Terminal kidney patients are faced with lower quality of life, restricted diets and higher morbidity and mortality rates while waiting for deceased donor kidney transplantation. Fortunately, living kidney donation has proven to be a better treatment alternative (e.g. in terms of waiting time and graft survival rates). We observed an inequality in the number of living kidney transplantations performed between the non-European and the European patients in our center. Such inequality has been also observed elsewhere in this field and it has been suggested that this inequality relates to, among other things, attitude differences towards donation based on religious beliefs. In this qualitative research we investigated whether religion might indeed (partly) be the explanation of the inequalities in living donor kidney transplants (LDKT) among non-European patients. Fifty patients participated in focus group discussions and in-depth interviews. The interviews were conducted following the focus group method and analyzed in line with Grounded Theory. The qualitative data analyses were performed in Atlas.ti. We found that religion is not perceived as an obstacle to living donation and that religion actually promotes helping and saving the life of a person. Issues such as integrity of the body were not seen as barriers to LDKT. We observed also that there are still uncertainties and a lack of awareness about the position of religion regarding living organ donation within communities, confusion due to varying interpretations of Holy Scriptures and misconceptions regarding the process of donation. Faith leaders play an important educational role and their opinion is influential. This study has identified modifiable factors which may contribute to the ethnic disparity in our living donation program. We argue that we need to strive for more clarity and awareness regarding the stance of religion on the issue of living donation in the local community. Faith leaders could be key figures in increasing awareness and alleviating uncertainty regarding living donation and transplantation.
Attitudes; Communication; Ethnicity; Kidney transplantation; Organ donation; Religion
With the notable growth in the qualitative investigation of living kidney donation, there is value in aggregating results from this body of research to learn from accumulated experience. The present paper aims to draw a complete portrait of living donors' and recipients' experience of donation by metasummarizing published studies. We found that donors' experience, particularly the decision-making process, has been more extensively studied than the recipients' perspective. Donors differ in their initial level of motivation to donate but on the whole report positive experiences and personal benefits. They also identify difficult periods and the need for additional resources. Recipients report an often positive but more ambivalent reaction to donation. In terms of relational issues between dyads, while the topic remains understudied, the donor-recipient relationship and gift reciprocity have received the most attention. Results are discussed in terms of their implications for future practice and research.
Background: Most deceased donor kidney allocation protocols are based on waiting time and do not take into account either recipient's life expectancy. This study investigates whether graft survival is affected by patient life expectancy.
Methods: A total of 640 adult kidney transplants were performed. Recipients were divided in group A (patients ≤ 50 years) and group B (patients > 50 years). The status of graft+recipient combination was characterized as: a) deceased recipient with functional graft, b) alive recipient with functional graft and c) deceased or alive recipient with nonfunctional graft.
Results: Mean kidney recipient survival was 15.15 (95% CI: 14.54, 15.77) and 12.40 (95% CI: 11.47, 13.33) years for groups A and B respectively (p < 0.0001). Mean graft survival was 13.62 (95% CI: 12.81, 14.43) and 12.42 (95% CI: 11.59, 13.25) years for groups A and B respectively (p=0.6516). Non-functional grafts were identified in 18.4% (n=57) and 16.4% (n=54) of group A and B respectively.
Conclusions: Allocation of renal grafts to older patients does not result in significant loss of graft-years. Recipients' life expectancy has a small impact on graft survival. We should not deviate from the basic principles of equality, when kidney allocation systems are designed.
waiting list; equality; utility; outcomes; survival
Policies for allocating deceased donor kidneys have recently shifted from allocation based on Human Leucocyte Antigen (HLA) tissue matching in the UK and USA. Newer allocation algorithms incorporate waiting time as a primary factor, and in the UK, young adults are also favoured. However, there is little contemporary UK research on the views of stakeholders in the transplant process to inform future allocation policy. This research project aimed to address this issue.
