Monday, July 2, 2018

Kidney exchange in all its aspects: a view from India

Here's a survey that sees kidney exchange, and all the advances that have been made in how to use it to facilitate more transplants, as a force for making medicine more inclusive around the world.

Kidney exchange transplantation current status, an update and future perspectives
Vivek B Kute, Narayan Prasad, Pankaj R Shah, Pranjal R Modi
World J Transplant. Jun 28, 2018; 8(3): 52-60
Published online Jun 28, 2018. doi: 10.5500/wjt.v8.i3.52

Abstract: "Kidney exchange transplantation is well established modality to increase living donor kidney transplantation. Reasons for joining kidney exchange programs are ABO blood group incompatibility, immunological incompatibility (positive cross match or donor specific antibody), human leukocyte antigen (HLA) incompatibility (poor HLA matching), chronological incompatibility and financial incompatibility. Kidney exchange transplantation has evolved from the traditional simultaneous anonymous 2-way kidney exchange to more complex ways such as 3-way exchange, 4-way exchange, n-way exchange,compatible pair, non-simultaneous kidney exchange,non-simultaneous extended altruistic donor, never ending altruistic donor, kidney exchange combined with desensitization, kidney exchange combined with ABO incompatible kidney transplantation, acceptable mismatch transplant, use of A2 donor to O patients, living donor-deceased donor list exchange, domino chain, non-anonymous kidney exchange, single center, multicenter, regional, National, International and Global kidney exchange. Here we discuss recent advances in kidney exchanges such as International kidney exchange transplantation in a global environment, three categories of advanced donation program, deceased donors as a source of chain initiating kidneys, donor renege myth or reality, pros and cons of anonymity in developed world and (non-) anonymity in developing world, pros and cons of donor travel vs kidney transport, algorithm for management of incompatible donor-recipient pairs and pros and cons of Global kidney exchange. The participating transplant teams and donor-recipient pairs should make the decision by consensus about kidney donor travel vs kidney transport and anonymity vs non-anonymity in allocation as per local resources and logistics. Future of organ transplantation in resource-limited setting will be liver vs kidney exchange, a legitimate hope or utopia?"

An interesting section of the paper discusses different practices regarding anonymity in kidney exchange centers in different countries:

There is disparity on standard practice of kidney exchange in developed and developing World in term of (non-) anonymity. There is variable practice on anonymity before and after surgery in different countries.
Conditional approach[38]: When the donor-recipient pairs give consent for meeting after surgery, they are allowed to meet each other after surgery in some countries such as the United States of America[39] and the United Kingdom[40]. In other countries, such as the Netherlands and Sweden[41], anonymity is absolute. Anonymity protects patients, donors and transplant hospital/ administration against the risks of revoking anonymity and prevents further commercialization of organs, and breach of patient donor privacy. An Ethical, Legal and Psychosocial Aspects of Organ Transplantation (ELPAT), a subsection of the European Society for Organ Transplantation reported that a conditional approach to anonymity should be possible after surgery[42]. Pronk et al[38] showed that most donor-recipient pairs who participated in anonymous donation process are in favour of a conditional approach to anonymity. Guidelines on how to revoke anonymity if both parties agree are needed and should include education about pros and cons of (non-) anonymity and a logistical plan on how, when, where, and by whom anonymity should be revoked.
Non-anonymous allocation[11,12]: Donor-recipient pairs are allowed to meet each other before allocation of donor for surgery and even after surgery. They can share medical reports of exchange donors before surgery and kidney transplant and donor surgery outcome after surgery. Donor-recipient pairs do not choose their match but donor-recipient pairs may decline a match or can withdraw from participation in the kidney exchange program at any time, for any reason. Non-anonymous allocation has the potential of commercialization of organs in case of compatible donor-recipient pairs along with breach in privacy of donor-recipient pairs. Kute et al[11,12] reported that donor-recipient pairs are willing for non-anonymous allocation process in single center study of 300 kidney exchange transplants in India. They reported that non-anonymity is more helpful in manual allocation in absence of computer software allocation which also increases trust between patients, donors and transplant hospital/administration and legal team. More long term prospective studies are required to explore the donor and recipient perspective on anonymity in living kidney donation in different socio-economic regions and countries."

Regarding Global Kidney Exchange they conclude:
"Global kidney exchange appears to provide life-saving kidney transplantation to poor donor-recipient pairs from developing countries that otherwise could die due to economic constrain[50-53]."

And here's their conclusion:
"Kidney exchange transplantation has increased living donor kidney transplantation for end stage renal disease patients with chronological incompatibility and financial incompatibility. The participating transplant teams and donor-recipient pairs should make the decision by consensus about kidney donor travel vs kidney transport and anonymity vs non-anonymity in allocation as per local resources and logistics. There is need of uniform algorithm for management of incompatible donor-recipient pairs."

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