Lean body mass in living kidney donors impacts postoperative renal function

PURPOSE

A living donor kidney transplant is the optimal treatment for chronic renal impairment. Our objective is to assess if lean skeletal muscle mass and donor factors such as body mass index, hypertension, and age impact on renal function following donor nephrectomy.

METHODS

Potential donors undergo CT angiography as part of their work-up in our institution. Using dedicated software (Horos®), standardized skeletal muscle area measured at the L3 vertebrae was calculated. When corrected for height, skeletal muscle index can be derived. Skeletal muscle mass index below predefined levels was classified as sarcopenic. The correlation of CT-derived skeletal muscle index and postoperative renal function at 12 months was assessed. Co-variables including donor gender, age, body mass index (BMI), and presence of pre-op hypertension were also assessed for their impact on postoperative renal function.

RESULTS

275 patients who underwent living donor nephrectomy over 10 years were included. Baseline pre-donation glomerular filtration rate (GFR) and renal function at one year post-op were similar between genders. 29% (n = 82) of patients met the criteria for CT-derived sarcopenia. Sarcopenic patients were more likely to have a higher GFR at one year post-op (69.3 vs 63.9 mL/min/1.73 m2, p < 0.001). The main factors impacting better renal function at one year were the presence of sarcopenia and younger age at donation.

CONCLUSION

When selecting donors, this study highlights that patients with low skeletal mass are unlikely to underperform in terms of recovery of their renal function postoperatively at one year when compared to patients with normal muscle mass and should not be a barrier to kidney donation.

The solicitation of altruistic kidney donations on Facebook

Chronic kidney failure poses a risk to human life and quality of life. Patients often receive renal replacement therapy or a kidney transplant, with the latter considered superior, though often inaccessible due to long waiting lists. While most kidney donations originate from the deceased, Israel has transformed as the first country where most kidney donations originate from altruistic living donors. This creates a social environment in which patients are tasked with kidney solicitation which often occurs on digital social networks. This study examines the phenomenon of digital kidney solicitation by employing a thematic analysis of 76 attempts of solicitation on Facebook. The analysis revealed the act of digital solicitation comprises of reflecting the inner conflicts of solicitation and justifying the kidney donation both in general and for the particular solicitor. This study sheds light on the phenomenon of people with kidney failure attempting to save their own lives through digital social networks. A phenomenon that could influence the social-health debate concerning the fair distribution of health resources in society.

Demographics of deceased donor renal transplants in Ireland: A 10 year review showing the worrying increase of suicide as a source for organ donation

INTRODUCTION

Kidney transplantation is the treatment of choice for patients with end stage renal disease. The primary aim of this study was to assess the demographics of deceased kidney donors over the last ten years and to assess for gender variations in deceased donor demographics over an extended period.

METHODS

A retrospective data analysis was carried out using data from the national renal transplant database. All deceased donors who donated a kidney between 1st January 2012 and 31st December 2021 were included. Data points extracted included gender, age, cause of death and month of death. Descriptive analyses were carried out using Excel v16.67.

RESULTS

A total of 1219 kidneys from 650 donors were donated over the ten-year period. The mean donor age was 44.01 years (range 1-74 years). The most common cause of death overall was subarachnoid haemorrhage (SAH), which was the cause of death in 27.8 % of donors (n = 180). Male donors accounted for 57.8 % of donors overall (n = 376). Variation in causes of death was observed between male and female donors, and between younger and older donors. 9 % of male deaths were from suicide compared with 5 % of female deaths. 6 % of male deaths were due to a traumatic head injury, with this accounting for 2 % of female deaths. Deaths due to assault made up 2 % of male donor deaths, but were not a cause of death for any female donors.

CONCLUSION

SAH and intracranial bleeds were the most common cause of death in both groups for deceased donor renal transplantation. Incidence of suicide as cause of death in deceased donors is rising in males.

Randomized intervention to assess the effectiveness of an educational video on organ donation intent among Hispanics in the New York metropolitan area

BACKGROUND

The Hispanic community has a high demand for organ donation but a shortage of donors. Studies investigating factors that could promote or hinder organ donation have examined emotional video interventions. Factors acting as barriers to organ donation registration have been classified as: (1) Bodily integrity; (2) medical mistrust; (3) “ick”-feelings of disgust towards organ donation; and (4) “jinx”-fear that registration may result in one dying due to premeditated plans. We predict that by providing necessary information and education about the donation process via a short video, individuals will be more willing to register as organ donors.

