- Email: [email protected]
Level of Acceptance of a Clinical Solid Organ Xenotransplantation Program Among Personnel in Organ Transplant-Related Services in Spanish, Mexican, and Cuban Hospital Centers
Level of Acceptance of a Clinical Solid Organ Xenotransplantation Program Among Personnel in Organ Transplant-Related Services in Spanish, Mexican, and Cuban Hospital Centers A. Rı´os, L. Martı´nez-Alarcón, M.A. Ayala-Garcı´a, M.J. Sebastián, A. Abdo-Cuza, A. López-Navas, A. López-López, E.J. Ramı´rez, G. Muñoz, A. Camacho, J. Suárez-López, R. Castellanos, J.S. Rodrı´guez, M.A. Martı´nez, A. Nieto, G. Ramis, P. Ramı´rez, and P. Parrilla ABSTRACT Introduction. Xenotransplantation is far from becoming a clinical reality. However, in vital organs it could be used as a bridge until a human organ becomes available, in an emergency situation. We analyzed the attitude toward xenotransplantation among personnel in transplant-related services in several hospitals in Spain and Latin America. Methods. A random sample stratified by type of service and job category (n ⫽ 738), in transplant-related services (procurement units, transplant units, and transplant patient follow-up units) was examined in eight hospital centers from three different countries: Spain (n ⫽ 349), Mexico (n ⫽ 269), and Cuba (n ⫽ 120). A self-administered validated questionnaire was completed anonymously. Results. Based on the assumption that all the results of xenotransplantation were similar to those achieved with human donors, most respondents [66% (n ⫽ 484)] would be in favor. The employees from Cuban centers had the most favorable attitudes (72% in favor), followed by the Spanish (64%) and the Mexicans (61%; P ⫽ .013). However, the differences were mainly determined by job category: Physicians showed the most favorable attitudes and auxiliary staff the least (67% vs 40%; P ⫽ .010). Attitudes were significantly related to beliefs about different types of human donation [deceased (P ⬍ .001) and living (P ⬍ .001)], the possibility of needing a transplant for oneself (P ⬍ .001), and a favorable attitude toward donating the organs of a deceased family member (P ⫽ .004). Conclusions. Currently, a third of health care employees working in transplant-related services are not in favor of xenotransplantation. More information should be provided about the subject, especially in centers with preclinical xenotransplantation programs. NCREASING NUMBERS of patients are on waiting lists due to the progressive increase in the number of indications for transplantation and the consequent organ deficit. In the search for solutions, research into xenotransplantation has been advancing in recent years,1 given that this could provide an unlimited source of organs. However, it is far from becoming a clinical reality, at least for vital organs, such as the kidney, which has the alternative of dialysis. However, for organs such as the liver, xenotransplanted organs could be used as a bridge in emergency situations until a human one becomes available.2,3 An important aspect is determining the attitudes of health care personnel to this technique, because they are the ones who would offer xenotransplantation if it became
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0041-1345/10/$–see front matter doi:10.1016/j.transproceed.2009.11.007 222
From the Departamento de Cirugı´a (A.R., L.M.-A., A.L.-N., A.L.-L., G.R., P.R., P.P.), Hospital Universitario Virgen de la Arrixaca, Servicio Murciano de Salud, El Palmar, Murcia, España; Hospital Regional de Alta Especialidad del Bajı´o y Universidad de Guanajuato (M.A.A.-G., E.J.R., G.M., J.S.R., M.A.M., A.N.), León, Guanajuato, México; Coordinación de DonaciónTrasplantes (M.J.S., A.C.), UMAE Hospital de Especialidades No. 25 IMSS, Monterrey, México; Centro de Investigaciones Médico-Quirúrgicas (A.A.-Z., R.C.), Cuba; and Hospital Hermanos Ameijeiras (J.S.-L.), Cuba. Address reprint requests to Dr Antonio Rı´os Zambudio, Avenida de la Libertad No. 208, Casillas, 30007, Murcia, España. E-mail: [email protected] © 2010 Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 42, 222–227 (2010)
ACCEPTANCE OF XENOTRANSPLANTATION
a clinical reality. For this reason, there is special importance to discover the level of acceptance of this potential therapy,4 above all in centers with preclinical xenotransplantation programs or with access to them, because they are the ones who will care for transplanted patients. Our hypothesis was that personnel in organ transplantrelated units (centers with a xenotransplantation program or centers that could have access to a program through their contacts) should have more favorable attitudes toward xenotransplantation than the general public. If these data were confirmed, this subgroup could act indirectly to promote xenotransplantation to the public. The objective of this study was to analyze attitudes toward animal organ donation among personnel from several hospitals with solid organ transplant-related programs (one of which has a preclinical liver xenotransplantation program), to determine the factors that affect attitudes. METHODS Study Population The data were obtained in eight hospital centers from three different countries as part of the international collaborative program “Proyecto Donante Xenotrasplante, Murcia.” The countries were Spain (n ⫽ 349), Mexico (n ⫽ 269), and Cuba (n ⫽ 120), each having a solid organ transplant program. Random sampling was stratified according to type of service and job category in transplantrelated services: physicians, nurses, nursing assistants, and auxiliary personnel. The services were grouped into three categories: (1) donor procurement units (intensive care unit, postoperative recovery unit, and neurosurgery unit); (2) transplant units (general surgery and digestive service, urology service, and cardiovascular surgery service); and (3) transplant patient follow-up units (internal medicine of the digestive system, nephrology, and cardiology). All services were within hospitals that perform solid organ transplants. In hospitals where there is no heart transplantation unit, we excluded heart surgery and cardiology. In those in which there is no liver transplantation, we excluded the general surgery and digestive apparatus service, and the service of internal medicine of the digestive system. The mean age in the studied group was 37 ⫾ 10 years, including 41% (n ⫽ 300) men and 59% (n ⫽ 431) women.
