Worldwide Cadaveric Organ Donation Systems (Transplant Organ Procurement) KAZEMEYNI SM1, BAGHERI CHIME AR2, HEIDARY AR3* 1Department of Urology, Dr. Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran 2Department of Neurology, Tesocoba University, Japan 3Management Center for Transplantation and Special Diseases, Ministry of Health and Medical Education, Tehran, Iran 157 Urology Journal UNRC/IUA Vol. 1, No. 3, 157-164 Summer 2004 Printed in IRAN Introduction Organ transplantation, thanks to scientific and technical advancements, is considered as a suc- cessful daily procedure. Over one million people worldwide have received allograft organs and some of them have already survived more than 25 years.(1) Five-year survival rates for most organ transplant programs are around 70%.(1) Ever-increasing need to transplant organs has led to different approaches and methods in differ- ent countries in view point of transplant organ procurement. Each system in organ procurement for transplantation has peculiar advantages and differences in their functions and donation rate are due to structural and cultural differences. The survey of all different systems in the world shows even the most successful ones can not pro- vide all the needs to transplant organs; how ever, living donation in some organs like liver, kidney, and lung has grown by following scientific and ethical issues. There are currently nearly 40000 patients waiting for a kidney in Western Europe.(1) Mortality rates for patients waiting for a heart, liver, or lung range from 15% to 30%.(1) The main purpose of this article is to briefly introduce different units/organizations in the world concerning transplant organ/tissue pro- curement. Considering a three-year activity in cadaveric organ procurement in Iran by the establishment of Iranian Network for Organ Procurement, comparing results and following useful experiences gained by leading countries in organ procurement can promote cadaveric organ donation to higher the current rate, 1 pmp (one per million population). Transplant Organ Procurement Unit/Organization/System Common aspects of different organ procure- ment units in different countries are presence of a center for national coordination and centralized organ allocation, presence of independent organ procurement unit in each hospital with transplan- tation department, and management of making connection with nation wide hospitals without transplant programs. There are also differences in multiple phases of organ procurement, which will be mentioned later. These differences are emerged from differ- ent approved protocols in different countries. One of the discriminative issues is family approach and getting consent. Even though we can consider two ways of fam- ily approach and getting consent as presumed (opting out) and informed (opting in), there is another way that we call it theoritically presumed consent, but practically informed. In countries without legal limitation with presumed consent system, merely for ethical issues, coordinators approach the family to get consent for organ donation. Different types of required consent in different countries listed in table 1.(1) Studies have shown that organ donation in countries with presumed consent is almost 15% easier. Nevertheless, even with same legislations and same national organizations, there are still differ- ences in countries (such as France, Italy, Spain) in refusal rate for donation.(2) Despite this supposition that donation rate is higher in countries with presumed consent, this rate is higher in Spain and the United States (table 1). Hence, it seems that the type of consent is less important than the function of the system, gener- al awareness, and presence of trained personnel *Corresponding author: Management Center for Transplantation and Special Diseases, Vanak, Tehran, Iran. email: omid1350ir@yahoo.com WORLDWIDE CADAVERIC ORGAN DONATION SYSTEMS (TRANSPLANT ORGAN PROCUREMENT) in such systems. In 1998, cadaveric donation rates were 15 pmp in Europe, 22 pmp in the United States and 31.5 pmp in Spain as the lead- ing one.