AIM

To determine perceptions and attitudes regarding barriers and facilitators to organ donation intention among Hispanic residents in the New York metropolitan area.

METHODS

This study was approved by the Institutional Review Board at Northwell Health. The approval reference number is No. 19-0009 (as presented in Supplementary material). Eligible participants included Hispanic New York City (NYC) residents, 18 years of age and above, who were recruited voluntarily through Cloud Research and participated in a larger randomized survey study of NYC residents. The survey an 85-item Redcap survey measured participant demographics, attitudes, and knowledge of organ donation as well as the intention to register as an organ donor. Attention checks were implemented throughout the survey, and responses were excluded for those who did fail. Participants were randomly assigned two-between subject conditions: To view a short video on organ donation and then proceed to complete the survey (i.e., video first) and view the same video at the end of the survey (video last). No intra-group activities were conducted. This study utilized an evidenced-based emotive educational intervention (video) which was previously utilized and was shown to increase organ donation registration rates at the Ohio Department of Motor Vehicles. Results were analyzed using Jamovi statistical software. Three hundred sixty-five Hispanic individuals were included in the analysis. Once consent was obtained and participants entered the survey (the survey sample is presented in Supplementary material), participants were asked to report on demographic variables and their general impression of organ donation after death. The video depicted stories regarding organ donation after death from various viewpoints, including from the loved ones of a deceased person who died waiting for a transplant; from the loved ones of a deceased person whose organs were donated upon death; and, from those who were currently waiting for a transplant.

RESULTS

Using a binomial logistic regression, the analysis provides information about the relationship between the effects of an emotive video and the intention to donate among Hispanic participants who were not already registered as donors. The willingness to go back and register was found to be significantly more probable for those who watched the emotive video before being asked about their organ donation opinions (odds ratio: 2.05, 95% confidence interval: 1.06-3.97). Motivations for participation in organ donation were also captured with many stating the importance of messages coming from “people like me” and a message that highlights “the welfare of those in need”. Overall, the findings suggest that using an emotive video that addresses organ donation barriers to prompt organ donation intentions can be effective among the Hispanic populous. Future studies should explore using targeted messaging that resonates with specific cultural groups, highlighting the welfare of others.

CONCLUSION

This study suggests that an emotive educational intervention is likely to be effective in improving organ donation registration intent among the Hispanic population residing in NYC.

Perioperative transcutaneous electrical acupoint stimulations as part of an enhanced recovery after surgery protocol for living donors undergoing nephrectomy: A randomized, controlled clinical trial

Objective

Living kidney donors (LKDs) experience perioperative anxiety. We designed the following study to evaluate the anxiolytic effect of transcutaneous electrical acupoint stimulation (TEAS) during the perioperative period in a group of LKDs undergoing laparotomy nephrectomy.

Methods

LKDs were randomly assigned to either the TEAS or control group. Participants in the TEAS group received 30min of intervention (6-15 mA, 2-100 Hz), at Yintang (EX-HN-3), bilateral Taichong (LR3) and Neiguan (PC6) one day before surgery (D₀), before induction of anesthesia (D₁) and one day after surgery (D₂). The participants in the control group received the same placement of electrodes but without electrical stimulation. Venous blood was collected before each intervention. Anxiety levels and recovery profiles were recorded.

Results

LKDs in the TEAS group had lower anxiety level than those in the control group at D₁, D₂ and three days after surgery (D₃). The percentage differences were: 33.3%, 25.0%, and 22.2%; [95% confidence interval (CI), (-55.1%, -11.6%), (-47.4%, -2.6%), and (-42.3%, -2.2%); P = 0.005, P = 0.034, and P = 0.035; respectively]. LKDs who received TEAS had better sleep quality and short-term recovery profiles than those in the control group. The plasma levels of 5-hydroxytryptamine (5-HT) and melatonin (MT) in the TEAS group were significantly higher than those in the control group at D₁ and D₂ (5-HT: P = 0.001, and P < 0.001; MT: P = 0.006, and P = 0.001). At the 3-month follow up, fewer LKDs in the TEAS group had incisional pain when compared to the control group (P = 0.032).