Questionnaire and Study Variables Attitudes were evaluated using a validated questionnaire.5–7 A representative from each service for each job category was responsible to hand out and collect the questionnaires in randomly selected work shifts. The self-administered survey was completed anonymously. Attitudes toward animal organ donation (xenotransplantation) were the dependent variable, assuming that the results were comparable with those achieved with human organs. The following metrics were used as independent variables: (1) sociopersonal variables: age, sex, marital status (single, married, separated/ widowed/divorced) and country (Spain, Mexico and Cuba); (2) job variables: type of transplant-related hospital (transplant hospital, donor-procuring hospital), type of clinical service (surgical/medical), job category (medical, nursing, nursing assistants, auxiliary personnel), and the respondent job (permanent position, temporary/contracted); (3) variables of knowledge about and attitude toward donation and transplantation: personal experience of organ donation and transplantation, attitude toward deceased organ
223 donation, a respondent’s belief that he/she might need a transplant for themselves, and attitude toward living donation (kidney and liver); (4) variables of social interaction: attitude toward donating a family member’s organs, having had a discussion about the subject of organ donation and transplantation within the family and a respondent’s partner’s attitude toward donation and transplantation; (5) variables of prosocial behavior and religious variables: participation in prosocial type activities, a respondent’s religion (Catholic, atheist, another religion), and knowing the attitude of one’s religion toward donation and transplantation.
Statistical Analysis The data were analyzed using the SPSS 15.0. statistical package. The descriptive statistical analysis carried out included: bivariate analysis using Student t test and the 2 test complemented by an analysis of normalized remainders. Multivariate analysis was performed using logistic regression with significant variables from the bivariate analysis; associations were considered to be significant when P values were less than .05.
RESULTS Attitude Toward Xenotransplantation
Based on the assumption that all the results of xenotransplantation were similar to those achieved with human donors, 66% (n ⫽ 484) of respondents were in favor, while 9% (n ⫽ 69) were against, and the remaining 25% (n ⫽ 185) unsure. Variables Associated With Attitude Toward Xenotransplantation
The following variables have been analyzed to see if they affected attitudes toward xenotransplantation. Sociopersonal Variables. With regard to age, we observed that the youngest workers had the most favorable attitudes compared to the older ones who were undecided (36 ⫾ 10 vs 39 ⫾ 10 years; P ⫽ .007). With regard to sex, males had more favorable attitudes toward xenotransplantation that females (76% vs 59%; P ⬍ .001). According to country of reference, professionals from Cuban centers were more in favor than those from Spanish or Mexican centers (72% vs 64% and 65%, respectively; P ⫽ .006). Marital status did not affect attitudes. Job Variables. An analysis by job category showed that physicians had the most favorable attitudes toward xenotransplantation, which were different from nurses (77% vs 58%; P ⬍ .001). Attitude was not affected by the following factors: type of service in which the respondent worked (surgical/medical; P ⫽ .127), respondent’s job contract situation (P ⫽ .234), or the type of transplant-related hospital center (P ⫽ .547). Variables Related with Knowledge and Attitude Toward Donation and Transplantation. Attitudes toward xenotransplantation were influenced by those toward human organ donation and transplantation (P ⬍ .001); personal experience of organ donation and transplantation (P ⫽ .045); attitude toward the donation of a family member’s organs (P ⬍ .001); and belief that he/she might need a transplant in the future (P ⬍ .001).
