Transplantation News Review

Items listed by date, starting with the most recent:

2000 - current

Second doctor suspended over illegal organ trade (January 2003)
Organ sales in Britain given new support (January 2003)
GP Struck off for trading human organs (October 2002)
Kidney shopping (October 2001)
Fetal implants fail in Parkinson's trial (July 2001)
New setback for Xenotransplantation (July 2001)
Anaesthesia in organ removal (Januray 2001)
Down's syndrome patients denied transplants (July 2000)

1997 - 1999

Bladders grown in laboratory successfully implanted (July 1999)
US doctors create artificial kidney from cloned human cells (July 1999)
Worsening crisis in transplant surgery (July 1999)
Indian doctors take kidney without consent (July 1999)
Presumed consent for organ transplants (April 1999)
Arm and Face Transplants (January 1999)
Chinese Doctors Condemn Forced Organ Donation (July 1998)
Selling prisoners' organs (April 1998)
Transplanted organs from prisoners (January 1998)
Concerns about unethical organ sources (January 1998)
Xenotransplantation progress (January 1998)
Japan and Italy aim to smooth organ transplantation (October 1997)
Shortage of organs for transplants continues (July 1997)
Successful intrauterine bone marrow transplantation (April 1997)
Retinal cell transplants from aborted fetuses (April 1997)
Britain to set up xenotransplantation regulatory authority (April 1997)

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January 2003

Second doctor suspended over illegal organ trade

Jarnail Singh, a doctor from Nuneaton, Warwickshire has been found guilty of professional misconduct by the General Medical Council following claims that he encouraged the illegal trade of human organs from live donors in India. He has been suspended for six months and must also attend an education programme.

Evidence was given by two undercover journalists who had sought Dr Singh's advice on the pretext that one of them had a father in need of a kidney transplant. They said that he discussed the possibility of going abroad for a live donor transplant, explaining costs, disadvantages of surgery outside England, and how to avoid the authorities.

Furthermore, they claim, he indicated that he had facilitated such activites in the past and gave the impression that he would assist them in any way he could. He refused to accept the £5,000 payment they offered. Their original reason for approaching him was information that he had helped a previous patient, Darshan Singh, go to India for similar surgery. Mr Singh died after contracting an infection.

This follows the case in August of London GP, Dr Bhagat Singh Makkar, who was struck off for similar claims. (Guardian 2002;15 October, bbc news online 2002;15 October)

Organ sales in Britain given new support

The government is considering paying donors for transplant organs, according to a Department of Health consultation paper.

The paper raised the possibility of a change in the law by asking the question, 'Should the prohibition of commercial dealings from living and/or deceased people remain? If not, why not?' At present it is an offence under the Human Organ and Transplant Act 1989 to take or receive money for supplying organs for transplant.

Professor Sir Peter Bell, vice-president of the Royal College of Surgeons, backed the move, which will be debated in Parliament next year. He said, 'Relatives giving kidneys.get the best results. We should be willing to consider paying them for the inconvenience, time off work and so on.' This suggests that the move will be more about compensation than payment, much like the system currently used for sperm donation. Compensation could be set at a level such that people are not deterred from donating because of inconveniences, without it being enough to encourage 'sales'.

Others fear that the move will lead to exploitation of the poor. Dr Liam Fox, shadow Health Secretary, said, 'We cannot have such an important issue treated with third world ethics.' (Times 2002;21 October, Metro 2002;21 October)

October 2002

GP struck off for trading human organs

A London GP has been struck off by the General Medical Council (GMC) having been accused of illegally trafficking human organs. Dr Bhagat Singh Makkar was found guilty of serious professional misconduct after offering to 'fix' a kidney transplant via the black market in return for a fee. He was caught on tape by a journalist posing as the son of a seriously ill man.

