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.

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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Trachea transplants and awful articulation: doing the BMJ podcast

Last week my colleague Sally Carter and I had a go at doing the news roundup for the BMJ podcast.

First, Sally spoke about the passing of the health reform bill in the US and all the BMJ‘s coverage of the legislation itself and the bill’s rocky passage. Then I covered a remarkable news story about a British boy who received fledgling trachea transplant built with his own stem cells that then grew into a fully functioning organ within his body.

I’ve always had trouble with public speaking and being articulate during presentations, so I was very nervous about doing my first podcast.  Despite our countless rehearsals, Sally and I both found it quite hard to simultaneously speak fluently and get all the facts into our segments.  The experience was a lot of fun though and I think the finished product turned out OK.  Have a listen and let me know what you think.

BMJ Podcast 26 March 2010: Variolae Vaccina

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What makes relatives agree to organ donation?

donor-cardThe BMJ has just published an interesting paper on the factors that determine whether family agree to donate the organs of a brain dead relative.

According to the meta-analysis by researchers at the University of Oxford, careful timing and having a transplant coordinator make the request are key factors in whether relatives consent to organ donation.

This time last year, more than 7,500 people in the UK were listed as actively waiting for a transplant.  The biggest barrier to living organ donation is refusal of consent by the relatives of the donor. A 2006 audit of all deaths in nearly 350 intensive care units around the UK found that as many as 41% of relatives refused to allow organ donation.

The authors of the BMJ study analysed 20 observational studies and audits, and identified the following six categories of modifiable factors that apparently influence relatives’ decisions to allow organ donation:

  • Information discussed during the request
  • Perceived quality of care of the donor
  • Understanding of brain stem death
  • Specific timing of the request
  • Setting in which the request is made
  • Approach and expertise of the individual making the request

The most important factor, quite understandably, was whether the request for donation occurred at the same time as the notification of death or testing for brain stem death.  In addition, medical professionals are involved with the request process had a considerable effect on consent rates – a combined approach by hospital staff and coordinators from an organ procurement organisation improved consent, as did the use of race-specific requestors and a dose of common courtesy.

Unsurprisingly, there was a correlation between staff training in organ donation request and donation rates. In fact, the consent rate differed throughout the year in accordance with the training programmes of medical residents.

The fact that the authors of this study were looking at modifiable factors is important – it’s no good looking at whether factors like religion influence the likelihood of relatives consenting to donation as doctors can’t influence such beliefs.  In order to increase the number of people agreeing to donation researchers need to identify elements of the decision making that they can have an effect on.

Targeting these modifiable factors could have a huge effect donation rates and could save lives. The authors point out that “organ donation may be of sufficient benefit to society generally, and to organ recipients specifically, to justify the study and modification of organ donation requests to maximize consent”.

Let’s hope that doctors and hospitals take this information on board and start to approach the families of potential donors with a renewed appreciation of the delicacy of the task.

Simpkin A et al. (2009) Modifiable factors influencing relatives’ decision to offer organ donation: systematic review. BMJ 21 April 2009 DOI: 10.1136/bmj.b991

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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.
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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Weird medical stories vol 1

When searching eTOCs or browsing the web, I can’t help but be drawn to slightly strange or bizarre medical cases. Not the ‘Pregnant man gives birth to a baby girl‘ genre of stories, although I will confess to a morbid fascination, but also disgust, at ‘Urgh look at this freak’ tales.

Given that I’m generally looking at clinical websites or the websites of journals I instead tend to pick out intriguing sounding case studies or clinical trials that have unexpected outcomes. This week’s weird medical story was brought to my attention by the British Medical Journal, which highlighted a case study that suggests that peanut allergy could be be transferred by lung transplantation.

The case, published in the Journal of Heart and Lung Transplantation, is of a middle-aged woman who developed peanut allergy following a lung transplant from a donor who had died of anaphylactic shock after eating a peanut-related food. Although the transplant recipient did not previously have any allergy to peanuts, following the transplant she experienced anaphylactic shock herself and had to steer well clear of nuts.

Interestingly, transfer of food allergies from donor to recipient has been seen in liver transplantation. The phenomenon is thought to be due to either the transfer of IgE antibodies bound to cells within the donor liver or to relate to post-transplant use of the immunosuppressant agent tacrolimus. An instance of allergy transfer following bone marrow transplant also suggests that transfer of IgE antibodies or immunosuppression might be to blame.

The report in the Journal of Heart and Lung transplantation is the first instance of allergy being transferred by lung transplantation, however. As the study authors say, “This case emphasizes the importance of considering donor allergy transfer when caring for all solid-organ transplant recipients.” I wonder if similar cases will start to appear in kidney transplant recipients and so on. Certainly this case could mean that finding an organ donor match could become more complicated, as it seems that potential donors with allergies might need to be struck off the list.

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