Conclusions

Perioperative TEAS decreased perioperative anxiety and facilitated postoperative recovery in the LKDs, and potential decreased the development of chronic pain. Trial Registration: Registered at ChiCTR2000029891, http://www.chictr.org.cn/listbycreater.aspx.

Current practice of live donor nephrectomy in Turkey

BACKGROUND

Over the last few years, the deceased donor organ donation rate was declined or remained stable, whereas the live donor organ donation rate has increased to compensate for the demand. Minimally invasive techniques for live donor nephrectomy (LDN) have also improved the live donor kidney donation rates. This increase has led to an interest in the surgical procedures used for LDN.

AIM

To evaluate the LDN techniques performed in Turkey, the structure of surgical teams, and the training received. Additionally, the number of kidney transplantations at different centers, the surgeon experience level, differences in surgical approach during donor surgeries, and outcomes were assessed.

METHODS

A questionnaire was sent to the Turkish Ministry of Health-accredited transplant centers. It inquired of the number of LDN surgeries, surgical techniques, complications, optimization protocols, the experience of surgeons, and the training. Descriptive statistics were outlined as follows: Discrete numeric variables were expressed as medians (minimum-maximum), while categorical variables were shown as numbers and percentages. As a result of the goodness-of-fit tests, if the significance of the differences between the groups in discrete numerical variables for which the parametric test statistical assumptions were not met, data were analyzed with the Mann Whitney U test and the χ² test.

RESULTS

The questionnaire was sent to 72 transplant centers, all of which replied. Five centers that reported not performing LDN procedures were excluded. Responses from the remaining 67 centers were analyzed. In 2019, the median number of kidney transplants performed was 45, and the median number of kidney transplants from living donors was 28 (1-238). Eleven (16.5%) centers performed 5-10, while 34 (50.7%) centers performed more than 100 live donor kidney transplants in 2019. While 19 (28.4%) centers performed the LDN procedures using the open technique, 48 (71.6%) centers implemented minimally invasive techniques. Among the centers preferring minimally invasive techniques for LDN, eight (16.6%) used more than one surgical technique. The most and the least common surgical techniques were transperitoneal laparoscopic (43 centers, 89.6%) and single port laparoscopic LDN (1 center, 2.1%) techniques, respectively. A positive association was found between the performance of minimally invasive techniques and the case volume of a transplant center, both in the total number and live donor kidney transplants (15 vs 55, P = 0.001 and 9 vs 42, P ≤ 0001 respectively). The most frequently reported complication was postoperative atelectasis (n = 33, 49.2%). There was no difference between the techniques concerning complications except for the chyle leak.

CONCLUSION

Turkish transplant centers performed LDN surgeries successfully through various techniques. Centers implementing minimally invasive techniques had a relatively higher number of live donor kidney transplants in 2019.

How a compensated kidney donation program facilitates the sale of human organs in a regulated market: the implications of Islam on organ donation and sale

BACKGROUND

Advocates for a regulated system to facilitate kidney donation between unrelated donor-recipient pairs argue that monetary compensation encourages people to donate vital organs that save the lives of patients with end-stage organ failure. Scholars support compensating donors as a form of reciprocity. This study aims to assess the compensation system for the unrelated kidney donation program in the Islamic Republic of Iran, with a particular focus on the implications of Islam on organ donation and organ sales.

METHODS

This study reviews secondary documents for philosophical argumentation and ethical analysis of human organ donation and sale for transplantation.

RESULTS AND DISCUSSION

According to Islamic law, organ donation is an act of sadaqatul jariyah, and individuals are permitted to donate organs with the intention of saving lives. The commercialization of humans as organ sellers and buyers is contrary to the Islamic legal maxim eethaar, undermining donors of 'selfless' or 'altruistic' motivations. Such an act should be considered immoral, and the practice should not be introduced into other countries for the sake of protecting human dignity, integrity, solidarity, and respect. I, therefore, argue that Iran's unrelated kidney donation program not only disregards the position of the Islamic religion with respect to the provision or receipt of monetary benefits for human kidneys for transplantation but that it also misinterprets the Islamic legal proscription of the sale of human organs. I also argue that the implementation of Iran's unrelated kidney donor transplantation program is unethical and immoral in that potential donors and recipients engage in a bargaining process akin to that which sellers and buyers regularly face in regulated commodity exchange markets. Conversely, I suggest that a modest fixed monetary remuneration as a gift be provided to a donor as a reward for their altruistic organ donation, which is permissible by Islamic scholars. This may remove the need to bargain for increased or decreased values of payment in exchange for the organ, as well as the transactional nature of 'buyer and seller', ensuring the philosophy of 'donor and recipient' is maintained.