Discrete Choice Experiment (DCE) questionnaires were used to establish priorities for kidney transplantation among different stakeholder groups in the UK. Questionnaires were targeted at patients, carers, donors / relatives of deceased donors, and healthcare professionals. Attributes considered included: waiting time; donor-recipient HLA match; whether a recipient had dependents; diseases affecting life expectancy; and diseases affecting quality of life.
Responses were obtained from 908 patients (including 98 ethnic minorities); 41 carers; 48 donors / relatives of deceased donors; and 113 healthcare professionals. The patient group demonstrated statistically different preferences for every attribute (i.e. significantly different from zero) so implying that changes in given attributes affected preferences, except when prioritizing those with no rather than moderate diseases affecting quality of life. The attributes valued highly related to waiting time, tissue match, prioritizing those with dependents, and prioritizing those with moderate rather than severe diseases affecting life expectancy. Some preferences differed between healthcare professionals and patients, and ethnic minority and non-ethnic minority patients. Only non-ethnic minority patients and healthcare professionals clearly prioritized those with better tissue matches.
Our econometric results are broadly supportive of the 2006 shift in UK transplant policy which emphasized prioritizing the young and long waiters. However, our findings suggest the need for a further review in the light of observed differences in preferences amongst ethnic minorities, and also because those with dependents may be a further priority.
Renal transplant; Allocation; Choice experiment; Stakeholder
Objectives: The introduction of the living donation in organ transplantation introduces important new psychological conflicts and ethical questions in the transplantation process. Operation related risks, as well as dependencies in the family structure, generate considerable pressure on potential donors. The aim of the study was to reconstruct the determinants of willingness to donate before transplantation.
Methods: Evaluation of 20 taped and transcribed interviews oriented to current approaches in qualitative interview research. The approach used is based on grounded theory, qualitative content analysis, and the concept of the ideal type.
Results: Before surgery, "openly motivated" donors push for an operation, leaving no room for ambivalence in the evaluation process. They idealise the relationship with the recipient, and link their donation with the individual—partly in subconscious expectations and wishes. In contrast, "openly ambivalent" donors formulate their anxieties and express arguments against donation.
Conclusions: Statements that claim ambivalence towards donation or utterance of arguments against donation indicate earlier coercion. Before transplantation, potential donors should have the opportunity to discuss their emotional situation to help their decision making process.
Transplantation is an effective, life-prolonging treatment for organ failure. Demand has steadily increased over the past decade, creating a shortage in the supply of organs. In addition, the number of deceased organ donors has reached a plateau.
Living-donor transplantation is increasingly an option, influenced by favourable clinical outcomes and increased waiting times at most transplant centres across North America. Living-donor kidney transplants have exceeded deceased-donor transplant rates at some centres.
Organ donations from living donors have challenged transplant programs to develop a framework for determining donor acceptability. After a multidisciplinary consensus-building process of discussion and debate, the Multi-Organ Transplant Program of the University Health Network in Toronto has developed ethical guidelines for these procedures. These proposed guidelines address ethical concerns related to selection criteria and procedures, voluntariness, informed consent and disclosure of risks and benefits to both donor and recipient.
Canada, akin to other developed nations, faces the growing challenges of end-stage renal disease (ESRD). Even with expanded donor criteria for renal transplantation (the treatment of choice for ESRD), the supply of kidneys is outpaced by the escalating demand. Remuneration for kidney donation is proscribed in Canada. Without an option of living-related transplantation (biological or emotional donors), patients often struggle with long waiting lists for deceased donor transplantation. Accordingly, many patients are now opting for more expedient avenues to obtaining a renal transplant. Through commercial organ retrieval programs, from living and deceased donors, patients are travelling outside Canada to have the procedure performed.
Between September 2001 and July 2007, 10 patients (7 males, 3 females) underwent commercial renal transplantation outside Canada. We describe the clinical outcomes of these patients managed postoperatively at our single Canadian transplant centre.
