Incentives for living kidney donation: what does the public think?

This mini-review describes a number of recent surveys that have been performed to study public opinion on the idea of introducing incentives for living kidney donation. The results of these surveys are comparable: about a quarter of the population is in favor of this idea, whereas the majority is opposed or undecided.     

Drug use and kidney donation: what are high-risk behaviors today?

BACKGROUND: "Social risk behaviors" are usually considered as contraindications for organ donation. The organ shortage, however, necessitates expansion of the donor pool. Reconsideration of the policy toward substance abusers may be important. Opinions of the overall population may be of use to define this cultural-sensitive issue. METHODS: A semistructured questionnaire on organ donation, including opinions on drug use (cannabis and cocaine), was administered to various groups of the general public and caregivers: high school students (liceo classico: 59 students, median age 18 years; istituto tecnico: 108, age 17); first- and fourth-year medical school (77, age 19; 46, age 22); continuing medical education (44, age 32); third-year nursing school (31, age 23); "senior citizen university" (51, age 63). RESULTS: Cannabis use was mainly accepted for kidney donation (48.6% yes, 26.6% no, 29.8% uncertain/blank), but cocaine use was not (22.1% yes, 44.2% no, 33.7% uncertain/blank). In the univariate analysis, opinions differed according to age, sex, and belonging to the health care teams upon multivariate analysis being a member of the health care team was the strongest predictor of responses (P<.01). CONCLUSION: It is difficult to define social risk behaviors. Since opinions are important for organ donation, further studies and discussion are needed to periodically analyze our policies.     

Living donor kidney transplant in Italy: is the underutilization justified?

Living donor transplants (LDtx) represent an underutilized resource in Italy. It is, however, a therapeutic option that deserves greater consideration not only due to the increasing gap between the number of uremic patients on waiting lists (6956) and the number (1464) of cadaveric transplants (CADtx), as evidenced in 2002, but also due to the advantages of LDtx over CADtx. The superiority of LDtx include better graft survival, independent of the donor/recipient relationship, less need for dialytic treatment with preemptive transplants and reduced immunogenicity of the graft due to the brain death-related "cytokine storm." Moreover, some emerging procedures namely laparoscopic nephrectomy instead of open surgery and spiral CT instead of renal angiography namely, reduce the physical and socioeconomic burden of the donor. In the light of these considerations, LDtx should be reconsidered in the Italian scenario of kidney transplantation.     

The kidney and the elderly: why does the risk increase?

Ageing is characterised by a decline in renal function and by a higher susceptibility to renal diseases. This has been defined by Fliser as the “myth of the inexorable decline of renal function with senescence” and is a consequence of multiple factors that predispose to renal damage. These include physiological factors that cannot be modified or treated, and pathological factors that can be treated and, sometimes, prevented; the former are represented by anatomic, molecular, and functional changes that physiologically occur during the ageing process; the latter-by acquired risk factors, whose incidence increases in the elderly, thus predisposing to or aggravating the renal damage. These include increased prevalence of age-related diseases, increased consumption of potentially nephrotoxic drugs, increased necessity of radiological procedures using iodinated contrast media, and increased necessity of major surgery. In this review we analyse these factors and their relevance in increasing the risk of renal damage in the elderly.     

Living donor kidney transplantation: chance for the recipient--financial risk for the donor?

BACKGROUND: With living donation, in addition to the medical risk, the financial risk for the donor is essential, especially in case of complications that potentially can led to disability and loss of work. We report the experiences of those who have donated a kidney in our transplant center. METHODS: We contacted 80 donors who donated a kidney at least 6 months prior to evaluation: 72% answered 33 questions. [mean age: 54 +/- 10 (33-75) years; 69% living related, 31% unrelated]. RESULTS: Of the 80 donors contacted, 91% (53) reported to have no financial expenses due to donation; 9% (5) had expenses, but only few of them clarified exact amount. One donor had to borrow money to cover the lack when he was unable to perform his job. Another claimed the disparity between normal salary and payment from insurance company as a financial expense. Evaluation procedure prior to donation was organized variously: some donors were on holiday while evaluated, some officially were ill, others had to take off some days without payment. None of the donors lost his or her job due to donation. CONCLUSION: The financial risk of living donation is theoretically well covered by different insurances. However, some of the donors had to cover some expenses by themselves. Fortunately, so far in our center no major complications occurred and all donors went home in good health after donation. If costs are covered when a healthy donor loses his or her ability to work due to donation remains unclear since no donor has experienced this problem.     

Is living kidney donation really safe?

