• Save
Gabriel Danovitch - USA  - Monday 28 - Alternatives to increase the number of living donors
Upcoming SlideShare
Loading in...5
×
 

Gabriel Danovitch - USA - Monday 28 - Alternatives to increase the number of living donors

on

  • 1,826 views

 

Statistics

Views

Total Views
1,826
Views on SlideShare
473
Embed Views
1,353

Actions

Likes
0
Downloads
0
Comments
0

6 Embeds 1,353

http://isodp2011.localhost 912
http://www.isodp2011.org.ar 380
http://test.isodp2011.org.ar 44
http://isodp2011.org.ar 9
http://131.253.14.250 6
http://www.incucai.gov.ar 2

Accessibility

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • Slight increases in the number of Asian and Hispanic living donors, but negligible change in number of minority living donors
  • Donor-related 1. Fear of surgery, pain, future kidney failure and need for kidney transplant 2. Lack of awareness of status as a potential donor - studies have shown that many potential donors are open to considering the option of live donation, but are unaware of their status as a potential donor. Candidate-related 1. A number of studies have found that less than half of kidney transplant candidates surveyed felt it was appropriate to request live donation from a family member or were willing to ask a family member to donate. This is often due to candidates’ concerns for the donor - harming their health, causing pain or inconvenience, and disappointing the donor if the kidney were rejected. Also stems from fear of coercing family into donating. Efforts to provide transplant candidates and potential donors with factual information about LDKT have assuaged many candidates’ concerns and increased their willingness to pursue LDKT. 2. Even when candidates have shown a willingness to accept an offer of live donation, many are reluctant to communicate with members of their inner circles about LDKT a. African American transplant candidates are less willing to ask a family member to donate or to discuss LDKT with family than Caucasian candidates b. Rodrigue et al found that white race, college education, fewer concerns about LDKT, and less favorable perceptions of candidates’ own health status predicted willingness to talk about LDKT c. Reese et al revealed that a preference for LDKT and a willingness to ask for help were positively associated with initiating conversations about LDKT Failure to communicate about LDKT has the potential to isolate the patient at a time when family support is crucial. Lack of open communication about LDKT may also delay transplantation and/or severely impair the search for a suitable donor. Indeed, research by Boulware et al. found that patient-physician discussion of LDKT was predicted by patients’ discussion of the topic with their partners. This suggests that family communication about LDKT is an essential component of the transplant process as it significantly improves candidates’ access to LDKT.
  • Cumulative incidence of live donor transplant access according to SES quartile at initial listing censored at deceased donor transplantation. SES quartiles at transplant were distributed as ≤41, 42 to 45, 46 to 49, and ≥50.
  • As in most European countries also in the Netherlands the waitlist for deceased donor kidney transplantation increased over the last decennia, from 400 to more than 1200 patients, but it stabilised in the the last years and even slightly decreased to approximately 1000 at the moment. While the total number of transplants remained more or less the same during the 90-ies, we observed a 60% rise in the last 8 years. That resulted from s everal approaches that were undertaken to overcome this discrepancy between demand and supply, especially by the (re)introduction of living kidney donation programs. due to the efforts of the the 7 transplant centers to do more living related transplantations.
  • Deceased donor kidney transplants did not change much over the last 20 years in the Netherlands, but on this slide you see that the rise in the total number of transplants mainly resulted from the spectacular rise in living donations. Last year in the Netherlands 45% of all kidneys, the blue bars, were derived from living donors. This year 2008 this percentage will be 55%. Till 31 oktober 291 postmortal and 352 living. .
  • As in most European countries also in the Netherlands the waitlist for deceased donor kidney transplantation increased over the last decennia, from 400 to more than 1200 patients, but it stabilised in the the last years and even slightly decreased to approximately 1000 at the moment. While the total number of transplants remained more or less the same during the 90-ies, we observed a 60% rise in the last 8 years. That resulted from s everal approaches that were undertaken to overcome this discrepancy between demand and supply, especially by the (re)introduction of living kidney donation programs. due to the efforts of the the 7 transplant centers to do more living related transplantations.