(1) Data related to donation and trans- plantation activities is shown in table 2. Procurement Organizations Well-established organ procurement systems in the world have organ exchange organizations with a specific name in each country. ONT (Organization National de Transplant) in Spain, UNOS (United Network for Organ Sharing) in the United States, SCOUT (Saudi Center for Organ Transplantation) in Saudi Arabia, and JOTNW (Japan Organ Transplant Network) are some examples of these kinds of organizations.(3,4,5) Centralized management and organ sharing are common tasks of these organizations. Continuous coordination between organ procurement units and transplant departments, equitable organ allo- cation based on approved protocols, and making connection with organ procurement networks in other countries are necessities to established such organizations. Now, these international connections lead to donate organs to completely matched patients and in most cases to the ones with life-threaten- ing conditions. Iranian System In Iran, centralized management and organ allocation are conducted in Iranian Network for Organ Procurement that is set up in Management Center for Transplantation and Special Diseases, affiliated to Ministry of Health and Medical Education. Patients' waiting list is continually updated in this center and in case of donation, organ shar- ing is done here following a general allocation policy: in priority order, locally, regionally, and nationally in non-urgent (elective) situations. Approved phases for donor detection and identifi- cation, brain death determination, and organ/tis- sue retrieval are shown in figure1.(6) Moreover, table 3 indicates briefly different phases of organ procurement. Designed systems for Iran is based on inde- pendent procurement units in each university of medical sciences. Some of these universities are working in this regard now and the others are going to establish such units. Each unit has a chief transplant coordinator who is in charge of making connection with Iranian Network for Organ Procurement. Specialists who are in charge of Brain death determination, based on legislation and decree, should be appointed by the minister of health and medical education and none of them are mem- bers of any transplant teams. In this system, two groups of coordinators have the major roles: transplant procurement coordina- tor (TPC) and recipient (clinical) coordinator. Organ allocation is managed in Iranian Network for Organ Procurement as a centralized conduc- tion. Each university has its own waiting list and procured organs are implanted first locally, then regionally, and finally, nationally. The United States' Model on Transplant Organ Procurement In the United States, there is an organization that works independently from transplant centers or wards and consists of two sections: recipient section and Host Organ Procurement Organization, which practices under the supervi- 158 ����������������� �� � � � ������������� �� �������� � ������������ � � � � � � � � � � � � � � � � � ����������� � � � � � � � � ������ ���������������������������� � � �������������� �� ���� �� � ������ ������ � �����!��� ������������� �� "�����#� ���������$��������%�� �#� ������ &������������������ �������� ������ �� ����'����� �!�������� �����!��� �!