OBJECTIVE: Living donor kidney transplantation (LDKT) yields the best results of all renal replacement therapies in terms of patient and graft survival. It is the main method in many countries because of worsening patient outcomes due to the accumulation of aged patients with long periods on dialysis and no possibility to increase the number of cadaver donor transplantations. Because of concerns dealing the risks inflicted on the donors, we sought to evaluate the long-term complications of LDKT. PATIENTS AND METHODS: We evaluated over 3 years 86 living kidney donors (58 men, 28 women) whose procedures were >1 year ago. The mean time postoperatively was 17.24 +/- 5.04 months and their mean age, 28.97 +/- 4.75 years. Basic information regarding current health status, including physical examination and blood pressure as well as serum urea, creatinine serum albumin, blood glucose, lipid profile, urinanalysis, and 24-hour urine protein were evaluated every 6 months after donation. Also an ultrasound of the kidney, urinary tract, and testis was performed at these times. RESULTS: Donor nephrectomies were left sided in 60 (69.8%) cases and right sided in 26 (30.2%) cases. The majority of the donors (n=80) were unrelated (93%). There was a total complication rate of 54.6%. The most common complication was hypertension (37.5%). Serious complications occurred in five cases (5.8%). In six (6.9%) the patients serum creatinine was >or=1.4 mg/dL. Microalbuminuria was found in 10.4%; hematuria in 13.9%; pyuria in 8.1%; and renal stone in 6.9%. Varicocele was found in 24.1% of male patients (23.3% of patients who had left nephrectomised). Persistent pain was reported by 44.1%. Antidepressants were prescribed to 9.3% of donors because of severe depression. CONCLUSION: Living kidney donation is not so safe and has some late complications. Precise predonation evaluation and long-term follow-up of kidney donors for detection and prevention of complications is necessary.     

Psychological barriers for living kidney donation: how to inform the potential donors?

BACKGROUND: This is the first large-scale interview study carried out in patients and potential donors who seem unwilling or unable to pursue living kidney donation. By investigating these groups, we explored whether further expansion of the living kidney donation program is feasible. METHODS: We interviewed 91 patients on the waiting list for a kidney transplant who did not pursue living kidney donation and their potential donors (n=53). We also included a comparison group. All respondents underwent an in-depth interview by a psychologist about topics that could influence their willingness to pursue living kidney donation. RESULTS: A total of 78% of the patients on the waiting list were willing to accept the offer of a living donor. The main reason for not pursuing living kidney donation was reluctance to discuss the issue with the potential donors. This was also found in the comparison group. Both groups indicated that if there was no donor offer, they tended to interpret this as a refusal to donate. This interpretation not always holds: more than one third (19 of 53) of the potential donors were open to consider themselves as a potential donor. On the other hand, a comparably sized group of potential donors (21 of 53) was reluctant about donation. The main reason for donor reluctance was fear for their health after donation. CONCLUSION: The majority of patients on the waiting list are willing to accept a living kidney donor, but adopt an awaiting attitude towards their potential donors. Offering those patients professional assistance should be considered.     

Information and anesthesia: what does the patient desire?

OBJECTIVE: The aim of the study was to assess the patient's desire for information regarding their preoperative care and to assess the anaesthetists' perception of that desire. STUDY DESIGN: Questionnaire. METHODS: The question: "Would you like to be fully informed about" 13 topics of the perioperative management was asked to 106 patients at the time of the preoperative visit. Two answers were possible: Yes I want to know; No I don't want to know. 22 senior anaesthesists were also interviewed and were asked to speculate about the patients response to each item. Data were compared with those of a similar questionnaire used in different countries. RESULTS: One hundred patients who underwent general, orthopaedic, urologic surgery were interviewed. Patients sought information most frequently concerning: postoperative pain and postoperative recovery (88%), time for ambulation (83%), duration of anaesthesia (77%) and different methods of anaesthesia (77%). Only 63% patients desired to be informed about all possible complications of anaesthesia. Senior anaesthesists had a correct perception of patients desire for information about the 4 important items but not for the complications of anaesthesia. CONCLUSION: Our study suggests that an exhaustive information about anaesthesia is not wished by every patients.     

Decoupling: what is it and does it really help increase consent to organ donation?

Although the notion of decoupling is simple and potentially controllable by organ donation requestors, evidence to date of its potential has been inconsistent. The impact of the timing of requests was analyzed using data from a study of organ donor-eligible patients and their families (N = 420), involving 9 trauma hospitals located in southwest Pennsylvania and northeast Ohio. In-depth interviews where conducted with family members, healthcare professionals, and organ procurement organization staff involved in the process. Only a weak effect was found for the impact of timing on the decision using a bivariate, correlational analysis. Moreover, we found that raising the issue before rather than after the pronouncement of death was most strongly associated with consent to donation. This effect disappeared after examining decoupling in relation to other factors. However, active consideration of the patient's donation wishes and a clear understanding of the families' initial inclination toward donation were associated with consent to organ donation.     

Expanding criteria for living kidney donors: what are the limits?

The need to evaluate potential living kidney donors is more pressing than ever before. Evaluating the potential medical risks to individual donors presents both medical and ethical questions related to quantitative hazards of donor nephrectomy. These include conditions commonly associated with age, such as the decline in glomerular filtration rate, the rise in arterial pressures, and weight gain. The “normal” ranges for many of these characteristics are changing as their importance as predictors of cardiovascular risk is reevaluated and the duration of exposure for a lifetime is considered. Many older donors in good health favor donating a kidney to a spouse, despite the presence of elevated blood pressure or even impaired glucose tolerance. The Mayo Kidney/Pancreas transplant program established an “extended criteria workgroup” to address these issues on an individual basis. Our program now stratifies medical criteria based upon age, allowing more liberal criteria for older donors. As a result, we accept treated hypertension in white donors, emphasizing the importance of informed consent and the need for vigilant follow-up. Our greatest concern relates to the development of obesity, particularly in younger individuals. Many of the long-term results of kidney donation are likely to hinge upon future behavior, including smoking, weight management, and medical follow-up care. Older donors are more likely to have established behavior patterns, an element that makes them better candidates in many respects. Studies to closely track the impact of donor nephrectomy in the current era with changing population demographics and expectations are essential.