NDT Advance Access originally published online on June 8, 2006
Nephrology Dialysis Transplantation 2006 21(7):1764-1765; doi:10.1093/ndt/gfl288
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The case for a fair compensation policy of economic consequences incurred by living kidney donors
Service de Néphrologie, Hôpital de la Pitié, Paris, France
Correspondence and offprint requests to: Claude Jacobs, MD, Service de Néphrologie, Hôpital de la Pitié, 83, Bovlevard de l’Hôpital, 75013 Paris, France. Email: claude.jacobs{at}psl.ap-hop-paris.fr
Keywords: costs; kidney transplantation; living-donor transplantation; reimbursements
Living-donor kidney transplantation (LDKTx) yields the best results of all renal replacement therapies (RRT) in terms of patient survival, but remains frequently underused in many countries. Reasons for this unsatisfactory situation are multifold, among which is the possibly overlooked or underestimated negative financial and/or economic consequences to the donors. This topic is addressed in a comprehensive review by Clarke et al. presented in this issue of the Journal.
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Living-donor kidney transplantation—successes and debates |
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The spectrum of kidney transplantation (Tx) has changed notably in recent years. Data from national/international Tx registries well-demonstrate that, in the last decade, LDKTx has become a major contributor in many countries to the development of kidney Tx as a whole [1–4] with an increasing percentage of non-genetically related donors [1,2,5–7]. In addition, while the 5 year survival rates of kidneys from deceased donors have remained stable over the last decade, those from living donors have improved by about 10% in some countries, being at all times about 15% better than transplants of cadaveric origin [1,5,6]. LDKTx also represents a very favourable condition for increasing the number of pre-emptive Tx, whose advantages are well-documented in terms of better patient and graft survival, quality of life and cost efficiency compared with results achieved in patients having undergone pre-transplant dialysis [8–12].
Nevertheless, serious notes of caution against LDKTx remain quite widespread among significant portions of the medical community and the public at large [13]. They include medical concerns dealing mainly with the peri-operative, short- and long-term risks inflicted to the donor, as well as those relevant to the long-term adequate function of the grafted organ and the fate of the recipient in case of graft failure. Most reservations are, at least in the western world, of an ethical and psycho-sociological nature. They concern the enforcement by each transplant team of a rigorous policy of donor selection based on a thorough medical and psychological evaluation. Furthermore, according to western world standards, organ donation can be accepted only with a fully autonomous decision from the donors. Donation should be totally altruistic without any form of overt or covert coercion, monetary compensation or any other form of reward [14].
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A fair reimbursement of the costs incurred by living-organ donors—a neglected issue? |
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In their article, Clarke et al. address the sensitive topic of the nature and amount of financial compensation acceptable for direct and indirect costs incurred by living kidney donors. The heart of the matter lies in clearly delineating the ‘thin red line’ that should not be crossed between totally legitimate reimbursement of all unequivocally justified out-of-pocket expenses borne by donors prior to, during and after organ donation and the slippery slope of transforming an honest compensation into a covert form of financial gain for organ donation. The line of thought set forward by the authors is that a comprehensive understanding of all the economic consequences faced by organ donors is essential to the process of informed consent and the creation of fair and sustainable programmes for reimbursement of out-of-pocket expenses. Clarke et al. reviewed 35 studies from 12 countries, describing the costs personally incurred by organ donors between 1964 and 2003. Seventeen studies (49%) were conducted in US, 12 in western European countries, two in Canada and Australia, one in Japan and Iran. The authors individualize ‘direct costs’, which include the expenses spent for travel, accommodation, long-distance phone calls, incidental medical costs not covered by public and private insurance, and ‘indirect costs’ which include the lost income due to absence from paid work and expenses linked to post-hospitalization dependency and housework support. Transportation and accommodation costs were claimed by 99 and 88% of the donors, respectively, while only scarce and moot data were reported on incidental medical costs. Wide differences are evidenced in the few available reports on patients’ loss of earnings, duration of hospitalization, return to work and loss of home productivity. The 30 year time frame encompassed in the study, which includes countries very different in size and in public and private healthcare systems, the incompleteness of the data set, numerous reasons for under- and misreporting and multiple errors inherent to a non-validated retrospective data collection design are among the main factors that limit the robustness of the study and prevent the authors from formulating any proposals that could be applicable and acceptable in the majority of countries. The great merit of this work lies, in fact, in paving the way for future, prospectively conducted research in this, as yet, largely undocumented area. Ensuring a fair compensation to organ donors of all the costs incurred by their generous initiative, through several means such as government grants, tax incentives, paid-leave programmes, social assistance and unemployment insurance, certainly represents an efficient means to remove potential barriers to living- kidney donation. In our times, an increasing contribution of LDKTx is necessary more than ever, both in developed and developing countries, to help bridge the current and predictably long-term profound gap between demand and supply of kidneys for transplantation. Relieving all economic disincentives from organ donors through fair and carefully monitored reimbursement policies is an important factor to be integrated to other strategies in progress for improving the adherence from larger parts of populations to this medically and economically optimal mode of renal replacement therapy [15,16].
Conflict of interest statement. None declared.
(See related article by Clarke et al. Nephrol Dial Transplant 2006; 21:1952–1960.)
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References |
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TopLiving-donor kidney...A fair reimbursement of...References |
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- Australia and New Zealand Dialysis and Transplant Registry (ANZDATA). Annual reports 2000–2005. http://www.anzdata.org.au.
- Eurotransplant: annual report 2005. Statistics, Section 2. http://www.eurotransplant.org.
- OPTN/SRTR, 2005 Annual report. http://www.ustransplant.org.
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- UK Transplant: activity report 2005, Section 3. http://www.uktransplant.org.
- United States Renal Data system. Reference tables: transplantation process and outcome. Annual reports 2000–2005. http://www.usrds.org.
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[Free Full Text] - Barry JM, Conlin M, Golconda M, Nordman D. Strategies to increase living donor kidney transplants. Urology 2005; 66 [Suppl 5]: 43–46[Medline]
Accepted in revised form: 26. 4.06
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Related articles in NDT:
- The direct and indirect economic costs incurred by living kidney donors—a systematic review
- Katherine S. Clarke, Scott Klarenbach, Sorina Vlaicu, Robert C. Yang, Amit X. Garg, and for the Donor Nephrectomy Outcomes Research (DONOR) Network
NDT 2006 21: 1952-1960.[Abstract] [FREE Full Text]
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