Trends in unrelated-donor kidney transplantation in the developing world

Paediatric nephrology in under-resourced areas

BACKGROUND

Nearly 50% of the world population and 60% of children aged 0 to 14 years live in low- or lower-middle-income countries. Paediatric nephrology (PN) in these countries is not a priority for allocation of limited health resources. This article explores advancements made and persisting limitations in providing optimal PN services to children in such under-resourced areas (URA).

METHODS

Medline, PubMed and Google Scholar online databases were searched for articles pertaining to PN disease epidemiology, outcome, availability of services and infrastructure in URA. The ISN and IPNA offices were contacted for data, and two online questionnaire surveys of IPNA membership performed. Regional IPNA members were contacted for further detailed information.

RESULTS

There is a scarcity of published data from URA; where available, prevalence of PN diseases, managements and outcomes are often reported to be different from high income regions. Deficiencies in human resources, fluoroscopy, nuclear imaging, immunofluorescence, electron microscopy and genetic studies were identified. Several drugs and maintenance kidney replacement therapy are inaccessible to the majority of patients. Despite these issues, regional efforts with support from international bodies have led to significant advances in PN services and infrastructure in many URA.

CONCLUSIONS

Equitable distribution and affordability of PN services remain major challenges in URA. The drive towards acquisition of regional data, advocacy to local government and non-government agencies and partnership with international support bodies needs to be continued. The aim is to optimise and achieve global parity in PN training, investigations and treatments, initially focusing on preventable and reversible conditions.

Burden of chronic kidney disease: North Africa

North Africa (NAF) is composed of six countries located in the African Sahara, namely the Western Sahara, Morocco, Algeria, Tunisia, Libya, and Egypt. Common features between these countries include similar climate, ecology, population genetics, and the socioeconomic environment. This commonality reflects on the chronic kidney disease (CKD) profile in these countries. While there are some estimates on the epidemiology of end-stage kidney disease, that of earlier stages is unknown. Several national screening programs are currently addressing this issue, such as the EGIPT-CKD project in Egypt and the MAREMAR study in Morocco. Preliminary results from the former suggest a prevalence of proteinuria in 10.6% of the relatives of patients on regular dialysis treatment. Despite the lack of reliable registries, it was possible to gather information on the etiology of CKD by direct contact with leading nephrologists in those countries. It turns out that glomerulonephritis (GN) accounts for 9–20%, diabetes 11–18%, hypertensive nephrosclerosis 10–35%, chronic interstitial nephritis 7–17%, and polycystic disease 2–3%. Compared to two decades earlier, diabetes has become more common at the expense of GN, proliferative GN, and amyloidosis regressed in favor of IgA and membranous nephropathies in Tunisian adults. Conventional schistosomal nephropathies are regressing in favor of hepatitis C viral (HCV) nephropathy in Egyptians. Focal segmental glomerulosclerosis is increasing at the expense of proliferative GNs in the region at large. Access to regular dialysis has been optimized during the past decade, with favorable outcomes despite the high incidence of HCV infection, tuberculosis, and protein-calorie malnutrition. Kidney transplantation is available in all NAF countries except the Western Sahara. About 650 transplants are performed annually from live donors, the majority in Egypt, where data from the largest center in Mansoura display a 10-year graft survival of 62%. Many transplants are performed from living unrelated donors, particularly in Egypt, which creates an ethical debate. Legislation for deceased-donor transplantation has been passed successively over the past two decades in Tunisia, Morocco, Algeria, and Egypt, which is expected to reflect quantitatively and qualitatively on the transplantation activity in the near future.

Key issues in transplant tourism

Access to organ transplantation depends on national circumstances, and is partly determined by the cost of health care, availability of transplant services, the level of technical capacity and the availability of organs. Commercial transplantation is estimated to account for 5%-10% (3500-7000) of kidney transplants performed annually throughout the world. This review is to determine the state and outcome of renal transplantation associated with transplant tourism (TT) and the key challenges with such transplantation. The stakeholders of commercial transplantation include: patients on the waiting lists in developed countries or not on any list in developing countries; dialysis funding bodies; middlemen, hosting transplant centres; organ-exporting countries; and organ vendors. TT and commercial kidney transplants are associated with a high incidence of surgical complications, acute rejection and invasive infection which cause major morbidity and mortality. There are ethical and medical concerns regarding the management of recipients of organs from vendors. The growing demand for transplantation, the perceived failure of altruistic donation in providing enough organs has led to calls for a legalised market in organ procurement or regulated trial in incentives for donation. Developing transplant services worldwide has many benefits - improving results of transplantation as they would be performed legally, increasing the donor pool and making TT unnecessary. Meanwhile there is a need to re-examine intrinsic attitudes to TT bearing in mind the cultural and economic realities of globalisation. Perhaps the World Health Organization in conjunction with The Transplantation Society would set up a working party of stakeholders to study this matter in greater detail and make recommendations.

