The shortage of organs for transplant is a universal problem. The World Health Organization is urging every nation to seek self-sufficiency regarding their organ procurement program. Reaching self-sufficiency inevitably requires the provision of a well-developed deceased-donor organ procurement program. Most countries represented by the Middle East Society for Organ Transplantation still rely on living-donor organ donations. Some of these countries have been relatively successful in promoting deceased-donor donation as well. In our region, deceased-donor organs are recovered exclusively from patients who have been declared brain dead. However, with improvements in preventive and therapeutic interventions, the pool of potential brain dead donors is rapidly shrinking. This should, therefore, stimulate our interest in developing a program for recovering organs after cardiac death. However, increasing the pool of donors, even to optimal levels, may still not be enough to meet the growing demand. More resources must be invested in reducing the demand for organs. This is especially true in our region, where primary care programs aimed at slowing or containing disease progression that may lead to organ failure are lacking. This problem is compounded by limited access to such programs and, for that matter, limited access to even the most basic primary care. Continued efforts to increase the supply of donor organs must be pursued. At the same time, we must work to more effectively treat the diseases that could lead to end-stage renal disease and the increased demand for donor organs. A comprehensive approach to the problem of donor organ shortages in countries in the Middle East also must consider the relatively limited financial resources that are available.
Key words : Deceased organ donation, Offer, Prevention
The shortage of organs for transplant has always been of great concern. However, when we discuss organ shortage, we frequently speak of the problem of supply and rarely mention the issue of demand.
In 2010, one hundred forty government officials, ethicists, and representatives of international scientific and medical bodies issued the World Health Organization Madrid Resolution on Organ Donation and Transplantation.1 This document stresses the responsibility of every nation to meet the health needs of its population in a comprehensive manner and addresses the conditions leading to the need for transplant, from prevention to treatment. Donation from deceased individuals was again confirmed as the priority source of organs for transplant.
However, as emphasized in the Madrid resolution: “Of equal importance, to infrastructure and professional development in organ donation and transplantation, is sustained investment in prevention to reduce future needs for transplantation, through interventions in the major risk factors for end stage organ failure and the development of health systems able to meet the challenges of chronic diseases.”1 The path to self-sufficiency includes, thus, 2 arms that have to be addressed concomitantly.2
Increasing the supply
Most countries in the Middle East are still relying on living-donor donations. Some of these countries, however, have also been successful in promoting deceased-donor donations. In our region, deceased-donor organs are recovered exclusively from patients who have been declared brain dead. However, with improvements in preventive and therapeutic interventions, the pool of potential brain dead donors is rapidly shrinking. This should, therefore, stimulate our interest in developing a program for recovering organs after cardiac death, especially because numerous religious sources question the criteria on which we base our diagnosis of brain death.3-5 However, increasing the pool of donors, even to optimal levels, may still not be enough to meet the growing demand.
Decreasing the demand
Depending on their needs, some countries may prioritize one arm over the other. In our region, we need to concentrate on decreasing the demand. This is especially true in areas where primary care programs that aim to slow or contain the progression of diseases that may lead to organ failure are lacking. Even when present, access to such programs and, for that matter, to even the most basic primary care is often nonexistent.
Decreasing the demand for organs for transplant can be done in 3 ways: (1) prevention, (2) efforts to avoid retransplant, and (3) proper selection of the living donor.
Preventing kidney failure
In an interview published in Transplantation in July 2016, Dr. Francis L. Delmonico states, “Demand is not going to be solved unless a focus to prevent kidney failure is accomplished.”6 If we look at the diseases that can lead to terminal renal failure and transplant, we will find that diabetes mellitus and diabetic nephropathy and hypertension and hypertensive nephrosclerosis are the main underlying causes.7 Together, they account for more than 70% of the pathologies that can lead to end-stage renal disease and transplant. How can we prevent or at least delay the onset of these 2 pathologies?
Diabetes mellitus is on the rise.8 More than 422 million people worldwide are reported to have diabetes. In the Middle East alone, the number of people with diabetes is expected to double by 2040, affecting 72.1 million people. In this region, the highest prevalence of diabetes mellitus seems to be in the Gulf countries (20%), followed by Egypt (16.7%) and Lebanon (13%).9
Diabetic kidney disease occurs in 20% to 40% of patients with diabetes and is the leading cause of end-stage renal disease.10-12 Individuals at high risk of developing type 2 diabetes can significantly delay disease onset and prevent its complications with specific interventions.13
For example, in patients with diabetes, life style modifications and metformin can lead to a 50% reduction in long-term complications.14 Glycemic control, that is, achieving glycosylated hemoglobin targets of less than 7%, has been shown to reduce the microvascular complications of diabetes.15
There is also strong and consistent evidence that weight reduction and weight management can delay progression from prediabetes to type 2 diabetes.16 Efforts to control obesity and, therefore, the development of diabetes may include bariatric surgery. The American Diabetes Association guidelines for diabetes prevention13 support the consideration of bariatric surgery for people with type 2 diabetes and a body mass index of greater than 35 kg/m2. Although we cannot yet prevent the development of overt diabetes, we can at least delay its onset and limit its vascular complications.
