Consensus statement on the live organ donor

One hundred consecutive living kidney donors: modern issues and outcomes

In order to define current issues and outcomes of living kidney donation, 100 consecutive living donors operated on between July 1996 and March 2001 were evaluated. The 64 women and 36 men ranged in age from 19 to 72 yr (mean 42.5 yr), and 65 were related to the recipient while 35 were unrelated donors. Hospital admission the morning of surgery and use of a minimal open approach to the donor kidney were standard, as were post-operative epidural pain control and plans for short hospital stay. The 100 donors were hospitalized for 2 (25), 3 (48), 4 (18), 5 (8), or 6 (1) days, with an average length of stay of 3.12 d (range 2-6 d). The mean charge for kidney donor hospitalization was 14,470 dollars (range 9671-22,808 dollars). There were no major intra or immediate post-operative complications. Six rehospitalizations occurred for post-donation nausea, vomiting, dehydration (n = 2); spinal headache; pneumonia and wound haematoma; and late wound reexploration (one hernia and one nerve entrapment). All donors returned to pre-operative functional status within 6 d to 6 wk of donation. All kidneys functioned immediately in the 100 recipients (50 women, 50 men) who averaged 46.6 yr of age (range 17-69 yr); recipient length of stay averaged 3.81 d (range 2-15 d). All donors survived in excellent health; recipient graft and patient survival, respectively, are 87 and 90% through the entire 5-yr period. Excellent long-term outcomes for living kidney donors may be accomplished using minimal open surgical technique, post-operative epidural pain control and plans for a brief hospitalization. Expansion of living donor resources in renal transplant programs may grow as unrelated kidney donation and non-directed donation as well as minimally invasive (open and laparoscopic) techniques evolve.

The living anonymous kidney donor: lunatic or saint?

Studies indicate that 11% to 54% of individuals surveyed would consider donating a kidney, while alive, to a stranger. The idea of 'living anonymous donors' (LADs) as a donor source, however, has not been embraced by the medical community. Reservations focus on the belief that LADs might be psychologically unstable and thus unsuitable donors. Our goal was to inform policy development by exploring the psycho-social make up and motivations of the LAD. Ninety-three unsolicited individuals contacted our center expressing interest in living anonymous donation. Of these, 43 participated in our study, completing two extensive inventories of psychopathology and personality disorder and taking part in the Comprehensive Psycho-Social Interview (CPSI). From the Personality Assessment Inventory (PAI), the revised NEO Personality Inventory (NEO PI-R), and the CPSI, coders assessed psychological health, psycho-social suitability, commitment, and motivations. Twenty-one participants passed the stringent criteria to be considered potential LADs. Content analysis of motivations showed that potential LADs were more likely than non-LADs (those who did not pass the criteria) to have a spiritual belief system and to be altruistic. Non-LADs were more likely than potential LADs to use donation to make a statement against their families. The authors conclude with a preliminary outline of eight policy recommendations.

Nonaltruistic kidney donations in contemporary Jewish law and ethics

BACKGROUND

In 2000, the Consensus Statement on the Live Organ Donor reported that "direct financial compensation for an organ from a living donor remains controversial and illegal in the United States" and took note of the position of the Transplantation Society that "Organs and tissue should be given without commercial consideration or commercial profit." Christian authorities insist that organ donors must not accrue economic advantage, and "selling" organs deprives the donation of its ethical quality.

METHODS

The writings of major contemporary authorities of Jewish law and ethics whose halakhic positions on bioethical issues are regularly considered by Orthodox, Conservative, and Reform ethicists were reviewed. Their positions on this issue were contrasted with those of various contemporary secular and religious authorities.

RESULTS

These Jewish authorities reject the notion that generosity and charity, rather than monetary gain and greed, must serve as the exclusive basis for donation of functioning organs.

CONCLUSION

Although nonaltruistic sale of kidneys may be theoretically ethical, ultimately its ethical status in Jewish ethics and law is inextricably connected to solving a series of pragmatic programs, such as creating a system that ensures that potential vendors and donors are properly informed and not exploited. Lacking such arrangements, ethical nonaltruistic kidney donations remain but a theoretical possibility.

Adult-to-adult living donor liver transplant: UK experience

BACKGROUND

Adult-to-adult living donor liver transplantation (ALDLT) is being adopted widely in the USA and mainland Europe, fueled by the increasing waiting lists for cadaver organs. The present report describes the first UK experience with the procedure in patients from overseas who have the lowest priority for cadaver organ allocation.

