Donor exchange programs in kidney transplantation: rationale and operational details from the north central donor exchange cooperative

Increasing transplantability in Brazil: time to discuss Kidney Paired Donation

Introduction:

Kidney transplantation (KT) is the best treatment for chronic kidney disease. In Brazil, there are currently more than 26 thousand patients on the waitlist. Kidney Paired Donation (KPD) offers an incompatible donor-recipient pair the possibility to exchange with another pair in the same situation, it is a strategy to raise the number of KT.

Discussion:

KPD ceased being merely an idea over 20 years ago. It currently accounts for 16.2% of living donors KT (LDKT) in the USA and 8% in Europe. The results are similar to other LDKT. It is a promising alternative especially for highly sensitized recipients, who tend to accumulate on the waitlist. KPD is not limited to developed countries, as excellent results were already published in India in 2014. In Guatemala, the first LDKT through KPD was performed in 2011. However, the practice remains limited to isolated cases in Latin America.

Conclusion:

KPD programs with different dimensions, acceptance rules and allocation criteria are being developed and expanded worldwide to meet the demands of patients. The rise in transplantability brought about by KPD mostly meets the needs of highly sensitized patients. The Brazilian transplant program is mature enough to accept the challenge of starting its KPD program, intended primarily to benefit patients who have a low probability of receiving a transplant from a deceased donor.

In Search of a Better Outcome: Opting Into the Live Donor Paired Kidney Exchange Program

Background

Live donor (LD) kidney transplantation is the best option for patients with end-stage kidney disease (ESKD). However, this may not be the best option if a patient's donor is older and considerably smaller in weight. Patient (A) with a less than ideal donor (Donor A) might enter into a live donor paired exchange (LDPE) program with the hopes of swapping for a better-quality organ. A second patient (B) who is in the LDPE may or may not benefit from this exchange with Donor A.

Methods

This medical decision analysis examines the conditions that favor Patient A entering into the LDPE compared to directly accepting a kidney from their intended donor, as well as the circumstances where Patient B also benefits by accepting a lower-quality organ.

Results

Under select circumstances, a paired exchange could benefit both Patients A and B. For example, a 30-year-old Patient A with a lower-quality donor might gain _1.201.52_1.84 quality adjusted life years (QALYs) by entering into a LDPE for a better-quality kidney, whereas a 60-year-old Patient B might gain _0.931.03_1.13 QALYs by accepting Donor A's kidney rather than waiting longer in the LDPE. The net benefit (or loss) of entering the LDPE differs by recipient age, donor organ quality, likelihood of Patient B being transplanted in LDPE, and likelihood of Patient A finding an ideal donor in the LDPE.

Conclusion

This study shows there are ways to increase live donor utilization and effectiveness that require further research and potentially changes to the LDPE process.

A review of the possibility of adopting financially driven live donor kidney transplantation

Kidney transplantation for end-stage renal disease remains the preferred solution due to its survival advantage, enhanced quality of life and cost-effectiveness. The main obstacle worldwide with this modality of treatment is the scarcity of organs. The demand has always exceeded the supply resulting in different types of donations. Kidney donation includes pure living related donors, deceased donors, living unrelated donors (altruistic), paired kidney donation and more recently compensated kidney donation. Ethical considerations in live donor kidney transplantation have always created a debate especially when rewarding unrelated donors. In this paper, we examine the problems of financially driven kidney transplantation, the ethical legitimacy of this practice, and propose some innovative methods and policies that could be adopted to ensure a better practice with accepted ethical guidelines.

Kidney Paired Donation and the "Valuable Consideration" Problem: The Experiences of Australia, Canada, and the United States

As organ donation rates remain unable to meet the needs of individuals waiting for transplants, it is necessary to identify reasons for this shortage and develop solutions to address it. The introduction of kidney paired donation (KPD) programs represents one such innovation that has become a valuable tool in donation systems around the world. Although KPD has been successful in increasing kidney donation and transplantation, there are lingering questions about its legality. Donation through KPD is done in exchange for-and with the expectation of-a reciprocal kidney donation and transplantation. It is this reciprocity that has caused concern about whether KPD complies with existing law. Organ donation systems around the world are almost universally structured to legally prohibit the commercial exchange of organs. Australia, Canada, and the United States have accomplished this goal by prohibiting the exchange of an organ for "valuable consideration," which is a legal term that has not historically been limited to monetary exchange. Whether or not KPD programs violate this legislative prohibition will depend on the specific legislative provision being considered, and the legal system and case law of the particular jurisdiction in question. This article compares the experiences of Australia, Canada, and the United States in determining the legality of KPD and highlights the need for legal clarity and flexibility as donation and transplantation systems continue to evolve.

