Kidney to Share Martha Gershun, John D. Lantos
2021, 2021-05-15
eBook
In Kidney to Share, Martha Gershun tells the story of her decision to donate a kidney to a stranger. She takes readers through the complex process by which such donors are vetted to ensure that they ...are physically and psychologically fit to take the risk of a major operation. John D. Lantos, a physician and bioethicist, places Gershun's story in the larger context of the history of kidney transplantation and the ethical controversies that surround living donors. Together, they help readers understand the discoveries that made transplantation relatively safe and effective as well as the legal, ethical, and economic policies that make it feasible. Gershun and Lantos explore the steps involved in recovering and allocating organs. They analyze the differences that arise depending on whether the organ comes from a living donor or one who has died. They observe the expertise—and the shortcomings—of doctors, nurses, and other professionals and describe the burdens that we place on people who are willing to donate. In this raw and vivid book, Gershun and Lantos ask us to consider just how far society should go in using one person's healthy body parts in order to save another person. Kidney to Share provides an account of organ donation that is both personal and analytical. The combination of perspectives leads to a profound and compelling exploration of a largely opaque practice. Gershun and Lantos pull back the curtain to offer readers a more transparent view of the fascinating world of organ donation.
The seventh phase of this longitudinal study investigated whether children born through third-party assisted reproduction experienced psychological problems, or difficulties in their relationship ...with their mothers, in early adulthood. The impact of disclosure of their biological origins, and quality of mother-child relationships from age 3 onward, were also examined. Sixty-five assisted reproduction families, including 22 surrogacy families, 17 egg donation families, and 26 sperm donation families, were compared with 52 unassisted conception families when the children were aged 20. Less than half of the mothers had completed tertiary education and less than 5% were from ethnic minority backgrounds. Standardized interviews and questionnaires were administered to mothers and young adults. There were no differences between assisted reproduction and unassisted conception families in mothers' or young adults' psychological well-being, or the quality of family relationships. However, within the gamete donation families, egg donation mothers reported less positive family relationships than sperm donation mothers, and young adults conceived by sperm donation reported poorer family communication than those conceived by egg donation. Young adults who learned about their biological origins before age 7 had less negative relationships with their mothers, and their mothers showed lower levels of anxiety and depression. Associations between parenting and child adjustment did not differ between assisted and unassisted reproduction families from ages 3 to 20. The findings suggest that the absence of a biological connection between children and their parents in assisted reproduction families does not interfere with the development of positive mother-child relationships or psychological adjustment in adulthood.
Public Significance Statement
Contrary to the concerns that have been raised regarding the potentially negative consequences of third-party assisted reproduction for children's psychological well-being, the findings of this longitudinal study point to positive family relationships and child adjustment from childhood to adult life. The findings also suggest that families may benefit from parents of children born through third-party assisted reproduction beginning to speak to their children about the circumstances of their birth at an early age, in an age-appropriate way, ideally before they start school.
In this book, Yasuoka reveals insight into Japan as the country with the most severe organ shortages and the lowest numbers of organ donations among medically advanced countries. This is the first ...book to delve into the challenging and taboo Japanese concepts of life and death surrounding organ transplantation.
Our main objective was to compare liver transplant (LT) results between donation after circulatory death (DCD) and donation after brainstem death (DBD) in our hospital and to analyze, within the DCD ...group, the influence of age on the results obtained with DCD donors aged >70 years and up to 80 years. All DCD‐LTs performed were analyzed prospectively. The results of the DCD group were compared with those of a control group who received a DBD‐LT immediately after each DCD‐LT. Later, the results obtained within the DCD group were analyzed according to the age of the donors, considering 2 subgroups with a cut‐off point at 70 years. Survival results for LT with DCD and super rapid recovery were not inferior to those obtained in a similar group of patients transplanted with DBD livers. However, the cost of DCD was a higher rate of biliary complications, including ischemic cholangiopathy. Donor age was not a negative factor.
Patient survival after liver transplantation from elderly donors (up to 80 years) due to circulatory death and super rapid recovery is acceptable, though with a higher rate of biliary complication.
This editorial proposes a system to collect verifiable data from organ procurement organizations to be used for research, regulation, and quality improvement of the organ donation process. See the ...article from Cannon et al on page 2756.
Cardiac transplantation remains the only definitive treatment for end‐stage heart failure. Transplantation rates are limited by a shortage of donor hearts. This shortage is magnified because many ...hearts are discarded because of strict selection criteria and concern for regulatory reprimand for less‐than‐optimal posttransplant outcomes. There is no standardized approach to donor selection despite proposals to liberalize acceptance criteria. A donor heart selection conference was organized to facilitate discussion and generate ideas for future research. The event was attended by 66 participants from 41 centers with considerable experience in cardiac donor selection. There were state‐of‐the‐art presentations on donor selection, with subsequent breakout sessions on standardizing the process and increasing utilization of donor hearts. Participants debated misconceptions and established agreement on donor and recipient risk factors for donor selection and identified the components necessary for a future donor risk score. Ideas for future initiatives include modification of regulatory practices to consider extended criteria donors when evaluating outcomes and prospective studies aimed at identifying the factors leading to nonacceptance of available donor hearts. With agreement on the most important donor and recipient risk factors, it is anticipated that a consistent approach to donor selection will improve rates of heart transplantation.
This meeting report outlines the proceedings of a conference sponsored by the American Society of Transplantation and represents the current donor selection practices of adult heart transplant centers in the United States, a suggested standardized approach to donor selection, and avenues for future research. See the editorial from Smits on page 2503.
