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Saudi Journal of Kidney Diseases and Transplantation
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EDITORIAL Table of Contents   
Year : 1999  |  Volume : 10  |  Issue : 4  |  Page : 464-469
Kidney Donation from Unrelated Living Donors

UCLA tissue Typing Laboratory and UNOS Scientific Renal Transplant Registry, USA

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How to cite this article:
Cecka J M. Kidney Donation from Unrelated Living Donors. Saudi J Kidney Dis Transpl 1999;10:464-9

How to cite this URL:
Cecka J M. Kidney Donation from Unrelated Living Donors. Saudi J Kidney Dis Transpl [serial online] 1999 [cited 2020 Jun 2];10:464-9. Available from: http://www.sjkdt.org/text.asp?1999/10/4/464/37203
Several years ago, an elderly couple went to a major transplant center in the United States carrying an article from the New England Journal of Medicine. [1] The article described the unexpectedly high success rates of kidney transplants between spouses. They asked whether it would be possible to have this procedure that they had read about. The husband was 76 years old and had been on dialysis for many years. The wife was also in her 70's and had been a caregiver for many years. Although the gentleman could have joined the waiting list for a cadaver kidney, the average waiting time was already more than three years. After a careful evaluation of both donor and recipient, the man received his wife's kidney and they have enjoyed traveling together and their independence from dialysis since then.

This true story illustrates a growing trend in renal transplantation. With current success rates approaching 90% at one year in many countries, the demand for transplant has grown for beyond that which can be satisfied with cadaver kidneys. The result is often a very long wait a relative who is willing to donate one of their kidneys, the wait for a cadaver kidney can e avoided. Dialysis and the additional problems of chronic disease can be avoided, [2] and, in most cases, a superior outcome can be anticipated. For patients who do not have a medically suitable or willing relative, now there are other options, although today these may not be widely available. Kidney transplantation from a living donor who is not related to the patient- a spouse, a foster parent to an adopted child, a friend who shares a strong emotional bond-can be performed with a good expectation of long­term success.

There has been great variability in the acceptance of living kidney donors in different parts of world, and even when living donors are encouraged, few unrelated donors have been accepted. [3] In many Asian countries, nearly all transplants have been performed using living donors because brain death was not or has only recently been recognized. In Germany and Austria, very few living donor transplants have been performed. In the US, living donations, which had accounted for about 20% of all US transplants for many years have increased by nearly 50% over the past five years. The most rapidly growing source of living donor kidneys has been among donors who are not genetically related to the patient. The number of unrelated donor transplants in the US has increased six fold over the past five years. The cadaver organ shortage has challenged the resistance to living donations and expanded beyond first­degree relatives as potential donors

Where both cadaveric and living donor transplants have been performed, it is well recognized that living donor kidneys result in better long-term success rates than cadaveric kidney transplants. Even with modern immunosuppression, living donor kidneys provide a clear long-term survival advantage over cadaver kidneys. When there is a willing living donor, the surgery can be scheduled to occur at an optimal time for both donor and recipient, the potential donor can be carefully evaluated for renal function and anatomy and immunosuppression can be initiated prior to surgery. In addition to the logistical advantages in planning the transplant, kidneys from relatives are more immunologically compatible when matched for one or both HLA haplotypes and express many of the same inherited minor histocimpatibility antigens, as well. Even for some physicians who do not advocate living donation, the survival advantage of a well-matched kidney transplant from a relative has justified the use of living donors. But by the same reasoning, the expectation that kidneys from genetically unrelated individuals or from siblings who do not share at least one HLA chromosome would yield poor results has discouraged the use of living donors outside the immediate family. Now there is growing evidence to suggest that the HLA differences can be overcome and that transplants between spouses and from other genetically unrelated but emotionally linked donors can be very successful.

For those actively involved in transplantation, this information is not new. But for those on the periphery-community nephrologists and dialysis centers-the recent rapid advances in transplantation may have gone largely unrecognized. Some physicians who trained more than 15 years ago may still regard transplantation as a high-risk experimental procedure with poor results. Those physicians who do not refer patients who might benefit from transplantation must be kept abreast of the current status of transplantation. Patients should not have to read medical journals or search the Internet for information that ought to be provided by their doctors.

