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Gabriel Danovitch - USA - Monday 28 - Alternatives to increase the number of living donors
1. Promotion of living kidney donation Gabriel M Danovitch: Buenos Aires 2011 … .and the case of the biologically unrelated donor
2. 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.
14. 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
15. 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
16. “… 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
17. “… 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
18. 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”.
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20. Living Donor Kidney Transplantation Rabin Med Center: Israel Era 1 (2006-2008): Era 2 (2008-2010 ) 0.0001 p,<
21. 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
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23. 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
24. 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
30. 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”
32. The non-directed live-kidney donor: ethical considerations and practice guidelines: A National Conference Report Adams et al. Transplantation 74;582-589:2002
33. Adams et al.The non-directed live-kidney donor:ethical considerations and practice guidelines:A National Conference Report. Transplantation 74;582:2002
34. Challenges in the Development of Living Donor Exchange Programs Gabriel Danovitch MD David Geffen School of Medicine at UCLA
45. 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!
Editor's Notes
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.
