The impending kidney transplant crisis for the Asian population in the UK

Kidney transplantation offers the opportunity of an improved quality of life for those patients suffering from renal failure. Unfortunately, this treatment is not available to all people as this is influenced by the increasing demand for a limited supply of suitable organs. This situation is particularly alarming for the UK's Asian population with their higher susceptibility to end-stage renal failure which has resulted in a greater demand for transplants. Consequently, the proportion of Asians on transplant waiting lists is growing rapidly. Coupled with this are problems of cross-racial tissue type matching which has led to longer waiting times for a transplant. The situation is clear, there is an urgent need to address the number of Asians requiring a kidney transplant otherwise the human and economic costs will be very severe. In the short term there needs to be a greater number of donors coming forward from the Asian communities to increase the pool of suitable organs. In the long term, there needs to be greater attention on preventive strategies to reduce the number of Asians requiring renal replacement therapy.     

Discriminators of willingness to consider cadaveric kidney donation among black Americans.

Black Americans were classified as either willing or unwilling to consider serving as kidney donors according to a combination of demographic and social psychological variables. Findings indicated that, in addition to selected religious variables, willingness to consider donation was associated with gender, age, source of information about organ donation, perceived need for transplants among blacks, self-acceptance of transplant organs and perception of bias in the selection of transplant recipients. Implications of the findings for social work practice and future research are discussed.     

Nosocomial infections in renal transplant patients: risk factors and treatment implications associated with urinary tract and surgical site infections

A prospective cohort study was conducted from January 2000 to December 2001 to determine the rate of bacterial nosocomial infections in renal transplant recipients. The patients were divided into two groups according to the origin of the allograft, namely deceased or living related donors. One hundred and sixty-three renal transplant recipients were reviewed during hospitalization; 110 (67.5%) kidneys were from deceased donors and 53 (32.5%) kidneys were from living related donors. The median length of hospitalization was 12 days for transplants from living related donors and 26 days for transplants from deceased donors (P<0.0001). Twenty-one (39.6%) recipients of kidneys from living related donors and 68 (61.8%) recipients of kidneys from deceased donors had bacterial nosocomial infectious episodes (P=0.019). The post-transplant nosocomial infections diagnosed during hospitalization included urinary tract infections (UTIs) (44.8%), surgical site infections (SSIs) (11%), pneumonia (6.1%), catheter-related bloodstream infections (4.2%) and others (1.8%). Risk factors for UTI included: recipient of kidney from a deceased donor, substitution of the initial immunosuppressive regimen, duration of urinary bladder catheterization, and length of hospitalization before the infection. Six Enterobacter cloacae strains with multiple resistances to antibiotics were identified in UTIs, and hospital dissemination was documented using molecular typing. UTI was the single most important hospital infection and was significantly higher in recipients of kidneys from deceased donors (P=0.001).     

Association between attitudes toward health promotion and opinions regarding organ transplants in Japan

Health promotion activities to educate the public about health lifestyles have been performed widely in industrialized countries where chronic adult diseases have become prevalent. According to a basic principle of health promotion activities, the symptoms of many diseases are regarded as the result of inadequate health behavior, curable by modifying health behavior. It is thus possible that an exposure to health promotion activities might instill negative attitudes towards organ transplants, because program participants may conclude that persons who need an organ transplant have become unhealthy as the result of their own poor health habits. In this study, two types of surveys were undertaken to test this hypothesis. The subjects of the first cross-sectional study were 712 male and female Japanese citizens, and those of the second case-control study were 240 female company employees in Japan. In the first study, a logistic regression analysis was used and the following findings were obtained. (1) Compared with the persons who felt that they did not have enough practical knowledge about individual health practices, those who felt that they had adequate knowledge were 0.66 times less likely to support organ transplants. (2) Compared with those who were not willing to spend money on healthful things, the persons who were willing to do so were 0.51 times less likely to support organ transplants. In the second case-control study, it was revealed that the subjects who had negative attitudes towards organ transplants had consistently healthier lifestyles than did those who had positive attitudes towards organ transplants. Based upon the present findings and the nature of the basic principles of health promotion activities, we infer that community health promotion activities have a negative influence upon citizens' opinions of organ transplants. Since these findings have health policy implications, more studies are necessary to conclusively evaluate the effects of health promotion activities upon attitudes toward organ transplants.     

