Living Organ Donation
Ronald D. Perrone, M.D. Associate Chief, Division of Nephrology Medical Director, Kidney Transplantation Tufts-New England Medical Center Professor of Medicine, Tufts University School of Medicine 6/23/07
Topics to Cover
• • • • • • Why should someone get a transplant? How does someone get a transplant? Types of kidney donors How do I donate a kidney? Risks and benefits of kidney donation Additional information
End Stage Renal Disease
• Signs and symptoms of kidney failure, collectively, are known as uremia or the uremic syndrome, irrespective of the cause of kidney disease • Replacement therapy (dialysis or transplantation) is effective in improving the most serious features of uremia, irrespective of the cause of kidney disease • Replacement therapy usually initiated when kidney function (GFR) is less than 15 ml/min
Why Get a Kidney Transplant?
• Preferred method of treatment for kidney failure • Confers better quality of life and better survival, for appropriate individual • Transplantation is a treatment for kidney failure, not a cure!
– Still need to take medications, see doctors, have blood tests – Long-term survival of transplanted kidney finite – Health maintenance extremely important
Time Course of Mortality Risk After Transplantation
Selection of Transplant Candidate
• • • • • • • Healthy heart; able to go through surgery Compliant with medical treatment No active infections No recent malignancy Teeth in good repair Medical insurance and medication coverage Discussion of potential donors
NEJM 341:1725, 1999
Usual Sources of Kidneys
• Deceased (cadaveric) donor
– kidney obtained from individual who has died, usually after brain death
Timing of Transplant
• Preemptive transplant
– performed prior to starting dialysis – no waiting time; scheduled; requires living donor – best outcomes
• Living-related donor
– kidney obtained from close relative, such as parent, child, sibling
• Living donor
– excellent outcomes, even after starting dialysis – one year graft survival 94% – long-term outcome, half-life 22 years
• Living-unrelated donor
– kidney obtained from friend, spouse, coworker, anonymous or good samaritan donor
• Deceased (cadaveric) donor
– – – – go on wait list when GFR less than 20 3-5 years on wait list (after starting dialysis) one year graft survival 89% long-term outcome, half-life 10 years
Wait list counts & listings
Figure 7.5
2006 Kidney Transplant Data
• 17,094 kidney transplants performed nationally • 10,659 (62%) involved deceased donors • 6,435 (38%) involved living donors
patients listed for kidney or kidneypancreas transplant on December 31 of each year.
http://www.optn.org/latestData/rptData.asp
Number of transplants, by donor type
Figure 7.1
Counts of transplants from living donors, by donor relation
Figure 7.2
transplant counts as known to the USRDS (reconciled from various sources).
transplant counts as known to the USRDS (reconciled from various sources).
Median wait time (in years), by state, 2004
Figure 7.7
Should I Be a Kidney Donor?
• Living donor kidneys likely to last longer, function immediately, and possibly require less immunosuppression • Selection of living donor in ADPKD families more complicated and optimally requires review of extended family situation, blood types, etc • Deceased donor kidney waiting list is more than 4 years in New England, longer in NY, shorter in the south
patients receiving deceased donor, kidney-only, first transplants, 2004, unadjusted. State is the state of residence of the transplant recipient.
Moving Forward with Living Donors
• Talk to friends and family • Donors do not need to be related • Family/Friends donor meeting with preliminary blood testing • Potential contraindications to donating: hypertension, diabetes, some types of cancers, active infections, history of kidney stones, and significant past medical/surgical history • No age cut off, but kidney function can decline with age • • • • • •
Family/Friends Donor Meeting
Donors meet recipient’s doctors Discuss process of live kidney donation Blood typing for compatibility Crossmatch blood test: to see if potential recipient will react to the donor organ Human Leukocyte Antigen (HLA) typing done on siblings- looking for “perfect match” Antibody screen on the recipient
Live Organ Donation
• • • • • • • • Voluntary No $ paid donors Non-coercive Informed consent Short- and long-term risks Insurance and disability issues Separation of donor and recipient interests Confidentiality • • • •
Donor Screening
Education about process Blood type ABO-compatibility Tissue type and X-match Donor selection
– – – – healthy age motivation matching (0 vs 1 vs 2-haplotype)
• Voluntary and confidential at all steps of process
Medical Evaluation
• Complete history and physical including BP • Laboratory evaluation including screening for hepatitis, HIV, etc. • 24-hour urine for protein, kidney function • CXR, EKG • Cardiac stress test (age > 50) • Psychosocial evaluation • CT-angiogram • Repeat X-match prior to Tx