METHODS

The 16 patients seen over the period November 1998 to March 2002 had end-stage cirrhosis from chronic hepatitis C virus (HCV) or hepatitis B virus (HBV) infection (13 cases), with single instances of cryptogenic cirrhosis, secondary biliary cirrhosis and alcoholic liver disease. Grafts were left lobe in the first two recipients and right lobe in the subsequent 14 recipients, donated by nine sons/daughters and seven brothers/sisters.

RESULTS

Twelve of the 16 recipients did well. The four recipients who died had recurrent sepsis; two of these died following hepatic arterial occlusion, and in three major surgical factors were present before transplantation. Serial computed tomography (CT) measurements in the survivors showed regeneration of the grafted lobe with final volumes reaching in each case the calculated standard liver volume for body size. In the donors, liver function tests had returned to normal by day 7-14, with rapid regeneration of the remaining lobe, although the final size attained that estimated before donation in only four donors.

CONCLUSIONS

ALDLT, although requiring considerable facilities and organization, can give good results for both recipient and donor. As with cadaver grafts, outcome in the recipient if the larger right lobe is used is dependent on surgical risk factors and the severity of clinical decompensation before transplantation. Measures to ensure the safety of the donors remain the main concern.

Adult-to-adult Right Hepatic Lobe Living Donor Liver Transplantation

Adult-to-adult right hepatic lobe living donor liver transplantation (LDLT) has rapidly emerged as an accepted treatment option for selected patients with end-stage liver disease. The two most important determinants in patient outcome are the careful selection of recipients, and the technical skill and experience of the surgical team. The most appropriate candidates for LDLT are patients who require an expedited transplant. Also, the candidate must not have significant comorbid conditions that could jeopardize the success of the procedure. The initial outcomes of LDLT recipients are similar to recipients with a cadaveric liver. However, direct comparison may not be possible, because LDLT recipients are currently selected for favorable outcomes. Most LDLT donors are able to undergo right-sided hepatectomy without significant morbidity. However, the risk of death associated with donation is estimated to be 1/300; approximately 20% have a measurable complication.

Living kidney donors in need of kidney transplants: a report from the organ procurement and transplantation network

BACKGROUND

Our aim was to use the Organ Procurement and Transplantation Network (OPTN) database to determine the number of renal waitlist candidates who previously had been living donors.

METHODS

All living renal donors in the OPTN database were cross-checked against the renal waitlist history files. Additionally, renal transplant programs were contacted that had listed candidates as qualified for four additional allocation points available to patients who previously had donated an organ. Confirmatory phone calls to transplant programs yielded additional cases previously unreported to the United Network for Organ Sharing.

RESULTS

A total of 56 previous living donors were identified as having been subsequently listed for cadaveric kidney transplantation. Forty-three have received transplants; 36 currently have functioning grafts. One died after transplantation. Two candidates died while waiting.

CONCLUSIONS

Living renal donation has long-term risks that may not be apparent in the short term. The numbers here reported underestimate the actual number of living donors with renal failure, because they include only patients listed for a kidney transplant. To determine risk factors for postdonation renal failure, long-term living-donor follow-up data are needed.

Review article: adult-to-adult right hepatic lobe living donor liver transplantation

Spurred on by the critical shortage of cadaveric livers, adult-to-adult right hepatic lobe living donor liver transplantation has grown rapidly as a therapeutic option for selected patients. In the USA alone, the number of living donor liver transplantations has increased six-fold in the last 4 years. The therapy can be complex, bringing together a variety of disciplines, including transplantation medicine and surgery, hepatology, psychiatry and medical ethics. Moreover, living donor liver transplantation is still defining itself in the adult-to-adult application. Uniform standards, guidelines and long-term outcomes are yet to be determined. Nevertheless, initial success has been remarkable, and a basic understanding of this field is essential to any physician contemplating options for their liver failure patients. This review covers a range of topics, including recipient and donor selection and outcomes, donor risk, controversies and future issues.

Life insurance for kidney donors: another update

BACKGROUND

Previous studies concluded that healthy kidney donors should be able to obtain life insurance at standard rates. However, we have become aware of a few donors for whom this was not the case. Clearly, this important issue needs to be readdressed.

METHODS

To investigate how American life insurance companies currently view and treat living kidney donors, we mailed a survey to the medical directors of 70 U.S. life insurance companies in the winter of 2001; we included the 20 largest companies ranked by assets.

