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Sunday, Nov. 11, 2012

NATURAL SELECTIONS

Japan's live organ donors enjoy better health than 'normal' citizens do


At age 56, Toshinobu Horiuchi was a desperate man. He had suffered kidney failure and needed a transplant. As a doctor, based in Tokyo, he knew better than most that he faced a long wait.

In Japan, nearly 13,000 people, according to the Japan Organ Transplant Network (JOTN), were waiting for a kidney transplant last year, but in the first half of 2011 only 186 kidney transplants were carried out.

It's a shockingly poor statistic: Japan has some of the lowest rates of organ transplantation in the developed world.

Horiuchi refused to join the waiting list. Money, he thought, could get him what he wanted. He went underground, paying the yakuza first ¥10 million, then when that deal failed, another ¥8 million, for a kidney. Gangsters procured him a kidney from a 21-year-old unemployed man.

However, apprehended and so thwarted before the transplantation could go ahead, Horiuchi was jailed in January for three years. It's just one story, but it vividly demonstrates how bad the problem of organ shortage is in Japan.

Some more data from the JOTN: There were 1.1 kidney transplants from dead donors for every 1 million people in Japan in 2003 — compared with 46.7 in Spain, 32.5 in France, 29.5 in the United States and 22 in Britain.

Put simply: People are dying in Japan who would be saved if they lived elsewhere.

Moreover, until 2010, organ transplants from children were prohibited in Japan, meaning that parents of sick children had to travel abroad in search of treatment for their offspring — if they could afford it.

The problem is mainly cultural. According to the ancient rites and beliefs of Shintoism, death is impure. An organ received from a dead person may be considered tainted, and in both Buddhist and Shinto tradition a dead body should remain intact.

As well as those religious reasons, there is mistrust of the definition of "brain death" that is accepted in the West. Organ donation from dead donors in Japan was only legalized in 1997 with the passing of the Organ Transplant Law, and it has yet to really catch on.

There are several possible solutions to the problem — the obvious one being to educate people about death and the potential benefits of organ transplantation from their own or their loved ones' otherwise useless cadavers.

Yasutsugu Takada, of the Ehime University Graduate School of Medicine in Shikoku, is at the forefront of another solution: Use living organ donors.

Around 70 percent of transplanted kidneys and 80 percent of liver donations performed in Japan are from live donors. In the U.S., 68 percent of kidney transplants and 98 percent of liver transplants in 1998 involved deceased donors.

Living-donor liver transplantation (LDLT) is Takada's specialty.

"With LDLTs being performed at increasing rates, it is important to understand the long-term outcomes for living donors," Takada says.

He and his colleagues have just published a report showing that the health-related quality of life (HRQOL) for donors following living-donor liver transplantation (LDLT) was better than the HRQOL for the overall Japanese population.

"Our study is the largest to investigate living liver donors' quality of life and to determine potential risk factors following transplantation," says Takada, whose results are published in the journal Liver Transplantation (DOI reference: 10.1002/lt.23509).

His team contacted 997 living donors who had each provided a piece of their liver for transplantations performed at Kyoto University Hospital between 1990 and 2004. Some 578 people responded, and analysis of their questionnaire answers suggests that they are healthier than "normal" Japanese.

"Kyoto University Hospital is one of the high-volume transplant centers in Asia. As such, we are keenly aware of the necessity and responsibility to report donors' long-term quality of life," says Takada. "Our findings suggest that careful follow-up and counseling are necessary for donors at risk of a poor quality of life."

For people with liver disease, help from a living donor can be a great solution. For the donor, it is actually a perfectly acceptable operation, thanks to the liver's amazing regenerative powers.

This is why we can drink alcohol regularly, subjecting our poor livers to damage from poisonous booze, and still not keel over dead. But for those who drink too much over years and end up with cirrhosis of the liver, a transplant of part of a healthy person's liver can save their life.

Living-donor liver transplantation is a relatively recent medical development. It was first carried out in Chicago in 1989, when a sick girl named Alyssa Smith received part of her mother's liver.

It is actually a more demanding operation for the surgeon than transplantation of a liver from a cadaver. This is where the cultural reasons for Japan's low rates of transplant actually have an advantage.

Like any operation, the one to remove part of the liver from a living donor comes with risks. Donor death from LDLT occurs in around 1 percent of cases in Europe, 0.3 percent in the U.S. — but currently nearly zero percent in Japan. Surgeons in Japan have become expert at performing the procedure. But there are still risks

So why were nearly 13,000 people in Japan waiting for a kidney transplant last year — but only 186 transplants carried out in the first half of 2011?

"Given the risks for living liver donors, we should make every effort to increase the number of deceased donors," Takada tells me. "Although there are still many problems to do with expanding the number of deceased donors, I believe it will increase gradually."

In Japan, if you want to donate body parts after your death, carry an ishihyōji kado (donor card) — available at ward offices, post offices and even convenience stores. Rowan Hooper (@rowhoop on Twitter) is the News Editor of London-based New Scientist magazine. The second volume of Natural Selections columns translated into Japanese is published by Shinchosha at ¥1,500. The title is "Hito wa Ima mo Shinka Shiteru (The Evolving Human)."


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