Six living unrelated and 4 deceased donor renal transplantations were performed on these 10 patients (mean age 49.5 years). All procedures were performed in developing countries and the postoperative complications were subsequently treated at our centre. The mean post-transplant serum creatinine was 142 μmol/L. The average follow-up time was 29.8 months (range: 3 to 73 months). One patient required a transplant nephrectomy secondary to fungemia and subsequently died. One patient had a failed transplant and has currently resumed hemodialysis. Acute rejection was seen in 5 patients with 3 of these patients requiring re-initiation of hemodialysis. Only 1 patient had an uncomplicated course after surgery.
Despite the kidney trade being a milieu of corruption and commercialization, and the high risk of unconventional complications, patients returning to Canada after commercial renal transplantation are the new reality. Patients are often arriving without any documentation; therefore, timely, goal-directed therapy for surgical and infectious complications is frequently delayed because of the time taken to establish an accurate diagnosis. Refuting the existence of commercial renal transplantation may not be a practical solution; more consistent communication and documentation with transplant teams may be more pragmatic. In the current climate, patients considering the option of overseas commercial renal transplantation should be advised of the potential increased risks.
Kidney transplantations at our center rely mainly on living donors. The purpose of this study was to suggest future donor supply directions by reviewing changing trends in donor type.
During the past 40 years, 1,690 kidney transplantations were performed at our center. We divided the follow-up period into four decades and the donor population into three groups: living related, living unrelated, and deceased. We analyzed changing trends in donors from each group for each decade. Patients receiving overseas transplantation were also included.
The proportion of living related donors decreased from 84% (54/64) in the 1970s to 61% (281/458) in the 2000s. Living unrelated donors showed a sustained proportion of around 20% after 1990. However, among living unrelated donors, the proportion of spouse donors increased from 4.6% (17/369) in the 1980s to 8.5% (39/458) in the 2000s. Transplants from deceased donors were only 3.3% (12/369) in the 1980s. However the proportion of deceased donors increased gradually, reaching 13.2% (105/799) in the 1990s and 19.9% (91/458) after 2000. Overseas transplantations increased after 2000 and reached 20% of all cases treated in our center during the 2000s. Such transplantations peaked in 2006 and decreased markedly thereafter.
The proportion of each donor type has continuously changed, and the changes were associated with changes in the social structure and system. We expect that this study could be an important reference for other countries to estimate future changes of donor type.
Kidney transplantation; Donor
Renal transplantation is the treatment of choice for a medically eligible patient with end stage renal disease. The number of renal transplants has increased rapidly over the last two decades. However, the demand for organs has increased even more. This disparity between the availability of organs and waitlisted patients for transplants has forced many transplant centers across the world to use marginal kidneys and donors. We performed a Medline search to establish the current status of marginal kidney donors in the world. Transplant programs using marginal deceased renal grafts is well established. The focus is now on efforts to improve their results. Utilization of non-heart-beating donors is still in a plateau phase and comprises a minor percentage of deceased donations. The main concern is primary non-function of the renal graft apart from legal and ethical issues. Transplants with living donors outnumbered cadaveric transplants at many centers in the last decade. There has been an increased use of marginal living kidney donors with some acceptable medical risks. Our primary concern is the safety of the living donor. There is not enough scientific data available to quantify the risks involved for such donation. The definition of marginal living donor is still not clear and there are no uniform recommendations. The decision must be tailored to each donor who in turn should be actively involved at all levels of the decision-making process. In the current circumstances, our responsibility is very crucial in making decisions for either accepting or rejecting a marginal living donor.
Complex living donor; deceased marginal donor; marginal kidney donor; non-heart-beating donor
In a universal, public health care system, access to kidney transplantation should not be influenced by residence location. We determined the likelihood of kidney transplantation from deceased donors among Canadian dialysis patients living in 7 geographic regions. Within each region we also determined whether distance from the closest transplant centre was associated with the likelihood of transplantation.
