Sources of Donor Kidneys

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Most transplanted kidneys come from people who have died, but there are not enough of these potential donors to meet the needs. A growing number of transplanted kidneys now come from living family members or friends. Most people can donate a kidney with little risk.

The advantages of a living donor are:

• The waiting period is eliminated.

• Kidneys from family members are more likely to be good matches.

• Kidneys from living donors don't need to be transported from one site to another.

• Living donation helps people on the waiting list for cadaveric kidneys by shortening the list.

Before donating a kidney, the donor needs thorough medical evaluation and must be evaluated to see if he or she is a good match. Suitability formerly depended on blood type (A, B, AB, or O) and other genetic markers called HLA factors. A higher number of matching factors seemed to increase the chances that the kidney would last for a long time.

Gradually these limitations have been circumvented, and now almost anyone can give a kidney to anyone else. Nevertheless, the prospective donor's blood is mixed with the patient's blood to see if a reaction occurs, which could be caused by antibodies.

The donor and the recipient are operated on at the same time, usually in side-by-side rooms. Most living donor surgery is now done through a small incision penetrated by an instrument called a laporoscope, through which the surgeon can see the donor's kidney and its blood vessels; the kidney is removed through a small incision. This means that postoperative incisional pain, which was formerly a prolonged complaint in many donors, is now almost nonexistent. A donor's average hospitalization is only 66 hours, and the risk of overall mortality is about 0.03 percent. Originally, doctors anticipated a long-term decline in the function of the remaining kidney, but there is no compelling evidence of that occurring. In fact, for unknown reasons, donation may improve the donor's quality of life and even life expectancy. Health insurance remains available for kidney donors. Age is no contraindication for kidney donation: Healthy grandparents are an excellent source for young patients. Children and mentally incompetent persons can also be donors, in theory, although this is widely felt to be unacceptable, because of the impossibility of informed consent. Financial rewards for giving a kidney have generally been disparaged in the United States, though there are dissenting voices.

In 2000 Michael M. Abecassis, speaking for a steering committee chosen from national organizations, issued a consensus statement concerning live organ donors: "The person who gives consent to be a live organ donor should be competent, willing to donate, free from coercion, medically and psychosocially suitable, fully informed of the risks and benefits as a donor, and fully informed of the risks, benefits and alternative treatment available to the recipient. The benefits to both donor and recipient must outweigh the risks associated with the donation and transplantation of the living donor organ."

The trouble with this statement is that it overlooks the possibility of "nondirected" kidney donation, that is, giving a kidney without knowing who the recipient may be. In a recent survey, a surprising fraction of the U.S. population expressed willingness to give a kidney without payment to someone they didn't know. Of course, many of these individuals might change their minds when faced with the reality. The detailed finances of this process remain to be worked out; clearly the donors should not incur significant expenses, but equally clearly, they should not receive a monetary reward for giving up a part of their anatomy.

For physicians, the main problem with this process is that it violates one of the precepts of the Hippocratic Oath, namely, first and foremost to do no harm. When a nondirected kidney is removed, the donor incurs a small but real risk, for which the only corresponding benefit is the pleasure of altruism. This makes most surgeons uncomfortable, and they suspect that the donor is emotionally unstable. Most transplant surgeons prefer that the donor should be emotionally close to the recipient.

Paying for a kidney (as has been done in recent years in several third-world countries) can lead to adverse consequences. In Iran, a questionnaire was recently sent to 100 kidney donors. Ninety percent did not know the recipients. Money was the principal motivation for donation in 97 percent of them. Yet three-quarters concluded that kidney sale should be banned. Half of them stated that they "hated" the recipients, and 82 percent were dissatisfied with their own behavior.

By contrast, donating a kidney, without payment, to a known recipient (friend or relative) has a strongly positive psychological impact. Unfortunately, many U.S. transplant centers do not actively encourage donations from spouses or friends, and a majority would not consider an altruistic stranger. Perhaps these attitudes will change.

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