Consensus statement on the live organ donor

The dynamics of recipient-donor relationships in living kidney transplantation

Psychosocial issues in kidney transplant donors and recipients are a cause for concern. We reviewed studies that investigated psychosocial issues in donors and recipients of living kidney transplants. A variety of instruments were used for this purpose. However, there was a lack of consensus regarding the structure and method of psychosocial assessment in living kidney donors. We found that only a few centers currently carry out a systematic psychosocial follow-up of recipients and their donors. The majority of psychosocial studies were of living kidney donors, indicating a preference of researchers to study psychosocial issues in live kidney donors. We believe living kidney transplant recipients are also an important group, and more studies should be done to better understand the psychosocial issues in this group. The majority of studies were retrospective in nature. We also discuss relationships, interactions, and communication patterns that characterize living kidney donation. We place emphasis on understanding the relational history of donors and recipients to provide supportive intervention and enable the potential donor make an informed decision about surgery. We recommend comprehensive psychosocial screening before and after transplantation and donation. This may decrease psychological problems and increase satisfaction with the transplantation process. Furthermore, the transplant community will need to address the type of instruments, duration of follow-up, and funding sources to carry out our recommendations.

Living-donor liver transplantation in the United States: identifying donors at risk for perioperative complications

Donor safety has been scrutinized by both the medical community and the media. Variability exists in reported donor complications and associated risk factors are ill defined. Use of administrative data can overcome the bias of single-center studies and explore variables associated with untoward events. A retrospective cohort study identifying living liver donors in two large healthcare registries yielded 433 right and left lobe donors from 13 centers between 2001 and 2005. Perioperative complications were identified using International Classification of Diseases, 9th Revision (ICD-9) coding data and classified according to the Clavien system. Logistic regression models identified factors associated with complications. There was one perioperative death (0.23%). The overall complication rate was 29.1% and major complication rate defined by a Clavien grade >or=3 was 3.5%. Center living-donor volume (OR = 0.97, 95% CI = 0.95-0.99) and the ratio of living-donors to all donors (living and deceased) (OR = 0.94, 95% CI = 0.92-0.96) were associated with a lower risk of all complications. Donor age >50 years (OR = 4.25, 95% CI = 1.22-14.87) was associated with a higher risk of major complications. Living liver donation is currently performed with a low risk of major morbidity. Use of administrative data represents an important tool to facilitate a better understanding of donor risk factors.

Evaluating living kidney donors: relationship types, psychosocial criteria, and consent processes at US transplant programs

We conducted a survey of 132 US kidney transplant programs to examine how they evaluate and select potential living kidney donors, focusing on donor-recipient relationships, psychosocial criteria, and consent processes. There is heterogeneity in donor-recipient relationships that are considered acceptable, although most programs (70%) will not consider publicly solicited donors. Most programs (75%) require a psychosocial evaluation for all potential living donors. Most programs agree that knowledge of financial reward (90%), active substance abuse (86%), and active mental health problems (76%) are absolute contraindications to donation. However, there is greater variability in how other psychosocial issues are considered in the selection process. Consent processes are highly variable across programs: donor and recipient consent for the donor evaluation is presumed in 57% and 76% of programs, respectively. The use of 13 different informed consent elements varied from 65% (alternative donation procedures) to 86% (description of evaluation, surgery and recuperative period) of programs. Forty-three percent use a 'cooling off' period. Findings demonstrate high variability in current practice regarding acceptable donor-recipient relationships, psychosocial criteria, and consent processes. Whether greater consensus should be reached on these donor evaluation practices, especially in the context of more expansive use of living donor kidney transplantation, is discussed.

Death of a living liver donor from illicit drugs

In children with acute hepatic failure, it has been suggested to offer living donor transplantation to all parents when a deceased donor organ can not be provided. Ethically, living related donation is coercive by its very nature, especially in emergencies. We report a 36-year-old woman who died from a drug overdose 57 days after living donor liver resection. The recipient was her 3-year-old son, who experienced acute hepatic failure as a result of acetaminophen intoxication. A deceased donor organ had not become available within 2 days after listing. Was the death of this living donor preventable or unpreventable? Certainly if the mother had decided not to take drugs, she would not have died from an overdose. One could argue that this was her personal choice, and beyond our influence. On the other hand, if we had not performed the surgery, the recipient might have died without receiving a liver transplant in time.

Differences in psychosocial profiles between men and women living kidney donors

BACKGROUND

The expansion of kidney transplantation by living donation has led to a disproportional increase in the women to men ratio among donors and this difference cannot be explained on the basis of medical exclusion. The present study was designed to test whether women donors are more likely to (i) display altruistic and gender-typed nurturing behaviour and (ii) be subtly influenced by family pressure to donate and less able to resist this pressure.

METHODS

All 71 (61% women) individuals who had donated a kidney at our centre between 1995 and 2005 were sent a survey. Thirty-nine individuals (71% response rate; 64% female participation) filled out and returned the survey, which included standardized measures of altruism, self-esteem, family dynamics and endorsement of gender-stereotyped roles, as well as sociodemographic questions and questions about donation.

RESULTS

Findings show no difference between women and men in terms of the psychological attributes measured. One woman and two men reported having felt pressure to donate, and 92% of women compared with 54% of men reported having felt free to change their mind. Men took longer than women to make the decision to donate.

