Special legal and ethical problems
Legal aspects
In countries with established transplant programs, organ transplantation is highly regulated. Of particular concern is organ donation, with legal, medical, and social issues surrounding the procurement of organs, without compensation, for transplantation. Many of those issues are overcome by organ registries, in which individuals choose to become organ donors. Through such registries, donors can indicate which organs they are willing to donate upon death. Whether a person is a registered organ donor can then be indicated on a personal identification card (e.g., a driver’s license), authorizing organ procurement once the individual is deceased. In the absence of legal consent via registration as an organ donor, organ procurement representatives are required to consult with next of kin for authorization to obtain organs from the deceased person.
Ethical considerations
Defining death
Transplantation raises important ethical considerations concerning the diagnosis of death of potential donors, and, particularly, how far resuscitation should be continued. Every effort must be made to restore the heartbeat to someone who has experienced sudden cardiac arrest or to restore breathing to someone who cannot breathe. Artificial respiration and massage of the heart, the standard methods of resuscitation, are continued until it is clear that the brain is dead. Most physicians consider that beyond this point efforts at resuscitation are useless.
In many countries, the question of how to diagnose brain death—that is, irreversible destruction of the brain—has been debated by neurologists and other medical specialists. Most of these experts agree that when the brainstem is destroyed, there can be no recovery. The brainstem controls the vital function of breathing and the reflexes of the eyes and ears, and it transmits all information between the brain and the rest of the body. Most countries have established strict guidelines for how brainstem death is to be diagnosed and what cases are to be excluded—for example, patients who have been poisoned, have been given drugs, or have developed hypothermia. The neurological signs of brainstem death must be elicited by a trained clinician who is not concerned directly with the transplant operation. These signs are reverified after an interval, and, if there is the slightest doubt, further reverifications are made until the criteria are unequivocally met. The guidelines are not seriously disputed, and there has never been a recovery in a case that fulfilled the criteria of brainstem death.
Shortage of donors
Another area of ethical concern is the dilemma posed by the shortage of donor organs. Advances in immunosuppressive therapy have put increasing pressure on the supply of donor organs, and medical personnel sometimes find themselves having to determine who among the potential recipients should receive a lifesaving graft. Furthermore, there is a danger of commercial interests becoming involved with people willing to sell their organs for personal gain, and there is definite risk of illegal organ trafficking, in which organs are procured from unwilling donors and then sold to facilities that offer transplant services.
Rejection
Humans possess complex defense mechanisms against bacteria, viruses, and other foreign materials that enter the body. These mechanisms, which collectively make up the immune system, cannot, unfortunately, differentiate between disease-causing microorganisms and the cells of a lifesaving transplant. Both are perceived as foreign, and both are subject to attack by the immune system. This immune reaction leads to rejection, the greatest problem in successful tissue and organ grafting.
Immune responses
In order to understand why rejection occurs and how it may be prevented, it is necessary to know something of the operations of the immune system. The key cells of the immune system are the white blood cells known as lymphocytes. These are of two basic types: T lymphocytes (T cells) and B lymphocytes (B cells). These cells have the capacity to distinguish “self” substances from such “nonself” substances as microorganisms and foreign tissue cells. Substances that provoke an immune reaction are recognized by the presence of certain molecules, called antigens, on their surface.
T lymphocytes are responsible for cell-mediated immunity, so named because the T cells themselves latch onto the antigens of the invader and then initiate reactions that lead to the destruction of the nonself matter. B lymphocytes, on the other hand, do not directly attack invaders. Rather, they produce antibodies, proteins that are capable of initiating reactions that weaken or destroy the foreign substance. The overall immune reaction is exceedingly complex, with T lymphocytes, B lymphocytes, macrophages (scavenger cells), and various circulating chemicals waging a coordinated assault on the invader.
Transplant rejection is generally caused by cell-mediated responses. The process usually occurs over days or months, as the T lymphocytes stimulate the infiltration and destruction of the graft. The transplant may be saved if the cell-mediated reactions can be suppressed. Antibody attack of transplanted tissues is most apparent when the recipient has preexisting antibodies against the antigens of the donor. This situation can arise if the recipient has been previously exposed to foreign antigens as the result of pregnancy (during which the mother is exposed to fetal antigens contributed by the father), blood transfusions, or prior transplants. Unlike a cell-mediated reaction, antibody-mediated rejection is rapid, occurring within minutes or hours, and cannot be reversed.
Selection of donor and tissue matching
The factors that provoke graft rejection are called transplantation, or histocompatibility, antigens. If donor and recipient have the same antigens, as do identical twins, there can be no rejection. All cells in the body have transplantation antigens except the red blood cells, which carry their own system of blood-group (ABO) antigens. The main human transplantation antigens—called the major histocompatibility complex, or the HLA (human leukocyte antigens) system—are governed by genes on the sixth chromosome. HLA antigens are divided into two groups: class I antigens, which are the target of an effector rejection response; and class II antigens, which are the initiators of the rejection reaction. Class II antigens are not found in all tissues, although class I antigens are. Certain macrophagelike tissue cells—called dendritic cells because of their finger-like processes—have a high expression of class II antigens. There has been much interest in trying to remove such cells from an organ graft, so that the rejection reaction will not be initiated.
