장기기증을 위한 뇌사자 관리

길은미,박재범 대한이식학회 2015 Korean Journal of Transplantation Vol.29 No.3

Since the Harvard criteria for brain death was proposed in 1968, deceased donor, mainly brain death donor (BD), organ transplantation has been performed worldwide and given the chance for a new life to patients suffering from end-stage organ disease. In Korea by the eager efforts promoting brain-dead organ donation, fortunately, the number of organ donations from the brain-dead has increased successfully in the last decade. However, the disparity between the number of patients awaiting organ transplantation on the list and the number of actual organ donations has become wider and the organ shortage remains a limitation for new lives by transplantation. Because of donor organ restriction, optimal management of brain-dead donors is increasingly important. In addition, the favorable clinical outcomes of recipients is directly associated with the well-preserved organ function of brain-dead donors, which can be accomplished by the maintenance of optimal perfusion. However the brain-dead condition leads to various and profound pathophysiological changes in the neuroendocrine and cardiovascular systems, and management of brain-dead organ donors usually includes active intensive care for maintaining organ function. Therefore, to enhance the potential organ graft function and increase the organ supply, physicians must have knowledge of the pathophysiology of brain death and must deal with rapid hemodynamic changes, endocrine and metabolic abnormalities, and respiratory complications. This article reviews the pathophysiologic changes resulting from brain death and the adequate management for maximizing use of organs recovered from brain death donors. 국내에서는 1969년 생체 기증자 신장이식을 시작으로, 1979년 최초로 뇌사자 장기이식을 성공하였고, 이후 이식관련 의료수준은 괄목할 만한 발전을 이루었으나, 여전히생체이식이 더 높은 비율을 차지하고 있다. 1999년 장기등 이식에 관한 법률이 제정되었고, 2000년에 장기이식 관리센터(Korean Network for Organ Sharing, KONOS)가 설립되었으며, 2010년 한국 장기기증원(Korea Organ Donation Agency, KODA)이 출범되었다. 2011년에는 뇌사 추정자신고제가 도입되어 뇌사자 장기이식 활성화를 위해 노력하고 있지만 아직 장기이식 대기자 수에 비해 장기 제공자의 수가 현저히 부족한 것이 사실이고 우리나라는 아직 뇌사자 장기이식이 활성화되지 못한 나라에 속한다. 2015년7월 말 기준 21,625명의 환자들이 장기이식을 대기하고 있으며(간장 4,565명, 신장 15,444명, 췌장 837명, 심장 541 명, 폐장 189명, 소장 20명, 췌도 29명) 이는 2000년 2,840 명과 비교하여 약 7.6배 정도 증가되어 매우 빠른 증가추세를 보인다. 2014년에 446명의 뇌사장기기증자(deceased organ donor)로부터 1,445건의 장기기증이 진행되었다. 이는 2000년 52명의 뇌사장기기증자에 비해 비약적인 증가이지만, 절대적인 기증자의 수는 여전히 이식 대기자 수에비교하여 부족한 현실이다. 공여장기가 부족한 현실에서 효율적인 장기의 분배 및이식을 위해서는 잠재기증자에 대한 활발한 신고와 중환자전문의(intensivist)를 통한 세심하고 적극적인 관리가중요하다. 최근 연구에서 잠재기증자 관리에서 중환자전문의가 포함된 팀을 적용 후 이식 가능한 장기구득의 수가유의하게 증가함을 보고하였다(1). 중환자전문의의 참여가 증가함에 따라 뇌사자 관리에 중환자 치료에 적용되는기준과 동일한 기준 적용이 확산되면서 뇌사자의 혈역학적 안정성 유지 및 장기구득의 향상을 보이고 있으나, 아직까지 뇌사자에 대해 특화된 표준관리지침은 매우 제한적이다(2,3). 이에 저자는 뇌사자의 병태생리적 변화에 대해 알아보고, 최근 보고된 연구들을 바탕으로 하여 적절한뇌사자 관리 및 치료에 대해 기술하고자 한다.

