Living donor transplantation in the USA: are there any lessons for Europe?
Guy's and St Thomas' NHS Foundation Trust, Renal Unit, Guy's Hospital, London, UK
Correspondence and offprint requests to: Dr John E. Scoble, Guy's and St Thomas' NHS Foundation Trust, Renal Unit, 6th Floor, New Guy's House, Guy's Hospital, St Thomas' Street, London SE9, UK. Email: john.scoble{at}gstt.nhs.uk
Keywords: living donor transplantation
There is a great disparity between the supply of kidneys available for transplantation and the number of individuals who would benefit from transplantation in both Europe and the USA. Traditionally, cadaveric organ donation has been the bedrock of national transplant programmes and living donation has been seen as a way of increasing transplant rates in countries such as the UK. Historically, living donation has been extremely active in Scandinavian countries but less so in the rest of Europe (Figure 1). Many of us have observed the Scandinavian approach where national programmes have, over many years, become an established part of the medical and social cultures. In a country such as the UK, changing the medical and social cultures is a challenging prospect. However, the experience with living donation in the USA has been different. In 1992, the proportion of living donor transplants in the USA equalled the proportion for the UK in 2002 (Figure 2). In the subsequent 10 years, the rate of living donation in the USA reached almost Scandinavian proportions. The graph shows that there is an 
2-fold higher rate of living kidney donation in the USA than in the UK. United Kingdom Transplant (UKT) and the Kidney Modernisation Project of the Guy's and St Thomas’ Charity felt it would be useful to look at what had brought about this change in the USA and visits were made to two large living donor centres in North America. The University of Minnesota and the Mayo Clinic were chosen because of their active living donor programmes: the two programmes combined perform significantly more than 300 living donor kidney transplants per year. The University of Minnesota has a large and well-established programme, whereas the Mayo Clinic has increased activity from 50 to 200 living donor transplants per year in the past 5 years. We looked at the differences in practice between the USA and the UK. These may not be directly applicable to all parts of Europe. The differences may, though, reflect the changes which have enabled the USA to increase living donation rates from those similar to current activity in many European countries to the Scandinavian levels to which we all aspire.
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Significantly, in a number of areas, there are no differences in practice. In the two units we visited there is no direct Scandinavian-style approach by physicians to relatives of patients with renal failure. There is no financial reimbursement for the donor. If anything, the donor criteria are more restrictive. Neither of the authors could be a living donor in one of the centres because of the fear of passing on ‘mad cow disease’!
The first difference is that living donor transplantation is viewed as the best treatment option for all patients with deteriorating renal function who are approaching renal replacement therapy. This is addressed before discussion of dialysis options. The recent data for pre-emptive transplantation have supported this approach [1,2]. In the UK system, listing for a cadaveric transplant is unlikely to lead to pre-emptive transplantation. In practice, this is only realistically achieved by a transplant from a living donor. The outcome for living donation transplantation in the UK and USA in comparison with that for cadaveric donation shows a large disparity even at 5 years (Figure 3). In the USA, the half life for cadaveric transplantation outcome is quoted as half that for living donation. In one of the units these facts are portrayed to the patient very graphically. The patients are told that if they are blood group B starting dialysis and are put on the transplant waiting list they have an equal chance of dying as they have of being transplanted. This is based upon the 10% per year rate of death on dialysis and the 5 year wait for a blood group B kidney transplant. Statistics in the UK may differ, but the thrust of the argument is the same with very much better outcome for living donation (Figure 3). There seems little controversy that living donor transplantation is the best option for patients and, especially, for those who are pre-dialysis. Unfortunately, in the UK this has been confused with a desire to increase overall numbers of transplants. If the thesis that living donor transplantation is best is correct then it is difficult to understand the differences between European countries. In the UK the imperative has been to increase transplant numbers. In fact, living donation should be put forward as the best clinical option, irrespective of the efficiency of the cadaveric transplant programme. It seems counterintuitive that in those countries in Europe with excellent cadaveric donation rates patients may be less able to receive the best option, living donation (Figure 1).
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The second major difference in the USA is the approach to recipient comorbidity. For example, there are more-relaxed criteria for recipient body mass index (BMI). In the UK, a BMI of 30 or greater is seen as a relative or absolute contraindication to transplantation. In the USA, this issue is seen as less important when compared with the benefit for the recipient of a living donor kidney transplant [2]. Living donor transplantation is seen as the best option for high-risk recipients. Patients with cardiac ejection fractions of <25% have been transplanted from living donor transplants, whereas in the UK these individuals would not be considered as potential recipients. It is salutary to observe that such patients have a very high mortality in both countries on dialysis treatment.