RESULTS

Thirty-eight companies, including 16 of the top 20, chose to participate. All of them said they would offer life insurance to a healthy kidney donor and only one believed it might raise the premium. Only one company thought that kidney donation might adversely affect longevity, and a majority of the companies did not consider healthy donors to be at increased risk for future medical problems.

CONCLUSIONS

These data suggest that most life insurance companies are still willing to insure healthy kidney donors at standard rates. Nevertheless, occasional donors may encounter difficulty when applying for life insurance. When this occurs, transplant centers should be prepared to help the donor obtain insurance.

Psychosocial outcome of living donors after living donor liver transplantation: a pilot study

In view of the scarcity of organ resources available for transplantation, living donor liver transplantation (LDLT) is gaining growing importance in the treatment of chronically terminal liver diseases. In the period between December 1999 and October 2000, 47 potential living liver donors were evaluated and 24 right hepatic lobes and two left lateral segments were transplanted at the Virchow-Klinikum of the Charité Hospital in Berlin. The present study looks into biomedical and psychosocial parameters of 23 donors before and 6 months after LDLT. Our aims were to investigate the development of psychosocial parameters after donation and the relationship between psychosocial findings and post-operative complications. Most donors showed an improved quality of life (QoL) after LDLT when compared with pre-operative results. Twenty-six percent of donors show high values for 'tiredness', 'fatigue' and 'limb pain' following donation. The post-operative complications had no influence on the psychosocial outcome. In this pilot study the resection of the right hepatic lobe amounts to a safe operation for donors and holds promise of a good psychosocial outcome for most donors, irrespective of donation-related complications. The pronounced complaints appears to indicate psychological tension and distress in some donors following donation.

Interview with Dr Joseph Murray (by Francis L Delmonico)

The Editors asked Dr Delmonico to interview Dr Joseph Murray, winner of the Nobel prize in Medicine 1990 for performing the first successful renal transplant, to record recollections of the issues of the 1950s, when clinical transplantation was born, on Dr Murray's medical career in transplantation, and on some contemporary issues.

Some Ethical and Psychiatric Aspects of Right-Lobe Liver Transplantation in the United States and Japan

Cadaver sources are insufficient for the increasing demand for liver transplantation. Right-lobe liver transplantation from living donors is fully developed in Japan and has been rapidly increasing in the United States during the past 2 years, although donor risk is greater than in other types of solid organ transplantation. The authors examine the psychiatric and ethical aspects of right-lobe liver transplantation in light of cultural differences between the United States and Japan.

The nondirected live-kidney donor: ethical considerations and practice guidelines: A National Conference Report

BACKGROUND

The success of kidney transplantation from a genetically unrelated living spouse or friend has influenced transplant physicians to consider the requests of individuals wishing to volunteer to be a kidney donor who have no intended recipient specified. Representatives of the transplant community gathered in Boston, MA, on May 31, 2001, to deliberate on the experience of live kidney donation from such volunteers, currently termed nondirected donors (NDD).

OBJECTIVE OF CONFERENCE PARTICIPANTS

The objective of the conference was to recommend ethical and practice guidelines for health care professionals considering the transplantation of a kidney from a live NDD.

CONFERENCE PARTICIPANTS

This conference was convened under the sponsorship of The National Kidney Foundation, with representation from The American Society of Transplantation and The American Society of Transplant Surgeons, The American Society of Nephrology, The United Resource Networks, The United Network for Organ Sharing, The Association of Organ Procurement Organizations, The National Institutes of Health, and The Division of Transplantation of the Health Resources and Services Administration (see Appendix).

CONFERENCE REPORT

The suggested content of screening interviews, which provide information regarding the donation process, elicits pertinent medical and psychosocial history, and assesses NDD motivation are presented in this report. Approaches to identifying the center that would evaluate the suitability of the NDD, to performing the kidney recovery, and to selecting the NDD recipient are also proposed. Other ethical issues such as the use of prisoners as an NDD, compensation for the NDD, media involvement, and communication between the NDD and recipient are discussed.

CONCLUSION

The willingness of health care professionals to consider NDD volunteers is driven by the compelling need to provide organs for an ever-expanding list of patients awaiting a kidney transplant. However, the psychological impact and emotional reward of donation has yet to be determined for NDD who may not have any relationship to the recipient or knowledge of the recipient's outcome. Transplant centers that accept NDD should document an informed consent process that details donor risks, assures donor safety, and determines that the goals and expectations of the NDD and the recipient can be realized.

