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The UK system at work

As soon as a potential donor is identified, two quick phone calls set in motion the complex chain of events, which will ensure that these organs are put to good use. Someone from the donor intensive care unit (ICU) rings the transplant co-ordinator for the region, who in turn gets through to the duty officer at the UK Transplant Support Service Authority (UKTSSA), whose many services underpin the entire transplant initiative in the UK and Republic of Ireland.

Within a few hours, several dozen people will be involved in giving new life to others (patients in kidney, liver, heart or lung failure) and restoring sight to two people with corneal disease.

One kidney is usually retrieved and grafted locally, within the 12 health regions. The second kidney is offered to the UKTSSA which maintains a computerised registry of waiting recipients for the national pool.

When a kidney becomes available, UKTSSA offers it for the best matched patient on the list. If for some reason it cannot be utilised for this patient, it is offered to the second best choice. On arrival at the transplant centre, the donor kidney is submitted to a final laboratory test.

If the result shows it could be soon rejected by the intended recipient, the UKTSSA computer is once again consulted for the next best matched patient. In this way a kidney, which can be stored for up to 36 hours in crushed ice and still remains stable, can be ferried to as many as three hospitals in a bid to find the most suitable recipient.

At present tissue matching is not carried out for other solid organs made available for transplantation. Hearts, lungs and livers are simply matched for blood group and for size and weight of donor and recipient. Here time is much shorter than it is with kidneys, with hearts, lungs and heart lung blocs (known as thoracic sets) only remaining viable for up to four hours.

Should the retrieval team need transport to and from the donating hospital, or if an organ is to travel unaccompanied, the UK Transport for Transplants (UKTFT) is available to help. IKTFT is a consortium of ambulance trusts, based in the West Midlands, which provides a 24-hour service arranging suitable transportation for donated organs or retrieval units.

As soon as a transplant unit accepts the offer of an organ, the potential recipient is called in. he or she is prepared for surgery. This is done somewhat on a standby basis in that no one can be sure, until the organ is brought back and checked for suitability, whether or not the operation will go ahead. Many would be recipients have had to sleep off their pre-medication and trek back home the next day.

A key figure in all this is the transplant co-ordinator, who maintains links with all parties involved in transplantation. The co-ordinator also undertakes care of donor families and fulfils the vital role of educating both health care personnel and the general public on the broad issues of transplantation.

The main problem facing everyone is a commitment to transplantation is the chronic shortfall in donor organs which leaves more than 6000 people in the UK and Republic of Ireland waiting for grafts at any one time. Many initiatives have been proposed to overcome this lack. These include various opting in schemes (one of which, the well know donor card, has been in existence since 1971); an opting out arrangement whereby the organs could be taken form a deceased patient who had not registered any objection to their retrieval; and a required request system, such as has been tried in the United States, where it is incumbent on the medical staff caring for the brainstem dead patients to seek consent from the families for the donation.

Fewer potential donors

None of these options would provide a complete answer to the problem. Moreover, in the early 1990's, following various audits in ICU's, it became obvious that the pool of potential donors is not as great as everyone had assumed. For more than a decade people had been working on an estimated figure of 4000 cases of brainstem death a year in the UK. Now, it emerged that the likely toll was probably slightly less than half the estimate- and, of course, not all brainstem-dead patients would be suitable as organ donors. A number of specific measures are required to boost the rate of transplantation.

These include: targeting ICU staff to increase the rate of donor referral; winning over some of the 20 per cent or so of the population who are opposed to donation; and making more effort to recover tissues which do not need to come from a beating heart donor (kidneys, heart valves, corneas) from patients dying elsewhere than in ICU's. There is for instance the somewhat controversial practice of 'elective ventilation', when, with the family's agreement, certain patients (mainly stroke victims) who are bound to die and who could be suitable as organ donors are transferred to intensive care, where they can put on ventilators shortly before death. However, in 1994, due to a question of legality, hospitals were advised by the Department of Health to discontinue this practice.

Meanwhile, when a transplant takes place, the transplant co-ordinator sends back follow-up information on the recipient's progress both to the donor family and to the donating hospital. Usually too, since the names and addresses of both parties must remain confidential, co-ordinators will forward letter from recipients to donor relatives, or vice versa.

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