CONCLUSIONS

Offering a fixed modest monetary incentive to organ donors would serve to increase organ supply while protecting donors' health and reducing human suffering without legalizing the human organ trade.

Apolipoprotein L1 Opinions of African American Living Kidney Donors, Kidney Transplant Patients, and Nonpatients

INTRODUCTION

The discovery of apolipoprotein L1 (ApoL1) has raised important ethical and clinical questions about genetic testing in the context of living and deceased kidney donation. Largely missing from this discussion are the perspectives of those African Americans (AA) most likely to be impacted by ApoL1 testing.

METHODS

We surveyed 331 AA potential and former living kidney donors (LKDs), kidney transplant candidates and recipients, and nonpatients at three United States transplant programs about their ApoL1 testing attitudes.

RESULTS

Overall, 72% felt that transplant programs should offer ApoL1 testing to AA potential LKDs. If a potential LKD has the high-risk genotype, 79% felt that the LKD should be allowed to make their own donation decision or participate in shared decision-making with transplant doctors. More than half of the potential LKDs (58%) would undergo ApoL1 testing and 81% of former LKDs would take the test now if offered. Most transplant candidates expressed a low likelihood of accepting a kidney from a LKD (79%) or a deceased donor (67%) with the high-risk genotype.

CONCLUSIONS

There is strong support among LKDs and transplant patients for ApoL1 testing when evaluating potential kidney donors of African ancestry. Inclusion of AA stakeholders in developing guidelines and educational programs for ApoL1 testing is critical.

The Gendered Body Work of Muslim Arab Mothers Who Donate a Kidney to Their Children

PURPOSE

Previous studies showed that among the pediatric ESRD patients who receive a kidney donation from a parent, in most cases the mother is the one that agrees to donate her kidney to the sick child, whereas fathers are less willing to donate. The present study sought to explore decision making regarding which parent would donate a kidney to their child among Muslim Arab parents of pediatric ESRD patients.

DESIGN AND METHODS

The study design is a cross sectional qualitative study. We conducted semi-structured interviews with thirty-one parents: twenty-five mothers and six fathers, who donated a kidney to their child.

RESULTS

Parents tended to refrain from donating a kidney to a sick daughter; mothers were more willing to donate than fathers. Our findings imply that culturally constructed notions of gender and motherhood are mobilized to the realm of health and illness, and mothers' body work is an influential factor in determining survival chances of pediatric ESRD patients and their quality of life.

CONCLUSIONS

Our study shows that kidney donation made by mothers to their children represents a gendered body work and powerfully demonstrate gender relations in Arab society. Cultural artefacts shape parents' differential propensity to donate organs for a female or a male offspring.

PRACTICE IMPLICATIONS

It is recommended that the nursing staff enlist the help of Muslim clerics to increase the willingness of fathers to donate a kidney for their offspring, and also to encourage both parents to donate a kidney to a sick daughter. Education campaigns are needed to raise awareness and encourage changes in the attitudes of the Muslim families of pediatric ESRD patients toward parental kidney donation.

Donor-Recipient Relationship and Risk of ESKD in Live Kidney Donors of Varied Racial Groups

RATIONALE & OBJECTIVE

Risk factors for kidney failure are the basis of live kidney donor candidate evaluation. We quantified risk for end-stage kidney disease (ESKD) by the biological relationship of the donor to the recipient, a risk factor that is not addressed by current clinical practice guidelines.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

A cohort of 143,750 US kidney donors between 1987 and 2017.

EXPOSURE

Biological relationship of donor and recipient.

OUTCOME

ESKD. Donors' records were linked to national dialysis and transplantation registries to ascertain development of the outcome.

ANALYTIC APPROACH

Donors were observed over a median of 12 (interquartile range, 6-18; maximum, 30) years. Survival analysis methods that account for the competing risk for death were used.

