The Process of Medical Last-Resort

"Transplant surgeons and transplant physicians are being faced with difficult decisions: Do we accept this organ or don't we?"
"That's sometimes a tough decision. But if the alternative is for a person to remain on dialysis, or with end-stage liver or end-stage lung disease, it may still make sense for them to accept the more marginal organ."
"There's no reason to believe that what was observed in Montreal [degraded organs due to older and/or obese donors] would not be observed in other parts of Canada."
Dr. Andreas Kramer, medical director, Southern Alberta Organ and Tissue Donation Program, Calgary

"Our data suggest that the characteristics and co-morbidities of brain-dead organ donors have somewhat deteriorated over the last decade."
Montreal research in donated transplant organs: Canadian Journal of Surgery

With organs in chronically scarce supply, doctors are increasingly turning to 'innovative measures' to expand the pool of donors, researchers have written in a new study. Wayne Cuddington, Postmedia News

Experts in the field of organ transplantation are now in the process of developing and testing the viability of organs derived from the elderly and from obese patients who have directed that their organs be harvested after death for transplant. The hope is that they will be able to predict whether compromised organs will be competent to the work required by the organ after transplant, before the decision has been reached to proceed with the transplant.

This "organ support systems" test is meant to determine the functionality of less-than-perfect organs before they are committed to being transplanted in replacement of a patient's failing organ, in an effort to save lives. Doctors, in acknowledging the severe shortage in Canada of organs for transplant, where the list of patients whose health is fast failing far outdistances the number of organs available, have expanded criteria for eligible donors.

Now, older people and patients with underlying health conditions like stroke that once would have been disqualifying factors are being accepted. A new study out of Montreal reviewed brain-dead organ donors from age 18 and up who had donated one or more organs to patients from the McGill University Health Centre between the years 2000 and 2012. Slightly more than half (56%) of the donors were men and almost half of those, with a median age of 47 were or had been smokers.

The men had other problems; 24% suffered from high blood pressure, seven percent had diabetes, and five percent had coronary artery disease. When the study further divided the donors, it was into two periods of time, from the year 2000 to 2005, and 2006 to 2012, revealing to the researchers that a significant BMI increase above 30 (the cutoff point for obesity) as well as other health conditions were associated with "worse outcomes" after transplantation.

The McGill study examined 1,040 brain-dead organ donors over 13 years. Wayne Cuddington, Postmedia News

Other research undertaken by other scientists had already demonstrated that older donor age and elevated BMIs are associated with "organ non-recovery". The obese are likelier to have diabetes, and elevated blood pressure is associated with "fatty livers". Dr. Kramer said even the average number of organs per donor has decreased over time; fewer overall transplants despite a steady number of donors. Within Canada, 4,612 people awaited a transplant organ in 2012 and while waiting, 230 died.

At one time organs were exclusively harvested from people who were medically declared to be brain-dead. And most of these represented young people involved in devastating vehicle crashes, suffering brain injuries. By virtue of their youth those victims who became organ donors tended to have healthy organs; kidneys, livers, hearts and other tissues. The advent of safer vehicles, seatbelt laws and above all more sophisticated medical care in head traumas resulted in fewer people progressing to "brain death".

The Montreal researchers studied 1,040 brain-dead organ donors over thirteen years, finding an "overall worsening" in the health of the donors, with the more recent ones likelier to have a higher body mass index, a history of smoking, coronary artery disease and abnormal blood fats as compared with the typical donors of a decade earlier. What was not made clear by this research was how well organs taken of "somewhat deteriorated" quality performed after transplant.

What is clear however, is that despite the presence and growing use of "more marginal" organs, the alternative remains no transplant, often leading to death.