Organ donation and transplantation remain the best and most cost-effective clinical solution for end-stage organ failure. Several agencies across the US and Europe provide legislative, regulatory, ...and humanitarian services to generate smoother applications in all transplantation processes and donor-recipient relationships. US and European statistics present nine types of grafts, with kidneys being the most transplanted organ worldwide. However, organ shortage, religion, underrepresented minority groups, difficulties in obtaining consent, lack of understanding, and general ethical concerns present challenging barriers to organ donation, reflecting the complexity of graft procurement and allocation. Breaking down these barriers to reduce the organ-supply imbalance requires an appropriate multifaceted approach. Some of the key areas include increasing the potential donor pool and consent rates, apt organ allocation, and improving organ health. Additionally, suitable policies and standardized guidelines for both donors and recipients, alongside educational initiatives, are needed to ensure patient safety and global awareness. Looking forward, novel and effective research plans and initiatives are needed if we are to avoid a colossal supply-demand gap.
•Different forms of organ donation: LOD, DCD, DBD, pDCD.•World's most transplanted organs: Kidney, Liver, Heart, Pancreas, Lung, Intestine.•Waitlist numbers and organ shortage are prevailing threats to organ transplantation.•Ethics, consent, race, religion as other barriers to organ donation.•Need for alternatives, expanded donor criteria, and new educative initiatives.
In transplant, meaningful international comparisons in organ utilization are needed. This collaborative study between the United Kingdom (UK) and the United States (US) aimed to develop a kidney ...utilization metric allowing for legitimate intercountry comparisons. Data from the UK and US transplant registries, including all deceased donor kidneys recovered from 2006 to 2017, were analyzed. To identify a potentially comparable kidney utilization rate (UR), several denominators were assessed. We discovered that the proportion of transplanted kidneys from elderly donors in the UK (10.7%) was 18 times greater than that in the US (0.6%). Conversely, en bloc pediatric kidney transplant was more common in the US. Donation after circulatory death utilization has risen in both countries but is twice as prevalent in the UK (39% of transplants) vs the US (20%). In addition, US and UK URs are not directly comparable due to fundamental system differences. However, using a suite of URs revealed practice areas likely to yield the most benefit if improved, such as efforts to increase kidney offer acceptance in the US and to reduce postacceptance discard in the UK. Methods used in this study, including novel intracountry risk‐adjusted UR trend logistic regression analyses, can be translated to other international transplant registries in pursuit of further global learning opportunities.
This international registry collaborative study explores meaningful comparable metrics for quantifying deceased donor kidney utilization and discusses intercountry differences in characteristics of recovered and transplanted kidneys. See an editorial from Manook and Kirk on page 1221.
It has been hypothesized that transplanting simultaneous pancreas kidney (SPK) grafts from donors with a history of cardiac arrest and cardiopulmonary resuscitation (CACPR) leads to inferior ...posttransplant outcomes due to organ hypoperfusion during cardiac arrest and mechanical trauma during resuscitation. Using Scientific Registry of Transplant Recipients data, we identified 13 095 SPK transplants from 2000‐2018, of which 810 (6.2%) were from donors with a history of CACPR. After inverse probability of treatment weighting on donor and recipient characteristics, we found that 1‐, 5‐, and 10‐year patient (CACPR: 96.4%, 89.9%, and 78.9%; non‐CACPR: 96.3%, 88.9%, and 76.0%; P = .3), death‐censored pancreas graft survival (CACPR: 89.3%, 82.7%, 75.0%; non‐CACPR: 89.9%, 82.7%, 76.3%; P = .7), and death‐censored kidney graft survival (CACPR: 97.0%, 89.5%, 78.2%; non‐CACPR: 96.9.9%, 88.7%, 80.0%; P = .4) were comparable between the two groups. There were no differences in the risk of pancreatitis (CACPR: 2.9%, non‐CACPR: 2.4%; weighted OR = 0.74 1.22 2.02; P = .4), anastomotic leak (CACPR: 1.6%, non‐CACPR: 2.0%; weighted OR = 0.54 1.02 1.93; P > .9), or median length of hospital stay (CACPR: 8 days, non‐CACPR: 9 days; P = .6) for recipients of CACPR vs non‐CACPR donors. Our findings suggest that CACPR donors could be used to expand the SPK donor pool without compromising short‐ or long‐term outcomes.
This national study of 13,095 simultaneous pancreas‐kidney transplants found similar patient survival, pancreas and kidney graft survival, and occurrence of postoperative complications in recipients of organs from donors with and without a history of cardiac arrest and resuscitation, suggesting that these donors could be used to expand the donor pool without compromising short‐ or long‐term outcomes.
The continuing shortage of deceased donor organs for transplantation, and the limited number of potential donors after brain death, has led to a resurgence of interest in donation after circulatory ...death (DCD). The processes of warm and cold ischemia threaten the viability of DCD organs, but these can be minimized by well-organized DCD pathways and new techniques of in situ organ preservation and ex situ resuscitation and repair post-explantation. Transplantation survival after DCD is comparable to donation after brain death despite higher rates of primary non-function and delayed graft function. Countries with successfully implemented DCD programs have achieved this primarily through the establishment of national ethical, professional and legal frameworks to address both public and professional concerns with all aspects of the DCD pathway. It is unlikely that expanding standard DCD programs will, in isolation, be sufficient to address the worldwide shortage of donor organs for transplantation. It is therefore likely that reliance on extended criteria donors will increase, with the attendant imperative to minimize ischemic injury to candidate organs. Normothermic regional perfusion and ex situ perfusion techniques allow enhanced preservation, assessment, resuscitation and/or repair of damaged organs as a way of improving overall organ quality and preventing the unnecessary discarding of DCD organs. This review will outline exemplar controlled and uncontrolled DCD pathways, highlighting practical and logistical considerations that minimize warm and cold ischemia times while addressing potential ethical concerns. Future perspectives will also be discussed.
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