CONCLUSIONS

Results suggest that among individuals who have already donated, there is no evidence that women may be more inclined to donate than man because of differences in their psychosocial profiles or because they may be more vulnerable to family pressure. Future research may gain from focusing on men and women donors and non-donors in families where transplantation is being considered.

The beauty of the gift: the wonder of living organ donation

In a recent opinion piece, Nancy Scheper-Hughes provides a sweeping indictment of living organ donation, even in cases where the gift is directed to a close family member. She describes the process with caustic powerful phrases such as "sacrificial violence" and a "call to 'self-sacrifice.'" She concludes that living organ donation "should be consigned to a back seat as an exceptional back-up to deceased donation." But her conclusions are based on anecdotes and data that are not representative of donor practice and motivation in the United States and other developed countries. At reputable transplant centers great care is taken to identify genuine volunteers and to protect their interests. Under these circumstances living organ donation remains a generally safe and beneficial procedure for the donor as well as the recipient, and a wonderful example of the goodness of people.

Insurability of living organ donors: a systematic review

Being an organ donor may affect one's ability to obtain life, disability and health insurance. We conducted a systematic review to determine if insurability is affected by living organ donation, and if concern about insurability affects donor decision making. We searched MEDLINE, EMBASE, SCI, EconLit and Cochrane databases for articles in any language, and reviewed reference lists from 1966 until June 2006. All studies discussing the insurability of living organ donors or its impact on donor decision making were included. Data were independently abstracted by two authors, and the methodological quality appraised. Twenty-three studies, from 1972 to 2006, provided data on 2067 living organ donors, 385 potential donors and 239 responses from insurance companies. Almost all companies would provide life and health insurance to living organ donors, usually with no higher premiums. However, concern about insurability was still expressed by 2%-14% of living organ donors in follow-up studies, and 3%-11% of donors actually encountered difficulties with their insurance. In one study, donors whose insurance premiums increased were less likely to reaffirm their decision to donate. Based on available evidence, some living organ donors had difficulties with insurance despite companies reporting otherwise. If better understood, this potential barrier to donation could be corrected through fair health and underwriting policies.

Laparoscopic Live Donor Right Nephrectomy: A New Technique to Maximize the Length of the Renal Vein Using a Modified Endo GIA Stapler

OBJECTIVES

To report the utilization of a modified Endo GIA vascular stapler to obtain the full length of the renal vein during transperitoneal laparoscopic live donor right nephrectomy.

METHODS

We used a modified Endo GIA stapler, in which the triple staggered rows of staples were removed from the kidney donor side to obtain the full length of the right renal vein. This technique has currently been used in nine consecutive transperitoneal laparoscopic right donor nephrectomies.

RESULTS

With this technique, the entire right renal vein length was harvested in all cases, without vascular complications. Mean renal warm ischemia time from clamping of the renal vessels to cold perfusion was 135s, and mean receptor postoperative glomerular filtration rate after 30 d was 67.3 ml/min. There were no graft losses.

CONCLUSIONS

A novel technique for laparoscopic live donor right nephrectomy is described. It allows harvesting the full length of the right renal vein in a safe and feasible way without compromising warm ischemia time.

Guidelines for the psychosocial evaluation of living unrelated kidney donors in the United States

Under the auspices of the United Network for Organ Sharing, the American Society of Transplant Surgeons and the American Society of Transplantation, a meeting was convened on May 25, 2006, in Washington, DC, to develop guidelines for the psychosocial evaluation of prospective living kidney donors who have neither a biologic nor longstanding emotional relationship with the transplant candidate. These 'unrelated' donors are increasingly often identified by transplant candidates via the Internet, print media and other public appeals. The expansion of living donor kidney transplantation to include significant numbers of donors with little to no preexisting relationship to the candidate has caused concern in the medical community regarding such psychosocial factors as donor psychological status, motivation, knowledge about donation and the potential for undue pressure to donate under some circumstances. Therefore, experts in mental health; psychosocial, behavioral and transplant medicine; and medical ethics met to specify (a) characteristics of unrelated donors that increase their risk for, or serve as protective factors against, poor donor psychosocial outcomes, (b) basic principles underlying informed consent and evaluation processes pertinent to these donors and (c) the process and content of the donor psychosocial evaluation. The meeting deliberations resulted in the recommendations made in this report.

Improving on-line information for potential living kidney donors

Individuals who consider becoming living kidney donors often search the internet for reliable information before contacting the transplant center. The quality of such information requires due consideration. Using the search engines Google and Yahoo and the WebMD information portal, two reviewers independently abstracted data on the classification, readability, and general quality of websites. The coverage and accuracy of each site's discussion of the risks, benefits, and process of living donation was also assessed against a checklist of recommended information. Eighty-six unique websites on living kidney donation were found. Most were created by transplant programs and transplant organizations. Although the content of most sites was accurate, almost all (98%) were written above the recommended patient reading level (i.e., fifth grade). On average, each site covered 38% of the recommended information on living donation (range 8-76%). Educational topics of potential long-term medical risks, psychological risks, and expected benefits to the donor were often missing. The most visited websites were often not ranked among the best sites to provide information. By better understanding the nature of on-line information, transplant professionals can direct their patients to the best available websites. Local educational efforts, including the effective use of internet resources, will ensure living donation and complete understanding of the risks by potential donors and recipients.