Gabriel Danovitch - USA  - Monday 28 - Alternatives to increase the number of living donors Gabriel Danovitch - USA - Monday 28 - Alternatives to increase the number of living donors Presentation Transcript

  • Promotion of living kidney donation Gabriel M Danovitch: Buenos Aires 2011 … .and the case of the biologically unrelated donor
  • Transplantation: 1954 “ Dr. Merrill and I had an honest and understandable difference of opinion about whether or not…native kidneys should be removed...When (this) exists a compromise is acceptable” - J.E. Murray, M.D.
  • Categories of living donors over time
    • 1954: Identical twins
    • 1960’s: First-degree relatives
    • Early1980’s: Spousal donors
    • Late 1980’s: Non-first degree relatives
    • Early 1990’s: Paired exchange/list exchange
    • Mid 1990’s: “Emotionally-related”
    • Late 1990’s: Non-directed donors (NDD)
    • Late 2000’s: NDD generated chains, bridges
    • Mid 1990’s: Donor “vending”
  • Shifting Landscape of Living Kidney Donation, United States UNOS, 2009
  • Shifting Landscape of Living Kidney Donation, EuroTransplant www.eurotransplant.nl
  • Percent Living Kidney Donors by Transplant Center (Among centers with >20 transplants, 2004) Range = 30-84% Median = 60.5%
  • Unrelated Living Donors (as % of all Living Donors), by Transplant Center (Among centers with >20 transplants, 2004) Range = 13-51% Median = 34.5%
  • Current U.S. Wait List
  • Living Donation & Minorities
  • Gore J, Pham T, Danovitch G, Singer J. Am J Transplant 5;2009. Yearly trends in odds of getting LDRT
  • Barriers to the Pursuit of LDKT
    • Donor-related
      • Fear
      • Lack of awareness of need
      • Absence of close emotion relationship
      • Financial and logistic constraints
    • Candidate-related
      • Reticence to request live donation
      • Reticence to accept offers of donation
      • “ Protection” of loved ones/paternalism
      • Personal isolation
      • Lack of communication about LDKT
  • Cumulative incidence of live donor transplant access according to SES quartile at initial listing censored at deceased donor transplantation. Axelrod D A et al. CJASN 2010;5:2276-2288 ©2010 by American Society of Nephrology
  • Categories of “unrelated” living kidney donors
    • Spousal/legal
    • Non-first degree relatives
    • Distant relatives
    • Close emotional bond
    • Distant emotional bond
    • Non-directed
    • Altruistic/Samaritan
  • Kidney Transplantation From Unrelated Living Donors: Time to reclaim a discarded opportunity Levey A,Hou S, Bush H N Engl J Med 314;914-916:1986
  • From Cynicism to Skepticism! Skepticism: A doubting or questioning attitude or state of mind Cynicism: An attitude of scornful or jaded negativity especially as a general distrust of the integrity or professional motivations of others
  • “… such donations would not be an act of love, and it is unclear to me what the prospective donor’s motivation would be, if not financial” Letter responding to Levey et al. N Engl J Med 314;713:1986
  • “… such donations would not be an act of love, and it is unclear to me what the prospective donor’s motivation would be, if not financial” Danovitch G . letter responding to Levey et al. N Engl J Med 314;713:1986
  • Epstein M. The declaration of Istanbul on Organ Trafficking and Transplant Tourism: an Important International Achievement with One Disturbing Loophole. BMJ 2008;336:1377 “… Perhaps ‘altruistic unrelated living donation’, as we currently know it, is just a legal fiction that conceals commercial transactions more often than not”.
  • Mor E. Kidney transplantation form unrelated donors. COOT 14:113:2009
    • 214 potential LURDs at an Israeli center
    • “ Cleared” by ethics committee
