The Organ Recovery Process
The organ recovery process involves a complex series of events coordinated by medical professionals in Organ Procurement Organizations (OPOs) and hospitals. The National Transplant Act of 1984 was enacted to help ensure the process is carried out in a fair and efficient way, leading to equitable distribution of donated organs. The Act established the national Organ Procurement and Transplant Network (OPTN) for matching donor organs to waiting recipients. The OPTN is managed through the United Network for Organ Sharing (UNOS) located in Richmond , Virginia . UNOS works with OPOs across the country, to place organs locally, regionally and nationally.

The Process:

1. A potential candidate for donation is identified by medical professionals. The nature of the injury leads a physician to declare the patient brain dead. Brain death is the complete and irreversible loss of all brain function, including the brain stem. Brain death is the legal definition of death. Using specific medical criteria, a physician can confirm brain death beyond any doubt.
2. The OPO is called on all patient deaths and imminent patient deaths. Information is provided on the patient's medical status and the OPO recovery coordinator conducts an evaluation of the patient. The evaluation includes a medical and social history and physical examination of the patient. This determines whether or not the patient is a suitable candidate for donation.
3. If the patient is a candidate for organ and tissue donation, at an appropriate time the legal next of kin is offered the option of donation. If the family consents, the legal next of kin signs a donor consent form. Under state law (Required Request), hospitals and OPO must offer the option of donation to the families of potential organ donors. Donation is discussed with the next of kin to obtain a medical and social history questionnaire to complete the donation process.
4. The patient is maintained medically by the OPO clinical coordinator in concert with the hospital staff. In some cases physician support is requested on a consultation basis.
5. The donor's blood type and body size is provided to UNOS by the OPO clinical coordinator. The UNOS computer then matches the donated organs to potential recipients.
6. Recipient selection is based on blood type, body size, medical urgency, and length of time on the waiting list. The heart, liver and lungs are matched by blood type and body size. In matching the pancreas and kidneys, genetic tissue type is also considered.
7. A computerized list of waiting patients in the matching blood group is provided to the OPO coordinator who seeks to match organs with recipients in the OPO’s service area. If a match cannot be made for the specific organ with this area, the organ is offered on a regional basis,then nationally if necessary.
8. When a match has been found the OPO coordinator calls the transplant center for the patient who matches the donated organ(s). It is up to the patient's transplant surgeon to accept the organ. If the surgeon declines the organ for that patient, the OPO coordinator contacts the next patient's transplant surgeon. This process continues for each organ until all of the organs have been appropriately matched with recipients. The OPO coordinator then arranges for the operating room (for the recovery of the organs) and the arrival and departure times of the transplant surgery teams.
9. When the surgical team arrives, the donor is taken to the operating room where the organs and tissues are recovered through a dignified surgical procedure. In accordance with federal law, physicians recovering the organs do not participate in the donor's care prior to the pronouncement of brain death.
10. Once the recipients have been identified, they are called by their transplant surgeons for the final pre-operative preparations while the organ recovery process is occurring at the donor hospital. Upon the organs' arrival at the transplant hospital, the recipients are taken to surgery and the transplants are performed.
11. Kidneys may not be matched with recipients until after the organ recovery has occurred. The OPO coordinator will take the kidneys and a sample of the lymph node tissue to a laboratory for tissue typing and subsequent matching with recipients. Other organs are taken directly to the recipients by the surgical recovery teams.
12. After the recovery process has occurred, the donor family can proceed with funeral or burial plans. Organ and tissue donation is a dignified and respectful process. The removal of organs does not interfere with funeral or burial arrangements, such as open casket visitations or cremation.

The OPO coordinator follows up each donation by sending letters to the donor family, hospital staff, physicians and nurses regarding the organs and tissues that have been transplanted.
OPO provides continuing support to donor families for the year following the donation, and longer if requested.

Matching Donors and Recipients
All patients accepted onto a transplant center's transplant waiting list are registered with the United Network for Organ Sharing (UNOS). UNOS maintains a centralized computer network linking all organ procurement organizations and transplant centers. This computer network is accessible 24- hours per day, seven days per week, with organ placement specialists always available to answer questions.

When a donor organ becomes available, the transplant center or organ procurement organization will access the UNOS computer, which generates a list of patients ranked according to the UNOS policies on organ allocation. .

Why does the patient who appears first on the waiting list not gel an organ? To answer this question, it is important to understand how organs are allocated.

