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Ethical Aspects of Renal Transplantation From Living Donors
DONORS
Ethical Aspects of Renal Transplantation From Living Donors P. Bruzzone and P.B. Berloco ABSTRACT Kidney transplantation from living donors is widely performed all over the world. Living nephrectomy for transplantation has no direct advantages for the donor other than increased self-esteem, but it at least remains an extremely safe procedure, with a worldwide overall mortality of 0.03%. This theoretical risk for the donor seems to be justified by the socioeconomic advantages and increased quality of life of the recipient, especially in selected cases, such as pediatric patients, when living donor kidney transplantation can be performed in a preuremic phase, avoiding the psychological and physical stress of dialysis, which in children is not well tolerated and cannot prevent retarded growth. According to the Ethical Council of the Transplantation Society, commercialism must be effectively prevented, not only for ethical but also medical reasons. The risks are too high, not only for the donors, but also for the recipients, as a consequence of poor donor screening and evaluation with consequent transmission of human immunodeficiency virus (HIV) or other infective agents, as well as of inappropriate medical and surgical management of donors and also recipients, who are often discharged too early. Most public or private insurance companies consider kidney donation a safe procedure without long-term impairment and therefore do not increase the premium, whereas recipient insurance of course should cover hospital fees for the donors. “Rewarded gifting” or other financial incentives to compensate for the inconvenience and loss of income related to the donation are not advisable, at least in our opinion. Our Center does not perform anonymous living organ donation or “cross-over” transplantation.
K
IDNEY transplantation from a living donor, successfully accomplished for the first time in 1954 by Murray, is now considered a good clinical solution, complementary to cadaver (CD) kidney transplantation, to increase the donor pool. With the increasing availability of dialysis, many centers subsequently discouraged transplantation from living donors; however, the introduction of Cyclosporine, a significant improvement of the results in CD kidney transplantation, and the dramatic growth in the
number of patients on the waiting list, due to an inadequate supply of CD kidneys, prompted again the expansion of criteria for acceptable living donors. The validity of this From the Divisione Trapianti d’Organo, Dipartimento “Paride Stefanini,” Università di Roma “La Sapienza,” Rome, Italy. Address reprint requests to Paolo Bruzzone, MD, Via Santa Maria Goretti 38/10 00199, Rome, Italy. E-mail: paolo.bruzzone@ fastwebnet.it
© 2007 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/07/$–see front matter doi:10.1016/j.transproceed.2007.05.009
Transplantation Proceedings, 39, 1785–1786 (2007)
1785
1786
kind of procedure is based on many ethical and clinical considerations, including the results that in most reports are better than with CD donor kidney transplantation, the willingness of the donor, and the limited amount of risks for the donor’s health. Both conventional and laparoscopic living donor nephrectomy are safe procedures, with worldwide overall mortality rates of 0.03%.1 However, at least 4 kidney donors all over the world developed end-stage renal failure and underwent kidney transplantation.2 Our center activated the living related donor (LRD) kidney transplantation program in 1967 and the living unrelated donor (LURD) kidney transplantation program in 1968, performing 62 kidney transplantations (of which 6 were LURD) under conventional therapy. In the Cyclosporine era, our group did a living donor kidney transplantation in 1982 and a LURD in 1983. DISCUSSION AND CONCLUSIONS
According to the Consensus Statement of the Amsterdam Forum on the Care of the Live Kidney Donor, held on April 1– 4, 2004 by the Ethics Committee of the Transplantation Society, “Minors less than 18 years of age should not be used as living kidney donors.”3 In agreement with the guidelines suggested by the Ethical Council of the Transplantation Society, commercialism must be effectively prevented by using as living unrelated donors only spouses or relatives in law with a great interest in the recipient’s health. One must be reminded that the results of truly commercial kidney transplantations are discouraging, providing a further issue against transplantation from paid donors, as a consequence of poor screening with consequent transmission of human immunodeficiency virus (HIV) or other infective agents, as well as of inappropriate medical and surgical management of recipients, who present unacceptable morbidity rates and often have been discharged too early to seek medical attention in their native countries. “Rewarded gifting” or other financial incentives to compensate for the inconvenience and loss of income related to donation are not advisable, at least in our opinion. All over the world most public or private insurance companies consider living kidney donation to be a safe procedure without long-term harm or impairment. Therefore, they do