Living anonymous liver donation: case report and ethical justification

Most living organ donations are from genetically or emotionally related donors. Although some transplant centers are willing to accept donations from living anonymous kidney donors (LAKDs), very few centers will accept donations from living anonymous liver donors (LALDs). The difference in acceptance rates is primarily due to the greater risk in liver donation, which is estimated to be 10-fold that of the risk in kidney donation. We present a case of donation from a LALD, the first reported in Canada. There are currently no established standards for LALDs. Our criteria for the ethical acceptability of LALDs require such donors to be physically healthy, mentally competent, altruistic, highly motivated, well-informed and able to give voluntary consent to donation. Another major ethical criterion is that the likely psychological benefit to the LALD balances the physical risks. Our case demonstrates that transplants from LALDs are medically successful and ethically justified under certain conditions.

Current trends in live liver donation

The introduction of living donor liver transplantation (LDLT) has been one of the most remarkable steps in the field of liver transplantation (LT), able to significantly expand the scarce donor pool in countries in which the growing demands of organs are not met by the shortage of available cadaveric grafts. Although the benefits of this procedure are enormous, the physical and psychological sacrifice of the donors is immense, and the expectations for a good outcome for themselves, as well as for the recipients, are high. We report a current overview of the latest trends in live liver donation in its different aspects (i.e. donor's selection, evaluation, operation, morbidity, mortality, ethics and psychology). This review is based on our center's personal experience with almost 200 LDLTs and a detailed analysis of the international literature of the last 7 years about this topic. Knowing in detail how to approach to the different aspects of living liver donation may be helpful in further improve donor's safety and even recipient's outcome.

Working up donors for high-urgency and elective adult-to-adult live donor liver transplantation

Donor workup for adult-to-adult live donor liver transplantation is done to ensure that the donor remains physically and psychologically healthy after saving or improving the life of the recipient. Even though two-thirds of the liver transplants in our center were from live donors, this life-saving procedure remains a mere treatment option, given the magnitude of the donor operation with the associated donor risks. Live donor liver transplantation was also adopted for high-urgency situations provided that the donor was suitable and the recipient considered salvageable. Donor workup in this setting had not been reported in the literature. In this cohort of 399 potential donors, 128 (32.1%) ultimately underwent donor surgery. Donors in the high-urgency situation had a lower operation rate of 28.4% (64/225) compared with that of 36.8% (64/174) of donors in the elective situation (P = 0.049). Dropouts from step 1 mainly because of ABO incompatibility, positive hepatitis serology, comorbidities, and voluntary donor withdrawal were 52.6% (210/399). Only 11.6% (22/189) of the potential donors who proceeded to subsequent steps of the workup dropped out (2 were psychologically unsuitable, 10 were anatomically prohibitive). The transplantation rate of potential recipients with 1 or more potential donors was also high. The rates were similar for the high-urgency (55%, 64/116) and the elective (51%, 64/125) situations. In a region with scarcity of deceased donor liver grafts, careful and expeditious initial donor workup minimizes dropouts from subsequent steps and allows timely transplantation in high-urgency situations.

Toward current standards of donor right hepatectomy for adult-to-adult live donor liver transplantation through the experience of 200 cases

OBJECTIVE

To define the current standards of donor right hepatectomy, including the middle hepatic vein for adult-to-adult live donor liver transplantation.

SUMMARY BACKGROUND DATA

Donor morbidity and mortality are inevitable given the ultra-major nature of the donor operation. Results from a matured center could define the true impact of this donor procedure most accurately.

PATIENTS AND METHODS

From May 9, 1996 to April 13, 2005, 200 consecutive donors underwent donor right hepatectomy at the University of Hong Kong Medical Center. All right liver grafts except one included the middle hepatic vein. Donor characteristics, operation time, blood loss, hospital stay, laboratory results, and complications graded by Clavien's classification divided into four eras (each consecutive 50 cases) were compared.

RESULTS

Donor characteristics of the four eras were generally comparable. Operative outcomes improved progressively through the four eras. From era 1 to era 4, operation time decreased from 598 minutes (range, 378-932 minutes) to 391 minutes (range, 304-635 minutes). Blood loss also decreased from 500 mL (200-1600 mL) of era 1 to 251 mL (range, 95-595 mL) of era 4. Overall complication rate was 20.5% (41 of 200). Complications rates from eras 1 to 4 were 34%, 16%, 16%, and 16%, respectively. The most common complications were of grade I (24 of 41, 58.5%). A late donor death occurred in era 4 from the development of a duodenocaval fistula 10 weeks postoperation, giving a donor mortality of 0.5% (1 of 200).

CONCLUSIONS

This study validated the estimated morbidity and mortality of donor right hepatectomy of 20% and 0.5%, respectively. The data provide reference for counseling potential donors and setting the standards of donor right hepatectomy in the current era.

Living donor kidney transplantation in a global environment

Live donor kidney transplantation has become a widely sought treatment by patients with end-stage renal failure. As the outcome for the genetically and emotionally related live donor transplants is the same, this review considers live kidney transplantation from the broad scope of current international practice. Unrelated live donor transplantation can now be performed for incompatible donor recipient pairs via a simultaneous paired kidney donation. However, acceptance of the scientific data that an unrelated live donor transplant can now be performed successfully should not be misconstrued as an acceptance that an unrelated kidney may be purchased via a vendor sale. At a recent World Health Organization (WHO) conference of Middle East transplant professionals a statement of unequivocal opposition to commercialism was drafted. In the United States, the Institute of Medicine has recently published a significant report that affirms the legal prohibition of organ sales. These documents are in accord with the guiding principles of the WHO and the membership policy of The Transplantation Society. The person who gives consent to be a donor should be competent, willing to donate, free of coercion, medically and psychosocially suitable, and fully informed of the risks and benefits as a donor. With these principles established, the Amsterdam Forum has set forth a comprehensive list of medical criteria that is now used internationally in the evaluation of potential kidney donors. Guidelines of a psychosocial evaluation are also presented in this report for individuals who come forward through internet solicitation and other public appeals. It is now evident that the annual number of available deceased donors will not resolve the ongoing shortage of organs. Nevertheless, live donor kidney transplantation may not be the realistic final solution to an international public health epidemic of renal failure that is the result of an aging population of patients that have had inadequate preventive medical care.

