- Email: [email protected]
Altruistic kidney donation
of medicine is littered with plausible hypotheses that have turned out to be false. The data they present are mainly mechanistic and epidemiological, which are potentially valuable but not conclusive. Only well designed, double-blind, randomised controlled trials (RCTs) provide evidence that minimises bias and confounding. We based our conclusions on systematic reviews of RCTs wherever possible. We summarised one such systematic review1 that indicated that H pylori eradication did not cause or protect against GORD in patients with peptic ulcer disease. That review did not find enough RCT evidence to determine whether H pylori eradication affects patients with pre-existing reflux disease. Since this systematic review, we have identified three further RCTs,2–4 giving a total of 586 GORD patients infected with H pylori with evaluable data randomised to eradication therapy or no antibiotics. Patients were treated with proton pump inhibitors and followed up for 8–24 months. There was no significant effect of H pylori eradication on the relapse of symptoms: those allocated to active therapy had a relative risk of symptomatic relapse of 1·13 (95% CI 0·92–1·39). There was also no significant effect of H pylori eradication on the relapse of oesophagitis (1·95, 0·93–4·07). Other RCT data suggest that this conclusion probably extends to functional dyspepsia.5 Although we cannot exclude the possibility that H pylori eradication could have a small positive or negative effect on reflux disease, all the available data suggest that the infection is unlikely to have a major effect in either protecting against or causing GORD. NJT has been a member of advisory boards of AstraZeneca, Axcan, EBMed, Giaconda, Solvay, Theravance, Yamanouchi, Boehringer-Ingelheim, and Chugai; has received research support from Merck, Forest, Novartis, Tap Pharmaceutical, and BoehringerIngelheim; and is supported by NIH RO1DK 65713-1 A1. PM has been a member of advisory boards and the speakers bureau of AstraZeneca and JanssenOrtho and Altana, and his chair is partly funded by an unrestricted grant given to McMaster University by AstraZeneca.
www.thelancet.com Vol 368 September 16, 2006
Paul Moayyedi, *Nicholas J Talley [email protected] Department of Medicine, Division of Gastroenterology, McMaster University Medical Centre, Hamilton, Ontario, Canada (PM); and Mayo Clinic College of Medicine, 200 First Street SW, PL-6-56, Rochester, MN 55905, USA (NJT) 1
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Raghunath AS, Hungin AP, Wooff D, Childs S. Systematic review: the effect of Helicobacter pylori and its eradication on gastro-oesophageal reflux disease in patients with duodenal ulcers or reflux oesophagitis. Aliment Pharmacol Ther 2004; 20: 733–44. Wu JC, Chan FK, Ching JY, et al. Effect of Helicobacter pylori eradication on treatment of gastro-oesophageal reflux disease: a double blind, placebo controlled, randomised trial. Gut 2004; 53: 174–79. Kuipers EJ, Nelis GF, Klinkenberg-Knol EC, et al. Cure of Helicobacter pylori infection in patients with reflux oesophagitis treated with long term omeprazole reverses gastritis without exacerbation of reflux disease: results of a randomised controlled trial. Gut 2004; 53: 12–20. Pilotto A, Perri F, Leandro G, Franceschi M, for the Aging and Acid-Related Disease Study Group. Effect of Helicobacter pylori eradication on the outcome of reflux esophagitis and chronic gastritis in the elderly: a randomized, multicenter, eight-month study. Gerontology 2006; 52: 99–106. Vakil N, Talley NJ, Stolte M, Sundin M, Junghard O, Bolling-Sternevald E. Patterns of gastritis and the effect of eradicating Helicobacter pylori on gastro-oesophageal reflux disease in Western patients with non-ulcer dyspepsia. Aliment Pharmacol Ther 2006; 24: 55-63.
Altruistic kidney donation The report by Robert Montgomery and colleagues (July 29, p 419),1 in which an altruistic kidney donor made two transplantations possible by a domino-paired donation procedure, describes further possibilities by which to expand the number of kidney transplants derived from living donors. In the Netherlands, we run a national paired kidney exchange programme for ABO-incompatible and crossmatch-positive donor-acceptor combinations under supervision of the Dutch Transplant Foundation.2 From January, 2004, we enrolled 158 couples and found compatible donors for 82 recipients. Although our programme is efficient, we cannot match all patients and therefore alternative strategies are justified.
Living donor list exchange is an option but has met with ethical objections since it will increase the waiting time for blood type O recipients. However, utilitarian arguments hold that benefits for an entire patient group can outweigh disadvantages for a subgroup. Recently, the Dutch Health Council installed a committee to advise on list exchange restricted to unsuccessful pairs in our direct exchange programme. Altruistic kidney donation to non-emotionally related people is another alternative.3 At the Erasmus Medical Center, 23 individuals were assessed for this procedure, resulting in five directed, five non-directed single, and nine domino-paired donations—ie, 28 transplantations. Non-directed donor kidneys were allocated according to the criteria applied for cadaveric kidneys. Couples participating in domino-paired exchange had been unsuccessful in the direct-paired exchange programme.4 Alternatives by which to expand the living kidney donor pool should be integrated in a national exchange programme under supervision of an independent allocation authority.
We do not have the rights to reproduce this image on the web.
We declare that we have no conflict of interest.
