Deceased donation in Asia: Challenges and opportunities†
Potential conflict of interest: Nothing to report.
1. The deceased donation rate is low in Asia, and there is a critical shortage of liver grafts.
2. The number of liver transplants in Asia has increased rapidly during the last decade, mainly because of the rapid increase in the use of living donor liver transplantation (LDLT).
3. Various social, cultural, religious, and economic factors account for the low rate of deceased donation, and there is marked diversity between different countries and even within individual countries.
4. There are excellent opportunities for the actualization of deceased donation through legislation, education, donor actions, and innovations.
5. In the foreseeable future, LDLT will continue to play a crucial role for patients with liver disease in Asia. Liver Transpl, 2012. © 2012 AASLD.
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HISTORY OF LIVER TRANSPLANTATION IN ASIA
Liver transplantation in Asia started early and yet progressed slowly.1 The first liver transplant in Asia was performed in 1964 by Nakayama in Chiba, Japan with a graft from a non–heart-beating donor. This was only 1 year after Thomas Starzl's historic first attempt in the world at human liver transplantation in Denver, CO. The second liver transplant in Asia was performed by Lin, Qiu, and Xia in Shanghai, China in 1978. More transplants were subsequently performed in China, but there were no long-term survivors. In Taiwan in 1984, Chen performed the first liver transplant with long-term survival at a time when there were still no brain death laws in that region. Brain death legislation was passed in Singapore and Taiwan in 1987 and in Korea and Japan later.
There are many reasons for the slow development of liver transplantation in Asia. Transplantation is a complicated service requiring extensive manpower and material and technological resources. Most countries in Asia were classified as developing, and transplantation began earlier in more affluent places such as Japan, Hong Kong, Korea, and Taiwan. The major obstacle, however, was the severe shortage of deceased donors. This critical graft shortage provided a powerful driving force for the development of LDLT. LDLT was first performed in Asia by Nagasue at Shimane University in Japan in 1989; this was also a year after the first attempt by Raia in Brazil in 1988. Liver transplant programs in Asia have repeatedly advanced the frontiers of LDLT through surgical innovations such as left liver grafts with or without the caudate lobe, right liver grafts, right lateral section grafts, and dual grafts.
CURRENT STATUS OF LIVER TRANSPLANTATION IN ASIA
There is no international registry for liver transplantation in Asia, but several countries have national registries. Extremely wide disparities exist in the status of liver transplantation across different countries. The China Liver Transplant Registry,2 for example, shows a unique pattern of development in China that is quite different from the rest of Asia, and it deserves a separate description. The changes reflect the rapid rise in demand, which was modified by the Chinese government's commitment to using legislative measures to regulate liver transplant activities in order to meet international standards. The initial enthusiasm in developing LDLT was rapidly discouraged by regulatory actions designed to prevent irregularities and commercialization in living donation. Hence, since 2010, LDLT has accounted for less than 5% of liver transplants. At the same time, a national donation after cardiac death program was started, and donation after cardiac death donors accounted for 12.9% of all liver transplants in the first half of 2012.2
The low rate of LDLT in China contrasts sharply with rates in the rest of Asia where LDLT predominates. An international survey showed that from 1995 to 2005, the annual number of LDLT procedures in other parts of Asia increased more than 10-fold, whereas rates for liver transplantation using deceased donors remained almost static for more than a decade.1 On average, LDLT was used for nearly 90% of liver transplants in most parts of Asia. Japan is the most extreme example because of its belated brain death legislation, but the latest data from the Japanese Liver Transplantation Registry3 show that the proportion of deceased donor liver transplantation increased to nearly 10% in 2011. Despite an encouraging trend of more deceased organ donation, the International Registry of Organ Donation and Transplantation showed that in the year 2008, the deceased organ donor rate in Asian countries ranged from 0.9 to 5.3 per million people per year, whereas the rates were 26.2 and 34.2 per million people per year in the United States and Spain, respectively.4
CHALLENGES IN DECEASED DONATION IN ASIA
Before we contemplate a discussion of the challenges facing deceased donation in Asia, it is important to recognize that in Asia there are extremely wide variations in economic, social, cultural, and religious factors not only between countries but even within individual countries. This diversity should be taken into consideration when possible solutions for promoting deceased donation are being implemented.
