Categories
Living Donor Research Living Kidney Donor

Once Again, Ship Kidneys Not Donors

During a 44 month period in Australia, 84 kidneys were transported for transplantation at a different center (16 were transplanted at the same center).

” A spontaneous fall in serum creatinine by at least 10% within 24 h was observed in 85% of recipients, with no difference between nonshipped and shipped kidneys.

There was no difference in recipients of nonshipped compared with shipped kidneys with regard to serum creatinine at 1 month, 1-year graft survival, or patient survival ”

 

 
Allen, R., Pleass, H., Clayton, P., Woodroffe, C., & Ferrari, P. (2016). Outcomes of kidney paired donation transplants in relation to shipping and cold ischaemia time Transplant International, 29 (4), 425-431 DOI: 10.1111/tri.12719

Categories
ACOT Living Donor Risks Living Kidney Donor

How Kidney Paired Donation Affects ALL Living Kidney Donors

If you haven’t already, you’ll want to see my prior post wherein I set the stage for why transplants aren’t necessarily cheaper than dialysis. (and PS I failed to mention the growing number of older folks being diagnosed with end-stage renal disease who are choosing not to have any treatment at all.)

Dissecting that explanation matters because as of this past week’s ACOT meeting, a practice that is supposed to be cost-effective (kidney paired donation) suddenly has expenses above and beyond directed living kidney donation.

See slide below:

KPD costs

 

According to the kidney paired donation workgroup, which includes Dorry Segev, whom I’ve written about before, the above are fees specifically related to kidney paired donation. My observations/explanations:

 

1. Many would-be kidney transplant recipients have multiple prospective living kidney donors, especially those that publicly solicit (with encouragement from transplant centers). This not something unique to kidney paired donation.

2. NDD = Non-directed donor. The few folks that present themselves as living kidney donors without an intended recipient. The transplant centers tend to use them in chains rather than to facilitate just one transplant – more bang for the buck, I guess? I’ll give them this one.

3. This refers to the fact that while blood type and HLA (antibody) testing only needs to happen once, every possible donor-recipient pair must be checked for sensitivity. In other words, drops of the prospective living kidney donor’s blood must be mixed with the recipient’s blood to see if the recipient’s antibodies will attack it as foreign, signifying the possibility of rejection. This is definitely an added expense

4. Aren’t there already administrative costs to running a hospital? A transplant program? A living donor transplant program? Without some real stats in front of me, I’m not confident running pairs/chains really adds to the burden.

5. This assumes an outside entity will coordinate the entire kidney paired donation program, which would, of course, require employees, infrastructure and the like. Theoretically more than what already exist in the various KPD programs already functioning around the country. Again, debatable.

6. If the kidney donor and recipient are not in the same facility, the kidney must be shipped to the recipient. Except, of course, that deceased donor organs are shipped all the time. And that sometimes one-to-one directed living donor transplants are done at different hospitals too, necessitating a traveling kidney. <- Of course, this is one of the reasons why transplant centers encourage kidney donors to donate at the same center as the recipient. Some of them flat-out lie and tell the LKD it’s not possible to have the surgeries at different hospitals.

7. I’m sorry, what? Surgeons performing the live donor nephrectomy get paid. Are they insinuating that a surgeon should get paid more for participating in a swap/chain? I don’t understand this at all.

8. Yes, because living donors engaged in a traditional directed donation NEVER have expenses related to complications or follow-up.

 

Tune in to Part III for a prominent appearance by #8…

Categories
Ethical Considerations Living Kidney Donor Organ Markets

The Complexities of a Solicited Living Donor

According to various news reports, Dolly Carew posted a profile on a donor-solicitation website. (I’m not naming such website because I think what they do is unethical and I’m not giving them more press. Yes, they charge a fee to the would-be recipients for posting a profile, but that’s not the only reason I find them repulsive). Usually, prospective living kidney donorss scroll through the list of would-be recipients, choosing one to be their beneficiary. Playing God, in other words.

But according to one report, Carew’s sister found Randall on the site’s list of available donors, so he had put himself out there to donate to whoever was willing to have him.

While the details are sketchy (darned privacy and HIPAA laws), a press release from Albert Einstein Medical Center states that Randall was cleared to be a living kidney donor, and offered a chance to donate through a paired donation. Carew and Randall (photo) would be paired with another would-be recipient and prospective donor and the kidneys swapped. Randall’s kidney would be transplanted into the other would-be recipient (a stranger, just as Dolly was a stranger when they hooked up on the website), while the other prospective living donor’s kidney would be transplanted into Dolly. Yes, Carew would still receive a transplant.

While we can’t know exactly why Einstein suggeted this route, kidney swaps and chains in general were created to A. increase the quantity of transplants done and B. improve the quality of transplanted organs. After all, blood type compatibilities prevent transplants from taking place, and HLA matching does affect the longevity of the graft post-transplant. In other words, the better the match, the longer the transplant lasts statistically speaking. Plus, the lower the match, the more anti-rejection meds the recipient must take, which have their own long-term detrimental side effects.

Carew and Randall talked it over and decided not to participate in a paired donation scenario. Randall wanted (and so did Carew), his kidney to be transplanted into her. By now, they had developed a “close relationship” – “bonded”, in their own words, despite his initial willingness to cough up a kidney to just anyone (as evidenced by his registration on the site). Eight days before the scheduled transplant, Einstein Medical Center cancelled the procedure, setting off a firestorm of angry words, speculative news articles and blogs, and really, really uninformed reader comments.

Einstein Medical Center issued the following statement to relevant media outlets:

“Einstein very much wanted to perform a kidney transplant for Dolly Carew and initially offered a paired kidney donation process. In this process, Bob Randall would have been able to donate a kidney through a paired exchange, but Ms. Carew would receive a kidney from a different donor. As he stated, Mr. Randall refused to donate in this way. As we continued the evaluation process, Einstein had reason to believe that Mr. Randall lied during the evaluation process for the donation to Ms. Carew, which precluded him from being her kidney donor. Einstein stands by its decision to postpone Ms. Carew’s transplant surgery. We regret the anguish this situation has caused Ms. Carew and her family, and we are sincere in our desire to help her. It is our hope that she understands we are looking out for her best interests and in no way are discriminating against her, which has been reported.”

Einstein also sent a letter to Bob Randall, which can be read here.

Carew tried another transplant center in the Philly area, but was deniedA previous “Internet connection” transplant in 2007 had resulted in “controversy.”

The public will never know Einstein’s real and detailed reasons for cancelling this surgery. A couple of news articles have hinted (per Carew and Randall) that Randall wasn’t eliminated as a living donor totally, just as Carew’s living donor. I didn’t get that impression at all, but there is always the possibility they are in possession of facts I am not privy to.

That being said, Carew is the single mother of a 9 year old daugther, and multiple articles stated the growing closeness of Randall with that child. An astute commenter revealed that Randall has a history of bad business practices on Ebay, but more importantly is a registered sex offender in Indiana. Could this be the “lie” or “compromising position” Einstein referred to in their missives? If so, the entire drama might’ve been prevented if Randall and Carew had remained strangers, or if Randall had agreed to the Paired Donation in the first place.

PS. The pair has found a hospital in Denver willing to perform the transplant, but Carew doesn’t have the money to make it happen so far from home.