Kidney Swap in Pakistan: Experience at the Sindh Institute of Urology and Transplantation

Kidney paired exchange is an established method of overcoming incompatibility in donor-recipient pairs and expanding the living-donor pool. It is infrequently performed in developing countries. We report the first kidney paired exchange in Pakistan, successfully performed at our center. One donor-recipient pair consisted of a 38-year-old female recipient (blood type, B positive) and her 40-year-old husband (A positive) as the potential donor. The second pair consisted of a 30-year-old male recipient (A positive) and his 30-year-old wife (B positive) as the potential donor. The donors were exchanged with the recipients, and both pairs were antigen matched for human leukocyte antigen A and human leukocyte antigen DR. Luminex antibody screening was negative, as were the crossmatches for T and B cells and for IgG and IgM. The transplant procedures and recoveries proceeded uneventfully. The recipients are maintaining serum creatinine levels around 0.78 mg/dL and 0.90 mg/dL, 1 year after transplant. Kidney paired exchange is a relatively low-cost option for overcoming the barrier of incompatibility in a resource-constrained setting.

Features and ethical considerations associated with living kidney and liver transplantations in South Korea

When the Organ Transplantation Act came into effect in 2000 in South Korea, living organ donations were legalized and the Korean Network for Organ Sharing (KONOS) had a duty to approve the application of donation. The number of living organ donors has increased and the waiting time of recipients has been steady or decreased. The Organ Transplantation Act mainly focuses on the informed consent process of donations, so unrelated directed donations are permitted unless there is a suspicion of organ trafficking. But the annual reports show that directed donations of unrelated and related donors may have an ethical concern about organ sales. The donations of family members show another ethical concern. The numbers of ABO-incompatible transplantations have steadily increased since 2008, and lineal descendants, including minors, comprised 61% of living liver donors in 2012. Addressing the unethical practices without inhibiting living organ donations is the current task in South Korea. Private agencies have actively operated the living organ donations programs. The web-based computerized organ exchange program has been cooperatively run by hospital-based organizations. The strict legal regulations that could decrease living organ donations are hard to adopt. In the current situation, the functions of the official system need to be more developed. A national organ exchange program run by KONOS could be an option which could reduce ABO-incompatible transplantations and relieve the ethical concern of organ sales in unrelated directed donations.

Liver, pancreas and small bowel transplantation: current ethical issues

We describe the medical state of the art in liver, pancreas and small bowel transplantation, and portray the ethical issues. Although most ethical questions related to these transplantations are not specific for liver, pancreas and small bowel, they do challenge ethical analysis as well as new policies and clinical procedures. Firstly, outcomes continue to be of utmost concern, as information is only limited available, is developing over time and is surrounded by many uncertainties. Secondly, characteristics of donors and recipients should be carefully evaluated. The question of what qualifies a donor and a recipient should be considered against the background of a quest for extended criteria, embracing marginal cases, and a judgment with regard to what counts as a good enough outcome. Thirdly, ethical principles of autonomy and fairness are pushed, given the circumstance of severe scarcity, towards limits that can easily be crossed.

The kidney-first initiative: what is the current status of preemptive transplantation?

Preemptive kidney transplant (PKT)-defined as transplant before dialysis-has numerous advantages as a treatment approach for patients with advanced renal disease. In the past 15 years, PKT has become more common and has been performed at higher levels of estimated glomerular filtration rate, particularly among recipients of live-donor transplants, among whom timing of transplantation is easier to control. However, recent studies have raised important new concerns about unintended consequences of early versus late PKT. In this article, we review the convincing evidence that PKT offers diverse advantages for patients, discuss potential problems that might emerge from PKT at higher levels of renal function, examine the feasibility of a "just-in-time" PKT strategy for transplant centers, and discuss whether a new kidney allocation system could affect rates of PKT.