���������� �� ! � ��%�� ���� ������&���������� � ���� �� ��"������ ��� ������ (������� ����� ������ ������ ��$��� ���������� "����� (������� � �������������� �� ������ � ������ ������ ��$���� FIG. 1. Algorithmic approach for brain death detection, identification, referral, determination, and transplant organs retrieval in Iran TABLE 1. Types of consents required in different countries(1) Presumed Consent Finland, Portugal, Austria, Sweden, Czech Republic, Slovakia, Hungary, Poland Informed Consent United states, Latin America, United Kingdom, Ireland, Denmark, Netherlands, Germany Theoritically Presumed Consent, but Practically Informed Consent Spain, Italy, Greece, Belgium, Luxembourg, France Both Informed and Family Consent Japan Informed or Family Consent Iran W O R L D W ID E C A D A V E R IC O R G A N D O N A T IO N S Y S T E M S (T R A N S P L A N T O R G A N P R O C U R E M E N T ) 1 5 9 � � ���� ������ ������ � ��� ������ ������� �� ���� ��� � � ����� ����� ������ ���� � � ������������ ������������� � ���������� ������������ ! � � �������� "�#� ���$%� &��� !�'� '�"� ����$�� (!�!)� ����$�� !� ������*� !�'� ���*� +,� ������ '-�((� �������� -�-(� ����.� ',�("� ���/����� )� ���/�0��� +�'(� )'�--� �1���� #� �2 �����.� ()�# � ��� )(,� ����.�� )-�#� ���������� ,�#+� ��.�/���$� 3������ �4� � ))� "�#� -,� -�)� ('(� "�"� --'� (�+� +#� +�#� )(� )�)� #!#� )�'� )+!� ' �+� ((� (�#� ),-� #�+� )#� '�+� ,'� +�+� '+,� "�-� !,� +�"� ,"(� '�+� +#- � ) �(� "),� "�"� -(� !�+� 54����6������ 3������ !�+� +#5� (-5� � (,�"5� )�#5� #-� 5� ,"�+5� #,�'5� "(�#5� ,+5� '"5� (+�(5� #(�,+5� +'�)5� � � ##5� ��.�/�.�$� ��.��*������������� �4� � " � ,�#� '+-� '"�-� ),')� )+�!� , +� '!�)� ,#� ,�#� )''� ))�(� ()� )!�)� -#(� "-�,� '!+� '!�(� +'"� '�,� "(� )'�!� "+� )#� � (+!� )#� � -'� )#�(� +)(� )"�'� ,-'-� ''�"� (#(� ))�,� '+,� -� � 7�/������.��*� ������������ �4� � '� )�,� #� !�#� +)'� "�(� #'� �)� ,)� ,�)� ,� !�,� #-� �"� -� !�+� +� !�+� -� !�)� � !�+� '� !�(� )")� !� � (,� -�#� )" � '�,� "! (� +�!� ''(� �'� ""� #�#� 7�/��� ����������899:� �4� � )� !�"� ((� (�"� !# � -�"� (-'� �+� ,� �,� -� �,� +"-� -�+� ,--� ))�#� '"� '�+� )#� !�#� "� )�!� � -'� ,�!� ##� �!� (-!� �!� ""+!� (�(� '")� �+� +"� ,�)� ������� ������������ �4� 89:� -� �-� ++� +�'� #+-� (�-� '#!� (�(� '� �'� +� !�+� ''(� +�(� '")� ,�,� #� !�#� )'� '�)� "� )�!� !� �-� "� "�-� ""� (�'� ), � +�+� )'"!� ,�-� +"� +�)� #)� "� � �����67���� ������������ �4� � � � )!� !�)� )(� !�"� � � )� #� !� � � � � � "� !� � � ()� !�,� "+� !�,� � "� !�)� ������������ �4� 89:� � ,� !�,� )),� )�)� '(2+)� �-� � � (+� �)� )(2-+� '�)� � � � � +#2))� '�+� '2)#� "�'� ",2'(� )�'� ,"-� '�'� #+� )�+� '"2"-� "�(� ��$����� ������������ �4� � � ) � )�!� )+,� )�)� "#� !�,� � )� !�)� +)� !�-� ),� !�#� � � � � +� !�(� "� !�+� )-� !�+� ) ,� "�+� � ,� !�-(� ��������� ������������ �4� � � � � -� !� � � � � � � � � � � � !� � � (-� !�'� � � (*) Heart-Lung Transplants P.M.P Included E.T: Eurotransplant Sk.T: Scandiatransplant E.F.G: Etablisement Francaise Des Greffes (**) Living Donors Included Germany Denmark I.S.S: Ostituto Superiore Di Sanit Austria Finland Belgium Norway Luxemburg Sweden The Netherlands TABLE 2. International Data on Organ Donation and Transplantation Activities in 1998 W O R L D W ID E C A D A V E R IC O R G A N D O N A T IO N S Y S T E M S (T R A N S P L A N T O R G A N P R O C U R E M E N T ) 1 6 0 ��������������� �� ��� � �� ����� ������� ��� � �������� �� �� ����� �� ���� ��� ������ � ��� ��� ���� �� ��� �� �� �� ����� �� ����� �� ��� � �� ��� � �� ����� ����� ��� ��� �� ���!� "�� � �������������� �� ������� � � �� ����� ��� ����� ���� �� ����� ��� � �� �������� � �� � ���� ������������ ������ ���������� ������ � ���������� �� ����������� �� ������ ������������� ������� �������� � ������� �� ���� ������ ��!���� ������������ ���� �� �"��#��� ��!���� ���� ������������ ��$�����%������ ����� �&� ����� ���� ������ ���� ��� ������'�(�� ������ ��������������� �� !��� ������� ��� ��� ��� �)�������� � ��������� ���� ��#��� ��� ���� �� ���*���� �&�� �� ���%�% �� %����� ������ ��� ���� ���� &� �"���� �����+��,� ������� �� -�(� ��� ��&������ �%���� ���� ���� "������,����%�������.��+� �� ������������� ���� ����� �&� %����� ������ ��&��������� %����� ������ �,� �������� !���'� $���'� /�����'� 0�����'�1 �������� ���� ��1����� ������ ��� �� ������ ��� !