Tissue Donation

A vascularized composite allograft (VCA) is a multi-tissue transplant involving structures such as nerves, skin, blood vessels, bone and connective tissue. It is a complex procedure that is characterized by the transplantation of these structures as a single unit, such as a hand or face, from a deceased donor to a recipient. VCAs are often considered to be a breakthrough in transplant science since it has the potential to serve as transplants for complex body parts. 

Successfully conducting a VCA requires careful planning and execution to reduce the risk of rejection. There must be a close match between the donor’s and recipient’s tissues to ensure compatibility. Additionally, the procedure involves intricate connections between nerves, blood vessels, and other tissues from the donor’s body part to the recipient’s body. Following the surgery, the recipient must take lifelong immunosuppressant medications as a preventative measure against the rejection of the transplanted tissues.

There are some unique concerns regarding VCAs in relation to end-of-life decisions and organ donation. Since the donation process involves deceased donors, ethical concerns about consent and donor wishes are inevitable. The donor’s family often has to make decisions about these donations immediately after the loss of a loved one. However, all VCAs require authorization in addition to the standard donor registration. Consent to VCA must be explicitly stated on the registration form by the donor or by a next-of-kin at the time of death. These actions ensure clarity of consent regarding VCAs and the appropriate use of donations. 

Similarly, since VCAs often involve visible body parts such as a face or hands, these transplants can be emotionally charged and sensitive for donor families. It is not uncommon for families and loved ones of a donor to continue associating VCAs with the donor, even though the transplant now belongs to the recipient. In most cases, donor families are not directly informed about the identity of the recipient unless it has been specifically arranged and agreed upon before the transplant.

Sources

“Vascularized Composite Allotransplantation”. Science Direct. https://www.sciencedirect.com/topics/medicine-and-dentistry/vascularized-composite-allotransplantation 

“Vascularized Composite Allotransplantation (VCA) Research”. American Society of Transplantation. https://www.myast.org/vascularized-composite-allotransplantation-vca-research 

“Vascularized Composite Allografts (VCAs)”. Donate Life America. https://donatelife.net/donation/types/vca-donation/ 

Donated tissues are primarily used for tissue grafts and tissue transplants, which are becoming far more common both in the U.S. and internationally. According to the U.S. Centers for Disease Control and Prevention, about 1 million tissue grafts are performed each year in the U.S. alone. These represent about half of all tissue released. The remainder of the tissue may be stored for use at a later time or, if quality has deteriorated, destroyed. 

Corneal transplants are among the most common tissue transplants, with approximately 80,000 transplants performed each year. The sclera (the white protective layer of the eye) can also be preserved and used to repair another person’s damaged sclera, nasal septum, ear drum or gums. Corneal transplants are successful about 95% of the time, and are one of the few transplants that require no tissue or blood-type match because the cornea has no blood supply.

Another common use for donated tissue are bone grafts. These are often used in hip or knee replacement surgeries, dental implants and to augment metal hardware used to repair badly broken bones. Some other common tissue transplants include:

• Skin grafts to aid the healing of burn victims and people who have had disfiguring injuries
• Tendon grafts to replace damaged tendons such as a torn anterior cruciate ligament or ACL
• Veins used in heart transplant surgeries and procedures to reroute or re-establish blood flow to damaged organs like the heart and lungs
• Heart valve replacement

Additionally, doctors are now performing vascularized allograft transplants (VCA), which is the transplantation of a composite of tissue such as skin, muscle, bone, nerves, arteries and veins. These transplants are most often performed when a person suffers a devastating, disfiguring injury in an accident such as a car crash or fire. The process can involve the transplantation of limbs, the face or one or both hands. The donor and recipient must be carefully matched for tissue and blood type, and the recipient must be on a strict regimen of immunosuppressive drugs for life. Still, the results can be life-changing. One dramatic example: In 2020, 22-year-old Joe DiMeo, underwent a face and double hand transplant at Langone NYU hospital after a devastating car wreck left him with burns over 80% of his body two years before. The transplants came from a single donor, and were the first of their kind to succeed. Today, Joe has facial features like eyelids, a nose and lips and is regaining function in his transplanted hands.