Sex differences in renal transplantation in Canada

To determine if a patient's sex influences access to renal transplantation in Canada, transplant recipient data for first cadaveric unrelated renal transplants were obtained from the Canadian Organ Replacement Register (CORR) for the period 1985-1992. There were 4683 first unrelated cadaveric transplant recipients during this time. Differences in the proportion of men and women registered with CORR who received a renal transplant were analyzed. In Canada between 1985 and 1992, 25% of males 40 years and older on dialysis received renal transplants compared with 18% of females (p < 0.0001, RR 1.54, 95% CI 1.40-1.67). There was no difference in the rates of transplants in males and females who were under 40 years of age. Adjusting for panel-reactive antibody data did not change the significance of the difference in transplant rates between the sexes. In Canada from 1985 to 1992, male patients with end-stage renal disease received proportionately more transplants than females.     

Prospective study of the quality of life in patients assessed for liver transplantation: outcome in transplanted and not transplanted groups.

The quality of life in adult patients with chronic liver disease who were considered for transplantation was assessed prospectively over a 2 year period, for both those who did and did not subsequently receive transplants. The main outcome measures were the Nottingham Health Profile and survival. Of the 109 patients who completed an entry profile, 27 were transplanted, 71 not transplanted during the study period, and 11 rejected for transplant. Quality of life and severity of liver disease at entry was worse for the transplant group, whose survival at 15 months from entry was 81% compared with 78% for those not transplanted. Among transplant survivors there were marked improvements in quality of life, whilst amongst those not receiving transplants there was little change. In conclusion, liver transplantation was effective in improving quality of life in patients with chronic liver disease, but comparison between transplant and non-transplant patients is difficult because of differences between the groups.     

Why are cadaveric renal transplants so hard to find in Japan? An analysis of economic and attitudinal aspects.

In view of the fact that in Japan treatment of end-stage renal disease depends disproportionately heavily on hemodialysis and almost negligible on transplants from cadaveric donors (hemodialysis 44.4/100,000; renal transplants 0.31/100,000 per year; cadaveric renal transplants 0.11/100,000 per year (1983 data)), we analysed the cost-effectiveness of hemodialysis and renal transplantation, predicted economic gains under expected changes in variables and described attitudes of the Japanese hampering cadaveric renal transplantation. Adjusted life expectancy of transplant recipients (live and cadaveric combined) under the current technical conditions is longer than that of those on hemodialysis (18.3 vs. 14.7 years) and the cost per year for maintaining the transplant is approximately one third of hemodialysis ($12,000 vs $32,000). If the proportion of cadaveric transplant recipients would increase to the levels of the USA (hemodialysis 30.8/100,000; transplants 2.6/100,000 per year; cadaveric transplants 1.9/100,000 per year (1983 data)) along with improvement in graft survival rate, the life expectancy for transplant recipients in Japan could increase by 2 years, thus reducing the annual cost even further. The current number of patients starting hemodialysis (11,500 cases per year) coupled with their life expectancy predicts the number of patients on hemodialysis to reach equilibrium at around 174,000 in a decade (Japanese population 110 million). Based on current price, their annual cost will be about 5.3 billion dollars. Medical expenditure of this magnitude for such a small fraction of people is expected to become an increasingly strong economic incentive for cadaveric renal transplantation. A review of studies on Japanese attitudes toward cadaveric renal transplantation in both urban and rural areas shows that approximately 60% are in favor of donating their kidney after death, though with the majority of cases the donation is contingent upon agreement of their family. It was suggested that the paucity of cadaveric kidney supply stems mainly from the custom of the Japanese to make decisions by consensus. It was also reported that more than 80% of physicians supported the donation of cadaveric grafts while this rate fell to 40% in case of brain death. As the first heart transplantation was carried out in 1968 under both medically and ethically dubious circumstances, distrust toward the diagnosis of brain death appears to be still quite strong. (Not a single heart transplantation has been attempted in Japan in the past 18 years).(ABSTRACT TRUNCATED AT 400 WORDS)     

The importance of HLA-matching before kidney transplantation: a recommendation of the Health Council of the Netherlands

In a recent report, the Health Council of the Netherlands concluded, on the basis of the literature, that HLA-matching is still relevant for graft survival in renal transplant patients. Since the HLA DR antigen system is less heterogeneous than the class I HLA antigen system, it would seem wise to match primarily for these antigens, since this may lead to a reduced exchange of organs between countries and shorten the cold ischaemia period. This may in turn improve the results of transplantation. In the Netherlands, the number of living donor kidney transplants has recently shown a remarkable increase, due partly to the introduction of the paired, living donor, kidney exchange protocol. The introduction of a living donor list exchange programme may further increase this number. Finally, citizens need to be motivated to list themselves as possible organ donors.     

