Cash for kidneys might not necessarily be unethical

Meeting the demand for kidney transplants is a big problem worldwide. In the UK, for example, only 18% of patients waiting on the kidney transplant list and 28% on kidney/pancreas transplant list received a transplant during 2008-09.

Donations from living people only made up 37% of the total UK kidney transplant programme in the same period, and as such this approach represents a key method by which to increase the number of organs available.

But how do you convince someone to just give away a kidney?  One very controversial way is to pay donors. Given that kidneys from living donors work so much better than those from deceased donors, even giving donors pretty large payments (for example, $90,000/£58,600) is thought to be a cost-effective way to increase the supply of kidneys available for transplantation.

Unsurprisingly, this approach hasn’t really got off the ground because people are worried about donors blithely selling a kidney without adequately weighing up the risks just to get their hands on some “easy money” or payment disproportionally luring poorer donors. Also, there’s a chance that payments may dissuade altruistic donation or cause potential altruistic donors to request financial compensation.

A study of a hypothetical regulated US market for kidneys has addressed all three of these questions and concluded that “theoretical concerns about paying persons for living kidney donation are not corroborated by empirical evidence.”

The authors surveyed 342 commuters on regional rail and urban trolley lines in Philadelphia County using 12 fictional scenarios in which the risk of subsequent kidney failure in the donor (0.1%, 1%, or 10%), the payment ($0, $10 000, or $100 000), and the recipient of the kidney (either a close family member or the next eligible patient on the waiting list) were varied. Participants responded to each scenario by stating their willingness to donate a kidney on a five-point scale ranging from “definitely would not donate” to “definitely would donate.”

As would be expected, people were more willing to donate to a family member than to a stranger. Lower risk and higher payment also encouraged donation, in particular when the scenario covered donating to a stranger.

More interestingly, incremental household income affected willingness to donate independent of payment – people with a household income of $20,000 a year or less were much more likely to donate than those who earned $100,000 or more. As such, “poorer persons may contribute disproportionately to the supply of organs with or without payment.”

The promise of hard cash didn’t affect people’s perception of the risk involved in living kidney donation: “the magnitude of reductions in willingness to donate associated with increased risk for renal failure was virtually identical across payment levels.” And the effect of a bigger paycheck on willingness to donate was the same across all income strata.

Finally, the introduction of payment for organs did not reduce the level of altruistic donation. “We found no evidence that any of the three main concerns with a regulated system of payments for living kidney donation would manifest if such a market were established,” the authors conclude.

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Halpern SD et al. (2010) Regulated payments for living kidney donation: an empirical assessment of the ethical concerns. Annals of Internal Medicine 152 (6): 358-65. PMID: 20231566

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Make it a DIET coke break, for the sake of your kidneys

Diet coke breakNew research published in PLoS One has shown that drinking two or more fizzy drinks a day can double a woman’s chance of developing signs of kidney disease – but only if she drinks full-sugar sodas.

David A Shoham and colleagues studied data from more than 9,000 individuals in the population-based National Health and Nutrition Examination Survey (1999–2004). They found that women who drank two or more cans of soda per day were nearly twice as likely to develop early signs of kidney disease compared with women who consumed fewer sugary soft drinks. Women who drank diet soda were not at increased risk of kidney disease, nor were men.

The rise in diabetes, obesity and kidney disease in the US has paralleled an increase in the use of high fructose corn syrup in American food. High fructose corn syrup is used in particular as a cheap way to sweeten fizzy drinks; thus, the authors investigated whether consumption of soft drinks is associated with albuminuria, a sensitive marker of early kidney damage.

In total, 11% of the sample population were found to have albumnuria, and 17% of the study group drank two or more sugary soft drinks per day. Individuals who drank more than two fizzy drinks a day were 40% more likely to have albuminuria than were participants with a more moderate intake of soda. Consumption of diet soda, however, was not associated with albuminura.