*Willem Weimar, Willij Zuidema, Marry de Klerk, Bernadette Haase- Kromwijk, Jan IJzermans [email protected] Renal Transplant Unit, Erasmus Medical Center, PO Box 2040, 3000 CA Rotterdam, Netherlands (WW, WZ, JI); Dutch Transplant Foundation, Leiden, Netherlands (WW, MdK, BH-K) 1
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Montgomery RA, Gentry SE, Marks WH, et al. Domino paired kidney donation: a strategy to make best use of live non-directed donation. Lancet 2006; 368: 419–21. De Klerk M, Keizer KM, Claas FH, Witvliet M, Haase-Kromwijk BJ, Weimar W. The Dutch national living donor kidney-exchange program. Am J Transplant 2005; 5: 2302–05. Hilhorst MT, Kranenburg LW, Zuidema W, et al. Altruistic living kidney donation challenges psychosocial research and policy: a response to previous articles. Transplantation 2005; 79: 1470–74. Zuidema W, Kranenburg LW, Kal-van Gestel J, Hilhorst MT, IJzermans JNM, Weimar W. Implementation of an altruistic living kidney donor program. World Transplant Congress; July, 2006; abstr 1587.
987
Science Photo Library
Correspondence
www.thelancet.com Vol 368 September 16, 2006
Paul Moayyedi, *Nicholas J Talley [email protected] Department of Medicine, Division of Gastroenterology, McMaster University Medical Centre, Hamilton, Ontario, Canada (PM); and Mayo Clinic College of Medicine, 200 First Street SW, PL-6-56, Rochester, MN 55905, USA (NJT) 1
2
3
4
5
Raghunath AS, Hungin AP, Wooff D, Childs S. Systematic review: the effect of Helicobacter pylori and its eradication on gastro-oesophageal reflux disease in patients with duodenal ulcers or reflux oesophagitis. Aliment Pharmacol Ther 2004; 20: 733–44. Wu JC, Chan FK, Ching JY, et al. Effect of Helicobacter pylori eradication on treatment of gastro-oesophageal reflux disease: a double blind, placebo controlled, randomised trial. Gut 2004; 53: 174–79. Kuipers EJ, Nelis GF, Klinkenberg-Knol EC, et al. Cure of Helicobacter pylori infection in patients with reflux oesophagitis treated with long term omeprazole reverses gastritis without exacerbation of reflux disease: results of a randomised controlled trial. Gut 2004; 53: 12–20. Pilotto A, Perri F, Leandro G, Franceschi M, for the Aging and Acid-Related Disease Study Group. Effect of Helicobacter pylori eradication on the outcome of reflux esophagitis and chronic gastritis in the elderly: a randomized, multicenter, eight-month study. Gerontology 2006; 52: 99–106. Vakil N, Talley NJ, Stolte M, Sundin M, Junghard O, Bolling-Sternevald E. Patterns of gastritis and the effect of eradicating Helicobacter pylori on gastro-oesophageal reflux disease in Western patients with non-ulcer dyspepsia. Aliment Pharmacol Ther 2006; 24: 55-63.
Altruistic kidney donation The report by Robert Montgomery and colleagues (July 29, p 419),1 in which an altruistic kidney donor made two transplantations possible by a domino-paired donation procedure, describes further possibilities by which to expand the number of kidney transplants derived from living donors. In the Netherlands, we run a national paired kidney exchange programme for ABO-incompatible and crossmatch-positive donor-acceptor combinations under supervision of the Dutch Transplant Foundation.2 From January, 2004, we enrolled 158 couples and found compatible donors for 82 recipients. Although our programme is efficient, we cannot match all patients and therefore alternative strategies are justified.
Living donor list exchange is an option but has met with ethical objections since it will increase the waiting time for blood type O recipients. However, utilitarian arguments hold that benefits for an entire patient group can outweigh disadvantages for a subgroup. Recently, the Dutch Health Council installed a committee to advise on list exchange restricted to unsuccessful pairs in our direct exchange programme. Altruistic kidney donation to non-emotionally related people is another alternative.3 At the Erasmus Medical Center, 23 individuals were assessed for this procedure, resulting in five directed, five non-directed single, and nine domino-paired donations—ie, 28 transplantations. Non-directed donor kidneys were allocated according to the criteria applied for cadaveric kidneys. Couples participating in domino-paired exchange had been unsuccessful in the direct-paired exchange programme.4 Alternatives by which to expand the living kidney donor pool should be integrated in a national exchange programme under supervision of an independent allocation authority.
We do not have the rights to reproduce this image on the web.
We declare that we have no conflict of interest.
*Willem Weimar, Willij Zuidema, Marry de Klerk, Bernadette Haase- Kromwijk, Jan IJzermans [email protected] Renal Transplant Unit, Erasmus Medical Center, PO Box 2040, 3000 CA Rotterdam, Netherlands (WW, WZ, JI); Dutch Transplant Foundation, Leiden, Netherlands (WW, MdK, BH-K) 1
2
3
4
Montgomery RA, Gentry SE, Marks WH, et al. Domino paired kidney donation: a strategy to make best use of live non-directed donation. Lancet 2006; 368: 419–21. De Klerk M, Keizer KM, Claas FH, Witvliet M, Haase-Kromwijk BJ, Weimar W. The Dutch national living donor kidney-exchange program. Am J Transplant 2005; 5: 2302–05. Hilhorst MT, Kranenburg LW, Zuidema W, et al. Altruistic living kidney donation challenges psychosocial research and policy: a response to previous articles. Transplantation 2005; 79: 1470–74. Zuidema W, Kranenburg LW, Kal-van Gestel J, Hilhorst MT, IJzermans JNM, Weimar W. Implementation of an altruistic living kidney donor program. World Transplant Congress; July, 2006; abstr 1587.
987
Science Photo Library
Correspondence