Tissue typing involves the identification of an individual’s HLA antigens. Lymphocytes are used for typing. It is important also that the red blood cells be grouped, since red-cell-group antigens are present in other tissues and can cause graft rejection. Although transplantation antigens are numerous and complicated, the principles of tissue typing are the same as for red-cell grouping. The lymphocytes being typed are mixed with a typing reagent, a serum that contains antibodies to certain HLA antigens. If the lymphocytes carry HLA antigens for which the reagent has antibodies, the lymphocytes agglutinate (clump together) or die. Typing serums are obtained from the blood of persons who have rejected grafts or have had multiple blood transfusions or multiple pregnancies; as previously stated, such persons may develop antibodies to transplantation antigens.
If the lymphocytes of both the recipient and the potential donor are killed by a given serum, then, as far as that typing serum is concerned, the individuals have antigens in common. If neither donor nor recipient lymphocytes are affected, then donor and recipient lack antigens in common. If the donor lymphocytes are killed but not those of the recipient, then an antigen is present in the donor and is missing from the recipient. Thus, by testing their lymphocytes against a spectrum of typing sera, it is possible to determine how closely the recipient and donor match in HLA antigens. As a final precaution before grafting, a direct crossmatch is performed between the recipient’s serum and donor lymphocytes. A positive crossmatch usually contraindicates the donor–recipient transplant under consideration.
There is now considerable knowledge concerning the inheritance of transplantation antigens, but, even so, tissue typing is not sufficiently advanced to give an accurate prediction of the outcome of a graft in an individual case, particularly when the donor and recipient are not related to one another. In accordance with Mendelian laws of inheritance, a person obtains one of a pair of chromosomes from each parent. Therefore, a parent-to-child transplant will always be half-matched for transplantation antigens. Siblings have a one-in-four chance of a complete match of the HLA antigens, a one-in-four chance of no match, and a one-in-two chance of a half-match.
The blood transfusion effect
Following a blood transfusion, some patients become sensitized to the transplantation antigens of the donor, so it was expected that prior blood transfusion could only harm the recipient’s prospects for a successful organ graft. Careful analysis of results, however, showed the contrary. Specifically, the results of kidney grafting in patients who had received previous blood transfusions without regard to HLA matching were much better than in patients who had never received a blood transfusion. Although a great deal of effort has been expended to determine the mechanisms involved, researchers still do not know how the immune system is modified by prior blood transfusions. Most centres now give blood transfusions before transplantation, though some patients do develop HLA antibodies against a wide spectrum of the population and therefore become very difficult to transplant. This pool of highly sensitized patients is getting larger throughout the world, not only from blood transfusions but also from patients who have rejected kidney grafts and are back on dialysis and from women who have had multiple pregnancies.
A special application of the blood transfusion effect involves repeated small blood transfusions from a potential donor who is a close relative of the patient. If sensitization does not occur, subsequent kidney graft results are excellent. Some patients, however, develop a positive crossmatch to donor lymphocytes and cannot receive a graft from that donor. This, combined with the increasing number of patients who readily develop HLA antibodies, has resulted in a decline in the use of donor-specific blood transfusion.
Immunosuppression
The aim of transplantation research is to allow the recipient to accept the graft permanently with no unpleasant side effects. With current drugs that are used for this purpose, after some months the dosage can often be reduced and sometimes even stopped without the graft’s being rejected. In such a case, the patient is no longer as susceptible to infections. There would appear to be adaptation of the recipient toward the graft and the graft toward the recipient. The adaptation is probably akin to desensitization, a process used sometimes to cure patients suffering from certain types of allergies by giving them repeated exposure to small doses of the allergen to which they are sensitive.
Azathioprine
Azathioprine is one of the most widely used immunosuppressive agents; it also has been used to treat leukemia. It can be given by mouth, but the dose must be carefully adjusted so that the blood-cell-forming tissues in the bone marrow are not damaged, which could lead to infections and bleeding. The white blood cell and platelet counts need to be determined frequently to make sure that azathioprine is not being given in too large a dose. It is an extremely valuable drug and has been the basis of most immunosuppressive regimens in patients with organ grafts. At first, high doses are given, but eventually the doses may be reduced. Even years after transplantation, small doses of azathioprine may still be needed to maintain coexistence between graft and host.
Corticosteroids
Cortisone and its relatives, prednisone and prednisolone, are very useful in patients with organ grafts. They can be given by mouth, but, although not damaging to the blood-forming cells, they do predispose the body to infection, cause stunted growth in children, and have other injurious effects. Persons receiving these substances may develop complexion problems with swollen faces and may tend to gain weight and become diabetic, and their bones may become brittle. Few recipients of organ transplants, however, can do without corticosteroids, particularly during an active rejection crisis.