RESULTS

Risk for ESKD varied by orders of magnitude across donor-recipient relationship categories. For Asian donors, risks compared with unrelated donors were 259.4-fold greater for identical twins (95% CI, 19.5-3445.6), 4.7-fold greater for full siblings (95% CI, 0.5-41.0), 3.5-fold greater for offspring (95% CI, 0.6-39.5), 1.0 for parents, and 1.0 for half-sibling or other biological relatives. For black donors, risks were 22.5-fold greater for identical twin donors (95% CI, 4.7-107.0), 4.1-fold for full siblings (95% CI, 2.1-7.8), 2.7-fold for offspring (95% CI, 1.4-5.4), 3.1-fold for parents (95% CI, 1.4-6.8), and 1.3-fold for half-sibling or other biological relatives (95% CI, 0.5-3.3). For white donors, risks were 3.5-fold greater for identical twin donors (95% CI, 0.5-25.3), 2.0-fold for full siblings (95% CI, 1.4-2.8), 1.4-fold for offspring (95% CI, 0.9-2.3), 2.9-fold for parents (95% CI, 2.0-4.1), and 0.8-fold for half-sibling or other biological relatives (95% CI, 0.3-1.6).

LIMITATIONS

Insufficient sample size in some race and relationship groups. Absence of data for family history of kidney disease for donors biologically unrelated to their recipients.

CONCLUSIONS

Marked differences in risk for ESKD across types of donor-recipient relationship were observed for Asian, black, and white donors. These findings warrant further validation with more robust data to better inform clinical practice guidelines.

The present and future of transplant organ shortage: some potential remedies

Transplantation remains the modality of choice for patients with end stage renal disease (ESRD). However, while there has been a steady rise in the number of patients with ESRD the supply of donors (combine living and deceased) has fallen far behind the need, resulting in an increasing number of qualified patients remaining on the wait-list, and thousands being removed from the list every year because of death or becoming too sick for transplantation. This has also fed to transplant tourism around the world. Several countries have implemented a variety of policies to overcome their organ shortage that are presented in this article. There is an urgent need for developing policies geared to the cultural norms of different societies and universally accepted ethical principles to remedy this public health issue.

A Clinical Study on Cadaveric Kidney Donors in Puerto Rico and the Survival outcome of the grafts: a retrospective study of 187 kidneys from 2009-2011

OBJECTIVE

In this study, we assessed the Kidney Donor Risk Index (KDRI) in Puerto Rican deceased kidney donors whose donations took place from 2009 to 2011 and evaluated short-term graft survival in the recipients of those kidneys. The results highlight differences between the distributions of KDRI values in the populations of the 48 contiguous states of the United States, Alaska, and Hawaii and that of Puerto Rico. Additionally, we evaluated the impacts of polyomavirus (BKV) infection and anti-donor HLA antibodies on the recipients.

METHODS

Of the 377 kidneys obtained from deceased donors by LifeLink of Puerto Rico from 2009 to 2011, 187 were transplanted in Puerto Rico. Data was collected from the deceased donors of these 187 kidneys for calculating KDRI, as well as from the transplant recipients. KDRI values of the donors were calculated using the same formula as previously reported for the United States; death-censored graft survival, incidence of antibody-mediated rejection, and prevalence of polyoma virus infection (BKV) were examined in the recipients.

RESULTS

The mean KDRI value was 1.19. However, the distribution of KDRI values in the Puerto Rican population deviates substantially from that of the United States (not including Puerto Rico). A 1-peak distribution pattern describes Puerto Rican KDRI values. Graft survival for the study period was 89.6%. The prevalence of BKV was 16.9%. Of the patients studied, 6.25% developed overt nephropathy, 46.2% developed de novo post-transplant donor-specific alloantibodies, and 19.5% had pre-existing alloantibodies.

CONCLUSION

Our study evidences the role of various characteristics in the distribution of KDRI values in the Puerto Rican population, suggesting that the identification of variables specific to a geographically distinct group may result in better donor categorization for predicting transplant outcomes. In addition, our graft-survival results, despite the elevated rates of BKV and anti-donor antibodies, highlight the increasing need to monitor the presence of antibodies in a prospective and an anticipatory manner to identify and manage patients at risk for antibodymediated rejection.

The non-directed living kidney donor: Why donate to strangers?

BACKGROUND

Kidney transplantation improves survival and quality of life for patients with end-stage kidney disease (ESKD). However, there is a shortage of donated organs, resulting in long wait times and the potential for death before a donor is found. Non-directed (also called altruistic) living kidney donation is a growing type of donation; however, few studies have examined the values and motivation of individuals evaluated to be a non-directed donor.