Brain death - too flawed to endure, too ingrained to abandon

The concept of brain death has become deeply ingrained in our health care system. It serves as the justification for the removal of vital organs like the heart and liver from patients who still have circulation and respiration while these organs maintain viability. On close examination, however, the concept is seen as incoherent and counterintuitive to our understandings of death. In order to abandon the concept of brain death and yet retain our practices in organ transplantation, we need to either change the definition of death or no longer maintain a commitment to the dead donor rule, which is an implicit prohibition against removing vital organs from individuals before they are declared dead. After exploring these two options, the author argues that while new definitions of death are problematic, alternatives to the dead donor rule are both ethically justifiable and potentially palatable to the public. Even so, the author concludes that neither of these approaches is likely to be adopted and that resolution will most probably come when technological advances in immunology simply make the concept of brain death obsolete.

Gender disparity in organ donation

Organ donation is affected by legal, cultural, religious, and racial factors, as well as by health considerations. Although organs in and of themselves are gender neutral and can be exchanged between the sexes, women account for up to two thirds of all organ donations. There are no clear reasons why women are more willing to undergo the risks of surgery than are men, nor is this gender disparity mirrored in the demand for donated organs. More men than women are recipients, and women are less likely to complete the necessary steps to receive donated organs. Internationally, ethical concern has been focused on possible human rights violations in the harvesting of organs from prisoners and, in poor countries, on the trafficking of organs from girls and women who are expected to financially help their families by selling their organs.

Pediatric living donor lobar lung transplantation

Living donor lobar lung transplantation (LDLLT) was developed in order to mitigate the growing competition for deceased donor (DD) lungs and resultant increase in waiting list mortality. Because each of the two donor lobes serves as an entire lung for the recipient, donors who are taller than the recipient are preferred. Therefore LDLLT is particularly well suited for pediatric recipients for whom adults serve as donors. Although long-term outcomes after LDLLT reported by the Organ Procurement and Transplantation Network (OPTN) are worse compared with DD recipients, overall pediatric outcomes as well as single center reports from the most experienced programs are more promising. Particularly encouraging are the findings that bronchiolitis obliterans (OB) is less frequent or less severe in LDLLT recipients in comparison to DD recipients. Moreover, outcomes may be improved by careful selection of donors to ensure adequately sized donor lobes and minimization of infectious risks. Although no donor deaths have been reported, there is a moderate risk of significant short-term complications. Long-term follow-up has not been reported. The use of LDLLT has decreased in recent years, and the recent change by the OPTN to an urgency/benefit allocation system for DD lungs in patients 12 yr and older may further reduce the demand. Nonetheless, we anticipate that LDLLT will continue to be utilized in select circumstances, particularly in children under 12 where access to DD organs remains challenging.

Limiting financial disincentives in live organ donation: a rational solution to the kidney shortage

Availability of kidney transplantation is limited by an inadequate supply of organs, with no apparent remedy on the immediate horizon and increasing reliance on living donors (LDs). While some have advocated financial remuneration to stimulate donation, the National Organ Transplant Act (NOTA) of 1984 expressly forbids the offer of 'valuable consideration.' However, recent developments indicate some fluidity in the definition of valuable consideration while evolving international standards highlight deficiencies (particularly regarding long-term care and follow-up) in the current American system. Recognizing that substantial financial and physical disincentives exist for LDs, we propose a policy change that offers the potential to enhance organ availability as well as address concerns regarding long-term care. Donors assume much greater risk than is widely acknowledged, risk that can be approximated for the purpose of determining appropriate compensation. Our proposal offsets donor risk via a package of specific benefits (life insurance, health insurance and a small amount of cash) to minimize hazard and ensure donor interests are protected after as well as before nephrectomy. It will fund medical follow-up and enable data collection so that long-term risk can be accurately assessed. The proposal should be cost effective with only a small increase in the number of LDs, and the net benefit will become greater if removal of disincentives stimulates even further growth. As importantly, by directly linking compensation to risk, we believe it preserves the essence of kidney donation as a gift, consistent with NOTA and implementable in the United States without altering current legal statutes.

Utilizing list exchange and nondirected donation through 'chain' paired kidney donations

In a list exchange (LE), the intended recipient in an incompatible pair receives priority on the deceased donor waitlist (DD-waitlist) after the paired incompatible donor donates a kidney to a DD-waitlist candidate. A nondirected donor's (ND-D) kidney is usually transplanted directly to a DD-waitlist candidate. These two established practices would help even more transplant candidates if they were integrated with kidney paired donation (KPD). We consider a scenario in which the donor of an LE intended recipient (LE-IR) donates to a compatible KPD intended recipient (KPD-IR), and the KPD donor (KPD-D) donates to the waitlist (an LE-chain). We consider a similar scenario in which an ND-D donates to a KPD-IR and the KPD-D donates to the DD-waitlist (an ND-chain). Using data derived from the New England Program for Kidney Exchange (NEPKE) and from OPTN/SRTR recipient-donor distributions, simulations are presented to evaluate the potential impact of chain exchanges coordinated with KPD. LE donors (LE-D) and ND-D who are ABO-O result in the highest number of additional transplants, while results for ABO-A and B donors are similar to each other. We recommend that both LE and ND donations be utilized through chain exchanges.

