Is it ethical to invite compatible pairs to participate in exchange programmes?

Compatible Donor and Recipient Pairs' Perspectives on Participation in Kidney Paired Donation Programs: A Mixed-Methods Study

Background:

Compatible pair participation in kidney paired donation (KPD) may increase the likelihood of finding suitable matches for all registered pairs. Retrospective studies have shown variable enthusiasm for participating in KPD in compatible pairs.

Objective:

The study objective was to gather potential living donor (PLD) and transplant candidate (TC) perspectives on compatible pair participation in KPD.

Design:

Surveys and qualitative interviews.

Setting:

Three transplant programs in Canada: Centre hospitalier de l’Université de Montréal in Montreal (Québec), Vancouver General Hospital, and St. Paul’s Hospital in Vancouver (British Columbia).

Patients:

Both PLDs and TCs undergoing evaluation for donation/transplantation between 2016 and 2018 at 3 transplant programs in Canada.

Methods:

Descriptive statistical analysis was performed for the results of the survey and thematic and content analysis method was used for the content of the qualitative interviews.

Results:

A total of 116 PLDs and 111 TCs completed surveys and an additional 18 PLDs and 17 TCs underwent semi-directed interviews. Of those surveyed, 61.2% of PLDs and 76.6% of TCs reported a willingness to participate in KPD as a compatible pair. The possibility of a more optimally matched kidney for the TC and policies ensuring prioritization of the TC for repeat transplantation in the event of early graft failure increased willingness to participate in KPD. Major concerns expressed during the interviews included the desire to retain the emotional bond of directed donation, the fear of chain breaks or donor reneging, delays in transplantation, and additional travel associated with participation in KPD.

Limitation:

The limitations of this study are that it was conducted in only 3 Canadian transplant programs and that the interviews and surveys were in French and in English. As a consequence, the results may not be reflective of the views of individuals not living in these 2 provinces and from ethnic minority populations.

Conclusion:

Most of the compatible PLDs and TCs surveyed were willing to participate in KPD. Ensuring timely transplantation and a more optimal match for TCs and offering a policy of reciprocity to ensure timely repeat transplantation for compatible recipients if their allograft fails post KPD transplant may further increase compatible pair participation in KPD.

Improving HLA matching in living donor kidney transplantation using kidney paired exchange program

BACKGROUND

The inclusion of compatible pairs within kidney paired exchange programs has been described as a way to enhance these programs. Improved immunological matching for the recipient in compatible pair has been described to be a possible benefit.

METHODS

The main purpose of our study was to determine if the introduction of compatible pairs in the Portuguese kidney paired exchange program would result in a better match for these patients, but also to assess if this strategy would increase the number of incompatible pairs with a possible match. We included 17 compatible pairs in kidney paired exchange pool of 35 pairs and performed an in-silico simulation determining HLA eplet mismatch load between the co-registered and matched pairs using HLA MatchMaker, version 3.0.

RESULTS

Our study showed that the inclusion of fully HLA-A, -B, -DR mismatched compatible pairs within the national Portuguese KEP increased matched rate within ICP (0.71%) and improved HLA eplet matching within compatible pairs. 16 of 17 (94.12%) of the CP obtained one or more transplants possibilities and 13 (81.25%) would have been transplanted with significantly lower HLA class I and class II total and antibody-verified eplet mismatch load (83.9 ± 16.9 vs. 59.8 ± 12.2, P = .002 and 30.1 ± 5.5 vs. 21.2 ± 3.0, P = .003, respectively).

CONCLUSIONS

This strategy is a viable alternative for compatible pairs seeking a better matched kidney and Portuguese KEP program should allow them this possibility.

