Saturday, June 13, 2015

Review of living kidney donor outcomes, in The Lancet

In The Lancet
Volume 385, Issue 9981, 16–22 May 2015, Pages 2003–2013

Living kidney donation: outcomes, ethics, and uncertainty
Dr Peter P Reese, MD,  Prof Neil Boudville, MD, Prof Amit X Garg, MD

Here's the summary:
"Since the first living-donor kidney transplantation in 1954, more than half a million living kidney donations have occurred and research has advanced knowledge about long-term donor outcomes. Donors in developed countries have a similar life expectancy and quality of life as healthy non-donors. Living kidney donation is associated with an increased risk of end-stage renal disease, although this outcome is uncommon  (less than .5 percent increase in incidence at 15 years). Kidney donation seems to elevate the risks of gestational hypertension and pre-eclampsia. Many donors incur financial expenses due to factors such as lost wages, need for sick days, and travel expenses. Yet, most donors have no regrets about donation. Living kidney donation is practised ethically when informed consent incorporates information about risks, uncertainty about outcomes is acknowledged when it exists, and a donor's risks are proportional to benefits for the donor and recipient. Future research should determine whether outcomes are similar for donors from developing countries and donors with pre-existing conditions such as obesity."

And this...
"In many countries, living kidney donation is the only affordable treatment for kidney failure. This is evident across large regions of India and Pakistan, for example, where chronic dialysis is rationed in units supported by government or community donations, or is only available with payments that are prohibitive for most patients. In this respect, chronic dialysis is viewed as a bridge to a life-saving kidney transplant from a living donor. In many developing countries, the infrastructure to procure deceased-donor organs does not exist.

"Unrelated and incompatible donors
Living kidney donation in unrelated donors (eg, friends, spouses, or distant relatives of the recipient) are becoming more common. In the USA, the proportion of living kidney donations from unrelated donors increased from 30% to 57% between 1999 and 2013. Similar trends are evident in Europe, Australia, and New Zealand.

"This rise in unrelated living kidney donation is largely associated with a declining emphasis on close HLA matches between donor–recipient pairs. With advances in immunosuppressive therapy, the longevity and function of the transplanted organ is now less dependent on the genetic donor–recipient relationship than in the past. The rise in unrelated donors has also been helped by so-called kidney paired donation, a strategy used to overcome donor–recipient incompatibility if the transplant candidate has antibodies to the donor's blood or HLA type. Such antibodies greatly increase the risk of donated-organ rejection and, in the case of anti-HLA antibodies, might develop because of previous pregnancies, blood transfusions, or transplants. As shown in figure 2, registries of incompatible donor–recipient pairs have enabled transplantation to proceed through paired exchanges, or donation chains in which each donor provides a kidney to an unrelated compatible recipient. Paired exchange has been helped by the transportation of living-donor kidneys between centres and by non-synchronous transplants, in which one or more donors wait to donate until new pairs enter the chain. In some cases, a transplantation chain begins when an individual with no relationship to any recipient donates a kidney (termed non-directed donation). In 2012, this type of altruistic donation enabled a 30-transplant chain to proceed."

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