The international realities of live donor kidney transplantation
2009; Elsevier BV; Volume: 75; Issue: 10 Linguagem: Inglês
10.1038/ki.2009.23
ISSN1523-1755
Autores Tópico(s)Organ Transplantation Techniques and Outcomes
ResumoHorvat and coauthors report on trends in living kidney transplantation in 69 countries, having assembled the data from registries, national societies, the medical literature, and direct contact with transplant centers. Assembling worldwide data on live-donor kidney transplants is a commendable accomplishment that serves the international transplant community well. Horvat and coauthors report on trends in living kidney transplantation in 69 countries, having assembled the data from registries, national societies, the medical literature, and direct contact with transplant centers. Assembling worldwide data on live-donor kidney transplants is a commendable accomplishment that serves the international transplant community well. In this issue of Kidney International, Horvat and coauthors1.Horvat L.D. Shariff S.Z. Garg A.X. Global trends in the rates of living kidney donation.Kidney Int. 2009; 75 (this issue)Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar report on trends in living kidney transplantation in 69 countries, having assembled the data from registries, national societies, and the medical literature. In those countries in which there were no registry data, the authors contacted the transplant centers directly to acquire the data. Assembling worldwide data on live-donor kidney transplants is a commendable accomplishment that serves the international transplant community well. What is now evident in many parts of the world is the reliance on the live donor as the preferred source of the kidney transplant. An explanation for this development is derived from widely known reference data initially compiled by Cecka more than a decade ago. The allograft survival for an unrelated kidney transplant (determined by kidney half-life) is equal to the survival achieved by the transplantation of a kidney from a parent or a child or from a haploidentical sibling (half-lives all approximately 16 years).2.Cecka J.M. The OPTN/UNOS Renal Transplant Registry.in: Cecka J.M. Teresaki P.l. Clin Transpl 2003. UCLA Immunogenetics Center, Los Angeles2004: 1-12Google Scholar Moreover, the outcome of transplantation of a kidney from a completely mismatched donor, whether known or anonymous to the recipient, is no different from that of a haploidentical match.3.Gjertson D.W. Survival tables for living-donor renal transplants: OPTN/UNOS data 1995–2002.in: Cecka J.M. Teresaki P.l. Clin Transpl 2003. UCLA Immunogenetics Center, Los Angeles2004: 337-386Google Scholar A better outcome is provided only by an HLA-identical sibling. These data and the advances in laparoscopic nephrectomy are the factors that probably account for the observations presented in the report by Horvat et al.1.Horvat L.D. Shariff S.Z. Garg A.X. Global trends in the rates of living kidney donation.Kidney Int. 2009; 75 (this issue)Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar, 4.Davis C.L. Delmonico F.L. Living-donor kidney transplantation: a review of the current practices for the live donor.J Am Soc Nephrol. 2005; 16: 2098-2110Crossref PubMed Scopus (256) Google Scholar The World Health Organization (WHO) is most receptive to efforts such as those of Horvat and coauthors.1.Horvat L.D. Shariff S.Z. Garg A.X. Global trends in the rates of living kidney donation.Kidney Int. 2009; 75 (this issue)Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar It has a keen interest in developing a global knowledge base in transplantation that can eventually provide rates of live and deceased organ donation. The WHO is aware of additional information on transplantation practices not presented by Horvat et al. For example, the estimate of kidney transplantation in Egypt alone approximates at least 1000, virtually all of these transplants being from live kidney vendors. Approximately 70 kidney transplantations are performed in Cyprus each year, at least 60% of these transplants being from live donors. Live-donor kidney transplantation has now been accomplished in developing countries such as Kenya and Guyana. The objective of establishing a data registry clearly includes the evaluation of transplantation performance. Thus, there are two other important data categories that might have been addressed by Horvat and coauthors1.Horvat L.D. Shariff S.Z. Garg A.X. Global trends in the rates of living kidney donation.Kidney Int. 2009; 75 (this issue)Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar in their pursuit of the collected information from each country: donor gender and donor deaths. The legal sanction to sell a kidney seems to influence the donor gender, with a predominance of male vendors, for example, in Iran; in contrast, female altruistic donors provide approximately 75% of the kidneys for transplantation in many other countries. Horvat et al.1.Horvat L.D. Shariff S.Z. Garg A.X. Global trends in the rates of living kidney donation.Kidney Int. 2009; 75 (this issue)Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar emphasize that one goal of a data registry should be ‘enhancing the safety and ethical framework of this practice.’ However, more recent accounts (not brought to attention by Horvat et al.) reveal a grim outcome of vendor transplantation for the ‘donor.’5.Naqvi S.A.A. Ali B. Mazhar F. et al.A socioeconomic survey of kidney vendors in Pakistan.Transpl Int. 2007; 20: 934-939Crossref PubMed Scopus (126) Google Scholar The report by Horvat et al.1.Horvat L.D. Shariff S.Z. Garg A.X. Global trends in the rates of living kidney donation.Kidney Int. 2009; 75 (this issue)Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar also seems to be selective in the Discussion section regarding the vendor donor, citing the program in Iran and concluding that there are lessons to be learned from ‘nations with successful wait list management [that] may serve as a model.’ However, the authors provide no direct information regarding the Iranian wait list. Further, the report by Horvat et al.1.Horvat L.D. Shariff S.Z. Garg A.X. Global trends in the rates of living kidney donation.Kidney Int. 2009; 75 (this issue)Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar overlooks the experience in neighboring Pakistan and the exploitation that is the reality of organ markets.5.Naqvi S.A.A. Ali B. Mazhar F. et al.A socioeconomic survey of kidney vendors in Pakistan.Transpl Int. 2007; 20: 934-939Crossref PubMed Scopus (126) Google Scholar Nations with ‘successful wait list management’ should include the following kinds of data if the program is to serve as a model and the data registry is to be comprehensive:How many end-stage renal disease patients die (for example, in Iran) each year without gaining access to the list;The impact of the vendor kidney model on living related kidney transplantation in that country;The impact of the live-vendor program on deceased donation of hearts and livers and other extrarenal organs not readily obtainable from a live donor. Among those who wish to present a vendor model as the ideal solution, some also suggest that the program should be ‘regulated.’6.Matas A.J. Hippen B. Satel S. In defense of a regulated system of compensation for living donation.Curr Opin Organ Transplant. 2008; 13: 379-385Crossref PubMed Scopus (46) Google Scholar A component of that regulation is to recommend a fixed price for the vendor. In contrast, the opponents of such markets dispute the possibility of fixing the vendor payment.7.Danovitch G.M. Leichtman A.B. Kidney vending: the ‘Trojan horse’ of organ transplantation.Clin J Am Soc Nephrol. 2006; 1: 1133-1135Crossref PubMed Scopus (43) Google Scholar For example, in Iran, additional payments are made by the recipient's family to the vendor's broker that are evidently customary.8.Harmon W. Delmonico F. Payment for kidneys: a government-regulated system is not ethically achievable.Clin J Am Soc Nephrol. 2006; 1: 1146-1147Crossref PubMed Scopus (22) Google Scholar In 2004, World Health Assembly Resolution WHA57. 18 urged member states ‘to take measures to protect the poorest and vulnerable groups from transplant tourism and the sale of tissues and organs, including attention to the wider problem of international trafficking in human tissues and organs.’9.Human organ and tissue transplantation. World Health Assembly, Geneva, Switzerland2004http://www.who.int/gb/ebwha/pdf_files/WHA57/A57_R18-en.pdfGoogle Scholar The WHO has estimated that organ trafficking and transplant tourism account for approximately 10% of organ transplants performed annually around the world.10.Budiani-Saberi D.A. Delmonico F.L. Organ trafficking and transplant tourism: a commentary on the global realities.Am J Transplant. 2008; 8: 925-929Crossref PubMed Scopus (176) Google Scholar These issues became the subject of a summit convened in Istanbul from 30 April to 1 May 2008 (Figure 1) by the Transplantation Society and the International Society of Nephrology. The result of these deliberations was the Declaration of Istanbul on Organ Trafficking and Transplant Tourism.8.Harmon W. Delmonico F. Payment for kidneys: a government-regulated system is not ethically achievable.Clin J Am Soc Nephrol. 2006; 1: 1146-1147Crossref PubMed Scopus (22) Google Scholar The consensus achieved at the Istanbul Summit was remarkable. The Istanbul participants emphasized that organ trafficking and transplant tourism should be prohibited because they violate the principles of equity, justice, and respect for human dignity. The Declaration is also clear regarding the consequences of transplant commercialism: ‘Because transplant commercialism targets impoverished and otherwise vulnerable donors, it leads inexorably to inequity and injustice and should also be prohibited. To be effective, these prohibitions must include bans on all types of advertising (electronic and print), soliciting, or brokering for the purpose of transplant commercialism.’ The report by Horvat et al.1.Horvat L.D. Shariff S.Z. Garg A.X. Global trends in the rates of living kidney donation.Kidney Int. 2009; 75 (this issue)Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar suggests appropriately that organ tourism influences many countries in different ways, but the report does not specify how this influence occurs. The Istanbul Declaration notes the following regarding transplant tourism: Travel for transplantation is the movement of organs, donors, recipients, or transplantation professionals across jurisdictional borders for transplantation purposes. Travel for transplantation becomes ‘transplant tourism’ if it involves organ trafficking and/or transplant commercialism or if the resources (organs, professionals, and transplant centers) devoted to providing transplants to patients from outside a country undermine the country's ability to provide transplant services for its own population.11.Organ trafficking and transplant tourism and commercialism: the Declaration of Istanbul. Steering Committee of the Istanbul Summit.Lancet. 2008; 372: 5-6Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar Not all recipient travel to a foreign country to undergo transplantation is unethical. Travel for transplantation may be acceptable if the following conditions are fulfilled: For transplantation from a live donor:The recipient has a dual citizenship, in the country of residence and in the destination country, and wishes to undergo transplantation from a live donor who is a family member in the destination country; orThe donor and recipient are genetically or emotionally related and wish to undergo donation and transplantation in a country not of their residence to gain access to better health services. For transplantation from a deceased donor:Official regulated bilateral or multilateral organ sharing programs exist between or among jurisdictions (countries). However, travel for transplantation should not result in the denial of organs to people of the destination country because rich people who pay for organs are preferentially cared for, nor should it impede the development of deceased or non-cash-paid live donation in the client country. The data from Cecka cited above also revealed that the outcome of a live-donor transplantation—even unrelated—exceeded the outcome achieved with a deceased donor (half-life of 16 versus 10 years for the deceased-donor transplant).2.Cecka J.M. The OPTN/UNOS Renal Transplant Registry.in: Cecka J.M. Teresaki P.l. Clin Transpl 2003. UCLA Immunogenetics Center, Los Angeles2004: 1-12Google Scholar Some have used those data to support unethical national practices. This report was filed on the Internet from the Philippines by Dr Enrique Ona: Of the 690 kidney transplants done in the Philippines in 2006, 158 (23%) of these were done for foreign recipients. In 2007, a total of 1046 were done; 536 (51%) of these were done in the 13 private hospitals that strongly objected to and ignored the 10% limit mandated by Philippine Administrative Order. ‘Two important facts on living donors have become established. One, it is safe to be a living kidney donor—one lives a normal life in terms of life expectancy, sexual activity, with no or little danger of a higher incidence of hypertension and albuminuria. Two, recipients with live donors have a significantly longer survival rate, compared to the best matched deceased donors. The above evidence-based medical facts have added to the tremendous demand of patients with ESRD to seek kidney transplantation as early as possible (pre-emptive), to look for a living donor beyond their family circle, and regardless of racial source.’12.E. Ona Kidney transplant in a globalizing world ABS-CBN News http://abs-cbnnews.com/views-and-analysis/07/01/08/kidney-transplant-globalizing-world%E2%80%94enrique-onaGoogle Scholar Horvat et al.1.Horvat L.D. Shariff S.Z. Garg A.X. Global trends in the rates of living kidney donation.Kidney Int. 2009; 75 (this issue)Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar conclude by suggesting that ‘communication across nations will continue to put living donation into the global context, enhancing the safety and ethical framework of this practice in the decades to come.’ This is a worthy objective but is hardly assured by a registry unless there is a prospective commitment. The live donor cannot become the target source of kidney transplantation unless proper follow-up is provided, with the same emphasis of care that is afforded the recipient.13.Delmonico F. Council of the Transplantation Society A Report of the Amsterdam Forum On the Care of the Live Kidney Donor: Data and Medical Guidelines.Transplantation. 2005; 79: S53-S66PubMed Google Scholar The author declared no competing interests.
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