224
RÍOS, MARTÍNEZ-ALARCÓN, AYALA-GARCÍA ET AL Table 1. Variables Affecting Attitude Toward Xenotransplantation Among Personnel in Transplant-Related Services (Bivariate Analysis) Variable
Socio personal variables Mean age (37 ⫾ 9 ys) Sex Male (n ⫽ 300) Female (n ⫽ 431) DK/NA (n ⫽ 7) Marital status Single (n ⫽ 253) Married (n ⫽ 417) Widowed/divorced/separated (n ⫽ 59) DK/NA (n ⫽ 9) Country Spain (n ⫽ 349) Mexico (n ⫽ 269) Cuba (n ⫽ 120) Job variables Type of hospital center Transplant center (n ⫽ 643) Procurement hospital (n ⫽ 95) Type of clinical service Surgical (n ⫽ 347) Medical (n ⫽ 391) Job category Physician (n ⫽ 281) Nurse (n ⫽ 335) Nursing assistant (n ⫽ 91) Auxiliary personnel (n ⫽ 10) DK/NA (n ⫽ 21) Job situation Permanent (n ⫽ 317) Temporary (n ⫽ 214) Contracted (n ⫽ 107) Resident (n ⫽ 66) DK/NA (n ⫽ 34) ODT variables Personal experience of ODT Yes (n ⫽ 254) No (n ⫽ 484) Deceased donation In favor (n ⫽ 584) Not in favor (n ⫽ 154) Possibility of needing a transplant Yes (n ⫽ 344) I do not know (n ⫽ 380) No (n ⫽ 14) Attitude toward living kidney donation In favor (n ⫽ 662) Not in favor (n ⫽ 76) Attitude toward living liver donation In favor (n ⫽ 602) Not in favor (n ⫽ 136) Variables of social interaction Donation of a family member’s organs In favor (n ⫽ 329) Would respect their wishes (n ⫽ 339) Against (n ⫽ 56) DK/NA (n ⫽ 14)
In Favor (n ⫽ 484; 66%)
Against (n ⫽ 69; 9%)
Undecided (n ⫽ 185; 25%)
P
37 ⫾ 10
39 ⫾ 11
39 ⫾ 10
.007
229 (48%) 252 (52%) 3
19 (28%) 49 (72%) 1
52 (29%) 130 (71%) 3
.000
170 (36%) 274 (57%) 35 (7%) 5
28 (41%) 34 (50%) 6 (9%) 1
55 (30%) 109 (60%) 18 (10%) 3
.414
224 (46%) 174 (36%) 86 (18%)
22 (32%) 36 (52%) 11 (16)
103 (56%) 59 (32%) 23 (12%)
.006
417 (86%) 67 (14%)
61 (88%) 8 (12%)
165 (89%) 20 (11%)
.547
226 (47%) 258 (53%)
40 (58%) 29 (42%)
81 (44%) 104 (56%)
.127
217 (46%) 194 (41%) 54 (12%) 4 (1%) 15
22 (32%) 37 (54%) 9 (13%) 0 (0%) 1
42 (23%) 104 (58%) 28 (16%) 6 (3%) 5
.000
203 (44%) 103 (28%) 73 (16%) 53 (11%) 25
30 (44%) 24 (35%) 9 (13%) 5 (8%) 1
84 (47%) 60 (33%) 25 (14%) 8 (5%) 8
.234
168 (13%) 316 (87%)
15 (42%) 54 (58%)
71 (32%) 114 (68%)
.045
419 (87%) 65 (13%)
40 (58%) 29 (42%)
125 (68%) 60 (32%)
.000
264 (55%) 213 (44%) 7 (1%)
29 (42%) 36 (52%) 4 (6%)
51 (28%) 131 (71%) 3 (1%)
.000
464 (96%) 20 (4%)
59 (86%) 10 (14%)
139 (75%) 46 (25%)
.000
435 (90%) 49 (10%)
44 (64%) 25 (36%)
123 (67%) 62 (33%)
.000
249 (52%) 211 (44%) 16 (3%) 8
19 (28%) 24 (36%) 24 (36%) 2
61 (33%) 104 (58%) 16 (9%) 4
.000
ACCEPTANCE OF XENOTRANSPLANTATION
225 Table 1. (continued)
Variable
Family discussion Yes (n ⫽ 567) No (n ⫽ 171) Partner’s opinion In favor (n ⫽ 385) Not known (n ⫽ 147) Against (n ⫽ 38) No partner (n ⫽ 113) DK/NA (n ⫽ 55) Prosocial and religious variables Prosocial activities Yes, I take part (n ⫽ 194) No, but I would like to (n ⫽ 465) No, never (n ⫽ 48) DK/NA (n ⫽ 31) Religion Catholic (n ⫽ 549) Another religion (n ⫽ 21) Atheist (n ⫽ 123) DK/NA (n ⫽ 45) Opinion of their religion In favor (n ⫽ 333) Against (n ⫽ 10) Not known (n ⫽ 248) DK/NA (n ⫽ 147)
In Favor (n ⫽ 484; 66%)
Against (n ⫽ 69; 9%)
Undecided (n ⫽ 185; 25%)
P
374 (77%) 110 (23%)
50 (72%) 19 (28%)
143 (77%) 42 (23%)
.665
296 (63%) 88 (19%) 17 (3%) 72 (15%) 11
26 (40%) 19 (29%) 6 (9%) 14 (22%) 4
63 (43%) 40 (28%) 15 (10%) 27 (19%) 40
.000
130 (28%) 317 (68%) 22 (4%) 15
16 (24%) 38 (58%) 12 (18%) 3
48 (28%) 110 (64%) 14 (8%) 13
.002
376 (79%) 12 (3%) 86 (18%) 10
54 (78%) 2 (3%) 13 (19%) 0
119 (79%) 7 (5%) 24 (16%) 35
.722
237 (58%) 6 (2%) 163 (40%) 78
34 (59%) 2 (3%) 22 (38%) 11
62 (49%) 2 (1%) 63 (50%) 58
.276
DK/NA, does not know/no answer; ODT, organ donation and transplantation.