Kidney Paired Donation and the "Valuable Consideration" Problem: The Experiences of Australia, Canada, and the United States

As organ donation rates remain unable to meet the needs of individuals waiting for transplants, it is necessary to identify reasons for this shortage and develop solutions to address it. The introduction of kidney paired donation (KPD) programs represents one such innovation that has become a valuable tool in donation systems around the world. Although KPD has been successful in increasing kidney donation and transplantation, there are lingering questions about its legality. Donation through KPD is done in exchange for-and with the expectation of-a reciprocal kidney donation and transplantation. It is this reciprocity that has caused concern about whether KPD complies with existing law. Organ donation systems around the world are almost universally structured to legally prohibit the commercial exchange of organs. Australia, Canada, and the United States have accomplished this goal by prohibiting the exchange of an organ for "valuable consideration," which is a legal term that has not historically been limited to monetary exchange. Whether or not KPD programs violate this legislative prohibition will depend on the specific legislative provision being considered, and the legal system and case law of the particular jurisdiction in question. This article compares the experiences of Australia, Canada, and the United States in determining the legality of KPD and highlights the need for legal clarity and flexibility as donation and transplantation systems continue to evolve.

Ethical and Logistical Issues Raised by the Advanced Donation Program "Pay It Forward" Scheme

The advanced donation program was proposed in 2014 to allow an individual to donate a kidney in order to provide a voucher for a kidney in the future for a particular loved one. In this article, we explore the logistical and ethical issues that such a program raises. We argue that such a program is ethical in principle but there are many logistical issues that need to be addressed to ensure that the actual program is fair to both those who do and do not participate in this program.

Reciprocity to Increase Participation of Compatible Living Donor and Recipient Pairs in Kidney Paired Donation

Inclusion of compatible living donor and recipient pairs (CPs) in kidney paired donation (KPD) programs could increase living donor transplantation. We introduce the concept of a reciprocity-based strategy in which the recipient of a CP who participates in KPD receives priority for a repeat deceased donor transplant in the event their primary living donor KPD transplant fails, and then we review the practical and ethical considerations of this strategy. The strategy limits prioritization to CPs already committed to living donation, minimizing the risk of unduly influencing donor behavior. The provision of a tangible benefit independent of the CP's actual KPD match avoids many of the practical and ethical challenges with strategies that rely on finding the CP recipient a better-matched kidney that might provide the CP recipient a future benefit to increase KPD participation. Specifically, the strategy avoids the potential to misrepresent the degree of future benefit of a better-matched kidney to the CP recipient and minimizes delays in transplantation related to finding a better-matched kidney. Preliminary estimates suggest the strategy has significant potential to increase the number of living donor transplants. Further evaluation of the acceptance of this strategy by CPs and by waitlisted patients is warranted.

Characteristics of compatible pair participants in kidney paired donation at a single center

Compatible pairs of living kidney donors and their intended recipients can enter into kidney paired donation (KPD) and facilitate additional living donor kidney transplants (LDKTs). We examined 11 compatible pairs (the intended recipients and their intended, compatible donors) who participated in KPD, along with the recipients' 11 matched, exchange donors. The 11 pairs participated in 10 separate exchanges (three were multicenter exchanges) that included 33 total LDKTs (22 additional LDKTs). All the intended donors were blood group O and female, with a mean living kidney donor profile index (LKDPI) of 27.6 (SD 16.8). The matched donors had a mean LKDPI of 9.4 (SD 31.7). Compatible pairs entered KPD for altruistic reasons (N=2) or due to mismatch of age (N=7) or body/kidney size (N=2) between the recipient and intended donor. In four cases, retrospective calculation of the LKDPI revealed that the matched donor had a higher LKDPI than the intended donor. Of the 22 recipients of LDKTs enabled by the compatible pairs, three were highly sensitized, with PRA >80%. In conclusion, most compatible pairs entered into KPD so that the recipient could receive a LDKT transplant from a donor whose age or body/kidney size were more favorable to post-transplant outcomes.

Providing Better-Matched Donors for HLA Mismatched Compatible Pairs Through Kidney Paired Donation

BACKGROUND

Participation of compatible pairs (CP) in kidney paired donation (KPD) could be attractive to CPs who have a high degree of HLA mismatch, if the CP recipient will gain a better HLA match. Because KPD programs were not designed to help CP, it is important to define allocation metrics that enable CP to receive a better-matched kidney, without disadvantage to incompatible pairs (ICP).

