours and a kidney for between 24 and 48 hours.

“What is absolutely key is that trained professionals are in the right place at the right time to take immediate action. The harvesting rate of organs is also heavily dependent on the will of the professionals involved – they must be motivated.”

He added: “We can improve on the current situation and the OPT takes responsibility for making improvements to the system.” 

How will improvements

be made?

There are numerous measures being taken by the OPT to try to improve the country’s organ collection rate.

“We are trying to improve the network of local co-ordinators, because, what we need is a transplant co-ordinator in the intensive care unit at every regional hospital. There must be better organisation so that staff can be in the right place to identify potential donors. It is a sensitive subject, of course, but, if there is a patient who is in intensive care and becomes brain dead, the question should be asked – ‘what can we do here to help someone else?’”

Abecassis made his views very clear: “Organs are not needed in heaven. Yes, it is very dramatic when someone dies, and I very much appreciate that it is very hard for the family of the deceased, however, for me, it is also dramatic if someone who desperately needs help is not given it.”

More education

He believes that there is a need for a special education programme to be implemented. “Medical staff in Portugal need to receive more education about the importance of organ harvesting and transplantation and become more motivated in this area. For example, by more medical staff having closer contact with someone on a waiting list for a transplant, the staff can become more aware of the need for organs and the life changing effects of transplants. We must motivate staff to give their best.

“Courses, which offer this type of training, are already being run in Spain. It is my proposal that Portugal’s Ministry for Health pays for staff from Portugal to take part in the excellent course that is being run there and, hopefully in the future, we could offer a similar course here in Portugal,” said Abecassis.

Currently, there is only a waiting list for kidneys managed on a national level and not for other organs. “The reason for this is that it is more complicated to find an ideal kidney match than it is for other organs, due to the complex tissue matching that must be carried out. With regard to hearts and livers, what is important is the organ size and blood type. However, we do aim to introduce nationally co-ordinated waiting lists for other organs in the future.”

Kidney transplants

After the cornea, kidney transplants are the most practised transplant operation in Portugal, but, this year, the number of kidney transplants performed fell from 436, to 380.

But, does the fall mean that patients for whom a kidney is not available die?

“It is quite normal for there to be a fluctuation in the number of kidney’s harvested from year to year, and patients on a kidney transplant list can survive for between five to 10 years with dialysis, although it is not the ideal situation. We can occasionally source organs from Spain and other European countries, but this does not mean that we must not strive to improve the harvesting rate here in Portugal,” said Abecassis.  

Live donors

In Norway, 50 per cent of kidneys donated are from live donors – humans can survive with just one kidney – whereas in Spain and Portugal the figure is less than 10 per cent.

According to Abecassis, kidney donation in Portugal is starting to become more popular among family members. There were 42 living donors in 2005, against 34 in 2004, and the rate could soon go up as the law governing kidney donation is probably about to change.

“Currently, in Portugal, kidneys from living donors can only be donated by immediate relatives of the patient. However, changes to this legislation, which propose that those with a close emotional relationship to the patient be allowed to donate, are currently being discussed in parliament, and are likely to be approved within the next few months.”

It is unlikely though, that the law will be opened up any further than this as, according to Abecassis, “the view here is that if this legislation is relaxed any further, we open ourselves up to organ trafficking, a problem which is rife in India and Pakistan, for example.”

Bone marrow donation

Worldwide, there is a database of 10 million potential bone marrow donors and Portugal can boast a real success story in this area.

“In this country, there are 50,000 people listed on the bone marrow donor register, while in Spain, there are 45,000, despite the fact that its population is four time’s greater than Portugal’s,” he said.

Manuel Abecassis was also proud to report that the OPT was able to provide a bone marrow donor for a patient in Seattle, America.

“A Portuguese girl on our register was discovered to be the perfect match for the American patient. She was on holiday in Faro at the time, but we arranged for her to quickly travel to Lisbon and donate her bone marrow, and the transplant was a success.”

How do other countries

compare to Portugal?

The current EU organ donation statistics show that Portugal is in sixth position, with 19.4 donors per million inhabitants. At the top of the list is Spain with 35 per million inhabitants. Meanwhile, in the UK, the rate is just 12 per million inhabitants. 

Differences in legislation

around the world

There are three systems of organ donation used in current practice around the world – opting in, opting out and required request.

Opting in

In the UK, for example, it is not automatically assumed that everyone wants to be a donor after their death. UK residents have to make their wishes known by telling their family, submitting their details to join the NHS Organ Donor Register or carrying a donor card. This is known as opting in.

Opting out

The opting out, or presumed consent, system means that every citizen is considered as a donor from birth, unless they specifically opt out by recording their unwillingness to give organs in writing.

This is the system that has been implemented in Portugal. If a person does not wish their organs to be retained, they must place their name on the Registo Nacional de Não Dadores, the national register of non-donors, which can be done at any Centro de Saúde (public health centre); an ID card will then be issued.

How does this affect foreign

citizens in Portugal?

Under Portuguese law, foreign citizens who are resident in Portugal are also considered as being donors unless they express, by registering their name on the list of non-donors, that they do not wish their organs to be harvested.

For those who occasionally visit Portugal or are on holiday here, their home country statutes will apply.

If the person is carrying a donor card with them from their own country, this will be accepted as permission for their organs to be used.

Required request

A policy of required request, or required referral, is operated in the United States. Required referral is defined “that it shall be illegal, as well as irresponsible and immoral to disconnect a ventilator from an individual who is declared dead following brain stem testing, without first making proper enquiry as to the possibility of that individual’s tissues and organs being used for the purposes of transplantation.”

The policy means opportunities for donation are less likely to be overlooked. Many individuals may be having their right to donate removed if their relatives are not approached.

The next of kin also have a moral and legal right to know they can donate organs and tissue if they, or the family, so wish.

Experience in other countries

Large disparities in organ donation rates exist throughout the world, despite the laws governing organ donation.

Some European countries, which have opt out systems, have higher donation rates.

However, there is no clear evidence that opt out is the sole factor. The fact that Sweden has an opt out law does not seem to influence the donation rate per million population, which is lower than that of the UK, which does not.

Within almost all countries, large local variations exist in donation rates, despite a common legislative background.

Different cultural attitudes to the disposal of bodies, greater provision of intensive care beds, more aggressive donation programmes and the number of road deaths, all play a part.

Spain is the only country which has sustained a year-on-year increase in organ donation for the last 10 years. This followed the implementation of a comprehensive national procurement system.

However, Spain also has significantly higher road traffic accident deaths than several other EU countries.

Changes to UK legislation

Sweeping changes to the way human organs are stored and donated in most of the UK came into force earlier this month, making the wishes of dead patients paramount for the first time.

The Human Tissue Act, which covers England, Wales and Northern Ireland, lays down a raft of new rules governing the removal, storage and transplantation of human organs. It also makes collecting DNA samples without permission illegal, with certain exceptions, such as police investigations.

From now on, relatives no longer have an automatic right to prevent doctors using organs from a dead family member. Now, the desires of the deceased must take precedence. If a dead patient has expressed a wish to donate, doctors can lawfully remove his or her organs even if relatives object.

Previously, it was first necessary to obtain a signed “lack of objection” from the family.

The future for Portugal

According to the OPT, so far this year, the harvesting rate has not dropped and there are signs of improvement against last year. “I would say that the figures, so far for this year, are similar to those recorded in 2004, which is an improvement.”

For further information (in Portuguese) about organ donation laws in Portugal, visit the Ministry for Health’s website, www.portaldasaude.pt