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Saudi Journal of Kidney Diseases and Transplantation
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EDITORIAL Table of Contents   
Year : 2004  |  Volume : 15  |  Issue : 2  |  Page : 125-128
Organ Donation Problems in Japan and Countermeasures


Department of Urology, Tokyo Women's Medical University, Tokyo, Japan

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How to cite this article:
Ishida H, Toma H. Organ Donation Problems in Japan and Countermeasures. Saudi J Kidney Dis Transpl 2004;15:125-8

How to cite this URL:
Ishida H, Toma H. Organ Donation Problems in Japan and Countermeasures. Saudi J Kidney Dis Transpl [serial online] 2004 [cited 2019 Oct 16];15:125-8. Available from: http://www.sjkdt.org/text.asp?2004/15/2/125/32892
The major reason for the stagnant state of organ transplantation in Japan is a shortage of organ donors. After 30 years of controversy following the first case of heart transplantation performed in Sapporo in 1968, a law was established to allow organ donation upon confirmation of brain-death. However, partially because of the strictness of the legal require­ments, there have been only 23 cases of organ donation during the six years since the establishment of the law, and transplantation medicine has thus made no progress in Japan.

To promote the donation of organs, it is necessary to elucidate the nature of these problems, and to determine who is to assume responsibility for their resolution. Thus, it is important to clarify the goals and the missions of transplantation medicine, and to specify the methods to be employed for achieving those goals.

In 1997, the Law of Organ Transplantation was enacted. The objectives of this law were to settle the problem of brain-death and to promote organ transplantation medicine in Japan in a satisfactory manner. More than six years have passed and the present situation can be described as follows. Till the end of December 2002, organs have been obtained from 23 brain-dead donors including hearts from 17 donors and livers from 21. Thus, despite the small number of donors, we can note that transplantation of organs from brain-­dead donors had been resumed.

What about the kidneys? While 808 patients underwent kidney transplantation in 1989 (including 261 patients who received live donated kidneys), transplantation of live donated kidneys has been decreasing conti­nuously since the establishment of the Japan Kidney Transplant Network in 1994 (which was reorganized as the Japan Organ Transplant Network in 1997 after promulgation of the Law of Organ Transplantation) [Figure - 1]. In 2002, the number of patients who underwent kidney transplantation decreased to only 122. [1]

The heart transplantation performed in Sapporo in 1968 induced a nationwide distrust, not only of transplantation medicine, but medicine as a whole. This distrust resulted in the 30-year gap in transplantation from brain-dead donors in Japan. The conclusion drawn from these years of controversy was that a system for ensuring the expression of the donor's will before death, reliable evaluation of brain-death, consent of the donor's family, as well as fair distribution of the donated organs should be established, and that organ transplantation medicine could not be realized in Japan unless these requirements were satisfied. Also, the establishment of such a system was believed to hold the promise of a bright future.


   Current Status Top


In Japan, most transplanted livers and kidneys are from living donors. This is obvi­ously an aberrant phenomenon considering the trend in foreign countries where trans­plantation of organs from cadavers accounts for the majority of cases.

Why has organ donation stagnated in Japan? The philosophy in Article 2 of the Law clearly states that the donor's desire to donate his/her organ(s), which was expressed while alive, should be respected. According to the opinion poll conducted by the Cabinet Office in 2002, 36% of the respondents answered that they had an intention to donate their organs. In another survey, approximately 50% of the respondents expressed this intention. Moreover, nine percent of the general public carry a donor card. Nevertheless, the number of kidneys donated from cases of brain-death is very few each year, and is 60 to 80 in the case of transplantable kidneys collected from non-heart beating donors. In Japan, the number of brain-death cases is estimated to be approximately 8000 per year. According to research done by the Japan Neurosurgical Society in 1997, donation of organs was medically feasible in about a half of the patients in whom brain-death was clinically confirmed. These facts appear to suggest that the intention of those who had a desire to donate their organs for transplantation while alive, is barely being realized.


   Where do the Problems Lie? Top


The biggest hurdle to organ transplantation in Japan is the shortage of donated organs. Consequently, the number of patients awaiting organ transplantation is much greater than the number of organs donated. What is required first to solve this problem is to understand it. Secondly, groups or individuals seriously recognizing the need to solve this problem and who are willing to act to solve it are needed. Thirdly, it is necessary to isolate the problem, to write out a prescription for it, and to construct a method to strategically cope with it. What we need most to tackle this problem of donor shortage is the third approach to the solution.