Characteristics of Rural and Urban Cadaveric Organ Transplant Donors and Recipients

CONTEXT: Health disparities have been found when comparing rural and urban populations. Purpose: To compare characteristics of rural and urban cadaveric transplant donors and recipients. METHODS: We used deidentified individual-level data on 55,929 cadaveric transplant donor-recipient exchanges between 2000 and 2003 and examined the relative rates of donating and receiving cadaveric transplants for rural compared to urban residents, as defined by ZIP Codes. FINDINGS: When compared to their urban counterparts, rural organ donors were more likely to have died from head trauma, drowning, motor vehicle accidents, or suicide and less likely to have died from cerebrovascular events, cardiac events, or homicide (P < .001 for all). Rural transplant recipients had lower levels of educational attainment and were less likely to have had the transplant financed by private insurance (P < .001 for all). While we found no statistical difference in days wait to organ transplantation, rural residents were more likely to donate than to receive cadaveric organs (P < .001). CONCLUSIONS: The differences in organ donation that we found warrant further exploration.     

Allogene hämatopoetische Stammzelltransplantationen in Mecklenburg-Vorpommern von 1991–2000

Allogeneic stem cell transplantation (alloSCT) is increasingly used in the treatment of hematological disorders. In order to demonstrate the national development of alloSCT as well as the effect of the foundation of local transplant centers, data of all alloSCT performed on patients living in Mecklenburg-Vorpommern (MV) during 1991 and 2000 were evaluated regarding date and location of the alloSCT, diagnosis and age of the patient as well as donor type. AlloSCT in patients from MV increased 6 fold from 1991 n=5 to 2000 n=30. Because of the lack of local transplant centers during the period between 1991 and 1997, alloSCT of patients from MV were exclusively performed in other locations, whereas in 2000 only 2 of 30 alloSCT were performed in transplants centers outside MV. With the establishment of local centers, the gap between the numbers of alloSCT between MV and Germany was closed (1991 Germany 4,17/Million inhabitants, MV 2,67/Million inhabitants, 2000 Germany 17,4/Million inhabitants, MV 16,7/Million inhabitants). The increase in the number of alloSCT was mainly due to an increased use of unrelated stem cell donors which increased from n=0 in 1991 to 12 out of 30 in 2000. Another important factor was the increase in the age limit with a mean age of 32 years in 1991 and 43 years in 2000 (upper range 60 years). Conclusion: The data reflect the dramatic increase in alloSCT during the last decade caused by factors listed above. In addition, the development of the numbers of transplants of patients in MV supports the need for local transplant centers, since with the opening of local transplant centers the difference of the frequency of alloSCT between Germany and MV was completely eradicated.     

Transplantation-transmitted tuberculosis--Oklahoma and Texas, 2007

Approximately 28,000 organ transplants were performed in the United States in 2007. When infections are transmitted from donors, the implications can be serious for multiple recipients. Tuberculosis (TB), a known infectious disease complication associated with organ transplantation, occurs in an estimated 0.35%-6.5% of organ recipients in the United States and Europe posttransplantation. In 2007, the Oklahoma State Department of Health identified Mycobacterium tuberculosis in an organ donor 3 weeks after the donor's death. This report summarizes results of the subsequent investigation, which determined that disseminated TB occurred in two of three transplant recipients from this donor, and one recipient died. Genotypes of the donor and recipient TB isolates were identical, consistent with transmission of TB by organ transplantation. To reduce the risk for TB transmission associated with organ transplantation, organ recovery personnel should consider risk factors for TB when assessing all potential donors. In addition, clinicians should recognize that transplant recipients with TB might have unusual signs or symptoms. When transmission is suspected, investigation of potential donor-transmitted TB requires rapid communication among physicians, transplant centers, organ procurement organizations (OPOs), and public health authorities.     