뇌사 판정 논의와 장기이식법의 개선방안 연구

이창규,김수동,김주희 원광대학교 법학연구소 2022 의생명과학과 법 Vol.28 No.-

The Act on Organ Transplantation makes it possible to judge brain death with the consent of the bereaved family, even if the donor does not express his/her intention to donate in writing before death, as long as the donor does not express his/her intention to the contrary. Legislation on long-term donations is a new area that was created relatively recently and is still developing with the development of medical and life science technology. It can be said that it is meaningful to examine the current state of overseas legal systems and the content of legislation in order to identify and improve the problems of laws related to transplantation of organs and other organs. In particular, Germany had an organ transplant scandal (Organspende-Skandal) based on changes in organ transplantation, followed by institutional changes. On this basis, we examined the long-term harvest requirements and consent of the German organ transplantation law and derived some improvements in our organ transplantation law. First, as with the consent requirements for determining brain death, there is a problem as to whether or not the bereaved family can refuse the donation despite the donor's consent. If the bereaved family has inherent rights to the long-term donation after the donor's death, the bereaved family will naturally have the right to veto the long-term donation. In the Korean method of determining the scope of relatives, which does not allow such relatives to have the right of veto, it would be a problem to neglect the person's right to self-determination. The second is the scope of long-term donors and recipients. Under the Organ Transplantation Law, family members or bereaved families are the subjects of consent or refusal of long-term donation of organs from donors. German long-term transplant law stipulates that close relatives and decision-making authority must only be given to the donor if they have had personal contact within the last two years prior to death. there is That is, close relatives are primarily spouses or registered Lebenspartners, children, parents, siblings and grandparents. In addition, if an arrangement is made among close relatives and there are multiple close relatives in the same position, it is sufficient if one of them satisfies the above circumstances. 2000년부터 시행되고 있는「장기 등 이식에 관한 법률」은 뇌사 이식에 대해, 제공자의 생전 서면에 의한 제공의 의사 표시가 없더라도, 반대의 의사 표시가 없다면, 유족의 승낙을 얻어 뇌사판정이 가능하게 되었다. 장기의 기증에 관한 법률은 비교적 최근에 창설된 새로운 법률로, 의생명과학기술의 발달로 인해 시대적 논의 반영이 필요하다. 이에 따라 우리의「장기 등 이식에 관한 법률」의 문제점 도출과 개선을 위한 해외 법제의 현황과 입법 내용을 검토하는 것은 의미가 있다고 할 수 있다. 특히, 독일은 장기이식의 변화에 기초한 장기이식스캔들(Organspende-Skandal)이 있었고 이후 제도의 변화가 일어났다. 이를 기초로 독일 장기이식법의 장기 적출요건과 동의를 알아보고, 우리의 장기이식법에서의 몇 가지 개선점을 도출하였다. 첫째, 뇌사판정의 동의요건과 마찬가지로 제공자 본인이 동의하고 있음에도 불구하고, 유족의 거부 의사표시가 있다면 장기를 제공할 수 없는지에 대한 문제가 발생한다. 장기기증에 대하여 친족인 기증자의 사후 장기기증에 대하여 유족이 고유의 권리를 갖는다면, 당연히 거부권도 인정이 되지만 독일과 같이 가족 간 실질적인 유대나 긴밀한 교류를 전제로 하지 않는 우리나라의 친족 범위의 결정 방법은 친족에게 거부권을 인정하고 본인의 자기결정권을 경시하는 것은 문제가 될 것이다. 둘째, 장기 제공자와 수령인의 범위의 축소에 관한 사항이다. 장기이식법 제4조 제6호에 가족 또는 유족은 장기 등 기증자로부터의 장기 제공에 대해 승낙・거부의 의사 표시의 주체이다. 독일 장기이식법 제4조 제2항에서는 근친자(nächste Angehörige)로 하고, 근친자가 의사 결정의 권한을 가진 것은 제공자에게 사망 전 직전 2년 이내에 개인적 접촉을 취한 경우에만 주어져야 한다고 규정하고 있다. 즉, 근친자는 우선 배우자 또는 등록한 공동생활자(Lebenspartner), 자녀, 부모, 형제자매, 조부모이다. 또한, 근친자들 사이에 순위를 마련하고, 동등한 지위에 있는 근친자가 복수로 있는 경우에는 그중 한 명이 위의 사정을 충족하면 충분하다고 할 수 있다.

