Transplants from living donors in the United Kingdom and Ireland: a centre survey

Living kidney donation in Europe: legal and ethical perspectives--the EUROTOLD Project

The demand for organ replacement by transplantation continues to outstrip supply, leading to unnecessary morbidity and health care costs. "Space capacity" (i. e. cadaver organs not currently harvested for transplant) has been tackled within Western Europe in particular by many strategies--medical, social, educational and legal--but with varying degrees of success. Despite this, the use of living donors has not been fully exploided in many European countries to fill this gap. The total picture is, however, one of marked differences between countries and between centres within countries. In Turkey and Greece, living donors generally account for 60-90% of all renal donors. Countries within Scandinavia also have a high rate of living donor use, especially Norway. By contrast the percentage is far more modest, for example in Spain, Ireland, France and Germany. In the United Kingdom the rate is only 6% with a range of between 0 and 20%. Sources of living donors also show substantial variations between countries, notably the extent to which non-genetically related donors are used. A European Commission sponsored study has been established to acquire a broad understanding of the interaction of ethical values, cultural traditions and social customs on willingness to donate. It will also aim to assess the effect of national laws on professional attitudes to living donor transplantation. This is a collaborative project between the University Department of Surgery, Leicester General Hospital, the Department of Law, De Montfort University and the Department of Mathematics, Newcastle University. Transplant units throughout Europe, including France, Germany, Switzerland, Norway, The Netherlands, Eire and Turkey are collaborating to exchange information and views on living donor transplantation.

Living-related organ donation: the donor's dilemma

New procedures for segmented organ transplantation of the lung and liver have again brought to public attention the issue of live organ donation. To provide a context for understanding the dilemmas faced by potential donors, the body of literature over the last 40 years regarding living-related organ donation with kidneys was reviewed. Results indicated that while psychological side effects have been reported including depression and family conflict these risks are generally under-emphasized. Risk factors for negative psychological consequences include high age, lack of social support, and organ rejection in the recipient. Instantaneous decision-making in favor of donation is generally described. However, researchers have neglected to consider social desirability factors when assessing donor motives. Furthermore, lack of awareness has been shown concerning the coercive processes involved in moral decision-making. Health professionals should be aware that merely raising the issue of live organ donation may instigate powerful psychological processes beyond the potential donor's voluntary control and leave little room for refusal without psychological cost. Implications for treatment are discussed with these circumstances in mind.

Current status of renal transplantation

The success rate of renal transplantation has improved considerably during the past decade, with substantial improvements in both graft and patient survival. The quality of graft function, however, and not graft survival alone is increasingly determining the standards by which transplantation outcome is being judged. As the demand for kidney transplants continues to rise and transplants are being offered to an ever-increasing number of patients, organs are being sought from new supply pools and efforts are being made to use current resources more efficiently. Improvements in clinical management have allowed short-term complications such as infection and rejection to be better prevented or better diagnosed and treated. Fundamental advances in the understanding of the immunologic processes underlying both allograft rejection and acceptance and the introduction of new immunosuppressive agents have allowed a better use of drug therapy and have moved the goal of acquired transplant tolerance closer to attainment. With improved initial transplant success rates, the long-term transplantation outcome is becoming more important. The role of tissue matching in preventing chronic rejection is becoming more appreciated, and the long-term risks of malignancy, arteriosclerosis, and chronic rejection are being better recognized and managed.

[Advantages and risks of kidney transplantation from related donors]

Living related kidney transplantation must offer the recipient distinct advantages over cadaveric grafting in order to justify the health risk undertaken by the donor. At Steglitz Medical Center in Berlin from 1970 to 1987 30 such transplantations were performed (5% of all kidney transplantations) where the donor was a relative of the recipient. In cases of haploidentity and positive mixed lymphocyte culture, the recipients were pretreated with donor-specific transfusions. The posttransplantation graft function rate was higher in the group where the donated kidney came from a relative than where it did not (after 2 years under cyclosporin: 92% vs 73%, P = 0.04), and corticosteroid treatment could be terminated more frequently under cyclosporin (95% vs 51%, P = 0.001). Transplantations from living related donors were performed more often in foreigners (43% vs 20%, P = 0.01) and children (19% vs 4%, P = 0.0001). Perioperative complications in the donor nephrectomy occurred in 63% of the cases, severe ones in 13% (bleeding, pneumonia, and late abscess). Late sequelae were not observed. The short waiting time, the high graft function rate, and the low steroid requirement justify kidney transplantation from living related donors providing strict indicational criteria are observed.