Hypertension and hypertensive nephrosclerosis
According to the 2011 United States Renal Data System, 28% of the pathologies leading to end-stage renal disease are attributed to hypertensive nephrosclerosis.17 Hypertensive nephrosclerosis, however, remains a poorly defined entity. It has no clear characteristics. Its pathophysiologic mechanisms are unknown, and the optimal treatment for patients with this condition remains debated. Of the 60 million individuals with hypertension reported in the United States, only 19 000 (1/2200) have developed end-stage renal disease. Factors other than hypertension have been postulated to explain the progression to renal failure.18
It is possible that hypertensive nephrosclerosis is a primary microvascular nephropathy on which the ill effects of hypertension are superimposed.18 This possibility has led Dr. Barry I. Freedman to doubt the existence of hypertensive nephrosclerosis as a diagnosis. Dr. Freedman expressed his view in an article in the Journal of the American Society of Nephrology entitled “Hypertension-associated kidney disease: perhaps no more.”19 However, even if it remains questionable, whether mild to moderate hypertension can cause end-stage renal disease in white patients, uncontrolled hypertension will certainly accelerate the decline of renal function in patients with primary renal disease.20 The control of blood pressure, therefore, remains an important step in delaying the onset of end-stage renal disease and should be addressed seriously.21,22 To this end, successful attempts at modifying the human genome have paved the way to gene editing and the correction of genetic defects, opening new avenues in our efforts at preventing end-stage renal disease.23
Efforts to avoid the need for retransplant
Ensuring the absolute success of all transplant procedures is obviously a utopia. Denying the chance of a second transplant to an unlucky patient is definitely unethical. It is estimated that as many as 30% of patients on the waiting list in the United States are awaiting a second transplant.24 This statistic highlights the need to review our criteria for the selection of the donor-recipient pair and stresses the need for a closer follow-up of both recipients and living donors.
Proper selection of the donor
Many donors who were considered to be healthy are themselves ending up on the waiting list for organ donation. The incidence is 0.5% to 3% of all living donors, depending on the quality and the length of follow-up.25 This incidence might seem small, but it might increase if restrictions on the selection of the donor are relaxed or if genetically related living donors in a highly consanguineous area are chosen.
A review of some of the proposals that were presented in the Amsterdam forum aimed at expanding the living donor pool by disregarding previously adopted restrictions on living donation is edifying.26 We are fortunate that the consensus guidelines overrode these proposals.
In our area, consanguinity is highly prevalent.
Dr. A. Barbari and colleagues demonstrated a close relation between consanguinity and hereditary renal disease.27 This relation between consanguinity and hereditary renal disease puts genetically related donors at a higher risk of developing end-stage renal disease. Rather than devising new allocation rules to prioritize living donors, a strict choice of potential donors should be adopted to protect them. As Dr. John S. Gill stated in a recent article, "It is ironical that stringent regulations are set for deceased donation, while living donation is most of the time left to the discretion of transplanting centers."28
The realization that every living-donor donation places a healthy person who donates an organ at potential risk demands our strongest efforts to meet the challenges of this unique field.29
We can only hope that efforts at disease control will eventually succeed in reducing the need for organ donations. With a significantly reduced demand, improving the supply may then bridge the gap between the need for and the supply of organ donations.
A trial investigating the formation of cultured nephron tissues is now completed. It is the first step toward organ replacement.30 This development might constitute a solution to the shortage of organs for transplant. Even if one day, thanks to scientific progress, human organ donation is no longer necessary, our efforts to encourage donation would not have been in vain. In a world dangerously drifting toward the ugliest forms of racism and religious fanaticism, we would have nurtured highly needed virtues, the virtues of solidarity and the virtue of self-sacrifice, a sacrifice strictly devoted to altruistic, anonymous organ donation.
Volume : 15
Issue : 1
Pages : 6 - 9
DOI : 10.6002/ect.mesot2016.L27
From the Lebanese American University, Beirut, Lebanon
Acknowledgements: The author declares that he has no sources of funding for this study, and he has no conflicts of interest.
Corresponding author: Antoine Stephan, Hobeika Center, 2nd floor, Hazmieh, Lebanon
Phone: +961 595 5902
E-mail: firstname.lastname@example.org; email@example.com