Single-Surgeon Laparoscopic Donor Nephrectomy and Renal Transplantation

OBJECTIVES

To demonstrate the feasibility of single-surgeon performance of laparoscopic donor nephrectomy and recipient living renal transplantation.

METHODS

Fifteen consecutive donor-recipient pairs were performed from August 2003 and July 2004 by a single surgeon at one institution. Routine donor and recipient outcome measures were prospectively assessed.

RESULTS

The mean donor height and weight was 66 in. and 151 lb, respectively. All donors underwent left nephrectomy. Renal arteries were paired in 3 (20%) of 15 donors. No donors underwent conversion or transfusion. No donor complications occurred. The mean operating room time, estimated blood loss, and hospital stay was 195 minutes, 200 mL, and 2 days, respectively. The mean recipient height and weight was 65 in. and 158 lb, respectively. The mean recipient age was 46 years (range 21 to 69). Of the 15 recipients, 3 (20%) had previously undergone transplantation. The mean operating room time, blood loss, and hospital stay for the recipients was 155 minutes, 100 mL, and 4.5 days, respectively. No recipient operative complications occurred. All allografts functioned immediately. The median recipient creatinine nadir was 1.1 mg/dL. Of the 15 recipients, 3 (20%) had postoperative complications during follow-up, including reintubation in 1, pneumonia in 1, and acute rejection in 1. The patient and graft survival rate were both 100%, and the mean serum creatinine was 1.16 mg/dL at a mean and median follow-up of 187 and 164 days (range 18 to 350), respectively.

CONCLUSIONS

We report the first series evaluating the performance of single-surgeon laparoscopic donor nephrectomy and living renal transplantation. Single-surgeon performance of both laparoscopic donor nephrectomy and living renal transplantation is technically feasible and logistically straightforward. The donor and recipient outcomes are consistent with those reported in published reports.

Should children ever be living kidney donors?

Living kidney donation by minors is an infrequently performed although highly controversial procedure. This manuscript reports the frequency of this practice in North America, Europe, Australia and New Zealand. The relevant laws and professional guidelines are reviewed and the ethical considerations discussed.

Living Kidney Donation: Evolution and Technical Aspects of Donor Nephrectomy

For more than 40 years, living donor nephrectomy was performed through a flank incision drawn on the urologic experience with nephrectomy for cancer. Since its introduction one decade ago, laparoscopic donor nephrectomy has gained widespread acceptance and popularity; currently over one-half of donor nephrectomies in the United States are performed with this technique. The changing practice of donor nephrectomy resembles in many ways the evolution of minimally invasive in other subspecialties. The lessons learned from these technical developments are valuable and can be adapted by general surgeons and urologists when called upon to perform nephrectomy for organ donation or kidney disease.

Is it ethical for patients with renal disease to purchase kidneys from the world's poor?

In many countries, the number of patients waiting for a kidney transplant is increasing. But there is a widespread and serious shortage of kidneys for transplantation, a shortage that can lead to suffering and death. One approach to tackling the shortage is for a patient with renal disease to buy a kidney from a living donor, who is often in a developing country, a sale that could--in theory at least--help to lift the donor out of poverty. Such kidney sales are almost universally illegal. Proponents of kidney sales argue that since the practice is widespread, it would be safer to formally regulate it, and that society should respect people's autonomous control over their bodies. Critics express concern about the potential for exploitation and coercion of the poor, and about the psychological and physical after-effects on the donors of this illegal kidney trade.

Psychosocial evaluation of candidates for living related kidney donation

Living kidney donation has raised practical and ethical questions since renal transplantation became possible 50 years ago. Nevertheless, living donors are a common source for badly needed organs in the pediatric population. The safety and well being of the living donor are important concerns. Among the risks of living donation are those of a psychological and social nature. To protect these donor interests, psychosocial evaluations of donors are done at some transplant centers, but there is a lack of consistency regarding standardization of the evaluation, the content of the evaluation, and the role of the interviewer. Goals of the overall living donor evaluation for kidney transplantation at The Children's Hospital of Philadelphia, and the components of the psychosocial evaluation protocol in particular, are presented. The protocol's strengths are discussed, including the standardization of evaluations for all potential donors; the broad spectrum of psychosocial domains assessed; the psychometric measures administered; the systematic handling of negative results and some donors' desire to opt out; and the protection of confidentiality. Future directions with regard to long-term psychosocial outcomes and research protocols are discussed.