Should all living donors be treated equally?

Recently, Matas et al. described a protocol to accept as potential donors altruistic strangers who offer to donate a kidney to any patient on the waiting list. The selection of donors would be the same as the process they use for living, emotionally related donors, except that the full work-up would have to be done at their institution and would include a detailed psychosocial evaluation. In this article, we present a case that raised the question of whether the medical standards for nonemotionally related donors should be the same as the standards for emotionally related donors. We argue that we must distinguish between the altruistic donation by a stranger and the voluntary donation by an emotionally related individual. We argue that voluntary donations have a degree of moral obligation based on intimacy and that intimacy allows, but does not require, that these donors take on slightly additional risk.

Quality of life after lobectomy for adult liver transplantation

INTRODUCTION

Adult-to-adult living donor liver transplants are being increasingly performed. Although considerable data are available on the quality of life after kidney donation, there is little comparable information on liver donors.

METHODS

Between August 1998 and July 2000, 48 adults received liver grafts from living donors. At least 2 months after donation, donors were mailed a structured questionnaire and the standardized Medical Outcomes Study Short-Form Health Survey (SF-36), a generic measure assessing health-related quality of life outcomes using eight scales: mental health, emotional limits, vitality, social function, physical function, physical limits, pain, general health.

RESULTS

Thirty donors (62.5%) responded at a mean of 280+/-157 days after donation. Fifteen (50%) of their recipients had major complications (two deaths, four retransplants, nine biliary complications). Regarding overall satisfaction, all said they would donate again. Compared to published U.S. norms (n=2474), our group of donors scored higher than the general population in seven of eight domains on the SF-36. Donors whose recipients had no complications scored significantly higher in mental health (P<0.007) and general health (P<0.008) compared with U.S. norms. Donors whose recipients had major complications scored significantly lower on the mental health scale than those with recipients without major complications.

CONCLUSIONS

Donors did not regret their decision to donate; several felt the experience had changed their lives for the better. Donors scored as well as or better than U.S. norms in general health. Quality of life after donation must remain a primary outcome measure when we consider the utility of living-donor liver transplants.

Determinants of willingness to donate living related and cadaveric organs: identifying opportunities for intervention

BACKGROUND

Although low rates of cadaveric organ donation have been attributed to potential cadaveric donors' concerns regarding their religious beliefs and mistrust of the health care system, it is unclear whether similar concerns are important to potential living related donors. It is also not known which factors might be most responsible for low rates of cadaveric and living related donation among the general public.

METHODS

We conducted a cross-sectional study of households in Maryland, using a standardized telephone questionnaire, to assess factors associated with willingness to donate cadaveric and living related organs. We compared factors (demographic, cultural, attitudinal, and clinical) related to willingness to donate cadaveric organs with factors related to willingness to donate living related organs. In multivariate analyses, we assessed the independent relation of factors to willingness to donate cadaveric and living related organs, and we assessed the relative importance of these factors in explaining variation in the general public's willingness to donate.

RESULTS

Of 385 participants (84% of randomized homes), 254 (66%) were extremely willing to donate to a sibling but only 179 (47%) had designated themselves a cadaveric donor on their drivers' licenses. In bivariate analysis, older age, comorbid conditions, mistrust in hospitals, and concerns about discrimination in hospitals were statistically significantly associated with less willingness to donate living related organs, although African-Americans, older age, lower education, lack of insurance, unemployment, comorbid conditions, and religion/spirituality were associated with less willingness to donate cadaveric organs. After adjusting for potential confounders, only mistrust in hospitals and concerns about discrimination remained strongly and independently associated with 50 to 60% less odds of willingness to donate living related organs [[relative odds [95% confidence intervals (CI)]: 0.4 (0.2-0.7) to 0.5 (0.3-1.0) and 0.4 (0.2-0.9), respectively]] although presence of dependents was associated with 70% higher odds of willingness to donate living related organs [relative odds (95% CI): 1.7 (1.0-3.0)]. In contrast, older age, employment status, religion/spirituality, and mistrust in hospitals were associated with 50 to 90% less odds of willingness to donate living related organs cadaveric organs [relative odds (95% CI): 0.3 (0.1-0.8), 0.4(0.2-0.8), 0.1 (0.1- 0.5) to 0.5 (0.2-0.9), and 0.3 (0.2-0.6), respectively]. Mistrust in hospitals and concerns about the surgical donation procedure contributed most to the variation in willingness to be a living related donor, although race contributed most to the variation in willingness to be a cadaveric donor.

