Should all living donors be treated equally?

Recently, Matas et al. described a protocol to accept as potential donors altruistic strangers who offer to donate a kidney to any patient on the waiting list. The selection of donors would be the same as the process they use for living, emotionally related donors, except that the full work-up would have to be done at their institution and would include a detailed psychosocial evaluation. In this article, we present a case that raised the question of whether the medical standards for nonemotionally related donors should be the same as the standards for emotionally related donors. We argue that we must distinguish between the altruistic donation by a stranger and the voluntary donation by an emotionally related individual. We argue that voluntary donations have a degree of moral obligation based on intimacy and that intimacy allows, but does not require, that these donors take on slightly additional risk.     

Should kidneys from older cadaveric donors be age-matched to the recipient?

Persistent shortage of kidneys for transplantation has forced most transplant centers to include procurement and use of kidneys from older donors. It is not clear whether the optimal use of these kidneys involve age-matching to the recipient. The aim of this study was to evaluate the clinical outcome of older cadaveric kidneys (>60 years), transplanted to young recipients (<50 years) and older recipients (>60 years). From 1989 through 2002, 252 first kidney grafts were procured from donors above the age of 60; 149 of the recipients to these grafts were above 60 years and 45 recipients were below 50. Minimum follow-up time was 12 months. Variables for waiting time to transplantation, DR mismatches, PRA, dialysis prior to transplantation, episodes of acute rejection, number of steroid-resistant rejections, creatinine levels, cold ischemia time, and causes of graft loss did not differ between the two groups. There was no significant difference in graft survival for young and older recipients receiving kidney from donors above 60 years of age. Graft survival at 1 year for young recipients was 90% and for older recipients 93% (NS). Five-year graft survival was 72% and 79%, respectively (NS). However, there was a significant positive effect on long-term graft survival if the donor kidney was less than 50 years. From our data, there is no evidence that age-matching of older donors has any beneficial effect on graft survival in kidney transplantation.     

Should commercial organ donation be legalized in Germany? An ethical discourse

OBJECTIVE: We evaluated the arguments pro and con concerning kidney sales from a German perspective. At present, we see social, medical, and ethical reasons why organ selling should not be legalized in Germany. DISCUSSION: Legalization of organ selling would weaken the principle of solidarity within the German health system. Conversely, profit making will undermine the principle of social justice. Within the present social system in Germany, there is no economic pressure to sell an organ to save life, and there is no medical need to buy a kidney. Also, there exists the risk that opening the market for organ sales will de-motivate potential directed organ donors. Relatives would have more doubts about giving their consent to donate organs of their deceased. Moreover, the historical experience with the "action T4" of the Nazi regime sensitized German society for the categorical imperative set forth by Immanuel Kant (1724-1804), namely that man is not a means, but an end to himself. By selling one's kidney, the donor uses himself as a means and as an instrument for the end result of gaining money. With directed organ donation, the welfare of the recipient is the end result. The pending reform of the German health system needs a more communitarian sense, which will be eroded should organs be sold and no longer donated as gifts. CONCLUSION: Germany's special historical experience and a deeply embedded consent toward ethical values give reason for the prohibition of organ selling in Germany.     

Should people who commit themselves to organ donation be granted preferred status to receive organ transplants?

Granting preferred status for transplantation to people who commit themselves to posthumous organ donation is an intriguing proposal designed to increase the pool of cadaveric organ donors. Under one version of this plan, all competent adults who had previously consented to having their organs removed and transplanted upon their deaths would be given priority to receive organs, should they ever need them, over potential recipients of equal need who had not agreed to donate. To see if this plan would be acceptable to the public, I contracted Harris Interactive to conduct a national telephone survey about this issue. One thousand fourteen adults living in the United States were queried. Fifty-three percent of the respondents thought that people who agree to donate their organs after death should be granted priority to receive cadaveric organ transplants over those who do not agree to donate. Only 30% of the respondents would definitely oppose this plan. These data suggest that a pilot study of preferred status should be considered.     

Should airguns be banned?