Factors related to sexual functioning in male patients undergoing hemodialysis and with kidney transplants

The sexual functioning of 13 male patients undergoing renal dialysis and 13 male patients who had received kidney transplants was compared. Standardized interviews were used to assess the frequency of intercourse before illness, during dialysis, and after transplantation and to assess sexual difficulties experienced during these periods. In addition, plethysmographic recordings of erection levels were obtained for three dialysis and three transplant patients at eight separate time periods corresponding to particular points in the dialysis cycle. Assessments of depression and anxiety (IDA scale) and renal functioning (Marital Patterns Test) were also carried out. Dialysis patients were less able to gain and maintain erections than transplant patients and intercourse was less frequent for couples where the husband was on dialysis. Dialysis patients were more depressed than transplant patients, although transplant patients showed greater levels of anxiety. More marital difficulties were experienced by patients on dialysis than patients who had received transplants. The implications of these findings for the treatment of sexual problems in these patients are discussed.     

Organ donation, retrieval, and transplantation in Italy, in 1994-98

Organ donation and transplantation activity in Italy have been always characterised by two contrasting features: first the constant positive trend in the improvement of the number of organ donors and transplants which allowed the country to exceed the value of 12 donors per million population in 1998; second the difficult situation in southern regions, so that the national distribution of the activity is highly and steadily non homogeneous. Herein we report the data regarding donation, retrievals and transplant activity in Italy in the years 1994-98, focusing on the activity of each region and the three interregional centres which encompass the majority of the national territory.     

Patients' decisions for treatment of end-stage renal disease and their implications for access to transplantation

Gaining access to kidney transplantation is a complex process that involves treatment decisions made by patients. Despite several advantages of kidney transplantation, some patients choose to remain on hemodialysis for treatment of end-stage renal disease. The present study was undertaken to describe the sociocultural factors influencing patients' decisions to remain on dialysis compared to those who sought a transplant. The study also examined whether African Americans made decisions different from European Americans which would offer insights into one of many factors resulting in them receiving disproportionately fewer kidney transplants. Using a qualitative approach supplemented by a quantitative approach, interviews employing open-ended questions and a card sort technique were conducted with 79 hemodialysis patients. Patients who preferred to remain on dialysis were significantly older and more likely to be unmarried and Protestant. The relationship between treatment decisions and ethnicity was inconclusive due to multiple, interrelated covariates. The three most common reasons patients reported for remaining on dialysis included: doing well on dialysis, fear of being "cut on" from a transplant, and knowing other patients whose kidney transplant failed. This study identified sociocultural and ethnomedical beliefs and values about the body and transplantation that inform patients' treatment decisions. This study also generated data that illuminate the complexity of patients' decisions and how these affect patients' preferences regarding transplantation. The results emphasize the need for policy makers to recognize patients' decisions when accounting for alleged difficulties in gaining access to transplantation.     

Utilisation of organs proceeding from donors with heart failure: review of the pathogenesis of organic damage and the possible mechanisms of prevention

There is an evident imbalance between the number of patients awaiting a kidney transplant and the availability of organs proceeding from donors with brain death. A high number of patients die each day from heart failure, whose organs could be used for transplants if specific care is employed. Although centres do exist where these methods of extraction are established, the problems of organic damage have yet to be resolved, since one third of the organs are still lost, besides the increase in the need for early dialysis, and the number of dysfunctioning grafts two years after the transplant, when this type or organ is employed. There is increasingly detailed knowledge of the pathogenesis of organic damage following heart failure and reanimation, as well as of the damage following the conservation and reimplantation of the kidney. Knowledge of the maximum time of hot ischemic that an organ can withstand is of crucial importance if organs are not to be unduly discarded. Besides, the increasing understanding of the physiopathology of oxidative stress could make it possible for us, through the use of antioxidants, to attempt to improve the utilisation of the organs and diminish the incidence of dysfunctions and rejections.     

Some ethical aspects of donation and transplantation

Ethical and legal consensus in our country bases the practice of donations and transplants on different ethical principles, which are contained in the legislation, closely conforming to the four principles of principialist bioethics: autonomy, beneficence, non-maleficence, and justice. The level of donations achieved in our milieu might, in fact, be related to a strict respect for these principles by the health professionals, as well as to the excellent organisation of the transplant world. Many scientific, technical and ethical challenges have had to be met to reach the present state of the transplant. And there are many current challenges. The article only analyses some of these due to their technical, ethical and social repercussions: organ transplants involving a live donor, the public request for organs, the organ market, the transplant of non-vital organs (basically the face transplant), the use of stem cells and the banks of umbilical cord cells. The aim of the article is to state the ethical problems raised by these new practices, in order to lay the foundations for a moral deliberation that must necessarily involve the whole of society.     

