Kidney Donation Rates Research Articles

Care of the Live Kidney Donor

The Editors of Transplantation are pleased to present to their readers this supplement which records the consensus of an International Forum on the care of the Live Kidney Donor held in Amsterdam, The Netherlands from April 1-4, 2004. The objective of the meeting was to develop an international consensus on the standard of care and a position statement of The Transplantation Society defining and affirming the responsibility of the transplantation community for the live kidney donor. The result was a real international consensus, with over 100 transplant experts from more than 40 countries around the world participating. This Forum was also in part a result of the involvement of The Transplantation Society with the World Health Organization (WHO) and functioned as a continuum of the Madrid WHO conference on organ donation and transplantation held in October 2003. What is presented is a detailed analysis of all relevant aspects of selection and management of live kidney donors. This document should serve as a useful benchmark for living donor programs all over the world. The Forum analyzed the sentinel events associated with live kidney donation; the data emphasized the extremely low operative mortality rates and the long-term safety of this procedure with, noting the absence of accelerated loss of renal function and lack of appearance of hypertension in normal donors post nephrectomy. Forum participants affirmed the necessity for live donors to receive complete medical and psychosocial evaluation prior to donation (1); they elaborated in detail the acceptance limits of donor hypertension, obesity, dyslipidemia, renal function, urine protein and blood, stone disease, and historical malignancy that still permit live kidney donation. A great detail of discussion focused on prevention of transmissible infectious diseases through live kidney transplantation. Specific recommendations for screening of various viral, bacterial, and parasitic diseases are presented. Likewise pre- and postoperative donor issues such as determination of cardiovascular risk in the live donor, the salutary effects of smoking cessation and alcohol abstinence, and the screening for pulmonary risk and thromboembolism are detailed. Readers will find the discussion of risk estimation for donor candidates with isolated medical abnormalities (hypertension, low grade proteinuria, microscopic hematuria, etc.) useful and somewhat reassuring in justifying decisions to include such people as potential living donors in specific instances. Readers of this supplement will also find interesting and provocative the discussion on how a number of aspects of live kidney donation vary around the world. Thus some of the extremely rigid blood and tissue donation restrictions currently enforced in certain countries should probably not be applied to organ donation where the risk/benefit ratio is so different. Also, restrictions on live unrelated kidney donation (presently prohibited in various countries because of the absence of HLA matches) are certainly not justified. Likewise, live donor exchanges specifically banned in certain countries as valued considerations should be allowed. The high rate of female live kidney donation was acknowledged and the potential role of coercion/discrimination in many countries was discussed and the need to deal with this issue in a culturally sensitive manner emphasized. The high rate of minors donating to adults was also identified and a consensus proposal that minors less than 18 years of age should not be used as living kidney donors was agreed to. The Editors of Transplantation hope that this supplement will be used where appropriate as a benchmark for standard of care in selection and management of live kidney donors. We welcome your thoughts and reactions to the ideas and recommendation contained therein. Weblinks http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14578768 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12451277

Improving kidney and live donation rates in Asia: Living donation

Organ transplantation started with organs donated by living subjects. Increasing demands brought cadaveric organ donation. The brain-death law, mandatory for this procedure, is prevalent in all countries involved in organ transplantation except Pakistan. Spain is the leading country in cadaveric organ donation (32.5 pmp). Despite the sources of living and cadaveric organs, both heart-beating and non–heart-beating, the gap between the demand and supply has widened. An example is the United States, where the numbers of patients on the waiting list for kidney transplantation have risen from 30,000 in 1988 to more than 116,000 in 2001. This has caused a resurgence in living donors all over the world. These can be related, unrelated, spousal, marginal, or ABO-incompatible donors. Family apprehensions, medical care costs, and nonexistent social security can be barriers to this form of organ donation. Unrelated organ donation can open the doors to commercialism. To make this process more successful, transplantation should be made reachable by all sectors of the population. This is possible when transplantation is taken to the public sector institutions and financed jointly by the government and community. To increase living organ donation especially in Asian countries, which face barriers of low literacy rates, ignorance, and cultural and religious beliefs, more efforts are needed. Public awareness and education play an important role. Appreciation and supporting the donors is necessary and justified. It is a noble act and should be recognized by offering job security, health insurance, and free education for the donor's children.

Unrelated living organ donation: ULTRA needs to go

The recent review of the Unrelated Live Transplant Regulatory Authority (ULTRA) provides administrative and statistical information regarding living donor kidney transplantation in the United Kingdom.1 However, it leaves much unsaid....

Factors limiting the rate of living-related kidney donation to children in an inner city setting.