A random sample of 7034 subjects initiating dialysis in Canada between 1996 and 2000 was studied. We used Cox proportional hazards models to examine the relation between residence location and the likelihood of kidney transplantation from deceased donors over a median period of 2.4 years.
There were significant differences in the likelihood of kidney transplantation from deceased donors and predicted waiting times between the different geographic regions. For example, the adjusted relative likelihood of transplantation in Alberta was 3.74 (95% confidence interval [CI] 2.95–4.76) compared with the likelihood in Ontario (p < 0.001). These differences persisted after further adjustment for differences in the rate of deceased organ donation. Within regions, patients who resided 50.1–150 km, 150.1–300 km and more than 300 km from the closest transplant centre had a similar adjusted likelihood of receiving a kidney transplant as those who lived less than 50 km away.
The adjusted likelihood of undergoing a kidney transplant from a deceased donor varied substantially between geographic regions in Canada. In contrast, the likelihood of transplantation within regions was not affected by distance from the closest transplant centre.
Due to organ shortage and difficulties for availability of cadaveric donors, living donor transplantation is an important choice for having allograft. Live donor surgery is elective and easier to organize prior to starting dialysis thereby permitting preemptive transplantation as compared to cadaveric transplantation. Because of superior results with living kidney transplantation, efforts including the usage of “Medically complex living donors” are made to increase the availability of organs for donation. The term “Complex living donor” is probably preferred for all suboptimal donors where decision-making is a problem due to lack of sound medical data or consensus guidelines. Donors with advanced age, obesity, asymptomatic microhematuria, proteinuria, hypertension, renal stone disease, history of malignancy and with chronic viral infections consist of this complex living donors. This medical complex living donors requires careful evaluation for future renal risk. In this review we would like to present the major issues in the evaluation process of medically complex living kidney donor.
Shortage of donor organs is one of the major problems for liver transplant programmes. Living liver donation is a possible alternative, which could increase the amount of donor organs available in the short term.
To assess the attitude towards living organ donation in the general population to have an overview of the overall attitude within Germany.
A representative quota of people was evaluated by a mail questionnaire (n = 250). This questionnaire had 24 questions assessing the willingness to be a living liver donor for different potential recipients. Factors for and against living liver donation were assessed.
Donating a part of the liver was almost as accepted as donating a kidney. The readiness to donate was highest when participants were asked to donate for children. In an urgent life‐threatening situation the will to donate was especially high, whereas it was lower in the case of recipient substance misuse. More women than men expressed a higher disposition to donate for their children. Sex, religion, state of health and age of the donor, however, did not influence other questions on the readiness to consider living organ donation. The will for postmortem organ donation positively correlated with the will to be a living organ donor.
The motivation in different demographic subgroups to participate in living liver transplantation is described. Differences in donation readiness resulting from the situation of every donor and recipient are thoroughly outlined. The acceptance for a living liver donation was found to be high – and comparable to that of living kidney donation.
Deceased donor kidneys are a scarce health resource, yet patient preferences for organ allocation are largely unknown. The aim of this study was to determine patient preferences for how kidneys should be allocated for transplantation.
Patients on dialysis and kidney transplant recipients were purposively selected from two centres in Australia to participate in nominal/focus groups in March 2011. Participants identified and ranked criteria they considered important for deceased donor kidney allocation. Transcripts were thematically analysed to identify reasons for their rankings.
From six groups involving 37 participants, 23 criteria emerged. Most agreed that matching, wait-list time, medical urgency, likelihood of surviving surgery, age, comorbidities, duration of illness, quality of life, number of organs needed and impact on the recipient's life circumstances were important considerations. Underpinning their rankings were four main themes: enhancing life, medical priority, recipient valuation, and deservingness. These were predominantly expressed as achieving equity for all patients, or priority for specific sub-groups of potential recipients regarded as more "deserving".