When a patient is accepted into a transplant program, his or her name is added to the "pool" of patient names. When an organ becomes available, each patient in this "pool" is matched by the computer against the donor's characteristics. The computer then generates a list of patients ranked in order based upon medical and scientific criteria comparing all patients in the pool to that particular donor.

Factors affecting ranking may include tissue match, blood type, length of time on the waiting list and immune status. In the case of heart, heart-lung, liver, lung and pancreas, how far the potential recipient is from the donor hospital is taken into consideration. Therefore, each donor will generate a differently ranked list of patients.

After receiving a printout of the waiting list, the transplant coordinator contacts the transplant team of surgeons and physicians for selection of a patient using the ranking list. Often the first patient will not get the organ for one of several reasons. When selected, he or she must be available, healthy enough to undergo major surgery and willing to be transplanted immediately. Also, a laboratory test to measure compatibility between the donor and recipient may be necessary. For example, patients with high antibody levels often prove incompatible to the donor organ and cannot receive the organ because the patient's immune system would reject it.

Once the patient is selected and contacted and all testing is complete, surgery is scheduled and the transplant takes place.

The United Network for Organ Sharing

What is UNOS?
The United Network for Organ Sharing (UNOS) is a non-profit organization that was awarded the contract by the Department of Health and Human Services to operate the OPTN and to develop a system to assure equal access for all p.atients needing organs for transplantation. .

The OPTN is responsible for operating a 24-hour a day waiting list and an organ matching system; coordinating the logistics of matching the organs, collecting, analyzing and publishing transplant data; and educating health professionals about the donation process.

How does the system work?

All patients accepted onto a transplant program's waiting list for transplantation are registered with UNOS. UNOS maintains a centralized computer network linking all organ procurement organizations and transplant centers. This computer network is accessibl.e 24-hours per day, seven days per week, with organ placement specialists always available to answer calls.
When a donor organ becomes available, the transplant center or organ procurement organization will access the UNOS computer, which generates a list of patients ranked according to the UNOS policies. Ranking is based upon objective, medical and scientific criteria.

Factors affecting ranking may include tissue match, blood type, length of time on the waiting list and immune status. In the case of heart, heart-lung, liver, lung or pancreas, distance is also considered.
After receiving a printout of the waiting list, the transplant coordinator contacts the transplant team of surgeons and physicians for selection of a patient using the ranking system. Once the patient is selected, donor and recipient testing can begin and surgery is scheduled. UNOS is charged with developing and operating a national organ allocation system that is fair and based on sound scientific findings and best medical practices.

What are the criteria for placement on the liver waiting list?
There are approximately 270 transplant centers in the United States , covering II regions. Each center establishes their own criteria for placing patients on the liver transplant waiting list. The placement factors include age range, cause(s) of end stage organ failure and a number of evaluative characteristics. Patients at risk of dying within 7 days without a liver transplant, Status 1 or 2A, received 34 percent of liver transplants between August1, 1999 and May 31,2000 . Those patients not classified as Status lor 2A remain on the waiting list for longer periods of time.

What is the current UNOS policy for allocating livers?
The United Network for Organ Sharing (UNOS) currently has a policy stating the sickest patients receive a large and increasing proportion of donated livers. Those patients who need a transplant within seven days or they will die should receive the new liver. Organs must first be allocated to patients locally in the region where the organ was donated. This ensures individuals waiting in the same region where the liver was obtained will have the opportunity to receive the transplant. If the donated organ is not matched with a local patient, it can be allocated regionally, then nationally.

What is the new UNOS liver allocation policy under consideration?
UNOS is considering a new policy for liver allocation. It is based on a "predictive formula" and hinges on specific medical test results. According to this proposed system, patients who are critically ill throughout the nation will receive priority for new livers. This differs from the existing policy of allocating livers locally first, then nationally. This new policy will ensure those across the United States who require a new liver within seven days priority in receiving liver transplants, regardless of locality. The proposal is scheduled for a public forum on September 28, 2000 in Dallas , Texas .

What are the issues surrounding the proposed allocation system?
Concerns exist regarding the proposed UNOS policy for liver allocation. Specifically, those who would receive the transplant - the sickest patients - have less of a chance of surviving the transplant than a healthier recipient would. In addition, the sicker patients may reject the organ and require another transplant, effectively "wasting" the first organ. A study by the Institute of Medicine found that the sickest patients reject organs 11 % of the time, compared with rejection rates of 2% to 5% for less sick patients. Another concern is the fact that local allocation encourages donors, whereas national allocation may cause a decrease in local organ donation. People are more likely to donate an organ when they know it is going to someone in their own community.