Greg Armstrong

Vice President, International transplant Coordinators Society

Brisbane, Australia

Cadaveric organ donation commenced in Australia in the 1960s with the first cadaveric organ transplant (kidney) being performed in 1963. Within a short period of time a number of renal transplant units were established and by the end of the decade this form of transplantation had become established. Although a number of attempts at cardiac transplantation occurred in the late 1960s the transplantation of extra renal organs did not develop until the mid- 1980s. By the 1980s liver, heart, lung, pancreas transplantation was well established in most capital cities.

Australia is a commonwealth of six states and two territories. Constitutional restrictions have meant that the federal government is not empowered to legislate with regard to donation and transplantation. It was there for necessary for the states and territories to implement legislation in this area.

Uniform stats and territory legislation was enacted between 1978 and 1985. These act allows for an opt- in system although in some states donation may proceed, under certain circumstances, if the deceased had not expressed an objection to donate in their lifetime. The respective legislation also covers definitions of death, ban trade in organs and tissues, and allow living donations. Transplantation and donation are state funded services with access to transplantation provided free of charge to taxpaying residents.

The state and territories from the basic units for the purposes of donor referral, organ and tissue donation, and allocation. As with donation and allocation the referral of donors is based on the states and territories. Procurement coordination is based in each capital city and provides a state or territory wide services. This coordination services are linked via informal arrangements to form a national net work. Allocation of kidneys is based on a HLA/patient driven national computers system. Kidneys are located to specific patients based on the ABO compatibity and HLA match with PRA and waiting time used as tie breakers. Extra- renal allocation differs from the kidney allocation mechanism in that the organ is offered to the transplant centre, not a particular patient, with the selection of the patient remaining the clinical decision of the unit. The donor state units have preference. If the unit cannot be use the organ then it is offered on a rotational basis to other state transplant units. Centre based allocation maintains clinical primary, is simple, minimize wastage, and ensures an equitable distribution of opportunities. This arrangements is also an informal network.   

Tissue procurement is limited to the capital cities and the immediate surroundings. This restriction on procurement area is due to a combination of a lack of funding and the large distances between population centres. Multiple tissue banks exist in each of the major centres. With the exception of one Centre these banks are limited to their own particular type of tissue e.g. Musculoskeletal tissue.Hospital staff education is minimal outside the capital cities again due to the combination of budgets and distance. Reginal seminars and workshops are the principal forms of education for the distant centres. The Australian Transplant Coordinators Association (ATCA) has developed “National Guidelines for Organ and Tissue Donation” and “National Operating Theater Guidelines for organ and tissue donation” both of which are for use by donor hospital staff. Every donor hospital in Australia has copies of these guidelines. Both of these resources are widely used.

Recent interest by government in the problems of donation has seen the establishment of formal donation organizations is most states. Different approaches have been adopted by these agencies but to little overall national effect on the donation rate, which has remained at between 10 and 11 per million population per annum. Public support for donation remains strong with approximately 50% of the population having taken some form of action on donation e.g. Completion of a donor card. Data derived from death audits indicate that the major barrier to increasing donation is within the health system itself. Poor donor identification rates and bad methods of discussing donation with families seem to be the major factors. A recent unpublished study of over 3000 hospital deaths showed the rate of converting medically suitable brain dead patients to donors as only 26%. In other words 7% of potential donors are either not identified or there is no consent. It is difficult to envision any great change in the donation rate until mechanisms that address these basic issues are implemented. The introduction of Donor Action is currently being considered by a number of State Donation Agencies. Donor Action has been shown to bring about sustained improvements in these key areas of the donation process and thereby a sustained increase in the donation rate.

Although the Australian system has a functional simplicity and is therefore efficient in the areas of allocation, retrieval and utilization of donated organs the donation rate itself remains low. Patient waiting lists continue to grow, as do deaths on the waiting list. The introduction of a structures hospital program such as Donor Action to address the deficiencies of the health system must be undertaken if Australia is to begin to reverse this situation.