Patients believed any wait-listed individual who would gain life expectancy and quality of life compared with dialysis should have access to transplantation. Equity of access to transplantation for all patients and justice for those who would look after their transplant were considered important. A utilitarian rationale based on maximizing health gains from the allocation of a scarce resource to avoid "wastage," were rarely expressed. Organ allocation organisations need to seek input from patients who can articulate preferences for allocation and advocate for equity and justice in organ allocation.
Transplantation is the treatment of choice for people with severe organ failure. However, demand substantially exceeds supply of suitable organs; consequently many people wait months, or years to receive an organ. Reasons for the chronic shortage of deceased organ donations are unclear; there appears to be no lack of 'in principle' public support for organ donation.
The PAraDOx Study examines community preferences for organ donation policy in Australia. The aims are to 1) determine which factors influence decisions by individuals to offer their organs for donation and 2) determine the criteria by which the community deems the allocation of donor organs to be fair and equitable. Qualitative and quantitative methods will be used to assess community preferences for organ donation and allocation.
Focus group participants from the general community, aged between 18-80, will be purposively sampled to ensure a variety of cultural backgrounds and views on organ donation. Each focus group will include a ranking exercise using a modified nominal group technique. Focus groups of organ recipients, their families, and individuals on a transplant waiting list will also be conducted.
Using the qualitative work, a discrete choice study will be designed to quantitatively assess community preferences. Discrete choice methods are based on the premise that goods and services can be described in terms of a number of separate attributes. Respondents are presented with a series of choices where levels of attributes are varied, and a mathematical function is estimated to describe numerically the value respondents attach to different options. Two community surveys will be conducted in approximately 1000 respondents each to assess community preferences for organ donation and allocation. A mixed logit model will be used; model results will be expressed as parameter estimates (β) and the odds of choosing one option over an alternative. Trade-offs between attributes will also be calculated.
By providing a better understanding of current community preferences in relation to organ donation and allocation, the PAraDOx study will highlight options for firstly, increasing the rate of organ donation and secondly, allow for more transparent and equitable policies in relation to organ allocation.
Previous multivariate analysis during 4/1/94-12/31/00 from the Organ Procurement Transplant Network/United Network for Organ Sharing (OPTN/UNOS) database has shown that kidneys from Black donors were associated with lower graft survival. We compared graft and patient survival of different kidney donor-to-recipient ethnic combinations to see if this result still holds on a recent cohort of US kidney transplants.
72,495 recipients of deceased and living donor kidney alone transplants from 2001-2005 were included. A multivariate Cox regression method was used to analyze the effect of donor-recipient ethnicity on graft and patient survival within 5 years of transplant, and to adjust for the effect of other donor, recipient and transplant characteristics. Results are presented as hazard ratios (HR) with the 95% confidence limit (CL) and p-values.
Adjusted HR's of donor-recipient patient survival: White to White (1), White to Black (1.22, p=.001). Graft survival HRS: Black to Black (1.40, p<0.001), Black to White (1.35, p<0.001), Black to Hispanic (0.87, p=0.18), Black to Asian (0.69, p=0.05).
Black donor Kidneys are associated with significantly lower graft survival when transplanted into Whites and Blacks and are only associated with lower patient survival when these kidneys are transplanted into White transplant recipients. The graft and patient survival rates for Asian and Latino/Hispanic recipients however were not affected by donor ethnicity. This analysis underscores the need for research to better understand the reasons for these disparities and how to improve the post transplant graft survival rates of Blacks.
Delayed renal allograft survival (DGF) after a deceased donor kidney transplant is associated with an increased risk of allograft loss. Inflammatory response and apoptosis are associated with increased risk of DGF.