When the authors broke down their results by gender, they found that women who reported drinking two or more sodas in the previous 24 hours were 1.86 times more likely to have albuminuria than were women who drank less soda. Drinking fizzy drinks had no significant effect on the risk of albuminuria in men.

An analysis of type of soda showed that consumption of sugary non-colas was most strongly linked with albuminuria, whereas sugary cola and diet cola and non-cola drinks showed no such association.

The authors conclude that the correlation between drinking sugary sodas and albuminuria indicates that high fructose corn syrup is in part responsible for the increase in kidney disease in the US. According to the National Kidney Foundation, about 26 million American adults have chronic kidney disease.

Dr Shoham, however, has said. “I don’t think there is anything demonic about high fructose corn syrup per se … People are consuming too much sugar. The problem with high fructose corn syrup is that it contributes to over consumption. It’s cheap, it has a long shelf life and it allows you to buy a case of soda for less than $10.”
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Shoham DA et al. (2008) Sugary Soda Consumption and Albuminuria: Results from the National Health and Nutrition Examination Survey, 1999–2004 PLoS ONE 3 (10) DOI: 10.1371/journal.pone.0003431

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‘Two for the price of one’ tactic improves outcomes after organ transplantation

A new study of more than a million transplant recipients has found that rejection rates are lower in patients who receive two organs at once than in those who receive a single organ.

The study, published in Annals of Surgery, found that the rejection rates for organs cotransplanted with a donor-specific liver, heart or kidney were significantly lower than those for organs transplanted alone.

It has been known for some time that transplanting a liver with another organ such as a kidney or a section of intestine reduces the likelihood of rejection of the primary organ, leading to the suggestion that liver allografts protect other organs from rejection. Combined liver and kidney transplantation is used in patients with hepatorenal syndrome – in which acute kidney failure occurs as a result of liver cirrhosis or fulminant liver failure – or in patients with end-stage renal disease who also have liver damage as a result hepatitis B or C virus infection. Simultaneous intestine and liver transplantation is used in patients with intestinal failure following the removal of a large section of intestine (e.g. because of a tumor) and end-stage liver disease, which may be due to receiving their meals intravenously following intestine removal (total parenteral nutrition).

The recent study by Rana et al. has revealed that heart and kidney allografts are also immunoprotective and are themselves protected when transplanted with another organ.

The authors searched the United Network for Organ Sharing database – which contains data about every transplant that has taken place in the US since 1986 – and identified all thoracic, kidney, intestine and liver transplant recipients over 18 years old.

In patients who simultaneously received heart and kidney transplants from a single deceased donor, the incidences of renal allograft rejection and cardiac allograft rejection at one year were lower than in patients who received either a heart or a kidney allograft alone. In addition, the rate of rejection-free survival at one year was higher in the combined organ recipients. Likewise, compared with patients who received a single organ, rejection of either organ and rejection-free survival were lower and higher, respectively, in individuals who received combined liver and kidney transplants.

On the other hand, cotransplantation of intestine or pancreas in patients undergoing kidney or liver transplantation did not lower the risk of rejection or improve rejection-free survival.

The authors suggest that combined simultaneous organ transplantation could be used more widely to reduce rejection rates and lower the need for immunosuppression in transplant recipients.
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Rana A et al. (2008) The Combined Organ Effect: Protection Against Rejection? Annals of Surgery 248 (5): 871-879 DOI: 10.1097/SLA.0b013e31817fc2b8

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Chronic kidney disease patients claim to know nothing about their condition

A study by Finkelstein and colleagues published recently in Kidney International has found that as many of a third of patients with chronic kidney disease (CKD) claim to know nothing about their disease or about their treatment options when their kidneys ultimately fail.