Experience with an organ procurement organization-based non-directed living kidney donation programme

The organ procurement organization (OPO)-based non-directed living kidney donation programme was developed to decrease wait times for kidney transplants, and to meet the community's desire for altruistic living donation. Community awareness was encouraged through information about non-directed living kidney donation on the state donor registry Web site, and through the media. The OPO received all inquiries and responded with phone calls, e-mails, printed information, medical/social history questionnaires, interviews, and referrals to the transplant centres. Kidneys were allocated according to the United Network for Organ Sharing (UNOS) wait list for the evaluating transplant centre. Between March 2002 and 23 September 2005, there were 608 inquiries to the OPO about non-directed living kidney donation. In 41 months, 20 transplants occurred with kidneys from non-directed donors. The donor registry and OPO-sponsored publicity led to 578 of the 608 inquiries and 15 of the 20 transplants. OPO screening saved transplant centre resources by ruling out 523 inquiries, referring 76 to transplant centres for complete evaluations. Optional donor/recipient meetings appeared to be beneficial to those participating. OPO-based non-directed living donor programmes can be effective and efficient. Standardization of evaluation, allocation, and follow-up will allow for better data collection and more widespread implementation.

Incompatible kidney donor candidates' willingness to participate in donor-exchange and non-directed donation

Although paired donation, list donation and non-directed donation allow more recipients to receive living donor transplants, policy makers do not know how willing incompatible potential donors are to participate. We surveyed 174 potential donors ruled out for ABO-incompatibility or positive cross-match about their participation willingness. They were more willing to participate in paired donation as compared to list donation where the recipient receives the next deceased donor kidney (63.8% vs. 37.9%, p < 0.001) or non-directed donation (63.8% vs. 12.1%, p < 0.001). Their list donation willingness was greater when their intended recipients moved to the top versus the top 20% of the waiting list (37.9% vs. 19.0%, p < 0.001). Multivariate logistic regression modeling revealed that potential donors' empathy, education level, relationship with their intended recipient and the length of time their intended recipient was on dialysis also affected willingness. For paired donation, close family members of their intended recipient (odds ratio (OR) = 3.01, confidence intervals (CI) = 1.29, 7.02), with high levels of empathy (OR = 2.68, CI = 1.16, 6.21) and less than a college education (OR = 2.67, CI = 1.08, 6.61) were more willing to participate compared to other donors. Extrapolating these levels of willingness nationally, a 1-11% increase in living donation rates yearly (84-711 more transplants) may be possible if donor-exchange programs were available nationwide.

What is the system failure?

As a result of the increasing use of live organ donors, international conferences have been held in Amsterdam and Vancouver to address the transplant community's concern for the well-being of such donors. Congress has considered arguments to permit a regulated market of organ sales but has rejected such a proposal, in part because of a fundamental ethical principle: selling one's kidney or any other part of one's body violates the dignity of the human person. The "system failure" is not only at the doorstep of organ donation. The expansion of the waiting list for kidney transplants is heavily composed of the elderly who could have benefited by preventive medical care.

Proposed classification of complications after live donor nephrectomy

OBJECTIVES

A standardized classification for the potential complications of living donor nephrectomy is an essential step in establishing a construct for monitoring and reporting the outcomes of this procedure. It is also helpful in informing potential donors about the inherent risks of the donor operation as part of the informed choice process.

METHODS

We reviewed 600 laparoscopic live donor nephrectomies performed at our center. A modification of the Clavien classification system describing procedure-related complications was developed and used to grade the severity of all complications.

RESULTS

We observed 43 complications (7.2%) in our series of 600 patients. Grade 1 defines all events that, if left untreated, would have a spontaneous resolution or needed a simple bedside procedure (39.5%). Grade 2 complications differ from grade 1 in that they are potentially life-threatening and usually require some form of intervention, but do not result in ongoing disability. We subdivided grade 2 complications (55.8% in our study) into 2a, 2b, and 2c. The latter describes complications requiring open conversion of laparoscopic donor nephrectomy for patient treatment. Grade 3 complications are events with residual or lasting disability (4.7% in our review). Grade 4 events are those resulting in renal failure or death because of any complication (none occurred in our series).

CONCLUSIONS

A graded classification scheme for reporting the complications of donor nephrectomy may be useful for maintaining registry information on donor outcomes and when informing potential donors about the risks and benefits of this procedure.

Anesthetic management of a pregnant living related liver donor

Pregnancy is often considered a contraindication to living related liver donation. There are serious medical and ethical considerations if a pregnant woman insists on undergoing partial hepatectomy to save her sick child. Herein we report a case of living related liver donation from a pregnant woman at 18 weeks of gestation to her 1-year-old child with decompensated cirrhosis due to biliary atresia. The left lateral segment of the liver was harvested for donation. Meticulous surgical technique and anesthetic management were mandatory in assuring a successful outcome. While this isolated case demonstrated that living related liver donation can be performed successfully with a pregnant donor, it should be undertaken only when there is absolutely no other donor and the recipient is in urgent need.

[Living donor liver transplantation from the perspective of the donor: results of a psychosomatic investigation]

OBJECTIVES

Living donor liver transplantation (LDLT) has been gaining importance in the treatment of endstage liver disease in adults. Thus far, only few empirical studies have been published on the psychosocial situation of donors who are faced with the risk of medical complications after resection of the right hepatic lobe. The aims were to describe the clinical problems before and after transplantation and to contribute to the discussion of ethical issues based on empirical findings.

METHODS

In the present overview, the pre-/post-transplant and follow-up periods are characterized from a psychosocial point of view using actual psychosocial and medical findings in living donors of the right hepatic lobe.

RESULTS

Before LDLT, 11 % of potential donors were not recommended for the transplantation due to marked ambivalence about the operation. After donation 26 % of donors showed high values for anxious depression and physical complaints despite low rates of surgical complications.