������ ����$���� ��!��� �+�� ���� ��&����� ������2�� &��� +��&����*����%����������� ��3������� � �� ���� &���� &��� +� ��� ���� ���� ��������������� �� ���� ������ ���������&�������&��� +�� ��!���&��� +�� � ������������ ��������������� �� ���� �� ������� ������� "���� ���� � � ���� �� �� � ������+� �� � ���������,���&�&������ ����� ���� �����&������ �� � ���������,���&�&������ ����� ���� ������� ��� � �������)������ &��� ��������� ������� � � �����&�������������,� ���� ��&������ ��1 ���� ��� ���� %�&���� ���� �&���� % ���������&������&������� ��� �������� ��4�4$ 5�0� �������0�4� � � 0!54��� ��(������ +� ���� � ����� ��� % ���� ��� ����&����+ ���������� �� ��&������� ����� � � ���� ��������� � �������&������� +�����������,� ����� ����� ��������� ��5����������������� ��� �����6���+� %+� ������������ ��������,�� � ��� ���� �� ������������ �� ��&���� �� �&� ����� �����%������ ���� �����+� ���� ������� �%��� ��� � +� ����� ��������� �+� ��� ���,���78�����&��� ���,���79�� � ��������� �� ���*3�:������������� ��;��4�� ���*1������������� ���4�� ���'� �"������)'� �:� ��%�'� � ��� �������+'� <� �+� �������'� � ������ �+� ��!����� �� ���������� � ���'������ ���� ����������&������� ��(�����,� �������#� ������88� *�� ��1�����#� ���88���0�� ����-�=�88��������������� ��!�� ����������������������%��"���� >?@9�����>A@9����������� ��!�� �� ���� ���� ������� &��� � �������������� �� �����,������� ������ �� �� ���4�� ������-�������%�%���� ����� �,� ,������������ �� ����� ��1 ����&�����&������� �������% �������������� ���� ���-������+� ��!�� �������� ��%�� ���������� ��� � �������� ����� - 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Stages of organ transplant procurement W O R L D W ID E C A D A V E R IC O R G A N D O N A T IO N S Y S T E M S (T R A N S P L A N T O R G A N P R O C U R E M E N T ) 1 6 1 ���������� �� ��� � �� ���� ������� ��� � �������� �� �� ����� �� ���� ��� ������ � ��� ��� ���� �� ��� �� �� �� ����� �� ����� �� ��� � �� ��� � �� ����� ����� ��� ��� �� ���!� "�� � �������������� �� ����������� ����� �� ������+����������� �������� ��� ���� �������,���� ������ �� ������,��+�;�������� ��������� ���������,��+�;������� � � � ����������%�������� ���� � � ����� ����� �&� �� ������ �&� ����� ��� ���� �����&���-;���79���0�� � � ���������� ,���� ������ ��� ��� �� ��� ��-���GD�GGH� ���33�I9� ��-�� �� ������ ��<�-��J��88H�� ���33��J9B�8���� ���1:�� �� ��� ��� ����� ��&�4*�� 9 ��0���'��33�� ��&���� ���������������&� �"���� ����� ���1�E�G8������� ��88�� ����E�A8������=��;8� ���4��E�7�����4��=��;��8��;�� ����-��E�G8� ����-��E�G9H� ���/����D��7�� � ��!�� ���� "���� �������� "���� ��� ��%����-�� � (����� &� �"���� ������ ������� ����� ������������� �������������� �����% �� -�J�88H� <�-�� �<�� ����� �&���� �����-��� ����%�%���������� �,� ,��� ��!���� ������������� ������������@� 4���� ������������ ���"�������������� � ����� �� ��� ���� ������� %� ���� � �@� ����� ��� � ��!�������������� ��������%��"������ >?@9 � �����>A@9 � �%+������� � �*"���� �� ���� ���:�������� ����������������� ����� � ��!������+�����������&��:�������� ��� ��3�� �� ������������ �&� "������ ���� ������ �&� ���� ��,�� %���� ����� &����� +@�� � � ����� ����E��98� ����� �C�=�>@9� �0��A@79�A@>9� 0�!��>8H� ��������� � ���������� � � ��!�� ���������� %��"���� ����� � � ������ ��!��#�� ������+���� ����%� ��+���� � ������������� �������������� ����� ��� � �� ������ ������� ����� � � ���� ������� ����������������� � ��< ���� ����� +�� ������ ���'� � ���'� % ���� ���� ����������& ����"������� ��1����� � � ����� ����%���� ��� �� ��)� ������*G?�� � � � ��!�� ���� ,��� ������� ��� �1�=G8� ��0�� ��!������+�� � ��� +��������������C'���'� ���'� �+� ����� �� %�� ���� ���� �&� ��&������� � � ��0+ ��� + ������� ��� %�� �������� "���� ���� ��� ��- �����������%����������%+�������� �� ��$��%��������� ������!��%����������%+� ������������ �� ������ +�� ������ ��� ��+ �����& ����� ������+ � ������� ���������� &��������� ��� �����,� +� � ��!