A second opinion in defense of the living donor trasplant | Organ Donation | Organ Transplantation

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Trasplantes, donante vivo.
  Health Policy, 16 (1990) 123-126 Elsevier 123 HPE 00362 A In second opinion defence of the living donor transplant rnt Jakobsen Department of Surgery 6 The National Hospital Rikshospitalet Oslo Norway Accepted 30 June 1990 Dr. Michielsen’s paper in this issue of Health Policy stimulates one’s own thinking regarding the questions raised by the use of the living donor as a source of organs for renal transplantation. The use of the living donor started at a time when there were few alternatives, no chronic hemodialysis and no HLA typing. Dr. Michielsen makes the point that this situation has now fundamentally changed. I am not so sure. Dr. Michielsen bases his opposition to the use of the living donor for renal transplantation on four points: [a) Long-lasting graft survival, is as good in cadaver transplants with good HLA- matching as with the use of living donors, infact, graft survival of cadaver transplant is often superior to that of the living donor one haplotype mismatch combination (i.e., the parent/child situation). (b) The living donor operation is a mutilation of a healthy person. The operation implies short- and long-term risks to the donor. (c) It is not easy to know whether the donor is giving a free and informed consent. Furthermore, adhering to the principle of not performing or allowing living donor renal transplants, is the only definite way in which to stop living donor transplantation performed for financial reward. (d) The only justificaton for the living donor is the shortage of cadaveric organs, but this is a problem that can be remedied. The introduction of an opting-out law in Belgium dramatically changed the supply of cadaveric organs with the result that, according to Michielsen, there is no longer a need for living donor transplants in Belgium. ’ Paper based on Discussions held at the Meeting ‘The Politics of Organ Transplantation in Europe‘ organized on 27-28 March 1990 by the European Health Policy Forum with the Hospital Committee of the EC, and the WHO Hospital Programme for Europe, in Brussels, Belgium. Address for Correspondence: Dr. Arnt Jakobsen, Kir. B, Rikshospitalet 0027, Oslo 1, Norway 016%8510/90/ 03.50 Q 1990 Elsevier Science Publishers B.V. (Biomedical Division)   24 I will group my comments into four chapters coinciding with Dr. Michielsen’s four points. Graft sunrival Identical siblings have a near 100 graft survival in most centers. In the Oslo material the graft survival is a 100 at 4 years for 43 consecutive transplants. Cadaver transplants cannot compete with this. For other groups of patients, it is not enough to divide them to well-matched cadaver recipients or either one or two haplotype mismatched living donor combinations. Age is one of these factors. The average age of recipient of a cadaveric graft in Norway is close to 55 years, some 10 are over 70 years. Even in the living donor group where the average age is lower, roughly 42 years, almost 20 of patients are older than 55 years. The Scandinavian Multicenter Trial showed quite clearly that patients over 55 years had inferior graft survival to patients under 55 years [ 11. Furthermore, the proportion of so-called high-risk patients, that is patients with other diseases such as diabetes and coronary disease, influence results, but is often differently defined at different centers. Another aspect which is necessary to consider when comparing graft survival between different centres, is the selection of patients that takes part prior to a patient being selected for an actual transplant. Countries that transplant 2040 of its uremic population select patients differently from countries that transplant 80 of its uremic population. It is, in other words not enough to look at crude 1 or 5 year graft survival figures and the source of the transplant organ. Mutilation of a healthy person The donor nephrectomy carries all the risk of an operation involving general anaesthesia. Furthermore, the donor’s renal function is now the result of one instead of two kidneys. The short-term risks include pulmonary embolism, coronary infarction, pneumonia, deep abcesses needing drainage, and superficial wound abcesses, all prolonging the hospital stay and general morbidity. We have so far carried out 840 living donor nephrectomies without any mortality. We have had one case of pulmonary emboli, one case of coronary infarction, and three cases of deep abcesses. About every 10th donor has received antibiotics for suspected pneumonia. Superficial wound abcesses were seen in some 1.5 of cases. Generally, our patients are back at work at 6 weeks after the operation, though some patients may need a little longer [2]. We have also looked into the fate of the donor 10 years after nephrectomy and found that there was no higher incidence of renal dysfunction or hypertension than is seen in a normal population [3]. I therefore disagree with Dr. Michielsen in his statement that the donor nephrectomy is a mutilation with potential serious hazards to the donor. If that was the case, I do not think anybody would do living donor transplants.   