Variables of Social Interaction. Both the attitude of the respondent’s partner toward donation and transplantation (P ⬍ .001) and the respondent’s attitude toward the donation of a family member’s organs (P ⬍ .001) affected responses toward xenotransplantation. Prosocial Behavior and Religious Variables. No significant differences were found (Table 1). Multivariate Analysis
Upon multivariate analysis, we observed the variables significantly related to attitude were: (1) sex (odds ratio [OR] ⫽ 1.721; P ⫽ .025); (2) attitude toward deceased donation (OR ⫽ 2.375; P ⬍ .001); (3) possibility of needing a transplant in the future (OR ⫽ 1.745; P ⫽ .005); (4) attitude toward living liver donation (OR ⫽ 1.992; P ⫽ .008); and (5) attitude against the donation of a family member’s organs (OR ⫽ 0.355; P ⫽ .007; Table 2). DISCUSSION
Xenotransplantation still is quite short of becoming a clinical reality, although it has overcome some barriers and may be a useful bridge for vital organs until a human source becomes available.4 In studies of the general public, acceptance rates of xenotransplantation were variable, ranging between 40% and 75%.7–12 In this respect, the attitude of health care workers toward this therapy is fundamental, because, as in human donation, information passed on by them to the public is highly credible.13
Our data showed that attitudes of personnel in services related to xenotransplantation were the same as or even less favorable than those described among the general public. For example, the data from Spanish employees showed that the general public showed more favorable attitudes than health care employees (74% vs 64%). This is a surprising finding, given their direct relationship with a preclinical liver xenotransplantation program from pig to baboon, such as the one being developed in these centers.4 These results may be explained in many ways, but are possibly due to controversies related to this type of research, such as the risk of xenoinfections and rejection,1 which could produce negative effects. Attitudes were the same among Mexican health care workers, although Cubans were more in favor. Currently, there are no data for the general public in Mexico and Cuba that would allow us to compare them with the general public in Spain. In Mexico, xenotransplantation has been performed using Langerhans and Sertoli pig cells for patients with diabetes type I.14 In these cases, the patients and family members perceived xenotransplantation pragmatically.15 A crucial factor within the hospital is job category. We found that physicians were those with the most favorable attitudes; those least in favor were the auxiliary personnel (77% vs 40%). This observation is important,16 because although the medical staff are potentially key players to provide a xenotransplantation program, we must not forget that other personnel have credibility for the public whatever their job category. Auxiliary personnel can cause social
226
RÍOS, MARTÍNEZ-ALARCÓN, AYALA-GARCÍA ET AL Table 2. Variables Affecting Attitude Toward Xenotransplantation in Personnel in Transplant-Related Services (Multivariate Analysis) Variable
Sex Female (n ⫽ 431) Male (n ⫽ 300) Attitude toward deceased donation Not in favor (n ⫽ 154) In favor (n ⫽ 584) Possibility of needing a transplant Not known (n ⫽ 380) Yes (n ⫽ 344) No (n ⫽ 14) Attitude toward living liver donation Not in favor (n ⫽ 136) In favor (n ⫽ 602) Actitud toward donation of a family member’s organs Would respect their wishes (n ⫽ 339) In favor (n ⫽ 329) Against (n ⫽ 56)
Regression Coefficient
Standard Error
Odds Ratio (Confidence Intervals)
P
0.543
0.242
1 1.721 (2.762–1.070)
.025
0.866
0.246
1 2.375 (3.846–1.468)
.000
0.556 0.224
0.198 0.735
0.688
0.261
1 1.745 (2.570–1.183) 1.252 (0.296–5.287) 1 1 1.992 (3.322–1.194)
0.319 ⫺1.034
0.210 0.386
1 1.375 (2.074–0.912) 0.355 (0.754–0.167)
alarm due to their less positive attitudes, which were more negative than the general Spanish-speaking general public.6 This point is important in the group of centers being investigated given their close relationship to each other and the presence of a preclinical xenotransplantation program in one of them with the possibility of its application in the others. There are a limited number of studies about the attitudes of health care personnel in countries other than Spain; there are generally less positive attitudes toward xenotransplantation. In a study of Australian acute care nursing personnel (n ⫽ 1728), Mohacsi et al17 reported that 66% of respondents did not like the idea of xenotransplantation; only 19% would accept it. In a French study about the acceptance of xenotransplantation among health care workers, Julvez et al18 observed that 34% of the nursing staff would accept it, a percentage that increased to 55% for physicians. If it were a life or death situation, these rates would be 61% and 72%, respectively. Regarding factors affecting attitudes toward xenotransplantation, there is a clear relationship between attitude toward human donation (living and deceased) and toward xenotransplantation. This association has already been described by authors, such as Omnell et al,19 where if a person is in favor of receiving a human organ, he/she is also prepared to receive an animal kidney or heart, assuming that the end result is the same as in human donation, as demonstrated by Terán-Escandón et al15 in diabetic patients with Langerhans and Sertoli pig cell transplants, who perceived xenotransplantation pragmatically. It is essential to remember that the results we have presented could change over time. In this respect, new knowledge and experience are fundamental. For example, even one news story, founded or unfounded, in favor or against xenotransplantation could cause a radical change in attitudes toward this matter.20 Therefore, it is fundamental
.005 .760
.008
.127 .007
to provide clear and simple information, because this is the main way for the general public and health care personnel in our area to become aware of our advances and to not be afraid of them. The results of this study showed that health care personnel fear our advances more than the public, revealing to a certain extent a failure to provide information about our research. To conclude, a third of health care personnel who work in transplant-related services were not in favor of xenotransplantation. Given the lack of awareness about the subject it has become necessary to provide more information, especially in centers with a preclinical xenotransplantation program or centers that have access to one, such as those in our study.
