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Informed Consent Living Donor Research Living Donor Risks

Pregnancy Post-Donation Includes Risk

Per a study from March 2016:

 

“A concern for donation-related risk was recently confirmed in an 11-year cohort study of 85 female donors and 510 healthy non-donors who were carefully matched on baseline risk factors. Donors were 2.4 times more likely to be diagnosed with gestational hypertension or preeclampsia compared with healthy non-donors.”

The confirmation above refers to prior studies that have also come to this same conclusion. Search the blog for other pregnancy related posts.

 

 

Sontrop, J., & Garg, A. (2016). Considerations for Living Kidney Donation Among Women of Childbearing Age: Evidence from Recent Studies Current Transplantation Reports, 3 (1), 10-14 DOI: 10.1007/s40472-016-0082-0

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Ethical Considerations Informed Consent Living Donor Research Living Kidney Donor

8-11x increased risk of kidney failure too low

Not surprisingly, researchers are still debating living kidney donors’ risk of end stage renal disease or kidney failure. The two most damning studies say that LKDs have an 8-11x increased risk ESRD as compared to their well-matched, two-kidneyed counterpart. Of course, the pro-living donor people tried to minimize these findings, calling it a “modest” 1% absolute lifetime risk. The fact that most people, meaning the public, has no idea what that really means, certainly helps in their information manipulation.

 

Steiner agrees that the prior studies’ findings are not absolute, but only because they tend to lump all living kidney donors together as a monolith. He asserts that certain classes of kidney donors assume a much *hgher* risk of end-stage renal disease than previously stated. If the risk of ESRD is due to the loss of nephrons at the time of donation (the conclusion of the aforementioned research) then LKDs under the age of 35 have a much *higher* risk than those older than 35, because they’re living more of their life without a Renal Reserve. Their already reduced nephrons will be damaged and become dysfunctional through disease, damage, toxins and age.

He also states that African-American donors and those with lower pre-donation GFRs are at a higher than previously stated risk. African-American folks have a much higher incidence of diabetes, the largest cause of kidney failure in the US, so this squares with all other data.

Too many transplant centers are still using the “one size fits all” pre-donation GFR cut-off, which severely harms LKDs who fall on the lower end of the spectrum. In 2010, a Consensus document on LKD medical evaluation called for a predonatoin GFR based on sex, age and Body Surface Area, but the members of OPTN (transplant centers and others who profit from transplant) removed it from the proposal. Steiner advocates a much higher predonation GFR cut-off, and utilizing older donors with minor medical abnormalities.

 

 

 

Steiner, R. (2016). Moving closer to understanding the risks of living kidney donation Clinical Transplantation, 30 (1), 10-16 DOI: 10.1111/ctr.12652

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Ethical Considerations Informed Consent Living Donor Research Living Donor Risks Living Kidney Donor

Understanding Kidney Donors’ Increased Kidney Failure Risk

By now, we’ve all seen the studies stating that living kidney donors have an 8-11x increased risk of kidney failure as compared to their well-matched, two-kidneyed cohort. And you’ve probably seen the transplant industry’s spin on that data, their sputtering “Well, but, the *absolute* risk is still really, really low”

But is it?

Steiner attempts to answer that question, at least some of it, by breaking down the overall risk into its important pieces-parts. He says:

 

“The 1% lifetime post-donation risk in the US study requires medical screening to predict ESRD in 96 of 100 candidates. This is particularly unlikely in the 30–35% of candidates under age 35, half of whose lifetime ESRD will occur after age 64. Many experts have attributed the increased relative risks in these studies to loss of GFR at donation, which ultimately means that high–normal pre-donation GFRs will reduce absolute post-donation risks.”

“Young vs. older age, low vs. high–normal pre-donation GFRs, black race, and an increased relative risk of donation all predict highly variable individual risks, not a single “low” or “1%” risk as these studies suggest.”

A uniform, ethically defensible donor selection protocol would accept older donors with many minor medical abnormalities but protect from donation many currently acceptable younger, black, and/or low GFR candidates.

I encourage everyone to read the whole thing. Your health may depend on it.