Cross Sectional Study
Setting & Participants
We first recruited 616 recipients of kidneys from 512 deceased kidney donors and the donor DNA was genotyped. These recipients who were included in a prospective cohort study of 9 transplant centers in the Delaware Valley region, had their DGF outcome obtained through medical record abstraction. Then, we identified the recipient (n=349) of the contralateral deceased kidney donor, if not part of the cohort, through the USRDS registry. The final cohort consisted of 965 recipients of deceased donor kidneys from 512 donors.
Donor single nucleotide polymorphisms (SNPs) in genes for tumor necrosis factor α (TNF), transforming growth factor β1 (TGFB1), interleukin 10 (IL10), p53 (TP53), and heme oxygenase 1 (HMOX1).
DGF, defined as need for dialysis in the first week post-transplant. Secondary outcomes included acute rejection and eGFR.
Information on DGF, acute rejection and eGFR for recipients in the Delaware Valley Cohort was obtained through medical record abstraction. For other recipients, information on DGF was obtained from UNOS forms and CMS claims in the USRDS registry.
The TGFB1, IL10, TP53 and HMOX1 genes were not associated with DGF. The G allele of TNF polymorphism rs3093662 was associated with DGF in an adjusted analysis (OR= 1.85 compared to A allele, 95% C.I.=1.16–2.96, p=0.01). However this association does not achieve statistical significance after adjusting for multiple comparisons.
Inadequate sample size for infrequent genotypes and multiple comparisons.
Due to the low frequency of donor SNPs of interest, a larger sample size and replication are necessary for conclusive evidence for the association of donor genotypes with DGF.
Kidney Transplant; Deceased Donor Genotypes; Delayed Graft Function
End-stage renal disease (ESRD) is an increasing problem in patients infected with the human immunodeficiency virus (HIV). The use of highly active antiretroviral therapy (HAART) has decreased the morbidity associated with HIV and has prompted renewed interest in renal transplantation.
We performed four cases of deceased donor renal transplantation in HIV+ recipients and three cases where laparoscopic live donor nephrectomy (LLDN) was utilized to obtain the kidney for transplantation into living-related HIV+ recipients. In the four deceased donor cases, conventional tacrolimus-based immunosuppression, without antibody induction was used. In the three living-related cases, the immunosuppressive regimen was based on two principles: recipient pretreatment and minimal posttransplant immunosuppression. Alemtuzumab 30 mg (Campath 1-H) was used for preconditioning followed by low-dose tacrolimus monotherapy.
Of the four deceased donor cases, one patient continues to have good graft function, and another is not yet on dialysis but has significant graft dysfunction. Rejection was observed in three patients (75%). Infectious complications occurred in one patient (25%), all non-acquired immunodeficiency syndrome (AIDs) defining. In the three living-related cases, all had good graft function, and none have experienced acute rejection. HIV viral loads remain undetectable. CD4 counts are slowly recovering. No infectious or surgical complications occurred. There were no deaths in either group.
These data suggest that living-related donor renal transplantation with steroid-free tacrolimus monotherapy in a “tolerogenic” regimen can be efficacious. However, long-term follow-up is needed to confirm this observation.
Living-related renal transplantation; HIV; Campath; Steroid-free immunosuppression
Primary hepatic carcinoid tumors (PHCT) are rare entities; they are even rarer than extrahepatic neuroendocrine gastrointestinal tumors with only about 95 cases reported in the literature. An extrahepatic primary tumor must be excluded to confirm the diagnosis of PHCT.
We report a case of a 42-year-old male patient with a primary hepatic neuroendocrine carcinoma, who successfully underwent living donor liver transplantation from his 70 years old mother with 10 years follow-up. Both donor and recipient are still alive and in the good health.
Living liver donation from elderly donors for the patients with irresectable neuroendocrine liver malignancies can be as safe as deceased donation or liver donation from young donors (age < 50). Living donation from elderly donors might significantly expand the donor pool for patients with liver neuroendocrine tumors (NET) and potentially reduce waiting list mortality. Especially young patients with irresectable NET can benefit from this option. However, case–control studies are needed to verify the advantage of living liver transplantation (LDLT) for the patients with irresectable liver NET and to define selection criteria for these patients.