At the time, the doctor was not aware that the conversation was being recorded but at the hearing he vehemently denied taking part in the trade of human organs from live donors. Whilst researching a piece for the Sunday Times on organ trafficking, freelance journalist Paul Samrai contacted Dr Makkar after getting his name from a doctor in Jalandhar, northern India. Dr Makkar reportedly gave the journalist a leaflet about his company, Health International Services, and told him that he was retiring from general practice to 'manage operations'. He was also recorded saying: 'In south India, like in Bombay, Hyderabad, the donor will be less expensive than Punjab... in Bombay there are loads of poor people.' He had previously told Samrai that a kidney would cost him three times more in Britain than anywhere else in the world, and said that payment for the operation should be made to him directly, with the price including his own 'administrative costs'.

Prof Peter Richards, the chairman of the GMC committee, said that Dr Makkar had acted with a 'reprehensible disregard' for the interests of potential donors. The GP denied serious professional misconduct or participating in the trade in human organs from live donors, and later claimed that at the time of the conversation with Samrai he had been 'tired, confused and upset after a long day dealing with emotional patients'.

As in most of the world, the trade in human organs is illegal in both the UK and India. However, the Voluntary Health Association estimates that more than 2,000 Indian people sell their organs each year. According to one surgeon, many of those travelling to the country in search of a kidney come from the UK and patients can expect to pay between £10,000 and £15,000. After their operation, many return to the UK suffering from serious complications. (Guardian 2002; August 31, BMJ 2002; 325:510)

October 2001

Kidney shopping

Between 30-50 Canadians travel abroad each year for kidney transplant operations due to waiting lists of up to six years at home. Buying and selling organs is illegal throughout Canada. No law, however, prevents Canadians going abroad for organs. The International Transplant Society and the World Health Organization have condemned this practice, and some health officials want the criminal code changed to make it illegal.

The practice has risks too. Some patients return with scars, but without kidneys despite having paid for them. Investigative journalists Lisa Priest and Estanislao Oziewicz reported in the Toronto Globe & Mail newspaper that a Vancouver businessman, Walter Klak, was acting as a middleman. Mr Klak had more than 100 patients on his waiting list and was frequently negotiating between patients and suppliers of kidney operations. They were awaiting operations at a Shanghai hospital where accident victims were taken.

Medical experts interviewed by the journalists estimated that Canadians paid between £35,700 and £103,600 ($50,000 and $145,000) for transplants in developing countries. Some return without any medical documents describing the operation or donor. This leaves doctors in Canada in the dark about donor screening for infections such as HIV or hepatitis. (BMJ 2001;322:1446, 16 June)

July 2001

Fetal implants fail in Parkinson's trial

A trial aimed at improving the symptoms of Parkinson's disease by implanting fetal cells in patient's brains has suffered a major setback, with devastating side effects occuring in 15 per cent of the subjects. Parkinson's disease strikes when dopamine-producing cells from the brain's substantia nigra region die and surgeons had hoped that brain cells from aborted fetuses would take over and replace the dead cells. Fetal cell tissue has been experimented with for brain repair since the 1980's and around 300 patients have been treated worldwide. However, due to variations in method, it has been impossible to draw conclusions from the different trials.

The group from Colorado University devised a new trial which included the controversial step of carrying out placebo 'sham surgery' on one patient group. The transplants grew and produced clinical improvement in the younger patients. However, the results showed that patients over 60 experienced no significant improvement in their condition. More disturbingly, in 15 per cent of patients the transplants exacerbated the patients already severe dyskinesia - one patient could no longer eat, and now must be fed using a nasogastric tube. The clinicians are planning a further trial to insert a kill-switch into the fetal cells for implantation. A drug could then be given to destroy the implants using the cells own destruction program if these side-effects occur in the future. (Times 2001; 15 March)

New setback for Xenotransplantation

According to a new report, the possibility of diseases being introduced into the general population by xenotransplantation cannot be ruled out. In their third annual report the UK Xenotransplantation Interim Regulatory Authority conclude that on the basis of current evidence the technique is unlikely to provide a viable means of reducing the current organ shortage in the near future. Xenotransplantation, the use of animal organs such as pig hearts as replacement organs in human patients, has always been regarded with caution because of the possibility that porcine diseases might cross the species divide, enabling them to infect humans. (BMJ 2001; 322:510, 3 March)

January 2001

Anaesthesia in organ removal

A leading anaesthetist has called for all patients who are about to have organs removed for transplant purposes to be given an anaesthetic to ensure that there is no possibility of them feeling pain. The editorial in Anaesthesia, the journal of the Royal College of Anaesthetists, called for anaesthesia to be given routinely during operations to remove the heart, lungs, liver and pancreas - all procedures carried out whilst the donor is still being ventilated.