A recent review of our center experience revealed that only 38% of our pediatric renal transplants come from living-related donors (LRD), which is 11% lower than the national average. The present study was designed to identify factors that limit the availability of LRD in our population pool. Retrospective chart reviews and subsequent telephone interviews were conducted with parents of all children who received renal replacement therapy (RRT) at our institution from 1990 to 1999. The availability of parents and their willingness to donate a kidney were noted. Self-reported willingness was defined as the verbal expression of a desire to donate. Firm willingness was defined as the completion of the steps necessary for donation, unless excluded by the medical team. Factors that may impact the ability to donate, such as donor age, ethnicity, religion, educational attainment, employment, and presence of other siblings younger than 18 yr of age, were evaluated. Statistical analyses were performed using the Student's t-test and chi-square analysis. Significant results were entered into a single-step multiple regression analysis. Sixty children were identified with RRT, of whom 60% were Blacks, 30% Hispanics, 7% Caucasians, and 3% Asian. Fifty-five mothers were available for interview. Forty-four mothers reported a desire to donate, nine were unwilling to donate, and two were undecided. However, only 35 attended for screening. Only 30 fathers were available and, of these, 27 reported willingness to donate, yet only 20 attended for screening. Seventy-four per cent (26 out of 35) of mothers screened and 55% (11 out of 20) of fathers screened were medically unsuitable for kidney donation. Nineteen potential donors had hypertension, diabetes and/or obesity, seven had renal disease, four had anemia, two had hepatitis C, and five had other conditions. Expressed unwillingness to donate was associated with a greater number of children (3.1 compared to 1.5 children in addition to the child with end-stage renal disease [ESRD]) (odds ratio 2.91, p < 0.05) and employment (26.3% vs. 4.0%, p < 0.05) (odds ratio 31.2, p = 0.05). Comparing mothers who were firmly willing to donate with mothers who did not complete screening and evaluation, unwilling mothers had, likewise, a greater number of children (2.9 vs. 1.2 in addition to the child with ESRD) (odds ratio 3.23, p < 0.01) and a greater number of years of education (12.4 vs. 10.4) (odds ratio 2.14, p < 0.05). Hence, the availability of living kidney donors for our inner city children is severely limited by a high rate of single parenthood and a high rate of comorbid conditions in the parental donor pool. Furthermore, there is a diminished capacity of the available parent, particularly the mother, to donate as she tends to have numerous other dependents.

OPEN VERSUS LAPROSCOPIC DONOR NEPHRECTOMY: IS THERE A DIFFERENCE IN RECIPIENT RENAL FUNCTION?

427 Laproscopic donor nephrectomy (LapNx) is now being used as a means of increasing living kidney donation rates. It has been reported to offer significant advantages to the donor over the open approach (OpenNx) by decreasing hospitalization duration and improving convalescence parameters. The renal function of recipients of LapNx has not been studied. The purpose of this study was to retrospectively review the outcomes of recipients of LapNx and compare them with those of OpenNx. The study group consisted of the first 143 consecutive LaproNx cases done at our center from 3/96 to 11/97. The control group consisted of the 100 consecutive OpenNx cases done at our center between 10/93 and 3/96, immediately prior to our conversion to LapNx as the standard harvesting technique. Mean duration of follow up was 0.75 y for LapNx and 2.6 y for OpenNx. The two groups were similar in terms of demographic characteristics, donor mean serum creatinine (SCr), CMV match, and mean CSA or FK-506 levels. Patients with LapNx were less likey to receive induction antilymphocyte prophylaxis (IAP). Mean SCr was higher in LapNx compared with OpenNx at one week (2.4 +/- 0.2 and 1.7 +/- 0.1 mg/dl, respectively; p = 0.001) and at one mo (2.0 +/- 0.1 and 1.6 +/- 0.1 mg/dl, p=0.04) following transplant. At 3 and 6 mo following transplant, the mean SCr was similar in LapNx and OpenNx (1.7 +/- 0.1 and 1.5 +/- 0.05 mg/dl at 3 mo; 1.7 +/- 0.1 and 1.7 +/- 0.1 at 6 mo). At one year after transplant, mean SCr for LapNx was less than that for OpenNx (1.4 +/- 0.1 and 1.7 +/- 0.1 mg/dl, p = 0.02). When adjusted for recipient age, recipient sex, recipient race, use of IAP, and mean CSA levels, mean SCr remained higher in LapNx at one week (mean difference in SCr = 0.5 mg/dl, p = 0.03) and remained lower at one year (mean difference in SCr = 0.2 mg/dl, p = 0.03). Adjusted SCr at 1, 3, and 6 mo were similar between groups. Kaplan-Meier analysis revealed similar combined graft and patient survival. The lengths of hospitalization after transplant (9.3 +/- 1.1 and 10.6 +/- 0.7 days) and need for dialysis in the first mo post transplant (9.1% and 5.0%, p=0.23) were similar in LapNx and Open Nx.. In summary, although laproscopically harvested kidney allografts initially function somewhat more poorly than those obtained by open procedure, we could not demonstrate any significant difference in renal function at one year in these patients.