REFERENCES 1. Petersen B, Carnwath JW, Niemann H: The perspectives for porcine-to-human xenografts. Comp Immunol Microbiol Infect Dis 32:91, 2009 2. Cozzi E, Bosio E, Seveso M, et al: Xenotransplantationcurrent status and future perspectives. Br Med Bull 75–76:99, 2006 3. Bruzzone P: New perspectives in organ transplantations. Clin Ter 156:299, 2005 4. Ramı´rez P, Montoya MJ, Rı´os A, et al: Prevention of hyperacute rejection in a model of orthotopic liver xenotransplantation from pig to baboon using polytransgenic pig livers (CD55, CD59, and H-transferase). Transplant Proc 37:4103, 2005 5. Rı´os A, Ramı´rez P, Martı´nez-Alarcón L, et al: Level of acceptance of a clinical xenotransplantation program among personnel in solid organ transplant-related services. Xenotransplantation 14:271, 2007 6. Rı´os A, Conesa C, Ramı´rez P, et al: Public atttitude toward xenotransplantation: opinión survey. Transplant Proc 36:2901, 2004 7. Rios A, Conesa C, Ramirez P, et al: Attitudes toward xenotransplantation among nonhealth service workers in a hospital with a preclinical xenotransplantation program. Transplant Proc 37:4615, 2005
ACCEPTANCE OF XENOTRANSPLANTATION 8. White DJ, Yannoutsos N: Production of pigs transgenic for human DAF to overcome complement mediatec hyperacute xenograft rejection in man. Res Inmunol 147:88, 1996 9. Hagelin J: Public opinion surveys about xenotransplantation. Xenotransplantation 11:551, 2004 10. Omnell M, Persson NH, Ranstam J, et al: Attitudes toward xenotransplantation—patients waiting for transplantation versus the general public. Transpl Int 14:334, 2001 11. Sanner MA: Giving and taking—to whom and from whom? People’s attitudes toward transplantation of organs and tissue from different sources. Clin Transplant 12:530, 1998 12. Rı´os A, Ramı´rez P, Martı´nez L, et al: British citizens in a regional community of southeastern Spain with a pre-clinical organ xenotransplantation program. A study of attitude toward xenotransplantation. Xenotransplantation 14:255, 2007 13. Rı´os A, Conesa C, Ramı´rez P, et al: Hospital personnel faced with organ xenotransplantation: an attitudinal survey in a hospital with a pre-clinical liver xenotransplantation program. Xenotransplantation 13:447, 2006
227 14. Valdés-González RA, Dorantes LM, Garibay GN, et al: Xenotransplantation of porcine neonatal islets of Langerhans and Sertoli cells: a 4-year study. Eur J Endocrinol 153:419, 2005 15. Terán-Escandón D, Terán-Ortiz L, Ormsby-Jenkins C, et al: Psychosocial aspects of xenotransplantation: survey in adolescent recipients of porcine islet cells. Transplant Proc 37:521, 2005 16. Rios A, Conesa C, Ramirez P, et al: Attitude toward xenotransplantation among residents. Transplant Proc 37:4111, 2005 17. Mohacsi PJ, Blumer CE, Quine S, et al: Aversion to xenotransplantation. Nature 378:434, 1995 18. Julvez J, Tuppin P, Cohen S: Survey in France of response to xenotransplantation. Lancet 353:726, 1999 19. Omnell M, Persson NH, Ranstam J, et al: Xenotransplantation public perceptions: rather cells than organs. Xenotrasplantation 10:72, 2003 20. Martinez L, Rios A, Conesa C, et al: Attitude toward xenotransplantation in kidney and liver patients on the transplant waiting list. Transplant Proc 37:4107, 2005
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From the Departamento de Cirugı´a (A.R., L.M.-A., A.L.-N., A.L.-L., G.R., P.R., P.P.), Hospital Universitario Virgen de la Arrixaca, Servicio Murciano de Salud, El Palmar, Murcia, España; Hospital Regional de Alta Especialidad del Bajı´o y Universidad de Guanajuato (M.A.A.-G., E.J.R., G.M., J.S.R., M.A.M., A.N.), León, Guanajuato, México; Coordinación de DonaciónTrasplantes (M.J.S., A.C.), UMAE Hospital de Especialidades No. 25 IMSS, Monterrey, México; Centro de Investigaciones Médico-Quirúrgicas (A.A.-Z., R.C.), Cuba; and Hospital Hermanos Ameijeiras (J.S.-L.), Cuba. Address reprint requests to Dr Antonio Rı´os Zambudio, Avenida de la Libertad No. 208, Casillas, 30007, Murcia, España. E-mail: [email protected] © 2010 Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 42, 222–227 (2010)
ACCEPTANCE OF XENOTRANSPLANTATION
a clinical reality. For this reason, there is special importance to discover the level of acceptance of this potential therapy,4 above all in centers with preclinical xenotransplantation programs or with access to them, because they are the ones who will care for transplanted patients. Our hypothesis was that personnel in organ transplantrelated units (centers with a xenotransplantation program or centers that could have access to a program through their contacts) should have more favorable attitudes toward xenotransplantation than the general public. If these data were confirmed, this subgroup could act indirectly to promote xenotransplantation to the public. The objective of this study was to analyze attitudes toward animal organ donation among personnel from several hospitals with solid organ transplant-related programs (one of which has a preclinical liver xenotransplantation program), to determine the factors that affect attitudes. METHODS Study Population The data were obtained in eight hospital centers from three different countries as part of the international collaborative program “Proyecto Donante Xenotrasplante, Murcia.” The countries were Spain (n ⫽ 349), Mexico (n ⫽ 269), and Cuba (n ⫽ 120), each having a solid organ transplant program. Random sampling was stratified according to type of service and job category in transplantrelated services: physicians, nurses, nursing assistants, and auxiliary personnel. The services were grouped into three categories: (1) donor procurement units (intensive care unit, postoperative recovery unit, and neurosurgery unit); (2) transplant units (general surgery and digestive service, urology service, and cardiovascular surgery service); and (3) transplant patient follow-up units (internal medicine of the digestive system, nephrology, and cardiology). All services were within hospitals that perform solid organ transplants. In hospitals where there is no heart transplantation unit, we excluded heart surgery and cardiology. In those in which there is no liver transplantation, we excluded the general surgery and digestive apparatus service, and the service of internal medicine of the digestive system. The mean age in the studied group was 37 ⫾ 10 years, including 41% (n ⫽ 300) men and 59% (n ⫽ 431) women.