OBJECTIVES

This qualitative study explores the motivations and values of individuals evaluated for non-directed donation.

DESIGN

Focus groups were conducted with individuals who had been evaluated for non-directed living kidney donation. Grounded theory method guided the data analysis.

PARTICIPANTS

Participants (N = 11) were individuals who completed the evaluation for a non-directed living kidney donation.

FINDINGS

Qualitative analyses revealed eight major themes participants considered in making their decision to donate to a non-related person: (i) motivation to donate; (ii) minimise perceived risk; (iii) ideal selected recipient; (iv) change in lifestyle; (v) source of donation knowledge; (vi) history of altruistic acts; (vii) donation chain and (viii) others' response.

CONCLUSIONS

Results suggest that non-directed living kidney donors think deeply about their decision and have a resolve to help others that is aligned with their values. As organ availability remains at a critical shortage, unwillingness to consider non-directed living donors (NDD) due to beliefs of ill motivations appears unsupported. Future directions call for the need of standard practice of care in kidney donation evaluations across transplant centers.

Living Kidney Donation: Strategies to Increase the Donor Pool

End-stage renal disease (ESRD) is a significant health care burden. Although kidney transplantation is the optimal treatment modality, less than 25% of waiting list patients are transplanted because of organ shortage. Living kidney donation can lead to better recipient and graft survival and increase the number of donors. Not all ESRD patients have potential living donors, and not all living donors are a compatible match to recipients. Kidney paired exchanges allow incompatible pairs to identify compatible living donors for living donor kidney transplants for multiple recipients. Innovative modifications of kidney paired donation can increase the number of kidney transplants, with excellent outcomes.

A care ethics approach to the Gender Kidney Donation Gap

Many studies have shown that women are more likely than men to be living kidney donors, and the discrepancy is particularly marked in heterosexual couples: wives are more likely than husbands to donate a kidney to their spouse. This 'Gender Kidney Donation Gap' can be understood in terms of Carol Gilligan's claims about gender differences in ethical decision-making style, making it appropriate to analyse responses to this imbalance using an ethic of care. This article centres the vast majority of living donors, those who donate in the context of a significant pre-existing relationship. A cost-neutral approach is unfair on donors who make society richer and healthier by helping a loved one. However, models of kidney sale fail to offer an acceptable alternative, either (a) compelling donors to sell into a pool where they do not know the recipient or (b) allowing affluent individuals unfair access to kidneys. Drawing on surrogacy law in England and Wales, a model of compensation is proposed that includes a range of non-financial benefits. This option celebrates donation and expresses gratitude to all donors while avoiding the pitfalls of the marketplace, with an emphasis on fair treatment of donors. Nevertheless, if more generous treatment led to a 10% increase in directed donation, then it would be equivalent to doubling 'altruistic' stranger donations. As long as the Gender Kidney Donation Gap persists, the best response is to minimise the discomfort and disruption caused to donors by their profound act of kindness.

Renal sulfate reabsorption in healthy individuals and renal transplant recipients

Inorganic sulfate is essential for normal cellular function and its homeostasis is primarily regulated in the kidneys. However, little is known about renal sulfate handling in humans and particularly in populations with impaired kidney function such as renal transplant recipients (RTR). Hence, we aimed to assess sulfate reabsorption in kidney donors and RTR. Plasma and urinary sulfate were determined in 671 RTR and in 251 kidney donors. Tubular sulfate reabsorption (TSR) was defined as filtered load minus sulfate excretion and fractional sulfate reabsorption (FSR) was defined as 1-fractional excretion. Linear regression analyses were employed to explore associations of FSR with baseline parameters and to identify the determinants of FSR in RTR. Compared to kidney donors, RTR had significantly lower TSR (15.2 [11.2-19.5] vs. 20.3 [16.7-26.3] μmol/min), and lower FSR (0.56 [0.48-0.64] vs. 0.64 [0.57-0.69]) (all P < 0.001). Kidney donation reduced both TSR and FSR by circa 50% and 25% respectively (both P < 0.001). In RTR and donors, both TSR and FSR associated positively with renal function. In RTR, FSR was independently associated with urinary thiosulfate (β = -0.18; P = 0.002), growth hormone (β = 0.12; P = 0.007), the intakes of alcohol (β = -0.14; P = 0.002), methionine (β = -0.34; P < 0.001), cysteine (β = -0.41; P < 0.001), and vitamin D (β = -0.14; P = 0.009). In conclusion, TSR and FSR are lower in RTR compared to kidney donors and both associated with renal function. Additionally, FSR is determined by various dietary and metabolic factors. Future research should determine the mechanisms behind sulfate handling in humans and the prognostic value of renal sulfate reabsorption in RTR.