Neuroendocrine tumors; Living donor liver transplantation; Primary hepatic neuroendocrine carcinoma; Elderly living donors
Expanding the criteria for deceased organ donors increases the risk of delayed graft function (DGF) and complicates kidney transplant outcome. We studied whether donor neutrophil gelatinase-associated lipocalin (NGAL), a novel biomarker for acute kidney injury, could predict DGF after transplantation.
We included 99 consecutive, deceased donors and their 176 kidney recipients. For NGAL detection, donor serum and urine samples were collected before the donor operation. The samples were analyzed using a commercial enzyme-linked immunosorbent assay kit (serum) and the ARCHITECT method (urine).
Mean donor serum NGAL (S-NGAL) concentration was 218 ng/mL (range 27 to 658, standard deviation (SD) 145.1) and mean donor urine NGAL (U-NGAL) concentration was 18 ng/mL (range 0 to 177, SD 27.1). Donor S-NGAL and U-NGAL concentrations correlated directly with donor plasma creatinine levels and indirectly with estimated glomerular filtration rate (eGFR) calculated using the modification of diet in renal disease equation for glomerular filtration rate. In transplantations with high (greater than the mean) donor U-NGAL concentrations, prolonged DGF lasting longer than 14 days occurred more often than in transplantations with low (less than the mean) U-NGAL concentration (23% vs. 11%, P = 0.028), and 1-year graft survival was worse (90.3% vs. 97.4%, P = 0.048). High U-NGAL concentration was also associated with significantly more histological changes in the donor kidney biopsies than the low U-NGAL concentration. In a multivariate analysis, U-NGAL, expanded criteria donor status and eGFR emerged as independent risk factors for prolonged DGF. U-NGAL concentration failed to predict DGF on the basis of receiver operating characteristic curve analysis.
This first report on S-NGAL and U-NGAL levels in deceased donors shows that donor U-NGAL, but not donor S-NGAL, measurements give added value when evaluating the suitability of a potential deceased kidney donor.
The present review outlines the principles of living donor liver transplantation, donor workup, procedure and outcomes. Living donation offers a solution to the growing gap between the need for liver transplants and the limited availability of deceased donor organs. With a multidisciplinary team focused on donor safety and experienced surgeons capable of performing complex resection/reconstruction procedures, donor morbidity is low and recipient outcomes are comparable with results of deceased donor transplantation.
Cirrhosis; Liver transplantation; Living donor; Morbidity; Right hepatectomy
Of the various options for patients with end stage renal disease, kidney transplantation is the treatment of choice for a suitable patient. The kidney for transplantation is retrieved from either a cadaver or a live donor. Living donor nephrectomy has been developed as a method to address the shortfall in cadaveric kidneys available for transplantation. Laparoscopic living donor nephrectomy (LLDN), by reducing postoperative pain, shortening convalescence, and improving the cosmetic outcome of the donor nephrectomy, has shown the potential to increase the number of living kidney donations further by removing some of the disincentives inherent to donation itself. The technique of LLDN has undergone evolution at different transplant centers and many modifications have been done to improve donor safety and recipient outcome. Virtually all donors eligible for an open surgical procedure may also undergo the laparoscopic operation. Various earlier contraindications to LDN, such as right donor kidney, multiple vessels, anomalous vasculature and obesity have been overcome with increasing experience. Laparoscopic live donor nephrectomy can be done transperitoneally or retroperitoneally on either side. The approach is most commonly transperitoneal, which allows adequate working space and easy dissection. A review of literature and our experience with regards to standard approach and the modifications is presented including a cost saving model for the developing countries. An assessment has been made, of the impact of LDN on the outcome of donor and the recipient.