CONCLUSIONS

Many factors affect the general public's willingness to donate organs, but their relative contribution is different for living related versus cadaveric donation. Efforts to improve organ donation rates should be directed toward factors that are most important in explaining the existing variation in willingness to donate.

Financial incentives for cadaver organ donation: an ethical reappraisal

A panel of ethicists, organ procurement organization executives, physicians, and surgeons was convened by the sponsorship of the American Society of Transplant Surgeons to determine whether an ethically acceptable pilot trial could be proposed to provide a financial incentive for a family to consent to the donation of organs from a deceased relative. An ethical methodology was developed that could be applied to any proposal for monetary compensation to elucidate its ethical acceptability. An inverse relationship between financial incentives for increasing the families' consent for cadaver donation that clearly would be ethically acceptable (e.g., a contribution to a charity chosen by the family or a reimbursement for funeral expenses) and those approaches that would more likely increase the rate of donation (e.g., direct payment or tax incentive) was evident. The panel was unanimously opposed to the exchange of money for cadaver donor organs because either a direct payment or tax incentive would violate the ideal standard of altruism in organ donation and unacceptably commercialize the value of human life by commodifying donated organs. However, a majority of the panel members supported reimbursement for funeral expenses or a charitable contribution as an ethically permissible approach. The panel concluded that the concept of the organ as a gift could be sustained by a funeral reimbursement or charitable contribution that conveyed the appreciation of society to the family for their donation. Depending on the amount of reimbursement provided for funeral expenses, this approach could be ethically distinguished from a direct payment, by their intrusion into the realm of altruism and voluntariness. We suggest that a pilot project be conducted to determine whether this kind of a financial incentive would be acceptable to the public and successful in increasing organ donation.

The use of a minor as a live kidney donor

An analysis of the UNOS database suggests a practice pattern that uses live minor kidney donors in clinical circumstances not endorsed by the recommendations of a recent consensus conference on live organ donation. These data reveal that minor donor kidneys were transplanted more frequently to adult than to pediatric recipients, that only 12% of all recipients were identical twins, and that the use of a minor donor provided no better outcome than that expected from an adult donor. Live organ donation from a minor should only be considered when there is no other living donor available and all other opportunities for transplantation have been exhausted.

Psychosocial data of potential living donors before living donor liver transplantation

In view of the scarcity of organ resources for transplantation, donation by living donors is assuming greater significance now that the technical-surgical problems involved have been solved. In the period between December 1999 and December 2000, 47 potential living liver donors were evaluated and a total of 27 hepatic lobes were transplanted at the Virchow-Klinikum of the Charité Hospital in Berlin. The close personal relationships between recipients and donors gives reason to anticipate high levels of psychosocial pressure during the pre-operative evaluation process; this process consists in part in looking into donor motivation, ambivalence and anxiety. The pre-operative psychometric evaluation of 40 potential living donors indicated that most of the potential donors see themselves as 'super-healthy' and tend to adapt to social expectations, while on the other hand those seven potential living donors not accepted for psychosocial reasons were marked by heightened values for anxious depression and pessimism. The results indicate in most cases a great willingness to donate and on the other hand a high level of obvious psychological pressure for a low number of potential donors. For the latter, both the clinical evaluation interview and the psychometric diagnostics used revealed clear-cut feelings of anxiety and ambivalence towards transplantation.

Living donor liver transplantation: summary of a conference at The National Institutes of Health

Living donor liver transplantation for adults was developed only recently in an attempt to increase the pool of donor organs; to reduce morbidity and mortality; and to improve the long-term survival of patients in need of liver transplant. Within a few brief years, this procedure has gained widespread support by both the public and transplant community. The procedure will soon be performed by nearly 80% of all liver transplant programs in the United States. Unfortunately, the long-term risks of the procedure to the recipient and especially the donor remain undefined. In response to the rapid growth and enthusiasm for this procedure, the National Institutes of Health sponsored a workshop, the goals of which were to review the scientific, medical, and nonmedical issues associated with living donor liver transplantation, and to define questions for future basic and clinical investigations which could improve the success and applicability of this procedure.