CONCLUSIONS

For clinical psychosomatic evaluations of potential donors it is important to provide donors an opportunity to report any misgivings and anxieties as openly as possible. The psychosocial impairment and physical complaints of some donors after transplantation are yet not clearly understood. More psychosocial studies in this field will be necessary to investigate ethical questions and to develop criteria for an evidence-based medical care of living donors.

Increasing the pool of transplantable kidneys through unrelated living donors and living donor paired exchanges

Renal transplantation is the best therapy for eligible patients with end-stage renal disease (ESRD). Unfortunately the ability to perform this procedure is limited by a severe shortage of transplantable kidneys. One of the most successful approaches to this serious problem has been to expand the pool of living donors. This has been accomplished primarily by lifting restrictions on the use of genetically unrelated volunteers. As a result, acceptable living kidney donors now include individuals who are related to their recipients only through emotional bonds (e.g., spouses) and, at some centers, even people who are not related to their recipients at all. Living donor paired kidney exchanges provide a novel means for increasing further the number of kidneys available for transplantation. Each of these approaches will be reviewed.

The expectancies of living kidney donors: do they differ as a function of relational status and gender?

BACKGROUND

While two-thirds of the living kidney donors continue to be genetically related to the recipient, there has been a 300% increase in unrelated living donors over the last 10 years. Also, women continue to represent more than half of all the living kidney donors. This study examined whether donor expectancies varied as a function of relational status or gender.

METHODS

362 kidney donor candidates (232 related, 130 unrelated) completed the Living Donation Expectancies Questionnaire (LDEQ). A 2 (relational status: related or unrelated) x 2 (gender: male or female) multivariate analysis of variance was conducted to examine main and interaction effects across the six domains of the LDEQ: interpersonal benefit (IB), personal growth (PG), spiritual benefit (SB), quid pro quo (QPQ), health consequences (HC) and miscellaneous consequences (MC).

RESULTS

The highest expectancies were for PG (54.1%) and IB (29.8%), followed by expectations of MC (18.2%), SB (16.9%), HC (14.4%), and QPQ (4.4%). Multivariate analyses showed a relational main effect [F = 4.18, P = 0.02] and a gender main effect [F = 5.09, P = 0.01]. Subsequent univariate analyses showed significant effects (P<0.05) for IB (related>unrelated), QPQ (men>women), HC (unrelated>related, men > women) and MC (unrelated > related).

CONCLUSION

Overall, donor candidate expectancies appear to be realistic in light of previous findings of donor benefit. However, some living donor expectancies may vary as a function of donor relational status and gender. It may be important to assess and appropriately address both positive and negative expectancies at the time of donor evaluation. The LDEQ may be a useful clinical tool for assessing such expectancies.

Aortic Stiffness, Living Donors, and Renal Transplantation

In subjects with renal disease, reduced renal function and increased arterial stiffness are significantly associated in cross-sectional studies. The relationship is independent of age, blood pressure (BP), and atherosclerosis. Because both variables are independent predictors of cardiovascular risk, time-dependent relationships between them are important to determine. Aortic pulse wave velocity was measured noninvasively by comparison with healthy volunteers in 101 living kidney donors and their 101 corresponding recipients. Healthy volunteers were divided into 2 groups: one was recipient related through familial links and the other was nonrecipient related. Independently of age, gender, and BP, pulse wave velocity was significantly elevated in donors and recipients by comparison with the 2 groups of healthy volunteers. Pulse wave velocity was significantly higher in the recipient-related than in the nonrecipient-related group. Whereas in healthy volunteers, pulse wave velocity was exclusively related to age, gender, and BP, in donors and recipients, it was rather associated with a cluster of cardiovascular risk factors, including smoking habits and plasma glucose. Major factors related to pulse wave velocity were renal: time since nephrectomy (donation date) in donors, in whom pulse pressure was specifically associated with proteinuria, and renal rejection in recipients. Plasma creatinine doubling secondary to chronic allograft nephropathy was significantly associated with renal rejection and donor pulse wave velocity, independent of age. Our findings strongly suggest consistent interactions (including familial factors) between kidney function and arterial stiffness. Assessment of cause–effect relationships and implication of biochemical and/or genetic factors warrant additional studies.

Direction of the Organ Procurement and Transplantation Network and United Network for Organ Sharing regarding the oversight of live donor transplantation and solicitation for organs

The Organ Procurement and Transplantation Network (OPTN) operated by United Network for Organ Sharing (UNOS) has taken recent steps to address public solicitation for organ donors and its oversight of live donor transplantation. This report provides the direction of the OPTN regarding deceased donor solicitation. The OPTN has authority under federal law to equitably allocate deceased donor organs within a single national network based upon medical criteria, not upon one's social or economic ability to utilize resources not available to all on the waiting list. The OPTN makes a distinction between solicitations for a live donor organ versus solicitations for directed donation of deceased organs. As to live donor solicitation, the OPTN cannot regulate or restrict ways relationships are developed in our society, nor does it seek to do so. OPTN members have a responsibility of helping protect potential recipients from hazards that can arise from public appeals for live donor organs. Oversight and support of the OPTN for live donor transplantation is now detailed by improving the reporting of live donor follow-up, by providing a mechanism for facilitating anonymous live kidney donation, and by providing information for potential live kidney donors via the UNOS Transplant Living website.