The absence of brainstem function is regarded as evidence of death in Britain and a patient's ventilator can only be switched off once this is confirmed. However, it is clear now that some brain dead patients still have evidence of electrical activity. The increase in heart rate and blood pressure in patients who have organs removed is also regarded by many as indicative of distress. In addition, many anaesthetists apparently also admit to lingering doubts about what is happening in the brains of donors. This is despite absence of response to brain stem tests and no question of their survival without a ventilator for more than a few days.

In a joint statement with the Association of Anaesthetists of Great Britain and Ireland, Prof Peter Hutton, president of the Royal College of Anaesthesia, gave assurance that brain dead donors cannot feel pain during operations to remove their organs. Sporadic EEG waves emitted from the brain surface do not necessarily indicate the perception of pain.

The Department of Health also issued a statement to say that brain dead donors feel no pain but there are now fears that there could be a further decrease in the number of people coming forward as donors as a result of the debate. The current level of donors continues to fall because of the decrease in the number of heart attacks and fatal road accidents. (Guardian 2000; 19, 20, 22 August)

July 2000

Down's syndrome patients denied transplants

Referring physicians and transplant centres are reluctant to consider an individual with Down's syndrome for heart or heart-and-lung transplantation. Currently referral rates do not reflect the high prevalence (40%) of surgically treatable cardiac problems in individuals with Down's syndrome. Physicians cite co-existing medical problems and high rates of infective and malignant complications of Down's syndrome as factors which could reduce the likelihood of a satisfactory outcome. They judge that because there is a limited supply of organs, it is ethically sound to use them preferentially for individuals without Down's syndrome. They also argue that it is difficult to obtain informed consent from individuals who are profoundly mentally handicapped. There is concern however that widely held beliefs are not supported by the evidence and that individuals with Down's syndrome are receiving sub-optimal care without justification (BMJ 2000;320:816-817, 25 March).

July 1999

Bladders grown in laboratory successfully implanted

Bladders grown in the laboratory by an American team with tissue engineering techniques have been successfully implanted and shown to function in animals. The ability to implant new bladders would potentially be useful in babies with congenital bladder conditions and in people who have lost their bladders to trauma or cancer. (BMJ 1999;318:350, 6 February)

US doctors create artificial liver from cloned human cells

US doctors have used cloned human cells to create an artificial liver, which is about to begin controlled trials. The prospect of being able to clone any type of cell from a patient, such as brain cells for Alzheimer's disease or muscle tissue for heart repair, is drawing closer. (Daily Telegraph 1999; 6 April).

Worsening crisis in transplant surgery

There is a worsening crisis in transplant surgery with waiting lists rising, a severe shortage of transplant surgeons and an inadequate supply of organs available for transplant (BMJ 1999;318:350, 6 February). Accordingly, the BMA will begin the debate on presumed organ donation at its annual meeting in the hope that this scheme will help alleviate the problem. Safeguards will be implemented to ensure that people are given a real opportunity to opt out (BMJ 1999;318:1131, 9 January).

Indian doctors take kidney without consent

In India, doctors have removed a healthy kidney from a deaf and mute man and given it to his brother, who is suffering from end-stage renal failure. The operation followed a six-week debate on the ethics of taking an organ from a donor unable to communicate or give consent for the operation (BMJ 1999;318:753, 20 March).