Donor morbidity associated with right lobectomy for living donor liver transplantation to adult recipients: a systematic review

The aim if this study is to determine donor morbidity associated with right lobectomy for living donor liver transplantation (LDLT) to adult recipients through a systematic review of the published literature. Data sources were English-language reports on donor outcome after LDLT. MEDLINE (1995 to June 2001) was searched using the MeSH terms "living donors" and "liver transplantation." Limits were set for human only and English language only. Bibliographies of retrieved references were cross-checked to identify additional reports; 211 reports were obtained. Population studies and consecutive and nonconsecutive series were included. All studies reported at least one of the following outcomes specific to living donors (LDs) of right hepatic lobes to adult recipients: surgical and hospital complications, length of hospital stay, readmissions, recovery time, return to predonation occupation, health-related quality of life, or mortality. Abstracts of relevant articles were reviewed independently using predetermined criteria, and appropriate articles were retrieved. Study design and results were summarized in evidence tables. Summary statistics of combined data were performed when possible. Twelve studies met the inclusion criteria. Data on donor morbidity associated with right lobectomy are limited. On the basis of reported data, morbidity associated with LD right lobectomy ranges from 0% to 67%. In conclusion, reported morbidity associated with right lobe donation for LDLT varies widely. Standardized definitions of morbidity and better methods for observing and measuring outcomes are necessary to understand and potentially improve morbidity. Future studies assessing LD outcomes should report donor outcome more explicitly.

The general public's concerns about clinical risk in live kidney donation

Difficulty in attracting live kidney donors may be related to fears regarding both the surgical procedure for kidney harvesting and future failure of the remaining kidney. We conducted a cross-sectional study of households in Maryland to identify public disincentives to living related kidney donation. In multivariate analyses, we assessed the independent effects of several factors on willingness to donate a kidney to a sibling. We also assessed thresholds for factors above which persons would not donate a kidney. Of 385 participants, 66% were extremely willing to donate to a sibling. After adjustment, those who considered the length of a hospital stay, out-of-pocket expenses, size and appearance of a scar, the time it takes to get to the transplant center, and the donor risk of developing kidney failure very important had 50-60% less odds of being extremely willing to donate. Median acceptable levels for risk of complications, hospital stay, compensated and uncompensated time from work, time requiring pain medications, and out-of-pocket expenses were greater than levels from clinical evidence regarding both laparoscopic and open nephrectomy. Unrealistic concerns among the general public regarding live donation may serve as potential disincentives to donation. Efforts to educate the public regarding live donation might help assuage fears and attract those who may not otherwise donate.

Solid organ donation between strangers

In August 2000, Arthur Matas and his colleagues de scribed a protocol in which their institution began to accept as potential donors, individuals who came to the University of Minnesota hospital offering to donate a kidney to any patient on the waiting list. Matas and his colleagues refer to these donors as nondirected donors by which is meant that the donors are altruistic and that they give their organs to an unspecified pool of recipients with whom they have no emotional relationship. This paper represents an ethical and policy critique of the nondirected donation protocol that was implemented at the University of Minnesota in August 1999. Specifically, I address the ethical questions: Whether altruistic living solid organ donations by strangers (nondirected donations) should be permitted? And if so, What are appropriate ethical guidelines for such donations?

The living donor experience: donor health assessment and outcomes after living donor liver transplantation

Despite the increasing use of living donor liver transplantation, little is known about donor needs, concerns, and experiences. The goal of this study is to assess morbidity associated with living donation from a donor perspective, functional status after donation, and overall satisfaction with the donation process. We surveyed all living donors (LDs) from our center. Demographics, perioperative experience, and satisfaction with donation were assessed. The Medical Outcomes Study 12-Item Short-Form Survey (SF-12), a well-validated tool, measured overall health-related quality of life. Of 27 subjects eligible for the study, 27 subjects (100%) participated. Forty percent reported an event they deemed an immediate complication, of which 60% were recorded in the medical record. Complications requiring readmission were reported by 22%. Mean recovery time was 12 weeks (range, 1 to 52 weeks). No significant change was reported in physical activity, social activity, or emotional stability, and 92% of donors resumed their predonation occupation. Regardless of recipient outcome, 100% of donors would donate again and recommend donation to someone in contemplation. All surveyed LDs at our institution are satisfied with their donation decision. Morbidity in the first year after donation may be greater than previously appreciated. Despite complications, postoperative functional status of donors is equal to or better than population norms.