In this article, we express concerns regarding the availability of airguns, the injuries that they cause and their abuse as weapons of assault. We wish to stimulate debate on this topic and report a 5-year retrospective analysis of all airgun injuries to the head and neck, presenting to Alder Hey Children's Hospital, Liverpool, from June 1998 to June 2003. We identified 16 patients who suffered such injuries with ages ranging from 5 to 15 years. The majority of cases were violent assaults, which is not in accordance with previous published reports. All of these occurred in public places outside the home. Most incidents occurred through the spring and summer period. Six patients required overnight stay in hospital. Nine patients required operative procedures to remove the airgun pellets. Two patients had serious eye injuries resulting in loss of vision. Two patients had penetrating neck injuries requiring exploration of the wound. The remaining group had either skin-penetrating injuries with lodgement of fragments in subcutaneous tissues or non-skin penetrating injuries. This study highlights serious injuries arising from the abuse of airguns as weapons of assault. Airguns are readily available to people without license. Recent legislation has increased the minimum age at which airguns can be carried in a public place, but we believe that stricter legislation is required to produce a reduction in the number of airgun-related injuries.     

Procuring organ donors as a health investment: how much should we be willing to spend?

BACKGROUND: This paper examines the benefits and costs that accrue when a cadaveric organ donor is procured. We estimate the cost per quality-adjusted life year (QALY) for donor procurement. Our objective was not only to see whether organ procurement is a "good" health investment, but also to clarify how much it is worth spending to obtain additional donors. METHODS: We calculated the average number of kidney, heart, and liver transplants that a typical cadaveric donor generates. Relying primarily on reviewing the published literature, we estimated for each organ type the average number of QALYs that transplants add and the average medical costs they generate. We multiplied per organ benefits and costs by the number of organs from the typical donor, and summed the results to calculate the cost per QALY from procuring an additional donor. We conducted extensive sensitivity analyses of the assumptions. RESULTS: Our central estimate indicates that the typical donor generates about 13 QALYs at an added medical cost of about $214,000, a cost of approximately $16,000 per QALY. Our high estimate is approximately $57,000. CONCLUSIONS: The implications of these findings depend upon how we choose to value QALYs. Most analysts agree that a figure of $100,000 is reasonable. At this value, the benefit obtained from one added donor would be $1.3 million (13 x $100,000) while the medical costs would be $214,000. The implication is that we should be willing to spend up to $1,086,000 ($1.3 million - $214,000) to obtain one more donor.     

Should keratoacanthoma be treated surgically?

Keratoacanthoma is a rapidly growing cutaneous neoplasia of adult persons that may regress spontaneously. It is believed to arise from the hair follicles. It is sometimes difficult to distinguish keratoacantoma from squamous cell carcinoma either clinically or histologically. During ten years period (1992-2001) we were treating 18 patients with keratoacanthoma of the skin. We discuss here our experience with this tumor, and we conclude that early, complete excision is the treatment of choice for it.     

Should Dialysate Calcium be Individualized?

The growing interest in a personalized choice of dialysate calcium concentration faces some important unsolved questions. First, the desired aims to be achieved should be clarified, as different d‐Ca concentrations might differentially impact dialysis calcium balance and serum calcium concentration. A second point to be addressed is how to achieve the desired goals; the kinetics of calcium during dialysis treatment are complex. This is not an easy task and probably only an automatic device able to read serum calcium concentration in real‐time and adjust d‐Ca to it might supply an effective method for individualizing d‐Ca. Finally, it is not even clear whether individualizing d‐Ca is worth doing; cost‐effectiveness studies might give some further insights into this intricate issue.     

Should aminoglycoside antibiotics be abandoned?

BACKGROUND: Aminoglycosides can cause nephrotoxicity and ototoxicity. Alternatives are available. METHODS: Surgical service antibiotic use, aminoglycoside toxicity, and perioperative culture/sensitivity results from July 1998 to June 1999 were reviewed. RESULTS: Of 289 positive cultures in 243 patients, 92 cultures (32%) grew 151 Gram-negative rods (GNRs). Aminoglycosides were used in 26 patients and 4 of 26 (15%) suffered nephrotoxicity. Of the 112 GNRs tested against ceftazidime, 111 (99%) were sensitive to it which was significantly better than amikacin (56 of 61, 92%, P = 0.038), gentamicin (116 of 134, 87%, P <0.001), and tobramycin (67 of 81, 83%, P <0.001). The proportion sensitive to cefuroxime (26 of 30, 87%) was equivalent to the proportions sensitive to gentamicin (87%, P = NS) and tobramycin (83%, P = NS). Of the 35 GNRs that were resistant to gentamicin and/or tobramycin, 15 (43%) were Pseudomonas aeruginosa. CONCLUSION: Aminoglycosides produce a significant rate of nephrotoxicity. There are antibiotics with equal or better sensitivity profiles than aminoglycosides against GNRs and Pseudomonas. Aminoglycoside use is rarely, if ever, indicated.