25 ree informed consent Of all the living donor transplantations carried out since the start of transplan- tation in early 60s only very, very few have been carried out between non-family members. I, personally, do not think it is difficult to know whether the act of giv- ing one of your kidneys to a family member, is something that is done without a willingness to do it, and without a financial reward to the donor. The act of giving up one kidney to your spouse who is suffering from uremia is likewise an act of free will. Ethnic homogenicity and not too urbane a society may well be factors influencing the willingness of family members coming forward as donors. Most of our donors feel a definite gratitude in being able to help a family member in this way. I do not think we, as doctors, have the right to deny them this feeling. Dr. Michielsen states that living donor transplantation performed for cases of financial reward to the donor is a practice that must be stopped. I fully agree. Dr. Michielsen makes the point that the only way to put an end to this form of medical and surgical practice is by drawing the line in front of a living donor transplantation, as if to say: ‘you cannot be just a little bit of a prostitute, you either are or are not’. When it comes to living donor transplantation, I think it is quite clear to all of us involved where that line; the line between acceptable and non-acceptable medical practice, should be drawn. Shortage of cadaver donors is the only justification for living donor transplants The supply of renal organs is the limiting factor regarding the total number of transplants that can be carried out. In spite of constant publicity within the medical profession, we have not been able to raise the number of donors in Norway past 12-14 per million per year. Austria and Belgium have been able to increase the supply of cadaveric kidneys quite dramatically during the last year or so, and they are now in the very fortunate position of being able to transplant something like 60 patients per million with cadaveric kidneys alone. One can only speculate as to the reason why some countries have a higher frequency. Both, Austria and Belgium have an ‘opting out’ law, but so does Norway. The rate of fatal car accidents is obviously one, so is the distance from the accident site to a hospital. However, most countries have not been able to harvest enough cadaveric donor organs and the result is an increasing number of patients on the waiting list. Living donor organs help bridge the gap between the supply of cadaveric kidneys and demand. I believe it is our duty as physicians and surgeons involved in renal replacement therapy also to have the view of the public at large heavily in mind when it comes to defining medical practice. Trying to evaluate the performance of a medical service to a community, its degree of success so to speak, is more than just looking at graft and patient survival. It is also looking at, to what extent patients with a disease obtain treatment, in other words, what percentage of patients with uremia eventually do get a transplant. The use of living donor at our center is now totaling some 38 of all renal transplants (840 living donor transplants out of a  126 total of 2192, by May 1990). This policy, has made it possible for the last 5 years on average, to transplant more than 40 patients per million, and has left us with a waiting list of between 20 and 23 patients per million. We have estimated that nearly 80 of patients in Norway with the diagnosis of uremia needing terminal renal replacement therapy, eventually get a transplant. And they usually get it within 6-8 months of being put on the waiting list. This would not have been possible without such a high frequency of living donor transplants. In conclusion let me first thank Dr. Michielsen for raising the issue, and secondly for the organizers of the meeting in allowing me to voice my disagreement. Firstly, I do not accept that the living donor nephrectomy is a mutilation of a healthy person. The operation carries certain risks, but I do not believe it to be hazardous. If this were the case, no one would accept this form of medical practice. I believe the results for matched groups of patients show superior or at least identical results of living donor transplants to transplants with cadaver donors. Furthermore, I believe there is a better chance for a long lasting good result using a living donor. Finally, living donors are an important source of organs helping to bridge the gap between supply and demand. The use of living donor organs increases the community’s ability to offer the medically best renal replacement therapy to as many of its members as possible, reducing numbers of patients on dialysis and the waiting time for those patients not having a living donor. Such a policy is medically sound, and is also economically good, because it reduces costs. References 1 Lundgten. G., Persson, H., Albrechtsen, D. et al., Recipient age - an important factor for the outcome of cadaver renal transplantation in patients treated with cyclosporine Transplant Proceedings, 21 (1989) 1653-1654. 2 Fauchald, P., Sodal, G., Albrechtsen, D. et al., The use of elderly living donors in renal transplantation (submitted for publication). 3 Talseth, T., Fauchald, P., Skrede, S. et al., Long-term blood pressure and renal function in kidney donors. Kidney International, 29 (1985) 1072-1076.
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