METHODS

Simulations using 46 ICPs and 11 fully HLA-mismatched CPs were undertaken using the Australian KPD matching algorithm. Allocations were preformed adding 1 CP at a time or all 11 CPs at once, and with and without exclusion of unacceptable antigens selected to give a virtual calculated panel-reactive antibody ranging 70% to 80% to improve HLA matching in CP recipients.

RESULTS

On average, most CP recipients could be matched and had a lower eplet mismatch (EpMM) with the matched donor (57 ± 15) than with their own donor (78 ± 19, P < 0.02). However, only recipients who had an EpMM to own donor greater than 65 achieved a significant reduction in the EpMM with the matched donor. The gain in EpMM was larger when CPs were listed with unacceptable antigens. Furthermore, inclusion of 1 CP at a time increased matching in ICP by up to 33%, and inclusion of all 11 CPs at once increased ICP matching by 50%.

CONCLUSIONS

Compatible pair participation in KPD can increase match rates in ICP and can provide a better immunological profile in CP recipients who have a high EpMM to their own donor when using allocation based on virtual crossmatch.

Attitudes of Lay Stakeholders and Transplant Professionals About Disclosure to Living Kidney Donors in Exchanges and Chains

Background:

Current policies require very limited informational disclosure between living kidney donors and recipients regardless of the relationship type. No specific policies exist to suggest that exchange/chain donors and their recipients should be treated differently. We surveyed transplant professionals (surgeons and nephrologists) and members of the National Kidney Foundation (NKF) to determine their support for disclosing to donors the health, health behavior, and social information of their exchange/chain donors and exchange/chain recipients.

Methods:

Twenty questions regarding disclosing to donors information about both their exchange/chain donors and exchange/chain recipients were included in 2 larger surveys on disclosure about kidney transplantation. Survey A was sent electronically to NKF list-servs, and survey B was sent to transplant professionals both electronically and by postal mail.

Results:

Survey A yielded 236 valid surveys from NKF donors and recipients (lay stakeholders). Survey B yielded 111 valid surveys from transplant professionals. Both sets of stakeholders support disclosing to donors some health and health behavior information of their exchange/chain donor and exchange/chain recipient, and mostly oppose disclosure of social information. Lay stakeholders favored disclosing significantly more information than transplant professionals. Among lay stakeholders, donor respondents were more supportive than recipient respondents in disclosing to donors health information about the exchange/chain recipient. Among transplant professionals, surgeons were more supportive than nephrologists in disclosing to donors information about the exchange/chain recipient that may impact graft survival.

Conclusions:

There is broad stakeholder support for disclosing some health and health behavior information to donors about their exchange/chain donors and recipients.

Increasing access to kidney transplantation in countries with limited resources: the Indian experience with kidney paired donation

According to the Indian chronic kidney disease registry, in 2010 only 2% of end stage kidney disease patients were managed with kidney transplantation, 37% were managed with dialysis and 61% were treated conservatively without renal replacement therapy. In countries like India, where a well-organized deceased donor kidney transplantation program is not available, living donor kidney transplantation is the major source of organs for kidney transplantation. The most common reason to decline a donor for directed living donation is ABO incompatibility, which eliminates up to one third of the potential living donor pool. Because access to transplantation with human leukocyte antigen (HLA)-desensitization protocols and ABO incompatible transplantation is very limited due to high costs and increased risk of infections from more intense immunosuppression, kidney paired donation (KPD) promises hope to a growing number of end stage kidney disease patients. KPD is a rapidly growing and cost-effective living donor kidney transplantation strategy for patients who are incompatible with their healthy, willing living donor. In principle, KPD is feasible for any centre that performs living donor kidney transplantation. In transplant centres with a large living donor kidney transplantation program KPD does not require extra infrastructure, decreases waiting time, avoids transplant tourism and prevents commercial trafficking. Although KPD is still underutilized in India, it has been performed more frequently in recent times. To substantially increase donor pool and transplant rates, transplant centres should work together towards a national KPD program and frame a uniform acceptable allocation policy.

Strategies to increase living kidney donation: a retrospective cohort study

BACKGROUND

Living kidney transplantation (LKT) offers the best medical outcomes for organ recipients. Historically, our centre had a low rate of LKT. In 2009, in an effort to increase living organ donation (LOD), a dedicated team was created. Its mandate was to promote LOD at our centre and at referring centres, to coordinate assessments of living organ donors, to facilitate the process, and to ensure long-term follow-up after the donation. In November 2010, our centre joined the national living donor paired exchange registry (LDPE).