The classical objections to living donations also need to be updated. There are three major concerns about transplanting kidneys from living donors in general and for some these take on added importance when considering donors who are genetically unrelated to the patient:

  1. Concerns that healthy individuals should risk major surgery with no benefit to themselves.
  2. Concerns that the results of HLA incompatible transplants would be inferior.
  3. Concerns that the door to paying individuals for their kidneys would be opened.

Although each of these concerns is still valid, their gravity has changed in recent years.

   Risk of surgery to an otherwise healthy individual Top

The risks of general anesthesia and surgery are an important concern, regardless of the relationship between the living donor and recipient and should be discussed with any potential donor. Fortunately, the incidence of mortality associated with kidney donation has been relatively low, 0.03-0.1% according to surveys and single center reviews. [4],[5],[6] Accor­ding to this estimate, three deaths in 10,000 donations might be expected. However, most deaths that were reported are now rather historical and despite the increasing use of living donors (more than 25,000 in the US during the past 10 years) no recent deaths have been reported in the US. If there have been no recent deaths, the risk of mortality today should be revised lower. Surgical complications have been reported more frequently (8-48%), and some have been serious. [5] However, the risks of complications associated with these surgeries today also may be even lower. [7],[8]

In addition to the risks of the surgery, there remain questions regarding the long-term outcome for uninephrectomized donors. [9],[10] Scattered reports of donors who develop end­stage renal disease and require dialysis or transplantation occasionally surface. [10] The United Network of organ Sharing (UNOS), which operates the organ procurement and transplantation, network for the US now will provide an advantage to anyone who has donated a kidney and later needs a transplant so that they will be transplanted more quickly. Unfortunately there are few thorough studies of the frequency of long-term complications among kidney donors and such studies should be performed by regular follow-up of all living donors.

The donor surgery can be socially and economically disruptive as well, requiring hospitalization and recovery time away from work. But other advances could reduce these disincentives to donation. Hospitalization prior to the donor surgery is probably unnecessary. [7],[11] Laproscopic surgery has been used to remove the donor kidney in a limited number of cases [12] and although this approach is technically demanding, proponents maintain that it will reduce recovery time and consequently the impact of the surgery on the donor.

There can benefits that arise during evaluation to a potential donor. Problems have been detected early and corrected because a potential donor was being evaluated. [5] The donation experience is generally favorable. According to surveys that have been conducted, fewer than 5% of living donors say they would not donate again and only 10% are uncertain. [13] An informal survey of spouses recently noted that 99% of 176 spouses who had donated would advise others to donate. [14] Thus, a great majority of donors supports transplantation and feels gratified that they were given an opportunity to help a family member, especially a spouse.

   Results of unrelated donor transplants Top

The results of transplants from living unrelated donors have been very encouraging. From a few pioneering transplant centers that were willing to perform these transplants, including many in the Middle Eastern countries [15],[16],[17] the early results were as good as or better than grafts from cadaver donors. The results of more than 2,000 unrelated donor transplants performed in the United States since 1991 have been similar to the results of grafts from parents or other relatives sharing one HLA haplotype as shown in [Figure - 1]. The results of living­unrelated donor transplants were as good as those that were achieved with HLA- matched cadaveric kidneys, although 90% had three or more HLA antigens mismatched. The half-life (T1/2) represents the number of years before half of those grafts surviving the first year will have failed. This measure of long-term unrelated donor grafts survival was also similar to that of one haplotype matched related donor grafts. Recent reports from Korea, [18],[19] Brazil [20] and Norway 8 also suggest that the results of grafts from relatives who shared no HLA haplotypes with the patient and those from spouses and other emotionally related donors were similar to those from more histocompatible relatives. The Collaborative Transplant Study [21] has reported that the results of unrelated transplants are more similar to those for cadaveric grafts and that the level of HLA mismatches has an important effect on the outcome.

The differences reported among centers and between large registries of transplant data probably reflect different attitudes about living unrelated donors or even living donors in general. The US transplant centers have been very selective. Few patients who received living unrelated grafts were diabetic, were sensitized or had previous transplants that were rejected. The genetic disparity of the unrelated donor results in more early rejections and the different centers' skill in recognizing and reversing these complications probably contributes to differing success rates among centers. Patient survival rates tend to be higher among recipients of living donor grafts suggesting that these patients are healthier on average than those who receive cadaver kidneys.

