During the past decade an increasing number of countries have adopted policies that emphasize donation after cardiocirculatory death (DCD) in an attempt to address the widening gap between the demand for transplantable organs and the availability of organs from donation after brain death (DBD) donors. In order to examine how these policy shifts have affected overall deceased organ donor (DD) and DBD rates, we analyzed deceased donation rates from 82 countries from 2000–2010. On average, overall DD, DBD and DCD rates have increased over time, with the proportion of DCD increasing 0.3% per year (p = 0.01). Countries with higher DCD rates have, on average, lower DBD rates. For every one-per million population (pmp) increase in the DCD rate, the average DBD rate decreased by 1.02 pmp (95% CI: 0.73, 1.32; p<0.0001). We also found that the number of organs transplanted per donor was significantly lower in DCD when compared to DBD donors with 1.51 less transplants per DCD compared to DBD (95% CI: 1.23, 1.79; p<0.001). Whilst the results do not infer a causal relationship between increased DCD and decreased DBD rates, the significant correlation between higher DCD and lower DBD rates coupled with the reduced number of organs transplanted per DCD donor suggests that a national policy focus on DCD may lead to an overall reduction in the number of transplants performed.

There are more than 1.7 million sufferers of end stage kidney disease (ESKD) worldwide and for many a donated kidney provides the only chance of regaining independence from dialysis. Unfortunately, the demand for kidneys for transplantation far exceeds the available supply. It is important, therefore, that we understand the factors that may influence kidney donation rates. While certain socio-demographic factors have been linked to kidney donation rates, few studies have examined the influence of multiple socio-demographic factors on rates of both living and deceased kidney transplantation (KT) and none have examined their comparative effect in large numbers of culturally and socio-politically diverse countries. In this study, we performed univariate and multivariate analyses of the influence of 15 socioeconomic factors on both the living donor (LD) and the deceased donor (DD) kidney transplantation rates (KTR) in 54 countries. Our analyses demonstrated that factors such as UN HDI (United Nations Human Development Index), religion, education, age, healthcare expenditure, presumed consent legislation and existence of a nationally managed organ donation program were associated with higher deceased KTR. In contrast, the only factors associated with living KTR were a highly significant negative association with presumed consent and variable associations with different religions. We suggest that by identifying factors that affect kidney transplantation rates these can be used to develop programs for enhancing donor rates in individual countries where those rates are below the leading countries.

Abstract:In the 50 years since the first successful human bone marrow transplant (BMT) was performed in 1959, BMT has become the optimal therapy for a wide variety of life-threatening paediatric haematological, immunological and genetic disorders. Unfortunately, while BMT generally provides the only possibility of cure for such afflicted children, few (25%) have a matched sibling available, and suitably matched unrelated donors are often not identified for many children in need of BMT. And even where BMT is possible, treatment is complex and arduous and associated with significant mortality and morbidity. The issues raised when either or both the donor and recipient are children and lack the capacity to make informed and rational decisions relating to BMT pose great challenges for all involved. This paper examines some of the ethical dilemmas that confront patients, families and medical practitioners when considering bone marrow transplantation in a child.Key words: bone marrow; ethics; paediatrics; stem cell; transplant.Born of the fallout from the most destructive force known to man, bone marrow (BM) transplantation (BMT) sits directly on an interesting ethical juncture between harm and cure in human history (haematopoietic stem cell transplant, haematopoietic progenitor cell transplantation and haematopoietic cellular transplant are all terms used to describe BMT; in this paper, we use the term BMT). Despite several early attempts to use transplanted BM therapeutically in the early 1940s, 1 it was not until radiation from the world's first nuclear tests began exposing human subjects to severe forms of radiation injury that focus was placed on developing the therapeutic potential of BMT. 2Despite extensive backing from the US government, early studies with BMT yielded only very limited success and led to the deaths of over 200 patients. It was not until 1959, when the French doctor Georges Mathé successfully restored haematopoiesis in six adult Yugoslavian victims of a radiation accident that the first partially successful BMT took place.1 BMT became a recognised therapy for other forms of BM failure, and in 1968, the world's first successful BM transplant was performed on a child with severe combined immunodeficiency syndrome. In the 50 years following Mathé's pioneering work, BMT has become the preferred treatment for a diverse range of fatal and debilitating diseases, including BM failure syndromes, immunodeficiencies, haematological malignancies, haemoglobinopathies and congenital metabolic disorders.There are two different types of BMT -autologous BMT and allogeneic BMT. In autologous transplantation, the stem cells are collected from and later re-infused into the same individual following the administration of high-dose chemotherapy. In allogeneic transplantation, the donor and recipient are different individuals. Allogeneic transplantation is further categorised according to: 1 The relationship between the donor and the recipient, which can be • syngeneic (identical twin),• related, and • unrelated. 2 T...

The limited availability of deceased donor kidneys for transplantation in Australia continues to be a matter of concern. Analysis of registry data suggests that the current renal transplant waiting list under-represents the real demand for three reasons. Firstly, a very low proportion of dialysis patients across all age groups are wait-listed for kidney transplantation; secondly, the percentage of dialysis patients listed for transplantation has fallen over time across all Australian states and territories; and thirdly, the number of patients wait-listed varies significantly across the country. We explore possible reasons for these issues and call for new eligibility criteria that are both transparent and justifiable and balance equity and utility.

Organ donation after brain death provides the most important source for deceased organs for transplantation, both because of the number of potential organ donors that it makes available and also because of the unparalleled viability of the organs retrieved. Analysis of worldwide deceased organ donation rates demonstrates that all countries with high deceased organ donation rates (>20 donors per million population per year) have high brain death rates (>40 brain deaths per million population per year). This analysis makes it clear that countries striving to increase their deceased organ donor rates to world leading levels must increase the rates of donation after brain death. For countries with end-of-life care strategies that stress palliation, advance care planning and treatment withdrawal for the terminally ill, the adoption of initiatives to meaningfully raise deceased donor rates will require increasing the rate at which brain death is diagnosed. This poses a difficult, and perhaps intractable, medical, ethical and sociocultural challenge as the changes that would be required to increase rates of brain death would mean conjugating an intimate clinical and cultural focus on the dying patient with the notion of how this person's death might be best managed to be of benefit to others.