Evaluation of the living kidney donor

Currently, due to the deficit of cadaveric tissues available for transplantation and due to the long waiting list for a kidney transplant, there is a clear tendency towards living donor kidney transplantations. Most donors are genetically related. Living donation should be considered a gift of extraordinary value, and should be made easy whenever a suitable donor is available. Worldwide, the number of patients on the waiting lists for a kidney transplantation has increased, in the last decades. Renal transplantation with living donor kidneys, is currently considered the best treatment for patients with end stage renal failure, due to the improved short and long-term survival benefits over dialysis treatment. Since considerable difference exist between countries in the evaluation and selection criteria for kidney donors, especially in selected patients such as older donors and those with associated comorbid conditions, it is necessary to discuss and establish minimal selection criteria for this cases. A common trend includes a complete clinical record, laboratory and radiologic evaluation which are described in detail in this paper. We also discuss the increasing acceptance of older kidney donors as well as the acceptance of individuals with comorbidities (such as obesity, hypertension, hyperglucemia, lithiasis and cancer) that were previously considered as not eligible for kidney donation.     

Continued increase in lung transplantation for coal workers’ pneumoconiosis in the United States

Background

Severe coal workers’ pneumoconiosis (CWP) is increasingly common, and sometimes requires lung transplantation.

Methods

Using Organ Procurement and Transplantation Network data, we updated the trend for CWP‐related lung transplants, described CWP patients who have been waitlisted but not transplanted, and characterized the primary payer of medical costs for CWP‐related and other occupational lung disease transplants.

Results

There have been at least 62 CWP‐related lung transplants; 49 (79%) occurred in the last decade. The rate of these procedures has also increased. Twenty‐seven patients were waitlisted but did not receive a transplant. Compared to other occupational lung diseases, transplants for CWP were more likely to be paid for by public insurance.

Conclusions

The increase in the frequency and rate of lung transplantation for CWP is consistent with the rising prevalence of severe CWP among U.S. coal miners. Effective exposure controls and identification of early stage CWP remain essential for protecting these workers.

     

Behavioural risk factors for acquisition of HIV infection and knowledge about AIDS among male professional blood donors in Delhi

In 1989-90 a study was carried out in Delhi of the risk behaviours and epidemiological characteristics exhibited by 15 paid blood donors who were positive for human immunodeficiency (HIV) virus and on 100 paid seronegative donors. All the donors were male. Compared with the seronegative donors, a significantly greater proportion of seropositive donors were unmarried, had lived in at least two cities in the previous 5 years, donated blood at least once per month, were heterosexually promiscuous, and had visited a clinic for sexually transmitted diseases. Awareness about acquired immunodeficiency syndrome (AIDS) was poor, and even those donors who had heard of AIDS were ignorant about certain important aspects. The results indicate that, based on the risk factors identified in this study, there is a need to adopt more careful selection criteria for blood donors in India.     

Protecting autonomy in organ procurement procedures: some overlooked issues

Organ procurement personnel in the United States appear to be unaware that the standard practice of asking the surviving families of all classes of potential donors (declared and undeclared) for permission to remove organs and tissues from these individuals is inconsistent with the provisions of most state UAGAs. The majority of these Acts vest first authority concerning the donation of body parts in those individuals whose organs and tissues are needed and judged medically acceptable for removal and transfer. These laws do not give families the right to veto the positive written declarations of dead relatives who have authorized the posthumous taking of their own body parts. Hence, seeking family consent for the removal of body parts from registered donors is unnecessary and inappropriate according to the provisions of most state UAGAs. The primary authority given to individuals under this legislation to control the taking of organs and tissues from their bodies after death arguably rests on the plausible premise that a person's body is his or her property in a significant sense. This gives individuals first authority to control the posthumous disposition of their body parts. Under current retrieval practice, however, families of deceased registered donors are seldom informed about the paramount rights of these individuals and are led to believe that they have final legal authority over the disposition of organs and tissues from these expatients. This is, in effect, an unwitting but nonetheless serious "sellout" of the moral-legal rights of these potential donors. I have attempted to show the weakness of one plausible line of argument for the claim that current retrieval practice with its family priority orientation ought to be continued in unamended form, irrespective of what the law says. I suggested an alternative procedure for approaching the surviving families of registered donors which I believe offers a socially acceptable compromise among three values which enter into competition at the death of a declared donor: (1) saving the maximum number of lives of ESOD victims, (2) respecting and protecting the rights of declared donors, and (3) honoring the needs of the grieving family.(ABSTRACT TRUNCATED AT 400 WORDS)