뇌사기증자 신장 분배제도의 현황

김미나,김세란,이수형,오창권,방준배 대한이식학회 2017 Korean Journal of Transplantation Vol.31 No.3

Background: This study was conducted to analyze the current system for allocation of deceased donor kidney transplantation in Korea, which includes an incentive regulation for candidates registered at the Hospital-based Organ Procurement Organization (HOPO). Methods: Between January 2011 and November 2016, there were 2,655 deceased donors in Korea. During the same period, there were 21,247 current candidates and recipients of kidney, pancreas and simultaneous pancreas-kidney transplants. We analyzed data from all of these donors, candidates, and recipients. Results: Mean waiting times for organ allocation of each priority differed significantly (2nd priority group, 1,701±974 days; 3rd priority group, 1,316±927 days; 4th priority group, 2,077±1,207 days). Additionally, HOPO candidates/deceased donor ratios were very different from each other (maximum, 49; minimum, 0.6). The number of deceased donors in region 1, 2, and 3 were 1,623, 429, and 603, respectively, while the number of transplantations in each region was 3,095, 597, and 1,165, respectively. The candidates registered at region 1 HOPO moved the longest distances on average for transplantation, and this value differed significantly different from that of other regions (56.18±91.9 km vs. 24.66±28.0 km vs. 26.20±37.3 km, P<0.05). Conclusions: The incentive system of current allocation system for deceased donor kidney in Korea does not coincide with the purpose of the ‘Declaration of Istanbul’ and unnecessary social costs have occurred. Therefore, we should make an effort to change our current allocation system to the geographic sequence of organ allocation system.

뇌사자신장이식에서 KONOS의 경계공여자 기준의 개선을 위한 다기관 연구 수행의 타당성을 평가하기 위한 예비연구

허우성 대한이식학회 2017 Korean Journal of Transplantation Vol.31 No.2

Background: The Korean Network for Organ Sharing (KONOS), which was established in December 31st, 1999, is a nationwide system of deceased donor detection and distribution. From its inception, KONOS has defined marginal donors and used this definition for over 15 years. However, this definition should be reevaluated to determine if it requires revision. This study was conducted to confirm the feasibility of the main study for revision of the marginal donor definition in deceased donor kidney transplantation. Methods: This study is a retrospective meta-analysis of 786 patients who had deceased donor kidney transplant from six centers. After the data validation process, multivariable analysis was conducted to evaluate whether the marginal donor criteria of KONOS or UNOS expected adequately in terms of graft survival and delayed graft function (DGF). Results: Neither the KONOS or UNOS criteria affected graft survival. Expanded criteria for donors of UNOS was a risk factor for DGF. However, KONOS criteria did not affect DGF. Conclusions: Based on this preliminary study, there is a need to conduct a study to revise the marginal donor criteria of KONOS in deceased donor kidney transplantation. Such a study should have large scale and long-term follow-up data.

잠재 뇌사자에서 성공적 장기 기증과 기증 동의와 관련된 인자

이은우,장혜연,한상엽,한금현,오세원,노영남 대한이식학회 2017 Korean Journal of Transplantation Vol.31 No.1

Background: This study was conducted to identify the factors influencing successful organ donation and families’ consent to donate after brain death. Methods: Medical records and data regarding organ donation counseling with the families of 107 brain-dead potential donors between September 2012 and March 2016 at a single tertiary medical center were retrospectively reviewed. Results: The final consent rate was 57.9% (62/107), and successful donation was performed in 40.2% (43/107) of cases. Univariate and multivariate analyses revealed that the independent factors associated with successful organ donation were age <60 years (odds ratio [OR], 3.384; 95% confidence interval [CI], 1.350 to 8.484; P=0.009), systolic blood pressure ≥90 mmHg (OR, 6.261; 95% CI, 1.418 to 27.653; P=0.015), and serum sodium level ≥150 mEq (OR, 4.215; 95% CI, 1.655 to 10.733; P=0.003). Family’s consent to donate was significantly associated with head trauma (OR, 3.538; 95% CI, 1.104 to 11.334; P=0.033) and serum sodium level ≥150 mEq (OR, 3.392; 95% CI, 1.404 to 8.194; P=0.007). Conclusions: Successful organ donation was associated with patient age, systolic blood pressure and serum sodium level. Family’s consent to donate was associated with head trauma and serum sodium level.