More than two-thirds of the unrelated donors in the US were spouse and wives donated 67% of the spousal kidneys. The disproportionate number of wives donating to their husbands might reflect cultural biases, but sensitization or concern about sensitization as a result of pregnancies may play a key role as well. Blood transfusions given before transplanta­tion seem to improve the results of spousal transplants [18],[22] but wives with prior pregnancies are frequently excluded from receiving their husband's kidney by this approach.

   Commercialization and coercion Top

If the results of transplants from unrelated living donors are excellent and the danger to the donor is minimal, then the remaining concerns are ethical. Whenever there is a living donor there must be some concern about the donor's motivation. The transplant community sanctions transplants between blood relatives because a strong bond perhaps even an obligation is perceived to exist between family members. Still it is difficult to exclude the possibility of coercion or of payments exchanged between family members. Often these may be covert and denied by the donor. Psychological pressure may be great even within the family. Identifying one sibling as HLA identical and therefore the optimum choice as a donor may place enormous pressure on that individual.

Although the prevailing reaction to the possibility of buying kidneys has been extremely negative and the experience of subsequently treating recipients of bought kidneys who were transplanted in India has also been very negative, [23],[24],[25] the International Forum for Transplant Ethics has recently decided to reopen the debate. [26] Their argument is that regulation of trade in organs may be preferable to prohibition. Such a view might diminish concerns for transplant professional that they could be deceived into performing an illegal transplant.

While there is clearly some responsibility for the physicians and the transplant team to prevent unwilling or overtly exploited donors, there is a risk of paternalism in too much oversight. The key may be to consider the relationship between the donor and recipient. The unexpectedly high graft survival rates reported for transplant between spouses may result from the fact that the donor and recipient live together and both have a very personal interest in the fate of the transplanted kidney. Spouses may be much closer than the patient's biological family. When the spouse is also the primary caregiver, there is a strong motivation to help the sick partner. Thus, the donor may benefit from donation and from a successful kidney transplant, as does the recipient. Furthermore, the patient is assured of support and medical compliance is usually very high when spouse donate.

Several years ago, Professor Daar proposed a "donor charter, [27] which eloquently outlined his own support for encouraging the use of living donors, both related and unrelated. In his charter, he suggested 10 points that should guide dialysis and transplant centers in encouraging living donations. Whether or not one agrees with each point in his charter, it remains a timely and important document because it recognizes the critical role of the transplant centers staff and the dialysis center staff in educating and informing potential recipients about transplantation.

Increased living donation should not be the final goal. Efforts directed to increasing the availability of cadaver organs or seeking other options still must be aggressively pursued. However, for patients today who may need to wait for a suitable cadaveric organ, highly motivated living-unrelated kidney donors, and particularly spouses should be informed of the option to donate and their altruism should not be discouraged.

