Kidney transplant donor sources - expanding the options and the debate. Originally posted for World Kidney Day, March 12 2009

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Kidney transplant donor sources - expanding the options and the debate

I can’t help but noticing that World Kidney Day came and went last week, and two items in particular caught my attention. In the New England Journal of Medicine (March 12, 2009), Rees and colleagues described a “chain of 10 kidney transplants initiated by a single altruistic donor (i.e. a donor without a designated recipient)” (1). This single act of generosity provoked a chain reaction whereby patients with willing but incompatible donors “swapped “with others in "paired transplant programs", the end-result being 10 kidney transplants over a period of 8 months. According to the authors of the report, their goal was to “highlight the potential of this strategy” of living donor recruitment. 

Two days earlier, our “national newspaper” ran a lengthy opinion piece from Sally Satel of the American Enterprise Institute entitled Kidney for sale: Let's legally reward the donor (2), in defense of legalizing organ sales. Ms. Satel made her point in a cogent and well-argued fashion, and I urge you to read it in its entirety at the link below.

As a pediatric nephrologist, I obviously have a keen interest in the plight of those described Ms. Satel. In 2006, the last year for which statistics are available, 1150 kidney transplants were performed in Canada, even though there were 20,465 patients on dialysis, with 5321 new cases added that year alone. As a result, the average wait for a cadaveric kidney was 3 ½ years, and 70 patients died that year while waiting. These numbers will continue to increase as our population ages.
Children do particularly poorly on dialysis, and transplantation is clearly their treatment of choice. Fortunately, most have loving families, and living donors are an option, accounting for 53% of first-time pediatric transplants across the country in the last decade. So I am clearly not opposed to the use of living donors. Nevertheless, I find Ms. Satels argument seriously flawed and dangerous. At one time, success rates were considerably higher with live donors, but modern anti-rejection therapy has closed this gap, which should have reduced the pressure on these donors. Despite this, she argues for upping the ante. Even without the financial element, the decision to donate a kidney is never uncoerced. How can it be, when someone’s life and well-being are at stake? And while I am the first to assure prospective donors that they can live long, healthy lives with only a single kidney, their decision is not risk-free. They will always be in danger of losing their kidney in an auto accident or if they develop kidney disease, hypertension, or diabetes. And even in experienced centers with rigorous screening, operative fatalities will still occur, though fortunately rarely (<= 1%).
What troubles me is that Ms. Satel did not promote measures to increase rates of cadaveric donation. Currently in this country, even if an individual has ‘opted in’ by signing a donor card, their wishes are as often as not overruled by grieving relatives, which could be remedied. Currently, there is a huge variability in donation rates across the country, ranging from 6 per million population in Manitoba to 18 in Quebec, and I see no reason why we shouldn’t achieve a national donation rate that at least matches that in the latter province. France and Spain have implemented ‘presumed-consent’ programs, where organs are obtained from cadaveric donors unless they have signed the equivalent of a non-donor card. This allows those who object to donation on religious or moral grounds to do so. In France and Spain, the donors’ family continues to have the final word, and their donor rates are 22.2 and 35.1 per million population, respectively. In contrast, the UK stands at 12.7 and Canada at 13.1. Presumed consent legislation was introduced in the UK in Nov 2008, and the current debate is vigorous and heated. Not wishing to oversimplify this debate, it is certainly clear that many factors besides the form of consent influence these rates, including ICU care, motor vehicle safety, local mores, and trained teams of ‘consent specialists’ to deal with grieving families. If we hope to effectively promote cadaveric donation, we need to better understand these factors, which makes them fertile ground for active research.

Given the disparity in cadaveric donation rates, it seems obvious that we should optimize these sources before contemplating the proposed free market solution. As the report by Rees et al further illustrates, other innovative programs also offer hope, such as ‘paired organ transplantation’, where families with willing but incompatible donors can swap with others, so that both can benefit. First proposed in a 1997 New England Journal of Medicine article, numerous variations have been successful, including the that described in the current NEJM. The point is that we are not limited to a single solution.

The problem with financial incentives are obvious and discussed by Ms. Satel, but one needn’t look far to see how evil ‘medical tourism’ has already become, as patients from largely developed nations (often those with cultural reluctance toward cadaveric donation) descend on the developing world in search of organs. The WHO has documented the sad reality of villages in Pakistan where half the population have sold a kidney for a pittance of a few hundred dollars, and forced donation is not unknown. According to the international monitoring agency Organ Watch, illegal transplants number in the thousands each year, and criminal prosecutions across the world have made clear how ugly this sordid business can be.

While I understand her argument that such exploitation is already a fact, which would be better off regulated, there is a limit to this logic. Gary Becker - Nobel Laureate in Economics - has established the ‘market price’ of a live kidney at $45,000 (assuming a 1% operative mortality, a 5% decrease in quality of life, a $7000 loss of income during convalescence, and related factors). If true, why should illegal trafficking in organs subside when there is still ‘value’ to be had on the black market? Believe me, I am keen to improve the donor situation, and I do believe donors should be compensated for lost income, convalescence and costs incurred in the event of complications. However, I believe there are measures to consider before adopting the program proposed by Ms. Satel. My fear is that unless we respond to her scheme with well-researched, definitive studies into practical and effective measures to promote alternate sources, demographic pressures may lead us to a deal with the devil that will be very difficult to undo, with consequences that affect us all, no matter where we reside.

Atul Sharma MD, FRCP(C)
Pediatric Nephrologist,
McGill University (Ret)

1) Rees et al, A Nonsimultaneous, Extended, Altruistic-Donor Chain, NEJM Mar 12 2009.

2) Satel, Kidney for sale: Let's legally reward the donor. March 10 2009.

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