Antilymphocyte and antithymocyte globulins
If rabbits receive repeated injections of mouse lymphocytes, they become immunized and develop antibodies against the mouse cells. The serum from the rabbits’ blood can be injected into mice and will often prevent them from rejecting grafts, both from other mice and even, sometimes, from other species. Such antilymphocyte serums can be produced between a variety of species, but in higher mammals, particularly humans, it has been difficult to obtain a powerful immunosuppressive serum without side effects of toxicity.
The activity of the antilymphocyte serum lies in its gamma globulin, which contains the antibody proteins. Antilymphocyte globulin is used in humans but contains many proteins that are ineffective and may be harmful. It can be added to immunosuppressant and steroid treatment regimens, and it is extremely useful in treating rejection crisis in kidney graft recipients who have not responded to corticosteroids. The horse has usually been used to produce antilymphocyte serum for the treatment of human patients, but some persons are sensitive to horse proteins and become extremely ill when treated with horse serum. Such patients may, however, be successfully treated with rabbit antilymphocyte globulin.
Antithymocyte globulin is a similar antibody treatment but is produced in animals, usually rabbits or horses, through inoculation with human thymocytes. Antithymocyte globulin triggers a significant reduction in levels of circulating T lymphocytes. It commonly is used to induce immune suppression for kidney transplantation, helping prevent graft rejection.
Monoclonal antibodies
An important development in antibody production followed the discovery that an antibody-forming lymphocyte can be fused with a cancerous bone marrow cell. The resulting hybrid cell produces the antibody specified by its lymphocyte progenitor, while from the cancer cell it obtains the characteristic of multiplying indefinitely in laboratory cultures. The culturing of the hybrid yields a clone of cells that produce one specific antibody—a “monoclonal” antibody. Such agents are exclusively specific in action and there is no theoretical limit to the number of antibodies that can be produced by different hybrid cell lines. Monoclonal antibodies can be regarded as highly specific antilymphocyte globulin without many of the unwanted materials that are present in the ordinary polyclonal antilymphocyte serum described above. Some monoclonal antibodies have been produced that are effective as immunosuppressive agents in humans.
Cyclosporine
Cyclosporine was found as a natural product of an earth fungus by researchers at the pharmaceutical company Sandoz Laboratories. It is a stable cyclic peptide with powerful immunosuppressive activity affecting especially the T lymphocytes. Cyclosporine was found to prevent organ graft rejection in a number of animal species. When the drug was used in humans, the expected immunosuppressive effect was again observed. It has been used in recipients of all types of organ grafts with improved immunosuppressive results. Cyclosporine can be toxic to the human kidney, however, and may cause permanent renal damage. The drug also increases the growth of hair on the face and body. It is a difficult drug to use because, being fat soluble, its absorption is variable and each patient needs to be individually studied to ensure that the dosage is adequate but not excessive.
It is clear that none of the agents so far used to prevent rejection is ideal. No one would use such dangerous agents except as a last resort in a desperate situation. This, unfortunately, is the exact plight of a person in need of a vital organ transplant. Immunosuppression is, however, much more effective and less dangerous than it used to be, and advances with chemical derivatives, in particular monoclonal antibodies and nontoxic analogues of cyclosporine, have brought significant improvements in immunosuppressive therapy.
Organ and tissue banks
Without a blood supply, organs deteriorate rapidly. Cooling can slow down the process but cannot stop it. Organs differ in their susceptibility to damage. At body temperature, irreversible destruction of the brain occurs after more than 3 to 5 minutes; of the heart, liver, pancreas, and lung, after 10 to 30 minutes; of the kidney, after 50 to 100 minutes; and of the skin and cornea, after 6 to 12 hours. The shorter the time the organ is deprived of its blood supply, the better. Although the cornea can be removed for grafting at relative leisure, every minute is of vital importance for a liver transplant. When a kidney is removed from a living donor, it is not necessary to use elaborate preservation techniques. The operations on the donor and recipient are performed at the same time, and the recipient is prepared to receive the graft by the time that the donor organ is removed. Cadaver kidneys are removed as soon as possible after the donor’s death, preferably within an hour. Cool solutions are infused into the blood vessels of the kidney, which is then kept at 4 °C (39 °F) in a refrigerator or surrounded by ice in a vacuum flask. At the same time, the recipient is prepared for operation. Kidneys can be conserved in this simple way for 24 to 48 hours with little deterioration, and during this time they can be moved for long distances. For a kidney to be preserved from 48 to 72 hours, a complicated machine is required to provide artificial circulation. Cool oxygenated physiological solutions with the same osmotic pressure as blood are passed through the blood vessels of the kidney. The imperfections of the machinery mean that there is a slow deterioration of the organ that does not occur normally in the body. To keep a kidney undamaged for longer than 72 hours is difficult. Blood cells, spermatozoa, and certain other dissociated tissue cells can be frozen to subzero temperatures and kept alive indefinitely. Special preserving fluids will prevent cell destruction by ice crystals, but these fluids have damaging effects if introduced into whole organs such as the kidney.
For the heart, lung, liver, and pancreas, grafting is performed as quickly as possible, preferably within eight hours for the liver and pancreas, four hours for the heart, and two hours for the combined heart-and-lung graft. Much research will be necessary before it is possible to keep organs banked in the way that blood can be stored.
Roy Yorke Calne