Recent Progresses in Organ Donation and Transplantation in Korea

The declaration of Istanbul and more recently the World Health Organization (WHO) have provided an ethical framework for organ donation and guiding principles for national-level responsibility with the goal to achieve self-sufficiency in the field of organ donation and transplantation.1,2 Moreover, the WHO in collaboration with the Organización Nacional de Transplantes/National Transplant Organization and The Transplantation Society supported by the European Commission has published the Madrid Resolution, adopting a comprehensive strategic framework for maximizing organ donation leading to self-sufficiency.3 The Madrid Resolution also emphasizes on the national accountability in meeting the needs of the patients. We have previously reported on measures that have been implemented to achieve self-sufficiency during the previous decade in Korea.4 Efforts of our national organ donation system have been emphasizing on transparency and were able to increase deceased donation markedly from 36 (0.75 pmp) in 2002 to 409 (8.03) in 2012. Here, we report on recent achievements and challenges of organ donation and transplantation in Korea. Governmental And Regulatory Systems After the introduction of the first Organ Transplant Act in February of 2000, organ donation (both living and deceased), determination of brain death, and organ allocation came under the auspices of a unified regulatory system.5 The Korean Network for Organ Sharing (KONOS) was founded in 2000 and has authority to approve living organ donation and transplantation while allocating deceased donor organs to recipients on nationwide waiting lists. Proof of noncommercialism is required for the approval of live donor transplantation. The KONOS has established a computerized allocation system prioritizing by waiting time, immune compatibility, prior living donation, regional proximity from donor hospital, and pediatric status for renal allocation and medical urgency for the allocation of liver, lung, and heart. With the revised Organ Transplant Act in 2011, the Korean Organ Donation Agency (KODA) has been legally designated as the National Independent Organ Procurement organization. The new law also included mandatory reports of all potential brain death patients to independent organ procurement organization. Numbers Of Transplant Programs A total of 78 hospitals have been approved for organ transplantation by the Ministry of Health and Welfare. In 2013, kidney and liver transplantation have been performed in 63 and 40 hospitals, respectively. Of note, approximately two-thirds of all approved hospitals perform less than 20 transplants per year, and only 6 and 7 hospitals performed greater than 50 kidney and liver transplants, respectively. Heart, lung, pancreas, and small-bowel transplants are performed in less than 10 hospitals. Donation Rates And Overall Transplant Volume Through the activity of KODA, the number of used deceased donors increased by 37.4%, reaching 368 (7.25 pmp) in 2011 compared with 268 (5.31 pmp) in 2010. Donor volume continued to increase during the recent years reaching 446 (8.69 pmp) in 2014 (Figure 1A). At the same time, numbers of organs transplanted per donor remained stable at 3.2 during the last 5 years (Figure 1B). The increase in deceased donation resulted into an overall growth in organ transplant activity, and significant improvements in the numbers of liver, kidney heart, lung and pancreas transplants. Although various efforts including public campaigns have supported the increase in deceased donations, numbers of live donors have increased as well reaching 1855 (1000 live kidney and 855 live liver transplants) in 2014 (Figure 1C). Of note, rates for live donation have reached a plateau during the recent years.FIGURE 1: Trends in organ donation activity in Korea. A, Number of deceased organ donors. B, Organs transplanted/donor. C, Number of organ transplants from live or deceased donors (pmp, per million population with pmp calculated based on statistics provided by the Ministry of Government Administration and Home Affairs).Data Systems Characteristics of waiting lists, organ allocation, and transplantation are collected in a database established by KONOS in 2000. It has to be noted that the database lacks comprehensive posttransplantation or postdonation follow-up data, such as graft function, graft survival, or complications. To compensate for this shortcoming, the Korean Society for Transplantation together with the Korean Center for Disease Control has designed the Korean Organ Transplant Registry, a web-based organ transplant registry in 2014.6 Although Korean Organ Transplant Registry is, at this time, a research-based program and reporting is not mandatory, the system includes posttransplant data for greater than 90% of donor and recipients in Korea; an initial report has been published recently.7 Barriers To Living/Deceased Donation Although the WHO has encouraged donation after circulatory death (DCD),8 DCD is not considered in Korea at this time. Two DCD occurred in 2010, and the volume has not changed significantly during recent years with 7 DCD in 2011, and 1 DCD donor each in 2012, 2013, and 2014. Under the Organ Transplant Act, brain death is not defining death but the approval of the condition is restricted to organ donation. Thus, withdrawal of life support in patients even with confirmed brain death remains prohibited; therefore, type III DCD donors are not approved. Cultural barriers remain to be in the way to establish other types of DCD. Future educational efforts, responsible policies, and jurisdictional modifications will hopefully address those issues. Significant Achievements And Challenges Educational campaigns tailored to health care professionals appear critical in capturing and diagnosing brain death. The KODA has implemented donation improvement programs that include the review of medical records, death files and discussions with medical professionals and hospital administrators. This program has been implemented since 2012; currently, 66 hospitals participate in this initiative. With the implementation of this program, the diagnosis of brain death has been captured in greater than 65% (a rate that has more than doubled from 2013 to 2014, Figure 2A). In parallel, the conversion rate has increased significantly (Figure 2B).FIGURE 2: Effects of the DIP, thus far implemented in 36 hospitals demonstrate a marked increase in identifying brain death donors and conversion rates. Recognition rate = (number of recognized brain death) × 100 / (number of potential brain death). DIP indicates donation improvement program.Summary Various efforts to improve organ donation and transplantation have been successfully implemented in Korea. Educational efforts addressing general public and health care professionals have been critical for the progress observed. The donation improvement program has shown promising result and is expected to roll out in all hospitals in Korea within the next years. With all public outreach activities, donation after cardiac death has not been implemented thus far. In moving forward, professional societies and nongovernmental organizations will need to focus on driving the DCD agenda forward to increase organ donation in the country.