Categories
Living Donor Protections Living Donor Research Living Donor Risks

Latest KDIGO Guidelines for Living Kidney Donors

Before reading the linked article, remember that many aspects of living donor evaluation, care and consequences have never been adequately documented or studied. So, those very real issues won’t be included or considered (the authors admit as much in their abstract), which results in yet *another* incomplete and tragically flawed guidance document.

 

Why bother posting it? Well, because it’s important to see if any progress has been made at all. Plus, prospective living donors should be aware of what to expect from their transplant centers.

Here you go: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5540357/

 

Keep in mind that transplant centers, essentially, make up their own rules in terms of what is, and isn’t, an acceptable living donor. Theoretically, a potential LKD could receive a much higher standard of care at one center as opposed to another. Frankly, I find that scary as hell.

 

 

Categories
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
OPTN Transplant Wait List

Transplant Wait List Watch 2016 #3

OPTN 8-11-2016As of 10:31 am on August 11, 2016, OPTN says there are 77,358 folks on the active US transplant wait list.

That’s a .33% decrease since May 10, 2016, and a 6.95% increase since this project began on April 19, 2011.

 

<- By using the larger statistic, OPTN, the government and the media are inflating the true wait list by 35.53%! 

 

Today, there are 107,290 kidney wait list registrations (active & inactive) and 99,387 candidates for a total of 7903 multiple listings (folks registered at more than one transplant center).*

 

May 10, 2016: 108,046 registrants and 100,102 candidates for 7944 multiple listings.

September 21, 2014108,989 kidney wait list registrations and 101,244 candidates, for 7745 multiple listings.

 

Kidney wait list registrants have decreased 1.55% since September 21, 2014. .

Kidney wait list candidates have decreased 1.83% since  September 21, 2014.

 

14.424 kidney wait list registrants have undergone at least one prior transplant. 13.44% of registrants.

13,109 kidney wait list candidates have undergone at least one prior transplant. 13.19% of candidates.

 

May 10, 2016: 14,601 kidney wait list registrants have undergone at least one prior transplant (compared with 16,054 on 9-21-2014. 14.7%) – 13.5%

13,252 kidney wait list candidates have undergone at least one prior transplant (compared with 14,493 on 9-21-2014. 14.3%) – 13.2%

 

Prior check-ins:

May 10, 2016: 77,617
March 18, 2016: 78,104
October 19, 2015: 79,052
August 23, 2011: 72,318
July 19, 2015: 78,296
May 19, 2015: 79,134.
April 9, 2015: 78,196
March 10, 2015: 78,012.
December 26, 2014: 79,870.
September 21, 2014: 79,127.
March 18, 2013: 74, 758.
January 20, 2013: 74,352.
November 9, 2012: 74,558
August 11, 2012: 73,104
June 24, 2012: 73,146
May 11, 2012: 73,141
January 30, 2012: 72,428
December 29, 2011: 72,656
November 28, 2011: 72,625
October 18, 2011: 72,642
Aug 4, 2011: 72,400
July 20, 2011: 72,345
July 10, 2011: 72,360
July 5, 2011: 72,319
May 23, 2011: 72,298
May 11, 2011: 72,244
April 29, 2011: 72,330

 

*Click on Data -> View Data Reports on OPTN’s menu. Then “National Data”. Category “wait list”. “overall by organ” Compare “Registrations” with “Candidates” to determine multiple listings.

 

**Back on that “National Data” screen. Choose “Organ by Previous Transplant”.

Categories
Liver Donor Living Donor Research Living Donor Risks

Liver Regeneration in Living Donors

The authors examined the liver function and liver volume of 91 right liver lobe donors.

Within a year of donating, 96% had regained full liver function but only 85% had full pre-donation liver volume.

 

Unfortunately, these results say nothing about the long term risk of scarring (cirrhosis) or otherwise.

 
Duclos J, Bhangui P, Salloum C, Andreani P, Saliba F, Ichai P, Elmaleh A, Castaing D, & Azoulay D (2016). Ad Integrum Functional and Volumetric Recovery in Right Lobe Living Donors: Is It Really Complete 1 Year After Donor Hepatectomy? American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons, 16 (1), 143-56 PMID: 26280997

Categories
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.