����� �������� ��� ��!�� ���� ������� �� �&� ������� � ����� �88����� ��!�� ���� �� ����� >98� (*C�� ��� %+� ���� ��� ��%����������� �������� ��;@9������?��*�������&������ � � ��4�� ����������� �� �������� ���:3������� �� ����)����� ���� ����� ������� �� ������������ 98������988 �� ����%+��:� � � �������� ������� ���������� ���������������������� �� �&���� ����-�(� !��� &��� +� ��� �"���� �&� ��������� ���� �������� ����������� ������ ��!���,� ���������������� ��!�� ����+� ���� ��F������ �������� &��� ���������� ��( ��������� ������ ��������� 3���� ���%�� ��� ����� +�K���������% �� ��&� ����� ��-������ �������� &�� ����� ���� �� %�� #� �� � � �� ��� ������� �� �,����� &��� ����� ��������� TABLE 3. Continued WORLDWIDE CADAVERIC ORGAN DONATION SYSTEMS (TRANSPLANT ORGAN PROCUREMENT) sion of Organ Procurement and Transplant Network (OPTN) and United Network for Organ Sharing (UNOS). Every transplant center cooper- ates with one of OPO's organizations.(7,8) The main duties of Host OPO are as fallows: 1- to identify, evaluate, and manage brain death cases, 2- to obtain consent from donor's family and to authorize legal processes, 3- to retrieve organ, 4- to supervise, guarantee, and confirm all con- servative, package and organ transfer meas- ures and carry out whole tests and tissue typ- ing and compatibility, 5- to share transplant organs. Fifteen patients die each day, while waiting for an organ to become available in the United States. More than 75 thousands males, females, and children are enrolled in transplant waiting list. Every 16 minutes one patient joins the list. Only 25% to 35% of those who need bone marrow transplantation will find a match among their family members.(3) Organ system practices in four major sections under the supervision of Division of Transplantation (DOT) in the Ministry of Health. The main duty of DOT is supervising of these practices. These four sections are as follows: 1- Organ Procurement and Transplantation Network (OPTN), 2- UNOS (a non-profit organization, its center is in Richmond, Virginia State) that was estab- lished in 1977 under the state laws. Transplant centers, OPOs, laboratories of tis- sue compatibility, charity centers, religious, legal, ethical, specific advisory committees, etc. are its members. UNOS covers whole the United States in the yield of procurement and transplantation.), 3- Scientific Registry of Transplant Recipient (SRTR) that follows up and analyses trans- plant results and survival studies, as well), 4- National Marrow Donor Program (NMDP) that consists of 94 centers of bone marrow donation and 118 transplant wards, 5- Increasing Organ and Tissue Donation (IOTD) that attempts to increase social awareness and public education and professional training, as well as to promote the culture of donation. Spanish Model in Procuring Transplant Organs(9,10) The first Spanish transplant coordinator team was established in 1985 in Clinic Hospital in Barcelona. This model was gradually extended to other centers, other areas and the whole country; consequently, an independent department by the name of Transplant Coordinator Department was established in each hospital. This department consists of transplant procurement manager (TPM), transplant coordinators and other staff, who play an important role in increasing organ donation and transplant activities. Medical care, training, research, and manage- ment and the quantity control are the main func- tions that is managed under the supervision of TPM. 1. Medical Care: Clinical tasks are: 1- to detect potential or possible donors: to find out donation potential in the subordinated area according to the number of ICU beds and brain deaths, 2- to facilitate brain death detection, 3- to supervise donor and to perform organ and tissue compatibility, 4- to interview the family. To observe legal aspects, 5- to coordinate organ and tissue extraction and their distribution. 