Donor system gives a chance of new life

Deng Qini was admitted to hospital with acute hepatic failure on April 22. Without an immediate liver transplant, she was likely to die within a week. The 21-year-old English major at Guangdong University of Foreign Studies, from Zhanjiang city, was wheeled into surgery the following day to undergo a liver transplant but she died 16 days after the operation.

The surgeon, Huo Feng, dean of the liver transplant center at a military hospital in Guangzhou, said Deng may have been the fastest organ recipient in the history of the hospital and, maybe, the fastest in the country. Usually, a patient has to wait at least one or two months to land a matched organ at Huo's hospital, one of 163 authorized transplant centers.

Official estimates show that about 1.5 million people on the mainland require a transplant each year, but less than 1 percent actually undergo the procedure mainly because of a severe shortage of organs.

"I didn't expect my daughter to undergo surgery so quickly, because we are just ordinary people with little money and few connections," said Deng Zhongwei, who expressed gratitude to the liver donor and those who helped with the medical bill of more than 400,000 yuan ($63,000).

Huang Hai, deputy director of the hospital, conceded that Deng might not have received the liver without a recently launched allocation system for organ donations.

The computerized system, which automatically grades all waiting patients according to a variety of factors, including the severity of the patient's condition and the time they have been on the waiting list, singled out Deng as first in line for the organ donation, shortly after her information was uploaded, recalled Li Peng, who heads the hospital's organ procurement organization.

Li's team, comprising as few as five members, works in conjunction with the local branch of the Red Cross Society of China to detect potential organ donors, mainly at intensive care units in the province. The team facilitates transplants after completing administrative procedures such as approaching potential donors, obtaining consent, removal of the organ, and its transportation.

Launched by the Ministry of Health and the Chinese Red Cross in April 2011, the system is designed to link transplant centers and OPOs nationwide.

China now has 163 OPOs on the mainland.

Organs are allocated via the public voluntary deceased organ donation system among patients awaiting a transplant in an open, transparent, and fair manner, said Wang Haibo, director of the China Organ Transplant Response System Center, which also runs the allocation system.

"That works to secure fair organ allocation. Without fair allocation no one would donate," he stressed.

Currently, more than 20 factors are taken into consideration when the decision is being made as to which patient will be offered the donated organ first, said Wang.

"These were identified after long-term discussions among senior experts from the transplantation and legal fields and key health officials in the country," he said.

"Organ allocation is actually life allocation and without fair practice, no one would donate organs," he reiterated.

However, "it takes time, patience, and cooperation to really work", said Wang Ping, director of the relief and health department of the society.

According to Jiang Wenshi, data analyst at the COTRSC, by January about 30 OPOs had filed donor information and organ allocation data in the system.

By the end of December, more than 50 livers had been allocated via the system, however during the same period the Chinese Red Cross had recorded 85 donations, with the 35 extra organs likely to have been donated outside the remit of the allocation system, said Wang Ping. "Some allocations obviously were conducted under the radar," he said.

At present, the system is only open to directors of transplant centers rather than patients, but the process is under the supervision of the health authorities and the Chinese Red Cross.

"The introduction of the system could somewhat help to redress the situation and prompt open, transparent, and fair allocation," according to Wang Haibo. However, he admitted that it's not an easy job and will take time to settle down, given that it represents a major change to the current mechanism and the entire landscape of organ allocation.

Since transplants were first performed in China in the 1970s, organ allocation has been mainly hospital-based, and insiders revealed that a lack of supervision had created loopholes that allowed some people to jump to the front of the line.

Wang Haibo conceded that transplant doctors on the mainland were facing external forces, such as pressure from powerful, wealthy people with the right connections, when deciding who should receive an organ donation.

Echoing Wang, Huo Feng acknowledged that the pressures existed. One case in point was that of the movie actor, Fu Biao, who died from late-stage liver cancer in 2005. Fu underwent two transplants, which stirred a public outcry after it was alleged that they only helped to extend his life by 15 months, while other patients, who could have lived for a further 15 years, were kept waiting.

Donor system gives a chance of new life

"In fact, a person's economic situation can largely determine the right to life, because of the severe organ shortage. With money at hand, Fu could choose to have transplants to help him live a little longer and improve his quality of life," said Shen Zhongyang, the surgeon who performed the transplants.

Wang Haibo said the new allocation system will mean that the situation doesn't arise again. Besides, "it actually makes it easier now for transplant doctors when responding to some patients' requests to undergo surgery earlier than others, because we will only work according to the system," he said. Although the system is still operating on a trial basis which is localized, "it has helped to achieve fair allocation within the hospital", he said.

However, not everyone believes that the new system will end the lottery of organ allocation. A veteran transplant surgeon in Beijing surnamed Shi, said that there are few acute cases among those awaiting kidney transplants, because, unlike patients suffering from liver problems, sufferers are often able to be treated by non-invasive procedures, such as dialysis. However, those on the kidney list are also subject to the usual criteria when organs are being allocated at the hospital where he works.

"In some cases, allocation can be flexible as long as it doesn't break the law and regulations. We human beings all have our feelings," he conceded, but stressed that the system "can't be abused for profit".

In addition, Shi expressed reservations about the quality of the organs received via the allocation system, noting that many of the donors had spent a long time in ICUs, which could result in damaged organs.

The system only allocates organs donated via the nation's organ donation system, and excludes those garnered from executed prisoners. In 2011, 227 kidney transplants were performed in Shi's hospital, with 200 of the organs coming from executed prisoners and just 27 from living donors.

Huo Feng said that during a donor's last days, hospitals use a process called "extracorporeal membrane oxygenation" to provide support and oxygenate the cardiac and respiratory systems of patients whose hearts and lungs are so severely diseased or damaged that they no longer function properly. The use of ECMO can ensure that organs destined for transplantation are kept in prime condition. However, Huo emphasized that the technology requires further research. "By showing respect for the death process, we can help donors to fulfill their promise of providing usable organs," he said. The use of ECMO adds between 30,000 to 50,000 yuan to the cost of treating each donor.

Chen Jingyu, deputy director of the Wuxi People's Hospital, said that he personally didn't agree with the use of ECMO purely for organ procurement. "It's kind of China unique and is considered a desperate solution," he said.

In China, where public awareness of brain death remains poor and it takes time to coordinate voluntary organ donations, ECMO is used as a means of maintaining the quality of organs for longer periods.

Without the use of ECMO, the quality of organs received after cardiac death is not as high as those harvested after brain death, he conceded.

By March 15, 206 people on the mainland had donated a total of 543 organs after cardiac death via the trial donation system, according to Hao Linna, vice-president of the Chinese Red Cross.

"The majority of them were from people in underprivileged rural families and 90 percent of the donor families have applied for humanitarian aid," she said. "We can hardly avoid the subject of the aid that is granted to make sure that the donation doesn't aggravate the financial situations of donor families," said Deputy Minister of Health Huang Jiefu.

"Given the small scale of the donations made so far, their demographic distribution is unable to represent how the picture will look when the donation system goes nationwide, and we receive a great many more donations," he added.

Francis Delmonico, president-elect of the Transplantation Society, said that unfair allocation creates a perception that the poor are donating organs to save the lives of the rich and powerful.

It's crucial to gain public trust and ensure the donated organs go to the right recipients, based on standards and principles recognized by all stakeholders, he said.