BRUZZONE AND BERLOCO
not increase the premium for these donors, whereas the recipients’ insurance companies of course should cover the donor’s hospital fees. Due to obvious ethical reasons, transplantation physicians and surgeons cannot take part in kidney donation from prisoners, even when such a procedure has been proposed to death-row inmates as an alternative to execution. To increase the possibility of LURD kidney transplantation between blood group incompatible pairs, Rapaport proposed in 1986 a national network to exchange kidneys harvested from living donors with a blood group not compatible with their emotionally related recipients. This suggestion was proposed again in 1997 by Ross as a local program and by Park et al.4 This so-called “cross-over” procedure could allow living kidney transplantation among couples with direct positive cross-matches and, if applied on a larger scale, could allow also HLA matching, which is probably useful in this kind of transplantation. Our Center does not perform cross-over transplantation. According to published data5 as well as to our personal experience,6 – 8 we concluded that there are neither clinical nor ethical objections to LURD kidney transplantation provided that organ commercialism is excluded. REFERENCES 1. Ciszek M, Paczek L, Rowinski W: Clinical outcome of living kidney donation. Transplant Proc 35:1179, 2003 2. Gracida C, Espinoza R, Cancino J: Can a living kidney donor become a kidney recipient? Transplant Proc 36:1630, 2004 3. The Ethics Committee of the Transplantation Society: The Consensus Statement of the Amsterdam Forum on the Care of the Live Kidney Donor. Transplantation 78:491, 2004 4. Park L, Moon JI, Kim SI, et al: Exchange donor program in kidney transplantation. Transplantation 27:336, 1999 5. D’Alessandro AM, Pirsch JD, Knechtle SJ, et al: Living unrelated renal donation: the University of Wisconsin experience. Surgery 124:604, 1998 6. Berloco P, Alfani D, Bruzzone P, et al: Is unrelated living donor a valid organ source in renal transplantation under CyA therapy? Transplant Proc 23:912, 1991 7. Alfani D, Pretagostini R, Bruzzone P, et al: Kidney transplantation from living unrelated donors. In Cecka JM, Terasaki PI (eds): Clinical Transplants 1998. Los Angeles, Calif: UCLA Tissue Typing Laboratory; 1999, p 205 8. Cortesini R, Pretagostini R, Bruzzone P, et al: Living unrelated kidney transplantation. World Surg 26:238, 2002
Ethical Aspects of Renal Transplantation From Living Donors P. Bruzzone and P.B. Berloco ABSTRACT Kidney transplantation from living donors is widely performed all over the world. Living nephrectomy for transplantation has no direct advantages for the donor other than increased self-esteem, but it at least remains an extremely safe procedure, with a worldwide overall mortality of 0.03%. This theoretical risk for the donor seems to be justified by the socioeconomic advantages and increased quality of life of the recipient, especially in selected cases, such as pediatric patients, when living donor kidney transplantation can be performed in a preuremic phase, avoiding the psychological and physical stress of dialysis, which in children is not well tolerated and cannot prevent retarded growth. According to the Ethical Council of the Transplantation Society, commercialism must be effectively prevented, not only for ethical but also medical reasons. The risks are too high, not only for the donors, but also for the recipients, as a consequence of poor donor screening and evaluation with consequent transmission of human immunodeficiency virus (HIV) or other infective agents, as well as of inappropriate medical and surgical management of donors and also recipients, who are often discharged too early. Most public or private insurance companies consider kidney donation a safe procedure without long-term impairment and therefore do not increase the premium, whereas recipient insurance of course should cover hospital fees for the donors. “Rewarded gifting” or other financial incentives to compensate for the inconvenience and loss of income related to the donation are not advisable, at least in our opinion. Our Center does not perform anonymous living organ donation or “cross-over” transplantation.