3D-multidetector CT angiography in the evaluation of potential donors for living donor lung transplantation

INTRODUCTION

In living donor lung transplant, donor lobectomies from 2 donors provide right and left lower lobes for transplantation. In the past, routine evaluation of pulmonary anatomy was not performed preoperatively. Intraoperatively, surgeons were often forced to sacrifice the lingular artery or right middle lobe segmental artery to obtain an adequate arterial cuff for safe reimplantation. This study was performed to evaluate the utility of preoperative 3D-multidetector CT angiography (3D-MDCTA) as a noninvasive method of assessing pulmonary arteries to improve donor selection and surgical planning for living lung donors.

SUBJECTS AND METHODS

Five potential lung donors for 2 recipients were included in the study. CT scanning with 4 channel multidetector-row CT was performed, using a modified pulmonary embolism protocol. Post-processing was performed using volume rendering techniques on a commercially available workstation.

RESULTS

3D-MDCT demonstrated that there are a number of variations in pulmonary arterial anatomy and that ideal anatomy was seldom encountered. Comparison of different donors determined which lower lobes were most favorable for transplantation. Surgery confirmed the accuracy of 3D-MDCTA. There were no pulmonary arterial complications, and no vessels were sacrificed.

CONCLUSION

Safely explanting lower lobes from living donors for lung transplantation poses challenges not encountered in harvesting cadaveric donors or performing lobectomies for malignancy. 3D-MDCTA of pulmonary arteries can noninvasively delineate the often-complex pulmonary anatomy, which may assist in donor selection as well as reduce donor intraoperative and postoperative vascular complications.

Laparoscopic donor nephrectomy: an update

PURPOSE OF REVIEW

Laparoscopic donor nephrectomy is considered the gold standard for renal donation. In the hands of experienced laparoscopists it provides a safe and equally effective alternative to open nephrectomy, and recipient graft function has been shown to be equivalent regardless of the procurement method utilized. Complication rates and postoperative donor renal function are equivalent to that of open nephrectomy, whereas recovery time is significantly shorter and surgical scars more cosmetic with the laparoscopic approach.

RECENT FINDINGS

Advances in preoperative imaging and laparoscopic technique have enabled surgeons to broaden the patient population considered for donor nephrectomy. Improved three-dimensional imaging facilitates operative planning and intraoperative dissection, and the retroperitoneoscopic approach has decreased operative time. Acquisition of laparoscopic skills has also enabled surgeons to perform donor nephrectomies on kidneys that previously would have been considered less desirable for donation (e.g. right-sided or with anomalous vasculature).

SUMMARY

End-stage renal disease and the need for renal transplantation continue to be major medical concerns in the United States and worldwide. Advances in donor nephrectomy have reduced the demand for organs by increasing the potential organ pool while limiting risk to donors. As imaging and laparoscopic techniques continue to advance, it is anticipated that minimally invasive donor nephrectomy will continue to evolve. This review summarizes the developments to date.

More on parental living liver donation for children with fulminant hepatic failure: addressing concerns about competing interests, coercion, consent and balancing acts

Parental living liver donation for children with fulminant hepatic failure raises complex ethical issues. According to a recent editorial in this journal, these include contradictory interests, the possibility of coercion and compromised consent and the need to balance the risks to the donor against the potential benefits for the recipient. Here I argue that in this setting, interests are often aligned rather than conflicted, that coercion of parental donors is rare, that consent may sometimes be valid even when it is not fully informed and that the correct balance to consider is the relative weights of risks and benefits for the donor. I conclude that living liver donation by parents of children with fulminant hepatic failure is consistent with societal norms of parental behavior, ethically acceptable and should be permitted regardless of the efficiency of the deceased donor organ recovery program.

The Ethics of Living Donor Lung Transplantation

A constant awareness of the risk to the living donors must be maintained with any living donor organ transplantation program, and comprehensive short- and long-term follow-up should be strongly encouraged to maintain the viability of these potentially life-saving procedures. There has been no perioperative or long-term mortality following lobectomy for living lobar lung transplantation, and perioperative risks associated with donor lobectomy seem to be similar to those seen with standard lung resections. These risks might increase, however, if the procedure is offered on an occasional basis and not within a well-established program. The long-term outcomes and functional effects of lobar donation raise important questions that are unanswered. This has proved difficult to follow closely, because of the fact that many donors live far from the transplant medical center and are reluctant to return for routine follow-up evaluation. The death of a recipient can further exacerbate this situation, because there is reluctance to insist on further routine examinations for a grieving donor. Prospective donors must be informed of the morbidity associated with lobectomy and the potential for mortality, and for potential negative recipient outcomes in regard to life expectancy and quality of life after transplantation. Although cadaveric transplantation must be considered because of the risk to the donors, living lobar lung transplantation should continue to be used under properly selected circumstances. The results reported by the authors' group and others are important if this procedure is to be considered as an option at more pulmonary transplant centers in view of the institutional, regional, and international differences in the philosophic and ethical acceptance of the use of living organ donors for transplantation. The integration of ethical discussion into topics that are relevant and of interest to thoracic surgeons, such as living lung donation, is a recent and welcome event. Many of the clinical situations that thoracic surgeons deal with on a daily basis have important and complex ethical implications, and there has been little training to deal effectively with these issues. This is changing as invited discussions on ethically compelling topics are finding their way into journals and the programs of national meetings. What may be of more importance, however, is the development of an ethics curriculum for those training in the specialty. The core curriculum recommended by the Thoracic Surgical Directors Association (which represents the leadership of the 89 approved residency training programs in the United States) has one lecture pertaining to ethics out of the several hundred offerings in its requisite curriculum. It is hoped that this will change in the near future.