    • 78% young men
    • 50% divorced
    • 66% no permanent employment
    • “ These findings strongly suggest that the younger, unemployed, divorced males of the unrelated group may have some financial incentive for ‘donating’ their kidney”
  • Living Donor Kidney Transplantation Rabin Med Center: Israel Era 1 (2006-2008): Era 2 (2008-2010 ) 0.0001 p,<
  • Graphic explains kidney-selling scheme that Levy Izhak Rosenbaum is accused of arranging. (AP) Brooklyn man's arrest on kidney-selling charges throws a spotlight on organ trafficking By: DAVID PORTER and CARLA K. JOHNSON Associated Press 07/25/09
  • Unrelated Kidney Donation in the USA: Legal fiction or ‘altruism’? Gore J,Singer J, Danovitch G. J Urol. In press
    • Are there are larger Socio-economic Score (SES) differences in living unrelated kidney donor-recipient pairs than related donor-recipient pairs in the United States?
  • Individual SES characteristics of donors and recipients   Related Unrelated p value Overall 41694 (82.4) 8878 (17.6) Recipient characteristics Age (years), Mean ± SD 42.6 ± 16.2 45.7 ± 13.9 <0.001 White race, no. (%) 28,830 (69.1) 6,902 (77.7) <0.001 College educated, no. (%) 7,942 (23.9) 2,341 (32.1) <0.001 Privately insured, no. (%) 25,947 (62.2) 5,870 (66.1 ) <0.001 Preemptive , no. (%) 14,027 (35.6) 3,263 (39.2) <0.001 Donor characteristics Age (years), Mean ± SD 39.9 ± 10.9 40.9 ± 10.4 <0.001 White race, no. (%) 29,112 (69.8) 7,407 (83.4) <0.001 College educated, no. (%) 6,939 (31.8) 2,003 (36.7) <0.001 Transplant center characteristics Laparoscopic donor nephrectomy 25,073 (70.3) 6,381 (76.3) <0.001 High volume ( ≥ 100) , no. (%) 19,624 (47.1) 4,547 (51.2) <0.001
  • Neighborhood characteristics of donors and recipients   Recipient  Donor Neighborhood characteristic Related Unrelated Related Unrelated Median income ($K) $46.0 ± $17.5 $48.0 ± $17.7 $46.1 ± $17.4 $47.0 ± $16.4 Median housing value ($K) $141 ± $102 $149 ± $109 $142 ± $102 $144 ± $103 Percent receiving int./div./rental income 36.1 ± 13.6 38.3 ± 13.1 36.0 ± 13.5 37.7 ± 12.6 Percent with a high school degree 29.0 ± 9.1 28.5 ± 9.5 28.7 ± 9.1 28.9 ± 9.2 Percent completed college 15.4 ± 8.6 16.7 ± 9.0 15.7 ± 8.7 16.3 ± 8.5 Percent professional 32.8 ± 11.7 34.4 ± 11.9 33.1 ± 11.7 33.8 ± 11.5 Socioeconomic status index -0.11 ± 3.85 0.51 ± 3.74 -0.07 ± 3.88 0.33 ± 3.61
  • Socio-Economic Score by donor type
  • Unrelated Kidney Donation in the USA: Legal fiction or ‘altruism’? Gore J,Singer J, Danovitch G. J Urol. In Press
    • Are there are larger Socio-economic Score (SES) differences in living unrelated kidney donor-recipient pairs than related donor-recipient pairs in the United States?
    • PRELIMINARY CONCLUSION: SES differences in living unrelated kidney donor-recipient pairs ARE NOT GREATER than related donor-recipient pairs in the United States?
    • This data cannot totally exclude the use of financial incentives in living unrelated donation in the USA but suggests that it is not systematic and that voluntarism (altruism) remains at its core
  • The Declaration of Istanbul on Organ Trafficking and Transplant Tourism
  • Dew et al. Guidelines for the psychosocial evaluation of living unrelated kidney donors in the United States. AJT 2007;7:1
    • Characteristics of unrelated donors that increase their risk for, or serve as protective factors against, poor donor psychosocial outcome
    • Basic principles underlying informed consent and evaluation processes pertinent to these donors
    • The process and content of the donor psychosocial evaluation
  • The Declaration of Istanbul on Organ Trafficking and Transplant Tourism