K
IDNEY transplantation from a living donor, successfully accomplished for the first time in 1954 by Murray, is now considered a good clinical solution, complementary to cadaver (CD) kidney transplantation, to increase the donor pool. With the increasing availability of dialysis, many centers subsequently discouraged transplantation from living donors; however, the introduction of Cyclosporine, a significant improvement of the results in CD kidney transplantation, and the dramatic growth in the
number of patients on the waiting list, due to an inadequate supply of CD kidneys, prompted again the expansion of criteria for acceptable living donors. The validity of this From the Divisione Trapianti d’Organo, Dipartimento “Paride Stefanini,” Università di Roma “La Sapienza,” Rome, Italy. Address reprint requests to Paolo Bruzzone, MD, Via Santa Maria Goretti 38/10 00199, Rome, Italy. E-mail: paolo.bruzzone@ fastwebnet.it
© 2007 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/07/$–see front matter doi:10.1016/j.transproceed.2007.05.009
Transplantation Proceedings, 39, 1785–1786 (2007)
1785
1786
kind of procedure is based on many ethical and clinical considerations, including the results that in most reports are better than with CD donor kidney transplantation, the willingness of the donor, and the limited amount of risks for the donor’s health. Both conventional and laparoscopic living donor nephrectomy are safe procedures, with worldwide overall mortality rates of 0.03%.1 However, at least 4 kidney donors all over the world developed end-stage renal failure and underwent kidney transplantation.2 Our center activated the living related donor (LRD) kidney transplantation program in 1967 and the living unrelated donor (LURD) kidney transplantation program in 1968, performing 62 kidney transplantations (of which 6 were LURD) under conventional therapy. In the Cyclosporine era, our group did a living donor kidney transplantation in 1982 and a LURD in 1983. DISCUSSION AND CONCLUSIONS
According to the Consensus Statement of the Amsterdam Forum on the Care of the Live Kidney Donor, held on April 1– 4, 2004 by the Ethics Committee of the Transplantation Society, “Minors less than 18 years of age should not be used as living kidney donors.”3 In agreement with the guidelines suggested by the Ethical Council of the Transplantation Society, commercialism must be effectively prevented by using as living unrelated donors only spouses or relatives in law with a great interest in the recipient’s health. One must be reminded that the results of truly commercial kidney transplantations are discouraging, providing a further issue against transplantation from paid donors, as a consequence of poor screening with consequent transmission of human immunodeficiency virus (HIV) or other infective agents, as well as of inappropriate medical and surgical management of recipients, who present unacceptable morbidity rates and often have been discharged too early to seek medical attention in their native countries. “Rewarded gifting” or other financial incentives to compensate for the inconvenience and loss of income related to donation are not advisable, at least in our opinion. All over the world most public or private insurance companies consider living kidney donation to be a safe procedure without long-term harm or impairment. Therefore, they do
BRUZZONE AND BERLOCO
not increase the premium for these donors, whereas the recipients’ insurance companies of course should cover the donor’s hospital fees. Due to obvious ethical reasons, transplantation physicians and surgeons cannot take part in kidney donation from prisoners, even when such a procedure has been proposed to death-row inmates as an alternative to execution. To increase the possibility of LURD kidney transplantation between blood group incompatible pairs, Rapaport proposed in 1986 a national network to exchange kidneys harvested from living donors with a blood group not compatible with their emotionally related recipients. This suggestion was proposed again in 1997 by Ross as a local program and by Park et al.4 This so-called “cross-over” procedure could allow living kidney transplantation among couples with direct positive cross-matches and, if applied on a larger scale, could allow also HLA matching, which is probably useful in this kind of transplantation. Our Center does not perform cross-over transplantation. According to published data5 as well as to our personal experience,6 – 8 we concluded that there are neither clinical nor ethical objections to LURD kidney transplantation provided that organ commercialism is excluded. REFERENCES 1. Ciszek M, Paczek L, Rowinski W: Clinical outcome of living kidney donation. Transplant Proc 35:1179, 2003 2. Gracida C, Espinoza R, Cancino J: Can a living kidney donor become a kidney recipient? Transplant Proc 36:1630, 2004 3. The Ethics Committee of the Transplantation Society: The Consensus Statement of the Amsterdam Forum on the Care of the Live Kidney Donor. Transplantation 78:491, 2004 4. Park L, Moon JI, Kim SI, et al: Exchange donor program in kidney transplantation. Transplantation 27:336, 1999 5. D’Alessandro AM, Pirsch JD, Knechtle SJ, et al: Living unrelated renal donation: the University of Wisconsin experience. Surgery 124:604, 1998 6. Berloco P, Alfani D, Bruzzone P, et al: Is unrelated living donor a valid organ source in renal transplantation under CyA therapy? Transplant Proc 23:912, 1991 7. Alfani D, Pretagostini R, Bruzzone P, et al: Kidney transplantation from living unrelated donors. In Cecka JM, Terasaki PI (eds): Clinical Transplants 1998. Los Angeles, Calif: UCLA Tissue Typing Laboratory; 1999, p 205 8. Cortesini R, Pretagostini R, Bruzzone P, et al: Living unrelated kidney transplantation. World Surg 26:238, 2002