Physician perceptions about living organ donation in patients with Amyotrophic Lateral Sclerosis

OBJECTIVES

Patients with Amyotrophic Lateral Sclerosis (ALS) have expressed desire to become living organ donors but are unable to do so with current organ donation policies. Our objective is to assess ALS patient's interest in organ donation, and perceived concerns of this practice by ALS neurologists.

PATIENTS AND METHODS

An electronic survey was administered to ALS neurologists across the United States regarding living organ donation in ALS patients prior to respiratory failure.

RESULTS

52 complete responses were received from 121 invites. 67% (35/52) of neurologists expressed no concerns about living organ donation in ALS patients, and 33% had concerns. The concerns related to respiratory failure, anesthesia exposure and renal dysfunction. With their concerns addressed, 71% of neurologists reported that they would endorse living organ donation. 49% of neurologists reported being asked by a patient for information regarding living organ donation. ALS neurologists felt that 22.8% of ALS patients (median 19%) would be interested in learning more about organ donation, while only 6% of neurologists broach this subject with their patients.

CONCLUSION

Our results indicate that 1 in every 4 ALS patients may be interested in exploring options for living organ donation, and this topic is not routinely addressed by ALS clinics. These results indicate an unexplored area of patient interest. To honor a patient's wishes to donate, the transplant community will have to accommodate living organ donation from terminally ill patients, and address neurologist concerns. Such a practice could benefit two groups of patients.

Influence of specific thoracic donor therapy on kidney donation and long-term kidney graft survival

OBJECTIVE

To analyze the impact of a specific thoracic donor-treatment protocol (including restrictive fluid balance) on kidney donation and on kidney graft survival.

METHODS

A cohort study. Lung Donors and kidney recipients from 2003 to 2008 were the pre-protocol cohort, and those from 2009 to 2013 were the protocol cohort. The main outcome variables were graft survival and rate of kidney donation.

RESULTS

Kidney donation rates were similar in both periods (86.2 vs. 86.2 %; p > 0.05). Both donors and kidney recipients were older and with more comorbidities in the protocol group and this is the reason there were more cases of delayed graft function (differences not statistically significant) and with higher sequential creatinine levels of kidney recipients during the protocol period. However, graft survival was similar in both groups. The probability of graft survival 5 years after transplantation was 0.75 (95 % confidence interval 0.65-0.85) in the pre-protocol cohort and 0.81 (0.70-0.92) in the protocol cohort.

CONCLUSIONS

Specific treatment for multi-organ donors including restrictive fluid balance does not affect kidney donation or kidney graft loss, and has no impact on long-term viability. Hemodynamics must be closely monitored by medical personnel with specific training.

Iranian kidney market in limbo: a commentary on "The ambiguous lessons of the Iranian model of paid living kidney donation"

Sigrid Fry-Revere's The Kidney Sellers: A Journey of Discovery in Iran, an allegedly first-hand examination of the Iranian paid kidney donation model, has been criticized by Koplin in an essay formerly published in the Monash Bioethics Review. Koplin especially challenges Fry-Revere's claim that financially compensating kidney vendors might facilitate altruistic kidney donation. The current situation in Iran, according to Koplin, suggests that the market model has undermined altruistic donation. On this point, this commentary tries to show that healthcare policymakers in Iran no longer see the Iranian paid kidney donation model as a sustainable and ethically justifiable status quo. Briefly touching on the criticisms that have been made even by some positive commentators of the Iranian model, this commentary aims to call attention to the fact that the current dynamic within healthcare policymaking in Iran seeks primarily to decrease its reliance on the organ market instead of revising and modifying it. This complicates the plausibility of any kind of extrapolation, replication or extracting empirical support from the Iranian model to create organ markets in other countries, for example, as Fry-Revere suggests to conduct a trial of a financially incentivized kidney donation scheme in the US. The conclusion is that the Iranian healthcare system should tackle the organ shortage through increasing altruistic living and postmortem kidney donations. This might also provide, finally, a space for conducting extensive and long-term follow-up studies on well-being, satisfaction and social integration of Iranian kidney vendors.