CKD encompasses many types of kidney damage and is characterized by the gradual loss of renal function, often with few symptoms bar raised blood pressure and nonspecific signs such as fatigue and reduced appetite. CKD is graded on a 5-point scale, with stage 1 being slightly diminished kidney function and stage 5 being established kidney failure. Despite treatment many cases progress, in some instances to the point of kidney failure, otherwise known as end-stage renal disease. Once a patient reaches end-stage renal disease, they have to regularly undergo life-saving treatment that mimics the roles performed by their now defunct kidneys. Some such treatments include dialysis and kidney transplantation.

In the study by Finkelstein et al., 676 patients with stage 3–5 CKD who had been receiving nephrology care for about 5 years completed a questionnaire to assess their knowledge of CKD and of renal replacement therapies. Only 23% of patients reported having a great deal or extensive knowledge about their CKD and 35% reported having very limited or no knowledge. When questioned about their knowledge of renal replacement therapy, 35% of patients reported knowing nothing about any end-stage renal disease treatment modality.

Various studies have shown that decent education about CKD can delay the onset renal failure, increase the likelihood of the patient choosing a less costly home-based therapy rather than elaborate hospital-based dialysis, and improve outcomes of patients after the start of dialysis.

The findings of the Finkelstein et al. study indicate that despite receiving specialized kidney care for several years, many patients with CKD feel they have little knowledge of their disease and are, therefore, ill equipped to make treatment decisions. In an editorial accompanying the research, Chester Fox and Linda Kohn of University at Buffalo, New York, suggest that, “A multidisciplinary team – including dieticians, social workers, nurse educators, and pharmacists – and access to transplant surgeons are necessary to improve patient knowledge and understanding about progression of CKD and treatment options.”

Finkelstein FO et al. (2008). Perceived knowledge among patients cared for by nephrologists about chronic kidney disease and end-stage renal disease therapies Kidney International 74 (9): 1178-1184 DOI: 10.1038/ki.2008.376
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Another recent study, this time published in Archives of Internal Medicine, measured whether the introduction of early detection guidelines had improved the number of patients with CKD who were aware that they had the disease. The authors specifically asked 2,992 patients with stage 1-4 CKD whether or not they had been told that they had weak or failing kidneys. Between 1999 and 2004, awareness improved only in patients with stage 3 CKD. Patients with risk factors for CKD such as diabetes or hypertension were most likely to be aware of their disease.

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Herbal remedies and acute kidney disease

Nature Clinical Practice Nephrology has recently published a review by Luyckx and Naicker highlighting the link between traditional medicines and kidney injury.

Traditional and herbal remedies are widely used worldwide, with as many as 80% of people in some populations using such treatments. The use of herbal remedies becoming increasing common in Western countries, as shown by a 2002 survey that found that 36% of people in the US use alternative or complementary medicines.

Herbal therapies all pass through the kidney on their way out of the body; consequently, many have been associated with acute kidney disease. Luyckx and Naicker report that “folk remedies account for up to 35% of cases of acute kidney injury and mortality rates for acute kidney injury range from 24% to 75%.”

The herbal remedies most commonly used in the US include echinacea, which is used as an immunostimulant, and St John’s wort, which is used to treat depression among other things. Echinacea, however, has been associated with acute kidney injury and St John’s Wort with kidney transplant rejection.

Various factors besides direct toxicity of the agent can contribute to kidney injury, such as contamination of the preparation or incorrect administration. In addition, the type of nephrotoxicity experienced by an individual taking a herbal remedy is dependent on which part of the kidney is affected, and the authors discuss these factors in more detail in their review.

Luyckx and Naicker do point out that the effects of herbal remedies are something of an unknown quantity; for example, some studies have shown that cranberry decreases the risk of kidney stones, whereas other studies find that cranberry increases this risk.

The review concludes by saying “The incidence and prevalence of acute kidney injury associated with the use of traditional remedies is unknown and probably varies greatly from place to place. Since the use of traditional remedies is common worldwide, it is probably safe to assume that the incidence of acute kidney injury is not high. Individual morbidity, however, can be considerable.”

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