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State of Living Kidney Donation in Europe

Like all such academically published articles, there’s good and bad.

 

The good?

Admitting that transplant centers benefit financially and otherwise from living kidney donor transplants:

We must also mention that the higher the number of transplantations, the better the reputation for the transplant centre. Furthermore, in some centres, the number of transplantations is so high that it is responsible for a substantial part of the hospital budget. This income can be used for the benefit of the centre, the surgeons and/or the transplant physicians. In other words, if a centre performs fewer transplantations, it may be inclined to reduce the number of physicians or other personnel involved in the field of transplantation.

 

And the scheduling convenience:

..the operation can be planned in advance, so everyone involved can plan ahead and look for the most beneficial time for the transplantation…It is no surprise that every surgeon and transplant physician prefers transplantation during daytime

 

Probably my favorite is this little bit (emphasis mine):

There should be no doubt that a living donation is a surgical procedure and carries some small but inherent risks. Thus, a living donor is certainly better off if he does not donate a kidney.

 

Believe me, you’ll never hear an American transplant physician admit any of the above, especially the last.

 

But then there’s the bad:

We now know that an increase in creatinine and the development of hypertension ranks among the most important risk factors for cardiovascular events and, thus, cardiovascular death. After donation, a number of donors develop an elevated creatinine, which could be associated with an increased cardiovascular mortality. At present, we cannot define a creatinine threshold above which a donation is associated with an increased cardiovascular mortality.

 

And why can’t they define a creatinine threshold? Because they never bothered to track or study living kidney donors in any sort of long-term or comprehensive fashion.

But at least he admits it:

Even for younger donors, the follow-up is limited to 5- or 15-year data, which is not particularly benficial as life expectancy in modern societies ranges between 75 and 85, implying a minimum follow-up of 20–30 years is necessary in order to offer meaningful data.

 

On to hypertension (emphasis mine):

There is no question that an increasing number of donors suffer from hypertension. This is likely attributable to donation although the rate of hypertension does not seem to be higher than in the general population. Furthermore, nowadays, imperfect donors are accepted and some of them have hypertension even before donation. 

The major question remains what to do in the case of more than one anti-hypertensive drug in a potential donor with well-controlled hypertension and no apparent side effects. As hypertension will certainly worsen after donation, this may be decided on a case to case basis in consideration of additional risk factors or diseases in the donor as well as the age of the donor. The older the donor, the more likely there will be no reduction in overall survival due to donation, so that an otherwise healthy donor of 70 years of age may have no real risk for donation, while a 30-year-old may. However, this is more speculation…

 

And proteinuria:

The consensus on proteinuria is much more advanced. Here, most guidelines suggest to restrict donation to people with a proteinuria of <300 mg/day. Although this threshold is somewhat arbitrary, a higher level of proteinuria clearly is associated with an increase risk of developing a kidney disease. However, we cannot rule out that such a threshold is too lax for younger donors and too strict for older ones as it will take some time to progress from low proteinuria to advanced kidney disease with all of its implications

 

The important part here, imo, is the admission that a one-size-fits-all template of living donor acceptability isn’t in the best interest of any living kidney donor.

 

And here comes the insurance issue:

in Germany, for example, living donation is considered a cosmetic operation, so that costs for the treatment of
problems arising from donation long term such as hernia operation or even dialysis may not be covered.

 

And finances:

Furthermore, there may be financial damage to the donor by higher costs for insurances or loss of work or even a prolonged recovery

 

The correlation between deceased donation and living donation is crucial (emphasis mine again):

…we can observe that in countries with a high rate of postmortem donation, the rate of living donors is relatively low. In these countries, the acceptance of donors is more selective than in countries with a low rate of postmortem donors

 

It doesn’t take an investigative genius to notice that the transplant industry spends all of its time promoting living donation over deceased. Hell, I just ran into an article this morning where Johns Hopkins used a NIH (national institute of health) grant to teach friends and family members how to be kidney brokers for their would-be recipient loved ones. They gave them six months of training and business cards and everything*.

And that little tale directly refers to this sentence in Heemnn’s study:

As the transplant physician may have his own agenda and is likely to be in favour of donation, and the potential donor may feel some emotional pressure,

 

Yeah….

 

I might kiss the researchers for this one (my emphasis):

Today, the steps being taken to strengthen donor rights are somewhat small and half-hearted.

Continued:

The only step taken by the EU is the implementation of a donor registry. However, it has not been explicitly stated for what period a donor has to be followed. In some countries, the followup stops with release from the hospital, in some after 1, 2 or 3 years. Only in very few countries are donors mandatorily followed for life. As the overall numbers are small, it is unlikely that, with such perfunctory measures, we will be able to adequately advise transplant centres and donors about the real risk of donation in the near future.

Sad to know that the US and Europe have one thing in common: treating their living kidney donors badly.

 

But I think this says it all:

At present, there is not even a public acknowledgement of the society to demonstrate the worth of donation.

Believe me, cries of “But you’re a HERO” don’t count.

 

*Yet living donors can’t get a funded registry??

 
Heemann, U., & Renders, L. (2012). State of living kidney donation in Europe Nephrology Dialysis Transplantation DOI: 10.1093/ndt/gfs144

2 replies on “State of Living Kidney Donation in Europe”

Truth is in the numbers: What percentage of transplant doctors and nurses actually are donors? If they talk the talk, let them walk the walk. I bet it’s close to zero.

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