Liver transplantation in cystic fibrosis

Liver disease is the second most common cause of death in patients with cystic fibrosis (CF). Improvement in surgical techniques, medical management, and imaging modalities has broadened the range of options for treatment of these patients. Medical management with ursodeoxycholic acid and nutritional support may help decelerate the progression of liver disease. A timely evaluation of CF patients with liver involvement for transplantation is important. Such evaluation should not be delayed until signs of hepatic decompensation occur. Combined lung-liver transplant can be considered for patients with advanced pulmonary disease. Pretransplant management of portal hypertension with a portosystemic shunt procedure is an option for patients with well-preserved synthetic liver function. Improvement in lung function after liver transplantation and no significant risk of pulmonary infection with immunosuppressive therapy have been reported. Review of individual center experiences have shown satisfactory survival and improved quality of life for CF patients undergoing liver transplant.

Ethical considerations and rationale of adult-to-adult living donor liver transplantation

Adult-to-adult living donor liver transplantation (ALDLT) is a reality; shortly after its introduction into clinical practice, it is being performed in approximately 50 centers throughout the United States and Europe. The quick development of ALDLT and some deaths among donors repropose old ethical dilemmas and confront the transplant community with new urgent problems. To minimize risks for recipients and, especially, donors, two key questions are addressed: (1) who can or should perform the procedure, and (2) what patient should undergo the procedure. The high risks taken by live donors undergoing a hemihepatectomy seem to be justified by the steadily increasing mortality of adult recipients waiting for transplantation. A comprehensive consent procedure is at the base of responsible decision making for both donors and recipients. In adherence to basic medical criteria, the autonomy of decision of donors and recipients may allow the extension of indications to patients not suitable to undergo transplantation with cadaveric grafts. The broadening of indications is appropriate only in centers with adequate experience and proven expertise in ALDLT. The medical community faces the duty of regulating ALDLT before external influences force undesired policy changes, particularly if not based on medical grounds. Individual centers and patients are ultimately responsible for the correct use of LDLT.

Current trends in lung transplantation

Lung transplantation provides very good short- and acceptable long-term survival for patients with advanced lung disease. More widespread use of marginal and distant donors can be employed in selected recipients without compromising early or late results. Lack of suitable donor lungs and the development of BOS represent the biggest obstacles to more widespread application and long-term success of lung transplantation. The high rate of acute rejection and subsequent BOS clearly indicates that current immunosuppression strategies are inadequate. Further clinical and laboratory research into the pathogenesis of BOS will perhaps reveal new treatment options.

Ethical issues in living organ donation: donor autonomy and beyond

Despite nearly 50 years of experience with living kidney donation, ethical questions about this practice continue to haunt us today. In this editorial I will address two of them: (1) Given the possibility of limited understanding and coercion, how can we be sure that a person who offers to donate an organ is acting autonomously? and (2) Do people have a right to donate? The universal requirement for informed consent is the traditional method for ensuring that a person is acting autonomously. But, while obtaining fully informed consent is desirable, it may not always be achievable or necessary. When the recipient is very dear to the potential donor, the donor may base his decision primarily on care and concern rather than on a careful weighing of risks and benefits. I will argue that consent that emanates from such deep affection should be considered just as valid as consent that is fully informed. But consent is not enough. There is no absolute right to donate an organ. If there were such a right, then some physician would be obligated to remove an offered organ upon request, regardless of the risks involved. I do not believe that physicians have such an obligation. Physicians are moral agents who are responsible for their actions and for the welfare of their patients. Therefore, while the values and goals of the potential donor should be given great weight during the decision-making process, physicians may justifiably refuse to participate in living organ donation when they believe that the risks for the donor outweigh the benefits.

Introduction of the certificate in transplant coordination in the United Kingdom

Training for transplant coordinators is not mandatory in the United Kingdom, although the United Kingdom Transplant Coordinators Association has provided informal courses since 1988. The authors of this article were responsible for the development of an accredited training program for transplant coordinators in the United Kingdom. Accredited by the University of Central England, the course modules have been run and managed by the Association since 1996. The course consists of 3 modules: Introduction to Transplant Coordination; Interpersonal and Professional Skills for Transplant Coordinators, and Introduction to Research Methods for Transplant Coordinators. Between 1996 and 1999, 64 transplant coordinators (60% of transplant coordinators currently in post) in the United Kingdom have undertaken at least 1 module. The Association feels that the accredited training program means one step further on the road to professional recognition of transplant coordinators in the United Kingdom.