Patient-Reported Outcomes Following Living Kidney Donation: A Single Center Experience

This article describes the development and implementation of an initiative at one transplant center to annually assess psychosocial outcomes of living kidney donors. The current analysis focuses on a cohort of adults (n = 208) who donated a kidney at BIDMC between September 2005 and August 2012, in which two post-donation annual assessments could be examined. One and two year post-donation surveys were returned by 59 % (n = 123) and 47 % (n = 98) of LKDs, respectively. Those who did not complete any survey were more likely to be younger (p = 0.001), minority race/ethnicity (p < 0.001), and uninsured at the time of donation (p = 0.01) compared to those who returned at least one of the two annual surveys. The majority of donors reported no adverse physical or psychosocial consequences of donation, high satisfaction with the donation experience, and no donation decision regret. However, a sizable minority of donors felt more pain intensity than expected and recovery time was much slower than expected, and experienced a clinically significant decline in vitality. We describe how these outcomes are used to inform clinical practice at our transplant center as well as highlight challenges in donor surveillance over time.

Towards a standardized informed consent procedure for live donor nephrectomy: What do surgeons tell their donors?

INTRODUCTION

Living kidney donors comprise a unique group of "patients", undergoing an operation for the benefit of others. The informed consent process is therefore valued differently. Although this is a team effort, the surgeon is responsible for performing the donor nephrectomy, and often the one held accountable, should adverse events occur. Although there is some consensus on how the informed consent procedure should be arranged, practices vary. The aim of this study was to evaluate the surgical informed consent procedure for live donor nephrectomy, with special regards to disclosure of complications.

METHODS

A web-based survey was sent to all kidney transplant surgeons (n = 50) in eight transplant centers with questions regarding the local procedure and disclosure of specific details.

RESULTS

Response rate was 98% (n = 49), of which 32 (65%) were involved in living donor education; overall, transplant- (50%), vascular- (31%), and abdominal surgeons (13%), and urologists (6%) performed donor nephrectomies in the eight centers. Informed consent procedures varied, ranging from assumed to signed consent. Bleeding was the only complication every surgeon mentioned. Risk of death was always mentioned by 16 surgeons (50%), sometimes by 13 (41%), three surgeons (9%) never disclosed this disastrous complication. Reported mortality rates ranged from 0.003% to 0.1%. Mentioning frequencies for all other complications varied.

CONCLUSION

Important complications are not always disclosed during the surgical informed consent process for live donor nephrectomy. Informed consent procedures vary. To optimally prepare living kidney donors for the procedure, a standardized informed consent procedure for live donor nephrectomy is highly recommended.

Transplantation of kidneys with tumors

The shortage of donors in the face of the increasing number of patients wait-listed for renal transplantation has prompted several strategies including the use of kidneys with a tumor, whether found by chance on harvesting from a deceased donor or intentionally removed from a living donor and transplanted after excision of the lesion. Current evidence suggests that a solitary well-differentiated renal cell carcinoma, Fuhrman nuclear grade I-II, less than 1 cm in diameter and resected before grafting may be considered at minimal risk of recurrence in the recipient who, however, should be informed of the possible risk and consent to receive such a graft.

Graft-versus-host disease after kidney transplantation

Graft-versus-host disease (GVHD) is a rare complication after kidney transplantation. We describe a 62-year-old female with end-stage renal disease due to hypertension. She received a kidney with 4 mismatched human leukocyte antigen (HLA) out of 6 HLA - A, B, DR from a deceased donor. After the procedure, the patient showed watery diarrhea on postoperative day (POD) 45. An endoscopic biopsy of the colon revealed some apoptotic cells consistent with GVHD. Thrombocytopenia was gradually developed on POD 54. She received steroid pulse therapy, and thrombocytopenia did not progress. However, pneumonia, renal failure, and cardiac failure occurred. She died due to multiple organ failure. We must consider GVHD in renal transplant recipients without homozygous or identical HLA, who had only watery diarrhea without other typical GVHD symptoms such as skin rash and fever, although GVHD is rare in renal transplant recipients.