 

 

Steiner, R. (2016). Moving closer to understanding the risks of living kidney donation Clinical Transplantation, 30 (1), 10-16 DOI: 10.1111/ctr.12652

Categories
Informed Consent Living Donor Research

Left Kidney Donation Preference

During living kidney donation, the left kidney is most often taken because the right kidney rests behind the liver. In simple terms, it’s easier to access the left kidney. But it also appears that the left kidney has a longer renal vessel than the right (an important consideration that is rarely, if ever, mentioned during living donor evaluation or informed consent).

The authors examined the outcomes of right vs left kidney transplants and found:

Transplants from deceased donors resulted in no discernible differences, BUT

Right kidney grafts from living donors had a much higher rate of “technical failure” than left kidney grafts.

 

Specifically:

“Technical failure was…defined as graft failure within 10 days without signs of acute rejection.”

 

If your surgeon suggests taking the right kidney over the left, do not be afraid to have this discussion.

 
Özdemir-van Brunschot, D., van Laarhoven, C., van der Jagt, M., Hoitsma, A., & Warlé, M. (2015). Is the Reluctance for the Implantation of Right Donor Kidneys Justified? World Journal of Surgery, 40 (2), 471-478 DOI: 10.1007/s00268-015-3232-0

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Ethical Considerations Informed Consent Living Donor Research Living Donor Risks Living Kidney Donor

Living Kidney Donors Over the Age of 55

The authors retrospectively analyzed 482 cases of living related kidney donation and transplantation. “The cases were divided into 2 groups by donor age > or =55 years (aged donor group, 136 cases) and <55 years (young donor group, 346 cases).”

“(eGFR) was lower in the aged donor group compared with in the young donor group. After transplant, the mean eGFR of the graft in the recipient was also lower in the aged donor group than in the young donor group.”

“Compared with the young donor group, in the aged donor group incidence of proteinuria and 24-hour urinary protein were significantly higher. However, the incidence of delayed graft function was not significantly different between the 2 groups. We found that aged kidney grafts had no significant effect on long-term patient and graft survivals.”

 

It’s not surprising the authors focused on the recipients’ results far more than the donors’. While I am hesitant about any study that aims to say “Yes! Let’s use living human beings as medical supply!”, this topic is an important one.

According to the USRDS, the average age of end-stage renal disease onset in the U.S. is 64.4 years old. Meanwhile, the average age of a living kidney donor in the U.S. is 40/41 years old.

 

As the U.S. population continues to age, the prevalence of ESRD will increase, as will the so-called “need” for donor kidneys. But…

  1. Family sizes are smaller, resulting in fewer potential biologically related donors (All the current emphasis on “altruistic” or “good samaritan” or non-related donors makes more sense now, doesn’t it?)
  2. Median age in the U.S. is increasing (Median = midpoint, where 50% are below and 50% are above)
  3. The U.S. population is suffering from obesity, diabetes, heart disease, etc., which reduces the pool of potential living donors.
  4. The longer a person  lives with one kidney (aka reduced kidney function), the higher their risk of long-term repercussions, cardiovascular disease and death, and renal failure.
  5. GFR declines naturally as we age, so an older recipient wouldn’t require the same post-transplant GFR as someone much younger.

 

So, with all that in mind, the use of “older” (over 55yoa) living kidney donors – IF THEY ARE IN REALLY, REALLY GOOD HEALTH AND FULLY INFORMED – makes sense. Transplant algorithms are designed to maximize efficiency, and it’s inefficient to give a recipient expected to live another 10 years a kidney predicted to survive 40 years. More so, the entire justification of living kidney donation is predicated on the idea of the benefit to the recipient outweighing the harm to the donor*, and that simply isn’t the case if the recipient receives 5 years of life while the donor is denied 30 years of full renal function (and all that it implies: adrenal, potassium, vitamin D, etc).

 

Of course, I also believe that every person who financially benefits from living donation should have to donate – put your money where your mouth is and all that – but for now, I’ll make do with incremental steps toward justice.

 

Cheng, K., Huang, Z., Ye, Q., Ming, Y., Zhao, Y., Liu, L., Zhang, S., Chen, Z., & Wang, Q. (2015). Midterm Outcome of Living-Related Kidney Transplantation From Aged Donors: A Single-Center Experience Transplantation Proceedings, 47 (6), 1736-1740 DOI: 10.1016/j.transproceed.2015.06.016

 

 

* I disagree with this justification, btw; I think it’s total bullshit and inaccurate and dismissive of living donors as separate from their recipients, but that is a subject for another day.