Questionnaire and Study Variables Attitudes were evaluated using a validated questionnaire.5–7 A representative from each service for each job category was responsible to hand out and collect the questionnaires in randomly selected work shifts. The self-administered survey was completed anonymously. Attitudes toward animal organ donation (xenotransplantation) were the dependent variable, assuming that the results were comparable with those achieved with human organs. The following metrics were used as independent variables: (1) sociopersonal variables: age, sex, marital status (single, married, separated/ widowed/divorced) and country (Spain, Mexico and Cuba); (2) job variables: type of transplant-related hospital (transplant hospital, donor-procuring hospital), type of clinical service (surgical/medical), job category (medical, nursing, nursing assistants, auxiliary personnel), and the respondent job (permanent position, temporary/contracted); (3) variables of knowledge about and attitude toward donation and transplantation: personal experience of organ donation and transplantation, attitude toward deceased organ
223 donation, a respondent’s belief that he/she might need a transplant for themselves, and attitude toward living donation (kidney and liver); (4) variables of social interaction: attitude toward donating a family member’s organs, having had a discussion about the subject of organ donation and transplantation within the family and a respondent’s partner’s attitude toward donation and transplantation; (5) variables of prosocial behavior and religious variables: participation in prosocial type activities, a respondent’s religion (Catholic, atheist, another religion), and knowing the attitude of one’s religion toward donation and transplantation.
Statistical Analysis The data were analyzed using the SPSS 15.0. statistical package. The descriptive statistical analysis carried out included: bivariate analysis using Student t test and the 2 test complemented by an analysis of normalized remainders. Multivariate analysis was performed using logistic regression with significant variables from the bivariate analysis; associations were considered to be significant when P values were less than .05.
RESULTS Attitude Toward Xenotransplantation
Based on the assumption that all the results of xenotransplantation were similar to those achieved with human donors, 66% (n ⫽ 484) of respondents were in favor, while 9% (n ⫽ 69) were against, and the remaining 25% (n ⫽ 185) unsure. Variables Associated With Attitude Toward Xenotransplantation
The following variables have been analyzed to see if they affected attitudes toward xenotransplantation. Sociopersonal Variables. With regard to age, we observed that the youngest workers had the most favorable attitudes compared to the older ones who were undecided (36 ⫾ 10 vs 39 ⫾ 10 years; P ⫽ .007). With regard to sex, males had more favorable attitudes toward xenotransplantation that females (76% vs 59%; P ⬍ .001). According to country of reference, professionals from Cuban centers were more in favor than those from Spanish or Mexican centers (72% vs 64% and 65%, respectively; P ⫽ .006). Marital status did not affect attitudes. Job Variables. An analysis by job category showed that physicians had the most favorable attitudes toward xenotransplantation, which were different from nurses (77% vs 58%; P ⬍ .001). Attitude was not affected by the following factors: type of service in which the respondent worked (surgical/medical; P ⫽ .127), respondent’s job contract situation (P ⫽ .234), or the type of transplant-related hospital center (P ⫽ .547). Variables Related with Knowledge and Attitude Toward Donation and Transplantation. Attitudes toward xenotransplantation were influenced by those toward human organ donation and transplantation (P ⬍ .001); personal experience of organ donation and transplantation (P ⫽ .045); attitude toward the donation of a family member’s organs (P ⬍ .001); and belief that he/she might need a transplant in the future (P ⬍ .001).