Blood Type Compatibility
• Recipient can receive from donor O O (universal donor) A A, O B B, O AB (universal recip.) AB, A, B, O • Rh factor (+ or -) doesn’t matter • Newer protocols can overcome blood type incompatibility, in some cases • Better to get a blood type compatible kidney
Exclusion Criteria
• • • • • • • • • • • <18, >65-70 (physiological age) BP 140/90 or on meds Diabetes or glucose intolerance Protein in the urine, >250 mg GFR <80 ml/min Recurrent kidney stones Blood in urine, urological abnormalities Significant medical illness (emphysema, cancer) Obesity (BMI >35) Increased risk of blood clots Psychosocial issues
Cross Match
• We can make antibodies that react with other people
– blood transfusions and pregnancy – prior transplants
• Presence of antibodies that react against many donors makes it less likely that any donor will be found • The presence of antibodies against a donor usually prevents a transplant from that donor • Newer procedures can sometimes overcome the presence of donor antibodies
Donor Issues in ADPKD
• Polycystic kidney disease family
– donors in ADPKD families require negative ultrasound after age 30; before age 30 may require genetic testing – may diagnose ADPKD in asymptomatic individual as the result of donor evaluation
Maximizing Live Donor Transplants in ADPKD Families
Grandparents Affected grandfather
Needs tx
Family I Affected mother Sibling IB unaffected Blood type A
Family II Affected uncle Cousin IIA affected Blood type A Cousin IIB unaffected Blood type O
• Consider extended family planning based on blood types
Sibling IA affected Blood type O
Sibling IB cannot donate to IA (A to O) but could donate to IIA Cousin IIB (universal donor) could donate to IIA or to IA Cousin IIB donates to IA (O to O), then IB could donate to IIA (A to A)
Kidney Donor Surgery
• Open surgery: traditional technique
– incision under rib cage: hurts to breath – optimal control
Donor Postoperative Complications
• Death (3/10,000)
– reoperation/readmission less than 1% – Blood transfusion less than 1.5%
• Laparoscopic technique
– surgery using scopes and cameras, 3 little holes in upper abdomen, kidney removed via bikini incision – quicker recovery and return to work, less pain – longer operation, technical issues – EXPERIENCE OF SURGEON!!!
• Other complications less than 3% combined
– – – – – – – blood clots in legs; could go to lungs heart attack pneumonia wound infection punctured lung pancreatitis injuries to spleen or adrenals
• Length of hospital stay 3-7 days • Full recovery 6-12 weeks
Long-term Risks
• No significant health impact • Slightly higher incidence of low level protein in urine • High blood pressure and kidney function (GFR) not different than expected for age • No penalty for life or health insurance • Some donors have needed transplants
Expansion of the Kidney Donor Pool
• Donation to waiting list in exchange for deceased donor graft to designee • Paired kidney exchange • Nondirected donation
Donation to Deceased Donor Waiting List
• Due to ABO incompatibility, willing person is unable to donate to recipient • Living donation to deceased donor waiting list • In exchange, recipient moves to top of regional waiting list and gets next acceptable kidney
List Exchange Donation
Donor 1
Blood type A
Recipient 1
Blood type O
Deceased Donor
Blood type O
Wait list Recipient
Blood type A
Paired Kidney Exchange
• Simultaneous living donor transplants between two pairs of ABO-incompatible donors (NEPKE: New England Program for Paired Kidney Exchange www.nepke.org) • Only applicable to 3-6% of recipients (A to A or B to B) • Ethical and logistical issues • Experience with paired exchanges increasing
Two Pair Kidney Exchange
An option for incompatible donor/recipient pairs
Donor 1
Blood type A
Recipient 1
Blood type B
Donor 2
Blood type B
Recipient 2
Blood type A
Successful donation and transplant
Nondirected Donation
• Altruistic donation of kidney by motivated recipient to anonymous recipient • Requires careful evaluation of donor • Limited actual experience
NEJM 343: 433, 2000
Non-Directed Donor (NDD) Chain
Also Known as Good Samaritan or Altruistic Donors
Non – Directed Donor
Blood type O
Successful donation and transplant
Paired Donor 1
Blood type O
Recipient 1
Blood type O 82% PRA
Paired Donor 2
Blood type A
Recipient 2
Blood type B PRA 13%
Wait list Recipient
Blood type A
Expansion of the Deceased Kidney Donor Pool
• Expanded criteria donors
– older than age 60 – age 50-60, deceased due to stroke or presence of high blood pressure or creatinine greater than 1.5 – 70% increase in likelihood of decreased initial function and shorter long-term kidney survival – consider for older individual (>60) or not doing well on dialysis
Ojo et al. JASN 2001
• ?Hepatitis C + donor for hepatitis C + recipient
Educational material on kidney transplantation
• • • • • • • unos.org kidney.org nephron.com transplantliving.org transweb.org Akfinc.org NEPKE.ORG