Perceptions in living kidney donation: what protagonists think and feel

BACKGROUND

Although donor perceptions of donation have been evaluated in several programs, evaluation of associated recipients has not been as frequent.

PURPOSE

Our aim was to evaluate and compare after transplantation, donor and recipient perceptions of donation.

METHODS

After transplantation 35 recipients and 45 donors completed a sociodemographic and a donation perception questionnaire. We applied the Fisher test to descriptive (absolute and relative frequency) data.

RESULTS

57.8% of donors were female and 62.9% of recipients male. 53.3% of donors were siblings, 44.5% parents, and 2.2% a daughter. Most recipients (71.9%) thought that the donation was the donors' initiative and 21.9% that it was suggested by medical team. 96.4% responded that it was the donor's wish that determined their decision; 51.4% had serious or some doubts about accepting the option, but for 48.6% it was an easy decision. Among the donors, 88.9% decided by themselves and 8.9% were asked for donation. For 91.1%, their wish was the main reason of the decision, but 8.9% felt a moral obligation; 77.8% thought it was an easy decision, and 17.8% hesitated a little 84.4% were not worried about their future health.

CONCLUSIONS

Altruistic motivations were predominant in both groups. Most recipients thought that the motivation for donation was self-determined, a finding that agreed with donor perceptions. Perceptions about the quality of and changes in emotional relationship were the same in both groups. Donors and recipients referred to the donation process as positive, but there were some negative emotions and perceptions.

Depression and anxiety in living kidney donation: evaluation of donors and recipients

BACKGROUND

Psychosocial status of donors before and after living kidney donor transplantation has been an important concern. Investigations of psychosocial issues in related recipients are not frequent.

AIM

The aims of this study were to evaluate and compare psychopathologic dimensions in donors and recipients before and after transplantation.

METHODS

Thirty-five recipients and 45 donors completed a psychosocial evaluation before and after transplantation. We applied Pearson chi-square, McNemar, Fisher, Wilcoxon, and Mann-Whitney tests as well as linear and logistic regression statistical methods.

RESULTS

Before transplantation 100% of the recipients presented total anxiety, compared with 64.4% of donors, with higher anxiety levels in all dimensions (P < .001). Also, 38.7% of recipients and 16.3% of donors had moderate/serious depression (P = .029). Men showed higher levels of cognitive anxiety before transplantation (odds ratio [OR] = 4.3; P = .008). After versus before transplantation central nervous system and cognitive anxiety had diminished in recipients (P = .031; P = .035, respectively); there were higher levels of cognitive anxiety than among the donors (P = .007). Depression showed no significant changes in recipients or donors; the differences were no longer significant. There were less severely depressed recipients but an increase among severely depressed donors. Male recipients and donors showed greater cognitive anxiety (P = .02; P = .04, respectively) at both times. Female recipients presented with more severe depression (P = .036).

CONCLUSIONS

Anxiety is an important symptom. Surgery had a positive impact to lower anxiety in recipients. Most protagonists displayed little or no depression; it was more prevalent among recipients. Donors and recipients maintained some psychopathologic symptoms after surgery. We defined vulnerable groups among these cohorts.

Global trends in the rates of living kidney donation

As the worldwide prevalence of end-stage renal disease increases it is important to evaluate the rate of living kidney donation in various countries; however there is no comprehensive global assessment of these rates. To measure this, we compiled data from representatives, renal registries, transplant networks, published reports in the literature, and national health ministries from 69 countries and made estimates from regional weighted averages for an additional 25 countries where data could not be obtained. In 2006, about 27,000 related and unrelated legal living donor kidney transplants were performed worldwide, representing 39% of all kidney transplants. The number of living kidney donor transplants grew over the last decade, with 62% of countries reporting at least a 50% increase. The greatest numbers of living donor kidney transplants, on a yearly basis, were performed in the United States (6435), Brazil (1768), Iran (1615), Mexico (1459), and Japan (939). Saudi Arabia had the highest reported living kidney donor transplant rate at 32 procedures per million population (pmp), followed by Jordan (29), Iceland (26), Iran (23), and the United States (21). Our study shows that rates of living donor kidney transplant have steadily risen in most regions of the world, increasing its global significance as a treatment option for kidney failure.

Medical tourism

Searches of the literature or Internet using the term "medical tourism" produce two sets of articles: travel for the purpose of delivering health care or travel for the purpose of seeking health care. The first usage primarily appears in the medical literature and is beyond the scope of this article, which focuses on travel to seek health care. Still, there are some aspects these two topics have in common: both are affected by ease and speed of international travel and communication associated with globalization, and both raise questions about continuity of care as well as issues related to cultural, language, and legal differences; both also raise questions about ethics. This article describes some of the motivating factors, contributing elements, and challenges in elucidating trends, as well as implications for clinicians who provide pretravel advice and those who care for ill returning travelers.