It’s that time again, where I don’t just read a recently published academic article, but dissect it and examine its tiny little pieces.
From the abstract: Our perspective is that altruism is the motivation for most living kidney donors and the decision to donate represents a shared responsibility among the donor, the donor’s physician, and the team of professionals at the transplant center. Thus, sound knowledge of the benefits and risks to donors and recipients is required for informed decisions, and all parties share in the responsibility for the outcomes after living kidney donation.
The authors compare the demographics of active wait list candidates with those of living donors*. Here are their thoughts: Although the difference in age is expected, the persistent differences in sex and race-ethnicity may reflect barriers to access to donation, particularly socioeconomic and cultural barriers.
This use of ‘expected’ in regards to the age difference between those on that wait list and LKDs made me chuckle. Expected by whom? And just because something is expected, does that make it ethical or right or fair?
After all, OPTN’s own documents admit that organs (esp kidneys) from deceased donors over the age of 50 are being discarded unnecessarily. And based on the Joint Societies’ LKD Evaluation Consensus Document, a “GFR of 85 would be of less concern for a 60 year old man, since that value is above average for that age and there is less remaining lifetime for GFR to decline. In contrast, the same GFR of 85 approaches two standard deviations below the mean in a 25-year-old donor.”
So imagine if all those 50+ deceased kidneys were utilized, and older folks were encouraged to become living donors because they were at less long-term risk than a younger people. Would that change the ‘expected age difference’ seen here?
As for the sex and race-ethnicity discrepancy, remember that the authors are pushing for increased living donation, not donation in general. African-Americans have a much higher incidence of diabetes, diabetes has a high hereditary component, and diabetes is the biggest kidney killer out there. If living donors are supposed to be uber-healthy, why would the authors advocate that folks at risk for future diabetes and kidney failure give up a kidney? In fact, maybe that’s part of the reason the percentage of African-American living kidney donors is so low. But instead of that possibility, the authors blame less education, lower income, and inadequate medical insurance. To their credit, at least they acknowledge that distrust in physicians is most likely a factor. Considering a lot of the stories I’ve heard from living donors, I’d turn that around and say that perhaps the problem is that whites trust in the medical community too much.
Back to the article: The criteria for kidney donation are designed to select medically and psychologically healthy donors with minimal short- and long-term risk for complications of the procedure.
Uh, except: A. There are no national standards in the US for living donor evaluation, selection, care or follow-up. And B. their reference is the 2000 Amsterdam Forum which NO ONE in the US adheres to. Yeah.
Extensive and detailed guidelines have been developed for the evaluation of living donors in general and specifically for unrelated donors.
A. Not true. They’re incredible vague and generic.
B. Guideline = VOLUNTARY. There’s no guarantee any transplant center follows any of them at all.
The short-term consequences of kidney donation are well known.
Wait – what? There is ZERO data prior to 1994, only death data from 1994-2000, and even though two years follow-up has been required since then, 40% of living donors are still ‘lost’ by one-year. That pretty much amounts to anything but ‘well-known’.
Mortality within 90 days is 0.031% and has not changed in the past 15 years.
And their reference? The infamous Segev article. Have a refresher.
To be continued…..
*In a post earlier this year, I compared the demographics of deceased donor organ transplant recipients with those of deceased organ donors.
Levey AS, Danovitch G, & Hou S (2011). Living donor kidney transplantation in the United States-looking back, looking forward. American journal of kidney diseases : the official journal of the National Kidney Foundation, 58 (3), 343-8 PMID: 21783290