2. Training and Education: Training is of great concern to TPM. Ideally, training teenagers for donation and transplantation, as well as coordina- tion with all groups and branches, which improve knowledge in the society, have great importance. Training professional groups (physicians, nurses, social workers, …) for transplantation is one of basic principles. 3. Research and Development: The aims of TPM in the field of research and development are to increase the number of donors and to promote transplant organ and tissue quality, as well as to improve donor detection methods. Also, introduc- ing new subjects such as NHBD (non-heart-beat- ing donor) and the use of marginal donor organs is another aim. 4. Management: The management of resources and different activities in organ donation and transplantation process is one of TPM responsi- bilities. It includes the detection of required sources (human, equipment, financial and cred- itable), obtaining such sources and planning for them. The most appropriate place for the activity of organ transplant procurement unit in Spain model are intra-hospital departments, which act separately from transplantation wards. 162 WORLDWIDE CADAVERIC ORGAN DONATION SYSTEMS (TRANSPLANT ORGAN PROCUREMENT) In this model, the needed number of TPMs varies from one to five, based on potential dona- tion capacity (30 to 60 brain death pmp) and practical donation (1 TPM per 12 practical donor). Effectiveness in a transplantation system is identified by donation rate, number of trans- plantations, and patient and graft survivals, which are dependent on the role of TPM. Other Models in Spain In addition to the above mentioned general models of transplant organ procurement organi- zation/unit, another structure also exists.(9) In this method, organ procurement is performed by a group of staff practiced at transplantation ward. This model was limited to some transplan- tation wards and is not popularized in different countries. Transplant organ procurement system in Japan Although the debate on organ transplant was started in Japan at public level and specialized scientific circles after performing first heart transplantation in 1968 in Saporo University three decades ago, systematic activity in trans- plant organ procurement began in 1995 by the establishment of Japan Kidney Transplant Network. This network developed into Japan Organ Transplant Network following the approval of organ transplant law in 1997.(11) Patients were obligated to travel to other coun- tries such as China to receive transplant organ before the approval of the above mentioned law and because of limited organ transplant from liv- ing donors and legal impediments in using organs of patients with brain death and cadav- ers.(12) Characteristics of Organ Transplant Law in Japan This law, which was approved in 1997, is only applied for cadaver organ transplant and cases with brain death and does not include living donor.(13) Living donor transplant currently fol- lows the obligations of Japan Organ Transplant Society. Other Characteristics of this Law 1- Decision card for organ donation: Patient's definition of death (respiratory arrest or com- plete heart and brain arrest), agreement or disagreement for organ donation and the kind of organ, are included in this card. There is a place for donor signature and family signa- ture, as well. 2- Consent: According to the above-mentioned law, patient consent, in addition to his family consent, should be included too. Thus, if organ donation card is only signed by organ donor with no signature of donor family, this card would not be legally valid. In addition, a sepa- rate consent form is obtained from patients' family. 