April 1999

Presumed Consent for Organ Transplants

The BMA's ethics committee has approved plans to presume the organ donation consent of any patient who dies in hospital. Organs would be removed unless the patient has previously chosen to opt out, thereby hopefully easing the severe shortage of organs for transplant. (The Telegraph 1998; 29 December)

January 1999

Arm and Face Transplants

The world's first arm transplant was performed in France on 23 September 1998. A brain-dead man's hand and forearm was sewn onto a New Zealand businessman's amputated stump (due to a chainsaw accident) in a 13-hour operation. There has been some hostile questioning, by leading surgeons, of the ethics of risking a patient's life and health in order to replace a non-vital organ.32 In addition to the risks of surgery, the patient is now beginning years of powerful immunosuppressant therapy to prevent his body from rejecting the donor hand.

Meanwhile, American doctors say it may be possible to have a complete face transplant in a few months. This would involve removing the face of a dead donor and giving it to someone who has been deeply disfigured through illness or accident. (The Telegraph 1998;25 September, The Telegraph 1998;1 October)

July 1998

Chinese Doctors Condemn Forced Organ Donation

The Chinese Medical Association has said that it regards the involuntary or forced removal and sale of organs as illegal and ethically unacceptable (BMJ 1998;316:956, 28 March). The statement followed a meeting with the World Medical Association to discuss allegations that Chinese doctors have been involved in trading organs from executed prisoners. (BMJ 1998;316:725, 7 March)

April 1998

Selling prisoners' organs

Two Chinese people have been arrested in New York after allegedly supplying organs cut from executed prisoners. Pancreata, livers and lungs were among organs offered to FBI agents posing as buyers in a 'sting' operation. China claims that body parts are only taken with prisoners' permission and are donated, rather than sold, to patients. But on a videotape one of the arrested men, a prosecutor from Hainan, said: 'Prisoners have no political rights, so we don't ask'.

In America it is illegal to sell or buy body parts and the two men could face more than ten years in jail. (The Daily Telegraph 1998; 25 February:12)

January 1998

Transplanted organs from prisoners

Human rights organisations have criticised China for its use of transplant organs taken from executed prisoners. It is estimated that 2,000 to 3,000 organs are obtained yearly from such prisoners. They are often offered through newspaper advertisements and foreign customers can reportedly pay up to US$30,000 for the operation. Fears have been raised that this practice will lead to human rights abuses and over-enthusiastic capital punishment, especially as it is carried out with the blessing of government institutions which profit financially from it. A Chinese government official has called the accusations 'a slanderous attack on China's judicial system'. (Lancet 1997;350:1307, 1 November)

Concerns about unethical organ sources

Two further articles give concern that the means to reach the end of increased organ donation will become increasingly unethical. In the first, Dr Jack Kevorkian, the well-known euthanasia practitioner from Detroit, plans to offer organs from his suicide patients. He has said, 'Here's a situation where we can end the suffering of a patient and get organs back to save lives'. (BMJ 1997;315:1116, 1 November)

In the second, calls have been made to kill certain PVS patients by lethal injection in order to harvest their organs. Once a decision has been made to stop treatment and withdraw food and water, death takes place over 10-12 days; their organs become dehydrated, damaged and are unsuitable for transplant. The International Forum for Transplant Ethics sees no moral distinction between allowing someone to die by starvation and actively ending life. The parents of Tony Bland, the PVS victim of the Hillsborough Disaster in 1989, have supported the call, saying that they would have preferred this option for their son even though it was not available at the time. A spokeswoman for the BMA, however, has said that, 'PVS patients are not suitable donors. There could be a risk of treatment decisions being muddied by the wish to use their organs'. (Guardian 1997;1, 31 October)

Xenotransplantation progress

Thousands die each year waiting for allotransplants and waiting lists keep on growing. Recent estimates state that it would take just 100 breeding sows to negate the entire UK kidney shortfall. Recent advances have made xenotransplantation look far more likely. For instance, genetic engineering has virtually abolished the problems of hyperacute rejection when transplanting animal organs into humans. Transgenic pigs now express human complement-inhibiting protein that suppresses the immune response. (Lancet 1997;350:868, 20 September)