   References Top

1.Terasaki PI, Ceeka JM, Gjertson DW, Takemoto S. High survival rates of kidney transplants from spousal and living unrelated donors. N Engl J Med 1995;333:333-6.  Back to cited text no. 1    
2.John AG, Rao M, Jacob CK. Peemptive live-related renal transplantation. Transplantation 1998;66:204-9.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Ceeka JM. In sickness and in health-high success rates of kidney transplants between spouses. Transplant Rev 1996;10:216-24.  Back to cited text no. 3    
4.Najarian JS, Chaves BM, McHugh LE, Matas AJ. 20 years or more of follow-up of living kidney donors. Lancet 1992;340:870-10.  Back to cited text no. 4    
5.Jones J, Payne WD, Matas AJ. The living donor-risks, benefits and related concerns. Transplant Rev 1993;7:115-28.  Back to cited text no. 5    
6.Taghavi R. Does kidney donation threaten the quality of life of the donor? Transplant Proc 1995;27:2595-6.  Back to cited text no. 6  [PUBMED]  
7.Jones KW, Peters TG, Charlton RK, et al. Current issues in living donor nephrectomy. Clin Transplant 1997;11:505-10.  Back to cited text no. 7  [PUBMED]  
8.Foss A, Leivestad T, Brekke IB, et al. Unrelated living donors in 141 kidney transplantations: a one-center study. Transplantation 1998;66:49-52.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.D'Almeida P, Keitel E, Bittar A, et al. Long-term evaluation of kidney donors. Transplant Proc 1996;28:93-4.  Back to cited text no. 9  [PUBMED]  
10.Nasseri A, Simforoosh N, Amiransari B, Forootan K, Gol S. The effect of kidney donation on total renal function. Transplant Proc 1995;27:2592.  Back to cited text no. 10    
11.Friedman AL, Goker O, Dennis KN, et al. Must living renal donors be hospitalized over night prior to surgery? Clin Transplantation 1996;10:444-6.  Back to cited text no. 11    
12.Flowers JL, Jacobs S, Cho E, et al. Comparison of open and laproscopic live donor nephrectomy. Ann Surg 1997;226:489-90.  Back to cited text no. 12    
13.Johnson EM, Najrarian JS, Matas AJ. Living kidney donation: donor risks and quality of life. In: JM Cecka, PI Terasaki, Eds. Clinical Transplants 1997. UCLA Tissue Typing Laboratory, Los Angeles 1998;231-40.  Back to cited text no. 13    
14.Terasaki PI, Ceeka JM, Gjertson DW, Cho YW. Spousal and other living renal donor transplants. In: JM Ceeka, PI Terasaki, Eds. Clinical Transplants 1997. UCLA Tissue Typing Laboratory , Loss Angeles 1998;269-84.  Back to cited text no. 14    
15.Simforoosh N, Bassiri A, Amiransari B, Gol S. Living-unrelated renal transplantation. Transplant Proc 1992;24:2421-2.  Back to cited text no. 15    
16.Fazel I. Renal transplantation from living related and unrelated donors. Trasplant Proc 1995;27:2586-7.  Back to cited text no. 16    
17.Haberal M, Velidedeoglu E, Arslan G, Bilgin N, Buyukpamukcu N, Karamehmetoglu M. The effect of DST in kidney transplantation between spouses. Transplant Proc 1995;27:2576.  Back to cited text no. 17    
18.Jin DC, Yoon YS, Kim YS, et al. Factors on graft survival of living donor kidney transplantation in a single center. Clin Transplantation 1996;10:471-7.  Back to cited text no. 18    
19.Park K, Kim SI, Kim Y-S, et al. Results of kidney transplantation from 1979 to 1997 at Yonsei University. In: JM Ceeka, PI Terasaki, Eds. Clinical Transplants 1997, UCLA Tissue Typing Laboratory, Los Angles 1998;149-56.  Back to cited text no. 19    
20.Sesso R, Josephson MA, Ancao MS, Draibe SA, Sigulem D. A retrospective study of kidney transplant recipients from living unrelated donors. J Am Soc Nephrol 1998;9:684-91.  Back to cited text no. 20    
21.Opelz G. HLA compatibility and kidney grafts from unrelated live donors. Collaborative Translpant study. Transplant Proc 1998;30:704-5.  Back to cited text no. 21    
22.Ceeka JM, Terasaki PI. Living donor kidney transplants: superior success rates despite Histoincompatibilities. Transplant Proc 1997;29:203.  Back to cited text no. 22    
23.AI Asfari R, Hadidy S. Yagan S. Results of kidney transplantation from living unrelated donors. Transplant Proc 1995;27:2591.  Back to cited text no. 23    
24.Chaballout A, Said R, Alboghadadly S, Huraib S, Selim H. Living-related, cadaveric and living unrelated donor kidney transplants: a comparison study at King Fahad Hospital, Riyadh. Transplant Proc 1995;27:2775.  Back to cited text no. 24    
25.Commercially motivated renal transplantation: results in 540 patients transplanted in India. The Living Non­related Renal Transplant Study Group. Clin Transplant 1997;11:536-44.  Back to cited text no. 25  [PUBMED]  
26.Radcliffe-Richards J, Daar AS, Guttman RD, et al. The case for allowing kidney sales. International Forum for Transplant Ethics. Lancet 1998;351:1950-2.  Back to cited text no. 26    
27.Daar AS. Living organ donation: time for a donor charter, In: PI Terasaki, JM Ceeka, Eds. Clinical Transplants 1994. UCLA Tissue Typing Laboratory, Los Angles 1995;376-80.  Back to cited text no. 27    

Correspondence Address:
J Michael Cecka
UCLA tissue typing Laboratory, 950 Veteran Avenue, Box 951652, Los Angeles, CA 90095
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