224
RÍOS, MARTÍNEZ-ALARCÓN, AYALA-GARCÍA ET AL Table 1. Variables Affecting Attitude Toward Xenotransplantation Among Personnel in Transplant-Related Services (Bivariate Analysis) Variable
Socio personal variables Mean age (37 ⫾ 9 ys) Sex Male (n ⫽ 300) Female (n ⫽ 431) DK/NA (n ⫽ 7) Marital status Single (n ⫽ 253) Married (n ⫽ 417) Widowed/divorced/separated (n ⫽ 59) DK/NA (n ⫽ 9) Country Spain (n ⫽ 349) Mexico (n ⫽ 269) Cuba (n ⫽ 120) Job variables Type of hospital center Transplant center (n ⫽ 643) Procurement hospital (n ⫽ 95) Type of clinical service Surgical (n ⫽ 347) Medical (n ⫽ 391) Job category Physician (n ⫽ 281) Nurse (n ⫽ 335) Nursing assistant (n ⫽ 91) Auxiliary personnel (n ⫽ 10) DK/NA (n ⫽ 21) Job situation Permanent (n ⫽ 317) Temporary (n ⫽ 214) Contracted (n ⫽ 107) Resident (n ⫽ 66) DK/NA (n ⫽ 34) ODT variables Personal experience of ODT Yes (n ⫽ 254) No (n ⫽ 484) Deceased donation In favor (n ⫽ 584) Not in favor (n ⫽ 154) Possibility of needing a transplant Yes (n ⫽ 344) I do not know (n ⫽ 380) No (n ⫽ 14) Attitude toward living kidney donation In favor (n ⫽ 662) Not in favor (n ⫽ 76) Attitude toward living liver donation In favor (n ⫽ 602) Not in favor (n ⫽ 136) Variables of social interaction Donation of a family member’s organs In favor (n ⫽ 329) Would respect their wishes (n ⫽ 339) Against (n ⫽ 56) DK/NA (n ⫽ 14)
In Favor (n ⫽ 484; 66%)
Against (n ⫽ 69; 9%)
Undecided (n ⫽ 185; 25%)
P
37 ⫾ 10
39 ⫾ 11
39 ⫾ 10
.007
229 (48%) 252 (52%) 3
19 (28%) 49 (72%) 1
52 (29%) 130 (71%) 3
.000
170 (36%) 274 (57%) 35 (7%) 5
28 (41%) 34 (50%) 6 (9%) 1
55 (30%) 109 (60%) 18 (10%) 3
.414
224 (46%) 174 (36%) 86 (18%)
22 (32%) 36 (52%) 11 (16)
103 (56%) 59 (32%) 23 (12%)
.006
417 (86%) 67 (14%)
61 (88%) 8 (12%)
165 (89%) 20 (11%)
.547
226 (47%) 258 (53%)
40 (58%) 29 (42%)
81 (44%) 104 (56%)
.127
217 (46%) 194 (41%) 54 (12%) 4 (1%) 15
22 (32%) 37 (54%) 9 (13%) 0 (0%) 1
42 (23%) 104 (58%) 28 (16%) 6 (3%) 5
.000
203 (44%) 103 (28%) 73 (16%) 53 (11%) 25
30 (44%) 24 (35%) 9 (13%) 5 (8%) 1
84 (47%) 60 (33%) 25 (14%) 8 (5%) 8
.234
168 (13%) 316 (87%)
15 (42%) 54 (58%)
71 (32%) 114 (68%)
.045
419 (87%) 65 (13%)
40 (58%) 29 (42%)
125 (68%) 60 (32%)
.000
264 (55%) 213 (44%) 7 (1%)
29 (42%) 36 (52%) 4 (6%)
51 (28%) 131 (71%) 3 (1%)
.000
464 (96%) 20 (4%)
59 (86%) 10 (14%)
139 (75%) 46 (25%)
.000
435 (90%) 49 (10%)
44 (64%) 25 (36%)
123 (67%) 62 (33%)
.000
249 (52%) 211 (44%) 16 (3%) 8
19 (28%) 24 (36%) 24 (36%) 2
61 (33%) 104 (58%) 16 (9%) 4
.000
ACCEPTANCE OF XENOTRANSPLANTATION
225 Table 1. (continued)
Variable
Family discussion Yes (n ⫽ 567) No (n ⫽ 171) Partner’s opinion In favor (n ⫽ 385) Not known (n ⫽ 147) Against (n ⫽ 38) No partner (n ⫽ 113) DK/NA (n ⫽ 55) Prosocial and religious variables Prosocial activities Yes, I take part (n ⫽ 194) No, but I would like to (n ⫽ 465) No, never (n ⫽ 48) DK/NA (n ⫽ 31) Religion Catholic (n ⫽ 549) Another religion (n ⫽ 21) Atheist (n ⫽ 123) DK/NA (n ⫽ 45) Opinion of their religion In favor (n ⫽ 333) Against (n ⫽ 10) Not known (n ⫽ 248) DK/NA (n ⫽ 147)
In Favor (n ⫽ 484; 66%)
Against (n ⫽ 69; 9%)
Undecided (n ⫽ 185; 25%)
P
374 (77%) 110 (23%)
50 (72%) 19 (28%)
143 (77%) 42 (23%)
.665
296 (63%) 88 (19%) 17 (3%) 72 (15%) 11
26 (40%) 19 (29%) 6 (9%) 14 (22%) 4
63 (43%) 40 (28%) 15 (10%) 27 (19%) 40
.000
130 (28%) 317 (68%) 22 (4%) 15
16 (24%) 38 (58%) 12 (18%) 3
48 (28%) 110 (64%) 14 (8%) 13
.002
376 (79%) 12 (3%) 86 (18%) 10
54 (78%) 2 (3%) 13 (19%) 0
119 (79%) 7 (5%) 24 (16%) 35
.722
237 (58%) 6 (2%) 163 (40%) 78
34 (59%) 2 (3%) 22 (38%) 11
62 (49%) 2 (1%) 63 (50%) 58
.276
DK/NA, does not know/no answer; ODT, organ donation and transplantation.