Lack of Brain-Death Legislation
The delay or absence of brain death legislation is the most obvious reason for the scarcity of brain-dead organ donors. Japan, for example, passed brain death legislation only in 1997, and the criteria for brain death certification are stringent. Despite an increase in the public awareness of deceased donation, the number of brain-dead donors remained low (<15 per year) until the brain death law was revised in 2010.3 China has introduced numerous laws in recent years to regulate organ transplantation, but brain-death legislation has not been successful. Although cultural resistance is a real issue, there is even more concern about the potential abuse of brain death certification and uneven law enforcement.
Cultural and Religious Barriers
It has been shown that Asians are more reluctant to donate organs than Caucasians.5 Within Asia and even within individual countries, there are numerous ethnic, social, cultural, and religious factors contributing to disparities in deceased donation.6 In China, for example, Confucian values and, to a lesser degree, Buddhist and Daoist beliefs, which associate an intact body with respect for ancestors or nature, have been shown to have a negative effect on the overall willingness to donate.7 On the other hand, there are striking differences in attitudes toward organ donation in various Muslim communities. Some religious thinking discourages deceased donation because of a sense of the sacredness of the body or a fatalistic approach to illness.8 Nonetheless, the commercial sale of organs has been widely reported in some Muslim countries.
Lack of Government Funding and Support
Deceased organ donation requires a system for donor identification, maintenance, and allocation. It needs a national organ transplant network that can be established only with a government mandate and funding. In the Philippines, for example, although individual centers have attempted to initiate liver transplant services and there are potential brain-dead donors in different hospitals, there is no network for linking the supply and the demand. In India, there was a living donor death that could have been avoided if logistics for the transport of a deceased donor organ had been available.9
Success of LDLT
Although LDLT provides an alternative and may increase the public awareness of the success of liver transplantation, some programs in Asia use LDLT as a replacement for deceased organ transplantation, and the success of LDLT has become a disincentive for the promotion of deceased donation. This is because the ability to perform LDLT has been taken as a sign of a center's strength and prestige, and by using LDLT, a center can avoid the unpredictable timing and logistics of deceased donor allocation and transplantation.
OPPORTUNITIES FOR DECEASED DONATION
For countries with no brain death laws, the most obvious way of starting deceased donation is to proceed with brain death legislation, although there are legitimate reason to be concerned about the potential for abuse in some countries. Another way to increase deceased donation is a presumed consent law. A recent multinational study showed a higher rate of deceased donor kidney transplantation in 22 countries with presumed consent laws versus 22 other countries with explicit consent laws.10 In this study, however, the only country from Asia with a presumed consent law was Singapore. Despite the implementation of an opt-out scheme including liver donation in revised legislation in 2004, there has been no increase in donor referral in Singapore11 because it is legal but irrational and unethical to enforce deceased organ retrieval in the face of resistance from family members.12 Furthermore, the utilization and actualization rates were low and highly variable among different hospitals. Many cases of nonactualization could not be attributed to any valid reasons.
Training transplant coordinators, establishing national organ transplant networks and organ allocation systems, and encouraging the declaration of an intent to donate through organ donation cards, driver's licenses and insurance documents can be accomplished only with the support of governments. Many of these measures, however, are greatly determined by the health care system of a country. Such donor actions are most effectively used in places with well-developed public health care systems such as Korea and Hong Kong.
Educational efforts to enhance people's knowledge of organ donation and cultivate a supportive attitude may take the form of a planned public campaign. The impact of ad hoc media coverage of transplant stories, however, should not be underestimated. The social influence of a public hero is best illustrated by the effect of extensive media coverage of the death of Cardinal Kim in Korea, which led to the promotion of organ donation and volunteerism.13 Media coverage of patients' appeals for organs and transplant success stories will arouse public support and boost public confidence in transplantation.
Non–heart-beating donors may provide an extra source of organs in addition to brain-dead heart-beating donors. In countries in which brain-death legislation is lacking, donation after cardiac death may be the only type of deceased donation, even for patients who are brain-dead. This strategy has become the main focus for the development of organ transplantation in China recently. There are concerns about higher rates of complications and inferior outcomes with liver transplantation using non–heart-beating donors. In addition, a reluctance to donate attributable to various reasons may be more obvious when the discussion with relatives has to be made before the patient is declared dead.
The promotion of deceased donation is challenging in Asia, and there are excellent opportunities for improvements through legislation, education, donor actions, and innovations. In the foreseeable future, LDLT will continue to dominate in Asia, but the potential for promoting deceased donation should continue to be explored.