Sources

“World’s first face and hands transplant gives New Jersey man a second chance at life”. CNN. https://www.cnn.com/2021/02/03/us/face-and-double-hand-transplant/index.html 

Unlike organ donation, which only takes place under very limited circumstances, the tissue donation process has few limitations. The potential donor does not need to die in a hospital or a nursing home. As long as an organ procurement organization or tissue bank is promptly notified and can retrieve the body within 24 hours, almost all body tissues, including tendons, ligaments, blood vessels, bone, heart valves and corneas, can be removed and stored for use later on. However, the process will vary slightly depending on the location of the donor at the time of death. 

Death in a Hospital 

In the United States, the National Organ Transplant Act of 1984 mandates that hospitals report all deaths to a regional organ procurement organization or OPO. When a person dies and the OPO is notified, the transplant coordinator or a designated agent first checks with the hospital to learn if the person is a suitable organ or tissue donor based on their medical condition at the time of death. If the person meets the criteria, the OPO then checks the state and national donor registries to determine if the patient was a registered organ and tissue donor. If they are, a representative will contact the next of kin and explain the process to the family. (Families cannot override first-person consent, but are contacted before donation occurs.)

If the person who died was not a registered organ donor, an OPO representative will contact the family or designated healthcare agent to discuss donation with them. If the family consents, the rest of the process will proceed. The family will also be asked to fill out an infectious disease and behavioral screening for the deceased. 

Once consent is established, the organ procurement organization will arrange for the body to be removed to a tissue bank, where all eligible tissue will be removed by a specially trained technician under sterile conditions. At that time, blood samples will also be obtained and screened for infectious diseases, including HIV, tuberculosis, hepatitis B, hepatitis C, CMV, syphilis, cytomegalovirus, (CMV) and Epstein-Barr virus (EBV).

After all tissues are harvested, the medical director of the tissue bank will review the medical records. Only tissue that is safe for transplantation (e.g. free of infectious diseases that can be transmitted to the recipient) will be released. In the meantime, all incisions are closed and the body is returned to the funeral home or family for burial or cremation. Cosmetic implants are made where necessary so the family can have an open casket viewing if they so desire. 

Death at Home or in a Nursing Home 

Nursing homes are not mandated by law to report a death to the regional OPO, so the process for tissue donation when a person dies at home or in a nursing home is essentially the same. The next of kin or designated healthcare agent is responsible for contacting the regional organ procurement organization and notifying them that a death has occurred. The OPO will then check the state and national donor registries to determine if the person is a registered donor. If they are, the OPO will contact a tissue bank, which will send a technician to retrieve the body so that tissue harvest can proceed. The next of kin or healthcare agent can also consent to donation at this time. 

Although tissues are less dependent on a steady blood supply than organs, there is nevertheless a short window in which to notify the OPO since tissue must be harvested within 24 hours of death. The best way to facilitate this is to have the contact information for your local OPO available and to make sure you have your loved one’s donor registration information on hand. You can locate your regional OPO on OrganDonor.gov.

Sources

“How Donation Works”. Health Resources & Services Administration. https://www.organdonor.gov/learn/process 

“First Person Consent: OPOS across the country are adapting to the change”. United Network for Organ Sharing. https://unos.org/wp-content/uploads/unos/registires_combined.pdf  First 

“About Cytomegalovirus”. Centers for Disease Control and Prevention. https://www.cdc.gov/cytomegalovirus/about/index.html 

“About Epstein-Barr Virus (EBV)”. Centers for Disease Control and Prevention. https://www.cdc.gov/epstein-barr/about/index.html 

“Volunteer Locally”. Health Resources & Services Administration. https://www.organdonor.gov/get-involved/volunteer