Ethical and Logistical Issues Raised by the Advanced Donation Program "Pay It Forward" Scheme

Medical-ethical guidelines: Living donation of solid organs

No abstract available.

Recent Advances and Clinical Outcomes of Kidney Transplantation

Recent advances in surgical, immunosuppressive and monitoring protocols have led to the significant improvement of overall one-year kidney allograft outcomes. Nonetheless, there has not been a significant change in long-term kidney allograft outcomes. In fact, chronic and acute antibody-mediated rejection (ABMR) and non-immunological complications following kidney transplantation, including multiple incidences of primary kidney disease, as well as complications such as cardiovascular diseases, infections, and malignancy are the major factors that have contributed to the failure of kidney allografts. The use of molecular techniques to enhance histological diagnostics and noninvasive surveillance are what the latest studies in the field of clinical kidney transplant seem to mainly focus upon. Increasingly innovative approaches are being used to discover immunosuppressive methods to overcome critical sensitization, prevent the development of anti-human leukocyte antigen (HLA) antibodies, treat chronic active ABMR, and reduce non-immunological complications following kidney transplantation, such as the recurrence of primary kidney disease and other complications, such as cardiovascular diseases, infections, and malignancy. In the present era of utilizing electronic health records (EHRs), it is strongly believed that big data and artificial intelligence will reshape the research done on kidney transplantation in the near future. In addition, the utilization of telemedicine is increasing, providing benefits such as reaching out to kidney transplant patients in remote areas and helping to make scarce healthcare resources more accessible for kidney transplantation. In this article, we discuss the recent research developments in kidney transplants that may affect long-term allografts, as well as the survival of the patient. The latest developments in living kidney donation are also explored.

The effect of the National Kidney Registry on the kidney-exchange market

We assess the causal effect of the National Kidney Registry (NKR), the largest national kidney-exchange network in the U.S., on kidney-exchange outcomes. Analyzing a unique database hosted by the Scientific Registry of Transplant Recipients (SRTR) that contains information on all kidney donors, wait-listed candidates, and transplant recipients in the U.S., we find that patients in an NKR hospital are 2.5-3 times more likely than their counterparts in a non-NKR hospital to receive a transplant from a living donor, conditional on wait-time. At the same time, NKR participation does not have a significant effect on the desirability of donors and the health status of recipients. We employ various approaches to ensure our finding is robust in addressing the non-random sorting of patients and donors. As far as the outcomes we study, the expansion of the NKR brings about an overall positive impact on the kidney exchange market.

Family-Based Consent to Organ Transplantation: A Cross-Cultural Exploration

This special thematic issue of The Journal of Medicine and Philosophy brings together a cross-cultural set of scholars from Asia, Europe, and North America critically to explore foundational questions of familial authority and the implications of such findings for organ procurement policies designed to increase access to transplantation. The substantial disparity between the available supply of human organs and demand for organ transplantation creates significant pressure to manipulate public policy to increase organ procurement. As the articles in this issue explore, however, even if well intentioned, the desire to maximize organ procurement does not justify undermining foundational elements of human flourishing, such as the family. While defending at times quite different understandings of autonomy, informed consent, and familial authority, each author makes clear that a principled appreciation of the family is necessary. Otherwise, health care practice will treat the family in a cynical and instrumental fashion unlikely to support social or individual good.

Evolving swaps in transplantation: global exchange, vouchers, liver, and trans-organ paired exchange

PURPOSE OF REVIEW

With the ongoing organ shortage, several mechanisms to facilitate organ exchanges and expand the scope of living kidney or liver donation have been proposed. Although each addresses at least one barrier to transplantation, these innovative programs raise important ethical, logistical, and regulatory considerations.

RECENT FINDINGS

This review addresses four recent proposals to expand living donor transplantation. For kidney transplantation, we discuss global paired exchange and advanced donation programs ('vouchers') and for liver transplantation, liver paired exchange. Lastly, this review considers trans-organ exchange. We explore the conceptual framework of the exchange, current status, benefits, and concerns for implementation among each of these evolving pathways.

