The Importance of Innovative Efforts to Increase Organ Donation

Abstract

IN THE UNITED STATES, PATIENTS WITH END-STAGE REnal disease have 2 treatment options: dialysis or a kidney transplant. Those choosing a transplant have 2 donor choices: a living donor or a deceased donor. Considerable information has been accumulated to help guide patient choices. Compared with dialysis, a transplant leads to a longer life, enhances quality of life, and is cost-effective for the health care system. Moreover, a living donor transplant (either related or unrelated) leads to better outcomes (patient and graft survival) than a deceased donor transplant. Thus, for patients with end-stage renal disease who are medically eligible for a transplant, the best treatment choice is a living donor transplant. In the last 2 decades, it has been recognized that unrelated living donor transplants have results equivalent to related living donor transplants. In 2004, unrelated living donor transplants accounted for more than 34% of living donor transplants performed in the United States. But what if no living donor is available? A transplant candidate might not have an eligible living donor for many reasons. First, the donor operation is associated with morbidity and mortality, so philosophically, many transplant personnel and community physicians do not encourage use of a living donor. For the same reason, eligible donor candidates may not volunteer. Second, the donor operation requires time off work, and some willing candidates without health or disability insurance may not be able to afford donating. Third, a donor must be in good health, have 2 normal kidneys, have normal kidney function, and not have any disease that would be transmitted with the transplanted kidney. Many transplant candidates have no family or friends who meet these criteria. Fourth, the donor must be compatible by blood type and immunologically compatible with the recipient. Blood type compatibility follows the same rules as for blood transfusions (eg, an individual with blood type O is a universal donor, but can only receive a kidney from a blood type O donor). Immunologic compatibility is determined by mixing recipient serum (containing antibodies), complement, and donor white blood cells (the test is called a crossmatch); if recipient antibody kills the donor cells (a positive crossmatch), the transplant is not performed. If, for any reason, a living donor transplant is not possible, the transplant candidate must go on the waiting list for a deceased donor transplant. In the last 2 decades, the number of candidates annually on the waiting list for a deceased donor transplant has exceeded the number of available kidneys (with little increase in deceased donation during this same period). As a consequence, waiting time has steadily lengthened. In 1980, a candidate on the waiting list could expect a transplant within 1 year. Currently, more than 62 000 candidates are on the national kidney waiting list, and the average waiting time in many parts of the country is longer than 5 years. This increased waiting time has significant negative consequences. Annually, about 7% of the candidates on the waiting list die. These deaths are not limited to older patients with extrarenal morbidity, but also occur in young ( 40 years) primary transplant candidates (V. Casingel, MD, unpublished data, 2005). The mortality rate decreases dramatically following transplantation. In addition, longer waits while continuing to undergo dialysis are associated with worse posttransplantation outcomes. For many years, immunologic barriers were thought to be the major hurdle in transplantation; today, many cite the organ shortage as the major limitation. Efforts to increase deceased organ donation have included public relation campaigns, improvements in the consent process, the use of expanded-criteria donors (ie, donors with characteristics associated with worse transplant outcomes), and the use of nonheartbeating donors. These efforts have resulted in a small increase in deceased donor transplants in the United States in the last 2 years. Unfortunately, as noted in a recent study by Sheehy et al, even if all potential deceased donors became actual deceased donors, there would still be a shortage of organs. During the last decade, the largest expansion of donation has been in the use of living donors, particularly unrelated living donors. The use of unrelated living donors has the greatest potential for increasing the number of donors in the future.