In a medical first this month, a 57-year-old male from the US with terminal heart disease was the recipient of a successful heart transplant from a genetically modified pig. This was the only option available to the patient after he was deemed ineligible for traditional transplant, which led to the US Food and Drug Administration granting emergency authorization through its compassionate use provision for this highly experimental surgery. A few months before, surgeons at NYU achieved the first kidney transplant from a genetically engineered animal (also a pig).

Known as xenotransplantation, the method of transplanting organs between different species is seen as a promising way through which to close the supply/demand imbalance in organ availability. In the US alone, only a third of the required number of organs were available in 2020, with demand for kidney transplants more than 4 times the supply.

As with most healthcare sectors, the COVID-19 pandemic shocked transplant programs. Total activity fell 25% in the UK between 2020 and 2021, for instance, while Japan saw a 66% drop in 2020 (compared to 2019 levels). Overall, the COVID-related global drop in transplants translated to 48,239 patient life-years lost in 2020 alone. Fortunately, pre-covid trends had been on the rise, with the EU seeing a 30% increase in the number of total transplants over the past decade, while India doubled over the same period (see here for charts by country and region). Importantly, and for the first time in the country’s history, the United States exceed 40,000 organ transplants in 2021.

Technology is seen as an important avenue for tackling the transplant issue. Regenerative medicine company Revivicor, for example, is already constructing a new clinical-grade facility to produce xenotransplants that can meet FDA standards, with a view to start trials by the end of 2023. Other technologies include the artificial production of organs (e.g. via 3D printing) or the faster delivery of organs via drones. These technologies are still early stage, however, and they will take time to scale.

Meanwhile, governments have multiple tools at their disposal to address the supply-demand challenges. Comprehensive policy is one of them. The 2009-2015 EU Action Plan on organ transplant played a key role in boosting both the number of donors and the number of transplants over the past decade, for example, while EU educational campaigns and donor action programs helped increase donations by 53% in the early 2000s. In Kuwait, the reimbursing expenses incurred by both living and deceased donors and their families, known as rewarded gifting, increased the supply of donor organs from 5% to 25% in the 1980’s.

Other options include a switch from ‘opt-in’ by default to ‘opt-out’ by default when it comes to donation in the eventuality of death. Though this has yielded important positive results in some countries (Spain, which implemented this decades ago, has the highest donor rates per capita in the world) it is unclear whether the effect is always present or as strong. A recent study of 35 OECD countries notably found that an opt-out system was “independently predictive of fewer living donors but was not associated with the number of deceased donors or with transplantation rates”.

Which lever to activate will ultimately depend on cultural and ethical considerations. But action is needed. Without it, illegal trafficking will continue to try fill the gap, with devastating consequences for the most vulnerable populations.

A Change of Heart