OBJECTIVE

To document the impact of the LOD team and LDPE registry on LOD rates at our centre.

DESIGN

Retrospective cohort study.

SETTING

Single center study in a university hospital with an adult kidney transplant program.

PATIENTS

Using our electronic database, we included all potential living organ donors who contacted our centre from 01/01/2005 to 31/12/2008 and from 01/01/2009 to 31/12/2012. Follow-up was conducted until 31/12/2013.

MEASUREMENTS

Number of transplantations from living donors, number of potential donors who contacted the centre, donor and recipient characteristics.

METHODS

We compared the number of transplantations from living donors performed and the number of potential donors who contacted the centre before and after the creation of the LOD team and participation in the LDPE.

RESULTS

A total of 50 renal transplantations were performed using organs from living donors during the first time period, whereas this increased to 73 in the 2009-2012 cohort (incidence rate difference (IRD): 0.030, 95% confidence interval (CI) 0.003-0.056). We also observed a significant increase in the number of individuals who contacted our centre to donate a kidney. During the 2005-2008 period (cohort 1), 191 individuals interested in donating a kidney contacted our centre, whereas this figure was 304 during the 2009-2012 period (cohort 2) (IRD: 0.143, 95% CI 0.091-0.196).

LIMITATIONS

Single center study, relatively low sample size.

CONCLUSION

The implementation of a LOD team, combined with our participation in the LDPE registry, was associated with a significant increase in the actual number of living kidney transplantations performed. These data support initiatives such as the creation of dedicated LOD teams and LDPE registry to increase LKT.

Should we perform kidney transplants on foreign nationals?

In Canada, there are currently no guidelines at either the federal or provincial level regarding the provision of kidney transplantation services to foreign nationals (FN). Renal transplant centres have, in the past, agreed to put refugee claimants and other FNs on the renal transplant waiting list, in part, because these patients (refugee claimants) had health insurance through the Interim Federal Health Programme to cover the costs of medication and hospital care. However, severe cuts recently made to this programme have forced clinicians to question whether they should continue with transplants for FNs, for financial and ethical reasons. This paper first examines different national policies (eg, in Canada, USA, France and the UK) to map the diversity of approaches regarding transplantation for FNs, and then works through different considerations commonly used to support or oppose the provision of organs to these patients: (1) the organ shortage; (2) the free-rider problem; (3) the risk of becoming a transplant destination; (4) the impact on organ donation rates; (5) physicians' duties; (6) economic concerns; (7) vulnerability. Using a Canadian case as a focus, and generalising through a review of various national policies, we analyse the arguments for and against transplantation for FNs with a view to bringing clarity to what is a sensitive political and clinical management issue. Our aim is to help transplant centres, clinicians and ethicists reflect on the merits of possible options, and the rationales behind them.

Successful three-way kidney paired donation with compatible pairs to increase donor pool

Despite heightened international interest in performing living donor kidney paired donation (KPD) transplantation after the publication of a research protocol by Ross and colleagues in 1997, only a few hundred have been performed worldwide. The major obstacle is that many individuals in end-stage renal disease are of blood type O and can only receive an organ from a donor of blood type O, whereas blood type O donors are "universal donors" and will be able to donate directly with an intended recipient of any blood type unless there is a positive crossmatch. To overcome this, patients with compatible but non-HLA identical donors over 45 years of age should be approached for inclusion in KPD program especially O blood group donors. Inclusion of all these additional pairs into the algorithm greatly increases chances of possible matches for O blood group recipients. We report successful three-way KPD transplantation resulting in transplantation of O blood group patient using compatible O blood group donor from India. None of the patients had delayed graft function or rejection and all had stable graft function on discharge without any medical and surgical complications. We need to allocate O blood group kidneys from compatible donors to overcome the barrier of HLA, non-HLA antibodies and other donor related factors to improve transplant quality and long term outcomes. This will increase transplantation of O blood group patients.