    • To address the growing problems of organ sales, transplant tourism and trafficking in organ donors in the context of the global shortage of organs, a Summit Meeting was held in Istanbul of more than 150 representatives of scientific and medical bodies from 78 countries around the world, including government officials, social scientists, and ethicists.
    Istanbul Summit April 30 th – May 2 , 2008
  • Henderson et al. The Living Anonymous Kidney Donor: Lunatic or Saint? AJT 3;203:2003 “ Contrary to our medical community's fears, there are a significant number of psychologically stable, altruistically motivated individuals who want to donate a kidney anonymously to a stranger, and seek no material compensation in return. The evidence is sufficiently compelling to consider developing LAD programs nationally and internationally. This is especially true for Canadian and European programs, which have been more reticent about LADs than their American counterparts”
  • Anonymous Living Kidney Donors, United States, 1999 - 2009 UNOS, 2009 5 81 141
  • The non-directed live-kidney donor: ethical considerations and practice guidelines: A National Conference Report Adams et al. Transplantation 74;582-589:2002
  • Adams et al.The non-directed live-kidney donor:ethical considerations and practice guidelines:A National Conference Report. Transplantation 74;582:2002
  • Challenges in the Development of Living Donor Exchange Programs Gabriel Danovitch MD David Geffen School of Medicine at UCLA
  • Chains
    • Rees et al. NEJM 2009; 360: 1096
  • Kidney Shipment
  •  
  • Real People, Real Results
  • Unanticipated benefits of living kidney donor chains
    • Impact on deceased donor waitlist
    • Bureaucratic “angst” replaces medical “angst”
    • Financial benefit to hospital
    • Program and staff morale
    • Institutional public relations
    • OPO public relations
    • Impact on ‘social solidarity’
    • Chains as a donation ‘catalyst’
    • /
  • KIDNEY WAITLIST AND TRANSPLANTS IN THE NETHERLANDS
  • KIDNEY TRANSPLANTS IN THE NETHERLANDS
  • KIDNEY WAITLIST AND TRANSPLANTS IN THE NETHERLANDS
  • Should living unrelated kidney donation be promoted?
    • With great care and application of published guidelines and provisions of Declaration of Istanbul
    • In “developed” countries?
    • In “developing” countries?
    • Spousal donation in developing countries?
    • IN CENTRAL AND SOUTH AMERICA?
  • The Document of Aguascalientes 2010
    • RECOMMENDATIONS FOR THE ACCEPTANCE OF THE LIVING DONOR
    • Living donor related by consanguinity : the donor of first, second, third or fourth
    • degree is acceptable.
    • Paired donor : These are only acceptable between couples with living donors who are
    • related by consanguinity or emotionally. All the couples must be evaluated by
    • specialized hospital commissions and must obtain authorization from the
    • corresponding Health and Judicial Authorities.
    • Living donor not related either by consanguinity or emotionally is not acceptable
    • except those included in the following category:
    • Altruistic donor : Without directed donation is acceptable. We recommend that all the
    • cases are carefully evaluated by committees of experts and authorized by the
    • corresponding Health and Judicial Authorities.
    • Emotionally-related living donor : Includes husband or wife, concubines, step-fathers
    • and step-mothers, step-sons and step-daughters; these are acceptable when legally
    • verified and approved by the corresponding Judicial Department.
    • Paid donor : This donor must not be accepted under any circumstance whatsoever.
  • One final thought ! If you plan to get chronic kidney disease ensure you are surrounded by loving and compatible family and friends. … ..probably not a bad idea even if your kidney function is normal!