Organ donation

The first organ transplantation in the modern sense was performed by the Bernese surgeon Theodor Kocher in 1883, when he transplanted human thyroid tissue under the skin of a young man's neck (Schlich 1998). J. H. Harrison, J. E. Murray, and J. P. Merril achieved the first successful human kidney transplantation in identical twins in Boston in 1954 (Pfitzmann 2001). Almost 10 years later, in 1963, T. Starzl performed the first liver transplant in Denver and in the same year J. Hardy performed the first lung transplant in Mississippi.

Only 3 years later, R. Lillehei in Minnisota transplanted the pancreas for the first time.

C. Barnard performed the first heart transplant in Cape Town in 1967.

In 1985, D. Grandt performed the first small intestine transplantation in Toronto (Brudermüller 2000).

Organ donation is understood to be the written willingness of the person concerned or close relatives to donate body organs.

The consent of the person concerned must be given during his or her lifetime, whereas the consent of close relatives is only possible after the brain death of the person concerned (for more details, see below).

Organ donation is regulated by the Transplantation Act (TPG), which came into force in Germany in 1997. It regulates the donation, removal, procurement and transfer of organs. The guideline authority for organ transplantation lies with the German Medical Association (Herold 2020).

In organ donation, a distinction is made between living and cadaveric donation.

Cadavericdonation: In the case of cadaveric donation, according to the Transplantation Act (TPG), the donor must have already consented to donation during his lifetime in the form of a so-called "donor card". The willingness to donate organs cannot be recorded in the will, as the time of a possible donation would already have passed by the time the will is made. If there is neither written consent nor an objection, next of kin can make this decision - taking into account the presumed will of the donor - within a reasonable time. However, the next of kin are only authorised to make a decision if they have had personal contact with the deceased in the last two years (Bundesministerium der Justiz und für Verbraucherschutz 2020).

Living donation: The TPG specifies exactly who is eligible for living organ donation (Kuhlmann 2015). Donors can be close relatives or persons from the immediate environment of the affected person who are personally closely connected to the recipient (Herold 2018).

Relative contraindications for living donor are:

- esity

- paired glucose tolerance

- creased risk of developing type 2 diabetes mellitus (Kuhlmann 2015).

Example kidney transplantation: In 2010, 2,903 kidney transplantations were performed in Germany, of which > 20% were living donors. In the same period, 7,869 patients were waiting for a transplant kidney. (Kasper 2015)

The Eurotransplant (ET) foundation, established in Leiden (the Netherlands) in 1967, is the central intermediary for post-mortem donated organs. Potential organ donors are reported to ET immediately after their death and are included in the allocation process.

The donor organ is allocated according to a precisely defined points system based on their urgency, likelihood of success and equality of opportunity (Krukemeyer 2008).

In the Netherlands and Belgium, so-called non-heart-beating donors are also possible, i.e. removal and placement of organs after cardiac arrest.

A distinction is made between several categories:

• Category I: This is a so-called "uncontrolled" donation, where the patient has already suffered a cardiac arrest on arrival at the hospital.
• Category II: This is also an "uncontrolled" donation, but where resuscitation was unsuccessful and has already been terminated.
• Category III: Category III is a so-called "controlled" donation, where cardiac arrest is already expected. Ventilation and drug therapy are deliberately discontinued and cardiac arrest is awaited. As soon as cardiac arrest has occurred, the organs are removed 10 minutes later.
• Category IV: This is also a so-called "controlled" donation, except that cardiac arrest occurs after brain death has already been established. As soon as the cardiac arrest has occurred, the organs are removed 10 minutes later. (Krukemeyer 2008)

In Germany, the number of organ donors has been declining since 2010 and had reached its lowest level ever in 2017 with 797 (Rahmel 2019). In 2019, the number of organs donated in Germany had risen again to 932 (Eder 2020). Austria, for example, has twice as many post-mortem donors as Germany (Gussnig 2020). Across Europe, Denmark had the highest number of donors in 2019, with 16.91 donors per million inhabitants (Gussnig 2020), although the proportion in Germany had already risen again to 10.1 per million inhabitants in 2019 (Eurotransplant International Foundation 2020).

Post-mortem organ donation may only take place after brain death or irreversible loss of brain function (IHA). These guidelines for "determining brain death" were first documented in 1982 and last revised in 2015 (Richter- Kuhlmann 2017). They precisely define the procedures for determining brain death or irreversible brain function loss (IHA) (Herold 2018).

Apparent failure of all brain functions is documented by cerebral circulatory arrest (CT- angiography) (Herold 2018).

Physical examinations for IHA are performed by two physicians who have several years of experience in the intensive care treatment of severely brain-injured patients and are board-certified specialists. At least one of the two physicians must be a specialist in neurology or neurosurgery (Richter- Kuhlmann 2017) and must not be a member of the transplant team (Herold 2018).

The diagnostic procedure consists of a three-step scheme to determine the IHA and must be repeated after at least 12 h in the case of primary supratentorial brain damage or after at least 72 h in the case of secondary brain damage (Brandt 2018).

The organ removal itself may only be carried out by doctors.

(Federal Ministry of Justice and Consumer Protection 2020).

Example kidney donation (see also kidney transplantation): Kidney donation is by far the most frequently performed transplantation.

The 5-year survival rate for cadaveric donation is about 77% and for living donation about 85% (Herold 2020), with the best long-term results for pre-emptive transplantation (transplantation before initiation of dialysis treatment) (Kuhlmann 2015).

However, living donation carries a certain mortality risk for the donor. It is 3.1 cases per 10,000 operations in the first 90 days postoperatively. However, long-term mortality is not increased - compared to an age-matched collective (Kuhlmann 2015). The risk of terminal kidney disease occurring later is generally not increased in donors. However, in one study, renal failure occurred in 1% of donors, with African Americans showing a significantly increased risk (Herold 2020).

For the recipient of a living donation, there is a 1-year graft survival chance of 75%-90%, which is thus significantly higher than that of a post-mortem donated kidney at 50%-60% (Kasper 2015).

Example liver donation: Liver donation is the second most common organ donation (Krukemeyer 2008). It is - in contrast to kidney donation - directly life-saving (Gutmann 2002). The mortality rate for transplantation due to malignant diseases is very high on average. The 5-year functional rate - regardless of the cause for transplantation - is 53% for post-mortem donation and 59% for living donation (Manns 2016).

Although living liver part donation shows better results than post-mortem donation, it is associated with risks for the donor.

Morbidity is 12.5% for right liver lobe donation and 9.8% for left lobe donation.

Donor lethality is 0.2% worldwide (0.09% after left lateral donation and 0.4%-0.5% for right lateral donation).

In donors, the main part of the regeneration process is already completed after 1 - 2 weeks, the actual remodelling phase lasts up to one year.

The 5 - year survival rate of recipients with living donation is 82.9 % and with post-mortem donation 82.1 % (Walter 2008).

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