우리나라 장기이식의 현황과 법률문제

문성제 ( Moon Seong-jea ) 한국외국어대학교 법학연구소 2006 외법논집 Vol.24 No.-

Organ transplantation, the finest example of modem medicine, is based on respect for human life in that it can deliver patients from malignant diseases incurable in past. Since the first successful operation in 1969 as followed by successful transplantation of liver extracted from a person with brain death in 1988, organ transplantation has been already one of most crucial medical arts in Korean and global medicine. Here, organ transplantation consists of 2 processes; one is transplanting organs for medical treatment of patients, and the other is extracting necessary organs from organ donor. The organ transplantation includes auto-transplantation(organ recipient = organ donor), xenograft(replacement with animal organs), insertion of mechanical organs and more. These cases don't involve any special legal issue except general issues in surgical operation such as medical adaptation for such treatments, technical criteria about such medical behaviors and patient’s agreement. But in case of xenograft that needs different organ donor from organ recipient, any one party concerned faces inevitable issues like lost organs or damaged corpse, and the other party benefits from survival or recovered health via transplantation. Because of this contradiction, the organ transplantation involves a question about how to resolve relevant legal issues. As shown here, it is also necessary to discuss extra legal considerations about different interests in organ transplantation between organ donor and recipient. Although there are issues concerned with organ transplantation in terms of organ recipient, it may be construed as general medical behaviors in regard to the nature of medical cure. However, from the standpoint of organ donor, even though the extraction of organ is indispensable for the cure of organ recipient, such extraction itself is not inherent behaviors of medical cure, so it is necessary to build up a series of legal principles to legitimate such behaviors. Here, they depend on whether certain organ is extracted from living organism or dead one. Furthermore, the extraction of organ from living or dead body involves a series of questions like whether to follow the intent of person who has a disposition authority, who the person is, which legitimate effects the expression of his/her intent may have in force, and so forth. In addition, in terms of organ transplantation from living organism for successful transplantation, conflicts concerned with brain death related to beginning and end of person as principal with capacity of enjoyment of rights have been already controversial in discussions between legal and medical circles since long decades ago. Fortunately, the latest enactment and enforcement of “Organ and Equivalent Transplantation Act” gives a clue to resolve these conflicts, but there are still little reviews and studies about potential issues concerned with human respect. It is possibly expected that there will be a series of brisk academic discussions about these issues. From this viewpoint, this paper focuses on posing questions related to organ transplantation and suggesting corresponding solutions.

확장범주 신장이식의 국내 현황과 한국형 기준의 필요성

양신석,박재범 대한이식학회 2017 Korean Journal of Transplantation Vol.31 No.1

The disparity between the number of patients awaiting kidney transplantation (KT) on the list and the number of actual number of KT from deceased organ donation has become wider despite the recent increase in the number of donations. Moreover, the proportion of donors aged 60 or more has rapidly increased. KT from expanded criteria donor (ECD) has been not only been necessary, but also inevitable with respect to maximizing the use of this scarce organ resource. However, we still use the “marginal donor criteria” implemented in 2000 when KONOS (Korean Network for Organ Sharing) was established. In the Korean transplantation environment, this “marginal donor criteria” does not have the power to predict graft outcome, and fails to discern grafts with inferior transplant outcomes from successful transplants. As a result, it does not meet the role of the criteria in Korea. Therefore, we should develop our own criteria based on our deceased donor kidney transplantation experience. Here, we review the current status of ECD KT in Korea in context with the progression of the ECD criteria system in UNOS (United Network for Organ Sharing) and present some considerations for the Korean donor criteria system.

자궁이식에 관한 법적, 윤리적 쟁점 연구

차승현,이봄이,이강미,전우휘,백수진 한국생명윤리학회 2022 생명윤리 Vol.23 No.1

2014년 스웨덴에서 선천적으로 자궁없이 태어난 30대 로키탄스키 신드롬(Mayer Roskitansky Küster-Hauser, MRKH syndrom) 여성이 자신의 어머니로부터 자궁을 이식받아 마침내 아이를 출산했다. 가까운 일본의 경우에도 2021년에 자궁이식 임상연구계획을 일본의학회를 중심으로 검토한 후 이를 승인한 바 있다. 국내에서도 2020년, 2021년 자궁이식과 관련된 심포지움이 개최되며 자궁이식 가능성이 논의되고 있다. 자궁은 생명과 직결되지 않는다는(non-vital) 측면에서 손, 팔, 다리 등과 유사하나 임신과 출산이라는 특별한 목적의 기능을 수행한다. 따라서 이식의 성공은 자궁의 안정적 ‘생착(engraftment)’으로만 보기는 어렵고 이식된 자궁을 통해 건강한 아이를 출산하는 것까지 담보되어야 한다. 그러나 아직 자궁이식으로 태어난 아이의 건강까지 보장할 수 있을지는 장담하기 어렵다.자궁이식이 지금까지는 소수의 의료전문가와 제한된 시설에서 연구적으로 시도되고 있지만 올바른 연구가 진행되기 위해서는 윤리적 기준에 대한 고찰이 함께 이루어져야 한다. 자궁이식에서 고려해야 하는 윤리적 기준은 이식술 연구와 임신과 출산에 대한 시술이 함께 수행되기 때문에, 일반적인 임상연구에서 요구되는 윤리적 기준과는 차이가 있다. 이에 본 연구에서는 자궁이식 현황 및 특성을 살펴보고, 자궁이식 임상연구와 의료시술로서 자궁이식에 법적, 윤리적 쟁점을 검토해 볼 것이다.