SUMMARY

Through highlighting novel mechanisms in organ exchange, greater awareness, discussion, or support can occur to create more avenues for transplantation. These innovative mechanisms require regulations and safeguards for donors to ensure informed consent, and proper follow-up is maintained.

Kidney exchange transplantation current status, an update and future perspectives

Kidney exchange transplantation is well established modality to increase living donor kidney transplantation. Reasons for joining kidney exchange programs are ABO blood group incompatibility, immunological incompatibility (positive cross match or donor specific antibody), human leukocyte antigen (HLA) incompatibility (poor HLA matching), chronological incompatibility and financial incompatibility. Kidney exchange transplantation has evolved from the traditional simultaneous anonymous 2-way kidney exchange to more complex ways such as 3-way exchange, 4-way exchange, n-way exchange,compatible pair, non-simultaneous kidney exchange,non-simultaneous extended altruistic donor, never ending altruistic donor, kidney exchange combined with desensitization, kidney exchange combined with ABO incompatible kidney transplantation, acceptable mismatch transplant, use of A2 donor to O patients, living donor-deceased donor list exchange, domino chain, non-anonymous kidney exchange, single center, multicenter, regional, National, International and Global kidney exchange. Here we discuss recent advances in kidney exchanges such as International kidney exchange transplantation in a global environment, three categories of advanced donation program, deceased donors as a source of chain initiating kidneys, donor renege myth or reality, pros and cons of anonymity in developed world and (non-) anonymity in developing world, pros and cons of donor travel vs kidney transport, algorithm for management of incompatible donor-recipient pairs and pros and cons of Global kidney exchange. The participating transplant teams and donor-recipient pairs should make the decision by consensus about kidney donor travel vs kidney transport and anonymity vs non-anonymity in allocation as per local resources and logistics. Future of organ transplantation in resource-limited setting will be liver vs kidney exchange, a legitimate hope or utopia?

Organ Vouchers and Barter Markets: Saving Lives, Reducing Suffering, and Trading in Human Organs

The essays in this issue of The Journal of Medicine and Philosophy explore an innovative voucher program for encouraging kidney donation. Discussions cluster around a number of central moral and political/theoretical themes: (1) What are the direct and indirect health care costs and benefits of such a voucher system in human organs? (2) Do vouchers lead to more effective and efficient organ procurement and allocation or contribute to greater inequalities and inefficiencies in the transplantation system? (3) Do vouchers contribute to the inappropriate commodification of human body parts? (4) Is there a significant moral difference between such a voucher system and a market in human organs for transplantation? This paper argues that while kidney vouchers constitute a step in the right direction, fuller utilization of market-based incentives, including, but not limited to, barter exchanges (e.g., organ exchanges, organ chains, and organ vouchers), would save more lives and further reduce human suffering.

Swaps and Chains and Vouchers, Oh My!: Evaluating How Saving More Lives Impacts the Equitable Allocation of Live Donor Kidneys

Live kidney donation involves a delicate balance between saving the most lives possible and maintaining a transplant system that is fair to the many thousands of patients on the transplant waiting list. Federal law and regulations require that kidney allocation be equitable, but the pressure to save patients subject to ever-lengthening waiting times for a transplant has been swinging the balance toward optimizing utility at the expense of justice. This article traces the progression of innovations created to make optimum use of a patient's own live donors. It starts with the simplest - direct donation by family members - and ends with voucher donations, a very recent and unique innovation because the donor can donate 20 or more years before the intended recipient is expected to need a kidney. In return for the donation, the intended recipient receives a voucher that can be redeemed for a live kidney when it is needed. Other innovations that are discussed include kidney exchanges and list paired donation, which are used to facilitate donor swaps when donor/recipient pairs have incompatible blood types. The discussion of each new innovation shows how the equity issues build on each other and how, with each new innovation, it becomes progressively harder to find an acceptable balance between utility and justice. The article culminates with an analysis of two recent allocation methods that have the potential to save many additional lives, but also affirmatively harm some patients on the deceased donor waiting list by increasing their waiting time for a life-saving kidney. The article concludes that saving additional lives does not justify harming patients on the waiting list unless that harm can be minimized. It also proposes solutions to minimize the harm so these new innovations can equitably perform their intended function of stimulating additional transplants and extending the lives of many transplant patients.