   Measures to Acquire Donors Top


Target Number

Transplantation medicine requires human organs, i.e., someone's death is a pre-condition for obtaining such organs. This is why trans­plantation medicine faces a difficulty which, in a sense, is different from the challenges faced by other fields of medicine. It is also the reason perhaps that this specialty has been a source of controversy, involving the general public, over the past 30 years. Many people probably understand the situation in which a precious life that cannot be saved without transplantation is ignored due to missing an opportunity for transplantation. However, not many people seem willing to give their consent when they think about a situation in which a member of their family becomes a potential donor after brain-death.

Therefore, the basic approach to promoting organ transplantation is to understand clearly the philosophy of the law in Japan. In other words, it is crucial to realize the intention of those who have expressed, while alive, their desire to donate organs. The specific number of donors can be estimated as follows. There are about 8000 brain-death cases per year, about 10% of the general public carries a donor card, and the organs are medically transplantable in about 50% of brain-death cases. If all these conditions were fulfilled, the number of donors available each year would be approximately 400.

Additionally, expression of one's intention in writing should not be a pre-condition for donation of a kidney. Considering the result of the consensus survey in which 36 to 50% of the general public expressed a desire to donate organs, donation from 5 out of 1,000,000 persons (at least 2000 kidneys per year) can be set as the specific goal. The rationale for this is that, in the United States, about 20 out of 1,000,000 persons donate this organ. Donations from Asian people, including Japanese, are the fewest in number, only about 10 per 1,000,000. [2]


   Hospital Development Model and Donor Action Program Top


In the "Study on promotion of the activities of coordinators' in kidney donation", conducted as a scientific investigation by the Ministry of Health, Labour and Welfare for the fiscal year 1999, creation of a model for increasing the donation of organs was started. This is a model for development of organ donor hospitals, in which effective and efficient investment and utilization of the existing resources is practiced. The target was the donation of 2000 kidneys, including 50 kidneys from brain-death cases. Each institution has its own coordinator, but their relationship with the network was unclear. Therefore, the relationship between the institutional coordinators and the network coordinators, as well as their specific roles, was clarified, and the institutional coordinators were assigned the role of being the main players in hospital development. At the same time, physicians specializing in transplantation, who have the best understanding of the current status of transplantation medicine and clearly under­stand the urgent need for organs, were given a supportive role. The institutional coordinators and the transplantation specialists are to co­operate in educating hospital personnel. For selection of the target hospitals, the number of brain-deaths encountered at the hospital and the degree of understanding of the top management of the hospital regarding trans­plantation medicine were examined, and then order of priority was given to each hospital. Once the target hospitals were selected, co­operation for organ donation was requested through hospital visits by the coordinators. Once a hospital agrees to co-operate, it is requested that intra-hospital coordinators be appointed. The basic role of the intra-hospital coordinators is the identification of potential donors within the hospital and communication with them. Duties beyond the scope of this role were discussed depending on the situation.

A marked increase in information regarding potential donors has been reported in areas that have participated in the hospital develop­ment program. At present, 12 institutions are using this program.


   Method of Organ Retrieval from Non­ Heart-Beating (Cadaveric) Donors Top


The most important point in regard to organ retrieval from non-heart-beating donors is whether permission for cannulation to flush with organ perfusion solution has been obtained from the family before the heart has stopped.

When the family has given permission for cannulation, the femoral artery and vein are cannulated at the bedside in the ICU in advance. When the agonal period is prolonged, 10,000 units of heparin are infused approxi­mately every eight hours through the cannula. Otherwise the cannula is kept clamped some­where along its length, and care is taken that no blood is lost, no perfusion solution escapes into the body, and death is not hastened. As soon as the heart stops, the clamp is released, the blood is removed, and the perfusion liquid is infused. Then, after proceeding to the operating room, organ retrieval is performed by the usual method. Warm ischemia time (WIT) is usually kept at less than five minutes.

When permission for cannulation has not been obtained from the family, as soon as the heart stops the attending physician starts to perform cardiac massage and proceeds to the operating room. The attending physician must continue to perform cardiac massage until the abdomen is opened and cannulation is performed through the incision. Since the WIT approaches about 30 minutes with this situation, particularly when the distance to the operating room is relatively far, it is natural that the viability of the organs dramatically decreases.

The interval between cardiac arrest and organ retrieval is generally under one hour, regardless of the institution. However, the viability of organs transplanted varies consi­derably according to whether or not the infusion of perfusion solution, described above, can be performed immediately after cardiac arrest.

 
   References Top

1.The Japan society for transplantation. Registry of kidney transplantations. 2002 Ishoku Gakkaishi 2003;137-42.  Back to cited text no. 1    
2.Rosendale JD, McBride MA. Organ donation in the United States: 1990-1999. Clin Transpl 2000;85-97.  Back to cited text no. 2    

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Correspondence Address:
Hiroshi Toma
Department of Urology, Kidney Center, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666
Japan
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PMID: 17642762

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