3- Age limitation for organ donation: Organ retrieval from children under 15 years is for- bidden according to Japan organ transplant law; therefore, children's organ donation card would be invalid. Japan constitutional law declares that children under 15 years can not make such decisions. Thus, children in need of receiving transplant organ could not find appropriate organ in many cases. Parents have no right too in this regard, while it seems that decision making in organ donation from children with brain death could solve the prob- lem of organ transplant in kids.(14) 4- Forbidding any organ trafficking as well as necessary prediction for any violation has been regarded in this low too. The Role of Organ Transplant Network According to the law, duties of organ network, which is a non-governmental and nonprofitable organization, are as follows: 1- to provide general training in organ transplant and donation in the society, 2- to distribute decision card for organ donation, 3- to collect data about organ donation, 4- to inform the family of patients and to per- form legal process of consent taking, 5- to carry out laboratory tests for donors, 6- to allocate organ, 7- to coordinate between organ donor and recip- ient hospitals, 8- to transfer transplant organ, 9- to provide special advice to donor families, fol- lowing donation, This network currently consists of 7 main cen- ters and one minor center at Japan and its activ- ities are supervised by direct supervision of Ministry of Health and it is mainly an executive body for organ transplant.(15) However, six years after the approval of organ transplant law in Japan, this has not been wel- comed in Japanese society due to social and cul- tural believes. Thus, despite high technical and scientific potentials in performing organ trans- plant, only 22 organ transplants has been con- ducted from brain death donors, while 13000 patients has been recorded in waiting list. 163 WORLDWIDE CADAVERIC ORGAN DONATION SYSTEMS (TRANSPLANT ORGAN PROCUREMENT) References 1. Meeting the organ shortage, current status and strate- gies for improvement of organ donation/ international figures on organ donation and transplantation in 1998. Newsletter Transplant 1999; 4(1). 2. Transplant Coordination manual, Manyalich M. TPM educational project. Barcelona (Spain): University of Barcelona; 2001. p. 50-51. 3. United Network for Organ Sharing. Available from: URL: http://www.unos.org. 4. Organ Procurement and Transplantation Network. Available from: URL: http://www.optn.org. 5. Organization National de Transplant. Available from: URL: http://www.msc.es/ont/esp/estadisticas. 6. Management Center for Transplantation and Special Diseases. Cadaveric organ transplantation (protocols and Stipulations) (1). Tehran: Ministry of Health and Medical Education; 2003. p. 10. 7. Phillips MG. Organ procurement, preservation and dis- tribution in transplantation. 2nd ed. UNOS; 1996. 8. Firouzan A, Shojaie S. Organ transplant systems in Europe and USA. Cadaveric transplantation congress abstract book. Tehran: 2000. p. 23-28. 9. Transplant Coordination manual, Manyalich M. TPM educational project. Barcelona (Spain): University of Barcelona; 2001. p. 11-23. 10. Transplant procurement Management, Manyalich M. Organization of Organ Donation and Role of Coordinators. Saudi Journal of Kidney Disease and Transplantation 1999: 175-182. 11. Japan Organ Transplant Network (JOTNW). Available from: URL: http://www.jotnw.or.jp/news.html. 12. Awaya T. Testimony at the U.S. Congress on the trans- plantation of Organs from executed prisoner in china. The review of Tokuyama University 1998 Dec; 50: 177- 189. 13. Ministry of Health, Labor and welfare. Manual for Legal diagnosis of Braindeath. Tokyo: Nippon Ijishinposha; 1999. 14. Bagheri A. Children competency and donors prior decla- ration. Eubio Journal of Asian and International Bioethics.2001 Nov; 11(6):195-196. 15. Hiraga S, Mori T, Asaura T. Current arrangement and activity of organ transplantation after new transplant legislation in Japan. Transplant Proc 2000; 32: 86-89. 164