The third major difference is that living donor transplantation in the USA is not geographically constrained. It is routine for recipients and donors to travel to a unit that is not local to them for transplantation. The major units in the USA are often supported by significant hotel capacity adjacent to the hospital. The rate of cadaveric transplantation in the USA is relatively stable. An active kidney transplant programme needs living donor activity to support a large clinical team. It has been suggested that in the USA it would be difficult to sustain a large kidney transplant programme with cadaveric transplantation alone. This competitive element is not present in the UK. Laparoscopic donor surgery is now widely used in the USA. Surgical trainees in transplantation in the institutions visited had never have seen an open donor nephrectomy! Laparoscopic donation has been introduced in the UK, but is not widespread in this country or across Europe. There are conflicting views as to whether the increase in living donation would have occurred in the USA without laparoscopic surgery, but it is universally agreed that a programme which does not offer this option would not be viable in the USA. In terms of resource, the inpatient stay of 36 h for a donor increases effective utilization of available beds. Two living donors can be treated per hospital bed per week. In the UK for open nephrectomy, bed occupancy is nearer one patient per bed per week. In the absence of a donor reimbursement programme in the USA, laparoscopic donation may sway individuals to donate. The ability to return to work earlier than with open surgery may be a significant economic advantage to the individual.
The fourth major issue is the relationship between donor and recipient. In the UK, donation from adult child to parent is uncommon. The experience of the Scandinavian programmes has been primarily first-degree relatives. However, spousal and non-spousal unrelated relationships are an increasing source. Figure 4 shows the changes in the USA of the relationships between donors and recipients over the last 10 years. In the UK, some of these relationships would not be permitted within the current legal framework. The Unrelated Live Transplant Regulatory Authority (ULTRA) in the UK authorizes all proposed living donor transplants between non-genetically related donor/recipient pairs. This applies to married couples, as ULTRA has to establish an emotional as well as a legal relationship between the two parties in order to authorize the donation to proceed. In the USA, each programme has a hospital ethics committee that considers these issues in the same way as research proposals are reviewed by local research ethics committees in the UK. Relationships such as worshipping at the same religious institution or working together are common between recipient and donor. Whilst the legal framework in the UK is currently under review and is likely to address many of these issues, it will be interesting to see if the guidelines for kidney donation become uniform throughout Europe.
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The fifth issue is that there is clear and effective information for donor and recipient. Centres use locally recorded videos/DVDs posted to potential donors. This means that individual donors have already received the pertinent information about living donation before the first consultation. There is a further advantage in that all potential donors are given the same information including the risks of the procedure. Potential donors are even offered the option of viewing a video of a laparoscopic donor operation!
A sixth issue is in the organization of the transplant process. The recipient costs are met by the relevant authorities in both countries. In the USA, all the donor costs are ascribed to the recipient insurer. In the UK, the tariff charged to the recipient health authority is for the donor kidney operation and single donor assessment. If more than one donor is investigated before successful donation occurs there is often no funding stream to support this in many centres. These costs may be less significant in centres performing a small number of living donor transplants, but are unsustainable for large programmes.
There are also specific initiatives in the USA which may expand the living donor pool. Both centres have a non-directed donor (altruistic stranger) donation programme. To date this has not been permitted in the UK, although the legislation does not prohibit it. The Mayo Clinic has a blood group (ABO) incompatible donation programme. In practice, neither leads to large numbers of additional transplants, but they signal a willingness to adopt innovative regimes to maximise patient benefit.
There is a last but controversial difference. There is no formal follow-up process for donors in the USA. This has been established in the UK with a National Donor Registry. In the USA, the funding for follow-up medical review is not sponsored by the insurers of either recipient or donor. The authors’ view is that this is an area where practice in Europe is in advance of that in the USA.
From our observations in the USA, the overwhelming impression is that if a living donor transplant is seen as beneficial for the recipient it should proceed. This is provided that informed and valid consent is given freely by both donor and recipient. The lessons that we might learn from the USA are how to achieve the transformation of a living donor rate which was similar to that which exists in the UK to one approaching Scandinavian proportions. The efficacy of living donation is proven. The statistics published by national programmes are in terms of overall numbers of transplants. If instead, the currency was ‘years off dialysis treatment per transplant’, then significantly more effort might be put into living donor transplantation. If we put ourselves in the position of the patients with deteriorating renal function we would endorse this approach. If this is adopted, significantly more patients will benefit from the advantages of a living donor transplant, but more recipients will die with a functioning graft than those who receive cadaveric kidneys. Historically, this has been seen as a failure, but it should be regarded as a success if it offers the best possible option for the patient.
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Acknowledgments |
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This investigation was supported by the Kidney Modernisation Project funded by the Guy's and St Thomas’ Charity. A full report appears on the United Kingdom Transplant web site (www.uktransplant.org.uk).
Conflict of interest statement. Both authors are employed by a medical institution with a large living donor programme.
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References |
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 Top References |
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- Mange KC, Joffe MM, Feldman HI. Effect of the use or nonuse of long-term dialysis on the subsequent survival of renal transplants from living donors. New Engl J Med 2001; 344: 726–731
[Abstract/Free Full Text] - Meier-Kriesche HU, Kaplan B. Waiting time on dialysis as the strongest modifiable risk factor from renal transplant outcomes. Transplantation 2002; 74: 1377–1381[CrossRef][ISI][Medline]
- Meier-Kriesche HU, Arndorfer JA, Kaplan B. The impact of body mass index on renal transplant outcomes: a significant independent risk factor for graft failure and patient death. Transplantation 2002; 73: 70–74[CrossRef][ISI][Medline]
- OPTN/SRTR 2003 Annual Report
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