donor nephrectomy; transplant; warm ischemia
End-stage liver disease, due to cholestatic liver diseases with an autoimmune background such as primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC), is considered a good indication for liver transplantation. Excellent overall patient and graft outcomes, based mostly on the experience from deceased donor liver transplantation (DDLT), have been reported. Due to the limited number of organ donations from deceased donors in most Asian countries, living donor liver transplantation (LDLT) is the mainstream treatment for end-stage liver disease, including that resulting from PBC and PSC. Although the initial experiences with LDLT for PBC and PSC seem satisfactory or comparable to that with DDLT, some aspects, including the timing of transplantation, the risk of recurrent disease, and its long-term clinical implications, require further evaluation. Whether or not the long-term outcomes of LDLT from a biologically related donor are equivalent to that of DDLT requires further observations. The clinical course following LDLT may be affected by the genetic background shared between the recipient and the living related donor.
Liver transplantation; Primary biliary cirrhosis; Primary sclerosing cholangitis; Living donor; Recurrence
Obese living donors who undergo donor nephrectomy have higher rates of intra-operative and post-operative complications. Many centres exclude obese donors from living donor transplant programs. Diet, exercise and medication are often ineffective weight loss interventions for donors, hence bariatric surgery should be considered.
We report the case of a 53-year-old Caucasian woman who underwent laparoscopically adjustable gastric banding. The procedure enabled her to lose sufficient weight to gain eligibility for kidney donation. After losing weight, she had an uncomplicated laparoscopic donor nephrectomy surgery, and the recipient underwent successful kidney transplantation.
Laparoscopically adjustable gastric banding should be considered for obese potential living kidney donors whenever transplantation units restrict access to donor nephrectomy based on the increased surgical risk for donors.
Background and objectives
Age and body mass index (BMI) of kidney donors and recipients affect kidney allograft outcomes. Moreover, while deceased donor and recipient body size mismatch have been reported to influence allograft outcomes, how BMI mismatch in living kidney donor–recipient pairs affect graft survival is not well defined.
Design, setting, participants, and measurements
We investigated trends in characteristics of 90,815 US. living kidney donors and their recipients between 1987 and 2008.
Median ages of donors and their recipients have risen over time, and the proportion of living donors age ≥50 years increased from 11 to 25%. Median BMI of recipients increased from 22.6 to 26.6 kg/m2; median BMI of kidney donors for the past 5 years has been 26.4 kg/m2. Only 35% of living donor-recipient pairs were in the same BMI category (<25, 25–29.9, 30–34.9, or ≥35kg/m2). BMI mismatch where the living donor was three categories heavier than the recipient was associated with a significant adjusted risk for death-censored allograft loss (HR 2.31, 95% CI 1.05–5.08).
Living kidney donors are donating at more advanced ages, and the majority are overweight or obese in recent years. In summary: (1) previous longitudinal studies of living kidney donor outcomes may not be generalizable to recent donors, and studies of contemporary living kidney donor cohorts may be informative, (2) the majority of living donor–recipient pairs have BMI mismatch, and (3) extreme BMI mismatch where the living donor is heavier may confer an independent risk for allograft loss.
Living kidney donation; Donor/recipient BMI mismatch; Donor age
Organs available for transplantation are scarce and valuable medical resources and decisions about who is to receive them should not be made more difficult by complicated calculations of desert. Consideration of likely clinical outcome must always take priority when allocating such a precious resource otherwise there is a danger of wasting that resource. However, desert may be a relevant concern in decision-making where the clinical risk is identical between two or more potential recipients of organs. Unlikely as this scenario is, such a decision procedure makes clear the interdependence of organ recipient and organ donor and hints at potential disadvantages for those who are willing to accept but unwilling to donate organs (free-riders). A combined opting-out and preference system weakens many of the objections to opting-out systems and may make the decision to donate organs on behalf of their deceased relatives easier for families.