WRNMMC, Bethesda, Md.  –   Walter Reed National Military Medical Center hosted a Director’s Grand Rounds forum in Clark Auditorium on May 21 to foster a discussion on organ transplanting and emerging ethical concerns related to balancing the interests of donors and recipients.

U.S. Navy Capt. (Dr.) Melissa Austin, Walter Reed’s director, welcomed attendees and speakers, shedding light on her hope to foster a greater sense of trust between potential organ donors and the medical community.

According to the Organ Procurement and Transplantation Network (OPTN), there were 46,632 organ transplants across the United States in 2023. Nearly 40,000 of those organs came from deceased donors, while nearly 7,000 came from living patients. The OPTN is a unique public-private partnership empowered by the U.S. Department of Health & Human Services to improve transplantation public safety and facilitate greater collaboration among organ procurement organizations (OPOs).

Walter Reed’s Organ Transplant Service (OTS) is the only certified transplant center within the Military Health System (MHS) and has a 5-star rating according to data published by the Scientific Registry of Transplant Recipients (SRTR).

“We perform about 50 kidney transplants a year, with the capacity to perform up to 80 surgeries annually,” shared U.S. Army Lt. Col. (Dr.) Jamie Diaz, the director of Walter Reed’s OTS and a professor at the Uniformed Services University’s (USU) F. Edward Hebert School of Medicine.

Saving Lives: Balancing the Interests of Donors and Recipients

Nearly 104,000 people are currently on the OPTN’s organ transplant waiting list. As the ability to transplant organs and tissues has grown, the demand for these procedures has increased as well – creating health equity tension because the demand far exceeds the supply, according to the National Institutes of Health (NIH).

Challenges for the medical community include pairing donors and recipients in accordance with saving the most lives. Ethical challenges include balancing the urgent care needs of donors and recipients, while preserving the viability of organs prior to transplanting.

While Walter Reed’s OTS only transplants kidneys in-house, it facilitates referrals for service members, veterans and other beneficiaries in need of liver, pancreas, heart or lung transplants by working with hospitals in the Washington, D.C. area.

“The reason why I tend to encourage [going through Walter Reed] is because it’s great for beneficiaries to keep all their care in MHS,” explained Diaz.

Walter Reed participates in the Department of Defense’s Military Share Program (MSP), which means that if a family member dies and the family directs one of the donor’s kidneys to be given to the U.S. military, that kidney may be transplanted into a patient here or utilized in the Baltimore Veterans Agency Vision Program.

Innovative Heart Transplant Method Creates Bioethical Tension

According to NIH nearly 3,000 heart transplants are performed annually in the United States, yet several hundred listed patients and several thousand unlisted patients die each year because of a lack of an available organ.

Controlled donation after circulatory-determined death (cDCD) is a potential source of additional hearts for transplantation, but is rarely used for cardiac transplantation, as explained in a white paper titled “Donation After Cardiac Death: A Necessary Expansion for Heart Transplantation.”

Heart procurement efforts from cDCD donors have used two main techniques: (1) direct procurement and perfusion (DPP) and (2) normothermic regional perfusion (NRP).

According to NIH, although DPP is generally accepted on ethical grounds, NRP for heart procurement during thoracoabdominal NRP (TA-NRP) has generated substantial ethical concerns because the donor heart may potentially be prepped for removal before the donor technically expires.

“One of my concerns is that not enough time and effort is invested into fully understanding the ethical considerations associated with increased medical capabilities while properly respecting the donor’s quality of life,” shared U.S. Army Chaplain (Maj.) Vincent Bain, who co-chair’s Walter Reed’s Health Care Ethics Committee.

Normothermic Regional Perfusion: A Viable Way to Increase Organ Availability

The American Society of Transplant Surgeons (ASTS) believes that NRP is ethically acceptable, but bioethicists believe that the medical community may need to refine its explanation of “informed consent” to potential donors and their families by explaining the NRP surgical procedure.

The use of a machine (ECMO) to pass blood (restore perfusion) through organs in a person’s body after the heart has irreversibly stopped beating in preparation for organ donation

• Only occurs in donation after circulatory death (DCD)
• Blood is drained from a large vein to a reservoir, passed through a gas exchanger and returned to a large artery
• Allows organs to recover from the DCD process
• Allows for viability assessment of organs
• 20-25% of organs are from DCD, NRP is the most viable way to increase organ availability
• Several studies demonstrate superiority of NRP over standard rapid recovery

Normothermic Regional Perfusion: The Controversy Explained

Diaz and Bain believe that the medical community and ethicists can educate potential donors and their families by providing details on the procedure and the donor’s quality of life during the organ transfer.

Conceptually
• NRP is not a resuscitative procedure. It is only used to facilitate evaluation and preservation of organs for transplantation in DCD.
• American Society of Transplant Surgeons (ASTS) statement supporting ethical acceptability of TA-NRP (August 2022):
*Donor is dead prior to initiation of NRP*

Technically
• Aortic arch vessels are occluded and vented prior to initiation of TA-NRP to prevent reperfusion of the brain.
• Otherwise NRP and Cardiopulmonary Bypass (CPB) are identical.
• NRP is meant to transform a DCD (super rapid recovery) into a standard recovery.

Fostering Trust and Transparency

Diaz, who is a member of the American College of Surgeons and the American Society of Transplant Surgeons, and Bain, who earned his master’s in bioethics from the Harvard School of Medicine, are championing efforts to foster more trust and transparency regarding organ transplants.

In October, Bain will host Walter Reed’s Health Care Ethics Symposium, a day long conference addressing the intersection of military medicine and ethics in an everchanging landscape.