Variables of Social Interaction. Both the attitude of the respondent’s partner toward donation and transplantation (P ⬍ .001) and the respondent’s attitude toward the donation of a family member’s organs (P ⬍ .001) affected responses toward xenotransplantation. Prosocial Behavior and Religious Variables. No significant differences were found (Table 1). Multivariate Analysis
Upon multivariate analysis, we observed the variables significantly related to attitude were: (1) sex (odds ratio [OR] ⫽ 1.721; P ⫽ .025); (2) attitude toward deceased donation (OR ⫽ 2.375; P ⬍ .001); (3) possibility of needing a transplant in the future (OR ⫽ 1.745; P ⫽ .005); (4) attitude toward living liver donation (OR ⫽ 1.992; P ⫽ .008); and (5) attitude against the donation of a family member’s organs (OR ⫽ 0.355; P ⫽ .007; Table 2). DISCUSSION
Xenotransplantation still is quite short of becoming a clinical reality, although it has overcome some barriers and may be a useful bridge for vital organs until a human source becomes available.4 In studies of the general public, acceptance rates of xenotransplantation were variable, ranging between 40% and 75%.7–12 In this respect, the attitude of health care workers toward this therapy is fundamental, because, as in human donation, information passed on by them to the public is highly credible.13
Our data showed that attitudes of personnel in services related to xenotransplantation were the same as or even less favorable than those described among the general public. For example, the data from Spanish employees showed that the general public showed more favorable attitudes than health care employees (74% vs 64%). This is a surprising finding, given their direct relationship with a preclinical liver xenotransplantation program from pig to baboon, such as the one being developed in these centers.4 These results may be explained in many ways, but are possibly due to controversies related to this type of research, such as the risk of xenoinfections and rejection,1 which could produce negative effects. Attitudes were the same among Mexican health care workers, although Cubans were more in favor. Currently, there are no data for the general public in Mexico and Cuba that would allow us to compare them with the general public in Spain. In Mexico, xenotransplantation has been performed using Langerhans and Sertoli pig cells for patients with diabetes type I.14 In these cases, the patients and family members perceived xenotransplantation pragmatically.15 A crucial factor within the hospital is job category. We found that physicians were those with the most favorable attitudes; those least in favor were the auxiliary personnel (77% vs 40%). This observation is important,16 because although the medical staff are potentially key players to provide a xenotransplantation program, we must not forget that other personnel have credibility for the public whatever their job category. Auxiliary personnel can cause social
226
RÍOS, MARTÍNEZ-ALARCÓN, AYALA-GARCÍA ET AL Table 2. Variables Affecting Attitude Toward Xenotransplantation in Personnel in Transplant-Related Services (Multivariate Analysis) Variable
Sex Female (n ⫽ 431) Male (n ⫽ 300) Attitude toward deceased donation Not in favor (n ⫽ 154) In favor (n ⫽ 584) Possibility of needing a transplant Not known (n ⫽ 380) Yes (n ⫽ 344) No (n ⫽ 14) Attitude toward living liver donation Not in favor (n ⫽ 136) In favor (n ⫽ 602) Actitud toward donation of a family member’s organs Would respect their wishes (n ⫽ 339) In favor (n ⫽ 329) Against (n ⫽ 56)
Regression Coefficient
Standard Error
Odds Ratio (Confidence Intervals)
P
0.543
0.242
1 1.721 (2.762–1.070)
.025
0.866
0.246
1 2.375 (3.846–1.468)
.000
0.556 0.224
0.198 0.735
0.688
0.261
1 1.745 (2.570–1.183) 1.252 (0.296–5.287) 1 1 1.992 (3.322–1.194)
0.319 ⫺1.034
0.210 0.386
1 1.375 (2.074–0.912) 0.355 (0.754–0.167)
alarm due to their less positive attitudes, which were more negative than the general Spanish-speaking general public.6 This point is important in the group of centers being investigated given their close relationship to each other and the presence of a preclinical xenotransplantation program in one of them with the possibility of its application in the others. There are a limited number of studies about the attitudes of health care personnel in countries other than Spain; there are generally less positive attitudes toward xenotransplantation. In a study of Australian acute care nursing personnel (n ⫽ 1728), Mohacsi et al17 reported that 66% of respondents did not like the idea of xenotransplantation; only 19% would accept it. In a French study about the acceptance of xenotransplantation among health care workers, Julvez et al18 observed that 34% of the nursing staff would accept it, a percentage that increased to 55% for physicians. If it were a life or death situation, these rates would be 61% and 72%, respectively. Regarding factors affecting attitudes toward xenotransplantation, there is a clear relationship between attitude toward human donation (living and deceased) and toward xenotransplantation. This association has already been described by authors, such as Omnell et al,19 where if a person is in favor of receiving a human organ, he/she is also prepared to receive an animal kidney or heart, assuming that the end result is the same as in human donation, as demonstrated by Terán-Escandón et al15 in diabetic patients with Langerhans and Sertoli pig cell transplants, who perceived xenotransplantation pragmatically. It is essential to remember that the results we have presented could change over time. In this respect, new knowledge and experience are fundamental. For example, even one news story, founded or unfounded, in favor or against xenotransplantation could cause a radical change in attitudes toward this matter.20 Therefore, it is fundamental
.005 .760
.008
.127 .007
to provide clear and simple information, because this is the main way for the general public and health care personnel in our area to become aware of our advances and to not be afraid of them. The results of this study showed that health care personnel fear our advances more than the public, revealing to a certain extent a failure to provide information about our research. To conclude, a third of health care personnel who work in transplant-related services were not in favor of xenotransplantation. Given the lack of awareness about the subject it has become necessary to provide more information, especially in centers with a preclinical xenotransplantation program or centers that have access to one, such as those in our study.
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227 14. Valdés-González RA, Dorantes LM, Garibay GN, et al: Xenotransplantation of porcine neonatal islets of Langerhans and Sertoli cells: a 4-year study. Eur J Endocrinol 153:419, 2005 15. Terán-Escandón D, Terán-Ortiz L, Ormsby-Jenkins C, et al: Psychosocial aspects of xenotransplantation: survey in adolescent recipients of porcine islet cells. Transplant Proc 37:521, 2005 16. Rios A, Conesa C, Ramirez P, et al: Attitude toward xenotransplantation among residents. Transplant Proc 37:4111, 2005 17. Mohacsi PJ, Blumer CE, Quine S, et al: Aversion to xenotransplantation. Nature 378:434, 1995 18. Julvez J, Tuppin P, Cohen S: Survey in France of response to xenotransplantation. Lancet 353:726, 1999 19. Omnell M, Persson NH, Ranstam J, et al: Xenotransplantation public perceptions: rather cells than organs. Xenotrasplantation 10:72, 2003 20. Martinez L, Rios A, Conesa C, et al: Attitude toward xenotransplantation in kidney and liver patients on the transplant waiting list. Transplant Proc 37:4107, 2005