However, many hurdles still stand. Recent research (Nature 1997;389:681-2) found that pig retroviruses are transmitted through the germline so that proviral DNA is present in all pig cells. These viruses, related to HIV-1 and HTLV-1, are difficult or impossible to remove by breeding and have been shown to infect human tissue. The effect on humans is not yet known but similar viruses from mice have caused thymic leukaemia in macaque monkeys. Some researchers now hope for primate trials to investigate the effect of the viruses on immunosuppressed hosts. (Lancet 1997;350:1148, 18 October). Meanwhile, a WHO meeting of experts said that, 'Xenotransplantation offers exciting opportunities but must be carefully monitored'. They stated that it is acceptable 'as long as the health of humans is protected and human dignity is respected'. (Lancet 1997;350:1378, 8 November)

October 1997

Japan and Italy aim to smooth organ transplantation

Although Japan's recent ruling on brain death (see last Nucleus) passed the Lower House of Parliament, stronger resistance is expected in the Upper House.[28] Italy is considering legislation which would assume consent to organ donation in the absence of explicit dissent. This would take Italy from the bottom to the top of western organ-transplantation statistics.[29]

July 1997

Shortage of organs for transplants continues

Despite public education, donor cards and the success and low cost of surgery, the number of transplants in Britain still falls short of the 6,000 patients awaiting new organs. Part of the problem is that the 1961 Human Tissue Act gives donor cards equivocal status and does not adequately define death. In addition, as many as 45% of potential donors are not detected. This is in part due to the failure of critical care teams to communicate with bereaved relatives.

The organ supply could be increased by training in communication skills or the introduction of an opt-out system whereby consent is assumed unless otherwise specified. This would lessen the need for animal organs and reduce pressure for procuring human organs by unethical means. (The Times Jan 21 1997, p37; BMJ 1997; 314:697)

April 1997

Successful intrauterine bone marrow transplantation

Several infants destined to develop the severe combined immunodeficiency syndrome (SCIDS) have had their disease prevented by in utero transabdominal bone marrow transplantation. The success of the technique may herald a new era in the treatment of some types of genetic disorders.

In two recent cases the infants were born and remain healthy with a reconstituted immune system. SCIDS is a hereditary immunodeficiency disorder leading to recurrent opportunistic infections and death, usually within the first two years of life. Conventional postnatal bone marrow transplantation for the condition is hampered by graft rejection, graft versus host disease and the need for immunosuppression.

This successful application of fetal bone marrow transplants has sparked hope for the prevention of other genetic diseases such as thalassaemia and sickle cell anaemia, Gaucher's, Hurler's and Tay-Sachs disease. (BMJ 1997; 314:170)

Retinal cell transplants from aborted fetuses

Four blind patients have had their vision partially restored with experimental fetal retinal cell transplants. They all had late-stage retinitis pigmentosa, an incurable hereditary disease.

Dr Manuel del Cerro of New York presented the results of eighteen patients at the Society of Neuroscience's annual meeting in November 1996. About one million photoreceptor cells from aborted fetuses aged 14-16 weeks were implanted into the fovea of one eye in each patient. In the future Dr del Cerro hopes to try transplants at an earlier stage of the disease. His work was well received at the meeting.

The ethics of fetal tissues in transplantation has been recently reviewed in Nucleus. (Nucleus July 1996; 16-20)

Britain to set up xenotransplantation regulatory authority

The British Government is to set up a regulatory authority to monitor all research into xenotransplantation (the transplantation of animal tissues into humans). This follows an advisory committee report Animal tissues into humans' which concluded that transplantation from pigs (but not primates) was ethically acceptable. The regulatory authority will be similar in nature to the Human Fertilisation and Embryology Authority'. Attitudes to regulation of xenotransplantation vary between the US and the UK. There are fears that if UK law is too strict then research companies will simply carry out work in countries where the regulations are more lax.

The interest in xenotransplantation stems from the large shortfall in the supply of donated organs compared to the demand. Pigs seem the ethical' choice due to their distance' from man. More research is required before transplantation becomes reality as there are still problems with rejection of animal tissue. Transgenic pigs are being developed to reduce these problems.

Although the advisory committee has recommended that clinical trials should not yet be carried out, they could start in as little as twelve months. New problems could be generated due to diseases, especially those caused by yet unidentified viruses, crossing over from animal to man. (BMJ 1997;314:242,247)